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Management USMLE 4 (603-698)

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

. Characterized by systemic signs of inflammation

. Predominantly treated symptomatically

. Characterized by a poor prognosis

. Usually more frequent in men

. Characterized by death secondary to a renal crisis

A 34-year-old woman with no PMH presents to the office for intermittent left lower quadrant pain, nonradiating for the past 24 hours. She had her menstruation 1.5 weeks ago. She has no nausea, vomiting, diarrhea, or constipation. She denies dysuria, urinary urgency, and urinary frequency. BP, 122/84 mm Hg; P, 90; R, 13 breaths/min; T, 98.7°F. ROS: Denies fever and chills; AS per RPI. PE: Abd: soft, nondistended, left lower quadrant tenderness is present on superficial and deep palpation. The pain radiates toward the midline. Which of the following is the next step in the management of this patient?

BHCG

CBC

. Pelvic US

. Morphine administration

. Abdominal CT

A 34-year-old woman, gravida 3, para 2, at 38 weeks gestation presents to the labor and delivery ward complaining of headache. She has no contractions. Her prenatal course was unremarkable until she noted the onset of swelling in her face, hands, and feet this week. Her obstetric history is significant for two normal spontaneous vaginal deliveries. She has no significant past medical or surgical history. Her temperature is 37 C (98.6 F), blood pressure is 160/92 mm Hg, pulse is 78/min, and respirations are 16/min. Examination reveals 3+ patellar reflexes bilaterally. A cervical examination reveals that her cervix is 3 cm dilated and 50% effaced and soft, and that the fetus is at 0 station and vertex. The fetal heart rate has a file:///D:/DES_Entry_2016MCQs/3C_USMLE/C-4Management/4Manag... 128 of 334 12/21/2016 3:59 PM baseline of 140/min and is reactive. The results from a 24-hour urine collection show 5200 mg of protein (normal < 300 mg/24 hours). The patient is given magnesium sulfate intravenously for seizure prophylaxis. Which of the following is the most appropriate next step in the management of this patient?

Expectant management

Intramuscular glucocorticoids

IV oxytocin

Subcutaneous terbutaline

Cesarean section

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

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

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

. Treatment with external beam radiation

. Implantation of radioactive cesium into the cervical canal

. Simple hysterectomy

. Simple hysterectomy with pelvic lymphadenectomy

. Radical hysterectomy

A 35-year-old previously healthy male develops cough with purulent sputum over several days. On presentation to the emergency room, he is lethargic. Temperature is 39°C, pulse 110, and blood pressure 100/70. He has rales and dullness to percussion at the left base. There is no rash. Flexion of the patient’s neck when supine results in spontaneous flexion of hip and knee. Neurologic examination is otherwise normal. There is no papilledema. A lumbar puncture is performed in the emergency room. The cerebrospinal fluid (CSF) shows 8000 leukocytes/μL, 90% of which are polys. Glucose is 30 mg/dL with a peripheral glucose of 80 mg/dL. CSF protein is elevated to 200 mg/dL. A CSF Gram stain shows gram-positive diplococci. Which of the following is the correct treatment option?

. Begin acyclovir for herpes simplex encephalitis

. Obtain emergency MRI scan before beginning treatment

. Begin ceftriaxone and vancomycin for pneumococcal meningitis

. Begin ceftriaxone, vancomycin, and ampicillin to cover both pneumococci and Listeria

. Begin high-dose penicillin for meningococcal meningitis

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

A 35-year-old woman at 30 weeks’ gestation discovers a lump in her left breast. Examination reveals a 2–3 cm, firm nodule in the upper outer quadrant. Which of the following is the most appropriate next step in the management of this patient?

Observation until after delivery

Thermography

Application of hot packs

Breast ultrasound

Fine-needle aspiration

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

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

Closure of the ventricular septal defect

Mitral annuloplasty to tighten an incompetent mitral valve

Mitral commissurotomy to open a stenotic mitral valve

Prosthetic replacement of the aortic valve

Prosthetic replacement of the mitral valve

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

. Restoration of blood volume with aggressive IV fluid resuscitation

. IV hydrochloric acid

. Intubation and hyperventilation

. This patient has no acid-based abnormality.

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

. Reassurance and re-examination

. Immediate excisional biopsy

. Aspiration of the cyst with cytologic analysis

. Fluoroscopically guided needle localization biopsy

. Mammography and reevaluation of options with new information

A 35-year-old woman presents with frequent and multiple areas of cutaneous ecchymosis. Workup demonstrates a platelet count of 15,000/μL, evaluation of the bone marrow reveals a normal number of megakaryocytes, and ultrasound examination demonstrates a normal-sized spleen. Based on the exclusion of other causes of thrombocytopenia, she is given a diagnosis of immune (idiopathic) thrombocytopenic purpura (ITP). Which of the following is the most appropriate treatment upon diagnosis?

. Expectant management with close follow-up of platelet counts

. Immediate platelet transfusion to increase platelet counts to greater than 50,000/μL

. Glucocorticoid therapy

. Intravenous immunoglobulin (IVIG) therapy

. Referral to surgery for laparoscopic splenectomy

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

. Expectant management

. Intravenous oxytocin

. Cesarean delivery

. Forceps-assisted vaginal delivery

. Vacuum-assisted vaginal delivery

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

A 36-year-old G1P0 woman pregnant with twins presents to her obstetrician for her routine 32-week appointment. She has gained 5.4kg (12-lb) in the past 2 weeks. When questioned about her weight gain, she states she has had headaches and some blurred vision for the past 2 weeks, which she thinks is secondary to dehydration. To circumvent this, she has been drinking a lot of water, which she claims “is making me swell, even my hands.” She also has had some epigastric pain for the past 2 weeks, which she attributes to “all the water I’ve been drinking.” Her blood pressure is 142/90 mm Hg, pulse is 105/min, and respiratory rate is 18/min. Urinalysis reveals 1+ glycosuria and 4+ proteinuria. Which of the following is the best next step in management?

Administer magnesium sulfate only

Administer oral antihypertensive therapy

Expectant management

Induce labor

Platelet transfusion

A 36-year-old male comes to the emergency department because of worsening right lower quadrant (RLQ) abdominal pain. One week ago he was started on cephalexin for furunculosis. He has had type I diabetes mellitus for 10 years and is on insulin. His temperature is 38.3C (101.9F). Examination shows multiple furuncles on the inner side of both thighs; most of them are in regression. Abdominal examination shows tenderness on deep palpation in RLQ without rebound or guarding; no masses are palpated; psoas sign is positive; bowel sounds are present. Rectal examination shows no abnormalities. Laboratory studies show: Hemoglobin 13.0 g/L, Leukocyte count 17,500/mm3. Which of the following is the most appropriate next step in management?

Appendectomy

Laparoscopy

. CT of abdomen

Colonoscopy

. AP and lateral lumbar films

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

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

. Prescribe combined oral contraceptive pills

. Conjugated estrogens for 3-months

. Cyclic progestins

. Endometrial ablation

. Endometrial biopsy

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

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

. Fluid restriction 24 hours preoperatively to prevent intraoperative congestive heart failure

. Initiation of an α-blocker 24 hours prior to surgery

. Initiation of an α-blocker at 1 to 3 weeks prior to surgery

. Initiation of a β-blocker 1 to 3 weeks prior to surgery

Escalating antihypertensive drug therapy with β-blockade followed by α-blockade starting at least 1 week prior to surgery

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

Modafinil

Selegiline

Venlafaxine

A 38-year-old female comes to your office with a recent episode of hemoptysis. The symptoms started one week ago with malaise, throat pain and dry cough. The cough progressed becoming productive of yellowish sputum. She started noticing speckles of red blood in her sputum as of yesterday. Her past medical history is significant for peptic ulcer disease. She has a 5 pack-year smoking history, but she quit 10 years ago. Her temperature is 98°F (36.7°C), blood pressure is 130/80 mmHg and heart rate is 87/min. Physical examination reveals scattered bilateral wheezes. Chest X-ray shows clear lung fields. Which of the following is the most appropriate next step in management?

. CT scan of the chest

. Pulmonary function tests

. Sputum Gram stain and culture

Observation

. Sputum cytology

A 38-year-old G1P1 comes to see you for her first prenatal visit at 10 weeks gestational age. She had a previous term vaginal delivery without any complications. You detect fetal heart tones at this visit, and her uterine size is consistent with dates. You also draw her prenatal labs at this visit and tell her to follow up in 4 weeks for a return OB visit. Two weeks later, the results of the patient’s prenatal labs come back. Her blood type is A–, with an anti D antibody titer of 1:4. Which of the following is the most appropriate next step in the management of this patient?

. Schedule an amniocentesis for amniotic fluid bilirubin at 16 weeks

. Repeat the titer in 4 weeks

. Repeat the titer at 28 weeks

. Schedule Percutaneous Umbilical Blood Sampling (PUBS) to determine fetal hematocrit at 20 weeks

. Schedule PUBS as soon as possible to determine fetal blood type

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

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

Naproxen

Amitriptyline

Prednisone

. Colchicine

Oxycodone

{"name":"Management USMLE 4 (603-698)", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"A 34-year-old woman complains bitterly of heartburn. Physical examination reveals healing lesions of the fingertips that she says were small ulcers, and there are small areas of telangiectasias on her face. Esophageal manometry reveals a decrease in the expected amplitude of smooth muscle contraction. Lower esophageal sphincter tone is subnormal, but relaxes normally with swallowing. Which of the following statements regarding this condition is most likely correct?, A 34-year-old woman with no PMH presents to the office for intermittent left lower quadrant pain, nonradiating for the past 24 hours. She had her menstruation 1.5 weeks ago. She has no nausea, vomiting, diarrhea, or constipation. She denies dysuria, urinary urgency, and urinary frequency. BP, 122\/84 mm Hg; P, 90; R, 13 breaths\/min; T, 98.7°F. ROS: Denies fever and chills; AS per RPI. PE: Abd: soft, nondistended, left lower quadrant tenderness is present on superficial and deep palpation. The pain radiates toward the midline. Which of the following is the next step in the management of this patient?, A 34-year-old woman, gravida 3, para 2, at 38 weeks gestation presents to the labor and delivery ward complaining of headache. She has no contractions. Her prenatal course was unremarkable until she noted the onset of swelling in her face, hands, and feet this week. Her obstetric history is significant for two normal spontaneous vaginal deliveries. She has no significant past medical or surgical history. Her temperature is 37 C (98.6 F), blood pressure is 160\/92 mm Hg, pulse is 78\/min, and respirations are 16\/min. Examination reveals 3+ patellar reflexes bilaterally. A cervical examination reveals that her cervix is 3 cm dilated and 50% effaced and soft, and that the fetus is at 0 station and vertex. The fetal heart rate has a file:\/\/\/D:\/DES_Entry_2016MCQs\/3C_USMLE\/C-4Management\/4Manag... 128 of 334 12\/21\/2016 3:59 PM baseline of 140\/min and is reactive. The results from a 24-hour urine collection show 5200 mg of protein (normal < 300 mg\/24 hours). The patient is given magnesium sulfate intravenously for seizure prophylaxis. Which of the following is the most appropriate next step in the management of this patient?","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}