Q_D_USMLE Management(photo) S_V

A 1-week-old black infant presents to you for the first time with a large, fairly well-defined, purple lesion over the buttocks bilaterally, as shown in the photograph. The lesion is not palpable, and it is not warm nor tender. The mother denies trauma and reports that the lesion has been present since birth. This otherwise well-appearing infant is growing and developing normally and appears normal upon physical examination. Which of the following is the most appropriate course of action in this infant?

A 10-month-old infant presents to the emergency department with a 24-hour history of low-grade fever and anorexia. The parents report several episodes in which the child has been suddenly inconsolable and crying, followed by periods of lethargy. He has had nonbilious vomiting and several loose stools. On examination, the infant is pale and mildly dehydrated. His abdomen is soft and nondistended, with fullness to palpation in the right upper quadrant. The child passed another stool in the emergency department (see Figure 6-14). Which of the following is the most appropriate next step in the diagnostic evaluation and management of this patient?

A 12-year-old boy comes to the emergency department complaining of vague left-sided chest discomfort. Two months ago, he was involved in a high-speed motor vehicle accident but sustained only minor injuries. He was observed in the emergency department overnight and discharged home. His past medical history is otherwise unremarkable. Vital signs are normal. Auscultation of the lungs shows decreased air entry into the left lower base. An x-ray of the chest is shown below. Which of the following is the most appropriate next step in management of this patient?

A 12-year-old boy is brought to the emergency department after being involved in a motor vehicle collision. He was in the rear seat and was thrown out of the car during the accident. He was immediately resuscitated, and the trauma work-up showed no abnormalities. His discharge was uneventful. Two months later he was seen in the emergency department because of vague chest pain and discomfort. Auscultation showed decreased air entry into the left lower base. An x-ray film of the chest is shown below. Which of the following is the most appropriate next step in management?

A 12-year-old boy notices a scaly, mildly pruritic rash on his arm (see image below). There is no associated fever, muscle pain, nausea, vomiting, diarrhea, or back pain. He recently started taking swimming classes. The rash is most likely to clear with which of the following therapies?

A 13-year-old boy has a 3-day history of low-grade fever, symptoms of upper respiratory infection, and a sore throat. A few hours before his presentation to the emergency room, he has an abrupt onset of high fever, difficulty swallowing, and poor handling of his secretions. He indicates that he has a marked worsening in the severity of his sore throat. His pharynx has a fluctuant bulge in the posterior wall. A soft tissue radiograph of his neck is shown. Which of the following is the most appropriate initial therapy for this patient?

A 13-year-old boy’s scrotum is shown below. He complains of several months of swelling but no pain just above his left testicle. He is sexually active but states that he uses condoms. On physical examination, the area in question feels like a “bag of worms.” Which of the following is the most appropriate management for this condition?

A 15-year-old presents with the complaint of a rash, as pictured below. Which of the following statements is correct concerning the management of this common condition?

A 19-year-old G1P0 woman at 32 weeks gestation presents for scheduled prenatal appointment. The pregnancy has been uncomplicated to date. However, she mentions that she recently noticed a hard lump on her neck. She denies pain or difficulty swallowing, speaking, or breathing. Physical examination reveals a firm, nontender, immobile, solitary nodule on the left hemithyroid. Ultrasound reveals a solid 2-cm mass. There is no cervical lymphadenopathy. Thyroid function tests reveal a thyroid-stimulating hormone level of 1.2 μU/mL and free thyroxine level of 0.9 ng/dL. Results of fine-needle aspiration biopsy are shown in the image. Which of the following is the best next step in management?

A 2-year-old child (Image A) presents with a 4-day history of a rash limited to the feet and ankles. The papular rash is both pruritic and erythematous. The 3-month-old sibling of this patient (Image B) has similar lesions also involving the head and neck. The most appropriate treatment for this condition includes which of the following?

A 2-year-old child is seen in the emergency center with a 10-day complaint of fever and a limp. The child has an elevated erythrocyte sedimentation rate (ESR) and the radiograph shown below. Which of the following statements about this child’s condition is correct?

A 2-year-old child presents with a 2-day history of painless rectal bleeding. On examination, the child is pale with tachycardia. The abdomen is nondistended and nontender. There is dark blood on rectal examination. The child has the following imaging study (see Figure 6-2). Which of the following is the most appropriate management?

A 21-year-old man presents to the ED with a red eye. The patient complains of rhinorrhea and a nonproductive cough but has no eye pain or discharge. He also has no associated ecchymosis, bony tenderness of the orbit, or pain on extraocular eye movement. His vision is normal, extraocular movements are intact, and intraocular pressure (IOP) is 12. A picture of his eye is shown below. What is the most appropriate management of this condition?

A 22-year-old female presents to the office with a three-day history of rash, fever, and malaise. There is no burning or itching associated with the rash. Two weeks ago, she had been camping in northern Massachusetts, and noted a tick bite after walking through the woods. She is twelve weeks pregnant. The rash is shown below. The examination is otherwise unremarkable. What is the most appropriate treatment for this patient?

A 22-year-old male presents with a 6-month history of a red, nonpruritic rash over the trunk, scalp, elbows, and knees. These eruptions are more likely to occur during stressful periods and have occurred at sites of skin injury. The patient has tried topical hydrocortisone without benefit. On examination, sharply demarcated plaques are seen with a thick scale. Pitting of the fingernails is present. There is no evidence of synovitis. What is the best first step in the therapy of this patient’s skin disease?

A 25-year-old female comes to the office for a follow-up visit. She was just diagnosed with type 1 diabetes mellitus a few days ago, when she presented at the emergency department with ketoacidosis. After successful management of her diabetic ketoacidosis (DKA), she was sent home on an insulin regimen with the following dosage: Before breakfast 10 units of NPH and 10 units of regular insulin, Before supper 10 units of NPH and 4 units of regular insulin. During this office visit, she shows the record of her fingerstick readings at home. For the last 2 days, her blood glucose levels were (see in pic). What is the most likely explanation for her 7:00 am blood glucose level?

A 25-year-old male presents with skin lesions over his elbows, knees and neck. He complains of intense itching and burning sensation over these lesions for the past 10 days. He was advised to follow a gluten-free diet on his previous visit, but was not compliant. His vital signs are stable. On examination, there are flesh-colored to erythematous vesicles distributed over the extensor aspects of elbows, knees, posterior neck and shoulders. Some of these lesions are shown in the picture below. Which of the following is the drug of choice for his skin condition?

A 27-year-old man presents with fever, malaise, anorexia, and fatigue for the last three days. He denies cough, chest pain, arthralgias, and diarrhea. He has history of rheumatic heart disease and recently underwent a dental cleaning. His temperature is 38.5°C (101.3°F), pulse is 90/min, respirations are 18/min, and blood pressure is 135/76 mm Hg. Examination of his fingernail is shown below. Cardiovascular examination reveals an early diastolic murmur in the mitral area. The chest x-ray is negative. Urinalysis shows microscopic hematuria. What is the most appropriate next step in the management of this patient?

A 27-year-old man who is otherwise healthy presents to the ED with a laceration on his thumb that he sustained while cutting a bagel. You irrigate and repair the wound and are about to discharge the patient when he asks you if he can receive an ECG. It is not busy in the ED so you perform the ECG, as seen below. Which of the following is the most appropriate next step in management?

A 3-day-old infant’s scrotum is shown below. Palpation reveals a tense, fluid-filled area surrounding the right testicle. The scrotum transil luminates well, and the amount of fluid does not vary with mild pressure. Which of the following is the most appropriate approach to this condition?

A 3-year-old boy presents to the emergency department with a fever and difficulty breathing. He is the product of a normal pregnancy and has been healthy since birth. His immunizations are up to date. This morning he appeared to be in his usual state of health and was dropped off at day care by his father. Later on, his teacher noticed that he had suddenly become fussy and flushed and could not be consoled with toys, rocking, or hearing a story. He also felt warm to the touch and was drooling more than usual. When she took his temperature, it was 39°C (102.2°F). His parents were contacted immediately, and the patient was brought to the emergency department. He appears toxic and anxious, and has loud labored breathing. He is sitting upright, bracing himself on his arms, with his neck hyperextended and mouth open. His temperature is 40°C (104°F), respiratory rate is 50/min, pulse is 140/min, blood pressure is 102/62 mm Hg, and oxygen saturation is 100% on room air. Lateral x-ray of the neck is shown in the image. Laryngoscopy reveals a large cherryred epiglottitis. What is the most appropriate next step in management?

A 3-year-old girl is admitted with the x-ray shown below. The child lives with her parents and a 6-week-old brother. Her grandfather stayed with the family for 2 months before his return to the West Indies 1 month ago. The grandfather had a 3-month history of weight loss, fever, and hemoptysis. Appropriate management of this problem includes which of the following?

A 31-year-old kindergarten teacher presents to the ED complaining of acute-onset substernal chest pain that is sharp in nature and radiates to her back. The pain is worse when she is lying down on the stretcher and improves when she sits up. She smokes cigarettes occasionally and was told she has borderline diabetes. She denies any recent surgeries or long travel. Her BP is 145/85 mmHg, HR is 99 beats per minute, RR is 18 breaths per minute, and temperature is 100.6°F. Examination of her chest reveals clear lungs and a friction rub. Her abdomen is soft and nontender to palpation. Her legs are not swollen. Chest radiography and echocardiography are unremarkable. Her ECG is shown below. Which of the following is the most appropriate next step in management?

A 32-year-old Italian-American man presents to your office for a routine check-up. He works as a business executive and admits to being under a lot of stress recently. He drinks alcohol occasionally and smokes one pack of cigarettes per day. Laboratory analyses reveal: Hemoglobin 10.1 mg/dl, RBC count 4.0 x 10^12/L, MCV 70fl, WBC count 5,500/mm3, Platelets 170,000/mm3, Serum calcium 10.1 mg/dl, Serum potassium 4.5 meq/L, Serum sodium 135 meq/L. Serial fecal occult blood tests are negative. A peripheral blood smear reveals the following: Which of the following is the best treatment for this patient?

A 32-year-old woman undergoes a cholecystectomy for acute cholecystitis and is discharged home on the sixth postoperative day. She returns to the clinic 8 months after the operation for a routine visit and is noted by the surgeon to be jaundiced. Laboratory values on readmission show total bilirubin 5.6 mg/dL, direct bilirubin 4.8 mg/dL, alkaline phosphatase 250 IU (normal 21-91 IU), serum glutamic oxaloacetic transaminase (SGOT) 52 kU (normal 10-40 kU), and serum glutamic pyruvic transaminase (SGPT) 51 kU (normal 10-40 kU). An ultrasonogram shows dilated intrahepatic ducts. The patient undergoes the transhepatic cholangiogram seen here. Which of the following is the most appropriate next management step?

A 34-year-old prostitute with a history of long-term intravenous drug use is admitted with a 48-hour history of pain in her left arm. She is tachycardic to 130 and her systolic blood pressure is 80 mm Hg. Physical examination is remarkable for crepitus surrounding needle track marks in the antecubital space with a serous exudate. The plain x-ray of the arm is shown here. Which of the following is the most appropriate next step in her management?

A 35-year-old woman develops an itchy rash over her back, legs, and trunk several hours after swimming in a lake. Erythematous, edematous papules and plaques are noted. The wheals vary in size. There are no mucosal lesions and no swelling of the lips. What is the best first step in management of her symptomatic rash?

A 35-year-old woman presents with abdominal pain and jaundice. Subsequent ERCP reveals the congenital cystic anomaly of her biliary system illustrated in the film shown here. Which of the following is the most appropriate treatment?

A 36-hour-old infant presents with bilious vomiting and an increasingly distended abdomen. At exploration, the segment pictured here is found as the point of obstruction. What is the best next step in management?

A 38-year-old female presents with one week of "shakiness" in her right arm, right leg weakness and unsteady gait. An MRI of her brain is shown below. Which of the following is the best treatment for this patient?

A 4-week-old boy presents with a 10-day history of vomiting that has increased in frequency and forcefulness. The vomitus is not bile stained. The child feeds avidly and looks well, but he has been losing weight. An ultrasound of the abdomen is shown. Which of the following is the most likely diagnosis?

A 4-year-old boy presents with a history of constipation since the age of 6 months. His stools, produced every 3 to 4 days, are described as large and hard. Physical examination is normal; rectal examination reveals a large ampulla, poor sphincter tone but present anal wink, and stool in the rectal vault. The plain film of his abdomen is shown. Which of the following is the most appropriate next step in the management of this child?

A 40-year -old man who underwent a renal transplant six months ago comes to the clinic with fever, chills, and a productive cough. His temperature is 39.4°C (103°F), pulse is 110/min, respirations are 22/min, and blood pressure is 110/65 mmHg. Chest x-ray shows a right lower lobe nodule with a cavity. Sputum gram stain is shown below. What is the most appropriate treatment of this patient's condition?

A 43-year-old woman develops acute renal failure following an emergency resection of a leaking abdominal aortic aneurysm. One week after surgery, the following laboratory values are obtained:Serum electrolytes (mEq/L): Na+ 127, K+ 5.9, Cl− 92, HCO3− 15Blood urea nitrogen: 82 mg/dLSerum creatinine: 6.7 mg/dLThe patient has gained 4 kg since surgery and is mildly dyspneic at rest. Eight hours after these values are reported, the following electrocardiogram is obtained. Which of the following is the most appropriate initial treatment in the management of this patient?

A 45-year-old man presents to the physician’s office for evaluation of a skin lesion on his abdomen. He states that the lesion has been present for 1 year, but has recently enlarged over the last 2 months. The mass is nontender, and he is otherwise asymptomatic. Past history is unremarkable. Examination reveals a 3-cm, pigmented, irregular skin lesion located in the left lower quadrant of the abdomen, as shown in Figure 6-12. Heart, lung, and abdominal examination are normal. There are no palpable cervical, axillary, or inguinal lymph nodes. Chest x-ray and liver function tests are normal. Which of the following is the most appropriate next step in management?

A 5-year-old boy presents with the severe rash shown in the photographs. The rash is pruritic, and it is especially intense in the flexural areas. The mother reports that the symptoms began in infancy (when it also involved the face) and that her 6-month-old child has similar symptoms. Which of the following is the most appropriate treatment of this condition?

A 50-year-old male comes to the office due to an ulcer in his right foot. He has type 2 diabetes, for which he takes glyburide. Laboratory investigations reveal an HbA1c of 9%, and random blood sugar of 180 mg/dL. X-ray of the leg/foot is normal. A picture of the foot ulcer is shown below. Which of the following is the most appropriate management of this patient's foot ulcer?

A 50-year-old man has respiratory failure due to pneumonia and sepsis after undergoing splenectomy for a traumatic injury. Which of the following management strategies will improve tissue oxygen uptake (ie, shifting the oxygen dissociation curve, depicted here, to the right)?

A 51-year-old woman presents to the physician’s office with a 2-month history of a right breast blood tinged nipple discharge. Past history is unremarkable. Family history is positive for postmenopausal breast cancer in a maternal grandmother. Examination reveals no palpable masses or regional adenopathy, but a serous discharge is easily elicited from a single duct in the right breast. Bilateral mammograms show no abnormalities. Cytology from the discharge was not diagnostic. A ductogram was ordered, and the results are shown in picture. Which of the following is the most appropriate next step in management?

A 54-year-old man presents to his primary care provider with the complaint of upper abdominal fullness and pain. He states that he has lost 2.3-4.6 kg (5-10 lb), but denies other symptoms. Physical examination reveals a firm mass in the epigastric area. Ultrasonography reveals a mass in the gastric antrum. A salivary gland biopsy reveals the pathology shown in the image. Which of the following therapies is expected to be part of his treatment plan?

A 55-day-old infant born prematurely at 27 weeks of gestation is shown below. The swelling is not tender, firm, hot, or red, and it does not transil luminate. It seems to resolve with pressure, but returns when the infant cries or strains. Which of the following is the most appropriate course of action at this point?

A 55-year-old male comes to the physician's office because of fatigue. He denies any other symptoms. His vital signs are stable. Examination shows pallor, massive splenomegaly, and mild hepatomegaly. CBC reveals pancytopenia with striking monocytopenia. His peripheral blood smear is shown below. Bone marrow biopsy shows a dry tap. What is the most appropriate treatment for this patient's condition?

A 55-year-old-woman presents to the physician’s office for evaluation of mammographic findings on a screening mammogram. She denies any breast masses, nipple discharge, pain, or skin changes. Past history is pertinent for insulindependent diabetes. Family history is positive for postmenopausal breast cancer in her mother. She has a normal breast examination and no axillary adenopathy. A mediolateral oblique (MLO) view of the right breast is shown. Which of the following is the most appropriate next step in management?

A 56-year-old woman presents to her primary care physician for a routine checkup. She states that she was recently hospitalized for surgery and was told she had some metal placed in a large blood vessel to prevent blood clots from moving to her lungs. An abdominal x-ray is shown here. Which of the following is the most appropriate indication for placement of this device?

A 58-year-old alcoholic is admitted with diagnosis of decompensated liver cirrhosis. The lab panel is shown below on the day of admission and 3 days later. Which of the following best explains the acid-base status change in this patient?

A 59-year-old male suffers a myocardial infarction. He is treated medically and is discharged home ten days later on aspirin, atorvastatin, metoprolol, lisinopril, and sublingual nitroglycerin. One month later, he presents to your office for a follow-up visit. He denies chest pain, dyspnea or lightheadedness. His blood pressure is 120/75 mmHg. His EKG is pictured below. Echocardiogram reveals an ejection fraction of 45%. What is the best next step in his management?

A 6-month-old Hispanic boy is brought to the office for a well-baby check-up and follow-up immunizations. His mother denies any new complaints. Physical examination reveals lesions that do not fade into the surrounding skin, shown in picture below. What is the most appropriate next step in the management of this patient?

A 6-year-old girl presents with a 2-day history of cough and fever. At your office she has a temperature of 39.4°C (103°F), a respiratory rate of 45 breaths per minute, and decreased breath sounds on the left side. Her chest x-ray is shown below. Which of the following is the most appropriate initial treatment?

A 60-year-old Caucasian female comes to the physician because of progressive shortness of breath for the past month. She has had a 13.6 kg (30 lb) weight loss during this period. She has a history of hypertension and hypothyroidism and takes metoprolol and levothyroxine. She has smoked two packs of cigarettes daily for 35 years. Her temperature is 36.7°C (98°F), blood pressure is 130/70 mmHg, pulse is 80/min, and respirations are 20/min. On examination, decreased breath sounds and dullness to percussion are noted on the right, middle and lower lobes of the lung. Her chest x-ray is shown below. Which of the following is the most appropriate next step in the management?

A 60-year-old man is found on a routine physical examination to have a 3-cm pulsatile mass in the right popliteal fossa. X-ray of the right of the right lower extremity is shown below. Which of the following is the most appropriate management of this patient?

A 62-year-old man comes to the emergency department because of severe abdominal pain. He states that he suddenly felt weak, diaphoretic, and had no energy. He is a smoker and has hypertension. His blood pressure on initial examination was 110/70 mm Hg. Physical examination shows a diffusely tender abdomen. During CT scan he becomes pale and drowsy. CT scan is shown below: Repeat examination shows a man with anxiety and a blood pressure of 80/50 mm Hg and pulse of 110/min Which of the following is the most appropriate next step in management?

A 62-year-old woman presents to the physician’s office with complaints of constipation. She has had constipation for the last 6 months, which has worsened over the last month, associated with mild bloating. She noted that her stool has become “pencil thin” in the last month, with occasional blood, but she continues to have bowel movements daily. Past history is unremarkable. Examination reveals normal vital signs and heart and lung examination. Abdominal examination reveals mild fullness, especially in the lower quadrants. Rectal examination shows no rectal masses, but the stool is hematest positive. A barium xray is obtained, and one view is shown in Figure 6-11. Which of the following is the most appropriate next step in management?

A 63-year-old woman on digitalis for chronic atrial fibrillation experiences fatigue, nausea, and anorexia. Her pulse is regular at 50 beats/min, and the heart sounds, chest, and abdominal examinations are normal. On the ECG, no P waves are visible and the QRS complexes are narrow and regular. Which of the following is the most appropriate management step?

A 64-year -old male with a history of hypertension presents with general malaise and a 'funny' heart rhythm for the past 2 weeks. He had an echocardiogram done last year, which revealed mild left atrial dilatation and left ventricular hypertrophy. He has been taking hydrochlorothiazide for hypertension. His blood pressure at today's visit is 180/98 mmHg. An EKG is obtained and is shown below. Which of the following is the most appropriate treatment for this patient?

A 65-year -old Hispanic male is brought to the emergency room with severe substernal chest pain and diaphoresis that began suddenly 1 hour ago. He reports that his pain started while he was at rest and radiates to his left shoulder. The patient notes having vomited twice when the pain first began. Despite administration of 2 baby aspirins and 3 tablets of sublingual nitroglycerin, the pain persists. His initial EKG is shown below. On physical examination, the patient's temperature is 36.9°C (98.4°F), blood pressure is 110/80 mmHg, pulse is 60/min, and respirations are 18/min. S1 and S2 are normal, and an S4 is heard. The lungs are clear to auscultation. There is no jugular venous distension or pedal edema. Interventions to achieve which of the following goals would most improve this patient's long-term prognosis?

A 65-year-old man presents to the physician’s office for his yearly physical examination. His only complaint relates to early fatigue while playing golf. Past history is pertinent for mild hypertension. Examination is unremarkable except for trace hematest-positive stool. Blood tests are normal except for a hematocrit of 32. A UGI series is performed and is normal. A barium enema is performed, and one view is shown in Figure 6-10. Which of the following is the most appropriate therapy following colonoscopy?

A 65-year-old man who is hospitalized with pancreatic carcinoma develops abdominal distention and obstipation. The following abdominal radiograph is obtained. Which of the following is the most appropriate initial management of this patient?

A 65-year-old white male who has a history of chronic obstructive pulmonary disease, congestive heart failure, and coronary artery disease presented with a three-day history of worsening shortness of breath, cough with yellowish expectoration, and fever. He is not on steroids and does not use oxygen at home. He takes ipratropium, albuterol, aspirin, digoxin, furosemide, metoprolol, and lisinopril. He lives at home with his wife. His temperature is 39.4°C (103°F), blood pressure is 110/70 mmHg, pulse is 110/min, and respirations are 24/min. He is saturating 88% on room air. He was started on 3-liters of oxygen to keep the saturations above 92%. The chest x-ray of the patient is shown below. What is the most appropriate next step in the management of this patient?

A 65-year-old woman presents to the physician’s office for evaluation of an abnormal screening mammogram. She denies any breast masses, nipple discharge, pain, or skin changes. Past history is pertinent for hypertension. Family history is positive for postmenopausal breast cancer in a sister. She has a normal breast examination and no axillary adenopathy. The remainder of her examination is unremarkable. An MLO view of the right breast is shown in Figure 6-6a along with a magnification view of the craniocaudal (CC) film (Figure 6-6b). Which of the following is the most appropriate next step in management?

A 67-year-old male presents to the ER with chest pain. His medical history is significant for stable angina for which he takes aspirin and isosorbide dinitrate, as well as hypertension and bronchial asthma. Occasionally, he uses an albuterol inhaler. He is admitted to the hospital and five hours later, he begins to feel lightheaded and weak. His blood pressure is 100/60 mmHg. An EKG is obtained and is shown below. Which of the following is the best next step in managing this patient?

A 68-year-old male presents to the emergency room with cough. Chest x-ray is clear of infiltrates but reveals a right upper lobe lung lesion incidentally. A chest CT scan with IV contrast is performed in the emergency department and reveals
a 1 cm x 2cm round lesion in the right upper lobe. The patient is admitted to the hospital, and by day 3 of his hospitalization, he has developed acute renal failure. The patient's past medical history is significant for hypertension,
hyperlipidemia, diabetes and coronary artery disease. His medications include aspirin, hydrochlorothiazide, clopidogrel, metoprolol, atorvastatin and lisinopril, all of which he has been taking for several years. He has no known drug allergies. He is a former smoker and does not use alcohol or drugs. His baseline blood pressure is 140/90 mm Hg and has remained in the 140s/90s throughout this admission. Physical examination is otherwise unremarkable. The patient's laboratory values from the time of admission to present are given below. Over the course of the next week, the patient's renal function returns to normal. Which of the following would most likely have prevented his renal failure?

A 69-year-old man with mild hypertension and chronic obstructive pulmonary disease (COPD) presents with transient ischemic attacks and the angiogram shown here. Which of the following is the most appropriate treatment recommendation?

A 72-year-old male is admitted to the hospital with chest pain. EKG and cardiac enzymes confirm a myocardial infarction and he is started on nitroglycerine, aspirin, simvastatin and low molecular weight heparin. Four days later, he complains of leg pain. Physical examination reveals a cold, pale leg. The angiogram is shown below. What is the best next step in his management?

A 72-year-old male with a history of poorly controlled hypertension develops a viral upper respiratory infection. On his second day of symptoms he experiences palpitations and presents to the emergency room. His blood pressure is 118/78 mmHg. The following rhythm strip is obtained. What is the best next step in the management of this patient?

A 76-year-old man who has had multiple episodes of pancreatitis presents to his physician’s office with mild epigastric pain and 9.1-kg (20.0-lb) weight loss over the past 6 months. The patient also describes daily foul-smelling stools that “float” in the toilet bowl. The physician pulls up his electronic medical record and finds that the patient presented to the emergency department last week for the same symptoms. During that visit he had a CT of the abdomen (see image). Which of the following is the most appropriate treatment?

A 79-year-old woman presents to her primary care physician complaining of memory loss. She reports increasing difficulty balancing her check book and remembering the names of new acquaintances over the last several months. Her only other complaint is occasional urinary incontinence, which she attributes to old age. She denies headache, vision changes, rash, nausea, or vomiting. Her past medical history is significant for hypertension controlled with felodipine. On exam her vital signs are within normal limits. The heart and lung exams are also unremarkable. The cranial nerves are intact, fundoscopic exam is normal, and no tremor is observed. Her gait is slow and shuffling, there is no dysmetria, and her Folstein mini-mental status score is 24/30. CT scan of her brain is shown below. Which of the following interventions is most likely to relieve her symptoms?

A chubby 6-month-old baby boy is brought to the clinic by his father. His father is concerned that his penis is too small (see photograph). The child is at the 95% for weight and the 50% for length; he has been developing normally and has had no medical problems. Which of the following is the most appropriate first step in management of this child?

A healthy 54-year-old man comes to the physician for a routine health maintenance examination. He has no complaints, but he is requesting for a CT scan of the abdomen. His father died at the age of 60 due to the sudden rupture of an undiagnosed abdominal aortic aneurysm. He has a history of hypertension and gouty arthritis. His social history is not significant. His vital signs are stable. Physical examination shows no abnormalities. ACT scan of the abdomen is shown below. Which of the following is the most appropriate next step in management?

A mother arrives to the clinic with her three children (ages 2 months, 18 months, and 36 months). The 18-month-old has an intensely pruritic scalp, especially in the occipital region, with 0.5-mm lesions noted at the base of hair shafts, as shown in the picture. Which of the following therapies should be avoided in this situation?

A patient has been in the coronary care unit for the past 24 hours with an acute anterior myocardial infarction. He develops the abnormal rhythm shown below, although blood pressure remains stable at 110/68 mmHg. Which of the following is the best next step in therapy?

A previously healthy 2-year-old black child has developed a chronic cough during the previous 6 weeks. He has been seen in different emergency rooms on two occasions during this period and has been placed on antibiotics for pneumonia. Upon auscultation, you hear normal breath sounds on the left. On the right side, you hear decreased air movement during inspiration but none upon expiration. Inspiratory (Image A) and expiratory (Image B) radiographs of the chest are shown below. Which of the following is the most appropriate next step in making the diagnosis in this patient?

A previously healthy 3-year-old male is brought to the emergency department with abdominal pain. The abdominal pain began several hours ago. Since then, he has had several episodes in which he clutches his stomach and screams. These episodes are associated with nonbloody, nonbilious vomiting and loose, watery stools. Between the episodes, the patient denies abdominal pain and is playful. On examination, his temperature is 99F (37.2C), pulse is 100/min, respiratory rate is 20/min, and blood pressure is 85/50 mmHg. The child is alert and in no acute distress. Abdominal examination reveals a soft, nontender, nondistended abdomen with bowel sounds present in all four quadrants. A tubular mass is felt in the right upper quadrant, and a rectal exam is hemoccult positive. An ultrasound image of the patient's abdomen is shown below. What is the best next step in the management of this patient?

A previously healthy 79-year-old woman presents with early satiety and abdominal fullness. CT scan of the abdomen, pictured here, reveals a cystic lesion in the body and tail of the pancreas. CT-guided aspiration demonstrates an elevated carcinoembryonic antigen (CEA) level. Which of the following is the most appropriate treatment option for this patient?

A previously well 1-year-old infant has had a runny nose and has been sneezing and coughing for 2 days. Two other members of the family had similar symptoms. Four hours ago, his cough became much worse. On physical examination, he is in moderate respiratory distress with nasal flaring, hyper- expansion of the chest, and easily audible wheezing without rales. His chest radiographs are shown. Which of the following is the appropriate next course of action?

A term infant is born at a small community hospital by cesarean section for failure to progress. The infant is noted to have the following abnormality at birth. Which of the following is the most likely diagnosis? Which of the following is the most appropriate initial management?

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?

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 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?

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 pharyngitis. She has no other medical problems and takes no medications. Her temperature is 39.4° C (103° F), 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 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 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?

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?

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 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?

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?

In a 6-month-old previously healthy male infant, an abnormality is revealed during a routine diaper change, as illustrated in Figure 6-19. The parents have noted this finding on and off on several occasions over the last month. On each occasion, the child has been feeding well, and is content and playful. Which of the following is the most appropriate management at this time?

In a 6-month-old previously healthy male infant, an abnormality is revealed during a routine diaper change, as illustrated in Figure 6-19. The parents have noted this finding on and off on several occasions over the last month. On each occasion, the child has been feeding well, and is content and playful. We decided to do surgical repair. Several weeks later, the child presents to the emergency department with a 4-hour history of irritability. He has had one episode of nonbilious vomiting and has refused to breast-feed. In the emergency department, the infant appears inconsolable. He is afebrile, and his abdomen is mildly distended but soft. On removal of his diaper, the same abnormality is documented (see Figure 6-19). Which of the following is the most appropriate management at this time?

The nurse from the level 2 neonatal intensive care nursery calls you to evaluate a baby. The infant, born at 32 weeks’ gestation, is now 1 week old and had been doing well on increasing nasogastric feedings. This afternoon, however, the nurse noted that the infant has vomited the last two feedings and seems less active. Your examination reveals a tense and distended abdomen with decreased bowel sounds. As you are evaluating the child, he has a grossly bloody stool. The plain film of his abdomen is shown. The next step in your management of this infant should include which of the following?

You are performing a well-child examination on the 1-year-old child shown in the picture. For this particular problem, which of the following is the most appropriate next step in management?

You are seeing a 4-year-old girl with the physical examination finding shown below. She has no significant past history. The most appropriate management is which of the following?