A 49-year-old male is referred to a dermatologist for evaluation of his lesions, shown in Figure A. Physical exam confirms that these blistering lesions are present on the patient's hands, forearms, face, and lower legs. He denies any abdominal pain but reports that he has been shaving more frequently recently due to increased hair growth on his cheeks. The patient cannot identify any changes or precipitating factors prior to the appearance of these lesions. Further work-up reveals grossly increased urinary porphyrin levels and pink-fluorescence of the urine under a Wood's lamp. Which of the following findings would be expected on biopsy of one of his skin lesions?

A 66-year-old man presents to his primary care physician complaining of increasing discharge from a lesion on his foot. He noticed it a month ago and states it has been gradually worsening. He has a long history of poorly controlled diabetes with complications including chronic renal failure and peripheral neuropathy. He denies any pain or fevers/chills. Physical exam is notable for the finding in Figure A. Laboratory evaluation is significant for an erythrocyte sedimentation rate of 226 mm/h. Which of the following would be the most accurate imaging test for this patient's condition?

A 6-month-old male presents for a routine visit to his pediatrician. Two months ago, the patient was seen for tachypnea and wheezing, and diagnosed with severe respiratory syncytial virus (RSV) bronchiolitis. After admission to the hospital and supportive care, the patient recovered and currently is not experiencing any trouble breathing. Regarding the possibility of future reactive airway disease, which of the following statements is most accurate?

A 32-year-old female visits her primary care physician because of recent changes to her health. She states that two weeks ago, following a trip to India, she began to experience severe fatigue, nausea, and vomiting. On exam, the findings in Figure A are observed. The physician obtains liver function tests which demonstrate significantly elevated AST and ALT. Further testing reveals that the patient is infected with an RNA hepevirus. Which of the following features, if present, would be very concerning?

A 7-year-old girl with no significant past medical history is brought to her pediatrician for persistent, blood-stained, foul-smelling vaginal discharge. This has been an ongoing issue for the last 2.5 months. The patient and her mother have been managing it at home with conservative treatments and improved hygiene, without improvement. They only recently received approval for health insurance, allowing them access to a pediatrician. Physical examination is significant for an anatomically normal vagina, mucosal erythema, and foul-smelling discharge with no sign of feculent material present. Pelvic imaging is obtained and is shown in Figure A. What is the best initial step in managing this patient?

A 4-month-old infant is brought to the office by his parents who are concerned of a recent rash. The infant is crying and has a erythematous, pruritic rash that affects his face, forearms, thighs, and scalp as noted in Figure A. The patients vitals are T 97.8, HR 110, BP 90/60, RR 18. Of note, the mother admits to a medical history of significant allergies, and the father suffers from asthma, treated by albuterol. Which of the following is the best diagnosis?

A 2-week-old boy presents to general pediatrics clinic with constipation. His mother reports that he has not had a bowel movement for over 5 days and is quite concerned. On further examination, you discover that the boy is in the 5th percentile for weight. Physical examination shows a distended abdomen. Rectal examination shows an absence of stool in the rectal vault. A contrast enema reveals the following seen in Figure A. A rectal biopsy is performed (Figure B). Which of the following is true regarding this illness?

A 26-year-old man presents to his primary care physician complaining of impotence. He reports that he has a healthy, long-term relationship with a woman whom he hopes to marry, but he is embarrassed that he is unable to have an erection. Which of the following is the next best step?

A 70-year-old man was diagnosed two days ago with a myocardial infarction and underwent percutaneous coronary intervention to reperfuse his left anterior descending artery. Two days later his creatinine is noted to be elevated (despite being normal the day before) and he complains of a "rash" on his foot (Figure A). Which of the following would most likely be found in laboratory studies?

A 17-year-old male presents to your office with right knee pain. He is the quarterback of his high school football team and developed the knee pain after being tackled in last night's game. He states he was running with the ball and was hit on the lateral aspect of his right knee while his right foot was planted. Now, he is tender to palpation over the medial knee and unable to bear full weight on the right lower extremity. A joint effusion is present and arthrocentesis yields 50 cc's of clear fluid. Which of the following exam maneuvers is most likely to demonstrate ligamentous laxity?

A 44-year-old man presents to his family physician with complaints of dry and scaly lesions on his bilateral elbows. He reports that these lesions developed in his 20's and have been growing in size since that time. He also reports similar lesions on the anterior portion of his knees. The lesions itch and they bleed when he scratches them. He denies any additional past medical history. Physical examination reveals the lesions shown in Figure A. Additional findings include pitting of the fingernails. Which of the following medications may worsen or exacerbate this patient's condition?

A 58-year-old woman presents to her family physician for an annual checkup. During the visit, the patient asks her physician for help quitting smoking cigarettes. She has unsuccessfully tried quitting several times previously and has also failed prior attempts with meditation and exercise. The physician prescribes a partial agonist of the nicotinic receptor to aid the patient in cessation. Which of the following is a potential side effect of this medication?

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A 45-year-old diabetic man presents to your office for routine follow-up. One year ago, the patient’s hemoglobin A1C was 7.2% and the patient was encouraged to modify his diet and increase exercise. Six months ago, the patient’s HA1C was 7.3%, and you initiated metformin. Today, the patient has no complaints. For which of the following co-morbidities would it be acceptable to continue metformin?

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A 17-year-old white female with a history of depression is brought to your office by her parents because they are concerned that she is acting differently. She is quiet and denies any changes in her personality or drug use. After the parents step out so that you can speak alone, she begins crying. She states that school has been very difficult and has been very depressed for the past 2 months. She feels a lot of pressure from her parents and coaches and says she cannot handle it anymore. She says that she has been cutting her wrists for the past week and is planning to commit suicide. She instantly regrets telling you and begs you not to tell her parents. What is the most appropriate course of action?

A 4-month old boy presents for follow-up in the orthopedic clinic. At birth, he was diagnosed with the condition pictured in Figure A, and has undergone stretching and serial casting since then. On exam, his right foot is still turned inward and cannot dorsiflex beyond 85 degrees. The joint feels rigid. What is the most appropriate next step?

A 33-year-old HIV-positive male is seen in clinic for follow-up care. When asked if he has been adhering to his HIV medications, the patient exclaims that he has been depressed, thus causing him to not take his medication for six months. His CD4+ count is now 33 cells/mm3. What medication(s) should he take in addition to his anti-retroviral therapy?

A 25-year-old medical student is doing an international health elective in the Amazon River basin studying tropical disease epidemiology. As part of his pre-trip preparation, he wants to be protected from malaria and is researching options for prophylaxis. Which of the following agents should be avoided for malarial prophylaxis in this patient?

A 37-year-old man with no significant past medical history is rear-ended in a motor vehicle accident. He reported significant neck pain to emergency responders, but otherwise denies weakness, numbness or tingling in his extremities. His vitals on presentation to the ED are HR 90, BP 140/80, RR 20, SpO2 98%. What is the most appropriate next step upon presentation to the emergency room?

A 28-year-old man presents to a urologist upon referral from a fertility medicine specialist who evaluated the patient and his wife. The patient was told that he had a low sperm count. Otherwise, the patient endorses dull and low grade testicular pain that is chronic in nature and unchanged from his baseline. The patient's vitals are unremarkable. Examination and palpation of the right scrotum and testicle reveals soft palpable cords on the right side which are not seen on the left. Additionally, the examination reveals right testicular atrophy. When the patient lies supine, there is no change in the appearance or size of the scrotum. An ultrasound and color Doppler study of the patient's right testicle is shown in Figure A. Which of the following is the best next step in the management for this patient?

A 75-year-old woman presents to the emergency department with 30 minutes of slurred speech and arm weakness. On the drive over to the hospital, her symptoms have resolved completely. The patient has a past medical history of hypertension, atrial fibrillation, diabetes, morbid obesity, gout, and vascular claudication. Her temperature is 99.0°F (37.2°C), blood pressure is 184/111 mmHg, pulse is 88/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam reveals cranial nerves II-XII as grossly intact with normal strength and sensation in the patient's upper and lower extremities. The patient's memory is intact and her speech seems normal and fluent. Her gait is stable with no ataxia. An initial head CT demonstrates diffuse atrophy which is consistent with previous head CT scans. Which of the following is the best next step in management?

A 29-year-old G2P1 woman at 37 weeks gestation presents to her primary care physician with a 3-day history of an abrupt onset of extremely pruritic, urticarial papules and blisters on the abdomen and trunk. Her pregnancy has otherwise been unremarkable and she is currently taking folate and a multivitamin. Her husband recently had an upper respiratory infection and her son recently had a fever and a rash. The patient has never been vaccinated nor has anyone else in the family. She has a history of cold sores and chickenpox. Her temperature is 98.0°F (36.7°C), blood pressure is 120/84 mmHg, pulse is 85/min, respirations are 14/min, and oxygen saturation is 98% on room air. Her physical exam is shown in Figure A. Which of the following is the most likely diagnosis?

A 56-year-old woman presents to the emergency department with abdominal swelling. She states that her abdomen has been swelling for the past several months but otherwise offers minimal history and is a poor historian. She thinks it worsened more rapidly last night. Her temperature is 97.0°F (36.1°C), blood pressure is 122/80 mmHg, pulse is 80/min, respirations are 12/min, and oxygen saturation is 98% on room air. A bedside ultrasound is performed as seen in Figure A and a sample of the fluid is taken and sent for analysis as seen below. Fluid sample: Cell count: < 50 leukocytes/mm^3 Albumin: 4.8 g/dL Culture: pending Total protein: 18.0 g/dL Gram stain: pending Laboratory values are notable for a serum albumin of 4.0 g/dL. What is the most likely cause of this patient's ascites?

A 45-year-old non-English-speaking, Asian male presents to your office. He shows you a lesion on his elbow (Figure A). He has been having decreased sensation in that area and now cannot feel sharp pinpricks on your physical exam. The lesion is biopsied (Figure B). Which of the following is the most likely diagnosis?

A 73-year-old woman with a history of diabetes presents to the emergency department with severe abdominal pain and constipation for 24 hours. Vital signs are T: 100.3 F, HR: 80 bpm, BP: 143/82 mmHg, RR: 24/min, O2 Sat: 95%. Abdominal exam is notable for diffuse abdominal tenderness to palpation, without rebound or guarding. Laboratory studies are notable for leukocytosis, though lactic acid is within normal limits. Abdominal x-ray is shown in Figure A. Which of the following are the best next management steps for this patient?

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A 56 year old female comes to the ED complaining of moderate right eye pain, headache, and acute onset of blurry vision, which she describes as colored halos around lights. She was watching a movie at home with her husband about an hour ago when the pain began. On physical exam of her right eye, her pupil is mid-dilated and unresponsive to light. Her right eyeball is firm to pressure. Intraocular pressure (IOP) measured with tonometer is elevated at 36mmHg. Which of the following is the most appropriate emergency treatment?

A 39-year-old female presents with complaints of redness and "acne" over her cheeks, nose and chin. A representative photo is shown in Figure A. She states that the redness worsens with emotional stresses, heat, and hot beverages. Which of the following is an appropriate treatment for this condition?

A 35-year-old female presents to the ED at the request of her husband after 3 weeks of erratic behavior. The patient has been staying up all night online shopping on eBay. Despite a lack of sleep, she is "full of energy" during the day at her teaching job, which she believes is "beneath [her], anyway." She has not sought psychiatric treatment in the past, but reports an episode of self-diagnosed depression 2 years ago. The patient denies thoughts of suicide. Pregnancy test is negative. The patient is acutely agitated and is pacing back and forth across the room and states she is going to leave. Which of the following is the best initial treatment?

A 47-year-old woman comes to her primary care doctor because of a new, pruritic rash. She was gardening in her yard two days ago and now has an eczematous papulovesicular rash on both ankles. You also note a single, 5 mm brown lesion with a slightly raised border on her left thigh. You prescribe a topical corticosteroid for contact dermatitis. Which of the following is the appropriate next step for the thigh lesion?

A 65-year-old previously healthy man presents to the primary care physician with the chief complaint of red colored urine over the past month. He states that he does not experience dysuria. On physical exam there is no costovertebral angle tenderness. With this presentation which is the most likely cause of this patient's hematuria?

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A 32-year-old man comes into your office because of pain in his right knee, left elbow, and left wrist. It started about a week ago but has particularly localized to his wrist. The patient states that he has 2 sexual partners. He states he has also had some white discharge from his penis with pruritis and pain during urination. His temperature is 97.6°F (36.4°C), blood pressure is 124/84 mmHg, pulse is 80/min, respirations are 12/min, and oxygen saturation is 98% on room air. Physical exam reveals pain upon palpation of the patient's left wrist which also appears erythematous and swollen. What is the best next step in management for this patient?

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A 3-year-old girl with no significant past medical history presents to the clinic with a 4-day history of acute onset cough. Her parents have recently started to introduce several new foods into her diet. Her vital signs are all within normal limits. Physical exam is significant for decreased breath sounds on the right. What is the most appropriate definitive management in this patient?

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A 5-year-old child is brought to his primary care physician for a well-child examination. The child was born when his mother was 43 years old. On physical exam, the child is of small stature, has palpebral fissures that are upward slanting, and inner epicanthal folds. Before proceeding to funduscopic examination, you notice the following in his iris (Figure A). Which of the following is/was most likely present in this child?

A 55-year-old IV drug user comes into the emergency department after four days of pain in his right ankle. The patient is lethargic and unable to answer any questions about his medical history. His vitals are HR 110, T 101.5, RR 20, BP 100/60. His physical exam is notable for track marks in his toes and his right ankle is erythematous and swollen. Moving any part of the right foot creates a 10/10 pain. A radiograph revels no evidence of fractures. A Gram stain of the joint fluid aspirate demonstrates purple cocci in clusters. The fluid is yellow, opaque, with more than 70,000 cells/mm^3 (80% neutrophils). What is the most likely diagnosis?

A 17-year-old girl is brought into the physician's office with complaints of nausea, vomiting, headache, and blurry vision. In preparation for final exams the patient's mother started her on an array of supplements and herbal preparations given the "viral illness" that is prevalent at her school. Despite these remedies, the girl has been feeling perpetually worse, and yesterday during cheerleading practice had to sit out after vomiting and feeling dizzy. The patient admits to falling during one of the exercises and hitting her head on another girl's shin due to her dizziness. When asked to clarify her dizziness, the patient states that she feels rather lightheaded at times. The patient's BMI is 19 kg/m^2. She endorses diarrhea of recent onset, and some non-specific, diffuse pruritus of her skin which she attributes to stress from her finals. The patient has a past medical history of anxiety, depression, and excessive exercise habits. On physical exam the patient is alert and oriented to place, person, and time, and answers questions appropriately. She denies any decreased ability to participate in school or to focus. Her skin is dry and peeling with a minor yellow discoloration. Her memory is intact at 1 minute and 5 minutes for 3 objects. The patient's pupils are equal and reactive to light and there are no abnormalities upon examination of cranial nerve III, IV or VI. Which of the following is the most likely cause of this patient's symptoms?

A 35-year-old man is brought to the emergency department from a kitchen fire. The patient was cooking when boiling oil splashed on his exposed skin. His temperature is 99.7°F (37.6°C), blood pressure is 127/82 mmHg, pulse is 120/min, respirations are 12/min, and oxygen saturation is 98% on room air. He has dry, nontender, and circumferential burns over his arms bilaterally, burns over the anterior portion of his chest and abdomen, and tender spot burns with blisters on his shins. A 1L bolus of normal saline is administered and the patient is given morphine and his pulse is subsequently 80/min. A Foley catheter is placed which drains 10 mL of urine. What is the best next step in management?

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A 38-year-old man presents to his gastroenterologist after being referred by his primary care physician (PCP). He has had intractable epigastric pain for the last 3 months following meals. His PCP prescribed him a course of ranitidine. After his symptoms did not resolve he was prescribed omeprazole. However, his symptoms persisted and he was referred to gastroenterology. The man undergoes an endoscopy, which finds a gastric ulcer (Figure A). Biopsy with silver staining is shown in Figure B. Which of the following is the most effective regimen for the treatment of this condition?

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A 33-year-old nurse who was born in the United States and has lived in the US all her life is referred to an infectious disease specialist after she exhibited a PPD skin test with 17 mm of induration. She denies any cough, shortness of breath, hemoptysis, weight loss, fatigue, fevers, or night sweats over the last several months. However, she works in the federal penitentiary system and has also provided aid on foreign medical mission trips to Haiti in the past few years. Her temperature is 97.0°F (36.1°C), blood pressure is 120/81 mmHg, pulse is 82/min, respirations are 15/min, and oxygen saturation is 98% on room air. An initial chest radiograph is unremarkable. Which of the following is the most appropriate management of this patient?

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