The medical student on the pediatric cardiology team is exam...

Sorry, only PEAK Subscribers can view this question

An 82-year-old man presents to the emergency department comp...

Sorry, only PEAK Subscribers can view this question

A 4-year-old boy is brought in by his grandmother for worsen...

Sorry, only PEAK Subscribers can view this question

A 37-year-old woman presents to the emergency department wit...

Sorry, only PEAK Subscribers can view this question

A 65-year-old male presents to his dermatologist to discuss treatment options. He was recently diagnosed with basal cell carcinoma located on his nose. It is currently 1 cm in diameter with a central depression (Figure A). Previous pathology findings demonstrate that it is an infiltrative sub-type. What is the most appropriate course of treatment for this individual?

A 68-year-old male presents to your office for his annual physical exam. He has no complaints at this time and his chronic hypertension is well controlled. You notice a .5cm papule on the patient's eyelid that has a pink pearly appearance, rolled borders, and overlying telangiectasias. On further questioning, you find out the patient was a door-to-door salesman and spent a lot of time outdoors, and he did not wear sunscreen. He has fair skin and blonde hair. The patient states that he first noticed the lesion about 6 months prior, and it has grown slightly since then. What is the most likely diagnosis?

A 26-year-old woman presents to the emergency department bec...

Sorry, only PEAK Subscribers can view this question

A 29-year-old male presents to the physician for evaluation of fever and a rash. He states that he recently returned from a camping trip in Minnesota, and a few days after his return he began to feel unwell. Yesterday, he noticed a rash in his axilla and also developed subjective fever and chills. He reports associated malaise. He has no past medical history and takes no medications. His temperature is 100.4°C (38.0°C), pulse is 90, blood pressure is 120/80, and respirations are 14/min. Examination of the patient's rash is shown in Figure A. No neck stiffness is noted. Lungs are clear to auscultation bilaterally. The remainder of the exam is unremarkable. Which of the following conditions may develop without appropriate treatment for this patient's condition?

A 65-year-old man with a past medical history of anterior myocardial infarction, peripheral arterial disease, and known patent foramen ovale presents to the emergency department after being found down from a fall on the sidewalk in the middle of winter. He states that his right leg feels numb and painful at the same time. He insists that he did not slip on ice or snow, yet fell suddenly. He is taking aspirin, simvastatin, and cilostazol. Vital signs show T 98.0 F, BP 100/60, HR 100, RR 18. His pulse is irregularly irregular. His right leg appears pale with no dorsalis pedis and posterior tibial pulses compared to 2+ pulses on the left. He cannot discern soft or sharp touch in his right leg. Which intervention will most likely improve the viability of this patient's right leg?

A 59-year-old man presents to the emergency department with ...

Sorry, only PEAK Subscribers can view this question

A 57-year-old immigrant from Nigeria presents to the emergen...

Sorry, only PEAK Subscribers can view this question

A 29-year-old man comes into his primary care physician's of...

Sorry, only PEAK Subscribers can view this question

A 14-month-old boy has iron-deficiency anemia refractory to iron therapy. His stool is repeatedly positive for occult blood. The parents bring the child to the emergency room after they notice some blood in his stool. Which of the following is the diagnostic gold standard for this patient's most likely condition?

A 65-year-old man with a past medical history of aortic sten...

Sorry, only PEAK Subscribers can view this question

A 3-year-old African-American boy presents with a rapid onset of severe abdominal pain. He has a palpably enlarged mass in the left upper quadrant of his abdomen. Complete blood count is notable for a hemoglobin of 7.2 g/dL. Serum haptoglobin level returns normal. Serum unconjugated bilirubin is elevated. The corrected reticulocyte count is elevated. Which of the following is the most likely explanation for the findings above?

An 2-year-old girl with a history of SS-hemoglobin is brought to her pediatrician by her mother, who noted an abdominal mass. On exam, the girl's spleen is palpably enlarged, and her palms and conjunctiva are noted to be extremely pale. Serum haptoglobin levels are normal. Which of the following is the most likely cause of this patient's symptoms?

A 70-year-old man is brought to the emergency department unc...

Sorry, only PEAK Subscribers can view this question

A 32-year-old G2P1 woman presents to the emergency department at 30 weeks of gestation with complaints of vaginal bleeding and abdominal pain. She first noticed the abdominal pain yesterday morning after she ate breakfast and over the course of the day, the symptoms progressed to include nausea and vomiting. She initially thought she had a minor case of food poisoning but became concerned when she noted a small amount of spotting this morning that progressed to much larger amounts of vaginal bleeding with worsening abdominal pain. Her previous pregnancy was without complications and the fetus was born at 41 weeks by vaginal delivery after induction of labor. Her medical history is significant for hyperlipidemia, but she does not currently take any medications. Her temperature is 98.7°F (37°C), blood pressure is 138/85 mmHg, pulse is 110/min, and respirations are 16/min. Fetal heart monitoring shows fetal distress with late decelerations. Which of the following is a risk factor for the most likely cause of this patient's symptoms?

A 21-year-old female presents to her primary care doctor for...

Sorry, only PEAK Subscribers can view this question

A 16-year-old boy presents to the emergency department due to right-sided hearing loss, headache, and nasal bleeding. He reports that for the past few months, he has found it difficult to breathe through his nose and has had nasal drainage. He also states that he has not been able to stop his nose from bleeding for the last few hours. His right-sided hearing loss began around the same time as his difficulty with nasal breathing. He denies any history of trauma to the nose, uncontrollable bleeding, and easy bruising. His family history is unremarkable. His temperature is 99°F (37.2°C), blood pressure is 112/67 mmHg, pulse is 95/min, and respirations are 20/min with an oxygen saturation of 99%. On physical examination, the patient appears anxious. There is an amber fluid collection in the right ear appreciated on otoscopy. Physical exam is notable for the finding in Figure A which does not remove with irrigation or the patient blowing their nose. Which of the following is the most appropriate next step in management?

During an emergency room shift, you encounter a disheveled looking man claiming that he is President Kennedy’s love child and the FBI is out to get him. He also endorses that the aliens are responsible for his fathers death and that the aliens implanted a chip in his head to constantly speak to him. Upon review of his medical record, you notice that he made a previous visit to the ER for a similar episode about 8 months ago. Besides his eccentric demeanor and disorganized speech, his vitals and physical exam are all within in normal range. No illicit substances were identified following a urinary toxicology screening. What type of medication would be best long-term for our patient?

A 69-year-old male presents to the emergency department for slurred speech and an inability to use his right arm which occurred while he was eating dinner. The patient arrived at the emergency department within one hour. A CT scan was performed of the head and did not reveal any signs of hemorrhage. The patient is given thrombolytics and is then managed on the neurology floor. Three days later, the patient is recovering and is stable. He seems depressed but is doing well with his symptoms gradually improving as compared to his initial presentation. The patient complains of neck pain that has worsened slowly over the past few days for which he is being given ibuprofen. Laboratory values are ordered and return as indicated below: Serum: Na+: 130 mEq/L K+: 3.7 mEq/L Cl-: 100 mEq/L HCO3-: 24 mEq/L Urea nitrogen: 7 mg/dL Glucose: 70 mg/dL Creatinine: 0.9 mg/dL Ca2+: 9.7 mg/dL Urine: Appearance: dark Glucose: negative WBC: 0/hpf Bacterial: none Na+: 320 mEq/L/24 hours His temperature is 99.5°F (37.5°C), pulse is 95/min, blood pressure is 129/70 mmHg, respirations are 10/min, and oxygen saturation is 98% on room air. Which of the following is the best next step in management?

A 21-year-old African-American male with a past medical hist...

Sorry, only PEAK Subscribers can view this question

A 13-year-old boy is brought to his pediatrician due to a left breast lump under his nipple. He noticed it last month and felt that it has increased slightly in size. It is tender to touch but has no overlying skin changes. There is no breast discharge. The patient has cryptorchidism as an infant and underwent a successful orchiopexy. In addition, he was recently diagnosed with ADHD and is currently on methylphenidate with improvement in his symptoms. He has a family history of type I diabetes in his father and breast fibroadenoma in his mother. On exam, the patient is at the 82nd percentile for height, 79th percentile for weight, and 80th percentile for BMI. He has tanner IV pubic hair. Testicular volume is 7 mL on each side, and both testes are smooth and freely mobile. Breast exam shows a normal right breast and a 3-centimeter round, firm, and slightly tender discrete mass under the left nipple. Which of the following is the most likely etiology of this patient’s condition?

A 39-year-old male is rushed to the emergency department after he developed a sudden-onset severe headache with ensuing nausea, vomiting, vision changes, and loss of consciousness. Past medical history is unattainable. He reports that the headache is worse than any he has experienced before. Noncontrast CT of the head is significant for an intracranial hemorrhage. Follow-up cerebral angiography is performed and shows a ruptured anterior communicating artery aneurysm. Which of the following has the strongest association with this patient's current presentation?

A 16-year-old female presents to her primary care physician due to lack of menstruation. She has never had a period and is anxious that she is not “keeping up” with her friends. She states that her breasts began developing when she was 13, and she had a growth spurt around the same time. Review of systems reveals that she has also been getting headaches every few months over the last year with some photosensitivity and nausea each time. Ibuprofen relieves her symptoms. The patient is a competitive ice skater and has never been sexually active. Her mother has a history of migraine headaches, and her older sister has a history of bipolar disorder. Both underwent menarche at age 15. At this visit, the patient’s temperature is 98.6°F (37.0°C), pulse is 70/min, blood pressure is 118/65 mmHg, and respirations are 13/min. Her body mass index is 23.8 kg/m^2. Cardiopulmonary and abdominal exams are unremarkable. Both breasts are Tanner IV with no expressable discharge. Pelvic and axillary hair growth is also Tanner IV. The patient is unable to tolerate a full pelvic exam, but the part of the vaginal canal that is examined is unremarkable. Laboratory studies are ordered and are below: Serum: Na+: 139 mEq/L K+: 4.1 mEq/L Cl-: 100 mEq/L HCO3-: 24 mEq/L Urea nitrogen: 12 mg/dL Glucose: 73 mg/dL Creatinine: 0.9 mg/dL Ca2+: 9.7 mg/dL Mg2+: 1.7 mEq/L AST: 11 U/L ALT: 11 U/L Follicle Stimulating Hormone (FSH): 16.2 mIU/mL (4.7-21.5 mIU/ml) Estrogen: 240 pg/mL (64-357 pg/mL) Abdominal ultrasound is performed and shows a normal uterus and ovaries. Which of the following is the most likely diagnosis?

A 13-year-old girl presents to her primary care physician du...

Sorry, only PEAK Subscribers can view this question

A 28-year-old woman presents to the emergency department wit...

Sorry, only PEAK Subscribers can view this question

A 2-day-old male is evaluated in the hospital nursery for vomiting. He has vomited three times in the last four hours and now shows little interest in feeding. His mother describes his last episode of emesis as green in color. The patient is sleeping and urinating well, but has not yet passed meconium. The patient was born at 35 weeks gestation to a 42-year-old gravida 3. The patient’s mother received sporadic prenatal care and did not undergo any prenatal testing. His birth weight was 2.80 kg (6 lb 3 oz), and his current weight is 2.30 kg (5 lb 1 oz). The patient’s temperature is 98.8°F (37.1°C), blood pressure is 56/41 mmHg, pulse is 137/min, and respirations are 32/min. On physical exam, he is in mild distress. His abdomen is soft and distended. Digital rectal exam reveals an absence of stool in the rectal vault. His abdominal radiograph can be seen in Figure A. A contrast enema is performed and can be seen in Figure B. Which of the following additional findings would most likely be found in this patient?

A 46-hour-old female is evaluated in the hospital nursery for difficulty feeding. Her mother reports that breastfeeding was going well for the first several feeds, but the patient now seems less interested in feeding and refuses to latch. A few minutes later, the patient has two episodes of biliary emesis. She has not yet had a bowel movement. The patient was born at 37 weeks gestation to a 39-year-old gravida 4. The pregnancy was uncomplicated. The patient’s family history is significant for a maternal uncle who died in his late 20's due to pulmonary disease. The patient’s father was adopted, and little is known about his biological family. The patient’s three older siblings are healthy. The patient’s temperature is 97.8°F (36.6°C), blood pressure is 62/44 mmHg, pulse is 140/min, and respirations are 36/min. On physical exam, the patient is crying, and her abdomen is markedly distended. There is no stool in the rectal vault on digital rectal exam. An abdominal radiograph is performed and can be seen in Figure A. A contrast enema is scheduled. Which of the following additional tests should be performed on this patient?

A 70-year-old woman is admitted to the hospital from a nursi...

Sorry, only PEAK Subscribers can view this question

A 64-year-old man presents to the emergency room with a head...

Sorry, only PEAK Subscribers can view this question

A 41-year-old woman presents to her primary care physician reporting fatigue for the past 3 months. On further questioning, she notes dry eyes and dry mouth, as well as whole-body itching for the past 3 months. She denies any change in skin color. For the past year, she has had a persistently elevated alkaline phosphatase around 300 IU/L (normal 40 to 120 IU/L) as well as elevated total bilirubin at 2.4 (normal 0.3 to 1.9 mg/dL) and direct bilirubin at 0.7 (normal 0 to 0.3 mg/dL). Her aminotransferase levels have been within normal limits and RUQ ultrasound was unremarkable. Further testing revealed a positive anti-mitochondrial antibody titer, and a liver biopsy was performed (Figure A). Which of the following is the most appropriate treatment for this patient at this time?

A 54-year-old man with known end-stage liver disease from al...

Sorry, only PEAK Subscribers can view this question

A 66-year-old man presents to the emergency department with dyspnea. Two days ago, he hosted his grandchild's birthday party, and since has noticed general malaise, fever, and dry cough. He does not know if he feels more dyspneic while supine or standing but has noticed difficulty breathing even while watching television. He has a past medical history of congestive heart failure and hypertension, for which he takes aspirin, metoprolol, furosemide, lisinopril, and spironolactone as prescribed. His blood pressure is 90/50 mmHg, pulse is 120/min, and respirations are 30/min. His radial pulse is barely palpable, and his wrists and ankles are cold and clammy. Physical exam reveals a S3 and S4 with a soft holosystolic murmur at the apex, decreased breath sounds up to the middle lung fields, jugular venous distention to the auricles, and 3+ pitting edema to the mid thighs. EKG shows ST depressions consistent with demand ischemia. Bedside echocardiogram shows global akinesis with an ejection fraction (EF) of 20%; previous reports show EF at 40%. A portable chest radiograph shows bilateral pulmonary edema. Metoprolol is held, dobutamine and furosemide drips are started, and BiPAP is started at 20/5 cm H2O. After 15 minutes, the nurse reports that urine output is minimal and blood pressure is now 75/40 mmHg and pulse is 130/min. What is the best next step in management?

A 41-year-old man presents to his primary care provider with...

Sorry, only PEAK Subscribers can view this question

A 38-year-old man presents to his primary care provider for ...

Sorry, only PEAK Subscribers can view this question

A 64-year-old male presents to his primary care physician with a chief complaint of left knee pain. He describes acute-onset knee pain last evening that was accompanied by redness of the skin around the joint. He denies any precipitating injury or recent activity that could have caused this pain. He describes a similar episode that occurred in his right knee 2 months ago; he did not seek medical treatment, and the pain mitigated after 5 days. Physical examination is significant for the following: left knee is warm-to-touch, erythematous, and extremely tender to palpation; range of motion in flexion and extension is limited by pain; crepitus noted with passive movement of the knee joint. The patient is noted to be afebrile with all vital signs within normal limits. Aspiration of the left knee joint is ordered and reveals the findings shown in Figure A. Which of the following findings could also be seen in this patient, associated with their current diagnosis?

A 6-month-old girl presents with her mother to the pediatric...

Sorry, only PEAK Subscribers can view this question

A 25-year-old Greek college student presents to the emergency department with wine-colored urine. He states that the change in urine color came on suddenly, and this has never happened to him before. Aside from the dark urine, he complains of minor muscle pain and soreness that is related to his training. The patient states he ran in a marathon today that he has been training for for the past year. The patient does not have a significant past medical history and is currently taking a multivitamin, fish oil, and a whey protein supplement. Urine dipstick is positive for red blood cells. An EKG is obtained and seen in Figure A. Urine toxicology is performed and returns positive for amphetamines and cocaine. On physical exam, you note an excitable young man who has no abnormal findings. Urine microscopy reveals an absence of red blood cells. Which of the following is the next best step in management?

An 18-month-old male with a past medical history of mild int...

Sorry, only PEAK Subscribers can view this question

A 39-year-old G4P3 woman 38 weeks pregnant presents to the emergency department with bright red vaginal bleeding that started one hour ago following sexual intercourse with her partner. She denies any abdominal pain. Her medical history is notable for three prior cesarean sections. She has not seen an obstetrician because she felt similar to her previous pregnancies. Her temperature is 98.6°F (37°C), blood pressure is 100/70 mmHg, pulse is 95/min, and respirations are 20/min. The fetal pulse is 130/min; its tracing is shown in Figure A. The patient's physical exam is unremarkable. Inspection of the vagina reveals no active bleeding. The transvaginal ultrasound machine is being prepared. What is the most likely diagnosis?

A 45-year-old African American woman presents to her primary...

Sorry, only PEAK Subscribers can view this question

A 59-year-old African American woman presents to the emergen...

Sorry, only PEAK Subscribers can view this question

A 3-year-old previously healthy female is brought to your office by her mother. The mother reports the child has been crying and pulling at her right ear over the past 2 days, and reports the patient has been febrile the past 24 hours. The patient’s past medical history is unremarkable, although the mother reports the patient had a “common cold” a week ago which resolved without intervention. Her temperature is 101.6 deg F (38.7 deg C), blood pressure is 100/70 mmHg, pulse is 120/min, and respirations are 22/min. Otoscopic exam is seen in Figure A. What is the most likely diagnosis?

A 25-year-old man presents to his primary care physician wit...

Sorry, only PEAK Subscribers can view this question

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

Sorry, only PEAK Subscribers can view this question

A 66-year-old male presents to a primary care clinic with a ...

Sorry, only PEAK Subscribers can view this question

A 31-year-old G1P0000 woman presents to the obstetric servic...

Sorry, only PEAK Subscribers can view this question

A 12-year-old boy is brought to the emergency department by ...

Sorry, only PEAK Subscribers can view this question