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https://step2.medbullets.com/testview?qid=109022 | A 47-year-old man presents to the emergency department with a headache. He suddenly developed a throbbing, bitemporal headache about 5 hours ago "out of nowhere." He has a history of migraine headaches, but he feels that this headache is significantly more painful than his typical migraines. The patient took his prescr... | Periosteum and galea aponeurosis | Arachnoid mater and pia mater | Dura mater and arachnoid mater | Skull and dura mater | B | Arachnoid mater and pia mater | This patient presents with a sudden, severe headache and a head CT showing bleeding in the subarachnoid space, which confirms a diagnosis of subarachnoid hemorrhage. The bleeding in a subarachnoid hemorrhage occurs between the arachnoid and pia mater.
Subarachnoid hemorrhages present with a sudden, severe headache ref... | nan |
https://bit.ly/42Cge5V | A 16-year-old boy presents to an ophthalmologist with blurry vision. Over the past several months, he has had increasing difficulty seeing the board from the back of the classroom at school. The patient is otherwise doing well in school and enjoys playing basketball. His medical history is otherwise significant for sco... | Extra copy of sex chromosome | Mutation of RET proto-oncogene | Defective metabolism of methionine | Mutation of chromosome 15 | D | Mutation of chromosome 15 | This patient presents with tall stature, upward lens subluxation, and a family history of aortic valve disease, which suggests a diagnosis of Marfan syndrome. Marfan syndrome is caused by an autosomal dominant mutation in the fibrillin-1 gene on chromosome 15.
The fibrillin-1 gene codes for a glycoprotein in the extra... | nan |
https://step2.medbullets.com/testview?qid=216501 | A 26-year-old man presents to his primary care physician with a 6-month history of increasing lower back pain. He first felt the pain while lifting boxes at work but thought that he had just strained a muscle. The pain appears to be worse in the mornings and after rest. Exercise and physical activity appear to temporar... | Bone scan | Computed tomography | Magnetic resonance imaging | Radiograph | C | Magnetic resonance imaging | This young man presents with low back pain that is relieved by physical activity, decreased spinal mobility, enthesitis of his patellar tendons, and elevated ESR/CRP values most likely has ankylosing spondylitis (AS). The most accurate diagnostic test for early ankylosing spondylitis is MRI.
Multiple imaging tests can... | Ultrasound |
https://bit.ly/3skGIMT | A 1-month-old girl presents to her pediatrician with her mother. The patient was born at 38 weeks gestation via Caesarean section for cervical incompetence. The patient’s mother has no complaints. The child had a runny nose and cough for a few days last week. The patient’s mother endorses decreased appetite during the ... | Decreased metabolism of bilirubin | Increased enterohepatic circulation of bilirubin | Increased production of bilirubin | Obstruction of the extrahepatic biliary tree | D | Obstruction of the extrahepatic biliary tree | This 2-month-old patient presents with jaundice, dark urine, mild transaminitis, and conjugated hyperbilirubinemia, which suggests the diagnosis of biliary atresia. Biliary atresia is characterized by obstruction of the extrahepatic biliary tree.
Biliary atresia is a progressive, obliterative disease of the extrahepat... | Obstruction of the intrahepatic biliary tree |
https://step2.medbullets.com/testview?qid=216438 | A 32-year-old man presents to the emergency department with pain upon defecation. His symptoms started a few weeks ago but have been worsening. Sometimes he notes blood on the toilet paper. He has to strain to have bowel movements and has trouble defecating secondary to pain. He is generally healthy and does not smoke.... | Testing for HIV, fecal occult blood, and sexually transmitted diseases | CT scan of the abdomen and pelvis | Surgical excision | Topical lidocaine, sitz baths, and fiber supplements | A | Testing for HIV, fecal occult blood, and sexually transmitted diseases | This patient is presenting with pain upon defecation, constipation, and a fissure lateral to the midline which is suggestive of an anal fissure. Anal fissures lateral to the midline are associated with inflammatory and infectious etiologies; thus, further workup (testing for HIV, fecal occult blood testing, and sexuall... | nan |
https://bit.ly/3OGVR2b | A 57-year-old man presents to the emergency department for weight loss and abdominal pain. The patient has felt steadily more fatigued over the past month and has lost 22 pounds without effort. Today, he fainted prompting his presentation. The patient has no significant medical history. He does have a 33-pack-year smok... | Intellectualization | Pessimism | Rationalization | Optimism | A | Intellectualization | This patient is using facts and logic to emotionally distance himself from his stressful diagnosis. This ego defense method is suggestive of intellectualization.
Intellectualization typically occurs in patients who have received a very stressful diagnosis or bad news for a close loved one. They will often focus on the... | nan |
https://bit.ly/3DDvy7X | A 27-year-old woman presents for her first prenatal visit at an estimated gestational age of 16 weeks and 4 days by last menstrual period. She is presenting late to prenatal care due to significant anxiety about her pregnancy, as she and her husband had struggled with infertility for several years prior to conceiving. ... | Couvade syndrome | Delusion of pregnancy | Feigned pregnancy | Pseudocyesis | D | Pseudocyesis | This patient presents with signs and symptoms of pregnancy but a nongravid uterus on ultrasound and a negative pregnancy test. The most likely diagnosis is pseudocyesis.
Pseudocyesis, or false pregnancy, most commonly presents with abdominal distension, breast tenderness, nausea, and other typical symptoms of pregnanc... | Recent miscarriage |
https://step2.medbullets.com/testview?qid=109241 | A 3-day-old boy is evaluated in the hospital nursery for the delayed passage of meconium. The patient is breastfed, has been feeding well every 2 hours, and is urinating over 8 times per day. He was born at 35 weeks gestation to a 27-year-old G4P4 mother. The patient is of Ashkenazi Jewish descent and the patient’s par... | Upper gastrointestinal series | Sweat testing | Abdominal radiograph | Abdominal CT | C | Abdominal radiograph | Delayed passage of meconium should be evaluated with an abdominal radiograph to rule out bowel perforation. Patients with a perforation require emergency surgery.
All neonates should pass meconium in the first 48 hours of life. Patients that fail do to so should be evaluated with an abdominal radiograph to exclude the... | nan |
https://step2.medbullets.com/testview?qid=109961 | A 37-year-old machinist presents to his primary care physician with eye problems. He has felt a mass in his eye that has persisted for the past month. The patient has a medical history of blepharitis treated with eye cleansing and squamous cell carcinoma of the skin treated with Mohs surgery. His temperature is 99.5°F ... | Chalazion | Foreign body | Hordeolum | Meibomian cell carcinoma | A | Chalazion | This patient presenting with a painless firm and rubbery nodule has symptoms that are suggestive of a chalazion.
Chalazion presents with a hard and painless eyelid nodule. This pathology occurs secondary to granulomatous inflammation of the Meibomian gland. The lesion can be treated with simple excision; however, recu... | nan |
https://step2.medbullets.com/testview?qid=217661 | A 53-year-old African-American woman presents to her primary care doctor with increasing difficulty climbing the stairs. She noticed the weakness approximately 3 months ago. It has gotten progressively worse since that time. She has also noticed increasing difficulty combing her hair, standing from a seated position, a... | Electromyography | MRI | Muscle biopsy | Serum aldolase | C | Muscle biopsy | This patient with insidious, subacute, progressive, symmetric proximal muscle weakness (difficulty climbing the stairs, combing her hair, standing from a seated position) without associated skin lesions most likely has polymyositis. The most accurate diagnostic test for polymyositis is muscle biopsy.
Polymyositis is c... | Serum creatine kinase |
https://bit.ly/3R0iH7u | A 70-year-old woman is brought to the emergency department by ambulance. She was found on the floor of her apartment after her neighbor called 911. She is confused and is unable to provide any history, but complains of generalized pain. Her temperature is 99.2°F (37.3°C), blood pressure is 129/64 mmHg, pulse is 63/min,... | Albuterol and IV fluid resuscitation | Calcium gluconate | Insulin, glucose, and IV fluid resuscitation | IV fluid resuscitation | B | Calcium gluconate | This patient with confusion, dark urine, and peaked T waves on electrocardiogram in the setting of a prolonged time spent down likely has developed rhabdomyolysis with associated hyperkalemia. For patients with suspected hyperkalemia and electrocardiogram changes, the most appropriate next step in management is treatme... | Sodium polystyrene sulfonate |
https://bit.ly/3GZtkBx | A 9-year-old girl presents to the emergency department with a fever and a change in her behavior. She presented with similar symptoms 6 weeks ago and was treated for an Escherchia coli infection. She also was treated for a urinary tract infection 10 weeks ago. Her mother says that last night her daughter felt ill, and ... | Gastroenteritis | Intentional contamination | Meningitis | Urinary tract infection | B | Intentional contamination | This patient is presenting with repeat sepsis, which is uncommon in a pediatric patient with no significant medical history. This abnormal concentration of infections when the patient is with her mother suggests a diagnosis of intentional contamination.
Factitious disorder by proxy (formerly Munchausen syndrome) occur... | nan |
https://step2.medbullets.com/testview?qid=216507 | A 7-year-old boy presents to the emergency department after an episode of jerking his extremities followed by confusion. This has happened in the past, but his mother thought he was fabricating his symptoms. She has taken him to a free health clinic to have him seen by a doctor who prescribed medication; however, she h... | Diazepam | Observation | Sumatriptan | CT head | B | Observation | This patient is presenting after a seizure (tonic-clonic jerking of his extremities) and is currently postictal given that he is obtunded. Given that the patient is not moving the left side of his body, he is likely suffering from Todd paralysis, which can occur after seizures and resolves on its own with only observat... | nan |
https://step2.medbullets.com/testview?qid=215182 | A 68-year-old man presents for evaluation by a neurologist for an involuntary hand tremor that started approximately 3 months ago. The shaking improves when he reaches for objects but returns when he is not using his hand. His temperature is 98.6°F (37.0°C), blood pressure is 115/70 mmHg, pulse is 70/min, and respirati... | Cerebellar stroke | Essential tremor | Huntington disease | Lacunar stroke | E | Parkinson disease | This patient who presents with a low amplitude, 4-6 Hz resting tremor that resolves with voluntary movement and associated rigidity most likely has Parkinson disease.
Parkinson disease is caused by degeneration of dopaminergic neurons in the substantia nigra pars compacta of the basal ganglia. This neurodegenerative p... | Parkinson disease |
https://step2.medbullets.com/testview?qid=217241 | A 72-year-old man with a history of type 2 diabetes mellitus, hypertension, and hyperlipidemia presents to his primary care provider for concerns about his cognitive decline. His wife has noticed that he has a worsening ability to organize, plan, and exhibit impulse control over the last month. The patient states that ... | Alzheimer disease | Mild cognitive impairment | Normal aging | Pseudodementia | E | Vascular dementia | This patient with cardiovascular risk factors (hypertension, type 2 diabetes mellitus, hyperlipidemia) who presents with sudden cognitive decline of executive function and neurologic symptoms consistent with vasculopathy and possible prior stroke given his neurologic exam likely has vascular dementia, which can be corr... | Vascular dementia |
https://bit.ly/3DkrY2C | A 54-year-old man presents to the clinic with 4 weeks of persistently worsening back pain. The pain is localized to 1 spot in his lower back and is worse with physical activity. His medical history is pertinent for intravenous drug use. He has no past surgical history. His temperature is 36.8°C (98.2°F), blood pressure... | Ankylosing spondylitis | Osteomyelitis | Degenerative spine disease | Metastatic tumor | B | Osteomyelitis | This patient with a history of intravenous drug use who presents with worsening focal back pain and elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) most likely has vertebral osteomyelitis.
Vertebral osteomyelitis typically occurs via three routes: hematogenous spread from a distant site (the... | nan |
https://step2.medbullets.com/testview?qid=109242 | A 7-week-old boy presents to the pediatrician for vomiting. Three weeks ago, the patient began vomiting after meals. The vomitus appears to be normal stomach contents without streaks of red or green. His parents have already tried repositioning him during mealtimes and switching his formula to eliminate cow’s milk and ... | Abdominal ultrasound | Intravenous hydration | MRI of the head | Pyloromyotomy | B | Intravenous hydration | This patient presents with nonbilious, forceful vomiting, poor weight gain, signs of dehydration, and a history of exposure to azithromycin, which suggests a diagnosis of pyloric stenosis. The most appropriate next step in management is intravenous hydration.
Pyloric stenosis classically presents in a male infant betw... | Thickening feeds |
https://step2.medbullets.com/testview?qid=216626 | A 55-year-old man presents to the emergency department after feeling lightheaded then fainting while he was carrying boxes upstairs. The patient works on a farm and does not see a doctor often. He has a history of hypertension but does not take medications routinely. He has not had any chest pain, dyspnea, or weakness ... | Wolff Parkinson White syndrome | ST elevation myocardial infarction | Torsades des pointes | Left ventricular hypertrophy | D | Left ventricular hypertrophy | This patient with chronic untreated hypertension is presenting with syncope and an ECG demonstrating large voltages in leads V1-V6 and a left ventricular strain pattern (ST depressions in V5/V6 and aVL), which are concerning for left ventricular hypertrophy.
Left ventricular hypertrophy occurs secondary to chronic hyp... | nan |
https://step2.medbullets.com/testview?qid=216637 | A 55-year-old man presents to the emergency department after fainting while moving furniture. He states that he has been working in a hot, humid attic all day and forgot his water bottle. He felt dizzy when standing up and then fainted and was unconscious for roughly 1 minute. He awoke at his neurologic baseline afterw... | Atrial fibrillation | Torsades des pointes | Stroke | Complete heart block | D | Complete heart block | This patient is presenting with dizziness and syncope in the setting of likely dehydration (working in a hot/humid environment without water) and feels better after rehydration, suggesting a diagnosis of orthostatic hypotension. An ECG is performed and incidentally demonstrates a bifascicular block, which is at high ri... | nan |
https://bit.ly/448sWLu | A 25-year-old man presents to his primary care physician with anxiety and fatigue. During this past week, he has been unable to properly study and prepare for final exams because he is exhausted. He has been going to bed early but is unable to get a good night’s sleep. He admits to occasional cocaine and marijuana use.... | Polysomnography | Sleep hygiene education | Alprazolam | Melatonin | B | Sleep hygiene education | This patient is presenting with trouble sleeping without a known organic cause, for which the most appropriate initial step in management is to discuss sleep hygiene with the patient.
In any patient that presents with a chief complaint of fatigue, it is always best to assess how they are sleeping. After a physical exa... | nan |
https://bit.ly/3s3wiAZ | A 67-year-old man is seen on the surgical floor after a transplant procedure. The previous day, the patient had a renal transplant from a matched donor. He is currently recovering and doing well. The patient has a medical history of IV drug use, diabetes mellitus, oral cold sores, hypertension, renal failure, and dysli... | Azithromycin | Low dose acyclovir | Penicillin | TMP-SMX | D | TMP-SMX | This patient is presenting status post renal transplant and is currently on immunosuppressive therapy. This patient should be started on TMP-SMX as prophylaxis against Pneumocystis jiroveci pneumonia (PJP).
After a transplant procedure, patients are started on immunosuppressive therapy in order to avoid rejection of t... | Valacyclovir |
https://step2.medbullets.com/testview?qid=216264 | A 69-year-old man passes away after a 3-week hospitalization for liver failure, complicated by a myocardial infarction. A medical student rotating in the intensive care unit asked if she can practice performing intubations during her rotation. The resident suggests performing one on the deceased patient, as the student... | Ask the resident if the patient’s family or the patient has been consented for this procedure | Consult the hospital ethics committee | Contact the patient's family to ask for permission to perform the procedure | Intubate the patient with the resident's supervision | A | Ask the resident if the patient’s family or the patient has been consented for this procedure | This medical student wants to perform a procedure on a deceased patient for educational purposes. Before proceeding, the student should ensure that permission has been obtained from the patient's family or the patient when he was alive.
Performing procedures on deceased patients is ethically permissible with appropria... | Report the resident to hospital administration |
https://step2.medbullets.com/testview?qid=108987 | A 71-year-old woman arrives to clinic with sudden vision loss. She was in her usual state of health until waking up this morning unable to see out of her right eye. She denies pain, but reports her right eye “feels funny.” The patient’s medical history is significant for a previous myocardial infarction, hypertension, ... | Papilledema | Retinal vein occlusion | Retinal detachment | Closed angle glaucoma | B | Retinal vein occlusion | This patient is presenting with sudden, painless, unilateral vision loss with a fundoscopic exam positive for venous dilation and retinal hemorrhage. These findings are consistent with the diagnosis of retinal vein occlusion.
Retinal vein occlusion can occur in either central or branch retinal veins and is often cause... | nan |
https://bit.ly/3BSwAMD | An 18-year-old man presents to his primary care provider with his parents for a sports physical. He was last seen in the clinic several months ago when he was diagnosed with attention deficit hyperactivity disorder (ADHD). He was started on methylphenidate at that time and the patient now reports improvement in his abi... | CGG trinucleotide repeat disorder | Anabolic steroid use | Failure of neuronal migration | Meiotic nondisjunction | D | Meiotic nondisjunction | This patient presents with tall stature, gynecomastia, and small testes with elevated FSH and LH, which suggests a diagnosis of Klinefelter syndrome. Klinefelter syndrome is usually caused by meiotic nondisjunction that results in a 47,XXY genotype.
Klinefelter syndrome is the most common cause of primary hypogonadism... | nan |
https://bit.ly/3LoaHJF | A 28-year-old woman presents to her primary care provider with a headache. Every few weeks she has an episode of a right-sided, throbbing headache. The episodes began several years ago and are accompanied by nausea and bright spots in her vision. The headache usually subsides if she lies still in a dark, quiet room for... | Topiramate | Sumatriptan | Acetazolamide | High-flow oxygen | B | Sumatriptan | This patient presents with episodic, unilateral throbbing headaches with photophobia, which suggests a diagnosis of migraine. The most appropriate treatment during these episodes is an abortive medication such as sumatriptan.
Migraines present with unilateral, "throbbing" pain and are associated with nausea and vomiti... | nan |
https://bit.ly/3Qj2QR9 | A 27-year-old woman presents to her primary care physician with pain in her hands, shoulders, and knees. The pain has lasted for several months but seems to have worsened recently. Any activity such as opening jars, walking, or brushing her teeth is painful. The patient has a medical history of a suicide attempt in col... | Anti-cyclic citrullinated peptide antibodies | Degenerated cartilage in weight bearing joints | Anti-dsDNA antibodies | Anti-histone antibodies | C | Anti-dsDNA antibodies | This patient is presenting with arthralgias, pancytopenia, possible malar rash, and a history of depression/abnormal behavior. Epidemiologically, the most likely diagnosis is systemic lupus erythematosus (SLE) which is associated with anti-dsDNA antibodies.
SLE is an autoimmune disorder that most commonly occurs in yo... | nan |
https://step2.medbullets.com/testview?qid=216403 | A 59-year-old man presents to the emergency department after a sudden onset of slurred speech and right upper extremity weakness. His symptoms lasted 20 minutes but by the time he arrived at the emergency department he was symptom-free. The patient denies any preceding symptoms. He has a history of diabetes, obesity, a... | CTA head/neck | MRI brain | Labetalol | Aspirin | D | Aspirin | This patient is presenting with a transient episode of neurologic dysfunction (slurred speech and right upper extremity weakness) that has completely resolved, which is concerning for a transient ischemic attack. In the setting of his normal head CT, aspirin should be administered next.
A transient ischemic attack (TI... | nan |
https://bit.ly/3Mv8f5p | A 59-year-old woman presents to her primary care physician for trouble sleeping. When she goes to bed at night, she has an urge to get up out of bed and walk around. The patient often wakes her husband when she does this which irritates him. There is a perpetual uneasiness and feeling of a need to move at night which i... | Alprazolam | Ferrous sulfate | Iron studies | Pramipexole | C | Iron studies | This patient is presenting with the need to get up and walk around at night, which is suggestive of restless leg syndrome. The most appropriate initial step in management is collecting iron studies to assess for iron deficiency.
Restless leg syndrome presents with a sustained sense of restlessness and a feeling of a n... | Supportive therapy and an exercise routine |
https://step2.medbullets.com/testview?qid=217097 | A 62-year-old woman is brought to a physician by her husband for fluctuating changes in behavior and hallucinations over the past 2 years. On occasion, she becomes difficult to understand and her speech becomes disorganized. She also frequently sees "small people" and animals on the dining room table, which is disturbi... | Figure A | Figure B | Figure C | Figure D | C | Figure C | This patient with fluctuating changes in behavior and cognition, visual hallucinations, memory loss, and extrapyramidal symptoms (bradykinesia, postural instability) most likely has Lewy body dementia. Lewy body dementia is characterized histologically by Lewy bodies, which are intracytoplasmic eosinophilic inclusions ... | Figure E |
https://step2.medbullets.com/testview?qid=109573 | A 25-year-old woman presents for a new patient physical exam. Aside from occasional shin splints, she has a relatively unremarkable medical history. She takes oral contraceptive pills and a multivitamin daily. All of her age appropriate immunizations are up to date. Her periods have been regular, occurring once every 2... | Colonoscopy in 5 years | Colonoscopy in 10 years | Mammogram now | Pap smear in 5 years | A | Colonoscopy in 5 years | This patient is presenting for a health evaluation with a family history significant for her father's death due to colon cancer at age 45. She should thus get a colonoscopy when she reaches the age 10 years prior to her father's age of diagnosis or in 5 years (at age 30).
The age threshold for colon cancer screening v... | Pap smear with human papillomavirus (HPV) DNA testing now |
https://bit.ly/44zO6BC | A 4-day-old neonate is brought to the pediatrician with vaginal discharge for the last 2 days. Her daughter has been feeding and voiding well. The neonate was delivered at 39 weeks gestation via an uncomplicated vaginal delivery and was discharged home after 2 days. The prenatal course was complicated by chlamydia in t... | Reassurance | Vaginal culture | Warm water irrigation of the vagina | Report to child protective services | A | Reassurance | This neonate presents with bloody vaginal discharge soon after birth without vulvar irritation, which is most consistent with physiologic neonatal vaginal discharge. Reassurance is the most appropriate next step in management.
Vaginal discharge in a neonate that is bloody and/or mucoid is most commonly due to the rapi... | nan |
https://bit.ly/45zXPbW | A 35-year-old G0P0000 woman presents to her gynecologist with complaints of irregular menstruation. She has had only 2 periods in the last year. She feels flushed without provocation and is experiencing occasional dyspareunia with post-coital spotting. She has also had more frequent headaches than usual. The patient ha... | Brain MRI | Combined oral contraceptive | Estradiol patch with oral medroxyprogesterone | Increase levothyroxine dose | C | Estradiol patch with oral medroxyprogesterone | This patient presents with oligomenorrhea, hot flashes, and dyspareunia, and her labs are notable for a high FSH and low estradiol, most consistent with premature ovarian insufficiency/failure (POI). The most appropriate next step in management is an estradiol patch with oral medroxyprogesterone.
POI is defined by the... | Vaginal estradiol gel |
https://bit.ly/3Qj2QR9 | A 27-year-old woman presents to her primary care physician with pain in her hands, shoulders, and knees. The pain has lasted for several months but seems to have worsened recently. Any activity such as opening jars, walking, or brushing her teeth is painful. The patient has a medical history of a suicide attempt in col... | Anti-cyclic citrullinated peptide antibodies | Anti-dsDNA antibodies | Anti-histone antibodies | Degenerated cartilage in weight bearing joints | B | Anti-dsDNA antibodies | This patient is presenting with arthralgias, pancytopenia, possible malar rash, and a history of depression/abnormal behavior. Epidemiologically, the most likely diagnosis is systemic lupus erythematosus (SLE) which is associated with anti-dsDNA antibodies.
SLE is an autoimmune disorder that most commonly occurs in yo... | IgM against parvovirus B19 |
https://bit.ly/3D2V2LR | A 4-week-old boy presents with his parents to the pediatrician for a well-child visit. His mother reports he was eating well until 1 week ago when he began vomiting after breastfeeding. His mother has tried increasing the frequency of feeds and decreasing the amount of each feed, but the vomiting seems to be getting wo... | Abdominal ultrasound | Trial of empiric proton pump inhibitor | Abdominal radiograph | Supplement breastfeeding with formula | A | Abdominal ultrasound | This patient presents with a history of nonbilious, forceful vomiting, poor weight gain, and signs of dehydration, which is consistent with pyloric stenosis. The most appropriate next step in management is abdominal ultrasound to confirm the diagnosis.
Pyloric stenosis presents in 4- to 6-week-old infants with nonbili... | nan |
https://step2.medbullets.com/testview?qid=108604 | A 24-year-old woman with no significant medical history presents to the emergency department for progressive shortness of breath. She endorses decreased exercise tolerance as well as intermittent palpitations. She returned from a recent missionary trip to South America 12 months prior where she endorsed eating a local ... | Benznidazole | Ganciclovir | Praziquantel | Amphotericin B | A | Benznidazole | This patient presents with symptoms of heart failure, eosinophilia, trypanosomes on peripheral smear, and a history of recent travel to South America consistent with the diagnosis of Chagas disease. Treatment options for Chagas disease include benznidazole and nifurtimox.
Chagas disease is caused by the parasite Trypa... | nan |
https://step2.medbullets.com/testview?qid=108601 | A 38-year-old man presents to the emergency department with nasal congestion, blurry vision, and diplopia. His nasal congestion started about 1 week ago and he noticed the blurry vision this morning when he struggled to read the words on his television screen. His medical history is significant for IV drug use, HIV (CD... | Brain biopsy | Empiric treatment with pyrimethamine-sulfadiazine | Empiric treatment with dexamethasone | Lumbar puncture | B | Empiric treatment with pyrimethamine-sulfadiazine | This patient with a past medical history of immunosuppression due to HIV (CD4 < 100/mm^3), new focal neurologic findings, and ring-enhancing lesions on head MRI should be treated empirically with pyrimethamine-sulfadiazine for 10-14 days.
The differential diagnosis for ring-enhancing lesions in patients with HIV is de... | Serology for anti-John Cunningham (JC) virus antibodies |
https://step2.medbullets.com/testview?qid=109092 | A 69-year-old man presents to his primary care provider for a general checkup. He has a medical history of type 2 diabetes mellitus, hypertension, depression, obesity, and a myocardial infarction 7 years ago. The patient's prescribed medications are metoprolol, aspirin, lisinopril, hydrochlorothiazide, fluoxetine, metf... | Heart sound after S2 | Holosystolic murmur at the apex | Heart sound before S1 | Fixed splitting of S1 and S2 | C | Heart sound before S1 | This patient who presents with poorly managed hypertension over a long period of time most likely has compensatory hypertrophy of the heart. The most likely heart sound in this patient is an S4 gallop that occurs immediately before S1.
Chronic hypertension that is poorly controlled can lead to concentric hypertrophy o... | nan |
https://bit.ly/44GDl0l | A 53-year-old man presents to the clinic with a non-tender mass in his right anterior neck. The mass has been slowly enlarging over the past 1 year. He reports no dysphagia, difficulty breathing, or changes to his voice. He also denies heat intolerance, palpitations, tremors, or diarrhea. He has hypertension and hyperl... | Repeat ultrasound in 6 months | Thyroidectomy followed by radioactive iodine | Methimazole | Radioactive iodine | B | Thyroidectomy followed by radioactive iodine | This patient who presents with a slowly enlarging neck mass has ultrasound (hypoechogenic nodule with microcalcifications) and histology findings (concentrically laminated calcifications called psammoma bodies) consistent with papillary thyroid carcinoma. The most appropriate next step in management would be thyroidect... | nan |
https://bit.ly/460v5JM | A 23-year-old woman presents with a 7-day history of abdominal pain, and now bloody diarrhea that brings her to her primary care physician. Review of systems is notable for a 12-pound unintentional weight loss and intermittent loose stools. She has a family history notable for a father with coronary artery disease and ... | Cobblestoning and skip lesions | Continuous lesion beginning in the rectum | Fistulae and stricture formation | Perianal disease | B | Continuous lesion beginning in the rectum | This patient presents with features suggestive of inflammatory bowel disease (IBD), and her colonoscopic and serologic studies suggest ulcerative colitis (UC). UC typically begins in the rectum and progresses proximally towards the ileocecal valve in a continuous fashion.
The diagnosis of IBD should always prompt furt... | Worse disease severity near the ileocecal valve |
https://bit.ly/43nVOhs | A 25-year-old man presents to his primary care physician with a chief complaint of "failing health." He states that he typically can converse with animals via telepathy but is having trouble right now due to the weather. He has begun taking an assortment of Peruvian herbs to little avail. Otherwise, he is not currently... | Brief psychotic disorder | Schizoid personality disorder | Schizotypal personality disorder | Schizophrenia | C | Schizotypal personality disorder | This patient has several odd and eccentric beliefs without frankly psychotic features and he is able to function in society. This suggests a diagnosis of schizotypal personality disorder.
Schizotypal personality disorder presents with eccentric behavior, magical thinking, odd beliefs, and perceptual disturbances. Thes... | nan |
https://bit.ly/48MbdvT | A 55-year-old man presents with a 2-day history of mono-articular joint pain. He is otherwise healthy and denies fever, chills, or recent trauma. His medical history is notable for a kidney stone 6 months ago. He underwent a dental procedure to extract an infected wisdom tooth 3 weeks ago. The patient does not take any... | Tophi | Heberden nodes | Juxta-articular osteoporosis | Chondrocalcinosis | D | Chondrocalcinosis | This patient is presenting with a joint aspiration positive for calcium pyrophosphate dehydrate crystals, suggesting a diagnosis of pseudogout, which may show chondrocalcinosis on radiography.
Pseudogout presents classically with mono- or oligo-articular arthritis that most often affects the knee and proximal joints o... | nan |
https://bit.ly/3GZtkBx | A 9-year-old girl presents to the emergency department with a fever and a change in her behavior. She presented with similar symptoms 6 weeks ago and was treated for an Escherchia coli infection. She also was treated for a urinary tract infection 10 weeks ago. Her mother says that last night her daughter felt ill, and ... | Gastroenteritis | Immunodeficiency | Intentional contamination | Meningitis | C | Intentional contamination | This patient is presenting with repeat sepsis, which is uncommon in a pediatric patient with no significant medical history. This abnormal concentration of infections when the patient is with her mother suggests a diagnosis of intentional contamination.
Factitious disorder by proxy (formerly Munchausen syndrome) occur... | Urinary tract infection |
https://bit.ly/3n1kBse | A 32-year-old man presents to his primary care provider for a headache. He reports that he has headaches at night several times a week. He first developed these headaches over 1 year ago, but they started up again 3 weeks ago. The episodes start suddenly and feel like a stabbing, electrical pain over his left eye. He a... | Verapamil | Sumatriptan | Carbamazepine | High-flow oxygen | A | Verapamil | This patient presents with an episodic, stabbing pain in the periorbital region that occurs at night, which is consistent with a diagnosis of cluster headaches. Verapamil is used as prophylaxis against cluster headaches.
Cluster headaches usually occur at night and may wake patients out of sleep. Cluster headaches may... | nan |
https://bit.ly/3v12XZt | A 6-month-old girl is brought to the pediatrician by her father for a scheduled check-up. She was in her usual state of health until 6 weeks ago when she was hospitalized for bacterial pneumonia. She received amoxicillin and had a resolution of her symptoms. Her father reports that she seems “back to normal.” She can r... | A | B | C | D | A | A | The thymus gland (labeled in A) is visible on a chest radiograph in infants and will change in response to illness due to its immunologic role.
The thymus gland is the site of T-cell maturation. The thymus is visible on a chest radiograph in infants and continues to grow throughout childhood. It is located in the ante... | E |
https://step2.medbullets.com/testview?qid=216244 | A 67-year-old man presents to the emergency room reporting sudden-onset abdominal and back pain that began 3 hours ago. He was eating dinner when he started feeling severe pain in his abdomen that made him lose his appetite. He denies any diarrhea or hematochezia and says the pain is not affected by movement. He has a ... | Ischemic colitis | Ruptured abdominal aortic aneurysm | Aortic dissection | Acute pancreatitis | B | Ruptured abdominal aortic aneurysm | This patient who presents with sudden-onset abdominal pain, hemodynamic instability (symptomatic hypotension with tachycardia), and significant history of hypertension and smoking most likely has a ruptured abdominal aortic aneurysm (AAA).
Abdominal aortic aneurysms are dilations in the vessel wall that can predispose... | nan |
https://step2.medbullets.com/testview?qid=216474 | A 57-year-old man is brought to the emergency department by his wife with confusion. He was seen in the emergency department 2 days ago for profuse epistaxis. His primary care provider was concerned and had advised him to go to the hospital, as the patient is on warfarin for atrial fibrillation. However, his bleeding r... | Penicillin | Piperacillin-tazobactam | Meropenem | Clindamycin | D | Clindamycin | This patient is presenting with nasal packing, hypotension, tachycardia, a dark, purpuric rash, and confusion, which are concerning for toxic shock syndrome. The most important initial step in management is to administer clindamycin.
Toxic shock syndrome is a life-threatening diagnosis caused by Streptococcus pyogenes... | nan |
https://step2.medbullets.com/testview?qid=216360 | A 55-year-old man with a history of polysubstance abuse is found down in his home acutely obtunded. Emergency medical services administered naloxone which immediately woke the patient up and improved his oxygen saturation from 40% to 90%. However, they noted subsequently that the patient demonstrated increased work of ... | Medication administration | Community acquired pneumonia | Atypical pneumonia | Poor cardiac function | A | Medication administration | This patient is presenting after administration of naloxone with respiratory distress, wheezing, crackles, and pulmonary edema on chest radiography, suggesting acute pulmonary edema. Given the presence of symptoms immediately following naloxone administration, the cause of the pulmonary edema is likely the naloxone (me... | nan |
https://step2.medbullets.com/testview?qid=214961 | A 51-year-old man presents to the emergency department complaining of fever and a cough with yellow-green sputum for the past 3 days. He denies any hemoptysis, facial pain, rhinorrhea, or night sweats. The patient reported similar symptoms 2 months ago. Chest radiograph performed at the time was notable for a right mid... | Interferon-gamma release assay | CT of the chest without contrast | Barium swallow | Serum immunoglobulin levels | B | CT of the chest without contrast | This patient's presentation with recurrent pneumonia in the same anatomical location is concerning for an anatomic abnormality. Given his history of heavy smoking, lung cancer should be ruled out with a chest CT with possible subsequent bronchoscopy for tissue biopsy.
Recurrent pneumonia can be classified either as th... | nan |
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