USMLE_Management IV

A 25-year-old HIV-positive male comes to a physician with complaints of headache and left-sided weakness of recent onset. His temperature is 38°C (100.8°F), blood pressure is 115/70mm Hg, respirations are 14/min, and pulse is 73/min. Neurological examination reveals decreased power, hyperreflexia, and upgoing plantars in the left upper and lower limb. Neuroimaging by CT shows multiple ring-enhancing lesions. What is the most appropriate next step in management?

A 25-year-old male comes to the clinic because of a painless ulcer on his penis. He denies fever or urethral discharge, but admits to recent sexual activity with a prostitute. He describes severe rash and face swelling with penicillin. Physical examination reveals a shallow, non-tender ulcer. There is no lymphadenopathy. Darkfield microscopy reveals spirochetes. Which of the following is the most appropriate treatment for this patient?

A 25-year-old man comes to the physician because of a mass in his mouth. He has just noticed this mass and has had no trauma to his oral cavity. He does not use tobacco, alcohol or drugs. He has had no weight loss. Physical examination shows a large mass located on the hard palate of the mouth. On palpation, the mass is immobile, fleshy with bony surroundings and measures 3x 3 cm. Which of the following is the most appropriate next step in management?

A 25-year-old man is brought to the emergency room after sustaining burns during a fire in his apartment. He has blistering and erythema of his face, left upper extremity, and chest. He also has circumferential frank charring of his right upper extremity with decreased capillary refill. He is agitated, hypotensive, and tachycardic. Which of the following is the most appropriate initial management of his wounds?

A 25-year-old man is found on a pre-employment chest x-ray film to have a 3-cm peripheral coin lesion. The patient has never smoked, and a chest x-ray film that he had 2 years ago when he enrolled in graduate school had been normal. Prompted by this finding, he undergoes a more thorough physical examination, which discloses the presence of a firm, 2-cm testicular mass of which he was not previously aware. There are also palpable inguinal nodes on the same side. Which of the following is the most appropriate next step in management?

A 25-year-old man is involved in a gang shoot-out and sustains an abdominal gunshot wound from a .22 pistol. At laparotomy, it is discovered that the left transverse colon has incurred a through-and-through injury with minimal fecal soilage of the peritoneum. Which of the following is the most appropriate management of this patient?

A 25-year-old man is shot with a .22 caliber revolver. The entrance wound is in the anteromedial aspect of his upper thigh, and the exit wound is about 3 inches lower, in the posterolateral aspect of the thigh. He has a large, expanding hematoma in the upper inner thigh. There are no palpable pulses in the foot. The bone is intact by physical examination and x-ray films. Which of the following is the most appropriate next step in management?

A 25-year-old man is shot with a .22-caliber revolver. The entrance wound is in the anterior, lateral aspect of his thigh, and the bullet is seen on x-ray films to be embedded in the muscles posterolateral to the femur. The emergency department physician cleans the wound thoroughly. Which of the following is the most appropriate next step in management?

A 25-year-old man is stabbed in the right chest. He comes in fully awake and alert, and, in a normal tone of voice, he states that he feels short of breath. His vital signs are normal and stable. On physical examination, he has no breath sounds at the right base, and only faint breath sounds at the apex. He is dull to percussion over the right base. A chest x-ray film confirms that he has a hemothorax on that side. Which of the following is the most appropriate next step in management?

A 25-year-old man is stabbed once in the right chest. The entrance wound is on the midaxillary line, at the level of the fifth intercostal space. He arrives at the emergency department moderately short of breath, but he is fully awake and alert, is talking with a normal tone of voice, and has no distended veins visible in his neck or forehead. His blood pressure is 130/75 mm Hg, and his pulse is 82/min. Physical examination of the chest shows the wound, which is not visibly "sucking air," and demonstrates no breath sounds at all on the right side, which is tympanitic to percussion. There is no evidence of mediastinal displacement. Which of the following would be the most appropriate next step in management?

A 25-year-old man presents to the physician's office because of a clenched fist injury ("fight bite") incurred during a gang fight. The injury occurred two days ago and he has now started to develop pain, swelling, and redness around the wound. His immunizations are up to date. His wounds are cleaned in the clinic. Plain films of hand do not show evidence of foreign body or osteomyelitis. Which of the following is the most appropriate antibiotic for his current condition?

A 25-year-old man presents with a painless, hard, 3-cm testicular mass that he discovered serendipitously while taking a shower. Physical examination confirms that the mass arises from the testicle itself, is not part of the epididymis, and is solid rather than a fluid collection. The rest of the physical examination is unremarkable. Which of the following would be the most appropriate next step?

A 25-year-old nulliparous woman at 35 weeks' gestation comes to the labor and delivery ward complaining of contractions, a headache, and flashes of light in front of her eyes. Her pregnancy has been uncomplicated except for an episode of first trimester bleeding that completely resolved. She has no medical problems. Her temperature is 37 C (98.6 F), blood pressure is 160/110 mm Hg, pulse is 88/minute, and respirations are 12/minute. Examination shows that her cervix is 2 centimeters dilated and 75% effaced, and that she is contracting every 2 minutes. The fetal heart tracing is in the 140s and reactive. Urinalysis shows 3+ proteinuria. Laboratory values are as follows: leukocytes 9,400/mm3, hematocrit 35%, platelets 101,000/mm3. Aspartate aminotransferase (AST) is 200 U/L, and ALT 300 U/L. Which of the following is the most appropriate next step in management?

A 25-year-old primigravid woman at 37 weeks gestation is brought to the emergency department because of severe uterine contractions and moderate vaginal bleeding. She has been followed for pre-eclampsia since her 32nd week of gestation. She is currently having intermittent bleeding. Ultrasonogram in the emergency department shows placental abruption and an intrauterine gestation consistent with dates. Placenta previa is ruled out. Her temperature is 37.0 C (98.7 F), blood pressure is 90/60 mmHg, pulse is 99/min and respirations are 20/min. Physical examination shows uterine tenderness and hyperactivity, increased uterine tone and vaginal bleeding. Her cervix is 1cm dilated and 10% effaced at the time of admission. Fetal heart tracing shows a rate of 110/min, a long-term variability of 4 cycles/min and a beat-to-beat variability of 20/min. Which of the following is the most appropriate next step in management?

A 25-year-old primigravid woman at 37 weeks gestation is brought to the emergency department because of severe uterine contractions and moderate vaginal bleeding. She has been followed for pre-eclampsia since her 32nd week of gestation. She is currently having intermittent bleeding. Ultrasonogram in the emergency department shows placental abruption and an intrauterine gestation consistent with dates. Placenta previa is ruled out. Her temperature is 37.0 C (98.7F), blood pressure is 90/60 mmHg, pulse is 99/min and respirations are 20/min. Physical examination shows uterine tenderness and hyperactivity, increased uterine tone and vaginal bleeding. Her cervix is 1em dilated and 10% effaced at the time of admission. Fetal heart tracing shows a rate of 110/min, a long-term variability of 4 cycles/min and a beat-to-beat variability of 20/min. Which of the following is the most appropriate next step in management

A 25-year-old primigravid woman comes to the physician for her first prenatal visit. Her last menstrual period was 7 weeks ago. She has had some nausea and vomiting but otherwise has no complaints. Past medical and surgical history are unremarkable. Her family history is significant for cystic fibrosis with an affected aunt. Her husband has an affected cousin. Physical examination is unremarkable. Given her family history, she is concerned about the risks of having a child with cystic fibrosis. She inquires about cystic fibrosis screening. Which of the following is the appropriate response?

A 25-year-old unhelmeted man involved in a motorcycle collision has multiple cerebral contusions on head computed tomographic (CT) scan. He is agitated but hemodynamically stable, with a heart rate of 80 beats per minute and a mean arterial pressure (MAP) of 90 mm Hg. An intracranial pressure monitor is placed, and the initial ICP reading is 30 mm Hg. Which of the following is the most appropriate in the management of his traumatic brain injury (TBI) over the next few days?

A 25-year-old woman at 28 weeks gestation comes to the ER because of strong, regular and painful uterine contractions that started 4 hours earlier with the passage of clear fluid from her vagina. She denies any vaginal bleeding. She has had no prenatal care. Vital signs are normal. A sterile speculum examination shows pooling of amniotic fluid within the vagina, and a cervix that is 4cm dilated and 80% effaced. Ultrasonogram in the emergency department shows an amniotic fluid index of 4 and bilateral renal agenesis in the fetus. Which of the following is the most appropriate next step in management?

A 25-year-old woman comes to the outpatient office complaining of a pruritic, painful vaginal discharge. She is sexually active with two male sexual partners but finds intercourse very uncomfortable because of her vaginal symptoms. For the past 8 months, she has been using the estrogen–progestin contraceptive patch. She exercises regularly by walking 2 to 3 miles a day. She is following a low-carbohydrate diet and takes a multivitamin preparation. Findings of her general examination are unremarkable. Speculum examination of the vagina shows a foul-smelling greenish, frothy discharge. Vaginal pH, using Nitrazine paper, is 6.5. A wet mount of vaginal secretions in a saline suspension reveals a highly motile organism. Which of the following pharmacologic agents would be the most appropriate treatment?

A 25-year-old woman comes to the physician because of a 3-day history of burning micturition and increased urinary frequency. She has suprapubic discomfort. She denies having unusual vaginal discharge. She has been sexually active and monogamous for the past 4 years with her husband. Her temperature is 37.1°C (98.9°F), blood pressure is 110/70 mm Hg, pulse is 68/min, and respirations are 15/min. Examination shows suprapubic tenderness without flank tenderness. The rest of the examination is normal. Urinalysis shows: Specific gravity 1.020, Blood Trace, Glucose Negative, Ketones Negative, Leukocyte esterase Positive, Nitrites Positive, WBC 40-50/hpf, RBC 6-10/hpf, Bacteria 50+. Which of the following is the most appropriate next step in management?

A 25-year-old woman comes to the physician for an annual examination. She has been feeling well over the past year. Her past medical and surgical histories are unremarkable. Past obstetrical history is significant for the term vaginal delivery two years ago of a male infant with spina bifida. Examination is within normal limits. The patient states that she would like to try to become pregnant within the next few months and wants to know if she needs to start taking any vitamins or medications. Which of the following supplements should this patient take?

A 25-year-old woman complains of dysuria, frequency, and suprapubic pain. She has not had previous symptoms of dysuria and is not on antibiotics. She is sexually active and on birth control pills. She has no fever, vaginal discharge or history of herpes infection. She denies back pain, nausea, or vomiting. On physical examination she appears well and has no costovertebral angle tenderness. A urinalysis shows 20 white blood cells per high power field. Which of the following statements is correct?

A 25-year-old woman delivered a baby boy at 38 weeks gestation. The newborn has a small body size with microcephaly, hypoplasia of the distal phalanges of the fingers and toes, excess hair and a cleft palate. He weighs 2.5kg (5.51b). Further history or evaluation of the mother would most likely reveal which of the following?

A 25-year-old woman delivered a baby boy at 38 weeks gestation. The newborn has a small body size with microcephaly, hypoplasia of the distal phalanges of the fingers and toes, excess hair and a cleft palate. He weighs 2.5kg (5.5lb). Further history or evaluation of the mother would most likely reveal which of the following?

A 25-year-old woman has a positive cervical culture for Neisseria gonorrhoeae. She has had at least two positive cultures for gonorrhea treated in the past. She is afebrile and has no symptoms. The incidence of penicillin-resistant gonorrhea in some areas of the United States is currently as great as 10%. Because of this, the recommended treatment for gonorrhea includes which of the following?

A 25-year-old woman is referred to the physician for lactation suppression after the death of her 1-month-old infant from severe sepsis. She is very depressed and complains of breast fullness and tenderness. Examination shows both breasts are warm, firm and tender to palpation. Prenatal records show no abnormalities except mild varicosities. Which of the following is the most appropriate next step in management?

A 25-year-old woman with no PMH, no PSH, and no allergies presents for unilateral nipple discharge. The patient states that it started about 3 weeks ago, appears whitish, and is unilateral. She does not think she felt any changes in her breast. She denies relation to her menstruation and uses condoms for contraception. She has never been pregnant and her last menstrual period (LMP) was 2 weeks ago. BP, 120/78 mm Hg; P, 85 beats/min; R, 15 breaths/min. Review of systems: Denies fever, chills, and weight loss, Denies chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, and constipation. Physical examination: Gen: Awake, alert, oriented x3, no acute distress, CVS: S1S2+RRRno m/r/g, Lungs: Clear to auscultation bilaterally, Abdomen: Soft, nontender, nondistended, + bowel sounds, Ext: No edema bilaterally, Breasts: Symmetric, no masses palpated, clear/whitish fluid expressed on manipulation of left breast. What is the next step in the management of this patient?

A 25-year-old woman, gravida 2, para 1, at 22 weeks' gestation comes to the physician with complaints of burning with urination and frequent urination. Her prenatal course has been uncomplicated except for a urinary tract infection (UTI) with E. Coli at 12 weeks' gestation, which was treated at that time. Physical examination is unremarkable. Urine culture demonstrates greater than 100,000 colony-forming units per milliliter of E. coli. After treating this patient for her current infection, which of the following is the most appropriate next step in management?

A 25-year-old, G3P0 white female in her 8th week of gestation comes to the antenatal clinic. Her obstetric history is significant for two second trimester abortions. She is currently taking folic acid and iron supplementation. She does not smoke, but she drinks alcohol on social occasions. She is in a monogamous relationship with her husband. She has never been diagnosed with or treated for any STDs. Laboratory studies reveal the following: VDRL positive, FTA-ABS negative, Hct 33%, WBC 7,000/mico-L, Platelets 70,000/micro-L, PT 10 sec, APTT 40 sec. What is the most appropriate next step in the management of this patient?

A 26 years old man is about to undergo an orchiectomy for testicular cancer. The anesthesiologist begins isoflurance and succinylcholine, and about 30 minutes later, the patient develops muscle rigidity, herthermia, an elevated heart rate, and abnormal ventilation patterns. There are numerous atrial premature complexes (APCs) and ventricular premature complexes (VPCs) noted on the monitor. The anesthesiologist is unable to open’s mouth because of masseter muscle rigidity. The patient become fever. Vital signs: BP 90/50 mm Hg, HR 140 beats/min, R 18 breaths/min, T0 1050F (40.380C). What is the best next step management?

A 26-year-old G0 woman is seen in her gynecologist’s office for a routine examination. She reports that she has been sexually active with four partners and has been treated for gonorrhea once in the past year. She has otherwise been healthy. Physical examination is unremarkable. Results of a Pap smear suggest a low-grade squamous intraepithelial lesion. What is the most appropriate next step in management?

A 26-year-old G1 P1 woman requests contraception after delivering a healthy baby three weeks ago. She is breastfeeding the child and plans to continue for at least six months. She does not want to get pregnant for at least one year. She has no medical problems and does not take any medication. She does not use tobacco, alcohol or drugs. Physical examination shows no abnormalities. Which of the following is the most preferred method of contraception you can advise for this patient?

A 26-year-old G1P1 woman requests contraception after delivering a healthy baby three weeks ago. She does not want to get pregnant for at least one year. She has no medical problems and does not take any medication. She does not use tobacco, alcohol or drugs. Physical examination shows no abnormalities. Which of the following is the most preferred method of contraception you can advise for this patient?

A 26-year-old graduate student presents at her husband's urging, complaining of severe pain during sexual intercourse. She says that she was a virgin when she married her husband two years ago, and that she has been experiencing severe "genital pain" during sex since then. As a result, she avoids sexual intimacy with her husband, which is placing a strain upon their marriage. She also complains of intense pain with her menses and when passing stool. She admits to sporadic pelvic pain that waxes and wanes with no discernible trigger. What would be the most appropriate treatment given this woman's condition?

A 26-year-old graduate student presents at her husband's urging, complaining of severe pain during sexual intercourse. She says that she was a virgin when she married her husband two years ago, and that she has been experiencing severe "genital pain" during sex since then. As a result, she avoids sexual intimacy with her husband, which is placing a strain upon their marriage. She also complains of intense pain with her menses and when passing stool. She admits to sporadic pelvic pain that waxes and wanes with no discernible trigger. What would be the most appropriate treatment given this woman's condition?

A 26-year-old man comes to the emergency department because of a sudden onset of severe right-sided flank pain. The pain is colicky and radiates from the flank to the scrotum. He also has nausea, vomiting and dark-colored urine. He has never had these symptoms before. His temperature is 37°C (98.6°F), blood pressure is 126/70 mm Hg, pulse is 90/min, and respirations are 18/min. Examination shows no abnormalities. He is given adequate analgesia. Non-contrast helical CT shows a 4 mm radiopaque stone in the right upper ureter. Laboratory studies show serum calcium of 9.8 mg/dl, serum creatinine of 0.9 mg/dl, and BUN of 15mg/dl. Urinalysis shows hematuria but no casts. Which of the following is the most appropriate next step in management?

A 26-year-old man comes with his girlfriend to the emergency department due to a very high fever. He just finished his second cycle of BEP (bleomycin, etoposide, cisplatin) chemotherapy for metastatic seminoma 4 days ago. Other than his fever, he has no complaints. He denies any chest pain, cough, diarrhea or any rash. He stopped smoking ever since he was diagnosed with his "deadly disease," but drinks alcohol occasionally. His temperature is 38.9°C (102°F), blood pressure is 118/70 mm Hg, pulse is 102/min, and respirations are 19/min. Physical examination reveals a pale man without any eyebrows or eyelashes. Chest auscultation is clear. Blood tests reveal: WBC 690/mm3 with 9% neutrophils, Hemoglobin 8.6 g/dl, Hematocrit 25%, Platelets 74,000/mm3. What is the best next step in the management of this patient?

A 26-year-old man is brought to the emergency room after being extricated from the driver’s seat of a car involved in a head-on collision. He has a sternal fracture and is complaining of chest pain. He is hemodynamically stable and his electrocardiogram (ECG) is normal. Which of the following is the most appropriate management strategy for this patient?

A 26-year-old man presents to the physician's office with a two-day history of multiple symptoms, including rash on his trunk, headache, fatigue, malaise, myalgias, and high-grade fever. The rash is not associated with pain, itching, or burning. It has expanded over the last two days. He went on a camping trip in Vermont two weeks ago, and recalls a tick bite at that time. There is a single lesion on his trunk, which is erythematous with central clearing. The rest of the examination is unremarkable. What is the most appropriate next step in the management of this patient?

A 26-year-old primigravid woman at 10-weeks' gestation comes to the physician for a routine prenatal appointment Her dating is based on a 6-week ultrasound. She has sickle-cell anemia. She has no past surgical history, takes prenatal vitamins, and has no known drug allergies. She tells the physician that she recently learned that the father of the baby has sickle-cell trait. On examination, her uterus is appropriate for a 10-week gestation, and fetal heart tones are heard. Her hematocrit is 37%. What is the most appropriate next step in the management of this patient?

A 26-year-old primigravid woman at 12 weeks' gestation comes to the physician because of pain and swelling in her right thigh. She first noted the onset of the pain 2 days ago, and since then it has grown worse. An ultrasound study performed on her lower-extremity venous system reveals evidence of a proximal thrombus in the right leg. She is started on low-molecular-weight heparin injections. Which of the following is an advantage of low molecular-weight heparin compared with unfractionated heparin?

A 26-year-old primigravid woman at 35 weeks' gestation comes to the labor and delivery ward because of painful uterine contractions and a gush of fluid. Sterile speculum examination reveals a pool of clear fluid in the vagina that is nitrazine positive. When the fluid is examined under the microscope, a "ferning" pattern is seen. Cervical examination shows the patient to be 4 cm dilated, 100% effaced, and at 0 station. Fetal fingers can be felt along side the fetal head. External uterine monitoring shows contractions every 2 minutes. External fetal monitoring shows the fetal heart rate to be in the 130s and reactive. Which of the following is the most appropriate next step in management?

A 26-year-old primigravida at 20th week gestation presents to the emergency room with a sudden onset of tearing chest pain radiating to her back and left arm. The patient is pale and diaphoretic. Her PR: 116/min; BP: 192/ 104 mmHg in left arm, and 123/65 mmHg in right arm; RR: 36/min. Her cardiac examination reveals a diastolic murmur along the left sternal border. Her previous prenatal care is not known. She is a smoker with a 10 pack/year history and drinks alcohol. Her ECG reveals mild left axis deviation and ST segment depression in lead II, III, and AVF. What is the most appropriate next step in the management of this patient?

A 26-year-old white nonsmoking woman returns for a follow-up appointment with her primary care provider. At a routine health maintenance visit 8 months earlier, her blood pressure was 179/97 mmHg. Since then she has adhered to a low-fat diet and exercises regularly. On repeat measurement 1 month later, her blood pressure was still elevated, despite her compliance with the prescribed hydrochlorothiazide and lisinopril. She has no complaints and denies headaches, chest pain, or mental status changes. On physical examination she is a slender woman in no apparent distress. An abdominal bruit that lateralizes to the left is heard. Her blood pressure is 178/99 mmHg in her left arm and 181/95 mmHg in her right arm. A basic metabolic panel and complete blood count are within normal range. Which of the following is the most appropriate next step in patient care?

A 26-year-old woman comes to the physician because of a lump in her vagina. The lump is nontender but is uncomfortable when she walks. She states that for the last 6 years this lump has appeared about once a year. When it occurs she goes to the doctor who puts a catheter into it, which is taken out in a few weeks. She has no other medical problems. She is sexually active with two partners. Examination shows a cystic mass approximately 4 cm in diameter on the right side of the vagina near the hymeneal ring. The mass feels like a discrete cyst. The rest of the pelvic examination is unremarkable. Which of the following is the most appropriate next step in management?

A 26-year-old woman comes to the physician for a routine annual visit. She has no complaints. She has no significant previous medical problems. She has been sexually active since the age of 19 with the same partner. They married 4 years ago. She has never had any sexually transmitted diseases. She had her last Pap smear 4 years ago and was within normal limits. She does not use tobacco, alcohol or illicit drugs. Pelvic examination shows no abnormalities. A repeat Pap smear now shows atypical squamous cells of undetermined significance (ASC-US). Which of the following is the most appropriate next step in management?

A 26-year-old woman G0P0 presents to the office for infertility. The patient states that she and her husband have been trying to conceive for almost 2 years without success. She menstruates regularly. Her cycles occur every 28 days with 5 or 6 days of bleeding. She does have some pain during menstruation but not more than usual. She has no medical, surgical, or sexually transmitted disease. The patient and her husband have sexual relations during ovulation on a daily basis. She has had multiple blood tests by her primary care provider (PCP), all of which are normal. BP, 120/80 mm Hg; P, 82 beats/min; R, 16 breaths/min; T, 97.8°F; body mass index (BMI), 24. Review of systems (ROS): Negative. Physical examination: Gen: Awake, alert, oriented x3, no acute distress, CVS: Normal, Lungs: Normal, Abd: Soft, nontender, nondistended, +bowel sounds, Pelvic exam: Within normal limits. Which of the following is most useful?

A 26-year-old woman presents to your office for her well-woman examination. She denies any medical problems or prior surgeries. She states that her cycles are monthly. She is sexually active and uses oral contraceptive pills for birth control. Her physical examination is normal. As part of preventive health maintenance, you recommend breast self-examination and instruct the patient how to do it. Which of the following is the best frequency and time to perform breast self-examinations?

A 26-year-old woman, gravida 2, para 1 at 28 weeks' gestation, comes to the physician for a follow-up ultrasound after a previous ultrasound demonstrated a marginal placenta previa. The present ultrasound shows complete resolution of the marginal previa, but the fetus is noted to be in breech presentation. The patient has otherwise had an unremarkable prenatal course. She has no medical problems and has never had surgery. She takes prenatal vitamins and is allergic to sulfa drugs. Assuming that the fetus stays in breech presentation, when should an external cephalic version be attempted?

A 26-year-old woman, gravida 2, para 2, complains of loss of small amounts of urine immediately after a spontaneous vaginal delivery. She received epidural anesthesia during labor and delivery because of severe pain. She has no fever, dysuria, urgency, or hematuria. She has no other medical problems, takes no medication except prenatal vitamins, and has no known drug allergies. Her vital signs are normal. Examination shows a soft, non-tender abdomen. Pelvic examination is normal. The patient voids 30-40ml of urine each time; her postvoid residual volume is 400 ml. The patient's labs reveal: Urine: Specific gravity: 1.020, Blood: trace, glucose: negative, Leukocytes esterase: negative, Nitrite: negative, WBC: 1-2/hpf, RBC: 3-4hpf. Which of the following is the most appropriate treatment for her incontinence?

A 26-year-old woman, gravida 2, para 2, complains of loss of small amounts of urine immediately after a spontaneous vaginal delivery. She received epidural anesthesia during labor and delivery because of severe pain. She has no fever, dysuria, urgency, or hematuria. She has no other medical problems, takes no medication except prenatal vitamins, and has no known drug allergies. Her vital signs are normal. Examination shows a soft, non-tender abdomen. Pelvic examination is normal. The patient voids 30-40ml of urine each time; her postvoid residual volume is 400 ml. The patient's labs reveal: Urine: Specific gravity: 1.020, Blood: trace, Glucose: negative, Leukocyte esterase: negative, Nitrites: negative, WBC: 1-2/hpf, RBC: 3-4/hpf. Which of the following is the most appropriate treatment for her incontinence?

A 26-year-old, drug-addicted man develops congestive heart failure over a period of a few days. He is febrile, has a loud, diastolic murmur at the right second intercostal space, and has a blood pressure of 120/20 mmHg. A physical examination performed a few weeks ago, when he attempted to enroll in a detoxification program, was completely normal. His blood pressure at that time was 120/80 mm Hg, and no murmurs were noted. In addition to long-term antibiotic therapy, which of the following is the most appropriate next step in management?

A 27-year-old African American woman presents with several months of prolonged menstrual bleeding and increased volume of menstrual flow. She also has a sensation of heaviness in her abdomen. She denies abdominal pain, nausea, vomiting, diarrhea, and constipation. She fatigues easily. Vital sign: Physical examination: Gen: Awake, alert, oriented x3, no acute distress, CVS: Regular rate and rhythm, no murmurs, rubs, or gallops, Lungs: Clear to auscultation bilaterally, Abd: Soft, nontender, nondistended, + bowel sounds, Pelvis: Cervix appears normal, no cervical motion tenderness, no adnexal masses felt. What is the term for what this patient is experiencing?

A 27-year-old Caucasian female with multiple sclerosis (MS) comes to the office for a follow-up visit. Six months ago, she experienced monocular vision impairment and clumsiness of the right hand, and both symptoms resolved completely. Three weeks ago, she experienced incoordination, weakness and spasticity in the right extremities. She was admitted in the hospital for treatment of an acute MS flare, and rapidly improved thereafter. Physical examination currently demonstrates slight weakness of the right leg with a hyperactive knee jerk. Which of the following medications may slow the long-term progression of this patient's disease?

A 27-year-old female comes to the physician's office for evaluation of infertility. She has not been able to conceive for 12 months despite frequent intercourse. Her menses started at age 12 and have always been irregular. She uses over the counter acne medications. She is also obese and has been unsuccessful with weight loss. Physical examination shows an obese woman with sparse hair over the upper lip. There is no galactorrhea, thyromegaly or clitoromegaly. Which of the following is the most appropriate therapy for this patient's infertility?

A 27-year-old female is found to have a positive hepatitis C antibody at the time of plasma donation. Physical examination is normal. Liver enzymes reveal ALT of 62 U/L (normal < 40), AST 65 U/L (normal < 40), bilirubin 1.2 mg/dL (normal), and alkaline phosphatase normal. Hepatitis C viral RNA is 100,000copies/mL. Hepatitis B surface antigen and HIV antibody are negative. Which of the following statements is true?

A 27-year-old female presents to your office for a follow-up. The previous two visits revealed an elevated blood pressure in the range of 150- 155/90-95 mmHg. She has no present complaints. Her past medical history is insignificant. She smokes 1/2 pack of cigarettes per day and does not consume alcohol. Her current medications include a combination oral contraceptive for the last 2 years, and an occasional acetaminophen for tension headache relief. There is no family history of hypertension or heart attacks. This visit, her blood pressure is 155/95 and her heart rate is 80/min. The physical examination is unremarkable. The ECG is normal. Her total cholesterol level, measured 6 months ago, was 170 mg/dL. Which of the following is the most appropriate next step in the management of this patient?

A 27-year-old G1 woman is 20 weeks pregnant. She is currently in her third year of a family practice residency and would like to travel to Africa and Asia as part of an outreach mission with her program. She has received all of her childhood immunizations. She presents to the obstetric clinic inquiring about the safety of immunizations during pregnancy. Which of the following vaccines is contraindicated in pregnancy?

A 27-year-old G1P0 woman at 27 weeks’ gestation presents to the emergency department after a motor vehicle accident. The patient denies any abdominal pain or cramping, contractions, or vaginal bleeding. Examination reveals a gravid, non-tender abdomen and a closed, non-effaced cervix with no evidence of vaginal bleeding. Fetal heart monitoring shows a fetal heart rate of 145/min, with variable accelerations and no decelerations. The patient is Rh negative with no history of blood transfusion, while the father is of unknown Rh status and unavailable. The results of the Kleihauer-Betke test, in which maternal blood is exposed to acid, shows a combination of pale and stained RBCs. Which of the following is the best next step in management?

A 27-year-old G2P1 at 38 weeks gestation was admitted in active labor at 4 cm dilated; spontaneous rupture of membranes occurred prior to admission. She has had one prior uncomplicated vaginal delivery and denies any medical problems or past surgery. She reports an allergy to sulfa drugs. Currently, her vital signs are normal and the fetal heart rate tracing is reactive. Her prenatal record indicates that her Group B streptococcus (GBS) culture at 36 weeks was positive. What is the recommended antibiotic for prophylaxis during labor?

A 27-year-old G2P1 woman comes to the labor and delivery unit with nausea, vomiting, and right lower-quadrant pain. She is at 19 weeks gestation. The symptoms started 12 hours ago and have become progressively worse. She has no chills, dysuria, or urinary frequency and is uncertain if she has had a fever. Her temperature is 38 C (100.4 F), blood pressure is 120/70 mm Hg, pulse is 98/min, and respirations are 18/min. Abdominal examination shows a gravid uterus just below the umbilicus. The fetal heart rate is 144/min. There is moderate tenderness to palpation in the right lower quadrant with guarding. Laboratory results are as follows: Hemoglobin: 12.4 g/L, Leukocytes: 16,000/μL. Which of the following is the most appropriate next step in management of this patient?

A 27-year-old G3P2002, who is 34 weeks gestational age, calls the oncall obstetrician on a Saturday night at 10:00 PM complaining of decreased fetal movement. She says that yesterday her baby has moved only once per hour. For the past 6 hours she has felt no movement. She is healthy, has had regular prenatal care, and denies any complications so far during the pregnancy. Which of the following is the best advice for the on-call physician to give the patient?

A 27-year-old man comes to the physician because of a 1-day history of fever and joint pains. He is being treated with cephalexin for a skin infection. His urine has turned darker. His temperature is 38.5°C (101.3°F), blood pressure is 125/70 mm Hg, pulse is 90/min, and respirations are 15/min. Examination shows a skin rash; examination otherwise shows no abnormalities. Urinalysis shows: 8 RBCs/HPF, 12 WBCs/HPF with white cell casts, eosinophiluria, and a mild degree of proteinuria. Laboratory studies show a BUN of 40 mg/dl and serum creatinine of 2.2 mg/dl. Which of the following is the most appropriate next step in management?

A 27-year-old man complains of chest palpitations and light-headedness for the past hour. He has no past medical history and is not taking any medications. He drinks a beer occasionally on the weekend and does not smoke cigarettes. His HR is 180 beats per minute, BP is 110/65 mmHg, and oxygen saturation is 99% on room air. An ECG reveals an HR of 180 beats per minute with a QRS complex of 90 milliseconds with a regular rhythm. There are no discernable P waves. Which of the following is the most appropriate medication to treat this dysrhythmia?

A 27-year-old man complains of episodic abdominal pain. The pain is concentrated in the epigastrium and is gnawing in quality. It wakes him up during the night and is promptly relieved by a glass of water and a piece of bread. He denies vomiting or diarrhea, but has experienced an occasional "dark stool." He has no significant past medical history and does not take any medications. His family history is significant for biliary disease in his mother and stomach cancer in his father. He smokes one pack of cigarettes a day and consumes a can of beer almost every day. His vital signs are with in normal limits. Physical examination shows mild epigastric discomfort on deep palpation. Which of the following is most likely to provide long-term symptom relief in this patient?

A 27-year-old man is brought to his primary care physician by his wife because he has not been himself for the past ten days. His wife says that her formerly reserved, quiet husband has been staying up all night lately gambling their savings away while playing poker with friends that he recently met. He is also not concerned about having missed work for the past week. When asked about this recent change in behavior, the man smiles and replies proudly that he no longer needs to work because he has invested a large sum of money in a company that will soon make him rich. He speaks very quickly and it is difficult for him to focus his attention at times. Which one of the following medications would be most appropriate in the treatment of this patient?

A 27-year-old man presents to his primary care physician complaining of feelings of inadequacy and hopelessness. In a quavering voice, he reports that he gets "extremely anxious" when he has to speak before a group of people at business meetings or other social events. He is unable to "just relax," even at small parties with friends or family, and he isolates himself as a result. He feels his social seclusion is limiting his career advancement, which bothers him greatly. Which of the following treatment combinations would be the most appropriate choice for this patient?

A 27-year-old nulliparous woman presents to your office complaining of a 7-week history of amenorrhea with a negative urine pregnancy test. Upon further questioning, she says that she feels fine and does not have any symptoms. She has a steady boyfriend and uses condoms for contraception. Her medical history is unremarkable, and she denies taking any medications beside vitamin supplements to help her in her workout. She is a senior college student and works as a secretary in a law firm. On physical examination, there is no hirsutism or galactorrhea. The rest of the examination reveals nothing abnormal. Her BMI is 28 kg/m2. Initial work-up reveals the following: Serum TSH 2.5 mU/mL (N= 0.5-5.0), Prolactin 10 ng/ml ( < 20 ng/ml). According to these findings, which of the following is the most appropriate next step in the management of this patient?

A 27-year-old primigravid woman at 28 weeks gestation comes to the physician's office because she has not felt any fetal movements for the past 48 hours. Her pregnancy thus far has been uncomplicated. Prenatal ultrasound at the 12th week of gestation showed an intrauterine gestation consistent with dates and showed no abnormalities. She has no history of trauma. She has no history of serious illness. Review of systems reveals no abnormalities. She does not use tobacco, alcohol or drugs. Fetal heart tones are not heard by Doppler. Vital signs are normal. Which of the following is the most appropriate next step in management?

A 27-year-old primigravid woman presents for a prenatal visit at 32 weeks’ gestation. She complains of a severe headache and epigastric pain for 24 hours. The headache is not relieved by acetaminophen. The epigastric pain is unrelieved by antacids. Her blood pressure (BP) today is 165/115 mm Hg. A urine dipstick test shows 3+ proteinuria. Her blood pressure on her first prenatal visit at 12 weeks’ gestation was 120/70 mm Hg. She experienced severe nausea and vomiting during the first trimester, requiring antiemetic treatment, but her total pregnancy weight gain has been 22 pounds. She has taken thyroid replacement medication after undergoing iodine 131 (131I) treatment for Graves disease 5 years ago. Which of the following medications would be indicated in the treatment of this patient?

A 27-year-old white female comes to the office and complains of ptosis, diplopia and difficulty in chewing. Her symptoms worsen in the evening. She is asymptomatic when she wakes up in the morning. She denies any sensory complaints or limb weakness. The Tensilon test is positive. Serological testing shows positive acetylcholine receptor antibodies. Which of the following is the best treatment to induce remission and provide long-term benefits in this patient?

A 27-year-old woman (G3P2) comes to the delivery floor at 37 weeks gestation. She has had no prenatal care. She complains that, on bending down to pick up her 2-year-old child, she experienced sudden, severe back pain that now has persisted for 2 hours. Approximately 30 minutes ago she noted bright red blood coming from her vagina. By the time she arrives at the delivery floor, she is contracting strongly every 3 minutes; the uterus is quite firm even between contractions. By abdominal palpation, the fetus is vertex with the head deeply engaged. Fetal heart rate is 130 beats per minutes. The fundus is 38 cm above the symphysis. Blood for clotting is drawn, and a clot forms in 4 minutes. Clotting studies are sent to the laboratory. Which of the following actions can most likely wait until the patient is stabilized?

A 27-year-old woman comes to the physician because of fevers and back pain. She states that a few days ago she had burning with urination. Over the next few days she developed fevers and chills and a pain on the right side of her back. She has no medical problems and takes no medications. Her temperature is 38.9 C (102 F), blood pressure is 110/70 mm Hg, pulse is 102/minute, and respirations are 16/minute. Examination shows a patient in mild distress with shaking chills and right costovertebral angle tenderness. Leukocyte count is 18,000/mm3. Urinalysis shows 100 leukocytes/high powered field. Which of the following is the most appropriate next step in management?

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?

A 27-year-old woman seeks your advice regarding pain and numbness in the right arm and hand. She reports that it is exacerbated by raising her arm over her head. On examination, the right radial pulse disappears when the patient takes a deep breath and turns her head to the left. A provisional diagnosis is made. Which of the following is the most appropriate initial treatment for this patient?

A 27-year-old woman with an intrauterine pregnancy at 39 weeks' gestation presented in active labor. The patient becamefully dilated and delivered a baby boy 5 minutes ago. The patient then delivered the placenta without complication. There were no lacerations visualized ofthe cervix, vagina, or vulva. However, the patient is continuing to bleed. Vital sign: BP, 120/75 mm Hg; P, 95 beats/min; R, 12 breaths/min; T, 98.6°F. What is the next step in the management of this patient?

A 27-year-old woman, gravida 2, para 1, at 12 weeks gestation comes to the physician because of a dark brown vaginal discharge. She had a mild brown vaginal discharge 3 weeks ago, which resolved without any intervention. She noticed similar discharge again two days ago. For the past two weeks, she has not had nausea or breast tenderness, which she used to have before. She does not use tobacco, alcohol or drugs. Her temperature is 37.0C (98.7 F), blood pressure is 110/60 mmHg, pulse is 85/min and respirations are 15/min. Physical examination shows a soft uterus and a closed cervix. Fetal heart tones are not present. Which of the following is the most appropriate next step in management?

A 27-year-old woman, gravida 3, para 0 (termination of pregnancy ´ 3) comes to your office for an annual examination. Over the past year she has been in good health except for recurrent upper respiratory tract infections. She smokes ½ pack of cigarettes per day. She has tried to stop smoking three times but is not ready to try again to stop now. She takes a combined oral contraceptive pill (OCP) with 35μg of estrogen in it. She takes no other medications and has no known drug allergies. Physical examination, including breast and pelvic exams, is significant for intermittent wheezes on chest auscultation. Regarding her birth control choice, which of the following is the most appropriate counseling?

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?

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?

A 28-year-old G0 woman presents to the clinic complaining of inability to conceive and amenorrhea. She has been taking a low-dose oral contraceptive pill for the past 6 years, which she discontinued 3 months ago when she and her husband decided they wanted to have children. They have been sexually active with each other two to three times per week over the past 3 months, but the patient has not become pregnant. The patient denies a history of sexually transmitted disease and states that until recently she has always had regular menstrual cycles. She has not had a period since discontinuation of the oral contraceptive. Which ofthe following is the most appropriate next step?

A 28-year-old G1 at 38 weeks had a normal progression of her labor. She has an epidural and has been pushing for 2 hours. The fetal head is direct occiput anterior at +3 station. The fetal heart rate tracing is 150 beats per minute with variable decelerations. With the patient’s last push the fetal heart rate had a prolonged deceleration to the 80s for 3 minutes. You recommend forceps to assist the delivery owing to the nonreassuring fetal heart rate tracing. Compared to the use of the vacuum extractor, forceps are associated with an increased risk of which of the following neonatal complications?

A 28-year-old G2, P1 woman in her 26th week of gestation comes to the office due to intermittent episodes of abdominal pain. She has been having these episodes for the past 4 days, and thinks that her fetus may be in distress. She points to her right flank when asked about the location of the pain, and says that it occasionally radiates to the groin area. She cannot identify any exacerbating or relieving factors. Her pregnancy has been uncomplicated so far. Her past medical history is significant for pelvic inflammatory disease. Her temperature is 37.5 C (99.5 F), blood pressure is 130/80 mm Hg, and pulse is 88/min. She is in considerable pain at the moment. Deep palpation of the right flank reveals tenderness. There is no CVA tenderness. Urinalysis shows: Specific gravity: 1.020; Blood: ++; Glucose: negative; Ketones: negative; Protein: negative; Leukocyte esterase: negative; Nitrites: negative. What is the best next step in the management of this patient?

A 28-year-old G2P2 presents to the hospital 2 weeks after vaginal delivery with the complaint of heavy vaginal bleeding that soaks a sanitary napkin every hour. Her pulse is 89 beats per minute, blood pressure 120/76 mm Hg, and temperature 37.1C (98.9F). Her abdomen is nontender and her fundus is located above the symphysis pubis. On pelvic examination, her vagina contained small blood clots and no active bleeding is noted from the cervix. Her uterus is about 12 to 14 weeks size and nontender. Her cervix is closed. An ultrasound reveals an 8-mm endometrial stripe. Her hemoglobin is 10.9, unchanged from the one at her vaginal delivery. β-hCG is negative. Which of the following potential treatments would be contraindicated?

A 28-year-old male comes for complete physical examination for a new job he is starting next week. He is healthy and has no complaints. He smokes 1 pack/day cigarettes for the last 10 years. He drinks 4 oz of alcohol daily. His mother has hypertension and father has heart problems. Vitals signs are with in normal limits. Physical examination is within normal limits except for a painless, hard mass in left testicle. Ultrasound shows high likelihood of a testicular tumor. What is the next best step in management?

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?

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?

A 28-year-old man is brought to the emergency department after being an unrestrained passenger in a motor vehicle collision. In the ambulance on the way to the hospital, he receives 2 L normal saline intravenously and 5l/min of oxygen by nasal cannula. His blood pressure is 80/42 mm Hg, pulse is 135/min, and respirations are 40/min. He is agitated and moves all 4 extremities spontaneously. His pupils are symmetric and reactive to light. Neck veins are distended, and his trachea is deviated to the right. Which of the following is the best initial management for this patient?

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?

A 28-year-old man with a past history of bilateral orchiopexy for cryptorchidism presents with a painless, unilateral right scrotal enlargement. On examination, there is a palpable right testicular mass and enlarged inguinal node. Scrotal ultrasonography demonstrates heterogeneity of the testis, with an associated hydrocele. A CT scan of the abdomen and pelvis demonstrated right-sided retroperitoneal adenopathy. CT scan of the chest is normal. Staging workup and surgery reveal a seminoma of the testicle, with positive inguinal and retroperitoneal nodes. Therapeutic management for this patient is which of the following?

A 28-year-old married nurse who works with you in clinic comes to you privately, saying that she "missed a period" this month. An over-the-counter urine pregnancy test confirms that she is pregnant. The first-trimester laboratory testing is performed, and she is found also to be HIV-positive. When you reveal the news of her HIV status to her, she is devastated. She hesitantly reveals that she had unprotected sexual intercourse with a former boyfriend several months ago. You explain that her husband's HIV status must be evaluated. Upon hearing this, the nurse is horrified and says. "No, I cannot tell him about this. He would never forgive me!" What is the most appropriate next step?

A 28-year-old mechanic with no past medical history presents to the ED after a small amount of battery acid was splashed in his right eye. He is complaining of extreme pain and tearing from his eye. Which of the following is the most appropriate next step in management?

A 28-year-old medical student seeks your attention because of a testicular mass. Biopsy is consistent with pure seminoma. There is no evidence of enlarged retroperitoneal lymph nodes on CT scan. Which of the following is the best treatment strategy for this patient?

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?

A 28-year-old primigravid woman comes to the outpatient prenatal clinic at 34 weeks’ gestation with a twin pregnancy. Her fundal height is 40 cm and the orientation of the fetuses in the uterus is cephalic–breech presentation. She was standing in the kitchen when she experienced a sudden gush of fluid that soaked her underwear and created a pool of fluid on the floor. Since then, she has had intermittent watery vaginal discharge for the past few days. She has had to wear a perineal pad for comfort. She denies dysuria or urinary burning but admits to urinary frequency. She is having occasional uterine contractions, up to three per hour. Which of the following is the most appropriate next step in the management of this patient?

A 28-year-old woman comes to the physician's office at 30 weeks gestation because she has not felt her baby's movements for the past week. Fetal heart tones are not heard by Doppler. An ultrasound shows an absence of fetal cardiac activity. Fetal demise is diagnosed. She underwent a cesarean section for her previous delivery to avoid a post-term pregnancy. She has no other medical problems. Vital signs are normal and physical examination shows no abnormalities. Her cervix is 3 cm dilated and 70 percent effaced. Laboratory studies show a platelet count of 230,000/mm and a fibrinogen level of 480 mg/dl (normal: 150-450mg/dl). Both the patient and her husband are shocked after hearing the news of fetal demise. Which of the following is the most appropriate next step in management?

A 28-year-old woman is brought to the emergency department by her sister after she experiences a generalized tonicclonic 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?