Paraclinic USMLE VTH2

613) A 72-year-old man with end stage renal disease secondary to hypertension presents with several months of back pain. He denies fever, weight loss, difficulty walking, altered sensation in his legs, or incontinence. He was diagnosed with renal disease 20 years ago and was managed medically for many years. However, 2 years ago he began hemodialysis because of a progressive decline in renal function. There is no family history of renal disease or malignancy. Physical examination is unremarkable. X-ray of the chest shows ill-defined bands of increased bone density adjacent to the vertebral endplates. What laboratory abnormalities is most likely in this patient?

614) A 72-year-old woman presents with pruritus for the past 6 weeks. She is careful to moisturize her skin after her daily shower and uses soap sparingly. She has never had this symptom before. The itching is diffuse and keeps her awake at night. Over this time she has lost 15 lb of weight and has noticed diminished appetite. She has previously been healthy and takes no medications. Physical examination shows no evidence of rash; a few excoriations are present. She appears fatigued and shows mild temporal muscle wasting. The general examination is otherwise unremarkable. What is the best next step in her management?

619) A 74-year-old man is brought to hospital because of urinary retention. He has a Foley catheter inserted to relieve the obstruction, and 1500 cc of urine is emptied from his bladder. Over the next few hours, he has 200cc/h of urine output. Which of the following urine electrolyte values is most likely in keeping with his diagnosis?

621) A 74-year-old woman presents to your office complaining of diarrhea and decreased appetite over the past week as well as increasing fatigue and occasional palpitations over the last few days. Her past medical history is significant for chronic atrial fibrillation for which she takes metoprolol, digoxin and warfarin. She smokes cigarettes and has for the past several years. On physical examination, her blood pressure is 140/90 mmHg and her heart rate is 70/min and irregular. Lung auscultation reveals scattered wheezes. Her abdomen is soft and non-tender. The liver span is 8 cm and the spleen is not palpable. There is no ankle edema. Her last measured INR was 2.3 two weeks ago. Which of the following is the best initial test in this patient?

624) A 75-year-old man is brought to the emergency department for severe pain in the left flank and back of 1 hour duration. He has a prior history of a myocardial infarction and coronary artery bypass grafting 8 years ago. On examination, he is found to have a BP of 80/50 mmHg, pulse rate of 110/min, respiratory rate of 15/min, and a pulsatile, tenderabdominal mass. He has had two large-bore IV linesplaced by the paramedics. He is alert and oriented, and gives consent for surgery. On postoperative day 3, the patient develops dark-colored diarrhea but remains normotensive, on full mechanical ventilation, and is awake. Laboratory analysis reveals normal electrolytes, blood urea nitrogen (BUN), and creatinine; hematocrit of 30; and WBC of 15,000. Which is the most appropriate next step in management?

627) A 75-year-old woman comes to the emergency department with complaints of nausea and nonbilious, nonbloody vomiting over the past 4 days. The patient reports that both the nausea and vomiting come in “waves”; that is, several hours will pass during which she feels well before the vomiting suddenly recurs. A detailed history reveals that the woman was told several months ago that she “has stones in her gall-bladder,” but she has been too frightened to undergo surgery. She has not had a bowel movement for 7 days. Her temperature is 38.4°C (101.1°F) and the abdomen is distended with high-pitched bowel sounds. Which of the following is the most appropriate initial test for a patient with suspected gallstone ileus?

628) A 75-year-old woman comes to the physician because of irregular vaginal bleeding. She has been menopausal for the past 25 years, but has noted on-and-off spotting for the past 2 years, which she finds intolerable. She has a complicated past medical history including hypertension, diabetes, and severe chronic obstructive pulmonary disease. Examination is unremarkable. An endometrial biopsy is performed that demonstrates an endometrial polyp with atypical cells that are difficult to grade. Which of the following is the most appropriate next step in management?

633) A 76-year-old man is admitted to the coronary care unit after an episode of substernal chest pain. His other medical problems include hypertension, hyperlipidemia, and type 2 diabetes mellitus. He has a history of a diverticular bleed 2 years ago. After initial workup, cardiac catheterization is performed and shows 50% left main coronary artery stenosis, 90% proximal left anterior descending artery stenosis, and 65% right coronary artery stenosis. Antiplatelet agents are stopped, and the patient is continued on a heparin drip in preparation for coronary artery bypass surgery the next day. Five hours after the catheterization, his blood pressure is 75/60 mm Hg and pulse is 120/min and regular. He complains of some generalized weakness and back pain but denies chest pain, shortness of breath, nausea, and abdominal discomfort. He appears to be diaphoretic and clammy. Neck veins are flat. Heart sounds are normal, and the chest is clear to auscultation. The groin site for arterial puncture is mildly tender, without subcutaneous hematoma. He receives 1000 ml of normal saline, with symptomatic improvement. His blood pressure is 96/60 mm Hg and pulse is 85/min. His ECG seems to be unchanged. Which of the following is the most appropriate next step in managing this patient?

634) A 76-year-old man with multi-infarct dementia is brought to the emergency department because of lethargy. For the past 6 months, he has had difficulties with feeding and occasionally regurgitates undigested food. In recent days, his condition has deteriorated, and he has become lethargic. He has a history of hypertension for 15 years, chronic atrial fibrillation for 7 years, dementia for 5 years, and frequent respiratory tract infections for the past year. His temperature is 37.8°C (101.5°F), blood pressure is 150/95 mm Hg, pulse is 120/min, and respirations are 26/min. Physical examination shows foul-smelling breath; there is a fluctuating mass in the left side of his neck. Auscultation shows crackles in the right lung base. An x-ray film of the chest shows multiple infiltrates without cavitation in the right lower lung field. The patient is admitted, sputum and blood cultures are sent, and antibiotics are started. Which of the following is the most appropriate next step in management?

635) A 76-year-old woman presents with complaints of severe vulvar itching for the past six months. She has tried over-the-counter topical lubricants without relief. Physical examination reveals numerous vulvar excoriations. The vulvar skin is thin, dry and white in color. The labia minora are difficult to visualize. Which of the following is the most appropriate next step in management?

652) A full-term, female infant is born to a 26-year-old, primigravid mother via C-section secondary to breech position. The mother has lived in New York City for the past 5 years. She denies the use of any drugs, alcohol or cigarettes during her pregnancy. She denies having any sexually transmitted infections. Her lead levels were within the normal range throughout her pregnancy. Prenatal ultrasound done at 30 weeks gestation showed normal anatomy of the fetus. The Apgar scores at 1 and 5 minutes are 7 and 9, respectively. There are some bluish-brown spots located on the infant's lumbosacral area. Flexion and abduction of the lower extremities reveal a palpable clunk. The rest of the physical examination is normal. Which of the following is the best next step in the management of this patient?

658) A middle-aged woman presents with a variety of cognitive and somatic symptoms, fatigue, and memory loss. She denies feeling sad, but her family physician is aware of this patient’s lifelong inability to identify and express feelings. He suspects she is depressed. Which of the following results is most likely to confirm a diagnosis of depression?

660) A neonate is noted to have aniridia of the right eye on physical examination. He was born by spontaneous vaginal delivery after an uncomplicated full-term pregnancy. The remainder of the physical examination is normal. Which of the following is the most appropriate next step before the infant is released from the hospital?

661) A nurse notices that a 1-week-old, premature infant in the neonatal unit is experiencing migratory jerks of the extremities. She picks the infant up and can feel that the muscle jerks are continuing to happen, even when she holds an involved extremity still. After about 5 minutes, the jerking movements stop. Which of the following is the most appropriate first step in diagnosis?

667) A patient presents for her first initial OB visit after performing a home pregnancy test and gives a last menstrual period of about 8 weeks ago. She says she is not entirely sure of her dates, however, because she has a long history of irregular menses. Which of the following is the most accurate way of dating the pregnancy?

670) A patient with severe neurological devastation after head trauma has a prolonged course in the intensive care unit. He has been mechanically ventilated for his entire hospital stay. Which of the following clinical findings is diagnostic of a ventilator-associated pneumonia?

676) A pregnant woman who is 7 weeks from her LMP comes in to the office for her first prenatal visit. Her previous pregnancy ended in a missed abortion in the first trimester. The patient therefore is very anxious about the well being of this pregnancy. Which of the following modalities will allow you to best document fetal heart action?

680) A recovering premature infant who weighs 950 g (2 lb, 1 oz) is fed breast milk to provide 120 cal/kg/d. Over the ensuing weeks, the baby is most apt to develop which of the following?

688) An 18-year-old girl comes to the office due to a three-week history of headaches that has been disturbing her daily activities, including her sleep. She describes these headaches as pulsatile, diffuse, and occasionally results in vomiting. Her school grades have deteriorated over the past 3 months. She complains of double vision when she looks sideways. Her family history is significant for migraine. She is afebrile. Her neurologic examination is significant for sixth cranial nerve palsy. The pupils are equal, and reactive to light and accommodation. There is no sinus tenderness. Fundoscopy reveals bilateral papilledema. MRI of the brain reveals an empty sella. What is the most appropriate next step in the management of this patient?

693) An 8-year-old boy presents to the pediatrician's office with a headache for the past 3 weeks. His mother also states that he has been more tired and has had frequent nose bleeding for the past month. On physical examination, his height and weight are both below the 5th percentile for his age. His blood pressure is 152/86 mm Hg in all four extremities. His pulse is 74/min, and respirations are 16/min. His heart examination is normal with no murmur. His peripheral pulses are strong and symmetric. Urinalysis and serum electrolytes are ordered. Which of the following is the most appropriate next step in diagnosis?

699) An 83-year-old man with Parkinson’s disease presents with low-grade fever and cough for several weeks. Lately, he has been experiencing more rigidity and difficulty with his walking. He is on a levodopa/carbidopa combination for treatment for the past 5 years. On examination, his gait is shuffling and slow. He has a tremor in his left hand at rest, and there is cogwheel rigidity of the forearm. There are crackles in the left lower lung field. CXR reveals a lung abscess in the left lower lobe. Which of the following is the most likely bacteriologic diagnosis for the lung abscess?

700) An 84-year-old Caucasian male is brought to the ER with severe chest pain, dyspnea and diaphoresis. His past medical history is significant for a long history of hypertension and diabetes mellitus, type 2. He experienced a severe myocardial infarction 6 months ago. His current medications are enalapril, metoprolol, aspirin, furosemide, potassium, glyburide and pravastatin, but he says that he has not been taking some of his medications recently. Physical examination reveals acrocyanosis and symmetric 3+ lower extremity edema. Point of maximal apical impulse is displaced to the left, and a holosystolic II/VI apical murmur is heard at the apex. Non-specific ST segment and T wave changes are present on ECG. The initial set of cardiac enzymes are positive. The patient continues to deteriorate, despite aggressive diuretic and vasodilator therapy. You perform an echocardiographic evaluation of left ventricular function and decide to proceed with pulmonary artery catheterization. Cardiac index (CI), total peripheral resistance (TPR) and left ventricular enddiastolic volume (LVEDV) are determined. Which of the following is most likely to present in this patient?

701) An 85-year-old man who resides in a nursing home presents with a 3-day history of lower abdominal pain and increasing fatigue and lethargy. He is afebrile, his BP is 160/92 mm Hg, and RR 16/min. His lungs are clear and his heart examination normal. There is diffuse abdominal tenderness on palpation and a large area of fullness and dullness to percussion starting just below the umbilicus and extending to the suprapubic area. His serum sodium is 130 mEq/L, potassium 4.9 mEq/L, BUN 75 mg/dL, and creatinine is 3.5 mg/dL. His baseline BUN and creatinine were 25 and 1.3 respectively as recently as 1 month ago. A Foley catheter is placed and 1200 cc of urine is obtained. What will be the likely clinical course for this patient with regard to his renal function?