A first-time mother of a healthy, full-term, newborn girl is...

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A 32-year-old G2P2 at 33 weeks and 4 days of gestation presents to the emergency room with low-grade fever, mild low back pain, and dysuria for 1 day. She has a history of urinary tract infections, including one during this current pregnancy that was treated successfully with cephalexin. On examination, she is nontoxic but mildly uncomfortable; she has CVA tenderness on her right side. Her urinalysis is positive for leukocyte esterase and nitrites, and she is admitted to the hospital for IV antibiotics with ceftriaxone. Her present condition places her at increased risk for which of the following:

A 78-year-old man presents to the emergency department with chest pain that started 1 hour prior to arrival with radiation to his arms and jaw, and associated nausea and diaphoresis. He has a history of hypertension, diabetes mellitus, and chronic kidney disease. His temperature is 98.6°F (37.0°C), pulse is 80/min, blood pressure is 90/65 mmHg, respirations are 20/min, and oxygen saturation is 93% on room air. An ECG is obtained as shown in Figure A. As he is being examined, he becomes unresponsive, pulseless, and apneic. CPR is initiated, but the patient is unable to be resuscitated. Which of the following is the most likely cause of death?

A 37-year-old female with a history of type II diabetes mellitus presents to the emergency department complaining of blood in her urine, left-sided flank pain, nausea, and fever. She also states that she has pain with urination. Vital signs include: temperature is 102 deg F (39.4 deg C), blood pressure is 114/82 mmHg, pulse is 96/min, respirations are 18, and oxygen saturation of 97% on room air. On physical examination, the patient appears uncomfortable and has tenderness on the left flank and left costovertebral angle. Which of the following is the next best step in management?

A 23-year-old woman presents to your office for a gynecological exam. She says that she has been in good health and has no complaints. She has been in a steady monogamous relationship for the past year. Physical examination was unremarkable. Screening tests are performed and return positive for gonorrhea. You treat her with an intramuscular injection of ceftriaxone and 7 day course of doxycycline. What else is recommended for this case?

A 25-year-old male presents to your clinic complaining of a yellow discharge from his urethra. He states that for the past week he has had pain with urination and yesterday the discharge developed. He admits to unprotected sex with multiple sexual partners. Gram stain of the discharge is shown in Figure A. What is the most appropriate treatment for this patient's condition?

A 76-year-old woman is brought to the emergency department after being found unresponsive in her room at her nursing facility. Past medical history is significant for Alzheimer's disease, hypertension, and diabetes. Surgical history is notable for an open cholecystectomy at age 38 and multiple cesarean sections. On arrival, she is non-responsive but breathing by herself, and her vital signs are T 102.9 F, HR 123 bpm, BP 95/64, RR 26/min, and SaO2 97% on 6L nasal cannula. On physical exam the patient has marked abdominal distension and is tympanic to percussion. Laboratory studies are notable for a lactic acidosis. An upright abdominal radiograph and CT abdomen/pelvis with contrast are shown in Figures A and B respectively. She is started on IV fluids and a nasogastric tube is placed to suction which returns green bilious fluid. Repeat vitals 1 hour later are T 101F, HR 140 bpm, BP 75/44, RR 30/min, and SaO2 is 100% on the ventilator after she is intubated for airway concerns. What is the next best step in management?

A 5-year-old male is brought to the pediatrician with complaints of a painful mouth/gums, and vesicular lesions on the lips and buccal mucosa for the past 4 days. The patient has not been able to eat or drink due to the pain and has been irritable. The patient also reports muscle aches. His vital signs are as follows: T 39.1, HR 110, BP 90/62, RR 18, SpO2 99%. Physical examination is significant for vesicular lesions noted on the tongue, gingiva, and lips, with some vesicles having ruptured and ulcerated, as well as palpable cervical and submandibular lymphadenopathy. Which of the following is the most likely causative organism in this patient's presentation?

An 11-year-old girl is brought into the clinic by her parents, who are distraught over her behavior. They state that over the past several months she has started to act oddly, combing the hair of her toy dolls for hours without stopping and repetitively counting her steps in the house. She is often brought to tears when confronted about these behaviors. The patient has no past medical history. When questioned about family history, the mother states she has needed close medical follow-up in the past, but declines to elaborate. The patient's vital signs are all within normal limits. On physical exam the patient is a well nourished 11-year-old girl in no acute distress. She has occasional motor tics, but the remainder of the exam is benign. What is the diagnosis in this patient?

A 35-year-old woman presents to clinic in emotional distress. She states she has been unhappy for the past couple of months and is having problems with her sleep and appetite. Additionally, she reports significant anxiety regarding thoughts of dirtiness around the house. She states that she cleans all of the doorknobs 5-10 times per day and that, despite her actions, the stress related to cleaning is becoming worse. What is this patient's diagnosis?

A 43-year-old male is brought to the emergency department after his son found him vomiting bright red blood. He is visibly intoxicated, and hospital records indicate a long history of alcohol substance abuse treated with antabuse (disulfiram). Vital signs include T 98.4, HR 89, BP 154/92, and RR 20. EGD is notable for mild esophagitis, and a longitudinal esophageal tear at the gastroesophageal junction, with no active bleeding. What is the next best course of action?

An 80-year-old male with known metastatic prostate cancer presents to your office with vague complaints of "achy bones." Strangely, he refers to you using the name of another physician. On physical exam, he is afebrile, but mildly tachycardic at 100 beats/min. Mucous membranes are dry. Cardiac exam shows regular rhythm and no murmurs. The patient has diffuse, nonfocal abdominal pain. He cannot articulate the correct date. You check the patient's serum calcium level, which is found to be 15.3 mg/dL. What is the best next step in management?

A 2-year-old is brought to the emergency department by his mother for intermittent abdominal pain. She states the pain seems to be relieved by flexing his knees to his chest. The mother states that she noticed this morning that he passed stool mixed with blood and mucus. On exam, you note abdominal tenderness. An abdominal ultrasound is performed, and the results are shown in Figure A. What is the most common underlying cause of this patient's condition?

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A 67-year-old woman presents to the physician for the evaluation of muscle aches. She reports pain and stiffness in her shoulders and hips over the last several months that is more prominent in the morning, but present throughout the day. She notes particular difficulty and pain when standing from a chair or combing her hair. She has a history of hypertension for which she takes lisinopril. Her temperature is 98.6°F (37.0°C), pulse is 80, blood pressure is 125/80 mmHg, and respirations are 14/min. On exam, strength is 5/5 in the upper and lower extremities. Laboratory studies reveal an ESR of 55 mm/hr. Which of the following is the most appropriate next step in management?

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A 46-year-old homeless male presented to the emergency department intoxicated, but a serum ethanol level is normal. Results from a urine study are shown in Figure A. Which of the following findings would you most likely expect in this patient? I: elevated serum anion gap II: elevated serum osmolar gap III: decreased serum pH

A 23-year-old female with a history of systemic lupus erythematous presents with 1 week of chest pain and shortness of breath. Exam is notable for increased respiratory rate, mild hypotension, and muffled heart sounds. Chest radiography is performed and the results are seen in figure F. Which of the following electrocardiograms would you expect to see in this patient?

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A 19-year-old man with unknown medical history is found down on a subway platform and is brought to the hospital by ambulance. He experiences two episodes of emesis en route. In the emergency department, he appears confused and is complaining of abdominal pain. His temperature is 37.0° C (98.6° F), pulse is 94/min, blood pressure is 110/80 mmHg, respirations are 24/min, oxygen saturation is 99% on room air. His mucus membranes are dry and he is taking rapid, deep breathes. Laboratory work is presented below: Serum: Na+: 130 mEq/L K+: 4.3 mEq/L Cl-: 102 mEq/L HCO3-: 12 mEq/L BUN: 15 mg/dL Glucose: 362 mg/dL Creatinine: 1.2 mg/dL Urine ketones: Positive The patient is given a bolus of isotonic saline and started on intravenous insulin drip. Which of the following is the most appropriate next step in management?

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A 20-year-old woman with type I diabetes mellitus presents to the emergency department with altered mental status. Her friend said that she has been out late either studying for upcoming tests or attending prayer group meetings. As far as the friend can recollect, the patient appeared to be in her usual state of health until only 2 days ago, when she was prescribed trimethoprim-sulfamethoxazole for a urinary tract infection. The patient complained that the medication was making her feel nauseous and bloated. The patient also relies on insulin glargine and lispro for glycemic control. Her temperature is 100.5°F (38.1°C), blood pressure is 95/55 mmHg, pulse is 130/min, and respirations are 30/min. Her pupils are equal and reactive to light bilaterally. The remainder of the physical exam is unremarkable. Her basic metabolic panel is displayed below: Serum: Na+: 116 mEq/L Cl-: 90 mEq/L K+: 5.0 mEq/L HCO3-: 2 mEq/L BUN: 50 mg/dL Glucose: 1,200 mg/dL Creatinine: 1.5 mg/dL Which of the following is true regarding this patient's presentation?

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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 26-year-old G1P0 woman presents to her first obstetric visit after having a positive urine pregnancy test at home. Her last menstrual period was 8 weeks ago. She has no significant medical history, but her mother has rheumatoid arthritis. For several weeks she has felt especially warm and has had muscle weakness. She has experienced mood swings, fatigue, and palpitations. Her temperature is 100.0°F (37.8°C), blood pressure is 140/81 mmHg, pulse is 106/min, and respirations are 17/min. Physical exam is notable for 3+ deep tendon reflexes bilaterally and 4/5 strength in both hips and shoulders. She appears anxious. Ultrasound confirms the presence of a fetal pole with heartbeat and shows a crown rump length that is consistent with a gestational age of 9 weeks and 3 days. Which of the following is the most appropriate therapy for this patient?

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A 26-year-old male comes into your clinic complaining of worsening asthma symptoms. He reports that when he was first diagnosed with asthma, he experienced shortness of breath and chest tightness around twice a month. Then last month he began to get short of breath three times a week. He uses his albuterol inhaler during these episodes with temporary improvement of his symptoms. He denies nighttime awakenings due to his symptoms, but he does complain that his symptoms are interfering with his marathon training. His past medical history is significant for type I diabetes. His current medications include insulin and his albuterol inhaler. When asked about over-the-counter medications, he reports that he takes a multivitamin and aspirin, which he has been using for muscle soreness associated with his increased training schedule. A review of systems is also notable for headaches, nasal congestion, rhinorrhea and anosmia. The patient’s temperature is 99°F (37.2°C), blood pressure is 120/78 mmHg, pulse is 84/min, and respirations are 14/min with an oxygen saturation of 98% O2 on room air. On physical exam, you note bilateral expiratory wheezing and lesions within the nasal cavity, shown in Figure A. Which of the following is the best initial treatment for this patient’s symptoms?

A 55-year-old female patient comes to your office complaining of white spots on her tongue. She reports that she first noticed them about one week ago. She denies pain or difficulty swallowing. Her past medical history is significant for asthma, hepatitis C, and heroin abuse. She had previously been homeless and only recently went to the doctor one month ago for the first time in over five years. At that time, her primary care physician prescribed sofosbuvir, an albuterol inhaler, and daily inhaled fluticasone, which she has been using as directed. She is sexually active with one male partner. Her last HIV test was negative, and she does not have a history of sexually transmitted diseases. She denies current alcohol or intravenous drug use. She smokes a pack a day of cigarettes and reports she has been smoking since she was 16. On physical examination, you note lesions on her oral mucosa that are easily scraped off, as shown in Figure A. Which of the following is the best treatment for this patient’s most likely diagnosis?

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A 65-year-old obese man presents to his primary care clinic feeling weak. He was in the military and stationed in Vietnam in his youth. His current weakness gradually worsened to the point that he had to call his son to help him stand to get on the ambulance. He smokes a pack of cigarettes every day and drinks a bottle of vodka a week. He has been admitted for alcohol withdrawal multiple times and has been occasionally taking thiamine, folic acid, and naltrexone. He denies taking steroids. His temperature is 98°F (36.7°C), blood pressure is 170/90 mmHg, pulse is 75/min, and respirations are 20/min. He is obese with a significant pannus. Hepatomegaly is not appreciable. Abdominal striae are present. His workup is notable for the following: Serum: Na+: 142 mEq/L Cl-: 102 mEq/L K+: 3.9 mEq/L HCO3-: 25 mEq/L BUN: 24 mg/dL Glucose: 292 mg/dL Creatinine: 1.5 mg/dL Ca2+: 10.1 mg/dL AST: 7 U/L ALT: 14 U/L 24-hour urinary cortisol: 400 µg (reference range < 300 µg) Serum cortisol: 45 pg/mL (reference range < 15 pg/mL) A 48-hour high dose dexamethasone suppression trial shows that his serum cortisol levels partially decrease to 25 pg/mL and his adrenocorticotropin-releasing hormone (ACTH) level decreases from 10 to 6 pg/mL (reference range > 5 pg/mL). What is the best next step in management?

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A 42-year-old female presents to her primary care provider complaining of numbness and tingling bilaterally in her hands for the past month. She has a past medical history of Crohn’s disease and underwent ileal resection 2 years ago. Previously, laboratory studies demonstrated glucose intolerance, which has been managed with lifestyle modifications. The patient’s vital signs are T 98.7 F, HR 98, BP 128/76, and O2 Sat 98%. CBC demonstrates a WBC 7.0, Hgb 10.8, Hct 31.1, and MCV 110. The patient’s Hgb A1c is 5.6%. MRI spine is performed, which shows the following finding (Figure A). What is the most likely cause of the patient’s presentation?

A 29-year-old man presents to the emergency department after experiencing a motor vehicle accident. The patient was the front seat passenger in a head on collision. The patient is responsive only to painful stimuli. His temperature is 99.5°F (37.5°C), blood pressure is 90/60 mmHg, pulse is 150/min, respirations are 17/min, and oxygen saturation is 95% on room air. The patient is started on IV fluids and is given blood products. A FAST exam reveals no signs of intra-abdominal bleeding. A chest radiograph is ordered as seen in Figure A. A pelvic binder is placed and fluid and blood resuscitation is continued. Fifteen minutes later his temperature is 99.5°F (37.5°C), blood pressure is 110/70 mmHg, pulse is 100/min, respirations are 13/min, and oxygen saturation is 97% on room air. The patient is now able to respond to questions. The patient's lab values are ordered and are as below: Serum: Na+: 137 mEq/L Cl-: 102 mEq/L K+: 4.2 mEq/L HCO3-: 24 mEq/L BUN: 20 mg/dL Glucose: 110 mg/dL Creatinine: 1.1 mg/dL Ca2+: 9.6 mg/dL AST: 12 U/L ALT: 14 U/L Hemoglobin: 11 g/dL Hematocrit: 30% Leukocyte count: 6,500 cells/mm^3 with normal differential Platelet count: 255,000/mm^3 The patient suddenly becomes short of breath. A chest radiograph is ordered as seen in Figure B. A FAST exam is repeated and is within normal limits. Repeat lab values are ordered as below: Hemoglobin: 13 g/dL Hematocrit: 36% Leukocyte count: 6,000 cells/mm^3 with normal differential Platelet count: 250,000/mm^3 Which of the following best describes the most likely diagnosis?

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A 23-year-old male is brought by police officers from a social gathering due combative behavior and altered mental status. The police say that phencyclidine was found on the premises. The patient is alone, and acquiring an accurate history proves difficult. However, you do learn that the patient is having visual hallucinations. Vital signs show a blood pressure of 155/95 mmHg, pulse is 103/min, respirations is 20/min, oxygen saturation of 99%. Airway, breathing, and circulation are intact. The patient appears violent, and is trying to remove his clothes. Multiple hospital staff are needed to restrain the patient in bed. A finger-stick glucose show 93 mg/dL. The team is unable to place an IV, and thus intramuscular midazolam is administered to achieve sedation; however, he is still agitated. What is the mechanism of action of the best alternative sedative drug for this patient?

A 36-year-old woman complains of recurrent headaches. The pain is located on the right side of the head, is accompanied by nausea, worsens when lifting heavy objects, and typically lasts 2 days. She describes the pain as pulsatile and says that they are usually triggered by eating chocolates. Her headache is not associated with an aura. She sits in a dark room due to her increased discomfort. The patient has tried multiple over-the-counter medications without relief. Which of the following is the mechanism of the most appropriate next treatment to administer?

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A 27-year-old woman presents to her primary care physician for a follow-up appointment. At her previous visit she had missed her previous two menses and also had a blood pressure of 147/100 mmHg. The patient has a past medical history of anxiety, depression, bulimia nervosa and irritable bowel syndrome. Her physician prescribed her an exercise program as well as started her on hydrochlorothiazide and ordered lab work. The results of the patient's lab work are below: Serum: Na+: 145 mEq/L K+: 2.9 mEq/L Cl-: 100 mEq/L HCO3-: 30 mEq/L BUN: 18 mg/dL Ca2+: 10.9 mg/dL Mg2+: 2.0 mEq/L Creatinine: 1.2 mg/dL Glucose: 110 mg/dL The patient's blood pressure at this visit is 145/100 mmHg and she has still not experienced her menses. Her cardiac, abdominal, and pulmonary exams are within normal limits. Inspection of the patient's oropharynx is unremarkable as is inspection of her extremities. The patient is started on furosemide and sent home. Which of the following is the most likely cause of this patient's presentation?

A 28-year-old G1P0 woman at 42 weeks gestation is admitted to the maternity ward for induction of labor. She states that her prenatal care has been notable for gestational hypertension. She has been taking her multivitamin daily. She feels fetal movement and denies any vaginal bleeding. Her temperature is 98.6°F (37°C), blood pressure is 107/54 mmHg, pulse is 72/min, and respirations are 20/min. Her cervix is 0 cm dilated, and the fetus is in cephalic position. The fetal heart monitor shows a heart rate of 130/min. She agrees to have an epidural catheter placed for analgesia. Shortly thereafter, amniotomy is performed. No vaginal bleeding is observed. While attending to documentation of the procedure, the nurse calls your attention to a change in the fetal heart monitor, shown in Figure A. What is the most likely cause for this finding?

A 28-year-old G1P0 woman who is 30 weeks pregnant presents to the women's health center for a prenatal checkup. She is concerned that her baby is not moving as much as usual over the past five days. She thinks she only felt the baby move eight times over an hour long period. Her prenatal history was notable for morning sickness requiring pyridoxine. Her second trimester ultrasound revealed no abnormal placental attachment. She takes a multivitamin daily. Her temperature is 98.6°F (37°C), blood pressure is 120/70 mmHg, pulse is 80/min, and respirations are 16/min. The patient's physical exam is unremarkable. Her fundal height is 28 cm, compared to 26 cm two weeks ago. The fetal pulse is 140/min with no accelerations. The patient undergoes external fetal monitoring. With vibroacoustic stimulation, the patient feels eight movements over two hours with no fetal heart rate accelerations. What is the best next step in management?

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