Family medicine-book

A 17-year-old adolescent boy presents to the ER with a temperature of 101.0°F (38.3°C), a deep nonproductive cough, and generalized malaise for 3 days. He doesn't recall being around any particular sick contacts but is around many people in his after-school job in sales and at school. He states that he never had the chicken pox and is unaware of what immunizations he received as a child. He was diagnosed at age 12 with leukemia but has since been healthy. He is worried that his cancer may no longer be in remission. A chest x-ray reveals bilateral, diffuse infiltrates. Which of the following is the most likely cause of illness?

A 35-year-old morbidly obese woman returns to clinic with sudden onset of night sweats, chills, shortness of breath, and cough productive of yellowishgreen sputum. Her vital signs show a temperature of 104.0°F, with a respiratory rate of 30 breaths/min, heart rate of 100 beats/min, pulse oximetry is 93% on room air. She was seen 8 days ago for headache, fever of 102.0°F, nonproductive cough, and myalgias. She was prescribed a dose of oseltamivir for 5 days. She felt better after taking the medication initially but now feels she is getting worse. She is sent to the emergency room for expedited evaluation. Assuming admission for pneumonia, which of the following is the best empiric antibiotic treatment for this patient?

A 76-year-old widowed man who lives alone presents to clinic with increasing shortness of breath and chest pain at rest for the past 2 weeks. He has had chronic hypertension and coronary artery disease (CAD) for 20 years for which he takes hydrochlorothiazide (HCTZ), enalapril, and aspirin 81 mg daily. Other medical problems include hyperlipidemia, peripheral vascular disease, and gastroesophageal reflux disease (GERO) which are controlled by lovastatin, warfarin, and omeprazole. Two years ago, he suffered a cerebrovascular accident that was localized to the brain stem. He now has dysphagia and is noted to cough frequently at night. He has no cough at present and has not been able to take his temperature at home. Which of the following is the best next step?

A 57-year-old man who has known New York Heart Association class II heart failure presents to clinic after noting to become dyspneic with significant exertion. On physical examination, his BP is 140/86 mm Hg, pulse 86 beats/min, and respiratory rate 20 breaths/min. A 2/6 pansystolic murmur is best heard at the right sternal border. There is no JVD, but 1 + pretibial and pedal edema are noted. He currently takes an ACEI and aspirin. Which one of the following additional medications has been shown to improve longevity in this situation?

A 52-year-old man with a long-standing history of marginally controlled hypertension presents with gradually increasing shortness of breath and reduced exercise tolerance with pain in his calves that causes him to stop walking after one block. His medications include enalapril and metoprolol. His physical examination reveals a blood pressure of 140/90 mm Hg, a respiratory rate of 22 breaths/ min, heart rate of 88 beats/ min, bibasilar rales, and trace pitting edema. Posterial tibial and dorsalis pedis pulses are 1+. Which of the following diagnostic tests is most appropriate in the further evaluation of this patient?

A 64-year-old man is noted to have congestive heart failure because of coronary artery disease. Over the past 2 days, he has developed progressive dyspnea and orthopnea. On examination, he is found to be in moderate respiratory distress, has JVD, and rales on pulmonary examination. He is diagnosed with pulmonary edema. Which of the following agents is most appropriate at this time?

A 70-year-old African-American man with New York Heart Association class III heart failure sees you for follow-up. He has shortness of breath with minimal exertion. The patient is adherent to his medication regimen. His current medications include lisinopril 40 mg twice daily, carvedilol 25 mg twice daily, furosemide 80 mg daily, and spironolactone 25 mg daily. His blood pressure is 100/60 mm Hg, and his pulse rate is 70 beats/min and regular. Physical examination findings include a few scattered bibasilar rales, an s3 gallop, and no peripheral edema. An ECG reveals a left bundle branch block and echocardiography reveals an ejection fraction of 25%. Which of the following is the best next step for this patient?

A 62-year-old woman presents for a routine physical examination. She is asymptomatic and is not taking any medications. Her blood pressure is found to be 145/85 mm Hg on two readings and her body mass index (BMI) is 29. Review of her chart reveals that her blood pressure was 143/84 mm Hg on a visit 4 months ago for a urinary tract infection. Which of the following is the most accurate statement regarding her blood pressure?

A 66-year-old Caucasian woman has an average blood pressure of155/70 mm Hg despite appropriate lifestyle modification efforts. Her only other medical problems are osteopenia, kidney stones, and mild depression. Her last lipid panel revealed a total cholesterol of 160 mg/ dL, high-density lipoprotein (HDL) 40 mg/dL, and low-density lipoprotein (LDL) 90 mg/dL. Which of the following would be the most appropriate treatment at this time?

A 48-year-old type 2 Caucasian diabetic man has had persistent blood pressure readings of 150/95 mm Hg for the past 6 months. Current medications include glyburide and metformin. His last HbA1c was 7.9% and the patient has a BMI of 24. On physical examination, position sense is intact but a peripheral neuropathy is detected in a stocking and glove pattern. Vibratory sensation is decreased bilaterally on both lower extremities. Eye examination shows mild papilledema but no cotton wool spots. When questioned, he says that he still occasionally sneaks a cookie after dinner and drinks alcohol nightly. Which of the following is the most appropriate treatment for him?

At a routine checkup, a 6-year-old boy is found to have a blood pressure of 150/90 mm Hg. R epeated blood pressure readings are consistently elevated. The child was delivered at 36 weeks by normal spontaneous vaginal delivery with no complications. All major milestones were met on time and he currently is enrolled in first grade. The child has been healthy up until this point. Which of the following is the most appropriate diagnosis and therapeutic step?

A 6-year-old boy left alone for 10 hours, now with hematemesis and pneumomediastinum on chest x-ray.

A 3-week-old male infant with 2 days of projectile, nonbilious vomiting, and constant feeding.

A 7-year-old boy with three episodes of severe abdominal pain and vomiting in the last month, previously diagnosed with failure to thrive.

4 An 8-month-old female infant with bilious vomiting, constant abdominal pain for 12 hours, and upper GI study showing beak-like appearance of contrast.

5 An 11-month-old male infant with intermittent bouts of crying and nonbilious vomiting, with a history of Meckel diverticulum. A small, elongated mass is felt on right side of his abdomen.

A 4-year-old girl with profuse vomiting, sweating, lacrimation, and diarrhea, who seizes in the emergency room.

A 65-year-old man reports a lifelong history of IBS with alternating bouts of constipation and diarrhea. He denies any so-called alarm symptoms, but does report that his symptoms have worsened over the last several months. He reports never having a colonoscopy before. Stool is negative for blood and leukocytes. Which of the following is the most important next step?

A 37-year-old woman reports a 10-year history of intermittent abdominal pain and constipation alternating with diarrhea. She has no weight loss, fever, or worrisome features on examination. Which of the following agents is clinically indicated as a first-line treatment for mild-to-moderate abdominal pain associated with IBS?

A 27-year-old graduate student in psychology is evaluated for intermittent abdominal pain. She is diagnosed with IBS. She asks whether there is a relationship between psychiatric disorders and IBS. Which of the following statements is most accurate?

A 26-year-old college student has been increasingly stressed before final examinations. She has been using over-the-counter antacids more days out of the week than not for an upset stomach and feeling full immediately after eating. She typically has one bowel movement per week and there is no blood in the stool. She feels immediate relief after passage of stool and flatulence. For the patient with constipation-predominant IBS, which of the following is the best first-line therapy?

A 25-year-old woman comes to your office worried that she might have IBS, which she heard about on the news. She reports abdominal pain and diarrhea for 3 months. She also reports observing blood in her stool several times. She is worried what impact her constantly having to use the bathroom is having on her job as a lawyer. Her physical examination is normal except for a hemoccult-positive test after a rectal examination. While looking over her records you notice that she has lost 20 lb since she last saw you 3 months ago. Which of the following is an appropriate next step?

A 35-year-old man who has never had a physical examination comes to clinic. He recently moved to the area and needs to establish with a new physician. He has had no previous medical problems to date and no pertinent family history. He denies any changes in bowel or bladder habits and does not smoke or drink alcohol. When prompted he says that he has noticed a "fluttering" in his chest for past 3 months that spontaneously resolves. He has had increased stress at work and has been drinking six cups of caffeinated coffee a day to complete his workload. He has not had time to exercise and his diet consists of what he can find in the office cafeteria. He denies any history of anxiety. Which of the following is the most common underlying etiology of his palpitations?

A 42-year-old asymptomatic woman is noted to have an abnormal finding on ECG. Which of the following is an indication for referral to a cardiologist or cardiac electrophysiologist?

Which of the following patients should undergo an exercise stress test for evaluation of his palpitations?

A 16-year-old adolescent boy comes to your office for a sports physical. He is planning to try out for his high school football team but first needs medical clearance. He has no cardiovascular complaints and his history is unremarkable, except for a family history which includes an uncle dying suddenly while jogging at age 25. His physical examination is unremarkable except for a harsh systolic murmur loudest over his left lower sternal border which increases with the Valsalva maneuver. You obtain an ECG which shows left ventricular hypertrophy. Which of the following is the most appropriate next step in management?

You are called to the bedside of a patient who was complaining of chest pain. When you get there you find the patient confused and not answering questions. The nurse informs you that the patient was speaking coherently only several minutes ago. The patient's pulse is 180 beats/ min, his systolic blood pressure is 60 mm Hg, and his diastolic blood pressure cannot be measured. Telemetry reveals supraventricular tachycardia. Which of the following is the most appropriate next step in the management of this patient?

A 32-year-old man with asthma and hypertension comes in for evaluation of an elevated bilirubin level that was detected on blood work required for a preemployment physical. The bilirubin level was 2.5 mg/dL (normal up to 1.0 mg/ dL) with an elevated unconjugated component. He feels well and generally drinks one beer per night. He is monogamous with his wife and has no history of IV drug abuse and has one tattoo. His sclerae are anicteric and there are no signs of jaundice. His liver enzymes, electrolytes, TSH, and CBC are normal. Which of the following is the next step in the evaluation of this patient?

A 45-year-old woman was diagnosed 6 months ago with acute hepatitis B infection. She is unaware of how she contracted the virus. She takes no medications and since the diagnosis, she has started taking a multivitamin and has started exercising. She now has the following serologies: HBsAg negative; anti-HBsAg positive; HBeAg negative; anti-HBcAg positive. Which of the following is the correct diagnosis

A 60-year-old retired Navy captain comes to the doctor after a 15-lb unintentional weight gain over the past 4 months. His medical history is significant for osteoarthritis and his only complaint is fatigue. He has smoked a pack of cigarettes daily since his early 20s and consumes two to three alcoholic beverages several times per week. On examination, he is slightly jaundiced, with no hepatomegaly or RUQ tenderness to palpation. He has mild shifting dullness in his abdomen, and significant lower extremity edema. His skin is noted to have several faded tattoos. Which of the following antibodies would most likely be present in this patient?

4 A 21-year-old college student plans to take a trip to Thailand with his friends in a couple of months. He confesses that he has experimented with illicit drugs including smoking marijuana as well as intranasal and intravenous cocaine and heroin. He is excited about the upcoming trip and wants to find out which immunizations he will need prior to his departure. Which of the following vaccinations and serologic tests will you recommend?

A 30-year-old woman with no significant medical history presents asking for advice. She recently attended a health fair where she tested positive for H pylori on a blood test. She denies any recent abdominal discomfort, nausea, vomiting, diarrhea, or melena. Occasionally, she uses over-the-counter acidsuppressive therapy after eating spicy foods or drinking alcohol when she develops dyspepsia and heartburn, and her symptoms resolve within a week. Which of the following is the most appropriate advice to give this patient regarding H pylori?

A 62-year-old man presents to clinic with increasing shortness of breath and fatigue over the last several days. Cardiac examination reveals regular rate and rhythm and lungs are clear to auscultation bilaterally. No jaundice, jugular venous distention (JVD), or peripheral edema is noted. Mucous membranes are pink with no evidence of cyanosis and capillary refill is brisk. CBC reveals a microcytic anemia and a gastric ulcer is diagnosed on upper GI endoscopy. Gastric mucosa biopsy confirms an H pylori infection. His last colonoscopy was 10 years ago and was unremarkable. Which of the following is the next most appropriate step in the workup of this patient?

A 41-year-old man presents for evaluation of upper GI discomfort present over the last 2 months. He says that he has a "full" sensation in the epigastric region. He recently began smoking again due to increased stress at work. He denies blood in his stool, denies vomiting, and has had no dysphagia. He has lost 10 lb in the last few weeks unintentionally, which he attributes to not eating. His mother has hemorrhoids, and no family member has ever had colon cancer. He has never had a colonoscopy. Which of the following is the most appropriate next step in workup of this patient?

A 19-year-old woman arrives at the emergency room with a 15-hour history of nausea, vomiting, and severe epigastric abdominal pain that awoke her from sleep. She admits to heavy alcohol consumption the prior evening that is common for her on the weekends. She takes no medications and does not take NSAIDs regularly. Her blood pressure is 100/60 mm Hg, pulse rate is 130 beats/min, respiratory rate is 14 breaths/min, and her temperature is 39°C (102.2°F). An acute abdominal series upon admission displayed a substantial amount of free air under the right hemidiaphragm. Which of the following is the most likely diagnosis?

A 36-year-old man presents to your office for follow-up after having been recently admitted to the hospital for hypoxia due to an acute asthma attack. A chest x-ray performed on admission was unremarkable. Upon admission, he was given intravenous corticosteroids and started on a PPI for stress ulcer prophylaxis. He was discharged home on a tapering course of oral corticosteroids and advised to continue the PPI until steroid therapy was completed. Which of the following complications from PPI therapy is most likely to occur in this patient?

A 16-year-old adolescent girl has had an increased craving for sweets. She often consumes two to three ice cream sundaes and four large sodas a day, but has still managed to maintain her weight. Friends often notice her using the bathroom more frequently to urinate but she denies any episodes of purging and states that she just has to urinate after drinking so much cola. On physical examination, she is 5 ft 8 in and 110 lb and her thyroid is not palpable. Which of the following test results is diagnostic of diabetes mellitus?

A 7 -year-old boy is brought to the office with symptoms of polydipsia, polyphagia, polyuria, and weight loss of 8 lb. For the past 24 hours, he has had abdominal pain and vomiting. A urinalysis performed in the office shows the presence of glucose and ketones. A finger-stick blood glucose is 530 mg/ dL. Which of the following is the most appropriate initial management in this patient?

An 83-year-old man was diagnosed with type 2 diabetes mellitus 3 months ago. He has modified his diet and tries to walk at least half a mile every evening. He drinks a glass of wine with lunch and dinner daily. For the past week, he has felt dizzy upon standing and has fallen on two occasions, but has never lost consciousness. After the last episode of falling, he presented to the local emergency room (ER) where his blood pressure was 155/76 mm Hg, heart rate was 74 beats/min, and respiratory rate was 16 breaths/min. A finger stick showed a random glucose level of 64 mg/ dL. Which of the following classes of medications has the lowest incidence of causing hypoglycemia when used as single-agent therapy?

A 39-year-old GlPO woman who is a new patient presents to the office at 10 weeks' gestation. She is known to have type 2 diabetes mellitus and currently takes metformin. Her last HbA1, was 10.4% 1 month ago. Her urinalysis is negative for ketones and leukocytes, and reveals only trace protein. She has no other medical problems and does not drink or smoke. On physical examination, she is 5 ft 4 in and weighs 202 lb with a BMI of 34.7. She inquires about the risk of diabetes to her fetus. Compared to gestational diabetes mellitus, this patient is at an increased risk for developing which of the following?

A 56-year-old man with cardiometabolic syndrome presents to discuss his diabetic management regimen. His last HbA1c was 8.8% and he currently takes metformin twice daily. He adamantly does not want to take insulin. He has seen a lot of commercials for new diabetic agents and wants to try one that will help to curb his appetite. Which of the following agents will likely cause early satiety?

A 25-year-old white woman who is in training for a competitive marathon complains of " hitting a wall" and "getting short of breath quicker than she should:' She complains of coughing at the end of her training runs, and states that she may be expecting too much of herself. She does not smoke, has no significant family history, and no history of occupational or environmental exposures. Her physical findings including lung examination are unremarkable. Spirometry reveals normal values both pre- and post-albuterol treatment. What would be the most reasonable first step in treatment of this patient?

A 34-year-old man with a past history of asthma presents to an acute care clinic with an asthma exacerbation. Treatment with nebulized albuterol and ipratropium does not offer significant improvement, and he is then admitted to the hospital. He is afebrile, has a respiratory rate of 24 breaths/ min, pulse rate is 96 beats/min, and oxygen saturation is 93% on room air. On examination, he has diffuse bilateral inspiratory and expiratory wheezes, mild intercostal retractions, and a clear productive cough. Which one of the following should be the next step in the management of this patient?

A 13-year-old adolescent boy has a nonproductive cough and mild shortness of breath on a daily basis. He is awakened by the cough at least five nights per month. Which one of the following would be the most appropriate treatment for this patient?

A 47-year-old obese woman presents to your office complaining of excessive daytime sleepiness, snoring, and frequent awakenings from sleep. She is having difficulty concentrating and her sleepiness is affecting personal and professional relationships. She smokes three-fourths of a pack of cigarettes per day, averages two glasses of wine per night, and has hypertension and hyperlipidemia. You perform a comprehensive sleep history and physical examination and determine that she is at increased risk for OSA. Which of the following physical examination findings is most suggestive of OSA?

You decide to perform an overnight PSG to confirm the diagnosis for the patient in question 57.1. The study is converted into a split-night study because her AHi was found to be over 40 in the first 2 hours of the study. What is the most likely diagnosis?

57.3 What is the next step in management of this patient?

A 54-year-old man comes to your clinic for a follow-up on OSA. He has been using PAP with a nasal mask for the last 3 years since he was diagnosed. He has recently purchased a CPAP machine and tells you he has been unable to use it because of facial discomfort. You check the machine and all the parts are in good condition. What is the next most appropriate step in management?

A 52-year-old man comes into the outpatient clinic for an annual "checkup:' He is in good health, and has a relatively unremarkable family history. He has never smoked cigarettes. For which of the following disorders should a screening test be performed?

A 62-year-old man with recently diagnosed emphysema presents to your office in November for a routine examination. He has not had any immunizations in more than 10 years. Which of the following immunizations would be most appropriate for this individual?

A 49-year-old sedentary man has made an appointment because his best friend died of an MI at age 50. He asks about an exercise and weight loss program. In counseling him, which of the following statements regarding exercise is most accurate?

A 38-year-old woman presents with progressively worsening dyspnea and cough. She has never smoked cigarettes, has no known passive smoke exposure, and does not have any occupational exposure to chemicals. Pulmonary function testing shows obstructive lung disease that does not respond to bronchodilators. Which of the following is the most likely etiology?

A 60-year-old man is diagnosed with moderately severe (stage II) COPD. He admits to a long history of cigarette smoking and is still currently smoking. In counseling him about the benefits of smoking cessation, which of the following statements is most accurate?

A 68-year-old patient of your practice with known COPD has pulmonary function testing showing an FEV 1 of 40% predicted has been having frequent exacerbations of his COPD. His Sa02 by pulse oximetry is 91%. Which of the following medication regimens is the most appropriate?

2.4 A 59-year-old man with a known history of COPD presents with worsening dyspnea. On examination, he is afebrile. His breath sounds are decreased bilaterally. He is noted to have jugular venous distension (JVD) and 2+ pitting edema of the lower extremities. Which of the following is the most likely cause of his increasing dyspnea?

A 24-year-old woman presents for an initial prenatal visit. She is at 9 weeks' gestation based on her LMP but, on further questioning, she is not certain of the first day of her LMP. Which of the following would be the most accurate estimate of her gestational age?

A 38-year-old pregnant woman presents for initial visit at 12 weeks' gestation. She requests a "genetic screen" because she is concerned about her advanced maternal age. She does not want any invasive testing that may cause a potential miscarriage. Which of the following is most appropriate to offer this patient?

A 28-year-old woman with a history of epilepsy presents for a preconception consultation visit. Which of the following is the most important advice to give to this patient?

A 28-year-old GlPO woman at 16 weeks' gestation is noted to be Rh negative. Which of the following is the most appropriate next step for this patient?

5.1 A 7-month-old male infant is brought into the office for a possible ear infection. In assessing the infant's posture, you note that he is not able to sit very well without support. You also observe other fine motor skills and speech. Which of the following is the most accurate statement?

A 5-year-old child presents to your clinic for a school physical. The child weighs 42 lb and is up-to-date on his immunizations. Which of the following anticipatory guidances is most appropriate for a child at this age?

5.3 A 4-month-old infant is brought into the family physician's office for routine checkup and immunizations. Which of the following vaccines is routinely recommended at this time?

5.4 A 5-year-old child is brought into the pediatrician's office for immunization and physical examination. The mother is concerned that her child is a little "under the weather': Which of the following is a contraindication to vaccinating the child?

Several friends develop vomiting and diarrhea 6 hours after eating food at a private party. Which of the following is the most likely etiology of the symptoms?

10.2 A 40-year-old man travels to Mexico and develops diarrhea 1 day after coming back to the United States. Which of the following is the most likely etiology of the symptoms?

10.3 A young woman eats raw seafood and 2 days later develops fever, abdominal cramping, and watery diarrhea. Which of the following is the most likely etiology of the symptoms?

10.4 During the winter, a young daycare worker develops watery diarrhea. Which of the following is the most likely etiology of the symptoms?

10.5 A 45-year-old man presents with 3 days of watery diarrhea and abdominal cramping. He has no sick contacts and has not traveled recently. He is not currently taking any medications, but he was prescribed amoxicillin 2 weeks ago for a sinus infection. Which of the following tests is most likely to identify the cause of his diarrhea?

10.6 In the patient described in question 10.5, which of the following is the treatment of choice for his diarrhea?

11.1 A 21-year-old woman presents for her first Pap smear. She received the full HPV vaccine series at age 19. Assuming that her examination and Pap smear results are normal, when would you recommend that she return for a followup Pap smear?

11.2 Which of the following situations is associated with an increased risk of intimate partner violence?

11.3 Which of the following statements regarding breast cancer screening is true?

11.4 A 48-year-old woman presents for a well-woman examination. She notes that she had a supracervical hysterectomy in the past. Your records reveal that she had her uterus removed, but the cervix and ovaries were left in place. You also note that she has had Pap smears with HPV cotesting every 5 years since her 20s and that all were normal. She read on the internet that women who have had a hysterectomy no longer need Pap smears. Which of the following would be your advice?

15.1 A 28-year-old woman is noted to have had 10-lb unintended weight gain, hair loss, dry skin, and fatigue. She is diagnosed with probable hypothyroidism. Which of the following laboratory test results is most consistent with hypothyroidism?

A 35-year-old G2P 1001 at 11 weeks' gestational age presents with complaint of palpitations, weight loss, nervousness and tremor. She denies prior history of thyroid problems. Laboratory studies confirm that TSH is severely suppressed. Which of the following is the best treatment for this patient at this time?

A 24-year-old woman who is 8 weeks pregnant is found to have a thyroid nodule. Biopsy is performed and malignancy of the thyroid is diagnosed. Which of the following management options is most appropriate?

15.4 A 28-year-old man presents to his physician for a health maintenance visit. He feels well and does not report changes in his appetite, weight, energy, or bowel movements. A firm nodule is palpated in the left lobe of his thyroid. The nodule is confirmed on ultrasound and measures 0.8 cm. Which of the following is the next step in the workup of this nodule?

A 30-year-old woman with no past medical history presents with a productive cough of 2-week duration. She states she also has a runny nose, body aches, congestion, and fevers for the past week. In office she is normotensive, with a normal pulse, and temperature of 101.2°F. Her physical examination is significant for sinus tenderness, boggy nasal turbinates, and crackles in the left lower lobe lung fields. Which one of the following is the best initial step in management?

19.2 A 55-year-old man with history of hypertension and diabetes presents with intermittent nighttime cough for a few months. He states he often has a "weird taste'' in his mouth a couple of hours after eating and is afraid of eating dinner because he gets terrible heartburn during the night. He states he has tried over the counter antacid and this has worked to somewhat alleviate his symptoms; however, his nighttime cough is still very bothersome. His vitals in office are within normal limits and physical examination is positive for epigastric tenderness upon palpation. Which one of the following is true regarding the most likely etiology of this patient's cough?

19.3 A 13-year-old adolescent girl presents with fever and sore throat of 48-hour duration. She has a temperature of 101°F in office and is tachycardic with a pulse of 118 beats/min. Her physical examination is positive for tender, enlarged left cervical lymphadenopathy and tachycardia. Her pharynx is erythematous but without tonsillar enlargement or exudate. She has had no cough. What is the best step in management?

A 58-year-old man presents to his physician for follow-up of his hypertension and hyperlipidemia. He also reports chest pain and feeling short of breath after climbing two flights of stairs or walking three to four blocks. The symptoms resolve after several minutes of rest. Which of the following drugs is contraindicated as a first-line agent in the treatment of this patient's new condition?

20.2 Which one of the following patients presenting with chest pain is at the highest risk for an acute myocardial infarction?

Which of the following ECG changes makes the determination of acute MI the most difficult?

20.4 A 64-year-old woman with a history of hypertension and angina pectoris presents with chest pain for the last 3 hours. She describes the pain as "sharp;' it is worse when she inhales deeply, and it is not relieved by sublingual nitroglycerin. Her ECG shows ST elevation in most leads. Which of the following is the most likely diagnosis in this patient?

21.1 A 56-year-old man with known CKD presents with a 3-day history of shortness of breath and rapid weight gain. On examination, you are able to auscultate an S3, hear crackles at the bases, and see moderate jugular venous distension (JVD). Which of the following is your next step in evaluation?

21.2 A 39-year-old woman with multiple medical problems has been noted to have progressively worsening renal insufficiency. Which of the following measures is most important in the prevention of end-stage renal disease?

21.3 A 72-year-old man, with a long history of hypertension, presents to the emergency department (ED) complaining of a 2-day history of emesis and 36 hours of no urination. On examination, the abdomen is firm and tender, and the prostate is enlarged. His serum creatinine level is 3.4 mg/ dL. Which the following is the best next step?

21.4 A 45-year-old woman with type 2 diabetes presents to the clinic with decreased vision in the left eye for 1 year, 1 + proteinuria, a baseline Cr of 1.6 mg/ dL, an low-density lipoprotein (LDL) of 135 mg/dL, blood pressure of 145/92 mm Hg, and occasional chest pain for the past 2 months. Which of the following is the best medication to start the patient on at this time?