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| # | Code | QID |
Subspecialty
|
Topic
|
Complexity
|
Importance
|
|
|---|---|---|---|---|---|---|---|
| 1 | M2.OMB.20.4886 | 214233 | A 33-year-old man is brought to the emergency department by emergency medical services after being rescued from a fire at the smelting plant where he works. The patient is anxious, mildly confused, and cannot recall what happened. His temperature is 99.0°F (37.2°C), blood pressure is 135/88 mmHg, pulse is 124/min, respirations are 27/min, and oxygen saturation is 94% on room air. An initial lactate is 3 mmol/L (normal < 2.0 mmol/L). The patient is protecting his airway and has a Glasgow coma scale of 14. He is started on a non-rebreather at 15 L/min. Upon reassessment 30 minutes later, the patient appears more confused. A repeat lactate is drawn at that time and is 7.0 mmol/L. The patient is complaining of a headache and begins vomiting. Which of the following is the pathophysiology of the most likely diagnosis? | Toxicology |
M 6
|
A
|
|
| 2 | M2.OMB.20.4887 | 214289 | A 21-year-old man presents to the emergency department for an allergic reaction. He says that he tried sushi for the first time today at a local restaurant. When he first tasted the fish he thought it had a very bitter, peppery taste. After eating it, he suddenly felt warm and flushed. He felt dizzy and developed palpitations, and his vision became blurred. He then states a rash appeared. His friend who was with him states that they had only tried tuna, mahi-mahi, herring, and mackerel. His temperature is 99.0°F (37.2°C), blood pressure is 100/61 mmHg, pulse is 117/min, respirations are 23/min, and oxygen saturation is 93% on room air. Physical exam is notable for the finding in Figure A and bilateral wheezing on pulmonary auscultation with good air movement. Which of the following is the most likely diagnosis? | Toxicology |
M 6
|
A
|
|
| 3 | M2.OMB.4895 | 214505 | A 27-year-old man presents to the emergency department after being brought in for belligerent behavior. The patient was at a bonfire party in the desert during the summer in Arizona. He attempted to assault law enforcement when they arrived. The patient's past medical history is otherwise unknown. His temperature is 99.3°F (37.4°C), blood pressure is 132/88 mmHg, pulse is 107/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam is notable for a belligerent young man who is given intramuscular olanzapine. The patient is unkempt and smells of urine. Cardiopulmonary exam reveals bilateral coarse breath sounds. Inspection of the patient's lower extremity reveals 2 paired vertical/parallel lacerations which are actively oozing serosanguinous fluid with swelling, erythema, and edema extending from the marks up to the patient's midcalf. Palpation of the lower extremity causes the patient to grimace. Which of the following is the most likely etiology of this patient's symptoms? | Toxicology |
M 6
|
A
|
|
| 4 | M2.OMB.4897 | 214600 | A 33-year-old man presents to the emergency department 7 minutes after an unknown chemical was released in the subway system. The patient has an unknown medical history. His temperature is 97.7°F (36.5°C), blood pressure is 94/64 mmHg, pulse is 40/min, respirations are 22/min, and oxygen saturation is 88% on room air. The patient is confused and drooling with notable wheezing. His undergarments are covered in urine and diarrhea. Which of the following appropriate treatments will lose efficacy if not administered immediately? | Toxicology |
M 7
|
A
|
|
| 5 | M2.OMB.4900 | 214727 | A 24-year-old man is brought to the emergency department with altered mental status. The patient was with his friends on a camping trip where they admitted to drinking and experimenting with drugs. The patient was found in his room staring at the walls stating that they were "breathing." He has no significant past medical history and takes no daily medication. His temperature is 99.3°F (37.4°C), blood pressure is 132/98 mmHg, pulse is 107/min, respirations are 21/min, and oxygen saturation is 99% on room air. Physical exam reveals a confused young man who states that he can hear the textures of the walls. His gait is stable and he is moving all extremities. Which of the following is the most likely etiology of this patient's symptoms? | Toxicology |
M 6
|
A
|
|
| 6 | M2.OMB.4902 | 214953 | A 27-year-old man presents to the emergency department with altered mental status. He has become gradually more confused over the past several days. His wife also notes he has had diarrhea, nausea and vomiting, and abdominal pain for the past week. The patient has a history of depression and multiple suicide attempts. He takes fluoxetine as well as over-the-counter pain medications for a recent muscle strain. He works in a large industrial compound that manufactures semiconductors. He exercises regularly and recently has started making his own beer at home. His temperature is 98.3°F (36.8°C), blood pressure is 107/75 mmHg, pulse is 110/min, respirations are 22/min, and oxygen saturation is 99% on room air. Physical exam reveals a confused man with a garlic odor on his breath and the finding in Figure A. Cardiopulmonary exam reveals a rapid heart rate with no murmurs and clear breath sounds. Which of the following is the most likely etiology of this patient's symptoms? | Toxicology |
M 6
|
A
|
|
| 7 | M2.OMB.4903 | 215168 | A 37-year-old man presents to the emergency department with agitation and palpitations. His mother brought him in when she thought he was behaving bizarrely. The patient states he feels fine and does not need help from anyone. His past medical history is significant for depression, multiple suicide attempts, hypertension, obesity, severe asthma, and polysubstance abuse. He is unsure about which medications he takes. His temperature is 101°F (38.3°C), blood pressure is 82/68 mmHg, pulse is 177/min, respirations are 24/min, and oxygen saturation is 99% on room air. Physical exam reveals an agitated man. The patient’s neurological exam reveals symmetric strength and sensation throughout with intact cranial nerves. His abdomen is non-tender, and his breath sounds are clear bilaterally. His pupils are 3 mm, symmetric, and reactive to light. He demonstrates a bilateral tremor in his upper extremities. Laboratory studies are ordered as seen below. Serum: Na+: 139 mEq/L Cl-: 100 mEq/L K+: 3.0 mEq/L HCO3-: 15 mEq/L Blood urea nitrogen (BUN): 20 mg/dL Glucose: 299 mg/dL Creatinine: 1.1 mg/dL Ca2+: 10.2 mg/dL The patient begins vomiting in the emergency department and subsequently demonstrates seizure activity. Which of the following is the most likely etiology of this patient’s symptoms? | Toxicology |
M 6
|
A
|
|
| 8 | M2.OMB.20.4889 | 214318 | A 23-year-old man presents to the emergency department with weakness and trouble breathing. He states it started after dinner and has been worsening. The patient states he went on a long hike today with his friends where they were exposed to many insects. They cooked their lunch of raw chicken over a campfire. They then came home after the trip and went to a new Japanese restaurant that just opened up for dinner. After dinner, the patient started feeling numbness in his extremities and had a headache. He now says he feels weak and is having trouble taking deep breaths. His temperature is 98.7°F (37.1°C), blood pressure is 120/80 mmHg, pulse is 83/min, respirations are 15/min, and oxygen saturation is 93% on room air. Physical exam is notable for lower extremity and upper extremity weakness. The patient's FEV1 is 60% of normal. Which of the following is the most likely diagnosis? | Toxicology |
M 6
|
A
|
|
| 9 | M2.OMB.4898 | 214651 | A 22-year-old man presents to the emergency department acutely altered. He was found at home obtunded. The patient has presented similarly in the past for suicide attempts. He lives at home with his grandparents who are on multiple medications that are not known to the paramedics. His temperature is 97.6°F (36.4°C), blood pressure is 84/44 mmHg, pulse is 40/min, respirations are 18/min, and oxygen saturation is 93% on room air. An ECG is performed as seen in Figure A. Laboratory studies are notable for the findings below. Serum: Na+: 141 mEq/L Cl-: 100 mEq/L K+: 4.36 mEq/L HCO3-: 25 mEq/L BUN: 20 mg/dL Glucose: 367 mg/dL Creatinine: 1.1 mg/dL Which of the following is the most likely etiology of this patient's symptoms? | Toxicology |
M 6
|
A
|
|
| 10 | M2.OMB.4890 | 214486 | A 24-year-old woman with a past medical history of hypertension, diabetes, IV drug abuse on maintenance therapy, and depression who is 33 weeks pregnant presents to the emergency department with altered mental status. She was found in her room next to a suicide note. The patient is on multiple medications that were recently started by her obstetrician. The patient was noted to have gestational hypertension and an impaired fasting blood glucose. Her temperature is 97.5°F (36.4°C), blood pressure is 62/42 mmHg, pulse is 55/min, respirations are 14/min, and oxygen saturation is 95% on room air. Physical exam is notable for miotic pupils and a patient who responds with words to sternal rub. Her fingerstick blood glucose is 135 mg/dL. Which of the following medications was most likely taken in overdose? | Toxicology |
M 7
|
A
|
|
| 11 | M2.OMB.4892 | 214494 | A 24-year-old man with an unknown past medical history presents to the emergency department with altered mental status. He was found stumbling around the mall profoundly confused until he passed out in a store. The patient is not able to offer a history but is protecting his airway. His temperature is 97.9°F (36.6°C), blood pressure is 114/64 mmHg, pulse is 110/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical exam reveals a profoundly stuporous man with slurred speech who is unable to walk without assistance. He has fruity-smelling breath, and his clothes are covered in urine. Laboratory studies are ordered as seen below. Hemoglobin: 13 g/dL Hematocrit: 39% Leukocyte count: 6,720/mm^3 with normal differential Platelet count: 222,400/mm^3 Serum: Na+: 130 mEq/L Cl-: 99 mEq/L K+: 4.3 mEq/L HCO3-: 22 mEq/L BUN: 15 mg/dL Glucose: 129 mg/dL Creatinine: 1.0 mg/dL Ca2+: 10.2 mg/dL Serum ethanol: 5 mg/dL Osmolar gap: 16.4 Acetone: 10 mmol/L (normal < 3 mmol/L) The patient is actively vomiting while in the department and complains of abdominal pain. Which of the following is the most likely etiology of this patient’s symptoms? | Toxicology |
M 6
|
A
|
|
| 12 | M2.OMB.4893 | 214495 | A 33-year-old homeless man is brought into the emergency department after having a seizure. The patient has a known seizure disorder but has not been following up with his neurologist for the past year nor does he take his medications regularly. His temperature is 99.2°F (37.3°C), blood pressure is 137/92 mmHg, pulse is 93/min, respirations are 16/min, and oxygen saturation is 100% on room air. A chest radiograph and head CT are performed and are negative. Urine is collected for urinalysis. While in the emergency department, the patient has a prolonged seizure and is given multiple doses of lorazepam, a loading dose of phenytoin, and then is started on standing IV phenytoin. His seizure activity improves with these measures and he is admitted to the neurology intensive care unit. While on the unit, his blood pressure is 97/52 mmHg, pulse is 43/min, respirations are 10/min, and oxygen saturation is 95% on room air. Laboratory studies are ordered as seen below. Serum: Na+: 142 mEq/L Cl-: 101 mEq/L K+: 3.9 mEq/L HCO3-: 10 mEq/L BUN: 22 mg/dL Glucose: 111 mg/dL Creatinine: 1.1 mg/dL Ca2+: 10.2 mg/dL The patient’s urine culture returns negative. Which of the following is the most likely etiology of this patient’s symptoms while on the neurology floor? | Toxicology |
M 6
|
A
|
|
| 13 | M2.OMB.4894 | 214504 | A 24-year-old man with a history of depression presents to the emergency department with nausea, vomiting, and confusion. The patient went on a camping trip with his friends where they foraged and caught their own food and cooked it. At the end of the hike, the patient had an episode of abdominal pain, nausea, and vomiting. This episode resolved, and the patient felt better the next day. However, the patient was subsequently found by his girlfriend the next day profoundly confused with discoloration of his skin early the next morning. The patient is otherwise healthy, is a vegetarian, and exercises regularly. His temperature is 99.2°F (37.3°C), blood pressure is 100/65 mmHg, pulse is 122/min, respirations are 26/min, and oxygen saturation is 100% on room air. Physical exam is notable for a somnolent man with yellowing of his skin. There are old healed scars on his wrists. Initial laboratory values are notable for an ALT of 1,772 U/L and an AST of 1,599 U/L. Which of the following is the most likely etiology of this patient's symptoms? | Toxicology |
M 6
|
A
|
|
| 14 | M2.OMB.4888 | 214317 | A 25-year-old man presents to the emergency department for a change in his behavior. The patient has a history of depression; however, his girlfriend has noticed he has been more depressed and more suicidal recently. The patient has not been taking care of himself, and his girlfriend noticed that he recently moved to a dilapidated, older building and has not been bathing. She brought him in today because he states he took all of his medications in an attempt to end his life. His temperature is 98.7°F (37.1°C), blood pressure is 130/82 mmHg, pulse is 84/min, respirations are 15/min, and oxygen saturation is 99% on room air. Physical exam reveals a patient with a restricted affect. He has a resting tremor and appears unkempt. His gait is mildly ataxic, and exam is notable for the finding in Figure A. Which of the following is the most appropriate treatment for this patient's underlying diagnosis? | Toxicology |
M 7
|
A
|
|
| 15 | M2.OMB.4896 | 214595 | A 33-year-old man presents to the emergency department with anxiety, palpitations, and weakness. His symptoms started while he was at a dental appointment for a procedure. He has never had these symptoms before and is generally healthy. His temperature is 97.7°F (36.5°C), blood pressure is 144/88 mmHg, pulse is 85/min, respirations are 19/min, and oxygen saturation is 98% on room air. Physical exam reveals a fatigued appearing man with perioral cyanosis and a rapid and regular heart rate. Initial laboratory studies are pending. Which of the following is the most appropriate treatment for this patient? | Toxicology |
M 7
|
A
|
|
| 16 | M2.OMB.4899 | 214726 | A 24-year-old man presents to a rural emergency department in Arizona for weakness and a change in his behavior. The patient was hunting and drinking with his friends in the wilderness. While they were hiking through brush in the dark, the patient thinks he may have been bitten by something. For dinner, they ate commercially canned food and cooked meat over a campfire. Shortly thereafter, the patient complained of weakness, and his friends noticed he was abnormally drowsy and drooling. He has no significant past medical history and takes no medications. His temperature on presentation is 97.7°F (36.5°C), blood pressure is 114/74 mmHg, pulse is 81/min, respirations are 12/min, and oxygen saturation is 94% on room air. Physical exam is notable for a lethargic man who is drooling and requires repeated verbal prompting during the exam. The patient complains of double vision when testing visual acuity. His strength is 2/5 in his upper extremities and 4/5 in his lower extremities. Inspection of his lower extremities reveals 2 small parallel marks which have a small amount of blood surrounding them with absent swelling or oozing. Which of the following is the most likely etiology of this patient's symptoms? | Toxicology |
M 6
|
A
|
|
| 17 | M2.OMB.20.4885 | 213898 | A 44-year-old man is brought to the emergency department as he was found intoxicated and belligerent at a public park. The patient was aggressive towards the police thus prompting them to bring him in. On the ride to the hospital, the patient became more confused and disoriented. On arrival, he has a Glasgow Coma Scale of 10 and is not answering questions coherently. His temperature is 97.6°F (36.4°C), blood pressure is 114/64 mmHg, pulse is 110/min, respirations are 25/min, and oxygen saturation is 99% on room air. Physical exam reveals a confused man who is covered in vomit. Initial laboratory studies are ordered as seen below. Hemoglobin: 14 g/dL Hematocrit: 42% Leukocyte count: 9,900/mm^3 with normal differential Platelet count: 222,000/mm^3 Serum: Na+: 139 mEq/L Cl-: 100 mEq/L K+: 4.2 mEq/L HCO3-: 10 mEq/L BUN: 35 mg/dL Glucose: 77 mg/dL Creatinine: 1.9 mg/dL Urinalysis is notable for the finding in Figure A. Which of the following toxic byproducts is most likely to be found in this patient? | Toxicology |
M 6
|
A
|
|
| 18 | M2.OMB.4891 | 214493 | A 24-year-old woman presents to the emergency department altered. She was at a night club with her friends when they noticed her somnolent in the corner of the club. They had left her alone as she was conversing with a new acquaintance. Her temperature is 98.1°F (36.7°C), blood pressure is 102/63 mmHg, pulse is 53/min, respirations are 9/min, and oxygen saturation is 95% on room air. Physical exam is notable for a somnolent woman who becomes quite agitated when sternal rub is performed. She has bilateral pinpoint pupils which are responsive to light. She is moving all extremities. An ECG is performed as seen in Figure A. Laboratory studies are ordered as seen below. Serum: Na+: 139 mEq/L Cl-: 102 mEq/L HCO3-: 25 mEq/L BUN: 20 mg/dL Glucose: 58 mg/dL Creatinine: 1.1 mg/dL Ca2+: 8.8 mg/dL AST: 22 U/L ALT: 30 U/L Creatine kinase: 1,290 U/L The patient is observed, and roughly 8 hours later she is back to her baseline. Which of the following is the mechanism of the etiology of this patient’s symptoms? | Toxicology |
M 6
|
A
|
|
| 19 | M2.OMB.20.4785 | 214305 | A 66-year-old man presents to the emergency department with chest pain, shortness of breath, and diaphoresis that started suddenly 25 minutes ago. His symptoms are ongoing upon arrival. The patient has a past medical history of diabetes, peripheral vascular disease, smoking, and IV drug abuse. The patient is given several medications and is taken to the cardiac catheterization lab. He is subsequently admitted to the medicine floor. The patient is recovering well; however, on day 4 of his hospital stay, he complains of sudden onset chest pain. His temperature is 99.3°F (37.4°C), blood pressure is 52/38 mmHg, pulse is 177/min, respirations are 34/min, and oxygen saturation is 99% on room air. The patient becomes unresponsive, and nursing is unable to palpate a femoral pulse. An ECG is performed as seen in Figure A. Which of the following is the most likely diagnosis? | Myocardial Infarction |
M 6
|
A
|
|
| 20 | M2.OMB.4790 | 214588 | A 67-year-old man presents to the emergency department with chest pain that radiates to both of his arms. It started suddenly 20 minutes ago and has been worsening. He has a past medical history of diabetes, hypertension, and a 45 pack-year smoking history. His temperature is 98.0°F (36.7°C), blood pressure is 174/114 mmHg, pulse is 50/min, respirations are 17/min, and oxygen saturation is 98% on room air. The patient is put on the monitor with the rhythm strip shown in Figure A. An ECG is being performed. Which of the following is the most likely etiology of this patient’s symptoms? | Myocardial Infarction |
M 6
|
A
|
|
| 21 | M2.OMB.20.4780 | 213803 | A 61-year-old man presents to the emergency department with chest pain. He states that he has intermittent and severe episodes of sharp chest pain over his left lower chest. These pains can last for several seconds and seem to then spontaneously resolve. He states he is currently having the pain and notes that it is worse with deep breaths. The pain is not associated with exertion. The patient has a history of diabetes, chronic kidney disease, and dyslipidemia and is not compliant with his medications. He recently recovered from a viral infection. Physical exam is notable for a comfortable appearing man. Cardiopulmonary exam reveals a normal S1 and S2 with good air movement and minor bibasilar crackles. The pain is not reproduced with palpation or stretching of the patient's arms when they are behind his head. His ECG is notable for the finding in Figure A. Troponin levels are 0.60 ng/mL and 0.60 ng/mL (normal < 0.4 ng/mL) spaced 4 hours apart. His d-dimer is 500 mcg/L. An initial chest radiograph is unremarkable. Which of the following is the most likely diagnosis? | Myocardial Infarction |
M 6
|
A
|
|
| 22 | M2.OMB.20.4784 | 214300 | A 55-year-old man presents to the emergency department with chest pain and dyspnea. He states that it started while he was bowling and has persisted for the past hour. The patient generally does not see a doctor, smokes 1-2 packs per day, and drinks 3 alcoholic beverages every night. He has a history of hyperlipidemia, hypertriglyceridemia, and a low high-density lipoprotein level. His temperature is 99.2°F (37.3°C), blood pressure is 140/81 mmHg, pulse is 90/min, respirations are 16/min, and oxygen saturation is 100% on room air. An ECG is performed as seen in Figure A. The patient is treated appropriately and is admitted to the hospital. On day 4, the patient is being discharged. Which of the following medications should be started in this patient? | Myocardial Infarction |
M 7
|
A
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|
| 23 | M2.OMB.4788 | 214491 | A 55-year-old man presents to the emergency department with severe epigastric pain that started 30 minutes ago. He states that it came on while he was cooking dinner, and he feels sweaty and weak. He has a past medical history of diabetes and hypertension. His temperature is 99.0°F (37.2°C), blood pressure is 174/105 mmHg, pulse is 103/min, respirations are 18/min, and oxygen saturation is 96% on room air. Physical exam reveals a normal S1/S2 and clear breath sounds bilaterally. An ECG is performed as seen in Figure A. Which of the following interventions is likely to have the greatest immediate mortality benefit in this patient? | Myocardial Infarction |
M 8
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A
|
|
| 24 | M2.OMB.4789 | 214492 | A 66-year-old man presents to the emergency department with chest pain and shortness of breath. He states that the pain is in his right chest and epigastric region and radiates to both of his arms. The patient has a past medical history of kidney failure, diabetes, and hypertension. His temperature is 97.6°F (36.4°C), blood pressure is 177/92 mmHg, pulse is 110/min, respirations are 19/min, and oxygen saturation is 98% on room air. Physical exam is notable for a sweaty man with a normal S1/S2 heart sound and bilateral clear breath sounds. An ECG is performed as seen in Figure A. Which of the following is the most likely diagnosis? | Myocardial Infarction |
M 6
|
A
|
|
| 25 | M2.OMB.4792 | 215072 | A 65-year-old man is brought to the emergency department by ambulance after collapsing in pain. He has been feeling some chest discomfort that he believed was acid reflux for most of the morning, but the pain became much more severe when he was walking to his car. He describes the pain as 10/10, crushing, and located in the center of his chest. He has no known medical history but has not seen a physician in many years. He has a 30-pack-year smoking history but quit 10 years ago. His temperature is 98.6°F (37°C), blood pressure is 175/98 mmHg, pulse is 124/min, and respirations are 20/min. ECG in the emergency department shows ST-segment elevations in leads V1 and V2. The emergency medicine team administers several therapies, one of which produces a sudden decrease in his chest pain. While this drug improves the patient's pain, it will not affect his mortality risk. Which of the following describes the mechanism of action of this medication? | Myocardial Infarction |
M 7
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A
|
|
| 26 | M2.OMB.20.4782 | 213899 | A 67-year-old man presents to the emergency department with dyspnea that started 1 week ago and has been gradually worsening. His dyspnea is worsened with exertion, and he endorses intermittent 4/10 chest pain at these times. He has had this chest pain for the past year and states it is unchanged and provoked with walking. He denies fevers, chills, nausea, vomiting, or diarrhea. He has a past medical of diabetes, chronic kidney disease, and peripheral vascular disease. His temperature is 97.5°F (36.4°C), blood pressure is 172/92 mmHg, pulse is 100/min, respirations are 27/min, and oxygen saturation is 90% on room air. An ECG is notable for T wave inversions which are similar to a previous ECG. An anterior-posterior chest radiograph is performed as seen in Figure A. An initial troponin is 0.7 ng/mL (normal < 0.4 ng/mL), and a repeat level is 0.6 ng/mL 3 hours later. His troponin at his last hospital visit was 0.7 ng/mL. An echocardiograph is performed and is notable for an ejection fraction of 38% with normal chamber size. The patient is admitted to the floor for high-risk chest pain. Myocardial stenting is performed the following day, and the patient states he is no longer short of breath. A repeat echocardiograph is notable for an ejection fraction of 65%. The patient is able to walk up and down the stairs without shortness of breath, which is new for him. Which of the following is the most likely diagnosis? | Myocardial Infarction |
A
|
||
| 27 | M2.OMB.20.4783 | 214293 | A 66-year-old man presents to the emergency department for sudden onset right leg pain. He states that it started 1 hour ago and has progressed to numbness in his right lower extremity. The patient was treated for a myocardial infarction 1 month ago and has been compliant with medical care. His temperature is 99.3°F (37.4°C), blood pressure is 142/88 mmHg, pulse is 87/min, respirations are 14/min, and oxygen saturation is 99% on room air. The patient's right lower extremity is cold to the touch and is notably pale. The physician is unable to palpate or Doppler a posterior tibial or dorsalis pedis pulse. The patient is subsequently treated appropriately for his chief complaint and is admitted to the hospital. Which of the following is the most appropriate next step in management? | Myocardial Infarction |
M 6
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A
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|
| 28 | M2.OMB.4787 | 214487 | A 65-year-old man presents to the emergency department with a sensation of palpitations. The patient was engaging in intercourse with his wife when he felt a sensation of chest discomfort that lasted for 2 seconds. The patient had a myocardial infarction 1 month ago which was treated with stenting. He has a history of diabetes, hypertension, obesity, and peripheral vascular disease. His temperature is 99.3°F (37.4°C), blood pressure is 152/98 mmHg, pulse is 77/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam reveals an obese man in no acute distress with a normal S1 and S2 and clear breath sounds. An ECG is performed as seen in Figure A, and an initial cardiac troponin is 0.05 mg/dL (normal < 0.01 mg/dL) with a recent troponin 1 week ago of 0.05 mg/dL. Which of the following is the most likely diagnosis? | Myocardial Infarction |
M 6
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A
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|
| 29 | M3.CV.12.2 | 214534 | A 24-year-old woman presents to the emergency department for chest pain that began approximately 1 hour ago. She denies any trauma to the chest and describes the pain as a "pressure-like" sensation affecting the middle of the chest. She has no medical history and takes oral contraceptive pills. A few hours ago she attended a party where she was smoking crack cocaine and subsequently developed this chest pain. Her blood pressure is 175/105 mmHg, pulse is 108/min, and respirations are 18/min with an oxygen saturation of 99% on room air. Chest auscultation is unremarkable. An electrocardiogram is demonstrated in Figure A. Which of the following is the most appropriate next step in management? | Myocardial Infarction |
M 7
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A
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| 30 | M3.CV.12.2 | 214683 | A 56-year-old man presents to the emergency department with substernal chest pain and describes it as "pressure-like." This chest pain worsens with exertion and improves with rest. He denies any lightheadedness, palpitations, or syncopal episodes. He has a medical history of hypertension and hyperlipidemia. He currently takes lisinopril and has stopped taking lovastatin due to muscle pain. In the emergency department, his blood pressure is 135/85 mmHg, pulse is 102/min, and respirations are 18/min. Cardiac auscultation is remarkable for an extra heart sound right after S2. Radiography of the chest is shown in Figure A, and electrocardiogram demonstrates ST depression in V1-4. Laboratory studies are shown below: Na+: 140 mEq/L Cl-: 100 mEq/L K+: 4.4 mEq/L HCO3-: 26 mEq/L Urea nitrogen: 15 mg/dL Glucose: 140 mg/dL Creatinine: 1.1 mg/dL Troponin: 8 ng/mdL Which of the following medications is contraindicated at this time? | Myocardial Infarction |
M 7
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A
|
|
| 31 | M2.OMB.4793 | 215145 | A 65-year-old man presents to the emergency department with sudden-onset shortness of breath that began 1 hour ago. The patient initially presented to the hospital 10 days ago with severe chest pain and was found to have an ST-elevation myocardial infection. He underwent successful emergent cardiac catheterization with the placement of 2 drug-eluting stents and was discharged home on postoperative day 6. In addition to the recent hospitalization and catheterization, the patient has a past medical history significant for insulin-dependent type 2 diabetes mellitus and mild aortic stenosis. His medications include clopidogrel, aspirin, and atorvastatin. On arrival, his temperature is 99°F (37.2°C), blood pressure is 112/72 mmHg, pulse is 110/min, respirations are 22/min, and oxygen saturation is 88% on room air. On exam, the patient is using accessory muscles to breathe and there are crackles throughout the bilateral lung fields. Cardiac auscultation demonstrates an apical systolic murmur that radiates to the axilla. Which of the following is the most likely cause of this patient's presentation? | Myocardial Infarction |
M 6
|
A
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| 32 | M2.OMB.20.4781 | 213804 | A 68-year-old man presents to the emergency department for chest pain. He has presented several times this past month for chest pain and was sent home each time after an unremarkable workup. He states that the pain occurs both at rest and with exertion and is currently present. He has a past medical history of obesity, chronic obstructive pulmonary disease (COPD), diabetes, a known left bundle branch block on ECG, and peripheral vascular disease. He recently returned on a flight after visiting his son who had 2 sick children at home. His temperature is 99.0°F (37.2°C), blood pressure is 164/94 mmHg, pulse is 100/min, respirations are 15/min, and oxygen saturation is 94% on room air. Cardiopulmonary exam is unremarkable, and the patient's abdomen is soft and non-tender. An ECG is performed as seen in Figure A. A chest radiograph is ordered and is pending. Initial laboratory studies including troponins are ordered and are pending as well. Which of the following is the most likely diagnosis? | Myocardial Infarction |
M 6
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A
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| 33 | M2.OMB.4794 | 215170 | A 50-year-old man presents to the emergency department with chest pain. He states that the pain is dull in quality, started 30 minutes ago, has been gradually worsening, and is worse with exertion. He also endorses some shortness of breath. He also believes the pain is worse when leaning back and improved when leaning forward. His wife noticed he fainted after the pain started but regained consciousness shortly after. He has a medical history of diabetes and hypertension for which he is on metformin and losartan. His temperature is 99.2°F (37.3°C), blood pressure is 130/87 mmHg, pulse is 99/min, respirations are 22/min, and oxygen saturation is 100% on room air. Physical exam reveals an overweight man. A normal S1 and S2 are auscultated with clear breath sounds. An ECG is performed as seen in Figure A. Which of the following is the most likely diagnosis? | Myocardial Infarction |
M 6
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| 34 | M3.CV.20.2 | 214558 | A 36-year-old woman presents to her primary care physician for her routine visit. She reports otherwise feeling well. She has a medical history of hypertension, hyperlipidemia, and type 2 diabetes. She smokes 1/2 pack of cigarettes daily and denies drinking alcohol. Her blood pressure is 119/80 mmHg, pulse is 85/min, and respirations are 16/min. Her body mass index is 35 kg/m^2. Physical examination is unremarkable. Which of the following is the most significant predictor of an adverse cardiovascular outcome? | Myocardial Infarction |
M 8
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| 35 | M2.OMB.4791 | 215005 | A 65-year-old man presents to the emergency department with diffuse chest pressure and pain, tremulousness, and diaphoresis that started suddenly 20 minutes ago while he was doing household chores. The patient states that the pain is constant and does not change with position. His past medical history is notable for hypertension, hyperlipidemia, and diabetes. His medications are metformin, atorvastatin, and lisinopril. He is adherent to his medication regimen. His temperature is 98.7° F (37.0°C), blood pressure is 162/90 mmHg, pulse is 105/min, and respirations are 19/min. In triage, an ECG is performed as seen in Figure A. The patient's labs are in the process of being drawn. Which of the following is the most likely diagnosis? | Myocardial Infarction |
M 6
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A
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| 36 | M2.OMB.4786 | 214424 | A 68-year-old man presents to the emergency department for anxiety. He has presented several times this past month for a similar chief concern and was sent home after an unremarkable workup each time. He states today he is anxious because he thinks his wife finds him unattractive. He has a past medical history of obesity, diabetes, and peripheral vascular disease. He denies chest pain, shortness of breath, nausea, vomiting, or any infectious symptoms. His temperature is 99.2°F (37.3°C), blood pressure is 150/95 mmHg, pulse is 92/min, respirations are 16/min, and oxygen saturation is 100% on room air. Physical exam is notable for an anxious obese man. Cardiopulmonary exam reveals minor bibasilar crackles. An ECG is performed as seen in Figure A. An ECG taken 2 years ago demonstrated normal sinus rhythm. The patient reports he feels much calmer in the ED. Which of the following is the most likely diagnosis? | Myocardial Infarction |
M 6
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A
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| 37 | M2.OMB.20.4872 | 213867 | A 35-year-old woman presents to her primary care physician complaining of decreased energy. She says she has been sleeping more than usual and is unable to "keep up with taking care of my family." On review of systems, she states she has gained 10 lbs, despite no change in appetite, and frequently feels constipated. She has no past medical history and is taking a daily multi-vitamin and fish oil. She works as a car mechanic and has had trouble bending her neck forward during routine labor. She has a 10-year smoking history and drinks alcohol occasionally. Her temperature is 97.9°F (36.6°C), blood pressure is 110/85 mmHg, pulse is 58/min, respirations are 18/min, and BMI is 31 kg/m^2. On physical exam, she has a mobile, nontender anterior neck mass with non-labored breathing. Her heart and lung sounds are normal. Her abdomen is soft with no masses. She has dry skin and 2+ deep tendon reflexes with delayed relaxation. The rest of the physical exam is unremarkable. Laboratory studies are shown below. Serum: Na+: 138 mEq/L Cl-: 110 mEq/L K+: 4.1 mEq/L HCO3-: 24 mEq/L BUN: 12 mg/dL Glucose: 98 mg/dL Creatinine: 0.7 mg/dL TSH: 4.2 µU/mL T4: 14 ug/dl T3: 200 ng/dl Ca2+: 8.5 mg/dL AST: 16 U/L ALT: 18 U/L Which of the following is the most likely cause of this patient's current symptoms? | Hypothyroidism vs. Hyperthyroidism |
M 6
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| 38 | M2.OMB.20.4879 | 213758 | A 44-year-old homeless man presents to the emergency department with slurring of his speech. He states he is planning on killing himself by jumping off a bridge and wants to come into the hospital. The patient has a history of multiple similar presentations in the past and typically elopes from the hospital the following morning. His temperature is 98.2°F (36.8°C), blood pressure is 107/58 mm Hg, pulse is 80/min, respirations are 7/min, and oxygen saturation is 95% on room air. Physical exam is notable for pinpoint pupils, scars in the antecubital fossa, and urine smell. The patient is observed in the emergency department. The following night, the patient appears more irritable and wants to leave the hospital. He appears tremulous, uncomfortable, and covered in sweat. His temperature is 100°F (37.8°C), blood pressure is 157/98 mm Hg, pulse is 170/min, respirations are 22/min, and oxygen saturation is 98% on room air. The patient appears confused and is restrained. An ICU bed is requested; however, it is expected the patient will be boarding in the emergency department for 24 to 48 additional hours given there is limited intensive care unit availability. Which of the following is the most appropriate management of this patient? | Substance Intoxication and Withdrawal |
A
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| 39 | M2.OMB.4881 | 214590 | A 44-year-old man presents to the emergency department with chest pain and dyspnea. His symptoms started suddenly 1 hour ago while he was playing poker with his friends. He has a history of alcohol abuse and takes no medications. His temperature is 99.2°F (37.3°C), blood pressure is 137/95 mmHg, pulse is 112/min, respirations are 22/min, and oxygen saturation is 100% on room air. Physical exam reveals a sweaty man with dilated but responsive pupils who is irritable. His heart rate is rapid and regular. An ECG is performed as seen in Figure A. Which of the following interventions is contraindicated in this patient? | Substance Intoxication and Withdrawal |
M 7
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| 40 | M2.OMB.1 | 215094 | A 25-year-old man is brought to the emergency department by paramedics for altered mental status. He was found lying down at a bus stop unresponsive. On arrival, the patient has slurred speech and is somnolent. Further is unable to be elicited. His temperature is 98.0°F (36.7°C), blood pressure is 130/80 mmHg, pulse is 80/min, and respirations are 12/min with a saturation of 97% on room air. Physical exam reveals a sleeping man with miotic pupils. The patient is easily arousable to voice and sternal rub but falls asleep rapidly. He has decreased bowel sounds. He is able to state his name and knows that he is at the hospital and has an otherwise normal neurologic exam. Which of the following is the most appropriate management? | Substance Intoxication and Withdrawal |
M 7
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A
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| 41 | M2.OMB.20.4880 | 214319 | A 25-year-old woman presents to the emergency department after she was found somnolent in her room by her roommate. The patient had just come home from a rave and has a history of alcoholism and IV drug abuse. She has attempted suicide multiple times in the past via overdose and wrist cutting. Her temperature is 96.0°F (35.6°C), blood pressure is 90/51 mmHg, pulse is 55/min, respirations are 8/min, and oxygen saturation is 93% on room air. Physical exam is notable for a somnolent patient who arouses to sternal rub. She has bilateral 1 mm pupils that constrict minimally to light. The patient has cold extremities and smells of urine. Which of the following is the mechanism of the most likely etiology of this patient's symptoms? | Substance Intoxication and Withdrawal |
M 6
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| 42 | M2.OMB.20.4771 | 213826 | A 27-year-old man with a past medical history of schizophrenia and bipolar disorder, well controlled on risperidone and lithium, presents to his primary care physician for a wellness appointment. He states he feels well and has no complaints at the moment other than a mild cough and runny nose. The patient was seen 2 days ago for increased urinary frequency but otherwise has nothing new to report. His past medical history is also notable for type I diabetes, anxiety, and substance abuse. His temperature is 98.4°F (36.9°C), blood pressure is 135/84 mmHg, pulse is 90/min, respirations are 21/min, and oxygen saturation is 94% on room air. Laboratory studies are ordered as seen below. Hemoglobin: 13 g/dL Hematocrit: 39% Leukocyte count: 9,500/mm^3 with normal differential Platelet count: 196,000/mm^3 Serum: Na+: 119 mEq/L Cl-: 101 mEq/L K+: 4.4 mEq/L HCO3-: 22 mEq/L BUN: 14 mg/dL Glucose: 154 mg/dL Creatinine: 1.5 mg/dL Ca2+: 10.0 mg/dL Urine: Color: Clear Glucose: Trace Ketones: Negative Blood: Negative Protein: 1+ Specific gravity: 1.000 Which of the following is the most likely diagnosis? | Syndrome of Inappropriate ADH (SIADH) |
M 6
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| 43 | M2.OMB.20.4839 | 213900 | A 33-year-old man with a history of alcoholism and IV drug use presents to the emergency department after being found obtunded in public. The patient was not responsive and was promptly brought to the emergency department. His temperature is 102°F (38.9°C), blood pressure is 107/55 mmHg, pulse is 148/min, respirations are 25/min, and oxygen saturation is 99% on room air. The patient is quickly intubated, and initial resuscitation is started. He is sent to the intensive care unit. Day 1 in the intensive care unit laboratory studies are ordered as seen below. Hemoglobin: 12 g/dL Hematocrit: 36% Leukocyte count: 19,500/mm^3 with normal differential Platelet count: 297,000/mm^3 Serum: Na+: 139 mEq/L Cl-: 100 mEq/L K+: 3.1 mEq/L HCO3-: 35 mEq/L BUN: 33 mg/dL Glucose: 111 mg/dL Creatinine: 1.6 mg/dL Venous blood gas: pH: 7.50 pCO2: 45 mmHg PO2: 40 mmHg Which of the following is the most appropriate treatment for this patient’s acid-base disturbance? | Electrolyte Disturbances |
M 7
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A
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| 44 | M2.OMB.20.4838 | 213825 | A 74-year-old man presents to the emergency department with a change in his behavior. Over the past few days the patient’s wife noticed he has become increasingly lethargic. The patient was found sleeping in his recliner soaked in urine. He has a past medical history of diabetes, a 20 pack-year smoking history, and hypertension; however, since moving 3 years ago he has not had time to follow up with a new primary care doctor and establish care. The only medications he has continued to take are his hydrochlorothiazide and lisinopril from leftover prescriptions. His temperature is 97.0°F (36.1°C), blood pressure is 104/54 mmHg, pulse is 138/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical exam is notable for a confused and elderly patient with midline lower spinal tenderness. He has dry mucous membranes. The patient's hemoglobin is 9.0 g/dL. Additional laboratory values are ordered as seen below. Serum: Na+: 139 mEq/L Cl-: 101 mEq/L K+: 3.9 mEq/L HCO3-: 28 mEq/L BUN: 40 mg/dL Glucose: 99 mg/dL Creatinine: 1.8 mg/dL Ca2+: 13.7 mg/dL Which of the following is the most likely etiology of this patient’s symptoms? | Electrolyte Disturbances |
M 6
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A
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| 45 | M2.OMB.4840 | 214592 | A 34-year-old man is found in the desert of Arizona. He is confused and is not able to offer a history. He has a pack with him with many supplies and appears to have been in the desert for several days. His temperature is 98.5°F (36.9°C), blood pressure is 103/61 mmHg, pulse is 140/min, respirations are 21/min, and oxygen saturation is 97% on room air. Physical exam reveals a confused man who is moving all extremities and is protecting his airway. Laboratory studies are ordered as seen below. Serum: Na+: 165 mEq/L Cl-: 102 mEq/L K+: 4.3 mEq/L HCO3-: 25 mEq/L BUN: 39 mg/dL Glucose: 77 mg/dL Creatinine: 1.15 mg/dL The patient is given 3 L of Ringer lactate. He then begins jerking his extremities and is not responding to commands. The episode lasts 3 minutes and terminates before medications can be given. The patient is subsequently somnolent. He then experiences another episode. Which of the following is the most likely underlying etiology of this patient's symptoms? | Electrolyte Disturbances |
M 6
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| 46 | M2.OMB.4891 | 215044 | A 47-year-old woman presents to the clinic with 3 weeks of increased thirst and urination. She has a history of obesity, hypertension, and depression for which she takes losartan and sertraline. She has smoked 1 pack of cigarettes per day for 30 years. Her temperature is 99.5°F (37.5°C), blood pressure is 148/90 mmHg, pulse is 84/min, and respirations are 15/min. Physical exam is unremarkable, including no costovertebral or suprapubic tenderness to palpation. Laboratory studies are performed and show: Serum: Na+: 140 mEq/L K+: 4.4 mEq/L HCO3-: 21 mEq/L Blood urea nitrogen (BUN): 38 mg/dL Creatinine: 1.1 mg/dL Glucose: 215 mg/dL Which of the following is the most appropriate screening test for nephropathy in this patient? | Diabetes Mellitus |
M 6
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| 47 | M2.EC.20.4889 | 214917 | A 50-year-old man presents to the primary care clinic for a routine health maintenance examination. He has no acute complaints. The patient has a past medical history of hypertension and osteoarthritis of the knee for which he takes chlorthalidone and ibuprofen. The patient’s temperature is 98.4°F (36.9°C), blood pressure is 140/90 mmHg, pulse is 75/min, and respirations are 16/min. His BMI is 32 kg/m^2. Physical exam reveals a well-appearing Caucasian man with a normal body fat distribution and without abnormal skin lesions or abdominal striae. Mucous membranes are moist. His fasting lab results are as follows: Serum: Na+: 138 mEq/L Cl-: 101 mEq/L K+: 4.4 mEq/L HCO3-: 24 mEq/L BUN: 16 mg/dL Glucose: 118 mg/dL Creatinine: 1.0 mg/dL Triglycerides: 210 mg/dL High-density lipoprotein (HDL) cholesterol: 55 mg/dL Low-density lipoprotein (LDL) cholesterol: 110 mg/dL Which of the following is the underlying pathophysiology of this patient's disease process? | Diabetes Mellitus |
M 6
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| 48 | M2.OMB.4890 | 215040 | A 52-year-old man presents to the clinic with a left foot ulcer that he noticed 6 days ago. He has a history of obesity, hypertension, type 2 diabetes mellitus, and depression. His current medications include metformin, aspirin, rosuvastatin, lisinopril, and fluoxetine. He has a 25-pack-year smoking history and drinks 1 glass of wine a day. His temperature is 98.6°F (37.0°C), blood pressure is 115/70 mmHg, pulse is 70/min, and respirations are 12/min. On physical exam, he has a 1.2 x 1.7 cm ulcer on the plantar surface of his left metatarsal head. Which of the following tests will most appropriately assess this patient’s future risk of foot ulcers? | Diabetes Mellitus |
M 8
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| 49 | M2.OMB.20.1 | 213856 | A 5-year-old boy is brought to the pediatrician by his mother for bedwetting. The patient has been waking up soaked in urine for the past 2 months. His mother states that he was previously toilet trained. She denies daytime accidents. She comments that he seems more hungry and thirsty than usual, but she has been trying to limit his fluid intake close to bedtime. The patient denies dysuria. His father has bipolar disorder. He also has a new, healthy younger brother who is 4 months old. The patient has a history of ear infections. He is on no medications. The patient's temperature is 98.6°F (37.0°C), blood pressure is 100/54 mmHg, pulse is 98/min, and respirations are 19/min. Since his annual check-up 5 months ago, the patient has lost 4 lbs. A urinalysis is obtained and is pending. Which of the following is the best management for the patient’s most likely diagnosis? | Diabetes Mellitus |
M 7
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A
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| 50 | M2.OMB.4892 | 215084 | A 74-year-old man with a history of polyuria, frequent skin infections, increased thirst, and fatigue was lost to follow-up and now presents to re-establish care. His past medical history includes hypertension and hyperlipidemia. He has not been taking any medications. Today, his temperature is 36.8°C (98.2°F), blood pressure is 155/86 mmHg, pulse is 80/min, respirations are 17/min, and oxygen saturation is 97% on room air. On review of his old medical records, there is a pathology slide from a renal biopsy performed a few years ago, shown in Figure A. Which of the following is an appropriate treatment for this patient's renal condition? | Diabetes Mellitus |
M 7
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| 51 | M2.OMB.1 | 214817 | A 6-year-old girl is brought to the pediatrician by her father for lethargy and polyuria. He states that over the past few months, she has been taking multiple naps throughout the day. She was previously toilet trained but has recently begun urinating in the bed again. The father also reports that the patient complains she is thirsty all of the time. The patient denies fever, chills, constipation, or diarrhea. Her father says she seems to eat a lot as well, but her BMI is 18.5 kg/m^2. She has no past medical history and takes no medications. Her temperature is 98.6°F (37.0°C), blood pressure is 90/50 mmHg, pulse is 105/min, and respirations are 25/min. A urinalysis is obtained, which reveals glucose and ketones. In addition to testing a fasting blood glucose level, which of the following is the most appropriate antibody to test for in this patient? | Diabetes Mellitus |
M 6
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| 52 | M3.OB.12.2 | 214704 | A 25-year-old, G1P0, woman at 8 weeks' gestation presents to the emergency department with acute onset nausea, vomiting, and abdominal pain. She was initially able to tolerate oral intake 5 days ago, but she then required an over-the-counter antiemetic 2 days ago. Now she is unable to consume liquids or solids and has worsening abdominal pain. She denies any trauma to the abdomen, abnormal bowel movements, sick contacts, or recent travel. She denies vaginal bleeding or leakage of fluid. She has a history of sickle cell disease and was last hospitalized when she was 20. She is up to date on all of her vaccinations. Her temperature is 101°F (38.3°C), blood pressure is 145/90 mmHg, pulse is 95/min, and respirations are 22/min. Physical examination is remarkable for right upper quadrant tenderness upon palpation and scleral icterus. Laboratory studies are shown below: Hemoglobin: 8.6 g/dL Leukocyte count: 14,000/mm^3 with normal differential Platelet count: 150,000/mm^3 Aspartate aminotransferase (AST, GOT): 125 U/L Alanine aminotransferase (ALT, GPT): 90 U/L Which of the following is the most likely diagnosis? | Sickle Cell Anemia |
M 6
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| 53 | M2.OMB.20.40 | 213759 | A 27-year-old man presents to the emergency department after falling off a wall while intoxicated and running from the police. He is currently combative and requires security to be restrained. He is talked down and states that his shoulder hurts. He is still intoxicated and cannot recall his medical history nor his home medications. His temperature is 99.1°F (37.3°C), blood pressure is 127/88 mm Hg, pulse is 110/min, respirations are 15/min, and oxygen saturation is 98% on room air. The patient's exam is notable for a deformity over his shoulder, and he is covered in small bruises and abrasions. A radiograph of the shoulder is performed as seen in Figure A. The patient becomes combative and begins attacking the physician when the physician attempts to examine the extremity. The patient is treated and calms down. Notably he demonstrates a nystagmus while relaxing in the bed. As the physician is about to examine the extremity, the patient demonstrates notable respiratory distress and severe stridor. Which of the following is the most likely etiology of this patient's symptoms? | Anesthesiology Medications |
M 7
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| 54 | M2.OMB.43 | 214644 | A 43-year-old man with a history of epilepsy and febrile seizures presents to the emergency department with malaise. He has been feeling worse over the past 3 days and now has a fever and chills. He admits to using heroin 1 week ago. The patient also admits to buying and using clonazepam from a local drug dealer. His temperature is 102°F (38.9°C), blood pressure is 110/74 mmHg, pulse is 110/min, respirations are 19/min, and oxygen saturation is 98% on room air. Physical exam reveals the finding in Figure A which is also noted on the patient's feet. The lesion is injected with a medication in preparation for a procedure, followed shortly by the patient demonstrating flexion and extension of his extremities with a lack of responsiveness. After the episode, the patient seems confused. His blood pressure is 90/64 mmHg, pulse is 40/min, respirations are 15/min, and oxygen saturation is 96% on room air. An ECG is performed as seen in Figure B. Which of the following is the most likely cause of this episode? | Anesthesiology Medications |
M 6
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| 55 | M2.OMB.4889 | 214729 | An 8-year-old boy is brought to the emergency department for worsening irritability and confusion for the past day. He has high-grade fevers, chills, and neck pain for the past 3 days. His temperature is 103.5°F (39.4°C), blood pressure is 95/55 mmHg, pulse is 110/min, and respirations are 25/min. He was born at term with no complications. He has not seen a physician for several years and is not up to date on his vaccinations. On physical examination, the boy appears lethargic. He is confused and oriented to person and place but not time. He has neck rigidity, and the cervical range of motion is limited by pain. The remainder of the physical exam shows no abnormalities. Laboratory studies demonstrate: Hemoglobin: 10.3 g/dL Leukocyte count: 16,000/mm^3 Platelet count: 200,000/mm^3 Blood cultures and a lumbar puncture are obtained. A peripheral smear is performed and the results are shown in Figure A. Which of the following pathogens is the most likely cause of this patient’s symptoms? | Sickle Cell Anemia |
M 6
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| 56 | M2.OMB.4890 | 214909 | A 19-year-old African American man presents with 2 days of fatigue. One week ago, he developed general malaise and subjective fevers. He is visiting from Libya, where he has worked in a uranium mine for several years. He has required blood transfusions intermittently since childhood due to chronic anemia. His temperature is 100.5°F (38.1°C), blood pressure is 112/62 mmHg, pulse is 120/min, and respirations are 22/min. Physical exam is notable for scleral icterus and hyperdynamic pulses. Laboratory workup shows: Leukocyte count: 11,000 /mm^3 Hemoglobin: 4.2 g/dL Platelet count: 240,000 /mm^3 Mean corpuscular volume: 82 µm^3 Mean corpuscular hemoglobin concentration: 34% Reticulocyte count: 1% Lactate dehydrogenase: 330 U/L Haptoglobin: 14 mg/dL Direct Coombs: No agglutination of red blood cells Serum: Total bilirubin: 3.3 mg/dL Direct bilirubin: 0.2 mg/dL Which of the following is the most likely underlying cause of this patient’s anemia? | Sickle Cell Anemia |
M 6
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| 57 | M2.OMB.4892 | 214969 | A 6-week-old boy is referred to a pediatric hematologist-oncologist for further evaluation following an abnormal newborn hemoglobinopathy screening. The father’s brother died of sickle cell anemia at an early age. Parental studies reveal that both mother and father are carriers of the sickle cell gene. The patient's temperature is 98.6°F (37.0°C), blood pressure is 80/45 mmHg, pulse is 130/min, and respirations are 25/min. The physician decides to repeat testing for the patient and his 3-year-old sister. The results are shown in Figure A. The physician begins counseling the family. Which of the following is the most likely complication that the patient may have in the future? | Sickle Cell Anemia |
M 8
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| 58 | M2.OMB.20.41 | 213896 | A 33-year-old man is brought to the emergency department after he was found minimally responsive at a homeless shelter. The patient has a history of IV drug use and malingering. He is unable to offer a history as he is obtunded. His temperature is 96.6°F (35.9°C), blood pressure is 84/44 mmHg, pulse is 150/min, respirations are 17/min, and oxygen saturation is 98% on room air. The patient’s vitals are unchanged after 3 liters of fluids. Physical exam is notable for multiple antecubital fossa abscesses and a murmur on cardiac auscultation. The patient’s Glasgow Coma Scale is 6, and he is subsequently given an induction agent and a paralytic and is intubated. His blood pressure declines over the next 15 minutes until stress dose steroids are started which rapidly correct his blood pressure. Which of the following is the most likely etiology of this patient’s hypotension following intubation? | Anesthesiology Medications |
M 7
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| 59 | M2.OMB.4891 | 214940 | An 18-year-old man presents for evaluation of left leg pain. He states that he was tackled during a football game last week and suffered an abrasion to his left shin. Since then, he has developed progressive left shin pain unresponsive to ibuprofen and now has difficulty bearing weight on the left leg. He also reports a subjective fever over the last 2 days. He has a history of sickle cell disease and has required blood transfusions intermittently since childhood. His only medication is hydroxyurea. His temperature is 101.3°F (38.5°C), blood pressure is 123/75 mmHg, pulse is 98/min, and respirations are 15/min. Physical exam is notable for a healing abrasion and tenderness, warmth, and erythema on the left anterior shin. A radiograph of the left lower extremity shown in Figure A. Which of the following is the most likely diagnosis? | Sickle Cell Anemia |
M 6
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| 60 | M2.OMB.44 | 214863 | A 33-year-old man presents to the emergency department after a motor vehicle collision. He was the front seat restrained passenger in a head-on collision at 45 miles per hour. He is having 10/10 left hip pain. His medical history is unremarkable and he takes no medications. His temperature is 97.5°F (36.4°C), blood pressure is 139/99 mmHg, pulse is 128/min, respirations are 25/min, and oxygen saturation is 99% on room air. Physical exam reveals a shortened and internally rotated right hip. A radiograph of the hip and pelvis is shown in Figure A. The patient is given a medication prior to applying traction to the leg. Shortly after administration of this medication, the patient demonstrates a rotary nystagmus followed by a calming effect with minimal patient response when significant force is applied to his leg. Which of the following is the mechanism of the medication administered? | Anesthesiology Medications |
M 6
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| 61 | M2.OMB.20.42 | 214187 | A 50-year-old man with a past medical history of hypertension presents to the emergency department after being struck by a car while riding his bicycle. The patient was obtunded and thus intubated in the field. On arrival, his temperature is 97.5°F (36.4°C), blood pressure is 120/82 mmHg, pulse is 100/min, respirations are 15/min, and oxygen saturation is 98% on a FiO2 of 25%. An initial focused assessment with sonography in trauma (FAST) exam is unremarkable and demonstrates normal cardiac contractility and lung sliding. The primary and secondary survey are noticeable for a head laceration, bruising over the scalp, and a deep yet hemostatic laceration over the left lower extremity with debris. The patient becomes agitated and attempts to self-extubate. He is subsequently given IV fluids, blood products, hypertonic saline, propofol, cefepime, and vancomycin. Subsequently, his temperature is 97.5°F (36.4°C), blood pressure is 100/62 mmHg, pulse is 120/min, respirations are 15/min, and oxygen saturation is 99% on a FiO2 of 25%. A repeat FAST is notable only for global decreased cardiac contractility with no other findings. An ECG demonstrates a right bundle branch without significant ST segment changes from a previous ECG. Which of the following is the most likely cause of this patient's hypotension? | Anesthesiology Medications |
M 7
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| 62 | M2.OMB.20.1 | 213872 | A 9-year-old boy presents to the pediatric emergency department for right lower extremity pain. The patient describes the pain as severe and sharp in nature. He developed the pain, which has yet to subside, a few hours prior to presentation, and he denies any trauma to the lower extremities. He endorses participating in intense sports and has not been drinking fluid during sports. He has had similar episodes in the past; however, the pain affected his back when he was 4-years-old and his chest when he was 6-years-old, requiring admission for pain management with intravenous morphine. Family history is remarkable for his father requiring hospitalization for acute and severe painful episodes. Additionally, his father passed away secondary to myocardial infarction. On physical examination, the patient appears uncomfortable but is cognitively intact. He has tenderness upon palpation of the right lower extremity. The extremity is mildly warm without evidence of erythema. Distal pulses are present. Confrontational motor strength testing is grossly normal although limited by pain. His sensory examination is unremarkable. Laboratory studies are remarkable for a hemoglobin of 8 g/dL and a hematocrit of 21%. A blood smear is demonstrated in Figure A. Which of the following is the most appropriate intervention to decrease the risk of developing a future acute painful episode in this patient? | Sickle Cell Anemia |
M 7
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A
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| 63 | M2.OMB.1 | 214560 | A 28-year-old woman comes to the clinic for her annual physical. She reports that she has recently been feeling nauseous. She vomited once this morning and has been sensitive to certain smells. She has a history of asthma and atopic dermatitis. She uses an albuterol inhaler and triamcinolone ointment as needed. She is sexually active with her husband of 4 years and uses condoms. She has never been tested for sexually transmitted diseases. In addition to a pregnancy test, which of the following is the most appropriate HIV screening for the patient? | Human Immunodeficiency Virus (HIV) |
M 7
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A
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| 64 | M2.OMB.4877 | 215026 | A 65-year-old man presents to his primary care physician for a routine appointment. He has no concerns. His past medical history is significant for human immunodeficiency virus (HIV) infection, diagnosed 15 years ago. The patient is intermittently compliant with his antiretroviral therapy (ART). His temperature is 99.0°F (37.2°C), blood pressure is 130/84 mmHg, pulse is 92/min, and respirations are 11/min. His most recent lab work showed a cluster of differentiation CD4 count of 150 cells/µL. He received a dose of the 13-valent pneumococcal vaccine and a dose of the 23-valent pneumococcal vaccine 15 years ago, as well as a second dose of the 23-valent pneumococcal vaccine 10 years ago. In addition to encouraging greater compliance with his ART, which of the following is indicated in this patient? | Human Immunodeficiency Virus (HIV) |
M 7
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A
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| 65 | M2.OMB.4878 | 215109 | A 35-year-old man presents after 1 month of worsening left-sided weakness. He reports progressive difficulty using his left arm for daily tasks, and now requires a cane to ambulate. He has a history of human immunodeficiency virus (HIV) infection and has not taken anti-retroviral medication for the last 5 months. His temperature is 98.0°F (36.6°C), blood pressure is 118/75 mmHg, pulse is 75/min, and respirations are 18/min. On exam, he demonstrates weakness in his left arm and leg, as well as decreased sensation on the left face, arm, and leg. A magnetic resonance imaging (MRI) study of the head is performed and is shown in Figure A. A lumbar puncture is notable for Epstein-Barr virus (EBV) DNA in the cerebrospinal fluid (CSF). Which of the following is the most likely etiology of this patient’s presentation? | Human Immunodeficiency Virus (HIV) |
M 6
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A
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| 66 | M3.ID.12.3 | 214791 | A 31-year-old man presents to the emergency department for fever, malaise, and cough. For the last week, his cough has been progressively worsening, and he has been noticing blood in his sputum. He denies any recent travel or sick contacts and infrequently smokes cigarettes. Approximately 5 weeks ago, he presented with similar symptoms and was found to have a right upper lobe lung infiltrate, a CD4 count of 40/mm^3, and an HIV viral load of 115,000 copies/mL. He was appropriately treated and discharged home. Four weeks after initiation of treatment, his CD4 count was over 400/mm^3 and HIV viral load was negligible. His temperature today is 102°F (38.9°C), blood pressure is 130/90 mmHg, pulse is 100/min, and respirations are 20/min. A radiograph of the chest demonstrates new nodules in the left upper lobe and hilar adenopathy. Which of the following is the most appropriate next step in management? | Human Immunodeficiency Virus (HIV) |
M 11
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A
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| 67 | M3.RL.20.3 | 214857 | A 25-year-old woman presents to her primary care physician for pain with urination that began approximately 3 days ago. She reports urinating more frequently but denies any blood in her urine. She denies fevers, chills, vaginal discharge, and abdominal or flank pain. She also denies any recent antibiotic use or hospitalizations. She has no medical history and takes no medications. She has been in a monogamous relationship for the past 4 years and uses a copper intrauterine device. Her temperature is 99°F (37.2°C), blood pressure is 125/75 mmHg, pulse is 72/min, and respirations are' 16/min. On physical examination, there is mild tenderness to palpation in the suprapubic area and no costovertebral angle tenderness. Which of the following is the most appropriate next step in management? | Urinary Tract Infections |
M 7
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A
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| 68 | M2.OMB.1 | 214469 | A 2-year-old girl is brought in by her father for urogenital pain. The father states that the patient complains of pain with urination, which has gotten worse over the past 4 months. He also reports that her diapers are constantly “damp” with urine. The patient is an otherwise healthy child. She can say sentences with 2-4 words, can name some animals, and has started to climb up and down the stairs. The patient’s father states that she has a history of infantile eczema. She uses topical hydrocortisone ointment as needed. On examination, the labia minora are fused, the urethral meatus is partially obstructed, and the vaginal opening is not visible. Which of the following is the most likely cause of the patient’s symptoms? | Urinary Tract Infections |
M 6
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A
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| 69 | M2.OMB.4883 | 214396 | A 55-year-old woman presents to the emergency department with burning on urination. She states that it started 3 days ago and has progressed to a fever today. She otherwise endorses a few episodes of nausea and vomiting. Her past medical history is notable for diabetes and hypertension, and she is not currently taking any medications. Her temperature is 101°F (38.3°C), blood pressure is 114/64 mmHg, pulse is 110/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for suprapubic and costovertebral angle tenderness. The patient is started on cefepime and IV fluids. An ultrasound is performed as seen in Figure A. Urine dipstick is performed as seen below. Urine Color: Amber Leukocytes: Many Bacteria: Many Red blood cells: Many Epithelial cells: None Which of the following is the appropriate management of this patient? | Urinary Tract Infections |
M 7
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A
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| 70 | M2.OMB.4880 | 215132 | A 65-year-old woman presents for a yearly wellness visit. She has a history of hypertension and calcific aortic stenosis. Her medications include losartan and carvedilol. Her only symptom at this time is persistent pain in one of her left lower molars. She was seen by her dentist earlier in the week and is scheduled for a root canal next week. Which of the following prophylactic antibiotics should this patient receive prior to her dental procedure to reduce her risk of endocarditis? | Endocarditis |
M 7
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| 71 | M2.OMB.4879 | 214490 | A 33-year-old man presents to the emergency department with a fever, chills, and malaise. His symptoms have been ongoing for the past week. He denies IV drug use and has a history of diabetes managed with metformin. His temperature is 102°F (38.9°C), blood pressure is 94/65 mmHg, pulse is 143/min, respirations are 18/min, and oxygen saturation is 98% on room air. Physical exam is notable for an uncomfortable young man. A normal S1 and S2 are auscultated. Physical exam reveals the finding in Figure A. An initial urine drug screen and urine dipstick are ordered as seen below. Urine: Barbiturates: Negative Amphetamines: Positive Benzodiazepines: Positive Cocaine: Positive Marijuana: Positive Opiates: Positive Methadone: Positive Bacteria: Negative Nitrites: Negative Leukocytes: Negative A chest radiograph is unremarkable, and a flu swab is negative. Blood cultures are drawn and pending. Which of the following is the most appropriate empiric antibiotic regimen for this patient? | Endocarditis |
M 7
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A
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| 72 | M2.OMB.20.4877 | 214209 | A 67-year-old man presents to the emergency department with fatigue, malaise, and a 33-pound weight loss over the past 2 months. He finally came into the ED when his son came home to visit and thought he looked ill. The patient states that he has felt weak, fatigued, and has had little appetite. The patient has a past medical history of obesity, diabetes, smoking, and alcoholism and is notably noncompliant with his medications. He has recently been visiting one of his nephews in prison. His temperature is 97.0°F (36.1°C), blood pressure is 157/88 mmHg, pulse is 84/min, respirations are 16/min, and oxygen saturation is 94% on room air. Physical exam is notable for temporal wasting and a frail-looking man. There is yellowing of the patient's sclera and skin. His abdomen is nontender, and rectal exam reveals no occult blood. The patient becomes hypotensive so a central line is placed, and he is started on IV antibiotics and vasopressors. The patient is admitted to the hospital, and on day 1 he becomes pulseless on the hospital floor. CPR is initiated; however, the patient ultimately is pronounced dead. Post-mortem analysis reveals a pulmonary embolism and multiple thrombi and vegetations on the aortic and pulmonary valve. These are found to be platelet thrombi with fibrin and without any organisms or neutrophils. Which of the following is the most likely diagnosis? | Endocarditis |
M 6
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| 73 | M2.OMB.4878 | 214488 | A 33-year-old man presents to the emergency department for malaise and dark urine. The patient is seen in the hospital frequently for opiate abuse and alcohol abuse/withdrawal. Today, he is complaining of gradually worsening fatigue and states that his urine went from amber to brown over the past week. He has frequent chills. He endorses IV drug use. He recently treated himself for a sore throat, cough, and runny nose with amoxicillin he had left over. His temperature is 103°F (39.4°C), blood pressure is 130/85 mmHg, pulse is 122/min, respirations are 22/min, and oxygen saturation is 100% on room air. Physical exam reveals a patient demonstrating rigors with bilateral pulmonary crackles and a rapid heart rate. Laboratory values are ordered as seen below. Hemoglobin: 12 g/dL Hematocrit: 36% Leukocyte count: 22,500/mm^3 with normal differential Platelet count: 331,000/mm^3 Serum: Na+: 139 mEq/L Cl-: 100 mEq/L K+: 4.3 mEq/L HCO3-: 25 mEq/L BUN: 33 mg/dL Creatinine: 2.2 mg/dL Urine dipstick: Color: Brown Red blood cells: Many Nitrites: Negative White blood cells: Many Bacteria: Negative Which of the following is the most likely diagnosis? | Endocarditis |
M 6
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A
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| 74 | M2.OMB.20.4834 | 213766 | A 27-year-old woman presents to the emergency department with chest pain. She recently returned from a vacation to Taiwan with her boyfriend, which she states went poorly. He left her after the trip. They had stayed in local hostels, and she noticed several individuals who appeared ill. She states the chest pain she has is worse with deep breaths and started when her boyfriend left her. The patient has a history of obesity, depression, anxiety, and several sexually transmitted infections. Her temperature is 97.0°F (36.1°C), blood pressure is 119/70 mmHg, pulse is 108/min, respirations are 22/min, and oxygen saturation is 95%. Cardiopulmonary exam is unremarkable. There are multiple healed scars over the patient's wrists bilaterally. During the physical exam, the patient begins hyperventilating and crying. She is given lorazepam and subsequently feels slightly calmer. An initial ECG is notable for sinus tachycardia, and a chest radiograph is performed as seen in Figure A. An initial troponin is 0.6 ng/mL (normal = 0.4 ng/mL). The patient subsequently complains of chest pain and shortness of breath again when one of the technicians enters the room who reminds her of her boyfriend. Which of the following is appropriate treatment for this patient's chief complaint? | Pulmonary Embolism |
M 7
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A
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| 75 | M2.OMB.20.4762 | 213813 | A 27-year-old man is brought to the emergency department from prison for back pain. He complains of worsening back pain, localized to the lower back, and states that he is now unable to urinate. He denies any trauma, endorses chills at night, and states he has intermittent diarrhea. The patient has a past medical history of IV drug abuse, homelessness, antisocial personality disorder, malingering, and multiple sexually transmitted infections. His temperature is 98.2°F (36.8°C), blood pressure is 127/77 mm Hg, pulse is 70/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam is notable for a normal S1 and S2 and clear bilateral breath sounds. Rectal exam reveals good rectal tone, and the patient has no sensory or strength deficits. Paraspinal muscle tenderness is noted with pain worsened when the patient touches his toes. Nursing attempts to catheterize the patient for a urine sample; however, the patient refuses and volitionally urinates instead with a post-void residual volume of 50 mL. Laboratory studies and urinalysis are seen below. Serum: Na+: 140 mEq/L Cl-: 100 mEq/L K+: 4.0 mEq/L HCO3-: 24 mEq/L BUN: 22 mg/dL Glucose: 116 mg/dL Creatinine: 1.2 mg/dL Ca2+: 9.9 mg/dL C-reactive protein (CRP): 1.0 mg/L Urine: Benzodiazepines: Positive Opioids: Positive A chest radiograph and ECG are unremarkable. Which of the following is the most appropriate next step in management? | Low Back Pain |
M 7
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A
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| 76 | M2.OMB.20.4835 | 213802 | A 45-year-old woman presents to the emergency department with chest pain and shortness of breath. Her symptoms started after she returned from a business trip to China. She states deep breaths cause her pain. She has a past medical history of obesity, menorrhagia, and anxiety and is currently taking lisinopril, metformin, oral contraceptive pills, and fluoxetine. The patient is also concerned that she may have syphilis as she engaged in sexual intercourse with a new partner recently. She also believes she has a concussion as she has had headaches intermittently over the past year and recalls falling and hitting her head. She recently recovered from a respiratory infection that presented with a cough and a low-grade fever. Her temperature is 98.4°F (36.9°C), blood pressure is 135/84 mmHg, pulse is 110/min, respirations are 21/min, and oxygen saturation is 94% on room air. Cardiopulmonary exam reveals clear breath sounds and a rapid, regular heart rate. Initial laboratory values are ordered as seen below. Hemoglobin: 9.0 g/dL Hematocrit: 30% Leukocyte count: 4,500/mm^3 with normal differential Platelet count: 199,000/mm^3 Serum: Na+: 140 mEq/L Cl-: 99 mEq/L K+: 4.4 mEq/L HCO3-: 24 mEq/L BUN: 27 mg/dL Glucose: 144 mg/dL Creatinine: 1.5 mg/dL D-dimer: 675 mcg/L (normal < 500 mcg/L) Troponin: 0.6 ng/mL (normal < 0.4 ng/mL) Ca2+: 10.1 mg/dL Which of the following is associated with the most likely diagnosis? | Pulmonary Embolism |
M 6
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A
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| 77 | M2.OMB.20.4836 | 213824 | A 35-year-old woman presents to the emergency department after fainting. She was visiting her family when she fainted upon arriving at their house. She woke up 1 minute later and was at her baseline mental status. Since then, she has felt persistently light-headed and weak since the event. She almost fainted again while in the emergency department. The patient has a past medical history of obesity and recently had knee surgery with her knee currently immobilized in a brace. She is currently taking metformin, oral contraceptive pills, and sumatriptan. Her temperature is 99.3°F (37.4°C), blood pressure is 72/48 mmHg, pulse is 177/min, respirations are 29/min, and oxygen saturation is 90% on room air. Physical exam is notable for an anxious young woman who is unable to walk without feeling light-headed. An ultrasound is performed demonstrating a dilated right ventricle with septal bowing and a hyperdynamic left ventricle. Which of the following is the most appropriate next step in management? | Pulmonary Embolism |
M 7
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A
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| 78 | M2.OMB.20.4763 | 214321 | A 7-year-old boy presents to the emergency department for a fever and back pain for the past several days. It has been gradually worsening and does not respond to ibuprofen or acetaminophen. The mother thinks the pain started the day after the child was helping his father move boxes in the basement. The child says moving makes the pain worse. The child was born at home and sees a chiropractor as his primary doctor. His temperature is 97.0°F (36.1°C), blood pressure is 110/61 mmHg, pulse is 100/min, respirations are 25/min, and oxygen saturation is 100% on room air. Physical exam reveals pain over the child's lumbar spine, pain with bending over, and pain with the straight leg test on both sides. An MRI is performed as seen in Figure A. Which of the following is the most likely diagnosis? | Low Back Pain |
M 6
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A
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| 79 | M2.OMB.4837 | 214652 | A 22-year-old woman on oral contraceptive pills presents to the emergency department for chest pain. She states that the pain is worse with deep breaths and has persisted for the past 10 hours. The patient is otherwise healthy and does not smoke. Her temperature is 99.2°F (37.3°C), blood pressure is 120/85 mmHg, pulse is 102/min, respirations are 16/min, and oxygen saturation is 95% on room air. Physical exam reveals a healthy young woman with clear breath sounds and non-tender lower extremities. The pain is reproduced with deep breaths and when the patient stretches her chest wall. Laboratory studies are ordered as seen below. Serum: Na+: 138 mEq/L Cl-: 100 mEq/L K+: 3.9 mEq/L HCO3-: 24 mEq/L BUN: 20 mg/dL Glucose: 88 mg/dL Creatinine: 1.0 mg/dL Ca2+: 10.2 mg/dL D-dimer: 800 ng/mL (normal < 500 ng/mL) Troponin: < 0.01 ng/mL hCG: undetectable While in the emergency department the patient’s chest pain improves with acetaminophen, and her pulse is 80/min after 1L of IV fluids. Which of the following is the most appropriate next step in management? | Pulmonary Embolism |
M 7
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A
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| 80 | M2.OMB.4838 | 214724 | A 57-year-old man with a past medical history of smoking, alcohol use disorder, type 2 diabetes, and hypertension presents to the emergency department with leg pain. He states it started this morning and has rapidly worsened. The patient does not regularly see a doctor and takes no medications, but has noticed weight loss, diarrhea, and yellowing of his skin recently. His temperature is 99.2°F (37.3°C), blood pressure is 110/65 mmHg, pulse is 72/min, respirations are 16/min, and oxygen saturation is 100% on room air. Physical exam reveals diffuse yellowing of the patient’s skin. His abdomen is nontender and his rectal exam demonstrates no blood. A CT scan demonstrates a mass in the pancreas. Inspection of the patient's lower extremity reveals the finding in Figure A which is tender and swollen compared to the other side. Which of the following is the most likely diagnosis? | Pulmonary Embolism |
M 6
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A
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| 81 | M2.OMB.20.4875 | 214306 | A 54-year-old woman presents to the emergency department with trouble breathing. She has had episodes like this before with unclear exacerbating factors. She has a past medical history of a car accident that required her to be intubated in the intensive care unit for over a week. The patient has a 44 pack-year smoking history and drinks alcohol regularly. Her temperature is 97.7°F (36.5°C), blood pressure is 133/74 mmHg, pulse is 110/min, respirations are 25/min, and oxygen saturation is 92% on room air. The patient appears uncomfortable and has an increased work of breathing. She demonstrates coarse breath sounds on auscultation that are loudest when the stethoscope is placed over the trachea. Which of the following is the most likely diagnosis? | Mechanisms of Trauma |
M 6
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A
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| 82 | M2.OMB.20.4874 | 214186 | A 23-year-old man presents to the emergency department acutely intoxicated. He was at a campsite drinking alcohol when he got in an altercation with another camper and was stabbed with a pocket knife. The patient’s past medical history is noncontributory, and he is not taking any medications currently. His temperature is 99.3°F (37.4°C), blood pressure is 112/78 mmHg, pulse is 107/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam is notable for a small 2 cm stab wound just inferior to the patient’s 4th intercostal space just anterior to the midaxillary line on the right. The patient is started on IV fluids, placed on the monitor, and packed red blood cells are ordered. Which of the following is the most appropriate next step in management? | Mechanisms of Trauma |
M 6
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A
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| 83 | M2.OMB.20.4872 | 214309 | A 61-year-old man presents to the emergency department with sudden onset slurring of his speech that started 20 minutes ago. He was eating dinner when his speech suddenly became unintelligible. He also fell to the ground as the right side of his body became weak. The patient has a past medical history of hypertension treated with lisinopril, atrial fibrillation treated with metoprolol and apixaban, and diabetes treated with insulin and metformin. His temperature is 98.0°F (36.7°C), blood pressure is 154/84 mmHg, pulse is 98/min, respirations are 14/min, and oxygen saturation is 98% on room air. On physical exam, the patient exhibits dysarthria and an asymmetric smile. He has a notable pronator drift of his right arm and substantial weakness of his right leg. The rest of his exam is unremarkable. An initial CT scan of the head is unremarkable. Which of the following is the most appropriate next step in management? | Stroke |
M 7
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A
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| 84 | M2.OMB.4874 | 215067 | A 67-year-old man presents to the emergency department with sudden onset right-sided facial droop and right upper extremity weakness. He states that it started 2 hours ago and has not improved. The patient has a history of diabetes, hypertension, and dyslipidemia for which he takes metformin, lisinopril, dapagliflozin, and atorvastatin. He had a subdural hemorrhage 2 months ago after falling off a horse. His temperature is 99.5°F (37.5°C), blood pressure is 178/92 mmHg, pulse is 88/min, and respirations are 16/min. Physical exam reveals 2/5 strength in the patient's right upper extremity with an abnormal finger-nose on that side. The patient's right leg demonstrates 4/5 strength as well with no drift to the bed. The patient is right-handed and is unable to write or manipulate utensils. A computed tomography (CT) scan of the head is performed as seen in Figure A. Which of the following is the most appropriate next step in the management of this patient? | Stroke |
M 7
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A
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| 85 | M2.OMB.20.1 | 214280 | A 25-year-old woman presents to the emergency department after developing slurred speech and left upper extremity weakness. Her symptoms began 2 hours prior to presentation and have progressively worsened. She has no significant medical history. She takes an oral contraceptive pill daily and recently returned from a trip to Japan. She has had leg pain over the last 2 days. Her temperature is 98.6°F (37.0°C), pulse is 90, blood pressure is 140/90 mmHg, and respirations are 14/min. Physical examination is notable for a left-sided facial droop with left-sided weakness that is more prominent in the upper extremity. The right lower extremity is erythematous and swollen compared to the left. A CT head without contrast demonstrates loss of differentiation between the grey-white matter junction in the distribution of the right middle cerebral artery. She is treated with intravenous thrombolytic therapy with improvement in her neurologic deficits. Which of the following studies will most likely reveal the underlying etiology of this patient's stroke? | Stroke |
M 6
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A
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| 86 | M2.OMB.4875 | 215177 | A 58-year-old man is brought to his primary care clinic by his wife 1 month after having a stroke. She notes that since the patient’s discharge from the hospital, he has been undergoing rehabilitation with minimal improvement in his symptoms. The patient’s speech is fluent, with proper tone and grammar but is incomprehensible. When asked if he knows where he is, the patient replies, “over the window.” In addition, he has trouble understanding spoken and written commands. His past medical history is significant for hypertension and hyperlipidemia. His medications include aspirin, atorvastatin, clopidogrel, and losartan. His temperature is 98.6°F (37.0°C), blood pressure is 145/86 mmHg, pulse is 78/min, and respirations are 12/min. Physical exam shows normal strength and sensation throughout. Ocular examination reveals a right superior quadrantanopia. Which of the following highlighted areas in Figure A represents the most likely location of ischemic injury in this patient? | Stroke |
M 6
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A
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| 87 | M2.OMB.4760 | 214418 | A 67-year-old man presents to the emergency department after fainting while mowing his lawn. He states that he stood up off his riding mower and fell to the ground. He reportedly regained consciousness within several seconds and was without symptoms. He denies associated chest pain. His past medical history is significant for hypertension and diabetes mellitus. His temperature is 98.7°F (37.1°C), blood pressure is 152/99 mmHg, pulse is 60/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam is notable for an obese man in no acute distress. Cardiopulmonary exam is unremarkable, and there is trace bipedal edema observed in the lower extremities. An ECG is obtained as shown in Figure A. A chest radiograph and head CT are performed and are unremarkable. Which of the following is the most likely diagnosis? | Atrioventricular (AV) Heart Block |
M 6
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A
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| 88 | M2.OMB.4761 | 214811 | A 67-year-old man with a history of hypertension and diabetes presents to the emergency department after an episode of syncope. The patient was gardening when he suddenly blacked out. His wife found him face down in the garden. The patient has had no chest pain, shortness of breath, or neurological symptoms during this time frame. He has a history of hypertension and hyperlipidemia for which he takes lisinopril and atorvastatin. His temperature is 98.1°F (36.7°C), blood pressure is 82/43 mmHg, pulse is 43/min, respirations are 15/min, and oxygen saturation is 98% on room air. On physical examination, the patient is unable to complete the gait examination as he becomes too light-headed when he attempts to stand up. An ECG is performed as seen in Figure A. Which of the following is the most appropriate next step in management? | Atrioventricular (AV) Heart Block |
M 7
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A
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| 89 | M2.OMB.20.4759 | 214230 | A 68-year-old man presents to the emergency department for evaluation after an episode of near syncope. He was at home and states that he nearly fainted while walking to the bathroom. His past medical history is significant for diabetes mellitus, hypertension, and smoking. His temperature is 99.0°F (37.2°C), blood pressure is 105/68 mmHg, pulse is 54/min, respirations are 15/min, and oxygen saturation is 95% on room air. Cardiopulmonary exam is notable for bradycardia. Lungs are clear to auscultation bilaterally. Exam is otherwise unremarkable. An electrocardiogram is obtained as seen in Figure A. Which of the following is the most likely diagnosis? | Atrioventricular (AV) Heart Block |
M 6
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A
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| 90 | M2.OMB.1 | 215158 | A 50-year-old man presents to the primary care clinic for a work physical. He does not complain of any symptoms. His medical problems are hypertension and diabetes for which he takes lisinopril and metformin. He is allergic to penicillin. He does not smoke and drinks alcohol socially. He was recently diagnosed with cellulitis and is being treated with cephalexin and is 4 days into his treatment. The patient is a recent immigrant from Laos and has had poor medical follow-up. He states that he had many male and female sexual partners when he was in his 30's and rarely used protection. His temperature is 98.2°F (36.8°C), blood pressure is 118/76 mmHg, pulse is 84/min, and respirations are 18/min. On physical exam, a 2/6 early decrescendo diastolic murmur is auscultated over the left lower sternal border. A transthoracic echocardiogram reveals dilation of the aortic root. A serum test for antibodies against a spirochete is reactive. Which of the following is the most appropriate next step in the management of this patient? | Syphilis (Adult) |
M 7
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A
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| 91 | M2.OMB.20.1 | 213835 | A 23-year-old gravida 4 para 2 abortus 1 woman presents to the obstetrician complaining of a vaginal rash. She states that the lesions appeared 4 weeks ago and have continued to grow. The lesions are painless, but the patient is worried because she is 25 weeks pregnant and doesn’t want to the rash to affect delivery. The patient has not attended any of her prenatal visits. Her medical history is significant for recurrent gonorrhea. She is allergic to shellfish and penicillin. Genital exam reveals a lesion on the vulva, as shown in Figure A. A Venereal Disease Research Lab test is positive. Which of the following is the most appropriate next step in management? | Syphilis (Adult) |
M 7
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| 92 | M2.OMB.4872 | 215193 | A 53-year-old man presents to clinic complaining of trouble walking for the past few months that has been steadily worsening. He notices this issue most when he gets up in the middle of the night to walk into the kitchen for water. He has also noted shooting pains down his legs. He has not seen a physician for the past several years, does not take any medications, has never had surgery, and has no allergies to medications. His temperature is 37.2°C (98.9°F), blood pressure is 138/89 mmHg, pulse is 73/min, respirations are 14/min, and oxygen saturation is 97% on room air. On exam, his pupils at baseline appear as shown in the top panel of Figure A, they appear as in the middle panel in response to light shone in the right eye, and they appear as in the bottom panel upon accommodation. His exam is also notable for a positive Romberg sign and decreased deep tendon reflexes. Which of the following is the most appropriate treatment for this patient? | Syphilis (Adult) |
M 7
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A
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| 93 | M2.CV.20.1 | 214380 | A 48-year-old man presents to his physician with sharp lower back and left lower extremity pain. He describes these painful episodes as sudden, severe, and lasting a few minutes. He denies any trauma to the lower back, lifting any heavy objects, but endorses episodes of urinary incontinence. He has fallen 3 times while walking in the dark and attributes it to "not knowing where my feet are before landing on the floor." Neurological examination is notable for his pupils not reacting to light but constricting to accommodation. His strength is normal, has diminished vibration and proprioception sensation, and has depressed ankle reflexes. He is unstable during Romberg testing. Which of the following is the most appropriate diagnostic study for this patient? | Syphilis (Adult) |
M 6
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| 94 | M2.OMB.4871 | 215011 | A 34-year-old G1P1 woman presents to the clinic with her 8-month-old boy for a well-child visit. She has no significant past medical history. She did not receive prenatal care during the pregnancy. The child was born at 39 weeks of gestation via an uncomplicated spontaneous vaginal delivery. She reports a prior history of multiple sexual partners and occasional intravenous drug use. She reports that her baby is doing well, but is developing a little differently from other children of the same age at daycare. The infant's temperature is 36.8°C (98.2°F), blood pressure is 96/50 mmHg, pulse is 120/min, respirations are 30/min, and oxygen saturation is 100% on room air. Physical exam reveals the findings shown in Figure A and B. Bilateral anterior bowing of the tibia is also noted. Which of the following is the most likely diagnosis? | Syphilis (Adult) |
M 6
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A
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| 95 | M2.OMB.81 | 214708 | A 29-year-old G2P1001 woman presents to labor and delivery at 37 weeks 5 days of gestation with 1 painful contraction every 20 minutes for the past 3 hours. Her pregnancy has been uncomplicated, with the exception of a positive vaginal group B streptococcus (GBS) screening culture found after her routine visit at 35 weeks of gestation. Her temperature is 98.6°F (37.0°C), blood pressure is 118/78 mmHg, pulse is 96/min, and respirations are 16/min. A transabdominal ultrasound is performed, followed by a pelvic exam. Her cervix is 90% effaced and 5 cm dilated. The fetus has a vertex lie. She is admitted in active labor. After being informed of the risk posed to her fetus, the patient decides to proceed with vaginal delivery and declines intrapartum antibiotics. She also requests that her child not be administered antibiotics after birth, as she believes "sickness will make the baby stronger," and antibiotics will harm her baby. The fetus's father lives internationally and does not plan to be involved in the infant's care. After extensive counseling, she affirms her choices. What are the most appropriate next steps in management? | Ethical Principles |
M 7
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A
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| 96 | M2.OMB.5665 | 215028 | A 6-month-old baby girl is brought to the pediatrician by her mother and father for a routine care appointment. The parents report that the patient is doing well. She is starting to eat solid foods in addition to breastfeeding and is sleeping through the night. She just started being able to sit up on her own a few days ago. She smiles and babbles. The child was born at 38 weeks of gestation to a 28-year-old G1P1 woman via spontaneous vaginal delivery. Her developmental history and past medical history are unremarkable. The patient's temperature is 98.6°F (37.0°C), blood pressure is 80/55 mmHg, pulse is 105/min, and respirations are 25/min. Physical exam is unremarkable. The patient is due for her 6-month vaccines, which include doses of the diphtheria/tetanus/pertussis and pneumococcal vaccines. The pediatrician explains the dosing schedule to the parents, but they state that they do not want their child to receive these vaccines because last time she developed upper respiratory symptoms a day after receiving her vaccines, so they are worried that the vaccines are making their child sick. The pediatrician thoroughly explains the mechanism, risks, and benefits of the vaccines and strongly recommends that the patient receive her scheduled vaccines at this visit. The parents express understanding but continue to refuse the vaccines. Which of the following is the most appropriate next step in management? | Ethical Principles |
M 5
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A
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| 97 | M2.OMB.20.4695 | 214301 | A 65-year-old man presents to the emergency department for the evaluation of chest pain. He states that his chest pain began 30 minutes prior. He describes his pain as a tearing sensation that starts in his chest and radiates between his shoulder blades. He denies associated shortness of breath or any other symptoms. He states that he has not seen a physician in many years. His temperature is 98.6°F (37.0°C), pulse is 95, blood pressure is 180/125 mmHg, and respirations are 20/min. On exam, the radial pulse is weaker on the right compared to the left. A CT angiogram of the chest is obtained as shown in Figure A. Which of the following is the most significant risk factor for this patient's condition? | Aortic Dissection |
M 6
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A
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| 98 | M2.OMB.4696 | 214820 | A 57-year-old man presents to the emergency department with sudden-onset chest pain. He states he was working on his car when his symptoms started. The patient has a history of hypertension and hypercholesterolemia but has not seen a primary care doctor recently to manage these conditions. He is a current smoker with a 20-pack-year history and currently takes no medications. He states that the chest pain is constant and does not radiate anywhere. His temperature is 99.3°F (37.4°C), blood pressure is 162/98 mmHg, pulse is 107/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam reveals symmetric upper extremity pulses and an uncomfortable-appearing man. A chest radiograph is performed as seen in Figure A. Which of the following is the most appropriate confirmatory test for this patient? | Aortic Dissection |
M 6
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A
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| 99 | M2.OMB.4697 | 215113 | A 65-year-old man presents to the emergency department with chest pain. He was seated at his desk at work when he experienced sudden-onset, severe chest pain that radiated to his back. The patient has a history of diabetes, hypertension, and chronic kidney disease. He is non-compliant with his medications, which include amlodipine and metformin. He smokes 1 pack of cigarettes per day and has a 55-pack-year smoking history. The patient’s temperature is 98.8°F (37.1°C), blood pressure is 132/78 mmHg in the right arm and 156/86 mmHg in the left arm, pulse is 104/min, and respirations are 18/min. On physical exam, the patient appears to be in acute distress and moans in pain. Cardiac auscultation reveals a soft, 2/6 diastolic decrescendo murmur over the left lower sternal border. Which of the following is the most appropriate next step to confirm the diagnosis? | Aortic Dissection |
M 6
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A
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| 100 | M3.CV.20.2 | 214394 | A 71-year-old man presents to his physician for episodes of fainting. He reports that prior to fainting he experiences lightheadedness. He regains consciousness within 20 seconds after fainting without any bowel or bladder incontinence, abnormal movements, or tongue biting. He also experiences chest pain and shortness of breath with exertion, which often improves with rest. He has a medical history of hypertension, hyperlipidemia, and asthma. Physical examination is notable for a systolic ejection murmur heard best at the right upper sternal border. Which of the following physical examination findings is suggestive of severe cardiac disease in this patient? | Aortic Stenosis |
M 10
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A
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| 101 | M2.OMB.4742 | 215087 | A 78-year-old woman presents to the emergency room after a syncopal ground-level fall. She had been outside doing some strenuous gardening work when she stood up, suddenly felt lightheaded, and lost consciousness. She regained consciousness several seconds later, at which point she was brought to the hospital. Her past medical history is notable for hypertension and osteoporosis for which she takes lisinopril and zoledronate. Past surgical history includes laparoscopic cholecystectomy 3 decades ago. Today, her temperature is 36.5°C (97.7°F), blood pressure is 136/82 mmHg, pulse is 88/min, respirations are 15/min, and oxygen saturation is 96% on room air. On exam, there is a systolic murmur most prominent at the right upper sternal border that radiates to the carotids. Which of the following is the most likely cause of her syncope? | Aortic Stenosis |
M 6
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A
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| 102 | M2.OMB.4743 | 215198 | A 78-year-old woman presents to her primary care doctor reporting several months of shortness of breath on exertion. She finally decided to see a doctor because she had a syncopal episode while gardening yesterday. Her past medical history is notable for hypertension and hyperlipidemia, both well-controlled on atorvastatin and losartan. Her temperature is 36.9°C (98.4°F), blood pressure is 132/83 mmHg, pulse is 94/min, respirations are 18/min, and oxygen saturation is 96% on room air. On auscultation, there is a systolic murmur best heard at the upper right sternal border, as well as a soft single S2. Which of the following is the most appropriate next step in management? | Aortic Stenosis |
M 7
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A
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| 103 | M2.OMB.4740 | 214567 | A 67-year-old man presents to his primary care physician with shortness of breath when he exerts himself. It has been gradually worsening over the past month, requiring the patient to avoid activities he previously enjoyed such as going for walks. Today, while walking, the patient felt short of breath and then fainted. He woke up roughly 10 seconds later and was at his baseline. His temperature is 98.0°F (36.7°C), blood pressure is 154/118 mmHg, pulse is 89/min, respirations are 18/min, and oxygen saturation is 98% on room air. Physical exam reveals bilateral clear breath sounds, a soft systolic murmur, and an absence of lower extremity edema. An ECG is performed as seen in Figure A. Which of the following is most likely present in this patient? | Aortic Stenosis |
M 6
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A
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| 104 | M2.OMB.20.1 | 214287 | A 19-year-old man comes to the clinic for an annual physical examination. He states that he feels well and has no complaints. He is in college and was just accepted for a volunteer position at a local hospital. For his new position, he needs to get a purified protein derivative (PPD) test. Below are 3 possible scenarios: A: The patient is a recent immigrant from Pakistan. B: The patient has mild, intermittent asthma. C: The patient is a kidney transplant patient. Figure A shows a table with choices of PPD screening criteria that could be used in each of these scenarios. Which of these choices is correct for all 3 of the patient scenarios described above that would results in a positive test? | Pulmonary Tuberculosis and PPD |
M 6
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A
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| 105 | M2.OMB.4874 | 215063 | A 56-year-old man presents to the emergency department with difficulty breathing along with subjective fevers, chills, and a nonproductive cough. The patient states that his symptoms began 4 days ago and have been progressively worsening. He recently returned from a month-long trip to South Africa. He is a longtime smoker with a 30-pack-year history and denies any other drug use. The patient takes atorvastatin for hyperlipidemia and hydrochlorothiazide for hypertension. His temperature is 101.3°F (38.5°C), blood pressure is 135/85 mmHg, pulse is 84/min, respirations are 20/min, and pulse oxygen saturation is 94% on room air. Physical exam shows dullness to percussion at the right posterior base. A chest radiograph reveals blunting of the right costophrenic angle. Pleural fluid analysis from his thoracentesis is as follows: Serum: Protein: 5.4 g/dL Lactate dehydrogenase (LDH): 215 U/L Pleural: Protein: 3.1 g/dL LDH: 90 U/L Lymphocytes: 86% Neutrophils: 10% Which of the following is the most likely etiology of this patient’s symptoms? | Pulmonary Tuberculosis and PPD |
M 6
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A
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| 106 | M2.OMB.4875 | 215176 | A 56-year-old man presents from prison with 1 month of subjective fevers, chills, cough, and night sweats. He noticed a gradual weight loss over the past year despite no changes to his diet or physical activity. He has never smoked cigarettes but does have a history of opiate use prior to incarceration. He does not take any medications. His temperature is 100.8°F (38.2°C), blood pressure is 142/88 mmHg, pulse is 78/min, and respirations are 12/min. Physical exam reveals a thin, ill-appearing man. Pulmonary auscultation reveals faint, inspiratory crackles in the right upper lobe. His chest radiograph is shown in Figure A. Which of the following is the most appropriate next step in management? | Pulmonary Tuberculosis and PPD |
M 7
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A
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| 107 | M2.OMB.20.4873 | 214327 | A 52-year-old man presents to the ED with 1 week of severe back pain. He describes the pain as 10/10 in severity and located in the center of his back along his spine. He reports a 6-month history of worsening shortness of breath and cough with occasional bloody sputum as well as intermittent night sweats. He denies nausea, vomiting, and diarrhea. His past medical history includes HIV, asthma, and hypertension. He recently traveled to his home country of Brazil 1 year ago and visited family in Ohio 6 months ago. His medications include dolutegravir, tenofovir, emtricitabine, albuterol, and hydrochlorothiazide, but he is not compliant. His temperature is 100.1°F (37.8°C), blood pressure is 145/85 mmHg, pulse is 90/min, and respirations are 18/min. On physical exam he appears thin but is in no acute distress. His pulmonary exam is unremarkable, and he has significant tenderness to palpation along the T6/T7 spinous processes. Chest radiograph is significant for the findings in Figure A. Which of the following is the most likely causative organism? | Pulmonary Tuberculosis and PPD |
M 6
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A
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| 108 | M2.OMB.4881 | 214966 | A 69-year-old man presents to clinic due to shortness of breath, worsening pain in his right shoulder, and episodes of hemoptysis. His symptoms began 3 months ago. He has also lost 18 pounds. He has a history of coronary artery disease and underwent an uncomplicated coronary angioplasty with stent placement 2 years ago. He routinely travels both domestically and internationally as a senior shipyard worker and has a 30-pack-year smoking history. He used to drink 4 cocktails a week. He has not smoke or drank alcohol in over 7 years. His temperature is 99.5°F (37.7°C), blood pressure is 140/60 mmHg, pulse is 97/min, and respirations are 13/min. Physical exam is notable for right pupillary constriction as well as paresthesias in his right fourth and fifth digits. There is no pain with active shoulder rotation. His chest imaging is shown in Figure A. Which of the following is most likely responsible for the patient’s symptoms? | Lung Cancer |
M 6
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A
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| 109 | M3.PL.12.3 | 214913 | A 67-year-old man presents to the emergency department with fever, shortness of breath, and cough, which has worsened over the course of 1 week. He endorses mild chest pain and denies any palpitations or hemoptysis. He denies any recent travel or sick contacts. He has had 4 similar presentations over the course of the past year and was successfully managed with intravenous antibiotics. His medical history is otherwise notable for hypertension, hyperlipidemia, and gastroesophageal reflux disease for which he takes lisinopril, atorvastatin, and omeprazole. The patient has smoked 1 pack of cigarettes daily for the past 40 years. His temperature is 101°F (38.3°C), blood pressure is 145/80 mmHg, pulse is 86/min, respirations are 18/min, and oxygen saturation is 93% on pulse oximetry. Radiography of the chest demonstrates a right middle lobe opacity, which is similar to his radiographs from his prior hospitalizations. Which of the following diagnostic studies is the most appropriate to confirm the underlying cause of this patient's symptoms? | Lung Cancer |
M 6
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A
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| 110 | M2.OMB.4880 | 214961 | A 51-year-old man presents to the emergency department complaining of fever and a cough with yellow-green sputum for the past 3 days. He denies any hemoptysis, facial pain, rhinorrhea, or night sweats. The patient reported similar symptoms 2 months ago. Chest radiograph performed at the time was notable for a right middle lobe consolidation. He was diagnosed with lobar pneumonia and completed a 7-day course of antibiotics with complete resolution of his symptoms. He has no other significant medical history and does not take any medications. He has smoked 1 pack of cigarettes a day for 35 years and drinks 3 beers per week. He is sexually active with his wife. His temperature is 101.7°F (38.7°C), blood pressure is 127/85, pulse is 102/min, and respirations are 22/min. Physical exam is notable for decreased breath sounds on the right side without wheezing and increased dullness to percussion on the right side. A chest radiograph is ordered and reveals a consolidation in the right middle lobe. Which of the following is the most appropriate next step in management? | Lung Cancer |
M 7
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A
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| 111 | M2.OMB.4877 | 215082 | A 14-year-old girl is brought to the pediatric emergency department by her father due to worsening nausea, vomiting, and abdominal pain that began over the last day. Yesterday, she was feeling more tired than usual and found herself falling asleep in class. Early this morning, she awoke in the middle of the night with nausea and has been vomiting since. She also reports cramping abdominal pain that is 10/10 in severity. She has no known past medical history and takes no medications. Temperature is 99°F (37.2°C), blood pressure is 102/53 mmHg, pulse is 110/min, and respirations are 26/min. On exam, she is lethargic and mucous membranes are dry. She is oriented to person only. The abdomen is tender throughout without rebound tenderness. Blood glucose is measured as 268 mg/dL. Which of the following is most likely in this patient? | Diabetic Ketoacidosis (DKA) |
M 6
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A
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| 112 | M2.OMB.4876 | 215105 | A 28-year-old woman presents 3 months after a radioactive iodine ablation for treatment of hyperthyroidism. She reports that she now feels lethargic and cold. Her temperature is 97.0°F (36.1°C), blood pressure is 105/78 mmHg, pulse is 55/min, and respirations are 12/min. On exam, she is tired appearing with delayed patellar and Achilles reflexes. Laboratory evaluation reveals: Thyroid-stimulating hormone (TSH): 7.6 mU/L Free thyroxine (T4): 0.1 ng/dL She is started on levothyroxine replacement therapy. Which of the following was the most likely original hyperthyroid etiology that prompted her to undergo radioactive iodine ablation? | Graves Disease |
M 6
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A
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| 113 | M2.OMB.20.4698 | 213752 | A 70-year-old man presents to the emergency department after a motor vehicle collision. He was in the front seat as a restrained driver in a head-on collision. He states that he hit the back of his head on the head rest but denies loss of consciousness or any symptoms at the time of the accident. He was removed from the car by the fire department, a cervical collar was placed, and was transported to the hospital. On arrival, the patient states that he feels weak. He has a past medical history of diabetes and atrial fibrillation and is currently being treated for these conditions. His temperature is 98.9°F (37.2°C), blood pressure is 109/70 mmHg, pulse is 88/min and irregular, and respirations are 15/min. Neurologic exam is notable for 2/5 strength in his upper extremities and 4/5 strength in his lower extremities. The patient has reduced temperature sensation in his upper extremities with normal sensation in his lower extremities. A postvoid residual volume is 772 mL. Which of the following is the most likely diagnosis? | Spinal Cord Lesions |
M 6
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A
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| 114 | M2.OMB.4875 | 214922 | A 25-year-old woman presents to the emergency department for evaluation of 2 days of urinary urgency and dysuria. She also reports mild lower abdominal pain but no fever, chills, or back pain. Her medications include a combined oral contraceptive and methimazole for Graves disease, which she started 2 weeks ago. Her temperature is 99.8°F (37.7°C), blood pressure is 115/72 mmHg, pulse is 95/min, and respirations are 18/min. Physical exam is notable for suprapubic tenderness to deep palpation, no abdominal rebound or guarding, and no costovertebral angle tenderness. Which of the following is the most appropriate next step in management? | Graves Disease |
M 7
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A
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| 115 | M2.OMB.4877 | 215110 | A 45-year-old woman presents to her primary care clinic with concerns about her increased anxiety and new heart palpitations over the past 2 months. She has trouble falling asleep and constantly feels fatigued. Despite no recent dietary changes, the patient has lost 10 pounds. Her past medical history is unremarkable. She denies any drug use. Her family history is significant for a mother and aunt with rheumatoid arthritis. Her temperature is 98.4°F (36.9°C), blood pressure is 142/90 mmHg, pulse is 116/min, and respirations are 12/min. Physical exam is notable for a nontender, diffusely enlarged mass of the anterior neck and fine hand tremors. Ocular exam is significant for conjunctival hyperemia as well as superior and inferior scleral show bilaterally. Lead I of the patient’s electrocardiogram is shown in Figure A. Which of the following is the most appropriate next step in management for this patient? | Graves Disease |
M 7
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A
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| 116 | M2.EC.20.4874 | 213863 | A 47-year-old woman with type I diabetes presents to her primary care physician complaining of abnormal appearance and swelling of her legs. The leg swelling started 1 year ago and has been getting worse to the point that she is no longer able to fit in her shoes. She also notes that the front of her legs are a different color than they used to be. She otherwise feels well, but reports a 10 lb. weight loss in the past year, occasional palpitations, and chronic diarrhea. Her medications include daily insulin. Her family history is significant for type I diabetes in her mother and congestive heart failure in her father. Her temperature is 98.3°F (36.8°C), blood pressure is 125/60 mmHg, pulse is 104/min, and respirations are 14/min. On physical exam, her heart rhythm is irregularly irregular, and her lungs are clear to auscultation bilaterally. Her abdomen is soft and nontender. Her legs appear as shown in Figure A. What additional finding would most likely be present in this patient? | Graves Disease |
M 6
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A
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| 117 | M2.OMB.4833 | 214500 | A 67-year-old woman presents to the emergency department with shortness of breath. She has had these symptoms before and was previously admitted to the intensive care unit for bilevel positive airway pressure (BiPAP) and diuresis. She has a past medical history of heart failure with a most recent ejection fraction of 31%. Her temperature is 97.7°F (36.5°C), blood pressure is 184/104 mmHg, pulse is 120/min, respirations are 29/min, and oxygen saturation is 78% on room air. Physical exam reveals prominent bilateral wheezes with poor air movement and pitting edema that extends to the patient's hips. The patient is started on a nitroglycerin drip, furosemide, and BiPAP and is admitted to the intensive care unit. On day 3, her symptoms have significantly improved, and she is sent to the medical floor. The patient is being discharged with a plan to follow up with her cardiologist. Which of the following medications at discharge is most likely to lower mortality in this patient? | Heart Failure |
M 8
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A
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| 118 | M2.OMB.4832 | 214489 | A 74-year-old man presents to the emergency department with shortness of breath. He states that his shortness of breath has been worsening over the past week, and he has had a cough and a fever during this time frame as well. He is normally on 2L of O2 for his chronic obstructive pulmonary disease (COPD) but has increased it to 5L on his own. The patient is an active smoker and has diabetes. His temperature is 101°F (38.3°C), blood pressure is 174/100 mmHg, pulse is 115/min, respirations are 27/min, and oxygen saturation is 82% on 5L of O2. Physical exam reveals diffuse wheezes bilaterally. Jugular venous distension and bilateral lower extremity pitting edema are noted as well as distant heart sounds. Hepatomegaly is palpated on the abdominal exam. An ECG is performed as seen in Figure A. A chest radiograph demonstrates diffuse interstitial infiltrates. Which of the following is most likely to be found in this patient? | Heart Failure |
M 6
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A
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| 119 | M3.CV.12.2 | 214687 | 56-year-old man presents to his primary care physician for a routine visit. He reports feeling otherwise well and has no acute complaints. He has a history of hypertension and hyperlipidemia that is being managed with diet and exercise. He smokes a half-pack of cigarettes daily for the last 15 years, drinks 3 alcoholic beverages per week, and denies any illicit drug use. Cardiac auscultation is notable for an extra heart sound right after S2. An electrocardiogram demonstrates left ventricular hypertrophy. A transthoracic echocardiogram demonstrates a left ventricular ejection fraction of 40%. Which of the following is the most appropriate treatment for this patient? | Heart Failure |
M 7
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A
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| 120 | M2.OMB.4840 | 214682 | A 6-month old boy is brought to the office by his parents for a routine checkup. The patient is able to sit with his hands propped on the exam table. When he tries to sit unsupported, he falls forward after a few seconds. He transfers a toy car from his left hand to his right hand; however, when handed his bottle, he is unable to hold it for more than 2 seconds before dropping it. He cries when the physician picks him up. When his mother calls his name, he turns to her and reaches for her. He is consoled once his mother holds him and smiles. He babbles but does not produce any coherent words. He is unable to stand or crawl. Family history is notable for a motor delay in his 3-year old brother who could not walk until 18 months of age. The patient is at the 40th percentile for length, 60th percentile for weight, and 50th percentile for head circumference. Babinski reflex is present. Which of the following best describes this child’s gross motor, fine motor, and social development? | Normal Development Landmarks |
M 6
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A
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| 121 | M2.OMB.20.1 | 213862 | A 54-year-old man presents to the emergency department with pain in his right calf. He says it started when he woke up this morning. His medical history is significant for hypertension, diabetes mellitus, chronic kidney disease, alcohol abuse, epilepsy, gastroesophageal reflux disease (GERD), and onychomycosis. He takes lisinopril, metformin, sodium valproate, griseofulvin, and calcium carbonate. He states 2 months ago he had total hip replacement surgery for his left hip. He drinks 4-5 beers a night. He denies any other recreational drugs. A physical examination reveals a swollen left lower leg. A compression ultrasound with Doppler of the left leg indicates a deep vein thrombosis. Heparin is started as a bridge to warfarin, which the patient is discharged on. The patient returns to the emergency department 1 week later with a nosebleed that is resistant to pressure and icepacks. His INR is 7.0. Which of the following medications may be responsible for the patient’s current presentation? | Anticoagulants |
M 7
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A
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| 122 | M2.OMB.200 | 214409 | A 65-year-old man presents to the emergency department with lower back pain. He states that it started 2 days ago and has been gradually worsening. He has a past medical history of diabetes and obesity and a 40 pack-year smoking history. His initial vitals are unremarkable, and his physical exam on presentation reveals normal strength, sensation, reflexes, and rectal tone. Despite treatment with acetaminophen, ibuprofen, lidocaine patches, and morphine, the patient complains of a sudden worsening of his back pain while in the ED and is requesting more IV pain medications. His temperature is 98.3°F (36.8°C), blood pressure is 87/45 mmHg, pulse is 158/min, respirations are 22/min, and oxygen saturation is 99% on room air. Which of the following is the most likely diagnosis? | Abdominal Aortic Aneurysm |
M 6
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A
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| 123 | M2.OMB.201 | 215016 | A 67-year-old man presents to clinic for a routine annual physical exam. He has no acute concerns he wishes to discuss this visit. His past medical history includes hypertension, hyperlipidemia, and type 2 diabetes mellitus. His medications include lisinopril, atorvastatin, and metformin. He does not drink alcohol but has smoked half a pack of cigarettes per day for the past 20 years. His temperature is 37.2°C (98.9°F), blood pressure is 137/92 mmHg, pulse is 89/min, respirations are 15/min, and oxygen saturation is 99% on room air. Physical examination reveals a pulsatile abdominal mass. Subsequently, an abdominal ultrasound and a computed tomography (CT) scan of the abdomen and pelvis are performed (Figure A). Which of the following characteristics of the abdominal aortic aneurysm (AAA) would prompt close monitoring with serial ultrasounds rather than surgical intervention? | Abdominal Aortic Aneurysm |
M 7
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A
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| 124 | M2.OMB.4841 | 215009 | An 11-year-old boy presents to his primary care physician with his parents for a general screening exam. The child previously suffered from obesity; however, his parents have been able to get him to engage in weightlifting. The child enjoys weightlifting, and this is one of the first times he has been actively participating in physical activity. The child is supervised by a personal trainer who has him using light weights with proper form, and they meet 5 times per week for an hour each session. The child otherwise has a history of metabolic syndrome, but has lost 10 pounds since starting this fitness routine 3 months ago and has improved his body composition. The patient's grandfather and grandmother both died of heart attacks at the age of 89 and 92, respectively. His temperature is 98.0°F (36.7°C), blood pressure is 122/83 mmHg, pulse is 77/min, and respirations are 16/min. Physical exam reveals an overweight boy who has an unremarkable neurological and musculoskeletal exam. Which of the following is the most appropriate recommendation for this patient? | Normal Development Landmarks |
M 8
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A
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| 125 | M3.CV.20.2 | 214456 | A 66-year-old man presents to his primary care physician for a routine examination. He currently has no acute complaints and reports being otherwise well. He has a medical history of hypertension, hyperlipidemia, and type 2 diabetes mellitus. He smokes approximately 1 pack of cigarettes daily for the last 35 years and drinks 2-3 glasses of wine every night. His blood pressure is 145/90 mmHg, pulse is 80/min, and respirations are 16/min. Physical examination is notable for a pulsatile mass in the abdomen with normal pulses in the bilateral lower extremities. Ultrasonography of the abdomen demonstrates an aortic diameter of 4.5 cm. Which of the following interventions would most likely decrease the rate of aneurysm expansion? | Abdominal Aortic Aneurysm |
M 12
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A
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| 126 | M2.OMB.4875 | 215161 | A 67-year-old woman presents to the emergency department with a headache. She was lifting weights when the headache suddenly developed. Although she occasionally has migraines, she describes her current headache as the worst of all her headaches. There is associated nausea and vomiting. Her medical history includes hypertension, hyperlipidemia, and atrial fibrillation. Her medications are chlorthalidone, atorvastatin, acetaminophen, and warfarin. She smokes 1 pack of cigarettes per day and has a 50-pack-year smoking history. Her temperature is 99.2°F (37.3°C), blood pressure is 144/92 mmHg, pulse is 50/min, and respirations are 8/min. On exam, the patient is lethargic and there is limited passive neck flexion. Laboratory results are below: Activated partial thromboplastin time (aPTT): 35 seconds Prothrombin time (PT): 51 seconds International normalized ratio (INR): 4.2 After the diagnosis is confirmed, which of the following is the most appropriate next step in management for the reversal of anticoagulation? | Anticoagulants |
M 7
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A
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| 127 | M2.OMB.20.1 | 214269 | A 25-year-old woman presents to the emergency department with severe left-sided retro-orbital pain. Her pain has progressively worsened over the course of 2 days and worsens with eye movement. She reports a loss of central vision and says that colors seem "washed out." She states that she has never experienced this before. Physical examination is notable for visual acuity of 20/200 in the left eye and 20/30 in the right eye. Fundoscopy examination shows a normal fundus. Both of her pupils are equal and reactive to light; however, when light is swung from the right eye to the left eye, both pupils dilate. Which of the following is the most appropriate next step in management? | Multiple Sclerosis |
M 6
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A
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| 128 | M3.NE.20.6114 | 214376 | A 36-year-old woman presents to the emergency department with severe left eye pain with associated vision loss. She denies any physical or chemical trauma to the eye, recent use of eye drops, or foreign body sensation within the affected eye. Approximately 2 weeks ago, she had an upper respiratory tract infection that was symptomatically managed with ibuprofen. She reports that 8 months ago, she experienced bilateral lower extremity weakness and urinary retention and was admitted to the hospital where she was appropriately treated. She did not follow-up for outpatient treatment. She has no past medical history and is only taking a daily multivitamin. On physical examination, she has consensual pupillary response when light is shined on the right eye. When light is swung from the right eye to the left eye, there is a relative dilation of both pupils. Her visual acuity in the right eye is 20/40 and in the left eye is 20/200. Her extraocular movements are intact; however, pain is produced with eye movement most notably involving the left eye. Which of the following is the most appropriate treatment option for this patient's symptoms? | Multiple Sclerosis |
M 11
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A
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| 129 | M3.NE.20.2 | 214548 | A 36-year-old woman presents to the emergency department with blurry vision of the right eye that has progressively worsened over the course of 2 days. She reports that approximately 8 months ago she experienced right upper extremity numbness that self resolved over the course of 2 weeks. Neurological examination is remarkable for visual acuity of 20/200 in the right eye and 20/25 in the left eye. There is an afferent pupillary defect and pain with movement of the right eye. An MRI of the brain and spinal cord with gadolinium demonstrates demyelinating lesions affecting the right optic nerve and the spinal cord, as well as non-enhancing periventricular lesions. She is started on 5 days of intravenous methylprednisolone and her symptoms begin improving. The patient is about to be discharged and undergo physical therapy. Which of the following is the most appropriate next step in management? | Multiple Sclerosis |
M 7
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| 130 | M2.OMB.202 | 215138 | A 76-year-old man presents to the emergency room complaining of lower back pain that started this afternoon and has gotten persistently worse. It is neither improved nor worsened with movement. His past medical history is notable for hypertension, hyperlipidemia, and type 2 diabetes mellitus. His medications include lisinopril, atorvastatin, and metformin. He has not had surgery in the past. He smokes 1 pack of cigarettes per day and has done so for the past 25 years. He denies drinking alcohol or using intravenous drugs. On initial exam, his temperature is 36.8°C (98.2°F), blood pressure is 115/75 mmHg, pulse is 105/min, respirations are 18/min, and oxygen saturation is 96% on room air. However, on repeat exam 15 minutes later, his blood pressure is noted to be 90/65 mmHg and pulse is now 126/min. Which of the following diagnoses is most likely in this patient? | Abdominal Aortic Aneurysm |
M 6
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| 131 | M3.NE.20.2 | 214476 | A 52-year-old woman presents to her neurologist for follow-up for her multiple sclerosis. She reports that her last multiple sclerosis flare was approximately 1 year ago. She is currently being treated with natalizumab infusions, which she has been tolerating. Over the course of the last 2 months, she has been experiencing increasing difficulty with ambulation. She feels that her right lower extremity has been more "rigid" and "heavy." She does not endorse any muscle spasms or worsening of her symptoms at night. Neurological examination is notable for spasticity affecting the right lower extremity. Which of the following is the most appropriate next step in managing this patient's symptom? | Multiple Sclerosis |
M 11
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| 132 | M2.OMB.1 | 214523 | A 5-year-old girl is brought to the office by her mother due to problems at summer camp. She has not yet started kindergarten but her mother enrolled her at a children’s summer camp 1 month ago. The patient’s summer camp counselor reports that she is very quiet during group activities. She refuses to participate when called upon and remains quiet while other children sing camp songs. During free time, she plays by herself and does not speak to other children. The patient’s mother states that she has not had any similar issues at home. At home, she talks and plays with her siblings comfortably. The patient was born at term with no prenatal or delivery issues. She is able to dress herself, skip, tie her shoelaces, and draw a triangle. On physical examination, she is initially shy during the interview but gradually warms up. She is able to speak fluently in 5-word sentences and exhibits appropriate comprehension. No other physical exam abnormalities are noted. Which of the following is the most likely diagnosis in this patient? | Normal Development Landmarks |
M 6
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| 133 | M2.OMB.20.103 | 214183 | A 28-year-old woman presents to the physician’s office with symmetric joint pains throughout her body. She states that she has never had these symptoms before, but recently began experiencing symmetric joint pain in her upper extremities that is worse in the morning and improved with exercise. Her joint pain is most notable in her hands and wrists. The patient is otherwise generally healthy. She states that she lives at home with her husband and son. She is stressed because her son is currently sick with a fever and has to accompany her throughout her daily routine (Figure A). Her mother has a history of rheumatoid arthritis, and her father suffers from osteoarthritis. Her temperature is 98.3°F (36.8°C), blood pressure is 122/82 mmHg, pulse is 80/min, respirations are 15/min, and oxygen saturation is 99% on room air. Physical exam including cardiopulmonary and dermatologic exam is unremarkable. Which of the following is the most likely etiology of this patient’s symptoms? | Rheumatoid Arthritis |
M 6
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| 134 | M2.OMB.20.1 | 214283 | A 44-year-old man presents with hand swelling and fatigue. He states that he has morning joint stiffness that lasts for nearly 3 hours every day. He has no medical history and takes no medications. His father has a “blood disorder.” Physical examination reveals non-tender subcutaneous nodules on the patient’s forearms and hands, joint tenderness involving the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints, and splenomegaly. A radiograph shows a slight subluxation of the MCP joints. Labs are obtained with the results shown below: Hemoglobin: 10.3 g/dL Leukocyte count: 3100/mm^3 Absolute neutrophil count: 900/µL Platelet count: 169,000/mm^3 Which of the following is the most likely diagnosis? | Rheumatoid Arthritis |
M 6
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| 135 | M2.OMB.4873 | 214904 | A 29-year-old woman presents to her primary care physician complaining of anxiety and weight loss. Despite increasing her caloric intake over the last few weeks, she has continued to lose weight. She has experienced palpitations and heat sensitivity. Her menstrual cycles have become irregular as well. Her last menstrual period 2 weeks ago was lighter than normal. She has no other significant medical history and does not take any medications except a daily multivitamin. She does not smoke or drink alcohol. She is not currently sexually active. Her temperature is 98.7°F (37°C), blood pressure is 120/80 mmHg, pulse is 105/min, and respirations are 14/min. Examination of the thyroid reveals a single, non-tender nodule in the thyroid. The thyroid is otherwise mobile and normal in size. Laboratory results are as follows: Thyroid-stimulating hormone (TSH): 0.1 µU/mL (normal: 0.5-5.0) Free thyroxine (T4): 45 µg/dL (normal: 5-12) Radioactive iodine uptake (RAIU) results are shown in Figure A. Which of the following is the most likely diagnosis? | Hypothyroidism vs. Hyperthyroidism |
M 6
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| 136 | M2.OMB.20.4869 | 213895 | A 57-year-old man presents to the emergency department with chest pain. He states that it is worsened with exertion, deep breaths, and occurs at rest. He has a past medical history of obesity, diabetes, heart failure, hypertension, and peripheral vascular disease. He has a 30 pack-year smoking history. He recently traveled on a flight from China visiting his relatives and was exposed to his sick grandchildren. His temperature is 97.7°F (36.5°C), blood pressure is 174/94 mmHg, pulse is 88/min, respirations are 14/min, and oxygen saturation is 95% on room air. Physical exam is notable for a sweaty and uncomfortable man. He demonstrates normal heart sounds; however, the physician is unable to auscultate the patient’s cardiac apex in the left lateral decubitus position secondary to patient discomfort. An ECG is performed as seen in Figure A. Initial laboratory values including a troponin are pending. Which of the following findings would be seen on bedside echocardiography? | Pericarditis |
M 6
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| 137 | M2.OMB.4870 | 214399 | A 37-year-old man presents to the emergency department with shortness of breath and chest pain. The patient states that his symptoms started a few days ago and have been gradually worsening. He recently had a cold from which he recovered but is otherwise healthy. His temperature is 98.3°F (36.8°C), blood pressure is 107/65 mmHg, pulse is 128/min, respirations are 18/min, and oxygen saturation is 99% on room air. Physical exam is notable for clear breath sounds, jugular venous distension, bilateral lower extremity edema, and obesity. Cardiac auscultation demonstrates an early diastolic sound. An ultrasound demonstrates a normal ejection fraction with restricted ventricular filling. Which of the following is the most likely diagnosis? | Pericarditis |
M 6
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| 138 | M2.OMB.20.4868 | 213762 | A 71-year-old man presents to the emergency department with chest pain and shortness of breath. It started 30 minutes ago and has been worsening. The patient states he is generally healthy and has not needed to see a doctor over the past 7 years. His temperature is 98.0°F (36.7°C), blood pressure is 165/90 mmHg, pulse is 88/min, and respirations are 15/min. The patient appears sweaty and uncomfortable. Cardiac auscultation is unremarkable, and the patient has minor bibasilar crackles. An ECG is performed as seen in Figure A. The patient is subsequently treated and discharged after a 2 day hospital stay. He returns 1 week later with chest pain again. An ECG is performed as seen in Figure B. Which of the following is appropriate definitive treatment for this patient? | Pericarditis |
M 7
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| 139 | M2.OMB.20.1 | 213796 | A 6-year-old boy is brought to his pediatrician for fever and cough. His mother states that the cough started yesterday and this morning he woke up drenched in sweat. The patient has a history of treatment-resistant bilateral otitis media. He's been hospitalized 5 times for pneumonia. His first hospitalization was at 8 months old. He takes no medications. He has an older brother and an older sister who are both healthy. There is no family history of immunodeficiencies. The patient's entire family is vegetarian, including himself. He does well in school but gets tired easily. The patient's temperature is 101.5°F (38.6°C), blood pressure is 100/54 mmHg, pulse is 98/min, and respirations are 18/min. Bilateral diminished breath sounds with rales are appreciated on lung auscultation. There are no palpable lymph nodes. A chest radiograph shows bilateral consolidations and a thymic shadow. Laboratory tests are obtained as shown below: Hemoglobin: 13.9 g/dL Leukocyte count: 3,850 cells/mm^3 Neutrophils: 88% Lymphocytes: 12% Platelet count: 350,000/mm^3 Serum: IgG: 145 mg/dL (Normal: 340-1000 mg/dL) IgA: 26 mg/dL (Normal: 30-230 mg/dL) IgM: 29 mg/dL (Normal: 40-200 mg/dL) Which of the following is the most likely cause of the patient’s presentation? | Table of Other Immunodeficiencies |
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| 140 | M2.OMB.4871 | 214899 | A 9-month-old boy is brought to the emergency department by his parents because of a fever and difficulty breathing. During the past 3 months, the patient has had several upper respiratory tract infections and poor weight gain. The mother’s pregnancy and delivery were uncomplicated, and the infant’s immunizations are up-to-date. The patient is breastfed, but the mother notes he is eating less lately. He is at the 30th percentile for length and the 5th percentile for weight. His temperature is 101.4°F (38°C), blood pressure is 80/50 mmHg, pulse is 150/min, and respirations are 50/min. Pulse oximetry shows an oxygen saturation of 85% on room air. Physical exam reveals a child in respiratory distress. Crackles are heard diffusely in both lung fields. A chest radiograph demonstrates bilateral, symmetric ground glass opacities. The child is intubated for worsening respiratory distress, and bronchoalveolar lavage (BAL) is performed. Silver staining demonstrates infection with Pneumocystis jirovecii. Laboratory results are notable for the following: Immunoglobulin A (IgA): 20 mg/dL (normal: 76-390 mg/dL) Immunoglobulin G (IgG): 100 mg/dL (normal: 650-1500 mg/dL) Immunoglobulin M (IgM): 500 mg/dL (normal: 40-345 mg/dL) Which of the following is the most likely cause of this patient’s condition? | Table of Other Immunodeficiencies |
M 6
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| 141 | M2.OMB.2 | 214408 | A 55-year-old man presents to the emergency department with dyspnea and shortness of breath. He has no known past medical history as he recently immigrated to the United States. He states that his shortness of breath is worsened by exertion and is relieved by rest. He has had lifelong shortness of breath worsened by cold weather and seasonal changes. His temperature is 97.0°F (36.1°C), blood pressure is 154/91 mmHg, pulse is 88/min, respirations are 27/min, and oxygen saturation is 88% on room air. Physical exam reveals bilateral wheezing with poor air movement. Bilateral lower extremity pitting edema is noted. A chest radiograph is performed as seen in Figure A. The patient is given albuterol, ipratropium, prednisone, and is started on bilevel positive airway pressure (BiPAP). After initial treatment, the patient's oxygen saturation is 94% on bilevel positive airway pressure, and his work of breathing has decreased though he is still notably short of breath. Which of the following treatments could also be given to this patient? | Asthma |
M 7
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| 142 | M2.OMB.4874 | 215054 | A 65-year-old man presents to the emergency department with anxiety and intermittent palpitations. He began feeling the palpitations 3 days ago while eating dinner. He denies chest pain, shortness of breath, or loss of consciousness. He has a history of hypertension, major depressive disorder, Raynaud disease, and chronic obstructive pulmonary disease (COPD) on 2 liters of oxygen at home. Current medications include lisinopril, inhaled umeclidinium-vilanterol, and as-needed albuterol. He drinks 4 beers a day and has smoked 1 pack of cigarettes a day for 40 years. His temperature is 98.9° F (37.2° C), blood pressure is 130/85 mmHg, pulse is 125/min, and respirations are 16/min. Physical exam is notable for an irregular pulse and scattered end-expiratory wheezes. An echocardiogram performed 1 month ago showed a left ventricular ejection fraction of 60-65%. The patient requires 3 liters of oxygen today. An ECG is performed as seen in Figure A. Which of the following is the most appropriate treatment for the patient’s tachycardia? | Atrial Fibrillation |
M 7
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| 143 | M2.OMB.4878 | 214754 | A 28-year-old woman comes to the office for follow-up evaluation of a chronic cough. For the past 3 months, she has had a nonproductive cough that is worse at night and frequent throat clearing during the day. She denies any accompanying chest pain, rhinorrhea, difficulty breathing, difficulty swallowing, or worsening of the cough with food. She is otherwise healthy and has no medical conditions. She has tried over-the-counter lozenges, herbal cough remedies, and calcium carbonate with little relief. She exercises regularly and has not noticed a change in her exercise tolerance. Her temperature is 98.6°F (37°C), blood pressure is 110/70 mmHg, pulse is 68/min, and respirations are 12/min. Cardiopulmonary examination and a chest radiograph show no abnormalities. Follow-up pulmonary function testing from her last visit reveals a normal FEV1 (forced expiratory volume in one second). Which of the following is the most appropriate next step in management? | Asthma |
M 7
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| 144 | M2.OMB.1 | 214311 | A 31-year-old G2P2 woman gave birth to her second child via vaginal delivery 8 hours ago. The patient received an epidural for pain control and delivery was uncomplicated. The patient’s pain is currently well-controlled, and she is resting comfortably. The patient’s mother comes to sit on the bed next to the patient and notes that the patient’s bed is wet. When you examine the patient, you note some suprapubic tenderness with abdominal exam. A bladder scan reveals a distended bladder. The patient has not voided since delivery. What is the best initial step in management for this patient? | Urinary Incontinence |
M 7
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| 145 | M2.OMB.4872 | 215141 | A 12-year-old boy presents to the emergency department with fever, headache, and lethargy. He rouses to voice but otherwise demonstrates little spontaneous activity. His mother states that he has been hospitalized for a “brain infection” 3 times in the past that was treated with ceftriaxone. His postnatal history was otherwise normal. He has no other medical history and is only taking acetaminophen. The patient’s temperature is 103.2°F (39.6°C), blood pressure is 90/60 mmHg, pulse is 112/min, and respirations are 28/min. Physical exam reveals a lethargic adolescent boy in a recumbent position. Flexion of his neck causes flexion at the hips and knees. A lumbar puncture is performed and a Gram stain of the cerebrospinal fluid (CSF) reveals gram-negative diplococci. Which of the following is the most likely underlying etiology of the patient’s condition? | Table of Other Immunodeficiencies |
M 6
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| 146 | M2.OMB.4877 | 213745 | A 34-year-old man presents to the emergency department with shortness of breath while he was hiking. He also reports that while hiking, he fell and hit his chest wall against a boulder, which he believes worsened his dyspnea. The patient endorses several recent upper respiratory infections that he recovered from without issue. He has chest pain with deep breaths as well. His temperature is 99.0°F (37.2°C), blood pressure is 124/64 mmHg at rest and 107/63 mmHg on inspiration, pulse is 130/min, respirations are 23/min, and oxygen saturation is 90% on room air. Physical exam is notable for an absence of wheezes and very poor air movement bilaterally. Initial laboratory tests including a venous blood gas and liver function tests are only notable for a pCO2 of 67 mmHg. Which of the following is the most likely etiology of this patient's variation in blood pressure? | Asthma |
M 6
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| 147 | M2.OMB.2 | 214506 | A 25-year-old man presents to the emergency department with eye pain. He was hiking when the strap from his backpack flipped forward under his glasses and hit him in the eye. He now complains of pain whenever he blinks. His temperature is 97.6°F (36.4°C), blood pressure is 120/81 mmHg, pulse is 70/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical exam reveals a healthy young man with erythema of his left eye. Fluorescein is applied to the eye and reveals the finding in Figure A. Which of the following is the most appropriate management of this patient? | Common Eye Injuries |
M 7
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| 148 | M2.OMB.4676 | 215076 | A 65-year-old woman presents to the emergency department with shortness of breath. She was previously able to jog 1.5 miles every day but is now unable to take more than 20 steps without sitting to catch her breath. She has no history of coronary artery disease. She has a history of breast cancer in remission for which she completed a treatment course 5 years ago that included cyclophosphamide, doxorubicin, and trastuzumab. She also has diabetes mellitus, for which she has been taking metformin and pioglitazone for 10 years. She was recently diagnosed with hypertension and started on amlodipine. She has never smoked and denies illicit drug use. The patient’s temperature is 97.8°F (36.6°C), blood pressure is 142/80 mmHg, pulse is 76/min, and respirations are 20/min. Physical exam is notable for bibasilar crackles on chest auscultation, jugular venous pressure of 12 cm H2O, and 2+ pitting edema in the lower extremities. An echocardiogram reveals a left ventricular ejection fraction of 40%. Which medication is most likely responsible for her symptoms? | Oncology Medications |
M 7
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| 149 | M2.OMB.5 | 215169 | A 27-year-old man presents to the emergency department after a bar fight. He was punched in the eye and is having pain and blurry vision. The patient is otherwise healthy and does not take any medications. His temperature is 98.1°F (36.7°C), blood pressure is 132/84 mmHg, pulse is 103/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for conjunctival injection of the patient’s left eye as shown in Figure A. Visual acuity reveals 20/20 vision in his right eye and 20/40 vision in his left. His left pupil is sluggish to constrict when compared to the right. A fluorescein stain is unremarkable and tonometry reveals a pressure of 45 mmHg in the left eye. Which of the following is the most appropriate next step in management? | Common Eye Injuries |
M 7
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| 150 | M2.ON.12.4675 | 214450 | A 40-year-old man with Hodgkin lymphoma presents for a right shoulder arthroscopy to repair a rotator cuff tear. His medications include bleomycin, doxorubicin, methotrexate, and vinblastine. During the operation, a right interscalene brachial plexus block is performed using dilute lidocaine with appropriate loss of pain sensation in his right shoulder, elbow, thumb, and index finger. The procedure proceeds uneventfully. After the patient is extubated and emerges from anesthesia in the recovery unit, he is discharged with anticipatory guidance that the nerve block will wear off in several hours. Ten hours later, the patient complains that all of his right-hand fingers feel more numb than usual. Physical exam reveals decreased sensation to touch of his right upper extremity, left upper extremity, and bilateral lower extremities. The patient's strength and proprioception are otherwise unremarkable. Which of the following medications is the most likely cause of this patient's symptoms? | Oncology Medications |
M 6
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