CK- UWSA 2- Block 2

A 68-year-old man comes to the office due to decreased hearing in the right ear.  The patient also feels that something is wrong with his head as his hat size has increased over the last 2 years.  Medical history is significant for hypertension and peptic ulcer disease.  His current medications are hydrochlorothiazide and enalapril.  He also takes ibuprofen for occasional headaches and famotidine for infrequent episodes of heartburn.  Laboratory results show an elevated alkaline phosphatase level but are otherwise normal.  Plain x-rays of the skull reveal bone thickening with areas of sclerotic and lytic lesions.  Which of the following is the most likely mechanism underlying this patient’s condition?

A 62-year-old man is intubated in the emergency department due to pulmonary edema resulting from acute kidney injury.  He requires urgent hemodialysis to remove excess fluid.  Before placing the dialysis catheter, the physician calls the patient’s wife to obtain verbal consent and explain the risks and benefits of the procedure.  After inserting the catheter into the right femoral vein, the physician realizes that the metal wire to guide catheter placement is missing.  Bedside x-ray reveals that the entire length of the guidewire is in the lumen of the femoral vein.  The physician then consults interventional radiology to have the guidewire removed.  After this is done, dialysis is initiated and the patient is soon extubated.  The medical team meets with the patient the next day.  Which of the following is the most appropriate statement to the patient?

A 45-year-old man comes to the emergency department due to a 1-day history of constant upper abdominal pain, nausea, and several episodes of vomiting.  The pain is partially relieved by sitting up or bending forward.  He has also had mild shortness of breath.  The patient’s other medical history includes hyperlipidemia and hypertension.  He uses tobacco and alcohol.  There is a family history of coronary artery disease and hypertension.  Temperature is 38.1 C (100.6 F), blood pressure is 110/70 mm Hg, pulse is 114/min, and respirations are 22/min.  There is dullness to percussion and decreased breath sounds at the left lung base.  Abdominal examination shows epigastric tenderness.  Laboratory results are as follows:

Which of the following plays a principal role in initial management of this patient’s current condition?

A 32-year-old woman, gravida 1 para 0, comes to the office at 35 weeks gestation for a routine prenatal visit.  The patient feels well other than having increased swelling in her hands and feet.  She has had no headaches, changes in vision, or right upper quadrant pain.  The patient has no contractions, leakage of fluid, or vaginal bleeding.  Fetal movement is normal.  The patient was diagnosed with gestational diabetes mellitus at 28 weeks; has been well controlled with diet.  She has no other chronic medical conditions, and her only daily medication is a prenatal vitamin.  Blood pressure is 148/98 mm Hg and pulse is 72/min.  Fundal height is 35 cm.  Cardiac examination is normal.  The lungs are clear to auscultation bilaterally.  Abdominal examination shows no right upper quadrant tenderness.  There is 2+ pitting edema in bilateral hands and feet.  Laboratory results are as follows:

A nonstress test is reactive.  A repeat blood pressure is 152/106 mm Hg.  Which of the following is the best next step in management of this patient?a

A 6-year-old boy is brought to the office for evaluation of nasal congestion.  He remains congested throughout the year despite the use of antihistamines and intranasal corticosteroids.  Each year since age 2, the patient has had 3 or 4 episodes of otitis media and sinusitis, but has otherwise been healthy.  He snores loudly at night and feels tired during the day.  The boy frequently reports, “I can’t breathe through my nose,” but he has no shortness of breath or wheezing.  He was born at 40 weeks’ gestation via spontaneous vaginal delivery and has been at the 75th percentile for height and weight since birth.  Developmental milestones have been achieved on time.  Immunizations are up to date.  Vital signs are normal.  Examination reveals an alert child in no acute distress who breathes loudly through his mouth.  Nasal turbinates are not enlarged or erythematous.  Tonsils are enlarged without erythema or exudate.  Mucopurulent postnasal drip is present.  Breath sounds are normal without wheezes, rales, or rhonchi.  Which of the following underlying abnormalities is likely to be the cause of this patient’s symptoms?

A 35-year-old woman comes to the office for follow-up accompanied by her husband.  She was diagnosed with ovarian cancer a year ago.  At that time, an adnexal mass was found on routine pelvic examination and confirmed by imaging.  Surgery was performed and a diagnosis of epithelial ovarian carcinoma was made.  Since a course of chemotherapy, the patient has had persistent sleep disturbance and fatigue.  She has pain on some days but says that it is tolerable, rating it 1-3 on a 10-point scale.  Although she initially returned to work after the surgery, at today’s visit the patient says that she has decided to resign her position as a paralegal due to problems with fatigue and concentration.  She also informs the physician that she has sent her 2 young children, ages 4 and 7, to live with her mother because she has “no energy” and doesn’t want “the children to see me this way.”  Her husband is very concerned that his wife seems tired all the time.  The patient’s medications include oxycodone and zolpidem.  She is 165 cm (5 ft 5 in) tall and weighs 66 kg (145.5 lb); BMI is 24 kg/m².  Temperature is 37 C (98.6 F), blood pressure is 120/70 mm Hg, pulse is 88/min, and respirations are 12/min.  Physical examination is normal.  Which of the following is the most appropriate next step in management of this patient?

A 58-year-old man comes to the office due to worsening sexual dysfunction for the past several months.  The patient reports decreasing firmness of his erections, which are now inadequate for vaginal penetration.  He also does not wake with early-morning erections as he did before, although he continues to have normal sexual desire.  The patient has had chronic low back pain since a work-related injury 2 years ago, and he frequently takes nonsteroidal anti-inflammatory drugs.  He also has a history of hypertension and hyperlipidemia, as well as a 28-pack-year smoking history.  The patient feels stressed because he had to stop working after the back injury and has occasional arguments with his wife.  Blood pressure is 134/80 mm Hg and pulse is 78/min.  Physical examination shows normal heart sounds.  External genitalia appear normal with intact cremasteric reflexes.  Back examination shows no deformity or tenderness.  Deep tendon reflexes are normal.  Which of the following is the most likely cause of this patient’s sexual dysfunction?

A hospital wishes to proactively reduce the incidence of bloodstream infections associated with central line catheter insertion.  An interdisciplinary team is convened to develop new guidelines for catheter insertion, including providers from nursing, surgery, medicine, infection prevention, pharmacy, and quality improvement.  To inform the development of the new guidelines, the team decides to use failure modes and effects analysis.  After goals of the analysis and process are defined, which is the most appropriate next step?

A 58-year-old man comes to the office due to 10 weeks of progressive weakness.  The patient has had difficulty climbing stairs and raising his arms above his head.  He has also had trouble standing up from a seated position without pushing off with his arms.  He has had no vision or swallowing problems or muscle aches.  The patient has hypertension and a 40-pack-year smoking history.  Temperature is 37 C (98.6 F), blood pressure is 126/80 mm Hg, and pulse is 78/min.  BMI is 19.5 kg/m².  There is moderate weakness of the proximal muscles of the upper and lower limbs, and deep tendon reflexes are absent throughout.  Plantar reflexes are flexor.  Sensory examination shows no abnormalities, and cranial nerve function is normal.  Which of the following is the most appropriate next step in management of this patient?

A 72-year-old woman is brought to the office by her son due to cognitive decline and frequent falls.  Over the last year, the patient has gotten lost multiple times while driving in a familiar neighborhood.  According to her son, she has “good days and bad days” with occasional episodes of agitation and disorientation.  Her movements and speech are slow.  On mini-mental state examination, she recalls 3 out of 3 subjects after a minute but has significant difficulty with clock drawing.  Which of the following would you expect most on this patient’s physical examination?

An 18-year-old woman, gravida 1 para 0, comes to the hospital at 35 weeks gestation due to leakage of fluid and contractions for the past 3 hours.  The patient was last seen in the office 2 weeks ago, and her prenatal care has been uncomplicated.  She has no chronic medical conditions and no medication allergies.  Temperature is 36.7 C (98 F), blood pressure is 102/68 mm Hg, and pulse is 84/min.  Speculum examination shows a vaginal pool of nitrazine-positive, clear fluid and the cervix dilated to 1 cm.  Transabdominal ultrasound reveals a fetus in vertex presentation, and the amniotic fluid has a deepest vertical pocket of 1.5 cm.  The fetal heart rate tracing has moderate variability and no decelerations.  The tocometer reveals contractions every 2-3 minutes.  Which of the following is the best next step in management of this patient?

A 65-year-old man is brought to the emergency department due to sudden-onset, severe pain in the right leg that began 5 hours ago.  He also states that the leg feels numb.  The patient has had no chest pain, shortness of breath, syncope, cough, or lower extremity edema.  Two months ago, he was hospitalized with anterior wall myocardial infarction but was not revascularized due to late presentation.  The patient was discharged home with aspirin, clopidogrel, metoprolol, lisinopril, and atorvastatin.  He quit smoking last year but previously smoked a pack of cigarettes per day for 40 years.  Temperature is 36.6 C (97.9 F), blood pressure is 110/67 mm Hg, and pulse is 87/min and regular.  Lungs are clear to auscultation.  The apical impulse is displaced to the left.  There is a 3/6 holosystolic murmur at the apex with radiation to the axilla.  The right leg is cold to the touch.  There is a palpable femoral pulse but no popliteal, posterior tibial, or dorsalis pedis pulses palpable on the right.  The pulses on the left are full.  ECG reveals normal sinus rhythm and deep Q waves in leads I, aVL, and V2-V5 with 4-mm ST-segment elevation, which is unchanged from readings at discharge 2 months ago.  Which of the following is the most likely diagnosis in this patient?

An 82-year-old woman is brought to the emergency department by her neighbor, who found her on the bathroom floor.  The patient says that she slipped on the wet floor and fell, landing on her left hip.  The neighbor adds that the patient lives alone and that he found her house in very poor sanitary condition.  His family occasionally provides the patient with dinner; otherwise she mostly eats breads and canned food products.  She does not use tobacco or alcohol.  Temperature is 36.5 C (97.7 F), blood pressure is 140/70 mm Hg, and pulse is 96/min.  She appears thin and weak.  Physical examination shows dry mucous membranes and poor dentition.  The patient has left hip tenderness.  Skin examination shows small, rough, papules at the hair follicles with surrounding hemorrhage, as shown in the image.  X-ray reveals a left femoral neck fracture.  The nutritional deficiency causing this patient’s skin findings is most likely to be associated with which of the following?

A 47-year-old man comes to the office due to intermittent rectal pain and bleeding.  Six months ago, the patient first noticed small amounts of blood on the toilet paper after wiping.  He self-treated with laxatives and sitz baths, but the symptoms persisted.  The patient was diagnosed with HIV a year ago and does not take antiretroviral medication consistently.  He has had receptive anal intercourse in the past but not since these symptoms began.  Vital signs are within normal limits.  The abdomen is soft and nontender with no organomegaly.  Anal examination shows a tender, 3-cm ulcer at the posterior anal verge with an indurated base that bleeds with light palpation.  He has no genital lesions or urethral discharge.  Two firm, nontender, 3-cm lymph nodes are present in the right groin.  Which of the following is the most likely cause of this patient’s current condition?

A 16-year-old nulligravid girl is brought to the office by her mother for discussion about contraception.  The patient recently started having sexual intercourse with her boyfriend, and both she and her mother agree that she needs reliable contraception.  The patient is a competitive swimmer and hopes to obtain an athletic scholarship for college.  She is interested in the intrauterine device because her mother has one and she was told that it is one of the most effective forms of contraception.  The patient is currently on day 3 of menstruation, and her last episode of unprotected intercourse was yesterday.  Menarche was at age 12; periods usually last 7-8 days with heavy bleeding and cramping.  She takes naproxen for dysmenorrhea and iron for anemia.  The patient has a latex allergy for which she carries an epinephrine pen.  Physical examination is normal.  Urine pregnancy and cervical nucleic acid amplification tests are negative.  Which of the following is a contraindication to the copper-containing intrauterine device in this patient?

A 59-year-old woman comes to the office for follow-up.  The patient was prescribed citalopram 8 weeks ago for treatment of major depression.  She is feeling much better and states, “I feel that the antidepressant has finally kicked in.  My concentration at work is improving.  I am sleeping well and have even started exercising at the gym.  I do feel a little bit tired after I take the medicine, but that passes quite quickly and overall my energy is better.”  The patient has a history of depression, hypertension, and seasonal allergies.  She also takes hydrochlorothiazide.  Blood pressure is 160/90 mm Hg, pulse is 72/min, and respirations are 14/min.  The patient admittedly does not take her antihypertensive medication consistently.  She says, “I know I have high blood pressure, and during many of my visits with you, we have gone over how not taking medications can have complications in the long run, but it’s hard to remember to take medications every day.”  Which of the following is the most likely explanation for this patient’s poor adherence to her antihypertensive medication?

A 19-year-old woman, gravida 2 para 0 aborta 1, at 31 weeks gestation comes to the emergency department due to fever, chills, and shortness of breath.  The patient reports progressive dyspnea over the last few hours but has no cough, chest pain, or hemoptysis.  Her symptoms began yesterday with fevers, chills, and back pain that radiates to the right flank.  She has had no prenatal care and last saw a medical provider more than a year ago.  Temperature is 38.9 C (102 F), blood pressure is 88/68 mm Hg, pulse is 115/min, and respirations are 24/min.  Pulse oximetry is 90% on room air.  Cardiac examination shows no murmurs and no jugular venous distension.  Pulmonary examination reveals diffuse, bilateral crackles.  There is tenderness over the right flank.  The uterus is nontender, and the cervix is 1 cm dilated and 50% effaced, with intact amniotic membranes.  Fetal monitoring shows a fetal heart rate baseline of 180/min with no decelerations; there are contractions every 4 minutes on the tocometer.  Chest x-ray reveals bilateral infiltrates.  Which of the following is the most likely diagnosis in this patient?

An 18-month-old girl is brought to the office by her parents for fever, rhinorrhea, and fussiness for 2 days.  She has been tugging at her left ear for a day but eating and drinking normally.  The patient was treated for acute otitis media 2 weeks ago, but did not complete her oral antibiotic therapy because she recovered quickly.  She takes no medications and has no drug allergies.  Temperature is 38.5 C (101.3 F).  Otoscopy of the left ear reveals an erythematous and mildly swollen external ear canal with an erythematous, bulging tympanic membrane that does not move with insufflation.  There are also erythema and tenderness to palpation immediately posterior to the left ear, which appears slightly lower than the right.  The lungs are clear to auscultation.  Which of the following is the most appropriate next step in management of this patient?

A 67-year-old man comes to the office due to slowly progressive shortness of breath for the past year.  He is an avid golfer and increasingly finds himself using the golf cart to get around.  He also has some dyspnea when walking up hills.  The patient has a mild morning cough productive of whitish sputum but has no chest pain, orthopnea, or paroxysmal nocturnal dyspnea.  He has coronary artery disease and had a drug-eluting stent placed 2 years ago.  He also has a history of hypertension and hyperlipidemia.  The patient, a retired truck driver, stopped smoking 12 years ago, but before then, he smoked 2 packs of cigarettes daily for 20 years.  Medications include aspirin, clopidogrel, atorvastatin, and metoprolol.  Blood pressure is 134/85 mm Hg, pulse is 62/min, respirations are 14/min, and pulse oximetry is 95% on room air.  BMI is 27 kg/m².  Estimated jugular venous pressure is 6 cm H₂O.  The patient’s lungs are clear to auscultation, and heart examination demonstrates a regular rate and rhythm with a fourth heart sound.  There is no lower extremity swelling.  Chest x-ray reveals no cardiomegaly or lung infiltrates.  Which of the following is the best next step in evaluating this patient?

A 58-year-old woman comes to the emergency department due to 2 days of nausea, vomiting, bloating, and mid-abdominal crampy pain.  The vomitus initially contained ingested food particles but now is mostly yellow liquid.  Her last bowel movement 24 hours ago was normal, and she has been passing flatus.  The patient has not consumed anything out of the ordinary and has had no fever.  She takes nonsteroidal anti-inflammatory drugs for osteoarthritic knee pain and had an abdominal hysterectomy 20 years ago due to dysfunctional uterine bleeding.  The patient occasionally drinks alcohol but does not use tobacco or illicit drugs.  Temperature is 37.0 C (98.6 F), blood pressure is 110/70 mm Hg, and pulse is 98/min.  BMI is 33 kg/m².  Physical examination shows a soft, distended, tympanitic abdomen with no succussion splash.  There is mild, diffuse tenderness to palpation without guarding and rebound tenderness.  Bowel sounds are increased and high-pitched.  Rectal examination reveals an empty rectal vault and no masses.  Laboratory results are as follows:

Abdominal x-ray reveals distended loops of small bowel with air-fluid levels.  There is air in the rectum.  Which of the following is the most likely diagnosis for this patient?

Item 1 of 3

A 53-year-old man comes to the office to establish care.  The patient has a history of a chronic hepatitis C (HCV) genotype 1a, for which he has never received any treatment.  He has no complaints and takes no medications.  Vital signs are normal.  BMI is 24 kg/m².  There is no jaundice or asterixis.  Abdomen is soft and nontender with no right upper quadrant tenderness and no shifting dullness.  There is no spider angioma, palmar erythema, or caput medusae present.  Laboratory results are as follows:

Viral load is 2 million IU/mL HCV RNA.  Abdominal ultrasound reveals no evidence of peritoneal fluid and no liver mass.  The patient has heard about a novel antiviral agent called SALVOHEP and is interested in pursuing treatment.  Based on the drug ad, which of the following is the most accurate statement?

Item 2 of 3

Prior to the development of SALVOHEP, the standard of care for chronic HCV was treatment with drug X, which was not associated with a high rate of virologic cure.  Based on this information and on the data provided in the drug ad, which of the following is the most likely design of the SALVOHEP study described?

Item 3 of 3

The authors of the drug ad did not include the sustained virologic response at 12 weeks for patients with baseline hepatitis C RNA <4 million UI/mL who received 12 weeks of treatment with SALVOHEP.  Which of the following is the most likely reason for this omission?

A 34-year-old primigravida is admitted to the labor and delivery unit at 41 weeks gestation for induction of labor.  As the patient reads through the consent forms, she states that she feels strongly against her child receiving erythromycin ophthalmic ointment when he is born.  She mentions that her cousin’s child had lifelong vision problems after receiving the medication.  The patient has no history of sexually transmitted diseases and is in a monogamous relationship with her partner.  Review of her medical history shows that she has been compliant with all prenatal care and tested negative for gonorrhea and chlamydia during the pregnancy.  Which of the following is the most appropriate initial response?

A 32-year-old woman comes to the office due to a 3-day history of pain and swelling in the left leg.  The pain is moderate in intensity and feels like a “toothache.”  The patient also has a purplish, blotchy rash on her hands, thighs, and legs that has been present for several months and worsens on exposure to cold temperatures.  Medical history is significant for migraine headaches, irritable bowel syndrome, and recurrent miscarriages.  She does not use tobacco, alcohol, or illicit drugs.  On examination, vital signs are normal.  The left calf and ankle appear swollen, and palpation of the left thigh and calf elicits tenderness.  The rash is shown in the image below.

Which of the following is most likely to be found on additional evaluation?

A 41-year-old woman comes to the emergency department due to persistent lower back pain that has worsened over the past week.  The pain is now so severe that she is unable to ambulate.  The patient has no weakness, loss of sensation, or new-onset urinary or fecal incontinence.  She has had increased leg swelling.  The patient was diagnosed with HIV infection 8 years ago, but has not seen a doctor in several years.  She has no other medical problems and takes no medications.  Menstrual periods are irregular with intermittent light spotting.  The patient does not use tobacco, alcohol, or illicit drugs.  There is no family history of any illness.  Blood pressure is 145/90 mm Hg, pulse is 99/min, and respirations are 16/min.  Abdominal examination reveals no palpable masses or hepatosplenomegaly.  There is no paraspinal or vertebral tenderness.  Bilateral lower extremities have 2+ edema; sensation and reflexes are intact.  CD4 count is 198/mm³.  Urinalysis is negative for blood and nitrites.  CT scan reveals a lower uterine segment mass that extends laterally.  Bilateral hydronephrosis is seen.  Which of the following is the most likely underlying pathology in this patient?

A 38-year-old man comes to the clinic due to difficulty walking, involuntary movements, and imbalance that have progressively worsened over the past few months.  He also has experienced headache and blurry vision.  The patient’s medical history is notable for papillary thyroid cancer treated with total thyroidectomy 10 years ago.  Current medications include levothyroxine, calcium carbonate, and calcitriol, although he has been noncompliant with follow-up visits and laboratory monitoring.  The patient smokes marijuana on a regular basis, but does not use tobacco or alcohol.  Family history is unremarkable.  Physical examination shows a resting hand tremor and increased muscle tone in the upper and lower extremities.  His gait is slow and unsteady.  The skin is dry and coarse.  Funduscopic examination shows fullness of the optic cups.  The remainder of the examination is unremarkable.  Laboratory results are as follows:

CT scan of the head without contrast reveals extensive calcifications in the basal ganglia bilaterally.  Which of the following is most likely responsible for this patient’s symptoms?

A 46-year-old African American man comes to the office due to peripheral edema.  The patient has type 2 diabetes mellitus, hypertension, and hyperlipidemia.  He has no history of coronary artery or cerebrovascular disease.  Three months ago, his serum creatinine level was 1.0 mg/dL and urinalysis showed trace protein.  The patient’s medications are lisinopril, hydrochlorothiazide, metformin, glipizide, and rosuvastatin.  Blood pressure is 162/98 mm Hg and pulse is 98/min.  BMI is 36 kg/m².  On physical examination, the lungs are clear.  No heart murmurs or additional heart sounds are present.  There is 2+ pitting peripheral edema bilaterally.  Laboratory results are as follows:

A 24-hour urine protein collection is 4.2 g/L.  Abdominal ultrasound reveals normal-size kidneys with no evidence of obstruction or hydronephrosis.  Which of the following is the best next step in management of this patient?

A 66-year-old man comes to the office due to worsening urinary frequency, hesitancy, and nocturia for the past 2 months.  The patient wakes up 2 or 3 times a night to urinate, causing him to be tired during the day.  He has had no dysuria or hematuria.  The patient has a history of hypertension, hyperlipidemia, and type 2 diabetes mellitus.  Chlorthalidone was recently added to his antihypertensive regimen due to inadequate blood pressure control.  Temperature is 37.1 C (98.8 F), blood pressure is 120/84 mm Hg, and pulse is 80/min.  The abdomen is soft and nontender to palpation and bowel sounds are normal.  The bladder is not palpable and there is no flank tenderness.  Rectal sphincter tone is normal, and the prostate is enlarged with a nodule on the right side.  Laboratory results show a fasting blood glucose level of 130 mg/dL and hemoglobin A1c of 7.2%.  Prostate-specific antigen level is 7.4 ng/mL (age-adjusted reference value: <4.5 ng/mL).  Which of the following is the best next step in management of this patient?

A 23-year-old man comes to the office for psychiatric follow-up.  He is accompanied by his parents, with whom he lives.  The patient first developed psychiatric symptoms in high school when, over the course of a year, he became progressively withdrawn from friends, was preoccupied with hidden meanings in song lyrics, and had increased academic difficulty.  He was eventually hospitalized at age 16 due to persistent auditory hallucinations and delusions of being monitored by the government.  Since then, he has been hospitalized twice for hearing voices and exhibiting paranoid behavior.  Family history is significant for schizophrenia in a maternal uncle.  The patient has been stable for the past 3 years while on risperidone and is considering returning to school to obtain his high school diploma.  His parents are concerned about his ability to handle stress, and they ask about his prognosis.  Which of the following is predictive of a good prognosis for this patient?

A 43-year-old man comes to the acute care clinic with fatigue, abdominal discomfort, and frequent falls.  The patient has experienced severe constipation recently.  He has had no vomiting, black stools, hematemesis, cough, or hemoptysis.  Medical history includes hernia surgery 7 years ago and peptic ulcer disease.  The patient has suffered from gastrointestinal bleeding in the past and is currently taking iron supplements.  On physical examination, weakness is observed on dorsiflexion of the right foot.  Peripheral blood smear findings are shown in the slide below.

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

A 19-year-old woman comes to the emergency department due to abdominal pain for the past several hours.  The pain was initially mid-abdominal and crampy, and now the patient has constant pain in the right lower quadrant.  She has had one episode of vomiting since the pain started.  The patient has no prior medical problems and takes no medications.  She is sexually active and her last menstrual period was 3 weeks ago.  Temperature is 38 C (100.4 F), blood pressure is 118/70 mm Hg, and pulse is 96/min.  The patient is supine on the bed with her hips flexed and reports worsening of the pain when her hips are extended.  There is mild tenderness in the right lower quadrant, with guarding.  Bowel sounds are decreased.  Pelvic examination reveals tenderness in the right adnexal area.  Her leukocyte count is 14,000/mm³ and urinalysis shows 10-20 leukocytes/hpf and 1+ blood.  Which of the following is the most likely cause of this patient’s current condition?

A 32-year-old woman, gravida 2 para 1, at 24 weeks gestation comes to the emergency department due to not feeling fetal movement for 2 days.  An ultrasound at 18 weeks gestation revealed a fetus with multiple anomalies and a posterio placenta.  The patient’s first pregnancy was uncomplicated, and the infant was delivered vaginally.  An ultrasound confirms the absence of fetal heart movement.  The patient is admitted to labor and delivery and delivers a 275 g (9.7 oz), stillborn infant vaginally after induction with multiple doses of misoprostol.  After 30 minutes, the placenta has not delivered, and an oxytocin infusion is initiated.  Ninety minutes after delivery of the infant, the patient has profuse bleeding that soaks the sheets.  Current temperature is 36.7 C (98 F), blood pressure is 110/60 mm Hg, and pulse is 100/min.  Examination shows a large volume of clotted blood in the vaginal vault.  Which of the following is the most likely cause of the patient’s bleeding

A 41-year-old man comes to the office due to 2 months of progressive exertional shortness of breath and frequent nonproductive cough.  Currently, he can hardly walk 3 blocks without stopping due to difficulty breathing.  He has had no chest pain, lightheadedness, syncope, or lower extremity swelling.  The patient has a history of Hodgkin lymphoma treated with combination chemotherapy a year ago.  The chemotherapy regimen included doxorubicin, bleomycin, vinblastine, and dacarbazine.  He has no family history of heart or lung disease.  The patient is afebrile.  Blood pressure is 122/75 mm Hg and pulse is 88/min and regular.  Lungs are clear to auscultation.  The apical impulse is palpated at the anterior axillary line in the sixth intercostal space.  A third heart sound is heard on cardiac auscultation.  Chest x-ray reveals clear lung fields and cardiomegaly.  Which of the following is the most likely underlying mechanism of this patient’s current presentation?

A 27-year-old woman comes to the office for evaluation of anxiety symptoms.  The patient’s boyfriend of 3 years broke up with her a week ago.  The night of the break-up, she could not fall asleep, so she watched television.  While flipping through the channels, she came across horror movies only and became frightened that her ex was “trying to send a message.”  The patient unplugged the television and disconnected all the electronics.  She stayed up the rest of the night, pacing in the living room and monitoring the front door.  The patient remained awake the next day and, at times, heard her ex whispering that she is “worthless” and “horrible.”  That night, the patient regularly looked out the window to check if her ex’s car was parked on the street.  She eventually fell asleep early in the morning and woke up feeling less anxious.  She returned to work that day and resumed her regular activities.  The patient drinks alcohol occasionally and does not use illicit drugs.  Medical history is unremarkable.  Vital signs are within normal limits.  Physical examination shows no abnormalities.  The patient is fully oriented, and her thoughts are organized.  She does not appear to be internally preoccupied.  Which of the following is the most likely diagnosis?

A 60-year-old man comes to the office due to a persistent glans penis ulcer.  The ulcer began several months ago and has slowly enlarged.  The patient has had no pain, fever, or dysuria.  He was treated for gonorrhea more than 30 years ago but has had no other sexually transmitted infections.  He also has a history of type 2 diabetes mellitus.  The patient has smoked a pack of cigarettes daily for 40 years.  Physical examination shows a 2-cm ulcer of the penile frenulum with superficial slough and a hard, indurated base.  Several enlarged, hard, mobile inguinal lymph nodes are present bilaterally.  He has no other skin rash or mucosal lesions.  Which of the following is the most likely cause of this patient’s penile ulcer?

A 64-year-old man comes to the office due to swelling at his left elbow that has progressively increased in size over the past 3 months.  There is no associated fever and no symptoms in any other joints.  Medical history is notable only for hypertension, for which he takes olmesartan.  The patient works as a carpet layer and is an avid tennis player.  His temperature is 37 C (98.6 F), blood pressure is 110/60 mm Hg, and pulse is 71/min.  Examination shows a soft, fluctuant swelling at his left elbow, as shown in the figure below, with minimal tenderness and no warmth.  Pain or discomfort is not elicited on flexion or extension of the elbow, supination or pronation of the forearm, or resisted extension of the wrist.  Examination of all other joints is normal.

Which of the following is the most likely diagnosis?

A 40-year-old man is brought to the emergency department after a motor vehicle collision.  After a prolonged extrication due to severe vehicular damage, the patient was found to have an open fracture of the left femur with profuse bleeding.  The paramedics stabilized the fracture and applied a compressive bandage, and the patient received rapid administration of 2 L of normal saline on the way to the hospital.  On arrival, blood pressure is 80/52 mm Hg, pulse is 130/min, and respirations are 22/min.  The patient is alert and diaphoretic.  On examination, breath sounds are symmetric bilaterally, and heart sounds are normal.  The abdomen is soft and mildly tender to palpation, without guarding.  Blood is present at the urethral meatus, and the left thigh is swollen with no active bleeding.  Portable chest x-ray is normal.  Focused assessment with sonography for trauma is negative for pericardial effusion and intraperitoneal free fluid.  Pelvic x-ray reveals a displaced fracture of the left pubic ramus.  Which of the following is the best immediate step in management of this patient?

A 5-year-old girl is brought to the office by her parents for assessment of anxiety.  The parents report that the patient is learning to read, enjoying school, and playing with friends in the neighborhood.  However, they have recently been concerned because she talks about death, asks them repeatedly if they are going to die, and insists on sleeping with a night-light on.  The patient worries when her father comes home from work late and frequently mentions a movie she has seen in which the children were left alone when the parents died in a car crash.  She also worries about her pet hamster who died 3 months ago and draws pictures of food for him “so he will not be hungry.”  Although the family buried the hamster in the backyard, she insists on keeping the cage in her room with the door open and talks to her pet as if he is still alive.  Family history is significant for panic disorder in the patient’s father.  The girl is in the 60th percentile for height and weight.  Blood pressure is 100/70 mm Hg, and pulse is 88/min.  Physical examination shows no abnormalities.  The patient insists on sitting on her father’s lap during the evaluation.  She is shy and reluctant to speak with the physician but responds to questions with her parents’ encouragement.  Which of the following is the most likely explanation for this patient’s behavior?