Q_D_USMLE Basic Para and Emergency(photo) S_V

A 10-year-old boy presents with a 1-day history of fever, cough, and chest pain. He has not been eating and has been listless. He does not have any previous history of health problems. On physical examination, his temperature is 40°C, and he is tachypneic. He looks ill. He has rales on his left posterior lower lung fields. You order a chest x-ray. Which of the following organisms is most likely responsible for his pneumonia?

A 13-year-old develops fever, malaise, sore throat, and a dry, hacking cough over several days. He does not appear to be particularly sick, but his chest examination is significant for diffuse rales and rhonchi. The chest radio- graph is shown below. Which of the following is the most likely pathogen?

A 13-year-old male is brought to the physician for evaluation of intermittent left knee pain that arose three months ago. He does not remember any trauma to his knee. The pain worsens after basketball games, but improves some with rest. He has been taking non-steroidal anti-inflammatory medications with some relief. On physical examination, he has edema and tenderness over the proximal tibia at the site of the patellar tendon insertion. Examination of the knee joint is normal and no effusion is present. His knee pain is reproducible by extending the knee against resistance. A lateral radiograph of his knee is shown below. Which of the following is the most likely cause of this patient's knee pain?

A 2-day-old boy in the newborn nursery was born at 39 weeks gestation to a 38-year-old woman by vaginal delivery. The mother received epidural fentanyl for severe painful contractions during labor, but the delivery was uncomplicated. Since birth, the boy has shown little interest in breast or bottle feeding. He spit up the last feed but has not vomited. He has not yet passed meconium. Physical examination shows a newborn with generalized hypotonia, a flat facial profile, low-set folded earlobes, and a single transverse crease on each palm. His abdomen is firm and distended. Digital rectal examination is notable for a tight anal canal and relieves an expulsion of gas and stool. Abdominal x-ray shows markedly distended loops of bowel with no gas in the rectum. What is the mostly likely mechanism for his findings?

A 2-year-old child in shock has multiple nonblanching purple lesions of various sizes scattered about on the trunk and extremities; petechiae are noted, and oozing from the venipuncture site has been observed. The child’s peripheral blood smear is shown below. Clotting studies are likely to show which of the following?

A 23-year-old, HIV-infected female presents with a five-day history of fever and productive cough. She is on antiretroviral therapy, and her CD4 count is 300/mm3. Her temperature is 39.0°C (102.5°F), pulse is 95/min, respirations are 22/min, and blood pressure is 115/76 mm Hg. Physical exam reveals dullness to percussion and bronchial breath sounds in the right lung base. Chest x-ray is shown below. What is the most likely cause of this patient's symptoms?

A 24-year-old woman comes to the physician complaining of a skin rash and pain in her wrists, ankles and elbows over the past 4 days. She has also had a fever and sweats, but denies headache, nausea or vomiting. She has no significant past medical history and does not take any medications. She recently took a vacation with her new boyfriend. She denies any previous sexually transmitted diseases but acknowledges having unprotected sex with her new boyfriend. She does not use tobacco, alcohol or illicit drugs. Her temperature is 38.5°C (101.3°F) and her pulse is 98/min. Her oropharynx is clear and there is no thrush or lymphadenopathy. Her abdomen is benign and the pelvic examination is within normal limits. She has pain along the tendon sheaths with active and passive hand movement. A photo of her skin rash is shown below. Which of the following is the most likely cause of her symptoms?

A 25-year-old man is recovering in the hospital from an open repair of his broken femur, which he suffered during an automobile accident. On postoperative day 3 he develops sudden onset shortness of breath and vague chest discomfort. His temperature is 37.6°C (99.6°F), heart rate is 108/min, blood pressure is 95/62 mm Hg, respiratory rate is 42/min, and oxygen saturation is 89% on room air. Physical examination is significant for jugular venous distention to 9 cm and an accentuated pulmonic component of S2. A pulmonary angiogram is shown in the image. Which of the following is most likely to be decreased?

A 29-year-old construction worker fell 15 ft from a roof and broke his right humerus, as depicted in the accompanying radiograph. Given his injury, which of the following nerves is most at risk?

A 3-year-old boy is brought to the pediatrician because his mother noticed a reddish-purple rash on his buttocks and thighs (see image). She notes that he has not seemed well since he had a mild cold 2 weeks earlier; he has been complaining of aches and pains in his legs and a stomach ache. Urinalysis shows 10–20 RBCs/ mm³ and 2+proteinuria. Which of the following is associated with this patient’s disease process?

A 31-year-old male presents to your office with a velvety skin rash in his axilla as shown on the slide below. Which of the following is the most
likely cause of this patient's condition?

A 32-year-old homosexual male with HIV infection presented to his physician with skin lesions. He first noted these lesions last month, and has since observed a change in color from pink to violet. There is no associated pain, itching, or burning. He was diagnosed with HIV infection three years ago and has been noncompliant with his medications. His pulse is 80/min, blood pressure is 115/70 mm Hg, respirations are 14/min, and temperature is 37.1° C (98.8°F). The appearance of his lesions is illustrated below. His CD4 count is 30/microl, and viral load is 300,000copies/ml. Which of the following is the most likely cause of his current condition?

A 38-year -old male is brought to the emergency room with high-grade fever, shaking chills, productive cough and shortness of breath that started two days ago. His medical history is significant for two hospital admissions for alcohol withdrawal seizures. He continues to drink alcohol every day. He has no other medical problems and does not take any medications. On admission, his temperature is 39.7°C (103.5°F), pulse is 110/min, blood pressure is 100/70 mmHg, and respirations are 20/min. His skin and mucous membranes are dry. Physical examination reveals crackles and bronchial breath sounds in the right lower lobe. Chest x-ray demonstrates right lower lobe consolidation. He is started on ceftriaxone, azithromycin and intravenous normal saline at 200 ml/hr. Six hours later the nurse calls you because he is breathing at 38/min and requiring 100% oxygen. Emergent intubation is performed. A repeat chest x-ray is shown below. Which of the following is now most likely to be present in this patient?

A 45-year-old black female presents to you because of a dry cough and has not been feeling well for the past month. She did have some pain in her shins a few weeks ago. She denies any allergies, smoking, or other medical problems. Her ECG shows normal sinus rhythm. The chest x-ray is shown below. What is the most likely pathophysiology in this patient?

A 45-year-old HIV-positive woman comes to her primary care physician complaining of a 2-day history of bloody diarrhea. She states that she has been feeling well until 2 days ago, when she developed abdominal pain. She denies fevers, chills, night sweats, nausea, or vomiting. She admits to feeling tired over the last couple of weeks and has had a 2.3-kg (5-lb) weight loss over the past 2 weeks. Her stool sample shows WBCs and RBCs. Her Gram stain is shown in the image. Her CD4+ cell count is 201/mm³. Which of the following is the most likely cause of this woman’s symptoms?

A 46-year-old construction worker is brought to the clinic by his wife because she has noticed an unusual growth on his left ear for the past 8 months (see photo below). The patient explains that, except for occasional itching, the lesion does not bother him. On physical examination, you notice an 8-mm pearly papule with central ulceration and a few small dilated blood vessels on the border. What is the natural course of this lesion if left untreated?

A 54-year-old female with a long history of hypertension and a recent hospitalization for atrial fibrillation with rapid ventricular response now returns to the hospital complaining of skin changes. Her medications include warfarin, hydrochlorothiazide and metoprolol. On physical examination, her temperature is 36.7°C (98°F), blood pressure is 130/80 mm Hg, pulse is 80/min and irregular, and respirations are 16/min. You observe the skin changes pictured below. Her exam is otherwise unremarkable. Which of the following is the primary cause of her condition?

A 6-year-old boy is brought to his pediatrician for a routine check-up. He has not been seen by a physician for the past 3 years. Recently, he has developed some patchy areas of hair loss on his scalp. The mother also notes he has had many colds over the past year. She says he has developed normally, although he started walking later than her other two children. On physical examination his wrists appear enlarged, and he has bowing of the forearms and legs. X-ray of the boy’s legs is shown in the image. Laboratory tests show a calcium level of 7.1 mg/dL, phosphate of 1.8 mg/dL, and intact parathyroid hormone of 130 pg/mL (normal: 10–65 pg/mL). Vitamin D level is normal. Treatment with vitamin D does not correct the patient’s hypocalcemia. Which of the following disorders best explains this patient’s findings?

A 61-year-old man is being evaluated for progressive exertional dyspnea and decreased exercise tolerance. He has also noticed some ankle swelling. The patient has a 40 pack-year smoking history but denies illicit drug use or occupational exposures. His chest x-ray is shown below. The abnormal diaphragmatic contour seen here most likely results in which of the following?

A 65-year-old chronic smoker presents to the hospital with increasing shortness of breath for the past few hours. He has been using albuterol occasionally, but it has not been helping him. He has been non-adherent to doctor's appointments and continues to smoke. He is afebrile. His oxygen saturation on room air is 86%. Examination shows elevated jugular venous pressure and lung auscultation reveals diffuse wheezing with no crackles. His heart sounds are muffled. Mild hepatomegaly and bilateral pitting pedal edema is present. Chest x-ray reveals hyperinflated lungs and a flattened diaphragm with no infiltrates. He is started on systemic steroids, bronchodilator nebulization and furosemide. His laboratory studies are shown below at the time of admission and five days later. Which of the following best explains the acid-base status change in this patient?

A 65-year-old female presents with 6 months of worsening dyspnea and dry cough. Whereas she had previously enjoyed an active lifestyle, she now becomes breathless after walking just a few steps. The patient denies fever or chest pain and does not use tobacco, alcohol or illicit drugs. Her only medicine is hydrochlorothiazide for hypertension. She is retired and lives with her husband. She has never travelled abroad and denies any history of exposure to pets. On physical examination, her temperature is 37.2°C (98.9°F), blood pressure is 140/86 mm Hg, pulse is 84/min and respirations are 18/min. Examination shows dry, late inspiratory crackles and finger clubbing. Her chest x-ray is shown below. Which of the following abnormalities is most likely to be present in this patient?

A 68-year-woman with hypertension and dyslipidemia presents with 30 minutes of retrosternal chest pain radiating to her neck. She is diaphoretic and in moderate distress. The ECG shows ST-segment elevation in the inferior leads. Which of the following mechanisms is the most likely cause of her condition?

A 69-year-old woman complains of easy fatigue and one episode of presyncope. On examination of the jugular venous pressure (JVP), there are irregular large a waves. The ECG has fixed PP and RR intervals but varying PR intervals. Which of the following conditions is this most likely caused by?

A 70-year-old Caucasian man comes to the emergency department because of the sudden onset of nausea, vomiting, diaphoresis, and chest pain. His other medical problems include hypertension, diabetes mellitus-type 2, and aortic stenosis. He has smoked one-and-a-half packs of cigarettes daily for 30 years and drinks 4 ounces of alcohol daily. His temperature is 37.2°C (99°F), blood pressure is 100/60 mmHg, pulse is 60/min, and respirations are 18/min. The patient's pulse oximetry showed 98% at room air. Examination shows normal first and second he sounds. Lungs are clear to auscultation. His EKG is shown below. Which of the following is the most likely mechanism of this patient's condition?

A 72-year-old woman notices progressive dysphagia to solids and liquids. There is no history of alcohol or tobacco use, and the patient takes no medications. She denies heartburn, but occasionally notices the regurgitation of undigested food from meals eaten several hours before. Her barium swallow is shown. Which of the following is the cause of this condition?

A 74-year-old Caucasian woman is brought to the emergency department after a fall. Her husband is concerned since she is on "blood thinners." Her other medical problems include hypertension, hearing loss, congestive heart failure, coronary artery bypass graft, transient ischemic attack, and atrial fibrillation. She does not use tobacco, alcohol, or drugs. Her medications include aspirin, metoprolol, digoxin, furosemide, and warfarin. Her temperature is 37.2°C (99°F), blood pressure is 140/90 mmHg, pulse is 72/min, and respirations are 14/min. CT scan of the head without contrast is shown below. Which of the following is the most likely cause of her condition?

A 76-year-old man is brought to the emergency department by his son who found him confused in his apartment. The son also reports that his father has been limping for the past two days. The patient's past medical history is significant for hypertension, diabetes mellitus, and cataract surgery six months ago. His medications are metoprolol, enalapril, and glyburide. He has also been taking ibuprofen for recent headaches. A head CT scan is obtained and is shown below. Which of the following is the most likely cause of this patient's condition?

A 80-year-old man with Type II diabetes and hypertension presents with increasing dyspnea. He appears short of breath, blood pressure is 170/95 mmHg, pulse 100/min and regular. The JVP is at 7 cm; there is a loud second heart sound and a systolic ejection murmur at the right sternal border, which does not radiate. The lungs have bibasilar crakles up to the scapula. The CXR has bilateral infiltrates and vascular redistribution. His echocardiogram reports aortic sclerosis, concentric left ventricular hypertrophy (LVH), and normal ejection fraction. Which of the following is the most likely mechanism for this condition?

A previously healthy 5-year-old boy has a 1-day history of low-grade fever, colicky abdominal pain, and a rash. He is well-appearing and alert. His vital signs, other than a temperature of 38°C (100.5°F) are completely normal. A diffuse, erythematous, maculopapular, and petechial rash is present on his buttocks and lower extremities, as shown in the photograph. He has no localized abdominal tenderness or rebound; bowel sounds are active. Laboratory data demonstrate Urinalysis: 30 red blood cells (RBCs) per high-powered field, 2+ protein. Stool: Guaiac positive Platelet count: 135,000/μL. These findings are most consistent with which of the following?

An otherwise healthy child has on his 1-year-old routine CBC the polymorphonuclear neutrophil shown below. This child likely has which of the following?

Shortly after birth, an infant develops abdominal distention and begins to drool. When she is given her first feeding, it runs out the side of her mouth, and she coughs and chokes. Physical examination reveals tachypnea, inter- costal retractions, and bilateral pulmonary rales. The esophageal anomaly that most commonly causes these signs and symptoms is illustrated by which of the following?

You see the newborn baby shown below for the first time in the nursery. You consult plastic and reconstructive surgeon as well as the hospital’s speech therapist. Understandably, the parents have many questions. Which of the following statements is appropriate anticipatory guidance for this family?

A 14-year-old boy presents at the pediatric clinic for a routine check-up. The patient had developed end-stage renal disease over the previous 2 years, and was successfully treated with a renal transplant 6 months prior. Since his operation, he has developed purple striae on his back and arms, central obesity, and an increasingly round face. During the subsequent blood analysis, which of the following results would be most likely?

) A 17-year-old girl has never had a menstrual period. On physical examination, she has minimal breast development and no axillary or pubic hair. She is color blind and has had a diminished sense of smell since birth. Laboratory evaluation would most likely reveal which of the following?

A 2-month-old infant is brought to the physician for evaluation of fever. The infant was born at 37 weeks gestation via normal spontaneous vaginal delivery. His mother had an uncomplicated pregnancy and delivery. He has been doing well until this morning when he developed a temperature of 101.5 F (38.6 C). His mother reports that he is still taking his formula well. He has some clear rhinorrhea and intermittent sneezing. His 3-year-old brother had an upper respiratory tract infection one week ago. The patient's chest radiograph is shown below. Which of the following best describes the findings on this patient's chest radiograph?

A 21-year-old man has a nonproductive cough, shortness of breath, and chest pain, which changes with breathing. He also has pain in the left arm. On examination, there is tenderness over the left shoulder, heart sounds are normal, and the lungs are clear. CXR reveals a lytic lesion in the left humerus and reticulonodular opacities in the upper and middles lobes. The eosinophil count is normal. Which of the following is the most appropriate initial diagnostic test?

A 22-year-old man with inflammatory bowel disease is noted to have a “string sign” in the ileal area on barium enema. In which of the following conditions is this sign most often seen?

A 25-year-old female with blonde hair and fair complexion complains of a mole on her upper back. The lesion is 8 mm in diameter, darkly pigmented, and asymmetric, with an irregular border (see illustration below). Which of the following is the best next step in management?

A 25-year-old G2, PI at 28 weeks gestation is brought to the emergency department by her boyfriend, who found her lying on her bed in a pool of blood. She is very drowsy, but denies any pain or uterine contraction. Her temperature is 38°C (100.4°F) and respirations are 18/min. Physical examination is suggestive of a transverse lie. Inspection of the perineum reveals gross blood and active bleeding per
vagina. Which of the following set of parameters would most likely be seen in this patient?

A 32-year-old man is intubated and mechanically ventilated after an opioid drug overdose. The ventilator triggers 12 breaths per minute, each delivering 500 ml of tidal volume at a flow rate of 60 L/min. You perform an inspiratory hold for 2 seconds following delivery of the tidal volume, and the airway pressure is measured to be 30 cm H2O. The measured pressure reflects which of the following?

A 33-year-old African-American woman presents with one week of painful skin lesions on her legs. She has no cough, shortness of breath or bowel symptoms, and denies any recent illness or travel. She has no other significant past medical history and does not take any medication. She smokes one pack of cigarettes and drinks one glass of wine daily. She denies a history of sexually transmitted diseases and has been married to a monogamous partner for the past eight years. Her mother was diagnosed with ovarian cancer at age 65. Her temperature is 37.2°C (98.9°F), and blood pressure is 126/76 mmHg. On examination, she has multiple tender pink to reddish nodules noted below the knee on the extensor surface, as shown below. Which of the following is the most appropriate next step in her management?

A 4-year-old girl is brought to the pediatrician’s office. Her father reports that she suddenly became pale and stopped running while he had been playfully chasing her and her pet Chihuahua. After 30 minutes, she was no longer pale and wanted to resume the game. She has never had a previous episode and has never been cyanotic. Her physical examination was normal, as were her chest x-ray and echocardiogram. An ECG showed the pattern seen on the next page, which indicates which of the following?

A 42-year -old male with a past medical history of bladder cancer and recurrent hematuria presents to the emergency room after "passing out" when he got out of bed this morning. The patient says that he was standing up to urinate shortly after waking when he began feeling dizzy. Fortunately he was able to return to his bed before losing consciousness for 7-10 minutes. His EKG at the time of admission is shown below. Which of the following most likely accounts for the observed EKG changes?

A 46-year-old man comes to the ER because of weakness and chest tightness. He has had these symptoms for the past one hour. He denies any past medical history. He does not smoke or drink alcohol. His father had a myocardial infarction at 68 years of age and his mother has myasthenia gravis. His EKG is shown on the slide below. The patient should be evaluated for which of the following?

A 50-year-old man presents to the emergency room with a 6-hour history of excruciating abdominal pain and distention. The abdominal film shown here is obtained. Which of the following is the most appropriate next diagnostic maneuver?

A 56-year-old male is being evaluated for increased fatigability. His past medical history is significant for severe aortic stenosis that required aortic valve replacement, diabetes mellitus, and osteoarthritis. Peripheral blood smear findings are shown on the slide below. Which of the following laboratory findings would you most expect to find in this patient?

A 58-year-old man is brought to the ED for a syncopal episode at dinner. His wife states that he was well until she found him suddenly slumping in the chair and losing consciousness for a minute. The patient recalls having some chest discomfort and shortness of breath prior to the episode. His rhythm strip, obtained by EMS, is shown below. Which of the following best describes these findings?

A 58-year-old white man complains of intermittent rectal bleeding and, at the time of colonoscopy, is found to have internal hemorrhoids and the lesion shown at the splenic flexure. Pathology shows tubulovillous changes. Repeat colonoscopy should be recommended at what interval?

A 61-year-old woman was on her way to the grocery store when she started feeling chest pressure in the center of her chest. She became diaphoretic and felt short of breath. On arrival to the ED by EMS, her BP is 130/70 mmHg, HR is 76 beats per minute, and oxygen saturation is 98% on room air. The nurse gives her an aspirin and an ECG is performed as seen below. Which of the following best describes the location of this patient’s myocardial infarction (MI)?

A 64-year -old African American male presents to you with complaints of a dry cough, weight loss and pain in his right arm. The symptoms started approximately 2 months ago. His past medical history is significant for type 2 diabetes mellitus and hypertension. He smokes 1 pack per day and drinks alcohol occasionally. He denies any drug allergies. Physical examination is unremarkable. ECG reveals normal sinus rhythm. An MRI of his chest is shown below. Which of the following is most likely responsible for this patient's symptoms?

A 65-year-old male comes to the office on a hot summer afternoon. He complains of blisters and intense itching all over his body for the past 2 days. He has been having "itchy red swelling all over" for the past 2 months, which he thinks is due to the summer heat. His pulse is 82/min, blood pressure is 140/80 mmHg, respirations are 14/min, and temperature is 36.8°C (98.4°F). On examination, lesions are seen on both normal and erythematous skin over flexural areas of the groin, axilla and legs. An image of one of these lesions is shown below. Which of the following is most likely seen with this patient's condition?

A 65-year-old man presents to his physician complaining of difficulty swallowing, occasional chest pain, and regurgitation of food. Over the past 2 months he has lost about 7 kg (15 lb). Results of a barium swallow study are shown in the image. What test should be performed to look for possible causes of his condition?

A 65-year-old woman presents to the physician’s office for her yearly physical examination. She has no complaints except for a recent 10-lb weight loss. Past history is pertinent for a 40 pack-year smoking history, hypertension, asthma, and hypothyroidism. Examination reveals a thin woman with normal vital signs and unremarkable heart and abdominal examinations. Lung examination reveals mild wheezing and a few bibasilar rales. A chest x-ray is obtained and is shown in Figure 6-13. A chest x-ray obtained 3 years ago was normal. Yearly laboratory tests including a CBC, electrolytes, and lipid panels are normal. Which of the following is the most appropriate next diagnostic test?

A 65-year-old woman presents to the physician’s office with a 6-month history of epigastric discomfort, poor appetite, and 10-lb weight loss. Past history is pertinent for hypertension, diabetes, a 30 pack-year smoking history, and occasional alcohol intake. Examination is unremarkable except for mild epigastric tenderness to deep palpation. An abdominal ultrasound reveals cholelithiasis, and one view of a UGI x-ray series is shown in Figure 6-8. Which of the following is the most appropriate next step in management?

A 69-year-old woman presents with left flank pain and hematuria. Physical examination suggests a left-sided abdominal mass. Computerized tomography (CT) scan of the abdomen reveals a 5-cm mass in the left kidney. Which of the following laboratory abnormalities might also be present (See Fig.)?

A 7-week-old, breast-fed, term infant presents with increasing jaundice, abdominal distention, and abnormal stools (Figure 6-20). Liver function tests demonstrate a conjugated hyperbilirubinemia, mildly elevated transaminases, and an elevated gamma-glutamyl transpeptidase. TORCH (congenital infection complex, including toxoplasmosis, rubella, cytomegalovirus, and hepatitis) serology and screening for inborn errors of metabolism are negative. As part of the diagnostic evaluation, the most sensitive imaging study in this clinical setting would be which of the following?

A 70-year-old man has dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. He has generalized cardiomegaly and pulmonary and systemic venous hypertension. The ECG is shown in Fig.What is the cardiac rhythm?

A 74-year -old Caucasian man is evaluated for occasional palpitations and poor exercise tolerance. He has been living alone since his wife died two years ago. His diet consists mainly of precooked food that he heats up in the microwave oven. He has a history of degenerative joint disease and hypertension. He takes a daily aspirin, hydrochlorothiazide, and glucosamine. He quit smoking 20 years ago and occasionally drinks alcohol. His peripheral blood smear is shown below. Which of the following substances is most likely elevated in this patient's blood?

A 75-year-old woman is brought to the emergency department from a nursing home for abdominal pain, distention, and obstipation over the last 2 days. Past history is pertinent for stroke, diabetes, atrial fibrillation, and chronic constipation. Examination reveals a temperature of 98.6°F, pulse rate 90/min and irregularly irregular, and BP 160/90 mmHg. Heart examination reveals irregularly irregular rhythm with no murmurs; lung examination reveals few bibasilar rales; and abdominal examination reveals a distended, tympanic abdomen with mild tenderness and no rebound tenderness. Plain abdominal x-rays reveal dilated loops of bowel, and a barium enema is obtained and shown in Figure 6-9. Which of the following is the most appropriate next step in management following NG tube decompression and resuscitation?

 

A 77-year-old woman comes to the emergency department because of feeling “light-headed and dizzy.” Except for the irregular pulse, her physical examination is normal. What is the rhythm in the lead tracing shown in Fig.?

A very upset mother brings her 8-month-old child to the emergency room because he will not move his leg. She reports that when she was carrying him to the car about half an hour ago, she slipped on some ice and fell on top of him. The mother, an 18-year-old African American woman, has been exclusively breast-feeding her child. She has only recently started him on cereals, and has not supplemented his diet with vitamins. A radiograph of the child’s leg is shown below. Which of the following laboratory findings would be expected?

An 18-year-old male complains of fever and transient pain in both knees and elbows. The right knee was red and swollen for 1 day during the week prior to presentation. On physical examination, the patient has a low-grade fever. He has a III/VI, high pitched, apical systolic murmur with radiation to the axilla, as well as a soft, mid-diastolic murmur heard at the base. A tender nodule is palpated over an extensor tendon of the hand. There are pink erythematous lesions over the abdomen, some with central clearing. The following laboratory values are obtained: Hct: 42, WBC: 12,000/µL with 80% polymorphonuclear leukocytes, 20% lymphocytes, ESR: 60 mm/h. The patient’s ECG is shown below. Which of the following tests is most critical to diagnosis?

Physical examination of a baby boy shortly after birth reveals a large bladder and palpable kidneys. The nurses note that he produces a weak urinary stream. A voiding cystourethrogram is shown below. He appears to be otherwise normal. Which of the following is the most likely diagnosis?

The ECG shown in Fig. Was obtained during the initial stages of an acute MI. The patient had just received thrombolytic therapy. What is the rhythm?

The photomicrograph below is of a urine specimen from a 15-year-old girl. She has had intermittent fever, malaise, and weight loss over the previous several months. Recently she has developed swollen hands, wrists, and ankles, the pain of which seems out of proportion to the clinical findings. She also complains of cold extremities and has some ulceration of her distal digits. Which of the following laboratory tests is most likely to assist in the diagnosis of this condition?

You are called by a surgical colleague to evaluate a 54-year-old woman with ECG abnormalities one day after a subtotal thyroidectomy for a toxic multinodular goiter. Her only medication is fentanyl for postoperative pain control. The patient denies any history of syncope, and has no family history of sudden cardiac death. Physical examination is unremarkable except for a clean postoperative incision at the base of the neck. Her ECG is reproduced below. What is the best next step in evaluation and management of this patient?

A 20-year-old man was found on the ground next to his car after it hit a tree on the side of the road. Bystanders state that the man got out of his car after the collision but collapsed within a few minutes. Paramedics subsequently found the man unconscious on the side of the road. In the ED, his BP is 175/90 mmHg, HR is 65 beats per minute, temperature is 99.2°F, RR is 12 breaths per minute, and oxygen saturation is 97% on room air. Physical examination reveals a right-sided fixed and dilated pupil. A head CT is shown below. Which of the following is the most likely diagnosis?

A 29-year-old male, known intravenous drug user presents to the emergency department with a chief complaint of dyspnea. Over the last few days, he has become short of breath and he has very little exercise tolerance. His other symptoms are a persistent dry cough, low-grade fever for the past two days, watery diarrhea, abdominal cramps, and general malaise. He self-treated his fever with acetaminophen. He has a history of anaphylaxis with sulfonamides. Physical examination reveals an emaciated man with numerous needle marks on his hands. Arterial blood gas analysis reveals a PCO2 of 32 mm Hg and PO2 of 64 mm Hg on room air. The chest x-ray is shown below. Which of the following is the most appropriate initial treatment regimen for this patient?

A 3-month-old infant is brought to your office for pallor and listless- ness. Your physical examination reveals tachycardia that is constant and does not vary with crying. He has no hepatomegaly and the lungs are clear. His ECG is shown. Which of the following is the most appropriate initial management of this patient?

A 34-year-old male presents to the emergency department with a red eye. He says, "I just woke up this morning and saw that my right eye was red." He denies any itching, pain or discharge. He has no known drug or environmental allergies. He takes no medication. His vital signs are stable. The photo of his eye is shown below. What is the best next step in his management?

A 4-year-old boy is brought into the emergency room by his parents for difficulty in breathing and swallowing. On physical examination the child is febrile, tachycardic, and tachypneic. He is anxious, drooling, and becomes increasingly exhausted while struggling to breathe. A lateral cervical spine radiograph is shown here. Which of the following is the most appropriate management of this patient?

A 40-year-old man with a history of untreated HIV for 8 years comes into the ED complaining of cough, fever, and malaise for 3 days. He is tachypneic and diaphoretic. Chest radiograph reveals bilateral infiltrates. Arterial blood gas (ABG) analysis is significant for a PaO2 of 62 on room air. His chest radiograph is seen below. Which of the following is the most appropriate initial management?

A 42-year-old male is admitted to the hospital with fever and shortness of breath. He has HIV infection, hepatitis C infection, and alcohol induced cardiomyopathy. His temperature is 38.6°C (101.5°F). Thrush is noted in the oropharynx. Chest x-ray reveals right lower lobe consolidation. He is started on fluconazole and moxifloxacin. His pneumonia and thrush improve over the next 2 days. However, on the third day, he develops palpitations. His EKG strip is shown below. Which of the following is the most appropriate next step in management?

A 46-year-old man collapsed while getting out of his bed. He has been feeling weak over the last several days and has complained of vague chest discomfort. He ascribed the symptoms to a recent respiratory infection and did not visit a doctor. His mother died of a stroke and his father suffered from recurrent myocardial infarctions. He eats a balanced diet and takes a multivitamin daily. His most recent blood cholesterol level was 200 mg/dl. An ECG strip taken by EMS is shown below. Which of the following is the best initial management of this patient?

A 47-year-old woman presents to the emergency department with an 8-day history of left lower quadrant pain and semi-formed stools. Starting this afternoon, she has noticed blood in her stool as well as dizziness when she gets up from sitting. She denies fever, nausea, vomiting, weight loss, and night sweats. Her temperature is 37°C (98.6°F), heart rate is 104/ min, blood pressure is 120/82 mm Hg supine and 103/63 mm Hg when she sits up, and respiratory rate is 18/min. Physical examination reveals no peritoneal signs and is remarkable only for fecal occult blood on rectal examination. Laboratory results reveal a WBC count of 13,000/mm³ and hematocrit of 29%. Results of an x-ray of the abdomen are shown in the image. What is the best next step in management?

A 48-year-old African American man presents to the emergency room with severe retrosternal chest pain. His temperature is 36.7°C (98°F), blood pressure is 190/ 100 mmHg, pulse is 100/min, and respirations are 16/min. On physical examination, his lungs are clear to auscultation and his heart sounds are normal. EKG shows evidence of left ventricular hypertrophy. A CT image of his chest is shown below. Which of the following is the most appropriate immediate pharmacotherapy for this patient?

A 48-year-old male presents to the doctor with a history of persistent cough, tenacious mucopurulent sputum, and intermittent chills. He has been treated with several courses of antibiotics without resolution of his symptoms. On examination, he has an emaciated appearance and there is decreased air entry in the right lung base. His sputum has a foul smell. High resolution CT scan of the chest is shown below. Which of the following is the most feared complication of this patient's condition?

 

A 51-year-old man with a long history of hypertension presents to the ED complaining of intermittent chest palpitations lasting for a week. He denies chest pain, shortness of breath, nausea, and vomiting. He recalls feeling similar episodes of palpitations a few months ago but they resolved. His blood pressure (BP) is 130/75 mmHg, heart rate (HR) is 130 beats per minute, respiratory rate (RR) is 16 breaths per minute, and oxygen saturation is 99% on room air. An ECG is seen below. Which of the following is the most appropriate next step in management?

A 55-year-old man presents to the ED with worsening weakness, muscle cramps, and paresthesias. His past medical history is significant for hypertension and diabetes. He smokes one pack of cigarettes per day. On examination, the patient is alert and oriented and diffusely weak. An ECG is seen below. Which of the following is the most important next step in management?

A 55-year-old woman complains of right leg swelling and tenderness following an international flight. A venous scan of the right lower extremity showed thrombosis of the right popliteal vein. She is sent home with oral warfarin and subcutaneous enoxaparin. One week later, she returns to the office for a follow-up appointment. Laboratory studies at the time of discharge and now are shown below: This patient's current condition predisposes her to which of the following?

A 58-year-old man comes to the emergency department complaining of colicky abdominal pain over the past 3 days that suddenly became more severe and constant over the past 6 hours. A contrast study is performed and results are shown in the image. What is the first-line treatment after fluid resuscitation and nasogastric tube placement?

A 59-year-old man presents to the ED with left-sided chest pain and shortness of breath that began 1 hour ago. Initial vital signs are BP 85/45 mmHg, HR 105 beats per minute, RR 20 breaths per minute, and oxygen saturation 94% on room air. An ECG is seen below. Which of the following is the most appropriate definitive treatment?

A 6-year-old boy is often teased at school because he has stooled in his underwear almost daily for the last 3 months. He was toilet trained at 2 years of age without difficulty, but over the last 2 years he had developed ongoing constipation. His family is frustrated because they cannot believe him when he says “I didn’t know I had to go.” He is otherwise normal; school is going well, and his home life is stable. His only finding on examination is significant for stool in the rectal vault. The plain radiograph of his abdomen is shown. Initial management of this problem should include which of the following?

A 6-year-old, fully immunized boy is brought to the emergency room with a 3-hour history of fever to 39.5°C (103.1°F) and sore throat. The child appears alert, but anxious and toxic. He has mild inspiratory stridor and is drooling. He is sitting on the examination table leaning forward with his neck extended. A lateral radiograph of his neck is shown below. Which of the following is the most appropriate immediate management of this patient?

A 62-year-old man presents to the emergency department (ED) with one hour of severe epigastric pain. He has been having some epigastric pain exacerbated by eating for the last several days. He feels nauseated, and has vomited once since the pain began. His past medical history is significant for hypertension, diabetes, hyperlipidemia, and coronary artery disease. He underwent coronary bypass surgery one year back. His current medications are simvastatin, aspirin, clopidogrel, metoprolol, enalapril and metformin. His blood pressure is 140/100 mmHg, and heart rate is 65/min. His ECG is normal. Chest x-ray findings are shown on the slide below. Which of the following is the best step in the management of this patient?

A 64-year-old Caucasian female is rushed to the emergency department (ED) due to a sudden onset of severe headache and altered mental status. By the time she arrived at the ED, she had deteriorated to a stuporous state. She developed a fever and severe dry cough yesterday, but did not take any medicine nor consult her physician. Her medical problems include hypertension, coronary artery disease, atrial fibrillation, mitral valve regurgitation, and psoriasis. Her medications include aspirin, metoprolol, warfarin, amiodarone, and multivitamin tablets. Her blood pressure is 162/80 mm Hg, pulse is 80/min, respirations are 16/min and temperature is 37°C (98°F). Her lab results are: Hb 13 g/dl, WBC 11,000/cmm, Platelets 180,000/cmm, Blood Glucose 118 mg/dl, Serum Na 138 mEq/L, Serum K 4.5 mEq/L, BUN 16 mg/dl, Serum Creatinine 1.0 mg/dl, PT 25.0sec, INR 4.0. Which of the following is the most appropriate next step in management?

A 64-year-old male is admitted in ICU for acute myocardial infarction. He is on metoprolol, lisinopril, aspirin, furosemide, and potassium supplements. All of a sudden, the nurse mentions that the patient has a change in his tele monitoring. His blood pressure is 120/60 mmHg. His potassium level is 4.2. He is alert, awake and oriented time, place and person. Examination shows scattered bilateral crackles, peripheral pedal edema and elevated JVI. Which of the following is the next best step in the management of this patient?

A 64-year-old man in the surgical intensive care unit goes into rapid atrial fibrillation on postoperative day one after a decortication for a loculated pulmonary empyema. He is given an appropriate loading dose of digoxin, but 4 hours after his second dose, the patient complains of increased palpitations and dizziness. The patient is conscious and hemodynamically stable. STAT serum blood tests show a potassium level of 5.0 mEq/L; all other electrolytes, including divalents, are in the normal range. The digitalis level is above the therapeutic range at 4 ng/mL (therapeutic range 0.5-2 ng/mL). Results of cardiac telemetry are shown in the image. Which of the following should be administered immediately?

A 65-year-old man develops palpitations and dizziness. His blood pressure is 80/50 mm Hg and his pulse is regular at 150/min. His ECG shows a “saw-toothed” pattern of P waves. Which of the following procedures is most appropriate in converting him back to sinus rhythm?

A 66-year-old male is rushed to the emergency department because he feels dizzy and light-headed. He denies chest pain or palpitations. He has a history of hypertension and diabetes. His blood pressure is 116/62 mmHg and his pulse is 35-40/min. He is alert, awake, and fully oriented. He is breathing comfortably and does not appear to be in any distress. His extremities are slightly cold and capillary refill is 3 seconds. His EKG is shown below. Which of the following is the most appropriate next step in management?

A 67-year-old white male with a long history of bronchial asthma and chronic obstructive pulmonary disease (COPD) presents to the emergency room complaining of acute onset of shortness of breath for the last 30 minutes. He says that for the past 2 or 3 days he has been having some difficulty breathing and a productive cough with thick phlegm, but nothing as bad as the current episode. He also has a history of congestive heart failure after suffering a myocardial infarction for which he is taking furosemide and lisinopril. While talking to you in halting sentences, you note that he appears cyanotic, confused and are sweating profusely. He normally takes albuterol, ipratropium and budesonide inhalers for his breathing difficulties, but they have not relieved his current symptoms. On examination, he is found to be markedly dyspneic and his PaO2 is 55 mm Hg. A chest x-ray done in the ER is shown below. Which of the following is the most appropriate next step in the management of this patient?

A 69-year-old male undergoes coronary artery bypass and aortic valve replacement surgery. The procedure goes well, and he is extubated and discharged to the step-down unit on postoperative day 2. That night, he complains of weakness, chest tightness and shortness of breath. His blood pressure is 70/30 mmHg, respiratory rate is 26/min, and heart rate is 148 beats per minute. Lung auscultation reveals bibasilar crackles. An EKG rhythm strip is obtained. Which of the following is the best next step in the management of this patient?

A 7-year-old boy was brought to the emergency department after falling onto his outstretched arm. He complains of pain in his left arm and refuses to move his arm at the elbow. On examination, the left arm is swollen, slightly pale, and edematous. His radial pulse is intact. The patient's radiograph is shown below. While the patient is waiting for the orthopedic resident on call to examine him, he continues to complain of increasing pain despite multiple doses of pain medication. Which of the following should you be most concerned about in this patient

A 70-year-old male with a history of mild chronic kidney disease, diabetes mellitus, and CHF is admitted to your inpatient service with decreased urine output, weakness, and shortness of breath. He takes several medications but cannot remember their names. Labs are pending; his ECG is shown below. Based on the information available, what is the best initial step in management?

A 72-year-old female is admitted to the ICU with severe chest pain. The initial set of cardiac enzymes is positive and her EKG reveals an anterior wall myocardial infarction. She receives treatment with aspirin clopidogrel, metoprolol nitroglycerine drip, and morphine. Two hours later, her telemetry monitor displays the following rhythm. Which of the following is the best next step in managing this patient?

A 75-year-old woman with a history of diabetes and coronary heart failure presents to the emergency department because of increasing
abdominal girth. In recent months she has been feeling increasingly fatigued, and although she has had decreased appetite, she has gained weight. Her
heart rate is 100/min and blood pressure is 112/70 mm Hg. She has scleral icterus; the skin over her face, neck, and lower legs is slightly bronze in
color; she has palmar erythema; and she has numerous ecchymoses over her body. Her abdominal examination is significant for ascites. Laboratory
tests show: Aspartate transaminase: 102 U/L, Alanine transaminase: 97 U/L, Alkaline phosphatase: 300 U/L, Total bilirubin: 1.9 mg/dL, Albumin: 2.9
g/dL, Prothrombin time: 22 sec, Partial thromboplastin time: 42 sec. An ultrasound of her abdomen shows a shrunken and nodular liver. A liver biopsy
using Perls Prussian blue stain is shown in the image. Which of the following is the most likely complication of her disease?

 

A full-term male newborn experiences respiratory distress immediately after birth. A prenatal sonogram was read as normal. An emergency radiograph is shown here. The patient is intubated and placed on 100% O2. Arterial blood gases reveal pH 7.24, PO2 60 kPa, and PCO2 52 kPa. The baby has sternal retractions and a scaphoid abdomen. Which of the following should be performed in the management of this patient?

An 18-year-old woman is brought to the ED by her mother. The patient is diaphoretic and vomiting. Her mom states that she thinks her daughter tried to commit suicide. The patient admits to ingesting a few handfuls of acetaminophen (Tylenol) approximately 3 hours ago. Her temperature is 99.1°F, BP is 105/70 mmHg, HR is 92 beats per minute,RR is 17 breaths per minute, and oxygen saturation is 99% on room air. On examination, her head and neck are unremarkable. Cardiovascular and pulmonary examinations are within normal limits. She is mildly tender in her right upper quadrant, but there is no rebound or guarding. Bowel sounds are normoactive. She is alert and oriented and has no focal deficits on neurologic examination. You administer 50 g of activated charcoal. At this point, she appears well and has no complaints. Her serum acetaminophen (APAP) concentration 4 hours after the reported time of ingestion returns at 350 μg/mL. You plot the level on the nomogram seen below. Which of the following is the most appropriate next step in management?

An 82-year-old white female is admitted to the hospital for observation after presenting to the emergency department with dizziness. After being placed on a cardiac monitor in the ER, the rhythm strip below was recorded. There is no past history of cardiac disease, diabetes, or hypertension. With prompting, the patient discloses several prior episodes of transient dizziness and one episode of brief syncope in the past. Physical examination is unremarkable. Which of the following is the best plan of care?

As you are examining the patient described in the previous question, he starts to complain of chest discomfort and shortness of breath and has another syncopal episode. His ECG is shown below. Which of the following is the most appropriate next step in management?