A 29-year-old G1P0 presents to her obstetrician for her first prenatal care visit at 12 weeks gestation by last menstrual period. She states that her breasts are very tender and swollen, and her exercise endurance has declined. She otherwise feels well. She is concerned about preterm birth, as she heard that certain cervical procedures increase the risk. The patient has a gynecologic history of loop electrosurgical excision procedure (LEEP) for cervical dysplasia several years ago and has had negative Pap smears since then. She also has mild intermittent asthma that is well controlled with occasional use of her albuterol inhaler. At this visit, this patient’s temperature is 98.6°F (37.0°C), pulse is 69/min, blood pressure is 119/61 mmHg, and respirations are 13/min. Cardiopulmonary exam is unremarkable, and the uterine fundus is just palpable at the pelvic brim. Pelvic exam reveals normal female external genitalia, a closed and slightly soft cervix, a 12-week-size uterus, and no adnexal masses. Which of the following is the best method for evaluating for possible cervical incompetence in this patient?

A 32-year-old G1P0000 presents to labor and delivery triage at 38 weeks gestation after several hours of contractions. Currently, they are timed about four minutes apart. Her contractions started after she tripped on a rug and fell on her side. She denies leakage of fluid and the baby has been moving normally, but she noted a small amount of blood on her underwear just before coming into the hospital. The pregnancy has been uncomplicated thus far. The patient has a past medical history of endometriosis, and this fetus was conceived by in vitro fertilization. Pelvic exam in triage reveals a cervix that is three centimeters dilated with a small amount of blood near the introitus. Fetal heart rate tracing at this time is shown in Figure A. Which of the following is the most likely diagnosis?

A 36-year-old G2P1 at 34 weeks gestation presents to the obs...

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A 35-year-old woman at 36 weeks gestation presents to the emergency department with voluminous bloody discharge from her vagina. The patient states that she was at home when her symptoms suddenly started. She states that she is currently experiencing abdominal pain and feels dehydrated. The patient has a past medical history of substance abuse, obesity, and hypertension. Her social history is significant for being a victim of domestic abuse. Her current medications include folic acid, ibuprofen, and sodium docusate. Her temperature is 99.5°F (37.5°C), blood pressure is 100/55 mmHg, pulse is 100/min, respirations are 19/min, and oxygen saturation is 98% on room air. External fetal monitoring is seen in Figure A. The patient is started on IV fluids and 100% oxygen. She continues to complain of abdominal pain. Which of the following best describes this patient's presentation?

A 35-year-old G3P2 woman currently 39 weeks pregnant presents to the emergency department with painful vaginal bleeding shortly after a motor vehicle accident in which she was a passenger. She had her seat belt on and reports that the airbag deployed immediately upon her car's impact against a tree. She admits that she actively smokes cigarettes. Her prenatal workup is unremarkable. Her previous pregnancies were remarkable for one episode of chorioamnionitis that resolved with antibiotics. Her temperature is 98.6°F (37°C), blood pressure is 90/60 mmHg, pulse is 130/min, and respirations are 20/min. The fetal pulse is 110/min. Her uterus is tender and firm. The remainder of her physical exam is unremarkable. What is the most likely diagnosis?

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A 68-year-old gentleman presents to the emergency department for decreased responsiveness. The patient was a successful businessman who managed a multi-billion dollar corporation until several months ago when he retired. Since then, he has had trouble taking care of himself as well as being reclusive and depressed. The patient's wife states that he no longer engages in any activities he once enjoyed and spends most nights awake, staring at the ceiling in tears. The patient has trouble getting out of bed and feels that his limbs are heavy and difficult to manipulate for everyday tasks. He has also been complaining of a numb and tingling sensation in his extremities for the past week. The patient no longer interacts with his wife and does not join her for meals or vacations. Since retirement, he typically stays in his room drinking yam-flavored schnapps all day. The patient does not have a significant past medical history. On physical exam, you see a confused gentleman who responds occasionally to your questions. He has a cough that recently started. He is poorly kempt, unshaven, and wearing a bathrobe. He does not cooperate with a neurological exam. On physical exam you note the findings in Figure A. The patient's skin is dry and unwashed. A chest radiograph is obtained and seen in Figure B. Lab values are below. Serum: Na+: 135 mEq/L K+: 4.2 mEq/L Cl-: 100 mEq/L HCO3-: 24 mEq/L Urea nitrogen: 9 mg/dL Glucose: 50 mg/dL Creatinine: 0.8 mg/dL Thyroid-stimulating hormone: 0.9 µU/mL Ca2+: 9.1 mg/dL Mg2+: 1.5 mEq/L Hemoglobin: 13.5 g/dL Mean corpuscular volume: 100 µm^3 Reticulocyte count: 1.5% Platelet count: 150,000/mm^3 Leukocyte count: 4,900/mm^3 Administration of which of the following is the next best step in management?

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A 27-year-old man presents to the emergency department after a motor vehicle accident. He was the unrestrained driver in a head-on collision. The patient is currently unresponsive and his clothes are soaked in blood. The patient is breathing on his own and grimaces in response to pain. His temperature is 99.5°F (37.5°C), blood pressure is 90/60 mmHg, pulse is 130/min, respirations are 19/min, and oxygen saturation is 95% on room air. The patient is started on intravenous fluids. A FAST exam is negative for signs of intra-abdominal trauma. A chest radiograph is within normal limits. Lacerations on the patient’s chest, back, and head are repaired, and the patient is given blood products. Repeat vitals reveal a blood pressure of 110/70 mmHg and a pulse of 90/min. The patient is observed in the trauma bay. Five hours later, his temperature is 99.5°F (37.5°C), blood pressure is 115/75 mmHg, pulse is 85/min, respirations are 23/min, and oxygen saturation is 84% on room air. A chest radiograph is ordered as seen in Figure A. An arterial blood gas is performed and reveals the findings below. Gases, arterial blood: pH: 7.56 PCO2: 23 mmHg PO2: 70 mmHg Which of the following is the best next step in management?

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A 16-year-old female presents to her physician’s office after noticing a round lump in her left breast 2 months ago. She reports that the lump seemed to enlarge and became tender just preceding her last 2 menses. It is otherwise painless, and the patient denies any discharge or skin changes. She has no past medical history but her grandmother, age 72, was just diagnosed with invasive ductal carcinoma of the breast. The patient is an avid softball player at her high school and denies alcohol, smoking, or illicit drug use. On exam, the breasts appear symmetric and normal. A 3-cm round, mobile mass is palpated in the upper outer quadrant of the left breast. There is slight tenderness to deep palpation of the mass. There is no axillary lymphadenopathy on either side. Which of the following is the most likely outcome of this patient’s condition?

An 8-year-old boy presents to his pediatrician for a well visit. He has been doing well in school and has many friends. The patient is a member of the chess club and enjoys playing video games. He has a medical history of asthma which is treated with albuterol. The patient is in the 99th percentile for weight and 30th percentile for height. His temperature is 99.5°F (37.5°C), blood pressure is 122/88 mmHg, pulse is 90/min, respirations are 11/min, and oxygen saturation is 98% on room air. The patient's body mass index is 39.1 kg/m^2 at this visit. The patient maintains eye contact and is excited to be at the doctor's office. Cardiopulmonary exam is within normal limits. Abdominal exam reveals normal bowel sounds and is non-tender in all 4 quadrants. Neurological and musculoskeletal exams are within normal limits. Which of the following is the most likely outcome in this patient within the next 10 years?

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A 48-year-old woman is transferred from her primary care physician's office to the emergency department for further evaluation of hypokalemia to 2.5 mEq/L. She was recently diagnosed with hypertension 2 weeks ago and started on medical therapy. The patient said that she enjoys all kinds of food and exercises regularly, but has not been able to complete her workouts as she usually does. Her temperature is 97.7°F (36.5°C), blood pressure is 97/64 mmHg, pulse is 120/min, respirations are 15/min, and SpO2 is 94% on room air. Her physical exam is unremarkable. Peripheral intravenous (IV) access is obtained. Her basic metabolic panel is obtained below. Serum: Na+: 135 mEq/L Cl-: 89 mEq/L K+: 2.2 mEq/L HCO3-: 33 mEq/L BUN: 44 mg/dL Glucose: 147 mg/dL Creatinine: 2.3 mg/dL Magnesium: 2.0 mEq/L What is the next best step in management?

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A 25-year-old woman presents to the urgent care clinic for cough for the past five days. She recently moved to the area and has not yet established a primary care doctor. She has noticed worsening runny nose with congestion, sneezing, and tearing over the past few days. She initially thought that it was just due to dust from moving boxes into her new apartment, but her symptoms did not improve after cleaning her belongings and vacuuming her floor. She feels some relief after splashing her face with cold water, but her symptoms recur within ten minutes. She has no pets and does not take any medications. Her physical exam reveals examples of findings shown in Figures A-C. No rales or wheezes are appreciated on lung auscultation, but bronchial breath sounds are heard at the bases. The patient states that she will need to drive back home after this visit. What is the best initial step in management?

A 7-year-old immigrant child is brought to the pediatrician for his first visit. The patient just immigrated to the United States and moved in with his adoptive family. The child is active and playing with the toys in the office. On physical exam, the child appears to be thin and small for his age. Inspection of his scalp is absent for lice. Examination of the head and neck reveals the findings in Figure A. On inspection of his upper extremities you notice the findings in Figure B. The child's abdomen is mildly distended and is non-tender to palpation. The child appears to be meeting normal developmental milestones, but is in the 15th percentile for height and weight. Laboratory values are obtained and are below. Serum: Na+: 135 mEq/L K+: 3.7 mEq/L Cl-: 100 mEq/L HCO3-: 24 mEq/L BUN: 8 mg/dL Glucose: 69 mg/dL Creatinine: .6 mg/dL Ca2+: 8.4 mg/dL Mg2+: 1.5-2.0 mEq/L Hemoglobin: 10 g/dL Hematocrit: 33% Mean corpuscular volume: 78 µm^3 Reticulocyte count: 1.9% Platelet count: 170,000/mm^3 Which of the following is most likely deficient in this patient?

A 64-year-old male is brought in by his granddaughter for confusion. She reports that since her grandmother died six months ago, the patient has become increasingly more irritable. Then yesterday, a neighbor called to say that she had found him aimlessly walking up and down the street. When the granddaughter went to check on him, she reported that there were multiple empty cans of beer and minimal food in the house. The patient has a past medical history significant for hypertension for which he takes chlorothiazide. His surgical history is significant for cataract surgery one year ago. When the patient is asked about his alcohol use, he angrily responds that it is “none of your business.” When asked about diet and weight loss, he admits that he eats very little due to his ongoing diarrhea. On physical exam, you note muscle wasting, balding, and a diffuse rash on his arms and legs, as shown in Figure A. What is the treatment of choice?

A 12-year-old boy is brought to his pediatrician by his mother who is concerned about his recent rash. She first noticed some red dots on his skin last week, and they have become more expansive in the last few days. The patient has been eating his normal diet, but he has been chewing more slowly and his gums have begun to bleed after brushing his teeth. He has been sleeping more than usual, though he is otherwise acting like himself. He has not been ill recently or received any vaccines. The boy had an unremarkable birth history and was diagnosed with autism spectrum disorder at age three. He is primarily nonverbal and attends a school for children with special needs. His younger sister has asthma, and his mother has atopic dermatitis. At this visit, the patient’s temperature is 98.2°F (36.8°C), pulse is 85/min, blood pressure is 110/62 mmHg, and respirations are 15/min. Exam reveals a thin boy who avoids eye contact and does not respond to verbal questions. Cardiopulmonary exams are unremarkable. The hair on his arms is particularly coiled. The child’s leg is shown in Figure A, and his gingiva are shown in Figure B. Which of the following is the best next step in management?

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A 46-year-old man with a history of hypertension, obesity, and hyperlipidemia presents with complaints of a new skin rash. He was in his usual state of health until 1 week prior when he noted dark urine and a non-pruritic skin rash of his hands. He endorses recent sore throat and rhinorrhea but denies any recent changes in his medications and states that his other medical conditions are well-controlled. He works as a butcher and denies recent travel. The patient denies tobacco use, but does endorse recently increasing his alcohol consumption to 3-4 shots of liquor per night. Figure A shows the findings on skin exam. His temperature is 99.1° F (37.3° C), pulse is 78/min, blood pressure is 135/85 mmHg, respirations are 12/min, and oxygen saturation is 99% on room air. His laboratory results are: Sodium: 138 mEq/L Potassium: 4.0 mEq/L Bicarbonate: 22 mEq/L Chloride: 105 mEq/L BUN: 20 mg/dL Creatinine: 1.0 mg/dL Glucose: 98 mg/dL Leukocyte count: 10,900/mm^3 Hemoglobin: 12.4 g/dL Platelets: 280,000/mm^3 Which of the following is the best treatment for this patient?

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A 38-year-old woman with a history of systemic lupus erythematosus, obesity, and hyperlipidemia presents to her primary care physician for evaluation of new bilateral blisters on her hands. She says that she first noticed these blisters shortly after returning from a weekend trip to the beach two weeks prior. She denies any fevers, joint pains, or other skin rash during this period. The patient works in the adult entertainment industry. On examination, there are multiple flaccid blisters of the bilateral dorsal hands with hemorrhagic crusts, mild scarring, and hyperpigmentation. In addition, increased hair growth is noted on the bilateral malar cheeks. Her temperature is 99.1° F (37.3° C), pulse is 95/min, blood pressure is 130/87 mmHg, respirations are 13/min, and oxygen saturation is 98% on room air. Her laboratory results are: Serum: Na+: 140 mEq/L K+: 4.5 mEq/L Cl-: 100 mEq/L HCO3-: 21 mEq/L BUN: 20 mg/dL Creatinine: 1.1 mg/dL Glucose: 104 mg/dL Leukocyte count: 9,000/mm^3 Hemoglobin: 12.4 g/dL Platelets: 400,000/mm^3 Anti-nuclear antibody titer 1:320 Which of the following would confirm the diagnosis in this patient?

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A 25-year-old man comes into your office for a yearly physical exam and check up. He has no current complaints and states that his family is healthy. He was originally born in Italy and is up to date with all of his vaccinations. His physical exam is within normal limits and his vitals are HR 80, BP 125/70, T 97.9 F, RR 11. His CBC is significant for Hgb 12.0, Hct 35, WBC 6.5, and Plts 210. Upon obtaining the differential for his low hemoglobin, you see an MCV of 65 along with a reticulocyte count of 4%. His iron studies are within normal limits. Figure A shows his peripheral blood smear. What is the most likely diagnosis?

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