DES C_Management (13) Prepared : CHILLY

A toddler is brought to the emergency department with burns on both of his buttocks. The areas are moist, have blisters, and are exquisitely painful to touch. The parents explain that the child accidentally pulled a pot of boiling water over himself. Which of the following is the most important step in management?

Referral to the proper authorities for suspected child abuse

Prompt administration of fluid resuscitation

Education of the parents on accident prevention

Early excision and grafting of the burned areas

Application of mafenide acetate to the burned areas

A very worried 25-year-old woman comes to the office, presents a positive pregnancy test, and says, "I'm six weeks pregnant. Two months ago, I received the rubella vaccine and my doctor told me to avoid getting pregnant for the next three months. I'm very concerned about the health of my unborn baby. I'd like to know all the available options to prevent any harm to my baby." What is the most appropriate next step in the management of this patient?

A victim of blunt abdominal trauma has splenic and liver lacerations as well as an unstable pelvic fracture. He is hypotensive and tachycardic with a heart rate of 150 despite receiving 2 L of crystalloid en route to the hospital. He was intubated prior to arrival due to declining mental status. He is taken emergently to the operating room for exploratory laparotomy and external fixation of his pelvic fracture. Which of the following is the best resuscitative strategy?

Infusion of packed red blood cells followed by fresh-frozen plasma and platelets as indicated by the PT and platelet counts on laboratory values

Infusion of packed red blood cells and early administration of fresh-frozen plasma and platelets prior to return of laboratory values

Infusion of another liter of crystalloid

Infusion of 500 mL of 5% albumin

Infusion of packed red blood cells and vitamin K

A well-appearing, 3200-g (7-lb, 1-oz) black infant is noted to have fifth finger (postaxial) polydactyly. The extra digit has no skeletal duplications and is attached to the rest of the hand by a threadlike soft tissue pedicle (see photograph). Appropriate treatment for this condition includes which of the following?

Chromosomal analysis Excision of extra digit Skeletal survey for other skeletal abnormalities Echocardiogram Renal ultrasound

A woman brings her 15-year-old daughter to her pediatrician for concerns about hair growth. The child has always had a lot of body hair and has been shaving her legs since she was 12 years old. The mother reports that her daughter has recently been noticing more hair, especially along the upper lip and on the chest and abdomen. The child is clearly distressed about her appearance. Further questioning reveals that although the girl had her first menses at 11 years old, her menstrual cycles are irregular, and she sometimes skips cycles for months at a time. Physical examination reveals a young, heavy-set, olive-skinned teenager with moderate acne and dark hair growth along her upper lip, across her chest, and over her lower abdomen. She exercises regularly. Which of the following is the most appropriate treatment for this child’s hirsutism?

A woman brings her 3-year-old son to the emergency room after witnessing him swallow a disk-shaped battery. She adds that he vomited once on the way to the hospital. The vomitus was non-bloody and did not contain the battery. Physical examination of the child's chest is unremarkable. Plain radiographs reveal that the battery is located in the esophagus. What is the most appropriate next step in the management of this patient?

Increase gastrointestinal motility with metoclopramide

Advance the battery into the stomach with a nasogastric tube

Observation for next 24-48 hours for spontaneous expulsion

Immediate endoscopic removal

Induce emesis to expel the battery

A woman is found to have a unilateral invasive vulvar carcinoma that is 2 cm in diameter but not associated with evidence of lymph node spread. Initial management should consist of which of the following?

A worried and anxious pregnant mother brings her 3-year-old son to the emergency room after he experienced several episodes of vomiting and abdominal pain for the past two hours. His vomit is coffee ground in appearance. He is irritable and lethargic. His BP is 80/40 mmHg and pulse rate is 120/min. Examination shows a normal oropharynx; chest auscultation is within normal limits. Abdomen is soft and mildly tender at the epigastrium; there is no hepatosplenomegaly. Extremities are cold to touch. Initial laboratory studies show: Hemoglobin 10.3 g/L, Leukocyte count 14, 500/mm3, Bicarbonate 18 mEq/L. Chest x-ray is normal limits. Abdominal imaging shows radiopaque tablets in the stomach. Intravenous normal saline is started. Which of the following is the most appropriate next step in management?

A young man has recently been bitten by a stray dog. He has a penetrating wound to the right forearm. The dog is nowhere to be found. In the emergency room, the wound is cleaned with water and povidone-iodine solution. Which of the following is the most appropriate next step in management?

Treat with oral doxycycline

Start IV acyclovir

Treat with IV ceftriaxone

Contact the local public health professional for further advice

Start postexposure prophylaxis

A young man is shot in the upper part of the neck with a .22 caliber revolver. Inspection of the entrance and exit wounds indicates that the trajectory of the bullet is all above die level of the angle of the mandible, but below the skull. He is fully conscious and neurologically intact. A steady trickle of blood flows from both wounds, and it does not seem to respond to local pressure. He is hemodynamically stable. Which of the following is the most appropriate next step in diagnosis?

A young man is shot with a .45 caliber revolver, point blank in the lower abdomen, just above the pubis. The entrance wound is at the midline, and there is no exit wound. X-ray films show the bullet embedded in the sacral promontory, to the right of the midline. Digital rectal examination and proctoscopic examination are negative, but he has gross hematuria. He is hemodynamically stable. Which of the following is the most appropriate next step in management?

A young man sustains a gunshot wound to the base of his neck. He was shot point blank with a .38 caliber revolver. The entrance wound is above the left clavicle, below the level of the cricoid cartilage, and just lateral to the sternomastoid muscle. The exit wound is just above the spinous process of the right scapula. He has normal breath sounds on both sides, is awake and alert, is talking with a normal tone of voice, is neurologically intact, and is hemodynamically stable. Portable x-ray films of the neck and chest taken in the emergency department show some air in the tissues of the lower neck, but are otherwise non-diagnostic. Which of the following is the most appropriate next step in management?

Immediate surgical exploration of the upper chest through a median sternotomy

Immediate surgical exploration of the lower neck through a collar incision

Angiogram, esophagogram, esophagoscopy, and bronchoscopy prior to surgical exploration

CT scan of the lower neck and upper chest

Observation for several hours

A young mother claims that her 4-week-old child sleeps best on his stomach. You tell her that the safest sleep position for infants is which of the following?

A young motorcycle driver is thrown against a concrete bridge abutment and sustains severe trauma about the face, with marked periorbital edema and ecchymosis as well as epistaxis. He is obtunded with rapid, shallow breathing. Which of the following is the next appropriate step in his workup and management?

Emergency tracheostomy

Emergency cricothyroidotomy

Oropharyngeal intubation with cervical in-line stabilization

Blind nasopharyngeal intubation with cervical in-line stabilization

Evaluation of the cervical spine

A23-year-old woman with no PMH presents to the office for her annual gynecologic examination. She has never been pregnant. She has had five lifetime partners. She does not have vaginal discharge, vaginal pruritus, or dyspareunia. Her menstruation is regular every 28 days and lasts for 5 days. BP, 125/75 mm Hg; P, 78 beats/min; R, 16 breaths/min; T, 98.4°F. In addition to the Pap smear, what else is indicated?

After 10 days of nasal congestion and rhinorrhea, a 3-month-old infant develops a severe hacking cough during which he repeatedly turns dusky and appears to choke on or to vomit profuse thick, clear nasopharyngeal mucus. For 7 days, the coughing continues unabated. On physical examination, he is afebrile and his lungs are clear. His chest x-ray is normal. His WBC count is 24,000/mm3, with 15% polymorphonuclear cells, 82% lymphocytes, and 3% monocytes. Which of the following antibiotics should be used to treat this patient?

After a weekend drinking binge, a 45-year-old man presents to the hospital with abdominal pain, nausea, and vomiting. On physical examination, the patient is noted to have tenderness to palpation in the epigastrium. Laboratory tests reveal an amylase of 25,000 U/dL (normal < 180U/dL). The patient is medically managed and sent home after 1 week. A CT scan done 4 weeks later is pictured here. Currently the patient is asymptomatic. Which of the following is the most appropriate initial management of this patient?

After being injured by a bull on his mother’s farm, a young man is placed in a cast for a supracondylar fracture of his humerus. A few hours later he begins to experience intense pain, swelling, and weakness in the ipsilateral hand. Pulses are normal in bilateral upper extremities. Which of the following is the most appropriate initial management of this patient?

After complete removal of a sessile polyp of 2.0 cm by 1.5 cm found 1 finger length above the anal mucocutaneous margin, the pathologist reports it to have been a villous adenoma that contained carcinoma in situ. Which of the following is the most appropriate next step in management?

External radiation therapy to the rectum

No further therapy

Abdominoperineal rectosigmoid resection

Anterior resection of the rectum

Reexcision of the biopsy site with wider margins

After her first urinary tract infection, a 1-year-old has a voiding cystourethrogram with findings shown below. Which of the following is the most appropriate treatment option?

After making a diagnosis in the patient in question 319, you recommended that she wear loose clothing and cotton underwear and to stop using tampons. After 1 month she returns, reporting that her symptoms of intense burning and pain with intercourse have not improved. Which of the following treatment options is the best next step in treating this patient’s problem?

After suitable calculations have been made using the modified Parkland formula, a 70-kg man with extensive third-degree burns is receiving Ringer's lactate at the calculated rate, which happens to be 750 mL/hr. The infusion was started within 30 minutes of the time when the burn occurred. Over the next 3 hours, his urinary output is recorded as 15 mL, 22 mL, and 18 mL. It is verified that the Foley catheter is open and draining freely. The urine is dark yellow, without blood, and has a specific gravity of 1040 and a sodium concentration of 10mEq/L. The patient's blood pressure is 100/70 mm Hg, his pulse is 98/min, and his central venous pressure is 2 cm H2O. On the basis of these findings, which of the following is the most appropriate next step in management?

The rate of fluid administration should be increased

Treatment is needed for renal failure

The rate of fluid administration should be decreased

Fluid administration should continue at the present rate

Diuretics should be given

An 11-month-old African American boy has a hematocrit of 24% on a screening laboratory done at his well-child checkup. Further testing demonstrates: hemoglobin 7.8 g/dL; hematocrit 22.9%; leukocyte count 12,200/μL with 39% neutrophils, 6% bands, 55% lymphocytes; hypochromia on smear; free erythrocyte protoporphyrin (FEP) 114 μg/dL; lead level 6 μg/dL whole blood; platelet count 175,000/μL; reticulocyte count 0.2%; sickle-cell preparation negative; stool guaiac-negative; and mean corpuscular volume (MCV) 64 fL. Which of the following is the most appropriate recommendation?

An 11-year-old boy presents with fever and sore throat. A rapid-strep test confirms streptococcal pharyngitis. He is leaving for a summer camp in 2 days. In the past, he has had problem finishing the whole course of antibiotic treatment. Which of the following is the best treatment for his streptococcal pharyngitis?

Erythromycin orally for 5 days

Penicillin V orally for 5 days

A single dose of procaine penicillin G intramuscularly

A single dose of ceftriaxone intramuscularly

A single dose of benzathine penicillin G intramuscularly

An 11-year-old girl is brought to the office by her mother due to headaches for the last 4 hours. The headaches are bifrontal, and are accompanied by nausea, vomiting, and sensitivity to light and noise. It is her second episode, and both episodes were preceded by dark spots in her visual field. The first episode was 2 weeks ago. She doesn't report any numbness or tingling in her extremities, and no behavioral change or decline in school performance was noted. Her vital signs are stable, and she is afebrile. The physical examination is normal. What is the most appropriate next step in the management of this patient?

An 11-year-old girl presents to your office because of a family history of medullary carcinoma of the thyroid. Physical examination is normal. Which of the following tests should you perform?

An 18-month-old boy has received 5 days of amoxicillin for otitis media. He continues to have fever, and on physical examination, the right tympanic membrane is bulging with purulent fluid behind it. Which of the following is the best antibiotic to use?

An 18-year-old college student, who has recently become sexually active, is seen for severe primary dysmenorrhea. She does not want to get pregnant, and has failed to obtain resolution with heating pads and mild analgesics. Which of the following medications is most appropriate for this patient?

An 18-year-old consults you for evaluation of disabling pain with her menstrual periods. The pain has been present since menarche and is accompanied by nausea and headache. History is otherwise unremarkable, and pelvic examination is normal. You diagnose primary dysmenorrhea and recommend initial treatment with which of the following?

An 18-year-old G1 has asymptomatic bacteriuria (ASB) at her first prenatal visit at 15 weeks gestation. Which of the following statements is true?

Fifteen percent of women develop a urinary tract infection after an initial negative urine culture

There is a decreased incidence of ASB in women with sickle cell trait

The prevalence of ASB during pregnancy may be as great as 30%

ASB is highly associated with adverse pregnancy outcomes

Twenty-five percent of women with ASB subsequently develop an acute symptomatic urinary infection during the same pregnancy and should be treated with antibiotics

An 18-year-old G2P1 presents to the emergency department with abdominal pain and vaginal bleeding for the past day. Her last menstrual period was 7 weeks ago. On examination she is afebrile with normal blood pressure and pulse. Her abdomen is tender in the left lower quadrant with voluntary guarding. On pelvic examination, she has a small anteverted uterus, no adnexal masses, mild left adnexal tenderness, and mild cervical motion tenderness. Labs reveal a normal white count, hemoglobin of 10.5, and a quantitative β-hCG of 2342. Ultrasound reveals a 10×5×6 cm uterus with a normal-appearing 1-cm stripe and no gestation sac or fetal pole. A 2.8-cm complex adnexal mass is noted on the left. In the treatment of this patient, laparoscopic salpingostomy has what advantage over salpingectomy via laparotomy?

An 18-year-old high school football player is kicked in the left flank. Three hours later he develops hematuria. His vital signs are stable. A CT scan demonstrates a grade II renal injury based on the Urologic Injury Scale of the American Association for the Surgery of Trauma. Which of the following is the most appropriate treatment for this patient?

Strict bed rest with serial hemoglobin levels

Exploration and wedge resection of the left kidney

Nephrostomy

Resumption of normal daily activity excluding sports

Exploration and suture of the laceration

An 18-year-old high school senior develops peripheral vision abnormalities. A CT scan of the brain reveals a cystic suprasellar mass with some calcification noted. Clinically, this is compatible with a craniopharyngioma. What is the best next step in treatment?

Surgical resection

Radiotherapy

Transsphenoidal decompression of the optic nerve and optic chiasm

Growth hormone therapy

Cerebral angiography with tumor embolization

An 18-year-old man climbs up a utility pole to retrieve his younger brother’s kite. An electrical spark jumps from the wire to his metal belt buckle and burns hisabdominal wall, knocking him to the ground. Which of the following should guide your treatment of this patient?

Cardiac conduction abnormalities are unlikely

Evaluation for fracture of the other extremities and visceral injury is indicated

Electric burns often result in a transient traumatic optic neuropathy

Intravenous fluid replacement is based on the percentage of body surface area burned

Injuries are generally more superficial than those from thermal burns

An 18-year-old man was assaulted and sustained significant head and facial trauma. Which of the following is the most common initial manifestation of increased intracranial pressure?

An 18-year-old previously healthy man is placed on intravenous heparin after having a pulmonary embolism (PE) after exploratory laparotomy for a small-bowel injury following a motor vehicle collision. Five days later, his platelet count is 90,000/μL and continues to fall over the next several days. The patient’s serum is positive for antibodies to the heparin-platelet factor complexes. Which of the following is the most appropriate next step management?

Cessation of heparin and transfusion with platelets

Cessation of heparin and institution of lepirudin

Cessation of heparin and institution of low-molecular-weight heparin

Cessation of heparin and immediate institution of high-dose warfarin therapy

Cessation of all anticoagulation therapy

An 18-year-old woman comes to the physician for advice regarding birth control. She has been sexually active since the age of 15 and has had numerous sexual partners since that time. She has tried the oral contraceptive pill twice, for approximately two cycles each time, but stopped because of irregular bleeding. She has had gonorrhea once and Chlamydia twice. She does not smoke. Physical examination is unremarkable. Which of the following forms of birth control should be recommended for this patient?

An 18-year-old woman comes to the physician for her annual physical examination. Her past medical history is unremarkable and she takes no medications. Her last menstrual period was 2 weeks ago, and she has regular menses lasting 4-5 days every 28 days. The patient became sexually active at age 16 and has had 3 partners since then. She is currently in a monogamous relationship with her boyfriend of a year and uses condoms regularly. The patient has no vaginal discharge, urinary complaints, or weight changes. Vital signs and general physical examination are within normal limits. She inquires about cervical cancer screening and human papillomavirus vaccine, which she has not received. What is the most appropriate next step in management of this patient?

Test for HPV and, if negative, give vaccine

Perform Pap smear with HPV testing

Give human papillomavirus (HPV) vaccine now

Perform Pap smear now

Reassurance and follow-up next year

An 18-year-old woman presents to the clinic because of 6 hours of severe abdominal pain, nausea, and vomiting. She describes 6 days of mild lower abdominal pain, low-grade fever, and abnormal vaginal discharge. She is sexually active with two male partners, and her last menstrual period was 10 days ago. Her temperature is 39.5C (103.2F), blood pressure is 100/60 mm Hg, heart rate is 110/min, and respiratory rate is 18/min. Physical examination reveals involuntary abdominal guarding. The patient will not allow a pelvic examination. Which of the following is the most appropriate management?

Hospitalization with oral antibiotics and intravenous hydration

Hospitalization for intravenous hydration without antibiotics

Hospitalization for intravenous antibiotics and hydration

Discharge home with oral antibiotics

Discharge home without antibiotics

An 18-year-old woman presents to the ED complaining of acute onset of RLQ abdominal pain. She also describes the loss of appetite over the last 12 hours, but denies nausea and vomiting. Her BP is 124/77 mm Hg, HR is 110 beats per minute, temperature is 102.1°F, RR is 16 breaths per minute, and oxygen saturation is 100% on room air. Abdominal examination reveals lower abdominal tenderness bilaterally. On pelvic examination you elicit cervical motion tenderness and note cervical exudates. Her WBC is 20,500/μL and β-hCG is negative. Which of the following is the most appropriate next step in management?

Bring her to the OR for immediate laparoscopy

Order an abdominal plain film

Bring her to the OR for an appendectomy

Begin antibiotic therapy

Perform a culdocentesis

An 18-year-old woman presents to the physician's office complaining of vaginal pruritus and discharge. She has no nausea, vomiting, or abdominal pain. She has had 2 sexual partners in the past six months and takes oral contraceptive pills. She has no other medical problems and takes no other medications. She has no known drug allergies. Her temperature is 37.2 C (98.9 F) and blood pressure is 120/72 mm Hg. Pelvic examination reveals mucopurulent cervical discharge and friable cervical mucosa. The remainder of the physical examination is unremarkable. A gram stain of the discharge reveals numerous polymorphonuclear leukocytes filled with gram-negative diplococci. What is the most appropriate next step in management?

An 18-year-old young man comes to your clinic with complaints of fatigue, malaise, fever, and sore throat for the past few days. His temperature is 38.8°C (101°F), pulse is 90/min, respirations are 18/min, and blood pressure is 135/70 mm Hg. Physical examination reveals cervical lymphadenopathy, pharyngeal hyperemia, and splenomegaly. Complete blood count shows leukocytosis with predominant atypical lymphocytes. The heterophile antibody test is positive. When you ask if he has any questions, he replies with, "Well, I'm a rugby player in school, so I need to know when I can start playing again." What is the most appropriate advice for this patient?

He can start playing whenever he wants

He can start playing when his physical examination is normal

He can start playing when his labs normalize

He can start playing when he becomes afebrile

He can start playing when he is no longer fatigued

An 8-month-old boy is seen by a pediatrician for the first time. The physician notes that there are no testes in the scrotum. Which of the following is the optimal management of bilateral undescended testicles in an infant?

Chorionic gonadotropin therapy for 1 month; operative placement into the scrotum before age 2 if descent has not occurred

Observation until age 5; if no descent by then, plastic surgical scrotal prostheses before the child enters school

No therapy; reassurance of the parent that full masculinization and normal spermatogenesis are likely even if the testicle does not fully descend

Immediate surgical placement into the scrotum

Observation until age 2; operative placement into the scrotum if descent has not occurred

An 8-month-old girl is brought to the clinic for a well-baby checkup. Her antenatal and birth histories are unremarkable. Her vital signs are stable, and all developmental milestones are appropriate. On examination, a head tilt is noted. Ophthalmoscopic examination reveals a red reflex and normal corneal light reflex. The cover test reveals moderate esodeviation of the left eye. What is the most appropriate next step in the management of this patient?

Measurement of intraocular pressure

Watchful waiting

Continuous covering of the deviated eye

Prompt surgical correction

Continuous covering of the normal eye

An 8-month-old infant arrives to the emergency department (ED) with a 2-day history of diarrhea and poor fluid intake. Your quick examination reveals a lethargic child; his heart rate is 180 beats per minute, his respiratory rate is 30 breaths per minute, and his blood pressure is low for age. He has poor skin turgor, 5-second capillary refill, and cool extremities. Which of the following fluids is most appropriate management for his condition?

An 8-month-old infant, who is up-to-date with his immunizations, is brought to the clinic by his mother. The mother states that she overheard other mothers talking about a varicella vaccination that their children have received. She does not want her son to have the chickenpox virus and therefore, wants him to receive the vaccine today. The physician explains that the infant has not yet reached the recommended age for the vaccine. If this visit is in November, when is the earliest that this patient can return for the varicella vaccine?

An 8-week-old female infant is brought to the office by her Caucasian mother for a well-baby examination. She was born at 34 weeks gestation, and weighed 2.9kg (6.5 Ib) at birth. She has been exclusively breastfed since birth, and her growth and development are normal for her age. The physical examination is normal, except for mild pallor. At this time, what is the most appropriate nutritional intervention for this patient?

An 8-year-old African American boy is brought in for evaluation of a mass on the scalp. On examination, he is afebrile and nontoxic. There is a boggy mass on his scalp with alopecia. His posterior cervical lymph nodes are enlarged but nontender. Which of the following is the most appropriate treatment?

Oral griseofulvin and selenium sulfide shampoo twice weekly

Selenium sulfide shampoo twice a week

Incision and drainage

Oral amoxicillin

IV naficillin

An 8-year-old boy is brought to your office with the complaint of abdominal pain. The pain is worse during the week and seems to be less prominent during the weekends and during the summer. The patient’s growth and development are normal. The physical examination is unremarkable. Laboratory screening, including stool for occult blood, CBC, urinalysis, and chemistry panel, yields normal results. Which of the following is the best next step in the care of this patient?

Observe the patient and reassure the patient and family

Recommend a lactose-free diet

Perform an upper GI series

Administer a trial of H2 blockers

Perform CT of the abdomen

An 8-year-old boy presents to your office for a second opinion. He has a 2-year history of intermittent vomiting, dysphagia, and epigastric pain. His father reports he occasionally gets food “stuck” in his throat. He has been on a proton pump inhibitor for 18 months without symptom relief. His past history is significant only for eczema and a peanut allergy. Endoscopy was performed 6 months ago; no erosive lesions were noted and a biopsy was not performed. You arrange for a repeat endoscopy with biopsy. Microscopy on the biopsy sample reveals many eosinophils. Treatment of this condition should include which of the following?

An 8-year-old girl is brought to the emergency department with fever for the past 6 days. Her parents report that she has been very "cranky" and has developed a new rash. Six weeks ago, she completed a 10-day course of amoxicillin for streptococcal(103°Fpharyngitis.Shehasnoothermedicalproblemsandtakesnomedications.Hertemperatureis39.4°C ), blood pressure is 110/60 mm Hg, pulse is 120/min, and respirations are 24/min. Physical examination shows injected lips and pharynx. Bilateral conjunctivae are also injected, with no exudates. A 1.7-cm mobile lymph node is palpated on the left neck. A blanching erythematous rash is present across her face, trunk, and extremities, including the palms and soles. Her mouth is shown below. What is the most appropriate next step in management of this patient?

An 8-year-old girl presents with well-controlled, moderately persistent asthma. Her therapies consist of occasional use of short-acting β-agonists, daily inhaled steroids, and a leukotriene inhibitor. She presents with white patches on her buccal mucosa. You recommend which of the following?

Rinse her mouth after use of her inhaled medications

Measurement of serum immunoglobulins

HIV testing

Tuberculosis skin testing

Discontinuation of all her asthma medications

An 8-year-old male presents to the emergency department with decreased mental status. His mother states that she has noticed he has been drinking and urinating more frequently over the past several weeks. He was hard to wake up this morning and complained of abdominal pain. Physical examination reveals an afebrile drowsy male with clear airways and mild tachycardia. Mucous membranes are dry and his lips are cracked. His abdomen is mildly tender to palpation diffusely, but there is no rebound or guarding. Laboratory evaluation reveals a glucose of 560 mg/dL and potassium of 5.9 mEq/L.An arterial blood gas analysis reveals a pH of 7.18. A urinalysis is positive for ketones and glucose. CT scan of the abdomen is normal. A chest x-ray film is clear. Two hours after initiation of treatment the physician adds potassium to the patient's IV fluids. Which of the following best explains this therapeutic decision?

Potassium should not have been added to the IV fluids

Hyperkalemia will protect the patient against dysrhythmias

Hyperglycemia causes potassium to shift to the extracellular space

Acidosis causes extracellular depletion of potassium

Hypokalemia will result as acidosis is corrected

An 80-year-old man is admitted to the hospital complaining of nausea, abdominal pain, distention, and diarrhea. A cautiously performed transanal contrast study reveals an apple-core configuration in the rectosigmoid area. Which of the following is the most appropriate next step in his management?

Evaluation of an electrocardiogram and obtaining an angiogram to evaluate for colonic mesenteric ischemia

Oral administration of metronidazole and checking a Clostridium difficile titer

Colon resection and proximal colostomy

Saline enemas and digital disimpaction of fecal matter from the rectum

Colonoscopic decompression and rectal tube placement

An 80-year-old man with advanced prostate cancer and bony metastasis is complaining of severe back pain that has been progressively worsening for the past two weeks. His pain is so severe that it restricts him from playing golf. Eight months ago, he underwent orchiectomy, after which he was free from bone pain until now. Physical examination reveals tenderness at two sites in the lumbar region. Radionuclide bone scan shows an increased uptake in these areas. Which of the following is the most appropriate next step in the management of this patient?

An 80-year-old woman was admitted to your service for dizziness. Cardiac monitoring initially revealed atrial fibrillation with rapid ventricular response. Her ventricular rate was controlled with beta-blocker. An echocardiogram revealed an enlarged left atrium and an ejection fraction of 50%. No evidence of diastolic heart dysfunction was noted. She is now asymptomatic, with blood pressure 130/80 mmHg, heart rhythm irregularly irregular, and heart rate around 80/minute. Which of the following is the best management strategy of this patient’s arrhythmia?

Electrical cardioversion plus prolonged anticoagulation

Continued rate control plus prolonged anticoagulation

Chemical cardioversion without anticoagulation

Chemical cardioversion plus prolonged anticoagulation

Electrical cardioversion without anticoagulation

An 81-year-old woman presents to your office complaining that her uterus fell out 2 months ago. She has multiple medical problems, including chronic hypertension, congestive heart failure, and osteoporosis. She is limited to sitting in a wheelchair because of her health problems. Her fallen uterus causes significant pain. On physical examination, the patient is frail and requires assistance with getting on the examination table. She has complete procidentia of the uterus. Which of the following is the most appropriate next step in the management of this patient?

An 82-year-old man develops severe abdominal distention, nausea, vomiting, and colicky abdominal pain. He has not passed any gas or stools for the past 12 hours. His vital signs are normal, and his pulse is regular. He has a distended, tympanitic abdomen, with hyperactive, highpitched bowel sounds. There are no signs of peritoneal irritation. Rectal examination is negative for masses or occult blood, and trie rectal vault is empty. Abdominal xray films show distended loops of small and large bowel, as well as a very large round gas shadow that is located in the right upper quadrant and tapers toward the left lower quadrant in the shape of a parrot's beak. The patient has never had any abdominal surgery, and he does not have any palpable hernias. Which of the following is the most appropriate next step in management?

Proctosigmoidoscopy

Emergency exploratory laparotomy

Emergency celiac and mesenteric arteriogram

Nasogastric suction, IV fluids, and observation

Repeated enemas and laxatives

An 82-year-old woman is brought to the ED by her daughter for worsening fatigue, dizziness, and light-headedness. The patient denies chest pain or shortness of breath. She has not started any new medications. Her BP is 140/70 mmHg, HR is 37 beats per minute, and RR is 15 breaths per minute. An IV is started and blood is drawn. An ECG is seen below. Which of the following is the most appropriate next step in management?

Administer aspirin, order a set of cardiac enzymes, and admit to the cardiac care unit (CCU)

Bed rest for the next 48 hours and follow-up with her primary-care physician

Place on a cardiac monitor, place external pacing pads on the patient, and admit to the CCU

Admit for Holter monitoring and echocardiogram

Place a magnet on her chest to turn off her pacemaker

An 83-year-old woman is being evaluated for confusion. She was admitted 3 days ago after having an acute MI. Her hospital course has been complicated by narrow-complex ventricular tachycardia, which has finally been stabilized on an antiarrhythmic medication. She was also started on a post-MI protocol and an antidepressant. One day after beginning these medications, she begins to develop confusion and slurred speech. Her temperature is 36.7°C (98.1°F), blood pressure is 138/60 mmHg, pulse is 88/min, and respiratory rate is 14/min. She is alert and oriented to person, but she does not realize she is in the hospital. Additionally, she exhibits difficulty with word articulation, although she speaks fluently, and she demonstrates a mild resting tremor. The remainder of her examination is normal. Which of the following medications is most likely to cause these central nervous system effects?

An 83-year-old woman presents to a mammographic facility for a screening mammogram. The technician notices a mass in the lateral right breast. The patient denies any breast pain, nipple discharge, skin changes, or breast trauma. A right breast CC view is shown in Figure 6-7. Which of the following is the most appropriate next step in management?

An 85-year-old male is placed on mechanical ventilation after a complicated elective hernia repair. After five days of endotracheal intubation with mechanical ventilation, the ratio of the rate of carbon dioxide produced to the rate of oxygen uptake is 1.05. What is the best explanation for these findings?

An 85-year-old man presents to the emergency room with an acute onset of midepigastric pain, nausea, vomiting, and hiccups starting 2 days ago. He is unable to keep any food down. Past history is pertinent for a long-standing hiatal hernia, hypertension, and diet-controlled diabetes. Examination reveals vital signs of pulse rate 82/min, BP 100/52 mmHg, respiratory rate 16/min, and temperature 97.2°F. The patient is in no acute distress, but has epigastric tenderness without guarding. Laboratory analysis revealed a hematocrit of 46 and a normal white blood cell (WBC) count. A chest x-ray is shown in Figure 6-5a. A fluoroscopically guided NG tube was placed using contrast, and his stomach was decompressed. After adequate fluid and electrolyte resuscitation, an upper gastrointestinal (UGI) contrast study was obtained and is shown in 6-5b. Which of the following is the most appropriate next step in management?

Endotracheal intubation and initiation of ventilatory support

Upper endoscopy

Thoracotomy or thoracoscopy and operative repair

Continued NG tube decompression and initiation of total parenteral nutrition (TPN)

Laparotomy or laparoscopy and operative repair

An 86-year-old woman presents to your office for her well-woman examination. She has no complaints. On pelvic examination performed in the supine and upright positions, the patient has second-degree prolapse of the uterus. Which of the following is the best next step in the management of this patient?

An 88-year-old man with a history of end-stage renal failure, severe coronary artery disease, and brain metastases from lung cancer presents with acute cholecystitis. His family wants “everything done.” Which of the following is the best management option in this patient?

Lithotripsy followed by long-term bile acid therapy

Laparoscopic cholecystectomy

Tube cholecystostomy

Open cholecystectomy

Intravenous antibiotics followed by elective cholecystectomy

An 89-year-old man has lost 30 lb over the past 2 years. He reports that food frequently sticks when he swallows. He also complains of a chronic cough. Barium swallow is shown here. What is the best treatment option for this patient?

Excision of the diverticulum and cricopharyngeal myotomy

Excision of the diverticulum and administration of a promotility agent

Placement of an esophageal stent

Diverticuloplasty

Excision of the diverticulum

An active 78-year-old female with history of hypertension presents with the new onset of left hemiparesis. Cardiac monitoring reveals atrial fibrillation. She had been in sinus rhythm on check-up 3 months earlier. Optimal management at discharge includes a review of antihypertensive therapy, a ventricular rate control agent, and which of the following?

Antiplatelet therapy plus warfarin with a target INR of 1.5

Warfarin with a target INR of 2.0 to 3.0

Immediate direct-current cardioversion

Automated implanted cardioverter-defibrillator (AICD)/permanent pacemaker to avoid the need for anticoagulation

Antiplatelet therapy such as aspirin, without warfarin

An agitated and nervous 24-year-old woman has had severe wheezing and shortness of breath for 2 days. After receiving oxygen, steroids, and salbutamol (Ventolin) in the emergency room, her breathing improves. She is still wheezing and now feels tremulous and anxious with a pulse of 110/min and respirations 30/min. Arterial blood gases on oxygen reveal a pH of 7.40, PO2 340 mm Hg, PCO2 40 mm Hg, and bicarbonate of 24 mEq/L. She is hospitalized for further treatment. Which of the following treatments or medications should be avoided in her?

An anxious 33-year-old woman, gravida 3, para 1, abortus 1, is seen for her first prenatal visit at 10 weeks’ gestation by dates. This was a planned pregnancy, and she discontinued the transdermal contraceptive patch 4 months ago. She is taking prenatal vitamins, including iron and folic acid. First trimester bleeding that progressed to hemorrhage complicated her first pregnancy, necessitating a suction dilatation and curettage at 8 weeks’ gestation. Her last pregnancy was uncomplicated prenatally. She went into spontaneous labor at 39 weeks’ gestation, progressing normally in labor with a reassuring electronic fetal heart rate monitor pattern. However, after an uncomplicated spontaneous vaginal delivery with neonatal Apgar scores of 8 and 9 at 1 and 5 minutes, respectively, her female neonate died on the second day of life from overwhelming group B -hemolytic streptococcal (GBS) infection. Which of the following statements best expresses what you will tell her about her current pregnancy?

Rapid nonculture assay tests are highly sensitive for the GBS organism

The GBS organism is a pathologic bacterium in the female genital tract

Appropriate treatment for a positive GBS vaginal culture can eradicate the organism

A negative vaginal GBS culture means the fetus will not be at risk at delivery

Most women with a positive vaginal GBS culture will have uninfected infants

An elderly woman with osteoporosis falls on her outstretched hand. She comes in with a deformed and painful wrist that looks like a dinner fork. X-ray films show a dorsally displaced, dorsally angulated fracture of the distal radius. There is also an associated fracture of the ulnar styloid. A neurologic examination is normal. Which of the following is the most appropriate management?

An exploratory laparotomy for multiple intra-abdominal injuries has lasted 3 and a half hours. Multiple blood transfusions have been given, and several liters of Ringer's lactate have been infused. When the surgeons are ready to close the abdomen, they find that the abdominal wall edges cannot be pulled together without undue tension. Both the belly wall and the abdominal contents seem to be swollen. Which of the following is the most appropriate management in this situation?

Approximate the skin only, using towel clips

Provide temporary bowel coverage with an absorbable mesh

Leave the abdomen and its contents open to the air

Give diuretics and close the abdomen in the usual way

Close the abdomen with heavy retention sutures

An imaging study detects a 3.5 cm abdominal aortic aneurysm in a 60-year-old male. He has no associated symptoms. His past medical history is significant for hypertension, type 2 diabetes, hypercholesterolemia and hypothyroidism. His medications include aspirin, metformin, glipizide, hydrochlorothiazide, lisinopril, low dose atorvastatin and levothyroxine. He has smoked 1-2 packs of cigarettes daily for the past 40 years, and he drinks 1-2 glasses of wine daily. On physical examination, his blood pressure is 160/90 mmHg and his pulse is 80/min. Heart sounds are normal and his lungs are clear. Laboratory studies show: Serum creatinine 1.7 mg/dL, Low density lipoprotein (LDL) 150 mg/dL, HbA1C 8.5%, Serum TSH 3.0. Which of the following interventions would most reduce the likelihood of his aortic aneurysm enlarging?

An in-hospital workup of a 78-year-old hypertensive, mildly asthmatic man who is receiving chemotherapy for colon cancer reveals symptomatic gallstones. Preoperative laboratory results are notable for a hematocrit of 24% and urinalysis with 18 to 25 WBCs and gram-negative bacteria. On call to the operating room, the patient receives intravenous penicillin. His abdomen is shaved in the operating room. An open cholecystectomy is performed and, despite a lack of indications, the common bile duct is explored. The wound is closed primarily with a Penrose drain exiting a separate stab wound. On postoperative day 3, the patient develops a wound infection. Which of the following changes in the care of this patient could have decreased the chance of a postoperative wound infection?

Using a closed drainage system brought out through the operative incision

Continuing the prophylactic antibiotics for 3 postoperative days

Treating the urinary infection prior to surgery

Increasing the length of the preoperative hospital stay to prophylactically treat the asthma with steroids

Shaving the abdomen the night prior to surgery

An infant born at term to a 22-year-old woman has a weak cry and is cyanotic at birth. His fingertips and oral mucosa appear blue. His blood pressure is 80/40 mmHg and his heart rate is 140/min. Chest x-ray shows clear lung fields bilaterally. PaO2 measured by arterial cannulation is 38 mmHg, and improves only minimally on 100% inspired oxygen. Which of the following is the best next step in managing this patient?

An infant is born with a defect in the anterior abdominal cavity. Upon examination there are abdominal contents (small bowel and liver) protruding directly through the umbilical ring. Which of the following should be considered in the management of this condition?

Enteral feeds for nutritional support should be initiated early prior to operative management

Topical antimicrobial solutions should be administered prophylactically

Broad-spectrum intravenous antibiotics should be administered prophylactically

A Silastic silo should be placed with immediate reduction of the viscera into the abdominal cavity

No further workup is indicated prior to closure of the abdominal wall defect

An infant is delivered vaginally to a 30-year-old G1P1 woman whose pregnancy was uneventful. Examination of the newborn reveals mild atrophy of the left calf. His left calcaneum and talus are in equinus and varus positions, his midfoot is in varus position, and his forefoot is in adduction. Dorsiflexion and plantar flexion of the ankle are limited. The neurologic examination is normal. What is the next best step in the management of this patient?

Casting of the whole leg up to the hip

Reassurance

Surgical correction within the first month of life

Stretching, manipulation, followed by serial casting

Watchful waiting

An infant weighing 1400 g (3 lb) is born at 32 weeks’ gestation. Initial evaluation was benign, and the infant was transferred to the level 2 nursery for prematurity. The nurse there calls at 1 hour of life and reports the infant is tachypneic. Vital signs include a heart rate of 140 beats per minute, a respiratory rate of 80 breaths per minute, a temperature of 35°C (95°F), and a peripheral oxygen saturation of 98%. The lungs are clear with bilateral breath sounds and there is no murmur; the infant is in no dis- tress. The child’s chest radiograph is shown. Which of the following is the most appropriate next step in evaluating the infant?

Place the infant under a warmer

Administer supplemental oxygen

Perform a lumbar puncture

Administer intravenously 5cc of D50W

Obtain a complete blood count and differential

An infertile couple presents to you for evaluation. A semen analysis from the husband is ordered. The sample of 2.5 cc contains 25 million sperm per mL; 65% of the sperm show normal morphology; 20% of the sperm show progressive forward mobility. You should tell the couple which of the following?

The sample is abnormal owing to a low percentage of forwardly mobile sperm

The sample is abnormal because of an inadequate number of sperm per milliliter

The sample is abnormal because the percentage of sperm with normal morphology is too low

The sample is normal and should not be a factor in the couple’s infertility

The sample is normal, but of no clinical value because of the low sample volume

An inner city family has been using a neighbor to care for their 3-year-old child while the parents work. The neighbor is diagnosed with pulmonary tuberculosis. PPD test of the 3-year-old is negative. Which of the following is indicated for the 3-year-old?

An intrauterine pregnancy of approximately 10 weeks gestation is confirmed in a 30-year-old G5P4 woman with an IUD in place. The patient expresses a strong desire for the pregnancy to be continued. On examination, the string of the IUD is noted to be protruding from the cervical os. Which of the following is the most appropriate course of action?

Perform a laparoscopy to rule out a heterotopic ectopic pregnancy

Terminate the pregnancy because of the high risk of infection

Remove the IUD immediately

Leave the IUD in place and continue prophylactic antibiotics throughout pregnancy

Leave the IUD in place without any other treatment

An obese 56-year-old female presents to her physician concerned that her asthma is worsening. She describes night-time cough and wheezing that have been increasing over recent months. She also reports feeling tired each morning because she works late hours and has no time to relax after dinner. On review of systems, the patient denies dyspnea on exertion, but acknowledges that her throat has been sore lately. Her past medical history is significant for bronchial asthma, type2 diabetes and hypertension. Her medications include an albuterol inhaler which she uses occasionally, lisinopril and aspirin. Her vital signs are within normal limits, and there are no abnormalities on physical exam. Which of the following is the most appropriate next step in the management of this patient?

An obese patient with a long-standing history of type 2 DM presents to his primary care physician. On examination he has decreased sensation in both lower extremities. Upon questioning of his compliance with his prescribed medications, he reports that he has stopped taking one medication because it gave him flatulence and abdominal pain. Which of the following did this man most likely stop taking?

An otherwise asymptomatic 65-year-old man with diabetes presents to the ER with a sports-related right shoulder injury. His heart rate is noted to be irregular, and this ECG is obtained. Which of the following is the best immediate therapy?

An otherwise healthy 24-year-old man presents in the emergency department with very severe pain of recent onset in his right scrotum. The pain is constant and began about 3 hours prior to his arrival. Physical examination shows a temperature of 39.4C (103F) but is otherwise unremarkable, except for the scrotal area. The testis on the affected side is in the normal position; however, it appears to be swollen and is exquisitely tender to palpation. The cord above the testis is equally painful and tender. Urinalysis shows pyuria. Which of the following is the most appropriate next step in management?

Emergency surgery and bilateral orchiopexy

Trans-scrotal biopsy and appropriate resection

Scrotal sonogram and antibiotics

Cystoscopy and bladder irrigation

Antiviral medication started within the hour

An otherwise healthy 40-year-old woman sees you because of recurrent abdominal pain. In the past month she has had four episodes of colicky epigastric pain. Each of these episodes has lasted about 30 minutes and has occurred within an hour of eating. Two of the episodes have been associated with sweating and vomiting. None of the episodes have been associated with fever or shortness of breath. She has not lost weight. She does not drink alcohol or take any prescription or over-the-counter medications. Other than three previous uneventful vaginal deliveries, she has never been hospitalized. Her examination is negative except for mild obesity (BMI = 32). A complete blood count and multichannel chemistry profile that includes liver function test is normal. A gallbladder sonogram reveals multiple gallstones. What is the next best step in the treatment of this patient?

An otherwise healthy 5-year-old boy is brought to the emergency department of a small hospital because of a simple 3-cm laceration in his forehead. The patient is crying and frightened. The practitioner decides to perform conscious sedation before suturing the laceration. Support personnel and equipment are available for monitoring the patient's vital status and carrying out resuscitation measures if needed. Which of the following is the most appropriate pharmacologic agent to achieve a safe level of conscious sedation in this situation?

Concomitant analgesic-sedative agents and muscle relaxants

Intravenous propofol

Intravenous ketamine

Oral or rectal midazolam or diazepam

Concomitant opioid and benzodiazepine administration

An upper GI series is performed on a 71-year-old woman who presented with several months of chest pain that occurs when she is eating. The film shown here is obtained. Investigation reveals a microcytic anemia and erosive gastritis on upper endoscopy. Which of the following is the most appropriate initial management of this patient?

Antacids

Surgical treatment

Proton-pump inhibitor

Histamine-2 blocker

Cessation of smoking, decreased caffeine intake, and avoidance of large meals before lying down

Approximately 2 weeks after a viral respiratory illness, an 18-month-old child complains of abdominal pain and passes some bloody mucus per rectum. A long, thin mass is palpable in the right upper quadrant of the abdomen. No peritoneal signs are present. Intussusception is suspected. Which of the following is the most appropriate next step?

Decompressive colonoscopy with placement of a rectal tube

Diagnostic laparoscopy with laparoscopic reduction

Hydrostatic reduction with air enema

Diagnostic air enema with subsequent observation and serial abdominal examinations

Exploratory laparotomy with bowel resection

As the on-call surgery resident, you are paged to see a patient on the ward who is having seizures. The patient is a 35-year-old male who underwent a cholecystectomy yesterday. His surgery was uneventful and the man appeared to be doing well until an hour ago when he developed altered sensorium. Upon arriving on the floor, you discover the patient to be confused and agitated. His vital signs include a temperature of 38°C (100.4°F), blood pressure of 134/86 mm Hg, pulse of 110/min, and respirations of 18/min. The man is diaphoretic and has tremors. His wound incisions show no evidence of inflammation, and biliary drainage appears adequate. A review of his medical record indicates his medical history to be unremarkable except for mild esophagitis. He smokes a pack of cigarettes per day and drinks 6-10 beers per night. His medications include folic acid, thiamine, and omepra zole. Laboratory results include the following: CBC: Hb 14.1 g/dL, Leukocyte count 7,100/cmm. Serum Chemistry: Sodium 137 mEq/L, Potassium 4.0 mEq/L, Chloride 101 mEq/L, Bicarbonates 24 mEq/L, BUN 12 mg/dL, Creatinine 1.0 mg/dL, Glucose 104 mg/dL. Arterial Blood Gas: PH 7.40, PO2 94 mm Hg, PCO2 40 mm Hg. Which of the following should be initiated immediately in this patient?

As you are about to step out of a newly delivered mother’s room, she mentions that she wants to breast-feed her healthy infant, but that her obstetrician was concerned about one of the medicines she was taking. Which of the woman’s medicines, listed below, is clearly contraindicated in breast-feeding?

Carbamazepine for her seizure disorder

Acyclovir for her HSV outbreak

Amphetamines for her attention deficit disorder

Labetalol for her chronic hypertension

Ibuprofen as needed for pain or fever

At exploratory laparotomy for blunt abdominal trauma, a 14-year-old boy is found to have a ruptured spleen. The spleen is shattered into multiple fragments, and there are other serious intraabdominal injuries that will require significant operative time. For the above reasons, it is decided that a quick splenectomy is indicated, and it is done. In the postoperative period, this young man should receive which of the following treatments?

At the 2-week checkup of a term female infant, the mother reports a grayish and sometimes bloody vaginal discharge since birth. The infant’s mother and grandmother are the only caretakers. Examination of the external genitalia reveals an intact hymen with a thin grayish mucous discharge. Which of the following is the most appropriate next step?

Children with sickle cell anemia are at increased risk of developing overwhelming infection with certain microorganisms. Which of the following is the most reasonable step to prevent such infection?

Early use of amoxicillin at home for episodes of fever

Prophylactic administration of oral penicillin daily

Withholding live virus vaccines

Periodic injections of gamma globulin

Injection of VZIG after exposure to varicella

Diuretics, vasodilators and oxygen are standard inpatient therapy for patients hospitalized with left-sided heart failure. When patients are discharged, a different outpatient regimen is instituted. A team of researchers compares long-term cardiovascular mortality between patients treated with two different outpatient regimens. The study results are depicted below. In comparison to the patients depicted by the dashed curve, those depicted by the solid line most likely received treatment with which of the following?

During a bar brawl, a 19-year-old man sustains a 4-in laceration on his left arm from glass and presents to the emergency room the following morning, 10 hours later. He is neurovascularly intact and the wound is deep, extending down to fascia. Which of the following is the most appropriate management of the wound?

Local wound care without wound closure or antibiotics

A single dose of intravenous antibiotics and closure of the skin and subcutaneous tissue

A single dose of intravenous antibiotics and closure of the skin only

Closure of the skin and subcutaneous tissue and administration of oral antibiotics for 1 week

Closure of the skin only and administration of oral antibiotics for 1 week

During a campaign appearance, a political candidate is shot point blank in the right chest with a .22 caliber revolver. The entrance wound is well above the nipple line, just under the third rib, at the level of the anterior axillary line. His motorcade brings him to the emergency department, but he makes it a point to walk in, holding his right chest with a bloody hand and waving for the news media. A chest x-ray shows a hemothorax on the right, and the bullet is seen to be embedded in the right paraspinous muscles. A chest tube is placed in the right pleural cavity, and 650 mL blood is recovered. Over the ensuing 4 hours, he continues to drain between 250 and 350 mL blood per hour. Which of the following is the most appropriate next step in management?

Thoracotomy, ligation of bleeding vessels, and removal of the bullet

Thoracotomy and pneumonectomy

Thoracotomy and ligation of bleeding vessels

A second chest tube in a better position to drain the blood

Continued observation and appropriate blood replacement

During a hunting trip, a young man is bitten by a coyote. The animal is captured and brought to the authorities alive. Which of the following is the most important criterion to determine the patient's need for rabies prophylaxis?

The events that took place have already established the need to proceed with rabies immunization

Killing the animal and examining the brain

Observing the animal's behavior over the next few days

The patient's clinical course over the next few weeks

The patient's history of previous immunizations

During a screening physical examination for participating in high school sports, a 14-year-old girl is found to have a late apical systolic murmur preceded by a click. The rest of the examination is unremarkable. Echocardiography shows superior displacement of the mitral leaflets of > 2 mm during systole into the left atrium, with a thickness of at least 8 mm. In addition, she states that her father also has some type of heart “murmur,” but she knows nothing else about it. Which of the following is the most appropriate management at this time?

Prophylactic antibiotics for dental procedures

Digoxin

Metoprolol

Instruct the patient to avoid all forms of strenuous activity

Mitral valve replacement

During an appendectomy for acute appendicitis, a 4-cm mass is found in the midportion of the appendix. Frozen section reveals this lesion to be a carcinoid tumor. Which of the following is the most appropriate management of this patient?

During diagnostic evaluation, a 14-year-old girl with menorrhagia, frequent nosebleeds, and iron deficiency anaemia is found to have a low platelet count with a normal coagulation profile. Bone marrow biopsy reveals abundant megakaryocytes. On abdominal examination, no organomegaly is noted. Which of the following is the most appropriate initial therapy for this patient?

Expectant, with intervention only if the patient develops significant clinical bleeding

Systemic steroids

Chemotherapy

Platelet transfusion when peripheral platelet count drops below 50,000/mL

Splenectomy

During diagnostic evaluation, a 14-year-old girl with menorrhagia, frequent nosebleeds, and irondeficiency anemia is found to have a low platelet count with a normal coagulation profile. Bone marrow biopsy reveals abundant megakaryocytes. On abdominal examination, no organomegaly is noted. The patient has a satisfactory response to the initial therapeutic intervention, but over 6–12 months’ time, the response is less dramatic and shorter in duration. There are signs and symptoms of increasing side effects from therapy. The next step in management should be to recommend which of the following?

During endoscopic biopsy of a distal esophageal cancer, perforation of the esophagus is suspected when the patient complains of significant new substernal pain. An immediate chest film reveals air in the mediastinum. Which of the following is the most appropriate management of this patient?

Thoracotomy with chest tube drainage and esophageal exclusion

Left thoracotomy with esophagectomy

Left thoracotomy, pleural patch oversewing of the perforation, and drainage of the mediastinum

Spit fistula (cervical pharyngostomy) and gastrostomy

Placement of a nasogastric tube to the level of perforation, antibiotics, and close observation

Eight days after a difficult hemigastrectomy and gastroduodenostomy for gastric ulcer, a patient begins to leak 2-3 L of greenish fluid per day through the right corner of his bilateral subcostal surgical incision. He is afebrile and has no clinical signs of an acute abdomen. At surgery, a feeding catheter jejunostomy was placed, through which the patient has been receiving 3 L/day of elemental diet with a caloric content of 1 cal per mL, and 1 g nitrogen per 100 cal. The nursing staffs have rigged a very effective collection device for the fluid that is leaking through the wound, and the skin around the site is well protected. Which of the following is the most appropriate next step in management?

Surgical reconstruction of die gastroduodenostomy

Surgical drainage of the operative area

Immediate discontinuation of the jejunal feeding, and replacement by 5 L/day of IV 5% dextrose-half normal saline

Addition of 2-3 L per day of IV Ringer's lactate

No changes in the present therapeutic plan

Five days after an uneventful cholecystectomy, an asymptomatic middle-aged woman is found to have a serum sodium level of 125 mEq/L. Which of the following is the most appropriate management strategy for this patient?

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