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https://step2.medbullets.com/testview?qid=108992 | A 64-year-old man presents to the emergency room with a headache and nausea. He reports that he was rocking his grandson to sleep when the symptoms began. He states the pain is constant and is primarily located on his right side. When asked to indicate the area of pain, he says that it surrounds his eye and upper foreh... | Acetazolamide | Amitriptyline | Clopidogrel | Epinephrine | Verapamil | A | Acetazolamide | This patient is presenting with sudden-onset unilateral vision loss and an orbitofrontal headache with a dilated pupil and a hard ocular globe suggesting a diagnosis of acute angle-closure glaucoma. Long-term management of angle-closure glaucoma can include acetazolamide.
Examination of the eye in a patient with acute... |
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 | Purkinje fibers > AV node > ventricles > atria | 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... |
https://step2.medbullets.com/testview?qid=216239 | A 3-year-old girl is brought to the office for a routine well-child appointment. She was delivered preterm at 35 weeks, and her medical history is significant for several ear infections over the last year. Her older brother has been diagnosed with attention-deficit hyperactivity disorder (ADHD), but the rest of her fam... | Audiometry testing | Autism spectrum screening questionnaire | Parent and teacher ADHD rating scales | Refer to genetic testing | Speech and language assessment | A | Audiometry testing | This patient who presents with trouble following directions, inconsistent response to the physician's questions, and lack of progression in her language skills may have an acquired hearing impairment. The patient should undergo audiometry testing.
Hearing impairment in children can be genetic or acquired. In a patient... |
https://step2.medbullets.com/testview?qid=216589 | A 64-year-old man presents with nausea, vomiting, and weakness. He states that his wife made him come in when he fainted today while attempting to stand up. He otherwise states he has noticed some visual changes, including noting a yellow tint to objects. He has a history of heart failure with reduced ejection fraction... | Amiodarone | Digoxin | Diltiazem | Procainamide | Propranolol | B | Digoxin | This patient with a history of heart failure with reduced ejection fraction and atrial fibrillation is presenting with nausea, vomiting, visual changes, bradycardia, and premature ventricular complexes, which are concerning for digoxin toxicity. Note that digoxin can be given in patients with poor cardiac function and ... |
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 | Vancomycin and ceftriaxone | 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-... |
https://bit.ly/3GZtkBx | A 9-year-old girl presents to the emergency department with a fever and a change in her behavior. She presented with similar symptoms 6 weeks ago and was treated for an Escherchia coli infection. She also was treated for a urinary tract infection 10 weeks ago. Her mother says that last night her daughter felt ill, and ... | Gastroenteritis | Immunodeficiency | Intentional contamination | Meningitis | Urinary tract infection | C | Intentional contamination | This patient is presenting with repeat sepsis, which is uncommon in a pediatric patient with no significant medical history. This abnormal concentration of infections when the patient is with her mother suggests a diagnosis of intentional contamination.
Factitious disorder by proxy (formerly Munchausen syndrome) occur... |
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 | Lyme arthritis | Pseudogout | Rheumatoid arthritis | Septic arthritis | 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... |
https://step2.medbullets.com/testview?qid=216610 | A 44-year-old nurse presents to the emergency department with confusion. This has happened several times this past month with increasing frequency. Each time her symptoms improved with eating. She is otherwise healthy. She lives with her mother who has diabetes whose medications include metformin, insulin, lisinopril, ... | Alpha cell tumor | Beta cell destruction | Beta cell tumor | Insulin overdose | Sulfonylurea overdose | C | Beta cell tumor | This patient is presenting with confusion, profound hypoglycemia, an elevated C-peptide level, and a negative sulfonylurea level, which are concerning for an insulinoma. An insulinoma is a beta cell tumor that secretes insulin.
An insulinoma is a beta cell tumor of the pancreas. The beta cells normally secrete insulin... |
https://step2.medbullets.com/testview?qid=216616 | A 67-year-old man presents to the emergency department after fainting. He was outside tending to his lawn for several hours in the heat, when he stood up suddenly from pulling weeds and fainted. He denies any preceding symptoms and returned to baseline within 1 minute. The patient is not aware of any medical problems a... | Acute myocardial infarction | Hypokalemia | Intermittent torsades des pointes | Previous myocardial ischemia | Pulmonary embolism | D | Previous myocardial ischemia | This patient is presenting after syncope, likely secondary to dehydration and orthostatic hypotension given his outdoor gardening in the heat and symptoms when standing up rapidly. The patient’s ECG reveals deep, pathologic Q waves, which in this case are an incidental finding indicative of a previous myocardial infarc... |
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 | Focused abdominal sonography for trauma exam | 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... |
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... | Acanthocytes | Codocytes | Degmacytes | Schistocytes | Spherocytes | C | 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... |
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 | Stool culture | 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 ... |
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 | Menstrual irregularity | 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... |
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 | Renal cell carcinoma | 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... |
https://bit.ly/40qTdn2 | A 17-year-old boy presents to his primary care physician with a chief concern of "bad" skin that has not improved despite home remedies. The patient has had lesions on his face that have persisted since he was 13 years of age. He has a diet high in refined carbohydrates and has gained 20 pounds since starting high scho... | Continue current therapy for 1 more month | Dietary intervention | Isoretinoin | Oral antibiotics | Topical antibiotics | E | Topical antibiotics | This patient is presenting with persistent acne vulgaris that is refractory to topical benzoyl peroxide and retinoids. The next step in management is topical antibiotics.
Acne vulgaris is caused by blockage or outlet obstruction of the pilosebaceous unit. It presents with erythema, pustules, and comedones typically in... |
https://bit.ly/3QOJp1p | A 55-year-old woman is brought to the emergency department by her husband with a 1 hour history of an unremitting headache. The headache started suddenly while she was eating dinner and she says it feels like the “worst headache of my life.” An emergent CT scan of the head without contrast confirms the diagnosis, and a... | Addison disease | Cerebral salt wasting | Diuretic overuse | Primary polydipsia | Syndrome of inappropriate anti-diuretic hormone | B | Cerebral salt wasting | This patient presents with a subarachnoid hemorrhage (“worst headache of my life”) which is treated and then subsequently develops nausea, vomiting, and altered mental status with reduced serum sodium concentration, indicative of symptomatic hyponatremia. In the setting of serum hypo-osmolality, urine hyper-osmolality,... |
https://step2.medbullets.com/testview?qid=216264 | A 69-year-old man passes away after a 3-week hospitalization for liver failure, complicated by a myocardial infarction. A medical student rotating in the intensive care unit asked if she can practice performing intubations during her rotation. The resident suggests performing one on the deceased patient, as the student... | Ask the resident if the patient’s family or the patient has been consented for this procedure | Consult the hospital ethics committee | Contact the patient's family to ask for permission to perform the procedure | Intubate the patient with the resident's supervision | 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... |
https://step2.medbullets.com/testview?qid=216501 | A 26-year-old man presents to his primary care physician with a 6-month history of increasing lower back pain. He first felt the pain while lifting boxes at work but thought that he had just strained a muscle. The pain appears to be worse in the mornings and after rest. Exercise and physical activity appear to temporar... | Bone scan | Computed tomography | Magnetic resonance imaging | Radiograph | 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... |
https://bit.ly/3BV4U9Y | A 62-year-old man presents to the emergency department with chest pain and shortness of breath that he experienced while barbecuing. The pain is over his chest and in his left arm. The patient has a medical history of obesity, type 2 diabetes mellitus, and hypertension. His current medications include insulin, metformi... | Angiography | Aspirin | Ibuprofen | Prednisone | Stenting | B | Aspirin | This patient is presenting with chest pain several days after sustaining a myocardial infarction and has an ECG suggestive of pericarditis. This presentation is consistent with Dressler syndrome and the most appropriate initial step in management is aspirin.
Dressler syndrome is pericarditis that can occur after a myo... |
https://bit.ly/3BoKeXI | A 6-year-old boy presents to the emergency department after falling from his scooter. He has dull, aching pain along his left side where he hit the ground. He fell sideways off the scooter as he rounded a curve in the road. He has never had any serious injuries but that he always seems to bruise easily, especially afte... | Anti-platelet antibodies | Factor 8 deficiency | Factor 9 deficiency | GP1b deficiency | Von Willebrand factor deficiency | B | Factor 8 deficiency | This young patient presents with extensive bruising following an injury, a family history of blood disorder, and a prolonged partial thromboplastin time (PTT) with a normal prothrombin time (PT) and bleeding time. These findings suggest a diagnosis of hemophilia A caused by factor 8 deficiency.
Hemophilia is a deficie... |
https://bit.ly/3D10TBk | A 4-week-old boy is brought to the pediatrician by his parents for an initial evaluation. His parents are concerned that he is not feeding well and has lost weight over the last 2 weeks. He was born at home via spontaneous vaginal delivery at 37 weeks of gestation to a G1P1 mother. His mother did not receive prenatal c... | Avoiding fruit juice and sweetened foods | Changing to a soy based formula | Providing imiglucerase enzyme replacement | Removing phenylalanine from maternal diet during pregnancy | Vitamin B6 supplementation | B | Changing to a soy based formula | This patient who presents with failure to thrive, hepatosplenomegaly, and bilateral cataracts most likely has classic galactosemia. Patients with this disorder should avoid lactose-containing products by changing to a soy-based formula.
Classic galactosemia is an autosomal recessive defect in galactose-1-phosphate uri... |
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 | Urgent surgery | 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 ... |
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,... | Blood acetaminophen levels | Charcoal | Lactated ringer bolus | N-acetylcysteine | Syrup of ipecac | D | 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... |
https://bit.ly/46AmGNy | A 22-year-old woman presents to the emergency department with shortness of breath. She was hiking when she suddenly felt unable to breathe and had to take slow deep breaths to improve her symptoms. The patient is a Swedish foreign exchange student and does not speak any English. Her medical history and current medicati... | Decreased airway tone | Increased FEV1 | Increased FEV1/FVC | Increased FVC | Normal DLCO | E | Normal DLCO | This patient who presents with dyspnea and poor air movement bilaterally most likely has an acute asthma exacerbation. DLCO is the one parameter that is normal in these episodes.
Asthma is an obstructive lung disease that results in intermittent episodes of respiratory compromise. Asthma presents with shortness of bre... |
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 | Sumatriptan | 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... |
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... | Ceftriaxone | Loperamide | Magnesium | Norepinephrine | Normal saline | B | 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 ... |
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-... | Clozapine | Dextroamphetamine | Fluoxetine | Haloperidol | Methylphenidate | D | 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... |
https://step2.medbullets.com/testview?qid=108601 | A 38-year-old man presents to the emergency department with nasal congestion, blurry vision, and diplopia. His nasal congestion started about 1 week ago and he noticed the blurry vision this morning when he struggled to read the words on his television screen. His medical history is significant for IV drug use, HIV (CD... | Brain biopsy | Empiric treatment with pyrimethamine-sulfadiazine | Empiric treatment with dexamethasone | Lumbar puncture | Serology for anti-John Cunningham (JC) virus antibodies | B | Empiric treatment with pyrimethamine-sulfadiazine | This patient with a past medical history of immunosuppression due to HIV (CD4 < 100/mm^3), new focal neurologic findings, and ring-enhancing lesions on head MRI should be treated empirically with pyrimethamine-sulfadiazine for 10-14 days.
The differential diagnosis for ring-enhancing lesions in patients with HIV is de... |
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 | Surgical soft tissue release | 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... |
https://bit.ly/3OXaArd | A 56-year-old woman presents to the emergency department with muscle weakness. Her symptoms have progressively worsened over the course of 2 weeks and are most significant in her lower extremities. She also notices increased urinary frequency. Approximately 1 month ago, she was diagnosed with calcium phosphate nephroli... | Administer hydrochlorothiazide | Administer intravenous insulin | Administer intravenous sodium bicarbonate | Begin potassium replacement therapy with dextrose | Increase methotrexate dose | C | Administer intravenous sodium bicarbonate | This patient's non-anion gap metabolic acidosis, hypokalemia, alkaline urine, and history of a calcium phosphate kidney stone and rheumatoid arthritis are suggestive of type 1 (distal) renal tubular acidosis. The treatment of choice is alkali replacement (sodium bicarbonate).
Type 1 (distal) renal tubular acidosis res... |
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... | Counsel on positioning and thickening feeds | Initiate proton pump inhibitor | Obtain abdominal ultrasound | Provide reassurance | Switch to hydrolyzed formula | A | 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... |
https://bit.ly/3skGIMT | A 1-month-old girl presents to her pediatrician with her mother. The patient was born at 38 weeks gestation via Caesarean section for cervical incompetence. The patient’s mother has no complaints. The child had a runny nose and cough for a few days last week. The patient’s mother endorses decreased appetite during the ... | Decreased metabolism of bilirubin | Increased enterohepatic circulation of bilirubin | Increased production of bilirubin | Obstruction of the extrahepatic biliary tree | Obstruction of the intrahepatic biliary tree | D | Obstruction of the extrahepatic biliary tree | This 2-month-old patient presents with jaundice, dark urine, mild transaminitis, and conjugated hyperbilirubinemia, which suggests the diagnosis of biliary atresia. Biliary atresia is characterized by obstruction of the extrahepatic biliary tree.
Biliary atresia is a progressive, obliterative disease of the extrahepat... |
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 | Rifaximin | 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... |
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 | 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.... |
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 | Stool toxin 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... |
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 | 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 ... |
https://step2.medbullets.com/testview?qid=216419 | A 27-year-old nurse presents to the emergency department with a 30-minute history of palpitations and chest pain. She has been experiencing nausea, vomiting, and diarrhea after eating leftovers 2 days ago. Her husband tells the physician that he is concerned that the patient has been increasingly obsessed about her wei... | Arterial blood gas | Complete blood count | Serum glucose | Urine chloride | Urine toxicology | D | Urine chloride | This patient who presents with hypokalemia and metabolic alkalosis may either be vomiting or engaging in diuretic abuse. A urine chloride test can be used to distinguish between these possibilities because urine chloride will be high in diuretic abuse and will be low/normal in surreptitious vomiting.
Metabolic alkalos... |
https://bit.ly/3DIAhW0 | A 2-year-old boy is brought to the emergency room by his mother, who states that her son has been coughing uncontrollably for 3 hours. The child has a medical history of obesity and atopic dermatitis and uses topical steroid cream. His birth history is unremarkable. His family history is notable for asthma in his older... | Balloon catheter removal | Endoscopic removal | Ipecac administration | Observation | Surgical extraction | B | Endoscopic removal | This child presents with foreign body ingestion with a button battery seen in the esophagus on radiography. The most appropriate next step in management is urgent endoscopic removal of the battery.
Button batteries are commonly used in watches and small electronic devices. If these objects are ingested (usually by chi... |
https://bit.ly/3QdXJSe | A 45-year-old man presents to a physician due to difficulty swallowing and slurred speech. For the past 3 months, the patient has been coughing when he drinks liquids. His speech also sounds different according to his wife. The patient has no significant medical history. His temperature is 98.6°F (37.0°C), blood pressu... | Baclofen | Dextromethorphan and quinidine | Edaravone | Riluzole | Tizanidine | D | Riluzole | This patient with dysphagia (difficulty swallowing water), dysarthria (altered and slurred speech), lower motor neuron deficits (tongue fasciculations and weakness), upper motor neuron deficits (exaggerated jaw jerk reflex), and preserved sensory function most likely has amyotrophic lateral sclerosis (ALS). Riluzole, a... |
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 | 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 ... |
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 | Ultrasound of abdomen | 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... |
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 | Ventilation perfusion scan | 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... |
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 | Meiotic nondisjunction | 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... |
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... | Antithrombin III deficiency | Factor V Leiden | Liver failure | Nephrotic syndrome | Prothrombin gene mutation | D | 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... |
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 | Piperacillin-tazobactam | 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... |
https://step2.medbullets.com/testview?qid=215172 | A 43-year-old man presents to the emergency department with bright red blood in his stool this morning. He noticed this yesterday as well, but it was much scanter. The patient is otherwise healthy. He was celebrating his birthday last night and admits having "too much to drink" and vomited profusely overnight. He curre... | Erosion into a gastric vessel | Inflammation and infection of colonic outpouching | Malignancy | Submucosal esophageal tear | Vascular malformation | E | Vascular malformation | This patient is presenting with bright red blood per rectum with a non-tender abdomen. Of the answer choices given, angiodysplasia is the most likely to cause such profuse and sudden bleeding.
Angiodysplasia is a vascular malformation found in the gastrointestinal (GI) tract, most commonly in the colon. The exposed ve... |
https://bit.ly/45a5Zb7 | A 5-year-old girl presents to the emergency room due to difficulty walking. She has been complaining of pain in her right leg for the last few days. Her neighbor’s cat bit her last week and her parents attributed the pain to her healing bite. At the time of the bite, they cleaned the wound and irrigated it with sterile... | Amoxicillin and clavulanate | Ampicillin and sulbactam | Doxycycline | Flucanozole | Vancomycin | B | Ampicillin and sulbactam | This young girl with a recent history of a cat bite and difficulty walking most likely has likely Pasteurella multocida osteomyelitis. Empiric IV antibiotic therapy with ampicillin-sulbactam is the most appropriate initial management.
Pasteurella multocida is a gram-negative rod that is associated with cat and dog bit... |
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 | West syndrome | 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... |
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 | Switch to hydrolyzed formula | 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... |
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 | Supportive care with return precautions | 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).
... |
https://step2.medbullets.com/testview?qid=216473 | A 37-year-old woman presents to the emergency department in cardiac arrest. She was found to have altered mental status at home, and during transport to the hospital, she became pulseless. Cardiopulmonary resuscitation is ongoing and 2 intravenous lines are placed. The patient is obese, and her only medication is an or... | Cardiogenic shock | Hemorrhagic shock | Neurogenic shock | Obstructive shock | Septic shock | D | Obstructive shock | This obese patient on oral contraceptive pills with recent orthopedic surgery (Achilles tendon repair) is presenting in cardiac arrest. Given the bedside echocardiograph that is notable for a dilated and hypokinetic right ventricle with septal bowing into a hyperkinetic left ventricle, the most likely diagnosis is a pu... |
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 | Histrionic | 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 ... |
https://step2.medbullets.com/testview?qid=109261 | An 8-week-old boy presents with his mother to the pediatrician for a well visit. The patient has been breastfed since birth, and usually feeds for 30 minutes every 2-3 hours. The patient’s mother is concerned that her milk production is not keeping up with the patient’s nutritional requirements. She reports that about ... | Initiate proton pump inhibitor | Obtain abdominal ultrasound | Reassurance and counseling on positioning | Recommend modification of mother’s diet | Switch to hydrolyzed formula | C | Reassurance and counseling on positioning | This patient presents with regurgitation after feeding, appropriate appetite after episodes of regurgitation, and good weight gain, which suggests a diagnosis of uncomplicated gastroesophageal reflux. The most appropriate next step in management is reassurance and counseling on proper positioning.
Physiologic or uncom... |
https://step2.medbullets.com/testview?qid=216262 | A 28-year-old G1P0 woman presents to initiate prenatal care after a positive home pregnancy test. The first day of her last menstrual period was 7 weeks prior to presentation. The patient has no medical conditions and takes no medications. Her temperature is 98.6°F (37.0°C), blood pressure is 110/70 mmHg, pulse is 64/m... | Avoid exercise during pregnancy | Avoid soccer during pregnancy, continue other activities | Continue the current exercise regimen | Limit moderate exercise to a maximum of 30 minutes per day during pregnancy | Reduce to walking only, beginning in the third trimester | B | Avoid soccer during pregnancy, continue other activities | This healthy primigravida woman presents to the clinic inquiring about her current exercise regimen involving 285 minutes of moderate to exercise weekly. With the exception of soccer, a contact sport, her exercise regimen is appropriate throughout her pregnancy.
The American College of Obstetricians and Gynecologists ... |
https://bit.ly/3N80FxZ | 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 | 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... |
https://bit.ly/3nctYpc | A 46-year-old man presents with his wife to his primary care provider for depression and strange movements. His wife reports that her husband has not been himself for the last 2 months. Whereas he was previously outgoing and “the life of the party,” the patient is now irritable and withdrawn. He is a partner at an acco... | Alpha-synuclein aggregates on brain biopsy | Dorsal striatum atrophy on head CT | Frontotemporal atrophy on head CT | Neurofibrillary tangles on brain biopsy | Positive 14-3-3 CSF assay | B | Dorsal striatum atrophy on head CT | This patient presents with recent mood changes, jerky movements of the upper extremities, and a history of early death in his father, which suggests a diagnosis of Huntington disease. Huntington disease is characterized by atrophy of the caudate nucleus, which is a structure of the dorsal striatum.
Huntington disease ... |
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 | E | 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... |
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... | Cerebrovascular accident | Giant cell arteritis | Idiopathic intracranial hypertension | Meniere disease | Migraine | C | 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... |
https://step2.medbullets.com/testview?qid=216270 | A 52-year-old man presents to the emergency department by ambulance for evaluation of hematemesis. His wife states that he began vomiting bright red blood this evening while eating dinner, and has produced about 5 cups total. He has a history of alcohol use disorder and has vomited small streaks of blood in the past, b... | Balloon tamponade | Ceftriaxone | Nadolol | Octreotide | Platelet transfusion | D | Octreotide | This patient with a history of alcohol use disorder and signs of liver failure (jaundice, ascites, spider angiomas, and ecchymoses) presents with acute hematemesis and hypovolemic shock (hypotension, tachycardia, tachypnea) most concerning for a variceal hemorrhage. The first step in the resuscitation of patients with ... |
https://bit.ly/41Hqt8O | A 38-year-old woman presents to the emergency department with difficulty eating. Over the past week, she has had increasing difficulty chewing her food and progressive pain in the left side of her jaw. This morning, she was unable to close her mouth for several minutes after taking a bite of her breakfast. Two months a... | Amphotericin B | Clindamycin | Metronidazole | Penicillin | Trimethoprim-sulfamethoxazole | D | Penicillin | This patient presents with fever, trismus, and cutaneous drainage of sulfur granules in the setting of a recent dental procedure, which points to a diagnosis of cervicofacial actinomycosis. The most appropriate treatment for this disease is penicillin.
Actinomyces is a gram-positive, filamentous rod that causes a cerv... |
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... | Aortic dissection | Medullary thyroid cancer | Osteoarthritis | Thromboembolic stroke | Wilms tumor | D | 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, ... |
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 | Perform an echocardiogram | 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... |
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 | Phenylephrine | 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 ... |
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 | Thyroidectomy followed by radioactive iodine | 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... |
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 | Transverse myelitis | 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... |
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 | Reevaluation at the next well-child visit | 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... |
https://step2.medbullets.com/testview?qid=216509 | A 17-year-old boy presents to the emergency department after a car accident. He drove his car into a pole while speeding at night. He has no past medical history and takes no medications. The patient is unable to offer a history and repetitively asks the nurses what happened. He knows his name and address and is able t... | Cerebral contusion | Concussion | Diffuse axonal injury | Epidural hematoma | Subarachnoid hemorrhage | B | Concussion | This patient is presenting after a motor vehicle accident with confusion, repeated questioning, and a normal neurologic exam aside from his inability to remember the events that occurred. This constellation of symptoms is concerning for a concussion.
A concussion occurs after blunt trauma to the head and is common in ... |
https://step2.medbullets.com/testview?qid=109022 | A 47-year-old man presents to the emergency department with a headache. He suddenly developed a throbbing, bitemporal headache about 5 hours ago "out of nowhere." He has a history of migraine headaches, but he feels that this headache is significantly more painful than his typical migraines. The patient took his prescr... | Arachnoid mater and pia mater | Dura mater and arachnoid mater | Periosteum and galea aponeurosis | Periosteum and skull | Skull and dura mater | A | Arachnoid mater and pia mater | This patient presents with a sudden, severe headache and a head CT showing bleeding in the subarachnoid space, which confirms a diagnosis of subarachnoid hemorrhage. The bleeding in a subarachnoid hemorrhage occurs between the arachnoid and pia mater.
Subarachnoid hemorrhages present with a sudden, severe headache ref... |
https://step2.medbullets.com/testview?qid=108988 | An 82-year-old man with a history of atrial fibrillation presents to the emergency room complaining of sudden-onset, painless vision loss in his right eye starting 2 days ago. When it started, he felt like a “curtain was pulled down” over his right eye but wasn't able to seek care immediately because it was snowing out... | Administer ranibizumab | Administer tissue plasma activator | Continue aspirin and start statin therapy | Start retinal photocoagulation | Start timolol drops | C | Continue aspirin and start statin therapy | This patient with a history of atrial fibrillation is presenting with acute-onset, painless, monocular vision loss and a fundoscopic exam positive for retinal whitening. This suggests a diagnosis of central retinal artery occlusion and management should focus on control of underlying risk factors given that he is 2 day... |
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 | Paget disease of the breast | 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... |
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 biopsy | Perform liver mass resection | E | 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... |
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 | Tetanus, diphtheria, and influenza | 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.
... |
https://step2.medbullets.com/testview?qid=109242 | A 7-week-old boy presents to the pediatrician for vomiting. Three weeks ago, the patient began vomiting after meals. The vomitus appears to be normal stomach contents without streaks of red or green. His parents have already tried repositioning him during mealtimes and switching his formula to eliminate cow’s milk and ... | Abdominal ultrasound | Intravenous hydration | MRI of the head | Pyloromyotomy | Thickening feeds | B | Intravenous hydration | This patient presents with nonbilious, forceful vomiting, poor weight gain, signs of dehydration, and a history of exposure to azithromycin, which suggests a diagnosis of pyloric stenosis. The most appropriate next step in management is intravenous hydration.
Pyloric stenosis classically presents in a male infant betw... |
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 | Verapamil | 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... |
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 | Trimethoprim-sulfamethoxazole and zoster 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 <... |
https://step2.medbullets.com/testview?qid=217155 | A 55-year-old woman is brought to the emergency department by her husband with a 1 hour history of an unremitting headache. The headache started suddenly while she was eating dinner and she says it feels like the “worst headache of my life.” An emergent CT scan of the head without contrast confirms the diagnosis, and a... | Addison disease | Cerebral salt wasting | Diuretic overuse | Primary polydipsia | Syndrome of inappropriate anti-diuretic hormone | B | Cerebral salt wasting | This patient presents with a subarachnoid hemorrhage (“worst headache of my life”) which is treated and then subsequently develops nausea, vomiting, and altered mental status with reduced serum sodium concentration, indicative of symptomatic hyponatremia. In the setting of serum hypo-osmolality, urine hyper-osmolality,... |
https://step2.medbullets.com/testview?qid=216512 | A 23-year-old woman presents to labor and delivery at 40 weeks gestation with abdominal contractions and leakage of fluid from her vagina. She subsequently undergoes an uncomplicated vaginal delivery. The child is healthy and is heated, suctioned, and stimulated. While holding her newborn, the mother endorses a headach... | CT head | Labetalol | Magnesium | MRV head | Ondansetron and morphine | C | Magnesium | This postpartum patient is presenting with hypertension, headache, blurry vision, and abdominal pain, which are concerning for a diagnosis of preeclampsia. The most appropriate initial intervention is magnesium.
Preeclampsia classically presents after 20 weeks gestation (or earlier in the setting of a molar pregnancy)... |
https://step2.medbullets.com/testview?qid=216474 | A 57-year-old man is brought to the emergency department by his wife with confusion. He was seen in the emergency department 2 days ago for profuse epistaxis. His primary care provider was concerned and had advised him to go to the hospital, as the patient is on warfarin for atrial fibrillation. However, his bleeding r... | Clindamycin | Meropenem | Penicillin | Piperacillin-tazobactam | Vancomycin | A | Clindamycin | This patient is presenting with nasal packing, hypotension, tachycardia, a dark, purpuric rash, and confusion, which are concerning for toxic shock syndrome. The most important initial step in management is to administer clindamycin.
Toxic shock syndrome is a life-threatening diagnosis caused by Streptococcus pyogenes... |
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 | Posterior displacement of the femoral head | 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... |
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 ... | Arrhythmogenic right ventricular dysplasia | Brugada syndrome | Hypertrophic obstructive cardiomyopathy | QT prolongation | Wolff Parkinson White syndrome | A | 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 ... |
https://step2.medbullets.com/testview?qid=216248 | A 48-year-old woman, gravida 3 para 3, presents to the clinic with a 5-month history of intermittent loss of urine. Her urinary leaking occurs throughout the day and night, and she often has to get up to use the bathroom while asleep. Exercising does not affect the loss of urine. She states that she often cannot make i... | Genitourinary syndrome of menopause | Mixed urinary incontinence | Overflow incontinence | Stress incontinence | Urge incontinence | E | Urge incontinence | This patient with a sudden need to void followed by loss of urine with urgency (unable to make it to the bathroom in time) most likely has urinary urge incontinence.
Urge incontinence is a form of urinary incontinence characterized by a sudden urge to urinate, resulting in the involuntary leakage of urine. Normally, b... |
https://bit.ly/3Q3WlAi | A 51-year-old man presents for his annual wellness visit with his primary care physician. His wife has noticed a tremor while he is working on his car and knows that his father died of Parkinson disease. He says that the tremor is nothing to worry about and only occurs during a few activities such as pouring drinks, po... | Alcoholics anonymous | Aripiprazole | Carbidopa | Phenobarbital | Propranolol | E | Propranolol | This patient who presents with a tremor that only occurs during terminal activity and is likely improved by alcohol (hence why he drinks prior to working on the car) has benign essential tremor. This is best treated with propranolol.
Benign essential tremor is a type of rhythmic oscillatory movement that occurs with p... |
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 | Whipple disease | 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... |
https://bit.ly/48uDHdl | A 33-year-old woman presents to the emergency department with muscle spasms. She has noticed "twitching" in both her upper and lower extremities over the past 3 days that have interfered with her training for a marathon. She has felt more fatigued over the past month. She has no significant medical history. She takes n... | Hypocalcemia | Hypomagnesemia | Hyponatremia | Hypothyroidism | Hypovolemia | B | Hypomagnesemia | This patient is presenting with what appears to be anorexia nervosa (thin habitus, possible excessive exercise in the setting of marathon running, thinning hair, dry mucous membranes, decreased free T4 level, and multiple electrolyte derangements). The lack of improvement in either her muscle spasms with fluid repletio... |
https://bit.ly/3R0iH7u | A 70-year-old woman is brought to the emergency department by ambulance. She was found on the floor of her apartment after her neighbor called 911. She is confused and is unable to provide any history, but complains of generalized pain. Her temperature is 99.2°F (37.3°C), blood pressure is 129/64 mmHg, pulse is 63/min,... | Albuterol and IV fluid resuscitation | Calcium gluconate | Insulin, glucose, and IV fluid resuscitation | IV fluid resuscitation | Sodium polystyrene sulfonate | 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... |
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 | Thyroid hormone replacement | 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... |
https://bit.ly/47rczKM | A 72-year-old man presents to his primary care physician for a general checkup. The patient works as a farmer and has no concerns about his health. He has a medical history of hypertension and obesity. His current medications include lisinopril and metoprolol. His temperature is 99.5°F (37.5°C), blood pressure is 177/1... | Audible click heard at the cardiac apex | Femoral artery murmur | Murmur that radiates to the carotids during systole | Rumbling heard at the cardiac apex | Wedge pressure lower than expected | B | Femoral artery murmur | This patient is presenting with aortic regurgitation which could be associated with Duroziez sign (femoral artery murmur).
Aortic regurgitation occurs when the aortic valve closes improperly resulting in retrograde flow during diastole. This is auscultated as a diastolic murmur heard best over the left upper sternal b... |
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 | Syringomyelia | 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... |
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 | Uterine sarcoma | 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... |
https://step2.medbullets.com/testview?qid=216587 | A 77-year-old man presents to the emergency department acutely obtunded. The patient lives alone and was found unresponsive by his son. Generally, the patient manages his own finances, medications, and works part-time. He has not been responding to phone calls for the past 3 days. The patient is unable to offer a histo... | Free T4 level | Levothyroxine administration | Thyroid stimulating hormone and free T4 level | Thyroid stimulating hormone level | Triiodothyronine administration | B | Levothyroxine administration | This elderly patient with a past medical history of hypothyroidism is presenting with altered mental status, hypotension, hypothermia, and bradycardia, which are concerning for myxedema coma. Empiric and immediate treatment with levothyroxine is the appropriate management of this condition prior to confirming the diagn... |
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 | 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... |
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 | Viral pneumonia | 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... |
https://step2.medbullets.com/testview?qid=216637 | A 55-year-old man presents to the emergency department after fainting while moving furniture. He states that he has been working in a hot, humid attic all day and forgot his water bottle. He felt dizzy when standing up and then fainted and was unconscious for roughly 1 minute. He awoke at his neurologic baseline afterw... | Atrial fibrillation | Complete heart block | Myocardial infarction | Stroke | Torsades des pointes | B | Complete heart block | This patient is presenting with dizziness and syncope in the setting of likely dehydration (working in a hot/humid environment without water) and feels better after rehydration, suggesting a diagnosis of orthostatic hypotension. An ECG is performed and incidentally demonstrates a bifascicular block, which is at high ri... |
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 | Vancomycin and piperacillin-tazobactam | 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... |
https://bit.ly/3LeIdlx | A 54-year-old man is brought to the emergency department following a skiing accident. The patient lost control of his skis and collided with a tree. He lost consciousness for about 30 seconds. When he woke up, he was mildly confused but able to ski down the rest of the mountain. The patient initially denied medical tre... | Damage to the cerebral bridging veins | Damage to the sphenoid bone | Occlusion of cerebral small penetrating arteries | Ruptured cerebral aneurysm | Secondary hemorrhage into prior area of infarction | B | Damage to the sphenoid bone | This patient presents with a lucid interval followed by worsening somnolence and a biconvex lesion on head CT, which suggests a diagnosis of acute epidural hematoma. Acute epidural hematomas are most commonly caused by damage to the middle meningeal artery from trauma to the sphenoid bone.
Patients with an epidural he... |
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 | Pyloric stenosis | 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... |
https://bit.ly/47X4aiT | A 15-year-old girl is brought to the clinic because her mother is worried the patient has not yet had her period. The patient’s older sister had her first period at age 14. The mother had her first period at age 13. The patient reports she is doing well in school and is on the varsity basketball team. Her medical histo... | CYP17 gene work-up | Estrogen levels | Gonadotrophin-releasing hormone stimulation test | Karotype | Luteinizing hormone levels | D | Karotype | The patient is presenting with primary amenorrhea and an increased follicle-stimulating hormone (FSH) level, suggesting a gonadal abnormality and making karyotyping the most appropriate next step in management.
Primary amenorrhea can be diagnosed if a patient has normal secondary sex characteristics but no menarche by... |
https://bit.ly/46Ngn9O | A 36-year-old G3P2002 woman presents to her obstetrician’s office for her 1st prenatal visit at 10 weeks and 2 days gestation. She has felt nauseous the last several mornings and has been tired for a few weeks. The patient has had 2 uncomplicated spontaneous vaginal deliveries at full term with her last child born 6 ye... | Amniocentesis | Anatomy ultrasound | Chorionic villus sampling | Genetic testing of patient’s sister | Nuchal translucency test | C | Chorionic villus sampling | This patient is over 35 years of age and concerned about the risk of Down syndrome (trisomy 21) in her fetus at just over 10 weeks gestation. At this gestational age, the most definitive method for determining whether such an aneuploidy is present is chorionic villus sampling (CVS).
CVS, or sampling of the placental t... |
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 | Into the lateral ventricles | 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... |
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... | Automatically consult neurology for patients with concerning neurologic symptoms | Empirically scan patients with concerning neurologic symptoms | Improve resident education | Perform a root cause analysis of the process | Perform a systems-based approach implementation | D | 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 ... |
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