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https://bit.ly/3LH7lCu | A 30-year-old man is evaluated in the post-anesthesia care unit for neck pain. He underwent a laparoscopic appendectomy and was treated for post-operative nausea and vomiting with metoclopramide. Approximately 20 minutes after receiving the medication, he developed pain and stiffness in his neck and eventually was unab... | Botulinum toxin injection | Ondansetron | Diphenhydramine | Observation | C | Diphenhydramine | This patient is suffering from a metoclopramide-induced acute dystonic reaction. Treatment of this complication includes IV diphenhydramine or benztropine.
Dystonic reactions are reversible extrapyramidal symptoms that may include involuntary spasms or sustained contractions of the face, neck, torso, pelvis, extremiti... | nan |
https://bit.ly/3qNCi0x | A 57-year-old woman presents to the emergency department for a headache. She was at home when a sudden headache began with greater severity than she had experienced in the past. She presented within 30 minutes of symptom onset. The patient has a medical history of sinusitis, constipation, diabetes, and pelvic inflammat... | Amoxicillin-clavulinic acid | CT of the head | Dexamethasone | MRI of the head | E | Piperacillin-tazobactam | This patient is presenting with symptoms suggestive of septic cavernous sinus thrombosis (CST). The most appropriate initial step in management is urgent broad-spectrum antibiotics and surgical drainage.
Cavernous sinus thrombosis is an emergency that requires immediate intervention. It typically occurs in a patient w... | Piperacillin-tazobactam |
https://bit.ly/3Qni72e | A 23-year-old man presents to the emergency department for altered mental status after a finishing a marathon. He has a medical history of obesity and anxiety and is not currently taking any medications. His temperature is 104°F (40°C), blood pressure is 147/88 mmHg, pulse is 200/min, respirations are 33/min, and oxyge... | 50% normal saline 50% dextrose | Dextrose solution | Hypotonic saline | Lactated ringer | D | Lactated ringer | This patient is presenting with hypernatremia and heat stroke for which the most appropriate next step in management is the administration of lactated ringer solution.
Heat stroke presents with hot/flushed skin, fever, altered mental status, and hypernatremia secondary to loss of free water. Patients should immediatel... | Normal saline |
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... | Fixed splitting of S1 and S2 | Heart sound after S2 | Heart sound before S1 | Holosystolic murmur at the apex | 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... | Normal S1 and S2 |
https://bit.ly/3QjJGL8 | A 68-year-old man presents to the emergency department with right ear pain that he developed 4 days prior, and it has progressively worsened. The pain is worse at night. He has associated fever and chills. This morning, he awoke with purulent, foul-smelling discharge on his pillow. He has a history of type II diabetes ... | Acyclovir | Amoxicillin | Ceftriaxone | Ofloxacin ear drops | E | Vancomycin and piperacillin-tazobactam | The patient in this vignette most likely has malignant otitis externa (also referred to as necrotizing otitis externa), which is a life-threatening infection requiring therapy with intravenous anti-pseudomonal and broad-spectrum antibiotics. Piperacillin-tazobactam and vancomycin is an appropriate initial regimen.
Mal... | Vancomycin and piperacillin-tazobactam |
https://bit.ly/3My1xLG | A 57-year-old man is brought to a neurologist by his wife for abnormal behavior. He was normal until around 3 months ago when he started forgetting important meetings and misplacing items around the house. One month ago, the patient was fired from his job as a software engineer after attempting to grope a coworker. The... | Alzheimer disease | Creutzfeldt-Jacob disease | Dementia with Lewy bodies | Frontotemporal dementia | B | Creutzfeldt-Jacob disease | This patient with rapidly progressive dementia over 3 months, declining executive function, impaired concentration, decreased memory, startle myoclonus (sudden jerking of extremities in response to unexpected stimulus), and elevated 14-3-3 protein levels on cerebrospinal fluid (CSF) analysis most likely has Creutzfeldt... | Subcortical leukoencephalopathy |
https://step2.medbullets.com/testview?qid=109135 | A 62-year-old man arrives at the emergency room complaining of chest pain and difficulty breathing. He reports that the dyspnea started 2 months ago after he had the flu. At first, the difficulty breathing occurred whenever he went up and down 1 flight of stairs, but the dyspnea progressively worsened since then. This ... | Cardiac tamponade | Cirrhosis | Constrictive pericarditis | Pulmonary arterial hypertension | C | Constrictive pericarditis | This patient is presenting with peripheral edema, ascites, elevated jugular venous distension, and pericardial calcifications on chest radiograph, which are all consistent with a diagnosis of constrictive pericarditis.
Constrictive pericarditis is the result of scarring and loss of elasticity of the pericardial sac. C... | Restrictive cardiomyopathy |
https://step2.medbullets.com/testview?qid=217746 | A 34-year-old man presents to the emergency room with pain behind his eyes. He had a similar episode about 1 month ago which resolved after a few hours. The pain feels like a stabbing sensation behind his right eye. He denies any symptoms on the left side. The last time he had an episode like this, his eye was tearing.... | Ibuprofen | Oxygen | Propranolol | Sumatriptan | E | Verapamil | This patient with a history of retro-orbital pain, unilateral miosis (2 mm pupil on the right), and history of lacrimation during a similar episode is likely experiencing cluster headaches. Verapamil may be used as prophylaxis in the treatment of cluster headaches.
Cluster headaches occur more commonly in men and pres... | Verapamil |
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 ... | Atypical pneumonia | Chronic obstructive pulmonary disease | Community acquired pneumonia | Medication administration | D | 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... | Poor cardiac function |
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... | Alteplase | CT head | Diazepam | Observation | D | 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... | Sumatriptan |
https://bit.ly/3Qq9vcA | A newborn boy is assessed in the newborn nursery due to central cyanosis that does not respond to oxygen therapy. The patient was born to a G1P1 mother at 39 weeks gestation. The mother had diabetes that was managed with exercise and insulin during the pregnancy. The mother has never been vaccinated and did not follow ... | Truncus arteriosus | Transposition of the great vessels | Tricuspid valve atresia | Total anomalous pulmonary venous return | B | Transposition of the great vessels | This patient is presenting with right axis deviation on ECG and an "egg on a string" heart on chest radiograph suggesting a diagnosis of transposition of the great vessels.
Transposition of the great vessels occurs when the spiral septum that divides the truncus arteriosus into the aorta and pulmonary artery fails to ... | nan |
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 | Amphotericin and 5-flucytosine | Ceftriaxone and vancomycin | Ceftriaxone, vancomycin and steroids | E | 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... | Supportive care and monitoring |
https://bit.ly/3qNCi0x | A 57-year-old woman presents to the emergency department for a headache. She was at home when a sudden headache began with greater severity than she had experienced in the past. She presented within 30 minutes of symptom onset. The patient has a medical history of sinusitis, constipation, diabetes, and pelvic inflammat... | MRI of the head | Piperacillin-tazobactam | Dexamethasone | Amoxicillin-clavulinic acid | B | Piperacillin-tazobactam | This patient is presenting with symptoms suggestive of septic cavernous sinus thrombosis (CST). The most appropriate initial step in management is urgent broad-spectrum antibiotics and surgical drainage.
Cavernous sinus thrombosis is an emergency that requires immediate intervention. It typically occurs in a patient w... | 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 ... | Increased serum methylmalonic acid level | Microcytes | Decreased serum homocysteine level | Prolonged partial thromboplastin time | A | 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... | nan |
https://bit.ly/3sB1jwE | A 55-year-old male bodybuilder presents to the emergency department with weakness of his right arm. The patient states he has experienced these symptoms for a few weeks; however, today his hand felt so weak he dropped his cup of tea. The patient has a medical history of diabetes. He drinks 2-7 alcoholic drinks per day ... | Apical lung tumor | Brachial plexopathy | Cerebral infarction | Scalenus anticus syndrome | A | Apical lung tumor | This patient is presenting with unilateral upper extremity paresthesia and weakness suggestive of compression of the neurovascular structures of the upper extremity secondary to an apical lung tumor.
An apical lung tumor can compress the neurovascular structures in its proximity and cause pain, numbness, and weakness ... | Subclavian steal syndrome |
https://step2.medbullets.com/testview?qid=216385 | A 49-year-old man presents with 3 months of generalized weakness. He has had a chronic cough and a 20 pound unintentional weight loss over the past 6 months. He has a medical history significant for high blood pressure, hyperlipidemia, and seasonal allergies with no prior surgical history. He has no history of tobacco ... | Prednisone taper | Bilateral adrenalectomy, prednisone, and fludrocortisone | Rifamycin, isoniazid, pyrazinamide, ethambutol, and hydrocortisone therapy | Hydrocortisone and immunoglobulin therapy | C | Rifamycin, isoniazid, pyrazinamide, ethambutol, and hydrocortisone therapy | This man from India presents with generalized weakness, chronic cough, unintentional weight loss, skin hyperpigmentation, hyponatremia, hyperkalemia, hypocortisolism, cosyntropin stimulation test failure, elevated ACTH, and bilateral adrenal calcifications on radiography. These symptoms and signs in this patient are mo... | nan |
https://step2.medbullets.com/testview?qid=215054 | A 65-year-old man presents to the emergency department with anxiety and intermittent palpitations. He began feeling the palpitations 3 days ago while eating dinner. He denies chest pain, shortness of breath, or loss of consciousness. He has a history of hypertension, major depressive disorder, Raynaud disease, and chro... | Amiodarone | Digoxin | Verapamil | Metoprolol | C | Verapamil | This patient’s new-onset palpitations, irregularly irregular pulse, and absent p-waves on ECG are consistent with atrial fibrillation. In hemodynamically stable patients with a relative contraindication to β-blockers (COPD on home oxygen with increasing oxygen need), rate control with a non-dihydropyridine calcium chan... | nan |
https://bit.ly/43RQXWn | Figure A is the lateral radiograph of a 44-year-old male who sustained a fall on his outstretched hand while rollerblading. The patient reports pain localized to the posterior elbow and refuses to attempt elbow extension secondary to pain and swelling. Which of the following is the most likely diagnosis in this patient... | Exacerbation of elbow arthritis | Olecranon bursitis | Lateral collateral ligament tear | Triceps rupture | D | Triceps rupture | The flake sign, as seen in Figure A is pathognomonic of a triceps tendon rupture.
Tricep tendon ruptures are rare injuries to the elbow extensor mechanism that most commonly occur as a result of forceful elbow contraction. Diagnosis can be made clinically, as patients with complete ruptures are unable to extend the el... | nan |
https://bit.ly/49ckvkP | A 24-year-old man presents to the emergency department with abdominal pain, nausea, and vomiting. The symptoms began towards the end of running a marathon and persisted after finishing the race. The patient is otherwise healthy and has no other medical problems. His temperature is 98.0°F (36.7°C), blood pressure is 105... | Cecal volvulus | Ileus | Sigmoid volvulus | Small bowel obstruction | A | Cecal volvulus | This young, healthy patient presents with abdominal pain, nausea, vomiting, and a distended, tender abdomen with a radiograph demonstrating the "coffee bean sign," likely has a cecal volvulus.
Cecal volvulus is the second most common cause of volvulus after sigmoid volvulus and presents with abdominal pain, constipati... | nan |
https://bit.ly/42tvFxa | A 41-year-old man presents to his primary care provider after seeing bright red blood in the toilet bowl after his last 2 bowel movements. He reports that he also noticed some blood mixed with his stool. The patient denies abdominal pain or any changes in his stool habits. He notes a weight loss of 8 pounds in the last... | Abdominal CT | Anoscopy | Barium enema | Colonoscopy | D | Colonoscopy | This patient presents with hematochezia and weight loss, which raises concern for colorectal cancer. The most appropriate next step in management is performing a colonoscopy.
The differential diagnosis of hematochezia includes colorectal cancer, inflammatory bowel disease, diverticulosis, and hemorrhoids. The evaluati... | Ultrasound of abdomen |
https://step2.medbullets.com/testview?qid=109238 | A 69-year-old woman presents with pain in her hip and groin. The pain is present in the morning but is nearly unbearable by the end of the day. Her medical history is notable for a treated episode of acute renal failure, diabetes mellitus, obesity, and hypertension. Her current medications include losartan, metformin, ... | Femoral neck fracture | Hyperdense foci in the ureters | Loss of joint space and osteophytes | Normal radiography | C | Loss of joint space and osteophytes | This patient is presenting with pain worse on exertion, decreased range of motion, and crepitus in her hip, suggesting a diagnosis of osteoarthritis. A loss of joint space and osteophytes (reactive bone formation) would be seen on radiography.
Osteoarthritis occurs due to wear and tear of the joint typically from repe... | Posterior displacement of the femoral head |
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 | Thickening feeds | MRI of the head | Intravenous hydration | D | 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... | nan |
https://bit.ly/3Q5BZZe | A girl presents to her pediatrician for a well-child visit. Her mother reports that she is eating well at home and sleeping well throughout the night. She can jump and walk up and down stairs with both feet on each step. In the doctor’s office, the patient builds a 6-cube tower and imitates a circle. She seems to have ... | Balances on one foot | Cuts with scissors | Follows two-step commands | Points to one body part | C | Follows two-step commands | This patient is able to walk up and down stairs, can build a 6 cube tower, has a 50+ word vocabulary, and uses 2-word phrases, which suggests she is 2 years of age. Another milestone at 2 years of age is following 2-step commands.
In the gross motor category, a child at 2 years of age should be able to jump and walk u... | Turns pages in book |
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... | nan |
https://step2.medbullets.com/testview?qid=216746 | A 21-year-old woman presents to her primary care physician due to a history of abdominal pain. She states that she has had recurrent bouts of mood swings, bloating, and abdominal pain that occur together approximately every 4 weeks. She states that when these symptoms occur, she gets into frequent arguments at work, is... | Premenstrual dysophoric disorder | Premenstrual syndrome | Major depressive disorder | Generalized anxiety disorder | A | Premenstrual dysophoric disorder | This patient with recurrent abdominal pain, bloating, and mood changes causing interpersonal difficulties related to the menstrual cycle likely has premenstrual dysphoric disorder. Premenstrual dysphoric disorder is a variant of premenstrual syndrome (PMS) characterized by prominent irritability and disruption of every... | nan |
https://bit.ly/45Vk2SF | A 3-year-old boy presents with his parents to a pediatrician for a new patient visit. The child was recently adopted and little is known about his medical or family history. The child seems to be doing well, but the patient is much larger than any of the other 3-year-olds in his preschool class. He eats a varied diet a... | Thromboembolic stroke | Wilms tumor | Osteoarthritis | Aortic dissection | A | Thromboembolic stroke | This patient presents with Marfanoid habitus, joint hypermobility, hyperelastic skin, developmental delay, and downward lens subluxation, which suggests a diagnosis of homocystinuria. Homocystinuria predisposes to thromboembolic events such as stroke.
Although homocystinuria shares many features with Marfan syndrome, ... | nan |
https://bit.ly/3QjJGL8 | A 68-year-old man presents to the emergency department with right ear pain that he developed 4 days prior, and it has progressively worsened. The pain is worse at night. He has associated fever and chills. This morning, he awoke with purulent, foul-smelling discharge on his pillow. He has a history of type II diabetes ... | Ceftriaxone | Ofloxacin ear drops | Amoxicillin | Vancomycin and piperacillin-tazobactam | D | Vancomycin and piperacillin-tazobactam | The patient in this vignette most likely has malignant otitis externa (also referred to as necrotizing otitis externa), which is a life-threatening infection requiring therapy with intravenous anti-pseudomonal and broad-spectrum antibiotics. Piperacillin-tazobactam and vancomycin is an appropriate initial regimen.
Mal... | nan |
https://step2.medbullets.com/testview?qid=215042 | A 4-year-old boy comes to the pediatrician with his mother with a 3-day history of cough and runny nose with decreased oral intake over the past 24 hours. His activity level has been normal and he has been attending school until this morning. He has no medical history or known allergies, but he has not received any of ... | Administer antitoxin and toxoid vaccine | Amoxicillin | Influenza testing and oseltamivir | Obtain chest radiography and respiratory virus panel | E | Supportive care with return precautions | This boy presenting with 3 days of progressive fever, rhinorrhea, cough, conjunctivitis, and tonsilar erythema most likely has viral pharyngitis. The appropriate treatment for this is supportive care with return precautions (instructing the mother to bring the child back to a physician if he becomes short of breath).
... | Supportive care with return precautions |
https://bit.ly/47U1Ppp | A 55-year-old man presents to the emergency department with right knee pain. He woke last night with sudden-onset, sharp, 10/10 non-radiating pain in his right knee. He denies recent trauma and he has no known medical problems. He denies tobacco use and will often drink 6-8 beers or spirits on weekend nights. His tempe... | Gout | Septic arthritis | Lyme arthritis | Pseudogout | A | Gout | The patient’s sudden-onset knee pain with effusion and synovial fluid findings are characteristic of gout.
Gout is caused by monosodium urate crystal deposition in joint spaces, most commonly in the big toe, ankle, or knee. Crystal deposition in the joint space leads to an intense inflammatory reaction that causes sev... | nan |
https://bit.ly/3om7HFU | A 25-year-old woman is brought to the emergency department by her family. They found her somnolent next to her computer with an empty pill bottle around 3 hours ago. The family cannot recall the types of pill bottles that they found and did not bring them to the ED. The patient's medical history is notable for anxiety,... | Lactated ringer bolus | N-acetylcysteine | Charcoal | Syrup of ipecac | B | N-acetylcysteine | This patient is presenting with acute acetaminophen intoxication. The most appropriate next step in management is to administer the antidote N-acetyl cysteine (NAC).
In a toxicology case where the ingestion is unknown, the most appropriate initial step in management is to begin treatment empirically with IV fluids, ch... | nan |
https://step2.medbullets.com/testview?qid=216269 | A 14-year-old boy is brought to the pediatrician for behavioral issues. At school, he interrupts class by making barking noises. His mother notes that he has been making throat-clearing noises daily for the past 2 years. He has no medical problems and takes no medications. He gets along with his 2 brothers, plays turn-... | Methylphenidate | Fluoxetine | Haloperidol | Dextroamphetamine | C | Haloperidol | This patient presents with multiple motor tics (grimacing, eye blinking) and phonic tics (barking, throat-clearing) on a daily basis for more than 1 year, which are consistent with Tourette syndrome. Tourette syndrome can be medically treated with antipsychotic agents such as haloperidol.
Tourette syndrome presents wi... | nan |
https://step2.medbullets.com/testview?qid=214791 | 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 | Discontinue antimicrobial treatment | Obtain a D-dimer level | 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=215049 | A 24-year-old motorcyclist is involved in a head-on collision with a motor vehicle and suffers various traumatic injuries. She has no significant medical history, is up to date on all vaccinations, and her last tetanus shot was 3 years ago. On arrival, her temperature is 36.7°C (98°F), blood pressure is 82/63 mmHg, pul... | Insertion of a nasogastric tube | Insertion of a thoracostomy tube | Prophylactic intravenous antibiotics | Tetanus vaccination | E | Vaccination against Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae | This patient has an extensive splenic injury and hemodynamic instability requiring splenectomy, as evidenced by trauma to the left posterior ribs and left flank, low blood pressures with reflex tachycardia, and evidence of splenic rupture and hemoperitoneum on computed tomography imaging. Subsequently, this asplenic pa... | Vaccination against Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae |
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 | Obstruction of the extrahepatic biliary tree | Obstruction of the intrahepatic biliary tree | C | 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... | nan |
https://bit.ly/44nTuaV | A 25-year-old woman presents to her primary care physician complaining of recent hair growth along her jawline, now requiring her to shave every 2 days. She has not shaved in about a week. She has also gained about 10 pounds in the last several months, and her periods have become irregular over the last year. Her last ... | Endometrial carcinoma | Ovarian cancer | Ovarian cyst rupture | Type 1 diabetes mellitus | A | Endometrial carcinoma | This patient presents with hirsutism, oligomenorrhea, and multiple follicles on pelvic ultrasound, which is most consistent with polycystic ovarian syndrome (PCOS). PCOS is associated with an increased risk of endometrial carcinoma.
PCOS is an acquired endocrinopathy characterized by ovarian dysfunction and high rates... | Virilization |
https://step2.medbullets.com/testview?qid=216746 | A 21-year-old woman presents to her primary care physician due to a history of abdominal pain. She states that she has had recurrent bouts of mood swings, bloating, and abdominal pain that occur together approximately every 4 weeks. She states that when these symptoms occur, she gets into frequent arguments at work, is... | Generalized anxiety disorder | Major depressive disorder | Panic disorder | Premenstrual dysophoric disorder | D | Premenstrual dysophoric disorder | This patient with recurrent abdominal pain, bloating, and mood changes causing interpersonal difficulties related to the menstrual cycle likely has premenstrual dysphoric disorder. Premenstrual dysphoric disorder is a variant of premenstrual syndrome (PMS) characterized by prominent irritability and disruption of every... | Premenstrual syndrome |
https://bit.ly/3PkQ1FJ | 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... | Radiograph | Bone scan | Magnetic resonance imaging | Ultrasound | 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... | nan |
https://bit.ly/4918Jtt | A 27-year-old woman presents to her primary care physician for an abnormal vaginal discharge. The patient has engaged in unprotected intercourse with 12 different partners. She has a medical history of asthma, IV drug abuse, and depression. She has 1 to 2 alcoholic drinks per day. She feels ashamed of her behavior and ... | Photosensitivity | Antigen exposure | IV drug use | Infection | B | Antigen exposure | This patient is presenting with urticaria whenever she engages in sexual intercourse suggesting a latex allergy (found in condoms). These allergies are due to antigen exposure.
Anaphylaxis and urticaria are immunologically mediated responses to environmental antigens that are typically IgE-mediated. This results in cr... | nan |
https://bit.ly/46ZosaU | A 59-year-old man presents to his primary care physician for fatigue. In general, he has been in good health; however, he recently has experienced weight loss, abdominal pain, and general fatigue. He has a medical history of anxiety, diabetes, a fracture of his foot sustained when he tripped, and a recent cold that cau... | Chronic lymphocytic leukemia | Chronic myeloid leukemia | Leukemoid reaction | Multiple myeloma | C | Leukemoid reaction | This patient is presenting with leukocytosis and an elevated leukocyte alkaline phosphatase suggestive of a leukemoid reaction.
A leukemoid reaction typically presents with a drastically elevated leukocyte count (typically > 50,000/mm^3) in the setting of an elevated leukocyte alkaline phosphatase score (LAP). This re... | nan |
https://step2.medbullets.com/testview?qid=216458 | A 66-year-old man presents to the emergency department with shortness of breath. He typically has poor exercise tolerance and is only able to walk from his house to his mailbox before becoming dyspneic. He now has shortness of breath even at rest. He had a cold recently but has no new medical problems. His past medical... | Albuterol and prednisone | Digoxin | Diltiazem | Intubation | B | Digoxin | This patient with a history of heart failure with reduced ejection fraction is presenting with respiratory distress (increased work of breathing, hypoxia, wheezes, and crackles) in the setting of atrial fibrillation (ECG with irregularly irregular rhythm without P waves) with rapid ventricular response and pulmonary ed... | Metoprolol |
https://bit.ly/3NOcdHz | A 17-year-old high school student was in shop class when he accidentally sawed off a portion of his right index finger. The teacher applied dressings and pressure to the patient's injured digit and immediately transported the patient to the emergency department. He arrived within 20 minutes of the accident. The patient... | Rinse the finger in normal saline, wrap the finger in moist gauze, put in a plastic bag, and place the bag in ice water | Rinse the finger with hydrogen peroxide, wrap the finger in moist gauze, and place on ice | Submerge the finger in ice water | Wrap the finger in moist gauze and place in a plastic bag | A | Rinse the finger in normal saline, wrap the finger in moist gauze, put in a plastic bag, and place the bag in ice water | This patient is presenting with a fingertip amputation with loss of pulp, nail, and bone (with a possibility for surgical reattachment and repair, efforts should be made to recover the severed tissue). The correct way to transport an amputated digit is to rinse the finger in normal saline to remove gross contaminants, ... | Wrap the finger in moist gauze and place on ice |
https://bit.ly/3UV1eNW | A 45-year-old man with history of IV drug use presents to the outpatient clinic with a history of fever for 5 days. He also endorses sweats, headache behind the eyes, sore throat, muscle and joint pain, and a new rash seen in Figure A. He reports that he traveled to Africa last year and returned from a vacation to Thai... | Blood culture | Blood smear | Serologic testing | Sputum with acid fast stain | C | Serologic testing | This patient is presenting with fever, headache with retro-orbital pain, muscle aches, joint pain, rash, leukopenia and thrombocytopenia, which are classic findings for dengue fever. The diagnostic test of choice for dengue is serology.
Dengue is a viral infection endemic to South Asia, Central and South America, and ... | Stool culture |
https://step2.medbullets.com/testview?qid=108977 | A 35-year-old man presents to his primary care physician with pain along the bottom of his foot. The patient is a long-time runner but states that the pain has been getting worse recently. When running and at rest he has a burning and aching pain along the bottom of his foot that sometimes turns to numbness. Taking tim... | Common fibular nerve compression | Herniated disc | Plantar fasciitis | Tarsal tunnel syndrome | D | Tarsal tunnel syndrome | This patient is presenting with pain, tingling, and numbness on the plantar surface of his foot that is not associated with exertion or rest suggesting a diagnosis of tarsal tunnel syndrome.
Tarsal tunnel syndrome occurs due to compression of the tibial nerve as it travels through the tarsal tunnel. Compression of the... | Vitamin B12 deficiency |
https://step2.medbullets.com/testview?qid=215183 | A 55-year-old woman presents to the primary care clinic for her annual visit. She has no complaints and is asymptomatic. She has a history of hypertension, hyperlipidemia, and diabetes. Her medications are lisinopril, amlodipine, atorvastatin, and metformin. There is no family history of malignancy. She is a non-smoker... | Fine needle aspiration | Propylthiouracil | Radioiodine ablation | Surgical removal of the mass | A | Fine needle aspiration | This patient’s presentation with an asymptomatic thyroid nodule with suspicious ultrasound features (≥ 1 cm hypoechoic mass with microcalcifications) and elevated TSH is concerning for thyroid malignancy. The most appropriate next step in management is a fine needle aspiration (FNA).
The first step in the diagnostic w... | Thyroid scintigraphy |
https://bit.ly/3CrrhE1 | A 76-year-old woman is brought to a primary care physician by her daughter who is concerned about her mother's growing inability to take care of herself. Initially, she attributed her mother's forgetfulness and word-finding difficulties to normal aging, but over the past few years, her mother's memory has worsened, her... | Alzheimer dementia | Creutzfeldt-Jakob disease | Frontotemporal dementia | Normal pressure hydrocephalus | A | Alzheimer dementia | This elderly patient who presents with slowly progressive memory loss, language difficulties, and progression to inability to care for herself most likely has Alzheimer dementia.
Alzheimer dementia is a neurodegenerative disorder that is characterized by a gradual and progressive cognitive decline (memory loss, visuos... | Vascular dementia |
https://bit.ly/3ZAMN3W | A 6-year-old boy is brought to the emergency department by his father for elbow pain. He was riding his bicycle when he fell onto his outstretched right hand. He immediately clutched his right elbow in pain and began crying. He refuses to move his elbow. He has no medical problems and takes no medications. His temperat... | Distal radius fracture | Both bone forearm fracture | Supracondylar humerus fracture | Olecranon fracture | C | Supracondylar humerus fracture | This young patient presenting with elbow pain and associated signs of anterior interosseous nerve neurapraxia (inability to make pincer, weak pincer grasp) and vascular injury (diminished radial pulse) after a fall on an outstretched hand most likely has a supracondylar humerus fracture.
Supracondylar humerus fracture... | nan |
https://step2.medbullets.com/testview?qid=216590 | A 33-year-old man presents to the emergency department with dizziness. He states he has a constant sensation that the room is spinning. He is now having trouble walking and has been vomiting intermittently. He has no past medical history and takes no medications. His temperature is 98.0°F (36.7°C), blood pressure is 12... | Prednisone | Epley maneuver | MRI brain | CT head | A | Prednisone | This young, healthy patient is presenting with constant vertigo, ataxia, vomiting, and a head impulse test revealing a corrective saccade, nystagmus, and test of skew (HINTS) exam, which suggests a peripheral etiology of vertigo, most likely vestibular neuritis. As the diagnosis can be made clinically, steroids are the... | nan |
https://bit.ly/49ckvkP | A 24-year-old man presents to the emergency department with abdominal pain, nausea, and vomiting. The symptoms began towards the end of running a marathon and persisted after finishing the race. The patient is otherwise healthy and has no other medical problems. His temperature is 98.0°F (36.7°C), blood pressure is 105... | Cecal volvulus | Ileus | Ogilvie syndrome | Sigmoid volvulus | A | Cecal volvulus | This young, healthy patient presents with abdominal pain, nausea, vomiting, and a distended, tender abdomen with a radiograph demonstrating the "coffee bean sign," likely has a cecal volvulus.
Cecal volvulus is the second most common cause of volvulus after sigmoid volvulus and presents with abdominal pain, constipati... | Small bowel obstruction |
https://step2.medbullets.com/testview?qid=215046 | A 46-year-old farmer presents to the office for a follow-up visit. He was seen 4 days ago for a new lesion on his arm that had been present for 1 week prior to that visit. A photograph of the lesion is shown in Figure A. At that time, he was prescribed treatment for the lesion and instructed to follow up as necessary. ... | Adverse effect of ciprofloxicin | Adverse effect of doxycycline | Allergic reaction to prescribed therapy | Progression of disease and alternative therapy is indicated | B | Adverse effect of doxycycline | This farmer has a cutaneous black eschar most consistent with cutaneous anthrax for which doxycycline is an appropriate treatment. A new blistering, erythematous rash after spending an hour outside that appears 4 days after starting treatment is consistent with a photosensitivity reaction, a known adverse effect of dox... | Progression of disease and surgical debridement is necessary |
https://step2.medbullets.com/testview?qid=216600 | A study is performed that looks at individuals who suffer from opioid use disorder and the effect the disorder has on their daily life and functionality. Individuals are surveyed using a validated method and followed up in 6-month intervals for 5 years. At the end of the study period, 40% of individuals have replied to... | Attrition bias | Confounding variable | Late-look bias | Recall bias | A | Attrition bias | This study following individuals who abuse opioids with a 40% follow-up response rate suggests that opioid use disorder (known for impairing daily functioning) has only a minor effect on patient functionality. This is most likely secondary to attrition bias, or a loss to follow-up of participants in a non-random fashio... | Volunteer bias |
https://step2.medbullets.com/testview?qid=109769 | A 62-year-old man presents to the emergency department with increased fatigue and changes in his vision. For the past month, he has felt abnormally tired and today noticed his vision is blurry. The patient also endorses increased sweating at night and new-onset headaches. He currently feels dizzy. The patient has a med... | IgA and IgG | Calcium | T-cells | IgM | D | IgM | This patient is presenting with symptoms of hyperviscosity, fatigue, and organomegaly suggestive of a diagnosis of Waldenstrom macroglobulinemia (WM). WM is characterized by increased IgM production.
WM occurs secondary to a clonal B-cell that pathologically overproduces IgM. High levels of IgM can lead to symptoms of... | nan |
https://bit.ly/45Rurxg | A 29-year-old woman comes to the emergency department complaining of painful genital ulcers that have been present for 4 days as well as low-grade fever and malaise. She denies any recent travel, new sexual partners, or antibiotic use. Physical examination reveals multiple clustered vesicles and shallow ulcers in the v... | Acyclovir | Amoxicillin | Fluconazole | Trimethoprim-sulfamethoxazole | A | Acyclovir | The patient's painful genital ulcers coupled with the presence of multinucleated giant cells on a Tzanck smear are indicative of a herpes simplex virus type 2 (HSV-2) infection. Acyclovir is the treatment of choice.
Herpes infections can present with painful genital ulcers and low-grade fever. The Tzanck smear showing... | nan |
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... | Administer intravenous lorazepam | Implant a pacemaker | Replete potassium and magnesium and start a beta-blocker | Replete potassium and magnesium and start procainamide | C | 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... | Start ethosuximide |
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 | Hypothyroidism | Hyponatremia | Hypomagnesemia | D | 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... | nan |
https://bit.ly/481p4x3 | A 55-year-old man presents to the emergency department with chest pain and shortness of breath. He has a medical history of hypertension, diabetes, and obesity. His temperature is 98.6°F (37.0°C), blood pressure is 177/118 mmHg, pulse is 127/min, respirations are 11/min, and oxygen saturation is 98% on room air. An ECG... | Cholesterol embolism | Medication side effect | Pancreatitis | Renal failure | A | Cholesterol embolism | This patient is presenting with abdominal pain and livedo reticularis after a catheterization procedure. These symptoms are suggestive of a cholesterol embolism.
A cholesterol embolism typically presents after any vascular procedure due to a dislodged cholesterol emboli. Symptoms include livedo reticularis, gastrointe... | nan |
https://step2.medbullets.com/testview?qid=216495 | A 43-year-old man presents to the emergency department acutely with altered mental status. He uses intravenous drugs and is unable to offer a history. He was found unconscious in a park. His temperature is 99.0°F (37.2°C), blood pressure is 80/40 mmHg, pulse is 156/min, and respirations are 26/min. Physical exam reveal... | Cardioversion | Epinephrine | Hydrocortisone | Normal saline | B | Epinephrine | This patient who uses intravenous drugs with skin abscesses (the likely source of his infection) is hypotensive and tachycardic, with a blood pressure that is not responding to IV fluids; this is concerning for septic shock. Given his persistent hypotension, he should be started on vasopressors of which norepinephrine ... | Phenylephrine |
https://bit.ly/3oZgxd5 | A 9-hour-old newborn girl is found in the newborn nursery with diffuse swelling of the scalp not present at birth. The child was born at 38 weeks of gestation to a 28-year-old G3P3 mother. The mother went into spontaneous labor but the delivery was complicated by a prolonged 2nd stage of labor. A vacuum-assisted vagina... | Between dura and arachnoid mater | Between periosteum and galea aponeurosis | Between periosteum and skull | Between scalp and galea aponeurosis | D | Between scalp and galea aponeurosis | This patient presents following a vacuum-assisted vaginal delivery with an ecchymotic swelling of the scalp that crosses the midline, which suggests a diagnosis of caput succedaneum. Caput succedaneum is caused by bleeding between the skin and the galea aponeurosis.
Caput succedaneum is an uncommon extracranial injury... | Into the lateral ventricles |
https://bit.ly/3qYGGdc | A 27-year-old woman presents to her primary care physician with new hair growth on her face and lower abdomen over the last month. She has started to develop pimples on her face and back over the last several months. Her last menstrual period was over 3 months ago and her periods have been irregular over the last year.... | Polycystic ovary syndrome | Adrenal tumor | Ovarian tumor | Ovarian hyperthecosis | C | Ovarian tumor | This young woman presents with rapid virilization, elevated testosterone, and a large left adnexal mass that is primarily solid on ultrasound. These findings are most consistent with an ovarian androgen-secreting tumor.
Sertoli-Leydig cell tumors are the most common androgen-secreting tumor of the ovaries and classica... | nan |
https://step2.medbullets.com/testview?qid=216427 | A 23-year-old man presents to the emergency department after he was rescued while hiking in Alaska. The patient was found on a mountain trail non-responsive. His temperature is 91°F (32.8°C), blood pressure is 103/61 mmHg, pulse is 60/min, respirations are 11/min, and oxygen saturation is 97% on room air. The patient i... | Elevated troponin | Hypocalcemia | Hypomagnesemia | Hypophosphatemia | B | Hypocalcemia | This patient is presenting after being found outside with hypothermia and frostbite (dark bullae noted on the extremities in the setting of being out in the cold). Frostbite can lead to rhabdomyolysis, which may cause hyperkalemia (causing ECG changes including peaked T waves and QRS widening as seen in this patient) a... | Red blood cells on urine microscopy |
https://bit.ly/3ZLKJGM | A 25-year-old man presents to his gastroenterologist for trouble swallowing. Whenever he eats solids, he regurgitates them back up. Given this patient's suspected diagnosis, the gastroenterologist performs a diagnostic test. Several hours later, the patient presents to the emergency department with chest pain and short... | Barium swallow | Gastrografin swallow | Magnetic resonance imaging | Ultrasound | B | Gastrografin swallow | This patient is presenting with chest pain and palpable crepitus after endoscopy suggesting a diagnosis of esophageal perforation. The most appropriate next step in management is a gastrografin swallow.
Esophageal perforation presents with severe chest pain and palpable crepitus typically occurring after endoscopy or ... | Urgent surgery |
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 | Intraductal papilloma | Invasive ductal carcinoma | Mammary duct ectasia | B | 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... | Paget disease of the breast |
https://step2.medbullets.com/testview?qid=215185 | A 19-year-old man presents to his primary care physician. He is asymptomatic and has no acute complaints, has no medical problems, and takes no medications. He was born in the United States but moved to El Salvador at age 11 and has only recently moved back to the United States in the past year. He was up to date on hi... | Influenza | Tetanus and diphtheria | Tetanus, diphtheria, acellular pertussis, and influenza | Tetanus, diphtheria, and acellular pertussis | D | Tetanus, diphtheria, and acellular pertussis | This patient has recently moved back to the United States after living in another country for several years and is behind on his tetanus, diphtheria, and pertussis vaccine series. The tetanus, diphtheria, and acellular pertussis (Tdap) vaccine is indicated at least once in adults who have not previously received Tdap.
... | Tetanus, diphtheria, and influenza |
https://bit.ly/436MoX6 | A 19-year-old woman presents to her primary care physician with headaches, blurry vision, and tinnitus over the past month. She started treatment for a skin condition with a new oral medication 2 months prior. She has not noticed any changes in her complexion as of yet. Her temperature is 98.2°F (36.8°C), blood pressur... | Idiopathic intracranial hypertension | Meniere disease | Giant cell arteritis | Cerebrovascular accident | A | Idiopathic intracranial hypertension | This young patient with severe nodulocytic acne who was started on a new oral medication (likely isotretinoin) is likely suffering from idiopathic intracranial hypertension, which can present with papilledema, headache, blurry vision, and diplopia.
Idiopathic intracranial hypertension is characterized by an increase i... | nan |
https://step2.medbullets.com/testview?qid=109452 | A newborn boy is evaluated in the hospital nursery 2 hours after birth. The patient was born at 39 weeks of gestation to a 30-year-old primigravid via vaginal delivery. The patient’s mother received routine prenatal care and the pregnancy was uncomplicated. The patient’s anatomy ultrasound at 20 weeks of gestation was ... | 4p | 5p | 7q | 15q | B | 5p | This patient presents with a characteristic mew, microcephaly, hypertelorism, wide nasal bridge, and hypotonia, which suggests a diagnosis of cri-du-chat syndrome. Cri-du-chat syndrome is caused by a deletion on chromosome 5p.
Cri-du-chat syndrome is most commonly caused by a de novo partial deletion of chromosome 5p.... | nan |
https://bit.ly/3ZgT30W | A 4-day-old girl presents with her parents to the pediatrician for a routine visit. She was feeding well until this morning when she had several episodes of vomiting. The parents describe the vomitus as “bright green” and the patient has shown little interest in feeding since then. She was born at 36 weeks gestation to... | Duodenal atresia | Hirschsprung disease | Intestinal malrotation | Jejunal atresia | C | Intestinal malrotation | This patient presents with bilious vomiting and an upper gastrointestinal series demonstrating the “corkscrew” appearance of the distal duodenum and proximal jejunum, which is consistent with a diagnosis of intestinal malrotation.
Intestinal malrotation most commonly presents in newborns with bilious emesis. This cond... | Meconium ileus |
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... | Flexion, abduction, and external rotation of the thigh | Internal rotation of the extended hip | Palpating the paraspinal muscles | Radiography | E | 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... | Straight leg raise |
https://bit.ly/3YmWmmI | A 27-year-old G1P0000 woman presents to her obstetrician’s office at 24 weeks gestation complaining of new hair growth on her upper lip. She now needs to shave her face every day or else thick hair appears. She also has worsening acne that started several weeks ago. Her pregnancy thus far has been complicated by gestat... | Spironolactone to treat hirsutism and acne | Laparoscopy to remove a malignancy | Reassurance | Percutaneous umbilical blood sampling to determine prognosis | C | Reassurance | This patient presents with hirsutism and acne, symptoms of hyperandrogenism, as well as a solid pelvic mass on ultrasound, most consistent with a luteoma. The most appropriate next step in management is reassurance as the mass tends to self-resolve after pregnancy.
Luteomas are ovarian tumors that arise during pregnan... | nan |
https://step2.medbullets.com/testview?qid=216598 | A resident physician places a patient’s home medications in for their admission orders during an overnight admission. They order the patient’s home medications including clobazam; however, they accidentally order clonazepam. Subsequently, the patient is over-sedated and has to be transferred to the ICU for airway monit... | Add an alert in the electronic medical system for medications that sound similar | Enter medications only on morning rounds with multiple providers | Have nursing perform the medication reconciliation | Reprimand and educate the resident to check medications more carefully | A | Add an alert in the electronic medical system for medications that sound similar | A medical error occurred where 2 similar-sounding medications were confused, leading to an adverse event. The most appropriate way to prevent this error from occurring is a system-based approach, such as adding an alert in the electronic medical system for medications that sound similar.
Medical errors commonly occur ... | Verify the patient’s home medications with the patient |
https://bit.ly/3CB9Cdn | A 69-year-old man presents to his primary care physician for a general checkup. The patient works as a farmer and gardens in his spare time. He has a medical history of poorly managed type 2 diabetes mellitus and irritable bowel syndrome. His current medications include lisinopril, metformin, insulin, fiber supplements... | Basal cell carcinoma | Squamous cell carcinoma | Melanoma | Poor wound healing secondary to diabetes | B | Squamous cell carcinoma | This patient with a non-healing ulcer on the site of a previous actinic keratosis most likely has sustained progression of the lesion to squamous cell carcinoma.
Squamous cell carcinoma (SCC) is a common dermatological malignancy. Patients can present with actinic keratosis, which is a pre-malignant lesion in sun-expo... | nan |
https://step2.medbullets.com/testview?qid=109292 | A newborn boy is evaluated 30 minutes after birth. He was born at 39 weeks gestation to a 27-year-old primigravid mother via cesarean section for cervical insufficiency. The pregnancy was complicated by gestational diabetes and the amniotic fluid was clear. Upon delivery, the patient had strong respiratory effort and a... | Meconium aspiration syndrome | Neonatal respiratory distress syndrome | Persistent pulmonary hypertension | Transient tachypnea of the newborn | D | Transient tachypnea of the newborn | This newborn is presenting with increased work of breathing and progressive tachypnea in the 1st hour of life, which is consistent with a diagnosis of transient tachypnea of the newborn.
Transient tachypnea of the newborn presents with respiratory distress and marked tachypnea within 2 hours of delivery. Transient tac... | Viral pneumonia |
https://bit.ly/3PCWiwF | A 4-week-old boy presents to the pediatrician for vomiting. The patient is breastfed and typically feeds for 20-30 minutes every 2 hours. One week ago, he began vomiting and regurgitating breastmilk through his nose after most feedings. His stools over the past week have also become blood-streaked. The patient does not... | Obtain abdominal ultrasound | Initiate a proton pump inhibitor | Switch to hydrolyzed formula | Modify mother's diet | D | Modify mother's diet | This infant presents with vomiting, bloody stools, and poor weight gain, which suggests a diagnosis of milk-protein allergy. The most appropriate next step in management is the modification of the mother’s diet to eliminate cow’s milk and soy.
Infant food protein-induced proctocolitis is caused by distal colon inflamm... | nan |
https://step2.medbullets.com/testview?qid=217603 | A 55-year-old woman presents to a primary care physician with persistent nausea and abdominal discomfort. She has experienced these symptoms daily for the past 3 months. She feels bloated and has episodic loose and watery stools. She has a history of hypertension and hyperlipidemia for which she takes amlodipine and at... | Bowel wall biopsy | CT scan of the abdomen | Lower endoscopy | Stool ova and parasite assay | D | Stool ova and parasite assay | This patient who presents with persistent abdominal discomfort, nausea, bloating, diarrhea, eosinophilia, and signs of malabsorption (thin-appearing, vitamin D deficiency) in the setting of immigration from a resource-limited country most likely has a gastrointestinal parasite infection (Ascaris lumbricoides). The most... | Stool toxin assay |
https://bit.ly/48elxeS | A 35-year-old man presents to the emergency department for evaluation of chest pain. The pain starts in his chest and moves into his back, arms, and abdomen. He describes the pain as tearing. He has no known medical history and takes no medications. His temperature is 37.0°C (98.6°F), pulse is 130/min, blood pressure i... | Aspirin | CT angiography of the chest, abdomen, and pelvis | Echocardiography | Lorazepam | B | CT angiography of the chest, abdomen, and pelvis | This patient with "tearing" chest pain, hypertension, and a chest radiograph demonstrating mediastinal widening likely has an aortic dissection. The most appropriate next step in management would be to obtain CT angiography of the chest, abdomen, and pelvis to confirm the diagnosis.
Aortic dissections develop due to a... | Serum troponin testing |
https://step2.medbullets.com/testview?qid=215054 | A 65-year-old man presents to the emergency department with anxiety and intermittent palpitations. He began feeling the palpitations 3 days ago while eating dinner. He denies chest pain, shortness of breath, or loss of consciousness. He has a history of hypertension, major depressive disorder, Raynaud disease, and chro... | Amiodarone | Clopidogrel | Digoxin | Metoprolol | E | Verapamil | This patient’s new-onset palpitations, irregularly irregular pulse, and absent p-waves on ECG are consistent with atrial fibrillation. In hemodynamically stable patients with a relative contraindication to β-blockers (COPD on home oxygen with increasing oxygen need), rate control with a non-dihydropyridine calcium chan... | Verapamil |
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... | Dissociation | Intellectualization | Optimism | Pessimism | B | 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... | Rationalization |
https://step2.medbullets.com/testview?qid=108735 | A 34-year-old man is brought to a rural emergency department by ambulance after being involved in a motor vehicle accident. Paramedics report that the patient was driving the car and crashed into a tree at roughly 25 miles per hour. There were no passengers and he was awake but disoriented at the scene. His temperature... | Abdominal and chest CT | Chest radiograph anterior-posterior and lateral | Diagnostic laparoscopy | Diagnostic peritoneal lavage | A | Abdominal and chest CT | This patient presents following a motor vehicle accident with a tender abdomen and stable vital signs. Given his stability, the most appropriate next step is an abdominal and chest CT.
In blunt abdominal trauma, the next step in management depends upon whether the patient is hemodynamically stable. With a normal blood... | Focused abdominal sonography for trauma exam |
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... | Empiric treatment with pyrimethamine-sulfadiazine | Lumbar puncture | Brain biopsy | Empiric treatment with dexamethasone | A | 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... | nan |
https://step2.medbullets.com/testview?qid=216396 | A 67-year-old woman presents from a nursing home with altered mental status. She was last known to be normal the night before. The patient has dementia at baseline and is minimally interactive. This morning, she was found to be obtunded. No further history was provided from the nursing home, and the patient is unable t... | Administer glucagon | Check serum TSH and free T4 levels | Obtain blood cultures and a serum lactate | Perform a CT scan of the head | B | Check serum TSH and free T4 levels | This patient is presenting with obtundation, bradycardia, hypotension, hypothermia, thinning of her hair, and hyponatremia, which are concerning for myxedema coma. A serum TSH and free T4 would be most informative in confirming this diagnosis.
Myxedema coma (decompensated hypothyroidism) is the most life-threatening m... | Perform an echocardiogram |
https://bit.ly/3QrrmQ1 | A 2-week-old boy is evaluated by his pediatrician for abnormal feet. The patient was born at 39 weeks via vaginal delivery to a G1P1 29-year-old woman. The patient has been breastfeeding and producing 5 stools/day. He is otherwise healthy. His temperature is 99.5°F (37.5°C), blood pressure is 60/38 mmHg, pulse is 150/m... | Botulinum toxin injections | Reassurance and reassessment in 1 month | Serial casting | Surgical pinning | C | Serial casting | This patient is presenting with talipes equinovarus (congenital clubfoot) for which the most appropriate initial step in management is serial casting using the Ponseti method.
Talipes equinovarus is described clinically as a foot that is cavus, adductus, varus, and equinus. Cavus occurs when the forefoot is pronated r... | nan |
https://step2.medbullets.com/testview?qid=210867 | 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://step2.medbullets.com/testview?qid=108996 | A 57-year-old immigrant from Nigeria presents to the emergency department for sudden, severe pain and swelling in her lower extremity. She was at a rehabilitation hospital when her symptoms started. The patient has a medical history of obesity, diabetes, bipolar disorder, and tonic-clonic seizures. Her current medicati... | Nephrotic syndrome | Factor V Leiden | Liver failure | Antithrombin III deficiency | A | Nephrotic syndrome | This patient who presents with a deep venous thrombosis (lower extremity swelling, ultrasound followed by treatment with heparin), anasarca, and asymptomatic hypocalcemia most likely has a diagnosis of nephrotic syndrome.
Nephrotic syndrome occurs when large amounts of protein are lost in the urine. This can lead to h... | nan |
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 | Degenerative spine disease | Herniated disc | Metastatic tumor | E | 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... | Osteomyelitis |
https://step2.medbullets.com/testview?qid=214976 | A 17-year-old girl presents to the clinic reporting 7 months without a menstrual period. Menarche was at age 12 and she had regular periods up until 2 years ago. At that time, her periods became less regular until around 7 months ago when they ceased altogether. She is otherwise healthy, participates in multiple school... | Hypothyroidism | Functional hypothalamic amenorrhea | Anorexia nervosa | Polycystic ovarian syndrome | B | Functional hypothalamic amenorrhea | This patient presenting with secondary amenorrhea (defined as 6 or more consecutive months without menstruation in women who have passed menarche) and a history of rigorous exercise most likely has functional hypothalamic amenorrhea.
Functional hypothalamic amenorrhea is a condition in which relative caloric deficienc... | nan |
https://step2.medbullets.com/testview?qid=210076 | A 39-year-old man presents to his doctor for a wellness checkup. He is concerned about a rash that does not seem to be improving. He was recently exposed to his grandfather who has vesicular lesions on his skin and is being treated. He has a family history of skin cancer, colon cancer, and ovarian cancer. The patient h... | Benign capillary proliferation | Edema of the epidermis | Healthy dermatologic development | Malignant blood vessel proliferation | A | Benign capillary proliferation | This patient who presents with red raised papules is presenting with a cherry angioma. These lesions are composed of benign capillary proliferations.
Cherry angiomas present with cherry red macules/papules that occur secondary to benign capillary and venule proliferation. The lesions are entirely benign and are cosmet... | Viral infection |
https://bit.ly/3Mqa3f2 | A 69-year-old man presents to the emergency department with shortness of breath. The patient has presented 3 times this month with similar complaints. He states his shortness of breath started when he was walking from his car to a local restaurant. He does not see a primary care physician and is not currently taking an... | A | B | C | D | C | C | This patient is presenting with symptoms of heart failure (CHF). The most likely laboratory abnormalities are elevated brain natriuretic peptide (BNP), high anti-diuretic hormone (ADH), low sodium, and low potassium.
Heart failure is characterized by the decreased performance of the cardiac ventricles resulting in ven... | E |
https://step2.medbullets.com/testview?qid=216255 | A 42-year-old man presents to the urgent care clinic with low back pain. He was working on a home improvement project the day prior to presentation when the pain started. He describes the pain as "achy and sore." It is not positional and does not radiate. He denies fevers, chills, paresthesias, and bowel or bladder inc... | Osteoarthritis | Vertebral compression fracture | Lumbar strain | Disc herniation | C | Lumbar strain | This patient presents with low back pain after activity with paravertebral tenderness and without red flag signs/symptoms, such as history of trauma or malignancy, intravenous drug use, saddle anesthesia (reduced perineal sensation), or neurological deficits. The most likely diagnosis is a lumbar strain.
The different... | nan |
https://bit.ly/3oZgxd5 | A 9-hour-old newborn girl is found in the newborn nursery with diffuse swelling of the scalp not present at birth. The child was born at 38 weeks of gestation to a 28-year-old G3P3 mother. The mother went into spontaneous labor but the delivery was complicated by a prolonged 2nd stage of labor. A vacuum-assisted vagina... | Between periosteum and galea aponeurosis | Between periosteum and skull | Between scalp and galea aponeurosis | Into the lateral ventricles | C | Between scalp and galea aponeurosis | This patient presents following a vacuum-assisted vaginal delivery with an ecchymotic swelling of the scalp that crosses the midline, which suggests a diagnosis of caput succedaneum. Caput succedaneum is caused by bleeding between the skin and the galea aponeurosis.
Caput succedaneum is an uncommon extracranial injury... | nan |
https://step2.medbullets.com/testview?qid=216599 | At a local community hospital staffed only by attending physicians, it is noted that the time to tissue plasminogen activator administration in suspected stroke patients is roughly 10 minutes from presentation. At a teaching hospital with residents, the time to tissue plasminogen activator administration is roughly 2 h... | Perform a systems-based approach implementation | Perform a root cause analysis of the process | Empirically scan patients with concerning neurologic symptoms | Automatically consult neurology for patients with concerning neurologic symptoms | B | Perform a root cause analysis of the process | This case outlines a delay in treating strokes at a teaching hospital. To determine the underlying cause, a root cause analysis to determine the underlying issue is the most appropriate way to begin to address this issue.
When a problem is found in healthcare, it is important to elucidate the underlying cause. A root ... | nan |
https://step2.medbullets.com/testview?qid=210076 | A 39-year-old man presents to his doctor for a wellness checkup. He is concerned about a rash that does not seem to be improving. He was recently exposed to his grandfather who has vesicular lesions on his skin and is being treated. He has a family history of skin cancer, colon cancer, and ovarian cancer. The patient h... | Benign capillary proliferation | Edema of the epidermis | Healthy dermatologic development | Viral infection | A | Benign capillary proliferation | This patient who presents with red raised papules is presenting with a cherry angioma. These lesions are composed of benign capillary proliferations.
Cherry angiomas present with cherry red macules/papules that occur secondary to benign capillary and venule proliferation. The lesions are entirely benign and are cosmet... | 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... | Serum creatine kinase | Muscle biopsy | Electromyography | Serum aldolase | B | 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... | nan |
https://bit.ly/45s1lW2 | A 27-year-old man presents to the emergency department after he developed pain in his right leg after landing off a ski jump. The patient is otherwise healthy and does not take any medications. He states his pain is 10/10. He is requesting medications and is crying out in pain. His temperature is 98.7°F (37.1°C), blood... | Anterior cruciate ligament tear | Apophysitis of the tibial tubercle | Patellar fracture | Posterior dislocation of the knee | E | Tibial plateau fracture | This patient is presenting after an axial load on his lower extremity (landing off a ski jump) with severe pain, a fracture on radiography, and severe pain with passive range of motion. This suggests compartment syndrome in the setting of a tibial plateau fracture.
Tibial plateau fractures occur as a result of an axia... | Tibial plateau fracture |
https://step2.medbullets.com/testview?qid=109238 | A 69-year-old woman presents with pain in her hip and groin. The pain is present in the morning but is nearly unbearable by the end of the day. Her medical history is notable for a treated episode of acute renal failure, diabetes mellitus, obesity, and hypertension. Her current medications include losartan, metformin, ... | Femoral neck fracture | Posterior displacement of the femoral head | Loss of joint space and osteophytes | Hyperdense foci in the ureters | C | Loss of joint space and osteophytes | This patient is presenting with pain worse on exertion, decreased range of motion, and crepitus in her hip, suggesting a diagnosis of osteoarthritis. A loss of joint space and osteophytes (reactive bone formation) would be seen on radiography.
Osteoarthritis occurs due to wear and tear of the joint typically from repe... | nan |
https://bit.ly/3My1xLG | A 57-year-old man is brought to a neurologist by his wife for abnormal behavior. He was normal until around 3 months ago when he started forgetting important meetings and misplacing items around the house. One month ago, the patient was fired from his job as a software engineer after attempting to grope a coworker. The... | Alzheimer disease | Creutzfeldt-Jacob disease | Frontotemporal dementia | Subcortical leukoencephalopathy | B | Creutzfeldt-Jacob disease | This patient with rapidly progressive dementia over 3 months, declining executive function, impaired concentration, decreased memory, startle myoclonus (sudden jerking of extremities in response to unexpected stimulus), and elevated 14-3-3 protein levels on cerebrospinal fluid (CSF) analysis most likely has Creutzfeldt... | nan |
https://bit.ly/43wFOdc | A 2-day-old boy has an episode of vomiting in the hospital nursery. The vomitus was described as “bright green” without any traces of blood. The patient has urinated several times since he was born but has not passed any stool. He was born at 37 weeks of gestation to a 38-year-old G3P3 woman. The pregnancy was uncompli... | Duodenal atresia | Hirschsprung disease | Intestinal malrotation | Meconium ileus | B | Hirschsprung disease | This pediatric patient presents with features of Down syndrome (trisomy 21), bilious vomiting, and colonic distention on an abdominal radiograph, which suggests a diagnosis of Hirschsprung disease.
Hirschsprung disease is associated with Down syndrome and presents with bilious vomiting, failure to pass meconium in the... | Pyloric stenosis |
https://step2.medbullets.com/testview?qid=215026 | A 65-year-old man presents to his primary care physician for a routine appointment. He has no concerns. His past medical history is significant for human immunodeficiency virus (HIV) infection, diagnosed 15 years ago. The patient is intermittently compliant with his antiretroviral therapy (ART). His temperature is 99.0... | Azithromycin and pneumococcal vaccine | Azithromycin and zoster vaccine | Trimethoprim-sulfamethoxazole and pneumococcal vaccine | Trimethoprim-sulfamethoxazole and varicella vaccine | C | Trimethoprim-sulfamethoxazole and pneumococcal vaccine | This patient with HIV and a CD4 count of 150 cells/μL requires trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis and another dose of the 23-valent pneumococcal vaccine.
All HIV patients with a CD4 count < 200 cells/μL require TMP-SMX as prophylaxis against Pneumocystis jirovecci pneumonia. Patients with CD4 counts <... | Trimethoprim-sulfamethoxazole and zoster vaccine |
https://step2.medbullets.com/testview?qid=215171 | A 59-year-old man presents to his primary care physician for abdominal pain and foul-smelling diarrhea that has persisted for the past 2 years. The patient has a medical history of alcoholism and has been admitted to the hospital multiple times for withdrawal, abdominal pain, and traumatic injuries from his drinking. T... | Ciprofloxacin | Loperamide | Oral rehydration | Pantoprazole | D | Pantoprazole | This patient with a history of alcoholism is presenting with steatorrhea (foul-smelling diarrhea that stains with Sudan Black, a stain that detects fat in the stool), hypocalcemia, and findings suggestive of chronic pancreatitis on CT scan (inflammatory changes and calcification). His steatorrhea can be improved with t... | Rifaximin |
https://step2.medbullets.com/testview?qid=216268 | A 72-year-old man presents to the clinic for his annual exam. For the past few months, he has pain in his chest with physical activity. The pain goes away after he takes a break. He reports no chest pain while he is resting, and the pain is not worsening. His past medical history is notable for hypertension, type 2 dia... | Stable angina | Costochondritis | ST elevation myocardial infarction | Unstable angina | A | Stable angina | This patient who presents with exertional chest pain that is relieved with rest without increasing frequency or intensity of chest pain, a normal electrocardiogram (ECG), and normal troponin level most likely has stable angina.
Angina pectoris is chest pain secondary to myocardial ischemia and is most commonly caused ... | nan |
https://bit.ly/3RhK2Tp | A 2-year-old boy is brought to the pediatrician’s office for a well-child visit. The parents have no concerns at this time and note he is starting to run around and speak in 3-word sentences. He has no remarkable medical history and his mother had an uncomplicated full-term pregnancy and delivery. He is appropriately m... | Biopsy | Genetic testing | Magnetic resonance imaging of the brain and orbits | Ophthalmology referral | D | Ophthalmology referral | This otherwise healthy patient presents with leukocoria, or a white pupillary reflex, and requires an urgent referral to ophthalmology for further evaluation given the concern for retinoblastoma.
The differential diagnosis for leukocoria includes retinoblastoma, cataract, vitreous hemorrhage, retinal detachment, and o... | Reevaluation at the next well-child visit |
https://step2.medbullets.com/testview?qid=108995 | A 45-year-old African American woman presents to her primary care physician for not feeling well. She states she has had a cough for the past week. She also has abdominal pain and trouble focusing that has been worsening and has lost 5 pounds recently. Her gastroesophageal reflux disease (GERD) has been poorly controll... | Antacid overuse | Increased 1,25-dihydroxyvitamin D | Increased parathyroid hormone | Malignancy | C | Increased parathyroid hormone | This patient is presenting with hypercalcemia and low phosphate levels suggesting a diagnosis of hyperparathyroidism.
Hyperparathyroidism can cause hypercalcemia which typically presents with "bones, stones, moans, and groans," which corresponds to symptoms of bone pain (increased bone resorption), kidney stones, GI p... | Viral illness |
https://bit.ly/3rSAzaC | A 6-month-old boy is brought to the physician by his mother for abnormal movements. Several times a day, he experiences paroxysmal episodes of crying, bending at the waist, and jerking of the arms and legs. These episodes last 1-2 seconds, but occur in clusters every 20-30 seconds for several minutes. His mother's preg... | Decreased gamma aminobutyric acid (GABA) levels | Vitamin B6 deficiency | Excess of corticotropin releasing hormone | Anti-N-methyl-D-aspartate (NMDA) receptor antibodies | C | Excess of corticotropin releasing hormone | This patient with infantile spasms (bending at the waist and jerking out the arms and legs), developmental regression (rolling over less frequently, worsening head control, loss of social smile), and hypsarrhythmia on video-EEG (slowing and multifocal epileptiform discharges) are characteristic of West syndrome. West s... | nan |
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