A 26-year-old medical student presents to occupational healt...

Sorry, only PEAK Subscribers can view this question

An 87-year-old man presents to the emergency department with decreased hearing. The patient states that for the past week he has had decreased hearing that is predominantly affecting his left ear. He denies any fever, chills, nausea, vomiting, or changes in his vision. The patient has a past medical history of asthma, HIV, and anxiety. His current medications include HAART, albuterol, and clonazepam. The patient states his last CD4 count taken 2 weeks ago was 650. His temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 100/min, respirations are 11/min, and oxygen saturation is 98% on room air. Laboratory values are obtained and shown below: Hemoglobin: 11 g/dL Hematocrit: 33% Leukocyte count: 2,500/mm^3 with normal differential Platelet count: 197,000/mm^3 Serum: Na+: 139 mEq/L Cl-: 100 mEq/L K+: 4.3 mEq/L HCO3-: 24 mEq/L BUN: 20 mg/dL Glucose: 99 mg/dL Creatinine: 1.1 mg/dL Ca2+: 10.2 mg/dL AST: 12 U/L ALT: 10 U/L On physical exam, you note an elderly man in no current distress. Cardiopulmonary exam is within normal limits. HEENT exam reveals the finding in Figure A but is otherwise unremarkable. Neurological exam reveals decreased hearing in the patient's left ear but is otherwise non-focal. On otoscopy, the tympanic membrane is hypomobile. Which of the following is the most appropriate next step in management?

A 38-year-old man presents to the emergency department with ...

Sorry, only PEAK Subscribers can view this question

A 24-year-old male is rushed to the emergency department after sustaining several gunshot wounds to the chest. He was found nonresponsive in the field and was intubated en route to the hospital. His vital signs are as follows: temperature is 98.8 deg F (37.1 deg C), blood pressure is 87/52 mmHg, pulse is 120/min, and respirations are 16/min. Physical examination is significant for decreased breath sounds and dullness to percussion over the right lung. A chest radiograph in the emergency department shows a large fluid collection in the right thoracic cavity. After aggressive fluid resuscitation is initiated, an emergent chest-tube was placed in the emergency department. The chest tube puts out 700 cc of frank blood and 300 cc/hr over the next 5 hours. A follow up post-chest tube insertion chest radiograph demonstrates significant residual right hemothorax. Which of the following is the next best step in management of this patient?

A 3-month-old boy is brought to the emergency department by his mom for breathing difficulty after a recent fall. His parents say that he rolled off of the mattress and landed on the hard wood floor earlier today. After an extensive physical exam, he is found to have many purplish bruises and retinal hemorrhages. A non-contrast head CT scan shows a subdural hemorrhage. He was treated in the hospital with full recovery from his symptoms. Which of the following is the most important follow up plan?

A 31-year-old man presents to the general health clinic for ...

Sorry, only PEAK Subscribers can view this question

A 46-year-old Caucasian male with past medical history of HIV (CD4: 77/mm^3), hypertension, hyperlipidemia, and osteoarthritis presents to the emergency department with sudden weakness of his right hand. He reports that the weakness has gradually been getting worse and that this morning he dropped his cup of coffee. He has never had anything like this happen to him before, although he was hospitalized last year for pneumonia. He reports inconsistent adherence to his home medications, which include raltegravir, tenofovir, emtricitabine, TMP-SMX, hydrochlorothiazide, pravastatin, and occasional ibuprofen. His father died of a myocardial infarction at the age of 60, and his mother suffered a stroke at the age of 72. The patient's temperature is 102.6°F (39.2°C), blood pressure is 156/92 mmHg, pulse is 88/min, and respirations are 18/min. On neurological exam, he has 3/5 strength in the distal muscles of the right extremity with preserved sensation. His neurological exam is normal in all other extremities. Which of the following is the best next step in management?

A 52-year-old male presents to his primary care provider for...

Sorry, only PEAK Subscribers can view this question

A 45-year-old man with history of IV drug use presents to th...

Sorry, only PEAK Subscribers can view this question

A 17-year-old male presents to the emergency department after a motor vehicle accident. The patient was an unrestrained driver in a head-on collision. He has a past medical history of asthma, depression, and anxiety. He is not currently taking any medications. His temperature is 99.5°F (37.5°C), blood pressure is 90/60 mmHg, pulse is 115/min, respirations are 22/min, and oxygen saturation is 99% on room air. The patient's cardiopulmonary exam is within normal limits. The patient is breathing on his own and has strong distal pulses. Ultimately, the patient is discharged with follow up instructions after no significant fractures or injuries are found. The patient then presents 4 months later to his primary doctor with weakness. The patient's strength in his upper extremities is 1/5. He has reduced sensation in his upper extremities as well. The patient's lower extremities reveal 5/5 strength with intact sensation. A chest radiograph and basic labs are ordered. Which of the following is the most likely diagnosis?

A 67-year-old landscaper presents to his primary care physician for a routine visit. On exam, the physician notes a 2x2 cm rash above his upper lip, shown in Figure A. Upon further questioning, the patient states the rash has been there for weeks, but it hasn’t really bothered him. It is not painful or pruritic. He does not recall any recent bug bites. Which of the following is the most important risk factor for this type of lesion?

A 65-year-old gentleman presents to his primary care physici...

Sorry, only PEAK Subscribers can view this question

A 65-year-old man with squamous cell carcinoma of the lung presents with a sodium of 118 and an altered mental status. He is started on 3% normal saline over the next several hours. The patient’s mental status improves and and a repeat sodium six hours later is 129. Three days after treatment he demonstrates quadriparesis and dysarthria. Which of the following best describes this cause of the patients symptoms after treatment?

A 26-year-old woman presents to the emergency department for shortness of breath. She was walking up a single flight of stairs when she suddenly felt short of breath. She was unable to resolve her symptoms with use of her albuterol inhaler and called emergency medical services. The patient has a past medical history of asthma, constipation, irritable bowel syndrome, and anxiety. Her current medications include albuterol, fluticasone, loratadine, and sodium docusate. Her temperature is 99.5°F (37.5°C), blood pressure is 110/65 mmHg, pulse is 100/min, respirations are 24/min, and oxygen saturation is 85% on room air. On physical exam the patient demonstrates poor air movement and an absence of wheezing. The patient is started on an albuterol nebulizer. During treatment, the patient's saturation drops to 72% and she is intubated. The patient is started on systemic steroids. A Foley catheter and an orogastric tube are inserted, and the patient is transferred to the MICU. The patient is in the MICU for the next seven days. Laboratory values are ordered as seen below. Hemoglobin: 11 g/dL Hematocrit: 33% Leukocyte count: 9,500 cells/mm^3 with normal differential Platelet count: 225,000/mm^3 Serum: Na+: 140 mEq/L Cl-: 102 mEq/L K+: 4.0 mEq/L HCO3-: 24 mEq/L BUN: 21 mg/dL Glucose: 129 mg/dL Creatinine: 1.2 mg/dL Ca2+: 10.1 mg/dL AST: 22 U/L ALT: 19 U/L Urine: Color: amber Nitrites: positive Leukocytes: positive Sodium: 12 mmol/24 hours Red blood cells: 0/hpf Which of the following measures would have prevented this patient's laboratory abnormalities?

A 28-year-old G2P1001 presents for a routine obstetric visit in her 36th week of pregnancy. She has a history of type I diabetes controlled by insulin and delivered 1 child by normal spontaneous vaginal delivery 2 years ago. Earlier in this pregnancy, she had 2 episodes of burning with urination and frequent urination. Urinalysis each time confirmed a urinary tract infection, and both urine cultures isolated organisms sensitive to nitrofurantoin. Her symptoms resolved with 10-day courses of nitrofurantoin. She has no complaints today. Urinalysis is positive for leukocyte esterase and nitrites. Which of the following is the best next step in management?

A 68-year-old man presents to his primary care physician with complaints of intermittent dysuria, pain with ejaculation, mild lower abdominal pain, and difficulty voiding for the last four months. There is no weight loss or change in stools. He has no known family history of cancer. His past medical history is notable for irritable bowel syndrome and hypertension. On examination, he is well-appearing but mildly uncomfortable. There are no abdominal or rectal masses appreciated; the prostate is mildly tender to palpation, but with normal size, texture, and contour. Urinalysis reveals trace leukocyte esterase and negative nitrite, negative blood, and no bacteria on microscopy. Which of the following is the most appropriate treatment?

A 17-year-old woman presents to the emergency department with dysuria. She denies any hematuria or dyspareunia. Her last menstrual period was 3 weeks ago, and she denies any recent sexual activity. Her temperature is 99.7°F (37.6°F), blood pressure is 127/67 mmHg, pulse is 90/min, and respirations are 17/min. An unusual odor is detected on inspection of the vagina and some gray discharge is noted. Speculum exam reveals a normal cervix and a bimanual exam is unremarkable for adnexal masses or tenderness. What is the next best step in management?

A 15-month-old boy is brought to the pediatrician’s office b...

Sorry, only PEAK Subscribers can view this question

A 53 year-old woman with history of ulcerative colitis presents to the emergency department with a severe flare. The patient reports numerous bloody loose stools, and has been febrile for two days. Vital signs are: T 101.9 HR 98 BP 121/86 RR 17 Sat 100%. Abdominal exam is notable for markedly distended abdomen with tympani and tenderness to palpation without guarding or rebound. KUB is shown in figure A. CT scan shows markedly dilated descending and sigmoid colon with no perforations. What is the next best step in management for this patient?

A 70-year-old women presents to her primary care physician with sudden episodes of dizziness that resolve in certain positions. On further questioning she describes a false sense of motion with occasional spinning sensation consistent with vertigo. She denies any recent illnesses or hearing loss aside from presbycusis. Her vital signs are normal. During the physical exam the the patient reports an episode of vertigo after transitioning from sitting to supine and horizontal nystagmus is concurrently noted. What is the mostly likely diagnosis?

A 42-year-old male with a history of ulcerative colitis presents to the emergency room with four-day history of nausea, bloody diarrhea, and abdominal pain. He is on medical management with 5-aminosalicylic acid (5 ASA). Examination shows an ill appearing man with a tense, tympanitic abdominal exam. He is unable to be fully examined due to the abdominal pain. Vitals are T 38.2 C, HR 102 bpm BP 133/92 mmHg,2 RR 20 bpm, and O2 Sat 100% on room air. In the ED an abdominal radiograph is shown in Figure A. Which of the following is the diagnosis?

A 22-year-old female college student comes to your clinic to establish care. She has no significant past medical history and her only complaint today is that she has had trouble maintaining a consistent weight. Her temperature is 98.6°F (37.0°C), blood pressure is 100/65 mmHg, pulse is 62/min, and respirations are 12/min. Her body mass index is 19.5. Her physical exam is significant for callused knuckles and dental enamel erosions. What laboratory abnormalities are likely to be found in this patient?

A 27-year-old male presents to clinic complaining of coughing up small amounts of blood daily for the past week. He denies smoking, sick contacts, or recent travel. Chest radiographs demonstrates interstitial pneumonia with patchy alveolar infiltrates suggestive of multiple bleeding sites. Urinalysis is positive for blood and protein. A positive result is returned for anti-glomerular basement membrane antibody (anti-GBM Ab). What is the most likely diagnosis?

A 37-year-old man presents to the emergency department for a...

Sorry, only PEAK Subscribers can view this question

A middle-aged homeless male is brought to the emergency department for alcohol withdrawal. He is a poor historian who cannot recall any of his past medical history. Testing reveals that the patient is HIV positive. Notably, physical exam reveals the following skin rash on the patient’s bilateral palms (Figure A), and a lesion on the patient’s tongue (Figure B). Given these findings, RPR/VDRL tests are performed and return as non-reactive. A biopsy of the skin lesion yields the following organism on dark-field microscopy (Figure C). What is the explanation for the patient’s negative RPR/VDRL tests?

A 35-year-old homeless man is admitted to the medical floor....

Sorry, only PEAK Subscribers can view this question

A 38-year-old obese male smoker presents to the emergency department complaining of severe chest pain. The pain is stabbing, burning and retrosternal. The pain has occurred intermittently for the last few months. The pain is not brought on by exercise, but he does experience it often at night upon lying down after dinner. He denies any dysphagia, weight loss, vomiting, or bloody stools, but does endorse a foul taste in his mouth. Vitals signs are T 98.8 F, HR 79 bpm, BP 123/89, RR 16 Sat 100%. Exam reveals an obese male with dental erosions; cardiopulmonary exam is unremarkable. An EKG is shown in Figure A. What is the next best step in management?

An 8-year-old African American girl presents to your office with complaints of unbearable lower back pain for the past three hours. Her past medical history is significant for four unplanned visits to the ER this year for episodes of excruciating pain in her thighs and abdomen, the most recent visit requiring her to miss two days of school while she received IV analgesic therapy. Her daily medication regimen includes 1 mg of folic acid. Figure A shows a peripheral smear of a blood sample taken during this visit. What is the most likely hemoglobin abnormality associated with this patient's presentation?

A 7-month-old boy is brought to the ED by his mother because...

Sorry, only PEAK Subscribers can view this question

A 7-month-old boy presents to the emergency room with three episodes of vomiting and severe abdominal pain that comes and goes for the past two hours. The patient's most recent vomit in the hospital appears bilious, and the patient had one stool that appears bloody and full of mucous. The mother explains that one stool at home appear to be "jelly-like." On physical exam, a palpable mass is felt in the right lower quadrant of the abdomen. What is the next best diagnostic test for this patient?

A 2-year-old boy presents to the emergency department with the complaint of acute onset abdominal pain and vomiting. Upon further questioning you find the patient has no past medical history except for occasional painless rectal bleeding the past couple of weeks. Physical exam is significant for an 8/10 sharp pain in the right lower quadrant. Bowel sounds are hyper-active. Laboratory analysis reveals a white blood cell count of 11,000 per mcL. Nuclear imaging is performed and can be seen in Figure A. What is the likely underlying medical condition that lead to this patient's clinical presentation?

A 48-year-old man presents to the emergency department for e...

Sorry, only PEAK Subscribers can view this question

A 57-year-old man presents to the emergency department for s...

Sorry, only PEAK Subscribers can view this question

A 68-year-old man presents to his primary care physician wit...

Sorry, only PEAK Subscribers can view this question

A 69-year-old man presents to his primary care physician wit...

Sorry, only PEAK Subscribers can view this question

A 17-year-old high school student was in shop class when he ...

Sorry, only PEAK Subscribers can view this question

A 27-year-old man rode his bicycle into a curb and hit his f...

Sorry, only PEAK Subscribers can view this question

29-year-old G2P2002 presents with foul-smelling lochia and fever. She is post-partum day three status-post cesarean section due to eclampsia. Her temperature is 101 F, and heart rate is 103. She denies chills. On physical exam, lower abdominal and uterine tenderness is present. Leukocytosis with left shift is seen in labs. Which of the following is the next best step in management?

A 55-year-old obese woman is admitted to your floor for chronic fevers. She states she has had fevers of of over 101F as measured on her oral thermometer for the past month. Her vitals are T 100.9 F, HR 95 and regular, RR 16, BP 150/95. On history she states that she has a history of diabetes and is noncompliant with her insulin. She was recently treated for a foot infection with antibiotics, but her fevers have remained. Her last HbA1C was 8.5%. On exam, the patient has no gross deficits, but does admit to pain in her left lower leg and foot. Physical exam reveals a Grade IV ulcer, as displayed in Figure A. She states she has severe pain when bearing weight on her left leg. Otherwise, all extremities have diminished pulses and sensation. There is no erythema in the surrounding area and no areas of fluctuance. Figure B shows AP and lateral radiographs of the patient's left leg. What is the most likely diagnosis?

A 35-year-old woman comes into your office because she has been feeling fatigued over the last few months. She states that she has no history of thyroid disease, but admits to menorrhagia since she was about 18 years old. She states she has to change pads every 2 hours for the first five days of her period and that her periods last 9-10 days on average. Her complete blood count (CBC) is significant for hemoglobin (Hgb) of 10.8, white blood cell count (WBC) of 5.5. The mean corpuscular volume of her RBCs is 73 and her iron studies are show low ferritin with increased total binding capacity (TIBC). Her peripheral blood smear is shown in Figure A. What is the most likely cause of her anemia?

A 54-year-old woman presents to her primary care physician w...

Sorry, only PEAK Subscribers can view this question

A 65-year-old man presents to the emergency department for s...

Sorry, only PEAK Subscribers can view this question

A 34-year-old woman presents to the clinic complaining of a rash that appeared on her left forearm after a scratch three days ago. This is not the first time she has experienced such a rash, as the patient states she had a similar looking lesion on her elbows three years ago. Upon further questioning, she states that her older sister has had problems with her skin, but she is unsure of the diagnosis. On physical exam you find a circular and scaly, pearl-colored rash superimposed over an abrasion on her left forearm (Figure A). Of note, the patient has has the following nail appearance (Figure B). What is the diagnosis in this patient?

A 35-year-old woman returns to her primary care physician for follow up after treatment for a peptic ulcer. She was diagnosed with a duodenal ulcer and gastritis; endoscopy and biopsy with Warthin Starry staining at the time of diagnosis showed the following (Figure A). She has completed a course with amoxicillin, clindamycin, and omeprazole. The patient reports resolution of symptoms. What is the next best step in management for this patient?

An 8-year old boy is brought to the pediatrician by his distraught mother who is concerned about "light spots" that first appeared 4 months ago and have been slowly expanding over different parts of his body. He is not bothered by these areas, and they do not itch, burn, or bleed. He has otherwise been well. There is no family history of this skin condition, though his mother has a history of hypothyroidism. His skin exam is notable for smooth, hypopigmented patches over his bilateral knuckles, knees, and inner thighs, as seen in Figure A. His exam is also notable for a tuft of leukotrichia over his occiput, as seen in Figure B. Which of the following will help to confirm the diagnosis?

A 68-year-old woman presents to her primary care provider fo...

Sorry, only PEAK Subscribers can view this question

A 35-year-old man is brought into the emergency department by emergency medical services with his right hand wrapped in bloody bandages. The patient states that he is a carpenter and was cutting some wood for a home renovation project when he looked away and injured one of his digits with a circular table saw. He states that his index finger was sliced off and is being brought in by his wife. On exam, his vitals are within normal limits and stable, and he is missing part of his second digit on his right hand distal to the proximal interphalangeal joint. How should the digit be transported to the hospital for the best outcome?

A 65-year-old man presents to his primary care physician for...

Sorry, only PEAK Subscribers can view this question

A 45-year-old man has a history of smoking 1 pack per day and drinking a six-pack of beer daily over the last ten years. He is admitted to the medical floor after undergoing a cholecystectomy. One day after the surgery, the patient states that he feels anxious and that his hands are shaking. While being checked for a clean surgical site, the patient starts shaking vigorously and loses consciousness. The patient groans and falls to the floor. His arms and legs begin to jerk rapidly and rhythmically. This episode lasts for almost five minutes, and the patient's airway, breathing, and circulation are stabilized per seizure protocol. What is the best next step for this patient?

A 27-year-old woman presents to her obstetrician for a regul...

Sorry, only PEAK Subscribers can view this question