A 44-year-old Caucasian man with a four-year history of diabetes mellitus presents to your office for a routine check-up. He has no complaints. His medications include metformin, aspirin, and a multivitamin. He works as an insurance salesman and has a sedentary lifestyle. He smokes one pack of cigarettes per day and drinks two cans of beer on weekends. He denies any illicit drug use. His diet includes mostly meat and large amounts of "junk food." On physical exam, his blood pressure is 157/96 mmHg, heart rate is 82 bpm. His BMI is 34.2 kg/m^2. The remainder of his physical exam is unremarkable. Laboratory studies reveal an HbA1c of 7.8%. At his last check-up one month ago, his blood pressure was 151/93 mmHg. Which of the following interventions would be most effective for lowering his blood pressure?

A 42-year-old woman presents to her doctor complaining of poor sleep. She has also been feeling restless and agitated for several months. Upon further questioning, she reveals that she has also been suffering from headaches and has gained 18 pounds over the same time period. She denies any chest pain, palpitations, diaphoresis, or increased appetite. She has no significant past medical history other than two uncomplicated pregnancies resulting in normal spontaneous vaginal deliveries. She denies any tobacco, alcohol, or illicit drug use. Her vital signs show Temp 37 C (98.6 F), BP 164/112 mm Hg, HR 88/min, and RR 12/min. Physical exam shows an overweight woman with no palpable thyroid nodules or abnormalities on cardiopulmonary exam. Laboratory evaluation reveals the following: Sodium 141 mEq/L, potassium 3.1 mEq/L, chloride 96 mEq/L, bicarbonate 25 mEq/L, BUN 10 mg/dL, creatinine 0.8 mg/dL, glucose 220 mg/dL, and calcium 9.5 mg/dL. Which of the following is the likely cause of her hypertension?

A 69-year-old male presents to his primary care provider for...

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A 27-year-old woman presents to your medical clinic with a chief complaint of bilateral lesions along the medial canthus of her eyes as shown in Figure A. She is quite concerned about the cosmetic appearance of these lesions and would like them removed. She has no other complaints nor any significant past medical history. In addressing this patient's chief complaint, what would be the next appropriate step in management?

A 35-year-old homeless woman presents to the emergency depar...

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A 25-year-old female with a history of childhood asthma presents to clinic complaining of a three month history of frequent, loose stools. She currently has three to four bowel movements per day, and she believes that these episodes have been getting worse and are associated with mild abdominal pain. She also endorses seeing red blood on the toilet tissue. On further questioning, she also endorses occasional palpitations over the past few months. She denies fevers, chills, headache, blurry vision, cough, shortness of breath, wheezing, nausea, or vomiting. She describes her mood as slightly irritable and she has been sleeping poorly. A review of her medical chart reveals a six pound weight loss since her visit six months ago, but she says her appetite has been normal. The patient denies any recent illness or travel. She is a non-smoker. Her only current medication is an oral contraceptive pill. Her temperature is 37°C (98.6°F), pulse is 104/min, blood pressure is 95/65 mmHg, respirations are 16/min, and oxygen saturation is 99% on room air. On physical exam, the physician notes that her thyroid gland appears symmetrically enlarged but is non-tender to palpation. Upon auscultation there is an audible thyroid bruit. Her cranial nerve and ocular exam are normal. Her abdomen is soft and non-tender to palpation. Deep tendon reflexes are 3+ throughout. Lab results are as follows: Serum: Na+: 140 mEq/L K+: 4.1 mEq/L Cl-: 104 mEq/L HCO3-: 26 mEql/L BUN: 18 mg/dL Creatinine 0.9 mg/dL Hemoglobin: 14.0 g/dL Leukocyte count: 7,400/mm^3 Platelet count 450,000/mm^3 TSH & Free T4: pending A pregnancy test is negative. The patient is started on propranolol for symptomatic relief. What is the most likely best next step in management for this patient?

A 57-year-old female presents to her primary care physician ...

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A 55-year-old man recently status post abdominal surgery is discharged from the PACU to the inpatient surgery ward where he remains NPO with an nasogastric tube in place to suction for bowel rest. You are called to the bedside because his blood pressure is 182/89. His heart rate is 89. He complains of 3/10 pain at the surgical site only. Recent lab results were within normal limits. You learn that he stopped taking his blood pressure medications (metoprolol 25mg twice daily) one week before surgery. Of the following choices, which is the best option for managing this patient's blood pressure?

A 52-year-old woman comes to your clinic for her annual physical exam. She is obese, does not exercise, and regularly eats fried foods. A random blood glucose is 249 mg/dL. Her hemoglobin A1C is 9.5. Which of the following treatments would be weight neutral or cause weight loss in this patient?

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A 54-year-old male is involved in a high speed motor vehicle...

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A 32-year-old-man presents to the emergency room with subacute worsening of chronic chest pain and shortness of breath. Vital signs areas follows: T 37C, HR 81 bpm, BP 127/83 mm Hg, RR 21/min, and O2 saturation of 99% on room air. Cardiac auscultation reveals a crescendo-decrescendo murmur, loudest under the right clavicle, peaking in late systole. Cardiac exam is also notable for a diminished A2. Troponins are negative. An EKG shows left axis deviation and meets criteria for left ventricular hypertrophy. An echocardiogram is ordered, and results are pending. The most likely cause of this man's symptoms is:

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A 60-year-old Caucasion male presents to your office complaining of shortness of breath on exertion. He undergoes an echocardiogram and is found to have an ejection fraction of 35%. Which of the following classes of drugs would decrease mortality in this patient?

A 67-year-old man presents to the emergency department with shortness of breath. He reports that the dyspnea began an hour ago while he was sitting in a chair watching television. He also endorses lightheadedness and fatigue but denies chest pain. Two weeks ago, he had a mitral valve repair for mitral insufficiency secondary to myxomatous degeneration. His medical history is otherwise significant for hypertension and diabetes mellitus, for which he takes metformin and lisinopril. His temperature is 98.8°F (37.1°C), blood pressure is 95/64 mmHg, pulse is 48/min, and respirations are 22/min. On physical exam, he appears to be in moderate distress. He has normal cardiac sounds with an irregular rhythm. His lungs are clear to auscultation bilaterally, and his electrocardiogram can be seen in Figure A. Which of the following is the best next step in management?

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

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A 68-year-old female presents to the emergency department after a syncopal episode at work. Physical exam reveals an obese, unresponsive female with bilateral nonpalpable radial, carotid, and distal pedal pulses. Vital signs are as follows: T 37.3, BP 88/47. An emergent EKG is obtained and displayed in Figure A. Which of the following is the best next step in management?

A 55-year-old man is brought to the emergency room by EMS with the sudden onset of chest pressure, palpitations, and shortness of breath. He reports that he suffers from occasional chest discomfort, but this is the most severe it has ever been. His past medical history is significant for hypertension and diabetes mellitus. His cardiac monitor shows concerning ST segment changes and atrial fibrillation at 125 beats/minute. As IV access is being established, the patient becomes unresponsive. The resident is unable to palpate carotid or femoral pulses, but sees the that cardiac monitor still shows atrial fibrillation at the same rate. What is the next step in management?

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A 73-year-old female with a history of COPD and hypertension presents to the emergency room with a primary complaint of altered mental status. Her husband reports that the patient was suffering from worsening fatigue and a productive cough over the last several days. Chest radiographs in the emergency department suggest a diagnosis of pneumonia. Blood cultures are obtained and ultimately grow S. pneumoniae. The patient is admitted to the ICU for management of pneumonia and sepsis. During the course of her admission, thyroid function studies are ordered and show decreased levels of total serum T3 and T4, high-normal TSH, and increased levels of reverse T3. Which of the following is the most appropriate next step in management of this patient's abnormal thyroid function test results?

An 81-year-old man with a long history of type II diabetes presents with altered mental status. He is accompanied with his wife who reports that he has become confused over the past twelve hours and has been complaining of thirst. She also notes that he has hardly been urinating. Initial assessment in the ER reveals blood pressure of 90/62 and heart rate of 124 but no fever. The patient is lethargic but has no other pertinent findings on his physical examination. Initial labs reveal a serum glucose of 720 mg/dL. What would be an additional cardinal feature of this clinical syndrome?

A 45-year-old Spanish-speaking man with type II diabetes mel...

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A 58-year-old African-American male is scheduled to undergo a cardiac treadmill stress test in 2 weeks. His family physician recommended the test, as the patient would like to begin a new exercise program in order to begin training to run a half-marathon later this year. His past medical history includes hypertension, which has been well-controlled with amlodipine, hyperlipidemia, for which he is taking simvastatin, and non-insulin dependent diabetes treated with metformin. His history is negative for prior myocardial infarction, heart failure, angina, or any form of coronary artery disease. Which of the following instructions should be given to the patient regarding his upcoming stress test?

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A 42-year-old Caucasian woman is enrolled in a randomized co...

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A 36-year-old G3P2 at 13 weeks’ gestation presents to the em...

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A 36-year-old woman with a long history of a heart murmur presents with one week of increasing fatigue and low-grade fevers. She had a dental cleaning two weeks ago. She denies any hematuria, neurological symptoms, or changes in the appearance of her hands and fingernails. Her past medical history is otherwise insignificant. On physical exam, her temperature is 38.1 C (100.6 F), heart rate is 92/min, blood pressure is 118/67, and respiratory rate is 16/min. She appears fatigued but in no acute distress. Cardiac auscultation reveals a III/VI holosystolic murmur best heart at the cardiac apex in the left lateral decubitus position. Pulmonary, abdominal, and extremity exams are within normal limits. An echocardiogram is performed and is shown in Figure A. The patient is started on empiric IV vancomycin and gentamicin. Three days later, 4/4 blood cultures grow Streptococcus viridans that is highly sensitive to penicillin. What is the next best step in management?

A 21-year-old male is brought to the local Level 1 Trauma Center by ambulance following an assault. Emergency medical services reports that he has been stabbed in the left chest wall. His temperature on arrival is 99.5°F (37.5°C), blood pressure is 80/35 mmHg, pulse is 100/min, respirations are 34/min, and oxygen saturation is 91% on high flow face mask oxygen. On exam, you note that the patient follows commands and is asking for his mother, his lungs are clear to auscultation, his heart sounds are muffled, and his neck veins are distended. FAST ultrasound is performed at the bedside. Of the following options, which is the next appropriate step in management?

A 38-year-old male arrives to the trauma center following a motor vehicle accident in which he was a restrained passenger. He denies any loss of consciousness. He is agitated and wants to go home. He has a Glasgow Coma Scale of 15. His vital signs are T 36.8, HR 125, BP 88/60, RR 29, and O2 98% on room air. His physical exam is only remarkable for ecchmyoses in the right and left upper quadrant of the abdomen and capillary refill of 4 seconds. Urine drug screen is positive for alcohol and marijuana. Which is the most appropriate first step in the management of this patient?

A 28-year-old Caucasian female presents to her primary care physician complaining of a one-week history of fatigue, progressively worsening shortness of breath, and swelling of her feet and ankles. She denies any chest pain. Her past medical history is unremarkable except for a recent cold two weeks prior to this presentation. She denies any past surgical history. She takes oral contraceptive pills as her only medication. She denies any recreational drug use. On physical exam, her temperature is 37 C (98.6 F), blood pressure is 120/70 mmHg, pulse is 84/min, and respiratory rate is 20/min. Her physical exam is also notable for bibasilar crackles, jugular venous distension, an S3 gallop, and 2+ pitting edema up to the ankles bilaterally. Her electrolytes and complete blood count are within normal limits. Transthoracic echocardiogram of her heart will likely show which of the following?

A 4-year-old boy is brought in by his grandmother for worsening seizure activity. She reports that whenever he runs around he “suddenly drops.” She reports that his first seizure occurred one year ago. Since then, he was put on valproic acid, but the seizure activity remains unchanged. The grandmother also notes that due to her own recent fall, she could no longer care for the patient while his mother was at work, so he was enrolled in daycare. Since then, the seizure activity has increased, and the daycare facility also noted concerns over his lack of response to voice commands. Family history is significant for a cousin who died suddenly at a young age. An EEG is performed, which is unrevealing. An EKG is show in Figure A. During the physical exam, you note that the patient does not look towards the sound when you snap your fingers in his left ear. While you are documenting exam findings, a nurse walks into the room, which startles the patient and he suddenly loses consciousness. An EKG is quickly performed and is shown in Figure B. An electrolyte panel is drawn with the following findings: Serum: Na+: 142 mEq/L Cl-: 88 mEq/dL K+: 3.4 mEq/L HCO3-: 24 mEq/L BUN: 11 mg/dL Glucose: 67 mg/dL Creatinine: 0.6 mg/dL Mg2+: 1.7 mg/dL What is the next best step in management?

A 37-year-old female presents to the general medical clinic with chest pain. She reports that the pain occurs at rest and feels as if an elephant is sitting on her chest. She has no other complaints. Her past medical history is significant for migraines but she has no history of smoking, hypertension, hyperlipidemia, or diabetes. Her vital signs are temperature 37 degrees Celsius, HR 70/minute, BP 110/80, RR 16/min, and oxygen saturation 99% on room air. Her physical examination reveals no murmurs. An EKG in the office during one of the episodes reveals the following as shown in figure A. Troponins are positive. She is admitted to hospital and undergoes emergent cardiac catheterization, where she is without obstructive coronary disease, but her symptoms can be provoked with administration of intravenous ergonovine. Which of the following treatments would be appropriate in this patient?

A 34-year-old woman comes to your office with complaints of ear pain that is aggravated with chewing. On exam, you note a "knocking" sound when the jaw is opened. Which of the following is commonly identified in the history of these patients?

A 5-year-old male presents to the pediatrician with a 10-day...

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