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A 59-year-old truck driver presents to the emergency department with excruciating pain around his anus after returning from his usual weeklong trucking trip. The patient admits to drinking beer when not working and notes that his meals usually consist of fast food. He has no allergies and takes no medications, and his vital signs are normal. On examination, a tender lump is noted on the right side of the anus which is visible without the aid of an anoscope. The lump is 1 cm in diameter, bluish, and surrounded by edema. It is soft and tender to palpation. The rest of the history and physical examination are unremarkable. Which vein drains the vessels responsible for the formation of this lump?
An 86-year-old woman is brought to the emergency department by her niece because she felt like she was spinning and about to topple over. This began around four hours ago, and although symptoms have improved, she still feels like she is being pulled to the right side. Blood pressure is 116/75 mm Hg, pulse is 90/min, and her oxygen saturation on room air is 99%. Physical examination reveals right-sided limb ataxia along with hypoalgesia and decreased temperature sensation on the right side of the face and left side of the body. An urgent non-contrast computed tomography (CT) scan of the head shows no evidence of hemorrhage. What other physical finding is most likely to be present on this woman's examination?
A 55-year-old woman presents with pain in both hands and wrists for several years. It is associated with morning stiffness that lasts for almost an hour. Physical examination reveals tenderness and swelling in both hands and wrists, most severe over the proximal interphalangeal joints. Laboratory investigation reveals the presence of anti-cyclic citrullinated peptide (anti-CCP). Which of the following immune-mediated processes is responsible for this patient’s condition?
A 25-year-old G1P0 woman, at an estimated gestational age of 9 weeks, presents for her first prenatal visit, following a positive home pregnancy test. She says she missed 2 periods, but assumed it was due to stress at work. She has decided to continue with the pregnancy. Her past medical history is significant for migraine headaches, seizures, and asthma. She takes multiple medications for these conditions. Physical examination is unremarkable. An ultrasound confirms a 9-week-old intrauterine pregnancy. Which of her current home medications poses the greatest risk to the fetus?
A 59-year-old man presents with intense, sharp pain in his toe for the past hour. He reports similar symptoms in the past and this is his 2nd visit to the emergency department this year with the same complaint. The patient is afebrile and the vital signs are within normal limits. On physical examination, there is significant erythema, swelling, warmth, and moderate pain on palpation of the right first toe. The remainder of the examination is unremarkable. A plain radiograph of the right foot reveals no abnormalities. Joint arthrocentesis of the inflamed toe reveals urate crystals. Laboratory studies show:
A 27-year-old man who recently emigrated as a refugee from Somalia presents with three weeks of fever, weight loss, fatigue, and exertional chest pain. His appetite has decreased, and he has lost 3 kg (6.6 lb) during this time. He denies any history of cardiac disease or other medical issues. The patient has always lived in overcrowded quarters and in close contact with cats. His blood pressure is 120/60 mm Hg, pulse is 90/min, and temperature is 38.0°C (100.4°F). Physical examination is significant for generalized pallor, an early diastolic murmur loudest at the left 3rd intercostal space, a tender and mildly enlarged spleen, and bilateral axillary lymphadenopathy. Laboratory results show a WBC count of 14,500/μL with 5% bands and 93% polymorphonuclear cells. An echocardiogram reveals 5-mm vegetation on the aortic valve with moderate regurgitation. Three sets of blood cultures are taken over 24 hours, followed by empiric antibiotic therapy with gentamicin and vancomycin. The blood cultures show no growth after five days. Following a week of empiric therapy, the patient continues to deteriorate. Which of the following would most likely confirm the diagnosis in this patient?
A large pharmaceutical company is seeking healthy volunteers to participate in a drug trial. The drug is excreted in the urine, and the volunteers must agree to laboratory testing before enrolling in the trial. The laboratory results of one volunteer are shown below:
A 70-year-old white woman presents with a 2-week history of blood-tinged sputum. Her past medical history is significant for peptic ulcer disease, for which she took triple-drug therapy. She has never smoked and worked as a teacher before retiring at age 60. A review of systems is significant for a weight loss of 6.8 kg (15 lb) over the last 5 months. Her vitals include: blood pressure 135/85 mm Hg, temperature 37.7°C (99.9°F), pulse 95/min, and respiratory rate 18/min. Physical examination is unremarkable. A contrast CT scan of the chest shows an irregular mass in the peripheral region of the inferior lobe of the right lung. A CT-guided biopsy is performed and reveals malignant tissue architecture and gland formation with a significant amount of mucus. Which of the following is the most significant risk factor for this patient’s most likely diagnosis?
A 47-year-old woman presents to her physician for difficulty swallowing. She states that she intentionally delayed seeing a physician for this issue. She says her primary issue with swallowing is that her mouth always feels dry so she has difficulty chewing food to the point that it can be swallowed. On physical examination, her oral mucosa appears dry. Both of her eyes also appear dry. Several enlarged lymph nodes are palpated. Which of the following patterns of reactive lymphadenitis is most commonly associated with this patient’s presentation?
A 35-year-old man presents to the emergency room after he was found to have a blood pressure of 180/100 mm Hg during a routine health check-up with his family physician. He has no significant past medical history, and both of his parents are healthy. He currently does not take any medication. Vital signs are temperature 36.8°C (98.2°F), heart rate 65/min, respirations 14/min, and blood pressure is 148/80 mm Hg when the emergency physician examines him. He has a round face, centripetal obesity, and striae on the skin with atrophy over the abdomen and thighs. You order a low-dose dexamethasone suppression test, which is positive, and you proceed to measure ACTH and obtain a high-dose dexamethasone suppression test. What laboratory abnormalities will be seen before and after the high-dose dexamethasone suppression test if this patient has a pituitary gland disorder?
An 11-year-old boy presents to the doctor's office with his mother for the evaluation of weight loss, rash, and several weeks of bloating and diarrhea. The mother states that the patient’s father had similar symptoms at his age. On physical examination, the patient is pale with dry mucous membranes. There is a vesicular rash on the bilateral lower extremities, which he says is "very itchy." Which of the following laboratory findings would help screen for the most likely diagnosis in this patient?
A 67-year-old woman presents to the clinic complaining of progressive fatigue over the past 4 months. She has been feeling increasingly short of breath after walking the same distance from the bus stop to her home. She denies chest pain, syncope, lower extremity edema, or a cough. She does not have difficulty breathing at rest, only with walking or other mildly strenuous activity. Her past medical history includes mild osteoporosis and occasional gastric reflux disease. She takes oral omeprazole as needed and daily low-dose aspirin. The patient is a retired accountant, has never smoked, and drinks a small glass of red wine daily with dinner for the past 5 years. She eats a Mediterranean diet that includes fruits, vegetables, and fish. She states that she has always been very healthy and has not seen a physician for the past 20 years. On physical examination, her vital signs are blood pressure 128/72 mm Hg, pulse 87/min, and oxygen saturation 94% on room air. HEENT examination demonstrates mild conjunctival pallor. Lung and abdominal examinations are within normal limits. Heart examination reveals a 2/6 systolic murmur at the right upper sternal border. Laboratory results show:
A 5-year-old boy is brought to the office by his mother with complaints of facial puffiness and "frothy" urine for four days. The puffiness first started in his eyes and then spread to the face. His mother does not provide any history of similar symptoms in the past. Past medical history is non-significant. His birth history is uneventful, and all his vaccinations are up to date. His blood pressure 100/62 mm Hg, pulse is 110/min, temperature is 36.7°C (98.0°F), and respirations are 16/min. There is pitting edema of the upper and lower extremities bilaterally on examination. Urinalysis results are as follows:
A 71-year-old woman with substernal chest pain was admitted to the hospital 8 hours ago for an acute anterolateral ST-elevation myocardial infarction (MI). She was treated with oxygen, beta-blockers, aspirin, low-molecular-weight heparin and is on continuous electrocardiographic monitoring. Since admission, she has required IV nitroglycerin drip for recurrent chest pain, and repeat troponin levels continue to rise. Vital signs are heart rate 122/min, blood pressure 80/40 mm Hg, and pulse oximetry 91% on 6L of oxygen by nasal cannula. Telemetry shows sinus tachycardia. The patient complains of shortness of breath, is breathing rapidly, and appears confused. On physical examination, her skin is cool, clammy, and pale. She has diffuse bilateral crackles, an S3 gallop, and no new murmurs. There is jugular venous distention, rapid and faint radial pulses, and 1+ pitting ankle edema. Bedside echocardiography shows hypodynamic anterior wall movement and an ejection fraction of 20% but no evidence of acute mitral regurgitation or rupture. Chest X-ray demonstrates pulmonary edema. What is the most appropriate next step in the stabilization of this patient?
A 49-year-old woman presents to her physician with complaints of breast swelling and erythema over her right breast for a month. She also mentions that the skin above her right breast appears to have thickened. She reports some pain. She denies any nipple discharge. Her past medical history is significant for a total abdominal hysterectomy 4 years ago for fibroids. The result of her last mammogram a year ago was normal. On examination, the right breast is significantly larger than the left, diffusely erythematous, and tender. The right nipple is retracted, and the right breast is warmer than the left breast. No localized mass is palpated. Which of the following statements best describes the patient’s most likely condition?
A 13-year-old boy presents with several light brown macules measuring 4–5 cm located on his trunk. He has no other medical conditions, but his mother has similar skin findings. He takes no medications, and his vital signs are within normal limits. Ophthalmic examination findings are shown in the image below. What is the most likely neoplasm that can develop in this child?
A 35-year-old woman presents with increased anxiety and a reeling sensation. Her complaint started 30 minutes earlier with increased sweating and palpitations and is gradually worsening. On examination, the blood pressure is found to be 194/114 mm Hg. She had normal blood pressure at the local pharmacy 5 days ago. She currently works as an event manager, and her job involves a lot of stress. The family history is significant for thyroid carcinoma in her father. Which of the following is most likely in this patient?