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

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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 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?

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?

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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?

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A 70-year-old female with a history of congestive heart fail...

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A 34-year-old male is brought to the emergency department by paramedics after being found down on the sidewalk. The paramedics are unable to provide any further history and the patient in unresponsive. On exam, the patient's vitals are: T: 36 deg C, HR: 65 bpm, BP: 100/66, RR: 4, SaO2: 96%. The emergency physician also observes the findings demonstrated in figures A and B. This patient most likely overdosed on which of the following?

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A 55-year-old male bodybuilder presents to the emergency dep...

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A 75-year-old woman with late-onset autoimmune diabetes mell...

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A 34-year-old woman is assaulted and suffers a number of stab wounds to her abdomen. Bystanders call paramedics and she is subsequently taken to the nearest hospital. On arrival to the emergency department, her vitals are T: 36 deg C, HR: 110 bpm, BP: 100/60, RR: 12, SaO2: 99%. A FAST and abdominal CT are promptly obtained which are demonstrated in Figures A and B, respectively. Her chart demonstrates no other medical problems and vaccinations/boosters up to date. The patient is diagnosed with a Grade V splenic laceration and is immediately brought to the OR for emergent splenectomy. The splenectomy is successfully performed with removal of the damaged spleen (Figure C). Following the operation, the patient should receive which of the following vaccines: (I) H. influenzae (II) Tetanus (III) N. meningitidis (IV) S. pneumoniae (V) Hepatitis B

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A 68-year-old male presents to his primary care physician with complaints of fatigue and pain in his upper arms and lower back for the past 2 months. Physical examination reveals pallor, hepatosplenomegaly, and focal bony tenderness to palpation over the lumbar vertebrae, bilateral humeri, and skull. Laboratory evaluation reveals hemoglobin 9.8 g/dL, serum calcium of 9.4 mg/dL, serum creatinine of 1.4 mg/dL, albumin of 3.7 g/dL, and rouleaux formation on peripheral blood smear. Serum protein electrophoresis reveals an elevated spike of a monoclonal IgG protein, with an M-protein serum concentration of 50 g/L. Which of the following radiographs would most likely be associated with this patient's condition?

The parents of 3 different children arrive at the pediatrici...

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A 27-year-old woman presents to the emergency department for bilateral, painful loss of vision. Her symptoms started last night and have persisted until this morning. She has experienced an episode of urinary incontinence as well. The patient has a medical history of anxiety as well as peripheral neuropathy which is currently treated with duloxetine. Her temperature is 99.5°F (37.5°C), blood pressure is 100/60 mmHg, pulse is 100/min, respirations are 15/min, and oxygen saturation is 98% on room air. On physical exam, the patient demonstrates 4/5 strength in her upper and lower extremities with decreased sensation in her fingers bilaterally. An MRI is obtained and is within normal limits. Which of the following is the most appropriate next step in management and corresponding finding?

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A 62-year-old man arrives at the emergency room complaining of chest pain and difficulty breathing. He reports that the dyspnea started 2 months ago after he had the flu. At first, the difficulty breathing occurred whenever he went up and down 1 flight of stairs, but the dyspnea progressively worsened since then. This morning, he developed chest pain and difficulty breathing while sitting at the kitchen table. The patient’s medical history is significant for hypertension, type 2 diabetes mellitus, and rheumatoid arthritis. His medications include aspirin, lisinopril, metformin, and sulfasalazine. His temperature is 97°F (36.1°C), blood pressure is 130/78 mmHg, pulse is 88/min, and respirations are 14/min with an oxygen saturation of 97% O2 on room air. On physical exam, jugular venous distension during both inspiration and expiration, mild abdominal distention, and 2+ bilateral lower extremity edema is noted. A chest radiograph is obtained and the result is shown in Figure A. Which of the following is the most likely cause of this patient's symptoms?

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A 57-year-old female presents to her primary care physician with a chief complaint of feeling tired all the time. She states her symptoms began several months ago, around the time that her husband committed suicide. Since then she has had thoughts of joining her husband. She complains of feeling excessively weak and states that she no longer has enough energy to go to the gym which she attributes to her 15 pound weight gain over the last month. The patient's medical history includes joint pain, a skin rash that recently resolved, obstructive sleep apnea, and metabolic syndrome. The patient takes ibuprofen and omeprazole as needed but otherwise cannot remember any other medications that she takes. On physical exam you note an overweight woman who has an overall depressed affect. The patient's cardiac exam reveals a normal rate and rhythm. The pulmonary exam reveals bilateral clear lung fields with good air movement. The patient's skin is very dry and tight appearing and her hair is coarse. Overall the patient appears somewhat unkempt. Laboratory work is performed and reveals the following: Hemoglobin: 13.0 g/dL Hematocrit: 37% Leukocyte count: 4,500 cells/mm^3 with normal differential Platelets: 250,000/mm^3 Serum: Na+: 140 mEq/L K+: 4.4 mEq/L Cl-: 102 mEq/L BUN: 15 mg/dL Glucose: 122 mg/dL Creatinine: 1.0 mg/dL Thyroid-stimulating hormone: 5.3 µU/mL Ca2+: 10.2 mg/dL AST: 11 U/L ALT: 13 U/L Which of the following laboratory findings is most likely to be abnormal in this patient?

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A 78-year-old female is brought to her primary care doctor by her daughter after developing worsening cough, shortness of breath, and shaking chills over the past 3 days. The patient's cough has not produced any sputum. She also complains of alternating feelings of being 'hot then cold.' Whenever she coughs or breathes deeply, she experiences a severe sharp pain in her chest. The patient lives at home with her daughter and is otherwise healthy. Her past medical history is significant for hypertension treated with losartan and hyperlipidemia managed with atorvastatin. The patient does not have a history of tobacco use. Vital signs recorded in the office are as follows: T 38.7, HR 101, BP 135/78, RR 16, and SpO2 94%. Physical exam is significant for crackles in the right upper lung field. The patient is transferred to the local emergency department for further evaluation and management and a chest radiograph is obtained (Figure A). Which of the following is the most likely causative organism in this patient's presentation?