A 51-year-old woman is evaluated in hospital. She takes a daily multivitamin. Her mom had a history of osteoporosis. Vitals are normal. Serum studies are shown.

Chloride                                         104 mEq/L
Bicarbonate                                 20 mEq/L
Sodium                                            135 mEq/L

Which of the following is the most likely explanation for this patient’s findings?

A) Aspirin toxicity
B) Diabetic ketoacidosis
C) Lactic acidosis
D) Renal insufficiency
E) Renal tubular acidosis

A 42-year-old man is evaluated in hospital.

Which of the following is most likely to be seen in this patient?

A) Antibodies against post-synaptic nicotinic receptors
B) Hepatic vein thrombosis
C) Hypothyroid state
D) Increased serum sodium
E) Reactive arthritis

A 49-year-old woman comes to the physician for a 2-month history of gradually worsening left hip pain. She has a history of dermatomyositis managed with prednisone. Physical examination shows duskiness of the eyelids bilaterally, violaceous papules on the knuckles, and rough-surfaced hands. Vitals are normal.

Which of the following is most likely to be seen in this patient?

A) Necrosis
B) Osteomalacia
C) Osteoporosis
D) Synovitis
E) Vasculitis

A 31-year-old woman comes to the physician for a 3-day history of mildly productive cough and fever. Physical examination shows a right lower lobe consolidation with dullness to percussion. She has lymphadenopathy of the head and neck. A peripheral smear is shown.

Which of the following is the most likely explanation for these findings?

A) Chronic lymphocytic leukemia
B) Chronic myelogenous leukemia
C) Cyanocobalamin deficiency
D) Jarisch-Herxheimer reaction
E) Leukemoid reaction

A 2-year-old boy is brought to the physician by his mother for a 3-day history of worsening redness on his left hand. She cannot recall any specific trauma or incident that precipitated the lesion. Physical examination demonstrates erythema and desquamation along the dorsomedial aspect of the right hand. Temperature is 99.5 F. Which of the following is the most appropriate initial pharmacotherapy?

A) Amoxicillin
B) Ceftriaxone
C) Flucloxacillin
D) Gentamicin
E) Vancomycin

A 39-year-old woman comes to the physician for a 1-week history of nosebleeding. She has no past medical history. Laboratory studies show:

Hemoglobin                                                                           11 g/dL
Leukocytes                                                                             5,000/μL
Platelets                                                                                   40,000/μL
Prothrombin time                                                              12 seconds
Partial thromboplastin time                                         27 seconds
Bleeding time                                                                        9 minutes

Which of the following is the next best step in management?

A) Cryoprecipitate
B) Fresh frozen plasma
C) Desmopressin therapy
D) Oral iron therapy
E) Prednisone therapy

A 64-year-old man comes to the physician for a 5-month history of progressively worsening fatigue and shortness of breath with exertion. He has a background of dyslipidemia and hypertension but takes no medications. He does not have diabetes. He is a non-smoker. Blood pressure is 150/90. Auscultation of the chest shows mild bibasilar crackles. A chest x-ray shows cephalization of the pulmonary vessels. Echocardiogram shows mild left-ventricular concentric hypertrophy with reduced ejection fraction and left atrial dilatation. Which of the following is the most appropriate next step in pharmacologic management?

A) Bisoprolol
B) Digoxin
C) Hydralazine and isosorbide dinitrate
D) Lisinopril
E) Spironolactone

A 54-year-old man comes to the physician for a 6-month history of progressively worsening shortness of breath on exertion. Around 6 months ago, he began feeling extra “winded” while doing errands and walking around a local mall. The past few months, he feels fatigued walking up two flights of stairs in his house. There is no chest pain. He has no symptoms at rest. He takes no medications. He has been smoking one-half pack of cigarettes daily for 36 years. His HbA1c is 5.6%. Blood pressure is 128/75. An baseline ECG shows no abnormalities. A resting echocardiogram shows an ejection fraction of 55%. Which of the following is the next best step in management?

A) Ambulatory ECG monitor
B) Carotid duplex ultrasonography
C) Exercise ECG stress test
D) Exercise echo stress test
E) Measure serum troponins

A 54-year-old man comes to the physician for a 3-week history of persistent productive cough, foul-smelling sputum, low-grade fever, and fatigue. For the past 2 days, he now reports night sweats and some sharp chest pain. Past medical history is otherwise unremarkable apart from on-and-off heavy drinking. A chest x-ray and CT are performed.

What is the most appropriate next step in management?

A) Bronchoscopy with transbronchial biopsy
B) CT-guided percutaneous drainage
C) Intravenous clindamycin therapy
D) Lobectomy
E) Sputum cytology for malignant cells

A 72-year-old man comes to the physician due to persistent dull pain in his right pelvis that has worsened over the past 6 months. He says the discomfort is present at rest and not related to physical activity. He denies recent trauma but reports that his hat size has increased over the past year. His medical history is notable for hypertension and hyperlipidemia, and he takes lisinopril and atorvastatin. On examination, there is mild bony enlargement and tenderness over the right pelvic region, and his hearing appears diminished during conversation. A CT of the head is shown.

Which of the following is the next best step in management?

A) Administer zoledronate
B) Check serum alkaline phosphatase levels
C) IV 0.9% NaCl
D) Scintigraphic bone assay
E) Skeletal survey