DES C_Management (14) Prepared : CHILLY

Following a 2-hour firefighting episode, a 36-year-old fireman begins complaining of a throbbing headache, nausea, dizziness, and visual disturbances. He is taken to the ER, where his carboxyhemoglobin (COHb) level is found to be 31%. Which of the following is the most appropriate next step in his treatment?
Perform flexible bronchoscopy with further therapy determined by findings
Administer 100% oxygen by mask
Begin bicarbonate infusion and give 250 mg acetazolamide (Diamox) intravenously
Transfer the patient to a hyperbaric oxygen chamber
Begin an immediate exchange transfusion
Following a boating injury in an industrial-use river, a patient begins to display fever, tachycardia, and a rapidly expanding area of erythema, blistering, and drainage from a flank wound. An x-ray shows gas in the soft tissues. Which of the following measures is most appropriate?
Wide debridement
Early closure of tissue defect
Administration of hyperbaric O2
Administration of an antifungal agent
Administration of antitoxin
Following blunt abdominal trauma, a 12-year-old girl develops upper abdominal pain, nausea, and vomiting. An upper gastrointestinal series reveals a total obstruction of the duodenum with a coiled spring appearance in the second and third portions. In the absence of other suspected injuries, which of the following is the most appropriate management of this patient?
Duodenojejunostomy
TPN (total parental nutrition) to increase the size of the retroperitoneal fat pad
Gastrojejunostomy
Nasogastric suction and observation
Duodenal resection
Following pelvic gynecologic surgery, a 34-year-old woman becomes dyspneic, her peripheral arterial O2 saturation falls from 94% to 81%, and her measured PaO2 is 52 on a 100% non-rebreather mask. She is hemodynamically stable. A CT angiogram is consistent with a right lower lobe pulmonary embolus. Which of the following is the next step in her management?
Placement of an inferior vena cava filter
Open pulmonary embolectomy
Thrombolytic therapy
Systemic anticoagulation with warfarin
Systemic anticoagulation with heparin infusion
Following significant head trauma, a 34-year-old woman undergoes a CT scan that demonstrates bilateral frontal lobe contusions of the brain. There is no midline shift. She has a GCS of 14. Which of the following is the best initial management of this patient?
Administration of 25 g of mannitol
Intubation and hyperventilation
Placement of an intracranial pressure monitor
Observation alone
Observation and administration of anticonvulsive medication for 1 week
Four days after surgical evacuation of an acute subdural hematoma, a 44-year-old man becomes mildly lethargic and develops asterixis. He has received 2400 mL of 5% dextrose in water intravenously each day since surgery, and he appears well hydrated. Pertinent laboratory values are as follows:Serum electrolytes (mEq/L): Na+ 118, K+ 3.4, Cl− 82, HCO324Serum osmolality: 242 mOsm/LUrine sodium: 47 mEq/LUrine osmolality: 486 mOsm/LWhich of the following is the best treatment of his hyponatremia?
Rapid infusion of 3% normal saline to correct the sodium to normal
Slow infusion of 3% normal saline until neurologic symptoms are improved
Insulin infusion to keep his glucose level less than 110 mg/dL
Desmopressin (DDAVP) administration
Administration of a loop diuretic
Four hours ago, a 28-year-old woman, gravida 1, para 0, at 38 weeks’ gestation was admitted to the labor and delivery suite. On admission, she had regular uterine contractions occurring every 2–3 minutes, a dilation of 4 cm on cervical examination, effacement of 80%, and blood pressure of 115/75 mm Hg. The fetus is in longitudinal lie and cephalic presentation with an estimated weight of 3,500 g (7 lb 11 oz) by abdominal palpation. Her prenatal course was characterized by first-trimester bleeding that spontaneously resolved. Her blood pressure (BP) has gradually increased over the past 4 hours; it is now sustained at 150/95 mm Hg. Her patella deep tendon reflexes are brisk, but she has no clonus. A urine dipstick test shows 2 albumin. Administration of which of the following agents is indicated as the next step in management?
Phenobarbital
Diphenylhydantoin
Magnesium gluconate
Diazepam
Magnesium sulfate
Four of your patients who came to the office today all have signs and symptoms of hyperthyroidism. After the appropriate evaluation, you decided to treat them with radioactive iodine. Hyperthyroid patients with which of the following disorders are most likely to develop hypothyroidism following radioactive therapy?
Ectopic production of thyroid hormones
Thyroid Cancer
Graves' disease
Multinodular goiter
Toxic adenoma
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?
Referral for elective surgical repair
Scrotal support
Referral to the emergency department for immediate surgical consultation
Reassurance to the parents that the abnormality will resolve without intervention
Antibiotics
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?
Urgent surgical exploration
Sedation with manual reduction, admission, rehydration, and surgical repair within 24–48 hours
Sedation with manual reduction and arrangements for elective surgical repair
Systemic antibiotics
Elective surgical repair
In preparation for an inguinal hernia repair, a 22-year-old man has a spinal anesthetic placed. The level of sensory block turns out to be much higher than had been planned, and shortly thereafter his blood pressure drops to 75/20 mm Hg. He looks warm and flushed, and his central venous pressure is near zero. Which of the following should be included in his therapy?
Vasoconstrictors and IV fluids
Vasodilators and IV fluids
Inotropic agents and cardiac assist pump
Whole blood and clotting factors
Diuretics and fluid restriction
In the course of a robbery, a young woman is stabbed repeatedly. On arrival at the emergency department, she is shivering and asks for a blanket and a drink of water; she is noted to be pale and perspiring. Her blood pressure is 72/50 mm Hg and her pulse is 130/min. Her neck and forehead veins are large and distended. A quick initial survey reveals entry wounds in her left chest and upper abdomen. She has bilateral breath sounds and a scaphoid, nontender abdomen. As IV infusions of Ringer's lactate are started, her systolic blood pressure drops further to 40 mm Hg, no distal pulses can be felt, and she loses consciousness. Her central venous pressure at that time is 28 cm H2O. Which of the following is the most appropriate next step in management?
Crash laparotomy in the emergency department to clamp the aorta
Bilateral chest tubes
Chest x-ray to direct further therapy
Diagnostic peritoneal lavage
Evacuation of the pericardial sac
In the evaluation of a 26-year-old patient with 4 months of secondary amenorrhea, you order serum prolactin and β-hCG assays. The β-hCG test is positive, and the prolactin level is 100 ng/mL (normal is < 25 ng/mL in nonpregnant women in this assay). This patient requires which of the following?
Evaluation for possible hypothyroidism
Bromocriptine to suppress prolactin
Repeat measurements of serum prolactin to ensure that values do not increase more than 300ng/mL
Computed tomography (CT) scan of her sella turcica to rule out pituitary adenoma
Routine obstetric care
In this patient, a benign gastric ulcer was found, and he was placed on a proton-pump inhibitor and triple antibiotics for Helicobacter pylori. He returns to the physician’s office 3 months later with similar complaints and, on re-evaluation, the gastric ulcer was found to persist. Which of the following is the most appropriate next step in management?
A trial of prostaglandins and re-evaluation in 2 months
A trial of sucralfate and re-evaluation in 2 months
Surgical management
A trial of H2 blockers with triple antibiotics and re-evaluation in 2 months
A second trial of proton-pump inhibitors with triple antibiotics and re-evaluation in 2 months
In your discussion with the patient regarding the risks and benefits of the different management options listed above, which of the following values should you quote regarding the expected 5-year survival rate following curative surgical resection?
5–10%
25–35%
40–50%
60–70%
15–20%
Incisional biopsy of a breast mass in a 35-year-old woman demonstrates cystosarcoma phyllodes at the time of frozen section. Which of the following is the most appropriate management strategy for this lesion?
Excision, postoperative radiotherapy, and systemic chemotherapy
Excision and postoperative radiotherapy
Lumpectomy and axillary lymphadenectomy
Modified radical mastectomy
Wide local excision with a rim of normal tissue
Mifepristone is an effective abortifacient if given within 72 hours of intercourse. Mifepristone contains which of the following?
High-dose estrogen only
Progestin only
Prostaglandin
Progesterone antagonist
Estrogen and progestin
On a newborn boy’s first examination, you note a prominent occiput, a broad forehead, and an absent anterior fontanelle. The baby’s head is long and narrow. The remainder of the physical examination, including a careful neurological evaluation, is normal. You note that the baby was born via cesarean section for cephalopelvic disproportion. When you enter the mother’s room, the first question she asks is about her baby’s head shape. Which of the following is the most appropriate statement to the mother about this infant’s condition?
The condition requires referral to a surgeon
The condition is associated with pituitary abnormalities
Patients with this condition usually develop seizures
The condition is usually associated with hydrocephalus
The condition is usually associated with other genetic defects
On a routine annual examination, a 43-year-old woman is found to have a 2-cm mass in the lateral aspect of her right breast. Which of the following is the most appropriate next step in management?
Mammography
Open biopsy
Segmental resection
Fine-needle aspiration
Repeat the breast examination after her next menses
On the 5th postoperative day, it is noticed that large amounts of clear, pink, salmon-colored fluid are soaking the wound dressings of a patient who had a negative exploratory laparotomy for a stab wound of the abdomen. The laparotomy was done through a midline supraumbilical and infraumbilical incision. When seen by the surgical staff, the patient is lying in bed in the supine position, with the dressings removed. In the dim light of his hospital room, the incision appears intact and not particularly red or inflamed, but there are indeed traces of the clear pink fluid on his skin. He has no specific complaints. He is still NPO and on IV fluids, but has already been passing gas per rectum, and plans had been made to feed him today. The abdomen is not distended, and he has normal bowel sounds. He is afebrile. Which of the following is the most appropriate next step in management?
Tape the wound securely, bind the abdomen, and avoid events that would suddenly increase his intra-abdominal pressure
Stop plans for oral feedings and start total parenteral nutrition
Help the patient out of bed and have him walk to the examining room for proper inspection of the wound
Gently probe the wound at several points until pus is found and drained
Culture the pink fluid and start empiric antibiotic therapy
One of your asthmatic patients arrives for a check-up. The mother reports that the child seems to need albuterol daily, especially when exercising, and she has coughing fits that awaken her from sleep about twice a week. Her grandmother had recommended a Chihuahua as a “cure” for her asthma, but her mother has seen no difference since the arrival of the pet. Appropriate treatment measures would include which of the following?
High-dose, inhaled corticosteroids with theophylline and short-actingβ-agonists
Medium-dose, inhaled corticosteroids with short-acting β-agonists
Inhaled nedocromil with short-actingβ-agonists
Short-acting, inhaled β-agonists, as needed
Daily leukotriene modifier with short-acting β-agonist
One of your patients with polycystic ovarian syndrome presents to the emergency room complaining of prolonged, heavy vaginal bleeding. She is 26 years old and has never been pregnant. She was taking birth control pills to regulate her periods until 4 months ago. She stopped taking them because she and her spouse want to try to get pregnant. She thought she might be pregnant because she had not had a period since her last one on the birth control pills 4 months ago. She started having vaginal bleeding 8 days ago. She has been doubling up on superabsorbant sanitary napkins 5 to 6 times daily since the bleeding began. On arrival at the emergency room, the patient has a supine blood pressure of 102/64 mm Hg with a pulse of 96 beats per minute. Upon standing, the patient feels light-headed. Her standing blood pressure is 108/66 mm Hg with a pulse of 126 beats per minute. While you wait for lab work to come back, you order intravenous hydration. After 2 hours, the patient is no longer orthostatic. Her pregnancy test comes back negative, and her Hct is 31%. She continues to have heavy bleeding. Which of the following is the best next step in the management of this patient?
Administer high-dose estrogen therapy
Administer antiprostaglandins
Send her home with a prescription for iron therapy
Perform a dilation and curettage
Administer a blood transfusion to treat her severe anemia
Renal ultrasound and intravenous pyelography (IVP) in a 65-year-old man evaluated for urinary incontinence reveal bilateral hydronephrosis. Which of the following is the most likely condition leading to this complication?
Alzheimer disease
Prostatic hyperplasia
Previous surgery
Normal pressure hydrocephalus
Age-associated detrusor overactivity
Six hours after undergoing laparoscopic bilateral inguinal hernia repairs, a 62-year-old man complains of suprapubic discomfort and fullness. He feels the need to void but has not been able to do so since the operation. There is a palpable suprapubic mass that is dull to percussion. Palpation of that mass exacerbates the symptoms. Which of the following is the most appropriate next step in management?
Loop diuretics
In and out bladder catheterization
Placement of indwelling Foley catheter
Increased rate of IV fluid administration
Abdominal x-ray films to ascertain the nature of the mass
Six months ago at the time of lumpectomy for breast cancer, a 60-year-old female attorney quit a 30-year smoking habit of 2 packs per day. She had the chest radiograph shown here as part of her routine follow-up examination. Based on her age and history of smoking, you are concerned for either a new primary lung or metastatic breast malignancy. Which of the following is the most appropriate next step in the management of this lesion?
Transthoracic fine-needle aspiration of the lesion
Thoracotomy with lobectomy
Mediastinoscopy
Magnetic resonance imaging of bilateral breasts to evaluate for recurrence of the breast cancer
Follow-up CT scan in 3 months
Stage Ib cervical cancer is diagnosed in a young woman who wishes to retain her ability to have sexual intercourse. Your consultant has therefore recommended a radical hysterectomy. Assuming that the cancer is confined to the cervix and that intraoperative biopsies are negative, which of the following structures would not be removed during the radical hysterectomy?
Uterosacral and uterovesical ligaments
The upper third of the vagina
Both ovaries
The entire parametrium on both sides of the cervix
Pelvic nodes
The 3-year-old sister of a newborn baby develops a cough diagnosed as pertussis by nasopharyngeal culture. The mother gives a history of having been immunized as a child. Which of the following is a correct statement regarding this clinical situation?
The 3-year-old sister should be immediately immunized with an additional dose of pertussis vaccine
Erythromycin should be administered to the infant
The risk to the infant depends on the immune status of the mother
Hyperimmune globulin is effective in protecting the infant
The mother has no risk of acquiring the disease because she was immunized
The father of a 1-week-old infant comes to the office in a panic. He has just noticed on his child a right anterior shoulder mass that seems ten- der. The father is an osteosarcoma survivor and fears the child has the same malignancy. In reviewing the baby’s discharge papers, you note the child was a term, appropriate-for-gestational-age vaginal delivery with a birth weight of 3200 g (7 lb, 1 oz). Apgar scores were 9 at 1 and 5 minutes. Your examination is significant for a large firm mass on the right clavicle; the rest of the examination is normal. Management of this problem should include which of the following?
Skin biopsy to test for osteogenesis imperfecta
Referral to an orthopedic surgeon
A biopsy of the mass for culture and cytology
Magnetic resonance imaging of the right shoulder
Reassurance and supportive care
The imaging studies demonstrate three lesions in the right hepatic lobe suspicious for metastatic disease, each measuring 3–4 cm in diameter. There was no evidence of extrahepatic disease. Which of the following is the most appropriate next step in management?
Repeat imaging studies in 3 months to determine the growth rate of the disease
Surgical resection
Radiation therapy to the liver
Systemic chemotherapy
Intra-arterial chemotherapy through the hepatic artery
The labor nurse calls you in your office regarding your patient who is 30 weeks pregnant and complaining of decreased fetal movement. The fetus is known to have a ventricular septal defect of the heart. The nurse has performed a nonstress test on the fetus. No contractions are seen. She thinks the tracing shows either a sinusoidal or saltatory fetal heart rate (FHR) pattern. Without actually reviewing the FHR tracing what can you tell the nurse?
The FHR tracing is probably not a sinusoidal FHR pattern because this pattern can be diagnosed only if the patient is in labor
The FHR tracing is probably not a saltatory FHR pattern because this pattern is almost always seen during rather than before labor
The FHR tracing of the premature fetus should be analyzed by different criteria than tracings obtained at term
Fetuses with congenital anomalies of the heart will invariably exhibit abnormal FHR patterns
Neither sinusoidal nor saltatory fetal heart rate patterns are seen in premature fetuses because of the immaturity of their autonomic nervous systems
The mother of a 2-year-old boy comes to the physician because her child awakens at night, with a blank gaze, screaming in bed without recognizing his parents. These episodes have occurred three times in the past 2 weeks, always in the first few hours of the night. The child goes back to sleep and seems to retain no memory of the episode the next morning. Which of the following is the most appropriate next step in management?
Therapy with chloral hydrate
Therapy with a tricyclic antidepressant
Avoidance of TV before going to bed
Behavioral therapy
Reassurance of parents about the nature of these manifestations
The mother of a 2-year-old girl reports that her daughter complains of burning when she urinates and that she has foul-smelling discharge from her vagina. She has some slight staining on the front of her underwear, but denies fever, nausea, vomiting, or other constitutional signs. The child does not attend day care, and she has demonstrated no change in behavior. The physical examination is normal with an intact hymen, but the child’s vulva is reddened and with a malodorous scent noted. Her urinalysis and culture are normal. Management of this condition includes which of the following?
Referral to social services for possible sexual abuse
Mebendazole to eradicate pinworm infestation
Advice to stop taking prolonged bubble baths
Progesterone cream to the affected area for a week
Complete genitourinary (GU) examination under general anesthesia
The mother of a 2-year-old male child states that she has noticed white, cheeselike material arising from his foreskin and also that he cannot fully retract the foreskin behind the glans penis. Which of the following is the correct advice for this parent?
Ultrasound of kidneys, bladder, and ureters is indicated to check for unidentified associated defects
The child likely has a previously undiagnosed hypospadias
The child is normal
The child has paraphimosis, and in addition to a circumcision, likely has an infection requiring topical antibiotics
The child has phimosis and requires a circumcision
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?
Removal of nasogastric tube, placement of a transpyloric tube and, after confirmation via radiograph of tube positioning, switching feeds from nasogastric to nasoduodenal
Stopping feeds, beginning intravenous fluids, ordering serial abdominal films, and initiating systemic antibiotics
Stool culture to identify the etiology of the bloody diarrhea and an infectious diseases consultation
Continued feeding of the infant, as gastroenteritis is usually self-limited
Surgical consultation for an emergent exploratory laparotomy
The parents of a 10-year-old girl with newly diagnosed, generalized tonic-clonic epilepsy come to the physician seeking advice regarding what they should do when the child has a seizure. Which of the following suggestions is appropriate?
Do not allow the child to return to her activities after recovery
Try to restrain the child during the seizure
Try to place the child on her side during the seizure
Put something in the child's mouth at the onset of seizure
Call an ambulance immediately as soon as seizure begins
The parents of a 14-year-old boy are concerned about his short stature and lack of sexual development. By history, you learn that his birth weight and length were 3 kg and 50 cm, respectively, and that he had a normal growth pattern, although he was always shorter than children his age. The physical examination is normal and his growth curve is shown on the next page. His upper-to-lower segment ratio is 0.98. A small amount of fine axillary and pubic hair is present. There is no scrotal pigmentation; his testes measure 4.0 cm3 and his penis is 6 cm in length. In this situation, which of the following is the most appropriate course of action?
Biopsy his testes
Obtain a computed tomographic (CT) scan of the pituitary area
Measure pituitary gonadotropin
Measure serum testosterone levels
Reassure the parents that the boy is normal
The parents of a 16-year-old girl bring their daughter to the Emergency Department due to their concerns regarding her recent behavior. Her mother reports, “She has always been a straight “A” student and has had an uneventful childhood until now.” Her developmental and medical history are insignificant except for a diagnosis of asthma when she was eight-years-old. Over the last two months, she has been spending time with new friends, dressing differently, and has become increasingly defiant. This morning, her parents received a call from her school counselor who reported that the patient missed three days of school last week and is in danger of having to attend next course because she is falling math. Last night, she did not return home until 3 am despite the fact that her curfew was 11 pm. The patient is annoyed and states, “What’s the big deal? I was just hanging out with my friends.” Initially, she refused to answer any questions. Her cooperation improves, however, when assessed without her parents present. Review of symptoms was negative and she confirms that her asthma was controlled. She denies abusing any substances. She confirms that her grades have dropped because she is tired of school. She also says, “I really don’t care if I fail, but I’m not going to next course. Me and my friends have plans.” She would not provide any further details. After interviewing both the parents and the adolescent individually, which of the following is the most appropriate course of action?
Reassure parents that the daughter’s behavior is normal
Obtain the patient’s academic records
Admit the patient t an adolescent psychiatric unit
Obtain a urine toxicology screen
Prescribe an SSRI antidepressant
The parents of a 16-year-old girl complain that she does not get enough sleep. They recently discovered that she stays awake most nights until 1:00 AM reading and text messaging her friends. She wakes at 6:30 AM for school, and complains of sleepiness during the day. On weekends she sleeps until noon. Her parents have tried taking away her computer and phone, but she still would go to bed at the same time. The parents are looking for advice in dealing with their “night owl” daughter. Which of the following is appropriate advice for this family?
Sleeping in on weekends should repay the “sleep debt”
Daytime sleepiness is a clear manifestation of an inadequate number of hours of sleep
Most teens get an adequate number of hours of sleep each night
Effects of puberty on melatonin cause a phase delay with later sleep onset
Teens need less sleep than adults
The patient continues to have a headache. She denies visual disturbances. Maternal Vital Sign: BP, 156/96 mm Hg; P, 89 beats/min Fetal Monitoring: Accelerations are present, good variability, no decelerations. Labs: CBC: White blood cells (WBCs), 6,300 /microL; hemoglobin (Hgb), 11.3 g/dL; hematocrit (Hct), 33.9%; platelets: 300,000/microL, CMP: Sodium, 127 mmol/L; potassium, 4. 7 mmol/L; chloride, 100 mmol/L; bicarbonate, 26 mmol/L; blood urea nitrogen (BUN), 10 mg/dL; creatinine, 0.9 mg/dL; glucose, 110 mg/dL, ALT: 22 IU/L, AST: 20 IU/L, Urinalysis: 2+ protein. What is the next step in the management of this patient?
Phenytoin
Induction of labor
Metformin
Magnesium sulfate
Delivery via C-section
The patient is a 25-year-old G1 P0 with an intrauterine pregnancy (IUP) at 24 weeks' gestation. She presents for her routine prenatal checkup. She has never had problems with blood pressure (BP). At her previous visit, her BP was 160/90 mm Hg. Now her vital sign: BP, 155/90 mm Hg; P, 85 beats/min; R, 12 breaths/min; T, 98F (37 C). She denies chest pain, denies shortness of breath, denies headache and blurry vision, denies abdominal pain and contractions, denies leakage of fluid, denies vaginal bleeding, fetal movement: present. Physical examination: cardiovascular: S1S2+ RRR no murmur, no rale, no gallop, lung: CTA bilaterally, extremities: 1+ edema, fundal height: 23 cm, fetal heart rate: 150s. What is the next step in the management of this patient?
Perform renal ultrasonography
Start lisinopril
Prescribe hydrochlorothiazide
Check urine dipstick
Observe BP
Two days after admission to the hospital for a myocardial infarction, a 65-year-old man complains of severe, unremitting midabdominal pain. His cardiac index is 1.6. Physical examination is remarkable for an absence of peritoneal irritation or distention despite the patient’s persistent complaint of severe pain. Serum lactate is 9 mmol/L (normal is < 3 mmol/L). Which of the following is the most appropriate next step in this patient’s management?
Defer decision to explore the abdomen until the arterial lactate is greater than 10mmol/L
Perform flexible sigmoidoscopy to assess the distal colon and rectum
Perform computed tomography
Perform laparoscopy
Perform mesenteric angiography
Two students from a university dormitory building have contracted meningitis due to Neisseria meningitides. Which of the following students in the dormitory are most likely to benefit from chemoprophylaxis?
Everybody in the dormitory, with meningococcal vaccine
Close contacts only, with oral rifampin
Everybody in the dormitory, with oral rifampin
Close contacts only, with oral amoxicillin
Everybody in the dormitory, with oral amoxicillin
Two weeks after hospital discharge for documented myocardial infarction, a 65-year-old returns to your office concerned about low-grade fever and pleuritic chest pain. There is no associated shortness of breath. Lungs are clear to auscultation and the heart is free of murmur, gallop, or rub. ECG is unchanged from the last one in the hospital. Which therapy is most likely to be effective?
An increase in antianginal medication
An anxiolytic agent
Anticoagulation with warfarin (Coumadin)
An anti-inflammatory agent
Antibiotics
While discussing a case presentation with a medical student, a nearby patient who just returned from getting an ankle radiograph done yells out in pain. You walk over to him and ask what is wrong. He states that since returning from the radiology suite, his automatic implantable cardioverter defibrillator (AICD) is discharging. You hook him up to the monitor and note that his rhythm is sinus. You observe a third shock while the patient is in sinus rhythm. Which of the following is the most appropriate next step in management?
Make a small incision over his chest wall and remove the AICD generator and leads
Place a magnet over the AICD generator to inactivate it and thereby prevent further shocks
Admit the patient to the telemetry unit to monitor his rhythm and find the cause of his AICD discharge
Administer pain medication and wait until the device representative arrives at the hospital to power off the AICD
Send the patient back to the radiology suite for another radiograph to desensitize his AICD
While playing football, a college student injures his shoulder. He comes in with his arm held close to his body, complaining of pain over the clavicle, rather than the shoulder joint. Physical examination shows a normal shoulder, but there is point tenderness at the junction of the middle and distal thirds of the clavicle. Gentle pressure elicits a gritty feeling of bone crunching on bone. He has normal pulses on that arm. After appropriate x-ray studies are performed, which of the following is the most appropriate initial step in management?
Open reduction and internal fixation
Arteriogram of the subclavian vessels
Immobilization by a figure-eight device
Immobilization by hanging cast
Analgesics only
While running to catch a bus, and old man twists his ankle and falls on his inverted foot. Anteroposterior (AP), lateral, and mortise x-ray films show displaced fractures of both malleoli. Which of the following would be the preferred form of treatment?
Closed reduction and casting
Fusion of the ankle joint
Replacement with a metal prosthesis
Open reduction and internal fixation
Skeletal traction
While working as the attending pediatrician in the neonatai ICU, you are called by nursing to examine a two-day-old male child who has recently begun vomiting. The child has failed to pass meconium since birth. Physical examination demonstrates significant abdominal distention. A rectal examination reveals no stool in the vault. You strongly suspect Hirschsprung disease and inform the child's mother that an abdominal radiograph and barium enema are necessary. The mother forbids you from proceeding with any further testing or procedures because she does not believe "there is anything wrong." What is the most appropriate next step?
Wait until the mother provides consent
Contact the hospital's ethics committee for guidance
Agree not to perform the tests
Obtain a court order to authorize testing
Proceed with tests
While working as the medical resident on call, you are paged to see a 72-year-old woman who complains of a headache. Upon seeing you, she snaps, "You look young and foolish. I hope you're more efficient than you seem." While you are performing a basic physical examination on her, she says, "I'm going to complain to the hospital administrators about you because you have no idea how to properly deal with a patient." Which of the following is the best response to her threat?
"Would you prefer that my attending see you instead?"
"You seem to be angry, and I don't know why."
"Feel free to do as you please."
"You're hurting me with your comments."
"Please allow me to complete the physical examination first."
While working on-site at a factory doing physical examinations for workers, a physician is suddenly called to help a worker who amputated his finger. Which of the following is the most appropriate next step in management in this situation?
Place the amputated finger in a plastic bag with water and bring it along with the patient to the emergency department
Place the amputated finger in saline moistened gauze in a plastic bag: place the bag on a bed of ice and bring it along with the patient to the emergency department
Place the amputated finger in a plastic bag with alcohol; place the bag on a bed of ice and bring it along with the patient to the emergency department
Place the amputated finger on a bed of ice and bring it along with the patient to the emergency department
Place the amputated finger in antiseptic solution and bring it along with the patient to the emergency department
You are a physician in charge of patients who reside in a nursing home. Several of the patients have developed influenza-like symptoms, and the community is in the midst of influenza A outbreak. None of the nursing home residents have received the influenza vaccine. Which course of action is most appropriate?
Give the influenza vaccine to all residents who do not have a contraindication to the vaccine; also give oseltamivir for 2 weeks to all residents
Give the influenza vaccine to all residents who do not have a contraindication to the vaccine (ie, allergy to eggs)
Do not give any prophylactic regimen
Give azithromycin to all residents to prevent influenza-associated pneumonia
Give amantadine alone to all residents
You are admitting to the hospital a 3-month-old infant who has been having poor feeding, emesis, and diarrhea for 3 days. In the emergency center, her electrolytes were found to be: sodium 157 mEq/L, potassium 2.6 mEq/L, chloride120 mEq/L, bicarbonate 14 mEq/L,creatinine1.8 mEq/L, blood urea nitrogen(BUN) 68 mEq/L, and glucose195 mEq/L. She was given a fluid bolus in the emergency center and has subsequently produced urine. Which of the following is the most appropriate next step in her management?
Rehydration with free water
Continued rapid volume expansion with 1/4 normal saline
Urinary electrolytes
Slow rehydration over 48 hours
Packed red blood cells (RBCs)
You are advised by the obstetrician that the mother of a baby she has delivered is a carrier of hepatitis B surface antigen (HBsAg-positive). Which of the following is the most appropriate action in managing this infant?
Do nothing because transplacentally acquired antibody will prevent infection in the infant
Administer hepatitis B immune globulin and hepatitis B vaccine to the infant
Screen the mother for hepatitis B “e”antigen (HBeAg)
Isolate the infant with enteric precautions
Screen the infant for HBsAg
You are asked to assist in the well-born nursery with neonatal care. Which of the following is a part of routine care in a healthy infant?
Placement of a computer chip in left buttock for identification purposes
Cool-water bath to remove vernix
Administration of hepatitis B vaccination for routine immunization
Administration of vitamin A to prevent bleeding problems
Administration of ceftriaxone cream to the eyes for prophylaxis for gonorrhea and chlamydia
You are asked to consult on a 23-year-old woman who is 18hours status-post cesarean delivery. She presented 20 hours ago, at 32 weeks’ gestation, with vaginal bleeding and contractions and a nonreassuring fetal heart rate tracing. She was rushed to the operating room for an emergent cesarean delivery. The placenta had a large retroplacental clot. The infant is in the neonatal intensive care unit. On examination, the patient has a temperature of 37.7C (99.9 F), blood pressure of 110/60 mm Hg, pulse of 124/min, and respirations of 14/min. The patient has bleeding from her abdominal incision and her intravenous sites. Laboratory studies show: Hematocrit: 18%; Leuckocytes: 16,000/mm3; Platelets: 62,000/mm3; Prothrombin time: 60sec; Partial thromboplastin time: 100sec. Appropriate management includes which of the following?
Fresh frozen plasma (FFP)
Penicillin
Terbutaline
Heparin
Magnesium sulfate
You are asked to evaluate a 4-year-old boy admitted to your local children’s hospital with a diagnosis of pneumonia. The parents state that the child has had multiple, intermittent episodes of fever and respiratory difficulty over the past 2 years, including cyanosis, wheezing, and dyspnea; each episode lasts for about 3 days. During each event he has a small amount of hemoptysis, is diagnosed with left lower lobe pneumonia, and improves upon treatment. Repeat radiographs done several days after each event are reportedly normal. His examination on the current admission is significant for findings similar to those described above, as well as digital clubbing. Which of the following is the most appropriate primary recommendation?
Nasal swab for viral culture
Bronchoalveolar lavage
Incentive spirometry
Modified barium swallow study to evaluate for aspiration
Intravenous cephalosporin and oral macrolide therapy
You are awakened in the night by your 2-year-old son, who has developed noisy breathing on inspiration, marked retractions of the chest wall, flaring of the nostrils, and a barking cough. He has had a mild upper respiratory infection (URI) for 2 days. Which of the following therapies is indicated?
Inhaled epinephrine and a dose of steroids
Rigid bronchoscopy
Observation for hypoxia and dehydration alone
Short-acting bronchodilators and a 5-day course of steroids
Intubation and antibiotics
You are called by a general practitioner to consult on a patient admit- ted to the hospital 4 days ago. The patient is a 7-month-old white boy with poor weight gain for the past 3 months, who has not gained weight in the hospital despite seemingly adequate nutrition. You take a detailed diet history from his foster mother, and the amounts of formula and baby food intake seem appropriate for age. Physical examination reveals an active, alert infant with a strong suck reflex who appears wasted. You note generalized lymphadenopathy with hepatomegaly. In addition, you find a severe case of oral candidiasis that apparently has been resistant to treatment. Which of the following is the most appropriate next step in the evaluation or treatment of this child?
Increase caloric intake because this is probably a case of underfeeding
Order human immunodeficiency virus (HIV) polymerase chain reaction (PCR). Testing because this is likely the presentation of congenitally acquired HIV
Send stool for fecal fat because this is probably a malabsorption syndrome
Perform a sweat chloride test because this is probably cystic fibrosis
Draw blood cultures because this could be sepsis
You are called by the hospice nurse to evaluate a 74-year-old man who refuses to eat. He has terminal colon cancer, which was diagnosed 8 months ago and has metastasized to his liver. He has already gone through chemotherapy with 5-Fiourouracil + oxaliplatin. During the past 4 months, his condition has gotten extremely worse. He has lost 501bs (27.6kg), and currently appears totally wasted. As you approach him, he says, "I don't feel like eating anything, and I don't want any more procedures, but I'll drink any pill that can make me feel better." His abdomen is distended with positive fluid thrills. His liver has several palpable nodules. What is the best pharmacological agent of choice for this patient's anorexia?
Megestrol acetate
Ondansetron
Metoclopramide
Dexamethasone
Dimenhydrinate
You are called to a delivery of a term infant, about to be born via cesarean section to a mother with multiple medical problems, including a 1-month history of a seizure disorder, for which she takes phenytoin; rheumatic heart disease, for which she must take penicillin daily for life; hypertension, for which she takes propranolol; acid reflux, for which she takes aluminum hydroxide; and a deep venous thrombosis in her left calf diagnosed 2 days ago, for which she was started on a heparin infusion. The obstetrician is concerned about the possible effects of the mother’s multiple medications on the newborn infant. Which of the following medications is most likely to cause harm in this newborn infant at delivery?
Propranolol
Aluminum hydroxide
Phenytoin
Heparin
Penicillin
You are called to examine a newly delivered infant, who is 41 weeks gestation and a product of an uncomplicated pregnancy. Physical examination reveals a matted mass of edematous bowel loops protruding from the abdomen. There is no covering over the bowel loops. The umbilical cord appears normal. Which of the following is the best next step in the management of this patient?
Immediate surgery
Initiate broad-spectrum antibiotics
Look for associated anomalies
Sterile wrapping of exposed bowel
Intravenous nutrition
You are called to see a 37-year-old G4P4 for a fever to 38.7C (101.8F). She is postoperative day 3 after cesarean delivery for arrest of active-phase labor. She underwent a long induction for postdate pregnancy and had rupture of membranes for more than 18 hours. Her other vital signs include pulse 118 beats per minute, respiratory rate 16 breaths per minute, and blood pressure 120/80 mm Hg. She complains of some incisional and abdominal pain, but is otherwise fine. HEENT, lung, breast, and cardiac examinations are within normal limits. On abdominal examination she has uterine fundal tenderness. Her incision has mild erythema around the staple edges and serous drainage along the left side. Pelvic examination reveals a tender uterus, but no adnexal masses. Which of the following is the most appropriate antibiotic to treat this patient with initially?
Oral Bactrim
Oral dicloxacillin
Intravenous cefotetan
Intravenous gentamicin
Oral ciprofloxacin
You are called to the oncology floor to examine a 57-year-old female who is complaining of severe nausea and vomiting. Her other symptoms include some general malaise and a sore throat. She is receiving combination ABVD chemotherapy (Doxorubicin, Bleomycin, Prednisone, and Procarbazine). She was diagnosed with stage II Hodgkin's lymphoma 4 weeks ago. She tells you that she does not want to continue her therapy anymore since it is "making life even more miserable." She has lost 30 lbs (12.6kg) in a month. Her temperature is 38.5°C (101.3°F), pulse is 88/min, respirations are 18/min, and blood pressure is 109/68mm Hg. Her pulse oximetry reading in room air is 92%. Physical examination reveals a significantly cachectic patient with a dry mouth, enlarged cervical lymph nodes and hepatomegaly. How can this patient's vomiting be best managed?
Tell the patient that her nausea will get better with time
Prochlorperazine
Stop the chemotherapy drugs
Ondansetron
Metoclopramide
You are counseling a 24-year-old woman who is a G2P1 at 36 weeks gestation. She delivered her first baby at 41 weeks gestation by cesarean section as a result of fetal distress that occurred during an induction of labor for mild preeclampsia. She would like to know if she can have a trial of labor with this pregnancy. Which of the following is the best response to this patient?
Yes, but only if she had a classical cesarean section
Yes, but only if her uterine incision was made in the uterine fundus
No, because once she has had a cesarean section she must deliver all of her subsequent children by cesarean section
Yes, but only if she had a low transverse cesarean section
No, since she has never had a vaginal delivery
You are counseling a new mother and father on the risks and benefits of circumcision for their 1-day-old son. The parents ask if you will use analgesia during the circumcision. What do you tell them regarding the recommendations for administering pain medicine for circumcisions?
The administration of sugar orally during the procedure will keep the neonate preoccupied and happy
Analgesia in the form of a penile block is recommended
Analgesia in the form of oral Tylenol is the pain medicine of choice recommended for circumcisions
Analgesia is not recommended because it is unsafe in newborns
Analgesia is not recommended because there is no evidence that newborns undergoing circumcision experience pain
You are delivering a 26-year-old G3P2002 at 40 weeks. She has a history of two previous uncomplicated vaginal deliveries and has had no complications this pregnancy. After 15 minutes of pushing, the baby’s head delivers spontaneously, but then retracts back against the perineum. As you apply gentle downward traction to the head, the baby’s anterior shoulder fails to deliver. Which of the following is the best next step in the management of this patient?
Push the baby’s head back into the pelvis
Instruct the nurse to apply fundal pressure
Perform a Zavanelli maneuver
Call for help
Cut a symphysiotomy
You are discussing surgical options with a patient with symptomatic pelvic relaxation. Partial colpocleisis (Le Fort procedure) may be more appropriate than vaginal hysterectomy and anterior and posterior (A&P) repair for patients in which of the following circumstances?
Do not desire retained sexual function
Have a history of urinary incontinence
Have cervical dysplasia that requires colposcopic evaluation
Need periodic endometrial sampling
Have had endometrial dysplasia
You are doing postpartum rounds on a 23-year-old G1P1 who is postpartum day 2 after an uncomplicated vaginal delivery. As you walk in the room, you note that she is crying. She states she can’t seem to help it. She denies feeling sad or anxious. She has not been sleeping well because of getting up every 2 to 3 hours to breast-feed her new baby. Her past medical history is unremarkable. Which of the following is the most appropriate treatment recommendation?
Referral to a psychiatrist who can administer electroconvulsive therapy
Referral to psychiatry for admission to a psychiatry ward and therapy with Haldol
A sleep aid
Referral to psychiatry for counseling and antidepressant therapy
Time and reassurance, because this condition is self-limited
You are examining a newborn infant in the well-baby nursery. The infant was the product of a benign pregnancy and vaginal delivery; he appears to be in no distress. Interestingly, your measurement of fronto- occipital head circumference is about 2 cm larger than the initial measurement done several hours before. Your examination otherwise is significant for tachycardia and a “squishy” feel to the entire scalp. You can elicit a fluid wave over the scalp. Management of this condition should include which of the following?
Surgical drainage
Elevation of the head of the crib
CT scan of the skull with bone windows
Transfer to the newborn ICU
Observation and parental reassurance
You are following a 22-year-old G2P1 at 39 weeks during her labor. She is given an epidural for pain management. Three hours after administrating the pain medication, the patient’s cervical examination is unchanged. Her contractions are now every 2 to 3 minutes, lasting 60 seconds. The fetal heart rate tracing is 120 beats per minute with accelerations and early decelerations. Which of the following is the best next step in management of this patient?
Administer Pitocin for augmentation of labor
Prepare for a cesarean section secondary to a diagnosis of secondary arrest of labor
Place a fetal scalp electrode
Rebolus the patient’s epidural
Place an IUPC
You are following a 38-year-old G2P1 at 39 weeks in labor. She has had one prior vaginal delivery of a 3800-g infant. One week ago, the estimated fetal weight was 3200 g by ultrasound. Over the past 3 hours her cervical examination remains unchanged at 6 cm. Fetal heart rate tracing is reactive. An intrauterine pressure catheter (IUPC) reveals two contractions in 10 minutes with amplitude of 40 mm Hg each. Which of the following is the best management for this patient?
Ambulation
Cesarean section
Expectant
Sedation
Administration of oxytocin
You are making rounds on a 29-year-old G1P1 who underwent an uncomplicated vaginal delivery at term on the previous day. The patient is still very confused about whether she wants to breast-feed. She is a very busy lawyer and is planning on going back to work in 4 weeks, and she does not think that she has the time and dedication that breast-feeding requires. She asks you what you think is best for her to do. Which of the following is an accurate statement regarding breast-feeding?
Breast-feeding is associated with a decreased incidence of childhood attention deficit disorder
Breast-feeding is associated with an increased incidence of childhood obesity
Breast-feeding is a poor source of nutrients for required infant growth
Breast-feeding is associated with a decreased incidence of sudden infant death syndrome
Breast-feeding decreases the time to return of normal menstrual cycles
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?
Reassure the mother that he will outgrow it
Refer immediately to ophthalmology
Defer patching or ophthalmologic examination until the child is older and better able to cooperate
Patch the eye with the greater refractive error
Patch the eye that deviates
You are seeing a 2-year-old child, brought by his father for a well-child examination. In providing age-appropriate anticipatory guidance, you should tell him which of the following?
Teach the child to swim so that the parents have the ability to allow the child to be alone in pools
Purchase a bed alarm to assist with the child’s nocturnal enuresis
Milk should be switched from whole to skim or low fat
Continue rear facing car seats
He should set his water heater to 71 C (160 F) to ensure the sterility of dishes and clothes, thereby decreasing the risk of infections
You are seeing a 38-year-old woman for her annual gynecologic examination. She asks you for some information regarding the HPV vaccine and whether you think it would be appropriate for her 17-year-old daughter. Which of the following statements regarding the quadrivalent human papillomavirus vaccine and HPV is true?
Women with a prior history of abnormal Pap smears are not candidates for vaccination
The vaccine is prepared from the proteins of four oncogenic (e.g., high-risk for cervical cancer) strains of HPV
The vaccine is given every month for 3 months
After vaccination, women no longer need routine Pap smears
The vaccine is recommended for women ages 11–26 but can be given as young as age 9
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?
Referral to social services for possible sexual abuse
Karyotypestudies
Topical steroid cream for a week
Surgical consultation for correction
Topical estrogen cream daily for a week
You are seeing a 41-year-old woman and her 19-year-old daughter in the emergency room because they think that they have been poisoned. The woman states that they have not been getting along with their landlord lately because they have been late on their last few rent payments. They say that the landlord is harassing them by banging on their floor at all hours of the night, turning down their heat, and asking the other tenants to spy on them. Last month, the woman thinks the landlord tried to spy on them by installing video cameras in her living room while they were out. Today, she tasted something odd in her food, and is convinced that she and her daughter have been poisoned in an attempt to get them out of the apartment once and for all. She came immediately to the hospital for treatment and to collect evidence of the poisoning. The mother is very protective of her daughter, who seems rather submissive and passive. She completely agrees with her mother's description of the events. Which of the following is the best course of action?
Admit the mother and the daughter to different psychiatric units
Admit the mother and the daughter to the same psychiatric unit
Admit the daughter to the psychiatric unit for treatment, but not the mother
Admit the mother to the psychiatric unit for treatment, but not the daughter
Discharge both the mother and the daughter after a complete physical examination and blood tests
You are seeing a 45-year-old female patient of your partner for the first time in your clinic. A quick review of the patient’s medical record shows that her systolic blood pressure was greater than 140 mmHg at both of her last clinic appointments. Her medical history is otherwise significant only for diabetes mellitus. Her blood pressure today is 164/92 mmHg. What is the best next step in her blood pressure management?
Arrange for echocardiogram to assess for end-organ damage
Prescribe a dihydropyridine calcium-channel blocker in addition to a heart healthy diet
Prescribe an ACE inhibitor in addition to heart healthy diet
Advise the patient to begin a heart healthy, low sodium diet and refer to a nutritionist
Ask the patient to keep a written record of her blood pressure and bring with her to a return appointment
You are seeing a patient in the emergency room who complains of fever, chills, flank pain, and blood in her urine. She has had severe nausea and started vomiting after the fever developed. She was diagnosed with a urinary tract infection 3 days ago by her primary care physician. The patient never took the antibiotics that she was prescribed because her symptoms improved after she started drinking cranberry juice. The patient has a temperature of 38.8C (102F). She has severe right-sided CVA tenderness. She has severe suprapubic tenderness. Her clean-catch urinalysis shows a large amount of ketones, RBCs, WBCs, bacteria, and squamous cells. Which of the following is the most appropriate next step in the management of this patient?
Arrange for a home health agency to go to the patient’s home to administer IV fluids and oral antibiotics
Admit the patient for an intravenous pyelogram and consultation with a urologist
Admit the patient for diagnostic laparoscopy
Admit the patient for IV fluids and IV antibiotics
Tell her to take the oral antibiotics that she was prescribed and give her a prescription of Phenergan rectal suppositories
You are seeing a patient in the hospital for decreased fetal movement at 36 weeks gestation. She is healthy and has had no prenatal complications. You order a BPP. The patient receives a score of 8 on the test. Two points were deducted for lack of fetal breathing movements. How should you counsel the patient regarding the results of the BPP?
The results are abnormal, and she should undergo umbilical artery Doppler velocimetry
The results are abnormal, and she should undergo emergent cesarean section
The results are normal, and she can go home
The results are abnormal, and she should be induced
The results are equivocal, and she should have a repeat BPP within 24 hours
You are seeing an established patient, a 4-year-old girl brought in by her mother for vaginal itching and irritation. She is toilet trained and has not complained of frequency or urgency, nor has she noted any blood in her urine. Her mother noted she has been afebrile and has not complained of abdominal pain. Mom denies the risk of inappropriate contact; the girl also denies anyone “touching her there.” Your physical examination of the perineum is significant for the lack of foul odor or discharge. You do note some erythema of the vulvar area but no evidence of trauma. Which of the following is the most appropriate course of action?
Treat with an antifungal cream for suspected yeast infection
Swab for gonorrhea and plate on chocolate agar, and send urine for Chlamydia
Refer to social services for suspected physical or sexual abuse
Counsel mother to stop giving the girl bubble baths, have the girl wear only cotton underwear, and improve hygiene
Refer to pediatric gynecology for removal under anesthesia of a suspected foreign body in the vagina
You are the physician on call for the extracorporeal membrane oxygenation (ECMO) service. There are 5 calls today, but only one machine and one technologist available. Which of the following patients is the most appropriate recipient of this service?
A 3-day-old boy preoperative for a congenital diaphragmatic hernia
A 5-year-old girl with rhabdomyosarcoma metastatic to the lungs
A neonate with a diagnosis of severe pulmonary hypoplasia who is in respiratory failure
75-year-old man with Alzheimer disease, severe pneumonia, and elevated pulmonary arterial pressure
A 1-day-old, full-term, anencephalic 4-kg boy suffering from meconium aspiration syndrome and hypoxia
You are treating a 31-year-old woman with danazol for endometriosis. You should warn the patient of potential side effects of prolonged treatment with the medication. When used in the treatment of endometriosis, which of the following changes should the patient expect?
Postcoital bleeding caused by the inflammatory effect of danazol on the endocervical and endometrial glands
More frequent Pap smear screening, since danazol exposure is a risk factor for cervical dysplasia
Heavier or prolonged periods, since danazol causes endometrial hyperplasia
Lighter or absent menstruation, since danazol causes endometrial atrophy
Occasional pelvic pain, since danazol commonly causes ovarian enlargement
You are volunteering with a dental colleague in a community indigent clinic. A nurse has prepared a list of patients who are scheduled for a dental procedure and may need antibiotic prophylaxis beforehand. Of the patients listed below, who would be most likely to benefit from antibiotic prophylaxis to prevent infective endocarditis?
65-year-old male with prosthetic aortic valve
42-year-old female with mitral valve prolapse
26-year-old female with a ventricular septal defect repaired in childhood
17-year-old male with coarctation of the aorta
72-year-old female with aortic stenosis
You evaluate a 48-year-old man for chronic renal insufficiency. He has a history of hypertension, osteoarthritis, and gout. He currently has no complaints. His medical regimen includes lisinopril 40 mg daily, hydro-chlorothiazide 25 mg daily, allopurinol 300 mg daily, and acetaminophen for his joint pains. He does not smoke but drinks 8 oz of wine on a daily basis. Examination shows BP 146/86 mm Hg, pulse 76, a soft S4 gallop, and mild peripheral edema. There is no abdominal bruit. His UA reveals 1+ proteinuria and no cellular elements. Serum creatinine is 2.2 mg/dL and his estimated GFR from the MDRD formula is 42 mL/minute. What is the most important element is preventing progression of his renal disease?
Changing the lisinopril to losartan
Obtaining a CT renal arteriogram to exclude renal artery stenosis
Adding a calcium channel blocker to improve blood pressure control
Discontinuing all alcohol consumption
Discontinuing acetaminophen
You evaluate an 18-year-old man who sustained a right-sided cervical laceration during a gang fight. Your intern suggests nonoperative management and observation. Which of the following is a relative, rather than an absolute, indication for neck exploration?
Expanding hematoma
Dysphonia
Pneumothorax
Hemoptysis
Dysphagia
You have an 11-day-old term infant in your office for a well-child visit. The mother notes that she received a letter that day from the state’s Department of Health reporting that her child’s newborn screen had come back abnormal, indicating possible galactosemia. Which of the following is the most appropriate management at this point?
Discontinue breast-feeding and initiate soy formula feedings
Ultrasound of pancreas
Refer to endocrinology for evaluation
Supplement her breast-feeding with a multivitamin
Discontinue oral feeds and begin total parenteral nutrition
You have been asked to evaluate a 42-year-old white male smoker who presented to the emergency department with sudden onset of crushing substernal chest pain, nausea, diaphoresis and shortness of breath. His initial ECG revealed ST segment elevation in the anterior-septal leads. Cardiac enzymes were normal. The patient underwent emergent cardiac catheterization, which revealed only a 25% stenosis of the left anterior descending (LAD) artery. No percutaneous intervention was performed. Which of the following interventions would most likely reduce his risk of similar episodes in the future?
Beginning therapy with a calcium-channel blocker
Beginning therapy with an ACE inhibitor
Beginning therapy with a beta-blocker
Placement of a percutaneous non-drug-eluting coronary artery stent
Placement of a percutaneous drug-eluting coronary artery stent
You have just diagnosed a 21-year-old infertile woman with polycystic ovarian syndrome. The remainder of the infertility evaluation, including the patient’s hysterosalpingogram and her husband’s semen analysis, were normal. Her periods are very unpredictable, usually coming every 3 to 6 months. She would like your advice on the best way to conceive now that you have made a diagnosis. Which of the following treatment options is the most appropriate first step in treating this patient?
Dexamethasone
In vitro fertilization
Metformin
Gonadotropins
Artificial insemination
You have just given a 10-year-old boy an injection of pollen extract as prescribed by his allergist. You are about to move on to the next patient when the boy starts to complain about nausea and a funny feeling in his chest. You note that his face is flushed and his voice sounds muffled and strained. Which of the following is the first priority in managing this episode of anaphylaxis?
Subcutaneous injection of 1:1000 epinephrine
Administration of corticosteroids
Intramuscular injection of diphenhydramine
Administration of oxygen
Preparation for endotracheal intubation
You have just performed diagnostic laparoscopy on a patient with chronic pelvic pain and dyspareunia. The patient had multiple implants of endometriosis on the uterosacral ligaments and ovaries and several on the rectosigmoid colon. At the time of the procedure, you ablated all of the visible lesions on the peritoneal surfaces with the CO2 laser. But because of the extent of the patient’s disease, you recommend postoperative medical treatment. Which of the following medications is the best option for the treatment of this patient’s endometriosis?
Continuous unopposed oral estrogen
Danazol
Gonadotropins
Parlodel
Dexamethasone
You performed a forceps-assisted vaginal delivery on a 20-year-old G1 at 40 weeks for maternal exhaustion. The patient had pushed for 3 hours with an epidural for pain management. A second-degree episiotomy was cut to facilitate delivery. Eight hours after delivery, you are called to see the patient because she is unable to void and complains of severe pain. On examination you note a large fluctuant purple mass inside the vagina. What is the best management for this patient?
Perform dilation and curettage to remove retained placenta
Place a vaginal pack for 24 hours
Incision and evacuation of the hematoma
Apply an ice pack to the perineum
Embolize the internal iliac artery
You receive a call from the parents of a 1 year old who is due for his well-child visit next week. They have just received a letter from their daycare center that an employee has hepatitis A. Which of the following is the best treatment plan?
Give hepatitis A immune globulin and hepatitis A vaccine
Give hepatitis A vaccine
No treatment is needed
Obtain hepatitis A serology and give hepatitis A vaccine
Treat with hepatitis A immune globulin
You receive a telephone call from the mother of a 4-year-old child with sickle-cell anemia. She tells you that the child is breathing fast, coughing, and has a temperature of 40°C (104°F). Which of the following is the most conservative, prudent course of action?
Admit the child to the hospital
Refer the child to the laboratory for an immediate hematocrit, white blood cell count, and differential
Make an office appointment for the next day
Make an office appointment for the next available opening
Prescribe aspirin and ask her to call back if the fever does not respond
You recently evaluated a 28-year-old woman who presented with complaints of shakiness and heat intolerance. The patient plans to have children and is currently using no contraception. On examination you noted tachycardia with an HR of 102, a fine tremor, a diffuse goiter, and proptosis. You now have the laboratory results and note a TSH < 0.001, elevated total T4 of 17.8, and increased T3 uptake. Radionuclide uptake by the thyroid gland is elevated. You tell her that she has Graves’ disease. What is the best treatment plan for this patient?
Propylthiouracil
Thyroid surgery
Oral corticosteroids
Radioactive iodine
Propranolol
You see five postmenopausal patients in the clinic. Each patient has one of the conditions listed, and each patient wishes to begin hormone replacement therapy today. Which one of the following patients would you start on therapy at the time of this visit?
Liver disease with abnormal liver function tests
Treated stage III endometrial cancer
Undiagnosed genital tract bleeding
Mild essential hypertension
Malignant melanoma
Your patient had an ultrasound examination today at 39 weeks gestation for size less than dates. The ultrasound showed oligohydramnios with an amniotic fluid index of 1.5 centimeters. The patient’s cervix is unfavorable. Which of the following is the best next step in the management of this patient?
Administer a cervical ripening agent in your office and have the patient present to the hospital in the morning for induction with oxytocin
Perform stripping of the fetal membranes and perform a BPP in 2 days
Write her a prescription for misoprostol to take at home orally every 4 hours until she goes into labor
Admit her to the hospital for cervical ripening then induction of labor
Admit her to the hospital for cesarean delivery
Your patient is a 48-year-old Hispanic male with a 4-year history of diabetes mellitus type 2. He is currently utilizing NPH insulin/Regular insulin 40/20 units prior to breakfast and 20/10 units prior to supper. His supper time has become variable due to a new job and ranges from 5 to 8 PM. In reviewing his glucose diary, you note some very low readings (40-60 mg/dL) during the past few weeks at 3 AM. When he awakens to urinate, he feels sweaty or jittery so has been checking a fingerstick blood glucose. Morning glucose levels following these episodes are always higher (200-250) than his average fasting glucose level (120-150). Which change in his insulin regimen is most likely to resolve this patient’s early AM hypoglycemic episodes?
Change regimen to glargine at bedtime with lispro prior to each meal
Discontinue both NPH and regular insulin; implement sliding scale regular insulin with meals
Change regimen to glargine at bedtime and continue morning and evening regular insulin
Decrease morning NPH and decrease evening regular insulin
Increase morning NPH and decrease evening NPH
Your patient presents with a complaint of a mass on her right cheek, which has been slowly enlarging. Biopsy shows a pleomorphic adenoma. Which is the next step in her management?
Total parotidectomy with resection of the facial nerve
Enucleation of the adenoma
Total parotidectomy with preservation of the facial nerve
Superficial parotidectomy with resection of the facial nerve
Superficial parotidectomy with preservation of the facial nerve
A 59-year-old man presents to the ED with left-sided chest pain and shortness of breath that began 2 hours prior to arrival. He states the pain is pressure-like and radiates down his left arm. He is diaphoretic. His BP is 160/80 mmHg, HR 86 beats per minute, and RR 15 breaths per minute. ECG reveals 2-mm ST-segment elevation in leads I, aVL, and V 3 to V 6. Which of the following is an absolute contraindication to receiving thrombolytic therapy?
Total hip replacement 3 months ago
Previous hemorrhagic stroke
Peptic ulcer disease
Systolic BP (SBP) greater than 180 mm Hg
Patient on Coumadin and aspirin
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?
Observation
DC cardioversion
Verapamil
Amiodarone
Digoxin
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