A 30-year-old man comes to the clinic due to a skin rash and itching involving his hands, wrists, and forearms.  The itching is worse at night and is only mildly relieved with over-the-counter antihistamines.  He has not changed soaps recently and does not use hand cream.  He states that his wife had a similar rash a while ago.  The rash is shown below.

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

A 37-year-old woman comes to the office for follow-up of type 1 diabetes mellitus, which was diagnosed 17 years ago.  Because of the recent development of proteinuria, the physician recommends improved glycemic control.  The patient declines an insulin pump and continuous glucose monitoring but is open to adjustments to her insulin regimen, which consists of 20 units of insulin glargine at night and 4-5 units of insulin lispro before each meal.  She regularly eats 3 meals a day.  Medical history is otherwise unremarkable, and her other medication is lisinopril.  The patient is not sexually active and has no plans to be pregnant in the near future.  Her recent self-measured blood glucose diary is as follows:

Hemoglobin A1c performed 3 weeks ago was 7.7%.  Which of the following is the best next step in adjusting this patient’s insulin regimen?

A 3-year-old girl is brought to the emergency department after telling her mother that she swallowed a coin.  Her mother is unsure when she ingested it.  The child has been eating and drinking well and has no symptoms.  She is afebrile; pulse is 100/min and respirations are 25/min.  Oxygen saturation is 98% on room air.  Examination shows no drooling or coughing.  The lungs are clear to auscultation bilaterally.  Chest x-ray is shown in the images below:

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

A 76-year-old male with mild dementia comes to the emergency department because of intermittent abdominal cramps and decreased appetite for the last 12 hours.  He could not sleep last night and had one episode of vomiting.  His past medical history is significant for hypertension, type 2 diabetes mellitus, hyperlipidemia, and atrial fibrillation.  His current medications include warfarin, digoxin, and metformin.  On physical examination, his blood pressure is 110/80 mmHg and his heart rate is 90/min and irregular.  The abdomen is distended, with high-pitched bowel sounds.  You palpate a small, tender mass in the right groin.  Laboratory studies show:

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

A 58-year-old woman comes to the office to discuss hypercalcemia.  She was recently seen at a local urgent care center for an uncomplicated urinary tract infection, at which time her serum calcium level was 10.6 mg/dL.  The patient was given a prescription for an antibiotic and advised to follow up with her primary care physician to discuss additional evaluation.  She has not experienced excessive urination, weight change, abdominal pain, loss of height, bone pain, or constipation.  Although she reports feeling ”anxious” sometimes, she has had no panic attacks or depressed mood.  Medical history is significant for hypertension and asthma, for which she takes lisinopril and a fluticasone inhaler.  The patient also takes a daily calcium and vitamin D supplement.  Family history is negative for cancer, thyroid disease, parathyroid disease, and osteoporosis.  The patient experienced menopause at age 51.  She walks about 2-3 miles per day.  Blood pressure is 134/90 mm Hg and pulse is 80/min.  Examination shows no palpable masses in the neck.  Follow-up laboratory results are as follows:

DXA shows a T-score of −0.5 at the lumbar spine, −0.2 at the femoral neck, and −0.5 at the distal radius.  Renal ultrasound is normal.  Which of the following statements is the most appropriate advice for this patient?

A 9-month-old boy is brought to the emergency department for evaluation of right leg pain.  The mother reports that 2 days ago the infant was sitting on the floor when his 18-month-old sister jumped off the couch and landed on his leg.  She says that her son has been crying and refusing to crawl since the incident.  The patient was born at term via vacuum-assisted vaginal delivery complicated by a large cephalohematoma and neonatal jaundice.  He received phototherapy and was discharged home on day of life 5.  When his sister was age 14 months, she had multiple finger fractures on her left hand but has otherwise been healthy.  Family history is noncontributory.  Temperature is 37.2 C (99 F), blood pressure is 98/66 mm Hg, pulse is 116/min, and respirations are 24/min.  On examination, the patient is fussy and crying.  Bilateral pupils are 4 mm and briskly reactive.  A 1-cm irregular café-au-lait macule is seen on the chest.  Two smaller café-au-lait macules are also seen on the lower back.  The abdomen is soft, nontender, and nondistended.  The right mid-thigh is swollen and tender to palpation but not tense.  Dorsalis pedis and posterior tibialis pulses are intact.  A radiograph of the femur is shown below:

The fracture is splinted and the infant is given appropriate analgesia.  Which of the following is the most likely underlying diagnosis?

A 54-year-old woman comes to the office for follow-up after a non-ST elevation myocardial infarction 3 weeks ago.  Percutaneous coronary angiography was performed at that time and a stent was placed in the patient’s right coronary artery.  She was discharged home 2 days later.  An echocardiogram performed before discharge revealed a left ventricular ejection fraction of 45%.  The patient has attended cardiac rehabilitation since discharge.  She has had no recurrent chest pain or shortness of breath in that time and currently feels well.  Other medical issues include hypertension and type 2 diabetes mellitus.  Temperature is 37 C (98.6 F), blood pressure is 119/78 mm Hg, pulse is 72/min, and respirations are 16/min.  Lungs are clear to auscultation.  Heart sounds are normal with no murmurs.  There is no peripheral edema.  Prior to her myocardial infarction, the patient worked as a secretary at a law firm; she asks if it is safe to return to work.

Item 1 of 2

Which of the following is the most appropriate response to the patient’s question?

Item 2 of 2

Review of the patient’s current medications shows that she was discharged on metformin, metoprolol, lisinopril, simvastatin, clopidogrel, and aspirin.  Laboratory results obtained during the current visit are as follows:

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

A 38-year-old man comes to the office due to elevated blood pressure, which was 140/90 mm Hg at his dentist’s office.  He has no history of hypertension.  The patient drinks 2 or 3 cups of coffee every day and 1 or 2 beers every night, and eats processed and canned food most days of the week.  He usually goes to bed at 12:00 AM and wakes up at 7:00 AM.  The patient is a computer programmer and has a sedentary lifestyle.  Blood pressure is 136/86 mm Hg in the right arm and 136/87 mm Hg in the left.  BMI is 29 kg/m².  Physical examination shows no abnormalities.  Laboratory results are as follows:

ECG shows no abnormalities.  In addition to increasing physical activity, which of the following will best address the elevated blood pressure in this patient?

A 29-year-old man comes to the emergency department due to chest pain and mild shortness of breath.  He started to experience shortness of breath yesterday afternoon and developed left-sided chest pain last night.  The chest pain worsens when the patient coughs or takes a deep breath.  Five months ago, he was diagnosed with a nonseminomatous germ cell tumor of the left testicle with metastases to the ipsilateral retroperitoneal lymph nodes.  He underwent a left radical orchiectomy with retroperitoneal lymph node dissection, and 3 months ago completed bleomycin-containing chemotherapy.  He has no other medical history and currently takes no medications.  Temperature is 37.8 C (100 F), blood pressure is 152/95 mm Hg, pulse is 112/min, and oxygen saturation is 91% on room air.  BMI is 22 kg/m².  Examination reveals decreased breath sounds and dullness to percussion at the left lung base.  Leukocytes are 9,000/mm³ with 72% neutrophils.  ECG shows sinus tachycardia.  CT scan of the chest is shown below.

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

A 52-year-old man comes to the office due to 2 months of progressive fatigue, decreased appetite, and increased abdominal girth.  He has lost 3 kg (6.6 lb) over this period.  The patient has a history of untreated chronic hepatitis B, and a liver biopsy 5 years ago showed mild portal inflammation with minimal fibrosis.  Medical history is also significant for an episode of acute pancreatitis 5 years ago secondary to alcohol consumption.  He stopped drinking alcohol 2 years ago but continues to smoke one pack of cigarettes per day.  The patient takes no medications.  Examination shows an enlarged liver and trace ankle edema.  Laboratory results are as follows:

Abdominal ultrasound reveals a 3-cm lesion in the right hepatic lobe.  Which of the following is the most likely origin of the lesion?

A 62-year-old African American male presents to the emergency department with a one week history of weakness, nausea, and cough productive of yellowish sputum.  He denies any chest pain.  He has also noticed some decrease in his exercise tolerance as well as ankle puffiness.  His past medical history is significant for hypertension, hyperlipidemia, type 2 diabetes mellitus, gout, and chronic kidney disease.  Medications include daily aspirin, insulin, simvastatin, furosemide and lisinopril.  During his last office visit, he agreed to have an arteriovenous fistula formed in his arm in preparation for chronic dialysis.  He has smoked one pack of cigarettes per day for the past fifteen years.  His blood pressure is 165/100 mmHg, heart rate is 90/min, and oxygen saturation is 93% on room air.  Bibasilar crackles are heard on lung auscultation.  His ECG is shown on the slide below.

Which of the following best explains the ECG findings in this patient?

A 3-month-old boy is brought to the emergency department due to worsening cough.  He was taken to the office 2 weeks ago due to cough and rhinorrhea.  The rhinorrhea resolved, but the cough has become more severe.  The patient’s father states, “It has become so harsh that his face turns blue, and he seems to be struggling to breathe.”  Some of the coughing episodes are followed by vomiting.  The patient’s parents are well, but his 16-year-old babysitter developed a mild cough about a week before he did.  He was born at term and has been otherwise healthy.  Temperature is 36.7 C (98.1 F), pulse is 124/min, and respirations are 28/min.  Oxygen saturation is 98% on room air.  The patient appears awake and alert but fussy.  The lungs are clear to auscultation without wheezing or rales.  Cardiac examination is normal.  There is no cyanosis.  Chest x-ray is unremarkable.  Complete blood count results are as follows:

Testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is negative.  Which of the following is the most appropriate therapy for this patient?

A 53-year-old woman comes to the office due to menopausal symptoms.  The patient has had no menstrual periods in over a year and is suffering from insomnia, hot flashes, and night sweats.  The hot flashes frequently happen at work, and she has to leave the room and “get some fresh air,” even during important meetings.  She also describes anticipation anxiety and says that the symptoms affect her work productivity and concentration.  The patient tried over-the-counter herbal supplements but did not experience any easing of symptoms.  Medical history is notable for hypertension and hypercholesterolemia, for which she takes valsartan, amlodipine, and rosuvastatin.  She also had a tubular adenoma removed during a screening colonoscopy 3 years ago.  Surgical history includes a cholecystectomy and appendectomy.  The patient does not smoke and has no history of stroke or coronary heart disease.  Her mother died of breast cancer at age 75, and her father died from complications of a stroke at age 80.  Mammogram and Pap test were normal a year ago.  Blood pressure is 132/80 mm Hg and pulse is 72/min.  BMI is 24 kg/m².  Physical examination is unremarkable.  Laboratory results are as follows:

The patient requests menopausal hormone therapy (MHT) to relieve her hot flashes and night sweats and would like to discuss the possible effects of treatment.  After discussing potential risks and benefits with the patient, which of the following is the most appropriate statement?

A 62-year-old man comes to the office for a routine preventive visit.  He feels well and has no symptoms.  Medical history is significant for hypertension, coronary artery disease, heart failure with reduced ejection fraction, and gastroesophageal reflux disease.  The patient had coronary artery bypass surgery 3 years ago and has had no recurrent chest pain or dyspnea.  Current medications include lisinopril, metoprolol, furosemide, aspirin, atorvastatin, and omeprazole.  He does not use tobacco, alcohol, or recreational drugs.  The patient gets a yearly influenza vaccination and received a pneumococcal conjugate vaccine (PCV20) and a tetanus–reduced diphtheria–acellular pertussis vaccine at age 60.  Colonoscopy 5 years ago revealed no polyps.  Blood pressure is 132/81 mm Hg, pulse is 62/min, and respirations are 14/min.  BMI is 30 kg/m².  Examination findings include moist mucous membranes, normal jugular venous pressure, normal first and second heart sounds, and clear lung fields.  There is no peripheral edema.  Laboratory results are as follows:

Which of the following is recommended for this patient?

A 5-month-old boy is brought to the emergency department due to 9 days of fever.  He has been irritable and has had a decreased appetite.  His mother states that he had a runny nose before the onset of fever.  This has since resolved, but his eyes have been erythematous for the past 2 days.  He has had no emesis or diarrhea.  The patient was born at full term after an uncomplicated pregnancy, and his height and weight have remained at the 50th percentile.  Immunizations are up to date.  He has no past illnesses and takes no medications.  There is no history of recent travel, and his close contacts have had no similar symptoms.  Temperature is 39.4 C (103 F), blood pressure is 100/70 mm Hg, pulse is 128/min, and respirations are 20/min.  On physical examination, he is awake and alert but fussy.  The anterior fontanelle is open and flat.  The pupils are equal and reactive to light and accommodation, and the conjunctivae are erythematous without discharge.  There is no rhinorrhea and the pharynx appears normal.  Lungs are clear to auscultation bilaterally.  S1 and S2 are normal without murmurs.  The abdomen is soft, nontender, and nondistended with no organomegaly.  There is a blanching, erythematous macular rash on the extremities.  The feet are edematous bilaterally but are nontender with normal range of motion.  Laboratory results are as follows:

Which of the following is the most likely explanation for this patient’s condition?

A 36-year-old Caucasian female comes to clinic complaining of right thigh pain that began after she bumped into a table.  Since then, her right thigh has become progressively more swollen and tender.  She denies any fever, chills, chest pain, abdominal pain, joint pain, or urinary symptoms.  Her past medical history is significant for hypothyroidism controlled with levothyroxine.  She had a laparoscopic cholecystectomy two years ago without complication.  She does not take any other medications.  There is no family history of bleeding disorders.  Her temperature is 36.7°C (98°F), blood pressure is 124/82 mm Hg, and heart rate is 78/min.  On physical examination, there are scattered bruises over her trunk and lower extremities.  Laboratory studies show the following:

Which of the following most likely accounts for this patient’s condition?