A 60-year-old male is admitted to the ICU for severe hypertension complicated by a headache. The patient has a past medical history of insulin-controlled diabetes, hypertension, and hyperlipidemia. He smokes 2 packs of cigarettes per day. He states that he forgot to take his medications yesterday and started getting a headache about one hour ago. His vitals on admission are the following: blood pressure of 160/110 mmHg, pulse 95/min, temperature 98.6 deg F (37.2 deg C), and respirations 20/min. On exam, the patient has an audible abdominal bruit. After administration of antihypertensive medications, the patient has a blood pressure of 178/120 mmHg. The patient reports his headache has increased to a 10/10 pain level, that he has trouble seeing, and he can't move his extremities and seems confused. After stabilizing the patient, what is the best next step to diagnose the patient's condition?

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A 52-year-old man is brought to the emergency department by police. The patient was found harassing patrons at a local pub. The patient has a past medical history of substance abuse. He is not currently taking any medications. His temperature is 99.5°F (37.5°C), blood pressure is 140/95 mmHg, pulse is 95/min, respirations are 15/min, and oxygen saturation is 99% on room air. On physical exam, the patient demonstrates poor grooming and poor dentition. He is currently resting. Cardiac exam demonstrates a normal rate and rhythm. Pulmonary exam reveals minor bibasilar crackles. Laboratory values are ordered as seen below. Hemoglobin: 9 g/dL Hematocrit: 30% Leukocyte count: 7,500 cells/mm^3 with normal differential Platelet count: 199,000/mm^3 Serum: Na+: 137 mEq/L Cl-: 100 mEq/L K+: 4.4 mEq/L HCO3-: 25 mEq/L BUN: 20 mg/dL Glucose: 99 mg/dL Creatinine: 1.1 mg/dL Ca2+: 10.0 mg/dL AST: 33 U/L ALT: 24 U/L An alcohol breath test reveals a value of .48. A peripheral smear is ordered as seen in Figure A. Which of the following enzymes is most likely impaired in this patient?

During the exam of a 2-day-old female neonate you determine that she appears lethargic, cyanotic, and has a coarse tremor of her right arm. The patient's mother explains that she observed what she believed to be seizure-like activity just before you arrived in the room. The mother has a history of type two diabetes mellitus and during childbirth there was a delay in cord clamping. You decide to get electrolytes and a complete blood count to work up this patient. The labs are significant for mild hypoglycemia and a hematocrit of 72%. What is the most effective treatment for this patient's condition?

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A 56-year-old woman is one week status post abdominal hysterectomy when she develops a fever of 101.4°F (38.6°C). Her past medical history is significant for type II diabetes mellitus and a prior history of alcohol abuse. The operative report and intraoperative cystoscopy indicate that the surgery was uncomplicated. The nurse reports that since the surgery, the patient has also complained of worsening lower abdominal pain. She has given the patient the appropriate pain medications with little improvement. The patient has tolerated an oral diet well and denies nausea, vomiting, or abdominal distension. Her blood pressure is 110/62 mmHg, pulse is 122/min, and respirations are 14/min. Since being given 1000 mL of intravenous fluids yesterday, the patient has excreted 800 mL of urine. On physical exam, she is uncomfortable, shivering, and sweating. The surgical site is intact, but the surrounding skin appears red. No drainage is appreciated. The abdominal examination reveals tenderness to palpation and hypoactive bowel sounds. Labs and a clean catch urine specimen are obtained as shown below: Leukocyte count and differential: Leukocyte count: 18,000/mm^3 Segmented neutrophils: 80% Bands: 10% Eosinophils: 1% Basophils: < 1% Lymphocytes: 5% Monocytes: 4% Platelet count: 300,000/mm^3 Hemoglobin: 12.5 g/dL Hematocrit: 42% Urine: Epithelial cells: 15/hpf Glucose: positive RBC: 1/hpf WBC: 2/hpf Bacteria: 50 cfu/mL Ketones: none Nitrites: negative Leukocyte esterase: negative Which of the following is most likely the cause of this patient’s symptoms?

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A 44-year-old G2P2 African American woman presents to her gynecologist for dysmenorrhea. She reports that for the past few months, she has been having severe pain during her menses. She also endorses menstrual bleeding that has been heavier than usual. The patient reports that her cycles are regular and occur every 30 days, and she denies both dyspareunia and spotting between her periods. Her last menstrual period was two weeks ago. In terms of her obstetric history, the patient had two uncomplicated pregnancies, and she had no difficulty becoming pregnant. She has never had an abnormal pap smear. Her past medical history is otherwise significant for hyperlipidemia and asthma. On physical exam, the patient’s uterus is tender, soft, and enlarged to the size of a pregnant uterus at 10 weeks of gestation. She is non-tender during vaginal exam, without cervical motion tenderness or adnexal masses. Her BMI is 24 kg/m2. A urine pregnancy test is negative. Which of the following is the most likely diagnosis for this patient?

A 42-year-old G3P3003 presents to her gynecologist for an annual visit. She complains of urinary incontinence when jogging since the birth of her last child three years ago. Her periods are regular every 30 days. The patient also has cramping that is worse before and during her period but always present at baseline. She describes a feeling of heaviness in her pelvis that is exacerbated by standing for several hours at her job as a cashier. The patient has had two spontaneous vaginal deliveries, one caesarean section, and currently uses condoms for contraception. She is obese and smokes a pack of cigarettes a day. Her mother died of breast cancer at age 69, and her aunt is undergoing treatment for endometrial cancer. The patient’s temperature is 98.6°F (37.0°C), pulse is 70/min, blood pressure is 142/81 mmHg, and respirations are 13/min. Pelvic exam is notable for a uterine fundus palpated just above the pubic symphysis and a boggy, smooth texture to the uterus. There is no tenderness or mass in the adnexa, and no uterosacral nodularity is noted. Which of the following is a classic pathological feature of this patient’s most likely diagnosis?

A 28-year-old female presents to her gynecologist with one year of secondary infertility. She had one first-trimester spontaneous abortion at age 24, after which she started taking oral contraceptives. That pregnancy was not conceived with her current partner. One year ago, she stopped taking birth control and has been having regular unprotected intercourse with her husband without success. She has regular periods every 28 days with mild dysmenorrhea. The patient has a past medical history of gonorrhea at age 18 which was treated. Her husband has no documented infertility and is a lawyer who cycles on the weekends. She has a family history of coronary artery disease in her father and recurrent pregnancy loss in her mother. At this visit, the patient’s temperature is 98.5°F (36.9°C), pulse is 80/min, blood pressure is 121/82 mmHg, and respirations are 13/min. Cardiopulmonary and abdominal exams are unremarkable. Pelvic exam reveals a normal cervix, retroverted uterus without tenderness, and no adnexal masses. A hysterosalpingogram (HSG) is performed and shown in Figure A. Which of the following is the most likely cause of this patient’s presentation?

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A 67-year-old man presents to the emergency department for a headache. The patient states his symptoms started thirty minutes ago. He states he experienced a sudden and severe headache while painting his house, causing him to fall of the ladder and hit his head. He has also experienced two episodes of vomiting and difficulty walking since the fall. The patient has a past medical history of hypertension, obesity, and atrial fibrillation. His current medications include lisinopril, rivaroxaban, atorvastatin, and metformin. His temperature is 99.5°F (37.5°C), blood pressure is 150/105 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 98% on room air. On physical exam, the patient localizes his headache to the back of his head. Cardiac exam reveals a normal rate and rhythm. Pulmonary exam reveals minor bibasilar crackles. Neurological exam is notable for minor weakness of the muscles of facial expression. Examination of cranial nerve three reveals a notable nystagmus. Heel to shin exam is abnormal bilaterally. The patient's gait is notably ataxic. A non-contrast CT scan of the head is currently pending. Which of the following is the most likely diagnosis?

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A 28-year-old Caucasian woman presents to her primary care physician due to decreased hearing of the right ear. She reports that her hearing has progressively worsened over the course of a year. In addition to her current symptoms, she has also noticed ear ringing of the affected ear, as well as dizziness. She states that her hearing is improved in a noisy environment and that her friends have noted that she usually speaks quietly during conversations. Medical history is significant for multiple episodes of acute otitis media and seasonal allergies. Family history is significant for her father having "ear surgery" when he was approximately 30-years-old. Otoscopy findings are seen in Figure A. Which of the following is most likely to be found on physical exam?

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A 45-year-old male presents to the emergency department by ambulance from a motor vehicle accident. The emergency medical technician states that the patient had been the driver and was hit on the driver’s side while crossing over the intersection. The patient will open his eyes and withdraw from pain and but can only make sounds with no coherent words. The patient’s temperature is 97°F (36.1°C), blood pressure is 98/63 mmHg, pulse is 112/min, and respirations are 24/min with an oxygen saturation of 94% on 15 L/min O2 via a non-rebreather mask. Upon physical exam, you note reduced breath sounds on the left. The patient is stabilized and a chest radiograph is obtained, as shown in Figure A. What is the most likely pleural fluid finding?

A 38-year-old G1P1 female arrives to your clinic complaining of pain during sexual intercourse. She reports that the discomfort has been happening for months, and despite a normal libido, it has been putting a strain on her relationship with her fiancé. The patient denies urinary symptoms but reports some vaginal itching. Her past medical history is significant for type I diabetes mellitus, generalized anxiety disorder, and Raynaud’s phenomenon. Her medications include insulin and citalopram. Her last menstrual period was two weeks ago. She smokes half a pack of cigarettes a day and marijuana two times a week to help relieve chronic joint pain. Physical exam is notable for dental abnormalities shown in Figure A. A pelvic exam is within normal limits, but the patient’s vaginal mucosa appears dry and mildly erythematous. There is minimal yellow-white discharge. Which of the following auto-antibodies is most likely to confirm the diagnosis?

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A 60-year-old woman is brought into the office by his son. His son states that the patient has been acting inappropriately over the last few years. She has been taking off her clothes in front of visitors and putting objects in her mouth. She has had no emotional response to the death of one of her close friends and was laughing at her funeral. She has almost no memory issues, but sometimes forgets how to use objects such as a telephone. She has no other medical issues and takes no medications. On exam, she has no focal neurological deficits and her mini-mental status exam is 25/30. What is the most likely diagnosis?

A 17-year-old male presents to the clinic with complaints of a new-onset rash. He describes initially seeing a circular lesion on his abdomen three days prior and then many smaller new lesions occurring in the following days. The skin lesions are generally asymptomatic, although some are intermittently itchy. His past medical history is significant for sickle cell trait and seasonal allergies. His medications include folic acid and fexofenadine as needed. In addition, he had a recent episode of sore throat associated with congestion and rhinorrhea for which he took azithromycin. He does well in school and is on the wrestling team. His temperature is 99.1°F (37.3°C), pulse is 60/min, blood pressure is 110/64 mmHg, respirations are 13/min, oxygen saturation is 99% on room air. Physical exam is notable for a diffuse rash on the trunk (Figure A). Which of the following is the most likely trigger of this patient’s skin condition?

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A 4-year-old immigrant from Africa presents to his pediatrician for an initial visit. The child just immigrated from Africa and is now living in his new home. The patient is small for his age and is in the 5th percentile for height and 10th percentile for weight. His parents are concerned as the child has complained of leg pain and chest pain ever since he was tackled while playing soccer. A radiograph of the chest is ordered and is seen in Figure A. Cardiac and pulmonary exam are within normal limits. Laboratory values are ordered. Which of the following laboratory changes are expected in this patient in Figure B?

A 27-year-old young man presents to his primary care physician for weakness and tingling in his hand. The patient is an avid bodybuilder and has noticed that his grip strength has gradually worsened in both hands with symptoms worse at the end of a long workout. The patient has a past medical history of anabolic steroid use in high school. His current medications include a multivitamin, fish oil, and whey protein supplements. On physical exam, you note a muscular young man with male pattern hair loss. The patient has a loss of sensation bilaterally over the volar and dorsal surfaces of the 4th and 5th digits. The patient has 3/5 grip strength of his left hand and 2/5 grip strength of his right hand. There is also notable weakness of finger adduction and abduction. The rest of the patient's physical exam is within normal limits. Which of the following is the most likely diagnosis?