A 52-year-old man comes to the office due to progressive insomnia over the past 2 weeks.  The patient has had difficulty concentrating during this period and is worried that he may be unable to complete some work projects on time.  His wife also reports that he has been more irritable and agitated, particularly over the last few days.  The patient has been taking his wife’s temazepam to help him sleep; nevertheless, the insomnia has not improved.  Three years ago, the patient was diagnosed with cirrhosis due to nonalcoholic steatohepatitis.  He has no history of hepatic encephalopathy or esophageal varices.  Two months ago, ultrasonography of the abdomen revealed moderate ascites and no liver masses; the patient was prescribed furosemide and spironolactone.  He also has a history of obesity, hyperlipidemia, and type 2 diabetes mellitus, which improved after gastric banding surgery 3 years ago.  The patient does not use tobacco, alcohol, or recreational drugs, and he maintains a low-sodium diet.  Temperature is 37.1 C (98.8 F), blood pressure is 120/70 mm Hg, pulse is 80/min, and respirations are 16/min.  BMI is 31 kg/m².  The patient is alert and oriented.  There is no scleral icterus and the mucous membranes are moist.  The lungs are clear to auscultation and heart sounds are normal with no murmurs.  The abdomen is protuberant but nontender, and the liver edge is not palpable.  A flapping motion occurs with hand dorsiflexion, but no focal neurologic deficits are present.  Laboratory results are as follows:

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

A 67-year-old woman comes to the emergency department due to generalized weakness that has slowly worsened over the past 3 days.  She has also been constipated, and her last bowel movement was 5 days ago.  The patient has metastatic breast cancer and is currently undergoing combination chemotherapy.  She takes oxycodone and docusate.  Temperature is 37.2 C (99 F), blood pressure is 130/80 mm Hg, pulse is 94/min, and respirations are 18/min.  Pulse oximetry shows 97% on room air.  Mucous membranes are dry.  Cardiopulmonary auscultation reveals clear lung fields and normal heart sounds.  The abdomen is mildly distended, soft, and nontender.  Lower extremities show no edema.  Neurological examination is normal.  Laboratory results are as follows:

12-lead ECG is performed.  Intravenous fluids are initiated, and the patient is admitted to the hospital.  Which of the following is the most appropriate next step in management of this patient?

A 57-year-old African American woman comes to the emergency department with dyspnea on exertion that has been gradually progressive over the last 4-5 weeks.  She has also had a nonproductive cough over the same time period, as well as fatigue and malaise for the last few months.  Medical history includes coronary artery disease with a stent placed 6 months ago, triple-negative breast cancer treated with breast-conserving therapy and adjuvant chemotherapy 3 years ago, hypertension, and hyperlipidemia.  The patient’s medications include lisinopril, rosuvastatin, aspirin, clopidogrel, and metoprolol.  She does not use tobacco, alcohol, or illicit drugs.  Family history is notable for coronary artery disease in both parents, who are now deceased.  Temperature is 37.2 C (99 F), pulse is 95/min, blood pressure is 125/75 mm Hg, respirations are 18/min, and oxygen saturation is 90% on room air.  Examination shows moist mucous membranes, no jugular venous distension, and no cervical lymphadenopathy.  Auscultation reveals absent breath sounds and dullness to percussion over the right lung base, as well as normal S1 and S2.  There is no edema.  Chest x-ray reveals a large, right-sided pleural effusion and is otherwise unremarkable.  A thoracentesis is performed and 1,250 mL of serosanguineous fluid is removed.  Laboratory studies of the pleural fluid show the following:

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

A 34-year-old man comes to the urgent care center due to a day of pruritic skin rash over the lower trunk and upper thighs.  He and his girlfriend are on vacation in Puerto Rico.  They arrived 4 days ago; and so far during their stay, they have hiked forest trails, eaten local cuisines, and swum at the resort pool.  The patient was bitten several times by insects during his hike.  He has had no fever, chills, headache, abdominal pain, diarrhea, dysuria, or joint pain.  The patient has a history of seasonal allergies but no other medical problems.  Temperature is 36.7 C (98.1 F), blood pressure is 120/60 mm Hg, and pulse is 70/min.  BMI is 26 kg/m².  Skin examination findings are shown in the image below.

The remainder of the examination is normal.  Which of the following is the most appropriate next step in management of this patient’s current skin condition?

A 62-year-old man comes to the clinic due to shortness of breath over the last 6 months.  The patient has gradually felt more fatigued after his usual amount of activity and frequently needs to stop and rest.  He has noticed that the symptoms are more severe in the morning.  For several years the patient has had an intermittent cough productive of clear sputum.  He has no orthopnea, lower extremity swelling, fever, chills, or weight loss.  Medical issues include coronary artery disease with a prior bypass surgery, hypertension, major depression, squamous cell skin cancer, and hypothyroidism.  He had a local excision of the skin cancer from his left forearm.  The patient smoked a pack of cigarettes daily for 40 years but quit 5 years ago.  He has consumed 2 or 3 beers daily for the past 40 years but has used no illicit drugs.  The patient worked in an automotive factory but is currently retired.  Temperature is 36.4 C (97.5 F), blood pressure is 136/82 mm Hg, pulse is 65/min, and respirations are 16/min.  Pulse oximetry shows 95% on ambient air.  Physical examination shows moist mucous membranes and no jugular venous distension.  Heart sounds are regular in rate and rhythm with clear S1 and S2 and no murmurs.  Scattered wheezes are heard over both lung fields.  Respiratory effort is normal.  The abdomen is soft, nontender, and nondistended.  There is no peripheral edema.  Laboratory testing, including complete blood count and metabolic panel, is normal.  Chest x-ray reveals no infiltrates.  Results of a flow-volume loop are as follows:

FEV1 is 60% of predicted and FVC is 75% of predicted.  Diffusing capacity of the lung for carbon monoxide is within normal limits.  No significant change in measured volumes is observed 15 minutes after administration of a bronchodilator.  Which of the following is the most likely diagnosis?

A 66-year-old man with end-stage renal disease comes to the emergency department due to left elbow pain.  He first noted the pain while undergoing hemodialysis the previous day.  The patient has no other joint symptoms, history of similar pain, or recent trauma to the elbow.  In addition to chronic kidney disease, medical history is notable for type 2 diabetes mellitus, hypertension, and peripheral arterial disease.  He quit smoking 3 years ago and does not use alcohol or recreational drugs.  Temperature is 36.8 C (98.2 F), blood pressure is 144/92 mm Hg, and pulse is 96/min.  Examination shows erythema and swelling at the posterior left elbow.  Range of motion is limited due to pain.  Laboratory results are as follows:

X-ray of the elbow is shown in the exhibit.  Which of the following is the most appropriate next step in evaluation of this patient?

A 55-year-old woman is brought to the emergency department after collapsing during a prolonged coughing episode at home.  Her husband reports that she has had a dry cough and shortness of breath for the last 5 days.  Shortly after arriving at the emergency department, the patient is intubated due to worsening tachypnea and increased work of breathing.  The patient has a history of type 2 diabetes mellitus, hypothyroidism, and a recent diagnosis of polymyositis.  She currently takes prednisone, azathioprine, metformin, and levothyroxine; her prednisone dose was recently reduced from 60 mg to 40 mg daily.  She has no known drug allergies, and does not use tobacco, alcohol, or receational drugs.  Temperature is 37.8 C (100 F), blood pressure is 110/60 mm Hg, pulse is 100/min, and respirations are 18/min.  Pulse oximetry reading prior to intubation was 76% on room air, improving to 98% with 60% FiO₂ after intubation.  The endotracheal tube is in place, and the patient has moist mucous membranes.  Cardiopulmonary auscultation reveals diffuse crackles and rhonchi.  Laboratory results are as follows:

Chest x-ray prior to intubation is shown below:

Pharmacological prophylaxis with which of the following medications would have most likely prevented the patient’s current condition?

A 28-year-old woman comes to the clinic due to generalized fatigue.  The patient has also had several months of intermittent heavy menstrual bleeding, “spots” on her skin, and small streaks of blood when she blows her nose.  She has had no dyspnea, fever, night sweats, or weight loss.  The patient has a history of hypothyroidism and asthma treated with levothyroxine and inhaled albuterol.  Her mother, father, and 2 siblings have no chronic medical problems.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 36.7 C (98.1 F), blood pressure is 120/70 mm Hg, pulse is 88/min, and respirations are 12/min.  BMI is 22 kg/m².  Mucous membranes are moist, and no thyromegaly is present.  Cardiopulmonary auscultation indicates clear lung fields and normal first and second heart sounds.  The abdomen is soft and nontender, with no hepatomegaly or splenomegaly.  Skin examination shows several flat, erythematous/violaceous 1- to 3-mm (.04- to .12-in) lesions on the lower extremities.  The color of the lesions does not change with pressure.  Laboratory results are as follows:

A peripheral smear shows a reduced number of morphologically normal platelets; hypochromic, microcytic red blood cells that vary in shape and size; and normal-appearing leukocytes.

Item 1 of 2

Which of the following is the most likely diagnosis for this patient?

Item 2 of 2

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

A 38-year-old man comes to the emergency department due to several weeks of subjective fever, night sweats, malaise, and shortness of breath.  He has also had anorexia, vague abdominal discomfort, and unspecified weight loss.  The patient was diagnosed with HIV 2 years ago but is not compliant with HIV-related medications.  His most recent visit to the HIV clinic was a year ago, and he does not know his last CD4 count or viral load.  The patient smokes marijuana and has used injection drugs in the past.  He was recently released from prison and is living with his mother in Massachusetts.  Temperature is 37.2 C (99 F), blood pressure is 118/78 mm Hg, pulse is 90/min, and respirations are 18/min.  The patient’s pulse oximetry shows 88% while breathing ambient air.  BMI is 19 kg/m².  Physical examination reveals bitemporal wasting, moist mucous membranes, and flat neck veins.  Diffuse, bilateral crackles are present on lung auscultation.  Heart sounds are normal with no murmur.  The abdomen is soft with mild right upper quadrant tenderness.  Bowel sounds are normal.  No extremity edema is present.  Neurologic examination is within normal limits.  Laboratory results are as follows:

Chest imaging findings are shown below.

This patient’s current symptoms are most likely due to active infection with which of the following?

A 61-year-old postmenopausal woman comes to the office for abdominal distension, bloating, and lower abdominal pain over the past 4 months.  The patient also reports an 8-kg (17.6-lb) unintentional weight loss during this time and says that it is due to decreased appetite; she is routinely unable to finish her meals.  The patient has a history of type 2 diabetes mellitus and hypertension controlled by oral medications.  She has had a laparoscopic cholecystectomy and appendectomy.  There is no history of gynecologic issues other than unexplained infertility.  Menopause was at age 54, and she used hormone replacement therapy for 5 years afterward.  The patient has had no postmenopausal bleeding.  Family history is significant for colorectal cancer in her father at age 70; otherwise, it is noncontributory.  Temperature is 36.7 C (98 F), blood pressure is 130/80 mm Hg, pulse is 72/min, and respirations are 18/min.  BMI is 32 kg/m².  On abdominal examination, there is mild tenderness to deep palpation in the right lower quadrant.  Bimanual examination reveals right-sided adnexal fullness.  Laboratory results are as follows:

Pelvic ultrasound reveals a small uterus with a thin endometrial lining and a 6-cm lobulated right adnexal mass with thick internal septations and mild ascites.  CT scan of the chest, abdomen, and pelvis confirms the adnexal mass and ascites with no distant lesions.  Which of the following is the best next step in management of this patient?

A 27-year-old woman, gravida 1 para 0, at 16 weeks gestation comes to the office after a recent exposure to sick children.  She is a preschool teacher, and 4 children in her classroom have been sent home with fever, red cheeks, and a lacy rash on the trunk over the past 2 weeks.  The patient is afebrile but has had a sore throat and cough for the past 24 hours.  She reports no vaginal bleeding or cramping.  Prior to this, her pregnancy was uncomplicated and all initial prenatal laboratory findings were normal.  She has allergic rhinitis for which she takes a daily antihistamine.  Surgical history includes a laparoscopic appendectomy.  The patient also takes a daily prenatal vitamin and occasional acetaminophen.  She does not use tobacco, alcohol, or illicit drugs.  The patient was adopted and is unaware of any family history.  Temperature is 37.1 C (98.8 F), blood pressure is 98/66 mm Hg, and pulse is 84/min.  The uterus is palpable 4 fingerbreadths below the umbilicus, and fetal heart rate is auscultated at 162/min via handheld Doppler.  She has no signs of a rash and can move her upper and lower extremities freely without pain.  Which of the following is the best advice for this patient?

A 52-year-old woman comes to the office 2 weeks after undergoing elective laparoscopic cholecystectomy for intermittent biliary colic.  The cholecystectomy revealed multiple small gallstones.  There were no complications, but the patient has had intermittent upper abdominal pain and nausea since the procedure.  She has been able to tolerate a regular diet but requires acetaminophen-hydrocodone for the pain.  The patient has a history of hyperlipidemia.  She does not use tobacco or recreational drugs and occasionally drinks alcohol.  Her father has cirrhosis.  Temperature is 37.1 C (98.8 F), blood pressure is 130/90 mm Hg, and pulse is 70/min.  BMI is 34.2 kg/m².  Sclerae are mildly icteric, and mucous membranes are moist.  The lungs are clear to auscultation, and heart sounds are normal.  The abdomen is soft with mild tenderness in the right upper quadrant; no rebound tenderness or guarding is present.  The surgical incisions are healing well without erythema or discharge.  Bowel sounds are normal.  Laboratory results are as follows:

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

A 34-year-old man comes to the office for follow-up 1 week after being discharged from the hospital.  The patient had gone to the emergency department due to sudden-onset left-sided flank pain.  He says, “The pain was like the pain I had when I passed a kidney stone 4 years ago.”  CT scan of the abdomen revealed a left-sided 3-mm ureteric calculus with no hydronephrosis.  The patient was treated with intravenous fluids and analgesics and passed the stone spontaneously.  He did not catch the stone for analysis, but his previous stone contained calcium.  The patient has no other medical conditions and takes no medications.  Temperature is 36.4 C (97.5 F), blood pressure is 120/80 mm Hg, and pulse is 74/min.  Physical examination shows no abnormalities.  Laboratory results are as follows:

Urinalysis shows no proteinuria, hematuria, or pyuria.  The patient says, “I’ve been drinking plenty of fluids since the last time I had this, but I still developed another stone.  Isn’t there something else I can do to prevent this?”  Which of the following is the best response to this patient?

An 82-year-old woman is brought to the emergency department after an episode of syncope.  Her daughter reports that they were standing in the lobby of their church when her mother collapsed.  The daughter did not witness any convulsions and says her mother regained consciousness after a few seconds.  The patient does not recall feeling lightheaded prior to this episode.  In the last 2 months she has had episodes of lightheadedness about 3 times a week while both sitting and standing.  She has a history of hypertension, osteoporosis, vitamin D deficiency, and gastroesophageal reflux disease.  She denies any history of vertigo.  The patient had a biopsy of a benign thyroid nodule a few years ago but has had no other surgery.  She takes amlodipine, enalapril, omeprazole, and a vitamin D supplement.  She has no allergies.  The patient does not use tobacco or alcohol.  Her mother died of a stroke at age 90.  Temperature is 36.1 C (97 F), blood pressure is 140/80 mm Hg, pulse is 61/min, and respirations are 14/min.  Pulse oximetry shows 97% on room air.  Height is 160 cm (5 ft 3 in) and weight is 65 kg (143.3 lb).  Physical examination reveals moist mucous membranes, normal jugular venous pressure, clear lung fields, and normal first and second heart sounds.  The abdomen is soft and nontender.  Lower extremity examination shows trace pretibial edema bilaterally.  Spine examination shows mild kyphosis, but there is no tenderness to palpation of the lower back or pain with range of motion of the neck.  Muscle strength is diffusely mildly reduced in the upper and lower extremities, but there are no focal deficits, and upper and lower limb deep tendon reflexes are 2+.  Laboratory results are below:

Chest x-ray reveals a previous vertebral compression fracture and a hiatal hernia, but there is no acute cardiopulmonary finding.  ECG reveals normal sinus rhythm with a right bundle branch block and a left anterior fascicular block.  Transthoracic echocardiogram shows normal left and right ventricular function and no significant valvular disease.  Which of the following is the most likely cause of this patient’s syncope?

A 29-year-old woman comes to the office for follow-up.  She was seen a month earlier for stomach upset, headaches, muscle aches and pains, insomnia, and fatigue.  Examination and routine laboratory tests were normal and she was treated symptomatically.  At today’s visit, the patient says, “I was worried I had some kind of flu, but it’s been going on too long.  I occasionally feel queasy during the day.  At night, I can’t sleep because my back and shoulders hurt and I lie awake with negative thoughts.”  Further questioning reveals that the patient has had intermittent headaches, anxiety, insomnia, and fatigue for several years.  She says, “I often feel overwhelmed and exhausted.  I put a lot of stress on my body worrying about every little thing.  I’m ‘keyed up’ all the time and snap at my husband and coworkers.  When I am under pressure at work my chest feels tight and I can get dizzy.  I’m always running to the bathroom.  On top of everything else, I’m depressed that my mother was recently diagnosed with breast cancer.”  Medical history is significant for eczema, insomnia, and migraine headache.  The patient drinks a glass of wine several times a week and does not use illicit drugs.  She drinks 2 cups of coffee in the morning but avoids caffeine at night.  Temperature is 36.7 C (98 F), blood pressure is 110/70 mm Hg, pulse is 84/min, and respirations are 16/min.  Physical examination is normal.

Item 1 of 2

Which of the following is the most likely diagnosis?

Item 2 of 2

The patient is given a referral for psychotherapy.  However, she returns 6 months later and reports that her insurance covered only 3 sessions, and she continues to experience chronic worry, anxiety, and tension.  The patient says, “I have difficulty falling asleep because I am thinking about stuff that occurred during the day and worrying how I will accomplish everything I have to do tomorrow on such little sleep.  I worry about every little thing and can’t slow my mind down.”  The patient continues to experience intermittent headaches, and shoulder and back pain.  She says, “I can’t even relax on weekends.  My husband is upset because I never want to do anything; I’m too tired.”  The patient asks if there is a medication she can take.  Which of the following would be the most appropriate pharmacotherapy?

A 47-year-old man comes to the office for follow-up of hypertension.  He reports increased fatigue, which he attributes to stress and describes as difficulty concentrating at work and lethargy during the day.  The patient also has occasional palpitations.  He has no chest pain, shortness of breath, syncope, or lower extremity edema.  He takes chlorthalidone, amlodipine, and lisinopril, and the dose of lisinopril was increased during the last visit 4 weeks ago.  The patient reports good medication adherence.  He is a lifetime nonsmoker.  He is single and lives alone.  Blood pressure is 152/90 mm Hg and pulse is 68/min.  BMI is 32 kg/m².  The lungs are clear on auscultation and heart sounds are normal.  Laboratory results are as follows:

Echocardiogram shows left atrial enlargement and mild left ventricular hypertrophy.  A short run of atrial fibrillation is revealed on 24-hour ECG monitoring.  Further evaluation of this patient should initially focus on which of the following pathologies?