PIC: USLME-DIAGNOSTIC 2

A 75-year-old woman is brought to the emergency department from a nursing home for abdominal pain, distention, and obstipation over the last 2 days. Past history is pertinent for stroke, diabetes, atrial fibrillation, and chronic constipation. Examination reveals a temperature of 98.6°F, pulse rate 90/min and irregularly irregular, and BP 160/90 mmHg. Heart examination reveals irregularly irregular rhythm with no murmurs; lung examination reveals few bibasilar rales; and abdominal examination reveals a distended, tympanic abdomen with mild tenderness and no rebound tenderness. Plain abdominal x-rays reveal dilated loops of bowel, and a barium enema is obtained and shown in Figure 6-9. Which of the following is the most likely diagnosis?

A boy has returned home from visiting his grandmother in a rural area. He spent most of his time swimming, playing in the yard, helping in the gardens, and chasing his Chihuahua; his grandma says “he was generally dirty!” He was noted 2 weeks ago to have “infected mosquito bites” on his neck and chin for which the local doctor had him just scrub with soap; a few remain and are shown in the photograph below. His mother brings him into the office with the complaint of dark urine, swelling around his eyes, and shortness of breath. You also find him to have hypertension and hepatomegaly. Which of the following is the most likely cause of his problem?

A college sophomore is found by his roommate emergency department. After resuscitation, the man complains of a severe headache and photophobia that is accompanied by dizziness, nausea, vomiting, and neck pain. Physical examination is noteworthy for positive Kernig’s and Brudzinski’s signs as well as petechiae on the trunk and mucocutaneous bleeding. Laboratory studies show: WBC count: 17,000/mm3, Hemoglobin: 11 g/dL, Platelet count: 70,000/mm3, Bleeding time: 10 min, Prothrombin time: 17 sec, Activated partial thromboplastin time: 47 sec, Thrombin time: 18 sec. A peripheral blood smear is shown in the image. Which of the following is the most likely diagnosis?

A male infant is delivered at 37 weeks’ gestation via cesarean section for breech presentation. The pregnancy was complicated by polyhydramnios. The 34-year-old mother is rubella immune and has blood type B. She is negative for Rh antibody, Group B streptococci, rapid plasma reagin, hepatitis B surface antigen, gonorrhea, and Chlamydia. At delivery there is no meconium. He has a birth weight of 2.7 kg (6 lb). The baby has a weak cry and is pale and frothing at the nose and mouth. He has nasal flaring and retractions, with a respiratory rate of 56/min. Heart rate is 140/min and he has a regular rhythm and a harsh 2/6 holosystolic murmur that is best heard at the left sternal border. On auscultation he has fine diffuse crackles in his lungs bilaterally. The infant is missing both thumbs and has fusion of the remaining digits of his upper extremities bilaterally. The pediatric resident is able to suction secretions from the patient’s nasopharynx and oropharynx; however, she is unable to pass a nasogastric or orogastric tube more than 10 cm down. X-ray of the chest is shown in the image. Which of the following is the most likely diagnosis?

A mother notices an abdominal mass in her 3-year-old son while giving him a bath. There is no history of any symptoms, but the boy’s blood pressure is elevated at 105/85 mm Hg. Metastatic workup is negative and the patient is explored. The mass shown here is found within the left kidney. Genetic testing reveals deletion of 2 genes on chromosome band 11p13. Which of the following anomalies in addition to the identified tumor is associated with these chromosomal deletions?

A newborn infant develops respiratory distress immediately after birth. His abdomen is scaphoid. No breath sounds are heard on the left side of his chest, but they are audible on the right. Immediate intubation is successful with little or no improvement in clinical status. Emergency chest x-ray is shown (Image A) along with an x-ray 2 hours later (Image B). Which of the following is the most likely explanation for this infant’s condition?

A previously healthy 4-year-old child pictured below presents to the emergency room (ER) with a 2-day history of a brightly erythematous rash and temperature of 40°C (104°F). The exquisitely tender, generalized rash is worse in the flexural and perioral areas. The child is admitted and over the next day develops crusting and fissuring around the eyes, mouth, and nose. The desquamation of skin shown in the photograph occurs with gentle traction. Which of the following is the most likely diagnosis?

A term, 4200-g (9-lb, 4-oz) female infant is delivered via cesarean section because of cephalopelvic disproportion. The amniotic fluid was clear, and the infant cried almost immediately after birth. Within the first 15 minutes of life, however, the infant’s respiratory rate increased to 80 breaths per minute, and she began to have intermittent grunting respirations. The infant was transferred to the level 2 nursery and was noted to have an oxygen saturation of 94%. The chest radiograph is shown. Which of the following is the most likely diagnosis?

An 8-hour-old infant develops increased respiratory distress, hypothermia, and hypotension. A complete blood count (CBC) demonstrates a white blood cell (WBC) count of 2500/μL with 80% bands. The chest radiograph is shown below. Which of the following is the most likely diagnosis?

An 85-year-old man presents to the emergency room with an acute onset of midepigastric pain, nausea, vomiting, and hiccups starting 2 days ago. He is unable to keep any food down. Past history is pertinent for a long-standing hiatal hernia, hypertension, and diet-controlled diabetes. Examination reveals vital signs of pulse rate 82/min, BP 100/52 mmHg, respiratory rate 16/min, and temperature 97.2°F. The patient is in no acute distress, but has epigastric tenderness without guarding. Laboratory analysis revealed a hematocrit of 46 and a normal white blood cell (WBC) count. A chest x-ray is shown in Figure 6-5a. A fluoroscopically guided NG tube was placed using contrast, and his stomach was decompressed. After adequate fluid and electrolyte resuscitation, an upper gastrointestinal (UGI) contrast study was obtained and is shown in 6-5b. Which of the following is the most likely diagnosis?

An 86-year -old known hypertensive woman is brought to the emergency department due to weakness of her left side, confusion, drowsiness and slurred speech for the last 2 hours. Her past medical history is significant for an inferior wall myocardial infarction 12 years ago, chronic atrial fibrillation, and severe backache secondary to osteoarthritis. She is currently on aspirin, warfarin, losartan, indomethacin, atenolol, and simvastatin. She doesn't go to anticoagulation clinic regularly. Her blood pressure is 180/110 mm Hg, temperature is 38°C (100°F), respirations are 16/min, and pulse is 70/min, irregularly irregular. The pertinent physical findings are: carotid bruit on both sides, 2/5-muscle strength in the left arm and leg, and slurred speech. Her deep tendon reflexes are exaggerated on the left side, and the Babinski sign is positive. EKG reveals atrial fibrillation. Her CT scan (performed in the ED) is shown below. What is the most likely diagnosis?

At the time of delivery, a woman is noted to have a large volume of amniotic fluid. At 6 hours of age, her baby begins regurgitating small amounts of mucus and bile-stained fluid. Physical examination of the infant is normal, and an abdominal x-ray is obtained (see below). Which of the following is the most likely diagnosis of this infant’s disorder?

The examination of a child’s back is shown below. Evaluation with ultrasound of this lesion may demonstrate which of the following?

The laboratory results shown in Table 1–1 are obtained from the investigation of a 37-year-old African-American woman who has a blood pressure at rest of 140/100 mmHg. Which of the following is the most likely diagnosis?

The pulmonary function studies shown in Table 12–1 are of a 65-year-old man with severe dyspnea and cough. Which of the following is the most likely diagnosis?

The rash and mucous membrane lesions shown in the photograph below develop in an infant 5 days into the course of an upper respiratory infection with otitis media; the child is being treated with amoxicillin. The child’s condition is likely which of the following?

Two and a half weeks after coronary artery bypass grafting, a 63-year-old man returns to the emergency department acutely short of breath. The patient states that he began having chest pain and shortness of breath approximately 1 hour earlier. He has a history of hypertension, diabetes, and two myocardial infarctions. On examination he is hypoxic with an oxygen saturation of 86% on room air. Other vital signs and results of a physical examination are normal. ECG shows no interval change from his most recent ECG. CT of the chest is shown in the image. What is the most likely etiology of this patient’s shortness of breath?

You are seeing a 2-year-old boy for the first time. His father denies any past medical or surgical history, but does note that the child’s day care recently sent a note home asking about several episodes, usually after the child does not get what he wants, when he “breathes funny” and sits in a corner with his knees under his chin for a few minutes. The day-care staffers think this “self-imposed time-out” is a good thing, but they worry about the breathing. One teacher even though he once looked blue, but decided that it was probably because of the finger paints he had been using. On examination, you identify a right ventricular impulse, a systolic thrill along the left sternal border, and a harsh systolic murmur (loudest at the left sternal border but radiating through the lung fields). His chest radio- graph and ECG are shown. Which of the following congenital cardiac lesions would you expect to find in this child?