A 52-year-old woman comes to the emergency department with left leg pain and swelling.  She is a commercial truck driver and first noticed the swelling 3 days ago.  The patient initially attributed the swelling to a long haul truck ride as she often gets mild “puffiness” of her ankles by the end of the day.  However, the swelling has persisted and now involves her entire left leg below the knee.  She has discomfort with walking but no chest pain, palpitations, syncope, or difficulty breathing.  The patient has a history of hypothyroidism and hypertension and takes levothyroxine and hydrochlorothiazide.  She has also been on menopausal hormone therapy using estrogen-progestin for intractable hot flashes.  She smokes a pack of cigarettes daily and drinks 2 beers each night.  Temperature is 37.2 C (99 F), blood pressure is 134/89 mm Hg, and pulse is 78/min.  BMI is 31 kg/m².  Extremity examination reveals a normal right leg and pitting edema and warmth over the left lower leg.  ECG shows normal sinus rhythm, and chest x-ray is normal with no infiltrates.  Serum creatinine level is 0.7 mg/dL.  Duplex ultrasound of the lower extremities reveals noncompressibility of the left popliteal and femoral veins.

Item 1 of 2

Which of the following is the best next step in management of this patient?

Item 2 of 2

The patient is started on rivaroxaban and scheduled to follow up with her primary care physician.  She is counseled on smoking cessation and agrees to enroll in a smoking cessation clinic.  The patient is also informed that her current menopausal hormone therapy (MHT) increases her risk of venous thromboembolism.  She is concerned about experiencing hot flashes again.  Which of the following is the most appropriate recommendation for treatment of this patient’s menopausal symptoms?

A 25-year-old man comes to the emergency department due to a sudden onset of left foot pain.  The pain started suddenly an hour ago, when he was sitting at his desk, and has progressed gradually.  He has no history of similar episodes or recent trauma to his left leg.  On review of systems, the patient admits to tiredness and some weight loss over the last 2 months, which he attributes to stress.  He has no significant medical history.  He is a college student.  The patient does not use tobacco, alcohol, or illicit drugs.  His mother was diagnosed with “a blood clot” after elective knee-replacement surgery.  Temperature is 37.2 C (99 F), blood pressure is 122/81 mm Hg, pulse is 86/min, and respirations are 14/min.  Examination shows clear lung fields and a regular rhythm, with a low-pitched diastolic murmur over the cardiac apex.  The abdomen is soft and nontender, with no palpable masses.  Examination of the extremities reveals adequate bilateral femoral pulses.  The left popliteal and dorsalis pedis pulses are absent.  The left foot appears pale and is cooler than the right.  Sensations on the left foot are intact, and the patient is able to voluntarily move the limb.  There is no tenderness on palpation of the lower left leg or foot.  Neurologic examination is within normal limits.  Which of the following is the most likely cause of this patient’s condition?

A 70-year-old woman is brought to the emergency department by her son for evaluation of shortness of breath.  She has had a sensation of choking since last night.  According to her son, for the past several weeks she has had a dry cough at night and has been taking over-the-counter cough drops.  The patient has had no chest pain, palpitations, back pain, abdominal symptoms, or lightheadedness.  She has a history of hypertension, hyperlipidemia, and type 2 diabetes mellitus.  She has been refusing statin therapy, as she heard statins cause multiple side effects.  The patient has also refused flu vaccinations over the last several years.  Her only hospital admission occurred 6 years ago when she underwent a spinal fusion for lower back pain.  She does not use tobacco, alcohol, or illicit drugs.  Family history is not significant.  Temperature is 36.1 C (97 F), blood pressure is 171/102 mm Hg, pulse is 92/min, and respirations are 34/min.  Pulse oximetry is 85% on room air.  BMI is 29 kg/m².  Bilateral crackles are heard on lung examination.  There are no heart murmurs.  ECG shows normal sinus rhythm, increased voltage in the precordial leads, and T-wave inversion in leads V5 and V6.  Chest x-ray is shown in the exhibit.  Oxygen is administered via 100% nonrebreather facemask.

Item 1 of 3

Which of the following is the most appropriate next step in management of this patient?

Item 2 of 3

The patient is placed on noninvasive positive pressure ventilation but still appears somewhat uncomfortable.  Laboratory results are as follows:

The first troponin I level is negative.  Repeat blood pressure is 176/105 mm Hg, pulse is 82/min, and respirations are 24/min.  Oxygen saturation is 94%.  What is the best next step in management of this patient?

Item 3 of 3

The patient is responding well to treatment.  The second troponin I level is negative.  Which of these tests is the most appropriate next step in management of this patient?

A 42-year-old man comes to the office due to a painless lump under the skin on his right upper back, which he first noticed 3 months ago.  He is incidentally noted to have a blood pressure of 180/110 mm Hg.  He has no symptoms.  The patient has no history of hypertension or other medical conditions and has not seen a physician since high school.  He takes no medications, does not use tobacco, and consumes 1 or 2 alcoholic beverages on weekends.  Family history is notable for hypertension in his mother and end-stage renal disease in a maternal uncle.  The patient exercised regularly until recently, when he started work as a supervisor at a warehouse.  He eats fast food at least 3 days a week.  Repeat blood pressure measurements after 15 minutes of rest are 180/105 mm Hg on the right arm and 185/110 mm Hg on the left.  Temperature is 36.7 C (98.1 F), pulse is 68/min, and respirations are 12/min.  BMI is 26.2 kg/m².  Cardiac examination reveals a diffuse and sustained apical impulse with normal heart sounds and no murmurs or gallops.  There is a 3-cm, soft, mobile, nontender, subcutaneous mass consistent with a lipoma in the right scapular region.  The remainder of the examination, including funduscopy, is normal.  Blood cell counts, serum electrolytes, serum creatinine, blood glucose, and urinalysis are within normal limits.  The ECG is shown in the exhibit.

Item 1 of 3

In addition to providing reassurance regarding the patient’s skin lesion, which of the following is the most appropriate next step in management?

Item 2 of 3

Which of the following is the best initial therapy for this patient?

Item 3 of 3

Which of the following additional tests is most appropriate for this patient?

A 28-year-old woman comes to the emergency department due to the abrupt onset of palpitations that started while she was watching television.  She says, “I suddenly started to feel like my heart was racing.”  The patient describes mild lightheadedness but no chest pain, shortness of breath, or syncope.  In the past, she has experienced similar episodes of palpitations that were nonsustained and terminated abruptly.  The patient has never sought medical care for these episodes and cannot identify any provoking factor.  She saw a physician for anxiety when she was a teenager but does not remember if she received any therapy.  The patient has no other medical problems and takes no medications.  She does not use tobacco, alcohol, or illicit drugs.  She jogs 2-3 miles a day.  The patient has no family history of coronary artery disease, cardiomyopathy, blood clots, or sudden cardiac death.  She appears mildly uncomfortable but not in any respiratory distress.  Temperature is 36.7 C (98 F), blood pressure is 100/60 mm Hg, pulse is 172/min, and respirations are 20/min.  Urine pregnancy test is negative.  ECG is shown in the exhibit.

Item 1 of 2

Which of the following is the most likely diagnosis?

Item 2 of 2

The patient receives antiarrhythmic therapy, and her pulse immediately decreases from 172/min to 68/min.  The palpitations resolve, and she states that she feels “normal now.”  Cardiac examination reveals no murmurs or additional sounds.  A 12-lead ECG is performed and is shown in the exhibit.  Which of the following is the most likely diagnosis?

A 70-year-old man comes to the hospital due to fever, lethargy, productive cough, and shortness of breath.  He has type 2 diabetes mellitus, hypertension, paroxysmal atrial fibrillation, and peripheral vascular disease.  His medications include warfarin, sotalol, insulin detemir, and lisinopril.  Chest x-ray shows infiltrates in the left lung base.  He is admitted and treated with azithromycin, ceftriaxone, and oxygen therapy.

Item 1 of 2

On the second day of hospitalization, he has 2 episodes of loss of consciousness associated with seizure-like activity.  The telemetry strips during one of these episodes is shown in the exhibit.  Which of the following is most likely to provoke a recurrent event in this patient?

Item 2 of 2

On examination, the patient is now awake and alert but oriented only to person.  His blood pressure is 120/70 mm Hg, pulse is 65/min, and respirations are 14/min.  Laboratory tests ordered 30 minutes before the first event are shown below.

Which of the following is the most appropriate next step in management of this patient?

A 60-year-old man undergoes imaging that reveals a 3.5-cm abdominal aortic aneurysm.  The finding is incidental; he has no associated symptoms.  Medical history is significant for hypertension, type 2 diabetes mellitus, hypercholesterolemia, and hypothyroidism.  Current medications include aspirin, metformin, glipizide, chlorthalidone, lisinopril, atorvastatin, and levothyroxine.  The patient has a 40-pack-year history and continues to smoke 1-2 packs a day.  He drinks 3 or 4 glasses of wine daily.  Blood pressure is 160/90 mm Hg and pulse is 80/min.  Cardiopulmonary examination is normal.  Laboratory results are as follows:

Which of the following interventions would most effectively decrease the likelihood of expansion of this patient’s aortic aneurysm?

A 51-year-old man comes to the office for a follow-up visit.  He has no concerns.  His medical conditions include type 2 diabetes mellitus, hypertension, and obesity.  The patient does not use tobacco, alcohol, or illicit drugs.  His mother and maternal grandfather also had diabetes.  His current medications include aspirin, glyburide, metformin, and lisinopril.  Blood pressure is 144/79 mm Hg and pulse is 88/min.  Weight is 120 kg (265 lb).  Examination shows no abnormalities.  Laboratory results are as follows:

Which of the following is the most appropriate therapy to prevent atherosclerotic cardiovascular disease in this patient?

An 80-year-old man is admitted to the cardiac care unit after undergoing a complicated percutaneous coronary intervention procedure.  He has chest discomfort and shortness of breath.  Blood pressure is 82/50 mm Hg and pulse is 114/min and regular.  Hemodynamic readings from the pulmonary artery catheter are shown below.

Which of the following is the most likely cause of this patient’s hypotension?