A 51-year-old woman with a history of type 2 diabetes mellitus presents to the clinic for a routine annual exam. A review of systems is positive for palpitations. She occasionally feels like her heart is racing, but she attributed this to stress or anxiety. Sometimes she can slow down her palpitations if she holds her breath. An ECG is shown in Figure A. She is prescribed 10 mg of atorvastatin daily in addition to her current metformin. One month later, she presents to the clinic complaining of malaise. She reports that she “feels off” with mild nausea, light-headedness, and persistent palpitations, despite trying to hold her breath. Her temperature is 98.7°F (37.1°C), blood pressure is 120/79 mmHg, pulse is regular at 215/min, and respirations are 14/min. Another ECG is shown in Figure B. Which of the following is the most appropriate initial therapy for this patient?

A 65-year-old female with a history of rheumatoid arthritis presents to her primary care physician because she is concerned about her skin. She states that over the past few months she has become extremely itchy, in spite of applying numerous creams and lotions. She states that she has not noticed any visible changes or rashes on her skin and feels well apart from mild fatigue. On exam, the physician appreciates hepatosplenomegaly and observes the findings shown in Figure A. Laboratory testing reveals elevated antimitochondrial antibodies and a liver biopsy is obtained which is demonstrated in Figure B. What is the most likely underlying pathophysiology of this patient's disease?

A 23-year-old woman presents to her primary care physician due to amenorrhea. The patient states that historically she has her period once every three months but recently has not had it at all. Otherwise, she has no other complaints. The patient recently started college and is a varsity athlete for the track team. She works part time in a coffee shop and is doing well in school. The patient is not sexually active and does not drink alcohol, use illicit drugs, or smoke. She has no significant past medical history and occasionally takes ibuprofen for headaches. Her temperature is 99.5°F (37.5°C), blood pressure is 100/55 mmHg, pulse is 50/min, respirations are 10/min, and oxygen saturation is 98% on room air. On physical exam, you note a young, lean, muscular woman in no acute distress. Which of the following is the most likely long-term outcome in this patient?

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A 30-year-old male presents to the emergency department with a complaint of abdominal pain. The patient states he was at a barbecue around noon. Lunch was arranged as a buffet without refrigeration. Within 2 to 3 hours, he had abdominal pain associated with multiple episodes of vomiting, retching, and watery diarrhea. On exam, vital signs are T 99.1, HR 103, BP 110/55, RR 14. Abdominal exam is significant for pain to deep palpation without any rebounding or guarding. There is no blood on fecal occult testing (FOBT). What is the most likely cause of this patient's presentation?

A 46-year-old female with a history of hypertension and asthma presents to her primary care physician for a health maintenance visit. She states that she has no current complaints and generally feels very healthy. The physician obtains routine blood work, which demonstrates elevated transaminases. The physician should obtain further history about all of the following EXCEPT:

A 6-month-old male presents to the emergency department with his parents after his three-year-old brother hit him on the arm with a toy truck. His parents are concerned that the minor trauma caused an unusual amount of bruising. The patient has otherwise been developing well and meeting all his milestones. His parents report that he sleeps throughout the night and has just started to experiment with solid food. The patient’s older brother is in good health, but the patient’s mother reports that some male members of her family have an unknown blood disorder. Her and her husband are healthy. On physical exam, the patient is agitated and difficult to soothe. He has 2-3 inches of ecchymoses and swelling on the lateral aspect of the left forearm. The patient has a neurological exam within normal limits and pale skin with blue irises. An ophthalmologic evaluation is deferred. Which of the following is the best initial step?

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A 63-year-old male with a history of type II diabetes, hypertension, and chronic kidney disease (CKD) stage IV presents to his primary care physician complaining of new onset swelling and calf tenderness in his right lower extremity. The patient has just returned from a trip to Europe for work. Examination of the extremity is shown in Figure A. The patient is referred to the Emergency Department, where he undergoes a right lower extremity duplex ultrasound shown in Figure B. Laboratory values are shown in Figure C. What is the next best step in management?

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A 78-year-old male presents to the emergency department with dysuria for two days. He also endorses increased urinary frequency and urgency, but denies hematuria. His past medical history is significant for hypertension and coronary artery disease, but he has been lost to follow up for many years. On physical exam, he has mild suprapubic pain without costovertebral angle tenderness. Urinalysis is positive for nitrites and leukocyte esterase with few white blood cells, large protein, and no blood. Urine culture grows Escherichia coli. The patient is diagnosed with a urinary tract infection and treated with levofloxacin as an outpatient. He is scheduled for an appointment with a nephrologist due to his urinalysis results and eventually undergoes kidney biopsy, which can be seen in Figure A. Which of the following is most likely associated with this patient’s renal disease?

A 39-year-old male presents with muscle weakness in his upper and lower extremities. The patient has also noticed some trouble with swallowing. On physical exam, signs of hyperreflexia, spasticity, fasciculations, and muscle atrophy are present in an asymmetric fashion. Tongue fasciculations are also present. No sensory loss is noted. The patient does not report any abnormality with his bowel or bladder function. What will most likely be found on muscle biopsy?

A 13-year-old is brought into your office by his father because of left knee pain. The father states that the patient has no medical conditions and that his birth history is normal. He is an avid basketball player and recently started playing for his school's basketball team. On exam, his vitals are within normal limits. There is no erythema or effusion in any of the knee compartments, and the patient has a full range of motion. The patient has full strength on flexion and extension, but does have pain on the tibial tubercle with palpation and resistance to knee extension. A lateral view of his left knee is shown in the radiograph in Figure A. What is the most likely cause of his knee pain?

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A 52-year-old man presents to his primary care physician for generalized pain. The patient states that he feels like his muscles and bones are in constant pain. This has persisted for the past several weeks, and his symptoms have not improved with use of ibuprofen or acetaminophen. The patient has a past medical history of alcohol abuse, repeat episodes of pancreatitis, constipation, and anxiety. He has a 22 pack-year smoking history. His temperature is 99.5°F (37.5°C), blood pressure is 140/95 mmHg, pulse is 70/min, respirations are 15/min, and oxygen saturation is 99% on room air. On physical exam, you note generalized tenderness/pain of the patient's extremities. Abdominal exam reveals normoactive bowel sounds and is non-tender. Dermatologic exam is unremarkable. Laboratory values are ordered as seen below. Hemoglobin: 12 g/dL Hematocrit: 36% Leukocyte count: 7,500/mm^3 with normal differential Platelet count: 147,000/mm^3 Serum: Na+: 138 mEq/L Cl-: 100 mEq/L K+: 4.2 mEq/L HCO3-: 24 mEq/L BUN: 20 mg/dL Glucose: 99 mg/dL Creatinine: 1.0 mg/dL Ca2+: 10.2 mg/dL Alkaline phosphatase: 252 U/L Lipase: 30 U/L AST: 12 U/L ALT: 10 U/L Which of the following is associated with this patient's condition?

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A 2-year-old male is brought to the emergency department by his mother. The patient awoke in the night screaming, and when the mother changed his diaper she found thick, bloody stool. The child was born at 35 weeks, via c-section, and required an overnight stay in the NICU for tachypnea. Developmentally, the child is at the 38th percentile for weight and has met all milestones. The child's pulse is 110/min, blood pressure is 90/60 mmHg, and respirations are 20/min. An abdominal ultrasound is obtained, and shown in Figure A. What is the next best step in management?

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A 17-year-old high school student presents to your office for recent mood and skin changes. The patient is a high school senior who is competing on the wrestling team and recently has lost weight to drop two weight classes over the past several months. He states he has dry, cracking, and irritated skin, as well as a sensation of tingling in his hands and feet. The patient also states that he has not been feeling himself lately. He finds himself more irritable and no longer enjoys many of the activities he once enjoyed. He finds that he often feels fatigued and has trouble concentrating. The patient does not have a significant past medical history and is not on any current medications. The patient admits to drinking alcohol and smoking marijuana on special occasions. He states that he uses supplements that his other team members use. Physical exam is significant for acne, dry, cracked skin around the patient's mouth in particular, and decreased sensation in his lower extremities. Laboratory values are as follows: Serum: Na+: 137 mEq/L Cl-: 101 mEq/L K+: 4.1 mEq/L HCO3-: 24 mEq/L BUN: 15 mg/dL Glucose: 79 mg/dL Creatinine: 0.9 mg/dL Ca2+: 9.2 mg/dL Mg2+: 1.5 mEq/L Homocysteine: 11.2 µmol/L (normal: 4.6 to 8.1 µmol/L) AST: 11 U/L ALT: 11 U/L Alkaline phosphatase: 27 U/L Albumin: 4.5 g/dL Total protein: 6.9 g/dL Total bilirubin: 0.5 mg/dL Direct bilirubin: 0.3 mg/dL Which of the following is the most likely diagnosis?

A 13-year-old male is brought by ambulance to the ED with bilateral foot pain. He reports making footprints on some freshly laid sidewalk cement the day before with his friends. He states that his jeans' heels were slightly soaked, and that he did not attempt to wash the cement off of them. On physical exam, there is marked tissue necrosis on both ankles extending down to the bone in some places (Figure A). Which chemical was this patient most likely exposed to?

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A 40-year-old female visits the emergency department with right upper quadrant pain and fever of 2-hours duration. She denies alcohol, cigarette, and drug use and reports no other medical problems. Body mass index is 30 kg/m^2. Her temperature is 38.5 degrees Celsius (101.3 degrees Fahrenheit), blood pressure is 130/80 mm Hg, pulse is 90/min, and respirations are 18/min. Jaundice is present in the sclera and at the base of the tongue. The abdomen is tender in the right upper quadrant. Liver function test (LFTs) reveal elevated direct and total bilirubin and alkaline phosphatase of 500 U/L. IV Ampicillin-gentamicin is administered, fluid resuscitation is initiated, and over 24 hours the patient’s fever improves. Which of the following is the next step in the management of this patient:

A 5-week-old male infant is brought to the Emergency Department with the complaint of vomiting. His parents state he has been unable to keep normal feedings down for the past week and now has projectile non-bilious vomiting after each meal. He was given a short course of oral erythromycin at 4 days of life for suspected bacterial conjunctivitis. Physical examination is significant for sunken fontanelles and dry mucous membranes. A palpable, ball shaped mass is noted just to the right of the epigastrum. Which of the following conditions is most likely in this patient?

A 77-year-old male is brought to your clinic at the insistence of his daughter for a regular check up appointment. The patient lives alone and has not seen a physician in several years. According to the daughter, the patient has been reclusive ever since his wife passed away and has been caring for himself. On physical exam, the patient is very thin and disheveled. He has poor dentition with swollen gingivae and skin findings as shown (Figure A). The rest of his exam is within normal limits. Which of the following is most likely affected in this patient?

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A 19-year-old male college student with no significant medical history presents to the emergency department with altered mental status. His girlfriend said that he drank multiple shots of vodka and gin throughout the weekend and was found slumped on the couch with some vomit on his shirt. He is afebrile, with a blood pressure of 128/60 mmHg, pulse of 100/min, respirations at 25/min, and SpO2 of 95% on room air. His pupils are equal and reactive to light bilaterally. He exhibits no tremors or myoclonus. The remainder of the physical exam is unremarkable. His basic metabolic panel is displayed below: Serum: Na+: 138 mEq/L Cl-: 90 mEq/L K+: 4.0 mEq/L HCO3-: 20 mEq/L BUN: 30 mg/dL Glucose: 100 mg/dL Creatinine: 0.8 mg/dL An arterial blood gas reveals the following: pH: 7.32 pCO2: 34 mmHg pO2: 89 mmHg The girlfriend is concerned that the patient's breathing appears uncomfortable. How do you respond?

A healthy 28-year-old woman at 30-weeks gestational age, has gained 35lbs since becoming pregnant. She complains of several weeks of bilateral numbness and tingling of her palms, thumbs, index and middle fingers that is worse at night. She also notes weakness gripping objects at the office. Which nerve is most likely affected?

A 27 year-old-male presents to the Emergency Room as a code trauma after being shot in the neck. En route, the patient’s blood pressure is 127/73 mmHg, pulse is 91/min, respirations are 14/min, and oxygen saturation is 100% on room air with GCS of 15. On physical exam, the patient is in no acute distress; however, there is an obvious entry point with oozing blood near the left lateral neck above the cricoid cartilage with a small hematoma that is non-pulsatile and stable since arrival. The rest of the physical exam is unremarkable. Rapid hemoglobin returns back at 14.1 g/dL. After initial resuscitation, what is the next best step in management?

A 45-year-old female presents to the emergency room as a trauma after a motor vehicle accident. The patient was a restrained passenger who collided with a drunk driver traveling approximately 45 mph. Upon impact, the passenger was able to extricate herself from the crushed car and was sitting on the ground at the scene of the accident. Her vitals are all stable. On physical exam, she is alert and oriented, speaking in complete sentences with a GCS of 15. She has a cervical spine collar in place and endorses exquisite cervical spine tenderness on palpation. Aside from her superficial abrasions on her right lower extremity, the rest of her examination including FAST exam is normal. Rapid hemoglobin testing is within normal limits. What is the next best step in management of this trauma patient?

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A 49-year-old female patient was sent from her primary care physician to the emergency department (ED) for the management of marked hypertension, and acute renal failure. In the ED, she claims that she has fatigue, stiffening in the joints, muscle pain, pain in her fingertips, and paleness in her fingers when she is in a cold environment. She has been having these symptoms for some time. She has noticed that the volume of urine she usually produces is significantly decreased. Vitals are remarkable for a blood pressure of 170/105 mmHg. Physical examination is notable for taut, thickened skin in the face, hands, and fingers (Figure A). Her creatinine is 4.2 mg/dL, from a baseline of 1.2 mg/dL. Which of the following is a property of the medication that will most likely improve survival in this patient’s current condition?

A 22-year-old woman arrives to your clinic complaining of a worsening rash. She reports the rash first appeared one year ago on her hands, but she had been too stressed with her final semester of classes to see a dermatologist. Since she first noticed it, the lesion has increased in size. The patient denies pain or pruritis, but notes that sometimes her hands are dry. Her past medical history is significant for seasonal allergies. Her current medications include only an oral contraceptive. Her family history is significant for a cousin with systemic lupus erythematous. She works part-time as a hair-dresser, which she started 6 months ago. She denies tobacco use, but has 3-4 glasses of wine on the weekend. Figure A shows a photograph of the patient’s hand. On physical exam you also note well-demarcated, de-pigmented patches in her armpits and a similar patch on her chest. Which of the following may be associated with this patient’s condition?

A 24-year-old woman presents to her physician complaining of intermittent vaginal discharge. She has noticed this for the last 3 months and states that it looks “like egg white”. Although she does not recall a specific pattern to the discharge, she notes that it happens every few weeks or so. She has not noticed a significant odor to the discharge. The patient has regular periods every 28 days with mild cramping and increased fatigue for one day each cycle. Her last period was 2 weeks ago. She has a past medical history of a recent urinary tract infection, for which she received a course of ciprofloxacin. Six months ago, she started having intercourse with a new partner and has not been using barrier protection. At this visit, her temperature is 98.4°F (36.9°C), blood pressure is 124/76 mmHg, pulse is 70/min, and respirations are 14/min. The patient has a soft, nontender abdomen, and speculum exam reveals a clear, thin discharge in the vaginal vault. There is no adnexal or cervical motion tenderness, and the vulvar skin is without erythema or irritation. A wet mount of a vaginal swab is shown in Figure A. Which of the following is the underlying etiology of this patient’s presentation?

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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 23-year-old male presents to his primary care physician for a follow-up after being discharged from the hospital following a motor vehicle accident a month ago. He was a restrained driver in a front end collision. He reports he has recovered well, but notes that he has experienced abdominal bloating, and can't eat as much as he used to. On physical exam, the patient's abdomen is moderately distended, with no fluid wave. Bowel sounds are normal, but the patient notes discomfort upon deep palpation, especially in the epigastric region. An abdominal CT is obtained and shown in Figure A. What is the best treatment for this patient?

A 58-year-old woman is followed in the nephrology clinic for longstanding chronic kidney disease (CKD) secondary to uncontrolled hypertension. Her glomerular filtration rate (GFR) continues to decline, and she is approaching initiation of hemodialysis. Plans are made to obtain vascular access at the appropriate time, and the patient undergoes the requisite screening to be enrolled as an end stage renal disease (ESRD) patient. Among patients on chronic hemodialysis, which of the following is the most common cause of death?