A 49-year-old male presents to his primary care physician for the first time in twelve years. His chief complaint is a new onset of diarrhea, which nothing seems to improve. He first noticed this diarrhea about a month ago. He complains of greasy stools, which leave a residue in his toilet bowl. Review of systems is notable for alcohol consumption of 12-16 cans of beer per day for the last two decades. Additionally, the patient endorses losing 12 lbs unintentionally over the last month. Vital signs are within normal limits and stable. Exam demonstrates a male who appears older than stated age; abdominal exam is notable for epigastric tenderness to palpation. What is the next step in diagnosis?

A 46-year-old male with an extensive history of alcohol abuse and smoking presents with constant epigastric pain, which seems to worsen after meals. The patient has had multiple bouts of acute pancreatitis in the past, but states this pain is not as severe, and has been constant for the last 3 weeks. Review of systems is notable for diarrhea and a 10 lb weight loss. Vital signs are as follow T 98.7 F HR 92 bpm BP 139/87 mmHg RR 19 Sat 92%. Laboratory studies demonstrate ALT 236 U/L AST 603 U/L, with a normal total bilirubin. The patient is referred for further imaging which is shown in Figure A. Which of the following is the next best step in management?

A 65-year-old man with a history of constipation is admitted to your floor with left lower quadrant pain. The patient states that he has been previously admitted with similar pain. He denies any medical history, but states that he does not like to eat vegetables. His wife states that he has had increasing pain over the last few days and that this time, the pain is more intense and that the patient has had higher fevers of up to 102°F (38.9°C). On exam, the patient's vitals are HR 102, T 101.9°F (38.8°C), BP 140/60, and RR 14. The patient has tenderness to palpation along with rebounding and guarding. Figure A shows a CT scan of the patient's abdomen and pelvis. What is the definitive treatment for this patient?

A 37-year-old woman with a history of systemic lupus erythematosus, on prednisone and methotrexate, presents to the dermatology clinic with three weeks of a diffuse, itchy rash. Physical exam is remarkable for small red papules in her bilateral axillae and groin and thin reddish-brown lines in her interdigital spaces. The following skin biopsy is obtained. Which of the following is the most appropriate treatment?

A 71-year-old female presents to her primary care physician with a four-day history of left lower quadrant abdominal pain. The patient also complains of diarrhea and mild nausea. She continues to tolerate a diet, though reduced in quantity. On exam, her vitals are T 101F HR 86, BP 130/92, RR 15, and SaO2 100%. Abdominal exam is notable for left lower quadrant tenderness to palpation without rebound or guarding. Urine dipstick is normal and complete blood count shows a minor leukocytosis with a left shift. A screening colonoscopy from a year ago is shown in Figure A. What is the next best step in management?

A 4-year-old male is brought into your office because his mother states he has been fatigued. He has not been acting like himself and has been getting tired easily while running around and playing with other children. As of last week, he has also been complaining of being short of breath. His vitals are temperature 98.6 deg F (37.2 deg C), blood pressure 100/75 mmHg, pulse 98/min, and respirations 22/min. On exam, the patient is short of breath, and there is a holosystolic murmur with an appreciable thrill along the left sternal border. There are no other noticeable abnormalities, and the mother states that the child's prenatal course along with genetic testing was normal. What is the most likely diagnosis?

A 70-year-old man with a history of chronic constipation presents to the emergency department with a two-day history of left lower quadrant abdominal pain. He is found to have a temperature of 100.8F, BP 140/90, HR 85, and RR 16. On physical examination, he is tender to light palpation in the left lower quadrant and exhibits voluntary guarding. Rectal examination reveals heme-positive stool. Laboratory values are unremarkable except for a WBC count of 12,500 with a left shift. Which of the following tests would be most useful in the diagnosis of this patient's disease?

A 66-year-old female with congestive heart failure, diabetes mellitus, depression, and osteoarthritis presents to the emergency department with fatigue, blurry vision, and diarrhea. Her home medications include furosemide, lisinopril, carvedilol, digoxin, metformin, glyburide, amitriptyline, and occasional ibuprofen for knee pain. She endorses recent knee pain and an increase in her glyburide dose. Her labs include the following: Serum: Na+: 137 mEq/L K+: 3.3 mEq/L Cl-: 99 mEq/L HCO3-: 24 mEq/L BUN: 17 mg/dL Cr: 1.62 mg/dL Glucose: 160 mg/dL An EKG can be seen in Figure A. What is the most likely inciting event for this patient's presentation?

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A 42-year-old African American female presents to your clinic complaining of excessive thirst and urination. She reports that these symptoms began one week ago, and they have been affecting her ability to work as a schoolteacher. Labs are drawn and are listed below. Serum: Na+: 145 mEq/L Cl-: 101 mEq/L K+: 4.4 mEq/L HCO3-: 25 mEq/L Urea nitrogen: 24 mg/dL Glucose: 115 mg/dL Creatinine: 0.7 mg/dL Hemoglobin: 10.5 g/dL Hematocrit: 25% Leukocyte count: 11,000/mm^3 Platelets: 200,000/mm^3 Urine: Specific gravity: 1.006 Epithelial cells: 5/hpf Glucose: negative Protein: 20 mg/dL RBC: 6/hpf WBC: 1/hpf Leukocyte esterase: negative Nitrites: negative Bacterial: none A water deprivation test is performed with the following results: Serum osmolality: 305 mOsm/kg Urine osmolality: 400 mOsm/kg Urine specific gravity: 1.007 Desmopressin is administered, and the patient's urine osmolality increases to 440 mOsm/kg. The patient's antidiuretic hormone is measured and is within normal limits. Which of the following may be associated with this patient’s condition?

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A 72-year-old man presents to his primary care physician with progressively worsening hearing loss. He states that his trouble with hearing began approximately 7-8 years ago. He is able to hear when someone is speaking to him; however, he has difficulty with understanding what is being said, especially when there is background noise. In addition to his current symptoms, he reports a steady ringing in both ears, and at times experiences dizziness. Medical history is significant for three prior episodes of acute otitis media. Family history is notable for his father being diagnosed with cholesteatoma. His temperature is 98.6°F (37°C), blood pressure is 138/88 mmHg, pulse is 14/min, and respirations are 13/min. On physical exam, when a tuning fork is placed in the middle of the patient's forehead, sound is appreciated equally on both ears. When a tuning fork is placed by the external auditory canal and subsequently on the mastoid process, air conduction is greater than bone conduction. Which of the following is most likely the cause of this patient's symptoms?

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A 28-year-old male presents with a recent onset of upsetting dreams, anxiety, and disturbing flashbacks. The patient reports that he returned from active duty in Iraq 3 months ago and was adjusting to life back at home until about 7 weeks ago when he began having intense fear of loud noises and seeing sudden flashbacks to bombing attacks he endured during his time in Iraq. He had to take a leave from his army instructor duties as he was not able to handle the familiar settings of practice shooting ranges and sudden loud explosions during battalion training. After refusing to leave his house, he was finally persuaded by his wife to visit your clinic. What is the most likely diagnosis?

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A 69-year-old man presents to his primary care physician for pain when he walks. He states that the pain is the worst in his left great toe but is also present in his hips and knees. He says that his symptoms are worse with activity and tend to improve with rest. His symptoms have progressively worsened over the past several years. He has a past medical history of obesity, type II diabetes mellitus, smoking, and hypertension. He drinks roughly ten beers per day. His current medications include metformin, insulin, lisinopril, and hydrochlorothiazide. The patient has a recent travel history to Bangkok where he admits to having unprotected sex. On physical exam, examination of the lower extremity results in pain. There is crepitus of the patient's hip when his thigh is flexed and extended. Which of the following is the most likely diagnosis?

A 27-year-old G2P2002 is recovering in the hospital on postpartum day 3 after a low transverse C-section. During morning rounds, she reports a “pus-like” discharge and shaking chills overnight. She also endorses increased uterine cramping compared to the day before, but her postpartum course has otherwise been uneventful with a well-healing incision and normal vaginal bleeding. The patient’s prenatal care was complicated by HIV with a recent viral load of 400 copies/mL, type I diabetes well controlled on insulin, and a history of herpes simplex virus encephalitis in her first child. She did not have any genital lesions during the most recent pregnancy. Four days ago, she presented to the obstetric triage unit after spontaneous rupture of membranes and onset of labor. She made slow cervical change and reached full dilation after 16 hours, but there was limited fetal descent. Cephalopelvic disproportion was felt to be the reason for arrest of descent, so prophylactic ampillicin was administered and C-section was performed. A vaginal hand was required to dislodge the fetus’s head from the pelvis, and a healthy baby boy was delivered. On postpartum day 3, her temperature is 101.5°F (38.6°C), blood pressure is 119/82 mmHg, pulse is 100/min, and respirations are 14/min. Her incision looks clean and dry, there is mild suprapubic tenderness, and a foul yellow discharge tinged with blood is seen on her pad. Which of the following is the most significant risk factor for this patient’s presentation?

A 10-year-old boy is brought into your clinic by his mother for sunburns that have not been healing. The mother states that he easily gets sunburned. The mother admits she gave birth to him at home and has never taken him to see a doctor. The patient walks with a wide stance gait and appears unstable on his feet. He has an extensive erythematous, scaling, hyperkeratotic rash on his face, neck, arms and legs. After extensive workup, the patient is found to have a genetic disorder that results in defective absorption of an important vitamin. Which of the following is likely to be low if measured?

A seven-day-old female presents to the emergency department for bloody stools. The patient was born at 39 weeks gestation to a 30-year-old primigravid via vaginal delivery. The patient’s mother declined all prenatal testing and delivered at home due to personal preference. She reports that the patient appeared well after delivery. The patient is being exclusively breastfed, and her mother reports that feeding is going well. The patient feeds every two hours and usually passes 3-4 loose, dark yellow stools per day. The patient’s mother reports that one day ago the patient began passing blood-streaked stools that have since become grossly bloody. She has also noticed that the patient has become more lethargic and has less interest in feeding. The patient’s mother denies any family history of bleeding disorders. The patient’s temperature is 97.7°F (36.5°C), blood pressure is 56/42 mmHg, pulse is 152/min, and respirations are 28/min. On physical exam, the patient appears somnolent. Her anterior fontanelle is tense and bulging, and she has scattered ecchymoses on her extremities. Laboratory testing is performed that reveals the following: Prothrombin time (PT): 32 seconds Partial thromboplastin time (PTT): 54 seconds A head CT is obtained and can be seen in Figure A. Which of the following is most likely to be found in this patient?

A 31-year-old obese Caucasian female presents to the Emergency Department late in the evening for left lower quadrant pain that has progressively worsened over the last several hours. She describes the pain as sharp and shooting, coming and going. Her last bowel movement was this morning. She has also had dysuria and urgency. Her surgical history is notable for gastric bypass surgery 2 years prior and an appendectomy at age 9. She is sexually active with her boyfriend and uses condoms. Her temperature is 99.5 deg F (37.5 deg C), blood pressure is 151/83 mmHg, pulse is 86/min, respirations are 14/minute, BMI 32. On physical exam, she has left lower quadrant tenderness to palpation with pain radiating to the left groin and left flank tenderness on palpation. Her urinalysis shows 324 red blood cells/high power field. Her pregnancy test is negative. What of the following is the next best step in management?

A 20-year-old female presents to your clinic for evaluation. She complain of months of daily rhinorrhea, which she describes as watery and clear, as well as nasal congestion bilaterally. In addition, she reports frequent watery and itchy eyes, as well as daily sneezing. Her temperature is 100.1 deg F (37.8 deg C), blood pressure is 120/70 mmHg, pulse is 70/min, and respirations are 15/min. On exam, you note edematous, boggy turbinates with watery rhinorrhea. Which of the following is a treatment for the patient’s condition?

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A 35-year-old female is brought to the emergency department after being found unconscious. The patient is found to have a blood glucose level of 35 mg/dL. Hgb A1c was found to be 5.1%. C-peptide level was found to be decreased. The patient returned to her baseline after glucose replacement. She states that she has never had an episode like this before. She has no significant past medical history but reports a family history of diabetes in her mother. She states that she has been undergoing a difficult divorce over the past few months. What is the likely cause of this patient's condition?

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A 36-year-old female presents to her primary care provider for tremor. She reports that she has always had a mild tremor but that she has begun noticing it more since learning to paint. She feels that she has trouble dipping her paintbrush in the paint and making precise strokes on the canvas. She has taken to painting while drinking wine, as she notices that the wine seems to improve her tremor. Her temperature is 97.6°F (36.4°C), blood pressure is 105/61 mmHg, pulse is 58/min, and respirations are 12/min. On exam, she has a high frequency bilateral hand tremor elicited on finger-to-nose testing. Her neurological exam is otherwise unremarkable. The patient is started on a new medication for her symptoms. One week later, she returns with a new complaint of abdominal pain for one day. She reports that she has noticed a darkening of her urine and now has difficulty raising her arms over her head to brush her hair. This patient was most likely treated with which of the following medications?

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A 32-year-old HIV positive female known to be non-adherent to her treatment regimen, presents to the hospital with the complaint of new-onset headaches. Her vital signs are only significant for a low-grade fever. Neurological examination reveals right-sided upper motor neuron signs, as well as a inattention and difficulty with concentration. The patient currently does not have a primary medical provider. A CT of the patients head is shown in the image below. What is the next best step in management for this patient?

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A 19-year-old man is brought to the emergency department by the police. The officers indicate that he was acting violently and talking strangely. In the ED, he becomes increasingly more violent. On exam his vitals are: Temp 101.1 F, HR 119/min, BP 132/85 mmHg, and RR 18/min. Of note, he has vertical nystagmus on exam. What did this patient most likely ingest prior to presentation?

A 63-year-old man undergoes uncomplicated laparascopic cholecystectomy for acute cholecystitis and is admitted to the surgical ward for postoperative management. On postoperative day 1, routine laboratory studies reveal an increase in serum creatinine to 1.46 mg/dL from 0.98 mg/dL before the operation; BUN is 37 mg/dL, increased from 18 mg/dL on prior measurement; K is 4.8 mEq/L and CO2 is 19 mEq/L. The patient has an indwelling urinary catheter in place, draining minimal urine over the last few hours. After ruling out urinary catheter obstruction, which of the following is the most appropriate next step in management?

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A 69-year-old gentleman presents to his primary care physician for pain in his right shoulder. The patient was helping his son move this past weekend, and he noticed after the move that he had pain and weakness in his right shoulder. The patient thought that this pain was just him being in poor shape so he started going to the gym and lifting weights which made his symptoms significantly worse. The patient has a past medical history of diabetes, obesity, and asthma. His current medications include albuterol, lisinopril, metformin, and glipizide. On physical exam you note an obese gentleman who seems to be in pain. You note prominent weakness of external rotation of his right upper extremity. When you ask the patient to slowly lower his right arm to his side when he holds it overhead, you note that he suddenly drops his arm and appears to be in pain. The patient's strength is 1/5 for abduction of the right arm. Which of the following is most likely injured in this patient?

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A 17-year-old male presents to the emergency department for eye pain. The patient states that he has had left eye pain for the past week that has been steadily worsening. The patient denies any changes to his vision, trouble moving his left eye, or recent trauma. The patient smokes one pack of cigarettes a day, drinks alcohol socially, and has had unprotected sex with two males and four females this past month. His current medications include loratadine, nasal saline spray, and diphenhydramine. His temperature is 99.5°F (37.5°C), blood pressure is 100/55 mmHg, pulse is 72/min, respirations are 11/min, and oxygen saturation is 98% on room air. On physical exam, you note a healthy young man. Cardiopulmonary exam is within normal limits. His physical exam reveals the finding in Figure A. Which of the following is the most likely diagnosis?

A 42-year old female comes to the emergency room complaining of facial droop. She reports that she first noticed the facial droop this morning while she had been getting ready for work. Her smile appeared asymmetric and she could not fully close her left eye. A review of systems is also significant for one month of foul otorrhea. The patient’s medical history is significant for recurrent childhood ear infections. The patient’s temperature is 99.0°F (37.2°C), blood pressure is 110/65 mmHg, pulse is 72/min, and respirations are 14/min with an oxygen saturation of 99% O2 on room air. On physical exam, the patient’s mouth is drooping downward on the left, and the patient cannot fully close her left eye. She also has drainage from the left ear, and otoscopic examination demonstrates the finding seen in Figure A. An audiometric evaluation reveals conductive hearing loss in the left ear. Which of the following is the most likely explanation for these findings?

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