A 69-year-old man presents to his primary care provider for ...

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A 40-year-old patient is brought into the emergency department after suffering a motor vehicle crash where he was pinned underneath his motorcycle for about 30 minutes before a passerby called 911. While evaluating him per your institution's trauma guidelines, you discover pain upon palpation of his right lower extremity which is much larger than his left counterpart. The patient admits to decreased sensation over his right lower extremity and cannot move his leg. There are no palpable dorsalis pedis or posterior tibial pulses on this extremity, and it is colder and paler in comparison to his left side. Measured compartment pressure of his distal right leg is 35 mm Hg. What is the next best step in this patient's care?

A 27-year-old man presents to the emergency department following a motor vehicle accident. He was the unrestrained driver traveling at a high rate of speed prior to crashing into the back of a stopped semi truck. On arrival, he complains of shortness of breath and chest pain. He is alert and oriented and appears in acute distress. His temperature is 98.6°F (37.0°C), pulse is 120, blood pressure is 80/50 mmHg, respirations are 30/min, and pulse oximetry is 89% on room air. On exam, bruising is noted across the chest. Breath sounds are diminished over the left side of the chest. Jugular venous distention is noted. Which of the following is the most appropriate next step in management?

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A 55-year-old man presents to the emergency room with a skin lesion. It has persisted for several days without improvement. The patient has a medical history of alcohol abuse, intravenous drug abuse, diabetes, human immunodeficiency virus infection, and depression. He last used heroin 3 days ago and has been drinking 4-7 alcoholic drinks per day. He does not follow with a physician regularly. His temperature is 99.5°F (37.5°C), blood pressure is 157/98 mmHg, pulse is 100/min, respirations are 14/min, and oxygen saturation is 98% on room air. Cardiopulmonary exam is notable for a systolic murmur heard along the left sternal border. Dermatologic exam is notable for the finding in Figure A. The patient's abdominal exam and neurological exam are within normal limits. Which of the following is the most likely diagnosis?

A 23-year-old G1P0 woman presents to the emergency departmen...

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An 82-year-old man with a history of atrial fibrillation pre...

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A 26-year-old woman is found wandering in the street at 3 AM...

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A 7-year-old boy is brought to his pediatrician by his mother for recent fatigue and intermittent fevers over the past month. She also reports that her son has appeared much paler recently. Vital signs at today's visit are within normal limits. Physical examination is significant for pallor, petechiae, lymphadenopathy, and hepatosplenomegaly. A complete blood count reveals anemia, thrombocytopenia, and neutropenia. A peripheral blood smear is shown in Figure A. Bone marrow aspiration reveals 47% lymphoblasts. Which of the following is associated with this patient's presenting condition?

A 52-year-old man presents to his primary care physician. The man has been feeling very tired lately and thinks that he looks more pale. The physician orders a complete blood count, which shows: Hgb 8.5 g/dL; WBC 1,200/microliter; platelets 70,000/microliter. The patient is referred for bone marrow biopsy, which shows the findings in Figure A. Which of the following is the correct diagnosis?

A 25-year-old mother presents to her primary care physician for wrist pain. The patient recently gave birth to a healthy newborn at 40 weeks gestation. Beginning one week ago, she started having pain over her wrist that has steadily worsened. The patient notes that she also recently fell while walking and broke the fall with her outstretched arm. The patient is an accountant who works from home and spends roughly eight hours a day typing or preparing financial statements. Recreationally, the patient is a competitive cyclist who began a rigorous training routine since the birth of her child. The patient's past medical history is notable for hypothyroidism that is treated with levothyroxine. On physical exam, inspection of the wrist reveals no visible or palpable abnormalities. Pain is reproduced when the thumb is held in flexion, and the wrist is deviated toward the ulna. The rest of the patient's physical exam is within normal limits. Which of the following is the best next step in management?

A 48-year-old Caucasian female presents to her primary care physician for evaluation of progressive weakness and shortness of breath. She has had progressive shortness of breath over the last year with an intermittent non-productive cough. In addition, she complains of difficulty raising her arms to brush her hair. Her temperature is 99.6°F (37.6°C), pulse is 80/min, blood pressure is 130/85 mmHg, respirations are 18/min, and oxygen saturation is 95% on room air. Neurologic exam shows 4/5 strength in the deltoid muscles bilaterally. Diffuse dry crackles are heard on lung auscultation. A faint erythematous rash is noted on the malar cheeks, periorbital areas, lateral proximal thighs, and the elbows. Which of the following tests is most likely to confirm the diagnosis?

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A 15-year-old boy is brought to the emergency department for difficulty breathing. He states that he was at a new restaurant and had just began his meal when he began to have difficulty breathing. Shortly after, he states that his skin became itchy. He reports no significant past medical history and states that he takes no medications. His temperature is 98.6°F (37.0°C), pulse is 120, blood pressure is 85/60, respirations are 24/min, and pulse oximetry is 89% on room air. He appears to be in acute distress. Examination of the patients skin is shown in Figure A. Wheezing is noted throughout all lung fields. Supplemental oxygen is applied. Which of the following is the most appropriate next step in management?

A 5-year-old boy presents to the pediatrician for a well chi...

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A 36-year-old male with fluctuating levels of consciousness is brought to the emergency department by ambulance due to a fire in his home. He currently opens his eyes to voice, localizes painful stimuli, responds when asked questions, but is disoriented and cannot obey commands. The patient’s temperature is 99°F (37.2°C), blood pressure is 86/52 mmHg, pulse is 88/min, and respirations are 14/min with an oxygen saturation of 97% O2 on room air. Physical exam shows evidence of soot around the patient’s nose and mouth, but no burns, airway obstruction, nor accessory muscle use. A blood lactate is 14 mmol/L. The patient is started on intravenous fluids. What is the next best step in management?

A 4-year-old boy presents to his pediatrician for severe developmental delay. On exam he is noted to have macroorchidism, hypertelorism, large protruding ears, a large jaw, and a long thin face. Suspicious of what the diagnosis may be, the pediatrician orders a PCR and DNA sequencing. The results reveal an expansion of 250 repeats of CGG. What is the diagnosis of the boy?

A 28-year-old homeless male with a past medical history significant for asthma comes to your clinic complaining of a chronic rash on his scalp and feet. He describes the rash as “dry and flaky,” and reports it has been present for at least a year. He was using a new dandruff shampoo he got over the counter, with little improvement. The patient reports it is extremely itchy at night, to the point that he can't sleep. On exam, you note a scaly patch of alopecia, enlarged lymph glands along the posterior aspect of his neck, and fine scaling in between his toes and on the heel and sides of his foot. His temperature is 99°F (37°C), blood pressure is 118/78 mmHg, and pulse is 81/min. Which of the following is the most accurate test for the suspected diagnosis?

A 21-year-old female is being evaluated for worsening "flaky scalp." She does not remember exactly when it started, but reports it has been at least a couple months. Her symptoms then developed into a scaling patch at the top of her head. She has begun ritualistically and repetitively combing her hair to the left 3 times every time she feels any "flakes." The patient reports that in the past she chemically treated her hair, but stopped when she noticed the scalp scaling had developed into an area of balding. She admits to feeling tired lately and gained 5 lbs in the last 2 months, but admits she has been staying up late to study for exams. The patient's past medical history is significant for bipolar I disorder, for which she takes lithium, and acne, for which she uses topical salicylic acid. The patient reports fatigue, but denies headache, shortness of breath, chest pain, polyuria, hematuria, or other rashes. Vital signs include a temperature of 99°F (37°C), blood pressure of 122/76 mmHg, a pulse of 88/min, and an oxygen saturation of 99% on room air. Physical exam is negative except for scalp findings shown in Figure A. Routine lab values are drawn, including: Leukocyte count: 9,500/mm^3 Platelet count: 200,000/mm^3 Hemoglobin: 14.5 g/dL Serum: Na+: 144 mEq/L K+: 4.3 mEq/L Cl-: 85 mEq/L HCO3-: 22 mEq/L BUN: 11 mg/dL Creatinine: 1.2 mg/dL Serum osmolality: 295 mOsmol/kg H2O Urine osmolality: 320 mOsmol/kg H2O Which of the following is the best initial diagnostic test?

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A 34-year-old G3P2103 with a past medical history of preeclampsia in her last pregnancy, HIV (CD4: 441/mm^3), and diabetes mellitus presents to her obstetrician for her first postpartum visit. She delivered her third child via C-section one week ago and reports that she is healing well from the surgery. She says that feeding via formula has been going well and that her baby has nearly regained his birth weight. The patient complains that she has been more tired than expected despite her efforts to sleep whenever her baby is napping. She relies on multiple iced coffees per day and likes to eat the ice after she finishes the drink. Her diet is otherwise unchanged, and she admits that she has not been getting outside to exercise as much as usual. Her home medications include metformin and her HAART regimen of dolutegravir, abacavir, and lamivudine. Her temperature is 98.9°F (37.2°C), blood pressure is 128/83 mmHg, pulse is 85/min, and respirations are 14/min. On physical exam, she is tired-appearing with conjunctival pallor. This patient is at risk of developing which of the following conditions?

A 64-year-old female presents to her primary care physician for an annual checkup. She states that her health is adequate, but she has not been doing well since her husband died last year. She is able to get by but admits to having trouble caring for herself, cooking, cleaning, and paying her bills. The patient complains of diffuse muscle aches and pains. She has a past medical history of anxiety and seasonal affective disorder. She is not currently taking any medications. On physical exam, you note a gaunt woman with a depressed affect. You note that her body mass index (BMI) and height have both decreased since her last annual visit. On physical exam, her cardiac, pulmonary, and abdominal exams are within normal limits. Lab work is drawn and is as follows: Serum: Na+: 135 mEq/L K+: 3.7 mEq/L Cl-: 100 mEq/L HCO3-: 23 mEq/L Urea nitrogen: 7 mg/dL Glucose: 70 mg/dL Creatinine: 0.8 mg/dL Ca2+: 8.0 mg/dL Mg2+: 1.5 mEq/L Parathyroid hormone: 855 pg/mL Alkaline phosphatase: 135 U/L Phosphorus: 2.6 mg/dL Hemoglobin: 14 g/dL Hematocrit: 36% Platelet count: 187,000/mm^3 Leukocyte count: 4,700/mm^3 What is the most likely diagnosis?

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A 37-year-old G1P000 presents to her obstetrician for her first prenatal visit. She states that her last menstrual period (LMP) was 11 weeks ago, though she is unsure of the exact date as her periods are sometimes irregular. She and her husband had 5 months of timed, unprotected intercourse before she had a positive home pregnancy test 2 weeks ago. She has been feeling generally well but notes some morning nausea and vomiting. She also mentions that for the last 6 months or so, she has felt increasing pelvic pressure and worsening urinary frequency but has not sought medical care for these symptoms. The patient has a history of obesity and hypertension but is not on any medications. Her mother had a hysterectomy at age 64 for fibroids, and her sister had a twin pregnancy after assisted reproduction. At this visit, the patient’s temperature is 98.3° F (36.8° C), blood pressure is 142/85 mmHg, pulse is 82/min, and respirations are 14/min. She has gained 4 pounds since the last time she weighed herself 4 months ago. On exam, the patient’s fundus is palpated at the umbilicus, her cervix is closed and firm, and there are no adnexal masses. Her lab results are shown below: ß-hCG: 81,324 mIU/mL Thyroid stimulating hormone (TSH): 1.2 µIU/L Which of the following is the most likely diagnosis?

A 36-year-old woman, G1P1001, presents to her gynecologist f...

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A 42-year-old male with a history significant for IV drug use comes to the emergency department complaining of persistent fatigue and malaise for the past three weeks. On physical exam, you observe a lethargic male with icteric sclera and hepatomegaly. AST and ALT are elevated at 600 and 750, respectively. HCV RNA is positive. Albumin is 3.8 g/dL and PT is 12. A liver biopsy shows significant inflammation with bridging fibrosis. What is the most appropriate treatment at this time?

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A mother arrives to your clinic with her 5-year-old son afraid that he caught lice from a recent preschool outbreak. She reports that for the past week the son has had, “white flakes,” in his hair despite daily baths. The patient denies pain, but reports that his scalp is itchy at night. The patient has also developed a small area of hair loss which the mother feels is related to the patient scratching. The patient has no significant past medical history, but did have "cradle cap" when he was an infant. Family medical history is significant for eczema and asthma in the mother. Upon further questioning, the mother reports that the family got a new cat two months ago and that her other daughter has also been experiencing similar symptoms. On examination, the patient's scalp has a 1 cm scaly patch, with evidence of excoriation and an overlying yellow crust. There is a central area of alopecia. A skin scraping is performed. The results are shown in Figure A. Which of the following is the appropriate course of treatment?

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A 37-year-old G1P1001 delivers a male infant at 9 pounds 6 ounces after a C-section for preeclampsia with severe features. The mother has a history of type II diabetes with a hemoglobin A1c of 12.8% at her first obstetric visit. Before this pregnancy, she was taking metformin, and during this pregnancy, she was started on insulin. At her routine visits, her glucose logs frequently showed fasting fingerstick glucoses above 120 mg/dL and postprandial values above 180 mg/dL. In addition, her routine third trimester culture for group B Streptococcus was positive. At 38 weeks and 4 days gestation, she was found to have a blood pressure of 176/103 mmHg and reported a severe headache during a routine obstetric visit. She denied rupture of membranes or vaginal bleeding. Her physician sent her to the obstetric triage unit, and after failure of several intravenous doses of labetalol to lower her blood pressure and relieve her headache, a C-section was performed without complication. Fetal heart rate tracing had been reassuring throughout her admission. Apgar scores at 1 and 5 minutes were 7 and 10. After one hour, the infant is found to be jittery; the infant's temperature is 96.1°F (35.6°C), blood pressure is 80/50 mmHg, pulse is 110/min, and respirations are 60/min. When the first feeding is attempted, he does not latch and begins to shake his arms and legs. After 20 seconds, the episode ends and the infant becomes lethargic. Which of the following is the most likely cause of this infant’s presentation?

A 23-year-old man complains of lower back pain that began approximately 6 months ago. He is unsure why he is experiencing this pain and notices that this pain is worse in the morning after waking up and improves with physical activity. Ibuprofen provides significant relief. He denies bowel and bladder incontinence or erectile dysfunction. Physical exam is notable for decreased chest expansion, decreased spinal range of motion, 5/5 strength in both lower extremities, 2+ patellar reflexes bilaterally, and an absence of saddle anesthesia. Which of the following is the most appropriate next test for this patient?

A 17-year-old female presents to her primary care physician with right foot pain for the last 3 days. She states that the pain began gradually and is worse with weight bearing and activity. The patient states that she recently began to train for a marathon and is running much more than she did several months ago. She is healthy but has a 2-year history of irregular menstruation, with up to 3 months between periods. At this visit, her temperature is 98.5°F (36.9°C), blood pressure is 116/67 mmHg, pulse is 75/min, and respirations are 14/min. Her BMI is 17.1 kg/m^2, and she appears tired with a flat affect. Palpation of the dorsal surface of the right foot reveals point tenderness on the second metatarsal, though there is no redness, warmth, or swelling. The remainder of the exam is unremarkable. Plain radiograph of the right foot is performed and shown in Figure A. Which of the following is the best next step in management?

A 27-year-old G3P2002 presents to the clinic for follow-up after her initial prenatal visit. Her last period was 8 weeks ago. Her medical history is notable for obesity, hypertension, type 2 diabetes, and eczema. Her 2 current children are healthy. Her current pregnancy is with a new partner after she separated from her previous partner. Her vaccinations are up to date since the delivery of her second child. Her temperature is 98°F (37°C), blood pressure is 110/60 mmHg, pulse is 85/min, and respirations are 18/min. Her physical exam is unremarkable. Laboratory results are shown below. Hemoglobin: 14 g/dL Hematocrit: 41% Leukocyte count: 9,000/mm^3 with normal differential Platelet count: 210,000/mm^3 Blood type: O Rh status: Negative Urine: Epithelial cells: Rare Glucose: Positive WBC: 5/hpf Bacteria: None Rapid plasma reagin: Negative Rubella titer: > 1:8 HIV-1/HIV-2 antibody screen: Negative Gonorrhea and Chlamydia NAAT: negative Pap smear: High-grade squamous intraepithelial lesion (HGSIL) Which of the following is the most appropriate next step in management?

A 23-year-old woman presents to the emergency department for evaluation of abdominal pain. She states that her pain started yesterday and was initially in the center of her abdomen. When she awoke today, she states that her pain was much worse and is now located in the right lower quadrant of her abdomen. She reports associated nausea and vomiting that started this morning as well as fevers. She denies any other symptoms. Her temperature is 102.2°F (39.0°F), pulse is 102, blood pressure is 115/70 mmHg, and respirations are 18/min. On exam there is tenderness to palpation in the right lower quadrant with guarding and rebound tenderness. An abdominal CT scan is obtained as shown in Figure A. Which of the following best describes the pathophysiology of this patient's condition?

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A 27-year-old man presents to the emergency department with back pain. The patient states that he has back pain that has been steadily worsening over the past month. He states that his pain is worse in the morning but feels better after he finishes at work for the day. He rates his current pain as a 7/10 and says that he feels short of breath. His temperature is 99.5°F (37.5°C), blood pressure is 130/85 mmHg, pulse is 80/min, respirations are 14/min, and oxygen saturation is 99% on room air. On physical exam, you note a young man who does not appear to be in any distress. Cardiac exam is within normal limits. Pulmonary exam is notable only for a minor decrease in air movement bilaterally at the lung bases. Musculoskeletal exam reveals a decrease in mobility of the back in all four directions. Which of the following is the best initial step in management of this patient?

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A 43-year-old construction worker presents to the emergency department two hours after sustaining a deep laceration to his left forearm by a piece of soiled and rusted sheet metal. His vital signs are stable, there is no active bleeding, his pain is well controlled, and a hand surgeon has been notified about damage to his forearm tendons. He does not recall receiving any vaccinations in the last 30 years and does not know if he was vaccinated as a child. What is the appropriate post-exposure prophylaxis?