USMLE PICTURE DIAGNOSIS MANAGEMENT

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

12) A 63-year-old female presents to your clinic complaining of palpitations. For the past 3 weeks, she has noticed pounding of her heart that comes and goes. Her symptoms are more frequent at night. Her only medicine is insulin for diabetes mellitus. On physical examination, she is alert and oriented, and in no distress. Her EKG is shown below. Which of the following best accounts for this patient's symptoms?

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

22) You are performing medical screening of new military recruits when an 18-year-old male reports several episodes of palpitation and syncope over the past several years. Physical examination is unremarkable. An ECG is obtained with excerpts shown below. What is the most likely diagnosis?

26) A 56-year-old diabetic female comes to the clinic with complaints of dizziness which has been going on for 3 weeks. She denies any dyspnea or diaphoresis. She says her blood glucose is well controlled and denies any allergy. Her BP is 155/90 mmHg. Her chest-x ray is unremarkable and her blood work is normal. The ECG is recorded below. What is the most likely diagnosis?

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

38) A 42-year-old woman has anterior chest pain of a somewhat atypical nature for many years. The patient’s pain has been present and relatively stable for a number of years, and the ECG shown in Fig. Is a stable one. What is the diagnosis?

39) A 78-year-old man with advanced renal disease has the ECG shown in Fig. (lead II). What is the diagnosis?

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

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

46) A 55-year-old male is admitted to the ICU after being involved in a motor vehicle accident. He requires exploratory laparotomy for suspected bowel perforation. Two days after the surgery he remains hypotensive and requires both aggressive intravenous fluids and vasopressors to maintain his blood pressure. On physical examination, you note the fingertip changes pictured below. All four extremities feel cold to touch. Which of the following is most likely responsible?

49) A 23-year-old woman who is an elementary school teacher is brought to the ED after syncopizing in her classroom while teaching. Prior to passing out, she describes feeling light-headed and dizzy and next remembers being in the ambulance. There was no evidence of seizure activity. She has no medical problems and does not take any medications. Her father died of a “heart problem” at 32 years of age. She does not smoke or use drugs. BP is 120/70 mmHg, pulse rate is 71 beats per minute, RR is 14 breaths per minute, and oxygen saturation is 100% on room air. Her physical examination and laboratory results are all normal. A rhythm strip is seen below. Which of the following is the most likely diagnosis?

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

57) 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?

59) 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?

60) A 43-year-old woman presents to the emergency department because of chest pain, shortness of breath, and worsening fatigue for the past day. The chest pain initially worsened with lying down and improved with leaning forward, but now it seems equal in intensity over all positions. On physical examination she has labored, fast breathing and appears to be in pain. She has jugular venous distention. She is tachycardic, has a regular rhythm, and has distant heart sounds with a friction rub. Her lungs are clear to auscultation bilaterally, her abdominal examination is benign, and she has no peripheral edema. Her temperature is 39.0°C (102.2°F), pulse is 126/min, blood pressure is 89/66 mmHg, respiratory rate is 32/min, and oxygen saturation is 98% on room air. X-ray of the chest is shown in the image. Which of the following is the most likely diagnosis?

70) Three months after an anterior MI, a 73-yearold man has a follow-up ECG. He is clinically feeling well with no further angina symptoms. His ECG shows Q waves in the anterior leads with persistant ST-segment elevation. The current ECG is most compatible with which of the following diagnosis?

1) A 47-year-old woman develops accelerated hypertension (blood pressure 210/105 mmHg) but no clinical symptoms except frequent headaches. Which of the following findings are most likely on examination of the fundii?

2) A 32-year-old man presents for rountine evaluation. He has no symptoms but has noticed some new “nodules” on his legs. Physical examination reveals lumps on his Achillis tendon, yellow lesions around his eyes, and pigmentation of his iris. Which of the following is the most likely diagnosis?

3) A 54-year-old woman presents to the ED because of a change in behavior at home. For the past 3 years, she has end-stage renal disease requiring dialysis. Her daughter states that the patient has been increasingly tired and occasionally confused for the past 3 days and has not been eating her usual diet. On examination, the patient is alert and oriented to person only. The remainder of her examination is normal. An initial 12-lead ECG is performed as seen on the following page. Which of the following electrolyte abnormalities best explains these findings?

8) Image below is an x-ray of an asymptomatic 64-year-old male executive coming in for his regular annual medical checkup. He had an anterior Q wave MI 4 years ago. What is your diagnosis?

11) 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?

12) Image below is the x-ray and MR of an 8-year-old boy who had easy fatigability and a soft, continuous murmur in the upper back. ECG revealed minimal LVH. What is your diagnosis?

 

13) A 78-year-old woman presents to a nursing home physician complaining of palpitations over the past several months. Her episodes are not associated with any chest pain, dizziness, or loss of consciousness. The patient reports that she spent several weeks in the hospital as a child with rheumatic fever. ECG is shown in the image. Which of the following is the most likely diagnosis?

17) Auscultation of the heart of a 17-year-old boy reveals an increased intensity of the pulmonary component of the second heart sound. He complains of dyspnea on exertion but no other cardiac or pulmonary symptoms. Which of the following explanations is the most likely cause of his dyspnea?

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

19) A 58-year-old man with hypertension is brought to the emergency room after sudden onset chest pain that radiates to his back and arms. He is in moderate distress with a blood pressure of 160/90 mmHg in the left arm and 120/70 mm Hg in the right arm. Cardiac examination reveals a soft second heart sound and a murmur of aortic insufficiency. His ECG shows sinus tachycardia but no acute ischemic changes, and the chest x-ray (CXR). Which of the following is the most appropriate next step in confirming the diagnosis?

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

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

24) An 80-year-old woman comes to the office and appears very upset. She requests removal of a lesion on her neck because "it is greasy and unsightly." She is tired of people constantly staring at her neck. The lesion has been present "for quite a while," and has been gradually darkening. Aside from occasional itching, there are no other symptoms. A picture of the lesion is shown below. What is the most likely diagnosis?

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

29) A 42-year-old woman presents with painful skin lesions. She is unable to eat or drink because the lesions have involved her mouth and throat. Her other complaints include malaise, headache, sore throat, cough, nausea and vomiting prior to the onset of the skin lesions. She was in perfect health in the past, other than an episode of urinary tract infection 3 days ago. She was prescribed trimethoprim-sulfamethoxazole combination for this infection. Her pulse is 92/min, respirations are 14/min, blood pressure is 140/90 mmHg, and temperature is 38.3°C (101°F). On examination, the skin is hot and tender with erythematous macules. The oral mucosa shows blistering and erosions. A picture of her back is shown below. What is the most likely diagnosis?

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

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

40) A 70-year-old Caucasian male presents to your office for evaluation of skin lesions on his forehead. On physical exam you find that these papules have a sandpaper texture by palpation. The lesions are illustrated in the slide below. Which of the following is the most likely diagnosis in this patient?

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

56) A 50-year-old woman develops pink macules and papules on her hands and forearms in association with a sore throat. The lesions are target like, with the centers a dusky violet. What causes of this disorder are most likely in this patient?

67) A 46-year-old female complains of a "sandy" sensation in her eyes. Review of systems is notable for a 6 pound weight loss over the last month. A picture of her eyes is shown on the slide below. Which of the following most likely underlies this finding?

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

43) A 44-year-old white female presents with a 2-month history of low-grade fever, abdominal pain and bloody diarrhea. Over the past two days, her symptoms have increased. She does not use medications and she has no allergies. She has had a 10 lb (4.5 kg) weight loss over the past four weeks. Her temperature is 38.9°C (102°F), blood pressure is 102/70 mmHg, pulse is 118/min, and respirations are 22/min. Examination shows pale and dry mucus membranes. Abdominal examination shows diffuse tenderness and distention. Laboratory studies show: Hb 9.5 g/dl, WBC 16,000/cmm, Serum Na 145 mEq/L, Serum K 3.0 mEq/L. An x-ray film of the abdomen is shown below. Which of the following is the most likely diagnosis?

51) A 54-year-old male presents to the emergency department with a 1-week history of abdominal pain. His other symptoms are nausea, vomiting, low-grade fever, and loss of appetite. He does not use alcohol. He has a seizure disorder, for which he takes a "prescription drug." X-ray films of his chest and abdomen show no abnormalities. His abdominal CT scan is shown below. Which of the following is the most likely explanation for this patient's abdominal symptoms?

52) A 70-year-old male presents to the emergency room complaining of weakness, dizziness and back pain. He denies nausea, vomiting, diarrhea, chest pain, palpitations, shortness of breath, urinary symptoms, or black stools. His past medical history is significant for diabetes mellitus, diabetic nephropathy and retinopathy, hypertension, atrial fibrillation and chronic leg cellulitis. He takes warfarin for chronic anticoagulation. On physical examination, his blood pressure is 139/75 mmHg and his heart rate is 110 and irregular. His WBC count is 10,500/mm3, hemoglobin level is 7.0 mg/dl and platelet count is 170,000/mm3. An abdominal CT image is shown on the slide below. Which of the following is the most likely diagnosis?

81) A 73-year-old man is seen in the ED for abdominal pain, nausea, and vomiting. His symptoms have progressively worsened over the past 2 to 3 days. The pain is diffuse and comes in waves. He denies fever or chills, but has a history of constipation. He reports no flatus for 24 hours. Physical examination is notable for diffuse tenderness and voluntary guarding. There is no rebound tenderness. An abdominal radiograph is seen below. Which of the following is the most likely diagnosis?

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

83) 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?

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

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

98) A 45-year-old man with a long history of alcohol intake comes into the emergency room with upper gastrointestinal (UGI) bleeding. Urgent endoscopy reveals the following findings. Which of the following is the most likely diagnosis?

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

114) 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?

174) The dental condition illustrated in Fig is usually associated with a congenital infectious disease. The teeth are characterized by centrally notched, widely spaced, peg-shaped upper central incisors and molars that have poorly developed cusps. Which of the following is the most likely diagnosis?

182) A 25-year-old man is admitted with fever and rust-colored sputum. He looks unwell, temperature 38.4°C, pulse 100/min, and blood pressure 115/80 mm Hg. On auscultation, there are bronchial breath sounds in the right axilla and inspiratory crackles. The CXR is shown in Fig. Which of the following is the most likely diagnosis?

211) A 64-year-old man is admitted for hematuria after slipping on an icy pavement. His physical examination is normal. A selective angiogram of the left kidney is shown in Fig. Which of the following is the most likely diagnosis?

243) 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?

12) A 45-year-old white male presents with a 4-month history of headaches. The headache is generalized, dull, constant, and worsened by bending, coughing and sneezing. It is unresponsive to simple analgesics, and associated with nausea and vomiting. His wife says he has been acting strangely for the last few months, and she has noted a personality change. The neurological examination is non-focal. Fundoscopy reveals papilledema. His CT scan is shown below. Which of the following is the most likely diagnosis?

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

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

71) A 65-year-old man with a history of diabetes, hypertension, coronary artery disease, and atrial fibrillation presents with loss of vision in his left eye since he awoke 6 hours ago. The patient denies fever, eye pain, or eye discharge. On physical examination of the left eye, vision is limited to counting fingers. His pupil is 3 mm and reactive. Extraocular movements are intact. Slit-lamp examination is also normal. The dilated funduscopic examination is shown below. Which of the following is the most likely diagnosis?

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

73) A 56-year-old woman is brought to the hospital from a local restaurant after suddenly becoming short of breath. Her flow-volume loop is shown below. Which of the following is the most likely cause of her symptoms?

74) A 54-year-old black male from the southeast USA presents to you with complaints of generalized malaise, fever, and a cough. He claims that he has had intermittent hemoptysis for the past six months. He denies smoking and has never had tuberculosis. Examination is unremarkable and his chest x-ray is shown below. On changing position, you notice that the part of the lesion seen on x-ray also moves. The most likely diagnosis is?

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

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

93) A 69-year -old Caucasian man presents with a two-day history of increasing shortness of breath and lower extremity edema. He is currently short of breath at rest and has an occasional cough. There is no past history of hypertension or ischemic heart disease. He reports drinking half a bottle of vodka daily and has smoked 1 pack of cigarettes per day for 45 years. His blood pressure is 160/90 mm Hg, pulse is 90/min, and oxygen saturation is 90% on room air. JVP is elevated and auscultation of his heart reveals faint heart sounds. The liver span is 18 cm and ascites is also present. No rales are heard in the lungs. There is 3+ lower extremity pitting edema up to the knees. The chest radiograph is shown below. Which of the following is the most likely diagnosis?

99) A 64-year-old male is admitted to the hospital with abdominal pain, abdominal distention, and confusion. Upon arrival his blood pressure is 90/60 mmHg and pulse is 120/min. On physical examination, his abdomen is tender, distended, and rigid with positive rebound tenderness. His past medical history is significant for rheumatic fever as a child, hypertension, coronary artery disease and atrial fibrillation. He receives a total of 6 liters of normal saline and undergoes emergent laparotomy. Postoperatively he complains of shortness of breath. His respiratory rate is 34/min. He is emergently intubated because of poor oxygenation. His chest x-ray is shown below. This film is compared to a chest x-ray performed one week earlier, which was within normal limits. Currently, the pulmonary capillary wedge pressure is 8 mmHg. Which of the following is the most likely cause of his current condition?

102) A 35-year-old male from Arizona presents to the physician's office with a low-grade fever and cough of two months duration. He also reports malaise and a weight loss of 7 1bs over this same period. He has a history of HIV infection diagnosed two years ago. He received a pneumococcal vaccine at the time his HIV was diagnosed. He also receives an annual influenza vaccine. He is not on any antiretroviral therapy. His temperature is 37.7°C (99.8°F), pulse is 75/min, blood pressure is 130/80 mm Hg and respirations are 14/min. Examination shows clear lungs to auscultation. His current CD4 count is 450cells/microl. His chest radiograph is shown below. Which of the following is the most likely cause of his cough?

116) A 34-year-old woman presents with one week of low-grade fever, diarrhea, and lethargy plus two days of hemoptysis and severe pleuritic-type chest pain. In the past she abused heroin but is currently in a methadone program. She has a 20 pack-year cigarette smoking history. Her medical history is significant for HIV and hepatitis C infections. Her last CD4 count was 350/μl two months ago. PPD testing revealed 2 mm of induration at the same time. On physical examination today, her blood pressure is 130/80 mmHg, heart rate is 100/min, and temperature 38.1°C (100.6°F). Breath sounds are diminished at the base of the right lung. Chest CT is shown below. Which of the following is the most likely diagnosis?

133) A 21-year-old nonsmoking college student comes to the local emergency department because pf cough, weight loss, and low-grade fever. Occasionally his sputum is tinged with blood. X-ray of the chest is shown in the image. He reports traveling to Haiti on a “medical mission” trip several years ago. Which of the following is the most likely diagnosis?

146) A 24-year-old African American woman presents with mild dyspnea on exertion, fever, and a rash on her legs. Her symptoms have come on gradually and she reports no pleuritic chest pain, hemoptysis or sputum production. She has no significant past medical history, smokes 10 cigarettes/day and is not taking any medications. Physical examination reveals generalized lymphadenopathy and tender erythematous nodules on her legs. CXR shows bilateral symmetric hilar adenopathy and reticulonodular changes in both lungs. She has a restrictive lung disease pattern on pulmonary function testing. Which of the following is the most likely diagnosis?

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

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

153) A 27-year-old man presents with chest pain and feeling unwell. He describes cough with blood-tinged sputum, chills, and fever of 2 days’ duration. Physical findings reveal dullness and moist rales in the left lower chest. His CXR is shown in Fig. Which of the following is the most likely diagnosis?

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

155) 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?

256) A 60-year-old Caucasian woman comes to the physician because of joint pains in both hands. Her other medical problems include obesity and gastroesophageal reflux disease. She does not use tobacco, alcohol, or drugs. Family history is not significant. Her medications include omeprazole and acetaminophen. Her vital signs are within limits. X-ray of the joints is shown below. Which of the following is the most likely diagnosis?

268) A 71-year-old female is brought to your clinic by her daughter with a complaint of severe pain in her fingers. Her daughter says, "Mom has horrible problems with her joints and she has never tried to get help". The patient adds that her fingers have been swollen and painful for a few weeks. She claims that she had a similar condition in her foot last year. She was given a pain pill, but it was ineffective. She takes a water pill for her blood pressure. What is the most likely diagnosis in this patient?

269) A 52-year-old male presents with a long history of joint pain. He describes pain and stiffness of the small joints of his hand that is worse in the morning and can last several hours. He also complains of occasional digit swelling. A picture of the patient's hands is shown on the slide below. Which of the following is the most likely diagnosis?

6) A 67-year-old male presents to the ER with chest pain. His medical history is significant for stable angina for which he takes aspirin and isosorbide dinitrate, as well as hypertension and bronchial asthma. Occasionally, he uses an albuterol inhaler. He is admitted to the hospital and five hours later, he begins to feel lightheaded and weak. His blood pressure is 100/60 mmHg. An EKG is obtained and is shown below. Which of the following is the best next step in managing this patient?

9) A 59-year-old male suffers a myocardial infarction. He is treated medically and is discharged home ten days later on aspirin, atorvastatin, metoprolol, lisinopril, and sublingual nitroglycerin. One month later, he presents to your office for a follow-up visit. He denies chest pain, dyspnea or lightheadedness. His blood pressure is 120/75 mmHg. His EKG is pictured below. Echocardiogram reveals an ejection fraction of 45%. What is the best next step in his management?

10) Diuretics, vasodilators and oxygen are standard inpatient therapy for patients hospitalized with left-sided heart failure. When patients are discharged, a different outpatient regimen is instituted. A team of researchers compares long-term cardiovascular mortality between patients treated with two different outpatient regimens. The study results are depicted below. In comparison to the patients depicted by the dashed curve, those depicted by the solid line most likely received treatment with which of the following?

42) A 72-year-old male is admitted to the hospital with chest pain. EKG and cardiac enzymes confirm a myocardial infarction and he is started on nitroglycerine, aspirin, simvastatin and low molecular weight heparin. Four days later, he complains of leg pain. Physical examination reveals a cold, pale leg. The angiogram is shown below. What is the best next step in his management?

44) A 65-year -old Hispanic male is brought to the emergency room with severe substernal chest pain and diaphoresis that began suddenly 1 hour ago. He reports that his pain started while he was at rest and radiates to his left shoulder. The patient notes having vomited twice when the pain first began. Despite administration of 2 baby aspirins and 3 tablets of sublingual nitroglycerin, the pain persists. His initial EKG is shown below. On physical examination, the patient's temperature is 36.9°C (98.4°F), blood pressure is 110/80 mmHg, pulse is 60/min, and respirations are 18/min. S1 and S2 are normal, and an S4 is heard. The lungs are clear to auscultation. There is no jugular venous distension or pedal edema. Interventions to achieve which of the following goals would most improve this patient's long-term prognosis?

45) A 64-year -old male with a history of hypertension presents with general malaise and a 'funny' heart rhythm for the past 2 weeks. He had an echocardiogram done last year, which revealed mild left atrial dilatation and left ventricular hypertrophy. He has been taking hydrochlorothiazide for hypertension. His blood pressure at today's visit is 180/98 mmHg. An EKG is obtained and is shown below. Which of the following is the most appropriate treatment for this patient?

58) A 72-year-old male with a history of poorly controlled hypertension develops a viral upper respiratory infection. On his second day of symptoms he experiences palpitations and presents to the emergency room. His blood pressure is 118/78 mmHg. The following rhythm strip is obtained. What is the best next step in the management of this patient?

59) An otherwise asymptomatic 65-year-old man with diabetes presents to the ER with a sports-related right shoulder injury. His heart rate is noted to be irregular, and this ECG is obtained. Which of the following is the best immediate therapy?

60) A patient has been in the coronary care unit for the past 24 hours with an acute anterior myocardial infarction. He develops the abnormal rhythm shown below, although blood pressure remains stable at 110/68 mmHg. Which of the following is the best next step in therapy?

66) An 82-year-old woman is brought to the ED by her daughter for worsening fatigue, dizziness, and light-headedness. The patient denies chest pain or shortness of breath. She has not started any new medications. Her BP is 140/70 mmHg, HR is 37 beats per minute, and RR is 15 breaths per minute. An IV is started and blood is drawn. An ECG is seen below. Which of the following is the most appropriate next step in management?

73) A 31-year-old kindergarten teacher presents to the ED complaining of acute-onset substernal chest pain that is sharp in nature and radiates to her back. The pain is worse when she is lying down on the stretcher and improves when she sits up. She smokes cigarettes occasionally and was told she has borderline diabetes. She denies any recent surgeries or long travel. Her BP is 145/85 mmHg, HR is 99 beats per minute, RR is 18 breaths per minute, and temperature is 100.6°F. Examination of her chest reveals clear lungs and a friction rub. Her abdomen is soft and nontender to palpation. Her legs are not swollen. Chest radiography and echocardiography are unremarkable. Her ECG is shown below. Which of the following is the most appropriate next step in management?

78) A 63-year-old woman on digitalis for chronic atrial fibrillation experiences fatigue, nausea, and anorexia. Her pulse is regular at 50 beats/min, and the heart sounds, chest, and abdominal examinations are normal. On the ECG, no P waves are visible and the QRS complexes are narrow and regular. Which of the following is the most appropriate management step?

83) A 27-year-old man who is otherwise healthy presents to the ED with a laceration on his thumb that he sustained while cutting a bagel. You irrigate and repair the wound and are about to discharge the patient when he asks you if he can receive an ECG. It is not busy in the ED so you perform the ECG, as seen below. Which of the following is the most appropriate next step in management?

106) A 12-year-old boy notices a scaly, mildly pruritic rash on his arm (see image below). There is no associated fever, muscle pain, nausea, vomiting, diarrhea, or back pain. He recently started taking swimming classes. The rash is most likely to clear with which of the following therapies?

3) A 25-year-old male presents with skin lesions over his elbows, knees and neck. He complains of intense itching and burning sensation over these lesions for the past 10 days. He was advised to follow a gluten-free diet on his previous visit, but was not compliant. His vital signs are stable. On examination, there are flesh-colored to erythematous vesicles distributed over the extensor aspects of elbows, knees, posterior neck and shoulders. Some of these lesions are shown in the picture below. Which of the following is the drug of choice for his skin condition?

5) A 22-year-old male presents with a 6-month history of a red, nonpruritic rash over the trunk, scalp, elbows, and knees. These eruptions are more likely to occur during stressful periods and have occurred at sites of skin injury. The patient has tried topical hydrocortisone without benefit. On examination, sharply demarcated plaques are seen with a thick scale. Pitting of the fingernails is present. There is no evidence of synovitis. What is the best first step in the therapy of this patient’s skin disease?

6) A 35-year-old woman develops an itchy rash over her back, legs, and trunk several hours after swimming in a lake. Erythematous, edematous papules and plaques are noted. The wheals vary in size. There are no mucosal lesions and no swelling of the lips. What is the best first step in management of her symptomatic rash?

10) A 50-year-old male comes to the office due to an ulcer in his right foot. He has type 2 diabetes, for which he takes glyburide. Laboratory investigations reveal an HbA1c of 9%, and random blood sugar of 180 mg/dL. X-ray of the leg/foot is normal. A picture of the foot ulcer is shown below. Which of the following is the most appropriate management of this patient's foot ulcer?

25) A 25-year-old female comes to the office for a follow-up visit. She was just diagnosed with type 1 diabetes mellitus a few days ago, when she presented at the emergency department with ketoacidosis. After successful management of her diabetic ketoacidosis (DKA), she was sent home on an insulin regimen with the following dosage: Before breakfast 10 units of NPH and 10 units of regular insulin, Before supper 10 units of NPH and 4 units of regular insulin. During this office visit, she shows the record of her fingerstick readings at home. For the last 2 days, her blood glucose levels were (see in pic). What is the most likely explanation for her 7:00 am blood glucose level?

34) A 19-year-old G1P0 woman at 32 weeks gestation presents for scheduled prenatal appointment. The pregnancy has been uncomplicated to date. However, she mentions that she recently noticed a hard lump on her neck. She denies pain or difficulty swallowing, speaking, or breathing. Physical examination reveals a firm, nontender, immobile, solitary nodule on the left hemithyroid. Ultrasound reveals a solid 2-cm mass. There is no cervical lymphadenopathy. Thyroid function tests reveal a thyroid-stimulating hormone level of 1.2 μU/mL and free thyroxine level of 0.9 ng/dL. Results of fine-needle aspiration biopsy are shown in the image. Which of the following is the best next step in management?

84) A 76-year-old man who has had multiple episodes of pancreatitis presents to his physician’s office with mild epigastric pain and 9.1-kg (20.0-lb) weight loss over the past 6 months. The patient also describes daily foul-smelling stools that “float” in the toilet bowl. The physician pulls up his electronic medical record and finds that the patient presented to the emergency department last week for the same symptoms. During that visit he had a CT of the abdomen (see image). Which of the following is the most appropriate treatment?

92) A 54-year-old man presents to his primary care provider with the complaint of upper abdominal fullness and pain. He states that he has lost 2.3-4.6 kg (5-10 lb), but denies other symptoms. Physical examination reveals a firm mass in the epigastric area. Ultrasonography reveals a mass in the gastric antrum. A salivary gland biopsy reveals the pathology shown in the image. Which of the following therapies is expected to be part of his treatment plan?

9) A 55-year-old male comes to the physician's office because of fatigue. He denies any other symptoms. His vital signs are stable. Examination shows pallor, massive splenomegaly, and mild hepatomegaly. CBC reveals pancytopenia with striking monocytopenia. His peripheral blood smear is shown below. Bone marrow biopsy shows a dry tap. What is the most appropriate treatment for this patient's condition?

12) A 32-year-old Italian-American man presents to your office for a routine check-up. He works as a business executive and admits to being under a lot of stress recently. He drinks alcohol occasionally and smokes one pack of cigarettes per day. Laboratory analyses reveal: Hemoglobin 10.1 mg/dl, RBC count 4.0 x 10^12/L, MCV 70fl, WBC count 5,500/mm3, Platelets 170,000/mm3, Serum calcium 10.1 mg/dl, Serum potassium 4.5 meq/L, Serum sodium 135 meq/L. Serial fecal occult blood tests are negative. A peripheral blood smear reveals the following: Which of the following is the best treatment for this patient?

48) A 27-year-old man presents with fever, malaise, anorexia, and fatigue for the last three days. He denies cough, chest pain, arthralgias, and diarrhea. He has history of rheumatic heart disease and recently underwent a dental cleaning. His temperature is 38.5°C (101.3°F), pulse is 90/min, respirations are 18/min, and blood pressure is 135/76 mm Hg. Examination of his fingernail is shown below. Cardiovascular examination reveals an early diastolic murmur in the mitral area. The chest x-ray is negative. Urinalysis shows microscopic hematuria. What is the most appropriate next step in the management of this patient?

53) A 40-year -old man who underwent a renal transplant six months ago comes to the clinic with fever, chills, and a productive cough. His temperature is 39.4°C (103°F), pulse is 110/min, respirations are 22/min, and blood pressure is 110/65 mmHg. Chest x-ray shows a right lower lobe nodule with a cavity. Sputum gram stain is shown below. What is the most appropriate treatment of this patient's condition?

55) A 22-year-old female presents to the office with a three-day history of rash, fever, and malaise. There is no burning or itching associated with the rash. Two weeks ago, she had been camping in northern Massachusetts, and noted a tick bite after walking through the woods. She is twelve weeks pregnant. The rash is shown below. The examination is otherwise unremarkable. What is the most appropriate treatment for this patient?

77) A 68-year-old male presents to the emergency room with cough. Chest x-ray is clear of infiltrates but reveals a right upper lobe lung lesion incidentally. A chest CT scan with IV contrast is performed in the emergency department and reveals a 1 cm x 2cm round lesion in the right upper lobe. The patient is admitted to the hospital, and by day 3 of his hospitalization, he has developed acute renal failure. The patient's past medical history is significant for hypertension, hyperlipidemia, diabetes and coronary artery disease. His medications include aspirin, hydrochlorothiazide, clopidogrel, metoprolol, atorvastatin and lisinopril, all of which he has been taking for several years. He has no known drug allergies. He is a former smoker and does not use alcohol or drugs. His baseline blood pressure is 140/90 mm Hg and has remained in the 140s/90s throughout this admission. Physical examination is otherwise unremarkable. The patient's laboratory values from the time of admission to present are given below. Over the course of the next week, the patient's renal function returns to normal. Which of the following would most likely have prevented his renal failure?

86) A healthy 54-year-old man comes to the physician for a routine health maintenance examination. He has no complaints, but he is requesting for a CT scan of the abdomen. His father died at the age of 60 due to the sudden rupture of an undiagnosed abdominal aortic aneurysm. He has a history of hypertension and gouty arthritis. His social history is not significant. His vital signs are stable. Physical examination shows no abnormalities. ACT scan of the abdomen is shown below. Which of the following is the most appropriate next step in management?

107) A 58-year-old alcoholic is admitted with diagnosis of decompensated liver cirrhosis. The lab panel is shown below on the day of admission and 3 days later. Which of the following best explains the acid-base status change in this patient?

112) A 79-year-old woman presents to her primary care physician complaining of memory loss. She reports increasing difficulty balancing her check book and remembering the names of new acquaintances over the last several months. Her only other complaint is occasional urinary incontinence, which she attributes to old age. She denies headache, vision changes, rash, nausea, or vomiting. Her past medical history is significant for hypertension controlled with felodipine. On exam her vital signs are within normal limits. The heart and lung exams are also unremarkable. The cranial nerves are intact, fundoscopic exam is normal, and no tremor is observed. Her gait is slow and shuffling, there is no dysmetria, and her Folstein mini-mental status score is 24/30. CT scan of her brain is shown below. Which of the following interventions is most likely to relieve her symptoms?

122) A 38-year-old female presents with one week of "shakiness" in her right arm, right leg weakness and unsteady gait. An MRI of her brain is shown below. Which of the following is the best treatment for this patient?

143) A 21-year-old man presents to the ED with a red eye. The patient complains of rhinorrhea and a nonproductive cough but has no eye pain or discharge. He also has no associated ecchymosis, bony tenderness of the orbit, or pain on extraocular eye movement. His vision is normal, extraocular movements are intact, and intraocular pressure (IOP) is 12. A picture of his eye is shown below. What is the most appropriate management of this condition?

150) A 65-year-old white male who has a history of chronic obstructive pulmonary disease, congestive heart failure, and coronary artery disease presented with a three-day history of worsening shortness of breath, cough with yellowish expectoration, and fever. He is not on steroids and does not use oxygen at home. He takes ipratropium, albuterol, aspirin, digoxin, furosemide, metoprolol, and lisinopril. He lives at home with his wife. His temperature is 39.4°C (103°F), blood pressure is 110/70 mmHg, pulse is 110/min, and respirations are 24/min. He is saturating 88% on room air. He was started on 3-liters of oxygen to keep the saturations above 92%. The chest x-ray of the patient is shown below. What is the most appropriate next step in the management of this patient?

174) A 60-year-old Caucasian female comes to the physician because of progressive shortness of breath for the past month. She has had a 13.6 kg (30 lb) weight loss during this period. She has a history of hypertension and hypothyroidism and takes metoprolol and levothyroxine. She has smoked two packs of cigarettes daily for 35 years. Her temperature is 36.7°C (98°F), blood pressure is 130/70 mmHg, pulse is 80/min, and respirations are 20/min. On examination, decreased breath sounds and dullness to percussion are noted on the right, middle and lower lobes of the lung. Her chest x-ray is shown below. Which of the following is the most appropriate next step in the management?

178) A 3-year-old boy presents to the emergency department with a fever and difficulty breathing. He is the product of a normal pregnancy and has been healthy since birth. His immunizations are up to date. This morning he appeared to be in his usual state of health and was dropped off at day care by his father. Later on, his teacher noticed that he had suddenly become fussy and flushed and could not be consoled with toys, rocking, or hearing a story. He also felt warm to the touch and was drooling more than usual. When she took his temperature, it was 39°C (102.2°F). His parents were contacted immediately, and the patient was brought to the emergency department. He appears toxic and anxious, and has loud labored breathing. He is sitting upright, bracing himself on his arms, with his neck hyperextended and mouth open. His temperature is 40°C (104°F), respiratory rate is 50/min, pulse is 140/min, blood pressure is 102/62 mm Hg, and oxygen saturation is 100% on room air. Lateral x-ray of the neck is shown in the image. Laryngoscopy reveals a large cherryred epiglottitis. What is the most appropriate next step in management?

69) 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?

10) The newborn pictured below was born at home and has puffy, tense eye- lids; red conjunctivae; a copious amount of purulent ocular discharge; and chemosis 2 days after birth. Which of the following is the most likely diagnosis?

29) The adolescent shown presents with a 14-day history of multiple oval lesions over her back. The rash began with a single lesion over the lower abdomen (Image A); the other lesions developed over the next days (image B). These lesions are slightly pruritic. Which of the following is the most likely diagnosis?

41) 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?

76) 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?

90) The mother of a 3-day-old infant brings her child to your office for an early follow-up visit. The mom notes that the child has been eating well, has had no temperature instability, and stools and urinates well. She notes that over the previous 3 days the child has had a progressive rash on the face as pictured here. Which of the following is the most likely diagnosis?

91) 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?

101) Over the previous 2 to 3 weeks, a very active 13-year-old white boy is noted by his family to have developed deep pains in his leg that awaken him from sleep. The family brings him to your office with a complaint of a swelling over his distal leg, which he attributes to his being kicked while playing soccer about 1 week ago. He has had no fever, headaches, weakness, bruising, or other symptoms. A radiograph of the leg is shown below. Which of the following is the most likely explanation for his pain?

107) A 4-month-old baby boy arrives to the ER cold and stiff. The parents report that he had been healthy and that they put him to bed as usual for the night at the regular time. When they next saw him, in the morning, he was dead. Physical examination is uninformative. A film from a routine skeletal survey is shown below. Which of the following is the most likely diagnosis?

128) A patient with hair loss is shown below. The lesion does not fluoresce with a Wood lamp and has not responded well to a variety of topical agents. The lesion is boggy, is spreading, and has tiny pinpoint black dots throughout. Which of the following is the most likely diagnosis?

131) The parents of the child pictured below bring him to the office for evaluation of short stature. At 5 years of age, he is the shortest child in his kindergarten class. His development is normal, and he is reading on a first grade level. Both parents are of normal height, and this child resembles no one in the family. Which of the following is the most likely diagnosis?

134) The 16-month-old male infant pictured below was recently brought from a developing country to the United States. The family history reveals that his father had an eye and a leg removed. Which of the following is the most likely diagnosis?

154) You are called to the delivery room to evaluate an infant born at 28-weeks gestational age. The infant is tachypneic and cyanotic. Examination reveals intercostal and subcostal retractions along with nasal flaring. Lungs have coarse breath sounds bilaterally. After initial resuscitation, the patient is given respiratory support with continuous positive airway pressure and admitted to the neonatal intensive care unit. The patient's respiratory status continues to worsen over the next 24 hours. A chest radiograph from the patient is shown below. In addition to prematurity, which of the following is a risk factor for the development of this disease?

173) A 5-year-old girl is brought to the physician with low grade fever and rhinorrhea. Her symptoms began ten days ago. She has also had persistent purulent rhinorrhea, nasal congestion, and a dry cough during the day that worsens at night. Her symptoms do not seem to be improving. On examination, the child has erythema and swelling of the nasal turbinates with purulent nasal drainage. She has evidence of drainage in the posterior pharynx as well. The remainder of her examination is unremarkable. Computed topography of her face is shown below. Which of the following is the most common predisposing factor for her condition?

174) 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?

182) The 4-year-old child pictured below is noted to have the tooth decay as shown. This characteristic pattern of tooth decay is caused by which of the following?

183) 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?

192) The delivery of a newborn boy is remarkable for oligohydramnios. The infant (pictured) is also noted to have undescended testes and clubfeet, and to be in respiratory distress. Which of the following is the most likely diagnosis to explain these findings?

196) 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?

204) 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?

206) A 4-year-old boy presents to the physician with fever and a sore throat. His illness began with rhinorrhea, cough, and congestion one week ago, but in the last 24 hours he has developed fever, a sore throat, and neck pain. His mother also reports that he sounds hoarse. His appetite is decreased and he complains of dysphagia. His temperature is 39.7 C (103.5F), pulse is 100/min, and respiratory rate is 25/min. On examination, the child appears sick. He has cervical lymphadenopathy on the right and decreased range of motion of his neck. His voice is muffled and sounds hoarse. His oropharynx is erythematous and a bulge is noted in the posterior pharyngeal wall. A lateral radiograph of the neck is shown below. Which of the following is the most likely diagnosis?

207) 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?

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

216) A previously healthy 4-year-old boy is brought to the physician for evaluation of fever and respiratory distress. The patient developed fever three days ago. Since then, he has had increasing fatigue, irritability, and respiratory distress. His temperature is 100 F (38.2C), pulse is 144/min, respiratory rate is 45/min, and blood pressure is 95/60 mm Hg. On examination, the child appears to be in moderate respiratory distress with tachypnea and subcostal retractions. He is tachycardic with an III/IV holosystolic murmur best heard at the cardiac apex. Peripheral pulses are present and capillary refill is three seconds. His liver is palpated three centimeters below the costal margin. A chest radiograph is shown below. Which of the following is the most likely cause of this patient's symptoms?

242) A 24-year-old woman arrives in the emergency center in active labor. She is at term, but received no prenatal care after 16 weeks of gestation when she lost her insurance coverage. The mother has an uncomplicated vaginal delivery. You are paged shortly after birth when the baby is noted to have respiratory distress. The infant has diminished breath sounds on the left, and the PMI is shifted toward the right. A chest radiograph is shown. The NG tube you placed earlier reveals the stomach to be below the diaphragm. Which of the following is the most likely diagnosis at this point?

244) The 1-year-old boy in the photograph below, who recently had a circumcision, requires an additional operation on his genitalia that will probably eliminate his risk of which of the following?

246) The term infant pictured below weighs 2200 g (4 lb, 14 oz). He is found to have a ventricular septal defect on cardiac evaluation. This infant appears to have features consistent with which of the following?

255) 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?

260) 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?

280) You are called to the newborn nursery to evaluate a term infant with bilious emesis. Although the mother had poor prenatal care, she had a normal vaginal delivery with no complications. The infant began having bilious vomiting several hours after birth. The infant has urinated, but has not had a bowel movement. Vital signs are temperature 36.9 0C (98.4 0F), pulse 150/min, and respiratory rate 40/min. On examination, the abdomen is distended and there are decreased bowel sounds. The remainder of the physical examination is unremarkable. An abdominal radiograph is shown below. Which of the following is the most likely diagnosis?

286) 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?

298) A 7-year-old male is brought to the emergency department for a suspected femur fracture. He has had multiple fractures in the past after minor trauma. Today, his mother states that he was running and fell. He complained of pain in his thigh after he fell. His examination is remarkable for tenderness to palpation and slight deformity of his right proximal thigh. He has decreased muscle tone throughout. His eye examination is shown below. Which of the following is the most likely associated finding?

 

312) The newborn nursery calls to notify you that a 1-day-old baby boy has developed abdominal distension and bilious emesis. Prenatal history was significant for areas of echogenic bowel seen on ultrasound. You order an abdominal radiograph; based on the results you order a contrast enema. Both are shown here. This infant is most likely to have which of the following?

315) 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?

319) The infant in the following picture presents with hepatosplenomegaly, anemia, persistent rhinitis, and a maculopapular rash. Which of the following is the most likely diagnosis for this child?

334) 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?

337) For the past year, a 12-year-old boy has had recurrent episodes of swelling of his hands and feet, which has been getting worse recently. These episodes occur following exercise and emotional stress, last for 2 to 3 days, and resolve spontaneously. The last episode was accompanied by abdominal pain, vomiting, and diarrhea. The results of routine laboratory workup are normal. An older sister and a maternal uncle have had similar episodes, but they were not given a diagnosis. He presents today with another episode as shown in the photographs on the next page. Which of the following is the most likely diagnosis?

348) Two weeks after a viral syndrome, a 9-year-old boy presents to your clinic with a complaint of several days of weakness of his mouth. In addition to the drooping of the left side of his mouth, you note that he is unable to completely shut his left eye. His smile is asymmetric, but his examination is otherwise normal. Which of the following is the most likely diagnosis?

349) A 4-year-old girl is noticed by her grandmother to have a limp and a some-what swollen left knee. The parents report that the patient occasionally com- plains of pain in that knee. An ophthalmologic examination reveals findings as depicted in the photograph. Which of the following conditions is most likely to be associated with these findings?

355) 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?

368) The child shown below presents with a 3-day history of malaise, fever to 41.1C (106F), cough, coryza, and conjunctivitis. He then develops the erythematous, maculopapular rash pictured. He is noted to have white pinpoint lesions on a bright red buccal mucosa in the area opposite his lower molars. Which of the following is the most likely diagnosis?

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

374) 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?

376) The developmentally delayed 6-month-old child in the picture below had intrauterine growth retardation (including microcephaly), hepatosplenomegaly, prolonged neonatal jaundice, and purpura at birth. The calcific densities in the skull x-ray shown are likely the result of which of the following?

377) The infant pictured below develops infantile spasms. Which of the following disorders is most likely to be affecting this infant?

381) 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?

23) A chubby 6-month-old baby boy is brought to the clinic by his father. His father is concerned that his penis is too small (see photograph). The child is at the 95% for weight and the 50% for length; he has been developing normally and has had no medical problems. Which of the following is the most appropriate first step in management of this child?

25) You are performing a well-child examination on the 1-year-old child shown in the picture. For this particular problem, which of the following is the most appropriate next step in management?

45) After her first urinary tract infection, a 1-year-old has a voiding cystourethrogram with findings shown below. Which of the following is the most appropriate treatment option?

50) A previously healthy 3-year-old male is brought to the emergency department with abdominal pain. The abdominal pain began several hours ago. Since then, he has had several episodes in which he clutches his stomach and screams. These episodes are associated with nonbloody, nonbilious vomiting and loose, watery stools. Between the episodes, the patient denies abdominal pain and is playful. On examination, his temperature is 99F (37.2C), pulse is 100/min, respiratory rate is 20/min, and blood pressure is 85/50 mmHg. The child is alert and in no acute distress. Abdominal examination reveals a soft, nontender, nondistended abdomen with bowel sounds present in all four quadrants. A tubular mass is felt in the right upper quadrant, and a rectal exam is hemoccult positive. An ultrasound image of the patient's abdomen is shown below. What is the best next step in the management of this patient?

51) A 4-year-old boy presents with a history of constipation since the age of 6 months. His stools, produced every 3 to 4 days, are described as large and hard. Physical examination is normal; rectal examination reveals a large ampulla, poor sphincter tone but present anal wink, and stool in the rectal vault. The plain film of his abdomen is shown. Which of the following is the most appropriate next step in the management of this child?

52) A previously healthy 2-year-old black child has developed a chronic cough during the previous 6 weeks. He has been seen in different emergency rooms on two occasions during this period and has been placed on antibiotics for pneumonia. Upon auscultation, you hear normal breath sounds on the left. On the right side, you hear decreased air movement during inspiration but none upon expiration. Inspiratory (Image A) and expiratory (Image B) radiographs of the chest are shown below. Which of the following is the most appropriate next step in making the diagnosis in this patient?

53) A 13-year-old boy has a 3-day history of low-grade fever, symptoms of upper respiratory infection, and a sore throat. A few hours before his presentation to the emergency room, he has an abrupt onset of high fever, difficulty swallowing, and poor handling of his secretions. He indicates that he has a marked worsening in the severity of his sore throat. His pharynx has a fluctuant bulge in the posterior wall. A soft tissue radiograph of his neck is shown. Which of the following is the most appropriate initial therapy for this patient?

68) A 2-year-old child (Image A) presents with a 4-day history of a rash limited to the feet and ankles. The papular rash is both pruritic and erythematous. The 3-month-old sibling of this patient (Image B) has similar lesions also involving the head and neck. The most appropriate treatment for this condition includes which of the following?

82) You are seeing a 4-year-old girl with the physical examination finding shown below. She has no significant past history. The most appropriate management is which of the following?

84) A 3-year-old girl is admitted with the x-ray shown below. The child lives with her parents and a 6-week-old brother. Her grandfather stayed with the family for 2 months before his return to the West Indies 1 month ago. The grandfather had a 3-month history of weight loss, fever, and hemoptysis. Appropriate management of this problem includes which of the following?

86) A mother arrives to the clinic with her three children (ages 2 months, 18 months, and 36 months). The 18-month-old has an intensely pruritic scalp, especially in the occipital region, with 0.5-mm lesions noted at the base of hair shafts, as shown in the picture. Which of the following therapies should be avoided in this situation?

98) A 5-year-old boy presents with the severe rash shown in the photographs. The rash is pruritic, and it is especially intense in the flexural areas. The mother reports that the symptoms began in infancy (when it also involved the face) and that her 6-month-old child has similar symptoms. Which of the following is the most appropriate treatment of this condition?

106) A 2-year-old child is seen in the emergency center with a 10-day complaint of fever and a limp. The child has an elevated erythrocyte sedimentation rate (ESR) and the radiograph shown below. Which of the following statements about this child’s condition is correct?

115) A 4-week-old boy presents with a 10-day history of vomiting that has increased in frequency and forcefulness. The vomitus is not bile stained. The child feeds avidly and looks well, but he has been losing weight. An ultrasound of the abdomen is shown. Which of the following is the most likely diagnosis?

133) A 6-month-old Hispanic boy is brought to the office for a well-baby check-up and follow-up immunizations. His mother denies any new complaints. Physical examination reveals lesions that do not fade into the surrounding skin, shown in picture below. What is the most appropriate next step in the management of this patient?

142) A 13-year-old boy’s scrotum is shown below. He complains of several months of swelling but no pain just above his left testicle. He is sexually active but states that he uses condoms. On physical examination, the area in question feels like a “bag of worms.” Which of the following is the most appropriate management for this condition?

143) A 3-day-old infant’s scrotum is shown below. Palpation reveals a tense, fluid-filled area surrounding the right testicle. The scrotum transil luminates well, and the amount of fluid does not vary with mild pressure. Which of the following is the most appropriate approach to this condition?

144) An 8-year-old girl is brought to the emergency department with fever for the past 6 days. Her parents report that she has been very "cranky" and has developed a new rash. Six weeks ago, she completed a 10-day course of amoxicillin for streptococcal pharyngitis. She has no other medical problems and takes no medications. Her temperature is 39.4° C (103° F), blood pressure is 110/60 mm Hg, pulse is 120/min, and respirations are 24/min. Physical examination shows injected lips and pharynx. Bilateral conjunctivae are also injected, with no exudates. A 1.7-cm mobile lymph node is palpated on the left neck. A blanching erythematous rash is present across her face, trunk, and extremities, including the palms and soles. Her mouth is shown below. What is the most appropriate next step in management of this patient?

145) A 1-week-old black infant presents to you for the first time with a large, fairly well-defined, purple lesion over the buttocks bilaterally, as shown in the photograph. The lesion is not palpable, and it is not warm nor tender. The mother denies trauma and reports that the lesion has been present since birth. This otherwise well-appearing infant is growing and developing normally and appears normal upon physical examination. Which of the following is the most appropriate course of action in this infant?

162) A well-appearing, 3200-g (7-lb, 1-oz) black infant is noted to have fifth finger (postaxial) polydactyly. The extra digit has no skeletal duplications and is attached to the rest of the hand by a threadlike soft tissue pedicle (see photograph). Appropriate treatment for this condition includes which of the following?

184) A 55-day-old infant born prematurely at 27 weeks of gestation is shown below. The swelling is not tender, firm, hot, or red, and it does not transil luminate. It seems to resolve with pressure, but returns when the infant cries or strains. Which of the following is the most appropriate course of action at this point?

198) A previously well 1-year-old infant has had a runny nose and has been sneezing and coughing for 2 days. Two other members of the family had similar symptoms. Four hours ago, his cough became much worse. On physical examination, he is in moderate respiratory distress with nasal flaring, hyper- expansion of the chest, and easily audible wheezing without rales. His chest radiographs are shown. Which of the following is the appropriate next course of action?

199) A 6-year-old girl presents with a 2-day history of cough and fever. At your office she has a temperature of 39.4°C (103°F), a respiratory rate of 45 breaths per minute, and decreased breath sounds on the left side. Her chest x-ray is shown below. Which of the following is the most appropriate initial treatment?

205) The nurse from the level 2 neonatal intensive care nursery calls you to evaluate a baby. The infant, born at 32 weeks’ gestation, is now 1 week old and had been doing well on increasing nasogastric feedings. This afternoon, however, the nurse noted that the infant has vomited the last two feedings and seems less active. Your examination reveals a tense and distended abdomen with decreased bowel sounds. As you are evaluating the child, he has a grossly bloody stool. The plain film of his abdomen is shown. The next step in your management of this infant should include which of the following?

223) A 15-year-old presents with the complaint of a rash, as pictured below. Which of the following statements is correct concerning the management of this common condition?

224) An infant weighing 1400 g (3 lb) is born at 32 weeks’ gestation. Initial evaluation was benign, and the infant was transferred to the level 2 nursery for prematurity. The nurse there calls at 1 hour of life and reports the infant is tachypneic. Vital signs include a heart rate of 140 beats per minute, a respiratory rate of 80 breaths per minute, a temperature of 35°C (95°F), and a peripheral oxygen saturation of 98%. The lungs are clear with bilateral breath sounds and there is no murmur; the infant is in no dis- tress. The child’s chest radiograph is shown. Which of the following is the most appropriate next step in evaluating the infant?

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

41) 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?

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

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

72) 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?

76) A 65-year-old male cigarette smoker reports onset of claudication of his right lower extremity approximately 3 weeks previously. He can walk 3 blocks before the onset of claudication. Physical examination reveals palpable pulses in the entire left lower extremity, but no pulses are palpable below the right groin level. Non-invasive flow studies are obtained and are pictured here. What is the level of the occlusive process in this patient?

79) An 80-year-old man is found to have an asymptomatic pulsatile abdominal mass. An arteriogram is obtained (shown below). Which of the following is the most frequent and lethal complication of this condition?

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

82) 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?

87) 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?

88) An 83-year-old woman presents to a mammographic facility for a screening mammogram. The technician notices a mass in the lateral right breast. The patient denies any breast pain, nipple discharge, skin changes, or breast trauma. A right breast CC view is shown in Figure 6-7. Which of the following is the most likely diagnosis?

91) A 45-year-old woman complains to her primary care physician of nervousness, sweating, tremulousness, and weight loss. The thyroid scan shown here exhibits a pattern that is most consistent with which of the following disorders?

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

102) 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?

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

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

113) A 76-year-old woman presents with acute onset of persistent back pain and hypotension. A CT scan is obtained (shown below), and the patient is taken emergently to the operating room. Three days after surgery she complains of abdominal pain and bloody mucus per rectum. Which of the following is the most likely diagnosis?

119) A term infant is born at a small community hospital by caesarean section for failure to progress. The infant is noted to have the following abnormality at birth. Which of the following is the most likely diagnosis?

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

130) 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?

131) In a 6-month-old previously healthy male infant, an abnormality is revealed during a routine diaper change, as illustrated in Figure 6-19. The parents have noted this finding on and off on several occasions over the last month. On each occasion, the child has been feeding well, and is content and playful. Which of the following is the most likely diagnosis?

133) 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?

134) A neonate with bile-stained vomiting, abdominal distention, dilated loops of bowel on plain radiographs, and a small-caliber colon on contrast enema (Figure 6-17). Which one is the most likely diagnosis?

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

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

82) A 46-year-old male is brought to the emergency department after falling on his head and back during a downhill bike race and losing consciousness for 1 minute. He has severe back and abdominal pain. AP and lateral skull films show no abnormalities. Lumbar films show anterior compression wedge fractures of the bodies of L1 and L2. A brace is placed. CT scan of the abdomen shows a mild retroperitoneal bleed and splenic laceration. During the hospitalization he was treated conservatively with analgesics and supportive measures. On hospital day 3, he started to have abdominal distention, pain and nausea. His last bowel movement was 4 days ago and he is not passing gas. His abdomen is distended, tympanic and mildly tender without rebound or guarding. Bowel sounds are absent. An x-ray film of the abdomen is shown below: Which of the following is the most likely diagnosis?

85) A 7-year-old boy has been complaining of left hip pain for the past 8 months. Over recent weeks, he has developed a limp. When you examine his gait, you note that he takes short steps with his left leg. On physical examination, his left hip has significantly limited range of motion, and there is atrophy of the left proximal thigh muscle. X-ray of the patient's pelvis is shown below: W hich of the following is most likely responsible for this patient's condition?

89) A 53-year-old male comes to the emergency department complaining of sudden onset intense, stabbing epigastric pain. He also vomited once and a dull, aching pain then spread through his entire abdomen. He has had nonspecific epigastric pain for several months and saw a physician one month ago. He also has a history of constipation, type II diabetes mellitus and hyperlipidemia. He has smoked one and a half packs of cigarettes daily for 26 years. He drinks 4 oz of alcohol daily. His temperature is 38.3C (100.4F), blood pressure is 160/95 mm Hg, pulse is 100/min and respirations are 26/min. The entire abdomen is tender to palpation with rebound, but there is no guarding. No masses are palpable, and Murphy's sign elicits mild pain. Rectal examination shows no abnormalities. Abdominal ultrasound performed 2 weeks ago showed stones in the gall bladder. Upright chest x-ray is shown below: Which of the following is the most likely diagnosis in this patient?

94) A 55-year-old man comes to the physician because of chronic leg problems. He has had multiple medical problems and is unable to get good medical care due to lack of insurance. A photograph of his legs is shown below. Which of the following is the most likely cause of his condition?

102) A 35-year-old man is brought to the emergency department after a motorcycle accident. He is unconscious when the emergency medical team arrived. He regains consciousness on the way to the emergency department. Upon arrival, he is mildly confused and complains of headache and nausea. His temperature is 36.9° C (98.5° F), blood pressure is 102/60 mm Hg, pulse is 116/min, and respirations are 22/min. Pupils are equal and reactive to light. He moves all extremities on command, and deep tendon reflexes are symmetric. Head CT scan shows: Which of the following is the most likely diagnosis?

104) A 46-year-old man is brought to the emergency department after a fall during a downhill bike race. He lost consciousness for approximately 1 minute after the fall. He complains of severe back and abdominal pain. He has no other medical problems. Head computed tomography (CT) scan shows no intracranial bleeding. Lumbar films suggest a compression wedge fracture of the body of L2 vertebra, and a brace is placed. Abdominal CT scan shows a small retroperitoneal bleed and splenic laceration. He is conservatively treated with analgesics and supportive measures. On hospital day three, he complains of abdominal pain and nausea. His abdomen is distended, tympanic, and mildly tender, without rebound or guarding. Bowel sounds are absent. X-ray of the abdomen reveals. Which is the most likely diagnosis?

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

123) An 18-year-old woman presents with abdominal pain, fever, and leukocytosis. With the presumptive diagnosis of appendicitis, a right lower quadrant (McBurney) incision is made and a lesion 60 cm proximal to the ileocecal valve is identified (see photo). Which of the following is the most likely diagnosis?

49) A 62-year-old man comes to the emergency department because of severe abdominal pain. He states that he suddenly felt weak, diaphoretic, and had no energy. He is a smoker and has hypertension. His blood pressure on initial examination was 110/70 mm Hg. Physical examination shows a diffusely tender abdomen. During CT scan he becomes pale and drowsy. CT scan is shown below: Repeat examination shows a man with anxiety and a blood pressure of 80/50 mm Hg and pulse of 110/min Which of the following is the most appropriate next step in management?

76) A 12-year-old boy is brought to the emergency department after being involved in a motor vehicle collision. He was in the rear seat and was thrown out of the car during the accident. He was immediately resuscitated, and the trauma work-up showed no abnormalities. His discharge was uneventful. Two months later he was seen in the emergency department because of vague chest pain and discomfort. Auscultation showed decreased air entry into the left lower base. An x-ray film of the chest is shown below. Which of the following is the most appropriate next step in management?

94) A previously healthy 79-year-old woman presents with early satiety and abdominal fullness. CT scan of the abdomen, pictured here, reveals a cystic lesion in the body and tail of the pancreas. CT-guided aspiration demonstrates an elevated carcinoembryonic antigen (CEA) level. Which of the following is the most appropriate treatment option for this patient?

119) A 32-year-old woman undergoes a cholecystectomy for acute cholecystitis and is discharged home on the sixth postoperative day. She returns to the clinic 8 months after the operation for a routine visit and is noted by the surgeon to be jaundiced. Laboratory values on readmission show total bilirubin 5.6 mg/dL, direct bilirubin 4.8 mg/dL, alkaline phosphatase 250 IU (normal 21-91 IU), serum glutamic oxaloacetic transaminase (SGOT) 52 kU (normal 10-40 kU), and serum glutamic pyruvic transaminase (SGPT) 51 kU (normal 10-40 kU). An ultrasonogram shows dilated intrahepatic ducts. The patient undergoes the transhepatic cholangiogram seen here. Which of the following is the most appropriate next management step?

129) A 65-year-old man who is hospitalized with pancreatic carcinoma develops abdominal distention and obstipation. The following abdominal radiograph is obtained. Which of the following is the most appropriate initial management of this patient?

131) An upper GI series is performed on a 71-year-old woman who presented with several months of chest pain that occurs when she is eating. The film shown here is obtained. Investigation reveals a microcytic anemia and erosive gastritis on upper endoscopy. Which of the following is the most appropriate initial management of this patient?

135) A 35-year-old woman presents with abdominal pain and jaundice. Subsequent ERCP reveals the congenital cystic anomaly of her biliary system illustrated in the film shown here. Which of the following is the most appropriate treatment?

138) After a weekend drinking binge, a 45-year-old man presents to the hospital with abdominal pain, nausea, and vomiting. On physical examination, the patient is noted to have tenderness to palpation in the epigastrium. Laboratory tests reveal an amylase of 25,000 U/dL (normal < 180U/dL). The patient is medically managed and sent home after 1 week. A CT scan done 4 weeks later is pictured here. Currently the patient is asymptomatic. Which of the following is the most appropriate initial management of this patient?

141) A 36-hour-old infant presents with bilious vomiting and an increasingly distended abdomen. At exploration, the segment pictured here is found as the point of obstruction. What is the best next step in management?

165) A 34-year-old prostitute with a history of long-term intravenous drug use is admitted with a 48-hour history of pain in her left arm. She is tachycardic to 130 and her systolic blood pressure is 80 mm Hg. Physical examination is remarkable for crepitus surrounding needle track marks in the antecubital space with a serous exudate. The plain x-ray of the arm is shown here. Which of the following is the most appropriate next step in her management?

189) A 12-year-old boy comes to the emergency department complaining of vague left-sided chest discomfort. Two months ago, he was involved in a high-speed motor vehicle accident but sustained only minor injuries. He was observed in the emergency department overnight and discharged home. His past medical history is otherwise unremarkable. Vital signs are normal. Auscultation of the lungs shows decreased air entry into the left lower base. An x-ray of the chest is shown below. Which of the following is the most appropriate next step in management of this patient?

36) A 50-year-old man has respiratory failure due to pneumonia and sepsis after undergoing splenectomy for a traumatic injury. Which of the following management strategies will improve tissue oxygen uptake (ie, shifting the oxygen dissociation curve, depicted here, to the right)?

46) A 43-year-old woman develops acute renal failure following an emergency resection of a leaking abdominal aortic aneurysm. One week after surgery, the following laboratory values are obtained:Serum electrolytes (mEq/L): Na+ 127, K+ 5.9, Cl− 92, HCO3− 15Blood urea nitrogen: 82 mg/dLSerum creatinine: 6.7 mg/dLThe patient has gained 4 kg since surgery and is mildly dyspneic at rest. Eight hours after these values are reported, the following electrocardiogram is obtained. Which of the following is the most appropriate initial treatment in the management of this patient?

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

119) A 62-year-old man comes to the emergency department because of severe abdominal pain. He states that he suddenly felt weak, diaphoretic, and had no energy. He is a smoker and has hypertension. His blood pressure on initial examination was 110/70 mm Hg. Physical examination shows a diffusely tender abdomen. During CT scan he becomes pale and drowsy. CT scan is shown below. Repeat examination shows a man with anxiety and a blood pressure of 80/50 mm Hg and pulse of 110/min. Which of the following is the most appropriate next step in management?

125) In a 6-month-old previously healthy male infant, an abnormality is revealed during a routine diaper change, as illustrated in Figure 6-19. The parents have noted this finding on and off on several occasions over the last month. On each occasion, the child has been feeding well, and is content and playful. We decided to do surgical repair. Several weeks later, the child presents to the emergency department with a 4-hour history of irritability. He has had one episode of nonbilious vomiting and has refused to breast-feed. In the emergency department, the infant appears inconsolable. He is afebrile, and his abdomen is mildly distended but soft. On removal of his diaper, the same abnormality is documented (see Figure 6-19). Which of the following is the most appropriate management at this time?

131) A 56-year-old woman presents to her primary care physician for a routine checkup. She states that she was recently hospitalized for surgery and was told she had some metal placed in a large blood vessel to prevent blood clots from moving to her lungs. An abdominal x-ray is shown here. Which of the following is the most appropriate indication for placement of this device?

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

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

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

156) 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 appropriate next step in the diagnostic evaluation and management of this patient?

165) A 60-year-old man is found on a routine physical examination to have a 3-cm pulsatile mass in the right popliteal fossa. X-ray of the right of the right lower extremity is shown below. Which of the following is the most appropriate management of this patient?

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