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A 62-year-old male with a 40-year history of poorly controlled hypertension and Type 2 diabetes presents with fatigue, peripheral edema, and nocturia. His physical exam reveals bilateral lower extremity pitting edema. Lab results show a serum creatinine level of 3.5 mg/dL and a GFR of 22 mL/min/1.73 m². Urinalysis shows proteinuria. Which of the following is the most likely initial finding on a renal ultrasound? 

A 36-year-old female presents with a history of gradual onset of nervousness and fatigue. She has lost 15 pounds in the past year despite an increase in appetite.  She reports that she is not sleeping well, because she feels anxious all of the time. Her menses have become scant with frequent intermenstrual spotting, and she feels that she constantly prefers a cooler environment than those around her. On physical examination, she has a heart rate of 100/min with normal blood pressure, and a fine tremor of the fingers is noted. The skin is warm, moist, and has a smooth texture. The thyroid is diffusely enlarged to palpation. A lid-lag sign is easily demonstrable. Which of the following is a common complication of this disease?

A 30-year-old woman presents with episodes of dizziness. She is G1P1 and 8 hours postpartum. Her delivery was complicated by hemorrhage and she received multiple units of blood. She says that she is unable to feed her baby. Her vital signs are heart rate 95 bpm, blood pressure 100/62 mm Hg, respiratory rate 16 breaths/min, and temperature 98.6 °F (37 °C). Her physical examination findings are unremarkable. Laboratory tests show multiple low blood glucose readings during the last 18 hours. Her hemoglobin is 11.0 g/dL, hematocrit 35%, WBC count 5000/μL, platelets 275,000/μL, sodium 130 mEq/L, potassium 4.5 mEq/L , creatinine 0.8 mg/dL, and blood glucose level 60 mg/dL. What is the underlying pathophysiology of this patient’s disorder?

A 63-year-old man undergoes uncomplicated laparascopic cholecystectomy for acute cholecystitis and is admitted to the surgical ward for postoperative management. On postoperative day 1, routine laboratory studies reveal an increase in serum creatinine to 1.46 mg/dL from 0.98 mg/dL before the operation; BUN is 37 mg/dL, increased from 18 mg/dL on prior measurement; K is 4.8 mEq/L and CO2 is 19 mEq/L. The patient has an indwelling urinary catheter in place, draining minimal urine over the last few hours. After ruling out urinary catheter obstruction, which of the following is the most appropriate next step in management?

A 21-year-old woman presents with urinary frequency. Her BMI is 41. A urinalysis is positive for glucose. Her random blood sugar is 257 mg/dL, hemoglobin A1c is 8.5%, and C-peptide is 1.5 ng/mL. She is diagnosed with type 2 diabetes; diet and exercise are recommended.What is the drug of choice for managing her diabetes?

A 64-year-old female with PMH of hyperthyroidism presents to her primary care physician with new-onset palpitations. The patient states that she has intermittent palpitations, and she is worried about heart disease. She is currently asymptomatic and reports no chest pain or shortness of breath. An EKG is obtained (see image below). Vital signs reveal a T 98.6° F, BP 134/88 mm Hg, HR 108 beats/min, and RR 12/min. The pulse is noted to be irregularly irregular.  Based on this information, which of the following conditions is the most likely diagnosis for this patient? 

A 19-year-old man presents with itching, burning, tender lesions on his left index finger that started about 12 hours ago. He says nothing changed other than he has been sleeping less as he prepares for his final exams. An over-the-counter steroid cream reduces the itching, but the area remains unchanged and the itching always returns. He averages 3 drinks on weekends, does not smoke, does not use illicit substances, and does not take any prescription medications or supplements. His medical history reveals an episode of fever, pharyngitis, and gingivostomatitis with vesicular lesions when he was 12 to the extent that it interfered with his ability to eat and drink; history is otherwise unremarkable. Family history is also unremarkable. Vitals are within normal limits. On exam, you observe clusters of raised vesicles on an erythematous base, covering the medial side of his left index fingertip. The area is not fluctuant but is tender to palpation. Considering the most likely etiology, dormant infection of what tissue enables recurrent disease?

A 72-year-old man with a history of poorly controlled HTN and previous myocardial infarction presents with a nocturnal cough, bilateral ankle swelling, and dyspnea on exertion. He denies any fever, chills, URI symptoms, chest pain, headache, N/V, diaphoresis, or syncope. He further denies smoking, alcohol, or drug use. Physical exam reveals bipedal edema and bibasilar crackles. A chest X-ray is remarkable for enlargement of the cardiac silhouette and interstitial   infiltrates, while EKG analysis indicates deep S waves in lead V1 and tall R waves in lead V5. What is the most appropriate next step in the evaluation and management of this patient?

A 56-year-old man presents with a 1-week history of palpitations and shortness of breath. He has a longstanding history of poorly controlled hypertension. Physical examination reveals an elevated blood pressure of 190/98 mm Hg, elevated jugular venous pressure, mild hepatomegaly, bilateral pedal edema, and rales at the lung bases. Echocardiogram reveals concentric left ventricular hypertrophy without significant valvular abnormalities. What drug is beneficial in the treatment of the patient’s condition by causing afterload and preload reduction?

A 70-year-old woman with a history of hypertension, hyperlipidemia, and myocardial infarction presents with a 3-day history of shortness of breath at rest. She has found it difficult to walk short distances due to shortness of breath and is experiencing orthopnea and nocturnal dyspnea. She denies cough, fever, chills, nausea, abdominal pain, vomiting, diarrhea, or rashes. Upon physical examination, the patient is short of breath, requiring numerous pauses during conversation. General assessment reveals the patient is tachycardic and diaphoretic  Cool extremities. Heart exam reveals a diminished first heart sound, S3 gallop, and laterally displaced PMI. Lung exam reveals dullness to percussion, bibasilar rales, and expiratory wheezing. 2+ pitting edema of the lower extremities to the level of the mid-calf.  There is no JVD noted. What intervention will provide the greatest symptomatic relief to this patient?