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 36-year-old woman, G1P1001, presents to her gynecologist f...

Sorry, only PEAK Subscribers can view this question

A 31-year-old woman presents to her obstetrician for her fir...

Sorry, only PEAK Subscribers can view this question

A 67-year-old woman presents to her primary care physician w...

Sorry, only PEAK Subscribers can view this question

A 33-year-old female with no significant medical history pre...

Sorry, only PEAK Subscribers can view this question

A 43-year-old construction worker presents to the emergency department two hours after sustaining a deep laceration to his left forearm by a piece of soiled and rusted sheet metal. His vital signs are stable, there is no active bleeding, his pain is well controlled, and a hand surgeon has been notified about damage to his forearm tendons. He does not recall receiving any vaccinations in the last 30 years and does not know if he was vaccinated as a child. What is the appropriate post-exposure prophylaxis?

A 23-year-old man complains of lower back pain that began approximately 6 months ago. He is unsure why he is experiencing this pain and notices that this pain is worse in the morning after waking up and improves with physical activity. Ibuprofen provides significant relief. He denies bowel and bladder incontinence or erectile dysfunction. Physical exam is notable for decreased chest expansion, decreased spinal range of motion, 5/5 strength in both lower extremities, 2+ patellar reflexes bilaterally, and an absence of saddle anesthesia. Which of the following is the most appropriate next test for this patient?

A 23-year-old woman presents to the emergency department for evaluation of abdominal pain. She states that her pain started yesterday and was initially in the center of her abdomen. When she awoke today, she states that her pain was much worse and is now located in the right lower quadrant of her abdomen. She reports associated nausea and vomiting that started this morning as well as fevers. She denies any other symptoms. Her temperature is 102.2°F (39.0°F), pulse is 102, blood pressure is 115/70 mmHg, and respirations are 18/min. On exam there is tenderness to palpation in the right lower quadrant with guarding and rebound tenderness. An abdominal CT scan is obtained as shown in Figure A. Which of the following best describes the pathophysiology of this patient's condition?

A 43-year-old Caucasian female with a long history of uncontrolled migraines presents to general medical clinic with painless hematuria. She is quite concerned because she has never had symptoms like this before. Vital signs are stable, and her physical examination is benign. She denies any groin pain, flank pain, or costovertebral angle tenderness. She denies any recent urinary tract infections or dysuria. Urinary analysis confirms hematuria and a serum creatinine returns at 3.0. A renal biopsy reveals papillary necrosis and a tubulointerstitial infiltrate. What is the most likely diagnosis?

A 3-year-old boy presents to the pediatrician for a well-chi...

Sorry, only PEAK Subscribers can view this question

A 34-year-old man presents to the emergency department with ...

Sorry, only PEAK Subscribers can view this question

A 62-year-old woman presents to her primary care physician f...

Sorry, only PEAK Subscribers can view this question

A 27-year-old G3P2002 presents to the clinic for follow-up a...

Sorry, only PEAK Subscribers can view this question

A 72-year-old woman presents to the emergency department com...

Sorry, only PEAK Subscribers can view this question

A 56-year-old woman with a history of alcoholic cirrhosis and recurrent esophageal varices who recently underwent transjugular intrahepatic portosystemic shunt (TIPS) placement is brought to the emergency room by her daughter due to confusion and agitation. Starting this morning, the patient has appeared sleepy, difficult to arouse, and slow to respond to questions. Her temperature is 97.6°F (36.4°C), blood pressure is 122/81 mmHg, pulse is 130/min, respirations are 22/min, and oxygen saturation is 98% on room air. She repeatedly falls asleep and is combative during the exam. Laboratory values are notable for a potassium of 3.0 mEq/L. The patient is given normal saline with potassium. Which of the following is the most appropriate treatment for this patient?

A 21-year-old male comes to your office complaining of blurr...

Sorry, only PEAK Subscribers can view this question

A 30-year-old construction worker comes to your office compl...

Sorry, only PEAK Subscribers can view this question

A 42-year-old male presents to his primary care physician co...

Sorry, only PEAK Subscribers can view this question

A 27-year-old man presents to the emergency department with back pain. The patient states that he has back pain that has been steadily worsening over the past month. He states that his pain is worse in the morning but feels better after he finishes at work for the day. He rates his current pain as a 7/10 and says that he feels short of breath. His temperature is 99.5°F (37.5°C), blood pressure is 130/85 mmHg, pulse is 80/min, respirations are 14/min, and oxygen saturation is 99% on room air. On physical exam, you note a young man who does not appear to be in any distress. Cardiac exam is within normal limits. Pulmonary exam is notable only for a minor decrease in air movement bilaterally at the lung bases. Musculoskeletal exam reveals a decrease in mobility of the back in all four directions. Which of the following is the best initial step in management of this patient?

A 28-year-old man presents with one week of redness and discharge in his eyes, pain and swelling in his left second and third toes, and rash on the soles of his feet. He is sexually active with multiple partners and uses condoms occasionally. He denies any recent travel or illness and does not take any medications. Review of systems is otherwise unremarkable. On physical exam, he has bilateral conjunctivitis, dactylitis of the left second and third toes, and crusty yellow-brown vesicles on his plantar feet. Complete blood count and chemistries are within normal limits. Erythrocyte sedimentation rate (ESR) is 40 mm/h. Toe radiographs demonstrate soft tissue swelling but no fractures. Which diagnostic test should be performed next?

A 13-year-old boy presents to his primary care physician for...

Sorry, only PEAK Subscribers can view this question

A 55-year-old male presents to his primary care physician fo...

Sorry, only PEAK Subscribers can view this question

A 6-year-old boy presents to his pediatrician’s office for m...

Sorry, only PEAK Subscribers can view this question

A 37-year-old G1P1001 delivers a male infant at 9 pounds 6 ounces after a C-section for preeclampsia with severe features. The mother has a history of type II diabetes with a hemoglobin A1c of 12.8% at her first obstetric visit. Before this pregnancy, she was taking metformin, and during this pregnancy, she was started on insulin. At her routine visits, her glucose logs frequently showed fasting fingerstick glucoses above 120 mg/dL and postprandial values above 180 mg/dL. In addition, her routine third trimester culture for group B Streptococcus was positive. At 38 weeks and 4 days gestation, she was found to have a blood pressure of 176/103 mmHg and reported a severe headache during a routine obstetric visit. She denied rupture of membranes or vaginal bleeding. Her physician sent her to the obstetric triage unit, and after failure of several intravenous doses of labetalol to lower her blood pressure and relieve her headache, a C-section was performed without complication. Fetal heart rate tracing had been reassuring throughout her admission. Apgar scores at 1 and 5 minutes were 7 and 10. After one hour, the infant is found to be jittery; the infant's temperature is 96.1°F (35.6°C), blood pressure is 80/50 mmHg, pulse is 110/min, and respirations are 60/min. When the first feeding is attempted, he does not latch and begins to shake his arms and legs. After 20 seconds, the episode ends and the infant becomes lethargic. Which of the following is the most likely cause of this infant’s presentation?

A 25-year-old G2P1001 woman at 32 weeks of gestation present...

Sorry, only PEAK Subscribers can view this question

A 17-year-old female presents to her primary care physician with right foot pain for the last 3 days. She states that the pain began gradually and is worse with weight bearing and activity. The patient states that she recently began to train for a marathon and is running much more than she did several months ago. She is healthy but has a 2-year history of irregular menstruation, with up to 3 months between periods. At this visit, her temperature is 98.5°F (36.9°C), blood pressure is 116/67 mmHg, pulse is 75/min, and respirations are 14/min. Her BMI is 17.1 kg/m^2, and she appears tired with a flat affect. Palpation of the dorsal surface of the right foot reveals point tenderness on the second metatarsal, though there is no redness, warmth, or swelling. The remainder of the exam is unremarkable. Plain radiograph of the right foot is performed and shown in Figure A. Which of the following is the best next step in management?

A 39-year-old G2P1001 female presents to the obstetric triag...

Sorry, only PEAK Subscribers can view this question

A 28-year-old man presents to his primary care physician after experiencing intense nausea and vomiting yesterday. He states that he ran a 15-kilometer race in the morning and felt well while resting in a hammock afterward. However, when he rose from the hammock, he experienced two episodes of emesis accompanied by a sensation that the world was spinning around him. This lasted about one minute and self-resolved. He denies tinnitus or hearing changes, but he notes that he still feels slightly imbalanced. He has a past medical history of migraines, but he typically does not have nausea or vomiting with the headaches. At this visit, the patient’s temperature is 98.5°F (36.9°C), blood pressure is 126/81 mmHg, pulse is 75/min, and respirations are 13/min. Cardiopulmonary exam is unremarkable. Cranial nerves are intact, and gross motor function and sensation are within normal limits. When the patient’s head is turned to the right side and he is lowered quickly to the supine position, he claims that he feels “dizzy and nauseous.” Nystagmus is noted in both eyes. Which of the following is the best treatment for this patient’s condition?

A 24-year-old man presents to the emergency department for a...

Sorry, only PEAK Subscribers can view this question

A 17-year-old boy presents to the emergency department with ...

Sorry, only PEAK Subscribers can view this question

A 7-year-old girl presents to her pediatrician's office with...

Sorry, only PEAK Subscribers can view this question

A 6-hour-old newborn boy is noted to have a “lump on his hea...

Sorry, only PEAK Subscribers can view this question

A 5-year-old male presents to the pediatrician with a 10-day history of cough that is worse at night. The patient has a history of mild intermittent asthma and has been using his albuterol inhaler without relief. He has also been complaining of headache and sore throat, and his mother has noticed worsening rhinorrhea. The patient’s past medical history is otherwise unremarkable, and he has no known drug allergies. In the office, his temperature is 101.8°F (38.8°C), blood pressure is 88/65 mmHg, pulse is 132/min, and respirations are 16/min. The patient has purulent mucus draining from the nares, and his face is tender to palpation over the maxillary sinuses. His pharynx is erythematous with symmetric swelling of the tonsils. On lung exam, he has moderate bilateral expiratory wheezing. Which of the following is the best next step in management?

A 47-year-old woman presents to the emergency department with pain in her right knee. She states that the pain started last night and rapidly worsened, prompting her presentation for care. The patient has a past medical history of rheumatoid arthritis and osteoarthritis. Her current medications include corticosteroids, infliximab, ibuprofen, and aspirin. The patient denies any recent trauma to the joint. Her temperature is 99.5°F (37.5°C), pulse is 112/min, blood pressure is 100/70 mmHg, respirations are 18/min, and oxygen saturation is 98% on room air. On physical exam, you note erythema and edema of the right knee. There is limited range of motion due to pain of the right knee. Which of the following is the best initial step in management?

A 25-year-old man presents to the emergency department after...

Sorry, only PEAK Subscribers can view this question

A 7-year-old boy presents to the pediatric emergency departm...

Sorry, only PEAK Subscribers can view this question

A 3-year-old patient is brought to the emergency department by her mother due to inability to walk. The child has been limping recently and as of this morning, has refused to walk. Any attempts to make the child walk or bear weight result in crying. She was recently treated for impetigo and currently takes a vitamin D supplement. Physical exam is remarkable for an anxious appearing toddler with knee swelling, erythema, and limited range of motion due to pain. Her mother denies any recent trauma to the child's affected knee. Temperature is 103°F (39.4°C), pulse is 132/min, blood pressure is 90/50 mmHg, respirations are 18/min, and oxygen saturation is 99% on room air. Which of the following is the best initial step in management?

A 54-year-old male presents to the emergency department with nasal congestion and sore throat. He also endorses ten days of fatigue, rhinorrhea and cough, which he reports are getting worse. For the last four days, he has also had facial pain and thicker nasal drainage. The patient’s past medical history includes obesity, type II diabetes mellitus, and mild intermittent asthma. His home medications include metformin and an albuterol inhaler as needed. The patient has a 40 pack-year smoking history and drinks 6-12 beers per week. His temperature is 102.8°F (39.3°C), blood pressure is 145/96 mmHg, pulse is 105/min, and respirations are 16/min. On physical exam, he has poor dentition. Purulent mucus is draining from his nares, and his oropharynx is erythematous. His maxillary sinuses are tender to palpation. Which one of the following is the most common risk factor for this condition?

An 8-year-old female presents to her pediatrician with nasal congestion. Her mother reports that the patient has had nasal congestion and nighttime cough for almost two weeks. The patient’s 3-year-old brother had similar symptoms that began around the same time and have since resolved. The patient initially seemed to be improving, but four days ago she began developing worsening nasal discharge and fever to 102.6°F (39.2°C) at home. Her mother denies any change in appetite. The patient denies sore throat, ear pain, and headache. She is otherwise healthy. In the office, her temperature is 102.2°F (39.0°C), blood pressure is 96/71 mmHg, pulse is 128/min, and respirations are 18/min. On physical exam, the nasal turbinates are edematous and erythematous. She has a dry cough. Purulent mucous can be visualized dripping from the posterior nasopharynx. Her maxillary sinuses are tender to palpation. Which of the following organisms is most likely to be causing this patient’s current condition?

A 70-year-old obese male presents to the emergency department with shortness of breath and cough of sudden onset. The patient states that his symptoms came on while he was sleeping. The patient has a past medical history of type II diabetes and is currently taking lisinopril, metformin, insulin, and fish oil. On physical exam, you note bipedal edema and jugular venous distention (JVD). An EKG and chest radiographs are obtained (Figures A and B). The patient is started on BIPAP and medical therapy and his symptoms improve rapidly. Lab values are as follows. Serum: Na+: 137 mEq/L K+: 3.2 mEq/L Cl-: 100 mEq/L HCO3-: 31 mEq/L BUN: 20 mg/dL Glucose: 120 mg/dL Creatinine: 1.2 mg/dL Ca2+: 10.9 mg/dL Which of the following is the best explanation of this patient's current presentation?

A 37-year-old woman presents to her primary care physician f...

Sorry, only PEAK Subscribers can view this question

A newborn boy is evaluated 30 minutes after birth. He was bo...

Sorry, only PEAK Subscribers can view this question

A 1-day-old boy is evaluated in the hospital nursery for bil...

Sorry, only PEAK Subscribers can view this question

A 74-year-old woman with a past medical history of hypertens...

Sorry, only PEAK Subscribers can view this question

A 25-year-old man with a history of schizophrenia stable on his current antipsychotic regimen presents with a seizure. His mother noted that her son complained of a headache, stuffy nose, facial pain, and feeling warm for the past ten days. The headache was exacerbated whenever he bent over. This morning, the mother brought him to the hospital after he fell from the top of the stairs and appeared to convulse his arms and legs. He takes quetiapine and a multivitamin. In the trauma bay, the patient appears to be breathing comfortably and follows the nurse's commands. His temperature is 100.9°F (38.3°C), blood pressure is 140/70 mmHg, pulse is 80/min, respirations are 15/min, and his oxygen saturation is 95% on room air. He complains of a headache over the top of his eyebrows. He has a few scrapes and bruises throughout his body. His left arm and leg are weaker than his right limbs. His cranial nerves are grossly intact bilaterally. Computed tomography of his head is shown in Figure A. Which of the following is the most likely cause of this patient's presentation?

A 5-year-old boy is brought in by his parents for recurrent abdominal pain. The child has been taken out of class 5 times this past week for abdominal pain that resulted in him being sent home. The mother reports that her son's stools have remained unchanged during this time and are brown in color, without blood, and with normal consistency and scent. She also notes that while at home he seems to be his usual self and does not complain of any symptoms. Of note she presents to you that she has been preparing her son's lunches which consist of couscous, vegetables, fried rice, and chicken. The patient denies difficulty with producing stool and does not complain of any functional pain. The child's vitals and labs including BMP and CBC are unremarkable and within normal limits. An abdominal exam is performed and there is no tenderness upon palpation, and the abdomen is soft and non-distended. After a conversation with the child exploring his symptoms, which of the following is the next step in management for this child?

A 4-year-old is brought into the emeregency room by his mother. The mother states that the child had a slight cough one week ago that has since worsened. The mother states the child's cough sounds like someone barking and states that he has also had mild fevers along with rhinorrhea. The patient's vitals are significant for a fever of 100.8 F, and his physical exam reveals inspiratory stridor. What is the most likely organism responsible?

A 2-year-old boy in respiratory distress is brought to the emergency department by his parents. They state that approximately one hour after putting their child to sleep, a "hacking" cough was heard from his bedroom. After entering his room the parents state their child appeared to be in distress, making a high pitched noise with every breath. Beyond a runny nose for the past few days, the child has been healthy. He has no toys in his bed or access to any other small objects. Physical exam demonstrates a 2-year-old child in respiratory distress. Which of the following choices is the proper management for this patient?

A 53-year-old man presents to his primary care provider with...

Sorry, only PEAK Subscribers can view this question

A 61-year-old woman presents to the emergency department wit...

Sorry, only PEAK Subscribers can view this question