A 23-year-old woman with no significant past medical history...

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A 74-year-old female with a history of hypertension, dyslipidemia, and osteoarthritis presents to her primary care physician because of worsening shortness of breath and intermittent chest discomfort. The patient reports that she is usually able to walk five blocks around her cul de sac, but lately this same walk causes her these symptoms. She also complains of mild chest pain that began yesterday. Vital signs are as follows: T 98.8 F, HR 90 bpm, BP 150/100 mmHG, RR 15, O2 Sat 96%. On exam, carotid pulses are noted to be delayed from the cardiac cycle. Cardiac auscultation is notable for a late-peaking crescendo-decrescendo systolic ejection murmur loudest over the right upper sternal border. The patient is referred to the emergency department, where cardiac enzymes are negative. An EKG is shown in Figure A. The patient is referred for an echocardiogram, and pressure gradient recordings across the aortic valve are shown in Figure B. Which of the following is the appropriate next step for this patient?

A 27-year-old man is brought into the emergency department a...

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A 23-year-old woman is brought to the emergency department b...

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A 66-year-old female with congestive heart failure, diabetes mellitus, depression, and osteoarthritis presents to the emergency department with fatigue, blurry vision, and diarrhea. Her home medications include furosemide, lisinopril, carvedilol, digoxin, metformin, glyburide, amitriptyline, and occasional ibuprofen for knee pain. She endorses recent knee pain and an increase in her glyburide dose. Her labs include the following: Serum: Na+: 137 mEq/L K+: 3.3 mEq/L Cl-: 99 mEq/L HCO3_: 24 mEq/L BUN: 17 mg/dL Cr: 1.62 mg/dL Glucose: 160 mg/dL An EKG can be seen in Figure A. What is the most likely inciting event for this patient's presentation?

A 26-year-old woman presents to the emergency department with vaginal discharge. She states she noticed it a few days ago and states it has been gradually worsening. The patient works at a farmer's market selling produce. Her temperature is 98.4°F (36.9°C), blood pressure is 120/74 mmHg, pulse is 83/min, respirations are 12/min, and oxygen saturation is 98% on room air. Physical exam is notable for the finding in Figure A. Laboratory testing is ordered as seen below. Urine: Color: Amber Protein: Negative Red blood cells: Negative hCG: Positive Which of the following is appropriate treatment for this patient?

A 74-year-old female presents to the emergency room with abdominal pain. She notes several days of constipation and most recently has not had a bowel movement in 3 days. She is unable to remember if she has passed gas. Her vital signs are BP 118/76 mmHg, HR 97 beats per minute, RR 17 breaths per minute, and T 99.4 degrees Fahrenheit, and her abdomen is noticeably distended. A barium enema radiograph is shown in Figure A. Which of the following is the best next step?

A 48-year-old woman is transferred from her primary care physician's office to the emergency department for further evaluation of hypokalemia to 2.5 mEq/L. She was recently diagnosed with hypertension 2 weeks ago and started on medical therapy. The patient said that she enjoys all kinds of food and exercises regularly, but has not been able to complete her workouts as she usually does. Her temperature is 97.7°F (36.5°C), blood pressure is 107/74 mmHg, pulse is 80/min, respirations are 15/min, and SpO2 is 94% on room air. Her physical exam is unremarkable. Peripheral intravenous (IV) access is obtained. Her basic metabolic panel is obtained below. Serum: Na+: 135 mEq/L Cl-: 89 mEq/L K+: 2.2 mEq/L HCO3-: 33 mEq/L BUN: 44 mg/dL Glucose: 147 mg/dL Creatinine: 2.3 mg/dL Magnesium: 2.0 mEq/L What is the next best step in management?

A 54-year-old African American man presents to the emergency department with shortness of breath. He was at home watching television when his symptoms began. He has a past medical history of COPD, alcohol abuse, diabetes, asthma, obesity, pancreatitis, peripheral neuropathy, and hypertension. He has a 30 pack-year smoking history as well. His current medications include albuterol, insulin, nicotine patches, duloxetine, hydroxyurea, and lisinopril. Chest radiography confirms the diagnosis of a spontaneous pneumothorax. A chest tube is placed, and the patient is transferred to the medical floor. Laboratory results are ordered and are seen below: Hemoglobin: 9 g/dL Platelet count: 180,000/mm^3 Mean corpuscular volume: 125 µm^3 Reticulocyte count: 0.3% Serum: Na+: 139 mEq/L Cl-: 102 mEq/L K+: 4.2 mEq/L HCO3-: 24 mEq/L BUN: 20 mg/dL Glucose: 133 mg/dL Creatinine: 1.4 mg/dL Ca2+: 10.2 mg/dL Vitamin B12: 197 ng/L AST: 22 U/L ALT: 10 U/L Troponins: undetectable On the medical floor, the patient complains of continued fatigue and minor chest pain. A peripheral smear is ordered as seen in Figure A. An EKG is ordered and demonstrates a right bundle branch block which is unchanged from previous EKGs. Which of the following is the most likely diagnosis?

A 38-year-old woman presents to her primary care physician for complaints of insomnia. She states that for the last 8 months, she has had difficultly falling asleep. Additionally, she awakens in the middle of the night or early morning and cannot fall back to sleep. When further questioned, she reports decreased appetite with a 12-lb. weight loss in the last 6 months. She was recently demoted at her work as a baker due to trouble focusing and coordinating orders and excess fatigue. She feels she is to blame for her families current financial status given her demotion. She is given a prescription for fluoxetine at this visit with follow-up 2 weeks later. At the follow-up visit, she reports no improvement in her symptoms despite taking her medication consistently. What is the most appropriate next step in management?

A 24-year-old man presents to the clinic with a one week history of pain in his left hand and stiffness in his right knee, with associated malaise and chills. He has no other past medical history, denies intravenous drug abuse, and has had no sick contacts. Vital signs are: T 38.5 C, BP 135/85, P 78, RR 16. Physical exam reveals swelling on the dorsum of the left hand and a warm erythematous right knee. The following non-painful lesions on the patients hands and ankles can be seen in Figure A. Laboratory analysis reveals a mild leukocytosis and negative blood cultures. Which of the following conditions is causing the presentation of this patient?

A 16-year-old male high school basketball player presents to his primary care provider with complaints of fatigue and night sweats for the past month. He also recalls that, after suffering a hand laceration during a game, the nurse had a difficult time achieving hemostasis. Otherwise, the patient has no other medical problems. Three weeks later, the patient is admitted to the ICU with decreased level of consciousness. His temperature is 98.7°F (37.1°C), blood pressure is 96/72 mmHg, pulse is 110/min, respirations are 18/min, and oxygen saturation is 96% on room air. Lab tests are as follows: CBC: Hemoglobin: 9 g/dL Hematocrit: 35 % Leukocyte count: 10,000/mm^3 with normal differential Platelet count: 75,000/mm^3 Prothrombin time: 18 seconds Partial thromboplastin time: 55 seconds The findings in Figure A are seen on examination of the patient’s skin. Peripheral blood smear reveals the cell morphologies seen in Figure B. What is the underlying cause of this patient’s presentation?

A 9-year-old girl is brought to the pediatrician for a welln...

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A 35-year-old homeless woman presents to the emergency department complaining of a strange sensation in her chest. The patient is disheveled and dirty. The patient is an immigrant and does not speak English. On physical exam you note a sweaty and nervous woman who demonstrates a mild tremor and proptosis. Her pulse is 110/minute, temperature is 99°F (37.3°C), and blood pressure is 110/70 mmHg. IV fluids are started. An EKG is performed and the findings are shown in Figure A. Initial labs are drawn and pending. A urine toxicology returns negative for testable illicit substances. Which of the following is the next best step in management?

A 31-year-old man with a history of schizophrenia is brought to the emergency department by police after being found agitated and attempting to steal from a grocery store. His past medical history is only notable for a recent office note from his primary care doctor for treatment of seasonal allergies. His temperature is 101°F (38.3°C), blood pressure is 173/97 mmHg, pulse is 105/min, respirations are 16/min, and oxygen saturation is 98% on room air. Physical exam is notable for a man who is very irritable and restless. He is not cooperative with exam or history and becomes combative requiring intramuscular medications and security restraining him. After this event, the rest of his exam is notable for 7 mm pupils which are equal and reactive to light, spontaneous movement of all limbs, normal sensation, and warm and sweaty skin. The patient is answering questions and states he wants to kill himself. Which of the following substances was most likely used by this patient?

A 30-year-old male gang member is brought to the emergency room with a gunshot wound to the abdomen. The patient was intubated and taken for an exploratory laparotomy, which found peritoneal hemorrhage and injury to the small bowel. He required 5 units of blood during this procedure. Following the operation, the patient was sedated and remained on a ventilator in the surgical intensive care unit (SICU). The next day, a central line is placed and the patient is started on total parenteral nutrition. Which of the following complications is most likely in this patient?

A 58-year-old man with a past medical history of hypertension, hyperlipidemia, chronic obstructive pulmonary disease, and tobacco use is brought to the emergency department by his sister for confusion. His sister reports that she and the patient were watching television together when the patient asked her to call their mother, who is deceased. His sister then noticed that he had difficulty walking to the bathroom. She reports that the patient has started drinking more since losing his job several months ago, but she insists that he has not had any alcohol while she was with him today. The patient’s home medications include hydrochlorothiazide, rosuvastatin, and albuterol as needed. His temperature is 97.9°F (36.6°C), blood pressure is 145/93 mmHg, pulse is 82/min, respirations are 12/min, and SpO2 is 96%. On physical exam, he is alert and oriented to person, place, and time. His eyes appear to flick to the right when he is asked to look to the left. The patient’s blood alcohol level is normal. Additional laboratory tests are performed and reveal the following. Leukocyte count: 7,200/mm^3 Hemoglobin: 9.1 g/dL Hematocrit: 29% Mean corpuscular volume: 109 µm^3 Platelet count: 188,000/mm^3 A peripheral smear is performed and can be seen in Figure A. What is the most likely cause of the findings seen on peripheral smear?

A 29-year-old man who recently immigrated from Russia presents to the free clinic with multiple complaints. He has a sore throat, fatigue, a rash, and sensitivity to light. He states he has never seen a doctor in his country and his past medical history is not known. His temperature is 97.9°F (36.6°C), blood pressure is 118/74 mmHg, pulse is 82/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical examination reveals the finding in Figure A, glossitis, stomatitis, and a dry rash diffusely. Which of the following vitamins is most likely deficient in this patient?

A 4-year-old girl is brought to the physician for a routine checkup. She was recently adopted and has never seen a doctor before. The patient's parents state she was very emaciated when they adopted her and noticed she has trouble seeing in the evening. They also noted that she was experiencing profuse foul-smelling diarrhea as well, which is currently being worked up by a gastroenterologist. Her temperature is 97.8°F (36.6°C), blood pressure is 104/54 mmHg, pulse is 100/min, respirations are 19/min, and oxygen saturation is 98% on room air. The girl appears very thin. She has dry skin noted on physical exam. Laboratory studies are ordered as seen below. Hemoglobin: 12 g/dL Hematocrit: 36% Leukocyte count: 4,500/mm^3 with normal differential Platelet count: 191,000/mm^3 Serum: Na+: 139 mEq/L Cl-: 100 mEq/L K+: 3.8 mEq/L HCO3-: 28 mEq/L BUN: 20 mg/dL Glucose: 88 mg/dL Creatinine: 0.7 mg/dL Ca2+: 9.0 mg/dL Which of the following findings is also likely to be seen in this patient?

A 47-year-old homeless man is admitted from the emergency department with fever and shortness of breath. He is found to have a lobar pneumonia and is promptly treated with antibiotics. As he begins to recover, he reports that over the past 7 months, he has been experiencing eye dryness and has been having increasing difficulty seeing at night. His temperature is 97.0°F (36.1°C), blood pressure is 122/70 mmHg, pulse is 81/min, respirations are 12/min, and oxygen saturation is 98% on room air. On exam, he appears very thin. Physical exam is notable for the finding in Figure A. What other finding is likely to be found in this patient?