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THE LAST 1

A 15-year-old Caucasian male is brought to the office by his mother for the evaluation of a six-month history of unstable gait and speech difficulty which are getting worse over time. His past medical history is insignificant. He is not taking any medications, and denies smoking or alcohol consumption. His blood pressure is 120/70 mmHg and pulse is 80/min. Musculoskeletal examination showed scoliosis and feet deformity with 'hammer toes.' The neurologic examination showed dysarthria, dysmetria, nystagmus, and absence of deep plantar reflexes on lower extremities. What is the most common cause of death in this patient population?

Cardiomyopathy

Renal failure

Diabetes-related complications

Malignancy

Septic shock

A 19-year-old woman presents with 4 days of bilateral lower abdominal pain right greater than left. She also complains of a fever, nausea, vomiting, and general malaise. Her last menstrual period was 5 days ago. Vitals are HR 98 beats per minute, BP 110/65 mmHg, RR 18 breaths per minute, and temperature of 102.7°F. Pelvic examination demonstrates exquisite cervical motion tenderness and right adnexal tenderness. Laboratory reports are notable for a WBC 15,000/μL, an ESR of 95 mm/h, and a negative urine β-human chorionic gonadotropin (β-hCG). Transvaginal ultrasound demonstrates a right complex mass with cystic and solid components. Which of the following is the most appropriate next step in management?

. Prescribe her a 14-day course of levofloxacin (500 mg PO once per day) and urgent gynecology follow-up within 1 week

. Give her a dose of metronidazole (2 g PO) and prescribe her a 14-day course of cephalexin (500 mg) with urgent gynecology follow-up within 1 week

. Give her a one-time dose of oral metronidazole (2 g PO), azithromycin (1 g PO), and ceftriaxone (250 mg IM) with gynecology follow-up if she is not feeling better

. Given her a one-time dose with emergent gynecology consultation for possible laparoscopic drainage

. Give her a dose of ceftriaxone (250 mg IM), and prescribe her a 10-day course of doxycycline (100 mg PO BID) with urgent gynecology follow-up within 1 week

A 20-year-old primigravid woman at 32 weeks gestation comes to the physician because of swelling in her hands and ankles. She has no headache, visual disturbances or epigastric pain. She has no previous medical problems. She does not use tobacco, alcohol or illicit drugs. Her previous prenatal check-up at 28-weeks gestation was normal. Her medical records show no preexisting hypertension or proteinuria. Her blood pressure is 156/100 mmHg, and after 15 minutes of lateral rest, a repeat reading is 154/98mmHg. Physical examination shows 2+ pitting edema in both legs and hands. Deep tendon reflexes are normal. Fundoscopic examination shows no abnormalities. FetaI heart tones are audible by Doppler. Laboratory studies show: Hb: 13.0 g/dl; Hct: 50%; Platelets: 300,000/mm3; Creatinine: 1.1 mg/dl; Urinalysis shows 1+ proteinuria, which is new. Which of the following is the most likely diagnosis?

. Mild preeclampsia

. Severe preeclampsia

. Chronic hypertension

. Transient hypertension of pregnancy

. Eclampsia

A 23-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He has multiple organ injuries and is listed in critical condition. Physical examination shows an open wound in the right lower extremity and significant blood loss. He is in hypovolemic shock. Which of the following is the first parameter to change in hypovolemic shock?

. Systolic blood pressure

. Pulse rate

. Respiratory rate

. Level of consciousness

. Skin vasoconstriction

A 26-year-old woman with a history of depression is brought into the ED. She was found lying on the floor of her apartment next to an unlabeled empty pill bottle. Her HR is 117 beats per minute, BP is 95/65 mmHg, RR is 14 breaths per minute, and oxygen saturation is 97% on 2-L nasal cannula. On examination, the patient appears obtunded, and her pupils are 3 mm and reactive. Her oropharynx is dry and there is no gag reflex to pharyngeal stimulation. Her neck is supple. The heart is tachycardic without murmurs, the lungs are clear to auscultation, and the abdomen is soft. There is normal rectal tone and brown stool that is heme negative. Her skin is cool and moist with no signs of needle tracks. Neurologically, she is unresponsive but withdraws all extremities to deep palpation. Fingerstick blood glucose is 85 mg/dL. Her ECG reveals sinus tachycardia at 119 with a QRS complex of 140 milliseconds and a terminal R wave in lead aVR. Which of the following is the most appropriate next step in management?

. Orotracheal intubation, administer activated charcoal through orogastric tube, and IV naloxone

. Orotracheal intubation, administer activated charcoal through orogastric tube, and IV sodium bicarbonate

. Orotracheal intubation, administer activated charcoal through orogastric tube, and IV NAC

. Orotracheal intubation, administer syrup of ipecac through orogastric tube, and IV sodium bicarbonate

. Induce vomiting prior to intubation to lower the risk of aspiration then administer IV sodium bicarbonate

A 27-year-old man sustains a single gunshot wound to the left thigh. In the ER, he is noted to have a large hematoma of his medial thigh. He complains of paresthesias in his left foot. On examination, there are weak pulses palpable distal to the injury and the patient is unable to move his foot. Which of the following is the most appropriate initial management of this patient?

. Angiography

. Immediate exploration and repair in the operating room

. Fasciotomy of the anterior compartment of the calf

. Observation for resolution of spasm

. Local wound exploration at the bedside

A 3-month-old, previously well male infant presents to the emergency department in January with a 2-day history of clear rhinorrhea, low-grade fever, and poor appetite, but no cough. On physical examination, there are mild subcostal retractions, coarse breath sounds heard throughout the lung fields, and scattered expiratory wheezes. The child receives an intravenous fluid bolus in the emergency department and is admitted for observation. Which of the following is the most severe, life-threatening complication of this child's illness?

Apnea

Congestive heart failure

Dehydration

Hypoxemia

Wheezing

A 32-year-old man presented to the emergency department five hours ago with an acute asthma exacerbation. He has been receiving continuous albuterol nebulizer treatments since that time. He has a 20-year history of asthma but notes that recently the frequency of his attacks has increased. Presently, his blood pressure is 110/70 mmHg and heart rate is 120 and regular. On physical exam, the patient appears drowsy. Breath sounds are diminished bilaterally but there are no wheezes. The most recent ABG reveals: pH 7.32, pO2 65mmHg, pCO2 50mmHg. Which of the following is the best next step in managing this patient?

. Inhaled corticosteroids

. Ipratropium inhalation

. Intravenous theophylline

. Oral prednisone

. Endotracheal intubation

A 34-year-old construction worker is brought to the ED by EMS after falling 30 ft from a scaffold. His vital signs are HR 124 beats per minute, BP 80/40 mmHg, and oxygen saturation 93% on 100% oxygen. He has obvious head trauma with a scalp laceration overlying a skull fracture on his occiput. He does not speak when asked his name, his respirations are poor, and you hear gurgling with each attempted breath. Auscultation of the chest reveals diminished breath sounds on the right. There is no JVD or anterior chest wall crepitus. His pelvis is unstable with movement laterally to medially and you note blood at the urethral meatus. His right leg is grossly deformed at the knee and there is an obvious fracture of his left arm. Which of the following is the most appropriate next step in management?

. Insert a 32F chest tube into the right thoracic cavity

. Perform a DPL to rule out intra-abdominal hemorrhage

. Immediately reduce the extremity injuries and place in a splint until the patient is stabilized

. Create two Burr holes into the cranial vault to treat a potential epidural hematoma

. Plan for endotracheal intubation of the airway with in-line stabilization of the cervical spine

A 34-year-old homeless male is brought to the ER in a confused state. He complains of flank pain. His past medical history is unknown. His temperature is 36.8°C (98.2F), blood pressure is 110/60 mmHg, pulse is 110/min and respirations are 22/min. His appearance is disheveled. Pupils are equal, 4 mm in size and reactive to light. Funduscopic examination is within normal limits. Lungs have crackles at both bases. Mild costovertebral angle tenderness is present. Foley catheter is placed and urine appears red. Laboratory studies show: Serum sodium 136 mEq/L, Serum potassium 3.5 mEq/L, Chloride 93 mEq/L, Bicarbonate 6 mEq/L, Blood urea nitrogen (BUN) 34 mg/dl, Serum creatinine 2.8 mg/dl, Blood glucose 80 mg/dl, Calcium 6.5 mg/dl, Serum ketones negative, Plasma lactate 2.4 mEq/L. Which of the following is the most appropriate next step in management?

. Broad spectrum antibiotics

. Fomepizole

. N-acetylcysteine

. Regular insulin

. Glucagon

A 36-year-old female presents to the emergency room complaining of chest pain that started suddenly while she was shopping at the mall. She also reports shortness of breath, palpitations and diaphoresis. The pain is retrosternal and radiates to the left arm. There are no aggravating or relieving factors. On review of systems, the patient reports having had a runny nose, sore throat and dry cough for the past 3 days. Her past medical history is significant for panic attacks, for which she takes paroxetine, and dysfunctional uterine bleeding, for which she takes estrogen. Her family history is significant for the sudden death of her father at age 44 from a heart attack. Social history reveals that she has smoked one pack of cigarettes per day for the past 15 years. Which of the following is the most appropriate initial therapy for this patient?

. Lorazepam

. Heparin

. Aspirin

. Ibuprofen

. Acetaminophen

A 40-year-old man is brought to the emergency room after his wife found him alone in a confused state. He admits to overdosing in a suicide attempt, but does not specify the drug taken. En route to the hospital, he is drowsy and ataxic with blurred vision. His past medical history is significant for asthma, insomnia, depression, and substance abuse. His temperature is 38.3°C (100°F), blood pressure is 130/80mmHg, pulse is 100/min, and respirations are 22/min. Examination shows dry mucus membranes and skin; pupils are 8mm bilaterally. There is no neck stiffness. Lungs are clear to auscultation. Heart sounds are within normal limits. Abdominal examination shows reduced bowel sounds with no tenderness. A Foley catheter is placed in the ER and 600 ml of urine is collected over one hour. Which of the following is the most likely diagnosis?

. Salicylate intoxication

. Serotonin syndrome

. Cocaine intoxication

. Diphenhydramine poisoning

. Phencyclidine poisoning

A 49-year-old woman presents to the emergency department (ED) with profuse, foul-smelling, watery diarrhea and abdominal pain. Five days ago, she was hospitalized for urosepsis and treated with amoxicillin and sulbactam. She recovered well, and was discharged three days ago with a prescription for oral amoxicillin plus clavulanic acid. Her current temperature is 38.8°C (101.9°F), blood pressure is 110/70 mmHg, pulse is 102/min, and respirations are 15/min. Abdominal examination shows tenderness in the left lower quadrant. CBC shows a WBC count of 25,000/microl. She is started on intravenous normal saline in the ED. Which of the following is the most appropriate next step in management?

. Continue rehydration

. Start oral metronidazole

. Discontinue antibiotics

. Discontinue antibiotics and start oral metronidazole

. Discontinue antibiotics and start oral vancomycin

A 51-year-old man with a long history of hypertension presents to the ED complaining of intermittent chest palpitations lasting for a week. He denies chest pain, shortness of breath, nausea, and vomiting. He recalls feeling similar episodes of palpitations a few months ago but they resolved. His blood pressure (BP) is 130/75 mmHg, heart rate (HR) is 130 beats per minute, respiratory rate (RR) is 16 breaths per minute, and oxygen saturation is 99% on room air. An ECG is seen below. Which of the following is the most appropriate next step in management?

. Sedate patient for immediate synchronized cardioversion with 100 J

. Prepare patient for the cardiac catheterization laboratory

. Administer warfarin

. Administer amiodarone

. Administer diltiazem

A 64-year-old Caucasian male presents to the Emergency Room with a sharp, left-sided chest pain. He says that the pain is worse when he takes deep breaths, but he gets relief with leaning forward. He had an acute non-ST elevation myocardial infarction six months ago and had undergone angioplasty for the right coronary artery. His other medical problems include: diabetes, hypertension, hyperlipidemia, peripheral neuropathy, diabetic retinopathy, paroxysmal atrial fibrillation, hypothyroidism, and chronic renal insufficiency. His vital signs are BP 142/86 mmHg, PR 78/min, RR 16/min, and T 36.1°C (97°F). On examination, you find a pericardial rub. EKG shows diffuse ST elevation. Lab results are: Hb 9.0 g/dl, WBC 8,000/cmm, Platelets 210,000/cmm, Blood Glucose 248 mg/dl, Serum Na 135 mEq/L, Serum K 5.8 mEq/L, Bicarbonate 17 mEq/L, BUN 86 mg/dl, Serum Creatinine 4.4 mg/dl. Which of the following is the most appropriate management of this patient?

. NSAIDs

. Corticosteroids

. Pericardiocentesis

. Hemodialysis

. Echocardiography

A 64-year-old man with chronic obstructive pulmonary disorder (COPD) is hospitalized for an acute exacerbation of chronic bronchitis (AECB). At the time of admission, the patient is suffering from dyspnea, a productive cough with green-tinged sputum, and pleuritic chest pain. At that time his oxygen saturation is 80%. A blood gas reveals a pH of 7.35, a pO2 of 51 mm Hg, and a pCO2 of 58 mm Hg. The patient is treated with oxygen therapy, nebulized ipratropium and albuterol treatments, and azithromycin. Over the course of 5 days, the patient’s respiratory status improves. His cough and sputum production diminish and he is weaned from supplemental oxygen. At the time of discharge, his oxygen saturation is 90% on room air. A blood gas reveals a pH of 7.37, a pCO2 of 50 mm Hg, and a pO2 of 70 mm Hg. At this time, which of the following is an appropriate treatment for this patient?

. Continued antibiotics

. Home oxygen therapy

. Inhaled steroids

. Leukotriene inhibition

. Pneumococcal vaccine

A 65-year-old female who lives in nursing home and is bed ridden due to severe right hemiparesis is brought to the ER because of altered mental status and decreased oral intake. Her past medical history includes hypertension, diabetes, hyperlipidemia, and myocardial infarction. She has a chronic indwelling Foley catheter to avoid contamination of a sacral decubitus ulcer. She is febrile in the ER. Examination shows dry mucus
membranes and clear lungs. She is disoriented. The decubitus ulcer has good granulation tissue and does not appear infected. Labs show: Hemoglobin
12.0 g/L, Leukocyte count 12 500/mm3, Blood urea nitrogen (BUN) 28 mg/dL, Serum creatinine 0.8 mg/dL, Serum bicarbonate 24 mg/dL. Urinalysis:
Specific gravity 1.036, Protein 1+, pH 8.5, Blood negative, Glucose 1+, Ketones negative, Leukocyte esterase positive, WBC 50-100/hpf, Bacteria
few. Which of the following is the most likely cause of her altered mental status?

. Urinary tract infection from Escherichia coli

. Urinary tract infection from Klebsiella species

. Urinary tract infection from Proteus species

. Urinary tract infection from Pseudomonas aeruginosa

. Urinary tract infection from Candida species

A 73-year-old man presents to the emergency department complaining of lower abdominal pain and nausea. He denies any vomiting or diarrhea, and his last bowel movement was two days ago. The patient also notes that several days ago he began taking amitriptyline for chronic neck pain. He does not smoke or consume alcohol. On physical examination, his blood pressure is 160/70 mmHg and his heart rate is 100/min. His lung fields are clear to auscultation. Palpation of the abdomen reveals fullness and tenderness along the midline below the umbilicus. Which of the following is the best initial management for this patient?

. Abdominal CT scan

. Upright abdominal x-ray

. Barium enema

. Broad spectrum antibiotics

. Urinary catheterization

A 75-year-old woman is brought to the ED by EMS after she had a witnessed seizure on the street. A bystander reports that the patient fell to the ground, had tonic-clonic activity, and was drooling. Her BP is 162/85mmHg, HR is 95 beats per minute, temperature is 99.4°F, and RR is 16 breaths per minute. On examination, the patient is unresponsive and has a bleeding superficial scalp laceration. Which of the following electrolyte disturbances is least likely to cause a seizure?

. Hypoglycemia

. Hyperglycemia

. Hyponatremia

. Hypernatremia

. Hypokalemia

A 75-year-old woman is brought to the emergency department after being found unresponsive at her home. She was last spoken to by her daughter on the phone 24 hours earlier, at which time she complained of chills, lethargy, and weakness. The woman has had a heart attack in the past, she has high blood pressure, and she had a total thyroidectomy performed a decade ago for cancer. The daughter had returned from several months out of town, and is unsure if the patient was taking her medications. Her temperature is 34.9°C (94.9°F), pulse is 48/min, blood pressure is 110/65 mmHg, oxygen saturation is 99% on 100% oxygen, and glucose is 85 mg/dL. On examination the patient is unresponsive, obese, and edematous with periorbital edema. Her cardiac and pulmonary examinations are normal. CT of the head reveals no signs of trauma or increased intracranial pressure, and ECG demonstrates no acute ischemic changes. Blood is drawn for laboratory testing. Which of the following is most appropriate for treating the patient’s mental status change?

Glucagon

Aspirin

Hemodialysis

Levothyroxine

Metoprolol

A 76-year-old man presents to the ED in acute respiratory distress, gasping for breath while on face mask. Paramedics state that he was found on a bench outside of his apartment in respiratory distress. Initial vitals include an HR of 90 beats per minute, a BP of 170/90 mmHg, and an RR of 33 breaths per minute with an oxygen saturation of 90%. Upon physical examination, the patient is coughing up pink, frothy sputum, has rales two-thirds of the way up both lung fields, and has pitting edema of his lower extremities. A chest radiograph reveals bilateral perihilar infiltrates, an enlarged cardiac silhouette, and a small right-sided pleural effusion. After obtaining IV access and placing the patient on a monitor, which of the following medical interventions is most appropriate?

. Morphine sulfate only

. Nitroglycerin only

. Nitroglycerin and a loop diuretic

. Aspirin

. Antibiotics

A 79-year-old woman is brought to the emergency department due to a suspected cerebrovascular accident on her right side. She complains of diffuse paresthesias and tingling in her right hand. She did not lose consciousness. The physical examination reveals normal speech, symmetric deep tendon reflexes (2/4 on both upper extremities, 2/4 both patellar reflexes, and 0/4 both Achilles reflexes), a cold right hand, and undetectable arterial radial pulse. Tinel and Phalen's signs are negative. The rest of the examination is normal. What is the most appropriate next step in the management of this patient?

. CT scan of the brain without contrast

. MRI scan of the brain with diffusion images

. Doppler of the carotid arteries

. Schedule for EMG, and nerve conduction studies

. Immediate vascular surgery consultation for intervention

A previously heathy 3-year-old boy is brought to the emergency department (ED) due to stridor of sudden onset. Last night, he suddenly developed a high fever followed by breathing difficulty. His temperature is 40C (104F), pulse is 130/min, and respirations are 40/min. In the ED, the child is toxic-appearing, sitting up, leaning forward and drooling. His lungs are clear, and oxygen saturation is 85% in room air. What is the most appropriate next step in management?

Admit the patient and start him on broad spectrum antibiotics

Start the patient on intravenous methylprednisolone

Endotracheal intubation with a set-up for tracheostomy

Admit the patient and start him on nebulized racemic epinephrine

Start the patient on oral dexamethasone

An 8-month-old male infant is brought to the emergency department (ED) by his mother due to vomiting and a decreased urine output. Three days ago, he had a fever, sore throat and ear pain. He was subsequently diagnosed with otitis media and treated with oral amoxicillin. Today, in the ED, his temperature is 40.0C(104F), pulse is 80/min, respirations are 40/min and irregular, blood pressure is 100/60 mm Hg, and weight is 8kgs ( 15 lbs). He is lethargic and arousable only to painful stimuli. His anterior fontanel is full and tense. His tympanic membranes are red and bulging. His pupils are reactive, but his eyes do not focus well on his parents. What is the most appropriate next step in the management of this patient?

Lumbar puncture

Start intravenous amoxicillin

CT scan of the brain

MRI of the brain

Start cefotaxime

An infant is born at terrn to a 27-year-old Caucasian female. The prenatal course was uncomplicated. The amniotic fluid is clear. Immediately after the delivery, the infant starts crying and is moving all four extremities actively. Heart rate is 140/min. He is making a grimace on the attempt to put the suction catheter into his nostrils. His body is pink, but extremities are cyanotic. Which of the following is the next best step in the management of the infant?

Intubate the child

Dry the infant and keep warm

Apply silver nitrate solution to the eyes

Administer vitamin K (IM)

Place umbilical catheter

Several days following esophagectomy, a patient complains of dyspnea and chest tightness. A large pleural effusion is noted on chest radiograph, and thoracentesis yields milky fluid consistent with chyle. Which of the following is the most appropriate initial management of this patient?

. Immediate operation to repair the thoracic duct

. Immediate operation to ligate the thoracic duct

. Tube thoracostomy and low-fat diet

. Observation and low-fat diet

. Observation and antibiotics

You are called to the emergency department to consult on a 34-year-old woman at 22 weeks’ gestation with a skin rash and shortness of breath. She states that the skin rash started 2 days ago on her trunk and has spread to her extremities. Earlier today she developed shortness of breath. She has been feeling like she has fever and chills, but she has not taken her own temperature. She has no other medical problems and has never had surgery. She works as a third-grade teacher. She has not been traveling recently, but one of her students recently had the chicken pox. On physical examination, her temperature is 38.1 C (100.6 F), blood pressure is 100/70 mm Hg, pulse is 116/min, and respirations are 18/min. Her lungs have diminished breath sounds bilaterally. Chest x-ray demonstrates diffuse, nodular, peribronchial infiltrates. Which of the following is the most appropriate next step in management?

. Admission and intravenous acyclovir

. Admission and intravenous erythromycin

. Outpatient management with oral azithromycin

. Bronchoscopy and intubation

. Outpatient management with oral erythromycin

{"name":"THE LAST 1", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"A 15-year-old Caucasian male is brought to the office by his mother for the evaluation of a six-month history of unstable gait and speech difficulty which are getting worse over time. His past medical history is insignificant. He is not taking any medications, and denies smoking or alcohol consumption. His blood pressure is 120\/70 mmHg and pulse is 80\/min. Musculoskeletal examination showed scoliosis and feet deformity with 'hammer toes.' The neurologic examination showed dysarthria, dysmetria, nystagmus, and absence of deep plantar reflexes on lower extremities. What is the most common cause of death in this patient population?, A 19-year-old woman presents with 4 days of bilateral lower abdominal pain right greater than left. She also complains of a fever, nausea, vomiting, and general malaise. Her last menstrual period was 5 days ago. Vitals are HR 98 beats per minute, BP 110\/65 mmHg, RR 18 breaths per minute, and temperature of 102.7°F. Pelvic examination demonstrates exquisite cervical motion tenderness and right adnexal tenderness. Laboratory reports are notable for a WBC 15,000\/μL, an ESR of 95 mm\/h, and a negative urine β-human chorionic gonadotropin (β-hCG). Transvaginal ultrasound demonstrates a right complex mass with cystic and solid components. Which of the following is the most appropriate next step in management?, A 20-year-old primigravid woman at 32 weeks gestation comes to the physician because of swelling in her hands and ankles. She has no headache, visual disturbances or epigastric pain. She has no previous medical problems. She does not use tobacco, alcohol or illicit drugs. Her previous prenatal check-up at 28-weeks gestation was normal. Her medical records show no preexisting hypertension or proteinuria. Her blood pressure is 156\/100 mmHg, and after 15 minutes of lateral rest, a repeat reading is 154\/98mmHg. Physical examination shows 2+ pitting edema in both legs and hands. Deep tendon reflexes are normal. Fundoscopic examination shows no abnormalities. FetaI heart tones are audible by Doppler. Laboratory studies show: Hb: 13.0 g\/dl; Hct: 50%; Platelets: 300,000\/mm3; Creatinine: 1.1 mg\/dl; Urinalysis shows 1+ proteinuria, which is new. Which of the following is the most likely diagnosis?","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}