USMLE_Management XII

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USMLE Management Quiz XII

Test your knowledge with the USMLE Management Quiz XII, designed specifically for medical professionals and students preparing for the USMLE exams. This quiz comprises 30 challenging multiple-choice questions that cover a wide range of management scenarios in clinical practice.

By participating in this quiz, you will:

  • Enhance your clinical reasoning skills.
  • Review essential management practices in various medical cases.
  • Prepare effectively for your board examinations.
100 Questions25 MinutesCreated by ThinkingDoctor574
A 62-year-old Caucasian man with hypertension and chronic kidney disease complains of poor sleep. He describes a sensation of spiders crawling over both legs about 15-20 minutes after going to bed. Sometimes he has to sit up in bed and massage his legs. His wife's sleep has deteriorated as her husband's leg movements have gotten worse. Pharmacotherapy for this patient's disease is typically directed at which of the following?
. Norepinephrine
. Dopamine
. Serotonin
. Acetylcholine
. GABA
A 62-year-old female is brought in by EMS due to a severe right-sided headache, nausea and eye pain. She was fixing a light bulb, when she suddenly felt pain in her right eye. She decided to rest, but the eye pain only got worse. In the next few minutes, she developed loss of vision, photophobia and redness in the same eye. She took medications to relieve the accompanying headache, but the eye pain persisted. She denies any trauma. Her past medical history is significant for diabetes and hypertension. She appears to be in intense pain with bouts of nausea. Her right eye is red, with conjunctival flushing and visual acuity of 20/200. Her right pupil is mid-dilated and non-reactive to light. The same eye feels hard on palpation. The one treatment that should be avoided in this patient is:
. Mannitol
. Acetazolamide
. Pilocarpine
. Timolol
. Atropine
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?
. Vancomycin
. Enalapril
. Metoprolol
. Verapamil
. Metformin
A 62-year-old male is brought to the emergency department with a chief complaint of weakness. He says that he was walking his dog 1 hour ago when he began to limp and noticed some weakness in his left arm. His past medical history is significant for hypertension treated with hydrochlorothiazide, and type II diabetes mellitus managed with metformin. He denies nausea, vomiting, chest pain, fever or chills. He does note occasional palpitations and tension headaches at baseline. On physical examination, his blood pressure is 170/95 mmHg and his heart rate is 76/min and regular. His blood glucose level is 190 mg/dl and his HbA1c is 7.6%. The neurological examination is significant for profound left-sided weakness and an up going Babinski reflex on the left. Non-contrast head CT is negative for any intracranial bleed. Which of the following is most likely to affect his chance of neurological recovery?
. Insulin for tight glucose control
. Labetalol
. Aspirin
. Fibrinolytic
. Heparin
A 62-year-old man comes to the emergency department because of severe abdominal pain. He states that he suddenly felt weak, diaphoretic, and had no energy. He is a smoker and has hypertension. His blood pressure on initial examination was 110/70 mm Hg. Physical examination shows a diffusely tender abdomen. During CT scan he becomes pale and drowsy. CT scan is shown below: Repeat examination shows a man with anxiety and a blood pressure of 80/50 mm Hg and pulse of 110/min Which of the following is the most appropriate next step in management?
. Exploratory abdominal surgery
. Obtain ultrasound
. Check amylase and lipase
. Laparoscopy
. Drain fluid from the abdomen
A 62-year-old man comes to the emergency department because of severe abdominal pain. He states that he suddenly felt weak, diaphoretic, and had no energy. He is a smoker and has hypertension. His blood pressure on initial examination was 110/70 mm Hg. Physical examination shows a diffusely tender abdomen. During CT scan he becomes pale and drowsy. CT scan is shown below. Repeat examination shows a man with anxiety and a blood pressure of 80/50 mm Hg and pulse of 110/min. Which of the following is the most appropriate next step in management?
. Exploratory abdominal surgery
. Obtain ultrasound
. Check amylase and lipase
. Laparoscopy
. Drain fluid from the abdomen
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?
. Heller myotomy of the lower esophageal sphincter
. Laparoscopic Nissen fundoplication
. Transhiatal total esophagectomy
. Transthoracic resection of the lower esophagus
. Vagotomy, pyloroplasty, and fundic gastric wrap
A 62-year-old man is suffering from arrhythmias on the night of his triple coronary bypass. Potassium has been administered. His urine output is 20 to 30 mL/h. Serum potassium level is 6.2. Which of the following medications counteracts the effects of potassium without reducing the serum potassium level?
. Sodium polystyrene sulfonate (Kayexalate)
. Sodium bicarbonate
. 50% dextrose
. Calcium gluconate
. Insulin
A 62-year-old man visits his family physician because of generalized aches and pains. He denies associated fevers, headaches, chest pain, or abdominal discomfort. His past medical history is significant for an inferior wall myocardial infarction 6 years ago. His other medical problems include hypertension, diabetes, hypercholesterolemia, and gout. His current medications are aspirin, losartan, naproxen, atenolol, glipizide, colchicine, and simvastatin. On physical exam today, he is afebrile, with blood pressure 130/90 mmHg, pulse 80/min and respirations 18/min. Lab results are as follows: Sodium 140 mEq/L, Potassium 4.2 mEq/L, Bicarbonate 21 mEq/L, Chloride 100 mEq/l, BUN 30 mg/dl, Creatinine 1.6 mg/dl, AST 113 IU/L, ALT 120 IU/L, Creatine phosphokinase 14,998 mg/dl. What is the most appropriate next step in the management of this patient?
. Stop losartan
. Stop simvastatin
. Start N-acetylcysteine
. Order hepatitis panel
. Obtain liver biopsy
A 62-year-old man who had a motorcycle accident has been in a coma for several weeks. He is on a respirator, has had pneumonia on and off, has been on pressors, and shows no signs of neurologic improvement. The family inquires about brain death and possible organ donation. An independent neurologic evaluation confirms that the patient is brain dead. What advice should be given to his family?
Anyone who has had pneumonia is excluded as a donor
He is not a suitable donor because of his age
Patients on respirators cannot donate organs
The harvesting team should evaluate him as a potential donor
The use of pressors precludes organ donation
A 62-year-old man with a history of benign prostatic hyperplasia and hypertension presents to his primary care provider for a routine health maintenance visit. He reports that he feels “better than ever” and explains that his daughter made him come in for his annual visit. He takes prazosin daily and occasionally some acetaminophen. He has no drug allergies and denies smoking, drinking, or the use of illicit drugs. His physical examination is within normal range except for his rectal examination, which revealed an enlarged prostate. His temperature is 36.8°C (98.2°F), respiratory rate is 13/min, pulse is 82/min, and blood pressure is 138/86 mmHg. Which of the following is the most likely adverse effect of α1-adrenergic blockade in this patient?
Decreased urine flow
Increased blood pressure
Increased sexual drive
Irritability
Orthostatic hypotension
A 62-year-old woman comes in for her scheduled chemotherapy administration for her metastatic cancer of the breast. Although she is asymptomatic, the laboratory reports that her serum sodium concentration is 122 mEq/L. If it were deemed advisable to correct this electrolyte abnormality, which of the following is the best way to do it?
. Intravenous hypertonic saline
. Loop diuretics
. Oral sodium supplementation
. Osmotic diuretics
. Water restriction
A 62-year-old woman comes to the office for evaluation of a pigmented lesion on her left forearm. The lesion occasionally itches but is otherwise asymptomatic. She admits that she only came because her daughter had persuaded her to do so. On examination, there is a slightly elevated, brown-colored lesion measuring 7 mm in diameter with irregular borders. What is the best next step in management?
Shave biopsy
Excisional biopsy
Dermoscopy
Excision with 1 cm margins
Incisional biopsy
A 62-year-old woman comes to the physician because of bleeding from the vagina. She states that her last menstrual period came 11 years ago and that she has had no bleeding since that time. She has hypertension and type 2 diabetes mellitus. Examination shows a mildly obese woman in no apparent distress. Pelvic examination is unremarkable. An endometrial biopsy is performed that shows grade I endometrial adenocarcinoma. Which of the following is the most appropriate next step in management?
. Chemotherapy
. Cone biopsy
. Dilation and curettage
. Hysteroscopy
. Hysterectomy
A 62-year-old woman comes to the physician because of vaginal itch and pain with intercourse. She had her last menstrual period at age 52. She has no medical problems, takes no medications, and is allergic to penicillin. Pelvic examination demonstrates pale vaginal mucosa with no rugae present. The vagina is dry with no discharge. A potassium hydroxide (KOH) and normal saline wet preparation is negative. Which of the following is the most appropriate initial step in management?
Clotrimazole vaginal cream
Estrogen vaginal cream
Metronidazole vaginal cream
Oral fluconazole
Oral metronidazole
A 62-year-old woman has a 4-cm, hard mass under the nipple and areola of her rather small left breast. The mass occupies most of the breast, but the breast is freely movable from the chest wall. There is no dimpling or ulceration of the skin over the mass, and careful palpation of the axilla is completely negative. A core biopsy of the breast mass has established a diagnosis of infiltrating ductal carcinoma, and the mammogram showed no other lesions in that breast or the other one. A chest x-ray film and liver function tests are normal. She has no symptoms suggestive of brain or bone metastasis. Which of the following should be offered to this woman?
. Lumpectomy only
. Lumpectomy with axillary sampling and post-op radiation
. Total mastectomy only
. Modified radical mastectomy (including axillary sampling)
. Radical mastectomy (including complete axillary dissection)
A 62-year-old woman presents to her physician with complaints of heartburn, fatigue, and intermittent upper abdominal pain. The pain is often worse after meals and especially with spicy foods. She reports no recent nausea, vomiting, weight loss, dysphagia, or bright-red blood per rectum. However, her stools are darker than normal. Her last colonoscopy 2 years ago was unremarkable. Stool guaiac test result is positive. An initial complete blood cell count reveals: Hemoglobin: 10.1 g/dL, Hematocrit: 33.2%, Mean corpuscular volume: 74.6/mm³, Mean corpuscular hemoglobin concentration: 25.8%, WBC count: 9200/mm³ Platelet count: 176,000/mm³ Ferritin: 11 ng/mL. The patient undergoes upper endoscopy, which reveals erosive gastritis. She is started on omeprazole, 40 mg twice a day and oral iron sulfate supplementation, 325 mg three times a day with meals. Six months into treatment, abdominal pain and heartburn are resolved, but the patient still has fatigue and is pale. Repeat laboratory tests show: Hemoglobin: 9.9 g/dL, Hematocrit: 30.2%, Mean corpuscular volume: 74.2/mm³, Mean corpuscular hemoglobin concentration: 25.1% , WBC count: 9800/mm³ Platelet count: 198,000/mm³ Ferritin: 10 ng/mL. Repeat upper endoscopy is negative for bleeding and erosive gastritis. Stool guaiac test result is negative. Which of the following is the next best step in management?
Bone marrow biopsy
Determine blood type and screen for transfusion
Discontinue omeprazole therapy
Initiate darbepoetin therapy
Initiate parenteral iron therapy
A 62-year-old woman presents to the ED with general weakness, shortness of breath, and substernal chest pain that radiates to her left shoulder. Her BP is 155/80 mmHg, HR is 92 beats per minute, and RR is 16 breaths per minute. You suspect that she is having an acute MI. Which of the following therapeutic agents has been shown to independently reduce mortality in the setting of an acute MI?
Nitroglycerin
Aspirin
Unfractionated heparin
Lidocaine
Diltiazem
A 62-year-old woman presents to the physician’s office with complaints of constipation. She has had constipation for the last 6 months, which has worsened over the last month, associated with mild bloating. She noted that her stool has become “pencil thin” in the last month, with occasional blood, but she continues to have bowel movements daily. Past history is unremarkable. Examination reveals normal vital signs and heart and lung examination. Abdominal examination reveals mild fullness, especially in the lower quadrants. Rectal examination shows no rectal masses, but the stool is hematest positive. A barium xray is obtained, and one view is shown in Figure 6-11. Which of the following is the most appropriate next step in management?
. Proctoscopy and passage of a rectal tube
. Proctoscopy and biopsy
. colonoscopy
. Endoscopic dilation of the stricture
. NPO, IV fluids, and antibiotics
A 62-year-old woman undergoes a pancreaticoduodenectomy for a pancreatic head cancer. A jejunostomy is placed to facilitate nutritional repletion as she is expected to have a prolonged recovery. What is the best method for delivering postoperative nutrition?
. Institution of enteral feeding via the jejunostomy tube after return of bowel function as evidenced by passage of flatus or a bowel movement
. Institution of enteral feeding via the jejunostomy tube within 24 hours postoperatively
. Institution of supplemental enteral feeding via the jejunostomy tube only if oral intake is inadequate after return of bowel function
. Institution of a combination of immediate trophic (15 mL/h) enteral feeds via the jejunostomy tube and parenteral nutrition to provide total nutritional support
. Complete nutritional support with total parenteral nutrition
A 62-year-old woman with a history of coronary artery disease presents with a pancreatic head tumor and undergoes a pancreaticoduodenectomy. Postoperatively, she develops a leak from the pancreaticojejunostomy anastomosis and becomes septic. A Swan-Ganz catheter is placed, which demonstrates an increased cardiac output and decreased systemic vascular resistance. She also develops acute renal failure and oliguria. Which of the following is an indication to start dopamine?
. To increase splanchnic flow
. To increase coronary flow
. To decrease heart rate
. To lower peripheral vascular resistance
. To inhibit catecholamine release
A 63-year-old female presents to your office for a routine check-up. She has no present complaints. Her past medical history includes OM, type 2, and hypertension. Her current medications include glyburide and atenolol. She does not smoke. She drinks 2-3 glasses of wine 1-2 times a week. Three consecutive BP measurements were in the range of 138-142/87-90 mmHg. Physical examination is within normal limits. Her recent fasting glucose level was 250 mg/dl. ECG recorded 1 month ago showed left ventricular hypertrophy. Which statement about the BP control in this patient is the most accurate?
. BP is within acceptable range
. BP is within optimal range
. It is better to keep systolic pressure less than 130 mmHg to slow end-organ damage
. Diastolic BP is within acceptable range, but systolic is not
. Systolic BP is within acceptable range, but diastolic is not
A 63-year-old insurance agent is brought to the ED by paramedics for shortness of breath and an RR of 31 breaths per minute. The patient denies chest pain, fever, vomiting, or diarrhea. His wife says he ran out of his “water pill” 1 week ago. His BP is 185/90 mmHg, HR is 101 beats per minute, oxygen saturation is 90% on room air, and temperature is 98.9°F. There are crackles midway up both lung fields and 2+ pitting edema midway up his legs. An ECG shows sinus tachycardia. The patient is sitting up and able to speak to you. After placing the patient on a monitor and inserting an IV, which of the following is the most appropriate next step in management?
. Obtain blood cultures and complete blood cell (CBC) count, and begin empiric antibiotic therapy
. Order a statim (STAT) portable chest x-ray
. Administer oxygen via nasal cannula and have the patient chew an aspirin
. Administer oxygen via non-rebreather, furosemide, nitroglycerin, and consider non-invasive respiratory therapy
. Rapid sequence endotracheal intubation
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?
. Packed red blood cell transfusion
. Platelet transfusion
. Vitamin K
. Desmopressin
. Fresh frozen plasma
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?
. Neck exploration and ligation of the thoracic duct
. Subdiaphragmatic ligation of the thoracic duct
. Thoracotomy and repair of the thoracic duct
. Thoracotomy and ligation of the thoracic duct
. Thoracotomy and abrasion of the pleural space
A 63-year-old man undergoes a partial gastrectomy with Billroth II reconstruction for intractable peptic ulcer disease. He presents several months postoperatively with a megaloblastic anemia. Which of the following is the best treatment for this surgical complication?
. Transfusion with 1 unit of packed red blood cells
. Oral iron supplementation
. Oral vitamin B12 supplementation
. Intravenous vitamin B12 (cyanocobalamin) supplementation
. Oral folate supplementation
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?
. Addition of vasopressors along with the inotropes
. Transfusion of packed red blood cells
. Return to the operating room for exploration of the mediastinum
. Placement of an intraaortic balloon pump
. Infusion of streptokinase into the mediastinal chest tube
A 63-year-old man with history of poorly controlled diabetes presents with right leg swelling and pain. The patient denies trauma to the leg and reports it was normal yesterday. Examination of the right lower extremity is significant for extreme tenderness to palpation, erythema, and edema extending up to the knee. X ray of the right leg shows tissue swelling without gas or osteomyelitis. The patient’s vital signs are normal and he is started on broad-spectrum IV antibiotics and insulin. An hour later the patient’s heart rate increases to 125 beats per minute and the erythema has progressed to the thigh with new blister formation on the leg. Which of the following is the most appropriate next step in management?
. Repeat x-ray of the right lower extremity
. CT scan of the right lower extremity
. MRI of the right lower extremity
. Bone scan of the right lower extremity
. Immediate surgical intervention with incision and direct visualization of potentially infected tissue
A 63-year-old man with multiple rib fractures and a pulmonary contusion requires prolonged intubation. He is unable to be weaned from the ventilator and is on a volume control mode. He has a tracheostomy and a percutaneous gastrotomy in place through which he is being fed. The surgeon orders a respiratory quotient (RQ), which is the ratio of the rate of carbon dioxide production over the rate of oxygen uptake. The RQ is 1. Based on this information, which of the following is the next step in his management?
. Decrease the inspired concentration of oxygen
. Decrease the rate on the ventilator
. Increase the rate on the ventilator
. Decrease the carbohydrates in his enteral feeds
. Increase the total number of calories in his enteral feeds
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?
. Inhaled albuterol
. Sequential compression devices to her lower extremities
. Elevation of the head of the bed
. Decreasing the dose of her postoperative opioids
. Postoperative benzodiazepines
A 63-year-old retired farmer presents to the clinic complaining of red scaly spots on his head for the past 9 months. Physical examination is remarkable for numerous erythematous hyperkeratotic papules and plaques. The lesions are confined to the head and forehead and have poorly defined borders. Which of the following is the most appropriate next step in management of this patient?
. Punch biopsy of one of the lesions
. Application of hydrocortisone cream to affected areas and follow-up in 4 weeks
. Reassurance that this is a benign finding and follow-up in 6 months
. Application of fluocinide cream to affected areas and follow-up in 4 weeks
. Application of 5-fluorouracil cream to affected areas and follow-up in 4 weeks
A 63-year-old woman complains of leg swelling that is especially bothersome in the evening. She also complains of chronic cough and exertional dyspnea. She has been smoking one pack of cigarettes per day for the past 30 years. She also drinks one or two cans of beer on weekends. Her medical history is significant for a hospitalization for a "chest infection" two years ago, for which she was treated with antibiotics, steroids, and inhalers. She also reports having been diagnosed with hypertension, but says that she has never taken medications for it. On physical examination, her blood pressure is 160/90 mmHg and her heart rate is 80/min. Chest examination reveals bilateral scattered wheezes and prolonged expirations. Her jugular venous pulsation is seen 2 cm above the sternal angle with the head of the bed elevated 30°. Her abdomen is soft and non-distended. On examination of her lower extremities, you note bilateral pitting edema and dilated, tortuous, superficial veins. Which of the following is most likely to relieve this patient's edema?
. Smoking cessation
. Frequent leg elevation
. Dietary sodium restriction
. Control of hypertension
. Oxygen therapy
A 63-year-old woman has a 3-cm pruritic lesion on her right labia majora that she has noted for approximately 9 months. She has been treated with various topical creams and ointments for vulvar candidiasis without resolution of her symptoms or lesion. When you examine this woman, the lesion is still present. Which of the following is the most appropriate intervention?
Papanicolaou (Pap) smear of the lesion
Colposcopy of the lesion
Biopsy of the lesion
Wide local excision of the lesion
Vulvectomy
A 63-year-old woman has Type II diabetes mellitus, which is well-controlled. Her physical examination is positive for peripheral neuropathy in the feet and nonproliferative retinopathy. A urinalysis is positive for proteinuria. Which of the following treatments is most likely to attenuate the course of renal disease?
Calcium channel blockers
ACE inhibitors
Hepatic hydroxymethylglutaryl- coenzyme A (HMG-CoA) inhibitors
Dietary carbohydrate restriction
Weight reduction
A 63-year-old woman is undergoing a total abdominal hysterectomy (TAH) for atypical endometrial hyperplasia. She mentioned to her doctor 2 weeks prior to the surgery that she has had problems with leakage of urine with straining and occasional episodes of urinary urgency. A urine culture at that visit is negative. She has had preoperative cystometrics done in the doctor’s office showing loss of urine during Valsalva maneuvers along with evidence of detrusor instability. The doctor has elected to do a retropubic bladder neck suspension following the TAH. A Marshall-Marchetti-Krantz procedure (MMK) is done to attach the bladder neck to the pubic symphysis. The patient does well after her surgery and is released from the hospital on postoperative day 3. Which of the following should her doctor advise her prior to her discharge?
. Urinary retention is very common after an MMK procedure and often requires long-term self-catheterization.
. She has a 5% risk of enterocele formation.
. The MMK procedure is highly effective, with greater than 90% long-term cure rate.
. Osteitis pubis occurs in approximately 10% of patients after an MMK, but is easily treated with oral antibiotics.
. She will not need any additional treatment for her bladder dysfunction.
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?
. No further therapy is indicated.
. Chemotherapy.
. External beam radiotherapy.
. Radioiodine ablation.
. Chemotherapy, external beam radiotherapy, and radioiodine ablation.
A 63-year-old woman on digitalis for chronic atrial fibrillation experiences fatigue, nausea, and anorexia. Her pulse is regular at 50 beats/min, and the heart sounds, chest, and abdominal examinations are normal. On the ECG, no P waves are visible and the QRS complexes are narrow and regular. Which of the following is the most appropriate management step?
An increase in digitalis dose
Complete cessation of digitalis
Withdrawal of digitalis for one dose
Addition of a beta-blocker
Addition of a calcium channel blocker
A 63-year-old woman presents with dyspnea and coughing up foul smelling purulent sputum. She has had many similar episodes in the past. There are no other constitutional symptoms and she denies excessive alcohol intake. On physical examination, she appears chronically ill with clubbing of the fingers. Heart sounds are normal, JVP is measured at 4 cm, and there are inspiratory crackles heard at the lung bases posteriorly. There is no hepatosplenomegaly or any palpable lymph nodes. CXR shows scaring in the left lower lobe, which on chest CT scan is identified as cystic changes with airway dilatation and bronchial wall thickening. Which of the following is the most appropriate initial next step in management?
Antibiotics and postural drainage
Steroids
Radiotherapy
Aerosols
INH
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?
. Percutaneous drainage of the lung abscess
. Systemic antibiotics directed against the causative agent
. Tube thoracostomy
. Left upper lobectomy
. Surgical drainage of the abscess
A 64-year -old male with a history of hypertension presents with general malaise and a 'funny' heart rhythm for the past 2 weeks. He had an echocardiogram done last year, which revealed mild left atrial dilatation and left ventricular hypertrophy. He has been taking hydrochlorothiazide for hypertension. His blood pressure at today's visit is 180/98 mmHg. An EKG is obtained and is shown below. Which of the following is the most appropriate treatment for this patient?
. Immediate cardioversion
. Lidocaine
. Adenosine
. Carotid massage
. Diltiazem
A 64-year-old male patient with deep vein thrombosis is being treated with unfractionated heparin. On the 4th day of treatment, his platelet count drops to 80,000/cmm. His previous platelet count on day 2 was within normal range. He denies any bleeding-related complications, and is completely asymptomatic. His complete examination does not reveal any signs of bleeding. His blood pressure is 128/80mm of Hg, pulse is 78/min, and respirations are 20/min. He is afebrile. What is the most appropriate next step in the management of this patient?
. Switch to low molecular weight heparin
. Stop heparin and start warfarin
. Stop heparin
. Start plasmapheresis
. Stop heparin and start platelet transfusion
A 64-year-old male presents to the ER with chest pain. His history is significant for a hospitalization 2 weeks ago for an acute myocardial infarction. The patient reports that he is afraid his heart attack is recurring. He localizes the pain to the middle of the chest, and says that he can only take shallow breaths because deep breaths make the pain worse. Leaning forward in his chair makes the pain somewhat better. He notes some associated neck pain and general malaise, but denies shortness of breath, palpitations, syncope or cough. His temperature is 36.7°C (98°F), blood pressure is 135/84 mmHg and heart rate is 90/min. EKG shows ST segment elevations in all limb and precordial leads except in aVR, where ST depression is seen. Which of the following is the best next step in the management of this patient?
. Anticoagulation with heparin
. Anticoagulation with warfarin
. Nitroglycerin and beta-blockers
. Broad-spectrum antibiotics
. Non-steroidal antiinflammatory agent
A 64-year-old male presents to the physician's office with increasing shortness of breath. He denies orthopnoea, paroxysmal nocturnal dyspnea, or chest pain. He was hospitalized for pneumonia four years ago but has otherwise been healthy. He has smoked one pack of cigarettes daily for the past 30 years. He does not take any medications. His temperature is 37.2°C (98.9°F), blood pressure is 124/76 mm Hg, pulse is 82/min and respirations are 16/min. Pulse oximetry reveals an oxygen saturation of 88%. On chest auscultation, breath sounds are diminished throughout, and the expiratory phase is prolonged. Heart sounds are regular and there are no murmurs or gallops. There is no peripheral edema or jugular venous distention. Laboratory studies show a hematocrit of 56% and WBC count of 6,700/mm3. Which of the following interventions will have the maximum impact on this patient's survival?
. Maintenance oral steroids
. Prophylactic antibiotics to reduce exacerbations
. Influenza and pneumococcal vaccinations
. Long-term supplemental oxygen therapy
. Long-term beta-blocker therapy
A 64-year-old male with a past medical history of hypertension, diabetes and chronic renal insufficiency presents with gross hematuria. His baseline serum creatinine is 1.6-1.7 mg/dl. The patient's medications include aspirin, hydrochlorothiazide, enalapril, and simvastatin. He has no known environmental, medication, or contrast allergies. On physical examination, the patient has a blood pressure of 130/80 mm Hg. The examination is otherwise unremarkable. Contrast CT scan of the abdomen is planned to evaluate his condition. Which of the following interventions would be most helpful in preventing contrast-induced kidney damage?
. Prednisone
. Non-ionic contrast agent
. Furosemide
. 100% oxygen mask
. Stopping simvastatin
A 64-year-old male, who rarely sees the doctor and doesn't believe in screening procedures, comes to office with the complaint of severe back pain. He has not felt comfortable for the past 4 months and is having severe pain in the back. He has found it difficult to sleep. He has hypertension, for which he takes hydrochlorothiazides regularly. He thinks that he has lost some weight. On examination, his BP is 165/90mm of Hg, while rest of vitals are stable. On rectal examination you find a rock hard 2 cm nodule in prostate. Biopsy shows poorly differentiated adenocarcinoma. Bone scans shows wide spread metastasis all over his skeleton. What is the most appropriate treatment for his metastatic disease?
. Leuprolide
. Diethylstilbestrol (DES)
. Flutamide
. Radicle prostatectomy
. Complete androgen blockade with Leuprolide and Flutamide
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?
. Aspirin
. Warfarin
. Low-dose heparin
. High-dose heparin
. Low-molecular-weight heparin
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?
. Pneumatic compression stockings
. Warfarin
. Heparin
. Thrombolysis
. Inferior vena cava filter
A 64-year-old woman develops severe diarrhea 2 weeks after finishing antibiotics for pneumonia. She has also noticed decreased urine output despite drinking lots of fluids. On examination, she has a postural drop in her blood pressure, the JVP is low, and the abdomen is soft but diffusely tender. Despite giving 4 L of normal saline, her urine output remains low. The urinalysis is positive for heme-granular casts and the urine sodium is 42mEq/L. Which of the following medications should be held during the recovery phase of this woman’s ARF?
Acetaminophen
Digoxin
Lorazepam
Enalapril
Simvastatin
A 64-year-old woman presents with diffuse hair loss. She says that her hair is “coming out by the handfuls” after shampooing. She was treated for severe community-acquired pneumonia 2 months ago but has regained her strength and is exercising regularly. She is taking no medications. Examination reveals diffuse hair loss. Several hairs can be removed by gentle tugging. The scalp is normal without scale or erythema. Her general examination is unremarkable; in particular, her vital signs are normal, she has no pallor or inflammatory synovitis, and her reflexes are normal with a normal relaxation phase. What is the best next step in her management?
. Reassurance
. Measurement of serum testosterone and DHEA-S levels
. Topical minoxidil
. Topical corticosteroids
. CBC and antinuclear antibodies
A 64-year-old woman undergoes a total abdominal hysterectomy and bilateral salpingo-oophorectomy for uterine prolapse. On postoperative day 1, a complete blood count shows the following: Leukocytes: 5500/mm3; Hematocrit: 36%; Platelets: 245,000/mm3. By postoperative day 2, the patient is alert and able to ambulate without difficulty. She has no complaints. She has not taken in nutrition orally but is receiving IV fluids. She is voiding without difficulty and has passed flatus. Her temperature is 37 C (98.6 F), blood pressure is 124/72 mm Hg, pulse is 86/min, and respirations are 12/min. Examination shows her abdomen to be soft, nontender, and non distended. The incision is clean, dry, and intact. The rest of the examination is unremarkable. Which of the following is a reason for keeping this patient hospitalized for a longer period of time?
. Absent oral intake
. Evidence of infection
. Hematocrit
. Urinary tract function
. Vital signs
A 64-year-old woman undergoes left radical mastectomy for breast cancer. A 4-cm infiltrating ductal carcinoma is found on pathologic examination. Four of 20 axillary lymph nodes are positive for malignancy. Neoplastic cells are immunoreactive for estrogen and progesterone receptors. No evidence of metastatic disease is found on bone scanning with 99mTc-labeled phosphate or chest x-ray films. The patient receives appropriate radiation therapy and multidrug chemotherapy. Which of the following is the most appropriate adjunctive therapy in this setting?
Danazol
Ethinyl estradiol
Megestrol acetate
Medroxyprogesterone acetate
Tamoxifen
A 65-year -old Hispanic male is brought to the emergency room with severe substernal chest pain and diaphoresis that began suddenly 1 hour ago. He reports that his pain started while he was at rest and radiates to his left shoulder. The patient notes having vomited twice when the pain first began. Despite administration of 2 baby aspirins and 3 tablets of sublingual nitroglycerin, the pain persists. His initial EKG is shown below. On physical examination, the patient's temperature is 36.9°C (98.4°F), blood pressure is 110/80 mmHg, pulse is 60/min, and respirations are 18/min. S1 and S2 are normal, and an S4 is heard. The lungs are clear to auscultation. There is no jugular venous distension or pedal edema. Interventions to achieve which of the following goals would most improve this patient's long-term prognosis?
. Decrease myocardial oxygen demand
. Decrease blood coagulability
. Restore coronary blood flow
. Prevent ischemia-induced arrhythmias
. Prevent reperfusin myocardial injury
A 65-year-old African-American man is hospitalized after a car accident. He has a vertebral fracture at the level of the fifth thoracic vertebra and is unable to move his lower extremities. Since his injury, he has needed a catheter for micturition. Which of the following is the most effective measure for decreasing the risk of a urinary tract infection in patients requiring bladder catheterization?
. Antibacterial creams applied to the urethral meatus
. Prophylactic antibiotics
. Antibacterial washes of external genitalia
. Bladder irrigation with antibacterial solutions
. Intermittent catheterization
A 65-year-old Caucasian male comes to the office because of bilateral foot pain, which is present at rest and worsens at night. He has been having this symptom for the past few months. Other accompanying symptoms are hyperesthesia and paresthesia in both lower limbs. His medical problems include diabetes for the past twenty years. His daily medication is insulin. Physical examination reveals bilateral loss of ankle reflexes, loss of vibratory sensation and altered proprioception below the knees. His HbA1c level is 9%. Urine is positive for microalbuminuria. Which of the following is the most appropriate treatment for his leg pain?
. Amitriptyline
. Corticosteroids
. Oxycodone
. Acetaminophen
. Ketorolac
A 65-year-old Connecticut resident calls your office after finding a 3 mm red-brown tick attached to his right leg. He just returned from a hiking trip and was about to a take a shower when he discovered the tick. Which of the following is the best advice to give this patient?
. Crush the tick with your fingers
. Remove the tick with tweezers
. Apply petroleum jelly over the tick
. Come to the office tomorrow for tick removal
. Let the tick detach spontaneously
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?
. Prescribe amitriptyline for his pain
. Obtain Doppler ultrasound examination
. Obtain resting and post-exercise systolic blood pressures in the ankle and arm
. Segmental volume plethysmography
. Obtain MRI of the spine
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?
High-dose IV penicillin G and broadspectrum antibiotics
High-dose IV penicillin G, broadspectrum antibiotics, and local wound care with unroofing of bullae and culture of wound drainage
High-dose IV penicillin G, broadspectrum antibiotics, with surgical debridement only if and when there is no improvement with antibiotics
Radical surgical debridement
High-dose IV penicillin G, broadspectrum antibiotics, radical surgical debridement, and hyperbaric oxygen therapy
A 65-year-old female is admitted to the hospital with increasing shortness of breath, weight gain and lower extremity edema. She has a history of hypertension, nonischemic cardiomyopathy with an ejection fraction of 30%, and hyperlipidemia. Her home medications include oral aspirin, digoxin, furosemide, metoprolol, lisinopril and atorvastatin. She is started on intravenous furosemide. On day three of hospitalization telemetry reveals six beats of wide complex ventricular tachycardia. Physical examination now shows decreased leg edema and clear lungs. Which of the following is the most appropriate next step in the management of this patient's tachycardia?
. Add spironolactone
. Add metolazone
. Measure serum electrolytes
. Discontinue atorvastatin
. Discontinue metoprolol
A 65-year-old G2P2 postmenopausal woman presents to a gynecologist for the first time in many years complaining of vaginal bleeding, pelvic pain, and increased urinary frequency. She reports she is sexually active with her husband. After an appropriate work-up, a diagnosis of locally invasive squamous cell carcinoma of the cervix is made. The tumor has extended approximately 9 mm into the cervical stroma, grading the cancer as stage IB. The patient is informed of the diagnosis and wishes to undergo definitive therapy. What is the definitive therapy for this patient’s disease?
Chemotherapy
Cold knife cone excision
Loop electrosurgical excision procedure
Radical hysterectomy
Uterine artery embolization
A 65-year-old Hispanic male is brought to the emergency department after having one seizure episode. His past medical history is significant for non-small cell lung carcinoma, which was diagnosed two years ago and treated surgically. He had no residual disease at that time. CT scan of the brain with contrast now shows a solitary cortical mass in the right hemisphere of the brain at the grey-white matter junction. His chest x-ray is clear. He is admitted for further management and started on phenytoin. Which of the following is the most appropriate management for this patient?
. Focal radiation to brain mass
. Whole brain radiation
. Surgical resection of the mass
. Combination chemotherapy
. Palliative pain therapy and seizure prophylaxis
A 65-year-old lady comes to the office for the evaluation of her deteriorating memory. She has become increasingly forgetful over the last several months, and now appears very concerned about her memory loss. She used to pride herself for her sharp memory, but has been forgetting the most trivial things and has become "extremely inefficient." She also complains of easy fatigability, poor appetite, and frequent awakening at night. She feels worthless and has lost interest in her favorite hobby, which is gardening. On coughing or laughing, she loses urine involuntarily, and this is adding to her misery. She lives with her husband, who says that she has become very "cranky and irritable" lately. Her medical history is significant for hypercholesterolemia, for which she refuses to take medication. She is presently not on any hormonal therapy. The physical examination is completely normal. Laboratory studies are unremarkable. CT scan of the head is normal. What is the best next step in the management of this patient?
. Start hormonal replacement therapy
. Treat her with donepezil
. Start selective serotonin reuptake inhibitor
. Surgical bypass shunting
. Reassurance
A 65-year-old male comes to the emergency department because of a sudden, painless loss of vision in his right eye that occured a half an hour ago. Five hours ago, he experienced a similar but transient loss of vision in the same eye, which lasted for five minutes. He has hypertension, diabetes, hypercholesterolemia, and peripheral vascular disease. He had an anterior wall myocardial infarction six years ago. His medications include glyburide, captopril, atenolol, simvastatin and aspirin. His temperature is 36.7°C (98.0°F), respirations are 16/min, pulse is 88/min, and blood pressure is 146/88 mmHg. Examination of the right eye reveals visual acuity of 20/60 and subtle retinal whitening. A right carotid bruit is heard. Which of the following is the most appropriate next step in the management of this patient?
. Acetazolamide IV
. Ocular massage and high flow oxygen
. Administer systemic steroids
. Instillation of topical beta blocker
. Administer thrombolytics
A 65-year-old male comes to the office and complains of nausea and early satiety for the past several months. His other complaints are anorexia and abdominal bloating. He denies any heartburn or epigastric pain. He has diabetes, and has been taking insulin for the last fifteen 15 years. His blood glucose readings using the home blood glucose monitor range between 40 to 400 mg/dL. Most of the low blood glucose readings occur after meals. Which of the following is the most appropriate management of this patient's symptoms?
. Promethazine
. Ondansetron
. Ibuprofen
. Metoclopramide
. Ranitidine
A 65-year-old male complains of fatigue for the past one month. He has been living alone since the death of his wife one year ago. He does not like to cook, and his diet consists mostly of canned food, hot tea, and toast. He drinks one glass of white wine nightly with dinner. Examination shows pallor of the skin, nail beds and conjunctiva. Rectal exam is heme-negative. His physical examination is otherwise unremarkable. Administration of which of the following would be most helpful in treating his condition?
. Vitamin B12
. Folic acid
. Vitamin C
. Vitamin D
. Vitamin E
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?
. Stat chest x-ray
. Arterial blood gas analysis
. Pericardiocentesis
. Needle thoracostomy
. Intravenous fluids and dopamine
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 38.7°C (101.7°F), blood pressure 120/76 mm Hg, pulse 110/min and respirations 26/min. His condition worsened over the next several hours and required orotracheal 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?
. Stat chest x-ray
. Arterial blood gas analysis
. Pericardiocentesis
. Needle thoracostomy
. Intravenous fluids and dopamine
A 65-year-old male presents to the emergency department with substernal chest pain, severe shortness of breath, and diaphoresis that began suddenly 40 minutes ago. Since the pain started, the patient has vomited twice. The pain radiates to his left arm and does not remit with sublingual nitroglycerine. EKG shows 2 mm ST elevations in the anterior leads. On physical examination, the patient's temperature is 36.9°C (98.4°F), blood pressure is 110/70 mmHg, pulse is 60/min, respirations are 32/min, and oxygen saturation is 90% on 4L oxygen by nasal canula. Cardiac exam reveals a muffled S1 and S2 and the presence of an S3. Lung exam reveals basilar crackles that extend halfway up the lung fields bilaterally. Which of the following is the best next step in managing this patient?
. Metoprolol
. Digoxin
. Furosemide
. Spironolactone
. IV fluids
A 65-year-old male with oxygen-dependent chronic obstructive pulmonary disease, chronic atrial fibrillation, and depression comes into the Emergency Room, with symptoms of increased dyspnea and worsening cough pattern. His recent history had been significant for a gradual worsening of his baseline lung disease over the past month, which had been treated by his outpatient doctor with increased frequency of inhaled beta-agonist and azithromycin. This morning he had a severe shortness of breath that was unresponsive to "stacked" home nebulizer treatments. The ER physician notes that the patient is in moderate severe respiratory distress. His temperature is 37.2°C (99°F), blood pressure is 150/90 mmHg, pulse is 110/min, and respirations are 28/min. Accessory muscle use was noted. Lung exam shows diffuse rhonchi and wheezing. A pulse oximetry revealed an oxygen saturation of 80% on room air. His chest x-ray showed no new infiltrates. His WBC count is 7,000/cmm with normal differential. The ER physician had given nebulization, and the patient is on 5-liters of oxygen. Which of the following should also be considered in this patient?
. Gatifloxacin
. Methylprednisolone
. N-acetylcysteine
. Clarithromycin
. Aminophylline
A 65-year-old man complains of blood in his urine for the past 2 months. He has had no similar episodes in the past. He is otherwise healthy and denies abdominal pain, any trauma, fever, chills, anorexia, or dysuria. He reports having a good urinary stream and no nocturia or dribbling. He is not sexually active. He has no other medical problems and is not taking any medications. His vital signs are stable. Lung, heart, abdominal, and groin examination are unremarkable. Rectal exam reveals a nontender prostate with no masses or enlargement- Urinalysis reveals packed red cells, a few white cells, and no casts. Which of the following is the most appropriate management?
Prescribe levofloxacin
Schedule a prostatic biopsy
Schedule a renal angiogram
Schedule a cystoscopy
Schedule a pelvic CT scan
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?
. anticoagulation
. Exercise program
. Coronary artery bypass grafting
. Aortofemoral bypass grafting
. Placement of a vena cava filter
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?
. echocardiography
. Anticoagulation with heparin
. Anticoagulation with warfarin
. arteriography
. Alkalinization of the urine with IV sodium bicarbonate
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?
. r-TPA (tissue plasminogen activator) infusion following anticoagulation
. Administration of vasodilators
. four-compartment fasciotomy
. thromboembolectomy
. Anticoagulation and close observation
A 65-year-old man presents to the physician’s office for his yearly physical examination. His only complaint relates to early fatigue while playing golf. Past history is pertinent for mild hypertension. Examination is unremarkable except for trace hematest-positive stool. Blood tests are normal except for a hematocrit of 32. A UGI series is performed and is normal. A barium enema is performed, and one view is shown in Figure 6-10. Which of the following is the most appropriate therapy following colonoscopy?
. Proximal colostomy with mucous fistula
. Radiation therapy
. chemotherapy
. Surgical resection and primary anastomosis
. Surgical bypass (colocolostomy)
A 65-year-old man sustains a 50% TBSA burn while burning trash in the backyard. The patient is resuscitated with lactated Ringer (LR) solution using the Parkland formula and a weight of 80 kg. What is the rate of LR given in the first 8 hours?
. 100 mL/h
. 500 mL/h
. 1000 mL/h
. 5000 mL/h
. 10,000 mL/h
A 65-year-old man who is hospitalized with pancreatic carcinoma develops abdominal distention and obstipation. The following abdominal radiograph is obtained. Which of the following is the most appropriate initial management of this patient?
. Urgent colostomy or cecostomy
. Discontinuation of anticholinergic medications and narcotics and correction of metabolic disorders
. Digital disimpaction of fecal mass in the rectum
. Diagnostic and therapeutic colonoscopy
. Detorsion of volvulus and colopexy or resection
A 65-year-old man who smokes cigarettes and has chronic obstructive pulmonary disease falls and fractures the third, fourth, and fifth ribs in the left anterolateral chest. Chest x-ray is otherwise normal. Which of the following would be the most appropriate next step in his management?
. Strapping the chest with adhesive tape
. Admission to the hospital and treatment with oral analgesia
. Tube thoracostomy
. Placement of an epidural for pain management
. Surgical fixation of the fractured ribs
A 65-year-old man with a history of occasional painless rectal bleeding presents with 2 to 3 days of constant, dull RLQ pain. He also complains of fever, nausea, and decreased appetite. He had a colonoscopy 2 years ago that was significant for sigmoid and cecal diverticula but was otherwise normal. On physical examination he has RLQ tenderness with rebound and guarding. His vitals include HR of 95 beats per minute, BP of 130/85 mm Hg, and temperature of 101.3°F. The abdominal CT demonstrates the presence of sigmoid and cecal diverticula, inflammation of pericolic fat, thickening of the bowel wall, and a fluid-filled appendix. Which of the following is the most appropriate next step in management?
. Discharge the patient with broad-spectrum oral antibiotics and surgical follow-up
. Begin IV hydration and broad-spectrum antibiotics, keep the patient npo (nothing by mouth), and admit the patient to the hospital
. Begin IV antibiotics and call a surgical consult for an emergent operative procedure
. Arrange for an emergent barium enema to confirm the diagnosis
. Begin sulfasalazine 3 to 4 g/d along with IV steroid therapy
A 65-year-old smoker previously diagnosed with chronic obstructive pulmonary disease presents to the emergency department complaining of worsening cough and sputum production. She reports feeling breathless when climbing the stairs to her first floor walk-up apartment, and has moderate difficulty in providing her history in complete sentences. X-ray of the chest shows hyper inflated lungs with flattened diaphragms, attenuated vascular markings, and a narrow mediastinum. What agent(s) will provide the greatest relief of symptoms in the emergency department?
Albuterol and ipratropium bromide
Antibiotics
Magnesium sulfate
N-acetylcysteine
Theophylline
A 65-year-old white male who has a history of chronic obstructive pulmonary disease, congestive heart failure, and coronary artery disease presented with a three-day history of worsening shortness of breath, cough with yellowish expectoration, and fever. He is not on steroids and does not use oxygen at home. He takes ipratropium, albuterol, aspirin, digoxin, furosemide, metoprolol, and lisinopril. He lives at home with his wife. His temperature is 39.4°C (103°F), blood pressure is 110/70 mmHg, pulse is 110/min, and respirations are 24/min. He is saturating 88% on room air. He was started on 3-liters of oxygen to keep the saturations above 92%. The chest x-ray of the patient is shown below. What is the most appropriate next step in the management of this patient?
. Admit the patient and give ampicillin
. Outpatient trimethoprim-sulfamethoxazole
. Admit the patient and start levofloxacin
. Admit the patient and start ciprofloxacin
. Admit the patient and start vancomycin
A 65-year-old white man comes to the Emergency Room complaining of headache, insomnia, palpitations, and vomiting. His past medical history is significant for chronic obstructive pulmonary disease (COPD) treated with theophylline, ipratropium, and occasional albuterol. He had a puncture wound of the foot one week ago, and it is being treated effectively with amoxicillin-clavulanate and ciprofloxacin. For the past three days, his shortness of breath is worsening, and his primary care physician gave oral prednisone. His blood pressure is 150/80 mmHg and heart rate is 105/min with frequent ectopic beats. You suspect that drug toxicity may be responsible for this patient's complaints. Which of the following drugs is most likely responsible for his condition?
. Theophylline
. Ipratropium
. Albuterol
. Ciprofloxacin
. Steroids
A 65-year-old woman has a life-threatening pulmonary embolus 5 days following removal of a uterine malignancy. She is immediately heparinized and maintained in good therapeutic range for the next 3 days, then passes gross blood from her vagina and develops tachycardia, hypotension, and oliguria. Following resuscitation, an abdominal CT scan reveals a major retroperitoneal hematoma. Which of the following is the best next step in management?
. Immediately reverse heparin by a calculated dose of protamine and place a vena caval filter (eg, a Greenfield filter).
. Reverse heparin with protamine, explore and evacuate the hematoma, and ligate the vena cava below the renal veins.
. Switch to low-dose heparin.
. Stop heparin and observe closely.
. Stop heparin, give fresh-frozen plasma (FFP), and begin warfarin therapy.
A 65-year-old woman is found to have osteoporosis on DEXA scan. She underwent right knee surgery five years ago and developed post-operative deep venous thrombosis, for which she was treated with 6 months of warfarin therapy. She also has severe gastroesophageal reflux disease and takes lansoprazole daily. Her mother died of breast cancer, her maternal aunt has endometrial cancer, and her paternal aunt has a history of ovarian cancer. She does not want to use bisphosphonates because of her reflux symptoms, and would like to consider raloxifene. Which of the following is a contraindication to raloxifene in this patient?
. History of breast cancer in her mother
. History of endometrial cancer in her maternal aunt
. History of ovarian cancer in her paternal aunt
. History of deep vein thrombosis
. History of colon cancer
A 65-year-old woman is very worried because she recently had a close family member and friend die, one after the other. First, her 85-year-old mother died of an ovarian cancer that was diagnosed 3 years ago. Last week, she lost her best friend to lung cancer that metastasized to the liver and brain. Today, her 58-year-old sister learned that she has breast cancer. She has regular pap smears and breast examinations. She has read in the paper that there are a few ways that have proved to be very successful in preventing breast cancer. Which of the following measures has the best evidence of preventing breast cancer in high-risk women?
. Prophylactic oophorectomy
. BRCA screening
. Low-fat diet
. Tamoxifen
. Having mammograms every month
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?
. Radical mastectomy
. lumpectomy, irradiation, and axillary node dissection
. Lumpectomy and axillary node dissection
. Irradiation of the breast and axilla
. quadrantectomy, irradiation, and axillary node dissection
A 65-year-old woman presents to the physician’s office for evaluation of an abnormal screening mammogram. She denies any breast masses, nipple discharge, pain, or skin changes. Past history is pertinent for hypertension. Family history is positive for postmenopausal breast cancer in a sister. She has a normal breast examination and no axillary adenopathy. The remainder of her examination is unremarkable. An MLO view of the right breast is shown in Figure 6-6a along with a magnification view of the craniocaudal (CC) film (Figure 6-6b). Which of the following is the most appropriate next step in management?
. observation, with repeat mammogram in 6 months
. observation, with repeat mammogram on an annual basis
. biopsy
. lumpectomy, radiation therapy, and SLN biopsy
. Total mastectomy
A 65-year-old woman with PMH of hypertension treated with lisinopril and hydrochlorothiazide (HCTZ) presents to the office for vaginal bleeding. The bleeding started last month. It was lighter than her menstruation used to be and lasted for 4 days. Vital sign: BP, 135/80 mm Hg; P, 76 beats/min; R, 18 breaths/min; T, 98.9°F. Review of system: No fever, chills, or weight loss, No chest pain or shortness of breath, No abdominal pain, nausea, vomiting, diarrhea, constipation, or distention. Physical examination: Gen: Awake, alert-oriented x3, no acute distress, CVS: S1S2 + RRR no m/r/g, Lungs: CTA bilaterally, Abd: Soft, nontender, nondistended, + bowel sounds, Ext: No edema, Pelvic: Cervix appears normal, no lacerations seen, bimanual examination findings within normal limits. What is the next step in the management of this patient?
. Transabdominal US
. Endometrial biopsy
. No further management is needed
. CTscan
. MRI
A 66-year-old man complains of exertional dyspnea that has progressed over the last two years. As a result, he has had to limit his physical activities to avoid becoming short of breath. He denies any significant chest pain, but does note having a recurrent cough productive of whitish sputum. His past medical history is significant for hypertension controlled with hydrochlorothiazide. He has a 40 pack-year smoking history. His family history is significant for a stroke in his mother. His blood pressure is 160/90 mmHg and his heart rate is 80/min. Physical examination reveals a mildly overweight patient in no acute distress. His anteroposterior chest diameter is markedly increased. Breath sounds are decreased bilaterally with scattered expiratory wheezes. Which of the following agents is most likely to reduce this patient's symptoms?
. Alpha-adrenergic blocker
. Beta-adrenergic blocker
. Muscarinic antagonist
. Dopamine agonist
. Alpha 2-adrenergic agonist
A 66-year-old man has progressive shortness of breath due to COPD. He is currently able to do his activities of daily living, but has trouble walking more than one block. His physical examination reveals hyperinflation, increased resonance to percussion, and bilateral expiratory wheezes. He is on appropriate medical therapy for his stage of COPD. Which of the following is also indicated in the management of this condition?
Meningococcal vaccination
Yearly influenza vaccination
Weight reduction if obese
Haemophilus influenzae B vaccination
Pneumococcal vaccination
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?
. Psychotherapy
. Pharmacologic therapy
. Erectile nerve reconstruction
. Implantable penile prosthesis
. Pudendal artery revascularization
A 66-year-old white male comes to the physician's office for the first time because of generalized muscle weakness. His review of systems is otherwise negative. He has a past medical history of hypertension, type- 2 diabetes, hyperlipidemia, chronic renal insufficiency and ischemic cardiomyopathy. Neurological examination shows mild weakness of the lower limbs, depressed reflexes and normal sensation. Laboratory studies show: Serum sodium 134 mEq/L, Serum potassium 6.0 mEq/L, Bicarbonate 24 mEq/L, Blood urea nitrogen (BUN) 38 mg/dl, Serum creatinine 2.8 mg/dl, Calcium 8.2 mg/dl, Blood glucose 298 mg/dl. A dose of sodium polystyrene sulfonate is given. Which of the following additional interventions is most important in this patient's management?
. Review all his current medications
. Measure serum renin and aldosterone levels
. Obtain electromyography
. Obtain acetylcholine receptor antibodies
. Start oral prednisone therapy
A 66-year-old white male presents for evaluation of progressively worsening dyspnea that affects him at rest and wakes him from sleep. He also notes bilateral ankle swelling. His medical history is significant for coronary artery disease for which he has undergone angioplasty and coronary artery bypass grafting. On examination today, his pulse is 86/min, blood pressure is 110/70 mmHg, and respirations are 19/min. His neck veins are distended and there is bilaterally symmetric pitting ankle edema. On chest auscultation, you hear crackles at the bilateral lung bases and a third heart sound. Chest x-ray shows an enlarged cardiac silhouette and bilateral alveolar and interstitial pulmonary edema. Of the medications listed below, which has not been shown to improve survival in patients with the above presentation?
. Captopril
. Losartan
. Metoprolol
. Digoxin
. Aspirin
A 67 -year-old man presents to your office with a one month history of progressive fatigue and exertional dyspnea. He has no significant past medical history. Physical examination reveals enlarged, non-tender axillary lymph nodes bilaterally. His abdomen is soft and non-tender and the liver span is 10 cm. Serial fecal occult blood tests are negative. Laboratory values are as follows: Hemoglobin 7.8 mg/dl, MCV 90 fl, MCHC 33 g/dl, Reticulocytes 7%, WBC count 22,000/mm3, Platelets 200,000/mm3. Which of the following is most likely to improve this patient's symptoms?
. Folic acid
. Iron
. Prednisone
. Pyridoxine
. Erythropoietin
A 67-year-old homeless male presents 24 hours after the onset of substernal chest pain and is diagnosed with an anterior wall myocardial infarction. There is no history of previous chest pain, dyspnea, palpitations, syncope or leg swelling. He has no hypertension or diabetes mellitus. He does acknowledge a 40 pack-year smoking history. Upon discharge, echocardiography shows normal left ventricular size, left ventricular anterior wall hypokinesis and an ejection fraction of 50%. Two years later, the patient is found dead in the street. Autopsy reveals a dilated left ventricle with a globular shape and thinned walls along with a scar on the anterior wall. Which of the following would have most likely prevented this patient's pathologic findings?
. Aspirin
. Enalapril
. Amlodipine
. Isosorbide dinitrate
. Digoxin
A 67-year-old male comes to the clinic for medical clearance prior to an elective abdominal aortic aneurysm repair. He denies any cough, shortness of breath or chest pain. He has coronary artery disease, diabetes and hypertension. He does not use tobacco, alcohol or drugs. His blood pressure is 120/76 mm Hg, pulse is 60/min, and respirations are 14/min. Examination shows no abnormalities, except prominent epigastric pulsations. Which of the following interventions would be most helpful in preventing postoperative pneumonia in this patient?
. Albuterol inhalers
. Prophylactic antibiotics
. Incentive spirometry
. Continuous positive airway pressure
. Intercostal nerve blocks for pain control
A 67-year-old male comes to the office for a routine physical exam. He retired this year and wants "a clean bill of health." He has no complaints. He stopped smoking 10 years ago, but smoked for 40 years prior to that. He only takes a "water pill" for hypertension. His vital signs are normal. The physical examination reveals a bruit in his neck. His chest x-ray, EKG, and blood work have normal results. Duplex ultrasonography of his neck reveals a 70% irregular lesion at the right common carotid artery bifurcation. The left common carotid artery has a 40% lesion. What is the best next step in the management of this patient?
. Left carotid surgery
. Right carotid surgery
. Long term ASA therapy
. Temporal artery biopsy
. Heparin
A 67-year-old male presents to the ER with chest pain. His medical history is significant for stable angina for which he takes aspirin and isosorbide dinitrate, as well as hypertension and bronchial asthma. Occasionally, he uses an albuterol inhaler. He is admitted to the hospital and five hours later, he begins to feel lightheaded and weak. His blood pressure is 100/60 mmHg. An EKG is obtained and is shown below. Which of the following is the best next step in managing this patient?
. Cardiac catheterization
. Pacemaker insertion
. Adenosine
. Digoxin
. Metoprolol
A 67-year-old male presents with a six-month history of rigidity, gait problems, tremor and slowness of movements. His condition has progressively worsened over the last few months, and he is now unable to perform his routine daily activities due to the slowness of his movements. He is not taking any medications. On examination, he is alert and conscious. His face is without expression. There is a resting tremor of his hands. He has a stooped posture and shuffling gate. There is rigidity of his limb muscles. Which of the following is the most appropriate initial treatment for this patient?
. L-dopa
. Amantadine
. Selegiline
. Clozapine
. Benztropine
A 67-year-old man presents to his primary care physician with a 1-cm skin lesion on his left forearm. On examination, it has a waxy appearance with rolled pearly borders surrounding a central ulcer. Which of the following is the most appropriate management of this patient?
. Mohs surgery
. Curettage of the lesion
. Electrodesiccation of the lesion
. Laser vaporization of the lesion
. Surgical excision
A 67-year-old man with a history of gout presents with intense pain in his right great toe. He has a complex past medical history, including hypertension, coronary artery disease, congestive heart failure, myelodysplasia, and chronic kidney disease with a baseline creatinine of 3.2 mg/dL and a uric acid level of 10 mg/dL. His medications include aspirin, simvastatin, clopidogrel, furosemide, amlodipine, and metoprolol. What is the best therapy in this situation?
. Colchicine 1.2 mg po initially, followed by 0.6 mg 1 hour later
. Allopurinol 100 mg po daily and titrate to uric acid less than 6 mg/dL
. Prednisone 40 mg po daily
. Naproxen 750 mg po once followed by 250 mg po tid
. Probenecid 250 mg po bid
A 67-year-old woman with a past medical history significant for hypertension, hypercholesterolemia, and type 2 diabetes calls 911 for severe shortness of breath. Her symptoms started 2 hours ago with chest pain and progressed rapidly to orthopnea and shortness of breath. Her blood pressure is 170/ 100 mmHg and heart rate is 120/min and regular. A third heart sound is present. Bilateral crackles are heard on chest auscultation. Her oxygen saturation is 78% with 40% inspired oxygen. She is intubated in the field by paramedics for progressive respiratory failure and is treated with nitrates and diuretics. After the initial resuscitation, breath sounds on the left side are markedly decreased. Which of the following is most likely to restore breath sounds to this hemithorax?
. Left-sided chest tube
. Left-sided needle thoracostomy
. Pericardiocentesis
. Endotracheal tube withdrawal
. Tidal volume increase
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