A 16-year-old boy comes to the emergency department for evaluation of severe abdominal pain.  The pain began suddenly on his right side approximately 6 hours ago and has radiated to the groin for the past 2 hours.  He has had 3 episodes of emesis since the onset of the discomfort but no diarrhea or fever.  A year ago, the patient experienced a similar episode that was accompanied by hematuria and self-resolved after a day.  Laboratory studies are as follows:

Urine pH is 6.1, specific gravity is 1.025, and many red blood cells are present.  Which of the following is the most likely cause of this patient’s symptoms?

A 36-year-old man comes to the office due to an itchy rash on the buttocks and thighs.  The patient has had these symptoms on and off over the last year and has tried over-the-counter hydrocortisone cream with little relief.  Two months ago, he was treated for urticaria with loratadine.  He has no chronic medical problems but occasionally takes antacids for heartburn and bismuth subsalicylate for abdominal cramps and diarrhea.  The patient has been sexually active with 2 female partners over the last year and has used condoms consistently.  He does not smoke cigarettes but smokes marijuana on weekends.  He emigrated from the Dominican Republic 10 years ago.  His older brother has psoriasis.  Temperature is 36.7 C (98 F), blood pressure is 134/83 mm Hg, and pulse is 78/min.  BMI is 23 kg/m².  Oropharyngeal examination is normal.  Cardiopulmonary auscultation reveals clear lung fields and normal heart sounds.  The abdomen is soft and nontender with no organomegaly.  No genital rash or inguinal lymphadenopathy is present.  On the buttocks and upper thighs there is a raised, erythematous, linear rash with excoriations.  Laboratory results are as follows:

HIV testing is negative.  Which of the following is the most likely diagnosis?

A 19-year-old woman comes to the office due to persistent abdominal pain, loose stools, and fatigue.  She has severe Crohn disease that has been unresponsive to treatment with corticosteroids and tumor necrosis factor blockers.  She does not use tobacco, alcohol, or illicit drugs.  The patient appears extremely concerned because her treatment is not having any effect on her condition.  Her Crohn Disease Activity Index score is 525.

Item 1 of 3

Based on the drug ad, which of the following is most limiting in applying the study intervention to this patient?

Item 2 of 3

According to the drug ad, patients who had a clinical response during the induction studies were randomized into VENELLAN 90 mg subQ every 8 weeks or placebo for the maintenance study.  All patients randomized in the maintenance study received a single induction dose of VENELLAN.  The primary endpoint in the maintenance study was clinical remission, defined as a Crohn Disease Activity Index score <150 at 52 weeks.  Based on the results of the maintenance study, which of the following approximates how much more likely patients who received VENELLAN treatment (90 mg every 8 weeks) are to achieve clinical remission compared to patients who received placebo?

Item 3 of 3

A group of physicians decide to conduct a study of VENELLAN in the clinical setting.  Patients with evidence of active Crohn disease (defined by C-reactive protein >3.0 mg/L; fecal calprotectin level >250 mg/kg; or endoscopic ulcerations in the ileum, colon, or both) are invited to participate in the study.  Participants are randomly allocated to receive either a single intravenous infusion of a weight range–based dose that approximates 6 mg/kg body weight of VENELLAN or placebo.  The physicians want to ensure that the study population is as similar as possible to the population on which the intervention is meant to be used, reflecting the normal range of disease severity, comorbidities, age, sex, and social and ethnic groups seen in routine clinical practice.  Which of the following best describes the study design that the physicians propose?

A 22-year-old college student comes to the university health center due to irregular menstrual periods.  Her last period was 3 months ago and she has missed several periods over the past 2 years.  Medical history is unremarkable and she takes no medications.  The patient describes cold intolerance and occasional constipation and dizziness.  She does well academically and expects to graduate from college this year.  She has dated in the past but does not currently have a partner.  The patient, who is visibly thin, says, “I am a runner and have always been like this.  I think I could lose a few more pounds to be at my ideal running weight.  I like to eat several small meals a day to control my weight.”  She does not use tobacco or illicit drugs.  She drinks alcoholic beverages occasionally.  Physical examination is normal apart from a thin appearance and fine facial hair.  The patient is 170 cm (5 ft 7 in) tall and weighs 46 kg (102 lb); BMI is 16 kg/m².  Temperature is 36.7 C (98 F), blood pressure is 95/60 mm Hg, and pulse is 56/min.

Item 1 of 2

Without treatment, this patient is at greatest risk for developing which of the following complications?

Item 2 of 2

The diagnosis of anorexia nervosa is made.  The physician explains the illness and the risk of medical complications.  In addition to nutritional rehabilitation to restore weight, which of the following is the most appropriate treatment for this patient?

Title:  Efficacy of warfarin sodium therapy for stroke prevention in atrial fibrillation, and the risk for bleeding complications in elderly patients.

Hypothesis:  Adjusted-dose warfarin may be superior to minidose warfarin and to warfarin plus aspirin for stroke prevention in elderly patients with atrial fibrillation.

Methods:

• Design:  Randomized, controlled trial.

• Participants:  677 outpatients with chronic atrial fibrillation age ≥60 (median age 74 years).

• Intervention:  Warfarin sodium, 1.25 mg/day (minidose warfarin group); warfarin sodium, 1.25 mg/day, plus aspirin, 300 mg/day (warfarin plus aspirin group); aspirin, 300 mg/day (aspirin group); and warfarin therapy with the dose adjusted to INR 2.0-3.0 (adjusted-dose warfarin group).

• Outcome measures:  Primary outcome was stroke or a systemic thromboembolic event within a year; secondary outcome was transient ischemic attack, acute myocardial infarction, or death within a year.

Results:  The following data were reported for the rate of primary adverse events within a year:

^*Chi-square test for difference between groups.

Of the 677 participants:

• Thromboembolic event within a year: documented 39 cases.

• Stroke within a year: 37 documented cases.

A 72-year-old man comes to the emergency department due to palpitations that began approximately 3 hours ago.  He has a history of hypertension, type 2 diabetes mellitus, and gastroesophageal reflux disease.  Temperature is 37.1 C (98.8 F), blood pressure is 106/60 mm Hg, pulse is 140/min, and respirations are 24/min.  Cardiac examination reveals tachycardia with an irregularly irregular tachycardic rhythm.  ECG demonstrates atrial fibrillation with rapid ventricular rate.  The patient is stabilized and admitted to the hospital.  Given his elevated CHA₂DS₂-VASc score, he is offered anticoagulation therapy.

Item 1 of 3

Based on the abstract, which anticoagulant therapy provides the greatest reduction in risk for a stroke or a systemic thromboembolic event for the patient?

Title:  Efficacy of warfarin sodium therapy for stroke prevention in atrial fibrillation, and the risk for bleeding complications in elderly patients.

Hypothesis:  Adjusted-dose warfarin may be superior to minidose warfarin and to warfarin plus aspirin for stroke prevention in elderly patients with atrial fibrillation.

Methods:

• Design:  Randomized, controlled trial.

• Participants:  677 outpatients with chronic atrial fibrillation age ≥60 (median age 74 years).

• Intervention:  Warfarin sodium, 1.25 mg/day (minidose warfarin group); warfarin sodium, 1.25 mg/day, plus aspirin, 300 mg/day (warfarin plus aspirin group); aspirin, 300 mg/day (aspirin group); and warfarin therapy with the dose adjusted to INR 2.0-3.0 (adjusted-dose warfarin group).

• Outcome measures:  Primary outcome was stroke or a systemic thromboembolic event within a year; secondary outcome was transient ischemic attack, acute myocardial infarction, or death within a year.

Results:  The following data were reported for the rate of primary adverse events within a year:

^*Chi-square test for difference between groups.

Of the 677 participants:

• Thromboembolic event within a year: documented 39 cases.

• Stroke within a year: 37 documented cases.

Item 2 of 3

Based on the abstract, which of the following is the most accurate statement about the study results?

Title:  Efficacy of warfarin sodium therapy for stroke prevention in atrial fibrillation, and the risk for bleeding complications in elderly patients.

Hypothesis:  Adjusted-dose warfarin may be superior to minidose warfarin and to warfarin plus aspirin for stroke prevention in elderly patients with atrial fibrillation.

Methods:

• Design:  Randomized, controlled trial.

• Participants:  677 outpatients with chronic atrial fibrillation age ≥60 (median age 74 years).

• Intervention:  Warfarin sodium, 1.25 mg/day (minidose warfarin group); warfarin sodium, 1.25 mg/day, plus aspirin, 300 mg/day (warfarin plus aspirin group); aspirin, 300 mg/day (aspirin group); and warfarin therapy with the dose adjusted to INR 2.0-3.0 (adjusted-dose warfarin group).

• Outcome measures:  Primary outcome was stroke or a systemic thromboembolic event within a year; secondary outcome was transient ischemic attack, acute myocardial infarction, or death within a year.

Results:  The following data were reported for the rate of primary adverse events within a year:

^*Chi-square test for difference between groups.

Of the 677 participants:

• Thromboembolic event within a year: documented 39 cases.

• Stroke within a year: 37 documented cases.

Item 3 of 3

The researchers of the trial decide to focus their attention on the effectiveness of the adjusted-dose warfarin therapy in preventing stroke or systemic thromboembolic events within a year compared with aspirin therapy.  They estimate the number needed to treat is 125.  Which of the following best describes these results?

A 32-year-old woman, gravida 1 para 0, at 16 weeks gestation comes to the office for an initial prenatal visit.  The patient has noted that for the past week her gums have bled when she brushes her teeth.  She has vomited daily since becoming pregnant and says that “the only things I don’t vomit are rice, crackers, and sports drinks.”  She has not had pelvic pain or vaginal bleeding.  The patient has no chronic medical conditions.  She underwent a tonsillectomy at age 15 with no complications.  She has had difficulty taking a daily prenatal vitamin due to the nausea.  The patient has not used tobacco, alcohol, or illicit drugs during the pregnancy.  Blood pressure is 110/70 mm Hg and pulse is 70/min.  BMI is 24 kg/m².  Fetal heart rate is 150/min by bedside Doppler ultrasound.  On physical examination, the gingivae appear erythematous and bleed after contact with a cotton applicator.  There are no areas of oral petechiae or ecchymoses.  Pelvic examination reveals a 16-week-sized uterus and no adnexal masses or tenderness.  Laboratory results are as follows:

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

A 7-year-old boy is brought to the clinic by his parents due to 6 days of fever, pharyngitis, and myalgias as well as a day of difficulty walking.  The patient began having a sore throat, body aches, and fevers as high as 39.4 C (103 F) last week.  He was kept home from school for 2 days.  For the last 3 days, his fever has decreased and he has started eating normally.  Urine output and bowel movements are normal.  His parents say, “This morning he started to walk strangely and was walking on his toes when he got out of bed.”  The child is otherwise healthy and fully immunized other than his annual influenza vaccination.  He lives with his parents and older brother.  The patient has no known sick contacts at home, but several children in his second-grade class were ill over the last week.  Temperature is 39.2 C (102.6 F).  Physical examination reveals tenderness over the calves bilaterally and weakness on dorsiflexion.  No redness, induration, or fluctuance is noted.  Knee and hip range of motion is normal.  The patient is asked to walk around the room, as shown in the exhibit.  The remainder of the physical examination is unremarkable.  Laboratory results show a creatine kinase level of 2,000 IU/L.  Urinalysis results are as follows:

Which of the following is the most likely diagnosis?

A 52-year-old woman comes to the office due to fatigue.  The patient says, “I had a mild cold and congestion about 2 weeks ago that improved by itself after a few days, but since then I have felt more tired than usual.  I am also urinating less than before, have nausea, and have lost my appetite.”  She has had no cough, dyspnea, abdominal pain, diarrhea, dysuria, or hematuria.  The patient has a history of obesity, hyperlipidemia, and type 2 diabetes mellitus.  She takes atorvastatin and metformin, and was initiated on lisinopril 6 months ago due to microalbuminuria.  The patient has also taken omeprazole daily for the past month due to dyspepsia.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 37.3 C (99.2 F), blood pressure is 140/70 mm Hg, pulse is 92/min, and respirations are 14/min.  BMI is 31.6 kg/m².  Mucous membranes are moist and there is no jugular venous distension, extremity edema, or skin rash.  The lungs are clear on auscultation and heart sounds are normal with no murmur, rubs, or gallops.  The abdomen is nondistended, soft, and nontender with normoactive bowel sounds.  There is no hepatosplenomegaly or abdominal bruit.  Laboratory results are as follows:

Serum creatinine was 0.8 mg/dL 6 months ago.  Renal ultrasonography reveals bilateral symmetric and normal-sized kidneys with no hydronephrosis.  Which of the following is the most likely cause of this patient’s current condition?

A 3-year-old boy is brought to the emergency department by his mother for hip pain that has worsened over the last week.  The mother states, “My son initially had occasional pain while playing and would point to his left hip, but now he limps and says that his right thigh hurts as well.”  She reports that he is usually very active but now only wants to lie down and watch television.  There is no known history of trauma, and the child has been well recently except for a runny nose that his mother attributes to allergies.  The patient’s 7-year-old sister had an upper respiratory illness last week, but no other family members have been sick.  Temperature is 37.8 C (100 F).  The patient is well-appearing and cooperative.  Cardiac and pulmonary examinations are unremarkable.  Testicular examination shows normal male external genitalia with the testes descended bilaterally.  When lying down on the examination table, the child keeps his left hip flexed and externally rotated.  He winces when his hips are internally rotated, and there is decreased range of motion on examination.  There is a small abrasion on the left shin but no bruising or petechiae.  The rest of the examination is unremarkable.

Item 1 of 3

Which of the following is the best next step in evaluation of this patient’s hip pain?

Item 2 of 3

Laboratory findings show a white blood cell count of 10,000/mm³ and a C-reactive protein of 1.5 mg/L.  Ultrasound of the left hip shows a small effusion.  Which of the following is the best next step in management of this patient’s condition?

Item 3 of 3

The mother is worried and would like to know the prognosis.  Which of the following statements would be the best response to this mother regarding her child’s condition?