Management USMLE 7 (907-1000)

A 50-year-old man comes to the emergency department due to acute onset respiratory difficulty. He also has periorbital, circumoral and facial edema. Two weeks ago, he experienced chest pain, profuse sweating and anxiety, and was subsequently admitted to the cardiac intensive care unit. At that time, his ECG showed ST segment elevation and Q waves in the inferior leads. He was taken to the catheterization lab and had an angioplasty with stent done for 100% occlusion of the right coronary artery. He was discharged with the following medications: aspirin, clopidogrel, metoprolol, enalapril, simvastatin and isosorbide mononitrate. In the ED, his pulse is 102/min, blood pressure is 110/70 mmHg, respirations are 24/min and temperature is 36.8°C (98.4°F). Which of the following is most likely responsible for his present symptoms?

A 51-year-old man presenting to the clinic for routine examination mentions that he has not been able to get over the flu. Further questioning clarifies that he has had a nonproductive cough for the past 3–4 months and is unable to sustain his normal walking pace for prolonged periods. He reports feeling more fatigued than he recalls feeling last year. His medical history is significant for hypertension, alcoholism, and obesity. His blood pressure is well controlled on losartan and hydrochlorothiazide. He has no known drug allergies. His mother died of complications of type 2 diabetes mellitus. His father had a fatal myocardial infarction at age 56 years. The patient smokes half a pack of cigarettes per day and has done so for the past 7 years. He has worked all his adult life as an accountant and has no known exposures to asbestos or organic dusts. His blood pressure is 134/96 mm Hg, heart rate is 78/min, respiratory rate is 16/min, temperature is 37°C (98.6°F), and oxygen saturation is 94% on room air. Lung examination reveals bilateral inspiratory crackles in the lung bases. High-resolution CT shows patchy areas of ground glass, reticular abnormalities, and traction bronchiectasis. Laboratory findings are normal except for an elevated erythrocyte sedimentation rate of 54 mm/hr. What is the recommended treatment for this patient’s cough?

A 51-year-old woman presents to the ED after 5 consecutive days of crushing substernal chest pressure that woke her up from sleep in the morning. The pain resolves spontaneously after 20 to 30 minutes. She is an avid rock climber and jogs 5 miles daily. She has never smoked cigarettes and has no family history of coronary disease. In the ED, she experiences another episode of chest pain. An ECG reveals ST-segment elevations and cardiac biomarkers are negative. The pain is relieved with sublingual nitroglycerin. She is admitted to the hospital and diagnostic testing reveals minimal coronary atherosclerotic disease. Which of the following is the most appropriate medication to treat this patient’s condition?

A 52-year-old man develops sudden-onset shortness of breath on postoperative day 4 after a hemicolectomy for colon cancer. His surgery went well with no operative complications. He reports no cough, sputum, or pleuritic chest pain. His blood pressure is 155/90 mm Hg, pulse 100/min, temperature 37.8°C, lungs are clear, and heart sounds normal. He has bilateral pedal edema, but no discomfort in his legs. His CXR and ECG are normal. A chest CT with contrast reveals a thrombus in his right upper lobe artery. Which of the following statements concerning the management of this condition is most likely correct?

A 52-year-old man presents to his primary care physician’s office for routine care. He has hypertension, hypercholesterolemia, and type 2 diabetes mellitus, and has smoked one pack of cigarettes per day for the past 30 years. Medications include hydrochlorothiazide, atorvastatin, and glipizide. There is a family history of myocardial infarction in the maternal grandfather at age 60. The patient has undergone screening for colon and prostate cancer. Physical examination reveals a pleasant, obese man who is 175 cm (5􀆍9􀆎) tall and weighs 108 kg (238 lb). His blood pressure is 155/81 mmHg, heart rate is 78/min, respiratory rate is 14/min, and temperature is 36.8°C (98.3°F). What one action would most reduce the patient’s stroke risk?

A 52-year-old woman with a past medical history of hypertension presents for a lump in her breast. The patient noticed that her left breast was becoming slightly deformed and appears swollen on one side. The patient states that she first realized it when she was getting dressed about a month ago. She thought that it would go away on its own, but it seems to be growing. She is very concerned. BP, 136/82; P, 73 beats/min; R, 18 breaths/min; T, 98.6°F. Review of system: Denies weight loss, pain in the breast, nipple discharge, and erythema of the breast, Denies chest pain, shortness of breath, and abdominal pain. Physical examination: Gen: Awake, alert, oriented x3, no acute distress, Breasts: Asymmetric. Left breast slightly larger than right, with mass on left upper outer quadrant of breast. Thickening of skin in the same area. Palpation significant for a 2 in x 3 in mass in the left upper outer quadrant, nontender, nonmobile. The right breast is unremarkable. Which of the following the next step in the management of this patient?

A 52-year-old woman with cirrhosis presents with increasing abdominal distension. Her treatment regimen was amended three days ago, when furosemide was added to spironolactone and sodium/water restriction. However, her distension persists, and today she is very somnolent and has passed very little urine. Her past medical history is remarkable for chronic hepatitis type B, cirrhosis, encephalopathy, and 2 bleeding episodes from esophageal varices; the bleeding was controlled with sclerotherapy. Her temperature is 36.5°C (97.6°F), blood pressure is 90/60 mm Hg, pulse is 80/min, and respirations are 18/min. Abdominal examination shows distension, shifting dullness, and no tenderness; bowel sounds are present. Laboratory studies show: Hemoglobin 11.0 g/L, Leukocyte count 3,500/mm3, Serum sodium 125 mEq/L, Serum potassium 5.5 mEq/L, Chloride 103 mEq/L, Blood urea nitrogen 60 mg/dL, Serum creatinine 1.8 mg/dL, Prothrombin time 18 sec, Partial thromboplastin time 35 sec. Urinalysis shows no abnormalities. Ultrasound of the kidney is unremarkable. Which of the following is the most appropriate next step in management?

A 53-year-old man presents to the emergency room with left lower quadrant pain, fever, and vomiting. CT scan of the abdomen and pelvis reveals a thickened sigmoid colon with inflamed diverticula and a 7-cm by 8-cm rim-enhancing fluid collection in the pelvis. After percutaneous drainage and treatment with antibiotics, the pain and fluid collection resolve. He returns as an outpatient to clinic 1 month later. He undergoes a colonoscopy, which demonstrates only diverticula in the sigmoid colon. Which of the following is the most appropriate next step in this patient’s management?

A 55-year-old man presents to his physician with 6 months of mild intermittent pain in both knees. The pain is aggravated by walking and weight bearing, and is partially relieved by rest. He also complains of morning stiffness that lasts for 10 minutes. He does not smoke but drinks alcohol occasionally. His BMI is 25 Kg/m2, temperature is 37°C (98.6°F), pulse is 75/min, and blood pressure is 130/80 mmHg. Examination reveals crepitus over both knee joints. Which of the following is the most appropriate initial treatment for this patient?

A 55-year-old man presents to the emergency department with left lower quadrant abdominal pain. The pain has been file:///D:/DES_Entry_2016MCQs/3C_USMLE/C-4Management/4Manag... 204 of 334 12/21/2016 3:59 PM present for 1 week, but has increased in intensity over the last 2 days associated with nausea, constipation, and dysuria. Past history is unremarkable. Examination reveals a temperature of 101°F, pulse rate of 95/min, BP of 130/70 mmHg, and normal heart and lung examinations. Abdominal examination reveals fullness and marked tenderness in the left lower quadrant, with voluntary guarding and decreased bowel sounds. Laboratory tests reveal a WBC count of 18,000 with a left shift and 20–50 WBCs in the urinalysis. A CT scan of the abdomen reveals a thickened sigmoid colon with pericolonic inflammation. He is admitted to the hospital for treatment. We find this patient has diverticulitis. Which of the following is the most appropriate management of this patient?

A 55-year-old woman is brought to the emergency department by fi re and rescue personnel because of intractable back and thigh pain for the past 3 hours. Upon presentation she says that the pain is 9 of 10 in severity and localized to her lower back. She lives with her sister, and she has no primary care physician. She denies any complaints aside from fatigue, which she attributes to her multiple jobs and caring for her sister’s children. She has a pulse of 110/min, blood pressure of 140/88 mm Hg, respiratory rate of 20/min, and temperature of 37.8C (100.1F). On physical examination she is exquisitely tender over the L2–3 area of the spine. She also has point tenderness over the anterior right thigh. Sensation is intact over the lower extremities bilaterally and she has 5/5 strength in the lower extremities bilaterally. Breast examination reveals a retracted nipple and dimpling of the right breast. What will likely represent the mainstay of treatment for this patient’s symptoms?

A 56-year-old chronic alcoholic has a 1-year history of ascites. He is admitted with a 2-day history of diffuse abdominal pain and fever. Examination reveals scleral icterus, spider angiomas, a distended abdomen with shifting dullness, and diffuse abdominal tenderness. Paracentesis reveals slightly cloudy ascitic fluid with an ascitic fluid PMN cell count of 1000/μL. Which of the following statements about treatment is true?

A 56-year-old male is admitted to the ICU for the management of hepatic encephalopathy. He is a known alcoholic. He is started on oral neomycin, lactulose, and a low-protein, high-carbohydrate diet. His blood pressure is 116/78 mm Hg, pulse is 78/min, temperature is 37.5°C (99.5°F), and respirations are 18/min. His labs reveal the following: Hb 10.2 g/dl, WBC 7,400/cmm, Hct 27%, Platelets 4 2,000/mm3, PT 18 sec, INR 2.02, PTT 31 sec. He has no evidence of active bleeding. Which of the following should be administered to this patient at this time?