Part 5 episode 5

114) A 45-year-old man with poorly controlled hypertension presents with severe chest pain radiating to his back. An ECG demonstrates no significant abnormalities. A CT scan of the chest and abdomen is obtained, which demonstrates a descending thoracic aortic dissection extending from distal to the left sub-clavian take off down to above the iliac bifurcation. A Foley catheter is placed, and urine output is 30 to 40cc/h. His feet are warm, with less than 2-second capillary refill. Which of the following is the most appropriate initial management?

115) 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?

116) A 57-year-old man comes to the physician for a routine checkup. He complains of right-sided leg cramps accompanied by fatigue while walking. He also complains of occasional right thigh pain. He denies chest pain, syncope, nausea, and abdominal pain. His sexual performance has decreased over the past 1 year. His other medical problems include stage 3 chronic kidney disease, type 2 diabetes mellitus, hypertension, hyperlipidemia, gout, and gastroesophageal reflux disease. His blood pressure is 144/92 mm Hg, pulse is 67/min, and BMI is 29 kg/m2. Peripheral pulses are bilaterally palpable. There is a small ulcer at the base of the right great toe. The ankle-brachial index (ABI) is 1.0 (normal: 1.0 - 1.3). His laboratory values are significant for a serum creatinine level of 2.2 mg/dl and an HbA1c level of 7.5% but otherwise unremarkable. Which of the following is the most appropriate next step in managing this patient's leg pain?

118) A 55-year-old man with recent onset of atrial fibrillation presents with a cold, numb, pulseless left lower extremity. He is immediately taken to the operating room for an embolectomy of the left popliteal artery. Which additional procedure should be performed along with the embolectomy?

120) A 35-year-old woman presents to the clinic for a discussion on breast cancer risk. Her family history is pertinent for a grandmother who died of breast cancer at age 53, a mother who died of premenopausal breast cancer, and one of three sisters with breast cancer diagnosed at age 42. The sister with breast cancer underwent genetic testing and was found to have a BRCA1 mutation. Subsequently, the 35-year-old woman underwent genetic testing and was found to be a carrier of the same deleterious BRCA1 mutation. Which of the following ranges represents the lifetime risk for breast cancer that should be quoted for this patient?

121) A 35-year-old woman presents to the clinic for a discussion on breast cancer risk. Her family history is pertinent for a grandmother who died of breast cancer at age 53, a mother who died of premenopausal breast cancer, and one of three sisters with breast cancer diagnosed at age 42. The sister with breast cancer underwent genetic testing and was found to have a BRCA1 mutation. Subsequently, the 35-year-old woman underwent genetic testing and was found to be a carrier of the same deleterious BRCA1 mutation.For this patient, which of the following strategies represents an accepted management option for her high-risk status?

122) A 38-year-old woman presents to the physician because of right upper quadrant pain associated with nausea and vomiting for the past 12 hours. She has had similar pain previously, usually precipitated after the ingestion of fatty foods. However, past episodes have always resolved within one to two hours. She has type 2 diabetes mellitus, hypertriglyceridemia, and hypercholesterolemia. Her current medications include metformin, fenofibrate, and a statin. Her temperature is 38.3° C (101° F), blood pressure is 130/70 mm Hg, pulse is 98/min, and respirations are 20/min. Her BMI is 32 kg/m2. Examination shows right upper quadrant tenderness. Abdominal ultrasound reveals gallstones, a thickened gallbladder wall with edema, and a normal common bile duct. Her alkaline phosphatase level is normal. Which of the following is the most appropriate next step in the management of this patient?

123) A 40-year-old, obese, white woman, mother of five children, gives a history of repeated episodes of right upper quadrant abdominal pain. The pain is brought about by the ingestion of fatty foods and is relieved by the administration of anticholinergic medications. The pain is colicky, radiates to the right shoulder and around to the back, and is accompanied by nausea and occasional vomiting. The patient has no pain at this time, but is anxious to avoid further episodes. She is afebrile, and physical examination is unremarkable. Which of the following is the most appropriate next step in management?

124) 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?

126) A 75-year-old woman with history of angina is admitted to the hospital for syncope. Examination of the patient reveals a systolic murmur best heard at the base of the heart that radiates into the carotid arteries. Electrocardiogram (ECG) is notable for left ventricular hypertrophy with evidence of left atrial enlargement. ECG reveals an aortic valve area of 0.7 cm2. What is the most appropriate next step in her management?

127) A pediatrician's office gets a phone call from a frantic mother. Her 7-year-old daughter was playing under the sink and accidentally spilled Liquid Plumber (a strong, corrosive alkaline drain cleaner) all over her arms and legs. The nurse on the phone can hear the girl screaming in the background. Which of the following are the most appropriate instructions to give the mother?

128) A 59-year-old man sustains blunt trauma in an automobile accident, resulting in multiple intra-abdominal injuries. Surgery for the repair of these injuries takes several hours and requires multiple blood transfusions and infusions of Ringer's lactate. Before all the operative steps are completed, the patient develops a significant coagulopathy, a core body temperature less than 34 C (93.2 F), and refractory acidosis. The anesthesiologists are administering fresh frozen plasma and platelet packs. Which of the following is the most appropriate next step in management for the surgeon?

129) A previously healthy 19-year-old man presents to the emergency department with a penetrating wound to the right neck. There were reports of bleeding at the scene. The patient is talking, complaining of pain at the injury site and pain with swallowing. On examination, he has a normal respiratory rate, clear air entry on auscultation, blood pressure of 120/70 mmHg, and heart rate of 95 beats/min. There is a penetrating right neck wound in zone 2 (between the clavicle and the lower part of the mandible), with a surrounding hematoma. On probing, there is violation of the platysma. Which of the following is the best next step in the management of this patient?

130) A 45-year-old man is brought to the emergency department after being involved in an automobile crash. He is alert and oriented, with a normal neurologic examination. His respiratory rate is 20/min, with clear lungs, pulse rate of 120/min, and blood pressure of 80/40 mmHg. On examination, he is noted to have a distended abdomen, with decreased bowel sounds, and a fracture of the right ankle. IV access is established, and the patient receives a rapid infusion of 2 L of saline, without changes to pulse rate or blood pressure. Which of the following is the most appropriate next step in his management?

132) 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?

133) A 55-year-old man comes to the emergency department because of severe retrosternal chest pain that suddenly started a few hours ago. He has been having some chest pain and epigastric burning for the past few days but says that the current pain is different. His other medical problems include nonischemic cardiomyopathy for which he takes furosemide, carvedilol, spironolactone, lisinopril, and potassium chloride. He also has HIV infection but has chosen not to take any medication related to this diagnosis. His temperature is 38.9° C (102° F), blood pressure is 110/65 mm Hg, pulse is 110/min, and respirations are 22/min. Examination shows that he is in obvious distress secondary to pain. His lungs are clear to auscultation. The remainder of the examination shows no abnormalities. His ECG is within normal limits. Chest x-ray shows a widened mediastinum and some mediastinal air. Which of the following is the most appropriate next step in the management of this patient?

134) A 36-year-old woman presents with palpitations, anxiety, and hypertension. Workup reveals a pheochromocytoma. Which of the following is the best approach to optimizing the patient preoperatively?

135) A 35-year-old woman is involved in a motor vehicle crash, sustaining a severe pelvic fracture, with disruption of the pelvic ring. In the trauma resuscitation room, she is confused and tachypneic, with a blood pressure of 90 mmHg systolic and a heart rate of 130/min. Laboratory investigations include serum electrolyte analysis, revealing a sodium of 139, a chloride of 103, and a bicarbonate of 14 meq/L. Which of the following is the most appropriate management of this acid-based derangement?

136) A 33-year-old pregnant woman notices a persistent, painless lump in the left breast. On examination the left breast has a single mobile mass without evidence of skin changes or lymphadenopathy in the neck or axilla. An ultrasound demonstrates a solid, 1-cm mass in the upper outer quadrant of the breast. A core-needle biopsy shows invasive ductal carcinoma. The patient is in her first trimester of pregnancy. Which of the following is the most appropriate management of this patient?

137) A 40-year-old woman presents with a rash involving the nipple-areola complex for the last month with associated itching. On physical examination there is crusting and ulceration of the nipple with surrounding erythema involving the areola and surrounding skin, no palpable breast masses, and no cervical or axillary lymphadenopathy. Which of the following is the most appropriate next step in the management of this patient?

138) A 54-year-old woman presents to her physician for an opinion regarding additional therapy following curative resection of recently diagnosed colon cancer. She underwent uncomplicated sigmoid resection for invasive colon cancer 4 weeks ago. The pathology revealed carcinoma invading into, but not through, the muscularis propria, with one of eight positive mesenteric nodes. There was no evidence of liver metastases at the time of operation. Preoperative chest x-ray and CT scan of the abdomen showed no evidence of distant disease. Preoperative carcinoembryonic antigen (CEA) level was normal. Past history is positive for diabetes and mild hypertension. Examination is unremarkable except for a healing abdominal incision. Which of the following is the most appropriate recommendation regarding adjuvant therapy?

139) A 55-year-old man presents to the physician’s office for his yearly physical examination. He is asymptomatic. Past history is pertinent for hypertension. Family history is positive for breast cancer in his mother at age 70 and colon cancer in his father at age 65. His examination is unremarkable except for guiac positive stool. Barium enema shows a sigmoid colon polyp. Colonoscopy confirms a 3-cm pedunculated polyp in the sigmoid colon, and snare polypectomy is performed. Pathologic examination reveals an adenomatous polyp with a focus of invasive carcinoma in the head, with a 4-mm resection margin and no tumor noted in the stalk. Which of the following is the most appropriate next step in management?

140) An elderly woman with osteoporosis falls on her outstretched hand. She comes in with a deformed and painful wrist that looks like a dinner fork. X-ray films show a dorsally displaced, dorsally angulated fracture of the distal radius. There is also an associated fracture of the ulnar styloid. A neurologic examination is normal. Which of the following is the most appropriate management?

141) During endoscopic biopsy of a distal esophageal cancer, perforation of the esophagus is suspected when the patient complains of significant new substernal pain. An immediate chest film reveals air in the mediastinum. Which of the following is the most appropriate management of this patient?

142) 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?

143) A 27-year-old woman seeks your advice regarding pain and numbness in the right arm and hand. She reports that it is exacerbated by raising her arm over her head. On examination, the right radial pulse disappears when the patient takes a deep breath and turns her head to the left. A provisional diagnosis is made. Which of the following is the most appropriate initial treatment for this patient?

144) A 35-year-old man with a history of melanoma status post wide local excision with negative margins and lymph node dissection presents with 2, peripherallylocated pulmonary lesions seen on chest CT scan. Percutaneous biopsy of the lesion is consistent with metastatic melanoma. He has no evidence of recurrence or extrathoracic disease and is in good general health. Which of the following is the most appropriate management of this patient?

146) A 65-year-old man presents to the emergency department with sudden onset of pain and weakness of the left lower extremity of 2-hour duration. Past history reveals chronic atrial fibrillation following a myocardial infarction 12 months ago. On examination, he is found to have a cool, pale left lower extremity with decreased strength and absent popliteal and pedal pulses. The opposite leg has a normal appearance with palpable pulses. Which of the following is the treatment of choice for this patient?

147) A 53-year-old woman presents with complaints of weakness, anorexia, malaise, constipation, and back pain. While being evaluated, she becomes somewhat lethargic. Laboratory studies include a normal chest x-ray, serum albumin 3.2 mg/dL, serum calcium 14 mg/dL, serum phosphorus 2.6 mg/dL, serum chloride 108 mg/dL, blood urea nitrogen (BUN) 32 mg/dL, and creatinine 2.0 mg/dL. Which of the following is the most appropriate initial management?

148) A 44-year-old homeless woman presents to the emergency department because she is "bleeding from the breast." Physical examination shows a huge, fungating, ulcerated mass that occupies the entire right breast and is firmly attached to the chest wall. The right axilla is full of hard masses that are not movable either. Core biopsies of the breast are read as highly undifferentiated infiltrating ductal carcinoma, and assay for estrogen and progesterone receptors are negative. Which of the following is the most appropriate next step in management?

149) A 64-year-old woman complains of right calf pain and swelling. She recently underwent an uncomplicated left hemicolectomy for diverticular disease. A duplex ultrasound confirms the presence of deep vein thrombosis (DVT) of the calf. Which of the following is the most appropriate initial management of this patient?

152) A 45-year-old woman presents with a 7-cm renal cell carcinoma with radiologic evidence of abdominal lymph node involvement with no distant metastases. Which of the following is the most appropriate management of this patient?

153) A 58-year-old man is found to have high serum prostate–specific antigen (PSA) concentration with a normal prostate examination. A biopsy of the prostate confirms low-grade carcinoma. The patient wishes to avoid therapy involving any risk for impotence. Which of the following is the most appropriate management of this patient?

154) A 28-year-old man with a past history of bilateral orchiopexy for cryptorchidism presents with a painless, unilateral right scrotal enlargement. On examination, there is a palpable right testicular mass and enlarged inguinal node. Scrotal ultrasonography demonstrates heterogeneity of the testis, with an associated hydrocele. A CT scan of the abdomen and pelvis demonstrated right-sided retroperitoneal adenopathy. CT scan of the chest is normal. Staging workup and surgery reveal a seminoma of the testicle, with positive inguinal and retroperitoneal nodes. Therapeutic management for this patient is which of the following?

155) A patient with mild skin pigmentation is admitted emergently to your service because of sudden abdominal pain, fever, and a rigid abdomen. Her blood work indicates a marked leukocytosis, a blood sugar of 55 mg/dL, a sodium value of 119 mEq/dL, and a potassium value of 6.2 mEq/dL. Her blood pressure is 88/58-mmHg. She undergoes an exploratory laparotomy. Which of the following is the definitive treatment for her primary condition?

157) A 45-year-old woman presents with left-sided weakness. A CT scan of the head demonstrates a well-circumscribed mass abutting the skull in the right hemisphere. Workup of the mass reveals a meningioma. Which of the following is the best next step in treatment?

158) A 30-year-old man presents to the emergency department with sudden onset of severe epigastric pain and vomiting 3 hours ago. He reports a 6-month history of chronic epigastric pain occurring nearly every day and relieved by antacids. On examination, he appears sweaty and avoids movement. Vital signs reveal a temperature of 100°F, BP of 100/60 mmHg, pulse rate of 110/min, and respiratory rate of 12/min. The remainder of his examination reveals diminished bowel sounds and a markedly tender and rigid abdomen. A chest x-ray and abdominal films reveal pneumoperitoneum. Which of the following is the most appropriate next step in management?

159) An 18-year-old high school senior develops peripheral vision abnormalities. A CT scan of the brain reveals a cystic suprasellar mass with some calcification noted. Clinically, this is compatible with a craniopharyngioma. What is the best next step in treatment?

160) A 65-year-old diabetic man presents to the emergency department with a history of a penetrating wound to his buttock by a wooden stump while working in his garden 24 hours earlier. On examination, he is febrile, the tissue around the wound is violaceous in color, and several bullae and crepitus are noted in the buttock. The drainage from the wound is foul smelling, watery, and grayish in appearance. The optimal treatment for this patient would include which of the following?

161) A 26-year-old man is brought to the emergency room after being extricated from the driver’s seat of a car involved in a head-on collision. He has a sternal fracture and is complaining of chest pain. He is hemodynamically stable and his electrocardiogram (ECG) is normal. Which of the following is the most appropriate management strategy for this patient?

162) 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?

163) 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?

164) A 60-year-old man is admitted to the coronary care unit with a large anterior wall myocardial infarction. On his second hospital day, he begins to complain of the sudden onset of numbness in his right foot and an inability to move his right foot. On physical examination, the right femoral, popliteal, and pedal pulses are no longer palpable. The left lower extremity is normal. Which of the following is the most appropriate management of this patient?

166) A 46-year-old woman, who had always been in good health, comes in because of the sudden onset of very severe back and leg pain that she experienced 2 hours ago when attempting to lift a heavy object. She says that she felt "a bolt of lightning" running down the back of her leg, and she still has very severe pain that prevents her from walking or moving. The pain is exacerbated by coughing, sneezing, or straining. She keeps the affected leg flexed; straight leg rising gives her excruciating pain. She has good sphincter tone and intact sensation in the perineum. Once the diagnosis is confirmed with the appropriate studies, which of the following will be the most appropriate treatment?

167) During diagnostic evaluation, a 14-year-old girl with menorrhagia, frequent nosebleeds, and iron deficiency anaemia is found to have a low platelet count with a normal coagulation profile. Bone marrow biopsy reveals abundant megakaryocytes. On abdominal examination, no organomegaly is noted. Which of the following is the most appropriate initial therapy for this patient?

168) A 70-year-old woman undergoes a cardiac catheterization for exertional chest pain. Her pain continues to worsen and she is interested in having either surgery or percutaneous coronary intervention (PCI). Which of the following would be an indication for her to undergo either coronary artery bypass grafting or PCI?

169) 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?

170) A 39-year-old woman presents to the physician’s office for evaluation of a palpable nodule in the neck of 2 years’ duration. Her past history is pertinent for Hashimoto’s disease diagnosed 5 years ago, for which she takes thyroid hormone. She has a history of low-dose chest irradiation for an enlarged thymus gland during infancy. On examination, a 2.5-cm nodule is palpable in the left lobe of the thyroid and is firm and non-tender. Which of the following is the most appropriate next step in her management?

171) A 58-year-old man presents with tachycardia, fever, confusion, and vomiting. Workup reveals markedly elevated (triiodothyronine) T 3 and (thyroxine) T4 levels. He is diagnosed as having a thyroid storm. Which of the following is the most appropriate next step in the management of this patient?

172) A 35-year-old man falls on an outstretched hand and comes in complaining of wrist pain. He relates that he was not able to break the fall, and that the heel of his hand took the brunt of his full weight as it hit the pavement. On physical examination, he is distinctly tender to palpation over the anatomic snuff box. Anteroposterior and lateral x-rays are negative. Which of the following are the most likely diagnosis and most appropriate next step in management?

174) A 34-year-old man is extricated from an automobile after a motor vehicle collision. The patient has an obvious deformity of his right thigh consistent with a femur fracture. Upon closer examination of the right thigh, there is bone visible through an open wound. Which of the following is the most appropriate management of his open femur fracture?

175) A 43-year-old woman comes in because of a breast mass. Two days ago, she noticed a lump on self-examination. She has a 2-cm, firm, nontender mass in the left breast, which is movable from the chest wall, but not movable within the breast. She has no prior history of breast disease, but she is well read and well informed, and she specifically requests that a biopsy be done with a mammotome. Before proceeding, which of the following is the most appropriate initial step?

176) A 55-year-old woman presents with a 6-cm right thyroid mass and palpable cervical lymphadenopathy. Fine-needle aspiration (FNA) of one of the lymph nodes demonstrates the presence of calcified clumps of sloughed cells. Which of the following best describes the management of this thyroid disorder?

177) A 45-year-old woman is found to have suspicious appearing calcifications in the right breast on a screening mammogram. Stereotactic biopsy of the calcifications shows lobular carcinoma in situ (LCIS). On examination both breasts are dense without palpable masses. The neck and bilateral axilla are negative for lymphadenopathy. Which of the following is the most appropriate management of this patient?

178) A 32-year-old, previously healthy man is a victim of a drive-by shooting, sustaining a gunshot wound to the left lower extremity. The entrance wound is located over the medial aspect of the calf, with an exit wound over the anterior pretibial region. Neurovascular examination of the extremity is normal. There is associated soft-tissue injury from the blast effect and a severely comminuted tibial fracture demonstrated on radiographs. Appropriate management of this injury includes which of the following?

179) 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?

180) A 41-year-old woman has noted bilateral thin serous discharge from her breasts. There seems to be no mass associated with it. Which of the following statements would be appropriate to tell the patient?

181) A 42-year-old woman presents to the ER with the worst headache of her life. A noncontrast CT scan of the head is negative for lesions or hemorrhage. She then undergoes a lumbar puncture, which appears bloody. All 4 tubes collected have red blood cell counts greater than 100,000/mL. Which of the following steps is the most appropriate management of this patient?

182) 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?

183) After being injured by a bull on his mother’s farm, a young man is placed in a cast for a supracondylar fracture of his humerus. A few hours later he begins to experience intense pain, swelling, and weakness in the ipsilateral hand. Pulses are normal in bilateral upper extremities. Which of the following is the most appropriate initial management of this patient?

184) A 39-year-old man presents with an isolated fracture of the tibia after being hit on the leg with a car. The patient is stable and a radiograph of the leg shows a tibial shaft fracture with severe dislocation. Which of the following is the most appropriate management of the fracture?

185) A 63-year-old woman notices lumps on both sides of her neck. A fine-needle aspirate is nondiagnostic, and she undergoes total thyroidectomy. Final pathology reveals a 2-cm Hürthle cell carcinoma. Which of the following is the most appropriate postsurgical management of this patient?

186) A 51-year-old man presents with a 2-cm left thyroid nodule. Thyroid scan shows a cold lesion. FNA cytology demonstrates follicular cells. Which of the following is the most appropriate initial treatment of this patient?

187) A 25-year-old man is stabbed once in the right chest. The entrance wound is on the midaxillary line, at the level of the fifth intercostal space. He arrives at the emergency department moderately short of breath, but he is fully awake and alert, is talking with a normal tone of voice, and has no distended veins visible in his neck or forehead. His blood pressure is 130/75 mm Hg, and his pulse is 82/min. Physical examination of the chest shows the wound, which is not visibly "sucking air," and demonstrates no breath sounds at all on the right side, which is tympanitic to percussion. There is no evidence of mediastinal displacement. Which of the following would be the most appropriate next step in management?

190) A 40-year-old previously healthy man presents with sudden onset of severe abdominal pain that radiates from the right loin (flank) to groin. This pain is associated with nausea, sweating, and urinary urgency. He is distressed and restless, but an abdominal examination is normal. Which of the following is the most appropriate next step in management?

191) 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?

192) A 36-year-old woman, 20 weeks pregnant, presents with a 1.5-cm right thyroid mass. FNA is consistent with a papillary neoplasm. The mass is cold on scan and solid on ultrasound. Which of the following methods of treatment is contra-indicated in this patient?

193) A 45-year-old man presents to the physician’s office complaining of dysphagia and retrosternal pressure and pain of 2-year duration. The symptoms have worsened over the last 3 months. He has a 30 pack-year smoking history and drinks beer on weekends. Vital signs include a BP of 150/90 mmHg, pulse rate of 90/min, and respiratory rate of 12/min, with a normal temperature. Examination reveals a thin man with a normal heart, lung, and abdomen examination. An esophagogram reveals a 6-cm, smooth, concave defect in the mid-esophagus with sharp borders. Esophagoscopy reveals intact overlying mucosa and a mobile tumor. Which of the following is the most appropriate next step?

194) A 45-year-old woman presents with dysphagia, regurgitation of undigested food, and weight loss. She had x-rays shown here as part of her workup. Upper endoscopy reveals no evidence of malignancy and esophageal motility studies show incomplete lower esophageal sphincter relaxation. Which of the following is the next best step in the treatment of this patient?

195) During diagnostic evaluation, a 14-year-old girl with menorrhagia, frequent nosebleeds, and irondeficiency anemia is found to have a low platelet count with a normal coagulation profile. Bone marrow biopsy reveals abundant megakaryocytes. On abdominal examination, no organomegaly is noted. The patient has a satisfactory response to the initial therapeutic intervention, but over 6–12 months’ time, the response is less dramatic and shorter in duration. There are signs and symptoms of increasing side effects from therapy. The next step in management should be to recommend which of the following?

196) A 70-year-old man is admitted to the ICU after repair of an abdominal aortic aneurysm. He has a prior history of hypertension and mild congestive heart failure, which were adequately controlled with digoxin and diuretics. To facilitate perioperative management, a Swan-Ganz (multilumen pulmonary artery) catheter was inserted in the operating room. During the first few hours postoperatively, the patient is noted to have a blood pressure of 140/70 mmHg, heart rate of 110/min, flat neck veins, a pulmonary arterial wedge pressure of 9 mmHg, and poor urine output. Several hours after this intervention a bolus of IV crystalloid, the patient is reassessed. The blood pressure is 150/85 mmHg, heart rate is 90/min, neck veins are distended, and the pulmonary arterial wedge pressure is 17 mmHg. Urine output is still low in volume. At this point, management should be which of the following?

197) A 19-year-old previously healthy man is an unbelted driver of a motor vehicle involved in a front-end collision. On arrival in the emergency department, the patient is noted to have stridor, with marked respiratory distress, and an oxygen saturation of 88% despite 100% oxygen by mask. He has obvious extensive facial injuries, a flail chest, and poor chest expansion. Bag-mask-valve ventilation is ineffective. Which of the following is the most appropriate next step in management?

198) A 32-year-old man presents with an asymptomatic mass in his right testicle. On examination, the mass cannot be transilluminated. Ultrasound shows a solid mass in the right testicle. Which of the following is the most accurate method in obtaining a diagnosis of testicular cancer?

199) 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?

200) 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?

201) 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?

202) A 63-year-old man underwent a 3-vessel coronary artery bypass graft (CABG) 5 hours ago. Initially, his mediastinal chest tube output was 300 mL blood/h, but an hour ago, there was no further evidence of bleeding from the tube. His mean arterial pressure has fallen, and several fluid boluses were administered. His central venous pressure (CVP) is elevated to 20 mm Hg, and he has required the addition of inotropes. Which of the following is the best management strategy?

203) An 89-year-old man has lost 30 lb over the past 2 years. He reports that food frequently sticks when he swallows. He also complains of a chronic cough. Barium swallow is shown here. What is the best treatment option for this patient?

204) A 23-year-old man presents to the emergency department with a soft-tissue injury to the left lower extremity. The injury was sustained 8 hours earlier in a motorcycle accident on a gravel road. On examination, the patient has a 7-cm deep laceration to the calf, with visible road debris. He had full tetanus immunization as a child and a tetanus booster immunization at age 15. Appropriate management of this injury would include which of the following?

205) A 6-year-old boy presents to the emergency department with a painful, markedly swollen elbow. While ice-skating, he fell with his arm outstretched. Radiographs of the elbow demonstrate a displaced, supracondylar fracture of the humerus. On examination, there is pain on passive flexion at the wrist and a decreased radial pulse, with diminished capillary refill in the hand. Which of the following is the most appropriate management of this injury?

206) A 25-year-old man is stabbed in the right chest. He comes in fully awake and alert, and, in a normal tone of voice, he states that he feels short of breath. His vital signs are normal and stable. On physical examination, he has no breath sounds at the right base, and only faint breath sounds at the apex. He is dull to percussion over the right base. A chest x-ray film confirms that he has a hemothorax on that side. Which of the following is the most appropriate next step in management?

207) A 35-year-old woman with a history of previous right thyroidectomy for a benign thyroid nodule now undergoes completion thyroidectomy for a suspicious thyroid mass. Several hours postoperatively, she develops progressive swelling under the incision, stridor, and difficulty breathing. Orotracheal intubation is successful. Which of the following is the most appropriate next step?

209) A 60-year-old man seeks medical attention because of recurrent urinary tract infections. The patient also reports a history of increasing difficulty in urination (decreased flow, straining, and hesitancy) over the last several months. A prostate-specific antigen (PSA) level is mildly elevated and a prostate biopsy proves benign. Which of the following is the most appropriate initial management of this patient with benign prostatic hyperplasia (BPH)?

211) A 25-year-old unhelmeted man involved in a motorcycle collision has multiple cerebral contusions on head computed tomographic (CT) scan. He is agitated but hemodynamically stable, with a heart rate of 80 beats per minute and a mean arterial pressure (MAP) of 90 mm Hg. An intracranial pressure monitor is placed, and the initial ICP reading is 30 mm Hg. Which of the following is the most appropriate in the management of his traumatic brain injury (TBI) over the next few days?

212) A 50-year-old woman complains of headaches and lateralizing weakness. A CT scan of the brain reveals an irregular mass in the right cerebral hemisphere. A biopsy documents that this is a glioblastoma. Which of the following is the best treatment strategy for potential cure?

214) A 49-year-old woman presents to her physician with dysphagia, regurgitation of undigested food eaten hours earlier, and coughing over the last 6 months. She was hospitalized 1 month ago for aspiration pneumonia and successfully treated with antibiotics. Examination reveals a thin-appearing woman with normal vital signs and unremarkable chest, heart, and abdominal examination. A UGI contrast study is performed and reveals a pharyngoesophageal (Zenker’s) diverticulum. Which of the following is the most important aspect of treatment?

215) A 40-year-old alcoholic is brought to the emergency department with frostbite to both lower extremities. His core body temperature is 36°C. Which of the following is the most appropriate initial treatment for the patient’s thermal injury?

216) A 35-year-old woman presents with a serum calcium level of 15.2 mg/dL and an elevated parathyroid hormone level. Following correction of the patient’s hypercalcemia with hydration and furosemide, which of the following is the best therapeutic approach?

217) A 65-year-old man presents to the emergency department with sudden onset of pain and weakness of the left lower extremity of 2-hour duration. Past history reveals chronic atrial fibrillation following a myocardial infarction 12 months ago. On examination, he is found to have a cool, pale left lower extremity with decreased strength and absent popliteal and pedal pulses. The opposite leg has a normal appearance with palpable pulses. Following successful treatment for an embolus to the left femoral artery with no evidence of a reperfusion injury (anticoagulation with heparin and thromboembolecctomy), which of the following long-term treatments would most likely decrease the chance of recurrent embolus?

218) A 63-year-old man has a chylothorax that after 2 weeks of conservative therapy appears to be persistent. The chest tube output is approximately 600 mL/day. Appropriate management at this time includes which of the following procedures?

219) A 32-year-old woman has a CXR screening, and a 1.5-cm mass is noted in the right lower lobe. She is a nonsmoker. Bronchoscopy shows a mass in the right lower lobe orifice, covered with mucosa. Biopsy indicates this is compatible with a carcinoid tumor. Imaging suggests ipsilateral mediastinal lymph node involvement but no extrathoracic disease. Which of the following is the most appropriate treatment plan?

220) A 55-year-old woman presents with a 6-month history of weight loss, abdominal cramps, and intermittent nonbloody diarrhea. On examination, her abdomen is mildly distended and there is a palpable mass in the right lower quadrant. Stool cultures yield normal fecal flora. CT scan with oral contrast demonstrates an inflammatory mass in the right lower quadrant, with thickening of the terminal ileum and ileocecal valve.Initial management should include which of the following?

221) A 33-year-old woman is found to have a palpable thyroid nodule during a routine medical checkup. A sonogram confirms the presence of a solid, 1.5-cm nodule in the right lobe of the thyroid gland. Fine needle aspirate cytology (FNA) is reported as "follicular tumor, otherwise unspecified." At surgery, a frozen section is read as follicular carcinoma. With the neck open, the surgeon can feel for enlarged jugular and peritracheal lymph nodes, and finds none. Which of the following is the most appropriate treatment?

222) A 63-year-old woman with chronic obstructive pulmonary disease (COPD) presents with a several-week history of fever, night sweats, weight loss, and cough. Her CXR is noted to have a density in the left upper lobe with a relatively thin-walled cavity. Bronchoscopy and computed tomographic (CT) scan are suggestive of a lung abscess rather than a malignant process. Which of the following is the most appropriate initial management of this patient?

223) A 4-year-old previously healthy girl presents to the emergency department with a 24-hour history of rectal bleeding and dizziness. She has no other gastrointestinal symptoms. On examination, she appears pale. Her heart rate is 140 beats/min, and she has a 20 mmHg postural drop in systolic blood pressure. The child’s abdomen is nondistended and nontender, and fresh blood and clots are in the rectal vault on rectal examination. Definitive management of this child should include which of the following?

224) A 29-year-old nonhelmeted motorcycle driver is involved in a single vehicular crash, resulting in a significant closed-head injury. He is intubated in the field and transported to a level 1 trauma center. On arrival, he is oxygenating well with assisted ventilation and has a normal blood pressure and moderate tachycardia. His Glasgow Coma Score is 7, and his pupils are equal and sluggishly reactive. After stabilization in the emergency department, the patient undergoes a CT scan of the head that demonstrates a small amount of subarachnoid blood and a right frontal lobe contusion with edema with no midline shift. CT scan of the abdomen is normal. The patient is transferred to the ICU. The optimal initial management of this patient’s intracranial pressure (ICP) would be which of the following?

225) A 49-year-old obese man has become irritable, his face has changed to a round configuration, he has developed purplish lines on his flanks, and he is hypertensive. A 24-hour urine collection demonstrates elevated cortisol levels. This is confirmed with bedtime cortisol measurements of 700ng/mL. Which of the following findings is most consistent with the diagnosis of Cushing disease?

226) A 70-year-old man presents with back pain and increasing difficulty with initiating a urinary stream. On rectal examination, he is found to have a hard, irregularly enlarged prostate. He has an elevated prostate-specific antigen (PSA), and osteoblastic lesions in the vertebral column and bones of the pelvis. A needle biopsy of the prostate shows well-differentiated adenocarcinoma. Which of the following is the treatment of choice?

228) A 5-week-old infant presents with a 1-week history of progressive nonbilious emesis, associated with a 24-hour history of decreased urine output. The infant continues to be active and eager to feed. On examination, the infant has a sunken fontanelle and decreased skin turgor. The abdomen is scaphoid, and with a test feed, there is a visible peristaltic wave in the epigastrium. Which of the following is the most appropriate next step in management of this infant?

229) A 49-year-old woman has a firm, 2-cm mass in the right breast that has been present for 3 months. Mammogram has been read as "cannot rule out cancer," but it cannot diagnose cancer either. A fine-needle aspiration of the mass (FNA) and cytology do not identify any malignant cells. Which of the following is the most appropriate next step in management?

230) A 60-year-old man sees a urologist for what he describes as bloody urine. A urine sample is positive for cytologic evidence of malignancy. Cystoscopy confirms the presence of superficial transitional cell carcinoma. Which of the following is the recommended treatment for stage A (superficial and submucosal) transitional cell carcinoma of the bladder?

231) A 36-year-old man presents to the emergency room with renal colic. His vital signs are normal and a urinalysis shows microscopic hematuria. A radiograph reveals a 1.5-cm stone. Which of the following is the most appropriate management of this patient?

232) An 8-month-old boy is seen by a pediatrician for the first time. The physician notes that there are no testes in the scrotum. Which of the following is the optimal management of bilateral undescended testicles in an infant?

233) A 55-year-old man presents to the emergency department with left lower quadrant abdominal pain. The pain has been 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?

234) A 39-year-old woman completed her last course of postoperative adjuvant chemotherapy for breast cancer 6 months ago. She now comes to the clinic complaining of constant back pain for about 3 weeks. She is tender to palpation over two well-circumscribed areas in the thoracic and lumbar spine. Which of the following is the most appropriate next step in management?

235) A 42-year-old woman returns to the clinic following an uneventful biopsy for a well-defined, mobile mass. The pathology report describes the mass as a fibro adenoma, but LCIS is identified in the breast parenchyma adjacent to the fibro adenoma and extending to the margin of resection. She has no current illnesses, is on no medications, and her family history is negative for breast cancer. Breast imaging studies show fatty breasts with no abnormal findings except for the fibro adenoma. Which of the following is the most appropriate management option?

236) A 59-year-old man is found to have a 6-cm thoracoabdominal aortic aneurysm which extends to above the renal arteries for which he desires repair, but he is concerned about the risk of paralysis postoperatively. Which of the following maneuvers should be employed to decrease the risk of paraplegia after repair?

237) A man who weighs 65 kg sustains second and third degree burns over both of his lower extremities when his pants catch on fire. When examined shortly thereafter, it is ascertained that virtually all of the skin from both groins to the tip of the toes, front and back, has been burned. According to the modified Parkland formula, which of the following is the approximate total amount of IV fluid that he can be expected to require during the first 24 hours post-burn?

238) A 65-year-old man presents to the emergency department with sudden onset of pain and weakness of the left lower extremity of 2-hour duration. Past history reveals chronic atrial fibrillation following a myocardial infarction 12 months ago. On examination, he is found to have a cool, pale left lower extremity with decreased strength and absent popliteal and pedal pulses. The opposite leg has a normal appearance with palpable pulses. Which of the following is the most appropriate first step in management of this patient?

239) A 29-year-old woman with a history of difficulty becoming pregnant presents to her primary care physician and is diagnosed with Grave disease on iodine uptake scan; her thyrotropin (TSH) level is markedly suppressed and her free thyroxine (T4) level is elevated. She desires to conceive as soon as possible and elects to undergo thyroidectomy. After she is rendered euthyroid with medications preoperatively, which of the following management strategies should also be employed to reduce the risk of developing thyroid storm in the operating room?

240) A 72-year-old woman with severe COPD who requires home oxygen is unable to ambulate inside her home without experiencing severe left hip pain. She was hospitalized 1 year ago for a viral pneumonia and was ventilator-dependent at that time for 6 weeks. On examination, her blood pressure is 165/80 mm Hg. She has weakly palpable bilateral femoral pulses. An angiogram demonstrates severe aortoiliac disease involving bilateral iliac vessels. Which of the following is the most appropriate vascular procedure for this patient?

241) A 52-year-old woman has terminal cervical cancer with extensive pelvic invasion, and requires strong opiate analgesia to control severe pain. Intermittent nausea and vomiting have precluded the use of oral agents. She was on fentanyl patches but she developed allergic skin reactions to the adhesive and now requests to be switched to parenteral medication. Because of prior chemotherapy treatments she has no available venous access, but she is willing to have her family administer intramuscular injections. Assuming equianalgesic dosages, which of the following would be the most appropriate pharmacotherapy?

242) A 71-year-old woman with a 40-year smoking history is noted to have a peripheral nodule in her left upper lobe on chest x-ray. Workup is consistent with small cell lung cancer with ipsilateral mediastinal lymph node involvement but no extrathoracic disease. What is the best treatment option for this patient?

243) A 42-year-old homeless man presents with a 3-week history of shortness of breath, fevers, and pleuritic chest pain. Chest x-ray (CXR) reveals a large left pleural effusion. Thoracentesis reveals thick, purulent-appearing fluid, which is found to have glucose less than 40 mg/dL and a pH of 6.5. A chest tube is placed, but the pleural effusion persists. Which of the following is the most appropriate management of this patient?

244) During a campaign appearance, a political candidate is shot point blank in the right chest with a .22 caliber revolver. The entrance wound is well above the nipple line, just under the third rib, at the level of the anterior axillary line. His motorcade brings him to the emergency department, but he makes it a point to walk in, holding his right chest with a bloody hand and waving for the news media. A chest x-ray shows a hemothorax on the right, and the bullet is seen to be embedded in the right paraspinous muscles. A chest tube is placed in the right pleural cavity, and 650 mL blood is recovered. Over the ensuing 4 hours, he continues to drain between 250 and 350 mL blood per hour. Which of the following is the most appropriate next step in management?

245) A 65-year-old woman presents to the physician’s office for a second opinion on the management options for recently diagnosed breast cancer. She presents with a 2.5-cm mass in the upper outer quadrant of the left breast associated with a palpable axillary node suspicious for metastatic disease. The remainder of her examination is normal. Mammography demonstrates the cancer and shows no other suspicious lesions in either breast. Chest x-ray, bone scan, and blood test panel, including liver function tests, are normal. Family history is positive for breast cancer diagnosed in her sister at age 65. Past history is unremarkable. The first physician recommended modified radical mastectomy. Which of the following is the most appropriate management option for locoregional control yielding results equally effective as mastectomy?

246) During a hunting trip, a young man is bitten by a coyote. The animal is captured and brought to the authorities alive. Which of the following is the most important criterion to determine the patient's need for rabies prophylaxis?

247) A 64-year-old man with a history of a triple coronary artery bypasses 2 years ago presents with peripheral arterial occlusive disease. His only medication is a thiazide diuretic. Which of the following medications would be most appropriate in the medical management of his atherosclerosis?

249) A 62-year-old man has had gastroesophageal reflux disease diagnosed by pH monitoring, and present for several years. He has been less than totally compliant with medical management, which he follows when the pain is bad, but discontinues when he feels better. Endoscopy and biopsies show severe peptic esophagitis, with Barrett's esophagus and early dysplastic changes, but no overt carcinoma. Additional tests show good esophageal motility, with low pressure in the lower esophageal sphincter and normal gastric emptying. Which of the following is the most appropriate treatment at this time?

1) A previously healthy 20-year-old man is admitted to the hospital with acute onset of left-sided chest pain. Electrocardiographic findings are normal, but CXR shows a 40% left pneumothorax. Appropriate treatment consists of which of the following procedures?

2) A 22-year-old professional basketball player falls on his outstretched hand during a scrimmage game. He has mild swelling at the wrist and tenderness to palpation in the anatomic snuffbox. No fracture is visible on multiple radiographs of the wrist and hand. Which of the following is the most appropriate management of this patient?

3) After suitable calculations have been made using the modified Parkland formula, a 70-kg man with extensive third-degree burns is receiving Ringer's lactate at the calculated rate, which happens to be 750 mL/hr. The infusion was started within 30 minutes of the time when the burn occurred. Over the next 3 hours, his urinary output is recorded as 15 mL, 22 mL, and 18 mL. It is verified that the Foley catheter is open and draining freely. The urine is dark yellow, without blood, and has a specific gravity of 1040 and a sodium concentration of 10mEq/L. The patient's blood pressure is 100/70 mm Hg, his pulse is 98/min, and his central venous pressure is 2 cm H2O. On the basis of these findings, which of the following is the most appropriate next step in management?

4) A 32-year-old woman in the 2nd month of pregnancy is found to have a 5-cm mass in the upper outer quadrant of her left breast. Mammogram shows no other lesions, and core biopsy reveals infiltrating ductal carcinoma. Which of the following would be the best course of action at this time?

5) 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?

6) A 37-year-old woman undergoes a lumpectomy and axillary dissection for a 3-cm infiltrating ductal carcinoma, diagnosed by core biopsies, located on the upper outer quadrant of her left breast. The pathology report of the surgical specimen is received 3 days after the operation. It indicates that all margins around the tumor are clear, and that 4 of 17 axillary lymph nodes have metastatic tumor. The tumor is reported to be estrogen and progesterone receptor negative. Which of the following should further therapy most likely include?

7) A 45-year-old man with alcoholic cirrhosis is bleeding from a duodenal ulcer. He has required 6 units of blood over the past 8 hours, and all conservative measures to stop the bleeding, including irrigation with cold saline, IV vasopressin, and endoscopic use of the laser have failed. He is being considered for surgical intervention. Laboratory studies done at the time of admission, when he had received only one unit of blood, showed a bilirubin of 4.5 mg/dL, a prothrombin time of 22 seconds, and a serum albumin of 1.8 g/dL. He was mentally clear when he came in, but has since then developed encephalopathy and is now in a coma. Which of the following best describes his operative risk?

8) A 22-year-old convenience store clerk is shot once with a .38 caliber revolver. The entry wound is in the left midclavicular line, 2 inches below the nipple. There is no exit wound. He is hemodynamically stable. A chest x-ray film shows a small pneumothorax on the left, and demonstrates the bullet to be lodged in the left paraspinal muscles. In addition to the appropriate treatment for the pneumothorax, which of the following will this patient most likely need?

9) A middle-aged homeless man is brought to the emergency department because of very severe pain in his forearm. He had passed out after drinking a bottle of cheap wine, and then slept on a park bench for an indeterminate time, probably more than 12 hours. Shortly after he woke up and began to walk, the pain began. There are no signs of trauma, but the muscles in his forearm are very firm and tender to palpation and passive motion of his fingers and wrist elicits excruciating pain. Pulses at the wrist are normal. Which of the following is the most appropriate next step in management?

10) A 66-year-old man with diabetes and generalized arteriosclerotic occlusive disease notices a gradual loss of erectile function over several years. Initially, he can get erections, but they do not last long enough. Later, he notices a decrease in the quality of his erections, and more recently he becomes, by his own criteria, completely impotent. He has occasional, brief nocturnal erections, but "he can never get an erection when he needs one." Which of the following is the most appropriate initial step in management?

11) A 54-year-old woman has a severe ureteral colic. An intravenous pyelogram shows a 7-mm ureteral stone at the ureteropelvic junction. She has a normal coagulation profile. Which of the following would most likely be the best therapy in this case?

12) A 31-year-old woman smashes her car against a bridge abutment. She sustains multiple injuries, including upper and lower extremity fractures. She is fully awake and alert, and she reports that she was not wearing a seat belt and distinctly remembers hitting her abdomen against the steering wheel. Her blood pressure is 135/75 mm Hg, and her pulse is 88/min. Physical examination shows that she has a rigid, tender abdomen, with guarding and rebound in all four quadrants. She has no bowel sounds. Which of the following would be the most appropriate step in evaluating potential intra-abdominal injuries?

13) A 72-year-old man has a 3-mm ureteral stone impacted at the ureterovesical junction. He has been having mild ureteral colicky pain for about 12 hours, and he has been given fluids and analgesics in the expectation that he will spontaneously pass the stone. He then has shaking chills, and spikes a temperature of 40C (104F). When seen shortly thereafter, he has flank pain and looks quite ill. Which of the following is the most appropriate next step in management?

14) A 72-year-old man is scheduled to have elective sigmoid resection for diverticular disease. He has a history of heart disease, and had a documented myocardial infarction 2 years ago. He currently does not have angina, but he lives a sedentary life because "he gets out of breath" if he exerts himself. During the physical examination, it is noted that he has jugular venous distention. He has hemoglobin of 12 g/dL. If surgery is indeed needed, which of the following should most likely be done prior to the operation?

15) A group of illegal immigrants is smuggled across the border in a closed metal truck in the middle of summer. When apprised by radio that the border patrol is on their trail, the smugglers abandon their charges in the middle of the desert, in the locked truck, with little water to drink. The victims are found and rescued 5 days later. One of them is brought to the emergency department, awake and alert, with obvious clinical signs of severe dehydration and a serum sodium concentration of 155mEq/L. Which of the following would be the best choice and rate of IV fluid administration?

16) A 55-year-old woman has been known for years to have mitral valve prolapse. She has now developed exertional dyspnea, orthopnea, and atrial fibrillation. She has an apical, high-pitched, holosystolic heart murmur that radiates to the axilla and back. Because of her deterioration, surgery has been recommended. Which of the following is the most appropriate procedure?

17) A 23-year-old woman seeks help for exquisite pain with defecation and blood streaks on the outside of her stools, which she has been having for several weeks. Because of the pain, she has avoided having bowel movements, and when she finally did the stools were hard and even more painful. When seen, she has no fever or leukocytosis. Physical examination has to be done under spinal anesthesia, because the patient was so afraid of the pain that she initially refused even inspection of the area. The examination confirms the suspected diagnosis, and she is placed on stool softeners and appropriate topical agents, but without success. She is willing to undergo more aggressive treatment. Which of the following is the most appropriate next step?

18) An exploratory laparotomy for multiple intra-abdominal injuries has lasted 3 and a half hours. Multiple blood transfusions have been given, and several liters of Ringer's lactate have been infused. When the surgeons are ready to close the abdomen, they find that the abdominal wall edges cannot be pulled together without undue tension. Both the belly wall and the abdominal contents seem to be swollen. Which of the following is the most appropriate management in this situation?

19) A 52-year-old nurse seeks medical retirement because of a "heart condition." She complains of disabling attacks of tachycardia and palpitations. The physical examination and ECG studies confirm that indeed her pulse is between 100 and 105/min at all times, and she is in and out of atrial fibrillation. It is also noted that she is fidgety and constantly moving, and various examiners remark that she arrives for tests lightly dressed when it is rather cold outside. Thyroid function studies show elevated free thyroxine (T4) and undetectable levels of thyroid stimulating hormone (TSH). Her thyroid gland is not clinically enlarged or tender. Which of the following is the most appropriate next step in diagnosis?

20) A 24-year-old woman is admitted to the hospital for a broken femur. The patient was in a motor vehicle accident 20 hours ago and was brought to the hospital by EMS. On the scene, she was found belted in her car in the driver’s seat, and her only documented injury was the leg fracture. She had no loss of consciousness or altered mental status. On arrival to the hospital, radiographs confirmed a fracture of her femur. She was stabilized overnight and scheduled for surgery the next day. Which of the following is the major surgical risk for this patient?

21) A young man sustains a gunshot wound to the base of his neck. He was shot point blank with a .38 caliber revolver. The entrance wound is above the left clavicle, below the level of the cricoid cartilage, and just lateral to the sternomastoid muscle. The exit wound is just above the spinous process of the right scapula. He has normal breath sounds on both sides, is awake and alert, is talking with a normal tone of voice, is neurologically intact, and is hemodynamically stable. Portable x-ray films of the neck and chest taken in the emergency department show some air in the tissues of the lower neck, but are otherwise non-diagnostic. Which of the following is the most appropriate next step in management?

22) A 31-year-old male immigrant from India is found on a routine physical examination to have a single, 2-cm nodule in the right lobe of his thyroid gland. The mass is firm, moves up and down with swallowing, and is not tender. The skin of his face and neck is pitted with multiple scars, which suggest smallpox; however, he explains that the scars are due to very severe acne that he had as a youngster, for which he eventually received external beam radiation therapy at the age of 14. His thyroid function tests are normal, and fine needle aspiration (FNA) cytology of the mass is read by the pathologist as "indeterminate." Which of the following is the most appropriate next step in management?

23) A 9-month-old infant is brought in by her parents because she has an umbilical hernia. Physical examination shows an umbilical defect about 1 cm in diameter, with a small bulge when the girl cries. The hernial contents can be easily reduced. The hernia is not painful, and the girl is otherwise asymptomatic. Which of the following is the most appropriate next step in management?

24) A 53-year-old male is brought to the emergency department after being involved in a motor vehicle accident (MVA) as an unrestrained driver. He was found unresponsive at the scene and was intubated by paramedics. He has received 1L of normal saline over the last 20 minutes. His blood pressure in the emergency department is 70/30 mmHg, and his heart rate is 100/min. On physical examination, he responds to strong vocal and tactile stimuli by opening his eyes. His pupils are equal and reactive to light. On exam, there are multiple bruises over the anterior chest and upper abdomen. The trachea is midline. A Swan-Ganz catheter reveals a pulmonary capillary wedge pressure of 12 mmHg. Rapid infusion of 1L of normal saline increases the pulmonary capillary wedge pressure to 17 mmHg, with a blood pressure of 75/30 mmHg and heart rate of 103/min. Which of the following is the best treatment for this patient?

25) A 63-year-old male presents to the urgent care center with a four hour history of abdominal pain which he describes as severe, diffuse and constant. He has had one episode of non-bloody vomiting since the pain started. His past medical history is significant for coronary artery disease, diabetes, hypertension, chronic atrial fibrillation and chronic kidney disease. His current medications are lisinopril, digoxin, warfarin, metoprolol, and simvastatin and insulin glargine. On physical examination, his blood pressure is 130/70 mmHg and his heart rate is 100/min and irregular. Physical examination reveals an overweight male in moderate distress. His abdomen is diffusely tender to palpation with positive rebound tenderness. His laboratory findings are as follows: Hemoglobin 9.5 mg/dl, WBC count 7,500/mm3, Platelets 90,000/mm3, Sodium 137 mEq/L, Potassium4.5 mEq/L, Chloride 101 mEq/L, Bicarbonate 22 mEq/L, Glucose 210 mg/dl, Creatinine 1.8 mg/dl, INR 2.1, Blood digoxin level therapeutic. An upright abdominal x-ray shows free air under the diaphragm. Which of the following is the best initial treatment for this patient?

26) A 62-year-old female is hospitalized with epigastric pain and vomiting. Her past medical history includes mild COPD, congestive heart failure, diabetes mellitus and a stroke that occurred 2 years ago. Her current medications are insulin glargine and aspirin. Her blood pressure is 110/70 and her heart rate is 76/min. Comprehensive work-up is suggestive of acute calculous cholecystitis, and a cholecystectomy is planned. Which of the following would reduce postoperative mortality in this patient?

27) A 50-year-old postman presents with a six-month history of left calf pain that is brought on by walking and is relieved by rest. The patient reports no other symptoms. He has smoked cigarettes for the past 25 years, but does not drink alcohol or use illicit drugs. On physical examination, he has a blood pressure of 158/92 mm Hg and a pulse of 88 beats per minute. The heart and lung examinations are normal. A bruit is heard over the left femoral artery. Popliteal, dorsalis pedis and posterior tibial pulses are palpable bilaterally. The electrocardiogram shows normal sinus rhythm and Q-waves in II, Ill, and aVF. Which of the following is the best next step in management?

28) An 85-year-old male is placed on mechanical ventilation after a complicated elective hernia repair. After five days of endotracheal intubation with mechanical ventilation, the ratio of the rate of carbon dioxide produced to the rate of oxygen uptake is 1.05. What is the best explanation for these findings?

29) A 42-year-old man develops right calf pain one week after having a left hemi-colectomy. On physical examination, there is moderate right ankle edema and right calf pain with dorsiflexion of the right foot. Duplex ultrasonography shows a clot in the right superficial femoral vein. Which of the following is the most appropriate initial treatment?

30) A 73-year-old male who is a nursing home resident underwent a laparotomy for intestinal obstruction. He has advanced dementia. On the 8th postoperative day, he complains of pain and swelling on the left angle of his jaw. His temperature is 38.90 C ( 102.00 F), blood pressure is 150/80 mm Hg, pulse is 90/min, and respirations are 16/min. Examination shows swelling, erythema, and tenderness in the region of the left parotid gland. Laboratory studies show a white blood cell count of 15,600/mm. Which of the following measures would most likely have prevented this complication?

31) A 23-year-old male is brought to the emergency department from the scene of a motor vehicle accident. He appears distressed and complains of severe abdominal pain and distention. Urgent laparotomy reveals splenic laceration, and splenectomy is performed. There are no post-operative complications. The patient has no significant past medical history. He drinks alcohol occasionally but denies smoking cigarettes or using illicit drugs. He works as a computer programmer in a small office. Which of the following vaccines is recommended in this patient?

32) A 68-year-old male undergoes colon resection surgery for diverticulosis. In the 24 hours following the surgery, he passes a total of 300 ml of urine. His past medical history is significant for coronary artery disease, right knee osteoarthritis and moderate chronic obstructive pulmonary disease. On physical examination, his blood pressure is 110/70 mm Hg and his heart rate is 90/min. His lungs are clearto auscultation and his abdomen is soft and non-distended. His current labs are given below: Hemoglobin 9.5 mg/dl, WBC count 13,000/mm3, Platelet count 160,000/mm3, Sodium 138 mg/dl, Potassium 5.1 mg/dl, Glucose 108 mg/dl, Creatinine 2.3 mg/dl, BUN 82 mg/dl, His indwelling bladder catheter is changed but no residual urine is drained. Which of the following is the best next step in managing this patient?

33) A 65-year-old diabetic male comes to the physician because of pain in his calf muscles. His pain increases with walking. He also has end stage renal disease, hyperlipidemia and hypertension. His temperature is 36.7C (98F), blood pressure is 150/96 mm Hg, pulse is 80/min and respirations are 16/min. Examination shows skin atrophy, shiny skin and loss of hair on both legs below the knee. Which of the following would be most appropriate next step in management?

34) A 63-year-old obese female undergoes an elective cholecystectomy after two episodes of acute calculous cholecystitis. Three days after surgery, her blood pressure is 150/100 mmHg, her heart rate is 90/min, and her arterial oxygen saturation is 91% on room air. She is afebrile. Which of the following would most likely increase her functional residual lung capacity?

35) A 28-year-old woman with sickle cell anemia presents to the urgent care clinic complaining of 12 hours of right upper quadrant pain. She has had similar pain previously, usually after eating fatty foods. However, past episodes have always resolved within one to two hours. On examination, her temperature is 38.3C and she has right upper quadrant pain with a positive Murphy's sign. Abdominal ultrasound reveals gallstones, a thickened gallbladder wall, and a normal common bile duct. Her alkaline phosphatase level is normal. What is the most appropriate next step in the management of this patient?

36) A 35-year-old man is brought to the emergency department after suffering a deep laceration from a rusted piece of barbed wire that was hidden in the grass. Examination shows a 6 cm laceration on the lateral leg that is contaminated with dirt and soil. The laceration is bleeding. The patient reports having received a complete set of childhood vaccinations. His last tetanus immunization was at age 23. Which of the following is the most appropriate next step in the management of this patient?

37) A 59-year-old man comes to the physician because of postprandial abdominal cramps, weakness, light-headedness, and diaphoresis. The symptoms begin 25-30 minutes after eating. He had a partial gastrectomy for intractable peptic ulcer disease two weeks ago. He takes no medications. His temperature is 36.7C (98F), blood pressure is 130/65 mmHg, pulse is 80/min, and respirations are 18/min. Which of the following is the most appropriate next step in management?

38) A 37-year-old male is brought to the emergency department immediately after being smashed in a hydraulic press at a local factory. He is alert and oriented. Despite 10mg of IV morphine given by the paramedics, he is crying with pain. His blood pressure is 110/70 mm Hg, pulse is 110/min, and respirations are 18/min. apparently, his left humeral shaft is fractured and the left arm is severely deformed being bent medially 90 degrees. Left radial artery pulse sensation and muscle strength in the left forearm are decreased compared to the right side. His right leg is shortened and externally rotated. Deformity of the right thigh is noted. Pedal pulses are symmetric. He has pain in the left anterior chest on antero-posterior sternal compression, but breath sounds are normal. Physical examination otherwise shows no abnormalities. The paramedics have placed 2 peripheral intravenous lines and immobilized the fractured limbs. Which of the following is the most appropriate next step in management?

39) A 65-year-old male presented to the ER with increasing shortness of breath, fever and productive cough of 2 days duration. He has smoked for several years and has been on home oxygen. Chest x-ray showed right lower lobe consolidation. His vital signs on admission were temperature 38.70 C (101.70 F), blood pressure 120/76 mm Hg, pulse 11 0/min and respirations 26/min. His condition worsened over the next several hours and required oro-tracheal intubation and mechanical ventilation. He was transferred to the intensive care unit. Placement of a central venous catheter in the right subclavian vein for IV access was attempted. After the line is successfully placed, the patient begins to deteriorate. Repeat vital signs are blood pressure 80/50 mm Hg and pulse 130/min. Examination shows absent breath sounds on the right side and distended neck veins. Which of the following is the most appropriate next step in management?

40) A 36-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He is in obvious distress. His blood pressure is 80/30 mm Hg, pulse is 140/min and respirations are 23/min. Examination reveals collapsed neck veins. Breath sounds are present bilaterally, heart sounds are normal and the trachea is midline. He is semiconscious and his pupils are bilaterally reactive. There is no obvious head injury. Abdominal examination shows distention with tenderness in all four quadrants with guarding and rigidity. After initial resuscitation including control of his airway, breathing and circulation, which of the following is the most appropriate next step in management?

41) A 42-year-old man is found unconscious at the scene of a motor vehicle collision. He is rushed to the emergency department, where his blood pressure is found to be 70/40 mm Hg and his respirations are 28/min. On physical examination, his trachea is deviated to the left and his breath sounds are decreased on the right side. His neck veins are distended bilaterally. You also note significant swelling over the right femur. Which of the following is the most appropriate next step in the management of this patient?

42) A 46-year-old man comes to the physician because of a two day history of worsening abdominal discomfort and persistent vomiting. He has not had a bowel movement or passed flatus for 3 days. He had an appendectomy for appendicitis 20 years ago. Examination shows a distended abdomen that is tympanic on percussion. High-pitched bowel sounds and splashing are heard on auscultation. The abdomen is diffusely tender on palpation without rebound or guarding. An x-ray film of the abdomen shows distended small bowel loops with air-fluid levels; no gas is seen in the colon. IV rehydration is started. Which of the following is the most appropriate next step in management?

43) A 25-year-old man comes to the physician because of a mass in his mouth. He has just noticed this mass and has had no trauma to his oral cavity. He does not use tobacco, alcohol or drugs. He has had no weight loss. Physical examination shows a large mass located on the hard palate of the mouth. On palpation, the mass is immobile, fleshy with bony surroundings and measures 3x 3 cm. Which of the following is the most appropriate next step in management?

44) A 22-year-old man is brought to the emergency department after falling from a motorbike. He has right wrist pain. His temperature is 37.1C (98.6F), blood pressure is 110/70 mm Hg, pulse is 80/min, and respirations are 17/min. He is well oriented and cooperative. His pupils are bilaterally reactive. Physical examination shows no signs of trauma except for marked tenderness in the right anatomical snuff box. An x-ray film of the wrist joint shows a radiolucent line across the waist of the right scaphoid bone. Which of the following is the most next step management?

45) A 23-year-old man is brought to the emergency department after being hit in the neck with a dull instrument. He has neck pain and stiffness. Vital signs are stable. Neurological examination shows no abnormalities. An astute medicine resident decides to order an angiogram of the neck vessels to rule out carotid artery injury. Diagnostic angiography shows an intimal flap in the left internal carotid artery just above the carotid bifurcation. Which of the following is the most appropriate next step in management?

46) A 35-year-old woman is being evaluated after having a screening mammography. A 3 x 3 cm speculated mass with coarse calcifications is seen in the upper outer quadrant of her right breast. She has no complaints. She has a history of bilateral reduction mammoplasty for mammary hyperplasia 12 years ago. She has no family history of medical problems. Breast examination shows her right nipple is slightly retracted. A fixed mass is palpated in the upper outer quadrant of the right breast. Ultrasonography of the breast shows a hypo-echoic mass. Multiple core biopsy samples show foamy macrophages and fat globules. Which of the following is the most appropriate course of action?

47) A 76-year-old woman comes to the emergency department because of left lower quadrant (LLQ) abdominal pain and fever. She takes acetaminophen for arthritis and docusate for constipation. A CT scan of the abdomen showed perisigmoid stranding suggestive of inflammation and sigmoid diverticulosis. She was started on intravenous ciprofloxacin and metronidazole; however, she had only mild improvement and is persistently febrile. Examination shows persistent LLQ tenderness to deep palpation. A repeat CT scan now shows a 5 x 6 cm mass in the left iliac fossa. Laboratory studies show: Hemoglobin 13.0 g/L, Platelets 360,000/mm3, Leukocyte count 16,500/mm3. Which of the following is the most appropriate next step in management?

48) A 44-year-old obese male is brought to the ER after a motor vehicle accident. His cervical spine is immobilized. He is alert and able to speak in complete sentences. He complains of abdominal pain. At the scene of the accident, his blood pressure is 90/60 mm Hg and pulse is 120/min. Lungs are clearto auscultation. Ecchymosis is present over the abdominal wall in distribution of the seat belt. Bowel sounds are decreased. Neck veins are collapsed. After receiving one liter of intravenous fluids, his blood pressure remains at 90/60 mmHg. A focused assessment with sonography for trauma is inconclusive due to the poor image quality. Which of the following is the most appropriate next step in management of this patient?

50) A 60-year-old man undergoes a laparotomy for intestinal obstruction secondary to postoperative adhesions. He has a history of diabetes mellitus, type 2, and hypertension. He underwent a cholecystectomy two years ago. His takes insulin, hydrochlorothiazide, enalapril, and pravastatin. On postoperative day number five, he has intense pain around the wound. His temperature is 38.3C (101F), blood pressure is 120/76 mm Hg, pulse is 100/min, and respirations are 16/min. Examination of the wound shows a cloudy-gray discharge and crepitus; sensation at the edges of the wound is decreased. Which of the following is the most appropriate next step in management?

51) 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?

52) 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?

53) A 46-year-old male is brought to the ER because of coffee ground emesis. He has a history of chronic hepatitis C and alcohol abuse. His temperature is 36.6C (97.9F), blood pressure is 120/70 mm Hg, pulse is 90/min and respirations are 14/min. He is oriented to time, place and person but somewhat sleepy. A flapping tremor is noted. His abdomen is soft, non-tender, and mildly-distended; liver and spleen are palpated below the costal margins; shifting dullness is present. Nasogastric tube aspiration shows bright red blood that was easily cleared with saline lavage. Endoscopy shows a fresh ulcer with a small adherent clot located high on the lesser curvature near the gastroesophageal junction. Non bleeding esophageal and gastric varices are also seen. Laboratory studies show: Hemoglobin 10.2 g/L, MCV 105 fl, Platelets 105,000/mm3, Leukocyte count 4,500/mm3, Prothrombin time 17 sec, Aspartate aminotransferase (SGOT) 78 U/L, Alanine aminotransferase (SGPT) 50 U/L, Which of the following is the most appropriate next step in management?

54) A 3-year-old girl is brought to the emergency department because she is not moving her right arm. Her mother states that the child was perfectly normal in the morning. She remembers that she lifted the child with the child's right forearm and since then she has not been moving her right arm. Examination shows the right arm is held in pronation against the chest. The child avoids any movement of her right arm. Which of the following is the most appropriate next step in management?

55) A 45-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He is unable to void. Examination shows blood at the urethral meatus and a scrotal hematoma. His temperature is 37C (98.6F), blood pressure is 100/50, pulse is 100/min and respirations are 16/min. Examination shows a high-riding prostate with no other signs of trauma. Which of the following is the most appropriate next step in management?

56) A 42-year-old woman is brought to the emergency department after being involved in a motor vehicle collision. On arrival she is unconscious with bilaterally round and reactive pupils. Her temperature is 37C (98.6F), blood pressure is 70/20 mm Hg, pulse is 11 0/min and respirations are 22/min. There is a low jugular venous pulse. She does not respond to vocal commands but responds to pain with all 4 limbs. She is not vocalizing. Lung auscultation is unremarkable. Abdominal examination shows a distended abdomen with absent bowel sounds and some bruising. She is intubated and is rapidly infused with 2L of lactated Ringer's solution. Her blood pressure is now 80/30 mm Hg and her pulse is 118/min. Which of the following is the most appropriate next step in management?

57) A 34-year-old woman is brought to the emergency department after being hit by a motorbike. Examination shows a 3 cm x 2 cm laceration on the left calf. The wound is dirty and the underlying fascia can be seen. She has had four doses of tetanus toxoid in her life; the last dose was 7-years ago. In addition to wound debridement and surgical management, which of the following is the most appropriate course of action to protect her from developing tetanus?

58) A 34-year-old man comes to the emergency department because of severe pain in his penis. He was having sex with his wife on top when he had sudden onset severe pain in the penis at the height of orgasm. Swelling of the penis and deviation of the penile shaft to the right followed the pain. Examination shows a man in severe distress. The penis is uncircumcised, grossly swollen and deviated to the right. There is no blood at the urethral meatus. Which of the following is the most appropriate next step in management?

59) A 34-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He has severe abdominal and left shoulder pain. His temperature is 36C (96.8F), blood pressure is 100/60 mm Hg, pulse is 110/min and respirations are 23/min. Examination shows tenderness in the left upper quadrant of the abdomen. An x-ray film of the chest shows fractures of the left 7th, 8th and 9th ribs. A CT scan of the abdomen is suggestive of splenic injury with some free fluid in the abdomen. He has not been vaccinated for H. Influenza or S. pneumoniae. Which of the following is the most important determinant for surgical versus non-surgical management in this patient?

60) A 75-year-old woman is brought to the emergency department after falling early in the morning. She is unable to move her right leg and has severe pain in her right hip. Her temperature is 36.9C (98.6F), blood pressure is 90/50 mm Hg, pulse is 100/min and respirations are 16/min. Examination shows the right lower extremity is shortened and is externally rotated with marked limitation of hip movement on the right side. An x-ray of the hip shows a markedly displaced fracture of the neck of the right femur. After hemodynamically stabilizing the patient, which of the following is the most appropriate step in management?

61) A 36-year-old male comes to the emergency department because of worsening right lower quadrant (RLQ) abdominal pain. One week ago he was started on cephalexin for furunculosis. He has had type I diabetes mellitus for 10 years and is on insulin. His temperature is 38.3C (101.9F). Examination shows multiple furuncles on the inner side of both thighs; most of them are in regression. Abdominal examination shows tenderness on deep palpation in RLQ without rebound or guarding; no masses are palpated; psoas sign is positive; bowel sounds are present. Rectal examination shows no abnormalities. Laboratory studies show: Hemoglobin 13.0 g/L, Leukocyte count 17,500/mm3. Which of the following is the most appropriate next step in management?

62) A 68-year-old man comes to the emergency department because of sudden onset back pain. He has never had back pain before and denies any trauma. He does not feel well and feels "like he is going to die". His blood pressure is 70/40 mm Hg, pulse is 110/min and respirations are 20/min. On examination, the abdomen is tender to palpation and there is a large pulsatile mass. Which of the following is the most appropriate next step in management?

63) A 45-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He is conscious but in severe pain. His blood pressure is 90/60 mm Hg, pulse is 100/min and respirations are 17/min. Physical examination shows marked swelling and some bruising over the right thigh; the skin is intact. An x-ray film of the leg shows a fracture of the mid shaft of the femur. After hemodynamically stabilizing the patient, which of the following is the most appropriate next step in management?

64) A 60-year-old male with a history of ischemic heart disease (IHD) is brought to the emergency department after a motor vehicle accident. On arrival, his blood pressure is 90/60 mm Hg, pulse is 110/min and respirations are 26/min. There are bruises on the left thigh, left side of the chest and tenderness over the same areas. He is started on intravenous normal saline. The presence of which of the following situations would require a blood transfusion in this patient?