(NEW) DES 2016-2017 : 2040-2299 (Fabien) 4

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

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

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

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

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

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

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

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

233) A 55-year-old man presents to the emergency department with left lower quadrant abdominal pain. The pain has been present for 1 week, but has increased in intensity over the last 2 days associated with nausea, constipation, and dysuria. Past history is unremarkable. Examination reveals a temperature of 101°F, pulse rate of 95/min, BP of 130/70 mmHg, and normal heart and lung examinations. Abdominal examination reveals fullness and marked tenderness in the left lower quadrant, with voluntary guarding and decreased bowel sounds. Laboratory tests reveal a WBC count of 18,000 with a left shift and 20–50 WBCs in the urinalysis. A CT scan of the abdomen reveals a thickened sigmoid colon with pericolonic inflammation. He is admitted to the hospital for treatment. We find this patient has diverticulitis. Which of the following is the most appropriate management of this patient?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

5) In the course of a robbery, a young woman is stabbed repeatedly. On arrival at the emergency department, she is shivering and asks for a blanket and a drink of water; she is noted to be pale and perspiring. Her blood pressure is 72/50 mm Hg and her pulse is 130/min. Her neck and forehead veins are large and distended. A quick initial survey reveals entry wounds in her left chest and upper abdomen. She has bilateral breath sounds and a scaphoid, nontender abdomen. As IV infusions of Ringer's lactate are started, her systolic blood pressure drops further to 40 mm Hg, no distal pulses can be felt, and she loses consciousness. Her central venous pressure at that time is 28 cm H2O. Which of the following is the most appropriate next step in management?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

65) A 34-year-old woman is admitted for septic shock secondary to a urinary tract infection. In the intensive care unit, she receives dopamine, intravenous fluids and antibiotics and requires central line placement for venous access. Which of the following is the most important safeguard to prevent respiratory and cardiac complications following central line placement?

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

67) A 24-year-old woman comes to the physician's office because of breast pain. She has a 2-month-old baby who she breastfeeds. Her temperature is 38.5C (101.9F). Examination shows a hard, red, tender and swollen area on her right breast. There is no fluctuance noted. Which of the following is the most appropriate next step in management?

68) A one-year-old boy is brought to the emergency department with scalds on both the buttocks and thighs. His mother states that the child was burned because she accidentally drew a bath for the child with water that was too hot. She states the injury occurred 2 days ago. On examination, the child is irritable. Second degree burns are noted on the buttocks, genitalia, waist, proximal thighs and feet. There is an abrupt demarcation between the burned and unaffected skin. A faint yellow patch of discoloration is noted on the left thorax with a slight violaceous hue. The child has not yet had his 1-year vaccinations. Which of the following is the most appropriate next step in management?

69) A 46-year-old male was admitted with epigastric pain radiating to the back. He has a previous history of endocarditis from intravenous drug use and cellulitis of the arm. Serum lipase is elevated. He was admitted and treated conservatively. Two days later he started to have a fever. He is awake but slightly disoriented. His temperature is 38.7C (101.6F), blood pressure is 120/76 mm Hg, pulse is 110/min and respirations are 16/min. He is tremulous and says bugs are crawling on him. His blood cultures are positive for gram negative rods. Empiric antibiotic therapy is started. CT scan of the abdomen shows a new 6 x 6 cm cystic lesion attached to the pancreatic head. Laboratory results show: Hematocrit 44.0 g/L, MCV 105fl, Leukocyte count 18,500/mm3, Amylase 255 U/L. Which of the following is the most appropriate next step in management?

70) A 40-year-old male developed shortness of breath during the postoperative recovery period. He had a large ventral hernia repair a few hours ago. He has no significant past medical history. He has never smoked. His temperature is 37.6C (99.8F), blood pressure is 100/60 mm Hg, pulse is 100/min and respirations are 30/min. Lungs are clear to auscultation except for a few rales at the bases. An x-ray film of the chest shows bibasilar atelectasis. Arterial blood analysis shows: pH 7.35, P02 70 mm Hg, PC02 45 mm Hg, HC03 28 mEq/L. Which of the following is the most appropriate next step in management?

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

72) A 55-year-old man comes to the emergency department because of severe right-sided chest pain. His temperature is 37.8C (100.4F), blood pressure is 138/88 mm Hg, pulse is 88/min and respirations are 19/min and shallow. Examination shows decreased respiratory movements on the right side of the chest and tenderness on palpation over the right mid-chest. An x-ray film of the chest shows a fracture of the right 6th rib. Which of the following is the most important goal in management of the rib fracture in this patient?

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

74) While working on-site at a factory doing physical examinations for workers, a physician is suddenly called to help a worker who amputated his finger. Which of the following is the most appropriate next step in management in this situation?