A 19-year-old man comes to the office due to worsening acne.  The patient initially had symptoms involving the face and started treatment with topical benzoyl peroxide and topical tretinoin, but he had no relief.  Over the past 2 months, the acne has spread to the back, causing local discomfort.  The patient is otherwise healthy.  He does not use tobacco, alcohol, or illicit drugs.  Vital signs are within normal limits.  Skin examination of the face, shoulders, and back reveal similar lesions as shown in the image below:

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

A 43-year-old woman, gravida 2 para 2, comes to the office for evaluation of heavy menstrual bleeding.  Previously, menses were every 30 days and lasted 3-4 days, with 1 day of heavier bleeding.  For the past 4 months, her periods have lasted 6-7 days, with heavy bleeding for 4 days requiring a thick pad every few hours.  The patient has also noticed intermenstrual bleeding.  She has no abdominal pain, weakness, or urinary symptoms.  Her medical problems include hypothyroidism, hypertension, and type 2 diabetes mellitus; all are currently controlled on oral medications.  Her last Pap test 2 years ago was normal, and she has no history of abnormal Pap results.  She is sexually active with one partner and had a bilateral tubal ligation.  The patient has no history of sexually transmitted infections.  Family history is significant for colon cancer in her mother at age 67.  The patient does not use tobacco, alcohol, or illicit drugs.  Blood pressure is 146/72 mm Hg and pulse is 62/min.  BMI is 35 kg/m².  Laboratory results are as follows:

Urine pregnancy test is negative.  Pelvic ultrasound reveals several uterine fibroids, the largest of which measures 6 cm in diameter.  Which of the following best addresses this patient’s condition?

A 46-year-old man comes to the office to follow up on his hypertension.  During an office visit a year ago, his blood pressure was 138/88 mm Hg, and lifestyle modification was advised.  The patient has been restricting dietary sodium, consuming more fruits and vegetables, and exercising regularly.  Since that time, his blood pressure has consistently been between 138/88 mm Hg and 142/92 mm Hg.  The patient has had no chest pain, shortness of breath, headache, dizziness, or focal weakness or numbness.  Two years ago, he experienced severe pain at the right great toe and was diagnosed with acute gout that responded to colchicine.  Since then, the patient reduced his alcohol intake and has had only one additional mild gout attack.  He has no other medical conditions and takes no medications.  Blood pressure today is 142/92 mm Hg in the right arm and 144/93 mm Hg in the left.  Temperature is 36.6 C (97.9 F), pulse is 76/min and regular, and respirations are 14/min.  BMI is 29 kg/m².  Neck veins are flat, the lungs are clear, and heart sounds are normal; abdominal examination reveals no abnormalities.  There is no edema in the lower extremities.  ECG shows normal sinus rhythm with no significant abnormalities.  Laboratory results are as follows:

Which of the following is the best initial pharmacotherapy for management of this patient’s hypertension?

A 65-year-old male is brought to the emergency room by ambulance for right lower quadrant abdominal pain and right groin pain for the past two hours.  He states that he was working in his garden when he suddenly felt a severe pain on his right side.  He went inside to lie down, but the pain persisted.  He is also feeling light-headed and short of breath.  He denies fever, chills, nausea, vomiting, chest pain, or diarrhea.  He has not noticed any blood in his stool or urine.  His past medical history is significant for atrial fibrillation, hypertension, and coronary artery disease.  Current medications include warfarin, lisinopril, metoprolol, and aspirin.  He is allergic to sulfa.  He does not smoke, and drinks alcohol socially.  Vital signs on arrival to the ER are temperature 36.5°C (97.7°F), pulse 110/min, respiratory rate 18/min, blood pressure 89/52 mmHg, and oxygen saturation 94% on 2 liters oxygen via nasal cannula.  On examination, he appears to be in mild distress and is fatigued.  Heart sounds are normal except for tachycardia.  Lungs are clear to auscultation bilaterally.  The abdomen is soft and nondistended.  There is pain to palpation in the right lower quadrant, but no rebound tenderness.  There is severe pain in the right lower quadrant upon flexion of the right hip.  There is no calf tenderness or lower extremity edema.  Laboratory studies show:

A urinalysis is normal and an ECG shows atrial fibrillation with a ventricular rate of 112/min.

Item 1 of 2

What is the best initial diagnostic test for this patient’s condition?

Item 2 of 2

The diagnosis is confirmed after the appropriate diagnostic test is done.  After 2 liters of normal saline are given, repeat vital signs are temperature 36.8 C (98.2 F), blood pressure is 103/62 mm Hg, pulse 95/min, and respirations are 16/min.  The patient continues to have moderate pain in the right lower quadrant.  Which of the following is the best next step in management?

An 82-year-old woman, who resides in a nursing home, is brought to the emergency department with cough, wheezing, and mild shortness of breath.  Medical history is significant for hypertension, hyperlipidemia, coronary artery disease, chronic obstructive pulmonary disease, and right knee osteoarthritis.  The patient had a coronary artery stent placed 10 years ago and a left-sided carotid endarterectomy 7 years ago after an episode of transient aphasia.  Surgical history is also significant for cholecystectomy.  Temperature is 37.2 C (99 F), blood pressure is 142/87 mm Hg, and pulse is 98/min.  Chest x-ray reveals dense left lower lobe consolidation.  The patient is admitted to the hospital and treated with broad-spectrum antibiotics and fluids.  A Foley catheter is placed for a day and then removed.  On the third day of hospitalization, the patient feels better; her cough has decreased in intensity, and her breathing has improved.  However, she feels weak and mildly dizzy when she moves from the bed to a chair.  She tolerates oral feedings with no difficulties but also has mild nausea and 2 or 3 episodes of loose stools.  On the fourth day of hospitalization, she is lethargic.  Current temperature is 38.3 C (100.9 F), blood pressure is 122/78 mm Hg, and pulse is 110/min and regular in rhythm.  Leukocytes are 28,000/mm³ (13,000/mm³ on admission), and platelets are 550,000/mm³ (230,000/mm³ on admission).

Item 1 of 2

Which of the following is the most likely finding on physical examination of this patient?

Item 2 of 2

Over the next 5 hours, the patient becomes hypotensive and requires high-volume intravenous fluid resuscitation.  She is transferred to the intensive care unit for further management.  Which of the following would be the most appropriate next step in diagnosing the cause of this patient’s deterioration?

A 68-year-old man comes to the office for a routine follow-up visit.  He has had mild fatigue but no chest pain, shortness of breath, or palpitations.  The patient has a history of hypertension, type 2 diabetes mellitus, hyperlipidemia, coronary artery disease, and chronic kidney disease.  He underwent coronary artery bypass surgery 10 years ago.  The patient says, “I regularly check my blood pressure and fingerstick glucose at home.  My blood pressure used to be much higher.”  Current medications include aspirin, metoprolol, lisinopril, diltiazem, empagliflozin, insulin glargine, atorvastatin, sevelamer, and calcitriol.  Blood pressure is 124/73 mm Hg and pulse is 78/min.  BMI is 20.5 kg/m².  There is no jugular venous distension.  The lungs are clear and no abnormal heart sounds are present.  Laboratory results are as follows:

Estimated glomerular filtration rate (GFR) is 20 mL/min/1.73 m².  Over the past year, the patient’s serum creatinine level has been 3.5-4.3 mg/dL and estimated GFR 17-25 mL/min/1.73 m².  The level of proteinuria is determined to be 1.2 g/day.  Which of the following is currently the best recommendation for this patient?

An 87-year-old female presents with two days of cough, fever, and mild shortness of breath.  On review of systems, she also notes several months of fatigue.  Her past medical history is significant for hypertension, chronic back pain, and a stroke two years ago without residual neurologic deficits.  She does not smoke or consume alcohol.  Her temperature is 38.3°C (101°F), blood pressure is 143/92 mmHg, and heart rate is 94/min.  Examination reveals coarse rhonchi over the right lower lobe.  Laboratory studies show:

Which of the following is most likely to reveal the cause of this patient’s anemia?

A 61-year-old man comes to the emergency department (ED) following 2 weeks of progressive, exertional shortness of breath.  He also reports significant weight loss with reduced appetite over the past 3 months.  The patient has no known medical problems and has never seen a primary care physician.  He lives alone in a single-bedroom apartment.  The patient has smoked a pack and a half of cigarettes daily for the past 42 years.  Family medical history is notable for breast cancer in his mother.  Vital signs are normal other than an oxygen saturation of 92% while breathing ambient air.  On physical examination, there is dullness to percussion as well as decreased breath sounds over the right mid-lower chest.  A chest x-ray confirms the presence of a large right-sided pleural effusion.  A thoracentesis is performed, and 1.5 liters of yellowish fluid are obtained.  Pleural fluid analysis reveals an exudative effusion containing adenocarcinoma cells.  The patient symptomatically improves after the procedure with full reexpansion of his lung.  A subsequent CT scan of the chest shows a 5-cm mass in the right upper lobe with regional adenopathy, pictured below.

The patient is discharged home with close outpatient follow-up.  He comes again to the ED 2 weeks later with similar symptoms after missing his outpatient appointment.  A chest x-ray reveals reaccumulation of the pleural effusion.  Which of the following is the most appropriate treatment option for this patient’s pleural effusion?

A 45-year-old man comes to the emergency department due to 10 days of exertional shortness of breath and dry cough.  The patient has also lost weight over the last 2 months despite no changes in dietary or exercise habits.  He has had no hemoptysis, orthopnea, abdominal pain, or diarrhea.  The patient is a former intravenous drug user and is currently in a methadone program.  He was diagnosed with HIV infection several years ago but has never received antiretroviral therapy.  He also has chronic hepatitis C infection.  The patient is homeless.  His last emergency department visit was 2 months ago for a skin infection on his right foot, which was treated with a short course of antibiotics.  He smokes a pack of cigarettes daily and consumes hard liquor at least twice a week.  Temperature is 37.9 C (100.3 F), blood pressure is 110/70 mm Hg, and pulse is 120/min.  Oxygen saturation is 93% on 2 L oxygen by nasal cannula.  BMI is 17.5 kg/m².  Oropharyngeal examination shows moist mucous membranes, poor dentition, and white patches on the buccal mucosa.  There is palpable anterior cervical lymphadenopathy.  Lung auscultation reveals scattered crackles bilaterally.  The abdomen is soft and nontender.  The liver edge is palpated 3 cm below the right costal margin.  No peripheral edema is present.  Chest x-ray is shown in the exhibit.  ECG shows sinus tachycardia with no significant ST-segment or T-wave changes.

Item 1 of 2

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

Item 2 of 2

The microbial etiology of this patient’s condition is confirmed by appropriate testing.  His leukocyte count is 2,600/mm³, hemoglobin is 9.8 mg/dL, and platelet count is 128,000/mm³.  The results of which of the following tests would most likely impact the management of the patient’s infection at this time?

A 64-year-old man comes to the office with a 3-month history of cough that is mostly dry but occasionally produces whitish phlegm.  He has no fevers, chills, night sweats, or chest pain.  The patient reports a 4.5-kg (10-lb) weight loss over the last 2 or 3 months.  His medical history is significant for Hodgkin lymphoma treated with combination chemotherapy 5 years ago.  He also has hypertension, type 2 diabetes mellitus, and hyperlipidemia.  The patient’s current medications are hydrochlorothiazide, metoprolol, lisinopril, metformin, pioglitazone, and atorvastatin.  He has a 20-pack-year smoking history but quit 7 years ago.  Blood pressure is 124/89 mm Hg and pulse is 67/min.  BMI is 23 kg/m².  On physical examination, no peripheral lymphadenopathy, skin rash, or joint deformity is present.  Breath sounds are decreased over the left mid lung field.  Chest x-ray is shown below.

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

A 53-year-old man comes to the office due to upper abdominal discomfort that has been steadily worsening over the past 2 months.  The discomfort is constant and dull and radiates to the back.  The patient has had no vomiting or diarrhea and has lost 7 kg (15.4 lb) since symptoms began.  He has no chronic medical conditions and has never had similar symptoms.  The patient has a 40-pack-year history and drinks 1 or 2 beers most days.  He has a remote history of injection drug use.  Diet consists mostly of fast food and processed meats.  He has worked in a rubber factory for the past 10 years.  CT scan of the abdomen with intravenous contrast is shown below.

Which of the following is the strongest risk factor for this patient’s current condition?