DES C_Management (6) Prepared : CHILLY

A 34-year-old man presents with substernal discomfort. The symptoms are worse after meals, particularly a heavy evening meal, and are sometimes associated with hot/sour fluid in the back of the throat and nocturnal awakening. The patient denies difficulty swallowing, pain on swallowing, or weight loss. The symptoms have been present for 6 weeks; the patient has gained 20 lb in the past 2 years. Which of the following is the most appropriate initial approach?

A 34-year-old obese female returns to the physician's office for a follow-up appointment at 16 weeks gestation. She was diagnosed with gestational diabetes at 12 weeks gestation and since then has been following dietary recommendations. She eats a balanced diabetic diet three times a day and avoids snacks. Her fasting blood sugars for the past two weeks have been in between 120 to 150 mg/dl. Her temperature is 37.0C (98.7F), blood pressure is 130/88 mmHg, pulse is 76/min and respirations are 14/min. Physical examination is unremarkable. Which of the following is the most appropriate therapy for this patient?

A 34-year-old primigravid woman at 30 weeks' gestation comes to the physician with regular contractions every 6 minutes. Her prenatal course was significant for type 1 diabetes, which she has had for 10 years. Over the course of 1 hour, she continues to contract, and her cervix advances from closed and long to a fingertip of dilation with some effacement. The patient is started on magnesium sulfate, penicillin, and betamethasone. Which of the following is the most likely side effect from the administration of corticosteroids to this patient?

A 34-year-old unrestrained male driver is brought to the ER after a motor vehicle accident. His cervical spine is immobilized. He is stuporous. At the scene of the accident, his blood pressure is 70/30 mm Hg and heart rate is 130/min. Lungs are clear to auscultation. Abdominal wall ecchymosis is present. Abdomen is mildly distended. Bowel sounds are decreased. Neck veins are collapsed. After two liters of intravenous fluids, his blood pressure is 80/40 mmHg. A focused assessment with sonography for trauma shows blood in the peritoneal cavity but no obvious solid organ injury. Which of the following is the most appropriate next step in management?

A 34-year-old woman comes the physician because of lower abdominal cramping. The cramping started 2 days ago. Examination is unremarkable except for a pelvic examination that reveals a 10-week sized uterus. Urine hCG is positive, and pelvic ultrasound reveals a 10-week intrauterine pregnancy with a fetal heart rate of 160. The patient states that she is not sure whether to keep the pregnancy. Which of the following is the most appropriate next step in management?

A 34-year-old woman comes to the physician for infertility evaluation. Her cycles have been irregular for the past 12 months and she has had no periods for the past 3 months. Before that time, her cycles were quite regular. She also has hot flashes, dyspareunia, and mood disturbances. She has been married for 6 years and has a 3-year-old daughter. The patient has a history of Hashimoto's thyroiditis and is on thyroid replacement therapy. She smokes a pack of cigarettes a day. Both her father and mother have type 2 diabetes mellitus. Vital signs are normal. Pelvic examination reveals atrophic vaginal mucosa. Serum FSH is markedly elevated, serum prolactin is normal, and pregnancy test is negative. Serum TSH is within normal limits. Which of the following is the most appropriate treatment for her infertility?

A 34-year-old woman complains bitterly of heartburn. Physical examination reveals healing lesions of the fingertips that she says were small ulcers, and there are small areas of telangiectasias on her face. Esophageal manometry reveals a decrease in the expected amplitude of smooth muscle contraction. Lower esophageal sphincter tone is subnormal, but relaxes normally with swallowing. Which of the following statements regarding this condition is most likely correct?

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?

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?

A 34-year-old woman presents to the physician's office for infertility evaluation. Her cycles have been irregular for the past 12 months and she hasn't had any periods for the past 3 months. Previously, her cycles were quite regular. She also has hot flashes, dyspareunia and mood disturbances. She has been married for 6 years and has a three-year-old daughter. She has a history of Hashimoto thyroiditis and is on thyroid replacement therapy. She smokes one pack of cigarettes daily. Vital signs are normal. Pelvic examination reveals atrophic vaginal mucosa. Serum FSH is markedly elevated, and serum prolactin is normal. Serum TSH is within normal limits. Which of the following is the most appropriate treatment for her infertility?

A 34-year-old woman presents to your office complaining of several months of chest pain. She says that the pain is left-sided, does not change with deep inspiration, and typically lasts several hours. The pain has no relation to physical activity, but worsens with emotional stress. The patient has no significant family history, and does not use tobacco, alcohol or drugs. She takes no medications and has no drug allergies. On exam, her blood pressure is 110/70 mmHg and her heart rate is 78/min. ECG is normal. Which of the following is the best next step in her management?

A 34-year-old woman, gravida 3, para 2, at 16 weeks' gestation comes to the physician concerned that she may have been exposed to an infectious disease. Yesterday, she and her 5-year-old son spent a day at the beach with one of his classmates. This morning, the classmate was sent home from school with a fever and rash that the teacher thought, were suspicious for chickenpox. The patient is unsure whether she had chickenpox as a child. Her temperature is 37 C (98.6 F), blood pressure is 100/70 mm Hg, pulse is 88/min, and respirations are 16/min. Her examination is unremarkable. An inquiry made by the physician confirms that the classmate has chickenpox. Which of the following is the most appropriate next step in management?

A 34-year-old woman, gravida 4, para 3, at 32 weeks gestation is brought to the emergency department because of vaginal bleeding. Her prenatal course, prenatal tests and fetal growth have been normal. Prenatal ultrasound at the 12th week showed an intrauterine gestation consistent with dates. Her temperature is 37.0C (98.7 F), blood pressure is 90/70 mm of Hg, pulse is 98/min and respirations are 18/min. Physical examination shows continuous bright red vaginal bleeding. Ultrasonogram in the emergency department shows complete placenta previa. Fetal heart tracing shows repetitive late decelerations. The patient's vital signs are stabilized with fluids, but the bleeding continues. Which of the following is the most appropriate next step in management?

A 35-year old male presents to your office complaining of nocturnal wheezing and chest tightness for the past three months. He has also noticed new hoarseness, particularly in the morning. He has no history of bronchial asthma, hypertension or diabetes. He is a non-smoker but occasionally drinks alcohol. On examination, he is an obese male in no acute distress. His pulse is 84/min, blood pressure is 130/80 mmHg, and respirations are 16/min. His chest is clear to auscultation and percussion. Laryngoscopy reveals a red and inflamed posterior pharynx and larynx. Which of the following pharmacotherapies would be most helpful for this patient?

A 34-year-old woman with breast cancer presents to her physician complaining of increased weakness, lower back pain, and urinary incontinence. She was diagnosed with breast cancer 2 years ago and is undergoing radiation and chemotherapy. Her back pain developed 2 days ago. Physical examination shows lower extremity weakness and hyporeflexia. Which of the following is the most appropriate next step in this patient's care?

A 35-year-old Caucasian female is hospitalized with swelling and tenderness of her right calf. Deep venous thrombosis is diagnosed through imaging studies, and the appropriate therapy is initiated. Three days later, she complains of right arm pain. Physical examination reveals a cold right upper extremity with no palpable peripheral pulse. Her laboratory values are listed below: Hematocrit 42%, WBC count 8,500/mm3, Platelets 76,000/mm3, PT 13 sec, aPTT 63 sec. Which of the following drugs was most likely used to treat this patient's deep venous thrombosis?

A 35-year-old Caucasian male with a chronic history of paranoid schizophrenia presents to the mental health clinic. He strongly believes that his wife recently stole his pill bottle of risperidone, which he feels caused him to start experiencing more frequent and intense auditory hallucinations. He says that the "voices" tell him to kill his wife because she cannot be trusted. He admits to having homicidal thoughts about his wife but denies any specific plan for harming her. He requests a refill of his risperidone. What is the most appropriate next step?

A 35-year-old female complains of nipple discharge. The discharge is from both breasts, brown in color and occurs intermittently. She has two children who are 5 and 8 years old. She has not been recently pregnant. Her last menstrual period was one week ago. She describes no other symptoms. Examination shows normal breasts without palpable lumps or nipple abnormalities. Brownish discharge is expressed from the nipples, and it is guaiac negative. Which of the following is the most appropriate next step in management?

A 35-year-old female presents to the emergency department with a 30-minute history of severe headache, palpitations, abdominal pain, nausea, and vomiting. She had similar episodes twice during the last month, but those were not so severe and resolved spontaneously in 30-40 minutes. She visited a doctor recently, and hypertension with elevated urinary vanillylmandelic acid level was diagnosed. She is not taking any medications, and denies substance abuse. Her blood pressure is 200/130 mmHg and heart rate is 130/min. She appears frightened. Physical examination reveals hand tremors and excessive sweating. Slow intravenous infusion of propranolol is started while waiting for the routine labs. What is the most probable reaction to the treatment given to the patient?

A 35-year-old G1 PO woman at 35 weeks gestation by last menstrual period and confirmed by a first trimester ultrasound comes to the hospital because of leakage of fluid one hour ago. She received her prenatal care at an outside hospital and the records are not available. She reports no other complications with this pregnancy thus far. She reports no medical problems, takes no daily medications other than a prenatal vitamin, and has no allergies to medications. She is examined and preterm premature rupture of membranes is confirmed by a positive nitrazine test, positive pooling test, and a positive ferning test. She is 2 cm dilated, 50% effaced, and at -2 station. She is admitted to the hospital. Transabdominal ultrasound confirms that the fetus is in a vertex presentation, and the amniotic fluid index is decreased at 3 cm. Fetal heart rate and contraction monitoring is started, and occasional uterine contractions are noted on the monitor. Which of the following is the most appropriate next step in management?

A 35-year-old G3P3 presents to your office 3 weeks after an uncomplicated vaginal delivery. She has been successfully breast-feeding. She complains of chills and a fever to 38.3C (101F) at home. She states that she feels like she has flu, but denies any sick contacts. She has no medical problems or prior surgeries. The patient denies any medicine allergies. On examination she has a low-grade temperature of 38C (100.4F) and generally appears in no distress. Head, ear, throat, lung, cardiac, abdominal, and pelvic examinations are within normal limits. A triangular area of erythema is located in the upper outer quadrant of the left breast. The area is tender to palpation. No masses are felt and no axillary lymphadenopathy is noted. Which of the following is the best option for treatment of this patient?

A 35-year-old G3P3 with a Pap smear showing high-grade squamous intraepithelial lesion of the cervix (CIN III) has an inadequate colposcopy. Cone biopsy of the cervix shows squamous cell cancer that has invaded only 1 mm beyond the basement membrane. There are no confluent tongues of tumor, and there is no evidence of lymphatic or vascular invasion. The margins of the cone biopsy specimen are free of disease. The patient above now asks you for your advice on how to treat her cervical disease. Your best recommendation is for the patient to undergo which of the following?

A 35-year-old G3P3 woman has been experiencing bilateral breast pain for the past year. Breast examination and mammography are normal. Conservative measures have failed. Which of the following medications is most likely to bring relief?

A 35-year-old Hispanic male comes to the office because of excruciating pain during defecation for the past week. The pain is so severe that he avoids using the toilet. He also adds that he has noticed bright red blood in his stool. The caliber of his stool has not changed. His past medical history is significant for chronic constipation. Rectal examination shows a posterior mucosal tear of the anus. Which of the following is the most appropriate next step in management?

A 35-year-old HIV-positive male comes to the physician's office because of pain on swallowing and substernal burning for the last 3 days. Examination of the oral cavity is unremarkable. Lungs are clear to auscultation and percussion. His current medications include zidovudine, didanosine, indinavir, trimethoprim-sulfamethoxazole, and azithromycin. His last CD4 count is 40cells/microl. What is the most appropriate next step in the management of this patient?

A 35-year-old male was involved in a motor vehicle injury and suffered serious chest trauma. A chest tube was placed for a hemothorax. 800 cc of blood was evacuated from the chest, and, after ten days, the patient was discharged home. He returns again with a low-grade fever and dyspnea. CT scan reveals a complex loculated effusion with a thick surrounding peel. A chest tube is placed; however, after 24 hours, there is little drainage, and the patient continues to have a low-grade fever. What is the next step in his management?

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

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?

A 35-year-old man presents to your office with severe back pain. The pain started three days ago when the patient was carrying a heavy pack. The pain radiates to the posterior surface of the right thigh. The straightleg raise test is positive. There is no bladder or bowel incontinence. Pain and temperature perception is preserved in the affected extremity, as well as in the perineal area. Anal reflex is normal. Which of the following is the best next step in the management of this patient?

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

A 35-year-old man with new diagnosis of Crohn disease presents with rapidly enlarging painful ulcerations on the lower extremities. Cultures of the lesion are negative, and skin biopsy reveals no evidence of malignancy. Which of the following is the most appropriate treatment option?

A 35-year-old white female presents with pain and stiffness of her wrist and hand joints for the last several months. Her morning stiffness lasts for more than an hour. She also complains of redness and joint swelling. Her past medical history is significant only for a similar episode one year ago. That episode resolved with over the counter ibuprofen. Examination of her joints shows redness, warmth, swelling and tenderness of proximal interphalangeal joints, metacarpophalangeal joints and wrists. X-ray shows periarticular osteopenia and erosions of the proximal interphalangeal and metacarpophalangeal joints. She started taking indomethacin with good relief. Which of the following is the most appropriate next step in the management of this patient?

A 35-year-old woman complains of aching all over. She says she sleeps poorly and all her muscles and joints hurt. Her symptoms have progressed over several years. She reports she is desperate because pain and weakness often cause her to drop things. Physical examination shows multiple points of tenderness over the neck, shoulders, elbows, and wrists. There is no joint swelling or deformity. A complete blood count and erythrocyte sedimentation rate are normal. Rheumatoid factor is negative. Which of the following is the best therapeutic option in this patient?

A 35-year-old woman has chronic auditory hallucinations in which she hears her father's voice. His voice said encouraging things to her in the past, but it has recently been scolding her and saying derogatory things about her. The woman is started on risperidone, and she returns two weeks later for a follow-up visit. Although she states that the hallucinations are much better, you notice that she is walking much slower than usual and is not swinging her arms. Also, the patient's facial expressions are rather flat and unchanging, and she admits that her writing has become smaller since starting the medication. Which of the following pharmacologic changes would be most appropriate?

A 35-year-old woman has dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, cough, and hemoptysis. The symptoms have been slowly progressive for about 5 years. She looks thin and cachectic, and has atrial fibrillation and a low-pitched, rumbling diastolic apical heart murmur. At age 15, she had rheumatic fever. Surgery has been recommended. Which of the following is the most appropriate management?

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?

A 35-year-old woman is being evaluated for a breast mass. She had a bilateral reduction mammoplasty for mammary hyperplasia 12 years ago. She has no family history of cancer. Breast examination shows a slightly retracted right nipple. A fixed mass is palpated in the upper outer quadrant of the right breast. Mammogram shows a 3 x 3 cm spiculated mass with coarse calcifications in the upper outer quadrant of the right breast. Ultrasonogram of the breast shows a hypoechoic mass. Multiple core biopsy samples show foamy macrophages and fat globules. Which of the following is the most appropriate course of action?

A 35-year-old woman is brought to the emergency department after being rescued from a burning home by firefighters. She is confused, agitated and tachypneic. Her temperature is 37C (98.6F), blood pressure is 100/60 mm Hg, pulse is 130/min and respirations are 24/min. Physical examination shows no burns and her skin color is normal. Auscultation shows normal bilateral air entry with scattered wheezes. Neurological examination shows no abnormalities except some confusion. Abdominal examination shows a soft abdomen; bowel sounds are present. Which of the following is the best immediate treatment for her acute confusional state?

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

A 35-year-old woman is seeing a psychiatrist for treatment of her major depression. After 4 weeks on fluoxetine at 40 mg/day, her psychiatrist decides to try augmentation. Which of the following is the most appropriate medication?

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

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

A 35-year-old woman presents with a lump in the left breast. Her family history is negative for breast cancer. On examination the mass is rubbery, mobile, and nontender to palpation. There are no overlying skin changes and the axilla is negative for lymphadenopathy. An ultrasound demonstrates a simple 1-cm cyst in the area of the palpable mass in the left breast. Which of the following represents the most appropriate management of this patient?

A 35-year-old woman presents with a right breast mass. You perform a thorough history and physical examination as well as a core biopsy of the right breast mass. In which of the following circumstances would a sentinel lymph node biopsy be indicated?

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

A 35-year-old woman, gravida 3, para 2, at 39 weeks' gestation, comes to the labor and delivery ward with contractions. Past obstetric history is significant for two normal spontaneous vaginal deliveries at term. Examination shows the cervix to be 4 centimeters dilated and 50% effaced. The patient is contracting every 4 minutes. Over the next 2 hours the patient progresses to 5-centimeters dilation. An epidural is placed. Artificial rupture of membranes is performed, demonstrating copious clear fluid. 2 hours later the patient is still at 5centimeters dilation and the contractions have spaced out to every 10 minutes. Which of the following is the most appropriate next step in management?

A 35-year-old woman, gravida 4, para 3, at 38 weeks' gestation comes to the labor and delivery ward after a gush of clear fluid from the vagina. After the gush, she has had increasing contractions. Sterile speculum examination shows a pool of clear fluid in the vagina that is nitrazine positive. Cervical examination shows that the patient is 5 cm dilated, with the fetal face presenting in a mentum anterior position. External uterine monitoring shows that the patient is contracting every 2 minutes, and external fetal monitoring shows that the fetal heart rate is in the 140s and reactive. Which of the following is the most appropriate next step in management?

A 36-year-old G1P1 comes to see you for a routine postpartum examination 6 weeks after an uncomplicated vaginal delivery. She is currently nursing her baby without any major problems and wants to continue to do so for at least 9 months. She is ready to resume sexual activity and wants to know what her options are for birth control. She does not have any medical problems. She is a nonsmoker and is not taking any medications except for her prenatal vitamins. Which of the following methods may decrease her milk supply?

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?

A 36-year-old male comes to your office complaining of progressive fatigability. His past medical history is significant for infiltrative pulmonary tuberculosis diagnosed two months ago. His current treatment includes isoniazid, rifampin, ethambutol, and pyrazinamide. Laboratory values are: Hemoglobin 8 g/dl, MCV 77 fl, MCHC 30%, ESR 17 mm/hr, Serum iron 170 micro-g/dl (N 50- 150 micro-g/dl ), Total iron binding capacity (TIBC) 280 micro-g/dl (N 300-360 micro-g/dl). Microscopy reveals two populations of red blood cells (RBC)-hypochromic and normochromic. What is the next best step in the management of this patient?

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?

A 36-year-old man presents for a well-patient examination. He gives a history that, over the past 20 years, he has had three episodes of abdominal pain and hematemesis, the most recent of which occurred several years ago. He was told that an ulcer was seen on a barium upper GI radiograph. You obtain a serum assay for H pylori IgG, which is positive. What is the most effective regimen to eradicate this organism?

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?

A 36-year-old woman comes to your office complaining of a 12-month history of inter-menstrual bleeding and heavy menses. She has had type-2 diabetes for the past 4-years, managed with glipizide and metformin. She has no family history of gynecological malignancies. She does not use tobacco or alcohol. Her temperature is 37.2 C (98.9 F), and blood pressure is 126/76 mm Hg. Her BMI is 30 Kg/m2. Physical examination shows pale mucus membranes. Pelvic examination is within normal limits; no vaginal lesions are noted. Urine pregnancy test is negative. Her hemoglobin is 10.8 g/dl and platelet count is 223,000/mm3. Coagulation studies are within normal limits. Which of the following is the most appropriate next step in management?

A 36-year-old woman presents to the emergency room complaining of pelvic pain, fever, and vaginal discharge. She has had nausea and vomiting and cannot tolerate liquids at the time of her initial evaluation. The emergency room physician diagnoses her with pelvic inflammatory disease and asks you to admit her for treatment. Which of the following is the most appropriate initial antibiotic treatment regimen for this patient?

A 36-year-old woman presents to your office for contraception. She has had three vaginal deliveries without complications. Her medical history is significant for hypertension, well-controlled with a diuretic, and a seizure disorder. Her last seizure was 12 years ago. Currently she does not take any antiepileptic medications. She also complains of stress-related headaches that are relieved with an over-the-counter pain medication. She denies any history of surgeries. She is divorced, smokes one pack of cigarettes per day, and has three to four alcoholic drinks per week. On examination, her vital signs include weight 90 kg, blood pressure 126/80 mmHg, pulse 68 beats per minute, respiratory rate 16 breaths per minute, and temperature 36.4C (97.6F). Her examination is normal except for some lower extremity nontender varicosities. She has taken birth control pills in the past and wants to restart them because they help with her cramps. Which of the following would contradict the use of combination oral contraceptive pills in this patient?

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

A 36-year-old woman who lives in the suburbs of a large city comes to your office for a tuberculin skin test. She will be volunteering in her daughter's school cafeteria and the school district requires tuberculin testing. You inject a small amount of Mycobacterium tuberculosis purified protein derivative (PPD) in the skin and 2 days later she returns for a reading. You measure 12 mm of induration. She reports no history of tuberculosis exposure and no underlying medical conditions. She has never before been tested for tuberculosis. She was born in the United States, is not a healthcare worker, and has never spent time in prison. What is the best next step in her management?

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

A 36-year-old woman, gravida 2, para 1, at 16 weeks' gestation undergoes amniocentesis for evaluation of Down syndrome. She has no past medical history. Immediately after the procedure she becomes breathless, cyanotic and loses consciousness. Minutes later, she experiences a generalized tonic-clonic seizure. A generalized purpuric rash is noted. Her blood pressure is 90/50 mm Hg, pulse is 110/min, and respirations are 26/min. Oxygen saturation is 75% on 100% facemask. Which of the following is the most appropriate next step in management?

A 36-year-old woman, gravida 3, para 3, is 2 days status post cesarean section for dystocia when she begins wandering the hallways of the hospital at 2 AM. She is extremely confused and thinks that she is at the police station. She states that she cannot sleep, feels very anxious, and wants to hurt her baby. Her prenatal course was unremarkable. She has no medical problems and had never had surgery. She has been taking Tylenol with codeine postpartum for incisional pain. Which of the following is the most appropriate next step in the management?

A 37-year-old healthy Caucasian male is seen in your office for a routine physical examination. He denies any symptoms or illness. He says he smokes a pack a day and drinks one to two beers every weekend. He has no allergies. Examination is unremarkable. The EKG reveals normal sinus rhythm with a heart rate of 72; there are frequent premature atrial beats present. The blood pressure is 120/65mm Hg. The next step in his management is:

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 anteroposterior 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?

A 37-year-old man comes to his primary care physician for the evaluation of slightly pruritic skin lesions around his anus. He denies fever, malaise, and anorexia. He is sexually active with multiple male partners and occasionally uses condoms. He has never been tested for HIV or other sexually transmitted diseases. He has no drug allergies. Examination shows skin-colored, verrucous, papilliform lesions around his anus. Which of the following is the most appropriate treatment for this patient?

A 37-year-old obese man returns to his doctor for a follow-up visit. One month ago, he was diagnosed with type II diabetes mellitus and was started on metformin. His fasting glucose is 122 mg/dl, and his blood pressure is 145/85 mm Hg. The patient looks rather dejected and admits it has been difficult to come to terms with his diagnosis. He has tried to exercise, watch his diet, and quit smoking as was suggested, but lately he has been feeling unmotivated and without energy. He admits to feeling sad and guilty about his weight, but is not sure he will be able to do anything about it. He continues to smoke despite attempts to cut back, and has been spending much of the day in bed watching television or sleeping. He has withdrawn from friends and family and took the last two weeks off from work, as he did not feel "up to going." Which of the following would be the best medication to prescribe at this time?

A 37-year-old obese, hypertensive female comes to the physician because of intermenstrual bleeding and heavy menses. Endometrial biopsy shows "complex hyperplasia without atypia." She has two young healthy children and does not want more children in the future. W hich of the following is the most appropriate next step in management?

A 37-year-old woman comes to the physician because of intermenstrual bleeding and heavy menses. Her other medical problems include hypertension, type 2 diabetes, and hyperlipidemia. Her blood pressure is 144/86 mm Hg. Her BMI is 40 kg/m2. Physical examination shows no obvious abnormalities. Endometrial biopsy shows "complex hyperplasia without atypia." She has three young healthy children and does not want more children in the future. Which of the following is the most appropriate next step in management?

A 37-year-old woman comes to the physician's office because of left breast discomfort. The discomfort has been there for several months, and she recently started having breast pain before menses. Yesterday she noticed a lump in her breast. She has no family history of breast cancer. She smokes one pack of cigarettes every day. She had a baseline mammogram at age 35, which showed no abnormalities. Examination shows a smooth, soft, mobile mass palpable in the upper outer quadrant of the left breast; some diffuse nodularity is present bilaterally. Vital signs are normal. Physical examination otherwise shows no abnormalities. Fine needle aspiration of the mass shows thin greenish, non-bloody fluid; the mass disappears completely after the aspiration. Which of the following is the most appropriate next step in management?

A 37-year-old woman has developed a 6-cm mass on her anterior thigh over the past 10 months. The mass appears to be fixed to the underlying muscle, but the overlying skin is movable. Which of the following is the most appropriate next step in her management?

A 37-year-old woman presents to your office with severe vertigo, postural instability, and vomiting. She also complains of "a buzzing sound" in her right ear. She has had two similar episodes over the previous year that lasted several hours and resolved spontaneously. She has no other medical problems. Her mother died of breast cancer at 55 years of age and her father is currently suffering from colon cancer. Her heart rate is 90/min and blood pressure is 130/80 mmHg. Her BMI is 25.3 kg/m2. Examination reveals horizontal nystagmus. Which of the following could have prevented this patient's symptoms?

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?

A 37-year-old woman, gravida 3, para 2, comes to her physician for follow-up on her ectopic pregnancy. She was diagnosed with an ectopic pregnancy 7 days ago and given methotrexate. She now presents with abdominal pain that started this morning. Examination is significant for moderate left lower quadrant tenderness. Laboratory analysis shows that her beta-hCG value has doubled over the past week. Transvaginal ultrasound shows that the ectopic pregnancy is roughly the same size but there is an increased amount of fluid in the pelvis. Which of the following is the most appropriate next step in management?

A 38-year-old woman comes to the physician for an annual examination and Pap smear. She has no complaints. She has a regular period every month. She is sexually active with her husband. She has migraine headaches and is status post a tubal ligation. She states that she uses numerous alternative medications for mood, sleep, and disease prevention. Examination, including pelvic and breast examination, is unremarkable. Which of the following is an appropriate question to ask this patient?

A 38-year-old woman complains of chronic aching pain and stiffness around the neck, shoulders, low back and hips. She fatigues easily and has been having problems with sleep. Even minor exertion worsens her pain. She has no muscle weakness, fever, malaise, weight loss or rash. She has a history of irritable bowel syndrome. Her vital signs are within normal limits. Examination shows multiple tender spots over specific points on her body. Power is 5/5 in all extremities and deep tendon reflexes are 2+. No sensory abnormalities are noted. Labs show: ESR 9 mm/hr, Hematocrit 43%, WBC count 7,000/microL, Platelet count 200,000/microL, TSH 3 microU/L, CPK 100 IU/L. Which of the following is the most appropriate pharmacotherapy for this patient?

A 38-year-old woman is 10 weeks pregnant with her second pregnancy and is found to have blood pressures exceeding the 150 to 160 mm Hg systolic range and 100 to 110mm Hg diastolic range at her first prenatal visit. She has no other medical problems. She had a cholecystectomy at the age of 20. She takes no medications and is allergic to sulfa drugs. Her family history is significant for hypertension on both her maternal and paternal sides. Physical examination is normal, including an obstetrical ultrasound demonstrating a 10-week intrauterine pregnancy. The patient is diagnosed with chronic hypertension. Which of the following should be used as first-line antihypertensive therapy for this patient?

A 38-year-old woman presents to your office complaining of urinary incontinence. Her symptoms are suggestive of urge incontinence. She admits to drinking several large glasses of iced tea and water on a daily basis because her mother always told her to drink lots of liquids to lower her risk of bladder infections. Urinalysis and urine culture are negative. After confirming the diagnosis with physical examination and office cystometrics, which of the following treatments should you recommend to the patient as the next step in the management of her problem?

A 38-year-old woman presents with several months of decreased libido and a 4.5-kg (10-lb) weight gain. She has not had her menstrual period for the past 3 months. Physical examination is unremarkable except that a small amount of white discharge is manually expressed from the nipples bilaterally. The serum prolactin level is 300 ng/mL. Which of the following is the most appropriate first-line treatment?

A 38-year-old woman, gravida 1, para 0, at 8 weeks' gestation comes to the physician for a prenatal visit. She has had no bleeding from the vagina or abdominal pain and no complaints. She has a long history of migraine headache and recently developed peptic ulcer disease (PUD). Examination shows a nontender 8-week sized uterus but is otherwise unremarkable. The patient is very concerned that her migraine headaches and peptic ulcer disease will make her pregnancy intolerable. Which of the following is the most appropriate response?

A 38-year-old woman, gravida 2, para 1, at 10 weeks gestation comes to the physician's office for prenatal counseling of genetic disorders. She has a healthy 3-year-old child. Given her age, she is worried about the risk of Down syndrome, and if her baby test is positive for Down syndrome she would like to terminate the pregnancy. Ultrasonogram shows increased fetal nuchal fold lucency. Which of the following is the most appropriate next step in management?

A 34-year-old man is traveling in Southeast Asia on business. He is staying in Western-style hotels and eating food in large restaurants. He has not eaten from street vendors. One week after arrival, he develops symptoms of anorexia, nausea, and abdominal cramps followed by the sudden onset of watery diarrhea. He has no fever or chills and there is no blood or pus in the stools. Which of the following is the most appropriate therapy for his condition?