CK- UWSA 2- Block 4

A 56-year-old woman comes to the office due to a progressive skin rash and fingernail changes over the past several months.  She has used several over-the-counter topical treatments and emollients that provide only short-lasting relief.  The patient has a history of poorly controlled hypertension, and a beta blocker was recently added to her antihypertensive regimen.  She is a former smoker and drinks alcohol on social occasions.  Temperature is 37 C (98.6 F), blood pressure is 140/90 mm Hg, and pulse is 64/min.  Cardiopulmonary examination is normal.  Skin examination shows scattered nonblanchable erythematous plaques on the extremities.  Nail examination findings are shown in the image below.

This patient is at greatest risk of developing which of the following due to her current condition?

A 44-year-old man is evaluated for a 6-month history of progressive fatigue and pruritus.  In addition, he has noticed yellowing of the eyes, dark urine, and pale-colored stools.  Vital signs are within normal limits.  Physical examination shows scleral icterus and skin excoriations.  Laboratory results are as follows:

Magnetic resonance cholangiopancreatography is shown in the exhibit.  What is the most likely diagnosis for this patient?

A 56-year-old man comes to the office for evaluation of a tongue lesion.  The patient first noticed a small, whitish lesion on the right edge of his tongue 1 month ago.  It causes mild discomfort while eating and has failed to heal despite daily use of oral antiseptics.  He has had occasional oral ulcers in the past that have spontaneously resolved.  The patient has a history of HIV infection and takes antiretroviral therapy.  His last CD4⁺ count was 450/mm³.  He is a former smoker with a 30-pack-year history and drinks alcohol occasionally.  The patient is sexually active and has had several male and female partners in his lifetime.  Vital signs are within normal limits.  Oral examination shows a 0.5-cm ulcer with indurated margins on the right edge of the tongue.  Dentition is poor, but there are no other mucosal abnormalities.  Which of the following is the best next step in management of this patient?

A 53-year-old man comes to the office due to depressive symptoms for the past 2 months.  The patient has a history of bipolar disorder, which is currently treated with escitalopram and lithium.  Although he has not had any affective episodes in the past 2 years, he has a history of multiple hospitalizations and a suicide attempt.  The patient states he feels tired and has difficulty staying focused at work.  He says, “I’m not even interested in sex anymore and that really bothers me.  My wife thinks I don’t find her attractive, but that’s not true.”  The patient’s lithium level from 2 weeks ago was 0.7 mmol/L (therapeutic range: 0.6-1.2).  Medical history is otherwise noncontributory.  Temperature is 36.3 C (97.3 F), blood pressure is 127/78 mm Hg, pulse is 64/min, and respirations are 14/min.  His weight has increased 2 kg (4.4 lb) since his prior visit 10 weeks ago.  Physical examination shows no abnormalities.  The patient has no suicidal ideation.  Which of the following is the most appropriate next step in management of this patient?

A 23-year-old man is evaluated for a cardiac murmur.  He states he has had a murmur since childhood but does not remember any details.  He has had no symptoms and reports good exercise tolerance.  Family history is unremarkable.  The patient’s blood pressure is 122/70 mm Hg and pulse is 78/min and regular.  In both upper and lower extremities, pulses are strong with a normal rate of rise and descent.  On chest auscultation, a loud holosystolic murmur is present; it is best heard in the fourth intercostal space along the left sternal border and is accompanied by a thrill.  Lungs are clear to auscultation.  Abdominal examination is unremarkable with no palpable masses, organomegaly, or bruits.  Which of the following is the most likely diagnosis?

A 15-month-old boy is brought to the clinic because he has been refusing to walk.  When the patient woke up this morning, he did not want to get out of bed.  He has been asking his mother to carry him and cries when he attempts to move his right leg.  A week ago, he had a low-grade fever and rhinorrhea, but the symptoms spontaneously resolved after 2 days.  The patient was born via cesarean delivery for breech presentation and has no chronic medical conditions.  Temperature is 39.2 C (102.6 F), blood pressure is 96/60 mm Hg, pulse is 118/min, and respirations are 18/min.  The patient appears anxious.  The right hip is abducted and externally rotated.  The patient cries with any movement of the right hip and refuses to stand or walk.  Skin examination reveals no erythema or rashes.  Laboratory studies reveal a leukocyte count of 19,800/mm³ and erythrocyte sedimentation rate of 55 mm/hr.  Which of the following is the most likely mechanism for this patient’s condition?

A 14-year-old girl is brought to the office by her mother for an annual physical examination.  The patient has no significant medical history and says she feels “fine.”  During the examination, the physician notes a few superficial scratches on her left forearm.  The patient explains, “Oh, it’s nothing.  I scratch my skin with my nails sometimes when I feel stressed.  Some of my friends do it, but it doesn’t seem to be helping me.”  The patient says she often feels bored and hates her parents, who do not understand her, but denies any persistently depressed mood, appetite or sleep disturbance, or psychotic symptoms.  She has no wish to be dead or active suicidal ideation, intent, or plan.  The patient has used alcohol at parties but has no other substance use.  She is not sexually active.  The patient is willing to speak with a therapist about how she handles stress but asks the physician not to tell her mother about scratching herself.  The mother asks the physician if any issues came up during the examination.  Which of the following is the most appropriate response to the patient’s mother?

A 62-year-old woman comes to the office with a 6-month history of diarrhea.  She describes 4-6 watery bowel movements a day that are not associated with any particular food type.  The patient has tried a lactose-free diet without any relief.  She has not lost any weight and has no nausea, vomiting, fevers, abdominal pain, back pain, blood in the stool, or melena.  Her medical history is significant for hypertension treated with lisinopril and frequent migraines treated with ibuprofen.  She does not smoke or use alcohol.  Her family history is negative for inflammatory bowel disease or colon cancer.  Blood pressure is 142/91 mm Hg and pulse is 78/min.  BMI is 27 kg/m².  The abdomen is soft, nontender, and nondistended.  Laboratory results are as follows:

Testing for occult blood, stool cultures, and ova and parasites is negative.  Colonoscopy reveals a macroscopically normal bowel mucosa.  Biopsies taken during the procedure are most likely to reveal which of the following?

An 18-year-old woman comes to the clinic for routine gynecologic care.  The patient is in a relationship with a new boyfriend, who recently informed her about his history of genital herpes.  He has outbreaks very rarely and takes antiviral medication during those periods.  She is interested in starting a sexual relationship with him but is concerned about acquiring herpes.  The patient takes estrogen/progestin oral contraceptives and no other medications.  Her last menstrual period was 3 weeks ago.  She has no other medical problems and no known drug allergies.  Vital signs are normal.  Physical examination shows no evidence of vaginal discharge, vesicular lesions, or other abnormalities.  Urine pregnancy test is negative.  Serologic testing shows that she does not have IgG against HSV-1 or HSV-2.  Nucleic acid amplification testing for chlamydia and gonorrhea is negative.  Which of the following is the single most effective strategy to prevent this patient from acquiring herpes simplex virus infection?

A 53-year-old man with a history of severe migraines and depression comes to the emergency department with an intractable headache.  He has severe pain, photophobia, and nausea.  Prior to arrival, he took his standing amitriptyline and valproate for migraine prophylaxis, as well as doses of an acetaminophen/caffeine combination, sumatriptan, and prochlorperazine in an effort to reduce his pain and nausea.  He has no other medical illness but occasionally smokes marijuana.  During the examination, the patient immediately stands up and begins to walk around the room.  He is not otherwise agitated and denies being anxious, but he states, “I don’t know why, I just need to walk.”  Temperature is 36.7 C (98.1 F), blood pressure is 130/80 mm Hg, pulse is 88/min, and respirations are 16/min.  He is not tremulous.  Which of the following is the most likely cause of this patient’s behavior?

A 77-year-old woman comes to the office for a new patient evaluation.  Overall she feels well but recently moved in with her daughter due to slowly progressive fatigue and weakness.  The patient has a history of breast cancer treated with surgery, radiation, and chemotherapy 15 years ago.  She has no other chronic medical problems, but her most recent routine laboratory testing showed mild anemia.  The patient moved shortly after receiving the results and has not followed up since.  Her only medication is a daily multivitamin.  She does not use tobacco or alcohol.  Blood pressure is 130/80 mm Hg and pulse is 86/min.  Physical examination shows moist mucous membranes, normal thyroid palpation, and no lymphadenopathy.  Hearts sounds are normal and lungs are clear to auscultation.  The abdomen is soft and nontender with no splenomegaly or hepatomegaly.  Skin examination shows scattered ecchymoses.

Peripheral smear shows neutrophils with decreased segmentation and decreased granulation.  Which of the following is the most likely diagnosis?

A 64-year-old woman is brought to the office by her husband for evaluation of confusion.  She has a history of cirrhosis with ascites due to primary sclerosing cholangitis.  The patient has had several hospitalizations for hepatic encephalopathy.  Since yesterday, she has been mildly confused and her movements have “slowed.”  The patient also had trouble sleeping last night.  She has 2 or 3 semiformed stools daily and has had no fever, abdominal pain, vomiting, or melena.  The patient takes ursodeoxycholic acid, spironolactone, furosemide, and lactulose and is compliant with the medications.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 37.2 C (98.9 F), blood pressure is 120/80 mm Hg, and pulse is 78/min.  Cardiopulmonary examination is normal.  The abdomen is nontender with moderate distension.  Stool guaiac is negative.  The patient has mild asterixis and incoordination.  She is not able to spell “world” backwards.  Laboratory testing shows normal electrolytes and creatinine.  Which of the following is the most appropriate additional treatment for this patient?

A 45-year-old man comes to the emergency department due to fever, mildly productive cough, and headache.  He visited an urgent care center yesterday for lethargy, abdominal cramps, and watery diarrhea and was discharged after receiving intravenous fluids.  The patient has no medical problems and takes no medications.  He recently returned from a trip to Hawaii.  He does not use tobacco and drinks alcohol only on social occasions.  Temperature is 38.9 C (102 F), blood pressure is 110/60 mm Hg, pulse is 74/min, and respirations are 20/min.  The pharyngeal mucosa is not erythematous, and there is no cervical lymphadenopathy.  Auscultation of the chest reveals reduced breath sounds and crackles in the right base.  The abdomen is soft, nontender, and nondistended, with no organomegaly.  Laboratory evaluation shows elevation of segmented neutrophils with band forms.  Which of the following is the best initial treatment for this patient while confirmatory tests are pending?

A 72-year-old man comes to the office for follow-up of his hypertension.  He was last seen a year ago; his blood pressure was well controlled at that time.  The patient has had some recent fatigue and has difficulty catching his breath when walking quickly.  He says he is “getting old” and needs to adjust his lifestyle accordingly.  He has not had any chest pain, shortness of breath, or palpitations.  The patient’s other medical problems include carpal tunnel syndrome, chronic neck pain, and acid reflux disease.  He takes amlodipine and quinapril for hypertension.  He is a lifetime nonsmoker.  His blood pressure is 145/75 mm Hg and pulse is 65/min and regular.  On examination, he has a 3/6 mid-systolic murmur best heard over the right upper sternal border and radiating to the neck.  The lung fields are clear to auscultation.  There is no peripheral edema.  ECG shows normal sinus rhythm with T wave inversions in leads V5 and V6.  Echocardiogram shows left atrial enlargement, concentric left ventricular hypertrophy, and a left ventricular ejection fraction of 70%.  The aortic valve appears calcified with restricted opening; the estimated aortic valve area is 0.9 cm².  Which of the following is the best next step in management?

A scientist conducting research on risk factors associated with breast and endometrial cancer in postmenopausal women performs a literature review.  After looking at various studies and meta-analyses, she summarizes the reported risk calculations (relative risks or odds ratios) with 95% confidence intervals, as shown in the table below:

Which of the following statements is best supported by these data?

A 17-year-old nulligravid girl is brought to the office by her mother for contraceptive counseling.  The patient recently became sexually active with one male partner and is interested in contraception.  Her mother agrees with this plan.  Next month, the patient will attend an out-of-state university and wants the most reliable option.  She received a swimming scholarship and will have a busy training schedule in addition to her school work.  Menarche was at age 13 and she has regular menses typically lasting 3-4 days.  Her only medical problem is asthma, for which she uses albuterol prior to exercise.  A urine pregnancy test is negative.  Gonorrhea and chlamydia testing is negative.  Which of the following is the best option for this patient?

A 16-year-old girl comes to the office due to severe acne on her face and upper back.  The patient has a 2-year history of acne that has worsened over the past several weeks.  She has used benzoyl peroxide cleansers, topical retinoids, and oral antibiotics with only minimal relief.  The patient is otherwise healthy.  She is sexually active and takes a combined oral contraceptive.  Her last menstrual period was a week ago.  Family history is not significant.  Physical examination findings are shown in the image below.

Two serum hCG levels are negative, and the remainder of the laboratory evaluation is normal.  Oral isotretinoin therapy is planned.  Which of the following additional interventions is most appropriate in this patient?

A 16-year-old boy is brought to the emergency department due to 2 hours of right groin and abdominal pain.  The patient says he was awakened early in the morning by the pain along with nausea and an episode of vomiting.  Two weeks ago, he had a brief episode of pain in the right scrotum, which he attributed to trauma during a basketball game.  The patient recently had unprotected sexual intercourse with his girlfriend.  Temperature is 37.2 C (99 F), blood pressure is 120/70 mm Hg, and pulse is 98/min.  He appears to be in severe pain.  The abdomen is soft, nondistended, and nontender.  The right scrotum is erythematous, swollen, and diffusely tender, and the cremasteric reflex is absent on the right side.  Which of the following is the most likely cause of this patient’s current condition?

A 2-month-old boy is brought by his parents for a well-infant visit.  The infant is doing well, but the parents are very worried about the behavior of their 3-year-old daughter.  In the last month, the girl has begun to act aggressively toward the baby.  The mother says, “It’s really hard to control because initially she is gentle and loving, but then she will suddenly pinch or hit the baby.  It’s gotten to the point where I am afraid to leave them unsupervised for a minute.”  The father says, “Yesterday, I had to pull her away because she was stroking the baby too roughly.  I have explained to her that this behavior is naughty, but she doesn’t listen.”  Apart from this behavior, they report no other concerns.  The daughter is playing with peers in preschool, riding a tricycle, using utensils, and speaking in 3-word sentences.  The parents ask for advice on the best way to handle the situation.  Which of the following is the most appropriate next step in management?

A 24-year-old woman, gravida 1 para 1, comes to the office for a routine 8-week postpartum examination and evaluation of vaginal bleeding.  The patient had an uncomplicated vaginal delivery with a second-degree perineal laceration.  Since the delivery, she has had a persistent pink discharge and spotting that partially stained 1 pad a day.  Six days ago, the bleeding became heavier and soaked 3 pads a day.  Today, the bleeding is minimal.  She is coping well and caring for her infant, although her husband was deployed for military duty 2 weeks after delivery.  The patient switched to formula a few weeks ago due to ongoing difficulties with latching.  Vital signs are normal.  Speculum examination shows a closed cervix with minimal blood from the os.  The perineum appears well healed, and the vagina has no lesions.  Which of the following is the best next step in management of this patient?

A 54-year-old man comes to the office due to recent-onset fatigue, nausea, and forgetfulness.  The symptoms have been present for 3 weeks and are worsening.  He has had no change in bowel or bladder habits.  His review of systems is otherwise negative.  The patient’s medical problems include hypertension, for which he takes amlodipine, and trigeminal neuralgia that is well controlled with carbamazepine.  He also takes occasional ibuprofen for knee pain.  The patient does not use tobacco, alcohol, or illicit drugs.  Blood pressure is 130/80 mm Hg without orthostatic changes and pulse is 80/min.  Oxygen saturation is 98% on room air.  Mucous membranes are moist.  Cardiopulmonary examination reveals no abnormalities.  Neurologic examination is normal.  He has no pedal edema.  His serum sodium level is 125 mEq/L.  Which of the following sets of laboratory values would be most likely in this patient?

A 33-year-old woman, gravida 2 para 2, comes to the office due to heavy menstrual bleeding.  The patient’s menses occur every 30 days and last 7 days, with 4 days of heavy bleeding that require a superabsorbent pad every hour.  She is sexually active with a new partner and has had 6 lifetime partners.  Two years ago, the patient had a copper intrauterine device (IUD) placed for contraception because she felt bloated on oral contraceptives.  The IUD was removed 6 months ago in an effort to decrease menstrual bleeding, but there has been no improvement.  Temperature is 37.2 C (99 F), blood pressure is 126/84 mm Hg, and pulse is 80/min.  BMI is 22 kg/m².  Pelvic examination shows a nontender, slightly enlarged uterus with an irregular contour.  Urine pregnancy test is negative.

Item 1 of 2
Which of the following is the most likely cause of this patient’s symptoms?

Item 2 of 2
Which of the following is the best next step in evaluation of this patient?

A 52-year-old man comes to the emergency department due to flank pain and hematuria and is diagnosed with nephrolithiasis.  He has had prior emergency department visits with similar symptoms over the last year.  He also has a past medical history of Crohn disease and suffers from chronic diarrhea.  The patient underwent partial ilial resection due to an abscess formation 2 years ago.  He is a cook in a local restaurant and spends a lot of time near the stove.  He takes no medications.  The patient smokes a pack of cigarettes a day and drinks 1 or 2 cans of beer on weekends.  He has no family history of kidney stones or renal disease.  Blood pressure is 110/71 mm Hg and heart rate is 75/min.  Physical examination reveals mild periumbilical tenderness without rebound or guarding.  There is no peripheral edema.  Stone analysis is consistent with a uric acid stone.  Which of the following factors most strongly predisposed this patient to develop kidney stones?

A 72-year-old woman comes to the office due to several weeks of intermittent headaches, dizziness, and blurry vision.  She has no nausea, vomiting, cough, orthopnea, chest pain, or unilateral weakness.  Blood pressure is 156/82 mm Hg and pulse is 78/min.  Cardiac examination shows the point of maximal impulse displaced to the left, and auscultation reveals a S3.  Breath sounds are normal.  Hepatosplenomegaly is present.  The lower extremities have 1+ bilateral pitting edema and scattered ecchymoses.  Laboratory results are as follows:

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

A 57-year-old man is brought to the emergency department after a brief syncopal episode.  The event was not witnessed, but his wife came into the room immediately after she heard a thud and found him on the floor.  She did not note seizure activity when she came in.  The patient woke up almost immediately and was oriented but had shortness of breath.  He had no dizziness or lightheadedness prior to the event.  His past medical history is significant for hypertension.  The patient smokes a pack of cigarettes a day.  He recently traveled to China for business and returned 3 days ago.  Temperature is 38 C (100.4 F), blood pressure is 85/65 mm Hg, pulse is 124/min, and respirations are 22/min.  Oxygen saturation is 89% on room air.  BMI is 32 kg/m².  The lungs are clear on auscultation and there are no audible murmurs.  There is 2+ bilateral lower extremity edema, more pronounced on the left side.  ECG shows sinus tachycardia and T wave inversion in leads V1 to V3.  Chest x-ray reveals right basilar atelectasis.  Which of the following is the most likely cause of this patient’s syncope before admission?

A 16-year-old girl is brought to the office by her mother due to concerns about her having unprotected sex.  The mother says, “My 15-year-old niece became pregnant last year and I want to make sure that the same thing does not happen to my daughter.”  When the patient speaks with the physician alone, she admits to unsafe sex on a regular basis with her 17-year-old boyfriend, but she does not seem concerned about protection.  The physician educates the patient on the use of birth control and condoms to help prevent pregnancy and sexually transmitted diseases.  Which of the following is most likely to influence this patient’s adherence with safe sexual practices?

A 3-year-old boy is brought to the emergency department by his parents due to penile pain and swelling.  A month ago, according to his mother, the patient had a “penis infection,” which improved with warm baths and a topical ointment.  Since then, she has been trying to keep his genitalia clean.  Several hours ago, while bathing the child, she retracted the foreskin and was unable to return it to its normal position.  The patient soon said he was in pain and has appeared progressively more uncomfortable.  He was able to void at home with mild pain.  The patient is otherwise healthy and is up to date with his vaccinations.  Physical examination shows edema and tenderness of the retracted foreskin and glans penis, which is pink and soft.  Which of the following is the most appropriate next step in management of this patient?

An 82-year-old nursing home resident is brought to the emergency department due to 3 days of progressively worsening abdominal pain.  He has had several episodes of vomiting during the past 24 hours.  The patient usually has a bowel movement every 2-3 days, but his last bowel movement was 4 days ago.  He has Alzheimer disease, hypertension, and osteoarthritis.  The patient has had no prior abdominal surgery.  Temperature is 37.2 C (99 F), blood pressure is 140/88 mm Hg, and pulse is 96/min.  Physical examination shows a distended and tympanitic abdomen with tenderness to palpation.  Peritoneal signs are absent.  Bowel sounds are high pitched and increased.  The patient has discomfort during rectal examination and no stool is present.  Blood counts and serum electrolytes are within normal limits.  Abdominal radiography reveals a markedly distended bowel loop, without any haustra, extending from the pelvis to the right upper quadrant in an inverted U shape.  There are several dilated small-bowel loops with air-fluid levels.  No air is present in the rectum.  Which of the following is the most likely cause of this patient’s abdominal pain?

A 17-year-old girl is brought to the office by her mother, who is concerned about her adjustment to a new school.  The family moved to a new home a few months ago, requiring the patient to transfer to a new school in her senior year.  Her mother is worried as her daughter’s grades have dropped and she has lost interest in applying to college.  The girl says, “What does it matter?  I can’t focus on the work; it’s just stupid.  I won’t get into a good college anyway.”  She has had difficulty making friends at the new school and explains that it is hard to fit in when social groups are already established.  She does not participate in any afterschool activities because she is “too tired” and frequently gets into bed after coming home.  The patient sleeps until 2:00 PM on weekends and has lost 6.8 kg (15 lb) since the start of the school year.  She has not made any effort to stay in contact with her old friends.  The mother says that her daughter is more moody than usual and overreacts to minor criticisms.  The mother blames herself for her daughter’s situation, as her job change was the reason for the move.  The girl has used marijuana on several occasions but does not use alcohol or other drugs.  Physical examination is normal.  The patient has no suicidal thoughts.  Which of the following is the most likely diagnosis?

A 62-year-old man comes to the office due to 3 months of progressive cough and chest discomfort.  The patient’s appetite has been poor, and he has lost 3 kg (6.6 lb) during this period.  Over the last few weeks, he has coughed up a small amount of dark blood multiple times.  The patient has a 45-pack-year smoking history but quit 2 years ago after an acute myocardial infarction.  Chest x-ray findings are shown in the image below:

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

A 27-year-old woman comes to the office due to recurrent episodes of anxiety, palpitations, shortness of breath, tremors, and numbness and tingling in her hands.  The patient describes breaking into a sweat suddenly and feeling dizzy several times a week.  The last time it happened she was terribly embarrassed as it occurred during a meeting at work.  She says, “I had to run out of the room.  My chest was pounding and I was shaking uncontrollably.  I felt like I was choking and couldn’t catch my breath.”  The patient now feels anxious all the time because she fears having another episode.  She does not feel depressed and reports no change in her sleep pattern or appetite.  She has no medical history.  Physical examination, laboratory evaluation, and ECG are normal.  Which of the following is the most appropriate pharmacotherapy for this patient?

A 4-year-old girl is brought to the emergency department by her parents due to walking “like she’s drunk” and frequently falling for the past several hours.  The patient has no history of major illness or trauma and has never had similar symptoms.  A week ago, she had a runny nose, sore throat, and low-grade fever, which spontaneously resolved after 2 days.  Birth history is unremarkable and normal developmental milestones were achieved.  The patient is up to date on immunizations.  The parents keep no medications or alcohol in the house.  The girl appears cranky but is alert and active.  Temperature is 37.1 C (98.8 F).  The patient is sitting comfortably on a chair and moves all extremities freely, with normal strength and sensation.  When she is asked to reach and handle a small object with either hand, a slight tremor is observed.  The patient has horizontal nystagmus, but her pupils are equal and reactive to light and accommodation.  When asked to ambulate, she consistently staggers and falls to the right.  Deep tendon reflexes are normal and symmetric, and sensation is normal bilaterally.  There is no neck stiffness.  Which of the following is the most likely diagnosis in this patient?

A 26-year-old primigravida at 11 weeks gestation comes to the office for follow-up due to severe nausea and vomiting with difficulty maintaining oral intake.  The patient has regularly attended her antenatal clinic, and her weight gain and blood pressure have been normal.  She has no longstanding medical problems, and her only current medication is a prenatal vitamin.  Her mother and maternal aunt have hypothyroidism; the patient had her thyroid function checked 6 months ago prior to attempting to conceive.  She has a 5-pack-year smoking history but quit as soon as she found out that she was pregnant.  Temperature is 36.7 C (98 F), blood pressure is 130/70 mm Hg, pulse is 92/min, and respirations are 16/min.  The thyroid gland is normal on palpation and is nontender.  The rest of the physical examination is unremarkable.  Thyroid function test results are as follows:

Which of the following is most likely responsible for the temporal change in this patient’s laboratory findings?

A 38-year-old man is brought to the emergency department by his wife due to behavioral changes after snorting large amounts of cocaine for the past 3 days.  The patient has been irritable, talking fast, not sleeping, and beginning multiple projects at home that he does not complete.  He is easily distracted and moves from one topic to another.  At night, he sits at the kitchen table and draws large geometric shapes, saying that he has “great ideas for designing the city of the future.”  The patient has a history of attention-deficit hyperactivity disorder, major depression, and hypertension, but takes no medications.  In the emergency department, he talks fast and is difficult to interrupt but is oriented and answers cognitive questions rapidly and correctly.  The patient is afebrile, blood pressure is 150/90 mm Hg, pulse is 112/min, and respirations are 20/min.  Physical examination is otherwise unremarkable, and laboratory results are normal except for a urine toxicology screen that is positive for THC and cocaine.  The patient is transferred to a psychiatric unit, where he initially has residual irritability for a couple of days and then feels depressed and tired for the subsequent few days.  Which of the following is the most likely diagnosis in this patient?

A 38-year-old woman comes to the emergency department due to a severe headache.  She has a history of migraines, which typically present with acute attacks of severe pulsatile pain on the left side of her head accompanied by nausea and vomiting.  She has had 2 previous emergency department visits for migraines.  The patient does not take any migraine prophylaxis medication.  Earlier this afternoon, she was running in the park when she experienced a severe, sudden-onset, generalized headache that became unbearable in seconds.  Her vision became blurry, which caused her to stumble, and she almost fell.  In the emergency department, the patient continues to have a severe headache and feels nauseated.  Blood pressure is 148/86 mm Hg and pulse is 94/min and regular.  Pupils are symmetric and reactive.  Funduscopy is unremarkable.  Deep tendon reflexes and sensation are normal and bilaterally symmetric.  Plantar reflexes are bilaterally flexor.  Which of the following is the best next step in the management of this patient?

A 66-year-old man is evaluated for groin pain and swelling.  His symptoms started several months ago with dull discomfort in the right groin, especially after prolonged standing or straining during defecation.  The discomfort improves with rest or lying down.  Two weeks ago, the patient noticed a bulge in the right groin.  During the resulting surgical treatment, a peritoneal sac originating above the inguinal ligament and medial to the inferior epigastric vessels is seen.  Which of the following is the most likely cause of this patient’s condition?

A 23-year-old woman, gravida 1 para 0, comes to the office at 22 weeks gestation for evaluation of itchy genital lesions.  The patient has had no contractions, vaginal bleeding, or loss of fluid.  A routine fetal anatomy ultrasound was normal at 20 weeks gestation, and the pregnancy has been uncomplicated.  The patient is sexually active with her lifetime partner; onset of sexual activity was at age 18.  Cervical cancer screening was normal last year.  The patient takes a daily prenatal vitamin and no other medications.  She does not use tobacco, alcohol, or illicit drugs.  Examination shows several clusters of 1-2 mm, pedunculated, flesh-colored growths on the labia majora and perineum.  Which of the following is the best next step in management of this patient?

A 63-year-old man comes to the clinic due to fatigue for the last 4 weeks.  He states that he feels “exhausted” by the end of the day and gets short of breath while climbing stairs or walking at a fast pace.  The patient has no chest pain, lightheadedness, lower extremity swelling, fever, or weight loss.  His urine turned dark recently.  He has a history of hypertension and hyperlipidemia.  A year ago, the patient’s mitral valve was replaced with a mechanical valve due to mitral valve prolapse.  He takes warfarin.  He is a lifetime nonsmoker.  Blood pressure is 122/70 mm Hg and pulse is 101/min and regular.  A 2/6 holosystolic murmur is heard at the apex.  The lungs are clear on auscultation.  ECG shows sinus tachycardia with occasional ventricular premature beats.  Laboratory results are as follows:

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