A 56-year-old Caucasian male presents to your office for a routine check-up.  He complains of chronic cough, fatigue, and occasional headaches.  He has longstanding hypertension, which is controlled with amlodipine and lisinopril.  Three months ago, he was diagnosed with acute bronchitis and treated with a short course of antibiotics.  He smokes one pack of cigarettes daily and consumes alcohol occasionally.  He denies any recreational drug use.  His family history is significant for prostate cancer in his father and renal cell carcinoma in his uncle.  His blood pressure is 147/82 mmHg, pulse is 93/min, temperature is 36.7 C (98 F), and respirations are 14/min.  His oxygen saturation is 94% on room air.  His BMI is 42 kg/m².  Physical examination is unremarkable.  His chest X-ray is normal.

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

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In three months, his repeat hemoglobin level is 19.0 g/dL.  His oxygen saturation in the office is 95% on room air.  His carboxyhemoglobin level is normal and serum erythropoietin level is elevated.  Iron studies and serum folate and vitamin B12 levels are all normal.  Urinalysis shows no blood, no RBCs, and trace protein.  Which of the following is the best next step in managing this patient?

A 52-year-old Caucasian woman comes to the office for a routine follow-up visit.  She complains of weakness and fatigue for the past two weeks.  She ‘feels tired’ even while doing minor household chores.  She denies fever or any changes in appetite or weight.  Three months ago, she underwent surgery for carcinoma of the breast and has been on chemotherapy ever since.  She is a retired nurse and lives at home with her husband.  She was diagnosed with hypertension twenty years ago.  Her current therapy includes cyclophosphamide, methotrexate, 5-flurouracil, ondansetron, atenolol and famotidine.  Her vital signs are within normal limits.  Examination is unremarkable, except for moderate pallor.  Rectal examination shows no abnormalities.  Her lab results reveal the following:

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The stool test for occult blood is negative.  Which of the following is most likely responsible for her condition?

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Which of the following is the most appropriate pharmacotherapy for this patient?

A 62-year-old hospitalized man is evaluated for new-onset, right lower extremity pain.  The patient underwent bypass surgery for 3-vessel coronary artery disease 2 months ago.  He arrived at the emergency department 2 nights ago due to recurrent chest pains.  At that time, ECG showed sinus rhythm with no ST-segment changes, but cardiac troponin I levels were elevated.  The patient was initiated on unfractionated heparin, antiplatelet agents, a beta blocker, and a nitrate.  A coronary angiogram was performed via the radial artery; it revealed graft insertion site stenosis and was treated with stenting.  Postintervention echocardiography revealed left ventricular ejection fraction of 50% with no regional wall motion abnormalities.  This morning, the patient had new, sudden-onset, right lower extremity pain.  He has never had pain in that extremity before.  The patient has a history of hypertension, hyperlipidemia, and type 2 diabetes mellitus.  Current medications include aspirin, clopidogrel, rosuvastatin, metoprolol, losartan, isosorbide mononitrate, basal-bolus insulins, and subcutaneous heparin at a prophylactic dose.  The patient is a former smoker with a 30-pack-year history.  Temperature is 37.6 C (99.7 F), blood pressure is 138/84 mm Hg, pulse is 96/min, and respirations are 18/min.  Physical examination reveals normal jugular venous pressure, clear lungs, no heart murmurs, and a soft, nontender abdomen.  The right leg is tender and cool to the touch when compared to the left leg.  Right lower extremity distal pulses are diminished, but capillary refill is intact.  Left leg examination is normal with the exception of healed scars from previous saphenous vein harvesting.  Neurological examination is normal.  Laboratory results are as follows:

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

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Analgesics and other supportive measures are provided, and vascular surgery is consulted.  Diagnostic studies are performed, but the results are pending.  Which of the following is the most appropriate next step in management of this patient?

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Immunoassay for heparin-induced thrombocytopenia antibody returns positive.  His condition improves with treatment.  Which of the following is the most accurate statement regarding heparin use and risk of recurrence of this patient’s current condition?

A 45-year-old woman comes to the emergency department due to worsening fatigue.  Today, the patient was so tired that she became short of breath doing household chores.  She has also had “spots” on her extremities and seems to bruise easily.  The patient has had no fever, night sweats, cough, chest pain, palpitations, or abdominal pain.  She has no chronic medical conditions and has had no recent cold or flu symptoms.  The patient takes no medications and does not use tobacco, alcohol, or recreational drugs.  Temperature is 38 C (100.4 F), blood pressure is 110/60 mm Hg, pulse is 92/min, and respirations are 16/min.  Physical examination shows moist mucous membranes, clear lung fields, and normal heart sounds.  The abdomen is soft and nontender with no hepatosplenomegaly.  Neurologic examination is within normal limits.  The extremities have no edema, but there are scattered petechiae and ecchymoses bilaterally.  Laboratory results are as follows:

Chest x-ray is normal.  A peripheral blood smear is shown in the exhibit.  First-line therapy for this patient’s condition exerts its effect through which of the following mechanisms?

A 43-year-old male presents to your office with several months history of progressive fatigue and occasional palpitations.  He had three episodes of acute respiratory infections over the last year; otherwise, his past medical history is insignificant.  He smokes two packs of cigarettes daily and consumes alcohol occasionally.  He is not taking any medications and denies drug abuse.  He has been sexually active with several partners recently.  The physical examination is insignificant.  His laboratory values are:

His HIV test results are negative.  Which of the following is the best next step in the management of this patient?

A 70-year-old woman comes to the office due to back pain, fatigue, and inability to carry out her daily work.  The pain began 6 months ago and has slowly intensified.  The patient had a hip fracture 3 months ago but has no other medical conditions.  She is a lifetime nonsmoker and drinks alcohol on social occasions.  She currently takes no medications.  The patient has no extremity weakness or paresthesia.  She has mild constipation; urination is normal.  Initial laboratory results are as follows:

Dipstick urinalysis is normal.

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

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The patient undergoes a bone marrow biopsy, which shows 20% plasma cells.  While discussing the options for further investigation and treatment, the patient says that, since her initial visit, she has had pain in her left shoulder and right flank after a minor fall.  Which of the following is the best next step in management?

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The patient is informed about the prognosis, potential risks, and benefits of therapy.  She declines treatment.  The physician documents their discussions and arranges for follow-up visits.  One month later, the patient is brought to the emergency department by family members due to acute-onset blurry vision, headache, confusion, and epistaxis.  A detailed history from the family members fails to identify any precipitating factor.  On examination, the patient is lethargic but arousable.  Scant gingival bleeding is noted.  The lungs are clear to auscultation; there is no peripheral edema.  Serum creatinine is 2.4 mg/dL.  Which of the following is the most likely cause of this patient’s acute change in status?

A 67-year-old woman comes to the emergency department due to sudden, severe low back pain that began after she lifted her grandson.  The pain does not radiate to the lower extremities, and the patient has had neither weakness nor sensory loss in her legs nor urinary incontinence.  The patient has been feeling tired lately; she has also had a poor appetite and lost 4.5 kg (10 lb) over the past several months.  Medical history includes osteoporosis diagnosed on screening DXA at age 65, for which she takes calcium and vitamin D daily and alendronate weekly.  The patient is a lifelong nonsmoker and drinks alcohol occasionally.  Blood pressure is 148/86 mm Hg and pulse is 96/min.  BMI is 21 kg/m².  On physical examination, tenderness to percussion is noted over the lower thoracic spine.  Bilateral lower extremity muscle strength, sensation, and deep tendon reflexes are normal.  Laboratory results are as follows:

Spine radiography reveals a T12 vertebral compression fracture.  In addition to analgesics, which of the following is the most appropriate next step in management of this patient?

A 60-year-old man comes to the clinic due to 2 months of fatigue.  He has also had an intermittent cough and fever, for which he takes ibuprofen.  The patient is otherwise healthy and takes no other medications.  He does not smoke cigarettes or drink alcohol.  Weight is 72.5 kg (160 lb), decreased from 79.4 kg (175 lb) 6 months ago.  Temperature is 38 C (100.4 F), and pulse is 110/min.  Cervical and axillary lymphadenopathy is present.  Cardiopulmonary examination is unremarkable.  The liver is palpable 4 cm below the costal margin.  Skin examination shows pallor but is otherwise unremarkable.  Complete blood count results are as follows:

Biopsy of a lymph node is shown in the exhibit.  Which of the following is the best next step in evaluation of this patient?

A 72-year-old woman is brought to the emergency department due to worsening generalized weakness.  The patient has had fatigue and an unintentional weight loss of 4.5 kg (9.9 lb) over the past month.  Outpatient evaluation revealed anemia, splenomegaly, and diffuse lymphadenopathy.  Lymph node biopsy and bone marrow aspiration biopsy 2 weeks ago established a diagnosis of high-grade B-cell lymphoma.  The patient has not yet started treatment.  Over the past 4 days, she has had increasing nausea, poor oral intake, weakness, and lethargy.  Medical history also includes hypertension and osteoporosis.  Temperature is 36.4 C (97.5 F), blood pressure is 116/68 mm Hg, pulse is 90/min, and respirations are 16/min.  BMI is 22 kg/m².  On physical examination, the patient appears frail.  Neck veins are flat.  Lung sounds are clear, and no cardiac murmurs are present.  The abdomen is nondistended, soft, and nontender.  Laboratory studies are as follows:

Renal function studies were within normal limits 2 weeks ago.  There is no hydronephrosis on renal ultrasonography.

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Which of the following is the best next step in evaluation of this patient’s renal dysfunction?

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The serum uric acid level is 13.3 mg/dL.  Which of the following is the best next step in management of this patient?

A 66-year-old woman comes to the office to have a lipoma removed from her elbow.  The lipoma does not cause her pain, but she does not like the way it looks when she wears sleeveless dresses.  Her other medical problems include hypertension and gastroesophageal reflux.  Review of systems is positive for 8 months of general malaise and fatigue, which the patient attributes to having started a more difficult Pilates routine.  Temperature is 37.2 C (98.6 F), blood pressure is 108/72 mm Hg, and pulse is 66/min.  Physical examination shows mild pallor and mobile, firm lymphadenopathy in her cervical and supraclavicular chains.  The jugular veins are not distended.  Cardiopulmonary and abdominal examinations are normal.  Her preoperative blood count is as follows:

Flow cytometry confirms the diagnosis.  Which of the following is correct about this patient?

A 66-year-old man is evaluated for fatigue and anorexia.  Examination shows splenomegaly and inguinal and axillary lymphadenopathy.  Excisional lymph node biopsy establishes the diagnosis of diffuse large B-cell lymphoma of germinal center B subtype.  Treatment with combination cytotoxic chemotherapy and rituximab is planned.  Pretreatment medical evaluation shows normal kidney function, and the patient receives rasburicase with chemotherapy.  Four days after treatment, laboratory results are as follows:

Which of the following best explains this patient’s laboratory findings?

A 55-year-old Caucasian male presents to your office complaining of easy fatigability.  He used to be physically active and always preferred to walk to work, which is five blocks away from where he lives.  Now he says, “Doc, I get short of breath when I walk even two blocks.”  He denies any palpitations, chest pain, cough, or lower extremity swelling.  He does not feel down and has no problems with sleep.  His past medical history is insignificant.  He is currently not taking any medications.  His blood pressure is 120/70 mm Hg and heart rate is 95/min.  The physical examination is significant for pallor of the conjunctivae and oral mucosa.  His laboratory values are:

Blood smear analysis shows microcytic erythrocytes with anisocytosis.  What is the best next step in the management of this patient?

A 29-year-old woman comes to the emergency department due to fever and headache for the last week.  The patient has a generalized tonic-clonic seizure while being evaluated.  Laboratory results are as follows:

Peripheral blood smear is shown in the exhibit.  Which of the following is the most likely underlying cause of this patient’s current condition?

A 54-year-old man with new-onset type 2 diabetes mellitus comes to the physician for his first screening ophthalmologic examination.  He has no eye symptoms and describes his vision as excellent.  He does not smoke.  His family history is significant for obesity and diabetes but negative for cancer.  Funduscopic examination shows a small, densely pigmented lesion with irregular borders in the peripheral right choroid.  The lesion is about 8 mm in diameter and is minimally raised (1 mm).  Comprehensive skin examination is unremarkable.

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Which of the following should be the next step in the management of this patient?

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The patient is lost to follow-up.  He returns 2 years later due to intermittent blurry vision.  His HbA_1c is 8.2%.  Repeat funduscopic examination shows that the pigmented lesion now measures 18 mm in diameter and its height is estimated at 4 mm.  Comprehensive skin examination is unremarkable.  Further evaluation shows no lesions beyond the right eye.  Which of the following is the best next step in the management of this patient?

A 45-year-old Caucasian female presents to your office with abdominal discomfort and distention that is especially bothersome after meals.  She has noticed recently that she gets tired more easily.  She feels “down”, but denies any sleep difficulty, crying spells and suicidal ideation.  She visited a doctor approximately one year ago due to similar complaints, and was told that the problem was psychological.  She underwent myomectomy for a large uterine fibroid 8 years ago.  She is not sexually active.  Her family history is significant for pancreatic cancer in her father and a thyroid disease in her mother.  The physical examination is significant for mild pallor of the conjunctivae.  The abdomen is somewhat distended with no palpable masses.  The laboratory values are:

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What is the best next step in the management of this patient?

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After taking the appropriate initial steps, you proceed with gastric endoscopy.  Which of the following findings is more likely to be present in this patient?