During the third day of a mountain-climbing expedition, a 39-year-old male is brought to your base camp clinic complaining of painful and itchy, violet-colored skin bumps mostly on the fingers and toes. Physical examination reveals macular, papular and nodular lesions. The patient has no history of similar lesions. This is his first mountain climb in Alaska. Which of the following agents should be prescribed?

A 45-year-old female presents to the clinic with questions about malaria prophylaxis. She is planning a trip to India for one month. She denies any underlying medical conditions. She has no known allergies. After discussing food/water, living conditions, and vaccines, you discuss malaria prophylaxis. Which one of the following options should be recommended?

A 23-year-old female, G1P0 presents at 35 weeks’ gestation with sudden onset of lower abdominal-pelvic pain. She reports that she did pass a small amount of dark-red blood vaginally after sexual intercourse. She relates that she has been complaint with prenatal visits. Her pap test was normal at her first OB visit. She has used cocaine in the past. Her remaining medical and surgical history is unremarkable. Her blood pressure is 98/60 mmHg; heart rate is 115. Transabdominally, her uterus is firm and tender to palpation. Which of the following is the most likely diagnosis?

A 38-year-old patient presents with a scalding burn on the dorsum of his foot (caused by boiling water). While varying sized blisters are noted on the dorsum of the foot, the interdigital web-spaces are spared. Which of the following is NOT INDICATED in the management of this patient’s presentation?

A 12-year-old, premenarchal female presents for a physical examination without complaints. She is noted to have pelvic height discrepancy and a prominent right scapula. X-ray identifies a 32 degree, right-sided thoracic curvature. What is the recommended management for this patient?

For the past three weeks, a 47-year-old man has had the feeling of heaviness in his chest while pushing his lawn mower. Yesterday the discomfort was more severe and lasted much longer after he rested. He says he has never been seen for these symptoms before and is having no symptoms at the moment. He is a former smoker with 20 pack-year history; quit smoking seven years ago. He has not had his cholesterol or blood pressure checked for more than 5 years. There are no abnormal findings on physical examination. EKG shows no abnormalities. Cardiac enzymes are normal. Which of the following is the most appropriate initial diagnostic study?

A 41-year-old woman has a nine-month history of nausea, constipation, dyspepsia, general fatigue, arthralgias, and increasing memory loss. She has no history of illness other than her present complaints; her menses have been regular. Physical examination is unremarkable. Laboratory findings include:

Serum calcium level 12.0 (elevated)

Serum phosphorus 0.3 (low)

Serum albumin 4.9 /dl (nl)

Creatinine level 1.0 (nl)

BUN 17 (nl)

Which of the following is the most likely diagnosis?

A 23-year-old male presents to your clinic as a new patient and states that he has been seeing a doctor for chronic pain in his right shoulder since a rotator cuff tear with resultant surgery and has become addicted to his pain medications. He is now “shopping” in multiple ED’s and urgent care clinics and has increased his use and is even buying it on the street. If he misses a dose, he has withdrawal symptoms. What is your intervention at this time?

A G2P1, 32-year-old female at 18 weeks gestation is exposed to cytomegalovirus (CMV). She presents for counseling on the risk to her fetus. Which one of the following disorders is her fetus at the greatest increased risk for as a result of this exposure?

A 42-year-old female is complaining of menorrhagia that has progressively worsened over the past year. After her last menses, she experienced orthostatic lightheadedness. Her hemoglobin/hematocrit are significantly decreased at 7/21. Ultrasound reveals submucosal uterine fibroids. The patient had a bilateral tubal ligation and does not desire more children. What is the most appropriate definitive treatment for this patient?

A 59-year-old male has a history of long-standing alcohol use and recurrent pancreatitis. Which one of the following characteristics is most suggestive of the development of exocrine pancreatic insufficiency?

A 52-year-old police officer presents describing a burning, painful numbness in his right lateral thigh for two months. He has no motor complaints. Interestingly, during a two-week vacation, the symptoms were notably reduced. Which of the following is the most likely diagnosis?

A 32-year-old female presents with a three-month history of amenorrhea; headaches; galactorrhea; nausea and generalized malaise. Serum HCG is negative; TSH is within normal range. Labs identify an elevation of her serum prolactin level. What is the next step in evaluating whether or not the etiology of the elevated prolactin level is causing any associated visual manifestations?

A 12-year-old male presents to the office with exertional pain in his legs that is gradually becoming worse over the past month. He is unable to ride a bicycle with his friends due to the pain in his legs. Cardiac examination reveals an ejection click and accentuation of the second heart sound which increases further with Valsalva. Blood pressure obtained in both arms is elevated. He has atrophy of the muscles of his lower extremities. Which one of the following is most commonly associated with his underlying condition?

A football player that sustained a direct blow to the promixal tibia while his leg was in full extension presents for evaluation three hours after the injury. After the injury, he experienced rather immediate pain and swelling. Although he can bear weight, the knee feels like “it is going to give out”. His examination reveals an obvious knee effusion as well as limited active range of motion testing of the knee. What is the most likely diagnosis?

A 16-year-old male presents with a three-week history of malaise, fever and sore throat. Physical examination identifies pharyngeal erythema with enlarged tonsils and exudate; enlarged, tender anterior and posterior cervical adenopathy; tenderness in the right upper quadrant. No splenomegaly is identified. Laboratory findings reveal a slightly elevated white blood count with 35% segmented neutrophils, 1% eosinophils and 64% lymphocytes (of which 42% are noted to be atypical). Which of the following is the next step in the evaluation of this patient?

A 25-year-old male from Greece arrives in your clinic as a new patient. He is asymptomatic and denies prior medical history. A CBC demonstrates: WBC 8,000; Hemoglobin 12.0; Hematocrit 35; MCV 65; Platelets 275,000. He reports a family history of anemia in several siblings. His stool test for occult blood is negative. What is the most likely diagnosis?

EMS arrives with a 64-year-old patient in a semi-comatose state. There is no available medical or surgical history. BP = 156/98, HR = 84, RR = 14, Afebrile. The patient has an obvious motor deficit involving the right lower extremity; Babinski sign and hyperrelexia are present only on the right. There are no signs of trauma to the head or right lower extremity. Which of the following is the most important initial diagnostic study in this patient?

A 21-year-old female presents to the university clinic with a 48 hour history of coughing. The cough produces white phlegm. Her illness began two days ago with a runny nose and nasal congestion. She is otherwise healthy. Her only medication is oral birth control pills. Her vital signs are normal. Her sinuses are non-tender and her lungs are bilaterally clear to auscultation. Which of the following is the most appropriate therapeutic recommendation?

Which one of the following is a classic finding in a patient with hypoparathyroidism as a consequence of total thyroidectomy for thyroid cancer?

A 12-year-old male presents with sudden pain in the right side of his scrotum. The orientation of the long axis of the right testicle is more horizontal than the left testicle. Doppler ultrasound demonstrates decreased blood flow in the right testicle. Which of the following is the most appropriate intervention?

The initial antibodies formed in the 16-year-old patient described in question 21 (above) are:

A 66-year-old male from a chicken farm in Kentucky presents with a mild cough and dyspnea. He has a history of hypertension treated with lisinopril. His examination identifies fine, scattered pulmonary crackles but no other abnormalities. A chext x-ray identifies diffuse small nodules with bilateral perihilar adenopathy. Which of the following is the most likely etiology of his underlying condition?

A 48-year-old female presents for her annual exam. Her previous examination one year ago was normal. She has a six-month history of increasing duration of her menses, increased bleeding, and mild dysmenorrhea. She denies dyspareunia. She states her periods have otherwise been regular. On physical examination, you note a slightly enlarged uterus of irregular shape; firm, mobile and nontender. Bilaterally the adnexa are without masses and nontender. Which of the following is the best way to further evaluate this patient initially?

A 72-year-old man is brought to the Emergency Department by his wife after experiencing a syncopal episode at home. He is currently alert and oriented. He denies a prodrome, and witnesses report no seizure activity. His past medical history is unremarkable. He denies hypertension, diabetes, coronary disease. He has no past surgical history. Physical exam reveals a grade 3/6 harsh, systolic, crescendo/decrescendo murmur heard best at the base and radiating into both carotids. His PMI is displaced laterally, and he has a sustained apical impulse. Cardiac catheterization identifies significant aortic stenosis with a high gradient. What is the prognosis if this condition is managed medically rather than surgically?

A four-month old is brought to your clinic for evaluation of a rash. The lesions are markedly erythematous; most prominent and numerous in the inguinal creases and under the scrotum. The borders of the confluent lesions are noted to be slightly raised; discrete satellite lesions are noted. Which of the following is the most likely diagnosis?

Which of the following is NOT a risk factor for cancer of the colon?

A 48-year-old male presents with a seven-day history of left facial drooping. He would have presented sooner but was traveling internationally and just returned home. His left eyebrow and the corner of his mouth are notably sagging; the nasolabial fold on the left is less prominent. When asked to close his left eye he can’t. The left side of his forehead does not wrinkle when asked to raise his eyebrows. The rest of his examination is unremarkable. He denies trauma, headache and fever. Which of the following options would be most beneficial for this patient?

The mother of a 4-year-old male notes that for three days her son has been limping. When questioned, the child localizes the pain to the groin and anterior thigh. There is no history of trauma. Approximately one week ago, the child did have some cold symptoms that resolved without incident. Physical examination reveals that the pain is exacerbated mostly by abduction. Which of the following would provide the most definitive differentiation of the diagnoses that you suspect?

A patient experiencing an exacerbation of asthma for 6 hours presents to the Emergency Department. The results of an arterial blood gas (ABG) drawn on room air are: pH=7.52; pCO2=33; O2=88; HCO3=23 Which of the following is the best interpretation of the ABG?

The most common cardiac structure involved in bacterial endocarditis in patients without a history of IV drug use is/are:

An 82-year-old woman arrives at your clinic complaining of severe abdominal pain. The pain started seven days ago and has progressively increased since the onset. The pain has now settled in her left-lower quadrant. Her temperature is 102ºF (orally) and she appears dehydrated. You decide to send her to the ED because you are concerned that she has:

A 62-year-old female patient presents to the ED with sudden onset of fever, chills, productive cough and shortness of breath. She reports to you that she was hospitalized 60 days ago for a hip fracture, went to physical rehabilitation, and was discharged home about a week ago.

Physical examination of the thorax suggests a consolidated pneumonia. Chest x-ray confirms a left lower lobe infiltrate with blunting of the costophrenic angle. Which of the following best describes this pneumonia based on the information provided?

A 76-year-old male presents with severe abdominal pain that began 90 minutes after dinner. He also reports a single bloody, loose stool since the pain began. The patient reports a history of mild abdominal pain commonly after eating. His history is positive for hypertension (35 years), an inferior-wall myocardial infarction (15 years earlier) and travel to the Rocky Mountains for a camping trip with his grandson three weeks ago. His examination reveals a diffusely tender abdomen with mild guarding; no rigidity. He has bilateral carotid bruits. Which of the following is the most likely diagnosis?

While working in a multi-specialist clinic, an EKG technician brings you the 12-lead EKG of a patient that you have not yet evaluated. The QRS pattern in lead II clearly demonstrates variation in waveform amplitude from complex-to-complex. The pattern reveals a QRS complex of greater amplitude followed by one of lesser amplitude followed by one of greater amplitude; this pattern repeats repetitively. Which of the following is the most likely diagnosis that explains this finding?

Which of the following laboratory abnormalities should suggest a diagnosis other than bulimia nervosa?

A 24-year-old insulin-dependent diabetic presents to the ED with marked fatigue, rapid respirations and palpitations. His membranes are notably dry. His serum bicarbonate level is markedly reduced; there is an elevated anion gap. Which of the following is most likely the diagnosis?

A 57-year-old male with a 10-year history of type 2 diabetes mellitus presents to the clinic with a 2-month history of pain in his right calf and foot when walking. He began having discomfort in his right leg only when walking his dog, but the past two days the pain occurs when walking from his living room chair to his bedroom. On physical examination the right lower leg has smooth and shiny skin. There is a loss of hair from mid-calf distally. The foot and lower leg feel cool to the touch and is pale compared to the contralateral side. There is an ulcer on the tip of his right great toe. What is the next step in the evaluation of this patient?

A complaint of dysphagia is not typical in which of the following conditions?

A 32-year-old female was referred to your office for evaluation. Upon entering the room you see a tearful, slow-to-react female who describes a gradual worsening in feelings of worthlessness and an inability to find any pleasure in life for the last month. She is fully oriented. She is unkempt in appearance. Which of the following in the most likely diagnosis?

The most common etiology of the sudden development of floaters and flashing lights is:

A 65-year-old male is noted to have a right carotid bruit during a routine physical examination. The patient has no history of symptoms associated with the bruit. The patient has a history of coronary artery disease. Physical examination does not identify a murmur. Which one of the following is the most appropriate next step in the management of this finding?

A 25-year-old female presents with complaints of abdominal distention and bloating; and intermittent, crampy, abdominal pain that is relieved by defecation. She has noted a relationship between the frequent, loose stools and the pain. She has not experienced weight loss. She relates a history of diarrhea on some occasions and constipation at other times. Her physical exam identifies diffuse discomfort; VS are stable. What lab findings would you expect to see for the most likely diagnosis explaining this presentation?

A 31-year-old woman has been experiencing worsening malaise, dyspnea, and low-grade fever for the past four weeks. She was recently treated for iritis. On physical examination, red nodules over the anterior lower legs and mild hepatomegaly are noted. Labs testing identifies hypercalcemia and an elevation of ACE. Chest x-ray study shows bilateral hilar adenopathy and ground glass appearance. Which of the following is the most likely diagnosis?

A patient is evaluated in the office for diffuse bilateral conjunctival injection for two days. The patient awoke with redness and a purulent discharge primarily from the right eye yesterday. This morning, both eyelids were matted together. Examination reveals thick, green, bilateral ophthalmic discharge. Which of the following is the most likely diagnosis?

A 54-year-old female is evaluated for the development of an erythematous maculopapular rash on her trunk that has been spreading to her extremities over the past 48hours. She was seen four days ago for a UTI and treated with trimethoprim-sulfamethoxazole which she has taken in the past. Which of the following is the best treatment option for this patient?

A 72-year-old gentleman is seen by you for a history of progressive claudication pain in his right leg. Six months ago, he was able to walk half-a-mile every morning; now he finds that he cannot make it to his mailbox (~ 120 feet) without having to stop several times because of the pain in his leg. He has a history of a left carotid endarterectomy, and had a stent placed by angioplasty about two years ago. On physical examination of his right leg, you would expect to find: