A 52-year-old female presents to the emergency room with severe right eye pain and vision loss. The symptoms started a couple hours ago while she was out to a late dinner. She denies ever feeling these symptoms before. In addition to the pain and blurry vision, she reports excessive tearing. She denies discharge from her eye. The patient’s past medical history is significant for hypertension and rheumatoid arthritis. Her medications include hydrochlorothiazide and sulfasalazine. She has a 40 pack-year smoking history. She works as a pre-school teacher at a local school. Figure A shows physical examination findings of both eyes. The right pupil is less reactive to light in comparison to the left pupil. Figure B shows a fundoscopic exam of the right eye. Fundoscopy of the left eye is unremarkable. Which of the following is the most accurate test to diagnose the patient’s condition?

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A 27-year-old man presents to the emergency department following a motor vehicle accident. He was the unrestrained driver traveling at a high rate of speed prior to crashing into the back of a stopped semi truck. On arrival, he complains of shortness of breath and chest pain. He is alert and oriented and appears in acute distress. His temperature is 98.6°F (37.0°C), pulse is 120, blood pressure is 80/50 mmHg, respirations are 30/min, and pulse oximetry is 89% on room air. On exam, bruising is noted across the chest. Breath sounds are diminished over the left side of the chest. Jugular venous distention is noted. Which of the following is the most appropriate next step in management?

A 16-year-old female presents to her pediatrician’s office because she has not yet started menstruating. On review of systems, she states that she has been increasingly tired, constipated, and cold over the last 6 months. She also endorses a long history of migraines with aura that have increased in frequency over the last year. She complains that these symptoms have affected her performance on the track team. She states that she is not sexually active. Her mother and sister both underwent menarche at age 15. The patient is 5 feet, 4 inches tall and weighs 100 pounds (BMI 17.2 kg/m^2). Temperature is 98.4°F (36.9°C), blood pressure is 98/59 mmHg, pulse is 98/min, and respirations are 14/min. On exam, the patient appears pale and has thinning hair. She has Tanner stage IV breasts and Tanner stage III pubic hair. Which of the following would be most useful in determining this patient’s diagnosis?

A 69-year-old female comes to the emergency department complaining of chest pain and difficulty breathing. She reports that she had a heart attack a few weeks ago that was treated with cardiac catheterization. At that time she had chest pain, but reports that this chest pain is different. A review of systems is significant for headaches, a productive cough with frothy sputum, and paresthesias in her fingertips. The patient’s temperature is 99°F (37.2°C), blood pressure is 130/78 mmHg, pulse is 78/min, and respirations are 20/min with an oxygen saturation of 96% O2 on room air. A chest radiograph is obtained, as shown in Figure A. Which of the following would you expect to find upon physical exam?

A 67-year-old male comes into the ED complaining of dyspnea and a heavy feeling in his chest. He reports that over the past month he has become more easily “winded" to the point that he now sleeps in his living room because he can’t make it up the stairs. A review of systems is notable for headaches and fatigue. On physical exam you note decreased breath sounds and a dullness to percussion on the right. A chest radiograph is obtained, which shows a right-sided pleural effusion. Thoracocentesis is performed and the fluid is analyzed, with results shown below: Volume: 30 cc of fluid Pleural fluid protein: 5.8 g/dL Serum protein ratio: 7.0 g/dL Lactate dehydrogenase (LDH): 258 U/L Which of the following conditions may have led to the findings in this patient’s pleural cavity?

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A 17-year-old girl presents to her primary care physician for a wellness checkup. The patient is currently doing well in school and plays soccer. She has a past medical history of childhood obesity that was treated with diet and exercise. The patient states that her menses have not changed, and they occur every 1 to 3 months. Her temperature is 99.5°F (37.5°C), blood pressure is 127/70 mmHg, pulse is 90/min, respirations are 13/min, and oxygen saturation is 98% on room air. The patient's BMI at this visit is 22.1 kg/m^2. On physical exam, the patient is in no distress. You note acne present on her face, shoulders, and chest. You also note thick, black hair on her upper lip and chest. The patient's laboratory values are seen as below. Hemoglobin: 14 g/dL Hematocrit: 42% Leukocyte count: 7,500/mm^3 with normal differential Platelet count: 177,000/mm^3 Serum: Na+: 137 mEq/L Cl-: 101 mEq/L K+: 4.4 mEq/L HCO3-: 24 mEq/L BUN: 27 mg/dL Glucose: 90 mg/dL Creatinine: 1.0 mg/dL Ca2+: 10.1 mg/dL Testosterone: 82 ng/dL 17-hydroxyprogesterone: elevated AST: 12 U/L ALT: 10 U/L Which of the following is associated with this patient's most likely diagnosis?

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A 67-year-old female presents to her primary care physician complaining of headaches in her left temple and scalp area, neck stiffness, occasional blurred vision, and pain in her jaw when chewing. The appropriate medical therapy is initiated, and a subsequent biopsy of the temporal artery reveals arteritis. Five months later, the patient returns to her physician with a complaint of weakness, leading to difficulty climbing stairs, rising from a chair, and combing her hair. The patient states that this weakness has worsened gradually over the last 2 months. She reports that her headaches, jaw pain, and visual disturbances have resolved. Physical examination is significant for 4/5 strength for both hip flexion/extension as well as shoulder flexion/extension/abduction. Initial laboratory work-up reveals ESR and creatine kinase levels within normal limits. Which of the following is the most likely diagnosis in this patient's current presentation?

A 73-year-old woman presents to her primary care physician with complaints of fatigue, night sweats, fever, and easy bleeding for 10 days. She reports no antecedent illness and denies sick contacts. She is otherwise healthy, with a medical history including hypertension. Her medications include lisinopril and amlodipine. Lab studies reveal white blood cell count of 2,100/uL with circulating blasts, hematocrit of 22%, MCV 88fL, and platelet count of 22,000/uL. A bone marrow biopsy (Figure A) is performed, and confirms the suspected diagnosis. Which of the following describes the pathophysiology of this patient's decreased hematocrit?

A 16-year-old boy is brought to the emergency department following a car accident in which he suffered multiple injuries. He is accompanied by his mother. She reports that his medical history is notable only for recurrent sinusitis and otitis as a child. He lost a significant amount of blood from the accident, and he is transfused two units of O-negative blood on arrival at the emergency department. Shortly thereafter, he complains of itching and increasing shortness of breath. He develops stridor. Which of the following could have prevented this reaction?

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A 25-year-old patient is brought into the emergency department after he was found down by the police in 5 degree celsius weather. The police state the patient is a heroin-user and is homeless. The patient's vitals are T 95.3 HR 80 and regular BP 150/90 RR 10. After warming the patient, you notice his left lower leg is now much larger than his right leg. On exam, the patient has a loss of sensation on his left lower extremity. There is a faint palpable dorsalis pedal pulse, but no posterior tibial pulse. The patient is unresponsive to normal commands, but shrieks in pain upon passive stretch of his left lower leg. What is the most probable cause of this patient's condition?

A 40-year-old patient is brought into the emergency department after suffering a motor vehicle crash where he was pinned underneath his motorcycle for about 30 minutes before a passerby called 911. While evaluating him per your institution's trauma guidelines, you discover pain upon palpation of his right lower extremity which is much larger than his left counterpart. The patient admits to decreased sensation over his right lower extremity and cannot move his leg. There are no palpable dorsalis pedis or posterior tibial pulses on this extremity, and it is colder and paler in comparison to his left side. Measured compartment pressure of his distal right leg is 35 mm Hg. What is the next best step in this patient's care?

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A 55-year-old man with no significant medical history returns for follow-up of a fasting blood glucose (FBG) of 110 mg/dL. His mother had a myocardial infarction at age 52. He weighs 90 kg and his body mass index is 35 kg/m2. His repeat FBG is 160 mg/dL and hemoglobin A1c (HbA1c) is 7.0%. He is started on metformin but is lost to follow-up. Two years later, his HbA1c is 7.6% despite maximal metformin usage, so the patient is started on glyburide. Three months later, his HbA1c is 7.3% while on both medications, and subsequently prescribed glargine and aspart. Three months later, he is brought by his wife to the emergency department for evaluation of altered mental status. His electronic medical record notes that he was started on nitrofurantoin recently for an urinary tract infection. He is disoriented to place and time. His temperature is 99°F (37.2°C), blood pressure is 83/59 mmHg, pulse is 130/min, respirations are 26/min. His basic metabolic panel is shown below: Serum: Na+: 119 mEq/L Cl-: 90 mEq/L K+: 4.2 mEq/L HCO3-: 24 mEq/L BUN: 25 mg/dL Glucose: 1,400 mg/dL Creatinine: 1.9 mg/dL His urine dipstick is negative for ketones. A peripheral intravenous line is established. Which of the following is the best initial step in management?

A 36-year-old female with a history of celiac disease presents to her primary care physician because of recent changes to her health. She states that over the past several months she has noticed her eyes and skin seem to have become more yellow in color and she has also noticed increased itchiness all over her body. On exam, the patients eyes are shown to be as demonstrated in Figure A and an additional finding is observed around her eyes as demonstrated in Figure B. The physician obtains liver function tests which demonstrate an increased direct bilirubin and an increased alkaline phosphatase. Further testing demonstrates increased serum mitochondrial antibodies and a liver biopsy is obtained as demonstrated in Figure C. What is the first-line treatment for this patient's condition?

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A 52-year-old man presents to his primary care physician. The man has been feeling very tired lately and thinks that he looks more pale. The physician orders a complete blood count, which shows: Hgb 8.5 g/dL; WBC 1,200/microliter; platelets 70,000/microliter. The patient is referred for bone marrow biopsy, which shows the findings in Figure A. Which of the following is the correct diagnosis?

A 7-year-old boy is brought to his pediatrician by his mother for recent fatigue and intermittent fevers over the past month. She also reports that her son has appeared much paler recently. Vital signs at today's visit are within normal limits. Physical examination is significant for pallor, petechiae, lymphadenopathy, and hepatosplenomegaly. A complete blood count reveals anemia, thrombocytopenia, and neutropenia. A peripheral blood smear is shown in Figure A. Bone marrow aspiration reveals 47% lymphoblasts. Which of the following is associated with this patient's presenting condition?

A 55-year-old man presents to the emergency room with a skin lesion. It has persisted for several days without improvement. The patient has a medical history of alcohol abuse, intravenous drug abuse, diabetes, human immunodeficiency virus infection, and depression. He last used heroin 3 days ago and has been drinking 4-7 alcoholic drinks per day. He does not follow with a physician regularly. His temperature is 99.5°F (37.5°C), blood pressure is 157/98 mmHg, pulse is 100/min, respirations are 14/min, and oxygen saturation is 98% on room air. Cardiopulmonary exam is notable for a systolic murmur heard along the left sternal border. Dermatologic exam is notable for the finding in Figure A. The patient's abdominal exam and neurological exam are within normal limits. Which of the following is the most likely diagnosis?

A 48-year-old Caucasian female presents to her primary care physician for evaluation of progressive weakness and shortness of breath. She has had progressive shortness of breath over the last year with an intermittent non-productive cough. In addition, she complains of difficulty raising her arms to brush her hair. Her temperature is 99.6°F (37.6°C), pulse is 80/min, blood pressure is 130/85 mmHg, respirations are 18/min, and oxygen saturation is 95% on room air. Neurologic exam shows 4/5 strength in the deltoid muscles bilaterally. Diffuse dry crackles are heard on lung auscultation. A faint erythematous rash is noted on the malar cheeks, periorbital areas, lateral proximal thighs, and the elbows. Which of the following tests is most likely to confirm the diagnosis?

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A 25-year-old mother presents to her primary care physician for wrist pain. The patient recently gave birth to a healthy newborn at 40 weeks gestation. Beginning one week ago, she started having pain over her wrist that has steadily worsened. The patient notes that she also recently fell while walking and broke the fall with her outstretched arm. The patient is an accountant who works from home and spends roughly eight hours a day typing or preparing financial statements. Recreationally, the patient is a competitive cyclist who began a rigorous training routine since the birth of her child. The patient's past medical history is notable for hypothyroidism that is treated with levothyroxine. On physical exam, inspection of the wrist reveals no visible or palpable abnormalities. Pain is reproduced when the thumb is held in flexion, and the wrist is deviated toward the ulna. The rest of the patient's physical exam is within normal limits. Which of the following is the best next step in management?

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A 36-year-old male with fluctuating levels of consciousness is brought to the emergency department by ambulance due to a fire in his home. He currently opens his eyes to voice, localizes painful stimuli, responds when asked questions, but is disoriented and cannot obey commands. The patient’s temperature is 99°F (37.2°C), blood pressure is 86/52 mmHg, pulse is 88/min, and respirations are 14/min with an oxygen saturation of 97% O2 on room air. Physical exam shows evidence of soot around the patient’s nose and mouth, but no burns, airway obstruction, nor accessory muscle use. A blood lactate is 14 mmol/L. The patient is started on intravenous fluids. What is the next best step in management?

A 64-year-old female presents to her primary care physician for an annual checkup. She states that her health is adequate, but she has not been doing well since her husband died last year. She is able to get by but admits to having trouble caring for herself, cooking, cleaning, and paying her bills. The patient complains of diffuse muscle aches and pains. She has a past medical history of anxiety and seasonal affective disorder. She is not currently taking any medications. On physical exam, you note a gaunt woman with a depressed affect. You note that her body mass index (BMI) and height have both decreased since her last annual visit. On physical exam, her cardiac, pulmonary, and abdominal exams are within normal limits. Lab work is drawn and is as follows: Serum: Na+: 135 mEq/L K+: 3.7 mEq/L Cl-: 100 mEq/L HCO3-: 23 mEq/L Urea nitrogen: 7 mg/dL Glucose: 70 mg/dL Creatinine: 0.8 mg/dL Ca2+: 8.0 mg/dL Mg2+: 1.5 mEq/L Parathyroid hormone: 855 pg/mL Alkaline phosphatase: 135 U/L Phosphorus: 2.6 mg/dL Hemoglobin: 14 g/dL Hematocrit: 36% Platelet count: 187,000/mm^3 Leukocyte count: 4,700/mm^3 What is the most likely diagnosis?

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A 37-year-old G1P000 presents to her obstetrician for her first prenatal visit. She states that her last menstrual period (LMP) was 11 weeks ago, though she is unsure of the exact date as her periods are sometimes irregular. She and her husband had 5 months of timed, unprotected intercourse before she had a positive home pregnancy test 2 weeks ago. She has been feeling generally well but notes some morning nausea and vomiting. She also mentions that for the last 6 months or so, she has felt increasing pelvic pressure and worsening urinary frequency but has not sought medical care for these symptoms. The patient has a history of obesity and hypertension but is not on any medications. Her mother had a hysterectomy at age 64 for fibroids, and her sister had a twin pregnancy after assisted reproduction. At this visit, the patient’s temperature is 98.3° F (36.8° C), blood pressure is 142/85 mmHg, pulse is 82/min, and respirations are 14/min. She has gained 4 pounds since the last time she weighed herself 4 months ago. On exam, the patient’s fundus is palpated at the umbilicus, her cervix is closed and firm, and there are no adnexal masses. Her lab results are shown below: ß-hCG: 81,324 mIU/mL Thyroid stimulating hormone (TSH): 1.2 µIU/L Which of the following is the most likely diagnosis?

A 34-year-old G3P2103 with a past medical history of preeclampsia in her last pregnancy, HIV (CD4: 441/mm^3), and diabetes mellitus presents to her obstetrician for her first postpartum visit. She delivered her third child via C-section one week ago and reports that she is healing well from the surgery. She says that feeding via formula has been going well and that her baby has nearly regained his birth weight. The patient complains that she has been more tired than expected despite her efforts to sleep whenever her baby is napping. She relies on multiple iced coffees per day and likes to eat the ice after she finishes the drink. Her diet is otherwise unchanged, and she admits that she has not been getting outside to exercise as much as usual. Her home medications include metformin and her HAART regimen of dolutegravir, abacavir, and lamivudine. Her temperature is 98.9°F (37.2°C), blood pressure is 128/83 mmHg, pulse is 85/min, and respirations are 14/min. On physical exam, she is tired-appearing with conjunctival pallor. This patient is at risk of developing which of the following conditions?

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A 28-year-old homeless male with a past medical history significant for asthma comes to your clinic complaining of a chronic rash on his scalp and feet. He describes the rash as “dry and flaky,” and reports it has been present for at least a year. He was using a new dandruff shampoo he got over the counter, with little improvement. The patient reports it is extremely itchy at night, to the point that he can't sleep. On exam, you note a scaly patch of alopecia, enlarged lymph glands along the posterior aspect of his neck, and fine scaling in between his toes and on the heel and sides of his foot. His temperature is 99°F (37°C), blood pressure is 118/78 mmHg, and pulse is 81/min. Which of the following is the most accurate test for the suspected diagnosis?

A 21-year-old female is being evaluated for worsening "flaky scalp." She does not remember exactly when it started, but reports it has been at least a couple months. Her symptoms then developed into a scaling patch at the top of her head. She has begun ritualistically and repetitively combing her hair to the left 3 times every time she feels any "flakes." The patient reports that in the past she chemically treated her hair, but stopped when she noticed the scalp scaling had developed into an area of balding. She admits to feeling tired lately and gained 5 lbs in the last 2 months, but admits she has been staying up late to study for exams. The patient's past medical history is significant for bipolar I disorder, for which she takes lithium, and acne, for which she uses topical salicylic acid. The patient reports fatigue, but denies headache, shortness of breath, chest pain, polyuria, hematuria, or other rashes. Vital signs include a temperature of 99°F (37°C), blood pressure of 122/76 mmHg, a pulse of 88/min, and an oxygen saturation of 99% on room air. Physical exam is negative except for scalp findings shown in Figure A. Routine lab values are drawn, including: Leukocyte count: 9,500/mm^3 Platelet count: 200,000/mm^3 Hemoglobin: 14.5 g/dL Serum: Na+: 144 mEq/L K+: 4.3 mEq/L Cl-: 85 mEq/L HCO3-: 22 mEq/L BUN: 11 mg/dL Creatinine: 1.2 mg/dL Serum osmolality: 295 mOsmol/kg H2O Urine osmolality: 320 mOsmol/kg H2O Which of the following is the best initial diagnostic test?

A 4-year-old boy presents to his pediatrician for severe developmental delay. On exam he is noted to have macroorchidism, hypertelorism, large protruding ears, a large jaw, and a long thin face. Suspicious of what the diagnosis may be, the pediatrician orders a PCR and DNA sequencing. The results reveal an expansion of 250 repeats of CGG. What is the diagnosis of the boy?

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A 42-year-old male with a history significant for IV drug use comes to the emergency department complaining of persistent fatigue and malaise for the past three weeks. On physical exam, you observe a lethargic male with icteric sclera and hepatomegaly. AST and ALT are elevated at 600 and 750, respectively. HCV RNA is positive. Albumin is 3.8 g/dL and PT is 12. A liver biopsy shows significant inflammation with bridging fibrosis. What is the most appropriate treatment at this time?

A mother arrives to your clinic with her 5-year-old son afraid that he caught lice from a recent preschool outbreak. She reports that for the past week the son has had, “white flakes,” in his hair despite daily baths. The patient denies pain, but reports that his scalp is itchy at night. The patient has also developed a small area of hair loss which the mother feels is related to the patient scratching. The patient has no significant past medical history, but did have "cradle cap" when he was an infant. Family medical history is significant for eczema and asthma in the mother. Upon further questioning, the mother reports that the family got a new cat two months ago and that her other daughter has also been experiencing similar symptoms. On examination, the patient's scalp has a 1 cm scaly patch, with evidence of excoriation and an overlying yellow crust. There is a central area of alopecia. A skin scraping is performed. The results are shown in Figure A. Which of the following is the appropriate course of treatment?