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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 |
https://bit.ly/3WPL8WV | A 25-year-old woman presents to her primary care physician with joint and muscle pain. She has a general aching/pain in her joints that lasts all day. The pain is constant and is not relieved by rest or activity. She also has pain in her hands at times and occasionally notices trouble swallowing when she is eating. She... | Anti-dsDNA | Anti-IgG Fc region | Anti-nuclear antibody | Anti-ribonuleoprotein | D | Anti-ribonuleoprotein | This patient is presenting with diffuse muscle/joint pain, Raynaud phenomenon, and dysphagia suggesting a diagnosis of mixed connective tissue disease. Anti-ribonucleoprotein (U1) antibodies are found in this disease.
Mixed connective tissue disease can present with a vast array of symptoms. The most common symptoms a... | Anti-Ro |
https://bit.ly/49HJCwj | A 32-year-old man presents to the emergency department for evaluation of headache. His symptoms started last night and have persisted. He occasionally has migraine headaches, but he has not had a headache like this in the past. He reports associated nausea, vomiting, fevers, and neck pain. He has a medical history of a... | Acyclovir | Ceftriaxone and vancomycin | Ceftriaxone, vancomycin and steroids | Supportive care and monitoring | D | Supportive care and monitoring | This patient with headache, fever, and neck stiffness has a presentation and CSF studies consistent with a diagnosis of viral or aseptic meningitis. Supportive care is the most appropriate management strategy for patients with viral meningitis.
Aseptic (viral) meningitis presents similarly to bacterial meningitis with... | nan |
https://bit.ly/41Hqt8O | A 38-year-old woman presents to the emergency department with difficulty eating. Over the past week, she has had increasing difficulty chewing her food and progressive pain in the left side of her jaw. This morning, she was unable to close her mouth for several minutes after taking a bite of her breakfast. Two months a... | Amphotericin B | Clindamycin | Metronidazole | Penicillin | D | Penicillin | This patient presents with fever, trismus, and cutaneous drainage of sulfur granules in the setting of a recent dental procedure, which points to a diagnosis of cervicofacial actinomycosis. The most appropriate treatment for this disease is penicillin.
Actinomyces is a gram-positive, filamentous rod that causes a cerv... | Trimethoprim-sulfamethoxazole |
https://step2.medbullets.com/testview?qid=215056 | A 26-year-old woman presents to the clinic with diarrhea, bloating, flatulence, and abdominal cramps. These symptoms have been going on for 2 months. She has lost 6 pounds (2.7 kg) over these 2 months. Her medical history is significant for mild intermittent asthma for which she uses an albuterol inhaler as needed. She... | Celiac disease | Crohn disease | Whipple disease | Tropical sprue | D | Tropical sprue | The patient is presenting with chronic diarrhea, weight loss, megaloblastic anemia (low hemoglobin and elevated MCV), and a biopsy showing blunted villi and mixed infiltrate following significant travel to South India. This is consistent with tropical sprue.
Tropical sprue is characterized by chronic diarrhea that occ... | nan |
https://bit.ly/3IgfxrD | A 34-year-old nulliparous woman presents to the clinic with 2 weeks of copper-colored discharge from her right nipple. Her breast has not been tender, and she has not noticed any changes to the skin. She is otherwise healthy and does not take any medications. Her temperature is 36.5°C (97.7°F), blood pressure is 110/82... | Ductal carcinoma in situ | Mammary duct ectasia | Invasive ductal carcinoma | Intraductal papilloma | D | Intraductal papilloma | This young patient who presents with non-painful unilateral bloody nipple discharge and no palpable mass on breast exam most likely has an intraductal papilloma.
Intraductal papilloma is a benign epithelial tumor that develops in the lactiferous ducts of the breast and is the most common cause of bloody nipple dischar... | nan |
https://step2.medbullets.com/testview?qid=108992 | A 64-year-old man presents to the emergency room with a headache and nausea. He reports that he was rocking his grandson to sleep when the symptoms began. He states the pain is constant and is primarily located on his right side. When asked to indicate the area of pain, he says that it surrounds his eye and upper foreh... | Acetazolamide | Clopidogrel | Amitriptyline | Epinephrine | A | Acetazolamide | This patient is presenting with sudden-onset unilateral vision loss and an orbitofrontal headache with a dilated pupil and a hard ocular globe suggesting a diagnosis of acute angle-closure glaucoma. Long-term management of angle-closure glaucoma can include acetazolamide.
Examination of the eye in a patient with acute... | nan |
https://bit.ly/46gXevP | A 30-year-old man presents to the emergency room with a laceration over the 4th metacarpophalangeal (MCP) joint of his right hand. He reports that he is a mailman, and his closed fist was bitten by a dog while he was delivering mail yesterday. He reports pain but denies fevers, chills, drainage, or any other symptoms. ... | Clindamycin | Amoxicillin-clavulanate | Clindamycin plus doxycycline | Wound closure and amoxicillin-clavulanate | B | Amoxicillin-clavulanate | This patient has suffered a clenched fist injury which are generally managed with irrigation and amoxicillin-clavulanate.
Amoxicillin-clavulanate is the usual first-line antibiotic for patients with a human or dog bite. Lacerations sustained from animal or human bites should not be sutured due to the risk of infection... | nan |
https://step2.medbullets.com/testview?qid=108740 | A 15-year-old boy is brought to his pediatrician for a follow-up visit. His parents report that he is doing well in school and has many friends. Their only concern is that he has a “difficult stomach.” Every few months, he complains of intermittent abdominal pain that takes several days to pass. He occasionally misses ... | Decreased mean corpuscular volume | Decreased serum homocysteine level | Increased serum methylmalonic acid level | Microcytes | C | Increased serum methylmalonic acid level | This patient with episodic abdominal pain, bloody stool, growth failure, and erythema nodosum most likely has Crohn disease. Disease involving the terminal ileum predisposes patients to vitamin B12 deficiency, which would cause anemia with an elevated serum methylmalonic acid level.
Crohn disease is an inflammatory bo... | Prolonged partial thromboplastin time |
https://bit.ly/3MdLLon | A 16-year-old boy presents to his primary care physician for a routine follow-up visit. He feels disappointed because his voice has not changed. He is concerned that he is not as tall as his classmates. He denies any headache, vision changes, nausea, or vomiting. He recently started playing for his high school basketba... | Karyotyping | Magnetic resonance imaging (MRI) of the brain with gadolinium | Radiograph of the hand and wrist | Reassurance with close follow-up | C | Radiograph of the hand and wrist | This patient is greater than 14 years of age without the development of secondary sex characteristics (e.g., testicular volume < 4 mL), which is concerning for delayed puberty. The patient should have a radiograph of the hand and wrist to evaluate for discrepancies between bone age and chronological age.
Delayed puber... | Testicular ultrasound |
https://step2.medbullets.com/testview?qid=109042 | A 13-day-old boy is brought by his mother for eye redness and ocular discharge. The mother reports that the patient has developed a cough and nasal discharge. Pregnancy and delivery were uncomplicated but the mother had limited prenatal care during the third trimester. Immediately after delivery, the baby was given sil... | Artificial tears | Oral erythromycin | Intravenous acyclovir | Topical erythromycin | B | Oral erythromycin | This patient is presenting with mucoid ocular discharge around 2 weeks post-birth, suggesting the diagnosis of neonatal chlamydial conjunctivitis. The most appropriate treatment for this disease includes oral erythromycin.
Neonatal chlamydial conjunctivitis is caused by Chlamydia trachomatis. It presents in newborns t... | nan |
https://step2.medbullets.com/testview?qid=216593 | A 55-year-old man presents to his primary care physician with persistent symptoms of depression. He started taking fluoxetine 3 weeks ago when he was diagnosed with major depressive disorder after a divorce. Since then, he notes that his symptoms are roughly unchanged. His other medications include albuterol. His tempe... | Change medication to bupropion | Increase dose of current medication | Maintain dose of current medication | Change medication to escitalopram | C | Maintain dose of current medication | This patient is presenting with major depressive disorder but has not given his current selective serotonin reuptake inhibitor (SSRI) at least 4 weeks to begin working. Thus, he should be reassured and maintained on the current dose of his SSRI, with follow-up after the 4 week mark to see if his symptoms have improved.... | nan |
https://bit.ly/3QOZdTR | A 35-year-old man is brought into the emergency department by ambulance for a stab wound to the left leg near the inguinal ligament. The patient has no significant medical history, and takes no other medication. He was not stabbed or otherwise injured elsewhere. His temperature is 98.6°F (37.0°C), pulse is 130, blood p... | Emergent surgical intervention | Wound closure | Observation | CT scan of the left lower extremity | A | Emergent surgical intervention | This patient with pulsatile bleeding from a wound to the left thigh and hemodynamic instability has hard signs of vascular injury. Patients with penetrating wounds and hard signs of vascular injury should be managed with emergent surgical intervention.
Vascular injury commonly occurs as a result of penetrating trauma,... | nan |
https://step2.medbullets.com/testview?qid=215186 | A 24-year-old man presents to the emergency room after a motor vehicle collision. He was the driver in a head-on collision and was not wearing a seatbelt. The patient is acutely intoxicated and is attempting to attack the nurses. Soon after presentation, he is sedated, paralyzed, and intubated. His medical history is u... | Needle thoracostomy | Pericardial window | Tube thoracostomy | Pericardiocentesis | D | Pericardiocentesis | This patient is presenting after trauma with hypotension, tachycardia, jugular venous distension, and electrical alternans on ECG, which is concerning for cardiac tamponade. The most important initial step in management is pericardiocentesis.
Cardiac tamponade can occur after trauma, infections, or malignancy. It can ... | nan |
https://bit.ly/3RSgtYc | A 24-year-old man with epilepsy refractory to valproic acid, phenytoin, and levetiracetam undergoes magnetic resonance imaging of his brain while monitored by anesthetic care. He wakes up screaming in pain due to an electrocardiogram lead having caused a significant thermal burn circumferentially around his left leg. H... | Amputation | Escharotomy | Fasciotomy | Intravenous fluid infusion based on Parkland formula | B | Escharotomy | This patient with a circumferential burn due to an ECG cable wrapped around his leg in an MRI machine now has clear evidence of compartment syndrome due to the eschar. The most appropriate next step in management is emergent escharotomy to restore blood flow.
Burns can be caused by chemical, thermal, electrical, and r... | Transfer to burn center |
https://step2.medbullets.com/testview?qid=217175 | A 1-year-old girl is brought to a neurologist due to increasing seizure frequency over the past 2 months. She recently underwent a neurology evaluation which revealed hypsarrhythmia on electroencephalography (EEG) with a mix of slow waves, multifocal spikes, and asynchrony. Her parents have noticed the patient occasion... | Cardiac rhabdomyoma | Glaucoma | Optic glioma | Polyostotic fibrous dysplasia | A | Cardiac rhabdomyoma | This patient with a seizure disorder, ash-leaf spots (innumerable hypopigmented macules), Shagreen patch (elevated irregular plaque on the lower back), and West syndrome (hypsarrhythmia on EEG and movements consistent with infantile spasms) likely has tuberous sclerosis. Tuberous sclerosis is associated with cardiac rh... | nan |
https://bit.ly/46vZtvp | A 60-year-old woman presents to the emergency department with back pain after gardening. Her pain is 7/10 in severity, non-radiating, and not relieved by rest. She has never experienced this pain in the past and denies fever, night sweats, unintentional weight loss, and bowel or bladder incontinence. She has hypertensi... | Herniated disc | Lumbosacral strain | Multiple myeloma | Spondylolisthesis | B | Lumbosacral strain | This patient presents with acute low back pain after physical exertion without radicular signs (e.g., motor or sensory changes in a nerve root distribution) and a negative straight leg raise, which are most consistent with lumbosacral strain.
The evaluation of acute low back pain is focused on eliciting clinical histo... | Vertebral compression fracture |
https://step2.medbullets.com/testview?qid=216246 | A 48-year-old man presents to the emergency room with a 2-hour history of severe abdominal pain, nausea, and vomiting. He states that he has not passed gas or had a bowel movement in 4 days and his pain has worsened and become constant over the past 2 hours. His only medical history includes an appendectomy that he und... | Broad-spectrum antibiotics and serial abdominal radiographs | CT angiography of the abdomen and pelvis | Nasogastric tube placement | Supportive care, NPO, and intravenous fluids | E | Urgent surgical intervention | This patient with abdominal pain, vomiting, and obstipation is now hemodynamically unstable with fever, leukocytosis, rising lactate, and worsening pain. He most likely has a complicated small-bowel obstruction (SBO) and should undergo immediate surgical intervention.
SBO occurs when the normal progression of intralum... | Urgent surgical intervention |
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, ... | Central retinal artery occlusion | Closed angle glaucoma | Papilledema | Retinal detachment | E | 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... | Retinal vein occlusion |
https://bit.ly/40Awtzi | A 27-year-old man presents to his primary care physician for exposure to toxic materials. The patient states that when he left for work this morning he was certain that he had closed the door to his pantry. Upon returning home, he saw that the door to his pantry was wide open. The patient is certain that his neighbors ... | Paranoid personality disorder | Borderline personality disorder | Narcissistic personality disorder | Schizoid personality disorder | A | Paranoid personality disorder | This patient is presenting with a history of mistrust and suspicion of others without frankly psychotic features suggesting a diagnosis of paranoid personality disorder.
Paranoid personality disorder is a cluster A personality disorder that is genetically associated with schizophrenia. These patients present with a pe... | nan |
https://step2.medbullets.com/testview?qid=108971 | A 65-year-old man presents to his primary care physician for stiffness in his arm. He has been having trouble combing his hair and reaching objects that are high on the shelf. The patient has a medical history of type 2 diabetes mellitus, obesity, and hypertension. His current medications include metformin, insulin, li... | Adhesive capsulitis | Biceps tendinopathy | Glenohumeral osteoarthritis | Rotator cuff impingement | A | Adhesive capsulitis | This patient is presenting with stiffness and a decreased range of motion in his shoulders suggestive of a diagnosis of adhesive capsulitis.
Adhesive capsulitis classically presents in elderly, sedentary patients with a chief complaint of stiffness. On physical exam, the key findings are a loss of active, but more imp... | Subacromial bursitis |
https://step2.medbullets.com/testview?qid=216419 | A 27-year-old nurse presents to the emergency department with a 30-minute history of palpitations and chest pain. She has been experiencing nausea, vomiting, and diarrhea after eating leftovers 2 days ago. Her husband tells the physician that he is concerned that the patient has been increasingly obsessed about her wei... | Arterial blood gas | Complete blood count | Serum glucose | Urine chloride | D | Urine chloride | This patient who presents with hypokalemia and metabolic alkalosis may either be vomiting or engaging in diuretic abuse. A urine chloride test can be used to distinguish between these possibilities because urine chloride will be high in diuretic abuse and will be low/normal in surreptitious vomiting.
Metabolic alkalos... | Urine toxicology |
https://bit.ly/47Zw1Ph | A 31-year-old man presents to the emergency department for fever, malaise, and cough. For the last week, his cough has been progressively worsening, and he has been noticing blood in his sputum. He denies any recent travel or sick contacts and infrequently smokes cigarettes. Approximately 5 weeks ago, he presented with... | Continue current anti-retroviral treatment, antimicrobial, and anti-tuberculoid therapies | Determine drug sensitivities against the patient’s pulmonary infection | Obtain a D-dimer level | Start high-dose glucocorticoid treatment and discontinue antiretroviral therapy | A | Continue current anti-retroviral treatment, antimicrobial, and anti-tuberculoid therapies | This patient with recently diagnosed HIV and tuberculosis infection (upper lung lobe infiltrate) is presenting with worsening symptoms after being appropriately treated. Worsening of symptoms after initiation of these therapies is concerning for immune reconstitution inflammatory syndrome (IRIS), which is managed by co... | nan |
https://step2.medbullets.com/testview?qid=216270 | A 52-year-old man presents to the emergency department by ambulance for evaluation of hematemesis. His wife states that he began vomiting bright red blood this evening while eating dinner, and has produced about 5 cups total. He has a history of alcohol use disorder and has vomited small streaks of blood in the past, b... | Balloon tamponade | Ceftriaxone | Nadolol | Octreotide | D | Octreotide | This patient with a history of alcohol use disorder and signs of liver failure (jaundice, ascites, spider angiomas, and ecchymoses) presents with acute hematemesis and hypovolemic shock (hypotension, tachycardia, tachypnea) most concerning for a variceal hemorrhage. The first step in the resuscitation of patients with ... | Platelet transfusion |
https://step2.medbullets.com/testview?qid=214943 | A 44-year-old homeless man presents to the emergency department after being stabbed multiple times in the abdomen. The patient is intoxicated and is unable to offer further history. His temperature is 97.5°F (36.4°C), blood pressure is 92/52 mmHg, pulse is 145/min, respirations are 33/min, and oxygen saturation is 90% ... | Thiamine | Vitamin C | Zinc | Riboflavin | C | Zinc | This homeless patient who likely has poor nutritional status presents with angular cheilitis, sparse hair that is falling out, diarrhea, and poor wound healing, all of which are suggestive of zinc deficiency.
Zinc is involved in many physiologic processes and is an important mineral to include in the diet. Zinc defici... | nan |
https://bit.ly/3Pmj3mJ | A 2-year-old girl presents to the pediatrician with her mother for a routine well-child visit. Her mother is concerned that the patient is a picky eater and refuses to eat vegetables. She drinks milk with meals and has juice sparingly. She goes to sleep easily at night and usually sleeps for 11-12 hours. The patient ha... | Fine motor skills | Social and receptive language skills | This child is developmentally normal | Expressive language skills | D | Expressive language skills | This child is meeting her milestones in every category but expressive language. By 2 years of age, a child should have a vocabulary of over 50 words and be using 2-word phrases.
Assessing whether a child is meeting developmental milestones is important for identifying delays and enabling early intervention. In the gro... | nan |
https://step2.medbullets.com/testview?qid=108515 | A 23-year-old woman presents to the emergency department with severe abdominal pain. The pain has been dull and progressive, but became suddenly worse while she was exercising. Her medical history is notable for depression, anxiety, and gonococcal urethritis that was appropriately treated. She is sexually active and do... | Inflammation of the pancreas | Obstruction of blood flow through the hepatic vein | Obstruction of the common bile duct by radio-opaque stones | Vascular ectasia within the liver | D | Vascular ectasia within the liver | This patient is presenting with constant right upper quadrant pain in the setting of oral contraceptives (OCP) and likely anabolic steroid use, suggesting a diagnosis of a ruptured hepatic adenoma (HA). The pathophysiology of HA is vascular ectasia from exposure to OCPs and androgens.
A hepatic adenoma typically occur... | nan |
https://bit.ly/48uDHdl | A 33-year-old woman presents to the emergency department with muscle spasms. She has noticed "twitching" in both her upper and lower extremities over the past 3 days that have interfered with her training for a marathon. She has felt more fatigued over the past month. She has no significant medical history. She takes n... | Hypocalcemia | Hypomagnesemia | Hyponatremia | Hypothyroidism | B | Hypomagnesemia | This patient is presenting with what appears to be anorexia nervosa (thin habitus, possible excessive exercise in the setting of marathon running, thinning hair, dry mucous membranes, decreased free T4 level, and multiple electrolyte derangements). The lack of improvement in either her muscle spasms with fluid repletio... | Hypovolemia |
https://step2.medbullets.com/testview?qid=109134 | A 6-month-old boy is brought to the pediatrician by his parents for a routine visit. His parents report that he is feeding and stooling well and they have just started experimenting with solid foods. His parents are concerned because a few weeks ago he started rolling from back to front in addition to front to back, bu... | Sphingomyelin | Glucocerebroside | GM2-ganglioside | Galactocerebroside | C | GM2-ganglioside | This 6-month-old boy who presents with developmental regression, a “cherry-red” macula, and hyperreflexia most likely has a diagnosis of Tay-Sachs disease. Tay-Sachs disease is caused by a deficiency of beta-hexosaminidase A that results in the accumulation of GM2-ganglioside.
Tay-Sachs disease is a genetic disorder c... | nan |
https://step2.medbullets.com/testview?qid=216593 | A 55-year-old man presents to his primary care physician with persistent symptoms of depression. He started taking fluoxetine 3 weeks ago when he was diagnosed with major depressive disorder after a divorce. Since then, he notes that his symptoms are roughly unchanged. His other medications include albuterol. His tempe... | Administer levothyroxine | Change medication to bupropion | Change medication to escitalopram | Increase dose of current medication | E | Maintain dose of current medication | This patient is presenting with major depressive disorder but has not given his current selective serotonin reuptake inhibitor (SSRI) at least 4 weeks to begin working. Thus, he should be reassured and maintained on the current dose of his SSRI, with follow-up after the 4 week mark to see if his symptoms have improved.... | Maintain dose of current medication |
https://bit.ly/3QOJp1p | A 55-year-old woman is brought to the emergency department by her husband with a 1 hour history of an unremitting headache. The headache started suddenly while she was eating dinner and she says it feels like the “worst headache of my life.” An emergent CT scan of the head without contrast confirms the diagnosis, and a... | Addison disease | Cerebral salt wasting | Diuretic overuse | Primary polydipsia | B | Cerebral salt wasting | This patient presents with a subarachnoid hemorrhage (“worst headache of my life”) which is treated and then subsequently develops nausea, vomiting, and altered mental status with reduced serum sodium concentration, indicative of symptomatic hyponatremia. In the setting of serum hypo-osmolality, urine hyper-osmolality,... | Syndrome of inappropriate anti-diuretic hormone |
https://step2.medbullets.com/testview?qid=216615 | A 5-year-old boy presents to his primary care physician for recurrent colds, fatigue, and fussiness. Over the past several weeks, the child has been more fatigued and his parents state that “he always seems to be sick.” They state that sometimes he complains about his bones hurting and they note that he is less playful... | Acute lymphoblastic leukemia | Acute myelogenous leukemia | Chronic myelogenous leukemia | Leukemoid reaction | A | Acute lymphoblastic leukemia | This pediatric patient is presenting with recurrent colds, fatigue, non-tender lymphadenopathy, hepatosplenomegaly, and leukocytosis with increased lymphoblasts, which are concerning for acute lymphoblastic leukemia (ALL).
ALL is the most common hematologic cancer in pediatric patients. It initially presents with a va... | Parvovirus B19 infection |
https://bit.ly/3QOZdTR | A 35-year-old man is brought into the emergency department by ambulance for a stab wound to the left leg near the inguinal ligament. The patient has no significant medical history, and takes no other medication. He was not stabbed or otherwise injured elsewhere. His temperature is 98.6°F (37.0°C), pulse is 130, blood p... | Angiography of the left lower extremity | CT scan of the left lower extremity | Emergent surgical intervention | Observation | C | Emergent surgical intervention | This patient with pulsatile bleeding from a wound to the left thigh and hemodynamic instability has hard signs of vascular injury. Patients with penetrating wounds and hard signs of vascular injury should be managed with emergent surgical intervention.
Vascular injury commonly occurs as a result of penetrating trauma,... | Wound closure |
https://step2.medbullets.com/testview?qid=109003 | A 69-year-old man presents to his primary care physician with hip and back pain. He states this weekend he had a barbecue. When he was lifting a heavy object, he suddenly felt pain in his lower back. He describes the pain as in his buttocks but states that at times it travels down his leg. He states that it feels elect... | Palpating the paraspinal muscles | Radiography | Straight leg raise | Flexion, abduction, and external rotation of the thigh | C | Straight leg raise | This patient is presenting with lower back pain that is electrical and travels down his legs after lifting an object suggesting a diagnosis of a herniated disc. The straight leg test can help confirm the diagnosis.
A herniated disc classically presents in a middle-aged or older individual who was lifting a heavy objec... | nan |
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 | Schizophrenia | Schizophreniform disorder | E | 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... | Schizotypal personality disorder |
https://bit.ly/45Y8H4f | A 6-hour-old newborn boy is noted to have a “lump on his head” by his mother. She denies that the lump was present at birth and is concerned about an infection. The child was born at 39 weeks gestation to a 34-year-old G2P2 mother by vacuum-assisted vaginal delivery after prolonged labor. His birth weight was 3.8 kg (8... | Incision and drainage | Intensive phototherapy | Neurosurgical decompression | Observation only | D | Observation only | This patient presents with a fluctuant swelling of the scalp that is limited by suture lines, which is the classic description of a cephalohematoma. The majority of cases of cephalohematoma self-resolve, thus the most appropriate next step in management is observation.
A cephalohematoma is a relatively common traumati... | Red blood cell transfusion |
https://bit.ly/42HsiTA | A 32-year-old woman presents to her primary care provider with pelvic pain. She reports that for the last several years, she has had chronic pain that is worse just before her menstrual period. Over the past 2 months, she has also had worsening pain during intercourse. She denies dysuria, vaginal discharge, or vaginal ... | Abdominal ultrasound | Hysterosalpingogram | Hysteroscopy | Laparoscopy | D | Laparoscopy | This patient presents with chronic pelvic pain that is worse before her menstrual period, vaginal tenderness on physical exam, and lateral displacement of the cervix, which is consistent with a diagnosis of endometriosis. Since this patient has failed therapy with oral contraceptive pills (OCPs), she should undergo lap... | Pelvic MRI |
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 | Report to child protective services | Vaginal culture | Vaginal exam under anesthesia | 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... | Warm water irrigation of the vagina |
https://step2.medbullets.com/testview?qid=216357 | A 77-year-old man presents to the emergency department with a complaint of sudden onset weakness in his right upper extremity. At home, the patient thought he was simply dehydrated, but he rapidly began to have trouble speaking. When his wife noted this she brought him into the hospital. On arrival to the emergency dep... | Intracerebral hemorrhage | Subdural hematoma | Subarachnoid hemorrhage | Epidural hematoma | A | Intracerebral hemorrhage | This patient with a medical history of hypertension on blood thinners (apixaban) is presenting with rapidly progressive neurologic symptoms. Initially, his symptoms are in his right upper extremity, which then progresses to affect his speech and cause altered mental status, obtundation, and seizures, which is suggestiv... | nan |
https://step2.medbullets.com/testview?qid=216513 | A 33-year-old woman presents to the emergency department with foul-smelling vaginal discharge. She states that it started 1 day ago and has not improved with hygiene products. She is sexually active and uses condoms. She does not complain of any abdominal or pelvic pain but states she has some mild burning when urinati... | Metronidazole | Ceftriaxone | Ceftriaxone and doxycycline | Ceftriaxone and azithromycin | C | Ceftriaxone and doxycycline | This nonpregnant woman is presenting with a thick, white cervical discharge, dysuria, and urethral discharge without cervical motion tenderness or adnexal tenderness which is concerning for urethritis without pelvic inflammatory disease. She should be treated with ceftriaxone and doxycycline to cover for the most commo... | nan |
https://step2.medbullets.com/testview?qid=210475 | A 15-year-old boy presents to his pediatrician after an appendectomy 1 week ago. The patient denies any abdominal pain, fevers, chills, nausea, vomiting, diarrhea, or constipation. He eats solids and drinks liquids without difficulty. He is back to playing basketball for his school team without any difficulty. His urin... | CT scan abdomen and pelvis with contrast | Renal biopsy | Repeat urinalysis | Urine dipstick in the morning and in the afternoon | D | Urine dipstick in the morning and in the afternoon | This patient is found to have proteinuria on urinalysis in the absence of clinical symptoms or signs of nephrotic syndrome. Given the likely diagnosis of transient proteinuria, the most appropriate next step is to repeat the urine dipstick in the morning and in the afternoon.
Transient proteinuria can be due to febril... | nan |
https://step2.medbullets.com/testview?qid=215170 | A 50-year-old man presents to the emergency department with chest pain. He states that the pain is dull in quality, started 30 minutes ago, has been gradually worsening, and is worse with exertion. He also endorses some shortness of breath. He also believes the pain is worse when leaning back and improved when leaning ... | Hypertrophic obstructive cardiomyopathy | Hypokalemia | Myocardial infarction | Hyperkalemia | C | Myocardial infarction | This patient is presenting with chest pain and an ECG demonstrating hyperacute T waves (leads V2-V6) which is an early finding concerning for a myocardial infarction.
A myocardial infarction occurs when an atherosclerotic plaque ruptures causing occlusion of a coronary artery. Patients classically present with chest p... | nan |
https://bit.ly/483O4Um | 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 | Ingrown eyelash follicle | 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... | Meibomian cell carcinoma |
https://bit.ly/40wICHc | A 10-year-old girl is admitted to the medical floor for a respiratory infection. The patient lives in a foster home and has been admitted many times. Since birth, the patient has had repeated episodes of pain/pressure over her frontal sinuses and a chronic cough that produces mucus. She was recently treated with amoxic... | Diastolic murmur best heard along the right lower sternal border | Hypocalcemia | Increased chloride in the patient's sweat | Repeat sinus infections secondary to seasonal allergies | A | Diastolic murmur best heard along the right lower sternal border | This patient is presenting with recurrent sinus infections suggestive of Kartagener syndrome. Dextrocardia is a common feature in this pathology, which results in right-sided heart sounds or a diastolic murmur best heard along the right lower sternal border for this patient's tricuspid stenosis.
Kartagener syndrome (p... | Social withdrawal and avoidance of eye contact |
https://bit.ly/3O2B9LC | A 4-year-old boy is brought in by his grandmother for worsening seizure activity. She reports that occasionally he “suddenly drops” when running around the house. She says that his first seizure occurred 1 year ago. Since then, he has been on valproic acid but the seizure activity remains unchanged. He was recently enr... | Implant a pacemaker | Replete potassium and magnesium and start a beta-blocker | Start ethosuximide | Administer intravenous lorazepam | B | Replete potassium and magnesium and start a beta-blocker | The patient who presents with deafness and long QT syndrome that progressed to torsades de pointes most likely has Jervell and Lange-Nielsen syndrome. The most appropriate next step in management is to replete potassium and magnesium and then start a beta-blocker.
Jervell and Lange-Nielsen syndrome is an autosomal rec... | nan |
https://bit.ly/47KxMQs | A 42-year-old woman is enrolled in a randomized controlled trial to study cardiac function in the setting of several different drugs. She is started on verapamil and instructed to exercise at 50% of her VO2 max while several cardiac parameters are being measured. During this experiment, which of the following represent... | AV node > ventricles > atria > Purkinje fibers | Purkinje fibers > ventricles > atria > AV node | Purkinje fibers > atria > ventricles > AV node | Purkinje fibers > AV node > ventricles > atria | C | Purkinje fibers > atria > ventricles > AV node | The conduction velocity of the structures of the heart are in the following order: Purkinje fibers > atria > ventricles > AV node. A calcium channel blocker such as verapamil would only slow conduction in the AV node.
The conduction velocity of cardiac tissue is determined by a wide variety of factors, including the n... | nan |
https://step2.medbullets.com/testview?qid=216357 | A 77-year-old man presents to the emergency department with a complaint of sudden onset weakness in his right upper extremity. At home, the patient thought he was simply dehydrated, but he rapidly began to have trouble speaking. When his wife noted this she brought him into the hospital. On arrival to the emergency dep... | Epidural hematoma | Intracerebral hemorrhage | Ischemic stroke | Subarachnoid hemorrhage | B | Intracerebral hemorrhage | This patient with a medical history of hypertension on blood thinners (apixaban) is presenting with rapidly progressive neurologic symptoms. Initially, his symptoms are in his right upper extremity, which then progresses to affect his speech and cause altered mental status, obtundation, and seizures, which is suggestiv... | Subdural hematoma |
https://step2.medbullets.com/testview?qid=216246 | A 48-year-old man presents to the emergency room with a 2-hour history of severe abdominal pain, nausea, and vomiting. He states that he has not passed gas or had a bowel movement in 4 days and his pain has worsened and become constant over the past 2 hours. His only medical history includes an appendectomy that he und... | Supportive care, NPO, and intravenous fluids | Urgent surgical intervention | Nasogastric tube placement | CT angiography of the abdomen and pelvis | B | Urgent surgical intervention | This patient with abdominal pain, vomiting, and obstipation is now hemodynamically unstable with fever, leukocytosis, rising lactate, and worsening pain. He most likely has a complicated small-bowel obstruction (SBO) and should undergo immediate surgical intervention.
SBO occurs when the normal progression of intralum... | nan |
https://bit.ly/3OXaArd | A 56-year-old woman presents to the emergency department with muscle weakness. Her symptoms have progressively worsened over the course of 2 weeks and are most significant in her lower extremities. She also notices increased urinary frequency. Approximately 1 month ago, she was diagnosed with calcium phosphate nephroli... | Administer hydrochlorothiazide | Administer intravenous insulin | Administer intravenous sodium bicarbonate | Begin potassium replacement therapy with dextrose | C | Administer intravenous sodium bicarbonate | This patient's non-anion gap metabolic acidosis, hypokalemia, alkaline urine, and history of a calcium phosphate kidney stone and rheumatoid arthritis are suggestive of type 1 (distal) renal tubular acidosis. The treatment of choice is alkali replacement (sodium bicarbonate).
Type 1 (distal) renal tubular acidosis res... | Increase methotrexate dose |
https://bit.ly/3QRYhxm | A 55-year-old woman presents to the emergency department for evaluation of headache. She had a headache that was present for a few hours before subsiding 2 days ago, and then today she developed a headache that was sudden in onset and at maximal intensity within minutes. She has never had a headache like this in the pa... | CNS vascular endothelial dysfunction | Dehydration and stress | Hypersensitivity of the trigeminal nerve | Muscular pain and strain | E | Rupture of a berry aneurysm | This patient with sudden-onset headache, neck pain, and a CT scan showing blood in the basal cisterns likely has a subarachnoid hemorrhage. The most common cause of non-traumatic subarachnoid hemorrhage (SAH) is rupture of a saccular (berry) aneurysm.
SAH typically presents with a sudden onset "thunderclap" headache t... | Rupture of a berry aneurysm |
https://bit.ly/3tU2wPT | A 37-year-old man presents to the emergency department for a persistent fever. The patient has felt unwell for the past week and has felt subjectively febrile. The patient has a medical history of a suicide attempt and alcohol abuse. He is not currently taking any medications. The patient admits to using heroin and coc... | Blood cultures | CT scan | Ultrasound | Vancomycin and gentamicin | A | Blood cultures | This patient is presenting with fever and a systolic murmur suggestive of bacterial endocarditis. The most appropriate initial step in management is to draw blood cultures.
Bacterial endocarditis presents with fever, systemic symptoms (aches, myalgias, and fatigue), and a new murmur typically in a patient with intrave... | nan |
https://bit.ly/3LKCkh8 | A 69-year-old patient presents to the emergency department with shortness of breath and substernal pain. The patient has a medical history of obesity, anxiety, and constipation. He is currently not taking any medications and has not filled his prescriptions for over 1 year. An ECG is obtained and is seen in Figure A. T... | Add hydrochlorothiazide | Add lisinopril | Add nifedipine | Continue current medications and schedule follow up | B | Add lisinopril | This patient is presenting after a myocardial infarction for a follow-up appointment. The most appropriate next step in management is to start an angiotensin-converting enzyme (ACE) inhibitor such as lisinopril.
When a patient experiences a myocardial infarction, there are certain medications that the patient should b... | Switch beta-blocker to carvedilol |
https://bit.ly/3HvRZyr | A 23-year-old woman presents to the emergency room for a self-inflicted laceration of her distal volar forearm. The patient states she knew her boyfriend was having sexual thoughts about the woman from the grocery store, prompting her decision to cut her own wrist. In the emergency department, the bleeding has stopped ... | Borderline | Dependent | Avoidant | Antisocial | A | Borderline | This patient is presenting with a suicide attempt, unstable relationships, and emotional lability suggesting a diagnosis of borderline personality disorder.
Borderline personality disorder classically presents with emotional lability, and intense, unstable relationships. These patients fear abandonment and will often ... | nan |
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