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π¨π¦ MCCQE1,2 | #Case_161
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An African American patient presented with yellow discoloration of sclera, dark urine, and unusually light stool of a week duration. Physical examination confirmed the diagnosis of jaundice. The rest of physical examination was normal. Urine analysis showed bilirubinuria and a set of other lab investigations was ordered. Which of the following lab findings would
support your presumptive type of jaundiced in this patient?
β€High reticulocyte count
πHigh serum alkaline phosphatase
πLow serum albumin
πIncreased red cell fragility
πPositive sickling test
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An African American patient presented with yellow discoloration of sclera, dark urine, and unusually light stool of a week duration. Physical examination confirmed the diagnosis of jaundice. The rest of physical examination was normal. Urine analysis showed bilirubinuria and a set of other lab investigations was ordered. Which of the following lab findings would
support your presumptive type of jaundiced in this patient?
β€High reticulocyte count
πHigh serum alkaline phosphatase
πLow serum albumin
πIncreased red cell fragility
πPositive sickling test
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β B
π Explanation
Jaundice with dark urine (due to bilirubinuria) and pale stool should prompt one to strongly suspect the diagnosis of obstructive jaundice which is typically associated with high serum levels of alkaline phosphatase (choice B). Conjugated bilirubin, which predominates in obstructive jaundice, is the form of bilirubin that can be filtered in the kidney and appears in urine. Also, metabolites of bilirubin are partly responsible for giving stool its normal color. In obstructive jaundice, conjugated bilirubin cannot reach the intestine but spills over in blood leading to lightening of stool color and
dark urine. In hepatocytes, alkaline phosphatase is concentrated in cell membranes near bile canaliculi and this is why its serum level increases in obstructive jaundice.
β High reticulocyte count (choice A), increased red cell fragility (choice C) and positive sickling test (choice E) are incorrect choices. These findings suggest the diagnosis of hemolytic jaundice which should not be suspected from the clinical picture of our patient. In hemolytic jaundice, bilirubin is predominantly of the unconjugated form that cannot be filtered in glomeruli because it is tightly bound to albumin plasma. Urine will thus be of normal color in patients with this type of jaundice. Also, in hemolytic jaundice stool may be darker in color due to excretion of large amounts of bilirubin
degradation products in stool.
β Low serum albumin (choice C) is not the correct choice because the half-life of albumin in serum is about 26 days. Its level is expected to be normal in acute liver diseases.
π Key point:
Dark urine and pale stool in presence of jaundice are highly suggestive of obstructive jaundice.
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β B
π Explanation
Jaundice with dark urine (due to bilirubinuria) and pale stool should prompt one to strongly suspect the diagnosis of obstructive jaundice which is typically associated with high serum levels of alkaline phosphatase (choice B). Conjugated bilirubin, which predominates in obstructive jaundice, is the form of bilirubin that can be filtered in the kidney and appears in urine. Also, metabolites of bilirubin are partly responsible for giving stool its normal color. In obstructive jaundice, conjugated bilirubin cannot reach the intestine but spills over in blood leading to lightening of stool color and
dark urine. In hepatocytes, alkaline phosphatase is concentrated in cell membranes near bile canaliculi and this is why its serum level increases in obstructive jaundice.
β High reticulocyte count (choice A), increased red cell fragility (choice C) and positive sickling test (choice E) are incorrect choices. These findings suggest the diagnosis of hemolytic jaundice which should not be suspected from the clinical picture of our patient. In hemolytic jaundice, bilirubin is predominantly of the unconjugated form that cannot be filtered in glomeruli because it is tightly bound to albumin plasma. Urine will thus be of normal color in patients with this type of jaundice. Also, in hemolytic jaundice stool may be darker in color due to excretion of large amounts of bilirubin
degradation products in stool.
β Low serum albumin (choice C) is not the correct choice because the half-life of albumin in serum is about 26 days. Its level is expected to be normal in acute liver diseases.
π Key point:
Dark urine and pale stool in presence of jaundice are highly suggestive of obstructive jaundice.
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π¨π¦ MCCQE1,2 | #Case_162
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An otherwise healthy 37-year-old male presents to your office with a 2-week history of redness and slight irritation in his groin. On examination a tender erythematous plaque with mild scaling is seen in his right crural fold. The area fluoresces coral-red under a Woodβs light. Which one of the following would be the most appropriate treatment at this time?
β€Amoxicillin
πErythromycin
πKetoconazole
πNystatin
πTriamcinolone
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An otherwise healthy 37-year-old male presents to your office with a 2-week history of redness and slight irritation in his groin. On examination a tender erythematous plaque with mild scaling is seen in his right crural fold. The area fluoresces coral-red under a Woodβs light. Which one of the following would be the most appropriate treatment at this time?
β€Amoxicillin
πErythromycin
πKetoconazole
πNystatin
πTriamcinolone
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β B
π Explanation
The characteristics of this lesion, including coral-red fluorescence under a Woodβs light, suggests Corynebacterium infection, which is associated with erythrasma. Tinea cruris caused by Microsporum infection fluoresces green, while intertrigo and tinea cruris caused by Epidermophyton or Trichophyton infections do not fluoresce. Erythromycin, either systemic or topical, is the treatment of choice
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β B
π Explanation
The characteristics of this lesion, including coral-red fluorescence under a Woodβs light, suggests Corynebacterium infection, which is associated with erythrasma. Tinea cruris caused by Microsporum infection fluoresces green, while intertrigo and tinea cruris caused by Epidermophyton or Trichophyton infections do not fluoresce. Erythromycin, either systemic or topical, is the treatment of choice
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π¨π¦ MCCQE1,2 | #Case_163
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You are asked to see a mentally challenged 45-year-old male from a nearby group home who has groin pain. On examination you notice that he has large ears, a prominent jaw, and large symmetric testicles. These findings are consistent with:
β€A variant form of Down syndrome
πAspergerβs syndrome
πKlinefelterβs syndrome
πHomocystinuria
πFragile X syndrome
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You are asked to see a mentally challenged 45-year-old male from a nearby group home who has groin pain. On examination you notice that he has large ears, a prominent jaw, and large symmetric testicles. These findings are consistent with:
β€A variant form of Down syndrome
πAspergerβs syndrome
πKlinefelterβs syndrome
πHomocystinuria
πFragile X syndrome
π1
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β E
π Explanation
Fragile X syndrome accounts for more cases of mental retardation in males than any other genetic disorder except Down syndrome; about one in 4000-6000 males is affected. Down syndrome, Klinefelterβs syndrome, and homocystinuria do not present with the described findings. Aspergerβs syndrome is a variant of autism in people of normal to high intelligence.
Patients with Klinefelterβs syndrome usually have small testicles
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β E
π Explanation
Fragile X syndrome accounts for more cases of mental retardation in males than any other genetic disorder except Down syndrome; about one in 4000-6000 males is affected. Down syndrome, Klinefelterβs syndrome, and homocystinuria do not present with the described findings. Aspergerβs syndrome is a variant of autism in people of normal to high intelligence.
Patients with Klinefelterβs syndrome usually have small testicles
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π¨π¦ MCCQE1,2 | #Case_164
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A 55-year-old male is brought to the emergency department with a complaint of pain in the right eye and reduced vision of about 10 minutesβ duration. His eye was injured while he was hitting a metal stake with a sledge hammer. He was not wearing safety goggles. On examination you note a subconjunctival hemorrhage completely surrounding the cornea. The iris is irregular. Which one of the following is
β€Administering an analgesic
πAttempting tonometry
πA visual acuity test
πUse of an eye shield
πAdministering an antiemetic
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A 55-year-old male is brought to the emergency department with a complaint of pain in the right eye and reduced vision of about 10 minutesβ duration. His eye was injured while he was hitting a metal stake with a sledge hammer. He was not wearing safety goggles. On examination you note a subconjunctival hemorrhage completely surrounding the cornea. The iris is irregular. Which one of the following is
contraindicated prior to emergency transfer to an ophthalmologist?β€Administering an analgesic
πAttempting tonometry
πA visual acuity test
πUse of an eye shield
πAdministering an antiemetic
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β B
π Explanation
The injury and findings described raise the possibility of globe rupture due to a fragment of steel penetrating through the cornea and pupil and into the globe. Relief of pain with an analgesic (choice A) is appropriate before transfer. Because of a risk of extruding intraocular fluid, tonometry (choice B) should not be attempted if globe rupture is suspected. A rapid assessment of gross visual acuity (e.g., counting fingers, seeing light versus dark) (choice C) may be performed. An eye shield (choice D) should be placed over the affected eye to avoid putting pressure on the eye during transport to the ophthalmologist. Because the Valsalva effect from vomiting may lead to extrusion of intraocular contents, an antiemetic (choice E) would be appropriate before transfer as well
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β B
π Explanation
The injury and findings described raise the possibility of globe rupture due to a fragment of steel penetrating through the cornea and pupil and into the globe. Relief of pain with an analgesic (choice A) is appropriate before transfer. Because of a risk of extruding intraocular fluid, tonometry (choice B) should not be attempted if globe rupture is suspected. A rapid assessment of gross visual acuity (e.g., counting fingers, seeing light versus dark) (choice C) may be performed. An eye shield (choice D) should be placed over the affected eye to avoid putting pressure on the eye during transport to the ophthalmologist. Because the Valsalva effect from vomiting may lead to extrusion of intraocular contents, an antiemetic (choice E) would be appropriate before transfer as well
π1
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π¨π¦ MCCQE1,2 | #Case_165
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Cardiogenic shock is a major, and frequently fatal, complication of a variety of acute and chronic disorders that impair the ability of the heart to maintain adequate tissue perfusion. These patients demonstrate clinical signs of low cardiac output, with adequate intravascular volume. Which of the following is usually found on physical examination?
β€Normal capillary refill
πNormal peripheral pulses
πBradycardia
πNarrow pulse pressure
πHigh urine output
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Cardiogenic shock is a major, and frequently fatal, complication of a variety of acute and chronic disorders that impair the ability of the heart to maintain adequate tissue perfusion. These patients demonstrate clinical signs of low cardiac output, with adequate intravascular volume. Which of the following is usually found on physical examination?
β€Normal capillary refill
πNormal peripheral pulses
πBradycardia
πNarrow pulse pressure
πHigh urine output
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β D
π Explanation
Cardiogenic shock characterized by primary myocardial dysfunction causes the heart to be unable to maintain adequate cardiac output. It is a medical emergency. These patients demonstrate clinical signs of low cardiac output, with adequate intravascular volume. The patients have cool and clammy extremities, poor capillary refill, tachycardia, narrow pulse pressure (choice D), and low urine output. Peripheral pulses are rapid and faint and may be irregular if arrhythmias are present.
β Normal capillary refill (choice A) is incorrect. Patients in shock usually appear ashen or cyanotic and have cool skin and mottled extremities.
β Normal peripheral pulses (choice B) is incorrect. Peripheral pulses are rapid and faint and may be irregular if arrhythmias are present.
β Bradycardia (choice C) is incorrect. The pulse pressure may be low, and patients are usually tachycardic.
β High urine output (choice E) is incorrect. These patients show signs of hypoperfusion, such as altered mental status and decreased urine output.
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β D
π Explanation
Cardiogenic shock characterized by primary myocardial dysfunction causes the heart to be unable to maintain adequate cardiac output. It is a medical emergency. These patients demonstrate clinical signs of low cardiac output, with adequate intravascular volume. The patients have cool and clammy extremities, poor capillary refill, tachycardia, narrow pulse pressure (choice D), and low urine output. Peripheral pulses are rapid and faint and may be irregular if arrhythmias are present.
β Normal capillary refill (choice A) is incorrect. Patients in shock usually appear ashen or cyanotic and have cool skin and mottled extremities.
β Normal peripheral pulses (choice B) is incorrect. Peripheral pulses are rapid and faint and may be irregular if arrhythmias are present.
β Bradycardia (choice C) is incorrect. The pulse pressure may be low, and patients are usually tachycardic.
β High urine output (choice E) is incorrect. These patients show signs of hypoperfusion, such as altered mental status and decreased urine output.
π1
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π¨π¦ MCCQE1,2 | #Case_166
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A 2-year-old boy is brought to the office by his father because of a 3-month history of decreased activity, poor appetite, sporadic vomiting, clumsiness and speech regression. Since his birth his family has lived in an old area of the city where there is demolition of old buildings. Examination of a peripheral blood smear is likely to show which of the following?
β€Basophilic stippling of erythrocytes
πDegranulation of eosinophils
πDiminished numbers of platelets
πHowell-Jolly bodies
πMacrocytic erythrocytes
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A 2-year-old boy is brought to the office by his father because of a 3-month history of decreased activity, poor appetite, sporadic vomiting, clumsiness and speech regression. Since his birth his family has lived in an old area of the city where there is demolition of old buildings. Examination of a peripheral blood smear is likely to show which of the following?
β€Basophilic stippling of erythrocytes
πDegranulation of eosinophils
πDiminished numbers of platelets
πHowell-Jolly bodies
πMacrocytic erythrocytes
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β A
π Explanation
This child suffers from lead poisoning. Prior to the 1970s, lead was used in paint, gasoline, water pipes, and many other products. During the demolition of older structures, lead is released and can become ingested by humans, primarily children. Exposure to excessive levels of lead can cause brain damage; affect a childβs growth; damage kidneys; impair hearing; cause vomiting, headaches, and appetite loss; and cause learning and behavioral problems. Lead eventually becomes associated with mitochondria in red blood cells and appears as basophilic granules via H & E staining. This is a form of sideroblastic anemia.
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β A
π Explanation
This child suffers from lead poisoning. Prior to the 1970s, lead was used in paint, gasoline, water pipes, and many other products. During the demolition of older structures, lead is released and can become ingested by humans, primarily children. Exposure to excessive levels of lead can cause brain damage; affect a childβs growth; damage kidneys; impair hearing; cause vomiting, headaches, and appetite loss; and cause learning and behavioral problems. Lead eventually becomes associated with mitochondria in red blood cells and appears as basophilic granules via H & E staining. This is a form of sideroblastic anemia.
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π¨π¦ MCCQE1,2 | #Case_167
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A 60 year old woman had an abdominal hysterectomy and salpingo-oophorectomy 3 days ago. She had an indwelling bladder catheter, which was removed in the recovery room. She has been voiding normally since then. She began ambulation on the 1st postoperative day, and has been as active as possible under the circumstances, including faithful adherence to a prescribed program of incentive spirometry. On the evening of the 3rd postoperative day, she spikes a fever, with a temperature to 39.4Β°C (103Β°F). Which of the following is the most likely source of the fever?
β€Atelectasis
πDeep thrombophlebitis
πIntra-abdominal abscess
πUrinary tract infection
πWound infection
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A 60 year old woman had an abdominal hysterectomy and salpingo-oophorectomy 3 days ago. She had an indwelling bladder catheter, which was removed in the recovery room. She has been voiding normally since then. She began ambulation on the 1st postoperative day, and has been as active as possible under the circumstances, including faithful adherence to a prescribed program of incentive spirometry. On the evening of the 3rd postoperative day, she spikes a fever, with a temperature to 39.4Β°C (103Β°F). Which of the following is the most likely source of the fever?
β€Atelectasis
πDeep thrombophlebitis
πIntra-abdominal abscess
πUrinary tract infection
πWound infection
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β D
π Explanation
The timing is our major clue. Fever on postoperative day 3 is usually from the urinary tract. The circumstances are also there: she had instrumentation of her urinary tract during the procedure. Atelectasis is usually seen on day 1, and she is doing everything possible to avoid this complication. Deep thrombophlebitis could show up this early, but is more likely to do so 5-7 days after surgery. Furthermore, the patient had adequate protection during surgery and has been moving around since early on. Intra-abdominal abscess would need at least 7-10 days to develop. This is too early for that
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β D
π Explanation
The timing is our major clue. Fever on postoperative day 3 is usually from the urinary tract. The circumstances are also there: she had instrumentation of her urinary tract during the procedure. Atelectasis is usually seen on day 1, and she is doing everything possible to avoid this complication. Deep thrombophlebitis could show up this early, but is more likely to do so 5-7 days after surgery. Furthermore, the patient had adequate protection during surgery and has been moving around since early on. Intra-abdominal abscess would need at least 7-10 days to develop. This is too early for that
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π¨π¦ MCCQE1,2 | #Case_168
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A 40 year old male is brought to the emergency department in a confused state. His past medical history is unremarkable. He is not taking any medications. He is complaining of severe, weakness and lightheadedness that began an hour ago. A STAT glucometer reveals a value of 2.5 mmol/L. The patient improved dramatically upon Dextrose 50% infusion. After careful history and physical exam, you ordered some lab tests that return abnormal for an elevated insulin levels and decreased C-Peptide. Which of the following is the most likely diagnosis?
β€Chronic pancreatitis
πFactitious disorder
πGlucagonoma
πInsulinoma
πSulphonylurea overdose
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A 40 year old male is brought to the emergency department in a confused state. His past medical history is unremarkable. He is not taking any medications. He is complaining of severe, weakness and lightheadedness that began an hour ago. A STAT glucometer reveals a value of 2.5 mmol/L. The patient improved dramatically upon Dextrose 50% infusion. After careful history and physical exam, you ordered some lab tests that return abnormal for an elevated insulin levels and decreased C-Peptide. Which of the following is the most likely diagnosis?
β€Chronic pancreatitis
πFactitious disorder
πGlucagonoma
πInsulinoma
πSulphonylurea overdose
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β B
π Explanation
Our patient has classic symptoms of hypoglycemia (confusion, weakness, lightheadednessβ¦), documented by lab test, then improved dramatically with glucose administration (Whippleβs triad). This patient is likely injecting insulin surreptitiously for a primary gain (factitious disorder or Munchausen syndrome). The exogenous industrial insulin is purified and does not have the C-peptide as a component; thus in a person who is injecting insulin, expect low glucose, high insulin and low C-peptide. Insulinoma would give high levels of both insulin and C-peptide (endogenous insulin). Sulphonylurea drugs make the Beta cells of the pancreas secrete insulin thus the lab tests will be similar to insulinoma; a urine toxicology screen for sulphonylurea drugs will clench the diagnosis. Glucagonoma presents with hyperglycemia and a characteristic rash (Necrolytic migratory erythema). Chronic pancreatitis may present with hyperglycemia and diabetes because of insulin deficiency. Please remember that the C-peptide is an endogenous substance which is not present in pharmaceutical insulin and you will answer all the tricky questions around this issue correct.
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β B
π Explanation
Our patient has classic symptoms of hypoglycemia (confusion, weakness, lightheadednessβ¦), documented by lab test, then improved dramatically with glucose administration (Whippleβs triad). This patient is likely injecting insulin surreptitiously for a primary gain (factitious disorder or Munchausen syndrome). The exogenous industrial insulin is purified and does not have the C-peptide as a component; thus in a person who is injecting insulin, expect low glucose, high insulin and low C-peptide. Insulinoma would give high levels of both insulin and C-peptide (endogenous insulin). Sulphonylurea drugs make the Beta cells of the pancreas secrete insulin thus the lab tests will be similar to insulinoma; a urine toxicology screen for sulphonylurea drugs will clench the diagnosis. Glucagonoma presents with hyperglycemia and a characteristic rash (Necrolytic migratory erythema). Chronic pancreatitis may present with hyperglycemia and diabetes because of insulin deficiency. Please remember that the C-peptide is an endogenous substance which is not present in pharmaceutical insulin and you will answer all the tricky questions around this issue correct.
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π¨π¦ MCCQE1,2 | #Case_169
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An otherwise healthy 40-year-old male comes to your office for follow-up of elevated liver enzymes on an insurance examination. He is 173 cm (68 in) tall and weighs 113 kg (250 lb) (BMI 37.7 kg/mΒ²). He says he drinks about two beers per week. Findings are normal on a physical examination, except for a slightly enlarged liver. AST and ALT levels are twice the upper limits of normal. Which one of the following would be the most appropriate next step?
β€A liver biopsy
πUltrasonography of the liver
πColonoscopy
πTesting for viral hepatitis
πRepeat AST and ALT levels in 3 months
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An otherwise healthy 40-year-old male comes to your office for follow-up of elevated liver enzymes on an insurance examination. He is 173 cm (68 in) tall and weighs 113 kg (250 lb) (BMI 37.7 kg/mΒ²). He says he drinks about two beers per week. Findings are normal on a physical examination, except for a slightly enlarged liver. AST and ALT levels are twice the upper limits of normal. Which one of the following would be the most appropriate next step?
β€A liver biopsy
πUltrasonography of the liver
πColonoscopy
πTesting for viral hepatitis
πRepeat AST and ALT levels in 3 months
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β D
π Explanation
Nonalcoholic fatty liver disease is the most likely diagnosis in this patient, but hepatitis B and C should be ruled out (choice D). The patient's alcohol consumption of less than two drinks per week makes alcoholic fatty liver disease unlikely.
β A liver biopsy (choice A) would not be appropriate at this time.
β Liver ultrasonography (choice B) should be considered after hepatitis B and C are ruled out.
β The patient is younger than the recommended screening age for colonoscopy (choice C).
β There is no rason to repeat previously repeated test results (lab error unlikely) (choice E).
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β D
π Explanation
Nonalcoholic fatty liver disease is the most likely diagnosis in this patient, but hepatitis B and C should be ruled out (choice D). The patient's alcohol consumption of less than two drinks per week makes alcoholic fatty liver disease unlikely.
β A liver biopsy (choice A) would not be appropriate at this time.
β Liver ultrasonography (choice B) should be considered after hepatitis B and C are ruled out.
β The patient is younger than the recommended screening age for colonoscopy (choice C).
β There is no rason to repeat previously repeated test results (lab error unlikely) (choice E).
π1
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π¨π¦ MCCQE1,2 | #Case_170
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A 32-year-old man presents with increased shortness of breath and he has had a cough for the past week. He appears dyspneic and has a temperature of 38.3Β°C (101.0Β°F). On physical examination he has bibasilar rales and generalized lymphadenopathy. Rectal examination shows multiple perianal contusions and a small amount of blood oozing from the anal orifice. Chest x-ray film shows bilateral patchy alveolar infiltrates. The most appropriate next step is:
β€Admit him to the hospital and begin administration of trimethoprim-sulfamethoxazole, intravenously
πAdmit him to the hospital and begin administration of penicillin and gentamicin, intravenously
πBegin administration of erythromycin, orally, and see him again the next day
πPrescribe isoniazid and rifampin, orally
πRecommend aspirin, fluids and rest at home
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A 32-year-old man presents with increased shortness of breath and he has had a cough for the past week. He appears dyspneic and has a temperature of 38.3Β°C (101.0Β°F). On physical examination he has bibasilar rales and generalized lymphadenopathy. Rectal examination shows multiple perianal contusions and a small amount of blood oozing from the anal orifice. Chest x-ray film shows bilateral patchy alveolar infiltrates. The most appropriate next step is:
β€Admit him to the hospital and begin administration of trimethoprim-sulfamethoxazole, intravenously
πAdmit him to the hospital and begin administration of penicillin and gentamicin, intravenously
πBegin administration of erythromycin, orally, and see him again the next day
πPrescribe isoniazid and rifampin, orally
πRecommend aspirin, fluids and rest at home
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β A
π Explanation
The history and physical raises the possibility of HIV infection. There is a strong suggestion of homosexuality, given that the rectal examination demonstrates multiple perianal contusions and blood oozing from the anal orifice. Furthermore, this
man has generalized lymphadenopathy; his chief complaint is of pulmonary distress with an x-ray consistent with Pneumocystis carinii pneumonia (PCP). Since the patient has become increasingly short of breath and is febrile, he should be treated with intravenous therapy. Treatment of choice for PCP is Bactrim (trimethoprim-sulfamethoxazole).
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β A
π Explanation
The history and physical raises the possibility of HIV infection. There is a strong suggestion of homosexuality, given that the rectal examination demonstrates multiple perianal contusions and blood oozing from the anal orifice. Furthermore, this
man has generalized lymphadenopathy; his chief complaint is of pulmonary distress with an x-ray consistent with Pneumocystis carinii pneumonia (PCP). Since the patient has become increasingly short of breath and is febrile, he should be treated with intravenous therapy. Treatment of choice for PCP is Bactrim (trimethoprim-sulfamethoxazole).
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π¨π¦ MCCQE1,2 | #Case_171
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A 2-month-old male is brought in by his mother who has noted unusual sounds while the baby is breathing. She states that it started about weeks ago, but yesterday, it sounded like it was getting worse. The breathing noise is usually heard when the baby is lying on his back or crying, and it improves when she holds the baby on her shoulder. She also noticed that the sounds are worse when the baby is breathing in but they get better on exhalation. The pregnancy and delivery were uneventful and the baby had been growing well since birth. On physical examination you note stridor that increases on inspiration heard best just above the sternal notch. Which of the following is the most likely diagnosis?
β€Airway foreign body
πChoanal atresia
πLaryngotracheobronchitis
πSubglottic stenosis
πLaryngomalacia
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A 2-month-old male is brought in by his mother who has noted unusual sounds while the baby is breathing. She states that it started about weeks ago, but yesterday, it sounded like it was getting worse. The breathing noise is usually heard when the baby is lying on his back or crying, and it improves when she holds the baby on her shoulder. She also noticed that the sounds are worse when the baby is breathing in but they get better on exhalation. The pregnancy and delivery were uneventful and the baby had been growing well since birth. On physical examination you note stridor that increases on inspiration heard best just above the sternal notch. Which of the following is the most likely diagnosis?
β€Airway foreign body
πChoanal atresia
πLaryngotracheobronchitis
πSubglottic stenosis
πLaryngomalacia
π1