A 76-year-old man is brought to the emergency department by ambulance 40 minutes after he tripped and fell to the floor in his bathroom. He reports severe pain to his right hip. He has no other injuries and reports no numbness or weakness to his legs or feet. Medical history is remarkable for hypertension, osteoarthritis, and hypercholesterolemia. Medications include aspirin, simvastatin, metoprolol, and acetaminophen as needed. Vital signs are temperature 37.0°C (98.6°F), pulse 70/min, respirations 18/min, and blood pressure 124/82 mm Hg. He is in obvious pain, but is alert and responsive. Pulmonary and cardiac examinations disclose no abnormalities. There is no tenderness to the neck or back and no gross deformity or rotation of the right lower extremity. There is tenderness to palpation over the lateral aspect of the right hip. The patient resists both passive and active range of motion of the hip due to pain. Distal pulses, capillary refill time, and sensation of the right lower extremity are normal. X-ray of the right hip shows degenerative changes with no fractures. An attempt is made to have the patient ambulate with assistance, but he is unable to bear any weight on his right lower extremity due to the hip pain. Which of the following is the most appropriate additional diagnostic study to obtain at this time?

A 75-year-old man comes to the office because he has had intermittent episodes of abdominal pain and weight loss during the past month. The abdominal pain is relieved by leaning forward. He also states that during this time his stools have changed in color and are now pale. Medical history is unremarkable and the patient takes no medications. He has smoked one pack of cigarettes daily for more than 55 years. He drinks alcoholic beverages occasionally. He is 183 cm (6 ft) tall and weighs 82 kg (180 lb), which is 9 kg (20 lb) less than his weight 1 month ago; BMI is 24 kg/m2. Vital signs are normal. Physical examination discloses mild jaundice. Abdominal examination discloses moderate epigastric tenderness with an associated epigastric bruit. Which of the following is the most appropriate diagnostic study?

A 78-year-old man comes to the emergency department because of a 1-month history of gradually worsening fatigue, increasing shortness of breath, and diminished exercise capacity. Medical history is significant for hypertension, hyperlipidemia, and a stroke 5 years ago, from which he has made a full recovery. Medications include atenolol and atorvastatin. He has had one glass of red wine nightly since his stroke. He does not smoke cigarettes. Vital signs are temperature 36.7°C (98.1°F), pulse 96/min and slightly irregular, respirations 16/min, and blood pressure 160/90 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Conjunctivae are pale and ocular movements are intact. Auscultation of the lungs discloses crackles at both bases. A grade 2/6 systolic murmur is audible along the left sternal border. Test of the stool is trace positive for occult blood. Neurologic examination discloses diminished sensation to touch and position sense in both feet. Results of laboratory studies are shown:

The laboratory reports that several neutrophils have greater than six segmentations. Which of the following additional studies is most appropriate at this time?

A 24-year-old woman comes to the emergency department because of severe pain in her left arm that began when she fell 4 hours ago. She says she slipped on her bathroom floor and struck her left arm on the sink as she fell. She rates the pain as an 8 on a 10-point scale. She also reports pain in her right ribs. Medical history is unremarkable and she takes no medications. She appears anxious and speaks slowly and quietly. Vital signs are normal. Pulse oximetry on room air shows an oxygen saturation of 99%. Physical examination discloses a swollen, deformed, and ecchymotic left forearm. There are greenish-brown ecchymoses on the right chest and scattered yellowish ecchymoses on the left chest. A resolving hematoma is noted on the left hip. Auscultation of the chest discloses no abnormalities. X-ray of the left upper extremity discloses a spiral fracture of the ulna and radius. In addition to placing the patient’s left upper extremity in a cast, which of the following is the most appropriate action prior to discharge?

A 25-year-old medical resident comes to the office because of a 1-month history of palpitations. He says he is concerned because he has had several episodes of feeling like his heart has skipped a beat. He has not had chest pain, dyspnea, or syncope. He has checked himself on a cardiac monitor and noted frequent premature atrial contractions and occasional premature ventricular contractions. He asks if he should start taking a β-blocking medication. He says he has been otherwise healthy and he currently takes no medications. He does not drink alcoholic beverages or smoke cigarettes. When asked, he admits to considerable stress and fatigue because of his work schedule but he feels that overall his residency is going well. Vital signs are normal. Physical examination discloses no abnormalities. Results of complete blood count and serum electrolyte concentrations are within the reference ranges. ECG obtained today shows frequent premature atrial contractions and occasional premature ventricular contractions. At this time, specific additional history should be obtained regarding which of the following?

Item 1 of 2

Which of the following is the most appropriate pharmacotherapy at this time?

Item 2 of 2

Which of the following is the most appropriate additional management?

A 67-year-old man, who underwent uncomplicated percutaneous coronary artery angioplasty and stent placement 2 days ago, has remained in the hospital because of increased serum creatinine concentrations. Medical history is significant for hypertension, hyperlipidemia, peripheral vascular disease, and type 2 diabetes mellitus. Pre-admission medications were metoprolol, hydrochlorothiazide, lisinopril, simvastatin, metformin, glyburide, and 81-mg aspirin. Metformin and glyburide were discontinued on admission and insulin therapy was started. Clopidogrel was added immediately after angioplasty and furosemide was substituted for hydrochlorothiazide today. Vital signs are temperature 36.9°C (98.4°F), pulse 60/min and regular, respirations 15/min, and blood pressure 122/62 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 95%. Cardiac examination discloses a grade 2/6 systolic murmur. Carotid pulse is 1+ bilaterally; femoral pulse is 1+ on the left and absent on the right. Dorsalis pedis and posterior tibial pulses are reduced on the left and absent on the right. There is trace edema of both ankles. The remainder of the physical examination discloses no abnormalities. Results of laboratory studies are shown:

Which of the following is the most likely cause of the increase in this patient’s serum creatinine concentration?

A 67-year-old white man is admitted to the hospital because of worsening shortness of breath during the past 5 days. He is unable to walk up a flight of stairs without having to stop and rest. He also has a cough that occurs only when he lies down at night. Medical history is significant for coronary artery disease with two myocardial infarctions, hypertension, and hyperlipidemia. He is adherent to his medication regimen, which includes metoprolol, furosemide, lisinopril, simvastatin, aspirin, and clopidogrel. Vital signs are temperature 37.2°C (99.0°F), pulse 100/min, respirations 24/min, and blood pressure 104/62 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 92%. Jugular venous pressure is 9 cm H2O at 30 degrees. Auscultation of the lungs discloses crackles bilaterally. Cardiac examination discloses an S3. Serum troponin concentrations are within the reference ranges. ECG shows a left bundle branch block and evidence of an old anterior wall myocardial infarction but no new ischemic changes. Chest x-ray shows mild pulmonary edema and cardiomegaly. Echocardiography done 3 months ago showed 2+ mitral regurgitation with an ejection fraction of 0.32. Once this patient’s condition is stabilized, which of the following is the most appropriate next step in pharmacotherapy?

A 25-year-old woman with a 7-year history of bipolar disorder is admitted to the hospital because of a 10-day history of decreased need for sleep, pressured speech, inflated self-esteem, being highly distractible, and online shopping sprees. Increasing her dose of lithium carbonate and adding olanzapine upon admission have only partially improved her current episode. Vital signs are temperature 37.0°C (98.6°F), pulse 72/min, respirations 12/min, and blood pressure 124/76 mm Hg. Physical examination discloses no abnormalities. It is decided to add valproic acid to the patient’s medication regimen. Addition of this medication requires routine measurement of which of the following?

A previously healthy 63-year-old man comes to the office after returning from a summer fishing trip in the mountains. He says that when he returned he began to have left-sided chest pain and that 2 days later he developed a pruritic rash as shown. Which of the following is the most probable late event in this patient?

Item 2 of 2

Which of the following is the most appropriate next diagnostic step?

A 14-year-old white boy is brought to the office because of substernal chest pain and difficulty swallowing. He says, “I was perfectly fine until yesterday morning. When I woke up I had this burning pain beneath my breast bone and it hurt to swallow.” On further questioning, the patient reports that the pain is precipitated by eating or drinking, and he has a sense of food “getting stuck” in his esophagus. He denies respiratory difficulties or gastrointestinal symptoms. He has not had heartburn in the past. Medications include only tetracycline, which you prescribed 1 week ago for his acne. He generally takes this medication at night, just before going to bed, but he admits to occasionally missing doses. He denies taking other medications or illicit drugs. Height is 165 cm (5 ft 5 in) and weight is 61 kg (135 lb). Vital signs are temperature 37.0°C (98.6°F), pulse 80/min, respirations 16/min, and blood pressure 110/65 mm Hg. Physical examination is normal except for acne. Which of the following is the most likely explanation for his symptoms?

An 83-year-old man comes to the health center because of fatigue. He says that for the past month he has had decreased energy. He feels well in the morning but as the day goes by he “feels more and more out of gas.” He has taken pride in his health and vigor, and this new condition bothers him. He says, “I would have come sooner except that I kept thinking I would get better. But instead I have gotten worse.” He denies depression, muscle aches or joint pains. He has had no fever, diarrhea, anorexia or vomiting. In the past he has had peptic ulcer disease and hepatitis, but he has no other active problems. Vital signs are temperature 36.8°C (98.2°F), pulse 82/min, respirations 16/min, and blood pressure 135/85 mm Hg. On physical examination he looks pale and has angular cheilitis. He has no goiter or lymphadenopathy. Heart sounds are normal, as is lung examination. There is no peripheral edema, skin bruising or muscle or joint tenderness. Neurologic examination is normal. In this patient laboratory studies will most likely show which of the following?

A 79-year-old retired executive schedules an urgent office visit because he had profound dizziness and difficulty walking when he arose from bed this morning. He says the dizziness began last night. He has a 20-year history of hypertension, for which he took medication, but for the past 10 years his blood pressure has been normal without pharmacotherapy. At his most recent visit 3 weeks ago his blood pressure was 150/90 mm Hg, and he was instructed to adhere to a low-sodium diet. He currently takes no medications. Vital signs this morning are pulse 78/min and regular, and blood pressure 180/110 mm Hg. Neurologic examination shows a broad-based gait with falling to the right. Funduscopic examination is normal. He has dysmetria on the right. Which of the following is the most likely diagnosis?

An 18-year-old woman comes to the student health center because of vaginal itching and discharge for 10 days. She has not noted any other changes except for a slight increase in vaginal discharge during the past 3 days. She has never been sexually active and has always been healthy. Vital signs are temperature 37.0°C (98.6°F), pulse 60/min, respirations 18/min, and blood pressure 118/64 mm Hg. On physical examination the abdomen is flat and soft with no masses or tenderness. Examination of the genitals shows lumpy white discharge coating the vaginal tissue; there is moderate redness and a faint odor. No lesions are seen. Bimanual examination discloses an anterior mobile uterus of normal size and mildly tender adnexa. Which of the following studies is most likely to establish the diagnosis?

A 2½-year-old white boy is brought to the office by his mother for a follow-up visit for speech and developmental delays. At the boy’s last visit 2 months ago he was referred to a developmental psychologist for testing because his mother had reported that he only uses single words to communicate and that he did not seem interested in playing with other children or with his family. Evaluation results show that his receptive language level is 13 months and his expressive language level is 15 months. Results of a cognitive and motor functioning assessment show a motor skill level of 26 months and an overall performance level of 14 months, or a ratio IQ of 56. He is 87 cm (34 in; 25th percentile) tall and weighs 12.5 kg (27.5 lb; 25th percentile). Vital signs today are normal and physical examination discloses no abnormalities. His mother asks what his chances are for improvement. Which of the following is the most appropriate response?

A 28-year-old primigravid woman at 28 weeks’ gestation comes to the labor and delivery unit of the hospital because, she says, “There is something coming out of my vagina.” Pelvic examination discloses a fetus in a footling presentation with a prolapsed pulsating umbilical cord. The cervix is 80% effaced and is 8 cm dilated. Ultrasonography discloses a fetal heart rate of 130/min. Which of the following is the most appropriate next step?

A 69-year-old woman comes to the office because of slurred speech and difficulty swallowing for the past 3 weeks. She says her speech becomes more slurred during telephone conversations and swallowing becomes more difficult during a long meal. She has a history of hypothyroidism, pernicious anemia, and vitiligo. Medications include levothyroxine and vitamin B12 (cyanocobalamin) injections. The patient is 170 cm (5 ft 7 in) tall and weighs 66 kg (146 lb); BMI is 23 kg/m2. Vital signs are temperature 37.0°C (98.6°F), pulse 76/min, respirations 14/min, and blood pressure 125/85 mm Hg. The patient’s speech initially is normal, but her speech becomes slurred as conversation continues. Physical examination shows impaired movement of the soft palate on volition. There is mild weakness of both extension and flexion of the neck. Muscle strength is 5/5 in all extremities. Deep tendon reflexes are intact. Hemoglobin concentration is 11.5 g/dL and mean corpuscular volume is 98 μm3. Which of the following studies is most likely to confirm the diagnosis?

A 36-year-old woman comes to the office because of a 2-month history of increasingly frequent episodes of chest pain, palpitations, and shortness of breath. The episodes now occur several times weekly and last from a few minutes to a half-hour. Medical history is significant for operative repair of a ventricular septal defect when the patient was a child, hypothyroidism caused by Hashimoto thyroiditis, and polycystic ovarian syndrome. Medications are levothyroxine, spironolactone, and an oral contraceptive. Family history is significant for anxiety in her mother and sister and alcohol use disorder in her father, who died of alcoholic cirrhosis at age 48 years. The patient is recently divorced, which she says has been difficult for her. She drinks two cups of tea each morning and one to two glasses of wine 3 to 4 nights weekly. She does not smoke cigarettes. BMI is 26 kg/m2. Vital signs are normal. The patient appears anxious but is not in distress. Physical examination discloses no abnormalities. Serum TSH concentration is 1.28 μU/mL. ECG shows no abnormalities. Which of the following factors in this patient’s history makes the patient most susceptible to having developed her condition?

Researchers reported the test characteristics of a three-question instrument developed for use in diagnosing depression and compared it with the standard multi-item questionnaire for depression. Results of the comparison are shown:

Which of the following is the specificity of the three-question instrument?

A 40-year-old man with type 2 diabetes mellitus comes to the office for a routine follow-up examination. The patient reports that his blood pressure measurement was 142/80 mm Hg during a visit to his physiatrist 1 week ago. Medical history is otherwise unremarkable. Medications are metformin, lisinopril, a multivitamin, and 81-mg aspirin. Today, BMI is 30 kg/m2; BMI at the patient’s previous visit was 32 kg/m2. Vital signs are temperature 37.2°C (99.0°F), pulse 80/min, respirations 18/min, and blood pressure 137/100 mm Hg. Physical examination discloses no abnormalities. The patient’s medical record indicates several other elevated blood pressure measurements ranging between 138/85–148/100 mm Hg during the past month. The patient was advised during his previous visits to decrease his dietary sodium intake and lose at least 15 lb, both of which he has done. Which of the following is the most appropriate intervention at this time?

A 24-year-old woman is admitted to the hospital because of a 7-day history of worsening anorexia, nausea, vomiting, epigastric pain, diarrhea, and one episode of hematemesis. She reports a 4-month history of worsening indigestion after meals. One month ago, she was admitted to the hospital after an episode of near-syncope. Iron deficiency anemia was diagnosed and she underwent a blood transfusion; she has been treated with ferrous sulfate since that time. Medical history also is significant for allergic rhinitis, eczema, and asthma. Additional medications are inhaled fluticasone and albuterol, loratadine, and ranitidine. Family history is significant for asthma in her mother. The patient’s BMI is 21 kg/m2. Vital signs are temperature 37.0°C (98.6°F), pulse 100/min, respirations 28/min, and blood pressure 95/60 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 92%. She appears pale and ill and is in mild distress. Physical examination discloses epigastric tenderness. Stool culture and examination for ova and parasites are negative. Serum IgE concentration is 1900 IU/mL, with increased concentrations in response to exposure to eggs, milk, corn, oats, rice, wheat, peanuts, and soybeans. CT scan of the abdomen and pelvis shows no abnormalities. Esophagogastroduodenoscopy shows diffuse erythema of the mucosa with atrophic and nodular gastric mucosa. Results of biopsies of the gastric mucosa are negative for Helicobacter pylori but show dense eosinophilic infiltration. Which of the following is the most likely diagnosis?

A 75-year-old man comes to the office because of a 2-week history of increasingly severe pain in his scrotum. He recalls no trauma to the area. He says that the pain originally was mild, but the area now is tender even without palpation. He has not had any pain with urination or penile discharge. He has not been sexually active for the past 15 years. Temperature is 37.1°C (98.8°F). Palpation of the scrotum discloses tenderness, particularly over the region closer to the base of the penis. Which of the following infectious agents is most likely causing this patient’s symptoms?

A 2-month-old boy is brought to the office by his mother for a follow-up examination. Two days after delivery, the patient had lethargy and severe hypoglycemia, which improved after increased feeding. However, since that time, the patient has had persistent hypoglycemia and hyperinsulinemia. Administration of oral diazoxide results in a modest improvement in the patient’s symptoms. Which of the following additional findings are most likely in this patient?

A 78-year-old woman comes to the office because of a lump on her left wrist that has been present for the past 8 months. The patient says the lump is not painful except when she writes or sews for long periods of time. Medical history is significant for hypertension, generalized anxiety disorder, hypothyroidism, and vitamin D deficiency. Medications are hydrochlorothiazide, sertraline, levothyroxine, and vitamin D3 (cholecalciferol). BMI is 24 kg/m2. Vital signs are normal. Examination of the left wrist is remarkable for the mass shown; there are no other masses present. Cardiopulmonary examination discloses no abnormalities. Extension of the left wrist is decreased. Grip strength is 5/5 bilaterally. The most likely complication resulting from this patient’s mass is compression of which of the following nerves?

A 17-year-old girl is brought to the emergency department by her father because of an 8-hour history of severe abdominal cramping. She has not had fever, chills, nausea, or vomiting. The patient says she has had worsening pain with menstruation since menarche occurred 2 years ago, but she has not yet been evaluated by a physician. Her current menstrual period began yesterday. Use of ibuprofen has provided minimal improvement of the pain. Medical history otherwise is unremarkable and she takes no routine medications. The patient had a normal bowel movement 8 hours ago. She is not yet sexually active and considers herself bisexual. BMI is 23 kg/m2. Vital signs are normal. She appears uncomfortable. Physical examination shows diffuse abdominal tenderness to palpation without guarding, rebound, or masses. Pelvic examination shows no abnormalities of the external genitalia, vestibule, or vagina. Speculum examination shows two cervices with scant blood at the ostia consistent with menses. The uterus is normal in size, globular, and nontender to palpation. Without treatment, which of the following is the most likely complication of this patient’s current condition?

A 77-year-old man, who was admitted to the hospital 1 day ago for treatment of a right femur fracture, has developed the inability to move except for the ability to open his eyes. He also is unable to answer questions. He has dementia, Parkinson disease, and major depressive disorder. His medications are donepezil, citalopram, and carbidopa-levodopa. Six hours ago, he received haloperidol and lorazepam because he was agitated and said he saw small animals running around his room. Vital signs are normal. Pulse oximetry on room air shows an oxygen saturation of 94%. Physical examination shows decreased range of motion of all extremities. Muscle tone is rigid throughout. Which of the following is the most likely cause of this patient’s current condition?

A 72-year-old man comes to the clinic because of a 3-day history of persistent postprandial abdominal pain, nausea, and vomiting. He has not had chest pain. His wife passed away 3 months ago, and he says, “I have not been myself since her death.” Medical history is remarkable for type 2 diabetes mellitus, familial hyperlipidemia, and major depressive disorder. Routine medications are metformin, pravastatin, and gemfibrozil; however, the patient says he stopped taking all of his medications 3 months ago because he has felt hopeless. He does not take anti-inflammatory drugs. He does not drink alcoholic beverages. He has been eating at a fast food restaurant daily during the past 6 weeks, as it is within walking distance of his house. BMI is 19 kg/m2. Vital signs are normal. The patient appears thin and seems to be in mild discomfort. Physical examination discloses tenderness to palpation in the epigastric region but no rebound tenderness. The remainder of the physical examination discloses no abnormalities. ECG shows no abnormalities. Fingerstick blood glucose concentration obtained today is 302 mg/dL. Results of which of the following studies are most likely to be abnormal in this patient?

Physician A works in a medical practice with Physician B, a female colleague who returned to work 6 months ago after mandated inpatient treatment for substance use disorder. During the past 3 weeks, Physician B has been late to the office five times and absent without excuse once. Physician A also has noted that Physician B has made uncharacteristically insulting comments to patients and staff, has left confidential patient records in public places, and has not responded to patient and staff requests for direction. Physician A recalls that Physician B exhibited similar behavior before her mandated treatment. Which of the following is the most appropriate action for Physician A to take?

A hospital’s patient safety officer is examining the relationship between patient falls and various objects and lighting settings in patient rooms. She obtains a list of patients who have fallen during the past 3 months and their room numbers from the head of nursing services. She visits each of those patient rooms and collects information about the distance from the bed to the bathroom, the amount of space on either side of the bed, the placement of monitoring equipment and lighting wattage, and the overhead location and number of light fixtures in the room. Using a second list that includes all of the patient room numbers in the hospital in which no patient has fallen during the past 3 months, she collects similar information. Which of the following measures of association is most appropriate for this study?

A 78-year-old woman with rheumatoid arthritis comes to the clinic for a follow-up examination 6 weeks after she was hospitalized for treatment of methotrexate toxicity. She says she feels well. Her last visit to the clinic was 2 years ago. Medical records from her rheumatologist show that she has taken methotrexate during the past year but has not undergone laboratory studies during this time. The clinic physician has treated other patients of this rheumatologist; those patients also had not undergone routine laboratory studies or had follow-up examinations. Last month, one of the patients was hospitalized for an overdose after the rheumatologist prescribed an opioid despite never having seen the patient. Which of the following is the most appropriate action by this clinic physician?

A 15-year-old girl is brought to the office by her mother to ensure she is up-to-date on her vaccinations before they move out of the area. Review of the patient’s medical records indicates she previously received two doses each of the hepatitis A and hepatitis B vaccines and four doses of inactivated poliovirus vaccine (IPV). She also received one dose each of tetanus-diphtheria-acellular pertussis (Tdap) and meningococcal vaccines at age 11 years. Medical history is unremarkable and she takes no medications. BMI is at the 60th percentile. Vital signs are normal. The patient appears well. Physical examination discloses no abnormalities. Which of the following is the most appropriate vaccination recommendation?

A 78-year-old man, who was admitted to the hospital 3 days ago for treatment of pneumonia, has now developed worsening shortness of breath and agitation. Since admission, he has been treated with intravenous fluids and piperacillin-tazobactam, and his pneumonia symptoms have improved. Medical history is remarkable for ischemic cardiomyopathy with an ejection fraction of 30%, type 2 diabetes mellitus, chronic obstructive pulmonary disease, and a stroke 2 months ago. Before his admission he resided in a nursing care facility. Routine medications, which have been continued since admission, are carvedilol, lisinopril, simvastatin, insulin, tiotropium, and 81-mg aspirin. Now, the patient appears acutely ill and is lethargic. Vital signs are temperature 38.1°C (100.6°F), pulse 114/min, respirations 20/min, and blood pressure 102/58 mm Hg. Pulse oximetry on oxygen at 4 L/min via nasal cannula shows an oxygen saturation of 89%. Auscultation of the lungs discloses new crackles in both lung bases. Cardiac examination discloses no murmur or friction rubs. Abdominal examination discloses no bruits. There is edema to the knees bilaterally. A Foley catheter is inserted and drains 75 mL of dark urine. Results of laboratory studies obtained after the onset of today’s symptoms are shown:

Which of the following is the most likely mechanism for this patient’s acute kidney injury?

A 26-year-old man is brought by ambulance to the emergency department 1 hour after the sudden onset of a severe headache. The patient had an episode of vomiting during transport and is unconscious on arrival. The patient’s girlfriend is with him and states that he has no history of serious illness, does not smoke cigarettes, and does not use illicit drugs. In the emergency department, he remains obtunded. BMI is 23 kg/m2. His temperature is 37.2°C (99.0°F), pulse is 90/min, respirations are 18/min, and blood pressure is 190/110 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 98%. On examination, the pupils are equal, round, and reactive. He is intubated, and an esmolol drip is started. CT scan of the head shows blood in the interhemispheric fissure and adjacent cortical parenchyma. The most likely cause of the hemorrhage in this patient is rupture or tear of which of the following?

A 40-year-old woman comes to the office because of a 1-year history of an intermittently occurring facial rash associated with a burning sensation. The patient says the rash typically lasts up to 3 days before resolving spontaneously. She says it mostly occurs after exercise or exposure to the sun and occasionally after drinking a hot beverage. Medical history is remarkable for asthma and hypertension. Medications are hydrochlorothiazide and inhaled albuterol. Vital signs are normal. Physical examination discloses the findings shown in the photograph. The remainder of the physical examination discloses no abnormalities. Which of the following is the most appropriate diagnostic study to order at this time?

A 13-year-old girl is brought to the office by her mother because of a 3-month history of a progressive facial rash. The rash started as a few pustular lesions. Medical history is unremarkable. She takes no medications. She is at the 75th percentile for height and 50th percentile for weight. Vital signs are within normal limits. Physical examination discloses the findings shown in the photograph. The most appropriate pharmacotherapy for this patient’s rash inhibits which of the following?

A 60-year-old man with type 2 diabetes mellitus comes to the office for a health maintenance examination. He sustained a myocardial infarction 2 years ago. He has not had chest pain. He says that his fingerstick blood glucose concentration measurements range between 100 mg/dL and 160 mg/dL. He has no other history of serious illness. Medications are metformin, metoprolol, atorvastatin, lisinopril, and 81-mg aspirin. His blood pressure is 134/86 mm Hg; other vital signs are within normal limits. Ophthalmologic examination shows proliferation of blood vessels. Urinalysis shows 2+ protein. Which of the following is considered primary prevention for this patient?

An 81-year-old woman comes to the clinic because of a 1-year history of increasingly severe pain in her fingers. She says that she now has difficulty grasping objects. She has no other bone or joint pain. Medical history is remarkable for atrial fibrillation, hypertension, and right-sided breast cancer treated with mastectomy 7 years ago. Current medications are diltiazem, hydrochlorothiazide, tamoxifen, and warfarin. BMI is 16 kg/m2. Temperature is 36.8°C (98.2°F), pulse is 75/min, respirations are 14/min, and blood pressure is 115/84 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 97%. Physical examination discloses the findings shown in the photograph. The hands are mildly tender to palpation at the proximal interphalangeal (PIP) joints; there is pain with movement at these joints. X-rays of the hands show narrowing of the PIP joint spaces; presence of osteophytes; and subchondral cysts affecting the distal interphalangeal joints. Which of the following is the most likely underlying cause of the joint findings in this patient?

A 12-year-old boy is being evaluated in the intensive care unit 1 day after undergoing uncomplicated transsphenoidal removal of a craniopharyngioma diagnosed 2 weeks ago. Medical history otherwise is unremarkable. Current medications are oral acetaminophen with hydrocodone for pain and intravenous 5% dextrose in 0.9% saline. Total urine output during the past 24 hours is 4 L. The patient has requested juice and ice chips frequently during the past 6 hours. He is at the 45th percentile for height and weight; BMI is at the 40th percentile. Vital signs are within normal limits. Pulse oximetry on room air shows an oxygen saturation of 99%. Physical examination shows mild edema over the nasal septum. Results of laboratory studies are shown:

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

A 16-year-old girl comes to the office seeking advice about birth control. She says she and her boyfriend are thinking about becoming sexually active, and she does not want to become pregnant. She has no history of serious illness and takes no medications. She appears nervous and says she does not want her parents to know she is thinking about sex. In addition to reassuring the patient that her comments will be confidential, which of the following is the most appropriate initial physician response?

A 57-year-old man is examined in the hospital because of nausea and abdominal bloating 3 days after he underwent operative resection of a jejunal leiomyoma. He recently began consuming clear liquids. Medical history also is remarkable for hypertension, hyperlipidemia, and perforated appendicitis treated with appendectomy. Current medications are atorvastatin, enoxaparin, hydromorphone, and lisinopril. BMI is 31 kg/m2. Temperature is 37.3°C (99.1°F), pulse is 90/min, respirations are 18/min, and blood pressure is 122/82 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 98%. Bowel sounds are hypoactive. Abdominal examination discloses moderate distention and mild tenderness to palpation. There is no rebound tenderness or guarding. Results of laboratory studies are shown:

Abdominal x-ray is shown. Which of the following is the most likely underlying cause of the findings in this patient?

A 59-year-old woman is admitted to the intensive care unit because of palpitations, flushing, and increased sweating that have persisted since their sudden onset 4 hours ago. The patient also reports a 2-day history of nausea and diarrhea. Medical history is remarkable for hyperlipidemia and major depressive disorder. Medications are simvastatin and bupropion. BMI is 22 kg/m2. Temperature is 38.5°C (101.3°F), pulse is 128/min, respirations are 20/min, and blood pressure is 178/94 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 94%. The patient appears restless. Physical examination discloses flushed, diaphoretic skin, an enlarged and tender thyroid gland, and tachycardia with an irregular rhythm. Lungs are clear to auscultation. The remainder of the physical examination discloses no abnormalities. Results of serum laboratory studies are shown:

ECG shows atrial fibrillation with rapid ventricular response. In addition to propylthiouracil, which of the following is the most appropriate pharmacotherapy to initiate at this time?

An 18-month-old boy is brought to the emergency department by his maternal grandmother because he has not moved his left leg since this morning. His grandmother, who is his primary caregiver, says he was fine 10 hours ago when she left for her night shift at work. His 18-year-old mother, who was caring for him overnight, says that he was fine when she put him to bed and does not know what happened to him. The patient has no history of serious illness and receives no medications. He lives in a three-bedroom apartment with his mother, grandmother, maternal great grandparents, 3-year-old half-brother, and 2-month-old half-sister. The family receives additional income in the form of Social Security benefits. On arrival, the patient is crying and inconsolable. He is 83 cm (33 in; 51st percentile) long and weighs 8.75 kg (19 lb; 5th percentile); head circumference is 46.5 cm (18 in; 25th percentile). Vital signs are within normal limits. The lower extremities are in a “frog-like” position; any attempt to move the left lower extremity results in the patient screaming. There are ecchymoses over both lower extremities. X-ray of the left lower extremity shows a femur fracture and four previous fractures that have healed well; there also is evidence of osteopenia. When discussing these findings with the grandmother, which of the following is the most appropriate opening remark by the physician?

An 88-year-old woman is transferred to the hospital at her family’s request from the nursing care facility where she resides because of a 3-day history of altered mental status. A written report from the nursing staff at the facility says that she has alternated between being combative and being somnolent. Previously, she had been non-ambulatory but able to sit up in a chair, and had been alert and awake most of the day but minimally verbal. She has hypertension and residual vascular dementia resulting from a stroke 12 months ago. She smells of urine, and her fingernails and toenails are overgrown. She is 160 cm (5 ft 3 in) tall and weighs 44 kg (96 lb); BMI is 17 kg/m2. Temperature is 38.6°C (101.5°F), pulse is 116/min, respirations are 16/min, and blood pressure is 90/60 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 100%. Physical examination shows ecchymoses over both wrists. There is a stage 2 decubitus ulcer over the sacrum and stage 3 decubitus ulcers over both heels. On mental status examination, she is nonverbal and not oriented to person, place, or time. She alternates between being alert and somnolent. Which of the following is the most appropriate next step in management?

A 76-year-old man is brought to the clinic by his wife because of an 18-month history of progressive memory loss. His wife says he is unable to recall recent events and is becoming increasingly forgetful. He no longer drives because he became lost many times during the past 6 months while driving home from the grocery store and his daughter’s house, which is located a few blocks away. The patient does not think he has any memory difficulties and says his wife is overreacting. Medical history is remarkable for hypercholesterolemia. His medications are rosuvastatin, aspirin, and a daily multivitamin. He is well groomed and appears mildly anxious. Vital signs are within normal limits. Physical examination shows no abnormalities. On cognitive testing, he recalls zero of three objects after 5 minutes. He does not know the date, year, or time. No other abnormalities are noted. MRI of this patient’s brain is most likely to show which of the following?

A 2-week-old male infant is admitted to the hospital through the emergency department (ED) because of a 4-hour history of respiratory distress. Rapid testing for respiratory syncytial virus obtained in the ED was positive. Three days prior to admission, the patient developed moderate nasal congestion and increased work of breathing that has worsened today. The mother did not take the infant’s temperature at home. The infant was born at 38 weeks’ gestation via spontaneous vaginal delivery to a 24-year-old woman, gravida 1, para 1, after an uncomplicated pregnancy. Family history is unremarkable. The patient is 47 cm (18.5 in; 3rd percentile) long and weighs 2800 g (6 lb 3 oz; 10th percentile); head circumference is 33 cm (13 in; 10th percentile). Temperature is 37.8°C (100.0°F), pulse is 150/min, respirations are 80/min, and blood pressure is 80/40 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 89%. The patient appears small and is in mild respiratory distress. Physical examination shows hypertelorism, low-set posterior rotated ears, and a high arched palate but no cleft. Examination of the chest discloses 1+ subcostal retractions with diffuse expiratory wheezes. Cardiac examination discloses a grade 2/6 mid-systolic crescendo-decrescendo murmur heard best at the second left intercostal space. Abdomen is soft with no hepatosplenomegaly. Genitourinary examination discloses undescended testes; penis and scrotum appear normal. Extremities are warm to the touch and well perfused. Which of the following is the most likely cause of this patient’s heart murmur?

A 70-year-old man comes to the office because of a 3-week history of shortness of breath, nonproductive cough, and malaise. The cough is associated with generalized chest pain, which has worsened during the past week and now occurs on deep inspiration as well. The cough has not produced any blood, and the patient has not had fever, chills, headache, runny nose, sore throat, leg swelling, or difficulty sleeping. Medical history is remarkable for hypertension, congestive heart failure, and paroxysmal atrial fibrillation despite electrical cardioversion 3 years ago. The patient also has a history of prostate cancer treated with radiation therapy. Current medications are amiodarone, losartan, atorvastatin, and apixaban. BMI is 33 kg/m2. Temperature is 36.7°C (98.0°F), pulse is 68/min, respirations are 16/min, and blood pressure is 128/68 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 90%. There is no jugular venous distention or lymphadenopathy. Cardiopulmonary examination discloses diffuse crackles bilaterally and normal cardiac rhythm. Examination of the abdomen and lower extremities discloses no abnormalities. Pulmonary function testing in this patient is most likely to show which of the following results?

A 4-day-old male newborn is brought to the office by his parents because of a 2-day history of a rash on his face and trunk. He was delivered at 40 weeks’ gestation and weighed 5015 g (11 lb 1 oz) at birth. Apgar scores were 9 and 10 at 1 and 5 minutes, respectively. He has been breast-feeding well and passes normal stools. Vital signs are within normal limits, including temperature of 37.0°C (98.6°F). Physical examination discloses the findings shown in the photograph. Which of the following is the most likely cause of the findings in this patient?