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https://bit.ly/3Pv88aE | A 66-year-old woman presents to the emergency room after experiencing a tonic-clonic seizure. She has been having worsening headaches and intermittent nausea over the past 5 months. The headaches are constant and dull, and they typically worsen when she sneezes or laughs. Recently, she has become increasingly nauseous ... | Cerebral toxoplasmosis | Glioblastoma multiforme | Hemorrhagic stroke | Metastatic brain tumor | B | Glioblastoma multiforme | This patient is presenting with symptoms of increased intracranial pressure (i.e., positional headaches, nausea, vomiting, and papilledema). Combined with her CT finding of a space-occupying butterfly-shaped lesion, the most likely diagnosis is glioblastoma multiforme.
Glioblastoma multiforme is the most common malign... | Neurosarcoidosis |
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 | Triceps rupture | Olecranon bursitis | Lateral collateral ligament tear | B | 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... | Anconeus avulsion fracture |
https://bit.ly/3MoRM2B | A 55-year-old man presents to the emergency department with nausea and vomiting for the past week. He decided to come in when his symptoms worsened. He feels that his symptoms are exacerbated with large fatty meals and when he drinks alcohol. His wife recently returned from a cruise with symptoms of vomiting and diarrh... | Adhesions | Enteric nervous system damage | Impacted stool | Norovirus | A | Adhesions | This patient is presenting with abdominal pain and a tympanitic abdomen, which are symptoms suggestive of a small bowel obstruction. In developed countries, these typically occur secondary to adhesions.
Small bowel obstructions (SBO) typically present with an absence of bowel sounds, bowel movements, and flatus, as we... | Twisting of the bowel |
https://step2.medbullets.com/testview?qid=216499 | A 24-year-old man presents to his primary care physician with left groin pain. The pain started a year ago and has progressed. He now has 8/10 pain when climbing stairs or rising from a seated position. He localizes the pain to the front of his groin. He denies any erythema or swelling. He has a history of hypertension... | Low BMI | Scuba diving | Alcohol use | History of sickle cell disease | D | History of sickle cell disease | This patient with sickle cell disease (SCD) presents with anterior groin pain, especially with weight-bearing, and radiographic findings of amorphous lytic and sclerotic lesions of the femoral head, consistent with avascular necrosis. SCD is a predisposing factor for avascular necrosis.
Avascular necrosis has a multit... | nan |
https://bit.ly/42mJcXw | A 26-year-old woman presents to the emergency department with 1 day of vaginal bleeding and lower abdominal pain. The pain is most pronounced in the lower abdomen and has gotten worse over the past day. Her last menstrual period was 7 weeks ago. She denies any recent abdominal or vaginal trauma. She has no other past m... | CT of the abdomen and pelvis | Laparoscopy | Methotrexate therapy | Repeat beta-hCG in 48 hours | B | Laparoscopy | This patient’s acute onset abdominal pain with uterine bleeding and tenderness, positive pregnancy test, anemia, and hemodynamic instability are concerning for a ruptured ectopic pregnancy. Emergency laparoscopy is the most appropriate next step in management.
An ectopic pregnancy, due to implantation of a fertilized ... | Transvaginal ultrasound |
https://bit.ly/3LX4YvI | A 27-year-old man presents to the emergency department with altered mental status. He has become gradually more confused over the past several days. His wife also notes he has had diarrhea, nausea and vomiting, and abdominal pain for the past week. The patient has a history of depression and multiple suicide attempts. ... | Acetaminophen | Arsenic | Cyanide | Iron | B | Arsenic | This patient who works in the semiconductor industry and presents with confusion, hypotension, tachycardia, a garlic odor, and Mees lines (Figure A) most likely has arsenic poisoning.
Arsenic poisoning can occur due to exposure to contaminated drinking water, industrial jobs, insecticides, and certain preservatives. A... | Lead |
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... | Initiate a proton pump inhibitor | Modify mother's diet | Obtain abdominal ultrasound | Provide reassurance | B | 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... | Switch to hydrolyzed formula |
https://step2.medbullets.com/testview?qid=216266 | A 30-year-old woman presents to the emergency department for palpitations. For 2 months, she has experienced intermittent palpitations along with menstrual irregularity and hair loss. At home, the air conditioner is at its coldest setting, but the patient still feels overheated. Her temperature is 99.5°F (37.5°C), bloo... | Exophthalmos | Hair loss | Heat intolerance | Thyromegaly | A | Exophthalmos | This patient presents with palpitations, tachycardia, tremor, heat intolerance, hair loss, menstrual irregularity, goiter, and exophthalmos concerning for hyperthyroidism due to Graves disease. Radioiodine ablation is the preferred definitive management for Graves disease, which can worsen exophthalmos.
Graves disease... | 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... | Aspirin | Atorvastatin | CTA head/neck | Labetalol | A | 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... | MRI brain |
https://step2.medbullets.com/testview?qid=215034 | A 31-year-old man presents to clinic for evaluation of a 3-year history of infertility. He has no significant medical history and takes no medications. He exercises twice a day, often with heavy weightlifting, and eats a high-protein diet. He reports occasional alcohol use and remote marijuana use. His temperature is 9... | Klinefelter syndrome | Cryptorchidism | Anabolic steroid use | Excess growth hormone use | C | Anabolic steroid use | This patient with infertility is presenting with decreased testicular size, receding hairline, gynecomastia (palpable breast tissue), and transaminitis. This is most likely due to exogenous testosterone from anabolic (androgenic) steroid use.
Young people (especially athletes and heavy weightlifters) looking to improv... | nan |
https://step2.medbullets.com/testview?qid=108516 | A 44-year-old woman presents to the emergency department with fluctuating right upper quadrant abdominal pain. The pain was initially a 4/10 in severity but has increased recently to a 6/10 prompting her to come in. The patient has a medical history of type 2 diabetes mellitus, depression, anxiety, and irritable bowel ... | Laparoscopy | ERCP with manometry | Analgesics and await resolution of symptoms | MRI of the abdomen | B | ERCP with manometry | This patient is presenting with classic symptoms of acute cholecystitis or choledocholithiasis such as right upper quadrant pain and direct hyperbilirubinemia with ultrasound findings demonstrating the absence of gallstones. In this setting, sphincter of Oddi dysfunction should be suspected, and ERCP with manometry sho... | 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 | 5q | 7q | 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.... | 15q |
https://bit.ly/3OrGevt | A 41-year-old man presents to his primary care provider with a 2-month history of abdominal pain. He says that the pain “comes and goes” throughout the day and usually lasts 20-30 minutes per episode. The pain is above his umbilicus. He denies any feeling of regurgitation or nighttime cough but endorses nausea. He used... | Crypt abscesses in the large intestine | Mucosal defect in the stomach | Noncaseating granulomas in the small intestine | PAS-positive material in the small intestine | E | Urease-producing organism in the small intestine | This patient presents with episodic epigastric pain and nausea that improves with the consumption of food, which suggests a diagnosis of a duodenal ulcer. Duodenal ulcers are often caused by infection with Helicobacter pylori, a urease-producing organism.
Duodenal ulcers are erosions and defects in the mucosal lining ... | Urease-producing organism in the small intestine |
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... | Anabolic steroid use | CGG trinucleotide repeat disorder | CTG trinucleotide repeat disorder | Failure of neuronal migration | E | 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... | Meiotic nondisjunction |
https://bit.ly/3PAOhbu | A 3-month-old boy presents to the pediatrician with his mother for a well-child visit. The patient drinks 4 ounces of cow’s milk formula every 3 hours. He usually stools 1 time per day and urinates up to 6 times per day. He regurgitates a moderate amount of formula through his nose and mouth after most feeds. He does n... | Provide reassurance | Counsel on positioning and thickening feeds | Obtain abdominal ultrasound | Initiate proton pump inhibitor | B | Counsel on positioning and thickening feeds | This patient presents with frequent regurgitation after feeding, worsening irritability, feeding aversion, and poor weight gain, which is concerning for gastroesophageal reflux disease (GERD). The most appropriate next step in management is counseling on proper positioning and thickening feeds.
Infants with GERD may p... | nan |
https://bit.ly/3CxfeFC | A 69-year-old man presents to his primary care physician for trouble sleeping. He recently retired from working the day shift at a cemetery. When the patient retired, his goal was to finally be able to go out with his wife; however, he finds that he is unable to stay awake past 6 pm in the evening. His wife is disappoi... | Advanced sleep phase disorder | Chronic insomnia | Delayed sleep phase disorder | Normal aging | A | Advanced sleep phase disorder | This patient is presenting with difficulty staying awake in the early evening suggesting a diagnosis of advanced sleep phase disorder (also known as advanced sleep phase syndrome).
Advanced sleep phase disorder can present in patients of all ages. Patients will experience difficulty staying awake in the early evening ... | Obstructive sleep apnea |
https://bit.ly/3Mv3U1Q | A 72-year-old man presents to his primary care physician with weakness. He has felt very weak every morning with his symptoms persisting throughout the day. He notes minor improvement when he rides his bike but otherwise has not noticed any change in his symptoms with rest or ibuprofen use. The patient has lost 12 poun... | Blood laboratory test | CT scan of the chest | Electromyography | Lung biopsy | C | Electromyography | This patient who presents with weakness that improves with activity in the setting of a lung mass most likely has Lambert-Eaton syndrome. The most appropriate diagnostic test to confirm this syndrome is electromyography.
Small cell lung cancer presents with fatigue, weight loss, cough, and a coin lesion on chest radio... | Muscle biopsy |
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 | Contact the patient's family to ask for permission to perform the procedure | Intubate the patient with the resident's supervision | Report the resident to hospital administration | 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... | nan |
https://step2.medbullets.com/testview?qid=109967 | 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 ... | nan |
https://bit.ly/3KxXaiO | A 6-week-old boy is referred to a pediatric hematologist-oncologist for further evaluation following an abnormal newborn hemoglobinopathy screening. The father’s brother died of sickle cell anemia at an early age. Parental studies reveal that both mother and father are carriers of the sickle cell gene. The patient's te... | Diabetes | Hematuria | Infection | Splenectomy | B | Hematuria | Based on the presence of both hemoglobin (Hb) A and S on gel electrophoresis, this patient has sickle cell trait. Episodes of painless hematuria are commonly seen in these patients.
Sickle cell trait is a condition that refers to carrying 1 normal and 1 abnormal beta-globin allele. On electrophoresis, this will presen... | Stroke |
https://step2.medbullets.com/testview?qid=216521 | A 15-month-old boy presents with his mother for his well-child exam. His mother is concerned about his vision, as she noticed him squinting while watching television. The patient was born at 39 weeks of gestation via spontaneous vaginal delivery. He is up to date with routine vaccinations. He is able to walk alone, spe... | Perform a Bielschowsky head tilt test | Brain MRI | Patch the left eye | Patch the right eye | D | Patch the right eye | This patient, with a history that suggests decreased visual acuity, a positive cover test (refixation of the misaligned eye upon covering the appropriately aligned eye), and an asymmetric corneal light reflex in Figure A, is presenting with strabismus. Of the answer choices, only patching the sound eye (right eye) is a... | nan |
https://bit.ly/3P8eDBc | A 37-year-old woman presents to her physician for mood changes and recent falls over the course of 3 months. She feels more irritable with her husband and children and does not find pleasure in creating art anymore. Over the last 2 weeks, she has been sleeping approximately 5 hours a night and had a fall while walking ... | Poor iron absorption | Prior Treponema pallidum exposure | Reduced central nervous system dopamine and serotonin | Reduced functional parietal cell count | D | Reduced functional parietal cell count | This patient's mood changes and findings concerning for subacute combined degeneration (fall in the dark, impaired proprioception, weakness, and brisk patellar reflexes), and history of Roux-en-Y gastric bypass surgery are concerning for vitamin B12 deficiency. Roux-en-y gastric bypass reduces parietal cell count, lead... | Subtherapeutic levothyroxine dose |
https://step2.medbullets.com/testview?qid=109967 | 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://bit.ly/3Lm4zC8 | A 36-year-old man presents to the office for follow up after initiating antidepressant therapy. Two months ago, he was started on citalopram after several weeks of depressed mood, loss of interest in activities, depressed appetite, and inability to sleep. Today, he reports minimal improvement in his symptoms. He had so... | Switch to paroxetine | Switch to phenelzine | Electroconvulsive therapy | Add mirtazapine | D | Add mirtazapine | This patient is being treated for depression without improvement in his symptoms after 6 weeks of medication use. In the setting of his reduced appetite and trouble sleeping, mirtazapine is an appropriate medication to add.
SSRIs (including paroxetine, citalopram, fluvoxamine, sertraline, and fluoxetine) are the first... | nan |
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... | Plantar fasciitis | Vitamin B12 deficiency | Tarsal tunnel syndrome | Herniated disc | C | 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... | nan |
https://bit.ly/3sorW7P | A 33-year-old man presents to the emergency department after slamming his finger in the car door 5 hours ago. He initially experienced pain which is currently well controlled with acetaminophen. The patient is otherwise healthy and does not take any medications. His temperature is 98.5°F (36.9°C), blood pressure is 123... | Excision and histological examination | Fingernail removal | Observation | Operative repair | E | Trephination | This patient is presenting after trauma to his finger with a subungual hematoma. Given that he has no other associated injuries, trephination is the only management indicated.
A subungual hematoma occurs after trauma to the finger leading to a collection of blood under the fingernail. Depending on the mechanism, this ... | Trephination |
https://step2.medbullets.com/testview?qid=215176 | A 56-year-old man presents from prison with 1 month of subjective fevers, chills, cough, and night sweats. He noticed a gradual weight loss over the past year despite no changes to his diet or physical activity. He has never smoked cigarettes but does have a history of opiate use prior to incarceration. He does not tak... | Ampicillin-sulbactam | Biopsy | Itraconazole | Rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE) therapy | D | Rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE) therapy | This patient likely has active tuberculosis (TB), as evidenced by his symptoms (fever, night sweats, cough, and weight loss), inmate status, and apical cavitary lesion on chest radiograph. He should be treated with RIPE therapy.
An active TB infection should be suspected in patients with a febrile illness, cough, nigh... | Vancomycin |
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... | Combined oral contraceptive | Increase levothyroxine dose | Brain MRI | Estradiol patch with oral medroxyprogesterone | D | 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... | nan |
https://bit.ly/3MCzFqw | A 23-year-old woman presents to the emergency department complaining of a worsening headache. The headache started 1 month ago. It is constant and “all over” but gets worse when she is lying down or in the setting of bright lights. A review of systems is significant for a low-grade fever, night sweats, cough, malaise, ... | Acyclovir | Amphotericin B and 5-flucytosine | Dexamethasone | Fluconazole | B | Amphotericin B and 5-flucytosine | The patient with a history of unprotected sex and intravenous drug use who presents with sub-acute fever, meningismus, photophobia, a low CD4+ count, and a positive India ink-stained lumbar puncture most likely has cryptococcal meningitis. Acute treatment for cryptococcal meningitis is intrathecal amphotericin B and 5-... | Vancomycin and ceftriaxone |
https://step2.medbullets.com/testview?qid=216508 | A 55-year-old man presents to the emergency department with worsening dyspnea over the past 48 hours. He recently had a cold that kept him home from work for the past week. He has a past medical history of diabetes, obesity, and hypertension. He had his Achilles tendon repaired 4 weeks ago and he has been less mobile. ... | Cardiac tamponade | Constrictive pericarditis | Myocardial infarction | Pulmonary embolism | B | Constrictive pericarditis | This patient is presenting with a preceding viral illness, dyspnea, jugular venous distension, pulsus paradoxus (blood pressure drop from 150/85 to 130/70 mmHg during inspiration), an echocardiogram with impaired diastolic filling, and diffuse ST elevation with PR depression on ECG. This constellation of symptoms is co... | Restrictive cardiomyopathy |
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 | Giardia | 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... | Whipple disease |
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 | Heart failure and reinfarction | Medication side effect | Pancreatitis | 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... | Renal failure |
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... | Laparoscopy to prevent detrimental effects on the fetus | Laparoscopy to remove a malignancy | Percutaneous umbilical blood sampling to determine prognosis | Reassurance | D | 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... | Spironolactone to treat hirsutism and acne |
https://step2.medbullets.com/testview?qid=216240 | A 15-year-old girl presents to the clinic due to concern that she may be pregnant. She had unprotected sexual intercourse earlier that morning and requests emergency contraception. She has had regular menses since menarche, and her last menstrual period ended 8 days ago. She has no significant medical history. Her temp... | Prescribe misoprostol pill | Prescribe levonorgestrel pill | Obtain parental consent before providing emergency contraception | Prescribe high-dose oral contraceptives | B | Prescribe levonorgestrel pill | This patient with recent unprotected intercourse and a negative pregnancy test is a candidate for postcoital emergency contraception. She should receive the levonorgestrel or ulipristal pill, which in most states does not require parental consent.
Patients with a positive pregnancy test are not candidates for emergenc... | nan |
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... | Serum glucose | Complete blood count | Urine chloride | Arterial blood gas | C | 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... | nan |
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... | Renal cell carcinoma |
https://step2.medbullets.com/testview?qid=106849 | A 26-year-old woman presents to the emergency department because she feels as though her heart is "beating out of her chest." She states that she feels well apart from the discomfort of that sensation. Her temperature is 97.9°F (36.6°C), blood pressure is 124/84 mmHg, pulse is 180/min, respirations are 22/min, and oxyg... | Disulfiram-like reaction | Flushing | Photosensitivity | Seizure | B | Flushing | This patient presents with a narrow complex tachycardia that is regular which is suggestive of supraventricular tachycardia (SVT) and was pharmacologically cardioverted with adenosine (as it has a very short half-life). Side effects of adenosine include flushing, hypotension, bronchospasm, and heart block.
SVT present... | Tachycardia |
https://bit.ly/3qLbsG6 | A 62-year-old man presents to the emergency department with skin lesions. He felt itchy recently, then noticed skin lesions that broke out prompting him to come to the emergency department. He recently went camping and hiking in the woods. The patient drinks 1-2 beers per day and smokes 1 pack of cigarettes per day. He... | IgG in a fish-net pattern | Linear IgG along the basement membrane | Multi-nucleated giant cells | Panniculitis | B | Linear IgG along the basement membrane | This patient is presenting with pruritic bullous skin lesions with a thick/tough covering suggesting a diagnosis of bullous pemphigoid. Linear IgG binding of anti-hemidesmosome antibodies along the basement membrane is the underlying cause of this disease.
Bullous pemphigoid presents with a urticarial prodrome in elde... | Type IV hypersensitivity reaction |
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 | Chest radiograph | CT scan | Ultrasound | 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... | Vancomycin and gentamicin |
https://bit.ly/47eGzd4 | An 84-year-old man presents to the physician with numbness and tingling in the right hand for the last 6 months. He reports these symptoms started intermittently in the middle finger after returning from a golfing trip but has progressed to being nearly constant. The thenar eminence, thumb, and other digits are spared.... | Amyotrophic lateral sclerosis | Carpal tunnel syndrome | Cervical spondylosis | Syringomyelia | C | Cervical spondylosis | This patient presents with chronic middle finger paresthesia, weakness in elbow extension and wrist flexion, and a diminished triceps reflex in the setting of a positive Spurling test (pain with axial loading during neck extension, rotation, and lateral bending towards the affected side), indicative of C7 cervical radi... | 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 ... | Hyperkalemia | Hypertrophic obstructive cardiomyopathy | Hypokalemia | Myocardial infarction | D | 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... | Pericarditis |
https://step2.medbullets.com/testview?qid=216584 | A 30-year-old man presents to the emergency department with diarrhea. He states he has had profuse, watery diarrhea for the past 24 hours. He notes that eating and drinking make him defecate more, thus he has been refraining from drinking. He is otherwise healthy and takes no medications. His temperature is 97.7°F (36.... | Stool PCR | Ciprofloxacin | Stool ova and parasite study | Rest and oral rehydration | D | Rest and oral rehydration | This patient is presenting with a likely diarrheal illness given he has profuse, watery diarrhea and his vitals normalized with oral and IV hydration. Since the patient is young and healthy, oral hydration and rest are all that is needed for management.
Diarrheal illness is a common chief complaint with variable worku... | nan |
https://step2.medbullets.com/testview?qid=109109 | A 1-hour-old newborn boy is evaluated in the delivery room. He was born at 37 weeks gestation to a 39-year-old G3P3 mother. The mother initially labored at home with a midwife but was transferred to the hospital for failure to progress. The infant was eventually delivered via Caesarean section. The mother declined all ... | Ventricular septal defect | Bicuspid aortic valve | A normal cardiac exam | Tetralogy of Fallot | C | A normal cardiac exam | This patient presents with a full-thickness defect in the abdominal wall lateral to the umbilicus with evisceration of the bowel, which suggests a diagnosis of gastroschisis. Gastroschisis is not associated with any cardiac defects.
Gastroschisis and omphalocele are the most common abdominal wall defects found in infa... | nan |
https://bit.ly/43OL5NI | A 32-year-old G1P0 woman delivers a boy at 40 weeks and 3 days of gestation. The delivery is uncomplicated and the neonate has Apgar scores of 9 and 9 at 1 and 5 minutes respectively. After 15 minutes, he attempts to nurse for the 1st time. His mother notices that his face, chest, and extremities turn dusky blue during... | Digital clubbing | Patent foramen ovale | Inability to pass a nasogastric tube | Areflexia in all extremities | C | Inability to pass a nasogastric tube | This neonate presents with central cyanosis upon feeding, resolution with crying, and midface hypoplasia on exam, most consistent with choanal atresia. A nasogastric (NG) tube would not pass through the nasal canal.
Choanal atresia is caused by failed recanalization of the nasal fossae during fetal development. This d... | nan |
https://step2.medbullets.com/testview?qid=216395 | A 67-year-old man presents with a recurrent episode of syncope. He states that this has happened to him multiple times, particularly when he changes body position from sitting to standing, exerts himself, or turns his head quickly. He says that he notes numbness, vertigo, and sometimes even trouble with speaking immedi... | Vagal event | Seizure | Blood vessel narrowing | Stroke | C | Blood vessel narrowing | This elderly patient with risk factors for vascular disease (diabetes, dyslipidemia, hypertension) is presenting with episodes of dizziness, vertigo, numbness/tingling, dysarthria, and syncope, which seem to be provoked by standing rapidly and changing head position. This is concerning for vertebrobasilar syndrome, cau... | nan |
https://bit.ly/44Zo5vi | A 3-week-old boy presents to the emergency department with vomiting. His parents report that he suddenly started vomiting this morning and has shown no interest in feeding since then. They describe the vomitus as green and without any traces of blood. Prior to today, the patient was feeding, voiding, and stooling well.... | Abdominal CT | Abdominal ultrasound | Contrast enema | Rectal suction biopsy | E | Upper gastrointestinal contrast series | This neonatal patient presents with sudden-onset bilious vomiting and an abdominal radiograph revealing a gasless abdomen, which is consistent with intestinal malrotation complicated by a midgut volvulus. The most appropriate next step in the diagnosis of intestinal malrotation is an upper gastrointestinal series.
Mal... | Upper gastrointestinal contrast series |
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 | Intravenous acyclovir | Intravenous ceftriaxone | Oral erythromycin | D | 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... | Topical erythromycin |
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% ... | Riboflavin | Thiamine | Vitamin C | Vitamin D | E | 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... | Zinc |
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 | Cerebral infarction | Scalenus anticus syndrome | Subclavian steal 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 ... | nan |
https://bit.ly/3JrjtWO | A 45-year-old man presents to his primary care physician with a rash. He first noticed the rash 2 weeks prior and he endorses intermittent itchiness from the rash. His medical history is significant for chronic hepatitis C infection, hypertension, type 2 diabetes mellitus, and heart failure. The patient works as a butc... | Atopic dermatitis | Lichen planus | Scabies | Psoriasis | B | Lichen planus | This patient presents with several purple, polygonal, pruritic papules and plaques. These findings are most consistent with a diagnosis of lichen planus.
Lichen planus is an inflammatory skin disorder most commonly characterized by an eruption of Purple, Polygonal, Planar, Pruritic, Papules and Plaques (the 6 P’s), of... | nan |
https://step2.medbullets.com/testview?qid=215043 | A 2-month-old girl is brought to the pediatrician by her mother for a follow-up visit. The patient was born at 29 weeks gestation to a G1P1 mother. Her postnatal course was complicated by a prolonged neonatal intensive care unit stay for neonatal respiratory distress syndrome (NRDS). Since discharge from the hospital, ... | Administer DTaP, HAV, HBV, HiB, PCV 13, poliovirus, and rotavirus vaccines | Administer DTaP, HBV, HiB, PCV 13, and poliovirus vaccines | Administer DTaP, HBV, HiB, PCV 13, poliovirus, and rotavirus vaccines | Delay all vaccines for 2 months due to the infant's history of NRDS | C | Administer DTaP, HBV, HiB, PCV 13, poliovirus, and rotavirus vaccines | This 2-month-old girl has a history of prematurity (born at 29 weeks gestation) complicated by a NICU stay for NRDS but is healthy at this time. It is recommended that she receive all vaccines (DTaP, HBV, HiB, PCV 13, poliovirus, and rotavirus vaccines) as scheduled during this visit.
Premature infants can safely be v... | Delay all vaccines for 2 months because the infant was born 2 months premature |
https://bit.ly/47NX9Au | 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... | Renal cell carcinoma |
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 | Wrap the finger in moist gauze and place in a plastic bag | Submerge the finger in ice water | Rinse the finger with hydrogen peroxide, wrap the finger in moist gauze, and place on ice | 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, ... | nan |
https://bit.ly/468jb0I | A 3-week-old girl presents with her parents to her pediatrician for a routine visit. The child is sleeping at regular 2-hour intervals and feeding and stooling well. The parents have noticed a “swelling of the belly button.” Cord separation occurred at 7 days of age. The swelling seems to come and go but is never large... | Elective surgical management | Expectant management | Histopathologic evaluation | Immediate surgical management | B | Expectant management | This infant presents with a soft, 1 cm bulge at the umbilicus that is easily reducible inside the umbilical ring, which suggests a diagnosis of an umbilical hernia. Most umbilical hernias in children resolve spontaneously and can be managed expectantly.
An umbilical hernia is a protrusion of bowel, omentum, or preperi... | Thyroid hormone replacement |
https://step2.medbullets.com/testview?qid=109024 | A 36-year-old woman, G1P1001, presents to her gynecologist for an annual visit. She has a medical history of hypertension for which she takes hydrochlorothiazide. The patient’s mother had breast cancer at age 68, and her sister has endometriosis. She states that she feels well and has no complaints. Her temperature is ... | Amenorrhea | Endometrial cancer | Iron deficiency anemia | Uterine prolapse | C | Iron deficiency anemia | This patient presents with an irregularly enlarged uterus on examination consistent with the intramural leiomyomas (fibroids) seen on ultrasound. Leiomyomas increase the risk of iron deficiency anemia due to heavy menstrual bleeding.
Leiomyoma are benign overgrowths of myometrial tissue. The most common presentation i... | Uterine sarcoma |
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... | Carbamazepine | High-flow oxygen | Sumatriptan | Topiramate | E | 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... | Verapamil |
https://bit.ly/3LZVzD7 | A 14-year-old boy presents to his pediatrician with a 2-month history of intermittent arm and leg spasms. He says that the spasms usually occur after he wakes up as he is getting ready for school, and consist of disorganized jerking motions that stop after a few minutes. He has also noticed that they occur when he stay... | Absence seizures | Alcohol intoxication | Cannabinoid use | Juvenile myoclonic epilepsy | D | Juvenile myoclonic epilepsy | This patient who presents with intermittent jerking of his extremities that occur primarily after waking up or when sleep-deprived most likely has juvenile myoclonic epilepsy.
Juvenile myoclonic epilepsy (JME) is a poorly understood condition that presents with intermittent myoclonic jerks of the extremities. These my... | West syndrome |
https://step2.medbullets.com/testview?qid=210373 | A 23-year-old woman is admitted to the inpatient psychiatry unit after her boyfriend reported she was “acting funny and refusing to talk.” The patient’s boyfriend states that he came home from work and found the patient sitting up in bed staring at the wall. When he said her name or waved his hand in front of her, she ... | Benztropine | Cyproheptadine | Electroconvulsive therapy | Haloperidol | E | Lorazepam | The patient has a history of depression and is presenting with decreased motor activity, waxy flexibility, lack of response to external stimuli, and mutism, suggesting the diagnosis of catatonia. Catatonia should initially be treated with benzodiazepines like lorazepam.
Catatonia is a state of psychomotor immobility a... | Lorazepam |
https://bit.ly/3FwRzGJ | A 67-year-old man presents to the emergency department 1 hour after sudden-onset weakness and double vision. His medical history is significant for hyperlipidemia and poorly controlled hypertension. His current medications include atorvastatin and amlodipine. His temperature is 98.6°F (37.0°C), blood pressure is 175/95... | Lateral medulla | Lateral pons | Posterior limb of internal capsule | Midbrain | D | Midbrain | This patient with a history of poorly controlled hypertension, acute onset of left-sided oculomotor nerve palsy (mydriasis, ptosis, and “down and out” pupil), right-sided paresis, and right-sided dysdiadochokinesia most likely has a lacunar stroke of the left midbrain.
Important structures in the midbrain often affect... | nan |
https://bit.ly/3GigfDn | A 55-year-old man presents to urgent care for weakness and weight loss. For the past several months, he has felt progressively weaker and has lost 25 pounds with intermittent abdominal pain. The patient has not seen a physician in 30 years and recalls being current on most of his vaccinations. A few years ago, he went ... | CT scan of the abdomen and pelvis | CT scan of the chest | HIDA scan | Smoking cessation advice and primary care follow up | A | CT scan of the abdomen and pelvis | This patient with weight loss and painless liver dysfunction has symptoms that are suggestive of pancreatic cancer. The most appropriate next diagnostic test is a CT scan of the abdomen and pelvis.
Pancreatic cancer presents with weight loss, jaundice, epigastric pain, and fatigue/malaise typically in an older male sm... | nan |
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 ... | Antisocial | Avoidant | Borderline | Dependent | C | 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 ... | Histrionic |
https://bit.ly/3OFDpHw | A 69-year-old man presents to clinic due to shortness of breath, worsening pain in his right shoulder, and episodes of hemoptysis. His symptoms began 3 months ago. He has also lost 18 pounds. He has a history of coronary artery disease and underwent an uncomplicated coronary angioplasty with stent placement 2 years ago... | Lung adenocarcinoma | Mesothelioma | Rotator cuff tendinopathy | Tuberculosis | A | Lung adenocarcinoma | This elderly patient with an extensive smoking history is presenting with hemoptysis, weight loss, and shortness of breath. Combined with neurological findings in the ulnar nerve distribution (paresthesias in fourth and fifth digits) and imaging evidence of a superior right lung mass, the most likely diagnosis is a Pan... | nan |
https://bit.ly/43fo59y | A 25-year-old G1P0 woman presents to her physician for a prenatal visit. She is at 12 weeks gestational age and has not received prior prenatal care. She has mild morning sickness but no other symptoms. She has no known medical problems and takes only a prenatal multivitamin. She has unprotected sexual intercourse with... | B | A | C | E | C | C | This pregnant patient presents with a positive HIV antibody test in the setting of unprotected sexual intercourse. An appropriate maternal HIV treatment regimen is abacavir, lamivudine, and raltegravir; prophylaxis in the infant consists of zidovudine alone if maternal HIV viral load is suppressed to < 50 copies/mL.
A... | nan |
https://step2.medbullets.com/testview?qid=216584 | A 30-year-old man presents to the emergency department with diarrhea. He states he has had profuse, watery diarrhea for the past 24 hours. He notes that eating and drinking make him defecate more, thus he has been refraining from drinking. He is otherwise healthy and takes no medications. His temperature is 97.7°F (36.... | Ciprofloxacin | Rest and oral rehydration | Stool culture | Stool ova and parasite study | B | Rest and oral rehydration | This patient is presenting with a likely diarrheal illness given he has profuse, watery diarrhea and his vitals normalized with oral and IV hydration. Since the patient is young and healthy, oral hydration and rest are all that is needed for management.
Diarrheal illness is a common chief complaint with variable worku... | Stool PCR |
https://step2.medbullets.com/testview?qid=108583 | A 21-year-old man presents to the emergency room with right lower quadrant pain that started this afternoon at his wrestling match. He also endorses loss of appetite and subjective fever. He has had vague, mild discomfort in the right upper quadrant since the start of this wrestling season. He endorses a history of unp... | Administer metronidazole | Administer sofosbuvir | Obtain follow-up CT of the abdomen in 3 months | Perform liver mass resection | D | Perform liver mass resection | This patient with a history of possible anabolic steroid use (wrestler with acne) who presents with right upper quadrant pain and an enhancing lesion in the liver most likely has a hepatic adenoma. The treatment of hepatic adenomas is surgical removal and discontinuation of precipitating agents.
Hepatic adenomas are b... | nan |
https://bit.ly/3OrGevt | A 41-year-old man presents to his primary care provider with a 2-month history of abdominal pain. He says that the pain “comes and goes” throughout the day and usually lasts 20-30 minutes per episode. The pain is above his umbilicus. He denies any feeling of regurgitation or nighttime cough but endorses nausea. He used... | Crypt abscesses in the large intestine | Mucosal defect in the stomach | Noncaseating granulomas in the small intestine | Urease-producing organism in the small intestine | D | Urease-producing organism in the small intestine | This patient presents with episodic epigastric pain and nausea that improves with the consumption of food, which suggests a diagnosis of a duodenal ulcer. Duodenal ulcers are often caused by infection with Helicobacter pylori, a urease-producing organism.
Duodenal ulcers are erosions and defects in the mucosal lining ... | nan |
https://bit.ly/3LSMEDm | A 65-year-old man presents to the emergency department with low back pain. The pain started 6 hours ago when he was gardening and carrying a heavy bag. The pain is rated as 10/10 in severity and radiates down the posterior aspect of the right thigh. He reports no fevers or chills. His only medical problem is hypertensi... | Acute inflammatory demyelinating polyneuropathy | L5/S1 disc herniation | Spinal stenosis | Cauda equina syndrome | D | Cauda equina syndrome | This patient presenting with acute, severe, radiating low back pain with sensorimotor deficits (3/5 strength in hip extension, knee flexion/extension, plantar flexion, reduced sensation to pinprick) in multiple nerve root distributions (L3-S5), lower motor neuron signs, urinary incontinence (wet underwear), and acute u... | nan |
https://bit.ly/3Pv88aE | A 66-year-old woman presents to the emergency room after experiencing a tonic-clonic seizure. She has been having worsening headaches and intermittent nausea over the past 5 months. The headaches are constant and dull, and they typically worsen when she sneezes or laughs. Recently, she has become increasingly nauseous ... | Glioblastoma multiforme | Cerebral toxoplasmosis | Neurosarcoidosis | Hemorrhagic stroke | A | Glioblastoma multiforme | This patient is presenting with symptoms of increased intracranial pressure (i.e., positional headaches, nausea, vomiting, and papilledema). Combined with her CT finding of a space-occupying butterfly-shaped lesion, the most likely diagnosis is glioblastoma multiforme.
Glioblastoma multiforme is the most common malign... | nan |
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... | Increased parathyroid hormone | Malignancy | Viral illness | Antacid overuse | A | 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... | nan |
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... | Testicular ultrasound | Radiograph of the hand and wrist | Karyotyping | Reassurance with close follow-up | B | 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... | nan |
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.... | Adrenal tumor | Congenital adrenal hyperplasia | Ovarian hyperthecosis | Ovarian tumor | D | 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... | Polycystic ovary syndrome |
https://step2.medbullets.com/testview?qid=216371 | A 68-year-old woman presents to the emergency room with several days of frequent, nonbloody, watery stools. She recently completed a course of clindamycin 2 weeks ago for a tooth infection. Her medical history is notable for hypertension and hyperlipidemia for which she takes amlodipine and atorvastatin. She traveled r... | CT imaging of abdomen and pelvis | Rectal swab for selective anaerobic culture | Abdominal radiograph | Stool toxin assay | D | Stool toxin assay | This patient presenting with cramping abdominal pain and frequent watery diarrhea a few weeks after finishing a course of antibiotics most likely has Clostridioides difficile infection, for which the most appropriate confirmatory test is a stool toxin assay.
C. difficile infection should be suspected in patients with ... | nan |
https://bit.ly/3OhgJgC | A 26-year-old man presents to the emergency department with fatigue and dark urine over the past day. He was recently diagnosed with cellulitis of his left leg, for which he was prescribed trimethoprim-sulfamethoxazole. He denies having nausea, vomiting, or diarrhea. He has no significant medical history and does not c... | Schistocytes | Codocytes | Acanthocytes | Degmacytes | D | Degmacytes | This patient presents with hemolytic anemia (low hemoglobin, elevated indirect bilirubin, and elevated lactate dehydrogenase) shortly after starting a sulfa medication (trimethoprim-sulfamethoxazole) in the setting of likely glucose-6-phosphate dehydrogenase deficiency. Degmacytes ("bite cells") will be seen on periphe... | nan |
https://bit.ly/3FgV041 | A 47-year-old man is brought in after a motor vehicle accident. He was driving under the influence of alcohol when he sustained a crash against a pole. His medical history is significant for hypertension but he does not take any medications. His temperature is 98.6°F (37.0°C), blood pressure is 110/80 mmHg, pulse is 60... | Blinking after saline is applied to the cornea | Conjugate eye movement to the left with rotation of the head to the right | Flexion of the thigh, leg, and foot upon noxious stimulation of the foot | Grimacing after noxious stimulus to the arm | C | Flexion of the thigh, leg, and foot upon noxious stimulation of the foot | This patient with a Glasgow coma score (GCS) of 3 and a known mechanism of injury due to motor vehicle accident trauma is normothermic, normotensive, not on sedatives, and without laboratory abnormalities so they are appropriate for examination of brain death. Cortical and brain stem function must be absent in brain de... | Spontaneous respiration 1 minute after disconnection from a ventilator |
https://step2.medbullets.com/testview?qid=216585 | A 44-year-old man presents to the emergency department acutely confused. The patient’s wife states she found him lethargic at home. He has been sick the past week with diarrhea and has been staying home from work. He is otherwise healthy and does not take any medications. His temperature is 97.5°F (36.4°C), blood press... | Loperamide | Norepinephrine | Ceftriaxone | Normal saline | A | Loperamide | This patient is presenting with infectious diarrhea (given his bloody diarrhea and hypotension) with unstable vitals that improve with fluids. In bloody diarrhea, loperamide is contraindicated and could worsen illness.
Bacterial diarrhea is commonly caused by organisms such as Campylobacter, Shigella, and Escherichia ... | 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... | Urine electrolytes and creatinine |
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... | Atria > Purkinje fibers > ventricles > AV node | AV node > ventricles > atria > Purkinje fibers | Purkinje fibers > ventricles > atria > AV node | Purkinje fibers > atria > ventricles > AV node | D | 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... | Purkinje fibers > AV node > ventricles > atria |
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... | Cerebroside sulfate | Galactocerebroside | Glucocerebroside | GM2-ganglioside | D | 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... | Sphingomyelin |
https://step2.medbullets.com/testview?qid=215169 | A 27-year-old man presents to the emergency department after a bar fight. He was punched in the eye and is having pain and blurry vision. The patient is otherwise healthy and does not take any medications. His temperature is 98.1°F (36.7°C), blood pressure is 132/84 mmHg, pulse is 103/min, respirations are 17/min, and ... | CT scan of the head and facial bones | Cyclopentolate | Lateral canthotomy | Orbital ultrasound | C | Lateral canthotomy | This patient is presenting after blunt trauma to the eye with eye pain, blurry vision, conjunctival injection, a sluggish pupil, and elevated intraocular pressure (> 20 mmHg) suggesting a diagnosis of a retrobulbar hematoma/hemorrhage causing orbital compartment syndrome. The most important initial step in management i... | Topical timolol and pilocarpine |
https://step2.medbullets.com/testview?qid=216371 | A 68-year-old woman presents to the emergency room with several days of frequent, nonbloody, watery stools. She recently completed a course of clindamycin 2 weeks ago for a tooth infection. Her medical history is notable for hypertension and hyperlipidemia for which she takes amlodipine and atorvastatin. She traveled r... | Abdominal radiograph | CT imaging of abdomen and pelvis | Flexible sigmoidoscopy | Rectal swab for selective anaerobic culture | E | Stool toxin assay | This patient presenting with cramping abdominal pain and frequent watery diarrhea a few weeks after finishing a course of antibiotics most likely has Clostridioides difficile infection, for which the most appropriate confirmatory test is a stool toxin assay.
C. difficile infection should be suspected in patients with ... | Stool toxin assay |
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... | Levothyroxine | Methimazole | Radioactive iodine | Repeat ultrasound in 6 months | E | 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... | Thyroidectomy followed by radioactive iodine |
https://bit.ly/3Waen6G | A 32-year-old G1P0 presents to the antenatal testing unit at 32 weeks of gestation for a non-stress test (NST). Yesterday she had several episodes of diarrhea and vomited once after attending a company picnic 2 days ago. She took loperamide with symptomatic relief. She is worried that she is dehydrated but otherwise fe... | Fetal sleep cycle | Maternal dehydration | Maternal medication use | Maternal smoking | A | Fetal sleep cycle | This patient presents with a nonreactive NST on routine testing. The most common explanation for a nonreactive NST is the fetal sleep cycle.
Patients with gestational diabetes are at increased risk of fetal demise and other perinatal complications. They require closer monitoring during the 3rd trimester of pregnancy. ... | Normal results |
https://step2.medbullets.com/testview?qid=216634 | A 7-year-old adopted boy presents to the emergency department after fainting. He just switched from being home-schooled to public school and joined the basketball team. He has fainted several times during basketball practices. He did not sustain any injuries or have any prodromes prior to these episodes. He is usually ... | Brugada syndrome | Wolff Parkinson White syndrome | Hypertrophic obstructive cardiomyopathy | Arrhythmogenic right ventricular dysplasia | D | Arrhythmogenic right ventricular dysplasia | This adopted pediatric patient is presenting with recurrent syncope and an ECG demonstrating an epsilon wave and T wave inversions, which are concerning for arrhythmogenic right ventricular dysplasia.
An epsilon wave is a small positive deflection at the end of the QRS complex. This is an ominous finding and suggests ... | nan |
https://step2.medbullets.com/testview?qid=216611 | A 72-year-old man presents to his primary care physician for a general checkup. He states that he has been a bit more fatigued lately but believes it is secondary to poor sleep at his new house. The patient is otherwise healthy and takes no medications. His temperature is 98.0°F (36.7°C), blood pressure is 141/90 mmHg,... | Acute lymphoblastic leukemia | Acute myelogenous leukemia | Chronic lymphocytic leukemia | Chronic myelogenous leukemia | C | Chronic lymphocytic leukemia | This elderly patient is presenting with minor fatigue, anemia, thrombocytopenia, and a leukocyte count >50,000/mm^3, which is most likely caused by chronic lymphocytic leukemia (CLL).
CLL is a monoclonal proliferation of incompetent mature B-cells. It is common in elderly men and is the most common form of leukemia in... | Hairy cell leukemia |
https://step2.medbullets.com/testview?qid=109453 | A 57-year-old man presents to the emergency department for shortness of breath. He was riding the train home from a business conference when his symptoms began. The patient has a medical history of obesity, diabetes, diabetic nephropathy, hypertension, and a 40-pack-year smoking history. His current medications include... | Aspirin | Cardiac troponins | CT scan of the chest without contrast | Heparin | D | Heparin | This patient is presenting with a score of 7.5 on Wells criteria suggesting a diagnosis of pulmonary embolism. The most appropriate initial step in management is heparin administration.
Patients with suspected pulmonary embolism (PE) can be evaluated with Wells criteria which consists of: clinical signs and symptoms o... | Ventilation perfusion scan |
https://bit.ly/3LBleST | A 4-day-old girl is brought in by her mother for bilateral purulent eye discharge. Pregnancy and delivery were uncomplicated. The newborn had been sleeping regularly and feeding well. Then 1 day ago, the patient developed eyelid edema and eye redness. This morning, the newborn developed a thick yellow-white eye dischar... | Artificial tears | Intramuscular ceftriaxone | Oral erythromycin | Topical bacitracin | E | Topical erythromycin | This patient is presenting with bilateral purulent eye discharge 4 days post-birth, suggesting the diagnosis of gonococcal conjunctivitis. Standard prophylaxis for this condition is topical erythromycin ointment.
Neonatal gonococcal conjunctivitis is caused by Neisseria gonorrhea and presents in newborns that are 0-5 ... | Topical erythromycin |
https://bit.ly/43fo59y | A 25-year-old G1P0 woman presents to her physician for a prenatal visit. She is at 12 weeks gestational age and has not received prior prenatal care. She has mild morning sickness but no other symptoms. She has no known medical problems and takes only a prenatal multivitamin. She has unprotected sexual intercourse with... | A | B | C | D | C | C | This pregnant patient presents with a positive HIV antibody test in the setting of unprotected sexual intercourse. An appropriate maternal HIV treatment regimen is abacavir, lamivudine, and raltegravir; prophylaxis in the infant consists of zidovudine alone if maternal HIV viral load is suppressed to < 50 copies/mL.
A... | E |
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 | Iron studies | Pramipexole | Supportive therapy and an exercise routine | B | 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... | nan |
https://bit.ly/44tTwi7 | A 45-year-old morbidly obese woman with a history of asthma and type 2 diabetes mellitus presents to her primary care physician for advice on weight loss. She thinks that her husband is having sex with other women because they have not had sex over the past year. She feels that her co-workers also disrespect her for he... | Fluconazole | Prednisone | Topical clobetasol | Topical imiquimod | E | Topical nystatin | This patient has a rash consistent with candidal intertrigo given the location and history of a damp, pruritic rash. The most appropriate next step in management is topical nystatin powder.
Intertrigo is caused by the Candida species and is characterized by pruritic, painful, and erythematous superficial patches surro... | Topical nystatin |
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... | Valacyclovir | Low dose acyclovir | TMP-SMX | Azithromycin | C | 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... | nan |
https://step2.medbullets.com/testview?qid=216588 | A 22-year-old man presents to the emergency department with difficulty breathing. He has experienced similar symptoms before. Today, he was hit in the face with a football, followed by significant swelling of his lips and tongue. The patient speaks with a muffled voice. His temperature is 98.1°F (36.7°C), blood pressur... | Diphenhydramine | Dexamethasone | Fresh frozen plasma | Epinephrine | C | Fresh frozen plasma | This patient is presenting with recurrent episodes of significant swelling of his lips and tongue with minor trauma, which are concerning for hereditary angioedema. Fresh frozen plasma is the most effective therapy for hereditary angioedema of the options listed.
Angioedema is a potentially life-threatening condition ... | nan |
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 ... | Left ventricular hypertrophy | Non-ST elevation myocardial infarction | ST elevation myocardial infarction | Torsades des pointes | A | 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... | Wolff Parkinson White syndrome |
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