A 57-year-old man comes to the emergency department due to fever, chills, generalized weakness, dysuria, and increased urinary frequency for the past several days.  He says he has “no energy” today and could not get out of bed.  The patient has a history of schizophrenia and HIV.  He does not remember his most recent CD4 cell count or the names of his current medications.  The patient is a retired fishing boat captain, drinks 1 or 2 beers daily, and has smoked 2 packs of cigarettes daily for 38 years.  Temperature is 38.3 C (101 F), blood pressure is 91/53 mm Hg, pulse is 122/min, and respirations are 20/min.  Pulse oximetry shows 94% on room air.  He is obese with weight of 80 kg, predicted body weight of 60 kg, and BMI of 32 kg/m².  The lungs are clear and there are no heart murmurs.  The abdomen is soft and nontender.  There is no peripheral edema.  Laboratory results are as follows:

The patient is admitted and intravenous fluids and empiric antibiotics are administered.  Three hours later, the patient becomes increasingly agitated, diaphoretic, and dyspneic.  Repeat vital signs include a temperature of 37.6 C (99.7 F), blood pressure of 104/70 mm Hg, pulse of 116/min, and respirations of 42/min.  Pulse oximetry shows 70% on 100% oxygen via nonrebreather mask.  Lung examination reveals bilateral crackles.  The remainder of the physical examination is unchanged.  ECG shows sinus tachycardia.  Chest x-ray reveals diffuse bilateral infiltrates.

Item 1 of 3

Which of the following is the most likely mechanism responsible for this patient’s current decompensation?

Item 2 of 3

Endotracheal intubation is performed and the patient is mechanically ventilated.  Several hours later, blood pressure is 123/80 mm Hg and pulse is 100/min.  Ventilator settings are as follows:  Fraction of inspired oxygen is 60%, tidal volume is 360 mL, positive end-expiratory pressure is 7 cm H₂O, and respiratory rate is 16/min.  The patient’s plateau pressure is 26 cm H₂O.  Arterial blood gases show pH is 7.37, PaO₂ is 48 mm Hg, and PaCO₂ is 38 mm Hg.  Which of the following is the most appropriate next course of action?

Item 3 of 3

The patient is maintained on mechanical ventilation, and his condition gradually improves over the next several days.  Today, arterial blood gases show pH is 7.35, PaO₂ is 94 mm Hg, and PaCO₂ is 45 mm Hg, with fraction of inspired oxygen of 60%, positive end-expiratory pressure of 5 cm H₂O, and tidal volume of 360 mL.  Which of the following is the most appropriate course of action at present?

A 22-year-old woman comes to the office for evaluation due to 9 months of amenorrhea.  Since menarche at age 15, the patient has had a history of irregular menstrual cycles, previously occurring every 2-3 months.  Menstrual periods were typically 2-3 days with light bleeding and no pain.  She has no chronic medical issues and takes no medications.  The patient, a professional ballerina, is sexually active and was treated for a chlamydial infection 3 years ago.  She does not use tobacco, alcohol, or illicit drugs.  Blood pressure is 110/80 mm Hg and pulse is 58/min.  Height is 155 cm (5 ft 1 in) and BMI is 18 kg/m².  Cardiopulmonary examination is normal.  Breasts are Tanner stage 4 and have no palpable masses or nipple discharge.  On pelvic examination, the vaginal epithelium appears thin with few rugae, and the cervix has a closed, nulliparous os; no lesions; and no cervical discharge.  Bimanual examination shows a mobile uterus and small, nontender ovaries.  Urine pregnancy test is negative.  Laboratory results are as follows:

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

An 85-year-old man is evaluated for fatigue.  Three weeks ago, his wife passed away from a massive intracranial hemorrhage.  Since then, the patient has been feeling sad and lonely and is unable to fall asleep at night.  He feels fatigued during the day and sometimes does not want to “do anything.”  The patient has no suicidal ideation.  He states, “Everyone has to go someday; I have to put my life back together and work on improving my overall health.”  His closest family member is his son, who lives 300 miles away.  Since his wife passed away, the patient has lived alone but is considering moving into an assisted living facility.  Medical history is notable for hypertension, hyperlipidemia, vitamin B₁₂ deficiency, chronic low back pain, and mild chronic kidney disease.  Current medications include valsartan, hydrochlorothiazide, pravastatin, aspirin, and a vitamin B₁₂ supplement.  The patient also takes acetaminophen intermittently for chronic back pain.  He does not use tobacco, alcohol, or illicit drugs.  Blood pressure is 146/70 mm Hg and pulse is 72/min.  Examination of the neck shows no enlargement of the thyroid.  The hands show periarticular bony enlargement at the proximal and distal interphalangeal joints.  Laboratory tests show a normal complete blood count.  Serum creatinine is 1.37 mg/dL.  Serum TSH is 6.2 µU/mL.  Repeat TSH is 6.3 µU/mL and free T4 is 1.23 ng/dL (normal: 0.9-1.7).  Which of the following is the most appropriate next step in management of this patient?

A 28-year-old woman comes to the office for medical evaluation prior to starting work as a radiology technician.  The patient has no symptoms or medical problems and takes no medications.  She has had no fever, night sweats, cough, anorexia, or weight loss and has no known exposure to a person with tuberculosis.  The patient immigrated to the United States from India 7 years ago and had a negative tuberculin skin test at that time.  She has received all recommended vaccinations, including Bacillus Calmette-Guérin (BCG) vaccine, as part of childhood immunization.  She does not use tobacco, alcohol, or illicit drugs.  Vital signs are within normal limits, and physical examination shows no abnormalities.  Interferon-gamma release assay (IGRA) is positive.

Item 1 of 2

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

Item 2 of 2

A subsequent chest radiograph reveals a discrete fibrotic scar in the right upper lobe with no airspace opacification, lymphadenopathy, or pleural effusion.  Which of the following is the most appropriate next step in management of this patient?

A 61-year-old woman comes to the emergency department due to fever, chills, and left flank pain that began abruptly last evening.  A month ago, the patient was treated for a urinary tract infection with a short course of ciprofloxacin.  She otherwise has no medical problems and currently takes no medications.  The patient has no history of hospitalizations or surgeries.  Temperature is 39.4 C (103 F), blood pressure is 80/40 mm Hg, pulse is 120/min, and respirations are 24/min.  Pulse oximetry shows 94% on room air.  Mucous membranes are dry and jugular veins are flat.  Cardiopulmonary auscultation reveals clear lung fields and normal heart sounds without murmurs.  The abdomen is soft and nontender.  Left costovertebral angle tenderness is present.  Skin examination is normal.  Extremities are warm with no edema.  Neurologic examination is within normal limits.  Laboratory results are as follows:

Broad-spectrum antibiotics and intravenous fluids are initiated, and the patient is admitted to the intensive care unit.  Enoxaparin is given for prophylaxis against deep vein thrombosis.  On hospital day 2, urine and blood cultures are positive for Escherichia coli, and antibiotics are narrowed based on culture sensitivities.  Repeat laboratory testing is similar to admission, except platelet count has dropped to 105,000/mm³.  Which of the following is the most appropriate next step in management of this patient?

A 3 year-old boy with sickle cell disease is brought to the emergency department due to abdominal pain.  The patient’s mother says that her son “seems so exhausted, refuses to eat or drink anything, and won’t stop crying from the pain.”  The boy first developed a “tummy-ache” yesterday, but the pain worsened significantly this morning.  He has also had 2 episodes of nonbloody, nonbilious emesis but no diarrhea.  His last stool was 3 days ago.  The mother gave him 2 doses each of ibuprofen and oxycodone this morning, with no significant improvement.  She is not sure if the boy’s father administered any other medications.  Medical history is significant for multiple prior hospitalizations for vaso-occlusive pain crises in the back and legs.  However, the patient has no history of severe abdominal pain.  Baseline hemoglobin is 9.8 g/dL.  He is given penicillin twice daily, and his immunizations are up to date.  Temperature is 36.7 C (98 F), blood pressure is 70/30 mm Hg, pulse is 162/min, and respirations are 36/min.  Examination shows a sleepy young boy lying on a stretcher with significant abdominal tenderness to palpation, particularly over the left side of the abdomen.  A spleen tip is palpated in the left lower quadrant.  Laboratory results are as follows:

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

A 50-year-old man is brought to the emergency department due to an episode of syncope.  The patient experienced a brief episode of palpitations and lightheadedness yesterday evening, which he attributed to a tiring day at work.  Today, while eating breakfast with his wife, he suddenly slumped to the table and lost consciousness for several minutes.  He has had no abnormal bowel movements or urinary incontinence.  By the time emergency medical personnel arrived, he was awake and alert.  The patient has had no chest pains or shortness of breath, but he has been having headaches and malaise for the past several days.  His wife adds that about a month ago, he had a bright red rash on the right calf for a week.  The patient says he had a full medical evaluation 6 months ago when he turned 50 and was told that he is in perfect health.  He takes no medication and does not use tobacco, alcohol, or illicit drugs.  The patient works in a veterinary clinic and says he likes animals and nature.  He recently took a bird-watching trip to Maine.  Temperature is 36.8 C (98.2 F), pulse is 46/min, blood pressure is 130/70 mm Hg, and respirations are 14/min.  Physical examination shows moist mucous membranes and normal jugular venous pressure.  The lungs are clear to auscultation and heart sounds are normal with no murmur.  The extremities are warm and without edema.  Neurologic examination is normal.  No skin rashes are present.  Laboratory results are as follows:

ECG shows sinus rhythm with 2:1 atrioventricular block.  Which of the following should be a component of treatment for this patient’s arrhythmia?

A 73-year-old woman is brought to the emergency department from an assisted living facility due to abdominal pain, diarrhea, and fever.  The patient’s symptoms began 24 hours ago with abdominal cramping and discomfort, which then progressed to frequent watery, brown bowel movements.  She also has had fever with progressively worsening abdominal pain.  Medical history includes hypertension, hypothyroidism, and knee osteoarthritis.  The patient recently underwent a tooth extraction and completed a 7-day course of oral clindamycin for a dental infection.  She does not use tobacco, alcohol, or illicit drugs.  She is allergic to penicillin, which causes skin rash.  Temperature is 39.1 C (102.4 F), blood pressure is 105/60 mm Hg, pulse is 110/min, and respirations are 19/min.  BMI is 19 kg/m².  The patient is frail and ill appearing.  Physical examination shows dry mucous membranes.  Auscultation of the heart and lungs is normal.  Bowel sounds are hypoactive, and moderate abdominal distension is present.  The abdomen is diffusely tender to palpation without guarding or rebound tenderness.  Stool occult blood testing is negative.  Laboratory results are as follows:

Stool samples are obtained for microbiologic testing, and intravenous fluids and empiric antibiotics are administered.  Which of the following additional interventions is most appropriate in management of this patient?

An 84-year-old man is evaluated in the intensive care unit due to fevers.  The patient was admitted 5 days ago for an acute exacerbation of chronic obstructive pulmonary disease with respiratory failure and required endotracheal intubation.  He remains intubated and on mechanical ventilation.  He is receiving bronchodilators, corticosteroids, and intravenous cefepime.  For the past 24 hours, the patient has had high-grade fevers.  There is no diarrhea, change in urine color, or increased respiratory secretions.  Medical history includes hypertension, severe pulmonary hypertension, and cor pulmonale.  The patient appears ill and is lightly sedated.  Temperature is 39.1 C (102.4 F), blood pressure is 100/60 mm Hg, and pulse is 102/min.  There is no erythema around the central venous catheter site and no rash.  Bilateral breath sounds are coarse.  No new murmurs are present.  Bowel sounds are decreased and the patient grimaces on abdominal palpation, but there is no rigidity.  Stool occult blood is negative.  He has 1+ pitting sacral edema.  Laboratory results are as follows:

Chest radiography demonstrates no new infiltrates or consolidation.  CT scan of the abdomen is notable for a nonspecific bowel gas pattern and a distended gallbladder with wall thickening.  There is mild pericholecystic fluid but no gallstones or biliary duct dilation.  Blood cultures are obtained.  Which of the following is the most appropriate next step in management of this patient?

A 21-year-old woman, gravida 1 para 0, at 35 weeks gestation comes to labor and delivery due to irregular contractions.  She is not having any leakage of fluid or vaginal bleeding.  Fetal movements are normal.  The patient initiated prenatal care at 8 weeks gestation and has had an uncomplicated prenatal course.  All prenatal laboratory results have been within normal limits except that she is a cystic fibrosis carrier; her partner is negative for cystic fibrosis.  Fetal anatomy scan at 20 weeks gestation demonstrated no abnormalities, and fetal growth has been appropriate.  The patient has a history of depression, for which she takes a selective serotonin reuptake inhibitor.  She does not use alcohol, tobacco, or illicit drugs.  Temperature is 36.7 C (98 F), blood pressure is 110/70 mm Hg, and pulse is 84/min.  The abdomen is gravid and nontender, and there are no palpable contractions.  Fundal height is appropriate.  Cervical examination reveals a closed cervix with no effacement and −3 station.  Bilateral lower extremities have minimal pedal edema.  Nonstress test results are as follows:

Over 40 minutes, fetal heart rate tracing remains unchanged.  Which of the following is the best next step in management of this patient?

A 35-year-old woman comes to the office due to an 8-month history of pain and stiffness of her hand joints.  The patient says, “I have had pain in my hands for several months, but now it seems like they hurt every day.  I can hardly move them when I wake up in the morning, although by the time I get to work they loosen up enough for me to type at my computer.  Ibuprofen helps the pain, but I am taking so much that it’s starting to bother my stomach.”  She has had no pain in other joints, skin rash, chest pain, shortness of breath, or bluish discoloration of the fingers.  Medical history includes allergic rhinitis that is well controlled with over-the-counter antihistamines.  The patient does not use tobacco, alcohol, or illicit drugs.  She is married and has 2 children.  Temperature is 37.2 C (98.9 F), blood pressure is 130/80 mm Hg, and pulse is 76/min.  Physical examination shows no oral mucosal lesions or cervical lymphadenopathy.  The lungs are clear to auscultation and heart sounds are normal with no murmur.  The abdomen is soft and nontender with no hepatosplenomegaly.  There is mild swelling, erythema, and tenderness of several metacarpophalangeal and proximal interphalangeal joints of both hands.  Blood cell counts, serum chemistries, and urinalysis are within normal limits.  Other laboratory results are as follows:

Which of the following is the most appropriate response to this patient regarding her current condition?

A newborn girl is evaluated on arrival in the hospital nursery.  Three hours ago, she was born at home via spontaneous vaginal delivery due to precipitous labor.  The umbilical cord was clamped in the ambulance, and intramuscular vitamin K and ophthalmic antibiotic prophylaxis were administered at the hospital.  Temperature is 36.7 C (98.1 F), pulse is 120/min, and respirations are 24/min.  On physical examination, the patient is awake, alert, and active.  The head is normocephalic and the anterior fontanelle is open and flat.  The pupils are equal and reactive to light and accommodation, extraocular movements are intact, and red reflexes are present bilaterally.  The nares are patent without rhinorrhea and there is no cleft lip or palate.  The clavicles are intact bilaterally without crepitus.  S1 and S2 are normal without murmurs, and the lungs are clear to auscultation bilaterally.  The abdomen is soft and nontender, with normal bowel sounds and no organomegaly.  Peripheral and femoral pulses are normal and symmetrical, and capillary refill is normal.  The skin is slightly ruddy, without rashes or lesions.  Laboratory results for venous blood are as follows:

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

A 57-year-old woman is evaluated on the surgical floor for continuous bilious emesis over the last 12 hours.  She has had 10 episodes of vomiting, which has continued despite intravenous antiemetic administration.  The patient underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and tumor debulking for epithelial ovarian cancer 4 days ago.  During the procedure, 2 liters of ascites was drained.  She ate solid food yesterday for lunch but is now unable to hold down even small sips of water.  Her last bowel movement was prior to surgery and she has not passed flatus.  The patient has type 2 diabetes mellitus controlled with diet, exercise, and metformin.  She is married and has 3 children, all born via cesarean delivery.  The patient does not use tobacco, alcohol, or illicit drugs.  She has no known drug allergies.  Temperature is 37.2 C (99 F), blood pressure is 134/74 mm Hg, and pulse is 78/min.  BMI is 37 kg/m².  Physical examination shows a markedly distended abdomen with a vertical skin incision, and bowel sounds are absent.  The incision is nontender to palpation, and the staples are clean and dry.  Laboratory results are as follows:

Abdominal x-ray reveals dilated loops of bowel with air in the distal colon and rectum.  In addition to intravenous fluid administration, which of the following is the best next step in management of this patient?

A 71-year-old woman comes to the emergency department due to a week of fever, nonproductive cough, and shortness of breath.  The patient states, “I have been healthy all my life but over the past year I have had 2 episodes of shingles, and I constantly feel tired.  Maybe I am just getting old.”  She has also had occasional loose stools, joint pains, and a 4.5-kg (10-lb) weight loss over the past year.  She has had no chest pain, palpitations, abdominal pain, or melena.  The patient takes no medications and recently received pneumococcal and zoster vaccinations.  She drinks a glass of wine with dinner every evening and does not use tobacco or illicit drugs.  The patient is widowed and lives alone but is socially active with her peers and frequently attends social gatherings.  Temperature is 38 C (100.4 F), blood pressure is 130/60 mm Hg, pulse is 98/min, and respirations are 24/min.  Pulse oximetry shows 90% on room air.  BMI is 20 kg/m².  There are several enlarged lymph nodes in the cervical and inguinal regions and small white patches in her mouth.  Lung auscultation reveals bilateral crackles, and heart sounds are normal with no murmur.  The abdomen is soft and nontender with no hepatosplenomegaly.  Bowel sounds are active.  Neurological examination shows no abnormalities.  There is no skin rash, extremity edema, or joint erythema or effusion.  Laboratory results are as follows:

Chest x-ray reveals bilateral interstitial infiltrates.  Appropriate antimicrobial therapy is administered.  Which of the following is the best next step in diagnosis of this patient?

A 78-year-old woman is brought to the office by her daughter due to several days of increasing confusion and disorientation.  Her daughter reports that the patient has been restless and confused, especially at night.  The patient has been seen talking with people who are not in the room.  Today, she was found frantically searching for clothing while saying, “I am late for work,” although she has been retired for 15 years.  The patient has a history of hypertension, hyperlipidemia, and cerebral infarction without residual deficits.  She also has mild memory deficits but independently performs activities of daily living.  Two weeks ago, the patient was hospitalized for chest pain and was found to have chest wall shingles.  She was started on antiviral therapy and amitriptyline for neuropathic pain.  Her rash is now largely resolved, but she continues to take amitriptyline daily for the pain.  Other medications include aspirin, lisinopril, and atorvastatin.  The patient does not use tobacco, alcohol, or illicit drugs.  Temperature is 37.2 C (99 F), blood pressure is 140/70 mm Hg, pulse is 82/min, and respirations are 14/min.  Oxygen saturation is 99% on ambient air.  She is disoriented to time and place but recognizes her daughter.  The patient remembers 0 out of 3 objects after 5 minutes.  The remainder of the physical examination reveals no abnormalities.  ECG shows normal sinus rhythm with nonspecific ST-T changes.  Laboratory results are as follows:

CT scan of the head demonstrates mild cortical atrophy.  Which of the following is the most appropriate next step in management of this patient?

A 7-year-old girl is brought to the office due to worsening ear pain.  The girl developed left ear pain 2 days ago, but her father is concerned because “there was a yellow stain on her pillow this morning.”  The patient received acetaminophen this morning for pain, but her father says, “She was so uncomfortable that I could not clean her ears with a cotton swab, which I normally help her with after she showers.”  The patient has no fever, cough, rhinorrhea, or sore throat.  She had 3 episodes of acute otitis media from age 2-4.  Immunizations are up to date, and her only daily medication is a multivitamin.  Temperature is 37.8 C (100 F), blood pressure is 100/60 mm Hg, pulse is 92/min, and respirations are 14/min.  Physical examination shows a nervous-appearing girl who winces with any attempt to examine her left ear.  Dried yellow discharge is noted posterior to the tragus.  The patient starts to cry when her auricle is pulled back for otoscopy.  Yellow discharge and erythema are seen in the ear canal.  The tympanic membrane is partially obscured by drainage, but the visible portion is translucent and pearly gray in color, with a light reflex.  There is no swelling or tenderness to palpation of the skin surrounding the ear.  Examination of the right ear reveals a normal-appearing canal and tympanic membrane.

Item 1 of 2

Which of the following is the most likely diagnosis?

Item 2 of 2

The diagnosis is discussed with the father, and appropriate therapy is prescribed.  Which of the following is the most likely etiology for this patient’s presentation?