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Management USMLE 11 (1408-1500)

After making a diagnosis in the patient in question 319, you recommended that she wear loose clothing and cotton underwear and to stop using tampons. After 1 month she returns, reporting that her symptoms of intense burning and pain with intercourse have not improved. Which of the following treatment options is the best next step in treating this patient’s problem?

Podophyllin

. Surgical excision of the vestibular glands

. Topical Xylocaine

. Topical trichloroacetic acid

. Valtrex therapy

An 11-month-old African American boy has a hematocrit of 24% on a screening laboratory done at his well-child checkup. Further testing demonstrates: hemoglobin 7.8 g/dL; hematocrit 22.9%; leukocyte count 12,200/μL with 39% neutrophils, 6% bands, 55% lymphocytes; hypochromia on smear; free erythrocyte protoporphyrin (FEP) 114 μg/dL; lead level 6 μg/dL whole blood; platelet count 175,000/μL; reticulocyte count 0.2%; sickle-cell preparation negative; stool guaiac-negative; and mean corpuscular volume (MCV) 64 fL. Which of the following is the most appropriate recommendation?

. Blood transfusion

. Oral ferrous sulfate

. Intramuscular iron dextran

. An iron-fortified cereal

. CalciumEDTA

An 11-year-old boy presents with fever and sore throat. A rapid-strep test confirms streptococcal pharyngitis. He is leaving for a summer camp in 2 days. In the past, he has had problem finishing the whole course of antibiotic treatment. Which of the following is the best treatment for his streptococcal pharyngitis?

. A single dose of benzathine penicillin G intramuscularly

. A single dose of ceftriaxone intramuscularly

. A single dose of procaine penicillin G intramuscularly

. Erythromycin orally for 5 days

. Penicillin V orally for 5 days

An 18-year-old college student, who has recently become sexually active, is seen for severe primary dysmenorrhea. She does not want to get pregnant, and has failed to obtain resolution with heating pads and mild analgesics. Which of the following medications is most appropriate for this patient?

. Prostaglandin inhibitors

. Narcotic analgesics

. Oral contraceptives

. Oxytocin

. Luteal progesterone

An 18-year-old G1 has asymptomatic bacteriuria (ASB) at her first prenatal visit at 15 weeks gestation. Which of the following statements is true?

. The prevalence of ASB during pregnancy may be as great as 30%.

. There is a decreased incidence of ASB in women with sickle cell trait.

. Fifteen percent of women develop a urinary tract infection after an initial negative urine culture.

Twenty-five percent of women with ASB subsequently develop an acute symptomatic urinary infection during the same pregnancy and should be treated with antibiotics.

. ASB is highly associated with adverse pregnancy outcomes.

An 18-year-old previously healthy man is placed on intravenous heparin after having a pulmonary embolism (PE) after exploratory laparotomy for a small-bowel injury following a motor vehicle collision. Five days later, his platelet count is 90,000/μL and continues to fall over the next several days. The patient’s serum is positive for antibodies to the heparinplatelet factor complexes. Which of the following is the most appropriate next step management?

. Cessation of all anticoagulation therapy

. Cessation of heparin and immediate institution of high-dose warfarin therapy

. Cessation of heparin and institution of low-molecular-weight heparin

. Cessation of heparin and institution of lepirudin

. Cessation of heparin and transfusion with platelets

An 8-month-old boy is seen by a pediatrician for the first time. The physician notes that there are no testes in the scrotum. Which of the following is the optimal management of bilateral undescended testicles in an infant?

. Immediate surgical placement into the scrotum

Chorionic gonadotropin therapy for 1 month; operative placement into the scrotum before age 2 if descent has not occurred

. Observation until age 2; operative placement into the scrotum if descent has not occurred

. Observation until age 5; if no descent by then, plastic surgical scrotal prostheses before the child enters school

No therapy; reassurance of the parent that full masculinization and normal spermatogenesis are likely even if the testicle does not fully descend

An 8-month-old girl is brought to the clinic for a well-baby checkup. Her antenatal and birth histories are unremarkable. Her vital signs are stable, and all developmental milestones are appropriate. On examination, a head tilt is noted. Ophthalmoscopic examination reveals a red reflex and normal corneal light reflex. The cover test reveals moderate esodeviation of the left eye. What is the most appropriate next step in the management of this patient?

Continuous covering of the normal eye

Continuous covering of the deviated eye

Prompt surgical correction

Measurement of intraocular pressure

Watchful waiting

An 8-year-old African American boy is brought in for evaluation of a mass on the scalp. On examination, he is afebrile and nontoxic. There is a boggy mass on his scalp with alopecia. His posterior cervical lymph nodes are enlarged but nontender. Which of the following is the most appropriate treatment?

Incision and drainage

Oral amoxicillin

IV naficillin

Selenium sulfide shampoo twice a week

Oral griseofulvin and selenium sulfide shampoo twice weekly

An 80-year-old man is admitted to the hospital complaining of nausea, abdominal pain, distention, and diarrhea. A cautiously performed transanal contrast study reveals an apple-core configuration in the rectosigmoid area. Which of the following is the most appropriate next step in his management?

. Colonoscopic decompression and rectal tube placement

. Saline enemas and digital disimpaction of fecal matter from the rectum

. Colon resection and proximal colostomy

. Oral administration of metronidazole and checking a Clostridium difficile titer

. Evaluation of an electrocardiogram and obtaining an angiogram to evaluate for colonic mesenteric ischemia

An 80-year-old woman was admitted to your service for dizziness. Cardiac monitoring initially revealed atrial fibrillation with rapid ventricular response. Her ventricular rate was controlled with beta-blocker. An echocardiogram revealed an enlarged left atrium and an ejection fraction of 50%. No evidence of diastolic heart dysfunction was noted. She is now asymptomatic, with blood pressure 130/80 mmHg, heart rhythm irregularly irregular, and heart rate around 80/minute. Which of the following is the best management strategy of this patient’s arrhythmia?

. Electrical cardioversion plus prolonged anticoagulation

. Electrical cardioversion without anticoagulation

. Chemical cardioversion plus prolonged anticoagulation

. Chemical cardioversion without anticoagulation

. Continued rate control plus prolonged anticoagulation

An 82-year-old man develops severe abdominal distention, nausea, vomiting, and colicky abdominal pain. He has not passed any gas or stools for the past 12 hours. His vital signs are normal, and his pulse is regular. He has a distended, tympanitic abdomen, with hyperactive, highpitched bowel sounds. There are no signs of peritoneal irritation. Rectal examination is negative for masses or occult blood, and trie rectal vault is empty. Abdominal xray films show distended loops of small and large bowel, as well as a very large round gas shadow that is located in the right upper quadrant and tapers toward the left lower quadrant in the shape of a parrot's beak. The patient has never had any abdominal surgery, and he does not have any palpable hernias. Which of the following is the most appropriate next step in management?

Nasogastric suction, IV fluids, and observation

Repeated enemas and laxatives

Emergency celiac and mesenteric arteriogram

Proctosigmoidoscopy

Emergency exploratory laparotomy

An 89-year-old man has lost 30 lb over the past 2 years. He reports that food frequently sticks when he swallows. He also complains of a chronic cough. Barium swallow is shown here. What is the best treatment option for this patient?

. Placement of an esophageal stent

Diverticuloplasty

. Excision of the diverticulum

. Excision of the diverticulum and administration of a promotility agent

. Excision of the diverticulum and cricopharyngeal myotomy

An active 78-year-old female with history of hypertension presents with the new onset of left hemiparesis. Cardiac monitoring reveals atrial fibrillation. She had been in sinus rhythm on check-up 3 months earlier. Optimal management at discharge includes a review of antihypertensive therapy, a ventricular rate control agent, and which of the following?

. Automated implanted cardioverter-defibrillator (AICD)/permanent pacemaker to avoid the need for anticoagulation

. Immediate direct-current cardioversion

. Antiplatelet therapy such as aspirin, without warfarin

. Antiplatelet therapy plus warfarin with a target INR of 1.5

. Warfarin with a target INR of 2.0 to 3.0.

An infant is delivered vaginally to a 30-year-old G1P1 woman whose pregnancy was uneventful. Examination of the newborn reveals mild atrophy of the left calf. His left calcaneum and talus are in equinus and varus positions, his midfoot is in varus position, and his forefoot is in adduction. Dorsiflexion and plantar flexion of the ankle are limited. The neurologic examination is normal. What is the next best step in the management of this patient?

Reassurance

Stretching, manipulation, followed by serial casting

Casting of the whole leg up to the hip

Surgical correction within the first month of life

Watchful waiting

An obese patient with a long-standing history of type 2 DM presents to his primary care physician. On examination he has decreased sensation in both lower extremities. Upon questioning of his compliance with his prescribed medications, he reports that he has stopped taking one medication because it gave him flatulence and abdominal pain. Which of the following did this man most likely stop taking?

An α-glucosidase inhibitor

Meglitinide

Metformin

Sulfonylurea

Thiazolidinedione

Children with sickle cell anemia are at increased risk of developing overwhelming infection with certain microorganisms. Which of the following is the most reasonable step to prevent such infection?

Periodic injections of gamma globulin

Injection of VZIG after exposure to varicella

Withholding live virus vaccines

Prophylactic administration of oral penicillin daily

Early use of amoxicillin at home for episodes of fever

During a bar brawl, a 19-year-old man sustains a 4-in laceration on his left arm from glass and presents to the emergency room the following morning, 10 hours later. He is neurovascularly intact and the wound is deep, extending down to fascia. Which of the following is the most appropriate management of the wound?

. Closure of the skin only and administration of oral antibiotics for 1 week

. Closure of the skin and subcutaneous tissue and administration of oral antibiotics for 1 week

. A single dose of intravenous antibiotics and closure of the skin only

. A single dose of intravenous antibiotics and closure of the skin and subcutaneous tissue

. Local wound care without wound closure or antibiotics

During a screening physical examination for participating in high school sports, a 14-year-old girl is found to have a late apical systolic murmur preceded by a click. The rest of the examination is unremarkable. Echocardiography shows superior displacement of the mitral leaflets of > 2 mm during systole into the left atrium, with a thickness of at least 8 mm. In addition, she states that her father also has some type of heart “murmur,” but she knows nothing else about it. Which of the following is the most appropriate management at this time?

Digoxin

Instruct the patient to avoid all forms of strenuous activity

Metoprolol

Mitral valve replacement

Prophylactic antibiotics for dental procedures

During diagnostic evaluation, a 14-year-old girl with menorrhagia, frequent nosebleeds, and iron deficiency anaemia is found to have a low platelet count with a normal coagulation profile. Bone marrow biopsy reveals abundant megakaryocytes. On abdominal examination, no organomegaly is noted. Which of the following is the most appropriate initial therapy for this patient?

. splenectomy

. Platelet transfusion when peripheral platelet count drops below 50,000/mL

. Systemic steroids

Chemotherapy

. Expectant, with intervention only if the patient develops significant clinical bleeding.

Eight days after a difficult hemigastrectomy and gastroduodenostomy for gastric ulcer, a patient begins to leak 2-3 L of greenish fluid per day through the right corner of his bilateral subcostal surgical incision. He is afebrile and has no clinical signs of an acute abdomen. At surgery, a feeding catheter jejunostomy was placed, through which the patient has been receiving 3 L/day of elemental diet with a caloric content of 1 cal per mL, and 1 g nitrogen per 100 cal. The nursing staffs have rigged a very effective collection device for the fluid that is leaking through the wound, and the skin around the site is well protected. Which of the following is the most appropriate next step in management?

No changes in the present therapeutic plan

Addition of 2-3 L per day of IV Ringer's lactate

Immediate discontinuation of the jejunal feeding, and replacement by 5 L/day of IV 5% dextrose-half normal saline

Surgical drainage of the operative area

Surgical reconstruction of die gastroduodenostomy

Following a boating injury in an industrial-use river, a patient begins to display fever, tachycardia, and a rapidly expanding area of erythema, blistering, and drainage from a flank wound. An x-ray shows gas in the soft tissues. Which of the following measures is most appropriate?

. Administration of an antifungal agent

. Administration of antitoxin

. Wide debridement

. Administration of hyperbaric O2

. Early closure of tissue defect

1497) Following significant head trauma, a 34-year-old woman undergoes a CT scan that demonstrates bilateral frontal lobe contusions of the brain. There is no midline shift. She has a GCS of 14. Which of the following is the best initial management of this patient?

. Observation alone

. Observation and administration of anticonvulsive medication for 1 week

. Placement of an intracranial pressure monitor

. Administration of 25 g of mannitol

. Intubation and hyperventilation

Four days after surgical evacuation of an acute subdural hematoma, a 44-year-old man becomes mildly lethargic and develops asterixis. He has received 2400 mL of 5% dextrose in water intravenously each day since surgery, and he appears well hydrated. Pertinent laboratory values are as follows:Serum electrolytes (mEq/L): Na+ 118, K+ 3.4, Cl− 82, HCO3− 24Serum osmolality: 242 mOsm/LUrine sodium: 47 mEq/LUrine osmolality: 486 mOsm/LWhich of the following is the best treatment of his hyponatremia?

. Insulin infusion to keep his glucose level less than 110 mg/dL

. Slow infusion of 3% normal saline until neurologic symptoms are improved

. Rapid infusion of 3% normal saline to correct the sodium to normal

. Desmopressin (DDAVP) administration

. Administration of a loop diuretic

Four of your patients who came to the office today all have signs and symptoms of hyperthyroidism. After the appropriate evaluation, you decided to treat them with radioactive iodine. Hyperthyroid patients with which of the following disorders are most likely to develop hypothyroidism following radioactive therapy?

. Graves' disease

. Toxic adenoma

. Multinodular goiter

. Ectopic production of thyroid hormones

. Thyroid Cancer

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