DES C_Management (14) Prepared : CHILLY

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?