USMLE_Management I

56-year-old man presents to your office complaining of progressively worsening fatigue. He also reports difficulty concentrating and increasing forgetfulness over the past several weeks. On review of systems, the patient reports having unintentionally gained 6 pounds over the last three months. His past medical history is significant for hypertension and atrial fibrillation. On physical examination, he has a blood pressure of 140/90 mmHg and a heart rate of 75/min. His lung fields are clear to auscultation. There is no ankle edema. His skin is dry. Which of the following drugs is most likely responsible for this patient's complaints?

A 1 -year old child is brought in for a well-baby check-up. His parents report that he has been of good health and began walking a few weeks earlier. They are concerned that he tends to bump into things and falls more than his older sister did. Family history is significant for retinoblastoma. On examination, the pediatrician notes leukocoria of the left eye. No significant lymphadenopathy is present, and there is no enlargement of the liver or spleen. The child's height and weight are normal for age. Which of the following is the most appropriate next step in management?

A 1-cm carcinoma of the breast is diagnosed by an excisional biopsy in a 36-year-old woman at 14 weeks’ gestation. The axillary nodes are negative. Which of the following is the best management of this patient?

A 1-day-old full-term boy is in the neonatal intensive care unit with cyanosis. His BP is 80/40 mmHg in all 4 extremities, HR is 140/min, and respirations are 55/min. Pulse oxymetry shows 80% and does not improve with 100% inspired oxygen by face mask. He is breathing comfortably, but his fingertips and oral mucosa are blue. A continuous machine-like murmur is heard on auscultation. Chest x-ray shows clear lung fields bilaterally. Which of the following is the best next step in management of this patient?

A 1-month-old infant is brought to the office for a routine neonatal visit. His prenatal and birth histories are unremarkable. His vital signs are normal. Examination reveals a harsh, loud holosystolic murmur over the left, lower sternal border. Palpation reveals a thrill over the precordial region. There is no cyanosis, and pulmonary auscultation reveals no rales. Chest radiograph reveals a heart of normal size and a slight increase in pulmonary vascularity. EKG is normal. Which of the following is the most appropriate course of action?

A 1-year-old child has repeated episodes of vomiting and abdominal distention. An x-ray shows obstruction at the second portion of the duodenum. Laparotomy is performed and an annular pancreas is discovered. For a symptomatic partial duodenal obstruction secondary to an annular pancreas, which of the following is the operative treatment of choice?

A 1-year-old child is brought in for a regular "well baby" check-up. The child appears to have strabismus. The reflection of a bright light from the ceiling of the examination room comes from a different place in each eye. The family explains that the child has always looked that way, and there has been no recent change in the appearance of his eyes. Which of the following is the most effective management?

A 1-year-old child is brought to the physician for a routine visit. He was born full term with a birth weight of 71b 8oz (34 kg) and a birth length of 20 in (50.8cm). He has had no major illnesses or hospitalizations His parents report that he was breastfed exclusively for 6 months. He now eats a variety of baby foods and is being transitioned to whole milk. He can pull up to stand and cruise around holding onto objects, but cannot walk independently yet. He can feed himself small pieces of table food with his thumb and first finger. The only words he knows are mama, dada, and ball. His parents are concerned about his growth because some of the other children in his day care class are bigger than him. On physical examination, he weighs 221bs (10 kg) and is 30 in (76.2cm) long. A complete examination is unremarkable. Which of the following should you tell his parents?

A 1-year-old child with cerebral palsy secondary to perinatal asphyxia presents to her general pediatrician for a well-child visit. She was delivered at 37 weeks’ gestation by emergency cesarean section for a tight nuchal chord. The patient has severe spastic quadriparesis that is limiting her movements. She also has mental retardation and is unable to speak. She has received physical and occupational therapy since early infancy; however, her parents are concerned by her lack of improvement. Which of the following is the best choice for treatment of spasticity in this child?

A 1-year-old presents for a well-child checkup, but the parents are concerned about giving the child his immunizations. Which of the following is a true contraindication to the administration of the fourth DTaP (diphtheria and tetanus toxoid and acellular pertussis) vaccine?

A 10-month-old girl is seen in clinic for a routine checkup. She weighs 11 kg (24.2 lb). The infant's mother reports that she drinks whole cow's milk and takes solid food poorly. The infant's activity is decreased, but her muscle tone is good and her developmental milestones are up to date. The only significant abnormal physical finding is parlor. Which of the following is the most appropriate next step in management?

A 10-year-old boy is brought to the ER by his mother because he has lost consciousness, while playing in the yard. He regained his consciousness quickly without following confusion. He never had such an episode before. His past medical history is significant for impaired hearing since birth and one episode of pneumonia three years ago, which required hospitalization. The family history is significant for a sudden cardiac death, in his cousin, at the age of 13. Physical examination is unremarkable. Blood pressure is 110/70 mmHg. Heart rate is 70/min, regular. Which of the following medication is most appropriate for this patient?

A 10-year-old boy is brought to the psychiatrist by his mother. She states that for the past 2 months he has been increasingly irritable, withdrawn, and apathetic. He has been refusing to do his homework, and his grades have dropped. Which of the following is the best next step in management?

A 10-year-old boy presents to the emergency room with pain in the left testicle. The pain was acute in onset and began 1 hour ago. On physical examination, he is noted to have a high-riding, firm, and markedly tender left testis. The right testicle is normal. Urinalysis is unremarkable. Which of the following is the most appropriate management of this patient?

A 10-year-old boy presents with red discoloration of the urine since the morning. He is healthy and otherwise asymptomatic. He denies dysuria, frequency, urgency, flank, or abdominal pain. His BP is normal. His examination is within normal limits including abdomen and genitourinary system. There is no rash or edema. His urine is pink in color; urinalysis is negative for hemoglobin or protein. No white cells, red cells, or bacteria are noted. Which of the following is the most appropriate next step?

A 10-year-old boy was the backseat belted passenger in a high-speed motor vehicle collision. On presentation to the ER, he is awake, alert, and hemodynamically stable. He is complaining of abdominal pain and has an ecchymosis on his anterior abdominal wall where the seatbelt was located. Which of the following is the best next step in his management?

A 10-year-old girl comes to medical attention because of recurrent attacks of wheezing and dyspnea. The attacks occur mostly at home or, if outdoors, soon after exercise. Exacerbations are noted in springtime. The severity of symptoms is mild- Pulmonary function tests show that peak expiratory flow (PEF) and forced respiratory volume per second (FEVj) are reduced during an attack but are relatively normal during symptom-free intervals. Height and weight are in the 60th percentile. Complete blood count shows 8% eosinophils; all other parameters are normal. Cutaneous testing shows the patient to be allergic to a variety of allergens, including dust mites, animal dander, and several pollens. Which of the following is the most effective step in management?

A 10-year-old girl is brought to the physician because of throat pain, anorexia, and fever for 2 days. Her temperature is 38.9 C (102 F). The patient's history is negative for allergic diseases. She has had two episodes of pharyngotonsillitis over the past several years. Examination reveals a purulent exudate in the posterior oropharynx and enlarged tonsils. There is bilateral tender enlargement of anterior cervical lymph nodes. Cardiac and chest auscultation is normal. A rapid strep test is positive. Which of the following is the most appropriate next step in management?

A 10-year-old girl is involved in a motor vehicle accident, sustaining multiple injuries to her head, arms, and abdomen. Her blood pressure is 90/60 mm Hg, and her pulse is 120/min. Her forearm is disfigured, and bone can be seen through the wound. She is breathing periodically and has cyanotic lips. Her abdomen is rigid, and there is flank discoloration. Which of the following is the most appropriate next step in management?

A 10-year-old girl with blue eyes and blonde hair is brought to the office by her mother for a routine check-up. All her immunizations are up to date. Her family history is significant for myocardial infarction in her father and schizophrenia in a maternal uncle. There is no family history of any skin malignancies. Her height is at the 60th percentile, and weight is at the 56th percentile. While you are examining her, the mother says with much concern that she saw a television program that claimed that the incidence of skin cancer is increasing dramatically. She wants to know the best way to prevent skin cancer in her daughter, especially since they live in California. What is the best advice to help prevent malignant melanoma in this child?

A 12-year-old African American male with known sickle cell disease presents with a 2 hours history of right-sided arm weakness ans slurred speech. He has been hospitalized before for pain crises and pneumonia. He takes hydroxyurea, oxycodones as needed, and folic acid. His temperature is 36.6 C, BP is 153/83 mmHg and HR is 112/min with regular rhythm. On physical examination, he has right arm weakness and mild dysarthria. His laboratory values are the following: Hemoglobin 8.2 mg/dL, WBC count 14, 000.mm3, Platelet count 210, 000/mm3, Creatinine 0.9 mg/dL. CT of the head shows no evidence of intracranial bleeding. Which of the following is the best initial management for this patient?

A 12-year-old boy comes to the emergency department at midnight with a complaint of severe scrotal pain since 7 PM. There is no history of trauma. Which of the following is the most appropriate first step in management?

A 12-year-old boy comes to the emergency department with severe shortness of breath, cough, and fever. He was diagnosed with cystic fibrosis when he was five years old. He is currently not taking any medications. His temperature is 39.4 C (103F), blood pressure is 80/40 mmHg, pulse is 120/min, and respirations are 30/min. He is excessively using his accessory respiratory muscles. Lung auscultation reveals bilateral lower lobe crackles and expiratory wheezing. Pulse oximetry shows Sa02 of 85% that improves to 92% after oxygen supplementation. Which of the following antibiotics or combinations is the best choice for this patient?

A 12-year-old boy is brought to the clinic because of a several-month history of strange behavior. According to his parents, the boy occasionally will start staring and not respond. He will also have tears in his eyes. These episodes last several seconds and he then returns to his baseline. He has not sustained any head trauma and is on no medications. Which of the following drugs is the most appropriate treatment?

A 12-year-old boy is brought to the office by his mother due to a two-week history of generalized edema which is gradually progressing. His past medical history is insignificant. He is not taking any medications. His blood pressure is 110/80 mmHg, pulse is 85/min, respirations are 18/min, and temperature is 36.7C (98F). The laboratory findings are as follows: Serum sodium 140 mEq/L, Serum potassium 3.7 mEq/L, Serum albumin 2.1 g/dl, Serum globulin 6.0 g/dl, Serum creatinine 1.0 mg/dl. Urinalysis reveals proteinuria 3+. What is the best next step in the management of this patient?

A 12-year-old boy is brought to the physician because of right groin pain, knee pain, and limping. He has had these symptoms for the past 2 weeks. He is at the 90th percentile for weight and 60th percentile for height. He is afebrile, and his other vital signs are within normal limits. Examination shows that the range of motion of the right knee joint is within normal limits but hip movements are restricted and the right foot points outward. There is external rotation of the right thigh on flexion of the hip. After confirming the diagnosis, which of the following is the most appropriate management?

A 12-year-old boy presents with an intensely pruritic rash for 3 days. He just went on a camping trip, during which he wore only short-sleeve shirts and short pants. His temperature is 37.6 C (99.7 F), blood pressure is 96/62 mm Hg, pulse is 65/min, and respirations are 12/min. There are numerous erythematous papules and vesicles on both arms and legs. Most of them are in a linear array. Which of the following is the most appropriate pharmacotherapy?

A 12-year-old boy with a femur fracture after a motor vehicle collision undergoes operative repair. After induction of anesthesia, he develops a fever of 40°C (104°F), shaking rigors, and blood-tinged urine. Which of the following is the best treatment option?

A 12-year-old boy with cystic fibrosis presents to the emergency department with a 3-day history of severe coughing, which is productive of a yellow-greenish purulent sputum. He had fever and chills at home. He also complains of chest congestion and chest pain that is worse with coughing. On physical examination, his temperature is 39.6 C (103.2 F), blood pressure is 98/68 mm Hg, pulse is 102/min, and respirations are 24/min. He is noted to be lethargic. He has rales on the left lower lung field on auscultation, and chest radiography shows an infiltrate in the left lower lobe. Which of the following is the most appropriate initial antimicrobial therapy for this patient?

A 12-year-old girl is seen by a pediatrician for a mild case of pneumonia. She is treated with an intramuscular injection of penicillin. About 15 minutes later, she develops extreme itchiness, accompanied by the development of wheals scattered over her chest and extremities. She also begins to wheeze and complain of difficulty breathing. The color of her lips and face remains rosy. Which of the following is the most appropriate first step in management?

A 12-year-old girl presents with a 2-month history of vaginal discharge. She describes it as clear and states that it stains her underwear. She says that she hates boys, and that "no way" has she ever had sex or even kissed a boy. She reports having had developing breasts for 2 years and thinks that her growth spurt was about a year ago. Genital findings include a pubic hair stage of Tanner III with no evidence of redness or irritation of the vulvovaginal area. A slight amount of odorless, clear mucus is seen. Microscopic examination of the mucus reveals epithelial cells and a few bacteria, but no white cells. The pH is between 3.5 and 4. Which of the following is the most appropriate next step in management?

A 12-year-old girl was hit in the face by a baseball 15 minutes earlier and has had her mandibular incisors knocked out. Which of the following represents the best plan of action?

A 12-year-old girl with a history of asthma has been admitted to intensive care units two times in the past and has had three emergency department visits during the past 12 months. Her only medication is inhaled albuterol as needed, and she uses it two to three times a day. She has nocturnal symptoms about two times a week. She is free of symptoms now but reports that she gets short of breath easily. Which of the following pharmacologic interventions is most appropriate?

A 12-year-old male is brought to the emergency department after direct blunt trauma to the upper abdomen. He has epigastric pain and repeated vomiting immediately after the trauma. He is afebrile and his other vital signs are stable. Barium examination shows duodenal obstruction. CT scan of the abdomen shows a duodenal hematoma and no other injuries are noted. Which of the following is the most appropriate next step in management?

A 12-year-old male is brought to the physician because of a two week history of right groin pain and limping. He is at the 60th percentile for height and the 90th percentile for weight. He is afebrile and his other vital signs are within normal limits. Examination shows the range of motion of the right knee joint is within normal limits, but hip movements are restricted and the right foot points medially. There is marked external rotation of the right thigh on flexion of the hip. After confirming the diagnosis, which of the following is the most appropriate management?

A 13-year-old girl presents with a 1-week history of a sore throat and a nonproductive cough. She has been previously healthy and has not been exposed to any other sick person. She has not been taking any medications. On examination, she has normal oxygen saturation and a low-grade fever. The remainder of the examination is unremarkable. Which of the following is the most appropriate pharmacotherapy?

A 13-year-old girl presents with lethargy, fever, severe headache, and a stiff neck. On examination, a unilateral fixed, dilated pupil and papilledema are noted. Which of the following is the most appropriate initial step in managing this patient?

A 13-year-old girl returns to her physician for followup of a strep throat, for which she had been treated 3 weeks previously. After performing a throat culture, the physician asks how school is going. There is dead silence. Her mother says that her daughter has missed the last 4 weeks of school. Which of the following is the most appropriate initial step in management?

A 14-year-old boy is brought to medical attention because of nasal fullness and bleeding. Inspection reveals enlarged cervical lymph nodes as well. Biopsy of a lymphnode confirms nasopharyngeal carcinoma. What is the best management strategy for this patient?

A 14-year-old boy is hit by an automobile while walking across the street and is immediately taken to the emergency department. On arrival, he is conscious and complains of shortness of breath and chest pain. Physical examination reveals an ecchymotic area over his right chest and subcutaneous emphysema. Breath sounds are absent on the right side. His trachea is deviated to the left, and his right hemithorax is tympanic to percussion. Which of the following is the most appropriate initial step in management of this patient?

A 14-year-old boy is seen in the ER because of a 3-week history of fever between 38.3C and 38.9C (101F and 102F), lethargy, and a 2.7-kg (6-lb) weight loss. Physical examination reveals marked cervical and inguinal adenopathy, enlarged tonsils with exudate, small hemorrhages on the soft palate, a WBC differential that has 50% lymphocytes (10% atypical), and a palpable spleen 2 cm below the left costal margin. Which of the following therapies should be initiated?

A 14-year-old boy presents with the complaint of “breast swelling.” The boy reports that he has been in good health and without other problems, but has noticed over the past month or so that his left breast has been “achy” and that he has now noticed some mild swelling under the nipple. He has never seen discharge; the other breast has not been swelling; and he denies trauma. Your examination demonstrates a quarter-sized area of breast tissue under the left nipple that is not tender and has no discharge. The right breast has no such tissue. He has a normal genitourinary examination, and is Tanner stage 3. Which of the following is the best next course of action?

A 14-year-old G1P0 girl who is 29 weeks’ pregnant with twins presents to the emergency department following a seizure. She was watching television and stood up to go to the bathroom when she “fell down and started shaking.” The patient has no history of seizures and is otherwise healthy. She missed her last obstetrician’s appointment, and her aunt states that her niece has had a lot of headaches and swelling over the past 2 days. On examination the patient is somnolent and difficult to arouse, and has edema of her hands and face. Her blood pressure is 205/120 mm Hg, pulse is 80/ min, and respiratory rate is 16/min. The fetal heart rate is 130/min. Which of the following is the most correct advice for the patient’s aunt?

A 14-year-old girl comes to the physician because of lower abdominal cramping. This cramping starts a few hours before, and lasts through, her menses, and then resolves completely. The cramping is primarily in the lower abdomen but also radiates to the back and thighs. She first noted this cramping approximately 6 months after her first menstrual period at age 12. She is not sexually active. Physical examination is unremarkable, including a normal pelvic examination. A pregnancy test is negative. Which of the following is the most appropriate next step in management?

A 14-year-old girl with a history of seizures is admitted to the hospital with the diagnosis of status epilepticus. Her valproic acid level is in the therapeutic range. You arrange a 24-hour video electroencephalogram (EEG). During the EEG, she has several episodes of tonic and clonic movements with moaning and crying, with no loss of bowel or bladder control. The neurologist tells you that during the events the EEG had excessive muscle artifact but no epileptiform discharges. Which of the following treatments is the most appropriate for this condition?

A 14-year-old high school student arrives to your clinic for well-child care. In reviewing his records you determine that his most recent immunization for tetanus was at 4 years of age. Which of the following should you recommend?

A 14-year-old phenotypically female child is brought to your office by her mother who is concerned that her daughter has not had menstrual bleeding yet. Her past medical history is significant for an episode of severe bilateral pneumonia that required hospitalization when she was seven years old. Physical examination reveals Tanner stage 3 breast development, but very little pubic and axillary hair. Bilateral inguinal masses are palpated. A blind vaginal pouch is noted on pelvic exam. A karyotype analysis showed 46 XY. Which of the following is the most appropriate next step in the management of this patient?

A 14-year-old white female presents with "spots" on her face that are "so embarrassing!" Physical examination reveals comedones with minimal inflammation. Her past medical history is insignificant. She does not smoke or consume alcohol. What is the best next step in the management of this patient?

A 14-year-old young woman with no PMH, no PSH presents to the office stating that she would like to begin birth control. She is sexually active with multiple male partners. Her last menstrual period (LMP) was 3 weeks ago. BP, 110/70 mm Hg; P, 82 beats/min; R, 16 breaths/min; T, 98.5°F. No fever, chills, abdominal pain, nausea, vomiting, diarrhea, constipation, chest-pain, shortness of breath, history of pulmonary embolism, or medical problems. Physical examination: Gen: Awake, alert, oriented x3, no acute distress, CVS: S1S2 + RRR no m/r/g, Lungs: CTA bilaterally, Abd: Soft, nontender, nondistended, + bowel sounds, Ext: no edema. Which of the following is the next step in the management of this patient?

A 15-month-old boy is brought to the ER because of fever and a rash. Six hours earlier he was fine, except for tugging on his ears; another physician diagnosed otitis media and prescribed amoxicillin. During the interim period, the child has developed an erythematous rash on his face, trunk, and extremities. Some of the lesions, which are of variable size, do not blanch on pressure. The child is now very irritable, and he does not interact well with the examiner. Temperature is 39.5C (103.1F). He continues to have injected, immobile tympanic membranes, but you are concerned about his change in mental status. Which of the following is the most appropriate next step in the management of this infant?

A 15-year old girl presents with a 5-day history of sore throat, low-grade fever, and easy fatigability. Physical examination shows bilateral tonsillar enlargement with exudate. Her spleen is palpable 3 cm below the left costal margin. Her throat culture is negative for group A Streptococcus. Monospot test is positive. Which of the following is the most appropriate management for this patient?

A 15-year-old boy comes to the physician for advice about his facial acne. On examination, the patient has mild to moderate acne, mostly consisting of open comedones, some closed comedones, and a few pustules on the forehead and cheeks. Which of the following is the best advice to give this patient?

A 15-year-old Caucasian boy is injured during a football game. He is taken to the emergency department for x-ray films of his leg to rule out a possible fracture. The radiologist reports that the boy has evidence of an aggressive bone tumor with both bone destruction and a soft tissue mass. Later, the pathologist reports that the bone biopsy reveals a bone cancer with some of the tumor tissue displaying neural differentiation. Which of the following is the most appropriate next step in management?

A 15-year-old female with a history of bipolar disorder and psychosis presents to her physician's office requesting a pregnancy test. Her last menstrual period was 2 months ago. She states that her menses usually occur every 30 days. She is sexually active with one partner and occasionally uses condoms. She is concerned because she has gained 10 pounds in the last two months, and also complains of breast tenderness and milky white discharge from both nipples. She denies headaches, nausea, vomiting, diarrhea, or fever. Her vital signs are normal. Physical examination is unremarkable. A urine pregnancy test is negative. Which of the following is most likely responsible for this patient's symptoms?

A 15-year-old female, who has recently emigrated from Asia, is found to have a heart murmur during her routine physical examination. She has no current complaints. She had a febrile illness with joint swelling and pain approximately one year ago. She plays table tennis and swims every weekend. Her blood pressure is 120/70 mmHg and her heart rate is 70/min, regular. Cardiac auscultation shows a loud first heart sound and mid-diastolic rumble at the apex. Her lungs are clear to auscultation. Which of the following is the best treatment for this patient at this point?

A 15-year-old girl is brought to the pediatric emergency room by the lunchroom teacher, who observed her sitting alone and crying. On questioning, the teacher learned that the girl had taken five unidentified tablets after having had an argument with her mother about a boyfriend of whom the mother disapproved. Toxicology studies are negative, and physical examination is normal. Which of the following is the most appropriate course of action?

A 15-year-old girl with type 1 diabetes mellitus presents to her primary care doctor for a routine checkup. Perusal of her blood sugar chart indicates that her recorded blood glucose levels are routinely between 120 and 150 mg/dL before breakfast, dinner and bedtime, with the normal being 116 mg/dL. She is on NPH and regular insulin. Which of the following is the next appropriate step?

A 15-year-old woman presents to your office for her first wellwoman examination while she is on summer break from school. She denies any medical problems or prior surgeries. She had chicken pox at age 4. Her menses started at the age of 12 and are regular. She has recently become sexually active with her 16-year-old boyfriend. She states that they use condoms for contraception. Her physical examination is normal. Which of the following vaccines is appropriate to administer to this patient?

A 16 year-old-girl with hereditary spherocytosis is scheduled for a splenectomy. She was previously managed with folate therapy and occasional blood transfusions, but her anemia became refractory to medical management alone. Before the operation, she is told that she will have an enhanced risk of developing pneumococcal sepsis. She then asks, "How long will these risks last?" What is the best response to her question?

A 16-year-old adolescent boy sustains head trauma in a motor vehicle collision. He has a GCS of 15 and an obvious depressed skull fracture with 1cm displacement. During his hospital stay, he notices clear fluid draining from his nose. What is the best management strategy for this patient?

A 16-year-old boy is brought to the emergency department after falling off a bicycle and hitting his head on the ground. He briefly lost consciousness but had no seizures. He had two episodes of vomiting and complains of mild headache. His mother accompanies him and demands immediate evaluation. He has no other medical problems. His blood pressure is 121/67 mm Hg and pulse is 78/min. Examination shows a small bruise on his forehead but no bony abnormalities. The rest of the physical examination, including neurologic examination, shows no other abnormalities. Which of the following is the most appropriate next step in management?

A 16-year-old boy presents to his pediatrician with scattered petechiae and a three-week history of fatigue. Laboratory evaluation and a bone marrow biopsy confirm the diagnosis of acute lymphoblastic leukemia. The boy's parents are divorced and have joint custody of him. His mother consents to the proposed chemotherapy and blood transfusion and requests that his treatment be started immediately. The father, however, refuses to agree to the treatment because of his religious beliefs. What is the most appropriate means of handling this situation?

A 16-year-old boy presents with a temperature of 38.4 C (101 F) and low back, wrist, and knee pain. He had a sore throat 1 month earlier. His arthritis is diffuse. Pea-sized swellings are noted over the skin on his knees. He has a serpiginous erythematous area on his anterior trunk. His blood and throat cultures are negative, and his CBC is unremarkable. His antistreptolysin-O (ASO) titer is high. Which of the following is the most appropriate therapy?

A 16-year-old boy was brought to the emergency department because of left shoulder and left hand pain after falling on his outstretched hand while playing soccer. He heard a crunching sound and had intense pain in his left shoulder area following the injury. Examination shows bruising around the clavicle area. He is holding his left arm with his right hand. There is a palpable gap in the middle of the clavicle. Auscultation shows a loud bruit just beneath the clavicle. An x-ray film of the left shoulder and chest shows the middle of the clavicle is fractured and displaced. Which of the following is the most appropriate next step in management?

A 16-year-old boy with a history of ulcerative colitis presents to the physician complaining of diarrhea and a rash. He states that his appetite has been decreased recently, and also complains of nausea and abdominal pain in addition to watery diarrhea. He has an erythematous rash on his distal arms and legs that "burns". His mother reports that he has had poor concentration and has been irritable lately. Vital signs are stable. Examination reveals a beefy red tongue that appears swollen. Abdominal examination is normal. The rash resembles a sunburn and is located on his distal arms and legs. It is symmetrical and tender to palpation. Neurological examination is normal. This patient's symptoms are most likely due to a deficiency of which of the following vitamins?

A 16-year-old Caucasian female is brought to your office by her mother who is concerned that her daughter has not had menstrual bleedings yet. Her past medical history is significant for an episode of severe bilateral pneumonia that required hospitalization when she was seven years old. Physical examination reveals Tanner stage 3 breast development, but very little pubic and axillary hair. A left-sided inguinal mass is palpated. A blind vaginal pouch is noted on pelvic exam. A karyotype analysis showed 46 XY. Which of the following is the most appropriate next step in the management of this patient?

A 16-year-old female comes to the emergency department because of heavy vaginal bleeding. She has no pain. Since menarche, menses have been irregular. She has a steady boyfriend and uses condoms for contraception. She has no other medical problems. She does not use alcohol, tobacco, or drugs. Her temperature is 37C (99F), blood pressure is 110/60 mm Hg, pulse is 90/min, and respirations are 16/min. Physical examination shows active vaginal bleeding. Pregnancy test is negative. Coagulation studies are within normal limits. Ultrasound shows no abnormalities. Her hemoglobin is 9.8 g/dl and hematocrit is 29%. Which of the following is the most appropriate next step in management?

A 16-year-old female presents to her pediatrician's office for a routine examination. She is wearing a sweater despite the warm weather, and admits she often feels cold. She states that she has otherwise been feeling fine, except for having difficulty losing weight. She wants to lose about 10 lbs (4.5 kg) because she believes she is "too fat." She has been on a strict diet and exercises two hours daily. She is also requesting a pregnancy test because she has not had a menstrual period for the past three months. Past medical history is significant for a supracondylar fracture of her right humerus at the age of seven. She is alert, cooperative, and in no apparent distress. Vital signs are temperature 36.2°C (97.2°F), blood pressure 88/58 mmHg, pulse 56/min, and respiratory rate 16/min. Her height is 5'5" (165 cm) and weight is 90 lbs (40.9 kg). What is the most appropriate next step in the management of her symptoms?

A 16-year-old G1P0 at 38 weeks gestation comes to the labor and delivery suite for the second time during the same weekend that you are on call. She initially presented to labor and delivery at 2:00 PM Saturday afternoon complaining of regular uterine contractions. Her cervix was 1 cm dilated, 50% effaced with the vertex at −1 station, and she was sent home after walking for 2 hours in the hospital without any cervical change. It is now Sunday night at 8:00 PM, and the patient returns to labor and delivery with increasing pain. She is exhausted because she did not sleep the night before because her contractions kept waking her up. The patient is placed on the external fetal monitor. Her contractions are occurring every 2 to 3 minutes. You reexamine the patient and determine that her cervix is unchanged. Which of the following is the best next step in the management of this patient?

A 16-year-old girl has had a fever, vomiting, and watery diarrhea for the past 24 hours. She also complains of intermittent abdominal pain and generalized myalgia. On examination, she is slightly lethargic. Her temperature is 39.4 C (103 F), blood pressure is 75/50 mm Hg, and pulse is 150/min. Her conjunctivae and pharynx are hyperemia. She has a generalized erythematous maculopapular rash that spares the wrists. Which of the following will be the most appropriate treatment?

A 16-year-old girl is being evaluated for primary amenorrhea. Her birth history is significant for low birth weight and bilateral swelling of the hands and feet. Her blood pressure is 170/96 mmHg. She has a short stature and webbed neck. Her karyotype examination results show 22 pairs of autosomes, one X, and one Y chromosome. Which of the following statements is true regarding this patient's condition?

A 16-year-old girl presents for evaluation of acne, which has been getting progressively worse over the past 2 weeks. Her medical history is significant for systemic lupus erythematosus (SLE) for which she has been taking prednisone for a recent exacerbation. Hydroxychloroquine is her only other medicine. She does not use tobacco, alcohol or drugs and her menstrual cycle is regular. On physical examination, her blood pressure is 110/76 mmHg and her pulse is 72/min. Her BMI is 22 kg/m2. Distributed over the face, arms and trunk are monomorphous erythematous papules. There are no open or closed comedones. The remainder of the physical examination is unremarkable. Which of the following is the most likely cause of her acne?

A 16-year-old girl with a history of ulcerative colitis managed with steroid therapy presents to the emergency department with a 36-hour history of nausea, crampy abdominal pain, and severe bloody diarrhea. On examination, the patient is febrile and pale, with a blood pressure of 90/60 mmHg and heart rate of 130 beats/min. Her abdomen is distended and diffusely tender. A complete blood count (CBC) demonstrates a leukocytosis with a left shift. The patient receives IV fluid resuscitation and nasogastric (NG) tube decompression. We inject high-dose IV steroids and broad-spectrum antibiotics. After 48 hours, there is no clinical improvement. Which of the following is the most appropriate next step in management?

A 16-year-old male is brought to the emergency department after falling off a bicycle and hitting the ground with his head. He briefly lost consciousness, but had no seizures. He has a mild headache but has no nausea or vomiting. Vital signs are stable. Examination shows no neurological deficit or any signs of fracture. Which of the following is the most appropriate next step in management?

A 16-year-old male is brought to the emergency department with a crush injury due to a farm accident. His immunization status is unknown. The wound is heavily contaminated with soil, and you are concerned about tetanus. Which of the following is the most appropriate management step?

A 16-year-old male, despondent over a recent breakup, tries to commit suicide by taking an unknown quantity of an unknown material he found at home. He is brought to the emergency center by his parents within 30 minutes of the ingestion. For which of the following household materials and medications should he be given activated charcoal as part of his emergency center treatment?

A 16-year-old nulligravid woman comes to the emergency department because of heavy vaginal bleeding. She states that she normally has heavy periods every month but missed a period last month and this period has been unusually heavy with the passage of large clots. She has no medical problems, has no history of bleeding difficulties, and takes no medications. Her temperature is 37 C (98.6 F), blood pressure is 110/70 mm Hg, pulse is 96/minute and respirations are 12/minute. Pelvic examination shows a moderate amount of blood in the vagina, a closed cervix, and a normal uterus and adnexae. Hematocrit is 30%. Urine hCG is negative. Which of the following is the most appropriate management?

A 16-year-old primigravida presents to your office at 35 weeks gestation. Her blood pressure is 170/110 mm Hg and she has 4+ proteinuria on a clean catch specimen of urine. She has significant swelling of her face and extremities. She denies having contractions. Her cervix is closed and uneffaced. The baby is breech by bedside ultrasonography. She says the baby’s movements have decreased in the past 24 hours. Which of the following is the best next step in the management of this patient?

A 16-year-old teenage girl presents to your office with her mother complaining of primary amenorrhea. Her past medical history is not significant. Her family history is significant for hypothyroidism in her mother. Her vital signs are normal. Examination reveals absent breasts, as well as pubic and axillary hair. The uterus and gonads are visualized on ultrasound, and the FSH level is increased. Which of the following is the most appropriate next step in the management of this patient?

A 17-year-old adolescent boy is stabbed in the left seventh intercostal space, midaxillary line. He presents to the ER with a heart rate of 86 beats per minute, blood pressure of 125/74 mm Hg, and oxygen saturation of 98%. Breath sounds are equal bilaterally. Which of the following is the most appropriate next step in his workup?

A 17-year-old adolescent boy sustains a small-caliber gunshot wound to the mid-epigastrium with no obvious exit wound. His abdomen is very tender; he is taken to the operating room and the bullet appears to have tracked through the stomach, distal pancreas, and spleen. The duct appears to have been injured. Which of the following is the best strategy for the management of this patient’s pancreatic injury?

A 17-year-old adolescent comes to your office seeking help for “heavy” menses. Your review of systems also reveals weekly epistaxis. Her only significant past history includes a tonsillectomy at age 6 after which she required blood transfusion for excessive bleeding. Her family history includes several people who seem to bleed and bruise more easily than others. The patient’s mother required a hysterectomy after child birth for excessive hemorrhage. You order a variety of laboratory tests. The patient has a hemoglobin of 6.5 mg/dL with an MCV of 60%; her platelet count is 350,000/μL. Her von Willebrand antigen and her von Willebrand factor (vWF) activity (ristocetin cofactor activity) are decreased. Her vWF is reported as normal but in decreased amounts. You have been unable to reach her to report the findings, but when she calls about 1 week later she reports she is having a mild to moderate nosebleed. You initiate therapy with which of the following?

A 17-year-old female comes to the physician's office for a routine physical examination. She has no complaints and has no previous medical problems. She has been having sex since the age of 14 and has had 3 sexual partners so far. Vital signs are stable and physical examination is unremarkable. Pap smear is performed and the report came back as "satisfactory for evaluation" and shows mild dysplasia (low grade intraepithelial lesion). Which of the following is the most appropriate next step in management?

A 17-year-old female comes to your office for advice. She says that she is planning to have sexual intercourse with her boyfriend for the first time. However, she is worried about contracting a urinary tract infection because she has heard that there is a high incidence of UTI's in sexually-active females. Which of the following is the most appropriate advice to give this patient to decrease her chance of contracting a urinary tract infection

A 17-year-old man comes to the physician because a one-week history of fever and abdominal pain. This began with mid-abdominal pain and nausea one week ago, but he was able to continue his usual activities. However, during the past two days, the pain has become worse. It is now localized to the right iliac fossa and impairs walking. He has had two episodes of vomiting during the past several hours. His temperature is 39.4C (103F), blood pressure is 110/70 mm Hg, pulse is 90/min, and respirations are 18/min. Examination shows a tender iliac fossa mass palpated on the right side; remaining abdominal examination shows no rigidity or guarding. Which of the following is the most appropriate next step in management?

A 17-year-old married girl comes to see you, complaining of “feeling tired all the time,” vomiting in the morning, and weight gain. Examination shows signs of pregnancy that is confirmed by laboratory studies. When informed of this, the girl is visibly distraught. “How could this happen?” she says, “I’ve been on the pill!” Mentioning that she and her husband live with her parents, she declares that she wants an immediate abortion. Which of the following is the best reply?

A 17-year-old white male presents to your office because the "spots" on his face "got so much worse recently!" He has several months history of acne. He has not visited a doctor before. Inspection reveals multiple papules with several pustules and nodules. Atrophic scars are seen. What is the best next step in the management of this patient? file:///D:/DES_Entry_2016MCQs/3C_USMLE/C-4Management/4Manag... 20

A 17-year-old woman at 22 weeks gestation presents to the emergency center with a 3-day history of nausea, vomiting, and abdominal pain. The pain started in the middle of the abdomen and is now located along her mid to upper right side. She is noted to have a temperature of 38.4C (101.1F). She denies any past medical problems or surgeries. How does pregnancy alter the diagnosis and treatment of the disease?

A 19-year woman presents to her physician's office for a routine health maintenance examination. She notes experiencing occasional wheezing and breathlessness following aerobic exercise, but has no symptoms at other times of the day or night. Her medical history is otherwise significant for allergic rhinitis and acne, for which she uses topical benzoyl peroxide and erythromycin cream. She does not use tobacco, alcohol or illicit drugs. On physical examination, her vital signs are within normal limits and chest auscultation is unremarkable. Which of the following is the most appropriate next step in her management?

A 19-year-old college student presents for a first visit because she is concerned about her "abnormal behavior." She says that she worries excessively about her door being locked and that she wakes several times throughout the night to confirm that the door is properly locked. She finds these thoughts distressing. Although she agrees that her fears are not rational, she feels unable to stop from acting on them. This frequent waking grossly impairs her sleep and as a result, she is finding it increasingly difficult to perform well academically. She has no history of psychiatric conditions, but her mother was recently diagnosed with trichotillomania. Vital signs include a temperature of 37.0°C (98.6°F), blood pressure of 118/84rnrnHg, pulse of 76/min, and respirations of 12/min. Physical examination is unremarkable. Which of the following medications would be the most appropriate treatment for her condition?

A 19-year-old college student presents to her primary care physician for emergency contraception. She had unprotected sexual intercourse 48-hours ago while on a trip to Mexico with her boyfriend. She wants to prevent pregnancy. Her last menstrual period was 18-days ago. She has no previous medical problems. Family history is significant for migraines in her mother. She does not use tobacco, alcohol or drugs. Vital signs are within normal limits. Physical examination shows no abnormalities. Which of the following is the most appropriate next step in management?

A 19-year-old female comes to the physician because of left lower quadrant pain for 2 months. She states that she first noticed the pain 2 months ago but now it seems to be growing worse. She has had no changes in bowel or bladder function. She has no fevers or chills and no nausea, vomiting, or diarrhea. The pain is intermittent and sometimes feels like a dull pressure. Pelvic examination is significant for a left adnexal mass that is mildly tender. Urine hCG is negative. Pelvic ultrasound shows a 6 cm complex left adnexal mass with features consistent with a benign cystic teratoma (dermoid). Which of the following is the most appropriate next step in management?