Management usmle

25) A 12-year-old boy comes to the emergency department complaining of vague left-sided chest discomfort. Two months ago, he was involved in a high-speed motor vehicle accident but sustained only minor injuries. He was observed in the emergency department overnight and discharged home. His past medical history is otherwise unremarkable. Vital signs are normal. Auscultation of the lungs shows decreased air entry into the left lower base. An x-ray of the chest is shown below. Which of the following is the most appropriate next step in management of this patient?

25) A 12-year-old boy comes to the emergency department complaining of vague left-sided chest discomfort. Two months ago, he was involved in a high-speed motor vehicle accident but sustained only minor injuries. He was observed in the emergency department overnight and discharged home. His past medical history is otherwise unremarkable. Vital signs are normal. Auscultation of the lungs shows decreased air entry into the left lower base. An x-ray of the chest is shown below. Which of the following is the most appropriate next step in management of this patient?

77) A 16-year-old G1P0 at 38 weeks gestation comes to the labor and delivery suite for the second time during the same weekend that you are on call. She initially presented to labor and delivery at 2:00 PM Saturday afternoon complaining of regular uterine contractions. Her cervix was 1 cm dilated, 50% effaced with the vertex at −1 station, and she was sent home after walking for 2 hours in the hospital without any cervical change. It is now Sunday night at 8:00 PM, and the patient returns to labor and delivery with increasing pain. She is exhausted because she did not sleep the night before because her contractions kept waking her up. The patient is placed on the external fetal monitor. Her contractions are occurring every 2 to 3 minutes. You reexamine the patient and determine that her cervix is unchanged. Which of the following is the best next step in the management of this patient?

89) A 17-year-old adolescent boy sustains a small-caliber gunshot wound to the mid-epigastrium with no obvious exit wound. His abdomen is very tender; he is taken to the operating room and the bullet appears to have tracked through the stomach, distal pancreas, and spleen. The duct appears to have been injured. Which of the following is the best strategy for the management of this patient’s pancreatic injury?

214) A 22-year-old woman presents to the emergency department in an agitated state, certain that she is "about to die." Fifteen minutes ago, she developed heart palpitations and a severe "viselike" tightness in her chest. She experienced a similar episode last week, which resolved in twenty minutes. She denies using any drugs and her medical history is unremarkable. Her father has a history of heart disease and her mother has diabetes mellitus. She takes no medications. Vital signs are temperature 37.0°C (98.6°F), blood pressure 132/74 mmHg, pulse 118/min, and respiratory rate 30/min. She is sweating profusely. EKG reveals sinus tachycardia. The most appropriate next step is administration of which of the following?

300) A 25-year-old Gl0 with an intrauterine pregnancy (IUP) at 38 weeks' gestation presents to the labor and delivery unit stating that she thinks she is in labor. She has had routine prenatal care. She states that she has generalized abdominal pain that comes and goes. Thepain has been going on for about 5 hours and is starting to become regular. She thinks it is contractions. Vital sign: BP, 115/75 mm Hg; P, 82 beats/min; R, 12 breaths/min; T, 98.6°F. Contractions: Present, Fetal movement: Present, Vaginal bleeding: Absent, Leakage of fluid: Absent. Physical examination: Gen: Awake, alert, oriented x3, mild pain distress, CVS: S1S2 + RRR no m/ r/ g, Lungs: CTA bilaterally, Abd: Gravid, Ext: 1+ edema bilaterally. What is the next step in the management of this patient?

362) 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?

362) 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?

404) A 28-year-old woman presents to the office for her routine Pap smear. She has had eight lifetime partners but has recently gotten married. For the past 5 years, she has only been sexually active with her husband. All of her previous Pap smear results have been normal. She denies any history of STIs. She has never been pregnant, although she would like to become pregnant soon. She denies any vaginal discharge, abnormal vaginal bleeding, or dyspareunia. VS: BP, 120/80 mm Hg; P, 83 beats/min; R, 15 breaths/min; T, 98.3°F. Review: Entire ROS is negative. Physical examination: Pelvic examination was done. Pap smear completed. No cervical discharge, no cervical, Lesions present. Bimanual Exam: No cervical motion tenderness, no adnexal enlargement or tenderness, no uterine enlargement. What is the next step in the management of this patient?

417) A 29-year-old G1P0 with an intrauterine pregnancy (IUP) at 37 weeks' gestation presents to the office for a routine prenatal visit. The patient states that she has a headache since this morning. She has no past medical history, no past surgical history, is taking no medications, and has no allergies. She denies visual disturbance, epigastric pain, nausea, and vomiting. Vital sign: BP, 150/90 mm Hg; P, 90 beats/min; R, beats/min; R, 16 breaths/min; T, 98.3°F (37.2 C). Fetal movement: Present. Contractions: Absent. Leakage of fluid: Absent. Vaginal bleeding: Absent. What is the next step in the management of this patient?

436) A 29-year-old woman, gravida 2, para 1, at 33 weeks’ gestation is referred to your office because of a possible herpes outbreak. She developed a painful vesicular rash a few days ago in her genital area. She has never before had any similar symptoms. She has no other medical problems, takes no medications, and has no known drug allergies. Examination reveals numerous erythematous vesicles and ulcerations. Testing of the lesion demonstrates herpes simplex virus infection and serologic testing reveals that it is a primary outbreak for the patient. Which of the following is the most appropriate management of this patient?

470) A 30-year-old G3P2 woman at 25 weeks’ gestation has a history of gestational diabetes in her previous pregnancy. Her fasting blood glucose level at her initial 10-week screening visit was 110 mg/dL and urinalysis was negative for glucose in the urine. The patient has not been taking her own blood sugars at home, but she has been adhering to a low-carbohydrate diet. Over the past several weeks, she has noticed increased fatigue and polyuria. Which of the following is the next most appropriate step?

514) A 32-year-old Caucasian male is admitted to the hospital due to a 1-week history of progressive paralysis of his upper and lower extremities. He had a flu-like illness 3 weeks ago, followed by paresthesias in his fingertips and toes. The weakness initially started in his lower extremities. He denies any changes in bowel and bladder functions. His blood pressure (supine) is 130/70mm Hg, heart rate is 82/min, respirations are 18/min, and temperature is 36.9°C (98.5°F). Physical examination reveals bilateral facial paralysis, orthostatic hypotension, areflexia in all four extremities, and distal paresthesias. His CSF analysis shows: Total WBC 10/cmm, Protein 120 mg/dl, Glucose 70 mg/dl, Gram stains No organisms. What is the most appropriate next step in the management of this patient?

522) A 32-year-old G3P2 woman at 35 weeks’ gestation has a past medical history significant for hypertension. She was well-controlled on hydrochlorothiazide and lisinopril as an outpatient, but these drugs were discontinued when she found out that she was pregnant. Her blood pressure has been relatively well controlled in the 120–130 mm Hg systolic range without medication, and urinalysis has consistently been negative for proteinuria at each of her prenatal visits. She presents now to the obstetric clinic with a blood pressure of 142/84 mmHg. A 24hour urine specimen yields 0.35 g of proteinuria. Which of the following is the most appropriate next step?

525) A 32-year-old generally healthy woman presents to the office for a routine preemployment physical. She uses a vaginal ring for birth control. Her LMP was 2 weeks ago. She has been pregnant three times and has had two full-term births via normal spontaneous vaginal delivery. She had one spontaneous miscarriage at 10 weeks' gestation. She is only sexually active with her husband. She has a family history of breast cancer in her mother. Her mother had breast cancer at age 40 years and again at age 56 years. Her aunt also had breast cancer at an early age. Her last Pap smear, including human papillomavirus (HPV) was negative last year. BP, 120/80 mm Hg; P, 75 beats/min; R, 14 breaths/min; T, 98.4°F. Physical examination: Gen: Awake, alert, oriented x3, CVS: S1S2+ RRR no m/r/g, Lungs: Clear to auscultation bilaterally, Breast: No breast mass felt. What should be done as a part of the evaluation?

551) A 32-year-old woman, gravida 1, para 0, with a history of infertility, underwent ovulation induction resulting in a twin pregnancy, now at 31 weeks’ gestation. An early obstetric sonogram at 7 weeks’ gestation showed dichorionic placentation. She has a positive group B –hemolytic streptococcus vaginal culture. Because of epigastric pain, vaginal bleeding, and uterine contractions, she is evaluated at the maternity unit. An obstetric sonogram shows twin A to be a female fetus in breech presentation and twin B to be a male fetus in transverse lie with the back down. The sonogram also shows a marginal anterior placenta previa. Her initial vital signs are as follows: temperature, 37.2C (99.0F); pulse, 95/min; respiration, 18/min; blood pressure, 165/115 mm Hg. Her urine dipstick test shows 2 glucose and 3 albumin. Which of the following is a contraindication to tocolysis in this case?

580) A 34-year-old G1P0 woman at 29 weeks’ gestation presents to the emergency department complaining of 2 hours of vaginal bleeding. The bleeding recently stopped, but she was diagnosed earlier with placenta previa by ultrasound. She denies any abdominal pain, cramping, or contractions associated with the bleeding. Her temperature is 36.8C (98.2F), blood pressure is 118/72 mm Hg, pulse is 75/min, and respiratory rate is 13/min. She reports she is Rh positive, her hemoglobin is 11.1 g/dL, and coagulation tests, fibrinogen, and D-dimer levels are all normal. On examination her gravid abdomen is non-tender. Fetal heart monitoring is reassuring, with a heart rate of 155/min, variable accelerations, and no decelerations. Two large-bore peripheral intravenous lines are inserted and two units of blood are typed and crossed. What is the most appropriate next step in management?

584) A 34-year-old G2P1001 with an IUP at 38 weeks' gestation presents to labor and delivery for contractions. The patient states that she has had gestational diabetes that was diet controlled throughout her pregnancy. She states that she has had routine prenatal care. Vital sign: BP, 125/88 mm Hg; P, 95 beats/min; R, 12 breaths/min; T, 98.6°F. Contractions: Present, Fetal movement: Present. Physical examination: Gen: Awake, alert, oriented x3, mild pain distress, CVS: S1S2+ RRR no m/r/g, Vaginal bleeding: Absent, Leakage offluid: Present, Lungs: CTA bilaterally, Abd: Gravid, contractions present, Ext: 1+ edema bilaterally. Cervical Examination: 7 cm, 100% effaced, -1 station. Fetal Heart Monitoring: Reassuring, good variability, accelerations are present, no decelerations. What is the next step in the management of this patient?

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

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

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

696) A 38-year-old male with a chronic history of schizophrenia is admitted to the hospital for deterioration in his condition. He is a known patient and was stable on risperidone for the past few years. Today, the patient does not respond when spoken to and he sits motionlessly. He makes no eye contact and his face remains expressionless. Vital signs include temperature of 37.0°C (98.6°F), blood pressure of 132/80 mm Hg, pulse of 88/min, and respirations of 14/min. Physical examination demonstrates diffuse muscle rigidity but is otherwise unremarkable. Which of the following would be the most appropriate next step?

722) A 39-year-old woman, gravida 3, para 2, at 39 weeks’ gestation comes to the labor and delivery ward with regular contractions and gush of fluid 1 hour ago. On examination she is found to have rupture of membranes and is 4 cm dilated. She is admitted to labor and delivery. Her prenatal course was significant for a 36-week vaginal culture that was positive for Group B Streptococcus (GBS) that is sensitive to clindamycin. She also has gestational diabetes that is treated with diet. She has no other medical problems and has never had surgery. She takes no medications and is allergic to penicillin. After she is admitted to the labor and delivery ward, a penicillin infusion is erroneously started. Soon thereafter, the patient develops generalized pruritus and urticaria with angioedema and difficulty breathing. Which of the following is the most appropriate next step in the management of this patient?

762) A 42-year-old African-American woman presents to your office with bilateral knee pain that severely limits her mobility. She also complains of joint stiffness in the morning that takes several hours to improve. Her hand joints are symmetrically swollen. She has been taking over-the-counter ibuprofen and aspirin with little relief of symptoms. She has no other medical problems and does not use tobacco, alcohol, or illicit drugs. Her vital signs are within normal limits. Physical examination shows pain and swelling of both wrists and knees. Laboratory studies reveal: Hemoglobin 8.4 mg/dl, Serum iron 30 μg/dL (normal 50-150 μg/dL), Total iron binding capacity 230 μg/dL (normal 300-360 μg/dL), Ferritin 300 ng/dl. Which of the following is most likely to improve this patient's anemia?

767) A 42-year-old man comes to the physician because of a 3-month history of burning substernal chest pain after every meal. His other medical problems include chronic alcoholism. Upper endoscopy shows mucosal irregularity and ulceration of the squamocolumnar junction above the lower esophageal sphincter. Multiple biopsies are taken. He complains of worsening substernal pain radiating to the back, left chest pain, and mild shortness of breath 4 hours later. His temperature is 37.1°C (98.9°F), blood pressure is 110/70 mm Hg, pulse is 120/min, and respirations are 34/min. A chest x-ray shows a small left pleural effusion that was not present on a chest radiograph taken 2 weeks ago. Which of the following is the most appropriate next step in management?

821) A 45-year-old man presents to the physician’s office for evaluation of a skin lesion on his abdomen. He states that the lesion has been present for 1 year, but has recently enlarged over the last 2 months. The mass is nontender, and he is otherwise asymptomatic. Past history is unremarkable. Examination reveals a 3-cm, pigmented, irregular skin lesion located in the left lower quadrant of the abdomen, as shown in Figure 6-12. Heart, lung, and abdominal examination are normal. There are no palpable cervical, axillary, or inguinal lymph nodes. Chest x-ray and liver function tests are normal. Which of the following is the most appropriate next step in management?

826) A 45-year-old man with advanced chronic renal failure comes to the physician because of edema of his feet. His temperature is 37°C (99°F), blood pressure is 150/100mm Hg, pulse is 78/min, and respirations are 15/min. Examination shows bilateral ankle edema. Laboratory studies show BUN of 62 mg/dl, serum creatinine of4.2 mg/dl, serum potassium of 5.6 meq/l, serum sodium of 146 meq/l, and total plasma cholesterol of 260 mg/dl. Which of the following is most likely to improve the prognosis of his disease?

833) A 45-year-old woman is undergoing chemotherapy for breast cancer. She presents 10 days after her last chemotherapy with fever (temperature > 38.5°C), but no other symptoms except a sore throat and mouth. On examination, she looks well, there is oral mucositis, ears are normal, lungs are clear, and the central line site is clean. The CXR, urinalysis, and biochemistry are normal. Her WBC is 800/mL and the absolute neutrophil count is low ( < 500). Which of the following is the most appropriate next step in management?

842) A 45-year-old woman with no PMH presents to the office for an increase in abdominal fullness and bloating, worsening over the past 3 or 4 months. The patient states that she feels nauseous all the time, although has not had any vomiting. She states because of the constant nausea, she has not been eating as much. She has had a 10-lb weight loss in the last 4 months. BP, 110/70 mm Hg; P, 97; R, 18; T, 98.6°F. ROS: Denies fever and chills, Weight loss has occurred (10 lb in 4 months), Denies chest pain, shortness of breath, and abdominal pain, Nausea is present with no vomiting, No diarrhea or constipation. PE: Gen: Awake, alert, oriented x3, Abd: Soft, nontender, distended bowel sounds are present, shifting dullness to percussion is present, Pelvic: Cervix normal, no cervical motion tenderness, right adnexal enlargement is present. Which of the following is the next step in the management of this patient?

859) A 47-year-old diabetic woman comes to the physician due to the recent onset of tremors. She has undergone combined pancreatic and kidney transplantation secondary to end stage renal disease and diabetes. She takes multiple medications, including immunosuppressants. Her temperature is 36.1° C (97°F), blood pressure is 152/90 mm Hg, pulse is 78/min, and respirations are 16/min. Examination shows gum hypertrophy. Laboratory studies show: Hb 13.0 g/dl, WBC 8,000/cmm, Serum Na 135 mEq/L, Serum K 5.3 mEq/L, BUN 26 mg/dl, Serum Creatinine 1.7 mg/dl. Which of the following immunosuppressants is most likely responsible for her presentation?

860) A 47-year-old male who has just returned from a cruise to the Bahamas presents to the hospital with a high-grade fever, productive cough and shortness of breath for the past two days. He also complains of frequent vomiting and diarrhea. He has no prior medical problems, does not take any medications, and denies using tobacco, alcohol or drugs. His temperature is 40°C (104°F), blood pressure is 110/65 mm Hg, pulse is 80/min, and respirations are 18/min. Lung examination reveals right lower lobe crackles. The abdomen is soft and non-tender. Chest x-ray demonstrates right lower lobe consolidation. Sputum Gram stain contains many neutrophils with no organisms. Which of the following antibiotics must be given to this patient?

873) A 48-year-old woman presents to her gynecologist because of vaginal bleeding. She states that after a year of hot flashes and irregular cycles, she finally stopped menstruating 4 months ago. Two days ago she began having some vaginal bleeding that was very similar to her prior menses. She is concerned because she heard that the first sign of endometrial cancer in postmenopausal women is vaginal bleeding. She is an otherwise healthy woman with no medical problems. She exercises three times a week and takes multivitamins. She had three children when she was 29–35 years old. She used oral contraceptive pills for contraception from the time she was 18 until she got married at the age of 28. Which of the following is the most appropriate next step in managing this woman’s vaginal bleeding?

874) A 49-year-old man presents to the clinic for a health maintenance visit. He has a family history of type 2 DM. His medical history is significant for gastroesophageal reflux disease, for which he takes omeprazole and over-the-counter antacids. He smokes one pack of cigarettes per day and drinks an average of two beers per night. The patient’s body mass index is 32 kg/m². Which of the following most greatly reduce(s) the patient’s risk of future coronary artery disease, renal failure, and retinopathy?

915) A 51-year-old man presenting to the clinic for routine examination mentions that he has not been able to get over the flu. Further questioning clarifies that he has had a nonproductive cough for the past 3–4 months and is unable to sustain his normal walking pace for prolonged periods. He reports feeling more fatigued than he recalls feeling last year. His medical history is significant for hypertension, alcoholism, and obesity. His blood pressure is well controlled on losartan and hydrochlorothiazide. He has no known drug allergies. His mother died of complications of type 2 diabetes mellitus. His father had a fatal myocardial infarction at age 56 years. The patient smokes half a pack of cigarettes per day and has done so for the past 7 years. He has worked all his adult life as an accountant and has no known exposures to asbestos or organic dusts. His blood pressure is 134/96 mm Hg, heart rate is 78/min, respiratory rate is 16/min, temperature is 37°C (98.6°F), and oxygen saturation is 94% on room air. Lung examination reveals bilateral inspiratory crackles in the lung bases. High-resolution CT shows patchy areas of ground glass, reticular abnormalities, and traction bronchiectasis. Laboratory findings are normal except for an elevated erythrocyte sedimentation rate of 54 mm/hr. What is the recommended treatment for this patient’s cough?

922) A 52-year-old man develops sudden-onset shortness of breath on postoperative day 4 after a hemicolectomy for colon cancer. His surgery went well with no operative complications. He reports no cough, sputum, or pleuritic chest pain. His blood pressure is 155/90 mm Hg, pulse 100/min, temperature 37.8°C, lungs are clear, and heart sounds normal. He has bilateral pedal edema, but no discomfort in his legs. His CXR and ECG are normal. A chest CT with contrast reveals a thrombus in his right upper lobe artery. Which of the following statements concerning the management of this condition is most likely correct?

962) A 55-day-old infant born prematurely at 27 weeks of gestation is shown below. The swelling is not tender, firm, hot, or red, and it does not transil luminate. It seems to resolve with pressure, but returns when the infant cries or strains. Which of the following is the most appropriate course of action at this point?

 

990) A 55-year-old woman is brought to the emergency department by fi re and rescue personnel because of intractable back and thigh pain for the past 3 hours. Upon presentation she says that the pain is 9 of 10 in severity and localized to her lower back. She lives with her sister, and she has no primary care physician. She denies any complaints aside from fatigue, which she attributes to her multiple jobs and caring for her sister’s children. She has a pulse of 110/min, blood pressure of 140/88 mm Hg, respiratory rate of 20/min, and temperature of 37.8C (100.1F). On physical examination she is exquisitely tender over the L2–3 area of the spine. She also has point tenderness over the anterior right thigh. Sensation is intact over the lower extremities bilaterally and she has 5/5 strength in the lower extremities bilaterally. Breast examination reveals a retracted nipple and dimpling of the right breast. What will likely represent the mainstay of treatment for this patient’s symptoms?

995) A 55-year-old-woman presents to the physician’s office for evaluation of mammographic findings on a screening mammogram. She denies any breast masses, nipple discharge, pain, or skin changes. Past history is pertinent for insulindependent diabetes. Family history is positive for postmenopausal breast cancer in her mother. She has a normal breast examination and no axillary adenopathy. A mediolateral oblique (MLO) view of the right breast is shown. Which of the following is the most appropriate next step in management?

997) A 56-year-old male is admitted to the ICU for the management of hepatic encephalopathy. He is a known alcoholic. He is started on oral neomycin, lactulose, and a low-protein, high-carbohydrate diet. His blood pressure is 116/78 mm Hg, pulse is 78/min, temperature is 37.5°C (99.5°F), and respirations are 18/min. His labs reveal the following: Hb 10.2 g/dl, WBC 7,400/cmm, Hct 27%, Platelets 4 2,000/mm3, PT 18 sec, INR 2.02, PTT 31 sec. He has no evidence of active bleeding. Which of the following should be administered to this patient at this time?

1063) A 6-year-old girl presents with a 2-day history of cough and fever. At your office she has a temperature of 39.4°C (103°F), a respiratory rate of 45 breaths per minute, and decreased breath sounds on the left side. Her chest x-ray is shown below. Which of the following is the most appropriate initial treatment?

1072) A 60-year-old female presents with transient loss of consciousness. She appears lethargic and confused. She also complains of hemoptysis and weight loss of 10 lbs (4.5kg) over a period of 2 months. She has smoked one pack of cigarettes daily for the last 40 years. Her temperature is 37.0°C (98.6°F), pulse is 75/min, blood pressure is 110/70 mmHg, and respirations are 16/min. Her mucus membranes are moist. There is no jugular venous distention. Her neurological examination is non-focal, and cardiovascular examination is unrevealing. There is no ankle edema or ascites. Serum studies show: Sodium 115 mEq/L, Potassium 3.7 mEq/L, Bicarbonate 22 mEq/L, Blood glucose 100 mg/dL, BUN 10.0 mg/dL. Serum osmolality is 250 mOsm/Kg, and urine osmolality is 500 mOsm/Kg. Urine sodium concentration is 40 mEq/L. Chest x-ray shows a mass in the right hilar region. What is the most appropriate next step in the management of this patient?

1085) A 60-year-old man is brought to the emergency department due to syncope. He has had similar episodes a few times during the past few weeks. These episodes usually occur after he exerts himself. He does not feel confused or tired after these episodes. He denies any chest pain or palpitation. His wife reports that when he collapses, he seems to lose consciousness for a few seconds, but then is back to being alert right away. She denies any jerking movement. His past medical history is significant diverticulosis, for which he takes fiber supplements. He is not on any other medication. His temperature is 37.1°C (98.8°F), blood pressure is 110/98 mm Hg, pulse is 88/min, and respirations are 14/min. On examination, he has a fourth heart sound and harsh 3/6 systolic murmur, best heard over the right sternal border. The murmur is accentuated on expiration. The lung fields are clear to auscultation. After performing an echocardiograph to confirm the diagnosis, which of the following management options is most appropriate?

1123) A 63-year-old insurance agent is brought to the ED by paramedics for shortness of breath and an RR of 31 breaths per minute. The patient denies chest pain, fever, vomiting, or diarrhea. His wife says he ran out of his “water pill” 1 week ago. His BP is 185/90 mmHg, HR is 101 beats per minute, oxygen saturation is 90% on room air, and temperature is 98.9°F. There are crackles midway up both lung fields and 2+ pitting edema midway up his legs. An ECG shows sinus tachycardia. The patient is sitting up and able to speak to you. After placing the patient on a monitor and inserting an IV, which of the following is the most appropriate next step in management?

1135) A 63-year-old woman is undergoing a total abdominal hysterectomy (TAH) for atypical endometrial hyperplasia. She mentioned to her doctor 2 weeks prior to the surgery that she has had problems with leakage of urine with straining and occasional episodes of urinary urgency. A urine culture at that visit is negative. She has had preoperative cystometrics done in the doctor’s office showing loss of urine during Valsalva maneuvers along with evidence of detrusor instability. The doctor has elected to do a retropubic bladder neck suspension following the TAH. A Marshall-Marchetti-Krantz procedure (MMK) is done to attach the bladder neck to the pubic symphysis. The patient does well after her surgery and is released from the hospital on postoperative day 3. Which of the following should her doctor advise her prior to her discharge?

1242) A 70-year-old woman has nausea, vomiting, abdominal distention, and episodic crampy midabdominal pain. She has no history of previous surgery but has a long history of cholelithiasis for which she has refused surgery. Her abdominal radiograph reveals a spherical density in the right lower quadrant. Which of the following is the definitive treatment for this patient’s bowel obstruction?

1359) A pedestrian is hit by a speeding car. Radiologic studies obtained in the emergency room, including a retrograde urethrogram (RUG), are consistent with a pelvic fracture with a rupture of the urethra superior to the urogenital diaphragm. Which of the following is the most appropriate next step in this patient’s management?

1366) A previously healthy 16-year-old girl presents to the emergency center with the complaint of “falling out.” She was with her friends at a local fast food restaurant when she felt faint and, according to her friends, lost consciousness for about a minute. There was no seizure activity noted, but the friends did notice her arms twitching irregularly. She is now acting normally. She denies chest pain or palpitations, and her electrocardiogram (ECG) is normal. Further management of this patient should include which of the following?

1384) A stockbroker in his mid-40s presents with complaints of episodes of severe, often incapacitating chest pain on swallowing. Diagnostic studies on the esophagus yield the following results: endoscopic examination and biopsy mild inflammation distally; manometry—prolonged high-amplitude contractions from the arch of the aorta distally, lower esophageal sphincter (LES) pressure 20 mm Hg with relaxation on swallowing; barium swallow 2 cm epiphrenic diverticulum. Which of the following is the best management option for this patient?

1402) A23-year-old woman with no PMH presents to the office for her annual gynecologic examination. She has never been pregnant. She has had five lifetime partners. She does not have vaginal discharge, vaginal pruritus, or dyspareunia. Her menstruation is regular every 28 days and lasts for 5 days. BP, 125/75 mm Hg; P, 78 beats/min; R, 16 breaths/min; T, 98.4°F. In addition to the Pap smear, what else is indicated?

1471) An otherwise asymptomatic 65-year-old man with diabetes presents to the ER with a sports-related right shoulder injury. His heart rate is noted to be irregular, and this ECG is obtained. Which of the following is the best immediate therapy?

 

1475) An upper GI series is performed on a 71-year-old woman who presented with several months of chest pain that occurs when she is eating. The film shown here is obtained. Investigation reveals a microcytic anemia and erosive gastritis on upper endoscopy. Which of the following is the most appropriate initial management of this patient?

1547) You are asked to evaluate a 4-year-old boy admitted to your local children’s hospital with a diagnosis of pneumonia. The parents state that the child has had multiple, intermittent episodes of fever and respiratory difficulty over the past 2 years, including cyanosis, wheezing, and dyspnea; each episode lasts for about 3 days. During each event he has a small amount of hemoptysis, is diagnosed with left lower lobe pneumonia, and improves upon treatment. Repeat radiographs done several days after each event are reportedly normal. His examination on the current admission is significant for findings similar to those described above, as well as digital clubbing. Which of the following is the most appropriate primary recommendation?

1580) You have just diagnosed a 21-year-old infertile woman with polycystic ovarian syndrome. The remainder of the infertility evaluation, including the patient’s hysterosalpingogram and her husband’s semen analysis, were normal. Her periods are very unpredictable, usually coming every 3 to 6 months. She would like your advice on the best way to conceive now that you have made a diagnosis. Which of the following treatment options is the most appropriate first step in treating this patient?

1588) Your patient had an ultrasound examination today at 39 weeks gestation for size less than dates. The ultrasound showed oligohydramnios with an amniotic fluid index of 1.5 centimeters. The patient’s cervix is unfavorable. Which of the following is the best next step in the management of this patient?