USMLE DIAG_Old_S_V

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

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

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

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

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

A previously healthy 7-year-old child suddenly complains of a headache and falls to the floor. When examined in the emergency room (ER), he is lethargic and has a left central facial weakness and left hemiparesis with conjugate ocular deviation to the right. Which of the following is the most likely diagnosis?

A previously healthy full-term infant has several episodes of duskiness and apnea during the second day of life. Diagnostic considerations should include which of the following?

A specific pattern of abnormalities has been identified among infants born to mothers who consume moderate-to-large amounts of alcohol during their pregnancies. Which of the following abnormalities is characteristic of these infants?

Acute renal failure occurs following aortic angiography in a 72-year-old man. His weight has been rising, his lungs show rales at both bases, and he is dyspneic. His fractional excretion of sodium is greater than 1. He has eosinophilia on his peripheral smear, an elevated erythrocyte sedimentation rate, and proteinuria with microscopic hematuria. Which of the following is the most likely cause of his renal failure?

An 18-month-old Caucasian boy is brought to the emergency department due to a 3-day history of fever and facial rash. His past medical history is significant for atopic dermatitis, which was diagnosed 1 week ago and treated with topical steroids. Examination reveals numerous umbilicated vesicles over erythematous skin of both cheeks. Submandibular adenopathy is present. What is the most probable diagnosis?

An 18-year-old female college student presents to student health services with a complaint of a burning sensation while urinating and abdominal pain. She denies urinary urgency or increased frequency. She has no significant past medical history. She is currently sexually active with a new partner. She does not use barrier contraception. She denies any previous history of sexually transmitted diseases. On examination she is afebrile, heart rate is 70/min, and blood pressure is 120/60 mm Hg. Examination reveals no peritoneal signs but there is tenderness to palpation over the suprapubic region. On pelvic examination the cervix appears edematous and friable with a small amount of discharge from the os. A urine sample reveals numerous WBCs but no organisms on Gram stain. A cervical swab is sent for Gram stain and culture. Which of the following is the most likely explanation for these findings?

A 78-year-old man comes to the physician because of a bloody urethral discharge for 3 days. He has had increasing frequency of urination and hesitancy for the past 2 years, but these symptoms have never been severe enough to require medical attention. Digital rectal examination reveals a slightly enlarged and firm prostate. Expressed prostatic secretions are negative for bacteria and leukocytes. Collection of clean-catch urine in separate aliquots reveals initial hematuria, with blood present in the first 5 mL. Which of the following is the most likely diagnosis?

An 80-year-old female is brought to your office, by her son, because of severe fatigue. She lives alone and is suffering from severe degenerative joint disease, which puts her in a house arrest-type state. Her son usually helps with getting grocery. Her only other medical problem is hypertension. She takes hydrochlorothiazide and acetaminophen. Her vitals are stable. On examination, she has pallor, and evidence of severe degenerative joint disease. Which of the following is the most likely cause of pallor in this patient?

A 9-year-old girl presents for evaluation of regular vaginal bleeding. History reveals thelarche at age 7 and adrenarche at age 8. Which of the following is the most common cause of this condition in girls?

A 90-year-old male complains of hip and back pain. He has also developed headaches, hearing loss, and tinnitus. On physical examination the skull appears enlarged, with prominent superficial veins. There is marked kyphosis, and the bones of the leg appear deformed. Serum alkaline phosphatase is elevated. Calcium and phosphorus levels are normal. Skull x-ray shows sharply demarcated lucencies in the frontal, parietal, and occipital bones. X-rays of the hip show thickening of the pelvic brim. Which of the following is the most likely diagnosis?

A four-year-old boy is brought to the physician because of discomfort in the left hip and left knee that is causing him to limp. Examination shows normal knee joints bilaterally, but there is marked limitation of internal rotation and abduction of the left hip. His temperature is 37.1 C (98.6F), blood pressure is 90/60 mm Hg, pulse is 80/min and respirations are 16/min. Laboratory studies including complete blood count and basic metabolic profile show no abnormalities. Which of the following is the most likely diagnosis?

A cyanotic newborn is suspected of having congenital heart disease. He has an increased left ventricular impulse and a holosystolic murmur along the left sternal border. The ECG shows left-axis deviation and left ventricular hypertrophy (LVH). Which of the following is the most likely diagnosis?

A full term neonate is being evaluated following an uncomplicated pregnancy and delivery on day 1 of life. He weighs 3.6kg (8ib), is 20in (50.8cm) tall, and has a head circumference of 13.5in (34cm). His physical examination is unremarkable. Initial laboratory data is shown below. Complete blood count: Hemoglobin 20g/L, Hematocrit 73%, Platelets 200,000/mm3, Leukocyte count 5,500/mm3, Neutrophils 56%, Eosinophils 1%, Lymphocytes 33%, Monocytes 10%. Which of the following findings is most likely to be detected in this neonate?

A 9-year-old boy is brought to the pediatrician's office for bed-wetting. His mother states that he has never been dry at night. Occasionally, he has problems controlling his bladder during the day. On physical examination, his blood pressure is 98/56 mm Hg. Both his weight and height are below the 5th percentile for his age. His bladder is enlarged and palpable above the symphysis pubis. Which of the following is the most likely cause of his problem?

A full-term neonate presents with hypotonia, lethargy and poor feeding over the past three hours. The pregnancy was uneventful, but during delivery, the neonate presented with shoulder dystocia and subsequently obtained a fracture of the clavicle. His Apgar scores are 7 and 8 at one and five minutes, respectively. His birth weight is 4000g. His vital signs are normal. Physical examination reveals an enlarged tongue, mild microcephaly, prominent occiput, prominent eyes and omphalocele. Abdominal palpation reveals an enlarged liver and kidneys. The initial work-up reveals hypoglycemia and hyperinsulinemia. What is the most likely diagnosis?

A healthy 59-year-old woman with no history of urinary incontinence undergoes vaginal hysterectomy and anteroposterior repair for uterine prolapse, large cystocele, and rectocele. Two weeks postoperatively, she presents to your office with a new complaint of intermittent leakage of urine. What is the most likely cause of this complaint following her surgery?

A mother brings her daughter in to see you for consultation. The daughter is 17 years old and has not started her period. She is 4ft 10 in tall. She has no breast budding. On pelvic examination, she has no pubic hair. By digital examination, the patient has a cervix and uterus. The ovaries are not palpable. As part of the workup, serum FSH and LH levels are drawn and both are high. Which of the following is the most likely reason for delayed puberty and sexual infantilism in this patient?

A newborn male has oliguria and a midline mass in the lower abdomen. What is the most likely diagnosis?

A pediatrician is called to the delivery room because a full-term infant has developed cyanosis and respiratory distress immediately after birth. A brief examination of the infant reveals cyanosis on room air not completely relieved by oxygen administered by mask, subcostal and intercostal retractions, absent air entry on the left with audible bowel sounds in the left chest, and poor air entry on the right chest. The heart is best heard in the right hemithorax; the abdomen is flat without organomegaly. Which of the following is the most likely diagnosis?

A pregnant 16-year-old girl with no prior pre-natal care presents to the emergency department in labor. A male infant is delivered precipitously. Prenatal laboratory test results are unknown. There is no meconium. He has a birth weight of 3 kg (6 lb 10 oz). He is pink and is crying, heart rate is 130/min, and respiratory rate is 36/min, with good respiratory effort. The emergency medicine resident notices the infant has ascites and a membrane-covered anterior abdominal mass at the base of his umbilical cord. Which of the following is the most likely diagnosis?

A premature infant develops respiratory distress several hours after birth. The infant is placed in an incubator with supplemental oxygen. The physician instructs the nurse to cover the infant's eyes to minimize the chance of damage by the high oxygen tension. Which of the following is characteristic of eye damage produced by exposure to high oxygen tensions in premature infants with respiratory distress?

A premature neonate develops respiratory distress syndrome several hours after birth. The infant is placed on a respirator and given other appropriate care. However, when the infant reaches a corrected gestational age of 36 weeks, he does not tolerate weaning from the ventilator. A chest x-ray film demonstrates alternating areas of hyperaeration and pulmonary scarring, resulting in parenchymal streaks and hyperexpanded areas. Which of the following is the most likely diagnosis?

A 68-year-old man is brought to the emergency department with excruciating back pain that began suddenly 45 minutes ago. The pain is constant and is not exacerbated by sneezing or coughing. He is diaphoretic and has a systolic blood pressure of 90 mm Hg. There is an 8 cm pulsatile mass deep in his epigastrium, above the umbilicus. A chest x-ray film is unremarkable. Two years ago, he was diagnosed with prostatic cancer and was treated with orchiectomy and radiation. At that time, his blood pressure was normal, and he had a 6-cm, asymptomatic abdominal aortic aneurysm for which he declined treatment. Which of the following is the most likely diagnosis?

A 7-day-old boy is admitted to a hospital for evaluation of vomiting and dehydration. Physical examination is otherwise normal except for minimal hyperpigmentation of the nipples. Serum sodium and potassium concentrations are 120 mEq/L and 9 mEq/L (without hemolysis), respectively; serum glucose is 40 mg/dL. Which of the following is the most likely diagnosis?

A 70-year-old man is brought to the hospital by his son because of worsening fatigue. His son states that his father does not like seeing doctors and has not seen a physician in the past 20 years. He has no medical problems. Physical examination of the prostate shows no abnormalities. Laboratory studies show: Hb 10.5 g/dl, WBC 7,400/cmm, Platelets 160,000/cmm, Serum Na 135 mEq/L, Serum K 5.0 mEq/L, BUN 50 mg/dl, Serum creatinine 3.0 mg/dl. Ultrasonogram of the abdomen shows bilateral small kidneys and no evidence of hydronephrosis. Kidney biopsy shows intimal thickening and luminal narrowing of renal arterioles with evidence of sclerosis. Which of the following is the most likely cause of this patient's findings?

A 70-year-old man presents to the ER with several fractures and a ruptured spleen after falling 20 ft. Which of the following will occur in response to the injury?

A 70-year-old woman presents to the ED with dark stool for 3 weeks. She occasionally notes bright red blood mixed with the stool. Review of systems is positive for decreased appetite, constipation, and a 10-lb weight loss over 2 months. She denies abdominal pain, nausea, vomiting, and fever, but feels increased weakness and fatigue. She also describes a raspy cough with white sputum production over the previous 2 weeks. Examination reveals she is pale, with a supine BP of 115/60 mm Hg and HR of 90 beats per minute. Standing BP is 100/50 mm Hg, with a pulse of 105 beats per minute. Which of the following is the most likely diagnosis?

A 75-year-old patient presents to the ER after a syncopal episode. He is again alert and in retrospect describes occasional substernal chest pressure and shortness of breath on exertion. His blood pressure is 110/80 mmHg and lungs have a few bibasilar rales. Which auscultatory finding would best explain his findings?

A 75-year-old white male comes to the physician's office for his routine health maintenance examination. He has no symptoms. He has a past medical history significant for hypertension and hyperlipidemia. He takes aspirin, hydrochlorothiazide and simvastatin. He does not smoke and consumes 1-2 beers on weekends. He walks 2 miles every morning and eats a balanced diet. His vital signs are within normal limits. His chest is clear to auscultation, and his abdomen is soft and nontender. Rectal examination shows a diffusely enlarged, firm prostate without nodules. Stool for occult blood is negative. The distal interphalangeal joints are enlarged, and his gait is normal. His labs are as follows: Total bilirubin 1.0 mg/dl, Alkaline phosphatase 420 U/L, Aspartate aminotransferase (SGOT) 20 U/L, Alanine aminotransferase (SGPT) 25 U/L, Serum creatinine 0.8 mg/dl, Calcium 8.8 mg/dl, Serum PSA 2.1 ng/ml. Which of the following is the most likely cause of the elevated alkaline phosphatase in this patient?

A 75-year-old woman comes to the physician because of abdominal distension. She states that she always feels bloated and that she gets full quickly when eating. She has hypertension, for which she takes an angiotensin converting enzyme (ACE) inhibitor, and no other medical problems. Examination shows abdominal distension and a positive fluid wave. Pelvic examination reveals a large, nontender right adnexal mass. Abdominal CT scan demonstrates masses on both ovaries, ascites, and omental caking. CA-125 level is significantly elevated. Serum alpha-fetoprotein (AFP) and human chorionic gonadotropin (hCG) are negative. Which of the following is the most likely diagnosis?

A 75-year-old woman is admitted to the hospital from a nursing home for abdominal pain and pneumonia. She was noted to be short of breath with increasing cough for 2 days before admission. Treatment, consisting of supplemental oxygen, IV antibiotics, and pulmonary toilet, is instituted, with improvement within 2 days. On the third hospital day, her abdominal pain worsens. Examination reveals a mildly distended abdomen with bowel sounds but no signs of peritonitis. Remainder of examination reveals a tender bulge in the medial left thigh below the inguinal ligament. Gentle pressure causes more pain but does not change the size or shape of the bulge. Abdominal films show a nonspecific bowel gas pattern. Laboratory analysis shows a WBC of 13,000, decreased from 18,000 at the time of admission. Which of the following is the most likely diagnosis?

A 76-year-old man was operated on for a strangulated inguinal hernia and had approximately 40 cm of small bowel resected. On the morning of his third post-operative day, he falls while getting out of bed. Immediately after the fall, he is responsive but his speech is slurred and he cannot explain what happened. His pulse is 122/min, blood pressure is 96/50 mmHg, and respirations are 23/min. Lungs are clear to auscultation and his heart has a regular rate and rhythm. His neck veins are distended. An ECG is remarkable for a new onset right bundle branch block (RBBB). Immediate resuscitation is started with wide open intravenous fluids, but he becomes unresponsive. Shortly thereafter, his pupils start to dilate and his heart rate drops to 45/min. He eventually dies despite resuscitative efforts. What is the most likely cause of his death?