DES C_Management (8) Prepared : CHILLY

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?

A 45-year-old man with advanced chronic renal failure comes to the physician because of edema of his feet. His temperature is 37°C (99°F), blood pressure is 150/100mm Hg, pulse is 78/min, and respirations are 15/min. Examination shows bilateral ankle edema. Laboratory studies show BUN of 62 mg/dl, serum creatinine of4.2 mg/dl, serum potassium of 5.6 meq/l, serum sodium of 146 meq/l, and total plasma cholesterol of 260 mg/dl. Which of the following is most likely to improve the prognosis of his disease?

A 45-year-old man with known cirrhosis due to hepatitis C is admitted to the hospital for abdominal discomfort and confusion. Physical examination reveals a distended abdomen, leg edema, and deep yellow discoloration of the skin and sclerae. Bibasilar crackles are heard on chest auscultation. His serum sodium level is 127 mEq/L, potassium level is 2.9 mEq/L, and creatinine level is 1.3 mg/dl. On day 3 of his hospitalization, the serum creatinine is 4.2mg/dl. A urinalysis reveals: Protein negative, Glucose negative, WBC 4-5/hpf, RBC 0-1/hpf. Renal ultrasound is normal and the post-void residual urinary volume is less than 50 ml. He is given 2 L of normal saline intravenously with no change in his serum creatinine concentration. This patient's kidney dysfunction can be best corrected by which of the following? 

A 45-year-old woman is undergoing chemotherapy for breast cancer. She presents 10 days after her last chemotherapy with fever (temperature > 38.5°C), but no other symptoms except a sore throat and mouth. On examination, she looks well, there is oral mucositis, ears are normal, lungs are clear, and the central line site is clean. The CXR, urinalysis, and biochemistry are normal. Her WBC is 800/mL and the absolute neutrophil count is low ( < 500). Which of the following is the most appropriate next step in management?

A 45-year-old woman presents to the ED with 1 day of painful rectal bleeding. Review of systems is negative for weight loss, abdominal pain, nausea, and vomiting. On physical examination, you note an exquisitely tender swelling with engorgement and a bluish discoloration distal to the anal verge. Her vital signs are HR 105 beats per minute, BP 140/70 mm Hg, RR 18 breaths per minute, and temperature 99°F. Which of the following is the next best step in management?

A 45-year-old woman presents with right eye pain and redness for 1 day. She has photophobia and watery discharge from the eye. She does not wear glasses or contact lenses and has no prior eye problems. On examination, the patient’s visual acuity is 20/20 in the left eye and 20/70 in the right eye. She has conjunctival injection around the cornea and clear watery discharge. On slit-lamp examination, the lids, lashes, and anterior chamber are normal. When fluorescein is applied, a branching, white-colored epithelial defect is seen. The remainder of the head examination is normal and the patient has no cutaneous lesions. Which of the following is the most appropriate treatment for this patient?

A 45-year-old woman with no PMH presents to the office for an increase in abdominal fullness and bloating, worsening over the past 3 or 4 months. The patient states that she feels nauseous all the time, although has not had any vomiting. She states because of the constant nausea, she has not been eating as much. She has had a 10-lb weight loss in the last 4 months. BP, 110/70 mm Hg; P, 97; R, 18; T, 98.6°F. ROS: Denies fever and chills, Weight loss has occurred (10 lb in 4 months), Denies chest pain, shortness of breath, and abdominal pain, Nausea is present with no vomiting, No diarrhea or constipation. PE: Gen: Awake, alert, oriented x3, Abd: Soft, nontender, distended bowel sounds are present, shifting dullness to percussion is present, Pelvic: Cervix normal, no cervical motion tenderness, right adnexal enlargement is present. Which of the following is the next step in the management of this patient?

A 46-year-old male comes to your office for a routine health examination. He has no current physical complaints and says he is compliant with his medications. His past medical history is significant for type 2 diabetes diagnosed two years ago that he has been able to control with diet, exercise and metformin. The patient also takes a daily aspirin. On physical examination, he has a temperature of 36.7°C (98°F), a blood pressure of 140/86 mmHg, a pulse of 80/min, and respirations of 14/min. His laboratory studies show: Total cholesterol 170 mg/dl, High density lipoprotein (HDL) 50 mg/dl, Low density lipoprotein (LDL) 65 mg/dl, Triglycerides (TG) 150 mg/dl, HbA1C 7.0. Serum chemistries are with in normal limits. Which of the following is the most appropriate next step in the management of this patient?

A 46-year-old man comes to the emergency department because of abrupt onset of epigastric pain radiating to the back and associated vomiting. He has had these symptoms for the past 1 day. The symptoms are progressively getting worse. He has no other medical problems or previous surgeries. He does not use tobacco, alcohol, or illicit drugs. His temperature is 36.5°C (97.6°F), blood pressure is 100/70 mm Hg, pulse is 100/min, and respirations are 20/min. Abdomen is mildly distended and very tender to palpation in the epigastric region; bowel sounds have decreased. There is no rebound tenderness or organomegaly. Rectal examination shows no abnormalities. Laboratory findings reveal: CBC: Hb 15.0 g/dL, Platelet count 223,000/mm3, Leukocyte count 14,500/mm3, Serum Chemistry: Serum Na 134 mEq/L, Serum K 3.6 mEq/L, Chloride 93 mEq/L, Bicarbonates 29 mEq/L, BUN 30 mg/dL, Serum creatinine 0.8 mg/dL, Calcium 10.3 mg/dL, Blood glucose 168 mg/dL, LFT 1.4 mg/dL. Total bilirubin: Alkaline phosphatase 220 U/L, Aspartate aminotransferase 88 U/L, Alanine aminotransferase 155 U/L, Lipase 523 U/L. Abdominal x-ray shows gaseous distention of the small bowel in the upper abdomen. Computed tomography (CT) scan with contrast shows diffuse hypodense enlargement of the pancreas and peripancreatic and perirenal fluid collections. Nasogastric suction, intravenous normal saline, analgesics, and antibiotics are started. Which of the following is the most appropriate next step in management?

A 46-year-old woman suffering from systemic lupus erythematosus (SLE) develops hematuria and proteinuria. She was diagnosed with SLE four years ago and has been treated with hydroxychloroquine. A renal biopsy is performed and shows diffuse proliferative glomerulonephritis. She is started on cyclophosphamide and prednisone and hydroxychloroquine is stopped. She continues these two medications for several weeks because of the low therapeutic response. This new therapeutic regimen puts her at an increased risk for which of the following conditions? 

A 47-year-old diabetic woman comes to the physician due to the recent onset of tremors. She has undergone combined pancreatic and kidney transplantation secondary to end stage renal disease and diabetes. She takes multiple medications, including immunosuppressants. Her temperature is 36.1° C (97°F), blood pressure is 152/90 mm Hg, pulse is 78/min, and respirations are 16/min. Examination shows gum hypertrophy. Laboratory studies show: Hb 13.0 g/dl, WBC 8,000/cmm, Serum Na 135 mEq/L, Serum K 5.3 mEq/L, BUN 26 mg/dl, Serum Creatinine 1.7 mg/dl. Which of the following immunosuppressants is most likely responsible for her presentation?

A 47-year-old male who has just returned from a cruise to the Bahamas presents to the hospital with a high-grade fever, productive cough and shortness of breath for the past two days. He also complains of frequent vomiting and diarrhea. He has no prior medical problems, does not take any medications, and denies using tobacco, alcohol or drugs. His temperature is 40°C (104°F), blood pressure is 110/65 mm Hg, pulse is 80/min, and respirations are 18/min. Lung examination reveals right lower lobe crackles. The abdomen is soft and non-tender. Chest x-ray demonstrates right lower lobe consolidation. Sputum Gram stain contains many neutrophils with no organisms. Which of the following antibiotics must be given to this patient?

A 47-year-old man with a history of hypertension presents to the ED complaining of continuous left-sided chest pain that began while snorting cocaine 1 hour ago. The patient states he never experienced chest pain in the past when using cocaine. His BP is 170/90 mmHg, HR is 101 beats per minute, RR is 18 breaths per minute, and oxygen saturation is 98% on room air. The patient states that the only medication he takes is alprazolam to “calm his nerves.” Which of the following medications is contraindicated in this patient?

A 48-year-old G2P2 presents for her well-woman examination. She had two uneventful vaginal deliveries. She had a vaginal hysterectomy for fibroids and menorrhagia. She denies any medical problems, but has not seen a doctor in 6 years. Her family history is significant for stroke, diabetes, and high blood pressure. On examination she is a pleasant female, stands 5 ft 3 in tall, and weighs 85 kg. Her blood pressure is 150/92 mm Hg, pulse 70 beats per minute, respiratory rate 14 breaths per minute, and temperature 37C (98.4F). Her breast, lung, cardiac, abdomen, and pelvic examinations are normal. The next appropriate step in the management of this patient’s blood pressure is which of the following?

A 48-year-old man sustains a gunshot wound to the right upper thigh just distal to the inguinal crease. He is immediately brought to the ER. Peripheral pulses are palpable in the foot, but the foot is pale, cool, and hypesthetic. The motor examination is normal. Which of the following statements is the most appropriate next step in the patient’s management?

A 48-year-old man with a past medical history of hepatitis C and cirrhosis presents to the ED complaining of acute-onset abdominal pain and chills. His BP is 118/75 mm Hg, HR is 105 beats per minute, RR is 16 breaths per minute, temperature is 101.2°F rectally, and oxygen saturation is 97% on room air. His abdomen is distended, and diffusely tender. You decide to perform a paracentesis and retrieve 1 L of cloudy fluid. Laboratory analysis of the fluid shows a neutrophil count of 550 cells/mm 3. Which of the following is the most appropriate choice of treatment?

A 48-year-old woman presents to her gynecologist because of vaginal bleeding. She states that after a year of hot flashes and irregular cycles, she finally stopped menstruating 4 months ago. Two days ago she began having some vaginal bleeding that was very similar to her prior menses. She is concerned because she heard that the first sign of endometrial cancer in postmenopausal women is vaginal bleeding. She is an otherwise healthy woman with no medical problems. She exercises three times a week and takes multivitamins. She had three children when she was 29–35 years old. She used oral contraceptive pills for contraception from the time she was 18 until she got married at the age of 28. Which of the following is the most appropriate next step in managing this woman’s vaginal bleeding?

A 49-year-old man presents to the clinic for a health maintenance visit. He has a family history of type 2 DM. His medical history is significant for gastroesophageal reflux disease, for which he takes omeprazole and over-the-counter antacids. He smokes one pack of cigarettes per day and drinks an average of two beers per night. The patient’s body mass index is 32 kg/m². Which of the following most greatly reduce(s) the patient’s risk of future coronary artery disease, renal failure, and retinopathy?

A 49-year-old man presents to the ED with nausea, vomiting, and abdominal pain that began approximately 2 days ago. The patient states that he usually drinks a six pack of beer daily, but increased his drinking to 2 six packs daily over the last week because of pressures at work. He notes decreased appetite over the last 3 days and states he has not had anything to eat in 2 days. His BP is 125/75 mm Hg, HR is 105 beats per minute, and RR is 20 breaths per minute. You note generalized abdominal tenderness on examination. Laboratory results reveal the following: White blood cells (WBC) 9000/μL Sodium 131 mEq/L Hematocrit 48% Potassium 3.5 mEq/L Platelets 210/μL Chloride 101 mEq/L Aspartate transaminase (AST) 85 U/L Bicarbonate 10 mEq/L Alanine transaminase (ALT) 60 U/L Blood urea nitrogen (BUN) 9 mg/dL Alkaline phosphatase 75 U/L Creatinine 0.5 mg/dL Total bilirubin 0.5 mg/dL Glucose 190 mg/dL Lipase 40 IU Nitroprusside test weakly positive for ketones Which of the following is the mainstay of therapy for patients with thiscondition?

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?

A 49-year-old woman presents to her physician’s office with a long-standing history of polydipsia, polyuria, central obesity, and hyperlipidemia. She is currently taking metformin, a sulfonylurea, and an angiotensin-converting enzyme (ACE) inhibitor. ACE inhibitors are most beneficial in preventing or slowing the progression of which of the following diabetic complication?

A 5-year-old boy is brought to his pediatrician's office after he falls from his bicycle and strikes his head against the sidewalk. There were no witnesses to this incident, which occurred 8 hours ago. The child is otherwise healthy, up-to-date on his immunizations, and not taking any medications. On physical examination, his vital signs are stable. He has a 5 × 4 cm abrasion on his forehead. He is alert and oriented to date, place and self. His motor and sensory examinations are normal and reflexes are normal. Which of the following constitutes reasonable management?

A 5-year-old boy is brought to the physician for evaluation of left hip pain after his parents saw him limping this morning. He spent time on the playground yesterday but his parents do not think he was injured then. The boy complains that the pain in his hip worsens when he moves or walks. For the past 3 days, he has had a runny nose and congestion. Review of systems is otherwise negative. His grandmother has rheumatoid arthritis treated with methotrexate. His temperature is 37.2° C (99° F), blood pressure is 100/65 mm Hg, pulse is 92/min, and respirations are 18/min. Physical examination shows a well-appearing child with clear rhinorrhea and intermittent dry cough. Lungs are clear to auscultation bilaterally. His left hip is slightly abducted and externally rotated with mildly decreased range of motion. He is able to stand and bear weight. The remainder of his examination is normal. X-rays of both hips are normal. His laboratory results are as follows: Complete blood count: Hemoglobin 12.5 g/dL, Platelets 287,000/mm3, Leukocyte count 8,500/mm3, Neutrophils 30%, Eosinophils 1%, Lymphocytes 64%, Monocytes 5%, Erythrocyte sedimentation rate 30 mm/h, C-reactive protein 9 mg/L (N: ≤ 8 mg/L). Which of the following is the best next step in management of this patient?

A 5-year-old Hispanic girl is brought to the emergency department (ED) due to a cat bite on her right upper extremity. She was bitten after rambunctiously playing for several minutes with the cat, which had just been given to her as a birthday gift. Her most recent booster tetanus vaccine was one year ago. Her temperature is 36.7°C (98°F), blood pressure is 108/70 mm Hg, pulse is 107/min, and respirations are 21/min. Physical examination reveals a deep puncture wound on the volar aspect of her right forearm. Before going to the ED, her mother cleaned the wound with hydrogen peroxide. There is no visible debris in the wound, and little bleeding is evident. Neurovascular function is intact. Her wound is cleaned in the ED with Betadine and lavaged with saline solution. What is the best next step in managing this girl's care? 

A 50-year-old Caucasian male comes to the office for the evaluation of polyuria and polydypsia for the last two months. He also complains of weakness and fatigue. He had one episode of transient proximal muscle weakness which lasted 30 minutes. He has a 20-pack year history of smoking. He does not drink alcohol. His past medical and family histories are insignificant. His pulse is 78/min, blood pressure is 150/96 mmHg and temperature is 36.7°C (98°F). The rest of the examination, including the neurological examination, is normal. Labs show: Plasma sodium 150 mEq/L, Potassium 2.6 mEq/L, Serum creatinine 0.8 mg/dL. Which of the following is the most appropriate next step in the management of this patient?

A 50-year-old diabetic woman presents for follow-up of her hypertension. Her blood pressure is 152/96 in the office today and she brings in readings from home that are consistently in the same range over the past month. Her current medications are amlodipine 5 mg daily and hydrochlorothiazide 25 mg daily. The diuretic was added when she developed peripheral edema on the amlodipine; now she has only trace peripheral edema. A spot urine specimen shows 280 µg of albumin per mg creatinine (microalbuminuria is present if this value is between 30 and 300 µg/mg). What would be the best next therapeutic step in this patient?

A 50-year-old female comes into your office complaining of four-month history of dry cough. She denies dyspnea or hemoptysis. Past medical history is significant for hypertension, diabetes, and gout. Her current medications include enalapril, metformin, hydrochlorothia zide, and allopurinol. She does not smoke or consume alcohol. Her vital signs are BP 130/80 mmHg, HR 80/min, T 36.7°C (98°F) and RR 16/min. Physical examination is within normal limits. The best next step in the management of this patient is: 

A 50-year-old male patient comes to the office because he is concerned about the marked tremors of his hands. His tremors disappear with voluntary activity and worsen with emotional stress. He finds it mild difficult to initiate movements. He does not have a family history of tremors. Physical examination reveals tremors that occur at a frequency of 3-4 cycles/sec. There is rigidity of his limb musculature. His gait and posture is minimally disturbed. His higher mental functions are intact. Which of the following is the most appropriate treatment for this patient?

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

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

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

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

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

A 52-year-old man with Burkitt lymphoma is admitted to the hospital for chemotherapy. He is started on chemotherapy without incident. Two days into his hospitalization, he develops new peaked T-waves on his ECG. Laboratory analysis reveals a serum potassium concentration of 6.2 mEq/L, and the patient is given one ampule of calcium gluconate emergently. His renal function is within normal limits. Which of the following additional interventions will most rapidly correct his hyperkalemia?

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?