Management USMLE 8 (1001-1047)
A 56-year-old morbidly obese man twisted his ankle five days ago and has been bed-ridden since. Today he presents to the emergency department with acute-onset shortness of breath and chest tightness. His past medical history is significant for diabetes mellitus, hypertension, right knee osteoarthritis, and a deep venous thrombosis. His current medications are lisinopril, metoprolol, and metformin. His blood pressure is 110/60 mmHg and his heart rate is 110/min. A CT scan of the chest with contrast is consistent with pulmonary thromboembolism. Which of the following is the best treatment for this patient?
. Start heparin now, and in 5-6 days stop heparin and start warfarin
. Start both heparin and warfarin now, and stop heparin in 1-2 days
. Start heparin and warfarin now, and stop heparin in 5-6 days
. Start heparin now and continue for 3-4 weeks
. Start warfarin now and continue for at least 6 months
A 56-year-old white male is being evaluated for having isolated IgG elevation. The level of serum IgG is 2400 (Normal is 700 to 1500), while the levels of the other paraproteins are within normal limits. The patient was previously admitted with a diagnosis of pneumonia, which resolved completely with levofloxacin. His other laboratory test results are as follows: Hemoglobin 13.0 g/dl, Serum Ca 8.0 mg/dl, BUN 18 mg/dl, Creatinine 1.1 mg/dl. Bone marrow biopsy reveals 2% of plasma lesions. What is the most appropriate next step in the management of this patient?
. Reassurance and regular follow-up
. Melphalan and prednisolone
Interferon
. Combination chemotherapy
. Autologus bone marrow transplantation
A 57-year-old female with a past medical history of bronchial asthma presents to the physician's office for evaluation of high blood pressure. On her previous two visits, her blood pressure has been 154/88 mmHg and 150/90 mmHg. Her blood pressure during this visit is 150/90 mmHg. She denies headaches and has no complaints. She uses fluticasone and albuterol inhalers for her chronic persistent asthma. She denies smoking or alcohol intake, and has no known drug allergies. Her family history is significant for myocardial infarction in both her mother and father. Exercise and a low salt diet have not improved her hypertension. Which of the following is the most appropriate next step in managing this patient's hypertension?
. Discontinue asthma medications
. Prescribe propranolol
. Prescribe enalapril
. Prescribe hydrochlorothiazide
. Obtain an echocardiogram
A 57-year-old G3P3 woman presents to her gynecologist with complaints of vaginal pruritus and increased vaginal discharge. The patient has no history of gynecologic surgery or sexually transmitted diseases; she is not currently sexually active. A bimanual examination and Pap smear are performed. The Pap smear is positive for malignant squamous cells. Follow up colposcopy shows no cervical lesions, but a small lesion is noted on the lower vagina. Biopsy of this lesion confirms the diagnosis of vaginal squamous cell cancer, while cross-sectional imaging excludes invasion of surrounding tissues. What is the most appropriate course of treatment?
Chemotherapy
Radiation therapy
Surgical excision
Surgical excision and chemotherapy
Surgical excision and radiation therapy
A 57-year-old male comes to your office in the middle of January. He complains of a 4-day history of a nonproductive cough and coryza. He also has vague muscle aches and a mild headache. He denies any shortness of breath or chest pain. His past medical history is significant for hyperlipidemia and impaired glucose tolerance. He takes aspirin and simvastatin 40 mg at bedtime. He has no known drug allergies. His medical records show that he did not show up for his scheduled annual influenza vaccine this year. His temperature is 38.5°C (101.3°F), blood pressure is 135/80 mm Hg, and pulse is 88/min. Physical examination shows conjunctival redness and an erythematous oropharynx. The tympanic membranes are clear. The heart sounds are audible with no added murmurs, rubs or gallops. His breath sounds are vesicular in quality and equal bilaterally. Which of the following is the most appropriate next step in management?
. Administer influenza vaccination now
. Write a prescription for amantidine
. Write a prescription for oseltamivir
. Advise bed rest and symptomatic treatment with acetaminophen
. Empiric trial of oral antibiotics
A 57-year-old man comes to the physician for a routine checkup. He complains of right-sided leg cramps accompanied by fatigue while walking. He also complains of occasional right thigh pain. He denies chest pain, syncope, nausea, and abdominal pain. His sexual performance has decreased over the past 1 year. His other medical problems include stage 3 chronic kidney disease, type 2 diabetes mellitus, hypertension, hyperlipidemia, gout, and gastroesophageal reflux disease. His blood pressure is 144/92 mm Hg, pulse is 67/min, and BMI is 29 kg/m2. Peripheral pulses are bilaterally palpable. There is a small ulcer at the base of the right great toe. The ankle-brachial index (ABI) is 1.0 (normal: 1.0 - 1.3). His laboratory values are significant for a serum creatinine level of 2.2 mg/dl and an HbA1c level of 7.5% but otherwise unremarkable. Which of the following is the most appropriate next step in managing this patient's leg pain?
. Aspirin, cilostazol, and verapamil
. CT angiography of the lower extremities
. Exercise testing with repeat ABI
. Tight glucose control and follow-up in 3 months
. Treatment for diabetic neuropathy
A 57-year-old man is undergoing a femoral-popliteal bypass of his right lower extremity because of severe peripheral vascular disease. This patient has a longstanding history of claudication and shortness of breath. He had a myocardial infarction 3 years ago and has had progressive limitation of his exercise capacity because of his peripheral vascular disease. He has not had any risk stratification after his infarction. Two weeks ago, he underwent a lower extremity arterial study that showed severe diffuse disease of his right leg arterial system. The patient is brought to the operating room, and, during the procedure, his right lower extremity is made bloodless by application of a thigh tourniquet for 1.5 hours. The surgeons complete their bypass and are preparing to restore blood flow. Which of the following is an expected consequence of this maneuver?
Decrease in blood pressure
Increase in cardiac output
Increase in preload
Increase in venous return
Sinus bradycardia
A 57-year-old man presents to the emergency department with worsening substernal chest pain occurring over the past 20 minutes. He has a medical history significant for a 2-packper- day smoking history, gout, obesity, hypercholesterolemia, hypertension, osteoarthritis of both knees, inflammatory bowel disease, and recently diagnosed type 2 diabetes mellitus that is well controlled on oral antiglycemics (haemoglobin A1c of 7.8%). On physical examination he is in moderate distress, diaphoretic, and nauseous. His temperature is 37.5°C (99.5°F), pulse is 112/min, blood pressure is 142/85 mmHg, and respiratory rate is 22/min. He tests positive for MI by serial cardiac enzymes. He is started on the appropriate therapy and is ready for discharge the following evening. What is the number one preventive measure this patient can take to decrease his immediate risk for a second MI?
Decrease the amount of cholesterol in his diet
Exercise three times a week
Lower his blood pressure to the 120/80 mm Hg range
Lower his blood sugar levels to achieve a hemoglobin A1c level < 7%
Quit smoking
A 57-year-old woman develops bony metastases 1 year after right modified radical mastectomy for breast cancer. The tumor was estrogen receptor-negative, progesterone receptor-negative and Her-2/neu positive. Which of the following agents is indicated for treatment of her metastatic disease?
. Antiestrogen (Tamoxifen)
. Selective estrogen receptor modulator (Raloxifene)
. Monoclonal antibody (Trastuzumab)
. Aromatase inhibitor (Anastrozole)
. 5-fluorouracil
A 57-year-old woman sees blood on the toilet paper. Her doctor notes the presence of an excoriated bleeding 2.8-cm mass at the anus. Biopsy confirms the clinical suspicion of anal cancer. In planning the management of a 2.8-cm epidermoid carcinoma of the anus, which of the following is the best initial management strategy?
. Abdominoperineal resection
. Wide local resection with bilateral inguinal node dissection
. Local radiation therapy
. Systemic chemotherapy
. Combined radiation therapy and chemotherapy
A 58-year-old man comes to the physician and complains of "problems with erection." He has recurrent and persistently painful erections. His other medical problems include ulcerative colitis, kidney stones, insomnia, depression, hypertension, drug-induced diabetes, obesity and hypercholesterolemia. He does not use tobacco, alcohol, or drugs. He takes prednisone, mesalamine, insulin, 6-mercaptopurine, simvastatin, glyburide, enalapril, trazodone, and fluoxetine. He has no known drug allergies. His vital signs are stable. The general physical examination is unremarkable. Avoidance of which of the following medications could have prevented his condition?
Fluoxetine
Trazodone
Enalapril
Glyburide
Simvastatin
A 58-year-old man is admitted to the coronary care unit for telemetric monitoring after an episode of bradycardia. While in the unit, he suddenly loses consciousness. His pulse is undetectable and his blood pressure drops to 40 mmHg. His airway is clear and patent, and he is still breathing on his own. An ECG shows electrical activity. Chest compressions are started and he is quickly given a bolus of intravenous sodium bicarbonate and atropine. When his tracing does not improve, the boluses are repeated twice, and finally his tracing returns to normal sinus rhythm. Moments later, when he regains consciousness, he complains of a dry mouth, blurred vision, and feeling flushed. What is the most appropriate next step in the management of this patient?
This patient has atropine toxicity and requires urgent administration of a cholinergic agonist
This patient has atropine toxicity and requires urgent administration of a muscarinic agonist
This patient has bicarbonate toxicity and requires urgent administration of calcium citrate
This patient is experiencing transient adverse effects of atropine and requires only supportive measures
This patient is experiencing transient adverse effects of bicarbonate and requires only supportive measures
A 58-year-old man is admitted to the intensive care unit with an exacerbation of his chronic obstructive pulmonary disease (COPD) and respiratory failure. After several hours on noninvasive ventilation the patient develops worsening respiratory distress and requires endotracheal intubation. Which of the following is a contraindication to the use of succinylcholine for rapid-sequence intubation?
Hyperkalemia
. COPD exacerbation
. Hepatic failure
. Hypokalemia
Hypercalcemia
A 58-year-old man is found to have high serum prostate–specific antigen (PSA) concentration with a normal prostate examination. A biopsy of the prostate confirms low-grade carcinoma. The patient wishes to avoid therapy involving any risk for impotence. Which of the following is the most appropriate management of this patient?
Observation
Chemotherapy
Prostatectomy
. Radiation therapy
. Hormonal therapy
A 58-year-old nurse with node-positive metastatic breast cancer comes to the office for her monthly follow-up visit. The tumor is estrogen receptor (ER) and progesterone receptor (PR) positive, and her whole body bone scan is positive for metastatic disease. She is being treated with systemic chemotherapy and hormonal therapy (Tamoxifen). She feels weak with vague muscle, joint, and bone pains. Physical examination reveals a hard, well-defined dominant mass in the left breast. Mucus membranes are moist. Laboratory studies show the following results. Sodium 145 mEq/dL, Potassium 3.9 mEq/dL, Chloride 103 mEq/dL, Bicarbonate 24 mEq/dL, Calcium 11.3 mg/dl, BUN 18 mg/dl, Creatinine 0.8 mg/dl, Glucose 146 mg/dl. Which of the following is the best next step in the management of her hypercalcemia?
. Corticosteroid therapy
. Zoledronic acid therapy
. Intravenous normal saline
. Furosemide therapy
. Intravenous mithramycin
A 58-year-old woman is seen for evaluation of a swelling in her right vulva. She has also noted pain in this area when walking and during coitus. At the time of pelvic examination, a mildly tender, fluctuant mass is noted just outside the introitus in the right vulva in the region of the Bartholin gland. Which of the following is the most appropriate treatment?
. Marsupialization
. Administration of antibiotics
. Surgical excision
. Incision and drainage
. Observation
A 58-year-old woman presents to the emergency department with severe headache and agitation. She describes her pain as right-sided and retro-orbital, and also reports blurred vision, constipation, and vomiting. Her medical history is significant for Parkinson's disease, hypothyroidism, hypertension and chronic hepatitis C. Work-up reveals that her current condition is medication-induced. Which of the following agents is most likely responsible?
Levodopa
Selegiline
. Bromocriptine
Trihexyphenidyl
Propranolol
A 58-year-old woman with multiple comorbidities and previous cardiac surgery is in a high-speed motor vehicle collision. She is intubated for airway protection. Because of hemodynamic instability, a central venous catheter is placed in the right subclavian vein. While the surgeon is securing the catheter, the cap becomes displaced and air enters the catheter. Suddenly, the patient becomes tachycardic and hypotensive. What is the best next maneuver?
. Decompression of the right chest with a needle in the second intercostal space
. Placement of a right chest tube
. Withdrawal of the central venous catheter several centimeters
. Placement of the patient in a left lateral decubitus Trendelenburg position
. Bilateral “clamshell” thoracotomy with aortic cross-clamping
A 59-year-old man presents to the emergency department (ED) complaining of new-onset chest pain that radiates to his left arm. He has a history of hypertension, hypercholesterolemia, and a 20-pack-year smoking history. His electrocardiogram (ECG) is remarkable for T-wave inversions in the lateral leads. Which of the following is the most appropriate next step in management?
. Give the patient two nitroglycerin tablets sublingually and observe if his chest pain resolves
. Place the patient on a cardiac monitor, administer oxygen, and give aspirin
. Call the cardiac catheterization laboratory for immediate percutaneous coronary intervention (PCI)
. Order a chest x-ray; administer aspirin, clopidogrel, and heparin
. Start a β-blocker immediately
1045) A 59-year-old man sustains blunt trauma in an automobile accident, resulting in multiple intra-abdominal injuries. Surgery for the repair of these injuries takes several hours and requires multiple blood transfusions and infusions of Ringer's lactate. Before all the operative steps are completed, the patient develops a significant coagulopathy, a core body temperature less than 34 C (93.2 F), and refractory acidosis. The anesthesiologists are administering fresh frozen plasma and platelet packs. Which of the following is the most appropriate next step in management for the surgeon?
. Provide hemostasis by liberal use of electrocoagulation
. Wash the abdomen with warm saline and continue to operate
. Complete the operation as soon as possible and do a formal abdominal closure
. Pack the bleeding surfaces and close the abdomen temporarily with towel clips
. Abort the operation and leave the abdomen open, covering the bowel with mesh
A 59-year-old man well known to his primary care physician presents complaining of excessive fatigue during the daytime. He is accompanied by his wife, who says that he wakes frequently during the night and snores loudly. She worries because sometimes it sounds like he is gasping for breath at night. The only finding on physical examination is morbid obesity. The diagnosis of obstructive sleep apnea is made. Which of the following is not true about this disorder?
. Hypertension is a frequent complication
. Weight loss may improve symptoms
. Apneic episodes may increase with age
. Cor pulmonale can develop as a complication
. Benzodiazepines are effective treatment
A 59-year-old white male comes to the office for the evaluation of a brief episode of right arm and leg weakness. The episode lasted for a few minutes, and was followed by a complete recovery. He had a similar episode one month ago. He has a 30 pack-year history of cigarette smoking. He has hypercholesterolemia, which is being treated with diet and exercise. His pulse is 76/min, regular, and blood pressure is 130/80 mmHg. His laboratory test results are: Hb 14.2 g/dl, WBC 7,000/cmm, Platelets 230,000/cmm, Blood Glucose 118 mg/dl, Serum Na 138 mEq/L, Serum K 4.5 mEq/L, BUN 16 mg/dl, Serum Creatinine 1.0 mg/dl. EKG shows normal sinus rhythm. CT scan of the head is unremarkable. MRI angiography of the head and neck fails to show any abnormality. Transesophageal echocardiography (TEE) is unremarkable. Which of the following is the most appropriate next step in management?
. Treatment with aspirin
. Treatment with heparin followed by warfarin
. Treatment with clopidogrel
. Treatment with combination of aspirin and dipyridamole
. Treatment with ticlopidine
A 59-year-old woman presents to the ED complaining of worsening lower abdominal pain over the previous 3 days. She describes feeling constipated recently and some burning when she urinates. Her BP is 135/75 mm Hg, HR is 89 beats per minute, temperature is 101.2°F, and her RR is 18 breaths per minute. Her abdomen is mildly distended, tender in the LLQ, and positive for rebound tenderness. CT scan is consistent with diverticulitis with a 7-cm abscess. Which of the following is the most appropriate management for this condition?
. Reserve the OR for emergent laparotomy
. Start treatment with ciprofloxacin and metronidazole and plan for CT-guided draining of the abscess
. Give an IV dose of ciprofloxacin and have the patient follow up with her primary physician
. Start treatment with ciprofloxacin and metronidazole and plan for an emergent barium enema
. Start treatment with ciprofloxacin and metronidazole and prepare for an emergent colonoscopy
1051) A 59-year-old woman undergoes an exploratory laparotomy for peritonitis and is found to have perforated diverticulitis. She undergoes a sigmoid resection with an end colostomy. She is administered a third-generation cephalosporin within 1 hour prior to the incision and the antibiotic is continued postoperatively. One week later, she develops an intra-abdominal abscess, which is percutaneously drained. Bacteroides fragilis is isolated from the cultures. Which of the following statements regarding her perioperative antibiotic regimen is most accurate?
. The preoperative dose of antibiotics should have been given closer to the time of incision.
. The patient should have received several doses of antibiotics prior to laparotomy.
. The patient should have received a first-generation cephalosporin.
. The patient did not have adequate gram-negative coverage.
. The patient did not have adequate anaerobic coverage.
A 6-month-old infant is brought to the clinic for the evaluation of sudden episodes of jerky movements of the neck, arms, and legs onto the trunk for past month. These episodes occur in clusters, last for a few minutes, and are often preceded by a cry. Her development has been normal. Her vital signs are normal. She is at 50th percentile for height, weight and head circumference. She has multiple small 1-2 cm oval irregular hypopigmented macules on her trunk and extremities. A head CT scan reveals cortical tubers in the cerebral cortex and multiple subependymal nodules in the lateral ventricles. Her EEG shows "hypsarrhythmia." What is the best medication for this patient's seizure?
Vigabatrin
ACTH
Ethosuximide
Carbamazepine
Phenobarbital
A 6-year-old boy presents to the emergency department with a painful, markedly swollen elbow. While ice-skating, he fell with his arm outstretched. Radiographs of the elbow demonstrate a displaced, supracondylar fracture of the humerus. On examination, there is pain on passive flexion at the wrist and a decreased radial pulse, with diminished capillary refill in the hand. Which of the following is the most appropriate management of this injury?
Admission to hospital for close observation, with immobilization of the elbow at 90 of flexion
Closed reduction with percutaneous pinning under general anesthesia
Open reduction and pinning under general anesthesia
Open reduction with pinning, and exploration of the brachial artery
Open reduction with pinning, exploration of the brachial artery, and decompression fasciotomy of the forearm fascial compartments
A 6-year-old, African-American boy presents with fever and pain in his extremities for the last several hours. The pain is unrelated to movement or posture. His pulse is 102/min, blood pressure is 110/70 mm Hg, temperature is 38°C (100.4°F), and respirations are 18/min. Physical examination reveals pallor, jaundice, and splenomegaly. Both lower legs are tender to palpation. Lab tests show the following: Hematocrit 20%, WBC count 13,000/micro-L, Platelet count 180,000/miro-L, Bilirubin 5.0 mg/dL, Direct bilirubin 1.2 mg/dL, Reticulocyte count 11%. Peripheral blood smear shows sickle shaped cells. Hemoglobin electrophoresis confirms the diagnosis of sickle cell anemia. After treating the child with analgesia, hydration, and oxygen therapy, the painful episode subsides. Which of the following measures should be employed to prevent aplastic crisis in this child?
. Supplementation with folic acid
. Supplementation with iron
. Vaccination against parvovirus
. Vaccination against pneumococcus
. Treatment with hydroxyurea
A 60-kg, 53-year-old man with no significant medical problems undergoes lysis of adhesions for a small-bowel obstruction. Postoperatively, he has high nasogastric output and low urine output. What is the most appropriate management of his fluids?
. Infusion of D5 0.45% normal saline at 100 mL/h
. Infusion of D5 0.9% normal saline at 100 mL/h
. Infusion of D5 lactated Ringer at 100 mL/h
. Replacement of nasogastric tube losses with lactated Ringer in addition to maintenance fluids
Replacement of nasogastric tube losses with 0.45% normal saline with 20 mEq/L of potassium chloride in addition to maintenance fluids
A 60-year-old male comes to the office due to edema of his face and ankles of two weeks duration. He denies any chest pain or breathlessness. He is a known diabetic for the past 15 years. His diabetes is being managed with exercise, dietary modification and glyburide. His glycosylated hemoglobin (HbA1C) level one month ago was 7.5%. His temperature is 37.0°C (98.6°F), pulse is 75/min, blood pressure is 146/87 mmHg, and respirations are 15/min. Examination is unremarkable, except for bilateral pitting edema around the ankles and periorbital edema. Lab results show: Serum sodium 140 mEq/L, Potassium 4.3 mEq/L, Bicarbonate 20 mEq/L, Blood glucose120 mg/dL, Blood urea nitrogen 37 mg/dL, Serum creatinine 24 mg/dL, Total cholesterol 300 mg/dl. EKG is normal. 24 hour urine collection shows 3.7 g protein/day. To alter the course of this patient's diabeticnephropathy, what is the most appropriate next step in management?
. Intensive glycemic control
. Intensive blood pressure control
. Very low protein diet
. Aggressive lipid management
. Aspirin therapy
A 60-year-old male patient is receiving aspirin, an angiotensin-converting enzyme inhibitor, nitrates, and a beta-blocker for chronic stable angina. He presents to the ER with an episode of more severe and long-lasting angina chest pain each day over the past 3 days. His ECG and cardiac enzymes are normal. Which of the following is the best course of action?
Admit the patient and add intravenous digoxin
Admit the patient and begin low-molecular-weight heparin
Admit the patient for thrombolytic therapy
Admit the patient for observation with no change in medication
Increase the doses of current medications and follow closely as an outpatient
A 60-year-old man is brought in by ambulance and is unable to speak. The EMS personnel tell you that a neighbor informed them he has had a stroke in the past. There are no family members present. His serum sodium is 118 mEq/L. Which of the following is the most helpful first step in the assessment of this patient’s hyponatremia?
. Order a chest x-ray
. Place a Foley catheter to measure 24-hour urine protein
. Clinical assessment of extracellular fluid volume status
. CT scan of head
. Serum AVP (arginine vasopressin) level
A 60-year-old man is brought to the ED complaining of generalized crampy abdominal pain that occurs in waves. He has been vomiting intermittently over the last 6 hours. His BP is 150/75 mm Hg, HR is 90 beats per minute, temperature is 99.8°F, and his RR is 16 breaths per minute. On abdominal examination you notice an old midline scar across the length of his abdomen that he states was from surgery after a gunshot wound as a teenager. The abdomen is distended with hyperactive bowel sounds and mild tenderness without rebound. An abdominal plain film confirms your diagnosis. Which of the following is the most appropriate next step in management?
. Begin fluid resuscitation, bowel decompression with a nasogastric tube, and request a surgical consult
. Begin fluid resuscitation, administer broad-spectrum antibiotics, and admit the patient to the medical service
. Begin fluid resuscitation, give the patient stool softener, and administer a rectal enema
. Begin fluid resuscitation, administer broad-spectrum antibiotics, and observe the patient for 24 hours
. Order an abdominal ultrasound, administer antiemetics, and provide pain relief
A 60-year-old man seeks medical attention because of recurrent urinary tract infections. The patient also reports a history of increasing difficulty in urination (decreased flow, straining, and hesitancy) over the last several months. A prostate-specific antigen (PSA) level is mildly elevated and a prostate biopsy proves benign. Which of the following is the most appropriate initial management of this patient with benign prostatic hyperplasia (BPH)?
. α-Adrenergic blocker
. 5-alpha reductase inhibitor
. α-Adrenergic blocker and 5-alpha reductase inhibitor
. Transurethral resection of the prostate (TURP)
. Open prostatectomy
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 file:///D:/DES_Entry_2016MCQs/3C_USMLE/C-4Management/4Manag... 227 of 334 12/21/2016 3:59 PM is the recommended treatment for stage A (superficial and submucosal) transitional cell carcinoma of the bladder?
. Topical (intravesicular) chemotherapy
. Radical cystectomy
. Radiation therapy
. Local excision and topical (intravesicular) chemotherapy
. Systemic chemotherapy
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?
. Surgical exploration
. Anti-staphylococcal antibiotics
. Culture the discharge
. Improve glycemic control
Observation
A 60-year-old man with a history of congestive heart failure presents to his physician. He has a 5-year history of excessive daytime sleepiness and snoring. He also admits to three drinks of alcohol per day. His temperature is 36.6°C (98.0°F), pulse is 85/min, blood pressure is 138/82 mmHg, respiratory rate is 14/min, and oxygen saturation is 99% on room air. His body mass index is 31 kg/m2. Physical examination is significant for macroglossia and a short neck. Polysomnography is performed and is significant for multiple nocturnal episodes of airflow cessation at the nose and mouth, despite evidence of continuing respiratory effort. Which of the following is the most effective management for this patient?
Avoidance of alcohol
Avoidance of supine posture
Nasal continuous positive airway pressure
Uvulopalatopharyngoplasty
Weight reduction
A 60-year-old man with known hepatitis C and a previous liver biopsy showing cirrhosis requests evaluation for possible liver transplantation. He has never received treatment for hepatitis C. Though previously a heavy user of alcohol, he has been abstinent for over 2 years. He has had 2 episodes of bleeding esophageal varices. He was hospitalized 6 months ago with acute hepatic encephalopathy. He has a 1 year history of ascites that has required repeated paracentesis despite treatment with diuretics. Medications are aldactone 100 mg daily and lactulose 30 cc 3 times daily. On examination he appears thin, with obvious scleral icterus, spider angiomas, palmar erythema, gynecomastia, a large amount ascites, and small testicles. There is no asterixis. Recent laboratory testing revealed the following: hemoglobin = 12.0 mg/dL (normal 13.5-15.0), MCV = 103 fL (normal 80-100), creatinine = 2.0 mg/dL (normal 0.7-1.2), bilirubin = 6.5 mg/dL (normal 0.1-1.2), AST = 25 U/L (normal < 40), ALT= 45 U/L (normal < 40), INR = 3.0 (normal 0.8-1.2). What is the next best step?
. Repeat liver biopsy
. Start treatment with interferon and ribavirin
. Refer the patient for hospice care
Continue to optimize medical treatment for his ascites and hepatic encephalopathy and tell the patient he is not eligible for liver transplantation because of his previous history of alcohol abuse
. Refer the patient to a liver transplantation center
A 60-year-old smoker is seen because of a 3-cm midline ulcerating mass that is visualized when he sticks out his tongue. Biopsy establishes that this is squamous cell carcinoma. Which of the following is the most appropriate treatment of his cancer?
. Radiation therapy alone
. Partial glossectomy
. Partial glossectomy and cervical lymph node sampling
. Partial glossectomy and bilateral neck dissections
. Partial glossectomy followed by chemoradiation
A 60-year-old woman with no previous medical problems undergoes a total colectomy with diverting ileostomy for a cecal perforation secondary to a sigmoid stricture. Postoperatively, she has 2 L of ileostomy output per day. Her heart rate is 110 beats per minute, her respiratory rate is 24 breaths per minute, and her oxygen saturation is 98% on 2-L nasal cannula (NC). Her hemoglobin levels have been stable postoperatively at 9.0 mg/dL. Her other laboratory values on postoperative day 6 are as follows:Na+: 128K+: 3.0Cl−: 102HCO3-: 20Which of the following statements is the best strategy for correcting her acid–base disorder?
. Her maintenance fluids should be changed to 0.9% normal saline with 20 mEq/L of potassium chloride.
. She should be intubated to correct her tachypnea and prevent respiratory alkalosis.
. She should be transfused 2 units of packed red blood cells.
. She should be treated with fluid replacement and stool-bulking agents.
. She should undergo immediate dialysis.
A 59-year-old patient with a 2-year history of metastatic breast cancer presents with the acute onset of severe low back pain. She underwent a radical mastectomy and lymphadenectomy 3 years ago. Four of seven nodes were positive at the time of her original diagnosis. One year ago she developed an asymptomatic metastasis to her right femur. On physical examination, she is in severe discomfort and finds movement extremely difficult. She has exquisite tenderness in the lumbar vertebral area, and any motion of her legs or lower back produces extreme pain. An emergent MRI reveals large lytic lesions in L3 and L4. Which of the following is the most appropriate next step in management?
Discuss her wishes regarding cardiopulmonary resuscitation (CPR)
Refer her to a pain management consultant
Prescribe bed rest with high-dose nonsteroidal anti-inflammatory drugs (NSAIDs)
Schedule her for radiation therapy to the lumbar spine
Schedule her for an emergency nuclear bone scan
{"name":"Management USMLE 8 (1001-1047)", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"A 56-year-old morbidly obese man twisted his ankle five days ago and has been bed-ridden since. Today he presents to the emergency department with acute-onset shortness of breath and chest tightness. His past medical history is significant for diabetes mellitus, hypertension, right knee osteoarthritis, and a deep venous thrombosis. His current medications are lisinopril, metoprolol, and metformin. His blood pressure is 110\/60 mmHg and his heart rate is 110\/min. A CT scan of the chest with contrast is consistent with pulmonary thromboembolism. Which of the following is the best treatment for this patient?, A 56-year-old white male is being evaluated for having isolated IgG elevation. The level of serum IgG is 2400 (Normal is 700 to 1500), while the levels of the other paraproteins are within normal limits. The patient was previously admitted with a diagnosis of pneumonia, which resolved completely with levofloxacin. His other laboratory test results are as follows: Hemoglobin 13.0 g\/dl, Serum Ca 8.0 mg\/dl, BUN 18 mg\/dl, Creatinine 1.1 mg\/dl. Bone marrow biopsy reveals 2% of plasma lesions. What is the most appropriate next step in the management of this patient?, A 57-year-old female with a past medical history of bronchial asthma presents to the physician's office for evaluation of high blood pressure. On her previous two visits, her blood pressure has been 154\/88 mmHg and 150\/90 mmHg. Her blood pressure during this visit is 150\/90 mmHg. She denies headaches and has no complaints. She uses fluticasone and albuterol inhalers for her chronic persistent asthma. She denies smoking or alcohol intake, and has no known drug allergies. Her family history is significant for myocardial infarction in both her mother and father. Exercise and a low salt diet have not improved her hypertension. Which of the following is the most appropriate next step in managing this patient's hypertension?","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
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