DES C_Management (12) Prepared : CHILLY

A 78-year-old female is being evaluated for recent weight loss and fatigue. Laboratory tests reveal abnormal thyroid function. She begins treatment with a single agent, but soon after is hospitalized with new onset atrial fibrillation and hand tremor. Which of the following treatments had she most likely received? 

A 9-month-old is brought to the emergency center by ambulance. The child had been having emesis and diarrhea with decreased urine output for several days, and the parents noted that she was hard to wake up this morning. Her weight is 9 kg, down from 11 kg the week prior at her 9-month checkup. You note her heart rate and blood pressure to be normal. She is lethargic, and her skin is noted to be “doughy.” After confirming that her respiratory status is stable, you send electrolytes, which you expect to be abnormal. You start an IV. Which of the following is the best solution for an initial IV bolus?

A 9-year-old boy comes to the office for a pre-participation physical examination for summer camp. His parents report that he still has episodes of bed-wetting. The boy’s father confides that he also had bed-wetting until he was 10. They are concerned about the bed-wetting, but they are more concerned about their son’s upcoming week at summer camp and that the other boys may harass him for wetting the bed. Which of the following statements about nocturnal enuresis is correct?

A baby is born to a mother who is positive for hepatitis B surface antigen (HBsAg). Your plan is to do which of the following? 

A businesswoman needs to make frequent trips to South America, but every time she is there, she develops traveler’s diarrhea, which requires her to change her business schedule. To prevent future episodes during business trips, she is inquiring about prophylaxis methods. Which of the following is the most helpful advice for her?

A full-term 6-day-old boy presents to a physician’s office for routine care. He is tolerating breast milk well. He is urinating, defecating, and sleeping normally. Physical examination reveals an alert new-born with mild eczema, good skin turgor, normal reflexes, and a musty odor. His newborn laboratory screen is notable for phenylketones in the urine. What is the best advice to give his parents regarding the boy’s diet?

A generally healthy 74-year-old woman who recently moved into the area visits the physician’s office for her first well-visit. She states that her previous doctor had been treating her with propylthiouracil (PTU) for subclinical hyperthyroidism, but that her prescription ran out several months ago. Laboratory studies reveal that her free thyroxine and triiodothyronine levels are normal, but her thyroid-stimulating hormone is depressed. PTU therapy is most important in this patient to prevent the development of which disorder?

A healthy 30-year-old G2P1001 presents to the obstetrician’s office at 34 weeks for a routine prenatal visit. She has a history of a cesarean section (low transverse) performed secondary to fetal malpresentation (footling breech). This pregnancy, the patient has had an uncomplicated prenatal course. She tells her physician that she would like to undergo a trial of labor during this pregnancy. However, the patient is interested in permanent sterilization and wonders if it would be better to undergo another scheduled cesarean section so she can have a bilateral tubal ligation performed at the same time. Which of the following statements is true and should be relayed to the patient?

A healthy 31-year-old G3P2002 patient presents to the obstetrician’s office at 34 weeks gestational age for a routine return visit. She has had an uneventful pregnancy to date. Her baseline blood pressures were 100 to 110/60 to70, and she has gained a total of 20 lb so far. During the visit, the patient complains of bilateral pedal edema that sometimes causes her feet to ache at the end of the day. Her urine dip indicates trace protein, and her blood pressure in the office is currently 115/75. She denies any other symptoms or complaints. On physical examination, there is pitting edema of both legs without any calf tenderness. Which of the following is the most appropriate response to the patient’s concern?

A healthy 32-year-old woman vaginally delivers a healthy full-term baby boy. You are called to consult postpartum because the patient has difficulty with voiding. The delivery was the patient’s third child and was uncomplicated. However, by the end of her second day of hospitalization she is able to urinate only 25 cc at a time. Straight catheterization by the nurse reveals postvoid residuals of more than 300 cc. The patient denies any history of urinary tract infection, kidney stones, or prior voiding difficulties. She has no neurologic complaints. She has no significant past medical history. Surgical history is significant for a laparoscopic cholecystectomy 5 years ago. Her only medications are prenatal vitamins. She does not smoke or drink. On physical examination, she is in no distress but appears fatigued. She is afebrile and vital signs are normal. Heart and lung examination is within normal limits. Abdomen is appropriate for her recent delivery, soft and nontender. It is difficult to elicit any suprapubic distention. Rectal examination shows good sphincter tone. There are no gross neurologic deficits of the extremities. All of her laboratory studies are normal as well, and urinalysis does not show any leukocyte esterase, nitrites, or white blood cells. You prescribe bethanechol to help with her current urologic condition. As the prescribing physician, about which of the following side effects must you inform this patient?

A middle-aged Asian American married couple comes to clinic for a routine examination. Both the husband and wife have been known patients of yours for many years. The husband is being treated for coronary artery disease and tension headaches. Today, he mentions that he "cannot get an erection" even when he feels sexual desire. He adds that he still finds his wife physically attractive and that they are mutually compatible in every respect. This recent development has been causing him significant anxiety and has been a source of concern for his wife. After ruling out medical and psychological causes for his erectile dysfunction by taking a detailed history and pursuing a thorough workup, you agree to his request that he be started on sildenafil. One week later, his wife places an urgent call to your office, reporting that her husband developed severe chest pain "after taking the new medication you prescribed." An EKG done in the emergency department reveals new inferior wall ischemia. You immediately realize that you should not have written him the prescription for sildenafil because he was already using a nitroglycerin patch for his coronary artery disease. What is the most appropriate next step? 

A middle-aged married couple brings their 10-year-old daughter to the pediatrician because "she just is too tired to play nowadays and sleeps all the time." The parents say that their daughter is winded with minimal exertion. Further inquiry reveals that for the past two weeks, the girl has had bleeding gums when she brushes her teeth. Physical examination demonstrates pallor and hepatosplenomegaly. An extensive workup indicates that the girl is suffering from acute lymphoblastic leukemia, and her parents are informed that chemotherapy will be necessary. The parents firmly refuse to comply with this treatment plan, however, because they are convinced that the side effects will be too severe. Despite a lengthy discussion about the benefits of treatment and the likely consequences for their daughter if therapy is withheld, the girl’s parents insist upon taking her home. What is the most appropriate next step?

A mother calls you on the telephone and says that your 4-year-old son bit the hand of her 2-year-old son 48 hours previously. The area around the injury has become red, indurated, and swollen, and he has a temperature of 39.4°C (103°F). Which of the following is the most appropriate response?

A pedestrian is hit by a speeding car. Radiologic studies obtained in the emergency room, including a retrograde urethrogram (RUG), are consistent with a pelvic fracture with a rupture of the urethra superior to the urogenital diaphragm. Which of the following is the most appropriate next step in this patient’s management?

A previously healthy 15-year-old boy is brought to the emergency room with complaints of about 12 hours of progressive anorexia, nausea, and pain of the right lower quadrant. On physical examination, he is found to have a rectal temperature of 38.18°C (100.72°F) and direct and rebound abdominal tenderness localizing to McBurney point as well as involuntary guarding in the right lower quadrant. At operation through a McBurney-type incision, the appendix and cecum are found to be normal, but the surgeon is impressed by the marked edema of the terminal ileum, which also has an overlying fibrinopurulent exudate. Which of the following is the most appropriate next step?

A previously healthy 16-year-old girl presents to the emergency center with the complaint of “falling out.” She was with her friends at a local fast food restaurant when she felt faint and, according to her friends, lost consciousness for about a minute. There was no seizure activity noted, but the friends did notice her arms twitching irregularly. She is now acting normally. She denies chest pain or palpitations, and her electrocardiogram (ECG) is normal. Further management of this patient should include which of the following?

A previously healthy 45-year-old man presents with a 9-month history of a slow-growing, painless right neck mass. He is a nonsmoker and has no significant past medical history. On examination, there is a nontender, discrete, 3-cm mass over the angle of the right mandible. Facial muscle function and sensation are normal. An oropharyngeal examination is normal. Which of the following is the best next step in the management of this patient?

A previously normal newborn infant in a community hospital nursery is noted to be cyanotic at 14 hours of life. She is placed on a face mask with oxygen flowing at 10 L/min. She remains cyanotic, and her pulse oximetry reading does not change. An arterial blood gas shows her PaO2 to be 23 mm Hg. Bilateral breath sounds are present, and she has no murmur. She is breathing deeply and quickly, but she is not retracting. While you are waiting for the transport team from the nearby children’s hospital, you should initiate which of the following?

A septuagenarian woman undergoes an uncomplicated resection of an abdominal aneurysm. Four days after surgery the patient presents with sudden onset of abdominal pain and distention. An abdominal radiograph demonstrates an air-filled, kidney-bean–shaped structure in the left upper quadrant. Which of the following is the most appropriate management at this time?

A stockbroker in his mid-40s presents with complaints of episodes of severe, often incapacitating chest pain on swallowing. Diagnostic studies on the esophagus yield the following results: endoscopic examination and biopsy mild inflammation distally; manometry—prolonged high-amplitude contractions from the arch of the aorta distally, lower esophageal sphincter (LES) pressure 20 mm Hg with relaxation on swallowing; barium swallow 2 cm epiphrenic diverticulum. Which of the following is the best management option for this patient?