USMLE_Diagnosis I

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USMLE Diagnosis Challenge

Test your medical knowledge with our USMLE Diagnosis quiz, designed for students and professionals alike. With a variety of scenarios covering a broad spectrum of conditions, this quiz will not only challenge your diagnostic skills but also enhance your understanding of vital medical concepts.

Key features of the quiz:

30 carefully crafted questions
Diverse clinical scenarios
Multiple-choice format
Immediate feedback on answers

200 Questions50 MinutesCreated by DiagnosingDoc42

A mentally retarded 14-year-old boy has a long face, large ears, micropenis, and large testes. Chromosome analysis is likely to demonstrate which of the following?

A 39-year-old paleontologist complains of right-sided hip pain that makes it very difficult for him to lay on his right side while sleeping. He localizes the pain to the outer surface of his thigh. Which of the following is the most likely cause of his pain?

A 1 and half -year-old girl is sent to a children's hospital for evaluation following a nosebleed which was so severe as to require nasal packing and transfusion of platelet concentrates. When a blood sample had been drawn in the emergency room for serum chemistry studies, the local hospital laboratory had noted that the clot that formed was unusual in that it failed to retract. Peripheral blood smear obtained by finger puncture showed an appropriate number of normal-sized platelets, all of which were individual, without clumping. At the children's hospital, it was noted that the child's parents were cousins. Special platelet studies showed that the child's platelet's failed to aggregate with any physiologic aggregating agent, including a high concentration of exogenous ADP. Which of the following is the most likely diagnosis?

A 1-day-old infant who received silver nitrate eye drops in the delivery room is suffering from bilateral purulent conjunctival discharge. Which of the following is the most likely cause of this child’s condition?

A 1-day-old infant who was born by a difficult forceps delivery is alert and active. She does not move her left arm spontaneously or during a Moro reflex. Rather, she prefers to maintain it internally rotated by her side with the forearm extended and pronated. The rest of her physical examination is normal. This clinical scenario most likely indicates which of the following?

Fracture of the left clavicle

Fracture of the left humerus

Left-sided Erb-Duchenne paralysis

Left-sided Klumpke paralysis

Spinal injury with left hemiparesis

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-day-old male infant has bilious vomiting after every feeding. He hasn't passed any stools yet. He had no prenatal care, and was delivered vaginally at term. He weighs 3kg (6.61b), and his APGAR scores were 6 and 7 at 1 min and 5 min, respectively. On examination, the neonate is hypotonic, he has a flat facial profile, short ears with downfolding ear lobes, a single palmar crease, and a depressed fontanel. There is abdominal distention which is most prominent in the upper abdomen. His abdominal x-rays show gastric and duodenal gas distension with no air distally. What other anomaly can also be expected in this infant?

A 1-month old boy is brought to the emergency department by his mother, who states that he has been having what she describes as "projectile vomiting" for the past several days. She states that he vomits every time she feeds him, and the situation seems to be getting worse, although he does not seem to be in pain. She describes the vomitus as non-bilious, and he has had normal stools with no blood in them. On examination, the infant appears to be mildly dehydrated, his abdomen is soft, and there is a palpable, olive-sized, firm moveable mass in the right upper quadrant. Which of the following is the most likely diagnosis?

A 1-month-old baby boy has bloody diarrhea. No infectious agent is identified, but the baby is found to be profoundly thrombocytopenic. The baby is also noted to have a skin rash, and a dermatologist diagnoses eczema. By three months of age, the baby begins to develop recurrent respiratory infections. If this child survives until adolescence, he is at particularly high risk of developing which of the following?

A 1-month-old infant is seen in a well-baby clinic. The mother states that the baby is constipated and feeds poorly. On examination, he is jaundiced, has a large posterior fontanel and an umbilical hernia, and exhibits poor muscle tone. He has gained only 300 g since discharge from the normal newborn nursery. Which of the following is the most likely diagnosis

A 1-month-old, previously healthy infant develops forceful projectile vomiting. No bile is seen in the vomitus. After the infant feeds, gastric peristaltic waves are visible crossing the epigastrium from left to right. Several minutes later, the projectile vomiting occurs. Which of the following is the most likely diagnosis?

A 1-week-old infant presents to her general pediatrician’s office for a well-child visit. She was born at 37 weeks’ gestation without complications. Her temperature is 37.0°C (98.6°F), pulse is 130/min, blood pressure is 72/54 mmHg, and respiratory rate is 28/min. She is currently at the 50th percentile for weight and 75th percentile for height. She is acyanotic and has a wide, fixed split S2, with a 2/6 systolic ejection murmur at the left upper sternal border. The remainder of the examination is unremarkable. Which of the following is the most likely diagnosis?

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 1-year-old African American infant is in for well-child care. He is primarily breast-fed. His parents do not give him much solid food because he has no teeth. He receives no medications or supplements. His parents are concerned about his bowed legs. On examination, you note some other bony abnormalities including frontal bossing, enlargement of the costochondral junctions, a protuberant sternum (pigeon chest), and severe bowing of the legs. You obtain x-rays to confirm your clinical diagnosis and also note a healing fracture of the left femur. Which of the following is the most likely diagnosis?

A 1-year-old boy is brought to the clinic by his 28-year-old Caucasian mother for the evaluation of his eyes. For the past several months, he has been bumping into objects. His perinatal history is unremarkable. Physical examination of the eyes reveals a bilateral white reflex. The retina cannot be visualized properly. Fundal reflection is absent, and the pupil is white. What is the most likely diagnosis?

A 1-year-old Caucasian boy is brought to your office with necrotic periodontal infection. The past medical history is significant for recurrent cutaneous and sinus infections revealing S. Aureus and P. Aeruginosa isolates. The separation of the umbilical cord was delayed (4 weeks). CBC shows leukocytosis and increased neutrophils. The number of peripheral lymphocytes is normal. Gamma-globulin level is increased on plasma protein electrophoresis. The Nitroblue tetrazolium (NBT) test is normal. Which of the following is the most likely defect present in this patient?

A 1-year-old child presents with failure to thrive, frequent large voids of dilute urine, excessive thirst, and three episodes of dehydration not associated with vomiting or diarrhea. Over the years, other family members reportedly have had similar histories. Which of the following is the most likely diagnosis?

A 1-year-old female infant is brought to the clinic by his 30-year-old mother due to feeding problems since birth. She still cannot walk nor speak. She began to sit when she was 8 months old. Her weight is in the 15th percentile, height is in the 20th percentile, and head circumference is in the 100th percentile for her age. She has multiple freckles in her armpit and groin area. She has cafe-au-lait spots on her skin, and the diameter of at least 20 of these spots is greater than 1.5mm. What is the most likely diagnosis?

A 1-year-old girl is brought to the emergency department by her mother because the child's "eyes and feet are dancing." On physical examination, the girl is well developed and in no acute distress. Her temperature 37.0 C (98.6 F), blood pressure is 100/55 mm Hg, pulse is 100/min, and respirations are 20/min. The patient has opsoclonus, myoclonus, and ptosis of the right eye. On history, the mother notes the child was born "looking like a blueberry muffin" and has had a persistent cough since the age of 2 months. Which of the following is the most likely diagnosis?

A 10-day-old infant is brought to the office by her mother for the evaluation of purulent discharge from both eyes. The discharge appeared three days ago, after which the child developed a cough. On examination, the infant's eyes appear normal, except for the presence of purulent discharge. Auscultation reveals diffuse rales without wheezing. Chest radiograph shows a hyperinflated thorax. What is the most likely diagnosis?

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-hour-old newborn is noted to have a swelling in the scalp which was not present at birth. The swelling is limited to the surface of one cranial bone. There are no visible pulsations, indentations of the skull, or discoloration of the overlying scalp. What is the most likely diagnosis?

A 10-month-old boy develops an upper respiratory tract infection 2 days before presentation. On the day of presentation, he has a generalized tonic-clonic seizure lasting 30 seconds. His temperature is 40.0 C (104 F), blood pressure is 90/60 mm Hg, and respirations are 22/min. He is alert and smiling. He has rhinorrhea, and his neck is supple. He has bruises below his knees. Which of the following is the most likely diagnosis?

A 10-month-old infant on long-term aspirin therapy for Kawasaki disease develops sudden onset of high fever, chills, diarrhea, and irritability. A rapid swab in your office identifies influenza A, adding her to the long list of influenza patients you have seen this December. Over the next few days, she slowly improves and becomes afebrile. However, 5 days after your last encounter you hear from the hospital that she has presented to the emergency center obtunded and posturing with evidence of liver dysfunction. Which of the following statements about her current condition is correct?

. With proper supportive care, the overall mortality rate is low.

. With her progressiveliver dysfunction, increased total serum bilirubin is anticipated.

. Administration of N-acetylcysteine is first-line therapy.

. Seizures are uncommon with this condition.

. Death is usually associated with increased intracranial pressures and herniation.

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 girl is brought to the office by her mother for the evaluation of recent changes in behavior. She has been sleeping poorly at night and has started wetting her bed. Her school grades have dropped significantly, and she has become irritable and cranky. She refuses to sleep at night until her father returns home and goes to bed. Her father works as a taxi driver, and is an alcoholic. Her mother is a close friend of yours, and appears very concerned. Prior to this office visit, you have known this girl to be cheerful and lively; however, as you attempt to talk to the young girl in the office, she suddenly bursts into tears. Which of the following should you consider at this point?

A 10-year-old boy from the Connecticut coast is seen because of discomfort in his right knee. He had a large, annular, erythematous lesion on his back that disappeared 4 weeks prior to the present visit. His mother recalls pulling a small tick off his back. Which of the following is a correct statement about this child’s likely illness?

. The tick was probably a Dermacentor andersoni

. The disease is caused by a rickettsial agent that is transmitted by the bite of a tick

. In addition to skin and joint involvement, CNS and cardiac abnormalities may be present

. Therapy with antibiotics has little effect on the resolution of symptoms

. The pathognomonic skin lesion is required for diagnosis

A 10-year-old boy has been having “bellyaches” for about 2 years. They occur at night as well as during the day. Occasionally, he vomits after the onset of pain. Occult blood has been found in his stool. His father also gets frequent, nonspecific stomachaches. Which of the following is the most likely diagnosis?

A 10-year-old boy is brought by his parents to the emergency department for the evaluation of headaches, fever, chills, and a rash over his neck, chest, and axillae. The rash appeared today, and for the past two days the child was complaining of a sore throat. He has no history of allergies, and his immunizations are up-to-date. His blood pressure is 112/70 mmHg, pulse is 1 08/min, respirations are 20/min, and temperature is 38.3C (101 F). Examination reveals an erythematous rash with a sandpaper-like texture, and which blanches with pressure. There is submandibular tender lymphadenopathy, and the throat is erythematous with gray-white exudates. What is the most likely diagnosis?

A 10-year-old boy is brought in with a chief complaint of multiple colds. On further questioning, you elicit a history of chronic, clear nasal discharge with no seasonal variation. Other symptoms include sneezing, itching of the nose and eyes, as well as tearing and occasional eye redness. Some relief is obtained with an over-the-counter cold medicine containing antihistamine and a decongestant. His history suggests which of the following?

A 10-year-old boy is brought to clinic because of increasing weakness and dyspnea over the past 6 months. He has been previously healthy and is on no medications. There is no significant family history of illness. On examination, he appears pale. His hematocrit is 20%, mean corpuscular volume (MCV) is 60/mm3, and iron level is normal. Smear reveals basophilic stippling. Hemoglobin electrophoresis is consistent with the absence of one beta-globin gene. Which of the following is the most likely diagnosis

A 10-year-old boy is brought to the emergency department due to abdominal pain and bloody diarrhea. The mother says that he was "fine" a few days ago, and then suddenly became ill. Physical examination shows a pale and jaundiced child. There is diffuse abdominal tenderness and 2+ pedal edema. Laboratory studies show anemia, thrombocytopenia and renal insufficiency. What is the most likely cause of the patient's symptoms

A 10-year-old boy is brought to the office by his mother after having a seizure this morning. All he can recall before the episode is "seeing funny little lights." According to his mother, his body went stiff; he lost consciousness, and then had jerky movements of the entire body. He bit his tongue, and started to drool. The seizure lasted for about one minute. After the seizure, he appeared confused for several minutes, and passed urine. He has been complaining of a headache for the past two hours. The neurological examination is normal. What type of seizure did this patient experience?

A 10-year-old boy is brought to the office by his parents because he is developing dark facial hair, deepening of the voice and a rapid height increase. He also complains of persistent headaches which are resistant to over-the-counter analgesics for the past 2 weeks. He denies nausea, vomiting or visual disturbances. His medical history is unremarkable. Physical examination reveals coarse pubic and axillary hair. Other pertinent findings include lid retraction, paralysis of upward and downward gaze, and poor pupillary reaction to light. His deep tendon reflexes are normal, Babinski sign is negative, and there are no focal neurologic signs. What tumor is most likely responsible for this child's symptoms?

A 10-year-old boy presents to the emergency room with chief complaints of fever and increasing fatigue. He was well until 2 weeks ago when he had an upper respiratory illness (URI). He has a decreased appetite and has lost 2 lbs over the last 2 weeks. He has some shortness of breath when he climbs the stairs. His past medical history is unremarkable. On examination his vital signs are normal, and his height and weight are at the 80th percentile. His conjunctiva are pale, and he has bilateral, mobile (about 1-2cm) and non-tender nodes in the cervical, axillary, and inguinal regions. Hepatosplenomegaly is present, and skin shows no lesions. Labs are Hemoglobin 7.3g/dl, platelet count 20,000/mm3, WBC count 42,100/mm3, with 24% lymphoblasts, 70% lymphocytes, and 6% atypical lymphocytes. Chest X-rays show clear lung fields but a wide mediastinum. Which of the following is the most likely diagnosis in this patient

A 10-year-old boy, the star pitcher for the Salt Lake City Little League baseball team, had a sore throat about 2 weeks ago but did not tell anyone because he was afraid he would miss the play-offs. Since several children have been diagnosed with rheumatic fever in the area, his mother is worried that he may be at risk as well. You tell her that several criteria must be met to make the diagnosis but the most common finding is which of the following?

A 10-year-old Caucasian boy is brought to the emergency room by his mother with right hemiplegia of sudden onset. The mother says that the child fell on a pencil in his mouth, ten hours before the onset of symptoms. His past medical history is insignificant. Family history is not significant. His blood pressure 110/60 mmHg and heart rate is 90/min. Physical examination reveals dense right hemiplegia, right hemianesthesia, and mild motor aphasia. Cardiac auscultation reveals S3. What is the most probable cause of this patient's condition?

A 10-year-old girl has had a “cold” for 14 days. In the 2 days prior to the visit to your office, she has developed a fever of 39°C (102.2°F), purulent nasal discharge, facial pain, and a daytime cough. Examination of the nose after topical decongestants shows pus in the middle meatus. Which of the following is the most likely diagnosis?

A 10-year-old girl is brought to a pediatrician because her mother notices that she stumbles frequency at night, even with adequate lighting. Visual field testing demonstrates a relatively narrow mid-peripheral ring scotoma. Ophthalmoscopy demonstrates dark pigmentation in a bone spicule configuration involving the equatorial retina. Additional findings include a waxy yellow appearance to the disk and narrowed retinal arteries. Which of the following is the most likely diagnosis?

A 10-year-old girl is brought to the office for a follow-up visit. She has been previously diagnosed with vesicoureteral reflux, and has had multiple episodes of acute urinary tract infections in the past. Intravenous pyelography (performed on her last visit) reveals bilateral focal parenchymal scarring and blunted calyces. What is the most likely diagnosis?

A 10-year-old girl is evaluated by a pediatrician. She is already 5'8" tall and is taller than other members of her family were at this age. Her arms are disproportionately long compared with her trunk, and her sternum is outwardly displaced. Her joints are hyperextensible, particularly at the knees. Ocular examination demonstrates dislocation of one lens. 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 10-year-old white boy is brought to the office by his foster parents for the evaluation of severe pain in his left knee for the last few days. His left knee has been hurting so bad that he is now unable to play with his peers. The pain is continuous and non-radiating. His knee appears swollen, but he denies any history of trauma. His family history is unknown. His vital signs are stable. Physical examination reveals a pale young boy. The left knee is tender, erythematous and swollen. Blood tests reveal: WBC 12,600/mm3, Hemoglobin 9.3 g/dl, Hematocrit 29%, Platelets 201,000/mm3, ESR 40. X-ray of the knee reveals that the lower end of the femur has a central lytic lesion, onion skinning and a moth-eaten appearance with some extension into the soft tissue. What is the most likely diagnosis?

A 12-month-old girl has been spitting up her meals since 1 month of age. Her growth is at the 95th percentile, and she is otherwise asymptomatic and without findings on physical examination. Which of the following is the most likely diagnosis?

A 12-month-old infant presents with bilious vomiting and abdominal distention for 10 hours. His mother states that the infant has been constipated since birth and failed to pass meconium during the first 48 hours of life. On examination, he is very irritable. His length and weight are both below the 5th percentile according to his age. His abdomen is moderately distended. After a digital rectal examination, a fair amount of stool ejects out from the anus. Which of the following is the most likely diagnosis?

A 12-week-old female infant is brought to the office by her mother due to a three-week history of weakness, poor appetite, and choking spells during feeding. Other accompanying symptoms include excessive sleeping, constipation and apathy. Her prenatal history is unremarkable. She was delivered vaginally at 38 weeks of gestation. Her weight and length at birth were within normal range. She is exclusively breastfed. Her mother's family history is unremarkable. The identity and family history of her father are unknown. The pertinent physical findings include apathy, weakness, hypotonia, large tongue, sluggish movement, abdominal bloating, and an umbilical hernia. Based on the given information, what is the most likely diagnosis?

A 12-year boy is brought to the emergency room by his parents after a several day history of progressive weakness. He has been a healthy child who has met all development milestones and all his immunizations are up to date. He reports that he had an upper respiratory infection 2 weeks ago. On physical examination, his vital signs are labile with a pulse range of 60-100/ min and systolic blood pressure ranging from 80-120 mm Hg. He is alert and oriented. Neurologic examination is impressive for bilateral weakness in the upper and lower extremities. Deep tendon reflexes are absent and sensation is intact. Which of the following is the most likely diagnosis?

A 12-year-old American boy comes to you with the complaints of abdominal pain and dark urine. On examination he has normal vitals, icteric sclerae, and abdominal tenderness with a mass palpable in right upper quadrant. His laboratory report shows bilirubin: 6.5 mg/di, negative viral serologies and mild elevations of amylase and lipase. Ultrasonography shows a cystic extra hepatic mass and a gall bladder separated from the mass. What is the most likely diagnosis in this patient?

A 12-year-old boy is accused of setting his neighbor's house on fire. His parents describe him as a hyperactive, talkative child. He earns excellent grades in school but frequently gets into fights with schoolmates and siblings. Two years ago, he was caught setting the interior of his father's car on fire. He has also been linked to several suspicious fires in the neighborhood, though no criminal charges were brought against him Based on this information, what is the most likely diagnosis?

A 12-year-old boy is brought to the clinic for a routine health maintenance exam. He has no complaints, but mentions some spots on his back, which he noticed during his physical education class. He does not know how long they have been there. He denies any allergies. He remembers having a few seizures some years ago, which have not recurred since. He does not take any medication. The physical examination reveals several white spots and nodules measuring 2x3 cm on his back. There are freckles on his face and axilla. Closer examination reveals some nodules on his iris. What is the concerning complication that this boy is prone to?

A 12-year-old boy is brought to the emergency department after being involved in a motor vehicle collision. He is in no distress and is admitted for observation. Two hours after admission, he develops tachypnea and tachycardia. His temperature is 36.7C (98F), blood pressure is 110/66 mm Hg, pulse is 110/min, and respirations are 22/min. Examination shows bruises on the right side of the chest, but palpation of the ribs does not elicit pain or suspicion for rib fractures. Breath sounds are decreased on the right side. ABG on 6 liters of oxygen shows PO2 of 60 mm Hg, PCO2 of 32 mm Hg, and pH of 7.42. An x-ray film of the chest shows a patchy irregular alveolar infiltrate in the right middle and lower lobes. Which of the following is the most likely diagnosis?

A 12-year-old boy is brought to the emergency department after falling from a tree. Examination shows tenderness and swelling over the left lower arm. An x-ray film of the arm shows a fracture of the distal end of the humerus with proximal and posterior displacement of the distal fracture segment. Closed reduction of the fracture is performed. However, postoperatively the patient complains of increasing pain in the left arm and forearm. Twelve hours postoperatively his forearm is pale and cold. There is marked pain on passive extension of the fingers. Which of the following is the potential dreaded complication of this condition?

A 12-year-old boy is brought to the physician because of pain in his right leg for the past 3 weeks. The pain frequently occurs at night and is localized to the tibia, a few centimeters below the knee. The mother reports that the pain is promptly relieved by aspirin and that the child has had no fever. Examination reveals no tissue swelling or redness about the site of pain. X-ray films show a 1-cm radiolucent focus in the tibial cortex surrounded by marked bone sclerosis. Which of the following is the most likely diagnosis?

A 12-year-old boy presents with a 2-month history of recurrent headache and deteriorating school performance. Neurologic examination is unremarkable except for bitemporal deficits in his visual field. X-ray and MRI of the head are performed. X-ray films show calcifications in the suprasellar region, while MRI images reveal a multicystic tumor displacing the optic chiasm. The patient undergoes neurosurgical operation for excision of the tumor. During the procedure, the surgeon notices that the cystic cavities contain a "machinery oil"-like fluid. Which of the following is the most likely diagnosis?

A 12-year-old child is brought to his pediatrician for a routine health maintenance visit. He has been well except for occasional attacks of asthma and has met all development milestones. His immunizations are up to date. He occasionally uses theophylline for his asthma. Physical examination is remarkable for a blood pressure of 150/90 mm Hg in both arms. Which of the following is the most likely cause of his hypertension?

A 12-year-old female comes to the physician because of a vaginal discharge. The discharge started about 2 months ago and is whitish in color. There is no odor. The patient has no complaints of itching, burning, or pain. The patient started breast development at 9 years of age and her pubertal development has proceeded normally to this point. She has not had her first menses and she is not sexually active. She has no medical problems. Examination is normal for a 12-year-old female. Microscopic examination of the discharge shows no evidence of pseudohyphae, clue cells, or trichomonads. Which of the following is the most likely diagnosis?

A 12-year-old girl comes to the office complaining of a small amount of left-sided ear discharge that has persisted for the last three weeks. She has completed two courses of antibiotics that were prescribed during her previous visits. She also complains of hearing loss on the left side. On examination, she is afebrile. Otoscopy reveals an intact left tympanic membrane with peripheral granulation and some skin debris. The patient should be evaluated for which of the following?

A 12-year-old girl complains of intermittent palpitations. She had previously been in excellent health and has met all development milestones. There is no family history of heart disease. She is on no medications and takes no drugs. She states that the palpitations begin and end suddenly and usually last a couple of hours. She is otherwise asymptomatic between episodes. The physical examination is normal. An ECG reveals a shortened PR interval and a slow upstroke of the QRS wave in lead III. Which of the following is the most likely diagnosis?

A 12-year-old girl has had a sore throat over 2 days. She now has a fever of 39.5°C and has difficulty opening her mouth, swallowing, or speaking. Her throat can be visualized with difficulty, the right tonsil is significantly more enlarged than the left, and the uvula is displaced to the left side. Which of the following is the most likely diagnosis?

A 12-year-old girl is taken to a pediatrician complaining of a sore mouth. On questioning, the child states that she has been feeling poorly, with fatigue and weakness. She began menstruating briefly and then stopped. Physical examination is notable for focal white crusting of the oral cavity; biopsy of one of these areas later shows candidiasis, Laboratory studies show the following: Sodium 127 mEq/L, Potassium 5.3 mEq/L, Bicarbonate 24 mEq/L, Calcium 7.5 mEq/dL, Phosphorus 5.5 mg/dL, Glucose 87 mg/dL. Which of the following is the most likely diagnosis?

Multiple endocrine neoplasia, type I

Multiple endocrine neoplasia, type IIA

Polyglandular deficiency syndrome, type I

Polyglandular deficiency syndrome, type II

Polyglandular deficiency syndrome, type III

A 12-year-old male is brought to your office by his mother because of a several month history of back pain. He also experienced bed wetting recently. His past medical history is insignificant. He tried acetaminophen for pain relief. He does not smoke or consume alcohol. His temperature is 36.7 C (98 F), blood pressure is 110/65 mmHg, pulse is 80/min, and respirations are 16/min. Physical examination reveals a palpable "step off" at the lumbosacral area. Straight-leg raising test is negative on both sides. Perianal sensation tested by pinprick test is decreased, but anal reflex is normal. What is the most probable diagnosis in this patient?

A 12-year-old white male wants to participate in sports at school. He has been growing normally since birth. His immunizations are up-to-date and he is not suffering from any known medical conditions. Which of the following measures should be taken to screen him for underlying heart disease that could cause sudden cardiac death?

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 13-year-old boy is seen for right knee pain that has persisted for the past 2 months despite the use of over-the-counter analgesics. His mother states that he has been limping since he started to have the pain. The pain is of insidious onset, but its intensity sometimes suddenly increases. On physical examination, the boy is obese; his weight is higher than the 90th percentile. Flexion of the right hip causes marked outward rotation and reproduces the pain. Internal rotation of the right hip is limited, and the right leg is slightly shortened compared with the left leg. Which of the following is the most likely diagnosis?

A 13-year-old girl had growth of breast buds at 11 years, followed by the appearance of pubic hair between the ages of 11.5 and 12 years. Which pubertal event is most likely to occur next?

A 13-year-old girl presents with parental concerns of poor posture. She has not had any back pain. On examination, she has unequal shoulder height, asymmetric flank creases, and a forward-bending test that shows rib asymmetry. The physical examination is otherwise normal. Which of the following is the most likely cause of her condition?

A 13-year-old healthy boy presents to the physician for a routine health maintenance visit. A urinalysis reveals 1+ proteinuria. There is no hematuria or bacteruria. His physical examination is unremarkable, revealing no edema and a normal blood pressure. Which of the following is the most likely diagnosis?

A 13-year-old, obese boy complains of persistent knee pain for several weeks. The family brings him in because he has been limping. He sits in the examining table with the sole of the foot on the affected side pointing to the other leg. Physical examination is normal for the knee, but shows limited hip motion. As the hip is flexed, the leg goes into external rotation and cannot be rotated internally. Which of the following is the most likely diagnosis?

. Avascular necrosis of the femoral head

. Developmental dysplasia of the hip

. Osteogenic sarcoma of the lower femur

. Slipped capital femoral epiphysis

. Tibial torsion with foot inversion

A 14-day-old male infant is brought to the emergency department due to spasms involving the whole body. He has been having very poor suckling over the last couple of days. He was delivered vaginally by an untrained birth attendant, and his mother never sought any pre- or antenatal care. The pertinent physical finding is a swollen and erythematous umbilical cord. What is the most likely diagnosis of this patient?

A 14-month-old infant suddenly develops a fever of 40.2C (104.4F). Physical examination shows an alert, active infant who drinks milk eagerly. No physical abnormalities are noted. The WBC count is 22,000/μL with 78% polymorphonuclear leukocytes, 18% of which are band forms. Which of the following is the most likely diagnosis?

A 14-month-old male infant presents to the emergency room with a chief complaint of high grade fever with no response to antipyretic therapy. This illness started suddenly with the abrupt onset of fever early yesterday morning. He then developed a severe cough and increased work of breathing. The mother reports that he is frequently ill. He was hospitalized 2 months ago for pneumococcal pneumonia. On examination: PR: 145/min; RR: 55/min; BP 100/60mm Hg; oxygen saturation 91%; weight 7 kg (154 lbs). He is listless, tired, and small for age. Both ear canals contain purulent drainage. An immunologic work-up is done and found to have markedly elevated IgM, undetectable IgG and IgA with diminished total B-lymphocytes and neutrophils. Which of the following is the most likely diagnosis?

. Bruton's agammaglobulinemia (XLA)

. Common variable immunodeficiency

. Transient hypogammaglobulinemia of infancy (THI)

. Hyper-IgM syndrome (HIM)

. Selective IgA deficiency

A 14-year-old African-American boy presents to your office with difficulty walking for the past several weeks. He complains of pain in the right hip. He describes two episodes of severe hip pain and one previous episode of abdominal pain requiring hospitalization. Physical examination reveals motion restriction in the right hip joint. His joint is not erythematous or tender to palpation. His hematocrit is 22%. This patient's difficulty walking is most likely secondary to which of the following?

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 14-year-old black male comes to the office for the evaluation of pain in his right hip that started several weeks ago. The pain has gradually progressed, and now it limits his daily activities. He has sickle cell disease and was hospitalized three months ago due to a painful crisis that was successfully treated with hydration, oxygen, and analgesics. His temperature is 37.2C (99F), blood pressure is 100/70 mmHg, pulse is 80/min, and respirations are 16/min. Physical examination reveals no local tenderness, but there is restriction of abduction and internal rotation of the hip What is the most likely diagnosis?

A 14-year-old boy has pain in his left leg. An x-ray shows a tumor and a biopsy reveals histopathologic features characteristic of neural origin. Which of the following is the most likely diagnosis?

A 14-year-old boy is brought to the emergency room because of persistent midepigastric pain for two days. The pain is getting no better, yet it is no worse, and radiates to his back. The boy also has had fever, as well as nausea and vomiting that is worse when his temperature rises in the afternoon. On examination, his temperature is 39.2C (102.5F) and there is marked upper abdominal tenderness with guarding. Mild abdominal distention is present with no audible bowel sounds. A complete blood count reveals an elevated leukocyte count and a normal serum amylase. Which of the following is the most likely diagnosis?

A 14-year-old boy is brought to the psychiatrist because for the past 15 months he has been irritable and depressed almost constantly. The boy notes that he has difficulty concentrating, and he has lost 5 lb during that time period without trying. He states that he feels as if he has always been depressed, and he feels hopeless about ever feeling better. He denies suicidal ideation or hallucinations. He is sleeping well and doing well in school, though his teachers have noticed that he does not seem to be able to concentrate as well as he had previously. Which of the following is the most likely diagnosis?

A 14-year-old boy presents with decreased exercise tolerance. He is noted to have a grade III/VI systolic ejection murmur best heard at the left upper sternal border and a grade II/VI mid-diastolic murmur at the lower left sternal border. The first heart sound is normal. The second heart sound is widely split and fixed. A right ventricular impulse is palpated. On a chest roentgenogram, the pulmonary artery segment is enlarged, and pulmonary vascular markings are increased. An ECG shows right axis deviation. Which of the following congenital heart diseases does this boy most likely have?

A 14-year-old boy presents with sudden onset of pain and swelling of his right testicle. There was no history of trauma, he is not sexually active, and denies any history of penile discharge. On examination, the scrotum is swollen and tender. The cremasteric reflex is absent. A testicular flow scan shows a “cold spot” or absent flow to the affected side. Which of the following is the most likely cause?

A 14-year-old Caucasian female presents to clinic for a routine check-up. She complains that her menstrual cycles are irregular and that her menses last seven to ten days. She underwent menarche one year ago and her last menstrual period was two weeks ago. She eats a balanced diet and works out in a gym on weekends. Her past medical history is insignificant and her BMI is 25 kg/m2. Which of the following is the most likely cause of this patient's complaints?

. Endometrial stimulation by progesterone

. Complex atypical hyperplasia of the endometrium

. Absent ovulation

. Increased FSH secretion

. Endometrial atrophy

A 14-year-old female is brought to the physician's office for evaluation of excessive menstrual bleeding. She experienced menarche at age 13, and since then her menses have been irregular and unpredictable. Her last menstrual period was 6 weeks ago and for the past week she has been having heavy menstrual bleeding. She has never been sexually active. Vital signs are stable. Her external genitalia are normal. She refused pelvic examination, and a pregnancy test is negative. Which of the following is the most likely cause of her symptoms?

A 14-year-old girl awakens with a mild sore throat, low-grade fever, and a diffuse maculopapular rash. During the next 24 hours, she develops tender swelling of her wrists and redness of her eyes. In addition, her physician notes mild tenderness and marked swelling of her posterior cervical and occipital lymph nodes. Four days after the onset of her illness, the rash has vanished. Which of the following is the most likely diagnosis?

A 14-year-old girl comes to the office for a health maintenance evaluation. She is concerned that she has not yet started her menstrual cycle. Her height has increased by 3 inches since her last visit 1 year ago, and her weight is up by 10 pounds. On physical examination, the physician notes a general enlargement of her breasts and areola. Examination of her genital area reveals pubic hair that is coarse and dark and extends past the medial border of the labia. Which of the following is the most likely diagnosis?

A 14-year-old girl complains of irregular, unpredictable heavy menstrual bleeding. She denies pain or cramping. Her first menstrual period was at age 13, and they have always been irregular, but the bleeding seems to be getting heavier. She has no chronic health problems and states she has never been sexually active. She appears well developed and well nourished, with normal female secondary sexual characteristics. Inspection shows normal female external genitalia. Results of a qualitative urine human chorionic gonadotropin (-hCG) test are negative. Which of the following is the most likely diagnosis?

A 14-year-old girl has a 9-month history of diarrhea, abdominal pain (usually periumbilical and postprandial), fever, and weight loss. She has had several episodes of blood in her stools. Which of the following is the most likely diagnosis?

A 14-year-old girl has a firm, movable, rubbery mass in her left breast. The mass was first noticed 6 months ago and has since grown to about 6 cm in diameter. Which of the following is the most likely diagnosis?

A 14-year-old girl has a history of red eyes with clear discharge that she suffers from in a seasonal pattern. Together with these symptoms, she reports itching, which is her most bothersome complaint. Physical examination shows conjunctival redness, tearing, and swelling, but there is no purulent discharge. This clinical picture is most compatible with a diagnosis of which of the following conditions?

A 14-year-old girl is brought to the physician’s office because of irregular menstrual periods. She had her menarche at age 13, and since then her periods have been irregular with the cycles varying from 3 to 6 weeks. She has no other symptoms. Physical examination is unremarkable. She has age appropriate secondary sexual characteristics. A urine pregnancy test is negative. Serum prolactin and thyroid stimulating hormone levels are normal. Administration of micronized oral progesterone results in withdrawal bleeding in 3 days. Which of the following most likely explains her irregular periods?

A 14-year-old girl presents to the emergency room for severe lower mid-abdominal pain that has been increasing over the past 12 hours. She describes it as crampy and sharp. Her last menstrual period was about 2 weeks ago. It was regular with no pain and lasted 4 to 5 days. She has had menstrual periods for nearly 2 years, and over the past 6 months she has noticed some cramping pain the first day or two of her menses. She denies sexual activity and has not had any vaginal discharge. Her bowel movements have been normal and she reports no urinary frequency, urgency, or burning with urination. Which of the following is the most likely diagnosis?

A 1400-g infant, born at 35 weeks' gestation, is 42 cm in length and a head circumference of 28 cm. One day after birth, she becomes very irritable, tremulous, and inconsolable. Her cry is high-pitched. Her pulse is 174/min. There are no dysmorphic facial features. To which of the following substances was this newborn most likely exposed in utero?

A 15-day-old male infant is brought to the emergency department by his mother due to vomiting and bloodstained stools since yesterday. The vomitus is green. Recently, the neonate has been feeding poorly. His birth history is not significant: he was absolutely normal and passed meconium within the first 12 hours of life. He has been breastfed since birth. His pulse rate is 122/min and blood pressure is 80/50mm Hg. He is irritable, his mucous membranes are dry, and his abdomen is distended. Based on these findings, what is the most likely diagnosis?

A 15-month-old Asian girl is brought to the physician's office because of persistent non-productive cough and skin rash. Other accompanying symptoms are a runny nose, sneezing and intermittent nasal obstruction. She has had these symptoms for the past four days. Her parents report that she seems to have lost interest in her usual activities and is irritable all the time. Her pulse is 130/min, temperature is 38.8C (102F), and respirations are 24/min. Her eyes are red and have a watery discharge; there is congestion that is more marked over the canthi; the inner conjunctiva has bluish white lesions on an erythematous background. Throat examination reveals erythema of the posterior pharyngeal wall and tonsillar pillars, and yellowish exudates on the tonsils. The buccal mucous membranes are red with bluish-white lesions. The face has blanching, erythematous "brick-red" maculopapular rash. No rash is present over the extremities. Cervical lymphadenopathy is noted. The lab results are as follows: Hct 46%, WBC count 3,000/mm3, Platelet 160,000/mm3, Urine Dipstick ++ for proteins. What is the most likely diagnosis?

A 15-month-old boy is brought into the clinic with a 1-day history of fever, decreased oral intake, and runny nose. His vital signs are within normal limits except for a temperature of 39.5 C (103.1 F). He is active and in no distress. His ears are clear bilaterally. There is a clear nasal discharge. Multiple small (1-2 mm) vesicular lesions are noted on the mucosa of the anterior tonsillar pillars and posterior palate. The rest of his examination is within normal limits. Which of the following is the most likely diagnosis?

A 15-month-old girl is brought to the office by her mother due to failure to thrive. For the past three months, the child has had foul-smelling, non-bloody, loose stools 7 to 8 times daily. On examination, she is irritable and has a protruding belly and trace pre-tibial edema. There are erythematous vesicles symmetrically distributed over the extensor surfaces of her elbows and knees. Preliminary laboratory investigations are significant for hypochromic microcytic anemia, and stool examination is negative for ova or parasites. What is the most likely cause of failure to thrive in this child?

A 15-year-old athlete is in your office for his annual physical examination before the start of football season. He has no complaints, has suffered no injuries, and appears to be physically fit. On his heart examination, you note a heart rate of 100 beats per minute, and a diffuse point of maximal impulse (PMI) with a prominent ventricular lift. He has a normal S1 and S2, with an S4 gallop. He has no murmur sitting, but when he stands you clearly hear a systolic ejection murmur along the lower left sternal edge and the apex. For which of the following conditions is this examination most consistent?

A 15-year-old boy comes to the physician because of hematuria and lower abdominal pain. This is his third episode of hematuria in the past 2 years. He has a family history of renal disease. His temperature is 37.1°C (98.9°F), blood pressure is 140/90 mm Hg, pulse is 80/min, and respirations are 14/min. Examination shows mild sensorineural deafness bilaterally. Urinalysis shows hematuria and proteinuria. Laboratory studies show BUN of 50 mg/dl and serum creatinine of 3.1 mg/dL; serum complement levels are normal. Renal biopsy shows foam cells, and immunofluorescence shows no immunoglobulins or complement. Electron microscopy shows alternating areas of thinned and thickened capillary loops with splitting of GBM. Which of the following is the most likely diagnosis?

. Alport's syndrome

. Acute interstitial nephritis

. Acute post infectious glomerulonephritis

. Anti-glomerular basement membrane disease

. Benign recurrent hematuria

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 15-year-old boy is brought to the physician because of a 15-day history of painful swelling of the right knee. The swelling and redness were immediate after hitting his knee on the door, but have not subsided after 15 days of ibuprofen. He states the pain is increasing. He has no other complaints. His temperature is 37.1C (98.9F), blood pressure is 110/75 mm Hg, pulse is 80/min, and respirations are 22/min. Laboratory studies show a normal ESR and elevated serum alkaline phosphatase. Examination shows the skin is warm and non-tender. An x-ray film of the femur and the knee joint shows an osteolytic lesion of the distal femur along with periosteal inflammation. Which of the following is the most likely diagnosis?

A 15-year-old boy is seen in the pediatrician's office for a health maintenance physical examination. The boy reports a heavy, dragging sensation in his left scrotum. The sensation is more pronounced after exercise. He denies any scrotal pain. He is not sexually active. Examination of his genitalia indicates Tanner stage 4. There is a palpable fullness over his left scrotum. Both testes are normal in size and smooth in contour. Which of the following is the most likely explanation of these findings?

A 15-year-old girl complains of low-grade fever, malaise, conjunctivitis, runny nose, and cough. After this prodromal phase, a rash of discrete pink macules begins on her face and extends to her hands and feet. She is noted to have small red spots on her palate. What is the most likely cause of her rash?

A 15-year-old girl has a round, 1-cm cystic mass in the midline of her neck, at the level of the hyoid bone. The mass is deep to the skin and moves slightly when the patient swallows. When the mass is palpated at the same time that the tongue is pulled, there seems to be a connection between the two. The mass has been present for at least 10 years, but only recently bothered the patient because it became infected. Which of the following is the most likely diagnosis?

A 15-year-old girl is admitted to the hospital with a 6-kg weight loss, bloody diarrhea, and fever that have occurred intermittently over the previous 6 months. She reports cramping abdominal pain with bowel movements. She also reports secondary amenorrhea during this time. Stool cultures in her physician’s office have shown only normal intestinal flora. A urine pregnancy test was negative, while an erythrocyte sedimentation rate (ESR) was elevated. Her examination is significant for the lack of oral mucosal ulcerations and a normal perianal examination. Anti-Saccharomyces cerevisiae antibodies (ASCA) are negative, while anti-neutrophil cytoplasm antibodies (p-ANCA) are positive. You confirm your presumptive diagnosis with a rectal biopsy. In counseling her about her disease, which of the following statements would be true?

. Inheritance is autosomal dominant

. Her risk of colon cancer is minimally elevated over the general population

. Intestinal strictures are common

. The most serious complication of her disease is toxic megacolon

. The intestinal involvement is separated by areas of normal bowel

A 15-year-old girl is being evaluated for primary amenorrhea. She has no other symptoms. She has not been sexually active. She has no other medical problems and does not take any medication. Her family history is unremarkable. On examination, you note fully developed breasts and absent axillary and pubic hair. External genitalia have a normal appearance, but the vagina is abnormally short and blind ended. Initial work-up reveals no uterus on ultrasound, a testosterone level of 400 ng/dl (Normal is 20-80 for a female), and a 46 XY karyotype. Which of the following events is most likely to have caused the absence of in utero development of the internal reproductive organs?

. Absence of mullerian inhibiting factor

. Presence of mullerian inhibiting factor

. Agenesis of Wolffian ducts

. Agenesis of mullerian ducts

. Testosterone surge

A 15-year-old girl is being evaluated for primary amenorrhea. She has no other symptoms. She has not been sexually active. She has no other medical problems and does take any medication. Her family history is unremarkable. On examination, you note fully developed breasts and absent axillary and pubic hair. External genitalia have a normal appearance, but the vagina is abnormally short and blind ended. Initial work-up reveals no uterus on ultrasound, a testosterone level of 400 ng/dl (Normal is 20-80 for a female), and a 46 XY karyotype. Which of the following events is most likely to have caused the absence of in utero development of the internal reproductive organs?

. Absence of mullerian inhibiting factor

. Presence of mullerian inhibiting factor

. Agenesis of Wolffian ducts

. Agenesis of mullerian ducts

. Testosterone surge

A 15-year-old girl is being evaluated for primary amenorrhea. She is otherwise healthy and has no previous medical problems. Vital signs are within normal limits. Physical examination reveals normal breast development, normal pubic and axillary hair, and a blind vagina; the uterus and adnexae could not be appreciated. Pelvic ultrasonography reveals 2 ovaries and no uterus is seen. The karyotype is 46 XX. Which of the following is the most likely diagnosis?

A 15-year-old girl presents to a pediatric cardiology clinic with a complaint of chest pain. She states the pain has come and gone over the past year, but has increased in frequency over the past few weeks. She describes it as a sharp pain over her left chest. Physical examination reveals a healthy-appearing 15-year-old girl. Her temperature is 37.2 C (99 F), pulse is 90/min, and respiratory rate is 20/min. Lung examination is normal. Cardiac examination reveals a late systolic murmur preceded by a click at the apex. No heave or rub is present. An electrocardiogram and chest x-ray film are unremarkable. Which of the following is the most likely diagnosis?

A 15-year-old girl presents to the emergency department with the sudden onset of watery diarrhea tinged with blood. The girl was previously healthy. Her only medications are topical benzoyl peroxide and oral clindamycin for acne vulgaris. Physical examination reveals a slightly distended abdomen that is diffusely tender. Her temperature is 38.1 C (100.5 F). She has not been exposed to any uncooked meat and has not eaten any unusual foods. Which of the following is the most likely diagnosis?

A 15-year-old girl presents with a 2-day history of pain and swelling in her left knee. She plays soccer regularly on her school team. There is no history of trauma. On physical examination, there is marked swelling and tenderness over her anterior tibial tuberosity. A radiograph of her left knee reveals irregularities of the tubercle contour and haziness of the adjacent metaphyseal border. Which of the following is the most likely explanation for her symptoms?

A 15-year-old male comes to your office with a one-week history of fever, non-productive cough, sore throat and headaches. Today he noticed a skin rash. His temperature is 38.5°C (101.3°F), pulse is 90/min, blood pressure is 115/78 mm Hg and respirations are 16/min. His throat is hyperemic, but there is no cervical lymphadenopathy. Chest auscultation and percussion reveal no abnormalities. You note dusky red, target shaped skin lesions over all four extremities. Chest x-ray reveals interstitial infiltrates in the left lower lobe. Sputum gram stain reveals polymorphonuclear cells but no organisms. Which of the following organisms is most likely responsible for this presentation?

A 15-year-old otherwise healthy female high school student begins to notice galactorrhea. A pregnancy test is negative. Which of the following is a frequently associated physical finding?

A 16-month-old is taken to the emergency room after falling while learning to walk. The toddler has an enlarging, swollen bruise on his forehead, which is now over two inches across. The parents say that the bruise is noticeably larger than it was when they entered the emergency room an hour earlier. A blood sample is drawn, and the child oozes blood at the puncture site for 25 minutes. Clotting studies on the blood sample show a prolonged PTT and a normal PT. Follow-up studies show very low levels of factor VIII. Which of the following is the most likely diagnosis?

A 16-year old girl has recently been referred to your family practice. She is a recent immigrant from Southeast Asia, and has been taking isoniazid (INH) and rifampin for uncomplicated tuberculosis. Routine blood tests are unremarkable, except for an elevated direct bilirubin. Other liver enzymes and function tests are completely normal. Which of the following is the most likely diagnosis?

A 16-year-old arrives to your office soon after beginning basketball season. He states that he has had progressive pain in his knees. A physical examination reveals, in addition to tenderness, a swollen and prominent tibial tubercle. Radiographs of the area are unremarkable. Which of the following is the most likely diagnosis?

A 16-year-old boy is brought to the office by his basketball coach because, "he is unable to work out with other boys." For the past several weeks, the boy has been complaining of left knee pain which is dull and worsens with running, especially on the court. In addition, he thinks he has lost some weight. He does not smoke or drink alcohol. He is sexually active with many partners, and does not use condoms. His vital signs are stable. On examination, his left knee is swollen and tender. X-ray reveals a sclerotic lesion in the distal femur with periosteum lifted and a "sun burst appearance”. What is the most likely diagnosis?

A 16-year-old boy is persuaded by his older brother to accompany him and his friends on a beer-drinking binge. This is the first such experience for the boy, and it leads to the development of severe colicky left flank pain. When rescued by his parents, he is diaphoretic and doubled up in pain. He relates that he began to urinate frequently and profusely after the third or fourth beer and that the pain seized him shortly thereafter. He is tender to fist percussion over the left costovertebral angle but is afebrile. Which of the following is the most likely diagnosis?

A 16-year-old boy is recommended for admission to the neurology department for rapidly deteriorating clinical symptoms. He is a college student, living in a dormitory. During past week, he was sick. He did not recover fully and during last 3 days, his condition deteriorated. He started to have high fever, terrible headaches. His roommate said he talked about "some foolish happenings" during his high fever, and did not remember what he said later. This morning, he vomited repeatedly and his condition deteriorated rapidly. You examined him and found: febrile man in acute distress with cyanotic pallor, petechiae on his trunk and legs, purpura on his back bilaterally, with cold extremities. He is still alert, but has clammy skin, rapid pulse and labored respiration. His meningeal signs are positive. You diagnose this patient with meningococcal meningitis with systemic progression and you fear that he can develop the Waterhouse-Friderichsen syndrome. What characterizes this syndrome?

A 16-year-old boy presents with a seven-month history of intermittent right knee pain and swelling. He states that his discomfort first began after a baseball injury. This injury was associated with pain, swelling, and restriction of movement in his right knee. He has had three subsequent episodes of pain and swelling in his right knee, not precipitated by trauma. The last episode occurred three days ago. He denies history of fevers or chills. There is no history of recent travel, other than a camping trip with his friends to Long Island, New York a few months ago. On physical examination, he has a marked effusion of his right knee and is unable to fully flex or extend his leg. X-ray reveals no bony abnormalities. What is the most probable diagnosis?

A 16-year-old female comes to the physician because of an increased vaginal discharge. She developed this symptom 2 days ago. She also complains of dysuria. She is sexually active with one partner and uses condoms intermittently. Examination reveals some erythema of the cervix but is otherwise unremarkable. A urine culture is sent which comes back negative. Sexually transmitted disease testing is performed and the patient is found to have gonorrhea. While treating this patient's gonorrhea infection, treatment must also be given for which of the following?

A 16-year-old female presents to the emergency room with severe right- sided abdominal pain. Her last menstrual period was 2 weeks ago and felt to be normal. She displays painful difficulty in positioning herself on the examination table. Her temperature is 38.5 C (101.3 F), blood pressure is 128/75 mm Hg, pulse is 80/min, and respirations are 22/min. Examination of the throat reveals mild pharyngitis. Her abdomen is diffusely tender, especially the lower abdomen. Rectal examination reveals tenderness anteriorly on the right side. Stool guaiac is negative. A pelvic examination is performed, and there is evidence of cervical tenderness and questionable fullness in the right adnexal area. Which of the following is the most likely diagnosis?

A 16-year-old female presents to the ER complaining of left lower quadrant abdominal pain that started suddenly 24 hours ago. The pain does not radiate and is 5/ 10 in severity. She denies having fevers, vomiting, dysuria, diarrhea or vaginal bleeding. Her last menstrual period was two weeks ago. She takes no medications. On physical examination, her temperature is 37.20C (98.9.F), blood pressure is 11 0/65 mmHg, pulse is 80/min and respirations are 14/min. There is mild left lower quadrant tenderness without rebound or rigidity, and the remainder of the examination is unremarkable. Which of the following is the most likely diagnosis?

A 16-year-old female presents to the ER complaining of left lower quadrant abdominal pain that started suddenly 24 hours ago. The pain does not radiate and is 5/10 in severity. She denies having fevers, vomiting, dysuria, diarrhea or vaginal bleeding. Her last menstrual period was two weeks ago. She takes no medications. On physical examination, her temperature is 37.2 C (98.9 F), blood pressure is 110/65 mmHg, pulse is 80/min and respirations are 14/min. There is mild left lower quadrant tenderness without rebound or rigidity, and the remainder of the examination is unremarkable. Which of the following is the most likely diagnosis?

A 16-year-old G0 female presents to your office for a routine annual gynecologic examination. She reports that she has previously been sexually active, but currently is not dating anyone. She has had three sexual partners in the past and says she diligently used condoms. She is a senior in high school and is doing well academically and has many friends. She lives at home with her parents and a younger sibling. She denies any family history of medical problems, but says her 80-year-old grandmother was recently diagnosed with breast cancer. She denies any other family history of cancer. She says she is healthy and has no history of medical problems or surgeries. She reports having had chicken pox. She smokes tobacco and drinks beer occasionally, but denies any illicit drug use. She had her first Pap smear and gynecologic examination last year with another doctor and reports that everything was normal. Her menses started at age 13 and are regular and light. She denies any dysmenorrhea. Her blood pressure is 90/60 mm Hg. Her height is 5ft 6 in and she weighs 130 lb. Based on this patient’s history, what would be the most likely cause of death if she were to die at age 16?

A 16-year-old girl comes to the physician's office because she has not begun menstruating yet. Both her mother and an older sister started menstruation at age 12. She takes no medication and denies strenuous exercise or excessive dieting. Her height is at the 50fh percentile for age; her weight is at the 60fh percentile. Both her breast and pubic hair development are at Tanner stage 4. Pelvic ultrasonography reveals a normal uterus and ovaries. Which of the following is the most likely diagnosis?

A 16-year-old girl is brought to clinic by her mother, who complains that the girl is "difficult to get along with lately." The mother says her daughter can no longer concentrate for prolonged periods and is easily fatigued. She has found her tossing in her sleep at night. She says that her daughter is generally considered by friends and family to be "high strung." Upon inquiry, the girl admits to feeling extremely apprehensive when taking tests at school. She feels this stems from her naturally competitive nature and her desire to be class valedictorian. She worries about being accepted to a good university and then business school. She says that she is unable to control her thoughts and sometimes takes a day off from school to "escape all the stress that comes with it” Which of the following is the most likely diagnosis?

A 16-year-old girl is brought to the office due to abdominal pain and bloody diarrhea for the past two days. Her immunizations are up to date. Her past medical history is unremarkable. On examination, she appears lethargic and weak. Her skin turgor is poor, face and extremities are swollen, and skin appears yellow. Abdominal examination shows moderate non-localized, abdominal pain. Laboratory studies show: Hb 64 g/dl, Hct 26.9%, Platelets 45,000/mm3, Creatinine 2.3 mg/dl, Total bilirubin 5.0 mg/dl. What is the most common complication of the patient's condition?

A 16-year-old girl is referred to the office because of chronic diarrhea and weight loss. She is experiencing large-volume watery diarrhea that is painless. The symptoms persist even when she is fasting, and there is no relationship to foods or liquids. She is not on any medications, and there is no travel history or other constitutional symptoms. Her physical examination is normal. Which of the following is the most likely diagnosis?

A 16-year-old girl presents for evaluation of acne, which has been getting progressively worse over the past 2 weeks. Her medical history is significant for systemic lupus erythematosus (SLE) for which she has been taking prednisone for a recent exacerbation. Hydroxychloroquine is her only other medicine. She does not use tobacco, alcohol or drugs and her menstrual cycle is regular. On physical examination, her blood pressure is 110/76 mmHg and her pulse is 72/min. Her BMI is 22 kg/m2. Distributed over the face, arms and trunk are monomorphous erythematous papules. There are no open or closed comedones. The remainder of the physical examination is unremarkable. Which of the following is the most likely cause of her acne?

A 16-year-old girl presents to the emergency department complaining of fever, chills, abdominal pain, and vaginal bleeding. She gives a history of unprotected sexual activity with her 17-year-old boyfriend over the past several months. Her last menstrual period was 8 weeks ago. She reports having a dilatation and curettage procedure at an unlicensed abortion clinic recently to try to abort the pregnancy. Her temperature is 38.7C (101.7F), heart rate is 120/min, and blood pressure is 100/70 mmHg. Pelvic examination reveals cervical motion tenderness, tissue in the internal os, and foul-smelling vaginal discharge. Urine is positive for β-human chorionic gonadotropin. Which of the following is the most likely diagnosis?

A 16-year-old girl presents with lower abdominal pain and fever. On physical examination, a tender adnexal mass is felt. Further questioning in private reveals the following: she has a new sexual partner; her periods are irregular; she has a vaginal discharge. Which of the following is the most likely diagnosis?

A 17-year-old African American man comes to the physician after an episode of gross hematuria that resolved spontaneously. He has no other complaints. His past medical history is insignificant. He takes no medications. He smokes occasionally. He does not use drugs or alcohol. His temperature is 36.7°C (98°F), blood pressure is 120/70 mm Hg, pulse is 70/min, and respirations are 14/min. Physical examination shows no abnormalities. Urinalysis shows many unchanged red blood cells/HPF, but is otherwise normal. Laboratory studies show a creatinine level of 0.9 mg/dl. Which of the following is the most likely diagnosis?

A 17-year-old boy comes to medical attention because of recurrent sinusitis and pneumonia, and persistent watery diarrhea due to Giardia lamblia. His parents and a sister are in excellent health. Physical examination reveals enlarged lymph nodes in cervical, axillary and inguinal regions. A lymph node biopsy shows hyperplastic follicles with an absence of plasma cells. Laboratory investigations show: Hematocrit44%, Leukocyte count9, 800/mm3, Neutrophils55%, Lymphocytes30%, Monocytes5%, CD4 T-cell count1000 cells/mm3, Proteins, serum6.2 g/dL, Albumin5.0 g/dL, Globulin1.2 g/dL. Additional studies demonstrate severely depressed levels of serum IgG, with slightly below-normal levels of IgM and IgA. Which of the following is the most likely diagnosis?

. Acquired immunodeficiency syndrome (AIDS)

. Common variable immunodeficiency

. Hodgkin disease

. Isolated IgA deficiency

. X-linked agammaglobulinemia of Bruton

A 17-year-old boy is brought to the emergency department by his parents with the complaint of coughing up blood. He is stabilized, and his hemoglobin and hematocrit levels are 11 mg/dL and 33%, respectively. During his hospitalization, he is noted to have systolic blood pressure persistently greater than 130 mm Hg and diastolic blood pressure greater than 90 mm Hg. His urinalysis is remarkable for hematuria and proteinuria. You are suspicious the patient has which of the following?

A 17-year-old female comes to the physician because she has not yet had a menstrual period. She also complains of a lack of breast development. Past medical history is significant for anosmia and color blindness. Past surgical history is significant for a cleft palate that was repaired in childhood. She takes no medications and has no allergies to medications. Examination is significant for absent breast development, and a hypoestrogenic vulva and vagina. Urine hCG is negative. Which of the following is the most likely diagnosis?

A 17-year-old female presents with a pruritic rash localized to the wrist. Papules and vesicles are noted in a band like pattern, with slight oozing from some lesions. Which of the following is the most likely cause of the rash?

A 17-year-old G1P1001 is now 5 weeks postpartum after a routine vaginal delivery. She calls your office to report a 3-week history of difficulty sleeping and “feeling blue.” On further questioning, she reports difficulty concentrating, very poor appetite, occasional wishes that she had never become pregnant, and feelings of guilt about those wishes. She has not left her home in more than a week because she “just can’t find the energy to go anywhere.” This patient’s symptoms are most consistent with:

A 17-year-old girl comes to the clinic with several weeks of joint pain and rash. The joint pain is most prominent in the hands. She states that the pain is most severe in the morning and tends to improve over the day. She has noted some swelling of her fingers. She has also had a rash on her face that becomes more prominent when she is outdoors. She states that sunlight tends to bother her eyes. On further questioning, she states that she has not felt well for several months. She has had intermittent fever, has been more tired than usual, and has lost weight although she has not been restricting her diet. On physical examination, she looks tired. She has lost 5 lbs since her last visit 1 year ago. She has an erythematous rash on her cheeks. She has several shallow ulcers in her mouth. She has fusiform swelling of her fingers and pain with movement of her fingers. Which of the following is the most likely diagnosis?

A 17-year-old girl is brought to the ER 30 minutes after an episode where she lost consciousness. She is accompanied by her father who witnessed the event. He says that the patient recently broke up with her boyfriend and has been under a lot of stress. Her sleep has been poor. She has had three similar episodes over the last month. On exam, her heart rate is 90/min, respirations are 13/min, and blood pressure is 120/70 mmHg. She seems sleepy but can be aroused easily. She gives her correct name but is disoriented to time and place. Pupils are symmetric and reactive to light. Blood glucose level is 100 mg/dl. Which of the following findings would you most expect in this patient?

A 17-year-old girl noted a 2-cm annular pink, scaly lesion on her back. Over the next 2 weeks she develops several smaller oval pink lesions with a fine collarette of scale. They seem to run in the body folds and mainly involve the trunk, although a few occur on the upper arms and thighs. There is no adenopathy and no oral lesions. Which of the following is the most likely diagnosis?

A 17-year-old girl presents to the clinic because she has not yet menstruated and does not have significant breast development. Family history is significant only for some cousins who are color blind. The patient denies ethanol, tobacco, and illicit drug use and sexual activity. Physical examination reveals a normal-appearing girl in no acute distress with minimal breast development and a lack of pubic hair. She is 168 cm (5'6") tall and weighs 61.2 kg (135 lb). Cardiac examination reveals no murmurs, rubs, or gallops, with point of maximal impulse at the left mid-clavicular line between the third and fourth intercostal space. Gynecologic examination reveals a vagina without rugae and a cervix that is easily visualized. There is no discharge. A urine test is negative for β-human chorionic gonadotropin. Which of the following is the most likely diagnosis?

A 17-year-old girl presents with a 4-week history of intermittent fever, increasing fatigue, generalized myalgia, and swelling of both her knees and ankles. There is a fine erythematous rash on her back, and she has swollen knees and ankles; the remainder of her physical examination is unremarkable. Initial laboratory evaluation shows: Leukocytes 11,400 cells/mm3, Hemoglobin 8.8 g/dL, Blood urea nitrogen 4 mg/dL, Creatinine 1.4 mg/dL, Glucose 98 mg/dL, C3 complement 36 mg/dL (normal >80 mg/dL), Antinuclear antibody titer 1:3200, Anti-double-stranded DNA titer 1:640, Antineutrophil cytoplasmic antibodies: Negative, Urinalysis Moderate hematuria (50 RBC/hpf), Moderate proteinuria (400 mg/dL). Which of the following is the most likely diagnosis?

A 17-year-old man is brought to the emergency room with confusion and incoordination. He is uncooperative and refuses to provide further history. Physical examination reveals an RR of 30; the vital signs are otherwise normal as is the general physical examination. Laboratory values are as follows: Na: 135 mEq/L, K: 2.7 mEq/L, HCO3: 15 mEq/L, Cl: 110 mEq/L. Arterial blood gases: PO2 92, PCO2 30, pH 7.28 Urine: pH 7.5, glucose—negative, Ca: 9.7 mg/dL, PO4: 4.0 mg/dL. Which of the following is the most likely cause of the acid base disorder?

. GI loss owing to diarrhea

. Proximal renal tubular acidosis

. Disorder of the renin-angiotensin system

. Distal renal tubular acidosis

. Respiratory acidosis

A 17-year-old man presents with a non-pruritic rash in his periumbilical area. The rash consists of firm, dome-shaped, flesh-colored papules with central umbilication. This patient's rash is most commonly associated with which of the following conditions?

A 17-year-old teenage girl presents to your office after having problems during sex with her boyfriend. She also states that she has been developing facial hair, which she has constantly been removing. She started her menstruations at the age of 13 and her cycles have always been regular. On examination she is obese but appears a little masculine and has an enlarged clitoris. Initial lab values are as follows: Serum LH 20 IU/L, Serum FSH 10 IU/L, 17 -hydroxyprogesterone 600ng/ml (Normal is 15ng/ml), Serum testosterone Normal, Serum DHEA 4.0ng/ml (Normal is 4.2ng/ml). What is the most likely diagnosis?

A 17-year-old teenage girl presents to your office with a 10-month history of lower abdominal pain that radiates to the upper thighs and back. The pain is colicky in nature and usually starts a few hours prior to menses, lasting 3-4 days. Menses have occurred at regular 28-day intervals over the past 2 years. She has no inter-menstrual bleeding. She became sexually active 6-months ago and does not use contraception. Physical examination shows healthy external genitalia and well-developed secondary sexual characteristics; the uterus is normal in size and freely mobile. Examination shows no other abnormalities. Which of the following is the most likely cause of her pelvic pathology?

A 17-year-old white female comes to the office for the evaluation of fatigue which has been present for the past 4 months. Her past medical history is insignificant. She denies the use of any drugs. Her pulse is 74/min, blood pressure is 110/70 mmHg, and temperature is 36.7°C (98.0°F). Physical examination shows scars on the dorsum of her hands and dental erosions. Laboratory studies show: Plasma sodium 139 mEq/L, Serum potassium 2.3 mEq/L, Bicarbonate 40 mEq/L. Urine chloride concentration is 15 mEq/L (Normal = 80-250 mEq/L). Based on these findings, what is the most likely diagnosis?

A 19-year-old female comes to the physician because she has not had a menstrual period. She experienced normal breast development through puberty but has yet to have a period. She has no other complaints. She has no medical problems. Examination shows the patient to be tall with long arms and big hands. The breasts are normal-appearing except that the nipples are immature and the areolae are pale. Pelvic examination shows scant pubic hair with a blind-ended vaginal pouch. Which of the following is the most likely diagnosis?

A 19-year-old G0 woman presents to her family physician complaining of dysmenorrhea for the past year. She reports severe right-sided pain that coincides with days 1–5 of her menstrual cycle. Her menses occur regularly every 28 days, and she requires three to four pads per day for the first 2 days of her bleeding and one to two pads per day for the remainder. She has never had surgery. She is not sexually active and does not smoke. Her last menstrual period was 1 week ago. Her temperature is 36.7C (98.1F), blood pressure is 121/74 mmHg, heart rate is 80/min, and respiratory rate is 14/min. Physical examination reveals a thin, healthy-appearing young woman. Pelvic examination reveals a normal sized uterus and no cervical motion tenderness. Which of the following is the most likely diagnosis?

A 19-year-old man is brought to the physician by his parents after he called them from college, terrified that the Mafia was after him. He reports that he has eaten nothing for the past 6 weeks other than canned beans because “they are into everything––I can’t be too careful.” He is convinced that the Mafia has put cameras in his dormitory room and that they are watching his every move. He occasionally hears the voices of two men talking about him when no one is around. His roommate states that for the past 2 months the patient has been increasingly withdrawn and suspicious. Which of the following is the most likely diagnosis?

A 19-year-old man sustains severe lower-extremity trauma, including a femur fracture and a crush injury to his foot. He requires vascular reconstruction of the popliteal artery. On the day after surgery, he becomes dyspneic and hypoxemic and requires intubation and mechanical ventilation. Which of the following is the most likely etiology of his decompensation?

A 19-year-old nulligravid woman at 38 weeks' gestation comes to her physician because she has passed bloody mucus discharge. Her prenatal course was unremarkable including a normal 19-week ultrasound. On speculum examination, there are no vaginal or cervical lesions. On vaginal examination, the cervix is 2 cm dilated and 100% effaced, and the fetus is at +1 station. The fetal heart rate has a baseline of 140 and is reactive. She has painful contractions every 2 minutes. One hour later the patient's cervix is 3 cm dilated, and a small amount of bloody mucus is noted on the examining glove. Which of the following is the most likely diagnosis?

A 19-year-old primigravid woman at 34 weeks gestation comes to the physician because of diffuse headache, right upper quadrant pain and visual disturbances. During her last visit two weeks ago she was found to have an elevated blood pressure and 1+ proteinuria. She was advised to follow-up closely and sent home on bed rest. Her blood pressure today is 176/120 mm Hg and pulse is 86/min. Physical examination shows 2+ pitting edema in both legs and right upper quadrant tenderness. Fetal heart tones are audible by Doppler. Urinalysis shows 3+ proteinuria. Serum aspartate aminotransferase (AST) is 88 U/L and alanine aminotransferase (ALT) is 80 U/L. Serum creatinine now is 1.4 mg/dl. Which of the following is the most likely cause of her right upper quadrant pain?

A 19-year-old primigravid woman at 39 weeks’ gestation is in active labor, and her cervix is 4 cm dilated, 90% effaced. Her amniotic membranes have been ruptured for 4 hours. Contractions are strong at 2- to 3-minute intervals and of 60- to 70-second duration. For the past 30 minutes, repetitive variable decelerations of the fetal heart rate have occurred. They have lasted 60–90 seconds, and the fetal heart rate has dropped as low as 60 beat per minute (BPM). You explain that there is a risk that the baby will become hypoxic and recommend a cesarean section. She refuses. Which of the following is the most appropriate course of action?

Obtain permission for the cesarean section from her mother

Perform a cesarean section as an emergency

Obtain a court order permitting a cesarean section

Counsel her carefully about the fetal risks but accede to her wishes

Assign her care to another obstetrician

A 19-year-old primigravida is expecting her first child; she is 12 weeks pregnant by dates. She has vaginal bleeding and an enlarged- for-dates uterus. In addition, no fetal heart sounds are heard. The ultrasound shown below is obtained. Which of the following is true regarding the patient’s diagnosis?

. The most common chromosomal makeup of a partial or incomplete mole is 46XX, of paternal origin

. Older maternal age is not a risk factor for hydatidiform mole

. Partial or incomplete hydatidiform mole has a higher risk of developing into choriocarcinoma than complete mole

. Vaginal bleeding is a common symptom of hydatidiform mole

. Hysterectomy is contraindicated as primary therapy for molar pregnancy in women who have completed childbearing

A 19-year-old primiparous woman develops toxemia in her last trimester of pregnancy and during the course of her labor is treated with magnesium sulfate. At 38 weeks’ gestation, she delivers a 2100-g (4-lb, 10-oz) infant with Apgar scores of 1 at 1 minute and 5 at 5 minutes. Laboratory studies at 18 hours of age reveal a hematocrit of 79%, platelet count of 100,000/μL, glucose 41 mg/dL, magnesium 2.5 mEq/L, and calcium 8.7 mg/dL. Soon after, the infant has a generalized convulsion. Which of the following is the most likely cause of the infant’s seizure?

A 19-year-old student is referred to the university health center for inability to complete his assignments. He has always been a good student, and was valedictorian of his high school class. However, since starting college, he has found it difficult to keep up with all the work. He audio-records every class, playing the tapes back later in the day to transcribe each entire lecture word for word. He admits to sometimes needing to go over certain sections multiple times to be sure he has heard correctly. He also takes a long time to complete assignments, as he always checks his work multiple times prior to handing it in. Because of this, he has had to ask for many extensions on his assignments. He is sure to complete all his assignments, even after they have been reviewed in class and even though they are not graded. He spends all his time doing his classwork, and is not involved in social activities. What is the most likely diagnosis?

. Asperger's disorder

. Generalized anxiety disorder

. Obsessive-compulsive disorder

. Obsessive-compulsive personality disorder

. Schizoid personality disorder

A 19-year-old woman comes to the emergency department and reports that she fainted at work earlier in the day. She has mild vaginal bleeding. Her abdomen is diffusely tender and distended. In addition, she complains of shoulder and abdominal pain. Her temperature is 37.2C, pulse rate is 120 beats per minute, and blood pressure is 80/42 mm Hg. Which of the following is the best diagnostic procedure to quickly confirm your diagnosis?

. Computed tomography of the abdomen and pelvis

. Culdocentesis

. Dilation and curettage

. Posterior colpotomy

. Quantitative β-human chorionic gonadotropin (β-hCG)

A 19-year-old woman comes to the physician because of fever, joint pain, and rash. The rash started on her face and is spreading down her body. She has pain in her fingers, wrists, and knees. She denies any neck stiffness, nausea, or vomiting. She has been sexually active with multiple partners. Her vaccination status is unknown. Her pulse is 86/min, blood pressure is 125/75 mm Hg, and temperature is 37.7°C (99.8°F). Physical examination reveals a maculopapular rash on her face and chest. Posterior auricular, cervical, and suboccipital lymphadenopathy is present. She has mild conjunctivitis. Oropharynx is clear. Chest is clearto auscultation. What is the most likely diagnosis?

A 19-year-old woman comes to the psychiatrist for a history of anger and irritability, which occurs on monthly on an average. During this time the patient also reports feeling anxious and “about to explode,” which alternates rapidly with crying spells and angry outbursts. The patient notes during this time she can’t concentrate and sleeps much more than she usually needs to do. During the several days these symptoms last, the patient must skip most of her classes because she cannot function. Which of the following is the most likely diagnosis?

A 19-year-old woman makes an appointment to see her primary care physician about a "personal concern." When she comes in for her visit, she says that she has been "deeply depressed" for the past several months because of her "enormous nose." She proceeds to describe in detail the numerous cosmetic aspects of her nose that prove troubling. She says that she is now so embarrassed that she is unwilling to go out with friends because "everyone just stares at my nose." She finds it difficult to concentrate on her studies because she is preoccupied with thoughts about undergoing corrective surgery. On examination, her nose appears completely normal. She pleads for a referral to a good plastic surgeon. Which of the following is the most likely diagnosis?

A 19-year-old woman presents to the emergency room with the chief complaint of a depressed mood for 2 weeks. She notes that since her therapist went on vacation she has experienced suicidal ideation, crying spells, and an increased appetite. She states that she has left 40 messages on the therapist’s answering machine telling him that she is going to kill herself and that it would serve him right for leaving her. Physical examination reveals multiple well-healed scars and cigarette burns on the anterior aspect of both forearms. Which of the following diagnoses best fits this patient’s clinical presentation?

A 2 and a half-year-old child is brought to the office for the evaluation of easy bruising, nosebleeds, and decreased activity over the past week. He had an upper respiratory infection that was treated with an antibiotic 2 weeks ago. On examination, he is well-developed, seems well-nourished, anicteric, and pale. Pertinent findings include some small palpable posterior cervical lymph nodes, sinus tachycardia, a grade I/VI systolic ejection murmur, ecchymoses on his left shoulder and both lower extremities, and petechiae over his extremities and groin. There is no hepatosplenomegaly. The laboratory findings are as follows: Hemoglobin 7.9 g/dl, Hematocrit 24%, Platelet count 12, 000/mm3, WBC 3,000/mm3, Reticulocyte count 0.5%. A bone marrow biopsy reveal a markedly hypocellular marrow with decreased megakaryocytes and precursors of the erythroid and myeloid cell lines. What is the most likely diagnosis?

A 2-day-old male infant presents with multiple episodes of bilious vomiting over the past 24 hours. He has a prominent tongue, flat occiput and slanting eyes. His hands are short, and there are wide gaps between his first and second digits. His abdomen is soft and without any distention, guarding or rigidity. On auscultation of the chest, there is a systolic ejection murmur along the left sternal border, with a wide and fixed splitting of S2. Abdominal x- rays show air trapped in the first portion of the duodenum and stomach. What is the most likely cause of the child's symptoms?

A 2-hour-old full-term newborn infant is noted by the nursing staff to be having episodes of cyanosis and apnea. Per nursery protocol they place an oxygen saturation monitor on him. When they attempted to feed him, his oxygen levels drop into the 60s. When he is stimulated and cries, his oxygen levels increase into the 90s. Which of the following is the most important next step to quickly establish the diagnosis?

A 2-hour-old male neonate has developed worsening cyanosis over the past few minutes. The infant was vaginally delivered (assisted with forceps) at full term and weighed 4.1 kg (9 lb). The Apgar scores were 7 and 8 at 1 and 5 minutes, respectively. Oxygen is administered by mask but does not relieve the cyanosis. Further examination reveals tachypnea, subcostal retractions, a normal first heart sound, a single and loud second heart sound (S2), and no murmur. Which of the following is the most likely cause of the infant's cyanosis?

A 2-month-old girl presents to her pediatrician's office for well-child care. Her mother complains of excessive tearing of the baby's left eye for the past 4 weeks. Each morning, a yellow crusty discharge is noted along the lashes of the left eye. The conjunctiva appears uninflamed. The right eye is not affected. On physical examination, the infant is otherwise well and achieving adequate weight gain on an exclusive breast milk diet. She is developmentally appropriate, including visually tracking 180 degrees. Which of the following is the most likely diagnosis?

A 2-month-old infant is brought to the clinic for the evaluation of poor feeding. He was born at 32 weeks of gestation with a birth weight of 1200 g. The pertinent physical findings are pallor, tachypnea, tachycardia, and flow murmurs. The laboratory studies are as follows: Hb 7 g/dl, WBC 7,000/mm3, Platelets 230,000/mm3, Reticulocytes Low. The peripheral smear shows normocytic normochromic RBC. What is the most likely diagnosis?

A 2-month-old infant is evaluated by a pediatric cardiologist. The infant was noted at birth to have an upper left sternal border ejection murmur. The infant at that time was not cyanotic, but slowly developed cyanosis over the next two months. At the time of the pediatric cardiologist's examination, an ECG showed right axis deviation and right ventricular hypertrophy. A chest x-ray film showed a small heart with a concave main pulmonary artery segment and diminished pulmonary blood flow. Which of the following is the most likely diagnosis?

. Complete atrioventricular canal defect

. Hypoplastic left ventricle

. Isolated atrial septal defect

. Tetralogy of Fallot

. Transposition of the great arteries

A 2-month-old male infant is rushed to the emergency department by his baby sitter. She says that the baby became unresponsive and blue while feeding. The whole episode lasted 45-60 seconds, but the baby still appears pale. She denies any history of coughing or choking. On examination, the infant appears cyanotic and tachypneic. His blood pressure is 90/60 mm of Hg; his pulse rate is 155/min and regular. On auscultation, a harsh pansystolic murmur is noted at the left sternal border, along with a single S2. Hepatomegaly is noted. Pulse oximetry shows an oxygen saturation of 80%. Based on this history and physical examination, what is the most likely diagnosis?

A 2-week-old Caucasian male presents with constipation since birth. He was born full term via a normal vaginal delivery. He did not pass meconium till his 3rd day of life, after he was given a glycerin suppository. He has since stooled every 3–4 days, only with the help of a suppository. The stools are pellet like. He has had increasing abdominal distention. On rectal examination, tone appears normal and the ampulla contains no stool. Which of the following is the most likely cause?

A 2-week-old infant is brought to the office for a newborn visit. His mother states that the he has been a very slow eater and that he is constipated, not having had a bowel movement in 3 days. On physical examination, the infant has poor muscle tone, an enlarged tongue, an umbilical hernia, an enlarged anterior fontanelle, and hypothermia. He also looks slightly jaundiced, with slightly dry skin and brittle hair. Which of the following is the most likely diagnosis?

A 2-week-old infant is noted to be jaundiced. The baby's stools are pale, and his urine darkly colored. Physical examination demonstrates hepatomegaly. Serum studies show elevations of AST, ALT, conjugated bilirubin, and unconjugated bilirubin. By 2 months of age, the baby is notably irritated by pruritus, has retarded growth, and has visible dilated veins in the periumbilical area. Ultrasound fails to demonstrate a gallbladder. Which of the following is the most likely diagnosis?

A 2-week-old infant presents with sudden onset of bilious emesis. Plain films of the abdomen show evidence of an intestinal obstruction. An upper gastrointestinal (UGI) contrast series reveals a midgut volvulus with the site of obstruction at the third portion of the duodenum. Which of the following is the most likely diagnosis?

. Necrotizing enterocolitis (NEC)

. Intussusception

. Hirschsprung disease

. Anomalies of intestinal rotation and fixation

. Hypertrophic pyloric stenosis

A 2-week-old male infant is brought to the office by his 28-year-old primiparous mother for the evaluation of jaundice that was noted two days ago. The infant's stool has a lighter color. He is exclusively breastfed. The pregnancy was uncomplicated, and prenatal screening tests for TORCH organisms were all negative. The infant was delivered vaginally with no complications. His temperature is 37.2 C (99F), pulse is 140/min, respirations are 50/min, and capillary refill is < 2 sec. Examination reveals jaundiced skin and mucous membranes. Abdominal palpation reveals hepatomegaly. The initial investigations show the following: Hb 18.0 g/dl, Hct 52%, Bilirubin, Total 5 mg/dl, Bilirubin, Direct 4 mg/dl, Blood type 0 + (The mother's blood type is B-), Coombs' test Negative. What is the most likely diagnosis?

A 2-week-old male infant is brought to the office by his mother due to fever and vomiting for the past two days. He appeared normal until two days ago. He is being breastfed. He was born at 32 weeks gestation and weighed 2.7kg (6 Ib) at birth. On examination, he is ill-looking, lethargic, and febrile. His abdomen is distended, bowel sounds are absent, and stool is guaiac-positive. An abdominal x-ray demonstrates pneumatosis intestinalis. What is the most likely diagnosis of this patient?

A 2-year-old boy has been vomiting intermittently for 3 weeks and has been irritable, listless, and anorectic. His use of language has regressed to speaking single words. In your evaluation of this patient, which of the following is the most reasonable diagnosis to consider?

A 2-year-old boy has had a purulent drainage from the right nostril for a week. He is afebrile and has had no associated symptoms, such as cough. Which of the following is the most likely diagnosis?

A 2-year-old boy is brought by his mother to the emergency department because of a high-grade fever which "does not go away" with acetaminophen. For the last four days, the child has been very irritable and is crying a lot. He is also pulling his ear and not eating well. He has been generally well, other than the occasional sore throat this season. His temperature is 38.8° C (102.2° F), blood pressure is 90/60 mm Hg, pulse is 119/min, and respirations are 24/min. He appears well nourished, but is irritable. Physical examination reveals enlarged cervical lymph nodes and splenomegaly. The tympanic membranes are inflamed. CBC shows: WBC 81,100mm3, Hemoglobin 8.0 g/dL, Hematocrit 25%, Platelets 16,000 mm3, Blast forms 80%, Prolymphocytes 10%, Lymphocytes 10%. The blast cells have condensed nuclear chromatin, small nucleoli and scant agranular cytoplasm. Subsequent histochemical staining reveals strongly positive periodic acid Schiff (PAS) reaction. No Auer rods were seen. Which of the following is the most likely diagnosis?

A 2-year-old boy is brought by his mother to the emergency department because of a high-grade fever which "does not go away" with acetaminophen. For the last four days, the child has been very irritable and is crying a lot. He is also pulling his ear and not eating well. He has been generally well, other than the occasional sore throat this season. His temperature is 38.8°C (102.2°F), blood pressure is 90/60 mm Hg, pulse is 119/min, and respirations are 24/min. He appears well nourished, but is irritable. Physical examination reveals enlarged cervical lymph nodes and splenomegaly. The tympanic membranes are inflamed. CBC shows: WBC 81,100 /mm3, Hemoglobin 8.0 g/dL, Hematocrit 25%, Platelets 16,000 /mm3, Blast forms 80%, Prolymphocytes 10%, Lymphocytes 10%. The blast cells have condensed nuclear chromatin, small nucleoli and scant agranular cytoplasm. Subsequent histochemical staining reveals strongly positive periodic acid Schiff (PAS) reaction. No Auer rods were seen. Which of the following is the most likely diagnosis?

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?

A 2-year-old boy is brought to the clinic by his mother because he is lethargic and not as active as the other kids on their block. He has difficulty walking and getting up, and he always appears tired. His mother thinks that she has a relative with a disorder that causes weakness. On examination, the child is alert but quiet. His calves appear hypertrophied. His reflexes are depressed. When he gets up from the floor, he uses his hands to climb on his legs to assume an upright position. What is the most likely diagnosis of this child?

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 due to a cough and a "whistling" sound with breathing. Two days ago, he developed rhinorrhea, fever, a hoarse cry and a progressively worsening, harsh, "barky" cough. His immunizations are up-to-date. His 6-year-old brother also has cold symptoms. His temperature is 37.5C (99.5F), pulse is 140/min, and respirations are 36/min. On examination, he is alert, in mild respiratory distress, has a dry barking cough, hoarse cry, and some clear mucoid rhinorrhea. His pharynx is slightly injected, but without enlargement or asymmetry. The lungs are clear on auscultation. Lateral neck x-rays reveal a mildly narrowed subglottic region. 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 2-year-old boy is brought to the office due to recurrent skin and soft tissue infections. When he was 2- months-old, he had a perianal furuncle that was incised and drained because it was unresponsive to oral antibiotics. At 7 months of age, he had a left inguinal Klebsiella pneumoniae lymphadenitis. His other past infections include a left calf cellulitis that grew Serratia marcescens and a left inguinal abscess that grew Staphylococcus epidermidis. On examination, he has hepatosplenomegaly, and enlarged axillary and inguinal lymph nodes. The screening tests for humoral, cell-mediated, and complement-mediated immunity are normal. The nitroblue tetra zolium (NBT) slide test is abnormal. What is the most likely diagnosis?

A 2-year-old boy is referred to your office for the evaluation of a white eye reflex. His mother suspects a hearing problem because he does not respond when she calls out his name. The physical examination reveals a continuous, machinery murmur over the right 2nd intercostal space and purple lesions on his arms and chest. The initial investigations reveal thrombocytopenia. What is the most likely diagnosis?

A 2-year-old boy presents to the emergency department with fever, irritability, and a skin rash 5 days after the onset of an upper respiratory infection. On examination, his temperature is 39.8 C (103.6 F), and his pulse is 94/min. There is an erythematous skin rash that involves his face, chest, back, and upper extremities. His skin is very tender to touch. Rubbing the skin causes separation of the epidermal layer. Which of the following is the most likely diagnosis?

A 2-year-old boy presents with refusal to use his right arm for 1 day. He is otherwise well. His mother states she pulled upward on his arm the previous evening to keep him from tripping down the stairs. Which of the following is the most likely diagnosis?

A 2-year-old child has had red, weeping, crusted lesions of the face, scalp, diaper area, and extremities since about age 2 months, with multiple periods of exacerbation and improvement. Attempts to remove potentially irritating substances have not modified the course of the rashes. The child is noted to be constantly scratching and rubbing involved areas. There is a strong family history of hay fever and asthma. Which of the following is the most likely diagnosis?

A 2-year-old child is brought to the office by his parents for the evaluation of failure to thrive and chronic diarrhea. His diarrhea is "almost continuous", and he also has recurrent episodes of fever. He was initially quite well and was on the 60th percentile for weight; however, for the past seven months, he didn't seem to grow and failed to gain weight. Over the past three months, he fell to the 3rd percentile for weight. His parents deny any use of drugs, but they drink occasionally. His mother mentions that her former boyfriend was a heroin addict. Physical examination reveals oral thrush, generalized lymphadenopathy and eczema. What is the most likely diagnosis in this patient?

A 2-year-old child is brought to the office due to vomiting. He is recovering from an upper respiratory infection, which was treated by his mother with over-the-counter aspirin. On examination he is irritable, lethargic, agitated and uncooperative. His height, weight and head circumference are at the 50th percentile. The pupils are equal and have a sluggish reaction to light. The sclera is non-icteric. The neck is supple and without adenopathy. The abdomen is flat, with normal bowel sounds. The lab findings are as follows: Serum bilirubin Normal, Serum ASAT and ALAT Increased, Serum ammonia Increased, Prothrombin time Prolonged. A CT scan of the brain shows cerebral edema. CSF analysis is normal, except for increased pressure. What is the most likely diagnosis?

A 2-year-old child is brought to the physician for a routine visit. He is growing and developing appropriately. He eats a variety of foods including meat, vegetables, and fruits, and drinks 3-4 glasses of whole milk each day. He is starting to put words together into short sentences. His mother has no concerns. Physical examination is unremarkable. Routine laboratory studies show the following: Hemoglobin 9.5 g/dl, RDW 14%, MCV 65 fl, Reticulocyte count 3.0%, Platelet count 212,000/mm3, Leukocyte count 6,500/mm3, TIBC 300 mcg/dl (240-450 mcg/dl), Ferritin 100 ng/ml (7 -140 ng/ml). What is the most likely cause for this child's anemia?

A 2-year-old child presents to the office with a paternal complaint of “bowlegs.” The girl has always had bowlegs; her previous pediatrician told the family she would grow out of it. Now, however, it seems to be worsening. Her weight is greater than 95% for age, and she has significant bowing out of her legs and internal tibial torsion; otherwise, her examination is normal. A radiograph of her lower leg is shown. Which of the following is the most likely diagnosis?

A 2-year-old child with minimal cyanosis has an S3 and S4 (a quadruple rhythm), a systolic murmur in the pulmonic area, and a middiastolic murmur along the lower left sternal border. An ECG shows right atrial hypertrophy and a ventricular block pattern in the right chest leads. Which of the following is the most likely diagnosis?

Tricuspid regurgitation and pulmonic stenosis

Pulmonic stenosis and a VSD (tetralogy of Fallot)

Atrioventricular canal

Ebstein anomaly

Wolff-Parkinson-White syndrome

A 2-year-old girl is brought to her pediatrician by her parents because of increasing lethargy and irritability. She has just started walking, and is teething and likes to chew on the woodwork around the windows. Physicalexamination reveals a tender abdomen. Laboratory studies indicate high iron and ferritin levels. The peripheral blood smear shows basophilic stippling. Which of the following is the most likely diagnosis?

A 2-year-old girl is brought to the emergency department due to severe, sudden-onset abdominal pain. She has nausea and vomiting, and her stools contain blood and mucus. Her parents say that she was in her usual state of health when she developed this problem. Her pulse rate is 116/min, blood pressure is 90/60mm Hg, temperature is 37.7C (100F), and respirations are 28/min. She looks lethargic and ill. She is crying and drawing her knees towards her chest. Her abdomen is tender to palpation, and there is a palpable, sausage-like abdominal mass. The bowel sounds are increased, and rectal examination reveals bloody mucus. What is the most likely cause of her symptoms?

A 2-year-old girl is brought to the physician because of protracted irritability, crying, and loss of appetite. She recently had a sore throat. Her temperature is 38.5 C (101.3 F). Physical examination is unremarkable, except for abnormalities of the tympanic membrane detected on otoscopic examination. Which of the following signs or symptoms correlates best with a diagnosis of acute otitis media?

A 2-year-old girl is taken to a pediatrician because she has developed a rash and seems unusually unsteady when she tries to walk. Physical examination demonstrates a diffuse rash on body parts exposed to sun. Also noted are short stature, possible mental retardation, and ataxia. Screening studies demonstrate increased total amino acids in the urine. Which of the following is the most likely diagnosis?

A 2-year-old girl presents to the office with a dry cough and a low-grade fever. Over the last two days, she has become very irritable and difficult to feed. She has also had a runny nose. On examination, there is significant wheezing and tachycardia. Evaluation of the nasal discharge confirms the diagnosis of respiratory syncytial virus infection. In the future, which of the following does this child have a slight risk of developing?

A 2-year-old patient arrives late to your office with his father and a sign-language translator. They are very apologetic, but the father communicates that he had car trouble at his dialysis center and thus was late picking up the child from day care. The father is concerned about his child’s having intermittent red, bloody-looking urine. A gross inspection of the child’s urine in your office looks normal, but the dipstick demonstrates 3+ blood. Which of the following is the most likely cause of this child’s hematuria?

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