A 64-year-old man with heart failure comes to the office for follow-up.  The patient has shortness of breath on exertion, increasing fatigue, and can barely climb a flight of stairs without stopping to catch his breath.  He has no chest pain, cough, or palpitations.  Six years ago, the patient had a myocardial infarction, and 3 years ago, he had a cardiac catheterization with stent placement following an episode of chest pain.  His other medical problems include hypertension, hyperlipidemia, and type 2 diabetes mellitus.  The patient’s medications include carvedilol, sacubitril-valsartan, aspirin, furosemide, atorvastatin, dapagliflozin, and spironolactone.  He does not use tobacco, alcohol, or illicit drugs.  Blood pressure is 131/78 mm Hg, and pulse is 76/min and regular.  Physical examination shows scattered bibasilar crackles on chest auscultation and trace peripheral edema.  Laboratory results are as follows:

A recent echocardiogram showed left ventricular dilation with inferior wall hypokinesis, mild left ventricular hypertrophy, and left ventricular ejection fraction of 25%.  His ECG is shown here.  Which of the following interventions is most likely to improve this patient’s survival?

A 36-year-old woman comes to the office to discuss weight gain.  During her pregnancy 6 years ago, she gained a significant amount of weight that she found difficult to lose; since then, she has slowly gained additional weight.  She has no polyuria/polydipsia, visual disturbances, fatigue, or heat/cold intolerance.  The patient has no significant medical history and takes no medications.  She uses an intrauterine contraception device.  The patient consumes fast foods 2 or 3 times a week.  She does not use tobacco, alcohol, or recreational drugs.  Family history is significant for myocardial infarction in her father.  Blood pressure is 129/78 mm Hg and pulse is 76/min.  Waist circumference is 88 cm (35 in), and neck circumference is 38 cm (15 in).  BMI is 29 kg/m².  Examination shows scattered, pale stretch marks across the upper and lower abdomen.  The remainder of the physical examination, including cardiopulmonary, thyroid, abdominal, and neurologic, is unremarkable.

Item 1 of 2

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

Item 2 of 2

Initial test results are normal.  Following patient-centered lifestyle counseling, the patient begins a calorie-restricted, low-carbohydrate diet and an appropriate exercise regimen.  She returns to the office in 6 months for follow-up; although she has made some lifestyle changes, she has found it difficult to adhere strictly to the regimen and has lost no weight.  The patient has experienced intermittent back pain but otherwise feels well.  BMI is now 31 kg/m².  The patient requests more aggressive weight loss intervention.  In addition to continuing lifestyle counseling, which of the following is most appropriate?

A 32-year-old man comes to the physician with groin discomfort on his right side.  Two weeks ago, he discovered a lump in his right groin that “comes and goes” and soon after was diagnosed with an inguinal hernia at an urgent care clinic.  The patient’s past medical history is significant for psoriasis treated with topical agents.  He does not take oral medications or illicit drugs.  The patient drinks 2–3 beers daily and smokes a pack of cigarettes each day.  As a construction worker, he regularly lifts objects up to 30 lb (13.6 kg).  The patient’s mother died of ovarian cancer, and his father was recently diagnosed with prostate cancer.  Blood pressure is 128/81 mm Hg and pulse is 87/min.  Body mass index is 22.5 kg/m².  Physical examination is significant for scaly patches on his back and both knees.  A reducible hernia is palpated in the right groin.  Laboratory results are as follows:

Red blood cell distribution width is normal.  Which of the following is the best next step in evaluation of this patient?

A 24-year-old woman, gravida 1 para 0, comes to the office for an initial prenatal visit.  She has no cramping or vaginal bleeding.  This was an unplanned pregnancy.  The patient started combination oral contraceptive pills 2 years ago, when she began methotrexate and hydroxychloroquine therapy for rheumatoid arthritis.  Since then, she has had irregular menses that occur every 1-2 months and consist of 2-3 days of spotting.  Several months ago, while visiting family abroad, the patient ran out of and skipped several days of her contraceptive pills.  She resumed taking her oral contraceptives after her return.  However, she became concerned when she did not have a menstrual period for several months and took a home pregnancy test.  The patient has no other chronic medical conditions and has had no prior surgeries.  She started taking a folate supplement and prenatal vitamin when she found out she was pregnant.  The patient does not use tobacco, alcohol, or illicit drugs.  Blood pressure is 100/70 mm Hg.  BMI is 24 kg/m².  Pelvic examination reveals a 15-week-sized uterus with no adnexal masses or tenderness.  Initial laboratory results include the following:

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

A multiyear, federal, cross-sectional analysis is conducted evaluating trends in per capita spending on health care services among various segments of the US population.  The results indicate that per capita spending has increased each year and is significantly higher compared to that in other countries.  Further analysis indicates that one segment of the population consistently incurs disproportionately higher spending, as seen in the shaded area on the graph below.

Which of the following is likely to be most commonly found in the shaded population?

A 62-year-old woman comes to the office due to a 2-month history of muscle weakness.  She has a feeling of heaviness in her legs and has had moderate to severe muscle pain after walking.  She also reports, “My hands feel clumsy, and sometimes I need help turning door knobs and opening jars.”  On most days the patient goes to sleep at 9 PM and wakes up at 8 AM, but her sleep is disrupted several times a night due to a “pins and needles” sensation in both hands.  She has been ”feeling down” recently and has a history of depression treated with fluoxetine.  The patient has had no cough, chest pain, abdominal pain, diarrhea, diplopia, or urinary symptoms.  Medical history is also notable for hypertension, for which she takes hydrochlorothiazide.  She was also recently diagnosed with hyperlipidemia but is not on lipid-lowering therapy as she wants to “control it with my diet.”  The patient smoked a pack of cigarettes a day for 30 years but quit 4 years ago.  She drinks a glass of wine occasionally on weekends.  Blood pressure is 150/83 mm Hg and pulse is 62/min.  BMI is 31 kg/m².  There is no muscle tenderness, joint deformities, or skin lesions.  Laboratory results are as follows:

Additional testing is most likely to find which of the following in this patient?

A 36-year-old man comes to the office due to an itchy rash on his arms.  He has never had a rash like this before.  He denies any skin cream use or recent changes in soap or laundry detergent.  He has not had any recent travel.  His past medical history is significant for hypertension and kidney stones.  Current medications include amlodipine, which he has been taking for 6 months.  The examination findings are shown in the picture below.

Which of the following is the most likely diagnosis?

A 63-year-old man comes to the office due to leg swelling that started 2 weeks ago.  He had a respiratory infection 2 months ago that was treated with antibiotics.  The patient has had no rash, joint pain, fever, cough, abdominal pain, or diarrhea.  Medical history is significant for hypertension, for which he takes lisinopril and chlorthalidone.  He has not been taking any nonsteroidal anti-inflammatory medications.  The patient does not use tobacco, alcohol, or recreational drugs.  Blood pressure is 135/70 mm Hg and pulse is 95/min.  There is 2+ symmetric pitting edema of both lower extremities.  Physical examination is otherwise unremarkable.  Laboratory findings are as follows:

Urinalysis is significant for 4+ protein.  A 24-hour urine collection shows protein excretion of 11.5 g/day.  The risk for which of the following is most likely to be significantly increased in this patient?

A 45-year-old man comes to the office due to persistent weakness and fatigue for the past year.  He also reports poor concentration and decreased sex drive.  The patient has no history of serious illness and takes no medications.  He does not use tobacco or illicit drugs and drinks alcohol occasionally.  The patient works as a hospital phlebotomist and lives alone after a recent divorce.  His father died from complications of cirrhosis.  Temperature is 37 C (98.6 F), blood pressure is 126/70 mm Hg, and pulse is 80/min.  BMI is 34 kg/m².  Cardiopulmonary examination is normal.  The abdomen is nondistended, soft, and nontender with no hepatosplenomegaly.  Laboratory results are as follows:

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

A 67-year-old man comes to the emergency department due to 2 days of progressive shortness of breath and cough productive of white sputum.  The patient reports no fever, chills, hemoptysis, palpitations, or syncope.  His medical history is significant for chronic obstructive pulmonary disease with a recent FEV1 that was 68% of the predicted value.  The patient uses 2 L of supplemental oxygen at home via nasal cannula.  His current medications include a combination fluticasone and salmeterol inhaler, a tiotropium inhaler, and an albuterol inhaler as needed.  The patient no longer smokes but has a 50-pack-year history.  Temperature is 37.2 C (99 F), blood pressure is 165/95 mm Hg, and pulse is 116/min and regular.  His respiratory rate is 28/min, and oxygen saturation is 89% on 2 L oxygen via nasal cannula.  On examination, the patient is in moderate respiratory distress and using accessory muscle of respiration.  He is alert and cooperative.  Breath sounds are decreased bilaterally with diffuse wheezing and prolonged expirations.  Heart sounds are distant.  The abdomen is soft and nontender.  There is no peripheral edema.  A chest x-ray reveals hyperinflated lung fields without infiltrates.  The initial arterial blood gas on 2 L nasal cannula oxygen shows the following:

In addition to systemic corticosteroids, antibiotics, and nebulized bronchodilators, which of the following is the best initial treatment for this patient?

A 17-year-old girl is brought to the office due to recurrent sore throat.  The patient says, “I’m the lead in my school’s musical, and rehearsals are every day after school, so I’ve been singing a lot.  I’ve already tried lozenges and tea with honey, but nothing has helped with the pain.”  She drinks 2 or 3 beers on the weekends and does not use other recreational substances.  The patient is sexually active with her boyfriend and uses condoms.  Menstrual cycles are regular.  Family history is significant for lung cancer in her father.  The patient receives above-average grades in school.  Temperature is 37.2 C (99 F), blood pressure is 110/68 mm Hg, and pulse is 88/min.  On physical examination, redness of the pharynx without exudates and mild parotid gland swelling are present.  The remainder of the physical examination is unremarkable.

Item 1 of 2

This patient’s symptoms require additional history regarding which of the following?

Item 2 of 2

The patient eats more than she intends to several times a week, consuming large amounts of ice cream, cookies, and chips.  She is concerned about gaining weight and shares that she makes herself vomit after eating too much to maintain a stable weight.  Complete blood count, basic metabolic panel, and serum electrolyte levels are normal.  BMI is 20 kg/m², at the 15th percentile for age.  In addition to cognitive-behavioral therapy, which of the following pharmacologic options is indicated for this patient?

A 23-year-old woman is brought to the emergency department due to muscle cramps and generalized weakness.  She is a nursing assistant, has no medical history, and does not use recreational substances or alcohol.  The patient is hesitant when answering questions.  Temperature is 36.6 C (97.9 F), blood pressure is 110/70 mm Hg, and pulse is 108/min.  The patient is alert but appears anxious.  Cardiopulmonary and neurologic examinations are normal.  Serum electrolyte results are as follows:

Arterial pH is 7.48.  Measurement of which of the following would be most helpful for establishing the cause of this patient’s multiple electrolyte abnormalities?

A 43-year-old male presents to your office with a painful lesion on his right calf.  Initially, he thought it was a spider bite because of a small amount of pain and redness.  However, a couple of days later, the lesion got progressively larger.  He also notes feeling weak and feverish.  He lives in Connecticut and travels to Long Island frequently.  He denies any trauma.  He has no other medical problems.  He does not drink alcohol, smoke tobacco or use any illicit drugs.  Today his temperature is 38.1°C (100.5°F), blood pressure is 128/78 mmHg, and heart rate is 92/min.  The lesion is shown on the slide below.

Which of the following is the best initial antibiotic choice for this patient?

A 64-year-old woman comes to the emergency department due to back pain.  For the past week, she has had slowly worsening, nonradiating back pain.  She has no history of trauma to that area but has had intermittent fever and chills.  The patient has a history of hypertension, type 2 diabetes mellitus, and end-stage renal disease due to diabetic nephropathy.  She receives intermittent hemodialysis via a tunneled subclavian catheter, which was placed 2 months ago due to a failed arteriovenous fistula.  The patient also underwent mitral valve repair for mitral regurgitation 4 years ago.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 38.3 C (101 F), blood pressure is 130/80 mm Hg, pulse is 96/min, and respirations are 18/min.  Physical examination shows a normal central venous catheter site, clear lung fields, and no significant heart murmurs.  The abdomen is soft and nontender.  Spine examination is notable for focal tenderness over the lower thoracic vertebrae.  Neurologic examination shows normal motor strength of both lower extremities.  Sensation to light touch is decreased over both feet but deep tendon reflexes are normal.  Laboratory results are as follows:

Spine imaging reveals T12-L1 vertebral body destruction with disk-space narrowing; no epidural or paravertebral fluid collection is present.  The patient is hospitalized and intravenous antibiotics are started.  Two sets of blood cultures grow gram-positive cocci in clusters <24 hours after being drawn.  The central venous catheter is removed by interventional radiology.  Which of the following is the most appropriate next test for this patient?

A 46-year-old man comes to the office due to fatigue for the past 3 months.  Symptoms have progressed, and the patient now requires frequent daytime napping.  Medical history is significant for ulcerative colitis diagnosed 12 years ago and treated with mesalamine.  Surveillance colonoscopy a year ago was normal.  The patient has had no fevers, chills, abdominal pain, or dysuria; he has 1 or 2 loose bowel movements per day.  Blood pressure is 125/78 mm Hg, and pulse is 81/min.  Physical examination is unremarkable.  Laboratory results are as follows:

Which of the following tests is most likely to confirm the diagnosis in this patient?