Management USMLE 6 ( 808-900)

A 45-year-old male comes to the emergency room complaining of shortness of breath that began 3 hours ago. He also file:///D:/DES_Entry_2016MCQs/3C_USMLE/C-4Management/4Manag... 169 of 334 12/21/2016 3:59 PM has a nonproductive cough, a low-grade fever and right-sided chest pain that worsen with inspiration. He denies coughing up blood, wheezing, palpitations, leg pain or swelling of his lower extremities. He recently returned home from a trip to Singapore. He has a history of hypertension and diabetes mellitus. His takes fosinopril, metformin and glyburide. He doesn't use tobacco, alcohol or illicit drugs. His temperature is 98.0°F (36.6°C), blood pressure is 115/70 mmHg, pulse is 128/min, respirations are 32/min, and O2 saturation is 84% on room air. Physical examination shows a slightly obese man in acute respiratory distress. He is alert and cooperative without any cyanosis or jaundice. He has a slightly displaced apical impulse with a S4. Chest-x ray shows mild cardiomegaly with no infiltrates. EKG shows sinus tachycardia and left ventricular hypertrophy without ST-T wave changes. His arterial blood gas analysis shows pH 7.52, pCO2 30, pO2 55, HC03 22. What is the next best step in the management of this patient?

A 45-year-old woman presents to the ED with 1 day of painful rectal bleeding. Review of systems is negative for weight loss, abdominal pain, nausea, and vomiting. On physical examination, you note an exquisitely tender swelling with engorgement and a bluish discoloration distal to the anal verge. Her vital signs are HR 105 beats per minute, BP 140/70 mm Hg, RR 18 breaths per minute, and temperature 99°F. Which of the following is the next best step in management?

A 46-year-old male comes to your office for a routine health examination. He has no current physical complaints and says he is compliant with his medications. His past medical history is significant for type 2 diabetes diagnosed two years ago that he has been able to control with diet, exercise and metformin. The patient also takes a daily aspirin. On physical examination, he has a temperature of 36.7°C (98°F), a blood pressure of 140/86 mmHg, a pulse of 80/min, and respirations of 14/min. His laboratory studies show: Total cholesterol 170 mg/dl, High density lipoprotein (HDL) 50 mg/dl, Low density lipoprotein (LDL) 65 mg/dl, Triglycerides (TG) 150 mg/dl, HbA1C 7.0. Serum chemistries are with in normal limits. Which of the following is the most appropriate next step in the management of this patient?

A 46-year-old man comes to the emergency department because of abrupt onset of epigastric pain radiating to the back and associated vomiting. He has had these symptoms for the past 1 day. The symptoms are progressively getting worse. He has no other medical problems or previous surgeries. He does not use tobacco, alcohol, or illicit drugs. His temperature is 36.5°C (97.6°F), blood pressure is 100/70 mm Hg, pulse is 100/min, and respirations are 20/min. Abdomen is mildly distended and very tender to palpation in the epigastric region; bowel sounds have decreased. There is no rebound tenderness or organomegaly. Rectal examination shows no abnormalities. Laboratory findings reveal: CBC: Hb 15.0 g/dL, Platelet count 223,000/mm3, Leukocyte count 14,500/mm3, Serum Chemistry: Serum Na 134 mEq/L, Serum K 3.6 mEq/L, Chloride 93 mEq/L, Bicarbonates 29 mEq/L, BUN 30 mg/dL, Serum creatinine 0.8 mg/dL, Calcium 10.3 mg/dL, Blood glucose 168 mg/dL, LFT 1.4 mg/dL. Total bilirubin: Alkaline phosphatase 220 U/L, Aspartate aminotransferase 88 U/L, Alanine aminotransferase 155 U/L, Lipase 523 U/L. Abdominal x-ray shows gaseous distention of the small bowel in the upper abdomen. Computed tomography (CT) scan with contrast shows diffuse hypodense enlargement of the pancreas and peripancreatic and perirenal fluid collections. Nasogastric suction, intravenous normal saline, analgesics, and antibiotics are started. Which of the following is the most appropriate next step in management?

A 48-year-old man sustains a gunshot wound to the right upper thigh just distal to the inguinal crease. He is immediately brought to the ER. Peripheral pulses are palpable in the foot, but the foot is pale, cool, and hypesthetic. The motor examination is normal. Which of the following statements is the most appropriate next step in the patient’s management?

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?

A 5-year-old boy is brought to his pediatrician's office after he falls from his bicycle and strikes his head against the sidewalk. There were no witnesses to this incident, which occurred 8 hours ago. The child is otherwise healthy, up-to-date file:///D:/DES_Entry_2016MCQs/3C_USMLE/C-4Management/4Manag... 184 of 334 12/21/2016 3:59 PM on his immunizations, and not taking any medications. On physical examination, his vital signs are stable. He has a 5 × 4 cm abrasion on his forehead. He is alert and oriented to date, place and self. His motor and sensory examinations are normal and reflexes are normal. Which of the following constitutes reasonable management?

A 5-year-old boy is brought to the physician for evaluation of left hip pain after his parents saw him limping this morning. He spent time on the playground yesterday but his parents do not think he was injured then. The boy complains that the pain in his hip worsens when he moves or walks. For the past 3 days, he has had a runny nose and congestion. Review of systems is otherwise negative. His grandmother has rheumatoid arthritis treated with methotrexate. His temperature is 37.2° C (99° F), blood pressure is 100/65 mm Hg, pulse is 92/min, and respirations are 18/min. Physical examination shows a well-appearing child with clear rhinorrhea and intermittent dry cough. Lungs are clear to auscultation bilaterally. His left hip is slightly abducted and externally rotated with mildly decreased range of motion. He is able to stand and bear weight. The remainder of his examination is normal. X-rays of both hips are normal. His laboratory results are as follows: Complete blood count: Hemoglobin 12.5 g/dL, Platelets 287,000/mm3, Leukocyte count 8,500/mm3, Neutrophils 30%, Eosinophils 1%, Lymphocytes 64%, Monocytes 5%, Erythrocyte sedimentation rate 30 mm/h, C-reactive protein 9 mg/L (N: ≤ 8 mg/L). Which of the following is the best next step in management of this patient?

A 50-year-old Caucasian male comes to the office for the evaluation of polyuria and polydypsia for the last two months. He also complains of weakness and fatigue. He had one episode of transient proximal muscle weakness which lasted 30 minutes. He has a 20-pack year history of smoking. He does not drink alcohol. His past medical and family histories are insignificant. His pulse is 78/min, blood pressure is 150/96 mmHg and temperature is 36.7°C (98°F). The rest of the examination, including the neurological examination, is normal. Labs show: Plasma sodium 150 mEq/L, Potassium 2.6 mEq/L, Serum creatinine 0.8 mg/dL. Which of the following is the most appropriate next step in the management of this patient?