Medicament USMLE VTH 2
377) A 27-year-old woman presents to your office complaining of mood swings, depression, irritability, and breast pain each month in the week prior to her menstrual period. She often calls in sick at work because she cannot function when she has the symptoms. Which of the following medications is the best option for treating the patient’s problem?
Progesterone
A short-acting benzodiazepine
A conjugated equine estrogen
A nonsteroidal anti-inflammatory drug (NSAID)
Selective serotonin reuptake inhibitors (SSRIs)
382) A 28-year-old attorney presents complaining of a six-month history of extreme nervousness, irritability, and restlessness. He is "plagued" by recurrent thoughts of not being able to properly carry out his responsibilities at the office. He dreads the possibility of not being offered a position as partner in the law firm. As a result, he finds himself unable to concentrate well or perform his duties efficiently. He is also engaged to be married, and spends sleepless nights thinking about the responsibilities of married life. He worries that he will not be a good husband or father. He denies any history of alcohol intake, but has recently begun drinking two bottles of beer every night for the past month as a means of escaping from his distressing thoughts. Which of the following is the treatment of choice for this patient?
Propanolol before a distressing situation
Alprazolam
Treatment for alcohol dependence
Ziprasidone
Buspirone
383) A 28-year-old female presents to her internist with a 2-day history of low-grade fever and lower abdominal pain. She denies nausea, vomiting, or diarrhea. On physical examination, there is temperature of 38.3°C (100.9°F) and bilateral lower quadrant tenderness, without point or rebound tenderness. Bowel sounds are normal. On pelvic examination, an exudate is present and there is tenderness on motion of the cervix. Her white blood cell count is 15,000/μL and urinalysis shows no red or white blood cells. Serum β-hCG is undetectable. Which of the following is the best next step in management?
Treatment with ceftriaxone and doxycycline
Endometrial biopsy
Surgical exploration
Dilation and curettage
Aztreonam
389) A 28-year-old male presents for a follow-up visit regarding his bipolar disorder, which has been managed with valproic acid for several years. He is accompanied by his mother who is very concerned because her son has been behaving strangely for the past two weeks, saying that he can hear the voice of his long-deceased father telling him to "come to me." The patient insists that he is able to ignore his father's voice and that he is not considering suicide at this time. The decision is made to start risperidone to treat the auditory hallucinations. This medication predominantly produces its antipsychotic effect by blocking which of the following receptors?
Alpha-1 adrenergic receptors
Dopamine-D2 receptors
Histamine- 1 receptors
Muscarinic cholinergic receptors
Serotonin 2A receptors
390) A 28-year-old male presents to the physician's office for a routine health maintenance examination. He has a two-year history of bronchial asthma for which he uses an albuterol inhaler. He states that he experiences asthma symptoms an average of 2 times per week, for which his albuterol inhaler provides relief. He has not had nighttime awakenings over the past month. He does not use tobacco, alcohol or illicit drugs. His family history is significant for asthma in his grandfather. Physical examination is unremarkable. Which of the following is the most appropriate next step in his management?
Add long-acting beta-2 agonist inhaler
Add inhaled corticosteroids
Add oral theophylline
Add oral prednisone
Continue current medical regimen
392) A 28-year-old man is brought to the ER for a severe head injury after a fall. He was intubated in the field for his decreased level of consciousness. He is tachycardic and hypotensive. On examination, he is noted to have an obvious skull fracture and his right pupil is dilated. Which of the following is the most appropriate method for initially reducing his intracranial pressure?
External beam radiotherapy
Multidrug combination chemotherapy
Combination radiotherapy and multidrug chemotherapy
Clinical surveillance
Laparotomy with pelvic and retroperitoneal node dissection
397) A 28-year-old patient with known Addison’s disease presents with abdominal pain and is hypotensive to a systolic pressure of 88 mmHg. He has a 2-week history of progressively worse nonproductive dry cough, sore throat, malaise, and headache. He has not checked his temperature at home but complains of constant chills. Which of the following is the best initial management?
Azithromycin
Check serum glucose
Hydrocortisone
Intravenous fluids
X-ray of the chest
400) A 28-year-old woman is brought to the emergency department by her sister after she experiences a generalized tonic- clonic seizure. The patient appears confused and is unable to answer any questions. The sister says the patient has never had a seizure before. The patient's medical history is unremarkable except for a long history of panic disorder for which she has been taking high doses of "some medication." The sister adds that the patient missed a few doses recently because they were staying at a friend's house, but she is sure that the patient was otherwise regular in taking her medication. Which of the following medications was the patient most likely taking?
Clonazepam
Clomipramine
Buspirone
Alprazolam
Paroxetine
401) A 28-year-old woman is diagnosed with bipolar disorder, manic type, when she was hospitalized after becomingpsychotic, hypersexual, severely agitated, and unable to sleep. She is started on a medication in the acute phase of her illness. Which of the following medications, recommended for acute use in manic patients, is recommended to be continued on into maintenance therapy?
Aripiprazole
Lamotrigine
Lithium
Olanzepine
Ziprasidone
405) A 28-year-old woman with no past medical history presents for her initial prenatal visit. Her last menstrual period (LMP) was 6 weeks ago. Vital sign: BP, 125/78 mmi P, 73 beats/mini R, 13 breaths/min, T: 98°F (37 C). She denies leakage of fluid, denies vaginal bleeding, denies fetal movement, and denies contractions, nausea and vomiting present. Labs: Complete blood count (CBC): white blood cells (WBCs); 8,000/ microL; hemoglobin (Hgb), 11.0 g/dL; hematocrit (Hct), 33.5%; platelets, 167,000/microL. CMP: Sodium, 128 mmol/ L; potassium, 4.5 mmol/L; chloride, 100 mmol/L; bicarbonate, 22 mmol/ L; blood urea nitrogen (BUN), 0.9 mg/dL; creatinine, 1 mg/dL; glucose, 97 mg/dL. Rubella IgG: positive. HIV: positive. CD4 count: 750. Viral load: 20,000 copies/mL. Hepatitis B sAg: Negative. HgbAlc: 5.6%. What is the next best step in the management of this patient?
Zidovudine now
Zidovudine starting in the second trimester
Zidovudine, lamivudine, ritonavir, and lopinavir now
Zidovudine, lamivudine, ritonavir, and lopinavir starting in the second trimester
Zidovudine, lamivudine, ritonavir, and lopinavir in 1 month later
409) A 28-year-old, HIV-infected female from Michigan is admitted with Pneumocystis jirovecii pneumonia (PCP) secondary to noncompliance with prophylaxis. She was diagnosed with HIV infection three years ago. Her CD4 count on admission is 30/microl, and viral load is 300,000copies/ml. Her pneumonia is adequately treated with IV antibiotics, and she subsequently receives zidovudine, lamivudine, nelfinavir, and trimethoprim-sulfamethoxazole. What is the most appropriate drug to be added to her current regimen?
Azithromycin
Rifabutin
Fluconazole
Itraconazole
Ganciclovir
413) A 29-year-old G0 comes to your OB/GYN office complaining of PMS. On taking a more detailed history, you learn that the patient suffers from emotional lability and depression for about 10 days prior to her menses. She reports that once she begins to bleed she feels back to normal. The patient also reports a long history of premenstrual fatigue, breast tenderness, and bloating. Her previous health-care provider placed her on oral contraceptives to treat her PMS 6 months ago. She reports that the pills have alleviated all her PMS symptoms except for the depression and emotional symptoms. Which of the following is the best next step in the treatment of this patient’s problem?
Spironolactone
Evening primrose oil
Fluoxetine
Progesterone supplements
Vitamin B6
414) A 29-year-old G0 comes to your office complaining of a vaginal discharge for the past 2 weeks. The patient describes the discharge as thin in consistency and of a grayish white color. She has also noticed a slight fishy vaginal odor that seems to have started with the appearance of the discharge. She denies any vaginal or vulvar pruritus or burning. She admits to being sexually active in the past, but has not had intercourse during the past year. She denies a history of any sexually transmitted diseases. She is currently on no medications with the exception of her birth control pills. Last month she took a course of amoxicillin for treatment of a sinusitis. On physical examination, the vulva appears normal. There is a discharge present at the introitus. A copious, thin, whitish discharge is in the vaginal vault and adherent to the vaginal walls. The vaginal pH is 5.5. The cervix is not inflamed and there is no cervical discharge. Wet smear of the discharge indicates the presence of clue cells. In the patient described in the question above, which of the following is the best treatment?
Reassurance
Oral Diflucan
Doxycycline 100 mg PO twice daily for 1 week
Ampicillin 500 mg PO twice daily for 1 week
Metronidazole 500 mg PO twice daily for 1 week
417) A 29-year-old G1P0 with an intrauterine pregnancy (IUP) at 37 weeks' gestation presents to the office for a routine prenatal visit. The patient states that she has a headache since this morning. She has no past medical history, no past surgical history, is taking no medications, and has no allergies. She denies visual disturbance, epigastric pain, nausea, and vomiting. Vital sign: BP, 150/90 mm Hg; P, 90 beats/min; R, beats/min; R, 16 breaths/min; T, 98.3°F (37.2 C). Fetal movement: Present. Contractions: Absent. Leakage of fluid: Absent. Vaginal bleeding: Absent. What is the next step in the management of this patient?
Betamethasone
Nonstress test
Labetalol
Urinalysis (UA)
Magnesium sulfate
421) A 29-year-old nonhelmeted motorcycle driver is involved in a single vehicular crash, resulting in a significant closed-head injury. He is intubated in the field and transported to a level 1 trauma center. On arrival, he is oxygenating well with assisted ventilation and has a normal blood pressure and moderate tachycardia. His Glasgow Coma Score is 7, and his pupils are equal and sluggishly reactive. After stabilization in the emergency department, the patient undergoes a CT scan of the head that demonstrates a small amount of subarachnoid blood and a right frontal lobe contusion with edema with no midline shift. CT scan of the abdomen is normal. The patient is transferred to the ICU. The optimal initial management of this patient’s intracranial pressure (ICP) would be which of the following?
Craniotomy
Fluid restriction, hyperventilation, and osmotic diuresis
fluid restriction, hyperventilation, and ventriculostomy
hyperventilation and IV steroids
normovolemia, normocarbia, sedation, and ventriculostomy
427) A 29-year-old woman complains of dysphagia with both solids and liquids, worse when she is eating quickly or is anxious. Manometry reveals normal basal esophageal sphincter pressure, with no relaxation of the sphincter on swallowing. Which of the following is the most appropriate next step in management?
beta-blocker therapy
partial esophagectomy
anticholinergic drugs
Calcium channel blockers
Dietary modification
436) A 29-year-old woman, gravida 2, para 1, at 33 weeks’ gestation is referred to your office because of a possible herpes outbreak. She developed a painful vesicular rash a few days ago in her genital area. She has never before had any similar symptoms. She has no other medical problems, takes no medications, and has no known drug allergies. Examination reveals numerous erythematous vesicles and ulcerations. Testing of the lesion demonstrates herpes simplex virus infection and serologic testing reveals that it is a primary outbreak for the patient. Which of the following is the most appropriatemanagement of this patient?
Expectant management
Immediate cesarean delivery
Immediate induction of labor
Intravenous acyclovir
Oral acyclovir
438) A 29-year-old woman, gravida 2, para 1, at 38 weeks' gestation comes to the labor and delivery ward with frequent painful contractions. Her prenatal course was significant for a urine culture that showed 100,000 colony forming units/milliliter of Group-B streptococci and asthma, for which she uses an albuterol inhaler. Examination shows that she is contracting every 2 minutes and her cervix is 5 centimeters dilated and 100% effaced. Which of the following medications should this patient be treated with during labor and delivery?
Betamethasone
Folic acid
Magnesium sulfate
Oxytocin
Penicillin
445) A 3-week-old male infant is brought to the office for the evaluation of red eyes. His temperature is 37.2 C (99F), pulse is 100/min, and respirations are 34/min. On examination, the infant has conjunctival congestion and scant mucoid discharge. The rest of the physical examination is normal. What is the most appropriate next step in the management of this patient?
Topical erythromycin
Topical silver nitrate
Topical steroids
Oral erythromycin
Oral tetracycline
447) A 3-year-old boy from a refugee camp is brought to the clinic for examination. His medical history is unknown. On examination, there is marked photophobia. He appears malnourished, and his weight is < 5th percentile for age after hydration. His bones and ribs are prominent, and little subcutaneous fat is identified. His abdomen is concave with decreased bowel sounds. There is marked scaling and fissuring at the corners of his mouth, as well as inflammation and cracking of his lips. His tongue is atrophic. The tongue and oropharyngeal mucous membranes are dark red. Conjunctival pallor is present. There are pinkish-red, erythematous, scaly patches on his eyebrows, cheeks, and nose. This dermatitis is also present on the scrotal skin and extends onto the medial aspect of both thighs. Otherwise, his skin is very pale, and his fingernails and toenails are brittle. What is the most appropriate intervention for this patient?
Dermatology referral
Ascorbic acid (vitamin C)
Ascorbic acid (vitamin C)
Riboflavin (vitamin B 2)
Thiamine (vitamin B 1)
459) A 30-year-old African-American woman with type- 1 diabetes and hypertension comes to the physician's office after obtaining a positive result from a home pregnancy test. She takes insulin and enalapril. She does not use tobacco, alcohol or illicit drugs. Her temperature is 37.2 C (99.0F), blood pressure is 130/80 mm Hg, pulse is 72/min, and respirations are 14/min. Physical examination is unremarkable. Her BUN is 18 mg/dl and creatinine is 1.4 mg/dl. A repeat β-HCG test performed in the office confirms pregnancy. Which of the following is the most appropriate next step in management?
Stop enalapril and start furosemide
Continue enalapril and add methyldopa
Stop enalapril and start labetalol
Stop enalapril and start losartan
Continue current therapy
461) A 30-year-old Caucasian female comes to the physician's office because of polyuria and polydipsia of recent onset. She has no other medical problems. She does not use tobacco, alcohol or drugs. She has no known drug allergies. Her mother has diabetes. Her temperature is 36.7°C (98°F), pulse is 75/min, blood pressure is 110/70 mmHg, and respirations are 15/min. The initial lab results are: Hb 12.7 g/dl, WBC 5,000 /cmm, Platelets 380,000/cmm, Blood glucose 90 mg/dl, Serum sodium 142 mEq/L, Serum potassium 4.0 mEq/L, Bicarbonate 26 mEq/L, BUN 15 mg/dl, Serum creatinine 0.9 mg/dl, Serum uric acid 9 mg/dl, Serum osmolality 295 mOsm/kg, Urine osmolality 160 mOsm/kg. After 12 hours of water deprivation, lab testing reveals:Serum sodium 151 mEq/L, Serum potassium 4.2 mEq/L, Bicarbonate 26 mEq/L, Serum osmolality 300 mOsm/kg, Urine osmolality 186 mOsm/kg. One hour after the subcutaneous administration of arginine vasopressin, the urine osmolality is 400mosm/kg. Which of the following is the most appropriate treatment for this patient?
Psychotherapy
Intranasal desmopressin acetate
Indomethacin
Hydrochlorothiazide
Demeclocycline
462) A 30-year-old Caucasian female patient is seen at the rheumatology clinic. She has a 4-year history of rheumatoid arthritis. Over the past year, she has noticed an improvement in her symptoms. Examination of her joints reveals less swelling and erythema than on the previous visit Laboratory studies show: CBC: Hb 10.8 g/dL, Ht 32%, MCV 104 fl, Platelet count 226,000/cmm, Leukocyte count 7,500/cmm, Neutrophils 65%, Eosinophils 1%, Lymphocytes 28%, Monocytes 6%. Serum: Serum Na 140 mEq/L, Serum K 3.9 mEq/L, Chloride 100 mEq/L, Bicarbonate 18 mEq/L, BUN 16 mg/dL, Serum Creatinine 1.1 mg/dL, Calcium 9.8 mg/dL, Blood Glucose 98 mg/dL. Which of the following medications is this patient most likely taking?
Hydroxychloroquine
Prednisone
Cyclosporin
Azathioprine
Methotrexate
464) A 30-year-old female presents with a chief complaint of palpitations. A 24-hour Holter monitor shows occasional unifocal premature ventricular contractions and premature atrial contractions. Which of the following is the best management for this patient?
Anxiolytic therapy
Beta-blocker therapy
Digoxin
Quinidine
Reassurance, no medication
469) A 30-year-old G2P0 at 39 weeks is admitted in active labor with spontaneous rupture of membranes occurring 2 hours prior to admission. The patient noted clear fluid at the time. On examination, her cervix is 4 cm dilated and completely effaced. The fetal head is at 0 station and the fetal heart rate tracing is reactive. Two hours later on repeat examination her cervix is 5 cm dilated and the fetal head is at +1 station. Early decelerations are noted on the fetal heart rate tracing. Which of the following is the best next step in her labor management?
Administer terbutaline
Initiate amnioinfusion
Initiate Pitocin augmentation
Perform cesarean delivery for arrest of descent
Perform cesarean delivery of early decelerations
475) A 30-year-old man comes to the psychiatrist for the evaluation of a depressed mood. He states that at least since his mid-20s he has felt depressed. He notes poor self-esteem and low energy, and feels hopeless about his situation, though he denies suicidal ideation. He states he does not use drugs or alcohol, and has no medical problems. His last physical examination by his physician 1 month ago was entirely normal. Which of the following treatment options should be tried first?
ECT
Hospitalization
Psychoanalysis
Venlafaxine
Amoxapine
476) A 30-year-old man has episodes of wheezing and shortness of breath two to three times per week. Approximately every 2 weeks he awakens at night due to cough and difficulties breathing. He reports having similar symptoms since he was a child, but believes that they are worsening somewhat now. His symptoms are worsened by cold air and exercise and are improved by rest. Which of the following is the most appropriate treatment?
Daily high-dose inhaled corticosteroid and β-agonist when needed
Daily high-dose inhaled corticosteroid with oral steroids for exacerbations and short-acting β-agonist when needed
Daily low-dose inhaled corticosteroid and short-acting β-agonist when needed
Daily oral steroids and long-acting β-agonist
Short-acting β-agonist when needed
478) A 30-year-old man is brought to the emergency room after he was found wandering on the streets with no shoes on in the middle of winter. He is admitted to the inpatient psychiatric unit and stabilized on antipsychotic medication. Looking at past records, his psychiatrist notes that he is repeatedly noncompliant with his medication postdischarge, and each time he relapses within 6 months. Which of the following medications is the best one for this patient to be maintained on?
Clozapine
Haloperidol decanoate
Chlorpromazine
Thioridazine
Quetiapine
479) A 30-year-old man is scheduled for a laparoscopic cholecystectomy for biliary colic. He reports a family history of prolonged paralysis during general anesthesia. Which of the following medications should be avoided during his procedure?
Succinylcholine
Vecuronium
Pancuronium
Halothane
Etomidate
495) A 31-year-old African American man presents with dyspnea on exertion. He also has fever and red tender rash on his shins. Physical examination reveals fine inspiratory crackles in both lower lung lobes and tender erythematous nodules on his legs. CXR shows bilateral hilar adenopathy and reticulonodular changes in both lungs. Transbronchial biopsy reveals noncaseating granulomas. Which of the following is the most appropriate next step in management?
Aspirin
Isoniazid (INH) and streptomycin
Steroids
Nitrogen mustard
No therapy
496) A 31-year-old African-American woman is diagnosed with uterine fibroids. Which of the following types of fibroids is most likely to interfere with conception and pregnancy?
Intracavitary
Intramural
Pedunculated
Submucosal
Subserosal
497) A 31-year-old Caucasian male complains of joint pains. He describes right knee pain, right heel pain and lowback pain. He was recently treated for urethral discharge at an outside clinic. He has no history of trauma or illicit drug use. He is afebrile, and his vital signs are stable. His right knee is swollen, tender and warm to touch; tenderness is also present over the Achilles tendon. Oral examination shows mouth ulcers. Synovial fluid analysis from the right knee shows a white blood cell count of 10,000/mm3 with many polymorphonuclear leukocytes but a negative Gram stain. Which of the following is the most appropriate initial pharmacotherapy for this patient?
Antihistamines
NSAIDs
Antibiotics
Colchicine
Allopurinol
498) A 31-year-old G3P2 woman at 37 weeks’ gestation presents to the labor and delivery floor after 2 hours of contractions of increasing frequency and intensity. An epidural anesthetic is requested on admission and placed. The patient continues to have contractions for the next 15 hours, during which time her membranes rupture spontaneously. Vaginal examination at that time reveals a cervix that is soft, 3 cm dilated, in an anterior position, and 80% effaced. The fetal head is at the -1 station. Fetal heart tracings reveal a baseline heart rate of 156/min, with variable accelerations and no significant decelerations. Which of the following is the best next step in management?
Apply intravaginal prostaglandin E2
Attempt forceps-facilitated delivery
Begin an infusion of oxytocin
Increase the rate of intravenous fluids to hydrate the patient
Proceed to cesarean section
511) A 32-year-old anxious-appearing male is wheeled into the emergency room with the sudden onset of excruciating left-sided chest pain. His temperature is 37.2°C (99°F), blood pressure is 160/88 mmHg, pulse is 125/min, regular and respirations are 20/min. Physical examination is normal, except for multiple venous track marks on his extremities and atrophic nasal mucosa. An EKG is done which shows ST depression and T wave inversion in leads V1-V6. Cardiac enzymes including CK-MB and Troponin Tare not elevated. Which of the following is the most appropriate next step in the management of this patient?
Cardiac catheterization
Administer metoprolol
Administer thrombolytics
Close observation
Intravenous diazepam
512) A 32-year-old Caucasian female presents to your office for a routine check-up. Her past medical history is significant for generalized seizures controlled with chronic phenytoin therapy. The last seizure was six months ago. She does not smoke or consume alcohol. Physical examination is insignificant, except mild pallor. Laboratory values are: Hb 10.8 g/dL, MCV 105 fl, Platelet count 180,000/cmm, Leukocyte count 7,500/cmm, Segmented neutrophils 68%, Bands 1%, Eosinophils 1%, Lymphocytes 24%, Monocytes 6%. Which of the following supplementations could have prevented this patient's anemia?
IV immunoglobulin and plasmapheresis
Administer botulinum antitoxin
IV methylprednisolone
Meticulous search for a tick
MRI of the spine
514) A 32-year-old Caucasian male is admitted to the hospital due to a 1-week history of progressive paralysis of his upper and lower extremities. He had a flu-like illness 3 weeks ago, followed by paresthesias in his fingertips and toes. The weakness initially started in his lower extremities. He denies any changes in bowel and bladder functions. His blood pressure (supine) is 130/70mm Hg, heart rate is 82/min, respirations are 18/min, and temperature is 36.9°C (98.5°F). Physical examination reveals bilateral facial paralysis, orthostatic hypotension, areflexia in all four extremities, and distal paresthesias. His CSF analysis shows: Total WBC 10/cmm, Protein 120 mg/dl, Glucose 70 mg/dl, Gram stains No organisms. What is the most appropriate next step in the management of this patient?
Intravenous methyl prednisolone
Intravenous immunoglobulin therapy
Intravenous acyclovir therapy
Botulinum antitoxin
Intravenous ceftriaxone and ampicillin
515) A 32-year-old female is crying as she approaches the office. She has had severe, unbearable pain in her face for the past five days. She describes the pain as knife-like, comes in paroxysms, occurs 10-20 times a day, and lasts a few seconds. She does not know what precipitates the attacks, but she has been unable to sleep, eat or go to work because of her symptoms. She has tried numerous pain medications, but nothing seems to relieve the pain. She denies any history of trauma, medication use or recent surgery. Vital signs are within normal limits. Physical examination is within normal limits. Which of the following agents will best benefit this patient?
Levodopa
Methotrexate
Carbamazepine
Lithium
Morphine
517) A 32-year-old G2P0101 presents to labor and delivery at 34 weeks of gestation, complaining of regular uterine contractions about every 5 minutes for the past several hours. She has also noticed the passage of a clear fluid per vagina. A nurse places the patient on an external fetal monitor and calls you to evaluate her status. The external fetal monitor demonstrates a reactive fetal heart rate tracing, with regular uterine contractions occurring about every 3 to 4 minutes. On sterile speculum examination, the cervix is visually closed. A sample of pooled amniotic fluid seen in the vaginal vault is fern and nitrazine-positive. The patient has a temperature of 38.8C, pulse 102 beats per minute, blood pressure 100/60 mm Hg, and her fundus is tender to deep palpation. Her admission blood work comes back indicating a WBC of 19,000. The patient is very concerned because she had previously delivered a baby at 35 weeks who suffered from respiratory distress syndrome (RDS). You perform a bedside sonogram, which indicates oligohydramnios and a fetus whose size is appropriate for gestational age and with a cephalic presentation. Which of the following is the most appropriate next step in the management of this patient?
Administer betamethasone
Administer tocolytics
Place a cervical cerclage
Administer antibiotics
Perform emergent cesarean section
518) A 32-year-old G2P1 woman at 16 weeks gestation presents to her obstetrician complaining of fatigue, anxiety, and palpitations. She says she has been feeling warm, even in her air-conditioned home, and has been having three or four loosestools per day, as compared to one or two prior to her pregnancy. She has a temperature of 37.1°C (98.9°F), heart rate of 105/min, and blood pressure of 128/76 mmHg. Neck examination reveals mild diffuse enlargement of the thyroid gland with no lymphadenopathy. Relevant laboratory findings include a total triiodothyronine level of 400 ng/dL, free thyroxine of 6.8 ng/dL, and thyroid-stimulating hormone of 0.01 μU/mL (normal: 0.4–4 μU/L). Results of a thyroid- stimulating hormone- receptor antibody test are positive. Which of the following is the most appropriate therapy for this patient?
High-dose iodine therapy
Methimazole
Propylthiouracil
Radioiodine ablation
Surgical resection
523) A 32-year-old G3P3 woman is postoperative day 5 after an emergent cesarean section due to fetal distress. The patient progressed rapidly through passive labor without incident, but after her membranes were ruptured manually, a fetal scalp probe was placed in the active phase secondary to several runs of mid-late decelerations. Cesarean section was ultimately performed after 2 hours of active labor secondary to fetal distress. The patient presents now with a fever to 38.7C (101.7F) and uterine tenderness. Laboratory tests reveal a WBC count of 14,000/mm3, with 70% neutrophils and 4% bands. Which of the following is the most appropriate treatment?
Ampicillin and gentamicin
Cefotaxime and levofloxacin
Clindamycin and gentamicin
Imipenem
Metronidazole and doxycycline
524) A 32-year-old G3P3 woman presents to her obstetrician for help conceiving. She states her menstrual cycles have not been regular since the birth of her third child 3 years ago. Furthermore, although she readily became pregnant with her other three children, she has failed to become pregnant despite trying over the past 2 years. She has no significant past medical history and takes only prenatal vitamins. Although she says she has not been ill lately, she reports feeling “tired and cold all the time.” She also reports she has had trouble sleeping over the past several months. Her physical examination is normal. Laboratory tests show: WBC count: 9000/mm3; Hemoglobin: 8.0 g/dL; Platelet count: 300,000/mm3; Hematocrit: 40%; Thyroid-stimulating hormone level: 0.5 μU/mL; Free thyroxine: 2.0 ng/dL; Luteinizing hormone: 0.5 mU/mL; Follicle-stimulating hormone: 0.5 mU/mL. Which of the following will this woman likely need to take to conceive?
Clomiphene
Levothyroxine
Prednisone
Progesterone
Propylthiouracil
528) A 32-year-old man from Arkansas presents to physician with a two-day history of fever, headache, malaise, and myalgias. His family says that he seems slightly confused. He recalls having a tick bite two weeks ago after walking through the woods. His temperature is 39°C (102°F), pulse is 90/min, and blood pressure is 125/80 mm Hg. Neck is supple and there is no lymphadenopathy noted. Oropharynx is clear. Chest auscultation is unremarkable. Abdomen is soft and non-tender. There is no rash evident. Neurologic examination is nonfocal. Laboratory testing shows: Complete blood count:Hemoglobin 14.0 g/L, MCV 88 fL, Platelets 78,000/mm3, Leukocyte count 2,500/mm3, Neutrophils 56%, Eosinophils 1%, Lymphocytes 33%, Monocytes 10%. Liver studies:Total protein, serum 6.5 g/dL, Total bilirubin 1.0 mg/dL, Direct bilirubin 0.8 mg/dL, Alkaline phosphatase 110 U/L, Aspartate aminotransferase (SGOT) 98 U/L, Alanine aminotransferase (SGPT) 105 U/L. What is the most appropriate next step in the management of this patient? . Doxycycline
Doxycycline
Chloramphenicol
Erythromycin
Ceftriaxone
Hepatitis serology
537) A 32-year-old woman comes to the physician because of amenorrhea. She had menarche at age 13 and has had normal periods since then. However, her last menstrual period was 8 months ago. She also complains of an occasional milky nipple discharge. She has no medical problems and takes no medications. She is particularly concerned because she would like to become pregnant as soon as possible. Examination shows a whitish nipple discharge bilaterally, but the rest of the examination is unremarkable. Urine human chorionic gonadotropin (hCG) is negative. Thyroid stimulating hormone (TSH) is normal. Prolactin is elevated. Head MRI scan is unremarkable. Which of the following is the most appropriate pharmacotherapy?
Bromocriptine
Dicloxacillin
Magnesium sulfate
Oral contraceptive pill (OCP)
Thyroxine
538) A 32-year-old woman comes to the physician because of recurrent painful outbreaks on her labia and vagina. Her first outbreak was six years ago. At that time she developed what she thought was a bad "flu" with malaise and a fever, along with a painful rash on her labia. This initial outbreak resolved, but since then she has had approximately 8 -10 outbreaks each year. Each outbreak is preceded by burning in her perineal area. A few days later she develops vesicles, then shallow, painful ulcers that resolve in about 10 days. Which of the following is the most appropriate pharmacotherapy?
Daily oral acyclovir
Daily oral estrogen
Daily topical estrogen
Daily oral ferrous sulfate
Daily oral penicillin
543) A 32-year-old woman presents to your office for her well-woman examination. She is also worried because she has not been able to achieve orgasm with her new partner, with whom she has had a relationship for the past 3 months. She had three prior sexual partners and achieved orgasm with them. She is taking a combined oral contraceptive pill for birth control and an antihypertensive medication for chronic hypertension. She has also been on fluoxetine for depression for the past 2 years. She smokes one pack per day and drinks one drink per week. She had a cervical cone biopsy for severe cervical dysplasia 6 months ago. Which of the following is the most likely cause of her sexual dysfunction?
Clonidine
Contraceptive pill
Disruption of cervical nerve pathways
Fluoxetine
Nicotine
544) A 32-year-old woman presents to your office with dysuria, urinary frequency, and urinary urgency for 24 hours. She is healthy but is allergic to sulfa drugs. Urinalysis shows large blood, leukocytes, and nitrites in her urine. Which of the following medications is the best to treat this patient’s condition?
Dicloxacillin
Bactrim
Nitrofurantoin
Azithromycin
Flagyl
548) A 32-year-old woman who is one week postpartum presents with dull pain in her left leg for the past three days. She denies any history of trauma, fever or chills. Her pregnancy and delivery were uncomplicated, and her past medical history is unremarkable. She does not use tobacco, alcohol or illicit drugs. Her temperature is 37.2C (98.9 F) and blood pressure is 120/76 mm Hg. Physical examination reveals a swollen, tender, and mildly erythematous left leg. Doppler ultrasonogram reveals a thrombus in the superficial part of the femoral vein of the left leg. Which of the following is the most appropriate next step in management?
Reassurance and ibuprofen
Anticoagulation with heparin
Inferior vena cava filter
Thrombolytic therapy
Antistaphylococcal antibiotics
555) A 32-year-old woman, gravida 3, para 2, at 30 weeks gestation comes to the hospital because of new onset painful, regular uterine contractions that began 5 hours ago. Her pregnancy has been uncomplicated. Her second pregnancy was complicated by preterm labor at 28 weeks gestation. She has no discharge, leakage of fluid or bleeding from the vagina; she has no dysuria or urgency. Her temperature is 37.0C (98.7F), blood pressure is 125/70 mmHg, pulse is 80/min and respirations are 18/min. Pelvic examination shows a soft, partially effaced and posterior cervix dilated to 2cm. A Nitrazine test is negative. Nonstress test shows a reassuring fetal heart pattern and uterine contractions occurring every 7 minutes. Which of the following is the most appropriate next step in management?
Tocolysis
Amnioinfusion
Reassure and discharge home
Augment delivery
Cervical cerclage
557) A 32-year-old woman, gravida 4, para 3, at 39 weeks' gestation comes the labor and delivery ward with painful contractions. Her prenatal course was unremarkable. Examination shows that her cervix is 5 cm dilated, 100% effaced and the fetal heart rate is in the 130s and reactive. She is given meperidine for pain control. She progresses rapidly and less than 2 hours later she delivers a 7-pound, 6-ounce (3,345g) male fetus. The one-minute APGAR score is 1 and the infant is making little respiratory effort. Which of the following is the most appropriate next step in management?
Blood transfusion
Glucose
Naloxone
Penicillin
Sodium bicarbonate
588) A 34-year-old male presents with palpitations for the past 4 hours without associated chest pain, shortness of breath, fevers, or chills. His medical history is significant for Wolff-Parkinson-White syndrome for the past ten years and three prior episodes of supraventricular tachycardia. He does not smoke cigarettes, and drinks alcohol on social occasions. He does report having had five cans of beer while at a party last night. On examination, his blood pressure is 120/80 mmHg and his pulse is irregularly irregular. EKG shows atrial fibrillation with a rate of 160/min. What is the best next step in the management of this patient?
Digoxin
Verapamil
Lidocain
Procainamide
Adenosine
596) A 34-year-old obese female returns to the physician's office for a follow-up appointment at 16 weeks gestation. She was diagnosed with gestational diabetes at 12 weeks gestation and since then has been following dietary recommendations. She eats a balanced diabetic diet three times a day and avoids snacks. Her fasting blood sugars for the past two weeks have been in between 120 to 150 mg/dl. Her temperature is 37.0C (98.7F), blood pressure is 130/88 mmHg, pulse is 76/min and respirations are 14/min. Physical examination is unremarkable. Which of the following is the most appropriate therapy for this patient?
Chlorpropamide
Tolbutamide
Insulin
Exenatide
Continue dietary therapy
601) A 34-year-old woman comes to the ER because of right lower leg swelling, redness, and pain. She has no significant past medical history and does not use any medications. Her mother has a history of pulmonary embolism. Her temperature is 36.7°C (98°F), pulse is 80/min, respirations are 16/min, and blood pressure is 120/76 mmHg. Examination shows tenderness to palpation in the right calf. Compressive ultrasonogram shows a deep vein thrombosis of the right leg. Further evaluation reveals an elevated plasma homocysteine level. She is started on heparin and warfarin therapy. What other additional therapy is indicated in this patient?
Clopidogrel
Streptokinase
Vitamin E
Pyridoxine
Simvastatin
614) A 35-year old male presents to your office complaining of nocturnal wheezing and chest tightness for the past three months. He has also noticed new hoarseness, particularly in the morning. He has no history of bronchial asthma, hypertension or diabetes. He is a non-smoker but occasionally drinks alcohol. On examination, he is an obese male in no acute distress. His pulse is 84/min, blood pressure is 130/80 mmHg, and respirations are 16/min. His chest is clear to auscultation and percussion. Laryngoscopy reveals a red and inflamed posterior pharynx and larynx. Which of the following pharmacotherapies would be most helpful for this patient?
Bedtime fluticasone inhaler
Bedtime albuterol inhaler
Oral theophylline
Oral omeprazole
Oral prednisone
615) A 35-year-old Caucasian female is hospitalized with swelling and tenderness of her right calf. Deep venous thrombosis is diagnosed through imaging studies, and the appropriate therapy is initiated. Three days later, she complains of right arm pain. Physical examination reveals a cold right upper extremity with no palpable peripheral pulse. Her laboratory values are listed below: Hematocrit 42%, WBC count 8,500/mm3, Platelets 76,000/mm3, PT 13 sec, aPTT 63 sec. Which of the following drugs was most likely used to treat this patient's deep venous thrombosis?
Aspirin
Danaparoid
Enoxaparin
Unfractionated heparin
Warfarin
619) A 35-year-old female presents to your office complaining of knee pain. She has a long history of rheumatoid arthritis affecting her hand and knee joints. The stiffness and pain has persisted over the last several months and has responded poorly to NSAIDs. Over the last two days the pain in her right knee has been interfering with her sleep. She had an episode of chills this morning. Her blood pressure is 120/70 mmHg, pulse is 90/min, temperature is 38.7°C (102°F) and respiratory rate is 18/min. Physical examination reveals swelling in the joints of her hand and wrist. The right knee is red and swollen; active and passive range of motion at the right knee is limited due to pain. This patient's current condition can be best treated with which of the following?
Colchicine
Corticosteroids
Anti-cytokine agents
Antibiotics
Antimetabolites
620) A 35-year-old G1 PO woman at 35 weeks gestation by last menstrual period and confirmed by a first trimester ultrasound comes to the hospital because of leakage of fluid one hour ago. She received her prenatal care at an outside hospital and the records are not available. She reports no other complications with this pregnancy thus far. She reports no medical problems, takes no daily medications other than a prenatal vitamin, and has no allergies to medications. She is examined and preterm premature rupture of membranes is confirmed by a positive nitrazine test, positive pooling test, and a positive ferning test. She is 2 cm dilated, 50% effaced, and at -2 station. She is admitted to the hospital. Transabdominal ultrasound confirms that the fetus is in a vertex presentation, and the amniotic fluid index is decreased at 3 cm. Fetal heart rate and contraction monitoring is started, and occasional uterine contractions are noted on the monitor. Which of the following is the most appropriate next step in management?
Urgent cesarean section
Tocolysis
Amnio dye test to confirm rupture of membranes
Betamethasone IM
Penicillin prophylaxis
621) A 35-year-old G3P3 presents to your office 3 weeks after an uncomplicated vaginal delivery. She has been successfully breast-feeding. She complains of chills and a fever to 38.3C (101F) at home. She states that she feels like she has flu, but denies any sick contacts. She has no medical problems or prior surgeries. The patient denies any medicine allergies. On examination she has a low-grade temperature of 38C (100.4F) and generally appears in no distress. Head, ear, throat, lung, cardiac, abdominal, and pelvic examinations are within normal limits. A triangular area of erythema is located in the upper outer quadrant of the left breast. The area is tender to palpation. No masses are felt and no axillary lymphadenopathy is noted. Which of the following is the best option for treatment of this patient?
Admission to the hospital for intravenous antibiotics
Antipyretic for symptomatic relief
Incision and drainage
Oral dicloxacillin for 7 to 10 days
Oral erythromycin for 7 to 10 days
623) A 35-year-old G3P3 woman has been experiencing bilateral breast pain for the past year. Breast examination and mammography are normal. Conservative measures have failed. Which of the following medications is most likely to bring relief?
Clomiphene
Tamoxifen
Danazol
Hydrochlorothiazide
Medroxyprogesterone
626) A 35-year-old HIV-positive male comes to the physician's office because of pain on swallowing and substernal burning for the last 3 days. Examination of the oral cavity is unremarkable. Lungs are clear to auscultation and percussion. His current medications include zidovudine, didanosine, indinavir, trimethoprim-sulfamethoxazole, and azithromycin. His last CD4 count is 40cells/microl. What is the most appropriate next step in the management of this patient?
Esophagoscopy with biopsy, cytology and culture
Oral Fluconazole
Oral Famotidine
Oral Acyclovir
Oral Ganciclovir
627) A 35-year-old homeless man presents to the emergency department with chief complaints of a cough and fever. He isintoxicated. He admits to drinking about a fifth of vodka every day and confirms a history of delirium tremens and blackouts. X-ray of the chest is significant for an air-fluid level in the superior segment of the right lower lobe. Which of the following is the most appropriate first-line agent for treating this patient’s condition?
Azithromycin
Clindamycin
Isoniazid
Moxifloxacin
Piperacillin-tazobactam
636) A 35-year-old white female presents with pain and stiffness of her wrist and hand joints for the last several months. Her morning stiffness lasts for more than an hour. She also complains of redness and joint swelling. Her past medical history is significant only for a similar episode one year ago. That episode resolved with over the counter ibuprofen. Examination of her joints shows redness, warmth, swelling and tenderness of proximal interphalangeal joints, metacarpophalangeal joints and wrists. X-ray shows periarticular osteopenia and erosions of the proximal interphalangeal and metacarpophalangeal joints. She started taking indomethacin with good relief. Which of the following is the most appropriate next step in the management of this patient?
Glucocorticoids
Methotrexate
Celecoxib
Azathioprine
Etanercept
637) A 35-year-old white male presents with high-grade fever, chills, rigors, malaise, and pain in his right calf for the last 24 hours. His temperature is 39.5°C (103.1°F), pulse is 105/min, blood pressure is 130/80 mmHg, and respirations are 15/min. Physical examination shows generalized swelling of the calf with linear streaks of erythema. The lesion is warm, tender, and not very well-demarcated. No pain is felt in the calf when the ankle is dorsiflexed. Scaling is found in the toe webs on the right side, and KOH preparation of these lesions show hyphae. Blood cultures are obtained. CBC shows a WBC count of 14,000 with 6% bands. What is the most appropriate next step in management?
Oral itraconazole
Oral terbinafine
Intravenous nafcillin
Oral dicloxacillin
Intravenous crystalline penicillin G
641) A 35-year-old woman has chronic auditory hallucinations in which she hears her father's voice. His voice said encouraging things to her in the past, but it has recently been scolding her and saying derogatory things about her. The woman is started on risperidone, and she returns two weeks later for a follow-up visit. Although she states that the hallucinations are much better, you notice that she is walking much slower than usual and is not swinging her arms. Also, the patient's facial expressions are rather flat and unchanging, and she admits that her writing has become smaller since starting the medication. Which of the following pharmacologic changes would be most appropriate?
Start benztropine
Start dantrolene
Start propranolol
Start sertraline
Discontinue risperidone and start haloperidol
648) A 35-year-old woman is seeing a psychiatrist for treatment of her major depression. After 4 weeks on fluoxetine at 40 mg/day, her psychiatrist decides to try augmentation. Which of the following is the most appropriate medication?
Lithium
Sertraline
An MAO inhibitor
Clonazepam
Haloperidol
657) A 35-year-old woman with type 2 diabetes comes to your office seeking pregnancy advice. Although she is not currently pregnant and has never been pregnant, she and her spouse, are planning to have their first child. She has previously managed her diabetes with diet and exercise. Approximately 4 months ago, however, you started her on metformin, as her fasting blood glucose levels were consistently elevated. Her hemoglobin A1c level at that time was 9%. She has no specific complaints today and her physical examination is unremarkable. A hemoglobin A1c level drawn 1 week before today’s visit is 6.2%. She would like to know which, if any, diabetic medications she can take during her pregnancy. Which of the following is the most appropriate pharmacologic monotherapy for her?
Acarbose
Glyburide
Insulin
Metformin
No medication, continue diet and exercise
661) A 36-year-old Caucasian male is brought to the emergency department due to weakness of his upper and lower extremities. Neurological examination reveals weakness, atrophy, fasciculations, spasticity and hyperreflexia of the involved muscles. His sensory, bowel, bladder and cognitive functions are intact. Serum creatine kinase is normal. Cerebrospinal fluid examination is within normal limits. Electromyography shows chronic partial denervation. The patient is subsequently diagnosed with amyotrophic lateral sclerosis. Which of the following has been approved for use in patients with amyotrophic lateral sclerosis?
Riluzole
Corticosteroids
Intravenous immunoglobulins
Plasmapheresis
Donepezil
662) A 36-year-old female presented to the emergency room with fever and a productive cough. The physician on call suspected community acquired pneumonia and prescribed azithromycin for 5 days. After 5 days of treatment, she comes to your office with no improvement of her symptoms and complains of worsening foul smelling sputum. Further inquiry reveals that she had undergone an upper GI endoscopy 8 days ago for a long history of heartburn and suspected peptic ulcer disease. She also reports a history of manic-type bipolar disorder. In your office she has a blood pressure of 130/80 mm Hg, her pulse is 108/min, temperature is 38.7°C (101.6°F) and respirations are 26/min. Chest x-ray showed a right upper lobe infiltrate. Which of the following additional therapies would be most helpful for this patient's condition?
Doxycycline
Ciprofloxacin
Trimethoprim-sulfamethoxazole
Clindamycin
Gentamicin+ ampicillin
666) A 36-year-old male comes to your office complaining of progressive fatigability. His past medical history is significant for infiltrative pulmonary tuberculosis diagnosed two months ago. His current treatment includes isoniazid, rifampin, ethambutol, and pyrazinamide. Laboratory values are: Hemoglobin 8 g/dl, MCV 77 fl, MCHC 30%, ESR 17 mm/hr, Serum iron 170 micro-g/dl (N 50- 150 micro-g/dl ), Total iron binding capacity (TIBC) 280 micro-g/dl (N 300-360 micro-g/dl). Microscopy reveals two populations of red blood cells (RBC)-hypochromic and normochromic. What is the next best step in the management of this patient?
Bone marrow biopsy
Iron preparations
Folic acid
Folic acid and vitamin B12
Pyridoxine
668) A 36-year-old man presents for a well-patient examination. He gives a history that, over the past 20 years, he has had three episodes of abdominal pain and hematemesis, the most recent of which occurred several years ago. He was told that an ulcer was seen on a barium upper GI radiograph. You obtain a serum assay for H pylori IgG, which is positive. What is the most effective regimen to eradicate this organism?
Omeprazole 20 mg orally once daily for 6 weeks
Ranitidine 300 mg orally once daily at bedtime for 6 weeks
Omeprazole 20 mg twice daily, amoxicillin 1000 mg twice daily, and clarithromycin 500 mg twice daily for 14 days
Pepto-Bismol and metronidazole twice daily for 7 days
Benzathine penicillin, 1.2 million units intramuscularly weekly for three doses
669) A 36-year-old man presents to the emergency room with renal colic. His vital signs are normal and a urinalysis shows microscopic hematuria. A radiograph reveals a 1.5-cm stone. Which of the following is the most appropriate management of this patient?
Hydration and analgesics
α-Adrenergic blocker
Extracorporeal lithotripsy
Percutaneous nephrostomy tube
Open surgery to remove the stone
672) A 36-year-old woman presents to the emergency room complaining of pelvic pain, fever, and vaginal discharge. She has had nausea and vomiting and cannot tolerate liquids at the time of her initial evaluation. The emergency room physician diagnoses her with pelvic inflammatory disease and asks you to admit her for treatment. Which of the following is the most appropriate initial antibiotic treatment regimen for this patient?
Doxycycline 100 mg PO twice daily for 14 days
Clindamycin 450 mg IV every 8 hours plus gentamicin 1 mg/kg load followed by 1 mg/kg every 12 hours
Cefoxitin 2 g IV every 6 hours with doxycycline 100 mg IV twice daily
Ceftriaxone 250 mg IM plus doxycycline 100 mg PO twice daily for 14 days
Ofloxacin 400 mg PO twice daily for 14 days plus Flagyl 500 mg PO twice daily for 14 days
675) A 36-year-old woman who lives in the suburbs of a large city comes to your office for a tuberculin skin test. She will be volunteering in her daughter's school cafeteria and the school district requires tuberculin testing. You inject a small amount of Mycobacterium tuberculosis purified protein derivative (PPD) in the skin and 2 days later she returns for a reading. You measure 12 mm of induration. She reports no history of tuberculosis exposure and no underlying medical conditions. She has never before been tested for tuberculosis. She was born in the United States, is not a healthcare worker, and has never spent time in prison. What is the best next step in her management?
Chest X-ray
Observation
Isoniazid for 6 months
Isoniazid with pyridoxine for 9 months
Isoniazid, rifampin and pyrazinamide for 8 weeks
678) A 36-year-old woman, gravida 3, para 3, is 2 days status post cesarean section for dystocia when she begins wandering the hallways of the hospital at 2 AM. She is extremely confused and thinks that she is at the police station. She states that she cannot sleep, feels very anxious, and wants to hurt her baby. Her prenatal course was unremarkable. She has no medical problems and had never had surgery. She has been taking Tylenol with codeine postpartum for incisional pain. Which of the following is the most appropriate next step in the management?
Fluoxetine
Morphine
Naloxone
Psychiatric hospitalization
Supervised visit to the nursery
681) A 37-year-old man comes to his primary care physician for the evaluation of slightly pruritic skin lesions around his anus. He denies fever, malaise, and anorexia. He is sexually active with multiple male partners and occasionally uses condoms. He has never been tested for HIV or other sexually transmitted diseases. He has no drug allergies. Examination shows skin-colored, verrucous, papilliform lesions around his anus. Which of the following is the most appropriate treatment for this patient?
Podophyllin
Penicillin
Erythromycin
Doxycycline
Tetracycline
682) A 37-year-old obese man returns to his doctor for a follow-up visit. One month ago, he was diagnosed with type II diabetes mellitus and was started on metformin. His fasting glucose is 122 mg/dl, and his blood pressure is 145/85 mm Hg. The patient looks rather dejected and admits it has been difficult to come to terms with his diagnosis. He has tried to exercise, watch his diet, and quit smoking as was suggested, but lately he has been feeling unmotivated and without energy. He admits to feeling sad and guilty about his weight, but is not sure he will be able to do anything about it. He continues to smoke despite attempts to cut back, and has been spending much of the day in bed watching television or sleeping. He has withdrawn from friends and family and took the last two weeks off from work, as he did not feel "up to going." Which of the following would be the best medication to prescribe at this time?
Bupropion
Fluoxetine
Modafini
Selegiline
Venlafaxine
683) A 37-year-old obese, hypertensive female comes to the physician because of intermenstrual bleeding and heavy menses. Endometrial biopsy shows "complex hyperplasia without atypia." She has two young healthy children and does not want more children in the future. W hich of the following is the most appropriate next step in management?
Hysterectomy
Cyclic progestins
Low dose oral contraceptives
Estrogen replacement
Raloxifen
685) A 37-year-old white female presents with galactorrhea and amenorrhea for the past 7 months. She denies any headaches, visual problems, vaginal dryness or dyspareunia. She is married, has two children, and remarks that her family is "complete." She does not use tobacco, alcohol or drugs. Her blood pressure is 120/80 mmHg, pulse is 72/min, temperature is 36.7°C (98.6°F) and respirations are 14/min. Visual field testing is within normal limits. Pregnancy test is negative. Her serum prolactin level is 150ng/ml. Pituitary MRI shows a 6mm pituitary adenoma. Which of the following is the most appropriate next step in the management of this patient?
Surgery
Treatment with cabergoline
Treatment with estrogens
Radiotherapy
Monitoring by serum prolactin and MRI
686) A 37-year-old woman comes to the physician because of intermenstrual bleeding and heavy menses. Her other medical problems include hypertension, type 2 diabetes, and hyperlipidemia. Her blood pressure is 144/86 mm Hg. Her BMI is 40 kg/m2. Physical examination shows no obvious abnormalities. Endometrial biopsy shows "complex hyperplasia without atypia." She has three young healthy children and does not want more children in the future. Which of the following is the most appropriate next step in management?
Hysterectomy
Cyclic progestins
Low dose oral contraceptives
Estrogen replacement
Endometrial ablation
689) A 37-year-old woman presents to your office with severe vertigo, postural instability, and vomiting. She also complains of "a buzzing sound" in her right ear. She has had two similar episodes over the previous year that lasted several hours and resolved spontaneously. She has no other medical problems. Her mother died of breast cancer at 55 years of age and her father is currently suffering from colon cancer. Her heart rate is 90/min and blood pressure is 130/80 mmHg. Her BMI is25.3 kg/m2. Examination reveals horizontal nystagmus. Which of the following could have prevented this patient's symptoms?
Caloric restriction
Low salt diet
Gluten-free diet
High complex carbohydrate diet
Calcium supplementation
695) A 38-year-old G3P2 at 40 weeks gestation presents to labor and delivery with gross rupture of membranes occurring 1 hour prior to arrival. The patient is having contraction every 3 to 4 minutes on the external tocometer, and each contraction lasts 60 seconds. The fetal heart rate tracing is 120 beats per minute with accelerations and no decelerations. The patient has a history of rapid vaginal deliveries, and her largest baby was 3200 g. On cervical examination she is 5 cm dilated and completely effaced, with the vertex at −2 station. The estimated fetal weight is 3300 g. The patient is in a lot of pain and requesting medication. Which of the following is the most appropriate method of pain control for this patient?
Intramuscular Demerol
Pudendal block
Local block
Epidural block
General anesthesia
696) A 38-year-old male with a chronic history of schizophrenia is admitted to the hospital for deterioration in his condition. He is a known patient and was stable on risperidone for the past few years. Today, the patient does not respond when spoken to and he sits motionlessly. He makes no eye contact and his face remains expressionless. Vital signs include temperature of 37.0°C (98.6°F), blood pressure of 132/80 mm Hg, pulse of 88/min, and respirations of 14/min. Physical examination demonstrates diffuse muscle rigidity but is otherwise unremarkable. Which of the following would be the most appropriate next step?
Increase risperidone dose
Initiate therapy with dantrolene sodium
Replace risperidone with quetiapine
Continue same dose of risperidone and add clozapine
Administer lorazepam
699) A 38-year-old woman has been complaining of a 2-year history of increasing dyspnea and fatigue. Physical examination reveals increased JVP and a reduced carotid pulse. Precordial examination reveals a left parasternal lift, loud P2, and right-sided S3 and S4. There are no audible murmurs. CXR reveals clear lung fields and an ECG shows evidence of right ventricular hypertrophy. Pulmonary function tests show a slight restrictive pattern. Primary pulmonary hypertension is diagnosed. Which of the following treatments is helpful in this condition?
Corticosteroids
Nitrates
Alpha-adrenergic blockers
Calcium channel blockers
Angiotensin-converting enzyme (ACE) inhibitors
700) A 38-year-old woman is 10 weeks pregnant with her second pregnancy and is found to have blood pressures exceeding the 150 to 160 mm Hg systolic range and 100 to 110mm Hg diastolic range at her first prenatal visit. She has no other medical problems. She had a cholecystectomy at the age of 20. She takes no medications and is allergic to sulfa drugs. Her family history is significant for hypertension on both her maternal and paternal sides. Physical examination is normal, including an obstetrical ultrasound demonstrating a 10-week intrauterine pregnancy. The patient is diagnosed with chronic hypertension. Which of the following should be used as first-line antihypertensive therapy for this patient?
Atenolol
Captopril
Lisinopril
Magnesium sulfate
Methyldopa
703) A 38-year-old woman presents with several months of decreased libido and a 4.5-kg (10-lb) weight gain. She has not had her menstrual period for the past 3 months. Physical examination is unremarkable except that a small amount of white discharge is manually expressed from the nipples bilaterally. The serum prolactin level is 300 ng/mL. Which of the following is the most appropriate first-line treatment?
Bromocriptine
Cortisol
Methyldopa
Metoclopramide
Octreotide
717) A 39-year-old woman known to have fibrocystic disease of the breast complains of persistent fullness and pain in both breasts. Which of the following drugs will be most effective in relieving her symptoms?
Tamoxifen
Bromocriptine
Danazol
Medroxyprogesterone acetate
Hydrochlorothiazide
719) A 39-year-old woman with a known history of von Willebrand disease has a ventral hernia after a previous cesarean section and desires to undergo elective repair. Which of the following should be administered preoperatively?
High-purity factor VIII: C concentrates
Low-molecular-weight dextran
Fresh-frozen plasma (FFP)
Cryoprecipitate
Whole blood
724) A 39-year-old woman, gravida 3, para 2, at term comes to the labor and delivery ward complaining of a gush of fluid. Examination shows her to be grossly ruptured, and ultrasound reveals that the fetus is in vertex presentation. The fetal heart rate is in the 120s and reactive. After a few hours, with no contractions present, oxytocin is started. Three hours later, the tocodynamometer shows the patient to be having contractions every minute and lasting for approximately 1 minute with almost no rest in between contractions. The fetal heart rate changes from 120s and reactive to a bradycardia to the 80s. Sterile vaginal examination shows that the cervix is 6 cm dilated. Which of the following is the most appropriate next step in management?
Discontinue oxytocin
Start magnesium sulfate
Perform forceps assisted vaginal delivery
Perform vacuum assisted vaginal delivery
Perform cesarean delivery
725) A 39-year-old woman, gravida 4, para 3, comes to the physician for a prenatal visit. Her last menstrual period was 8 weeks ago. She has had no abdominal pain or vaginal bleeding. She has no medical problems. Examination is unremarkable except for an 8-week sized, nontender uterus. Prenatal labs are sent. The rapid plasma reagin (RPR) test comes back as positive and a confirmatory microhemagglutination assay for antibodies to Treponema pallidum (MHA-TP) test also comes back as positive. Which of the following is the most appropriate pharmacotherapy?
Erythromycin
Levofloxacin
Metronidazole
Penicillin
Tetracycline
727) A 4-week-old infant presents with tachycardia, tachypnea, and poor weight gain. His arterial blood gas shows a pH of 7.34, a PaCO2 of 41 mm Hg, and a PaO2 of 74 mm Hg. A chest radiograph shows cardiomegaly. Echocardiography reveals a structurally normal heart, left ventricular dilatation, a left ventricular ejection fraction of 20%, and mild mitral and tricuspid regurgitation. IV administration of which of the following medications is the best initial step in management of this patient?
Angiotensin-converting enzyme inhibitor
Corticosteroid
Digoxin
Epinephrine
Furosemide
729) A 4-year-old boy is brought to the emergency department for a painful and swollen right forearm. He was bitten and scratched by a family cat 2 days ago in the affected area. His temperature is 39.6 C (103.2 F). The right forearm is erythematous, edematous, and tender to touch. Which of the following is the most appropriate antibiotic treatment for this patient?
Ampicillin
Amoxicillin-clavulanate
Clindamycin
Tetracycline
Trimethoprim-sulfamethoxazole
730) A 4-year-old boy presents with 5-day history of fever and increased irritability. His temperature is 40.2 C (104.3 F), blood pressure is 98/68 mm Hg, pulse is 112/min, and respirations are 24/min. On physical examination, he is noted to have bilateral cervical lymphadenopathy, cracked lips, strawberry tongue, and bilateral conjunctival injection. His palms and soles are erythematous. There is a polymorphous macular rash generalized on his body. Which of the following is the most appropriate pharmacotherapy?
Amoxicillin
Aspirin and corticosteroid
Aspirin and IV immune globulin
Corticosteroid
IV immune globulin
744) A 40-year-old female presents to the emergency room with palpitations and lightheadedness of acute onset. Also, she has experienced insomnia, fatigability, and weight loss lately. She does not smoke or consume alcohol. She is not taking any medication. Her blood pressure is 110/80 mmHg and heat rate is 120/min, irregular. Physical examination reveals lid lag and fine tremor of the outstretched hands. ECG shows atrial fibrillation with rapid ventricular response. What is the next best step in the management of this patient?
Digoxin
Propranolol
Lidocaine
Quinidine
Immediate cardioversion
746) A 40-year-old male presents with six months of worsening dyspnea. His symptoms have progressed to the point that walking even one block causes him to become shot of breath. He has a history of cigarette smoking, but quit 10 years ago. He drinks approximately one alcoholic drink daily. His medical history is significant for peptic ulcer disease for which he takes antacids. On physical examination, he is afebrile. His pulse is 86/min, blood pressure is 140/56 mmHg, and respiratory rate is 14/min. While examining his heat you note a high-pitched blowing, early diastolic, decrescendo murmur, which is heard best in the left third intercostal space and is intensified by handgrip. There is prominent cardiomegaly on chest x-ray. Which of the following medications would improve both this patient’s symptoms and cardiomegaly?
Quinidine
Metoprolol
Nifedipine
Ephedrine
Amiodarone
768) A 42-year-old man develops right calf pain one week after having a left hemi-colectomy. On physical examination, there is moderate right ankle edema and right calf pain with dorsiflexion of the right foot. Duplex ultrasonography shows a clot in the right superficial femoral vein. Which of the following is the most appropriate initial treatment?
Aspirin
Heparin
Streptokinase
Warfarin
Tissue plasminogen activator
771) A 42-year-old man sustains a gunshot wound to the abdomen and is in shock. Multiple units of packed red blood cells are transfused in an effort to resuscitate him. He complains of numbness around his mouth and displays carpopedal spasm. An electrocardiogram demonstrates a prolonged QT interval. Which of the following is the most appropriate treatment?
Intravenous potassium
Intravenous calcium
Intravenous digoxin
Intravenous parathyroid hormone
Intravenous bicarbonate
772) A 42-year-old man with advanced HIV infection has a two-week history of pain and difficulty with swallowing. He was given fluconazole for these symptoms one week ago, but his pain has worsened. His current medications include tenofovir, emtricitabine, efavirenz, and trimethoprim-sulfamethoxazole. His CD4 count is 90/microl and viral load is 300,000copies/ml. Endoscopy reveals large, irregular, linear ulcers in the esophagus. A biopsy of the abnormal mucosa reveals tissue destruction and the presence of intranuclear and intracytoplasmic inclusions. Which of the following is the most appropriate pharmacotherapy for this patient?
Prednisone
Acyclovir
Pentamidine
Ganciclovir
Itraconazole
773) A 42-year-old mildly overweight Caucasian male is being worked-up for his second episode of deep venous thrombosis in two years. Both episodes seem to have been unprovoked. He denies any recent prolonged immobility, long-distance travel or lower extremity trauma. He has no past medical history of diabetes, cancer or liver disease. A thrombophilia work-up is ordered for this patient. Use of which of the following drugs is most likely to give a false-positive result for protein S deficiency?
Heparin
Warfarin
Aspirin
Clopidogrel
Simvastatin
779) A 42-year-old woman presents to her physician with complaints of fever (38.2°C [100.8°F]) and mild-to-moderate anterior neck pain. On examination the physician finds her to be tachycardic and sweating, and to have an exquisitely tender thyroid gland. Her blood work shows a depressed thyroid-stimulating hormone level and increased free thyroxine. Which of the following is the most appropriate treatment at this time?
Acetaminophen
Ibuprofen
Levothyroxine
Prednisone
Radioactive iodine
785) A 42-year-old woman, gravida 2, para 1, at 10 weeks' gestation comes to the physician for her first prenatal visit. She has no complaints. She has a history of Trichomonas infection, but no other medical problems. Examination is significant for a 10-week sized, nontender uterus. During the speculum examination, a Pap smear is performed and gonorrhea and Chlamydia screening tests are taken. The next day, the gonorrhea test returns as positive. Which of the following is the most appropriate pharmacotherapy?
Ceftriaxone
Clindamycin
Doxycycline
Levofloxacin
Metronidazole
786) A 42-year-old woman, gravida 4, para 3, at 38 weeks' gestation, comes to the labor and delivery ward complaining of contractions. She has had type 1 diabetes since the age of 20. She has a history of syphilis that was adequately treated 4 years ago. She took insulin and prenatal vitamins throughout the pregnancy. Otherwise, her prenatal course was unremarkable, including normal screening. Her blood pressure is 140/90 mm Hg. Her cervix is 4 cm dilated and 100% effaced. She is admitted. Which of the following IV medications will this patient likely require during labor and delivery to prevent neonatal complications?
Hydralazine
Insulin
Labetalol
Meperidine
Penicillin
{"name":"Medicament USMLE VTH 2", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"377) A 27-year-old woman presents to your office complaining of mood swings, depression, irritability, and breast pain each month in the week prior to her menstrual period. She often calls in sick at work because she cannot function when she has the symptoms. Which of the following medications is the best option for treating the patient’s problem?, 382) A 28-year-old attorney presents complaining of a six-month history of extreme nervousness, irritability, and restlessness. He is \"plagued\" by recurrent thoughts of not being able to properly carry out his responsibilities at the office. He dreads the possibility of not being offered a position as partner in the law firm. As a result, he finds himself unable to concentrate well or perform his duties efficiently. He is also engaged to be married, and spends sleepless nights thinking about the responsibilities of married life. He worries that he will not be a good husband or father. He denies any history of alcohol intake, but has recently begun drinking two bottles of beer every night for the past month as a means of escaping from his distressing thoughts. Which of the following is the treatment of choice for this patient?, 383) A 28-year-old female presents to her internist with a 2-day history of low-grade fever and lower abdominal pain. She denies nausea, vomiting, or diarrhea. On physical examination, there is temperature of 38.3°C (100.9°F) and bilateral lower quadrant tenderness, without point or rebound tenderness. Bowel sounds are normal. On pelvic examination, an exudate is present and there is tenderness on motion of the cervix. Her white blood cell count is 15,000\/μL and urinalysis shows no red or white blood cells. Serum β-hCG is undetectable. Which of the following is the best next step in management?","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
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