USMLE_Management XI

A medical professional studying for the USMLE, surrounded by textbooks, a laptop, and clinical scenarios on a whiteboard in a bright, modern study environment.

USMLE Management Quiz

Test your medical knowledge with our USMLE Management Quiz! This quiz covers essential management strategies for various clinical scenarios, designed specifically for medical professionals and students preparing for the USMLE. Challenge yourself to see how well you understand the best treatment options for complex cases.

  • 56 questions on various clinical scenarios
  • Multiple choice format to test your critical thinking
  • Designed for medical students, residents, and practicing physicians
100 Questions25 MinutesCreated by DiagnosingDoctor452
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 56-year-old white male presents to his primary care physician for follow-up evaluation of high blood pressure noted on each of three prior visits over a period of 6 months (systolic blood pressure ranging 140-145, diastolic blood pressure ranging 90-96 mmHg). He has smoked a pack of cigarettes per day for the past 20 years and takes 5-6 drinks of alcohol daily. He has no other medical problems and takes no medications. There is no family history of diabetes mellitus, coronary artery disease, hyperlipidemia or hypertension. On physical examination today, his blood pressure is 146/97 mmHg and pulse is 80/min. The remainder of the exam is unremarkable. Which of the following nonpharmacologic interventions would be expected to have the greatest impact on his high blood pressure?
. Smoking cessation
. Increased consumption of complex carbohydrates
. Increased calcium consumption
. Decreased alcohol intake
. Decreased consumption of animal protein
A 56-year-old white male presents with dyspnea for the last 3 months. His dyspnea was initially exertional but it has worsened progressively and now he is breathless even at rest. He denies any chest pain or ankle swelling. He has been smoking one-pack/day cigarettes for the last 30 years and has been drinking alcohol heavily for the last 10 years. He is not taking any medication. His mother died of breast cancer at 57. His vitals are, PR 86/min, BP 113/76mmHg; Temperature 37.1°C (98.9°F); RR 13/min. On auscultation of his precordium an S3 is heard, but there are no murmurs. Chest auscultation reveals bilateral basal crepitations. Chest x-ray shows marked cardiac silhouette enlargement and pulmonary venous congestion. EKG shows non-specific ST-T wave changes. Echocardiography shows a dilated left ventricle and systolic dysfunction (EF of 25-30%). CBC shows hematocrit of 32%, WBC count of 6,000/microl, and platelet count of 60,000/microl. Peripheral blood smear shows MCV of 101 fl. LFTs show AST of 180U/L and AL T of 66 U/L. The findings of cardiac catheterization and coronary angiography are not compatible with the diagnosis of ischemic cardiomyopathy. Which of the following measures is most likely to reverse his heart failure?
. Cessation of cigarette smoking
. Abstinence from alcohol
. Reduced salt intake
. Use of ACE inhibitors
. Use of digoxin
A 56-year-old woman has nonspecific complaints that include an abnormal sensation when swallowing. An esophagram is obtained. Which of the following is most likely to require surgical correction?
. Large sliding esophageal hiatal hernia
. Paraesophageal hiatal hernia
. Traction diverticulum of esophagus
. Schatzki ring of distal esophagus
. Esophageal web
A 56-year-old woman is undergoing a cadaveric renal transplant. After revascularization of the transplanted kidney, the transplanted renal parenchyma becomes swollen and blue. The surgeon suspects hyperacute rejection. What is the treatment of choice for this patient?
. There is no therapy for hyperacute rejection
. Systemic anticoagulation
. Catheter-directed anticoagulation into the renal artery
. Intravenous steroids
. Intravenous steroids and cyclosporine
A 56-year-old woman presents to her primary care physician for a routine checkup. She states that she was recently hospitalized for surgery and was told she had some metal placed in a large blood vessel to prevent blood clots from moving to her lungs. An abdominal x-ray is shown here. Which of the following is the most appropriate indication for placement of this device?
. Recurrent pulmonary embolus despite adequate anticoagulation therapy
. Axillary vein thrombosis
. Pulmonary embolus due to DVT of the lower extremity that occurs 2 weeks postoperatively
. DVT in a patient with patient with metastatic carcinoma
. Pulmonary embolus in a patient with metastatic carcinoma
A 56-year-old woman presents to the outpatient clinic for a routine visit. On physical examination a 1-cm nodule is palpated in her thyroid. Her physical examination is otherwise unremarkable. Her heart rate is 70/min and regular, blood pressure is 126/82 mmHg, and temperature is 36.7°C (98.0°F). Which of the following is a poor prognostic indicator for the thyroid nodule?
Female gender
Hoarseness
Palpitations
Patient age of 56 years
Slow growth of nodule
A 56-year-old woman was recently started on medication for high blood pressure. At her next office visit her hypertension is under good control, but she now complains of “feeling strange” since she started the medication. On further questioning, she reports feeling chest tightness several times over the past 2 weeks, and has also noticed pain in her elbows and knees. Her blood pressure is 124/78 mmHg (146/82 mmHg on last visit), heart rate is 102/min, and respiratory rate is 14/min. Her examination is notable for several erythematous plaques on the malar distribution of the face, arms, and upper torso. What medication was she most likely started on during her last visit?
Captopril
Furosemide
Hydralazine
Metoprolol
Verapamil
A 56-year-old woman with cirrhosis presents with a 2-week history of increasing abdominal distension. She has mild encephalopathy and esophageal varices without bleeding. Her cirrhosis is due to chronic hepatitis type B. She has a past history of ascites treated successfully with conservative management. She is currently on sodium, water and protein restriction, maximal doses of spironolactone and furosemide, and lactulose. Her temperature is 36.6°C (97.9°F), blood pressure is 120/70 mmHg, pulse is 80/min, and respirations are 30/min. She has a flapping tremor and labored breathing. Abdominal examination shows marked abdominal distension. An x-ray film of the chest is unremarkable. Abdominal ultrasound shows peritoneal fluid and splenomegaly, liver hyperechogenicity and nodularity, and portal vein width of 16 mm; no masses are evident. Which of the following is the most appropriate next step in the management of this patient's ascites?
. Intravenous furosemide therapy
. Tapping of some amount of ascitic fluid
. Peritonea-jugular shunt
. Distal spleno-renal shunt (selective shunt)
. Side-to-side porto-caval shunt (non-selective shunt)
A 57-year-old Caucasian man presents complaining of "feeling overwhelmed by life." He has felt depressed for the past six months, and states that he has difficulty focusing on daily activities. His sleep is poor and he wakes frequently at night. Further inquiry reveals that he is a Vietnam War veteran and that he experiences flashbacks and nightmares about his combat experiences. He notes that the flashbacks began prior to his feelings of depression. He avoids watching war movies and refuses to discuss with anyone his time spent in Vietnam. This is his first visit to a psychiatrist and he asks to be started on some medication. Which of the following should be avoided in this patient?
. Lorazepam
. Nortriptyline
. Paroxetine
. Exposure therapy
. Cognitive therapy
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 male was involved in a motor vehicle accident and was immediately brought to the Emergency Room. He suffered minor head and neck injury, but was found to have a broken tibia. He underwent repair of the tibial fracture the following day. Five days later, he suddenly develops tachycardia and is tachypneic. He complains of increasing chest discomfort and has a syncopal episode. His blood pressure is 80/55 mmHg, pulse is 130/min, and respirations are 24/min. Pulse oximetry showed 82% on room air. Stat echocardiogram reveals obstruction in the main pulmonary artery. Which of the following choices is the most appropriate course of action?
. Heparin infusion
. Fibrinolytic therapy
. Embolectomy
. Inferior vena cava filter
. A CT scan of the lung
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 menopausal patient presents to your office for evaluation of postmenopausal bleeding. She is morbidly obese and has chronic hypertension and adult onset diabetes. An endometrial sampling done in the office shows complex endometrial hyperplasia with atypia, and a pelvic ultrasound done at the hospital demonstrates multiple, large uterine fibroids. Which of the following is the best treatment option for this patient?
. Myomectomy
. Total abdominal hysterectomy
. Oral contraceptives
. Uterine artery embolization
. Oral progesterone
A 57-year-old previously alcoholic man with a history of chronic pancreatitis presents with hematemesis. Endoscopy reveals isolated gastric varices in the absence of esophageal varices. His liver function tests are normal and he has no stigmata of end-stage liver disease. Ultrasound examination demonstrates normal portal flow but a thrombosed splenic vein. He undergoes banding, which is initially successful, but he subsequently rebleeds during the same hospitalization. Attempts tocontrol the bleeding endoscopically are unsuccessful. Which of the following is the most appropriate next step in management?
. Transjugular intrahepatic portosystemic shunt
. Surgical portocaval shunt
. Surgical mesocaval shunt
. Splenectomy
. Placement of a Sengstaken-Blakemore tube
A 57-year-old woman comes to the physician's office for evaluation of vaginal dryness, burning and dyspareunia. She also has dysuria and increased urinary frequency. The symptoms have been present for several months but have intensified recently. She has tried over-the-counter lubricants with little relief. Her last menstrual period was seven years ago. She takes hydrochlorothiazide for hypertension and pravastatin for hypercholesterolemia. Physical examination shows scarce pubic hair and reduced elasticity and turgor of the vulvar skin. Pale, dry and smooth vaginal epithelium is noted. Urine dipstick is normal. Which of the following is the most appropriate next step in management?
. Ciprofloxacin for one week
. Metronidazole for one week
. Discontinue hydrochlorothiazide
. Vaginal estrogen replacement
. High-potency corticosteroid cream
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 presents with adenocarcinoma of the right colon. Laboratory evaluation demonstrates an elevation of carcinoembryonic antigen (CEA) to 123ng/mL. Which of the following is the most appropriate use of CEA testing in patients with colorectal cancer?
. As a screening test for colorectal cancer
. To determine which patients should receive adjuvant therapy
. To determine which patients should receive neoadjuvant therapy
. To monitor for postoperative recurrence
. To monitor for preoperative metastatic disease
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 alcoholic is admitted with diagnosis of decompensated liver cirrhosis. The lab panel is shown below on the day of admission and 3 days later. Which of the following best explains the acid-base status change in this patient?
. Acute renal failure
. Bowel ischemia
. Loop diuretic therapy
. Opioid medication use
. Right lower lobe atelectasis
A 58-year-old asymptomatic male is found to have elevated levels of serum alkaline phosphate. His serum calcium and phosphate levels are normal. He denies any bone pain or deformity. His liver function tests are normal. The urinary hydroxyproline levels are increased. Nuclear bone scan reveals an increased uptake in the right scapula. Plain radiography confirms Paget's disease. Which of the following is the most appropriate next step in the management of this patient?
. No treatment is indicated at this stage
. Treatment with bisphosphonates
. Treatment with nasal calcitonin
. Treatment with calcium and vitamin D
. A CT scan of lung
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 a small mass in the right neck on a yearly physical examination. The patient reports that the mass has been slowly growing for the last few months and is not associated with pain or drainage. He has an otherwise negative review of systems. On examination there is a hard, mobile 2 cm mass along the mid-portion of the right sternocleidomastoid muscle. Which of the following is the most appropriate initial step in the workup of the neck mass?
. No further workup is needed. Reevaluate the mass after a course of antibiotics for 2 weeks.
. Fine-needle aspiration (FNA).
. Core needle biopsy.
. Incisional biopsy.
. Excisional biopsy
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 man presents with tachycardia, fever, confusion, and vomiting. Workup reveals markedly elevated (triiodothyronine) T 3 and (thyroxine) T4 levels. He is diagnosed as having a thyroid storm. Which of the following is the most appropriate next step in the management of this patient?
. Emergent subtotal thyroidectomy
. Emergent total thyroidectomy
. Emergent hemodialysis
. Administration of fluid, antithyroid drugs, β-blockers, iodine solution, and steroids
. Emergent radiation therapy to the neck
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 professional race car driver has an episode of gross, painless, total hematuria. CT scan reports the presence of a 2 cm mass arising from the cortex of the left kidney, and the radiologist confidently makes a diagnosis of renal cell carcinoma. The same study, however, is inconclusive as to the presence or absence of tumor growth into the renal vein, and the radiologist adds an MRI for that purpose. The MRI clearly excludes the existence of such growth into the vein. Chest x-ray is normal. Which of the following is the most appropriate next step in management?
. Inferior vena cavography
. Partial nephrectomy
. Percutaneous biopsy
. Radiation therapy
. Radical nephrectomy
A 58-year-old woman has a history of major depressive disorder that has been in remission for the past ten years. She takes phenelzine daily and sees her psychiatrist every other month. While on vacation, the patient and her husband indulge in a gourmet meal. Afterward, the patient becomes concerned as she believes one of the dishes may have contained aged cheese, which her psychiatrist had warned her about eating. She comes to the emergency department of the local hospital to express her concerns. Which of the following is most appropriate to monitor?
. Blood pressure
. Blood urea nitrogen and creatinine
. Creatine phosphokinase
. Liver function tests
. Temperature
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 male suffers a myocardial infarction. He is treated medically and is discharged home ten days later on aspirin, atorvastatin, metoprolol, lisinopril, and sublingual nitroglycerin. One month later, he presents to your office for a follow-up visit. He denies chest pain, dyspnea or lightheadedness. His blood pressure is 120/75 mmHg. His EKG is pictured below. Echocardiogram reveals an ejection fraction of 45%. What is the best next step in his management?
. Observation
. Amiodarone
. Digoxin
. DC cardioversion
. Verapamil
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?
. Dietary modification
. Endoscopy
. Barium swallow
. Octreotide
. Reconstructive operation
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?
. Infusion of a bolus of steroids immediately postoperatively with a continuous infusion for 24 hours
. Maintenance of intraoperative normothermia
. Clamping of the aorta proximal to the left subclavian artery
. Cerebrospinal fluid (CSF) drainage
. Extracorporeal membrane oxygenation
A 59-year-old man is planning to undergo a coronary artery bypass. He has osteoarthritis and consumes nonsteroidal anti-inflammatory drugs (NSAIDs) for the pain. Which of the following is the most appropriate treatment prior to surgery to minimize his risk of bleeding from his NSAID use?
. Begin vitamin K 1 week prior to surgery.
. Give FFP few hours before surgery.
. Stop the NSAIDs 1 week prior to surgery.
. Stop the NSAIDs 3 to 4 days prior to surgery.
. Stop the NSAIDs the day before surgery.
A 59-year-old man presents to the ED with left-sided chest pain and shortness of breath that began 2 hours prior to arrival. He states the pain is pressure-like and radiates down his left arm. He is diaphoretic. His BP is 160/80 mmHg, HR 86 beats per minute, and RR 15 breaths per minute. ECG reveals 2-mm ST-segment elevation in leads I, aVL, and V 3 to V 6. Which of the following is an absolute contraindication to receiving thrombolytic therapy?
Systolic BP (SBP) greater than 180 mm Hg
Patient on Coumadin and aspirin
Total hip replacement 3 months ago
Peptic ulcer disease
Previous hemorrhagic stroke
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
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 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
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
A 59-year-old woman presents with right lower quadrant pain, nausea, and vomiting. She undergoes an uncomplicated laparoscopic appendectomy. Postoperatively, the pathology reveals a 2.5-cm mucinous adeno-carcinoma with lymphatic invasion. Staging workup, including colonoscopy, chest x-ray, and computed tomography (CT) scan of the abdomen and pelvis, is negative. Which of the following is the most appropriate next step in her management?
. No further intervention at this time; follow-up every 6 months for 2 years
. Chemotherapy alone
. Neoadjuvant chemotherapy followed by right hemicolectomy
. Ileocecectomy
. Right hemicolectomy
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 Hispanic boy is brought to the office for a well-baby check-up and follow-up immunizations. His mother denies any new complaints. Physical examination reveals lesions that do not fade into the surrounding skin, shown in picture below. What is the most appropriate next step in the management of this patient?
Perform fundoscopy to rule out retinal hemorrhages
Coagulation tests to rule out a coagulopathy
Immediately report to the authorities for child abuse
Do nothing. Since it is likely that these lesions will disappear in the next few years
Schedule for excisional therapy with laser
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-month-old infant is diagnosed with her first episode of otitis media. She does not have any allergies to medications. Which of the following medications would be the recommended initial therapy for this infant?
Amoxicillin
Amoxicillin-clavulanic acid
Cephalexin
Ceftriaxone
Erythromycin
A 6-week-old girl comes to medical attention because of a bright red plaque on her neck. The plaque is slightly raised, measures 2 cm in greatest diameter, and blanches partially on pressure. The mother reports that the lesion appeared in the second or third week and has been gradually increasing in size. Which of the following is the most appropriate next step in management?
. No further diagnostic procedure or treatment is necessary
. MRI and/or CT studies
. Referral to a dermatologist for biopsy
. Treatment with corticosteroids or interferon-alpha
. Surgical excision
A 6-year-old boy has multiple, honey-colored, crusted lesions on his face, periungual areas, and forearms. The first lesion appeared 2 weeks ago on his philtrum. Since then the lesions have spread to his hands and arms. Each began as a small pustule on an erythematous base and eventually ruptured to form the crusted lesions now present. His temperature is 100.6 F, pulse is 100/min, and respirations are 14/min. The remainder of the physical examination is unremarkable. Which of the following is the most appropriate treatment?
Clarithromycin
Dicloxacillin
Penicillin G
Penicillin V
Vancomycin
A 6-year-old boy is brought to the clinic due to persistent leg pain. Over the last few months, he has been constantly complaining of pain in his legs. The painful episodes occur only at night, and last a few hours each. His mother has been treating him with over-the-counter medications. He is able to walk and run to school without any complaints. He has no fever, chills and history of trauma. On examination, there is no obvious trauma to his legs, and the limb exam is completely normal. His parents are very worried and ask that you "do something.” Which of the following is the most appropriate next step in management?
Plain radiographs
Bone scan
Blood cultures
Psychiatric evaluation
Observation and reassurance
A 6-year-old boy is brought to the office by his mother for the evaluation of a "skin disease." The physical examination reveals multiple vesiculopustular lesions on his face and neck. Some lesions are colored golden-yellow and encrusted. The crust is thick and adherent to the underlying skin. The rest of his physical examination is within normal limit. What is the most appropriate treatment for his skin condition?
. Topical erythromycin
. Topical mupirocin
. Oral penicillin
. Topical dicloxacillin
. Topical cephalexin
A 6-year-old boy is brought to the office by his parents after hearing that chicken pox is infectious and can occur in unimmunized contacts. One week ago, he and his family visited relatives, and one of his cousins had chicken pox at that time. He and his two other siblings are apparently healthy, and never had any "chicken pox shots." What is the best next step in the management of this patient?
Administer varicella vaccine to the patient
Give intravenous immunoglobulins to the patient
Administer varicella vaccine and intravenous immunoglobulins to the patient
Administer acyclovir to the patient
Tell the parents that the patient might develop a rash within the next two weeks
A 6-year-old boy is brought to the office due to a sudden onset of petechiae and epistaxis. Three weeks ago, he had an upper respiratory tract infection which resolved uneventfully. Physical examination shows a few petechiae over the trunk and extremities, but is otherwise unremarkable. Laboratory studies show: Hb 13.5g/dL, WBC 7, 000/mm3, Differential count normal, Platelets 60, 000/mm3. What is the most appropriate next step in the management of this patient?
Platelet transfusion
IV antibiotics
Observation
Splenectomy
Intravenous immunoglobulin
A 6-year-old boy is brought to the pediatrician because of a 3-day history of skin lesions. On physical examination, he has multiple yellow, crusted erosions below the nares and on the cheeks, chin, and upper extremities. The rest of the examination is normal. Which of the following is the most appropriate treatment for this condition?
. Oral acyclovir
. Oral amoxicillin
. Oral cephalexin
. Topical ketoconazole
. Topical 2% hydrocortisone
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 girl presents with a 2-day history of cough and fever. At your office she has a temperature of 39.4°C (103°F), a respiratory rate of 45 breaths per minute, and decreased breath sounds on the left side. Her chest x-ray is shown below. Which of the following is the most appropriate initial treatment?
N-acetylcysteine chest physiotherapy
Vancomycin
Partial lobectomy
Postural drainage
Placement of tuberculosis skin test
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 asymptomatic man presents to your office for a routine check-up. He has a 10-year history of type 2 DM, and a 12-year history of hypertension. His current medications include low-dose glyburide and a low-dose thiazide diuretic. His blood pressure is 140/90 mmHg and heart rate is 65/min. Physical examination shows a soft ejection systolic murmur at the base of the heart. Ophthalmoscopic evaluation reveals no abnormalities. ECG recorded 6 months ago showed left ventricular hypertrophy and non-specific ST segment and T-wave abnormalities. His recent fasting glucose level was in the range of 120 to 150 mg/dl, and HbA1c was 7.1 % (normal < 6%). 24-hour urine collection reveals microalbuminuria. Which of the following is the best measure to slow end-organ damage in this patient?
. Increase the dose of glyburide
. Increase the dose of thiazide diuretic
. Switch to insulin
. Add ACE inhibitor
. Add beta-blocker
A 60-year-old Caucasian female comes to the physician because of progressive shortness of breath for the past month. She has had a 13.6 kg (30 lb) weight loss during this period. She has a history of hypertension and hypothyroidism and takes metoprolol and levothyroxine. She has smoked two packs of cigarettes daily for 35 years. Her temperature is 36.7°C (98°F), blood pressure is 130/70 mmHg, pulse is 80/min, and respirations are 20/min. On examination, decreased breath sounds and dullness to percussion are noted on the right, middle and lower lobes of the lung. Her chest x-ray is shown below. Which of the following is the most appropriate next step in the management?
. Bronchoscopy
. Mediastinoscopy
. Thoracentesis
. Video-assisted thoracoscopy
. Open pleural biopsy
A 60-year-old Caucasian male presents to the office with erectile dysfunction that progressed slowly over the last several months. He finds it difficult to obtain an erection, and has noted a decrease in nocturnal erections. His past medical history is significant for diabetes mellitus, type 2 and benign prostatic hypertrophy (BPH). His current medications are glyburide and doxazosin. Physical examination is insignificant. HbA1c level measured two weeks ago was 7.5%. He is asking about a prescription for sildenafil. Which of the following is the best statement concerning the treatment of erectile dysfunction in this patient?
. Tightening of glycemic control improves erectile dysfunction
. Sildenafil is not a drug of choice for diabetics with erectile dysfunction
. Sildenafil and doxazosin should be given with at least a 4-hour interval
. Prostaglandins (alprostadil) are preferred in this patient
. Sildenafil should not be combined with glyburide
A 60-year-old Caucasian man presents to his family physician complaining of weight loss and fatigue. A review of systems is positive for a change in bowel habits. He says that in the past several weeks, he has developed pencil-thin stools. Further evaluation reveals the presence of colon carcinoma. The patient is told the diagnosis, and his treatment options and prognosis are discussed. He refuses any treatment and says he wants to die peacefully at home without any medical intervention. What would be the most appropriate means of handling the situation?
. Treat the patient against his wishes
. Contact his family and ask them to convince him to receive treatment
. Ask the patient why he is reluctant to be treated
. Respect the patient's decision
. Provide the patient with some literature about the benefits of chemotherapy
A 60-year-old Caucasian woman undergoes elective coronary artery bypass surgery and aortic valve replacement. Her postoperative course is complicated by acute renal failure, atrial fibrillation, and pulmonary edema. On the third postoperative day, extubation is attempted but not tolerated, thus warranting reintubation. On the fifth postoperative day, she develops a fever to 38.9°C (102°F). Her pulse is 110-120/min and irregular, respirations are 36/min, and blood pressure is 110/65 mmHg. Her chest x-ray shows right middle and lower lobe infiltrates. WBC count is elevated with bandemia. Gram stain of her sputum shows gram-negative rods. She is given intravenous ceftriaxone; however, she deteriorates over the next 24 hours. Which of the following is the most appropriate next step in the management of this patient?
. Stop ceftriaxone and start piperacillin-tazobactam
. Continue ceftriaxone and add vancomycin
. Stop ceftriaxone and start clindamycin
. Continue ceftriaxone and add ceftazidime
. Continue ceftriaxone and add amphotericin
A 60-year-old diabetic woman develops angina and will need a coronary angiogram for evaluation of coronary artery disease. She has a creatinine of 2.2. Which of the following is the most effective in reducing the risk of contrast induced nephropathy?
. Administer mannitol immediately after the contrast is given
. Perform prophylactic hemodialysis after the procedure
. Give IV hydration with normal saline or sodium bicarbonate prior to and following the procedure
. Indomethacin 25 mg the morning of the procedure
. Dopamine infusion before and after the procedure
A 60-year-old female presents with transient loss of consciousness. She appears lethargic and confused. She also complains of hemoptysis and weight loss of 10 lbs (4.5kg) over a period of 2 months. She has smoked one pack of cigarettes daily for the last 40 years. Her temperature is 37.0°C (98.6°F), pulse is 75/min, blood pressure is 110/70 mmHg, and respirations are 16/min. Her mucus membranes are moist. There is no jugular venous distention. Her neurological examination is non-focal, and cardiovascular examination is unrevealing. There is no ankle edema or ascites. Serum studies show: Sodium 115 mEq/L, Potassium 3.7 mEq/L, Bicarbonate 22 mEq/L, Blood glucose 100 mg/dL, BUN 10.0 mg/dL. Serum osmolality is 250 mOsm/Kg, and urine osmolality is 500 mOsm/Kg. Urine sodium concentration is 40 mEq/L. Chest x-ray shows a mass in the right hilar region. What is the most appropriate next step in the management of this patient?
. Normal saline
. Loop diuretics
. Water restriction
. Hypertonic saline
. Demeclocycline
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 is 2 days status post primary percutaneous coronary intervention (PCI) with stent placement. He had previously suffered from an antero-lateral myocardial infarction. His cardiac enzymes have been trending down since admission. He has recovered well and is ready for discharge. He is currently asymptomatic. His temperature is 37.5°C (99.5°F), blood pressure is 130/70 mmHg, pulse is 66/min, and respirations are 14/min He is discharged with instructions to take the following medications aspirin simvastatin, lisinopril metoprolol and sublingual nitroglycerine. In addition to the medications listed above, which of the following medications should this patient also be taking after discharge?
. Isosorbide mononitrate
. Low molecular weight heparin
. Waffarin
. Clopidogrel
. Amlodipine
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 male patient with hepatitis C with a previous history of variceal bleeding is admitted to the hospital with hematemesis. His blood pressure is 80/60 mmHg, physical examination reveals splenomegaly and ascites, and initial hematocrit is 25%. Prior to endoscopy, which of the following is the best initial management of the patient?
. Administration of intravenous octreotide
. Administration of a β-blocker (eg, propranolol)
. Measurement of prothrombin time and transfusion with cryoglobulin if elevated
. Empiric transfusion of platelets given splenomegaly
. Gastric and esophageal balloon tamponade (Sengstaken-Blakemore tube)
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?
. Hematocrit less than 35%
. Blood loss greater than 1500ml
. Evidence of hypoxia
. Lactic acidosis
. Fracture of femur
A 60-year-old man comes to the clinic because of right calf pain. He has a history of chronic diverticular disease and has had multiple attacks of diverticulitis in the past. His most recent attack occurred 3 weeks ago, and he was treated with antibiotics and underwent left hemicolectomy. He had a stable postoperative course and was discharged from the hospital 1 week ago. He developed right calf pain 3 days ago, with swelling and difficulty bearing weight on his right leg. He currently takes no medication. He does not use tobacco, alcohol, or illicit drugs. His temperature is 36.8°C (98.2°F), blood pressure is 120/70 mm Hg, pulse is 92/min, and respirations are 14/min. Physical examination reveals the right calf slightly larger than the left calf, moderate right ankle edema, and right calf pain with dorsiflexion of the right foot. Duplex ultrasonography shows a clot in the right distal portion of the femoral vein. Which of the following is the most appropriate initial treatment?
. Aspirin
. Heparin
. Streptokinase
. Warfarin
. Tissue plasminogen activator
A 60-year-old man comes to the physician because of a 2-week history of worsening fatigue. He has chronic renal insufficiency, hypertension, diabetes mellitus, hypercholesterolemia, hypothyroidism, polymyalgia rheumatica and depression. He was started on lisinopril for the prevention of proteinuria from diabetic nephropathy. Physical examination shows a few basal crackles. He is being considered for dialysis. Laboratory studies show hyperkalemia with serum K + of 6.0 mEq/L. EKG shows no abnormalities. Which of the following is the best treatment to remove K+ from his body?
. Sodium bicarbonate
. Beta agonists
. Calcium gluconate
. Kayexalate
. Insulin plus glucose
A 60-year-old man comes to your office complaining of difficulty hearing for the past few weeks. He has type 2 diabetes mellitus, which is well-controlled by diet alone. His past medical history is also significant for essential hypertension, congestive heart failure secondary to diastolic dysfunction, and chronic renal failure. Medications include aspirin, diuretics, an ACE inhibitor, and a beta-blocker. His pulse is 82/min, blood pressure is 140/90 mmHg, and respirations are 14/min. Examination reveals hearing loss in both ears. Which of the following medication is a potential cause of this patient's hearing problems?
. Lisinopril
. Aspirin
. Metoprolol
. Furosemide
. Hydrochlorothiazide
A 60-year-old man complains of pain in both knees coming on gradually over the past 2 years. The pain is relieved by rest and worsened by movement. The patient is 5ft 9 in. Tall and weighs 210 lb. There is bony enlargement of the knees with mild warmth and small effusions. Crepitation is noted on motion of the knee joint bilaterally. There are no other findings except for bony enlargement at the distal interphalangeal joint. Which of the following is the best way to prevent disease progression?
. Weight reduction
. Calcium supplementation
. Total knee replacement
. Long-term nonsteroidal anti-inflammatory drug (NSAID) administration
. Oral prednisone
A 60-year-old man is admitted to the coronary care unit with a large anterior wall myocardial infarction. On his second hospital day, he begins to complain of the sudden onset of numbness in his right foot and an inability to move his right foot. On physical examination, the right femoral, popliteal, and pedal pulses are no longer palpable. The left lower extremity is normal. Which of the following is the most appropriate management of this patient?
. Duplex imaging of the right lower extremity arteries
. CT angiogram of the right lower extremity
. CT angiogram of bilateral lower extremities
. Embolectomy of the right femoral artery
. Embolectomy of the right femoral artery with exploration of the contralateral femoral artery
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 is brought to the emergency department due to syncope. He has had similar episodes a few times during the past few weeks. These episodes usually occur after he exerts himself. He does not feel confused or tired after these episodes. He denies any chest pain or palpitation. His wife reports that when he collapses, he seems to lose consciousness for a few seconds, but then is back to being alert right away. She denies any jerking movement. His past medical history is significant diverticulosis, for which he takes fiber supplements. He is not on any other medication. His temperature is 37.1°C (98.8°F), blood pressure is 110/98 mm Hg, pulse is 88/min, and respirations are 14/min. On examination, he has a fourth heart sound and harsh 3/6 systolic murmur, best heard over the right sternal border. The murmur is accentuated on expiration. The lung fields are clear to auscultation. After performing an echocardiograph to confirm the diagnosis, which of the following management options is most appropriate?
. Aortic valvotomy
. Aortic valve replacement
. Close outpatient follow-up with serial echocardiograms
. Exercise test looking for arrhythmias
. Observe until the patient develops breathlessness
A 60-year-old man is found on a routine physical examination to have a 3-cm pulsatile mass in the right popliteal fossa. X-ray of the right of the right lower extremity is shown below. Which of the following is the most appropriate management of this patient?
. Antiplatelet therapy
. Anticoagulation
. Thrombolytic therapy
. Surgery
. Reassurance and re-examination if the patient develops symptoms
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 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 coronary artery disease, peptic ulcer disease, and gout presents to the emergency department with a 24-hour history of abdominal pain. The pain, which is most intense in the upper abdomen, was sudden in onset and has become progressively more severe. Free air in the abdomen is detected on x-ray films. The patient is in an agitated state. His extremities are cool and capillary refill time is 3 seconds. His blood pressure is 80/40 mmHg and heart rate is 130/min. The neck veins are flat and the lungs are clear to auscultation. His hemoglobin is 13.8 g/dL. A urinary catheter is inserted and 10 mL of urine is drained. What is the most appropriate treatment for this patient at this time?
Broad-spectrum antibiotics for presumed sepsis
Infusion of isotonic fluid
Infusion of norepinephrine
Inotropic support with dopamine, vasopressin, or dobutamine
Transfuse with 1 unit packed RBCs
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 61-year-old Caucasian male presents with ptosis, diplopia and limb weakness. These symptoms worsen in the evening and with exercise, and improve with rest. He also has fatigue, which is worse in the evening. He denies any tingling or numbness. On examination, he cannot sustain an upward gaze, and his eyelids tend to drift downward. Injection of edrophonium quickly restores power, and allows him to maintain an upward gaze. Which of the following is the best initial treatment for this patient?
. Treatment with pyridostigmine
. Treatment with edrophonium
. Treatment with atropine
. Treatment with prednisolone
. Treatment with intravenous immunoglobulins
A 61-year-old man has a non-ST-elevation MI and is admitted to the coronary care unit. The following day, he develops bradycardia but no symptoms. His blood pressure is 126/84 mmHg, pulse 50/min, and on examination, the heart sounds are normal, with no extra sounds or rubs. His ECG has changed. Which of the following ECG findings is the best indication for this patient to receive a pacemaker?
Persistent bradycardia
Second-degree AV block Mobitz type I
First-degree AV block
New right bundle branch block
Left bundle branch block (LBBB) and second-degree AV block Mobitz type II
A 61-year-old man in previously excellent health presents to his physician with com- plaints of hematochezia tenesmus, and rectal pain. On work-up the physician discovers that he has a rectal tumor that is 5 cm (2.0 in) from the anal verge. Which of the following is the most appropriate treatment?
Abdominoperineal resection
Imatinib
Low anterior resection
Radiation alone
Radiation plus chemotherapy
A 61-year-old man undergoes upper endoscopy for evaluation of weight loss and is identified to have a submucosal mass in the stomach. Biopsy is consistent with a gastrointestinal stromal tumor (GIST). Workup reveals the presence of liver metastases. Which of the following is the best initial treatment for this patient?
. Tyrosine kinase inhibitor (Imatinib)
. Monoclonal antibody against interleukin-2 receptor (Daclizumab)
. Monoclonal antibody against tumor necrosis factor α (Infliximab)
. Monoclonal antibody against vascular endothelial growth factor A (Bevacizumab)
. Monoclonal antibody against epidermal growth factor receptor (Cetuximab)
A 61-year-old obese man with a history of chronic alcohol abuse is diagnosed with type 2 DM. In addition to diet modification and exercise, his physician recommends he begin therapy with a hyperglycemic agent. Several days after starting therapy, his wife comes home from work and finds him sitting on the couch staring into space and breathing rapidly. When she speaks to him, she finds he is quite confused, and immediately takes him to the emergency department. Arterial blood gas analysis shows: pH: 7.2, HCO −: 19 mEq/L. Partial carbon dioxide pressure: 32 mmHg Partial oxygen pressure: 80 mmHg Lactate: 6 mmol/L. Which of the following drugs is most likely responsible for this patient’s symptoms?
Acarbose
Glipizide
Insulin
Metformin
Rosiglitazone
A 61-year-old woman with a history of unstable angina complains of hematemesis after retching and vomiting following a night of binge drinking. Endoscopy reveals a longitudinal mucosal tear at the gastroesophageal junction, which is not actively bleeding. Which of the following is the next recommended step in the management of this patient?
. Angiography with embolization
. Balloon tamponade
. Exploratory laparotomy, gastrotomy, and oversewing of the tear
. Systemic vasopressin infusion
. Expectant management
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