A 37-year-old man with no significant past medical history is rear-ended in a motor vehicle accident. He reported significant neck pain to emergency responders, but otherwise denies weakness, numbness or tingling in his extremities. His vitals on presentation to the ED are HR 90, BP 140/80, RR 20, SpO2 98%. What is the most appropriate next step upon presentation to the emergency room?

A 28-year-old man presents to a urologist upon referral from a fertility medicine specialist who evaluated the patient and his wife. The patient was told that he had a low sperm count. Otherwise, the patient endorses dull and low grade testicular pain that is chronic in nature and unchanged from his baseline. The patient's vitals are unremarkable. Examination and palpation of the right scrotum and testicle reveals soft palpable cords on the right side which are not seen on the left. Additionally, the examination reveals right testicular atrophy. When the patient lies supine, there is no change in the appearance or size of the scrotum. An ultrasound and color Doppler study of the patient's right testicle is shown in Figure A. Which of the following is the best next step in the management for this patient?

A 29-year-old G2P1 woman at 37 weeks gestation presents to her primary care physician with a 3-day history of an abrupt onset of extremely pruritic, urticarial papules and blisters on the abdomen and trunk. Her pregnancy has otherwise been unremarkable and she is currently taking folate and a multivitamin. Her husband recently had an upper respiratory infection and her son recently had a fever and a rash. The patient has never been vaccinated nor has anyone else in the family. She has a history of cold sores and chickenpox. Her temperature is 98.0°F (36.7°C), blood pressure is 120/84 mmHg, pulse is 85/min, respirations are 14/min, and oxygen saturation is 98% on room air. Her physical exam is shown in Figure A. Which of the following is the most likely diagnosis?

A 56-year-old woman presents to the emergency department with abdominal swelling. She states that her abdomen has been swelling for the past several months but otherwise offers minimal history and is a poor historian. She thinks it worsened more rapidly last night. Her temperature is 97.0°F (36.1°C), blood pressure is 122/80 mmHg, pulse is 80/min, respirations are 12/min, and oxygen saturation is 98% on room air. A bedside ultrasound is performed as seen in Figure A and a sample of the fluid is taken and sent for analysis as seen below. Fluid sample: Cell count: < 50 leukocytes/mm^3 Albumin: 4.8 g/dL Culture: pending Total protein: 18.0 g/dL Gram stain: pending Laboratory values are notable for a serum albumin of 4.0 g/dL. What is the most likely cause of this patient's ascites?

A 45-year-old non-English-speaking, Asian male presents to your office. He shows you a lesion on his elbow (Figure A). He has been having decreased sensation in that area and now cannot feel sharp pinpricks on your physical exam. The lesion is biopsied (Figure B). Which of the following is the most likely diagnosis?

A 73-year-old woman with a history of diabetes presents to the emergency department with severe abdominal pain and constipation for 24 hours. Vital signs are T: 100.3 F, HR: 80 bpm, BP: 143/82 mmHg, RR: 24/min, O2 Sat: 95%. Abdominal exam is notable for diffuse abdominal tenderness to palpation, without rebound or guarding. Laboratory studies are notable for leukocytosis, though lactic acid is within normal limits. Abdominal x-ray is shown in Figure A. Which of the following are the best next management steps for this patient?

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A 56 year old female comes to the ED complaining of moderate right eye pain, headache, and acute onset of blurry vision, which she describes as colored halos around lights. She was watching a movie at home with her husband about an hour ago when the pain began. On physical exam of her right eye, her pupil is mid-dilated and unresponsive to light. Her right eyeball is firm to pressure. Intraocular pressure (IOP) measured with tonometer is elevated at 36mmHg. Which of the following is the most appropriate emergency treatment?

A 47-year-old woman comes to her primary care doctor because of a new, pruritic rash. She was gardening in her yard two days ago and now has an eczematous papulovesicular rash on both ankles. You also note a single, 5 mm brown lesion with a slightly raised border on her left thigh. You prescribe a topical corticosteroid for contact dermatitis. Which of the following is the appropriate next step for the thigh lesion?

A 39-year-old female presents with complaints of redness and "acne" over her cheeks, nose and chin. A representative photo is shown in Figure A. She states that the redness worsens with emotional stresses, heat, and hot beverages. Which of the following is an appropriate treatment for this condition?

A 35-year-old female presents to the ED at the request of her husband after 3 weeks of erratic behavior. The patient has been staying up all night online shopping on eBay. Despite a lack of sleep, she is "full of energy" during the day at her teaching job, which she believes is "beneath [her], anyway." She has not sought psychiatric treatment in the past, but reports an episode of self-diagnosed depression 2 years ago. The patient denies thoughts of suicide. Pregnancy test is negative. The patient is acutely agitated and is pacing back and forth across the room and states she is going to leave. Which of the following is the best initial treatment?

A 65-year-old previously healthy man presents to the primary care physician with the chief complaint of red colored urine over the past month. He states that he does not experience dysuria. On physical exam there is no costovertebral angle tenderness. With this presentation which is the most likely cause of this patient's hematuria?

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A 32-year-old man comes into your office because of pain in his right knee, left elbow, and left wrist. It started about a week ago but has particularly localized to his wrist. The patient states that he has 2 sexual partners. He states he has also had some white discharge from his penis with pruritis and pain during urination. His temperature is 97.6°F (36.4°C), blood pressure is 124/84 mmHg, pulse is 80/min, respirations are 12/min, and oxygen saturation is 98% on room air. Physical exam reveals pain upon palpation of the patient's left wrist which also appears erythematous and swollen. What is the best next step in management for this patient?

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A 3-year-old girl with no significant past medical history presents to the clinic with a 4-day history of acute onset cough. Her parents have recently started to introduce several new foods into her diet. Her vital signs are all within normal limits. Physical exam is significant for decreased breath sounds on the right. What is the most appropriate definitive management in this patient?

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A 5-year-old child is brought to his primary care physician for a well-child examination. The child was born when his mother was 43 years old. On physical exam, the child is of small stature, has palpebral fissures that are upward slanting, and inner epicanthal folds. Before proceeding to funduscopic examination, you notice the following in his iris (Figure A). Which of the following is/was most likely present in this child?

A 55-year-old IV drug user comes into the emergency department after four days of pain in his right ankle. The patient is lethargic and unable to answer any questions about his medical history. His vitals are HR 110, T 101.5, RR 20, BP 100/60. His physical exam is notable for track marks in his toes and his right ankle is erythematous and swollen. Moving any part of the right foot creates a 10/10 pain. A radiograph revels no evidence of fractures. A Gram stain of the joint fluid aspirate demonstrates purple cocci in clusters. The fluid is yellow, opaque, with more than 70,000 cells/mm^3 (80% neutrophils). What is the most likely diagnosis?

A 17-year-old girl is brought into the physician's office with complaints of nausea, vomiting, headache, and blurry vision. In preparation for final exams the patient's mother started her on an array of supplements and herbal preparations given the "viral illness" that is prevalent at her school. Despite these remedies, the girl has been feeling perpetually worse, and yesterday during cheerleading practice had to sit out after vomiting and feeling dizzy. The patient admits to falling during one of the exercises and hitting her head on another girl's shin due to her dizziness. When asked to clarify her dizziness, the patient states that she feels rather lightheaded at times. The patient's BMI is 19 kg/m^2. She endorses diarrhea of recent onset, and some non-specific, diffuse pruritus of her skin which she attributes to stress from her finals. The patient has a past medical history of anxiety, depression, and excessive exercise habits. On physical exam the patient is alert and oriented to place, person, and time, and answers questions appropriately. She denies any decreased ability to participate in school or to focus. Her skin is dry and peeling with a minor yellow discoloration. Her memory is intact at 1 minute and 5 minutes for 3 objects. The patient's pupils are equal and reactive to light and there are no abnormalities upon examination of cranial nerve III, IV or VI. Which of the following is the most likely cause of this patient's symptoms?

A 35-year-old man is brought to the emergency department from a kitchen fire. The patient was cooking when boiling oil splashed on his exposed skin. His temperature is 99.7°F (37.6°C), blood pressure is 127/82 mmHg, pulse is 120/min, respirations are 12/min, and oxygen saturation is 98% on room air. He has dry, nontender, and circumferential burns over his arms bilaterally, burns over the anterior portion of his chest and abdomen, and tender spot burns with blisters on his shins. A 1L bolus of normal saline is administered and the patient is given morphine and his pulse is subsequently 80/min. A Foley catheter is placed which drains 10 mL of urine. What is the best next step in management?

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A 38-year-old man presents to his gastroenterologist after being referred by his primary care physician (PCP). He has had intractable epigastric pain for the last 3 months following meals. His PCP prescribed him a course of ranitidine. After his symptoms did not resolve he was prescribed omeprazole. However, his symptoms persisted and he was referred to gastroenterology. The man undergoes an endoscopy, which finds a gastric ulcer (Figure A). Biopsy with silver staining is shown in Figure B. Which of the following is the most effective regimen for the treatment of this condition?

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A 33-year-old nurse who was born in the United States and has lived in the US all her life is referred to an infectious disease specialist after she exhibited a PPD skin test with 17 mm of induration. She denies any cough, shortness of breath, hemoptysis, weight loss, fatigue, fevers, or night sweats over the last several months. However, she works in the federal penitentiary system and has also provided aid on foreign medical mission trips to Haiti in the past few years. Her temperature is 97.0°F (36.1°C), blood pressure is 120/81 mmHg, pulse is 82/min, respirations are 15/min, and oxygen saturation is 98% on room air. An initial chest radiograph is unremarkable. Which of the following is the most appropriate management of this patient?

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A 25-year-old male is brought into the emergency department by emergency medical services. The patient has a history of bipolar disease complicated by polysubstance use. He was found down in his apartment at the bottom of a staircase lying on his left arm. He was last seen several hours earlier by his roommate. He is disoriented and unable to answer any questions, but is breathing on his own. His vitals are HR 55, T 96.5, RR 18, BP 110/75. You decide to obtain an EKG as shown in Figure 1. What is the next best step in the treatment of this patient?

A 50-year-old man presents to the emergency department with chest pain. He states that it began earlier today and worsens with inspiration. It is non-exertional, 7/10 in severity, and sharp in nature. He states that he just returned from China yesterday and has not had any similar symptoms prior to today. He noticed that he has coughed up a small amount of blood-tinged sputum several times as well. He is otherwise healthy, other than having his foot splinted 4 days ago for an Achilles tendon injury he sustained while playing volleyball. His temperature is 97.9°F (36.6°C), blood pressure is 112/68 mm Hg, pulse is 120/min, respirations are 23/min, and oxygen saturation is 92% on room air. Physical exam is notable for an uncomfortable man who is mentating appropriately and moving all his extremities. Inspection of his lower extremities reveals a swollen and tender calf on the leg that is splinted. An ECG is seen in Figure A. The patient is started on IV fluids and oxygen. Which of the following is the next best step in management?

A 67-year-old male presents to your office one day after an injury. Yesterday he tried to play basketball with his grandchildren and he was doing well until he jumped to get the ball and landed awkwardly on his right foot, after which he could not bear weight on his foot. On exam, his right foot is significant for swelling with tenderness to palpation anterior to the Achilles tendon. The patient has no tenderness over his medial or lateral malleoli. Figure A is a radiograph of his right foot with the area of traumatic injury. What is the most likely diagnosis?

A 69-year-old male presents to the emergency room with back pain. He has a history of personality disorder and metastatic prostate cancer and was not a candidate for surgical resection. He began chemotherapy but discontinued due to unremitting nausea. He denies any bowel or bladder incontinence. He has never had pain like this before and is demanding morphine. The nurse administers IV morphine and he feels more comfortable. Vital signs are stable. On physical examination you note tenderness to palpation along the lower spine, weakness in the bilateral lower extremities, left greater than right. Neurological examination is also notable for hyporeflexia in the knee and ankle jerks bilaterally. You conduct a rectal examination, which reveals saddle anesthesia. Regarding this patient, what is the most likely diagnosis and the appropriate next step in management?

A mother brings her 4-year-old son to his pediatrician. Over the last eight months, her son has been exhibiting several "odd" behaviors. Most importantly, he repeatedly says that he is playing games with a friend named "Steven," though she is certain that he does not exist. She has often found him acting out magical scenarios as though someone else is present, when no one is there. What is the most likely diagnosis in this patient?

A 5-year-old male is brought to the pediatrician by his mother, who relates a primary complaint of a recent history of five independent episodes of vomiting over the last 10 months, most recently 3 weeks ago. Each time, he has awoken early in the morning appearing pale, feverish, lethargic, and complaining of severe nausea. This is followed by 8-12 episodes of non-bilious vomiting over the next 24 hours. Between these episodes he returns to normal activity. He has no significant past medical history and takes no other medications. Review of systems is negative for changes in vision, gait disturbance, or blood in his stool. His family history is significant only for migraine headaches. Vital signs and physical examination are within normal limits. Initial complete blood count, comprehensive metabolic panel, and abdominal radiograph were unremarkable. What is the most likely diagnosis?

A mother brings her 10 month-old boy to the pediatrician for a check-up. His birth was without complications and his development to-date has been progressing normally. He currently crawls, pulls himself up to standing, says 'mama' and 'dada' nonspecifically, and responds when called by his name. However, his mother is concerned, as she has noted over the past several weeks that he has periods where he stops breathing when he gets frightened or upset. These episodes last for 20-30 seconds and are accompanied by his lips and face become bluish. His breathing has always resumed normally within 45 seconds after the start of the episode, and he acts normally afterwards. One instance resulted in the child passing out for a 5-10 seconds before a spontaneous recovery. Which of the following is the most appropriate management of this patient's condition?

A 64-year-old woman presents to her primary care physician with complaints of fatigue, a sore mouth, as well as occasional abdominal pain and diarrhea for the past several months. She denies any loss of balance, trouble walking, numbness, pain, or tingling in her hands or feet. She has a past medical history of morbid obesity, depression, rheumatoid arthritis, suicide, anxiety, hypertension, diabetes, and factor V Leiden being managed by her PCP. Her temperature is 99.4°F (37.4°C), blood pressure is 154/94 mmHg, pulse is 87/min, respirations are 18/min, and oxygen saturation is 98% on room air. Physical examination is significant for the finding in Figure A. The patient's creatinine is 2.0 mg/dL at this visit. Which of the following is most likely to be found in this patient?

A 46-year-old woman presents to the emergency department with 1 day of painful leg swelling. She is otherwise healthy and takes only oral contraceptive pills. The patient does not regularly follow up with her primary doctor. Her temperature is 98.0°F (36.7°C), blood pressure is 122/78 mm Hg, pulse is 70/min, respirations are 13/min, and oxygen saturation is 99% on room air. Lower extremity examination shows mild calf swelling on her left leg, but otherwise is unremarkable. An ultrasound is performed as seen in Figure A. Which of the following is the most appropriate course of action?

A 42-year-old man with a history of tuberculosis presents to your office complaining of fatigue for 2 months. Serum laboratory studies reveal the following: WBC 7,000 cells/mm^3, Hb 9.0 g/dL, Hct 25%, MCV 75 fL, Platelet 450,000 cells/mm^3, Vitamin B12 500 pg/mL (200-800), and Folic acid 17 ng/mL (2.5-20). Which of the following is the most appropriate next step in the management of anemia in this patient?

A 79-year-old man presents to the emergency department with abdominal pain. The patient describes the pain as severe, tearing, and radiating to the back. His history is significant for hypertension, hyperlipidemia, intermittent claudication, and a 60 pack-year history of smoking. He also has a previously diagnosed stable abdominal aortic aneurysm followed by ultrasound screening. On exam, the patient's temperature is 98°F (36.7°C), pulse is 183/min, blood pressure is 84/46 mmHg, respirations are 24/min, and oxygen saturation is 99% on room air. The patient is pale and diaphoretic, and becomes confused and obtunded as you examine him. Which of the following is most appropriate in the evaluation and treatment of this patient?

A 55-year-old obese woman with a past medical history of a pulmonary embolism presents with shortness of breath and chest pain. It started this morning, and she can't recall any preceding symptoms. She feels short of breath and has chest pain with deep breaths. Her temperature is 97.6°F (36.4°C), blood pressure is 117/77 mmHg, pulse is 120/min, respirations are 22/min, and oxygen saturation is 92% on room air. A CTA is performed and the patient is subsequently treated with warfarin and admitted to the hospital. On hospital day 2, the patient complains of leg pain and demonstrates the finding in Figure A. Which of the following is the most likely etiology for this patient's presentation?

A 35-year-old woman presents to her family physician with a complaint of painful joints for the past 2 weeks. She reports symmetric bilateral joint pain in her hands, knees, and ankles. She has never had this before, and her past medical history is notable only for asthma. She states the pain is worse in the morning and improves throughout the day. Review of systems is notable for a recent low-grade fever with malaise. She works as a school teacher and is sexually active with men and women. Her temperature is 97.9°F (36.6°C), blood pressure is 120/84 mmHg, pulse is 70/min, respirations are 14/min, and oxygen saturation is 97% on room air. The patient is instructed to take ibuprofen and acetaminophen for her joint pain. She returns 1 month later stating that she has not needed to take the medications as her pain has been absent for the past 3 days. Which of the following is the most likely diagnosis?

An 86-year-old woman is brought to the emergency department from her nursing home facility. She has been more fatigued and less communicative over the past 3 days. The patient's only complaint is generalized weakness. She has had no witnessed falls and no signs of trauma during this time frame. Her past medical history is significant for mild dementia, well-controlled hypertension, and hyperlipidemia. Her medications include hydrochlorothiazide, losartan, and simvastatin. Her temperature is 97.6°F (36.4°C), blood pressure is 133/83 mmHg, pulse is 120/min, respirations are 16/min, and oxygen saturation is 98% on room air. Neurologic exam is unremarkable. There are no signs of trauma upon inspection. An ECG is performed as seen in Figure A. A previous ECG performed 2 weeks ago demonstrated normal sinus rhythm. An initial CBC, troponin, and serum chemistry are within normal limits. A chest radiograph, urinalysis, lumbar puncture, and flu swab are negative for any source of infection. Which of the following is the best next step in management?

A 22-year-old female presents to her PCP after having unprotected sex with her boyfriend 2 days ago. She has been monogamous with her boyfriend but is very concerned about pregnancy. The patient requests emergency contraception to decrease her likelihood of getting pregnant. A blood hCG test returns negative. The PCP prescribes the patient ethinyl estradiol 100 mcg and levonorgestrel 0.5 mg to be taken 12 hours apart. What is the most likely mechanism of action for this combined prescription?

A 66-year-old man presents to his primary care physician endorsing easy bleeding. He reports that roughly 5 days ago, he began noticing excessive bleeding while brushing his teeth. He has not noticed any bleeding since this event and is currently asymptomatic. He is otherwise healthy with a medical history including hypertension treated with amlodipine and depression for which he takes fluoxetine. On examination, he is well appearing. His lower extremities are notable for the finding in Figure A. No active bleeding is seen in his oropharynx and rectal exam is negative for occult blood. Laboratory studies are ordered as seen below. Hemoglobin: 15 g/dL Hematocrit: 44% Leukocyte count: 7,500/mm^3 with normal differential Platelet count: 31,000/mm^3 Which of the following is the most appropriate next step in management?

A 70-year-old male presents to the emergency department with fever and productive cough that has progressed rapidly over the past day. On exam, he is very ill appearing and his vitals demonstrate T: 39 deg C, HR: 95 bpm, BP: 80/40 mmHg, RR: 15, SaO2: 93%. A CBC is obtained which demonstrates a white blood cell count (WBC) of 14,000. A chest radiograph is obtained which is demonstrated in Figure A. The patient is subsequently diagnosed with severe sepsis secondary to pneumonia and is transferred to the ICU after intubation, appropriate antibiotic therapy, and resuscitation measures are initiated. The patient improves steadily over the subsequent days in the ICU with improving vitals and decreasing WBC. However, on hospital day 4 he develops a fever to 41 deg C, and his WBC elevates to 16,000. On exam, he appears to withdraw in pain when his abdomen is palpated. Liver function tests and amylase/lipase are ordered and shown to be within normal limits. An abdominal ultrasound is obtained which is demonstrated in Figure B. What is the most likely cause of this patient's current presentation?

A 46-year-old woman presents to her family physician for a general wellness checkup with a chief complaint of high levels of anxiety over the past year. Her anxiety has started to affect her performance at work, making her even more anxious and concerned that she will lose her job. She started psychotherapy several months ago and has experienced minimal improvement in her symptoms from this treatment. The patient is vehemently opposed to beginning any pharmacologic treatment for anxiety; however, she is interested in potential herbal remedies and has started taking kava. She also takes vitamin D, a multivitamin, fish oil, protein powder, and drinks goat milk regularly. The patient works as a commercial sex worker and has a history of IV drug abuse and alcohol abuse which she states she has not used in over a year. She has chronic tension headaches for which she self-administers acetaminophen usually multiple times per day. Her last wellness appointment was unremarkable and these problems are new. Laboratory values are ordered as seen below. Hemoglobin: 13 g/dL Hematocrit: 38% Leukocyte count: 6,870/mm^3 with normal differential Platelet count: 227,000/mm^3 Serum: Na+: 138 mEq/L Cl-: 102 mEq/L K+: 4.1 mEq/L HCO3-: 25 mEq/L BUN: 20 mg/dL Glucose: 111 mg/dL Creatinine: 1.0 mg/dL Ca2+: 10.2 mg/dL AST: 82 U/L ALT: 90 U/L Which of the following is the most likely cause of this patient's lab derangements?

A 17-year-old male is brought to the emergency department following a motor vehicle accident. He has suffered several wounds and is minimally responsive. There is a large laceration on his forehead as well as a fracture of his nasal bridge. He appears to be coughing and spitting blood. He is already wearing a soft collar. Vitals are as follows: T 36.4C, BP 102/70 mmHg, HR 126 bpm, and RR 18 rpm, and SpO2 is 88% on RA. He has 2 peripheral IVs and received 2L of IV normal saline on route to the hospital. There is frank blood in the oropharynx. Breath sounds are present bilaterally. Abdomen is distended and tender. Pulses are 1+. Which of the following should be the first step in management?

A 3-year boy with a history of atopic dermatitis is brought to his pediatrician for onset of a new facial rash. His skin exam (Figure A) is notable for erythematous erosions on his cheeks and surrounding his nares, some with an overlying honey-colored crust. What is the optimal first-line treatment for these lesions?