USMLE_Management V

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Comprehensive USMLE Management Quiz

Test your knowledge with this in-depth USMLE Management quiz designed for medical students and professionals preparing for their exams. With 30 challenging questions, each focusing on key aspects of patient management, this quiz will help you solidify your understanding and application of clinical knowledge.

Key Features:

30 expertly crafted multiple-choice questions
Covers a wide range of topics in patient care
Detailed explanations for each correct answer

100 Questions25 MinutesCreated by LearningDoctor927

A 28-year-old woman is diagnosed with bipolar disorder, manic type, when she was hospitalized after becoming psychotic, hypersexual, severely agitated, and unable to sleep. She is started on a medication in the acute phase of her illness. Which of the following medications, recommended for acute use in manic patients, is recommended to be continued on into maintenance therapy?

A 28-year-old woman presents to her obstetrician for her first prenatal visit in November. She is at 8 weeks gestation as determined by her last menstrual period. She has no medical problems and takes no medications. She does not smoke cigarettes and stopped drinking alcohol when she decided to become pregnant. She has no history of illicit drug use and has never been diagnosed with a sexually transmitted disease. She has been in a monogamous relationship with her husband for the past one year. Her family history is unremarkable. Her BMI is 23 kg/m2. Her physical examination, including vital signs, is within normal limits. Which of the following preventive measures is warranted at this visit?

A 28-year-old woman presents to her obstetrician for her first prenatal visit. She is at 8 weeks gestation as determined by her last menstrual period. She has no medical problems and takes no medications. She does not smoke cigarettes and stopped drinking alcohol when she decided to become pregnant. She has no history of illicit drug use and has never been diagnosed with a sexually transmitted disease. She has been in a monogamous relationship with her husband for the past one year. Her family history is unremarkable. Her BMI is 23 kg/m2. Her physical examination, including vital signs, is within normal limits. Which of the following preventive measures is warranted at this visit?

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?

A 28-year-old woman with no past medical history presents for her initial prenatal visit. Her last menstrual period (LMP) was 6 weeks ago. Vital sign: BP, 125/78 mmi P, 73 beats/mini R, 13 breaths/min, T: 98°F (37 C). She denies leakage of fluid, denies vaginal bleeding, denies fetal movement, and denies contractions, nausea and vomiting present. Labs: Complete blood count (CBC): white blood cells (WBCs); 8,000/ microL; hemoglobin (Hgb), 11.0 g/dL; hematocrit (Hct), 33.5%; platelets, 167,000/microL. CMP: Sodium, 128 mmol/ L; potassium, 4.5 mmol/L; chloride, 100 mmol/L; bicarbonate, 22 mmol/ L; blood urea nitrogen (BUN), 0.9 mg/dL; creatinine, 1 mg/dL; glucose, 97 mg/dL. Rubella IgG: positive. HIV: positive. CD4 count: 750. Viral load: 20,000 copies/mL. Hepatitis B sAg: Negative. HgbAlc: 5.6%. What is the next best step in the management of this patient?

. Zidovudine now

. Zidovudine starting in the second trimester

. Zidovudine, lamivudine, ritonavir, and lopinavir now

. Zidovudine, lamivudine, ritonavir, and lopinavir starting in the second trimester

. Zidovudine, lamivudine, ritonavir, and lopinavir in 1 month later

A 28-year-old woman with sickle cell anemia presents to the urgent care clinic complaining of 12 hours of right upper quadrant pain. She has had similar pain previously, usually after eating fatty foods. However, past episodes have always resolved within one to two hours. On examination, her temperature is 38.3C and she has right upper quadrant pain with a positive Murphy's sign. Abdominal ultrasound reveals gallstones, a thickened gallbladder wall, and a normal common bile duct. Her alkaline phosphatase level is normal. What is the most appropriate next step in the management of this patient?

. Conservative management and elective cholecystectomy

. Endoscopic retrograde cholangiography

. Emergent cholecystectomy

. HIDA scan

. Percutaneous transhepatic drainage

A 28-year-old woman, gravida 2, para 0, aborta 1, at 30 weeks' gestation comes to the physician because of a decrease in fetal movements. She has felt no fetal movements the past 18-hours. Her prenatal course, prenatal tests, and fetal growth have been normal up to this point. Triple test was performed at 14-weeks and showed no abnormalities. Her first pregnancy was terminated because her fetus was diagnosed with Down's syndrome. She does not use tobacco, alcohol, or drugs. Fetal heart tones are heard by Doppler. Non-stress test is non-reactive; therefore, biophysical profile is performed and shows a score of 8. Which of the following is the most appropriate next step in management?

. Reassurance and repeat biophysical profile in one week

. Perform contraction stress test

. Give steroids and repeat biophysical profile within 24hrs

. Advise continuous home fetal monitoring

. Deliver the baby immediately

A 28-year-old woman, gravida 3, para 2, at 35 weeks gestation is rushed to the emergency department because of vaginal bleeding. She was sleeping when she first noticed the bleeding. She has had no uterine contractions. Her prenatal course, prenatal tests and fetal growth have been normal. Prenatal ultrasound at the 14th week of gestation showed an intrauterine gestation consistent with dates and showed no abnormalities. Her previous pregnancies were uncomplicated. Her temperature is 37.0C (98.7F), blood pressure is 90/60 mmHg, pulse is 11 6/min and respirations are 16/min. Physical examination shows cold extremities and bright red vaginal bleeding. Which of the following is the most appropriate next step in management?

. Emergency transvaginal ultrasonogram

. Obtain blood for PT/INR and PTI

. Obtain venous access with two large bore needles

. Immediate vaginal examination

. Immediate cesarean section

A 28-year-old, HIV-infected female from Michigan is admitted with Pneumocystis jirovecii pneumonia (PCP) secondary to noncompliance with prophylaxis. She was diagnosed with HIV infection three years ago. Her CD4 count on admission is 30/microl, and viral load is 300,000copies/ml. Her pneumonia is adequately treated with IV antibiotics, and she subsequently receives zidovudine, lamivudine, nelfinavir, and trimethoprim-sulfamethoxazole. What is the most appropriate drug to be added to her current regimen?

A 29-week-old previously healthy male infant presents with fevers, abdominal distention, feeding intolerance, and bloody stools at 3 weeks of age. The patient undergoes x-ray and ultrasound examination for possible necrotizing enterocolitis. Which of the following findings on imaging is an indication for surgical management?

A 29-year-old African-American woman comes to the physician after discovering a mass on breast self-examination. Her last menstrual period was 2 weeks ago. She reports occasional bilateral gray nipple discharge that has not changed since menarche. She has no significant past medical history and does not take any medications. Examination reveals a 1.5-cm fluctuant mass in the upper and outer quadrant of the left breast. Which of the following is the best next step in management?

A 29-year-old female comes to the physician because of fevers and back pain. She is otherwise healthy with no significant past medical history. Examination is significant for a temperature of 38.3 C (101 F), moderate costovertebral angle tenderness, leukocytosis, and white blood cells and red blood cells in the urine. The patients is diagnosed with pyelonephritis and started on intravenous antibiotics. Over the next two days, she rapidly improves, and by hospital day 3, she is tolerating oral intake, voiding without difficulty, feeling no pain, and she has not had a fever for 48 hours. Which of the following is the most appropriate next step in management?

. Continue intravenous antibiotics for 2 weeks

. Discharge home and recommend post-coital prophylaxis

. Discharge home off all antibiotics

. Discharge home to complete a 2-week course of oral antibiotics

. Obtain surgical evaluation

A 29-year-old G0 comes to your OB/GYN office complaining of PMS. On taking a more detailed history, you learn that the patient suffers from emotional lability and depression for about 10 days prior to her menses. She reports that once she begins to bleed she feels back to normal. The patient also reports a long history of premenstrual fatigue, breast tenderness, and bloating. Her previous health-care provider placed her on oral contraceptives to treat her PMS 6 months ago. She reports that the pills have alleviated all her PMS symptoms except for the depression and emotional symptoms. Which of the following is the best next step in the treatment of this patient’s problem?

A 29-year-old G0 comes to your office complaining of a vaginal discharge for the past 2 weeks. The patient describes the discharge as thin in consistency and of a grayish white color. She has also noticed a slight fishy vaginal odor that seems to have started with the appearance of the discharge. She denies any vaginal or vulvar pruritus or burning. She admits to being sexually active in the past, but has not had intercourse during the past year. She denies a history of any sexually transmitted diseases. She is currently on no medications with the exception of her birth control pills. Last month she took a course of amoxicillin for treatment of a sinusitis. On physical examination, the vulva appears normal. There is a discharge present at the introitus. A copious, thin, whitish discharge is in the vaginal vault and adherent to the vaginal walls. The vaginal pH is 5.5. The cervix is not inflamed and there is no cervical discharge. Wet smear of the discharge indicates the presence of clue cells. In the patient described in the question above, which of the following is the best treatment?

. Reassurance

. Oral Diflucan

. Doxycycline 100 mg PO twice daily for 1 week

. Ampicillin 500 mg PO twice daily for 1 week

. Metronidazole 500 mg PO twice daily for 1 week

A 29-year-old G1P0 patient at 24 weeks gestational age presents to your office complaining of some shortness of breath that is more intense with exertion. She has no significant past medical history and is not on any medication. The patient denies any chest pain. She is concerned because she has always been very athletic and cannot maintain the same degree of exercise that she was accustomed to prior to becoming pregnant. On physical examination, her pulse is 72 beats per minute. Her blood pressure is 90/50 mm Hg. Cardiac examination is normal. The lungs are clear to auscultation and percussion. Which of the following is the most appropriate next step to pursue in the workup of this patient?

. Refer the patient for a ventilation-perfusion scan to rule out a pulmonary embolism

. Perform an arterial blood gas

. Refer the patient to a cardiologist

. Reassure the patient

. Order an ECG

A 29-year-old G1P0 presents to the obstetrician’s office at 41 weeks gestation. On physical examination, her cervix is 1 centimeter dilated, 0% effaced, firm, and posterior in position. The vertex is presenting at –3 station. Which of the following is the best next step in the management of this patient?

. Send the patient to the hospital for induction of labor since she has a favorable Bishop score

. Teach the patient to measure fetal kick counts and deliver her if at any time there are less than 20 perceived fetal movements in 3 hours

. Order BPP testing for the same or next day

. Schedule the patient for induction of labor at 43 weeks gestation

. Schedule cesarean delivery for the following day since it is unlikely that the patient will go into labor

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?

A 29-year-old G2P1001 with an intrauterine pregnancy (IUP) at 8 weeks' gestation presents to the office for a routine prenatal examination. The patient states that with her first pregnancy, she was told that she had blood type 0 negative. She states that she read online that this could be a problem with the second pregnancy, and she is extremely concerned. Vital sign: BP, 115/75 mm Hg; P, 82 beats/min; R, 12 breaths/min; T, 98.6°F. Contractions: Absent. Vaginal bleeding: Absent. Leakage of fluid: Absent. Physical examination: CVS: Normal, Lungs: Normal, Abdomen: Nontender, nondistended, +Bowel Sound, Extremities: No edema. What is the next step in the management of this patient?

A 29-year-old gravida 1, para 0 Caucasian female with a history of bipolar disorder presents at eight weeks of gestation for prenatal counseling. She has been taking a stable dose of lithium for the past year. Her last depressive episode was 16 months ago. Her family history is significant for bipolar disorder in her mother, which was successfully controlled with lithium. She does not smoke cigarettes or consume alcohol. She asks whether her baby will have any congenital abnormalities. Which of the following complications is her fetus at increased risk for?

A 29-year-old man sustained a gunshot wound to the right upper quadrant. He is taken to the operating room and, after management of a liver injury, is found to have a complete transection of the common bile duct with significant tissue loss. Which of the following is the optimal surgical management of this patient’s injury?

. Choledochoduodenostomy

. Loop choledochojejunostomy

. Primary end-to-end anastomosis of the transected bile duct

. Roux-en-Y choledochojejunostomy

. Bridging of the injury with a T tube

A 29-year-old nonhelmeted motorcycle driver is involved in a single vehicular crash, resulting in a significant closed-head injury. He is intubated in the field and transported to a level 1 trauma center. On arrival, he is oxygenating well with assisted ventilation and has a normal blood pressure and moderate tachycardia. His Glasgow Coma Score is 7, and his pupils are equal and sluggishly reactive. After stabilization in the emergency department, the patient undergoes a CT scan of the head that demonstrates a small amount of subarachnoid blood and a right frontal lobe contusion with edema with no midline shift. CT scan of the abdomen is normal. The patient is transferred to the ICU. The optimal initial management of this patient’s intracranial pressure (ICP) would be which of the following?

. craniotomy

. Fluid restriction, hyperventilation, and osmotic diuresis

. Fluid restriction, hyperventilation, and ventriculostomy

. Hyperventilation and IV steroids

. normovolemia, normocarbia, sedation, and ventriculostomy

A 29-year-old primigravid woman at 34 weeks' gestation comes to the physician for a prenatal visit. At 28 weeks, she failed her 50-g, 1-hour oral glucose-loading test. She also failed her follow-up 100-g, 3-hour oral glucose tolerance test, with a normal fasting glucose, but abnormal 1, 2, and 3-hour values. Over the past several weeks, she has maintained good control of her fasting and 2-hour postprandial glucose levels by adhering to the diet recommendations of her physician. She asks the physician what effect her type of diabetes can have on her or her fetus. Which of the following is the most appropriate response?

. Gestational diabetes is associated with fetal anomalies

. Gestational diabetes is associated with intrauterine growth restriction

. Gestational diabetes is associated with macrosomia

. Gestational diabetes is not associated with future diabetes

. Gestational diabetes with normal fasting glucose is associated with stillbirth

A 29-year-old primigravid woman is admitted to the labor and delivery ward with strong contractions every 2 minutes and cervical change from 3 to 4 cm. Over the next 5 hours she progresses to full dilation. After 3 hours of pushing, the physician cuts a mediolateral episiotomy, and the woman delivers a 3770-g (8-lb, 4-oz) boy. Which of the following is the main advantage of a mediolateral episiotomy over a median (midline) episiotomy?

A 29-year-old tall, thin man presents to the ED after feeling short of breath for 2 days. In the ED, he is in no acute distress. His BP is 115/70 mmHg, HR is 81 beats per minute, RR is 16 breaths per minute, and oxygen saturation is 98% on room air. Cardiac, lung, and abdominal examinations are normal. An ECG reveals sinus rhythm at a rate of 79. A chest radiograph shows a small right-sided ( < 10% of the hemithorax) spontaneous pneumothorax. A repeat chest x-ray 6 hours later reveals a decreased pneumothorax. Which of the following is the most appropriate next step in management?

. Discharge the patient with follow-up in 24 hours

. Perform needle decompression in the second intercostal space, midclavicular line

. Insert a 20F chest tube into right hemithorax

. Observe for another 6 hours

. Admit for pleurodesis

A 29-year-old woman comes to the emergency department because of abdominal distension and shortness of breath. Approximately 1 week ago, she underwent fertility treatment with ovulation induction and oocyte retrieval. She has a history of polycystic ovarian syndrome but no other medical problems. She had laparoscopy 1 year ago as part of a fertility evaluation. She has no known drug allergies. Her temperature is 37 C (98.6 F), blood pressure is 80/40 mm Hg, pulse is 130/min, and respirations are 28/min. Physical examination is remarkable for crackles at the lung bases bilaterally and a distended, nontender abdomen with a fluid wave. Ultrasound demonstrates bilaterally enlarged ovaries (each >10 cm) and free fluid in the abdomen. Urine hCG is negative. Which of the following is the most likely diagnosis?

A 29-year-old woman comes to the office of a primary care physician complaining of pain in her right knee for the last 3 months. The pain is getting progressively worse and is not moving anywhere. She has tried ibuprofen but found little comfort. She is a housewife and unable to do household work because of this pain. She does not smoke nor drink and has hypertension well controlled by hydrocholorothiazide. Her vitals are stable and she is afebrile. On examination her right knee is a little swollen and tender with reduced range of motion. On x-ray, there is soap-bubble appearance in the epiphysis of distal femur. What is the next best step in the management of this patient?

A 29-year-old woman complains of dysphagia with both solids and liquids, worse when she is eating quickly or is anxious. Manometry reveals normal basal esophageal sphincter pressure, with no relaxation of the sphincter on swallowing. Which of the following is the most appropriate next step in management?

A 29-year-old woman complains of postprandial right upper quadrant pain and fatty food intolerance. Ultrasound examination reveals no evidence of gallstones or sludge. Upper endoscopy is normal, and all of her liver function tests are within normal limits. Which of the following represents the best management option?

. Avoidance of fatty foods and reexamination in 6 months.

. Ultrasound examination should be repeated immediately, since the falsenegative rate for ultrasound in detecting gallstones is 10% to 15%.

. Treatment with ursodeoxycholic acid.

. CCK-HIDA scan should be performed to evaluate for biliary dyskinesia.

. Laparoscopic cholecystectomy for acalculous cholecystitis.

A 29-year-old woman has a long history of mild asthma. She now has a flare and experiences recurrent episodes of bronchial obstruction, fever, malaise, and expectoration of brownish mucous plug. On examination, there is bilateral wheezing. Infection is suspected and a CXR reveals upper lobe pulmonary infiltrates. The eosinophil count is 2000/mL, and serum precipitating antibodies to Aspergillus are positive. Which of the following is the most appropriate next step in management?

Antihelminthic therapy

A short course of systemic glucocorticoid therapy

Desensitization treatment

High-dose glucocorticoids by puffer

Long-term systemic glucocorticoid therapy

A 29-year-old woman is brought to the emergency department after burning her right upper extremity in a cooking accident Examination shows a circumferential burn of the right upper extremity. She is given fluids, an analgesic and a wound dressing. On day three she develops severe deep tissue pain in the right limb with edema of the hand. Examination shows a circumferential eschar over the right arm. Her right radial and ulnar pulses are faint compared to the left and she has paresthesias in her right hand. Which of the following is the most appropriate next step in management?

. Increase the dose of her analgesics and discharge her

. Do an angiography to assess arterial blood flow

. Do an escharotomy

. Look for a missed fracture of the right upper limb

. Elevation of the limb

A 29-year-old woman on oral contraceptives presents with abdominal pain. A computed tomography (CT) scan of the abdomen demonstrates a large hematoma of the right liver with the suggestion of an underlying liver lesion. Her hemoglobin is 6, and she is transfused 2 units of packed red blood cells and 2 units of fresh frozen plasma. Two hours after starting the transfusion, she develops respiratory distress and requires intubation. She is not volume overloaded clinically, but her chest x-ray shows bilateral pulmonary infiltrates. Which of the following is the management strategy of choice?

. Continue the transfusion and administer an antihistamine

. Stop the transfusion and administer a diuretic

. Stop the transfusion, perform bronchoscopy, and start broad-spectrum empiric antibiotics

. Stop the transfusion and continue supportive respiratory care

. Stop the transfusion and send a Coombs test

A 29-year-old woman presents for a routine prenatal visit She is 24 weeks pregnant by last menstrual period and ultrasound. She does not have any medical problems and does not take any medications. She does not use tobacco, alcohol or illicit drugs. She works as a financial advisor in a local firm. She and her husband have been monogamous since getting married 5 years ago. Vital signs are normal. Physical examination shows no abnormalities. At the end of the visit she tells you that her newborn niece recently had a group B streptococcal infection and she is afraid that her child might develop the same. Which of the following is the most appropriate response?

. Your niece would not have developed the infection if the obstetrician had followed the standard of care.

. You do not have any risk factors of harboring or transmitting that infection to your child.

. Only a small percentage of unfortunate children develop this infection. Most children will be fine.

. I understand your concern. Let me take vaginal and rectal swabs for culture now.

. I understand your concern. I will test for the infection 2 to 3 weeks prior to the expected date of delivery.

A 29-year-old woman presents for a routine prenatal visit. She is 24 weeks pregnant by last menstrual period and ultrasound. She does not have any medical problems and does not take any medications. She does not use tobacco, alcohol or illicit drugs. She works as a financial advisor in a local firm. She and her husband have been monogamous since getting married 5 years ago. Vital signs are normal. Physical examination shows no abnormalities. At the end of the visit she tells you that her newborn niece recently had a group B streptococcal infection and she is afraid that her child might develop the same. Which of the following is the most appropriate response?

. Your niece would not have developed the infection if the obstetrician had followed the standard of care

. You do not have any risk factors of harboring or transmitting that infection to your child

. Only a small percentage of unfortunate children develop this infection. Most children will be fine

. I understand your concern. Let me take vaginal and rectal swabs for culture now

. I understand your concern. I will test for the infection two weeks prior to the expected date of delivery

A 29-year-old woman presents with a 6-month history of erythema and edema of the right breast with palpable axillary lymphadenopathy. A punch biopsy of the skin reveals neoplastic cells in the dermal lymphatics. Which of the following is the best next step in her management?

. A course of nafcillin to treat the overlying cellulitis and then neoadjuvant chemotherapy for breast cancer

. Modified radical mastectomy followed by adjuvant chemotherapy

. Modified radical mastectomy followed by hormonal therapy

. Combined modality chemotherapy and radiation therapy to the right breast with surgery reserved for residual disease

. Combined modality therapy with chemotherapy, surgery, and radiation

A 29-year-old woman with a history of difficulty becoming pregnant presents to her primary care physician and is diagnosed with Grave disease on iodine uptake scan; her thyrotropin (TSH) level is markedly suppressed and her free thyroxine (T4) level is elevated. She desires to conceive as soon as possible and elects to undergo thyroidectomy. After she is rendered euthyroid with medications preoperatively, which of the following management strategies should also be employed to reduce the risk of developing thyroid storm in the operating room?

. Drops of Lugol iodine solution daily beginning 10 days preoperatively.

. Preoperative treatment with phenoxybenzamine for 3 weeks.

. Preoperative treatment with propranolol for 1 week.

. Twenty-four hours of corticosteroids preoperatively.

. No other preoperative medication is required.

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?

A 29-year-old woman, gravida 2, para 1, at 37 weeks gestation was admitted to the hospital. Her previous pregnancy was uncomplicated and she delivered a 3,500 g (7.7lb) baby vaginally. The current pregnancy demonstrated a breech presentation at 30 weeks gestation. A repeat ultrasonogram now shows persistent frank breech presentation with an estimated fetal weight of 2,800 g (6lb). No fetal or uterine abnormalities are noted. She has intact membranes. Examination shows a closed cervix. Fetal heart monitoring is reassuring. Which of the following is the most appropriate next step in management?

A 29-year-old woman, gravida 2, para 1, at 38 weeks' gestation comes to the labor and delivery ward with frequent painful contractions. Her prenatal course was significant for a urine culture that showed 100,000 colony forming units/milliliter of Group-B streptococci and asthma, for which she uses an albuterol inhaler. Examination shows that she is contracting every 2 minutes and her cervix is 5 centimeters dilated and 100% effaced. Which of the following medications should this patient be treated with during labor and delivery?

A 29-year-old woman, gravida 3, para 2, at 37 weeks gestation is rushed to the emergency department because of bright red vaginal bleeding. She has had no uterine contractions. She does not take any medications and has no history of trauma. Her prenatal course, prenatal tests and fetal growth have been normal. Prenatal ultrasound at the 12th week of gestation showed an intrauterine gestation consistent with dates. Her temperature is 37.0C (98.7F), blood pressure is 120/80 mmHg, pulse is 80/min and respirations are 16/min. Ultrasonogram in the emergency department shows complete placenta previa. After initial resuscitation, bleeding is stopped. Nonstress test is performed, and the strip is reactive and reassuring. Which of the following is the most appropriate next step in management?

A 29-year-old woman, gravida 3, para 2, at 37 weeks gestation is rushed to the emergency department because of gushing bright red vaginal bleeding. She has had no uterine contractions. She does not take any medications and has no history of trauma. Her prenatal course, prenatal tests and fetal growth have been normal. Prenatal ultrasound at the 12th week of gestation showed an intrauterine gestation consistent with dates. Her temperature is 37.0 C (98.7F), blood pressure is 120/80 mmHg, pulse is 80/min and respirations are 16/min. Ultrasonogram in the emergency department shows complete placenta previa. After initial resuscitation, bleeding is stopped. She is anxious and concerned about her baby. Which of the following is the most appropriate next step in management?

A 3-day-old girl has trouble feeding and pulmonary congestion. The mother says that the infant is so busy breathing, that she literally has no time to suckle. The girl was born at home, with the delivery attended by a midwife. Physical examination confirms that she is in respiratory distress and shows bounding peripheral pulses with a loud continuous precordial machinery like murmur. X-ray films show increased pulmonary vascular markings. Shortly thereafter, the infant goes into overt heart failure. Which of the following would most likely be required to correct this problem?

Indomethacin

Digitalis and diuretics

Emergency surgical closure of atrial septal defect

Emergency surgical closure of ventricular septal defect

Emergency surgical division of patent ductus arteriosus

A 3-day-old infant’s scrotum is shown below. Palpation reveals a tense, fluid-filled area surrounding the right testicle. The scrotum transil luminates well, and the amount of fluid does not vary with mild pressure. Which of the following is the most appropriate approach to this condition?

A 3-month-old boy is brought to the pediatrician because of a red growth on his arm. The pregnancy had been uncomplicated, and the infant has been meeting all development milestones. He has been healthy so far and has received all scheduled immunizations. He is currently being breast-fed. His skin was clear at birth, but when he was 2 months old, his mother noted a light red growth on his arm. Within the past month, it has increased in size and has turned bright red. Which of the following is the most appropriate treatment for this disorder?

A 3-month-old infant is brought to the emergency department for severe vomiting over the past 6 hours. The mother tells the physician that she has vomited at least 4 times during this period. She also noticed the infant was having difficulty feeding for 2 days. On examination, she is very fussy, and there is a swelling over the left side of the head. CT of the head shows a skull fracture of the left parietal bone with no evidence of intracranial damage. The mother explains that the baby rolled off the sofa onto the floor yesterday. Which of the following is the most appropriate next step in management?

Discharge the patient home with instructions concerning post-concussion symptoms

Monitor the infant for 12 hours for signs of increased intracranial pressure, discharge the patient home if asymptomatic thereafter

Obtain a neurosurgical consultation for the skull fracture

Obtain a skeletal survey

Repeat the CT scan of the head in 24 hours

A 3-week-old male infant is brought to the office for the evaluation of red eyes. His temperature is 37.2 C (99F), pulse is 100/min, and respirations are 34/min. On examination, the infant has conjunctival congestion and scant mucoid discharge. The rest of the physical examination is normal. What is the most appropriate next step in the management of this patient?

A 3-year-old African-American female is brought to the office due to a swelling in her abdomen. According to her parents, this swelling was first noted when she was 3 months old, and has been increasing in size over the past 6 months. It is more pronounced during crying and coughing. Examination reveals a soft swelling of the umbilical region that is 3 cm in diameter and covered by skin. It can be easily reduced through the fibrous ring at the umbilicus. The child is afebrile and in good health. What is the most likely diagnosis and best course of action for this patient?

Umbilical hernia, refer to pediatric surgeon for operative management

Umbilical hernia, observe for spontaneous resolution

Congenital omphalocele, refer to pediatric surgeon

Umbilical polyp, surgical excision

Gastroschisis, surgical management

A 3-year-old boy from a refugee camp is brought to the clinic for examination. His medical history is unknown. On examination, there is marked photophobia. He appears malnourished, and his weight is < 5th percentile for age after hydration. His bones and ribs are prominent, and little subcutaneous fat is identified. His abdomen is concave with decreased bowel sounds. There is marked scaling and fissuring at the corners of his mouth, as well as inflammation and cracking of his lips. His tongue is atrophic. The tongue and oropharyngeal mucous membranes are dark red. Conjunctival pallor is present. There are pinkish-red, erythematous, scaly patches on his eyebrows, cheeks, and nose. This dermatitis is also present on the scrotal skin and extends onto the medial aspect of both thighs. Otherwise, his skin is very pale, and his fingernails and toenails are brittle. What is the most appropriate intervention for this patient?

A 3-year-old boy is brought to the emergency department because of a worsening cough over the past week. His temperature is 38.9 C (102 F), and inspiratory stridor is noted. A plain film of the neck reveals subglottic swelling. He is noted to have copious thick secretions and a barking cough. He has not had such events previously, and his parents deny recent contact with sick children. The patient is in respiratory distress and is noted to be retracting his subcostal muscles to breathe. Which of the following is the next most appropriate step in management?

A 3-year-old boy is brought to the office by his Caucasian mother because his speech is difficult to understand. He is a very slow learner, is unusually calm, stays to himself, doesn't hug his parents, prefers to play by himself, speaks in mumbles, and repetitively tries to make towers with cubes. He becomes very aggressive if he is stopped from his activities. He was born at term from an uncomplicated pregnancy and delivery, and his physical growth has been normal. His brother used to be aggressive as a child, and was diagnosed with attention deficit hyperactivity disorder. In the office, the patient is sitting quietly and trying to make towers with cubes. He seems to be oblivious of his environment. On calling his name thrice, he turns towards you once and then resumes playing with the cubes. What do you tell his mother?

He has attention deficit hyperactivity disorder and would benefit from methylphenidate

This could be autism and would benefit from antipsychotics

He has hearing problems and he needs ear, nose and throat evaluation

He has autism and will need special behavioral and educational programs

His diagnosis is Asperger syndrome

A 3-year-old boy is brought to the physician for help with toilet training. He recently started day care and screams "no" when teachers try to place him on the toilet. He has bowel movements every other day and strains when he passes hard, pellet-like stools. The boy is a picky eater but loves milk and drinks up to 30 oz of chocolate milk daily. He has no medical problems and takes no medications. His weight and height have been tracking along the 75th percentile. Examination shows a cooperative, well-nourished boy. He runs well and can climb onto the examination table independently. He speaks in short sentences that are mostly understandable. The boy's abdomen is soft, nontender, and nondistended. He has normal Tanner I male genitalia. A small fissure is noted on the anal verge. Which of the following is the best next step in management of this patient?

A 3-year-old boy presents to the emergency department with a fever and difficulty breathing. He is the product of a normal pregnancy and has been healthy since birth. His immunizations are up to date. This morning he appeared to be in his usual state of health and was dropped off at day care by his father. Later on, his teacher noticed that he had suddenly become fussy and flushed and could not be consoled with toys, rocking, or hearing a story. He also felt warm to the touch and was drooling more than usual. When she took his temperature, it was 39°C (102.2°F). His parents were contacted immediately, and the patient was brought to the emergency department. He appears toxic and anxious, and has loud labored breathing. He is sitting upright, bracing himself on his arms, with his neck hyperextended and mouth open. His temperature is 40°C (104°F), respiratory rate is 50/min, pulse is 140/min, blood pressure is 102/62 mm Hg, and oxygen saturation is 100% on room air. Lateral x-ray of the neck is shown in the image. Laryngoscopy reveals a large cherryred epiglottitis. What is the most appropriate next step in management?

A 3-year-old boy suddenly begins choking and coughing while eating peanuts. On physical examination he is coughing frequently. He has inspiratory stridor and mild intercostal and suprasternal retractions. Initial management should include which of the following?

A 3-year-old girl 1s brought to the emergency department because she is not moving her right arm. Her mother states that the child was perfectly normal in the morning. She remembers that she lifted the child with the child's right forearm and since then she has not been moving her right arm. Examination shows the right arm is held in pronation against the chest. The child avoids any movement of her right arm. Which of the following is the most appropriate next step in management?

. Refer the child to an orthopedic surgeon for possible supracondylar fracture of humerus

. Report the case to child protection agency

. Gentle passive elbow flexion and forearm supination

. Closed reduction and casting of forearm and arm

. Do a skeletal survey of the child

A 3-year-old girl is admitted with the x-ray shown below. The child lives with her parents and a 6-week-old brother. Her grandfather stayed with the family for 2 months before his return to the West Indies 1 month ago. The grandfather had a 3-month history of weight loss, fever, and hemoptysis. Appropriate management of this problem includes which of the following?

Bronchoscopy and culture of washings for all family members

Placement of a Mantoux test on the 6-week-old sibling

Isolating the 3-year-old patient for 1 month

Treating the 3-year-old patient with isoniazid (INH) and rifampin

HIV testing for all family members

A 3-year-old girl is believed to have swallowed a marble. She presents to the emergency department unable to speak and begins to become cyanotic. Initial attempts at endotracheal intubation are unsuccessful. Which of the following is the most appropriate next step in management?

Continued attempts at endotracheal intubation

Crkothyroidotomy (surgical)

Face mask 100% 02 with succinylcholine

Formal tracheostomy

Needle crkothyroidotomy

A 3-year-old girl is brought to the emergency department because she is not moving her right arm. Her mother states that the child was perfectly normal in the morning. She remembers that she lifted the child with the child's right forearm and since then she has not been moving her right arm. Examination shows the right arm is held in pronation against the chest. The child avoids any movement of her right arm. Which of the following is the most appropriate next step in management?

. Refer the child to an orthopedic surgeon for possible supracondylar fracture of humerus

. Report the case to child protection agency

. Gentle passive elbow flexion and forearm supination

. Closed reduction and casting of forearm and arm

. Do a skeletal survey of the child

A 3-year-old girl presents to the pediatrician's office. The mother states that the girl has been having big, bulky stools that float in the toilet. She also has intermittent diarrhea. On examination, her height is 88 cm (34.6 in, < 5th percentile) and weight is 15.8 kg (34.8 lb, <5th percentile). In addition, she has an uncle who died of recurrent lower respiratory infections. Which of the following would be most effective for alleviating the gastrointestinal symptoms of this patient?

A 3-year-old male presents after having a tonicclonic seizure lasting about 1 minute. On examination, the child now has no neurologic abnormalities. He has a temperature of 40.3°C and has an obvious otitis media on the left but no other abnormalities on physical examination. You correctly counsel the family with which one of the following statements?

The child will need hospitalization, a lumbar puncture, and antibiotics

An EEG and CNS imaging must be done

Anticonvulsants must be stated and continued for 6 months

There is a slight increase in risk for development of epilepsy

The child must be monitored carefully for long-term neurologic damage

A 30-year-old African-American woman with type- 1 diabetes and hypertension comes to the physician's office after obtaining a positive result from a home pregnancy test. She takes insulin and enalapril. She does not use tobacco, alcohol or illicit drugs. Her temperature is 37.2 C (99.0F), blood pressure is 130/80 mm Hg, pulse is 72/min, and respirations are 14/min. Physical examination is unremarkable. Her BUN is 18 mg/dl and creatinine is 1.4 mg/dl. A repeat β-HCG test performed in the office confirms pregnancy. Which of the following is the most appropriate next step in management?

. Stop enalapril and start furosemide

. Continue enalapril and add methyldopa

. Stop enalapril and start labetalol

. Stop enalapril and start losartan

. Continue current therapy

A 30-year-old African-American woman with type-1 diabetes and hypertension comes to the physician's office after obtaining a positive result from a home pregnancy test. She takes insulin and enalapril. She does not use tobacco, alcohol or illicit drugs. Her temperature is 37.2 C (99.0F), blood pressure is 130/80 mm Hg, pulse is 72/min, and respirations are 14/min. Physical examination is unremarkable. Her BUN is 18 mg/dl and creatinine is 1.4 mg/dl. A repeat 13-HCG test performed in the office confirms pregnancy. Which of the following is the most appropriate next step in management?

. Stop enalapril and start furosemide

. Continue enalapril and add methyldopa

. Stop enalapril and start labetalol

. Stop enalapril and start losartan

. Continue current therapy

A 30-year-old Caucasian female comes to the physician's office because of polyuria and polydipsia of recent onset. She has no other medical problems. She does not use tobacco, alcohol or drugs. She has no known drug allergies. Her mother has diabetes. Her temperature is 36.7°C (98°F), pulse is 75/min, blood pressure is 110/70 mmHg, and respirations are 15/min. The initial lab results are: Hb 12.7 g/dl, WBC 5,000 /cmm, Platelets 380,000/cmm, Blood glucose 90 mg/dl, Serum sodium 142 mEq/L, Serum potassium 4.0 mEq/L, Bicarbonate 26 mEq/L, BUN 15 mg/dl, Serum creatinine 0.9 mg/dl, Serum uric acid 9 mg/dl, Serum osmolality 295 mOsm/kg, Urine osmolality 160 mOsm/kg. After 12 hours of water deprivation, lab testing reveals:Serum sodium 151 mEq/L, Serum potassium 4.2 mEq/L, Bicarbonate 26 mEq/L, Serum osmolality 300 mOsm/kg, Urine osmolality 186 mOsm/kg. One hour after the subcutaneous administration of arginine vasopressin, the urine osmolality is 400mosm/kg. Which of the following is the most appropriate treatment for this patient?

A 30-year-old Caucasian female patient is seen at the rheumatology clinic. She has a 4-year history of rheumatoid arthritis. Over the past year, she has noticed an improvement in her symptoms. Examination of her joints reveals less swelling and erythema than on the previous visit Laboratory studies show: CBC: Hb 10.8 g/dL, Ht 32%, MCV 104 fl, Platelet count 226,000/cmm, Leukocyte count 7,500/cmm, Neutrophils 65%, Eosinophils 1%, Lymphocytes 28%, Monocytes 6%. Serum: Serum Na 140 mEq/L, Serum K 3.9 mEq/L, Chloride 100 mEq/L, Bicarbonate 18 mEq/L, BUN 16 mg/dL, Serum Creatinine 1.1 mg/dL, Calcium 9.8 mg/dL, Blood Glucose 98 mg/dL. Which of the following medications is this patient most likely taking?

A 30-year-old female comes to the office complaining of vaginal discharge, dyspareunia and vulvar pruritus. She has a history of hypothyroidism and takes thyroid replacement therapy. She uses tobacco and alcohol every day. On examination, you notice a thin, grayish vaginal discharge and erythema and edema of the vulva and vaginal mucosa. The pH of the discharge is 6.0 and wet-mount examination reveals pear-shaped motile organisms. First line treatment is prescribed for both the patient and her partner. The patient must avoid which of the following during the treatment period?

A 30-year-old female presents with a chief complaint of palpitations. A 24-hour Holter monitor shows occasional unifocal premature ventricular contractions and premature atrial contractions. Which of the following is the best management for this patient?

A 30-year-old G1 at 28 weeks gestation with a twin pregnancy is admitted to the hospital for preterm labor with regular painful contractions every 2 minutes. She is 3 cm dilated with membranes intact and a small amount of bloody show. Ultrasound reveals growth restriction of twin A and oligohydramnios, otherwise normal anatomy. Twin B has normal anatomy and has appropriate-for-gestational-age weight. Which of the following is a contraindication to the use of indomethacin as a tocolytic in this patient?

A 30-year-old G1 with twin gestation at 28 weeks is being evaluated for vaginal bleeding and uterine contractions. A bedside ultrasound examination rules out the presence of a placenta previa. Fetal heart rate tracing is reactive on both twins, and the uterine contractions are every 2 to 3 minutes and last 60 seconds. A sterile speculum examination is negative for rupture membranes. A digital examination indicates that the cervix is 2 to 3 cm dilated and 50% effaced, and the presenting part is at −3 station. Tocolysis with magnesium sulfate is initiated and intravenous antibiotics are started for group B streptococcus prophylaxis. Betamethasone, a corticosteroid, is also administered. Which of the following statements regarding the use of betamethasone in the treatment of preterm labor is true?

. Betamethasone enhances the tocolytic effect of magnesium sulfate and decreases the risk of preterm delivery

. Betamethasone has been shown to decrease intraamniotic infections

. Betamethasone promotes fetal lung maturity and decreases the risk of respiratory distress syndrome

. The anti-inflammatory effect of betamethasone decreases the risk of GBS sepsis in the newborn

. Betamethasone is the only corticosteroid proven to cross the placenta

A 30-year-old G2 P 1woman at 38 weeks gestation presents to the hospital complaining of regular and painful uterine contractions that started two hours earlier. Pelvic examination reveals bulging membranes, and her cervix is 50% effaced and dilated to 3 cm. Her pregnancy was complicated by first trimester hemorrhage of unknown cause. Her past medical history is unremarkable. After placing a fetal heart monitor and an external tocometer on the patient, you note 3 separate 15 beat/min decreases in the fetal heart rate not coinciding with uterine contractions, each lasting for 25 seconds. Which of the following is the most appropriate next step in the management of this patient?

. Oxygen administration and change in maternal position

. Artificial rupture of membranes

. Amnioinfusion

. Fetal scalp pH testing

. Emergent cesarean section

A 30-year-old G2 P1 woman at 38 weeks gestation comes to the hospital because of regular and painful uterine contractions that started two hours ago. Pelvic examination reveals bulging membranes, and her cervix is 50% effaced and dilated to 3 cm. Her pregnancy was complicated by first trimester hemorrhage of unknown cause. Her past medical history is unremarkable. Upon observing the fetal heart rate monitor and an external tocometer for 20 minutes, you note 6 contractions. You also note 4 separate 15 - 20 beat/min decreases in the fetal heart rate with every contraction. The depth and duration of decelerations vary with successive uterine contractions. Which of the following is the most appropriate next step in the management of this patient?

. Oxygen administration and change in maternal position

. Artificial rupture of membranes

. Amnioinfusion

. Fetal scalp pH testing

. Emergent cesarean section

A 30-year-old G2P0 at 39 weeks is admitted in active labor with spontaneous rupture of membranes occurring 2 hours prior to admission. The patient noted clear fluid at the time. On examination, her cervix is 4 cm dilated and completely effaced. The fetal head is at 0 station and the fetal heart rate tracing is reactive. Two hours later on repeat examination her cervix is 5 cm dilated and the fetal head is at +1 station. Early decelerations are noted on the fetal heart rate tracing. Which of the following is the best next step in her labor management?

. Administer terbutaline

. Initiate amnioinfusion

. Initiate Pitocin augmentation

. Perform cesarean delivery for arrest of descent

. Perform cesarean delivery of early decelerations

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?

Administer a 3-hour glucose tolerance test

Administer a 50-g 1-hour glucose tolerance test

Begin insulin therapy

Check a urinalysis and start insulin if urinalysis reveals glucose in the urine

Prescribe metformin to be taken daily

A 30-year-old G3P3, who is 8 weeks postpartum and regularly breast-feeding calls you and is very concerned because she is having pain with intercourse secondary to vaginal dryness. Which of the following should you recommend to help her with this problem?

. Instruct her to stop breast-feeding

. Apply hydrocortisone cream to the perineum

. Apply testosterone cream to the vulva and vagina

. Apply estrogen cream to the vagina and vulva

. Apply petroleum jelly to the perineum

A 30-year-old G5P3 has undergone a repeat cesarean delivery. She wants to breast-feed. Her past medical history is significant for hepatitis B infection, hypothyroidism, depression, and breast reduction. She is receiving intravenous antibiotics for endometritis. Which of the following would prevent her from breast-feeding?

. Maternal reduction mammoplasty with transplantation of the nipples

. Maternal treatment with ampicillin

. Maternal treatment with fluoxetine

. Maternal treatment with levothyroxine

. Past hepatitis B infection

A 30-year-old male has recently been diagnosed with HIV infection. He denies drug abuse. He is currently asymptomatic, and physical examination is unremarkable. He is in a stable heterosexual relationship. Laboratory studies show a CD4 count of 350/microL, HIV viral load of 15,000 copies/mL, negative VDRL, negative toxoplasma serology, tuberculin skin test of 7 mm induration, negative HBsAg, and positive anti-HBsAg antibodies. Hepatitis C antibodies are negative. Complete blood count, serum chemistries, and liver function tests are within normal limits. He has not received any vaccinations since being diagnosed with HIV. Which of the following vaccines is indicated in this patient?

A 30-year-old male patient complains of fever and sore throat for several days. The patient presents to you today with additional complaints of hoarseness, difficulty breathing, and drooling. On examination, the patient is febrile and has inspiratory stridor. Which of the following is the best course of action?

. Begin outpatient treatment with ampicillin

. Culture throat for β-hemolytic streptococci

. Admit to intensive care unit and obtain otolaryngology consultation

. Schedule for chest x-ray

. Obtain Epstein-Barr serology

A 30-year-old man comes to the psychiatrist for the evaluation of a depressed mood. He states that at least since his mid-20s he has felt depressed. He notes poor self-esteem and low energy, and feels hopeless about his situation, though he denies suicidal ideation. He states he does not use drugs or alcohol, and has no medical problems. His last physical examination by his physician 1 month ago was entirely normal. Which of the following treatment options should be tried first?

A 30-year-old man has episodes of wheezing and shortness of breath two to three times per week. Approximately every 2 weeks he awakens at night due to cough and difficulties breathing. He reports having similar symptoms since he was a child, but believes that they are worsening somewhat now. His symptoms are worsened by cold air and exercise and are improved by rest. Which of the following is the most appropriate treatment?

Daily high-dose inhaled corticosteroid and β-agonist when needed

Daily high-dose inhaled corticosteroid with oral steroids for exacerbations and short-acting β-agonist when needed

Daily low-dose inhaled corticosteroid and short-acting β-agonist when needed

Daily oral steroids and long-acting β-agonist

Short-acting β-agonist when needed

A 30-year-old man is admitted to the hospital with a diagnosis of acute renal failure secondary to poststreptococcal glomerulonephritis. On his fifth hospital day, he develops retrosternal, non-radiating chest pain which is relieved by leaning forward. He denies the use of tobacco or drugs. He drinks alcohol occasionally. He has no past history of any serious illness. His temperature is 37.6°C (99.8°F), blood pressure is 145/95 mm Hg, pulse is 80/min, and respirations are 20/min. A pericardial friction rub is heard on chest auscultation. The rest of the examination shows no abnormalities. EKG shows ST segment elevation in all leads, with elevation of the PR segment in lead aVR. The chest x-ray is normal. Urinalysis shows hematuria, red cell casts and mild proteinuria. Laboratory studies show a BUN level of 60 mg/dl and a serum creatinine level of 3.8 mg/dl. What is the most appropriate next step in management?

A 30-year-old man is brought to the emergency room after he was found wandering on the streets with no shoes on in the middle of winter. He is admitted to the inpatient psychiatric unit and stabilized on antipsychotic medication. Looking at past records, his psychiatrist notes that he is repeatedly noncompliant with his medication postdischarge, and each time he relapses within 6 months. Which of the following medications is the best one for this patient to be maintained on?

A 30-year-old man is scheduled for a laparoscopic cholecystectomy for biliary colic. He reports a family history of prolonged paralysis during general anesthesia. Which of the following medications should be avoided during his procedure?

A 30-year-old man presents to the ED complaining of sudden onset of abdominal bloating and back pain lasting for 2 days. The pain woke him up from sleep 2 nights ago. It radiates from his back to his abdomen and down toward his scrotum. He is in severe pain and is vomiting. His temperature is 101.2°F and HR is 107 beats per minute. A CT scan reveals a 9-mm obstructing stone of the left ureter with hydronephrosis. Urinalysis is positive for 2+ blood, 2+ leukocytes, 2+ nitrites, 40 to 50 WBCs, and many bacteria. You administer pain medicine, antiemetics, and antibiotics. Which of the following is the most appropriate next step in management?

. Admit for IV antibiotics and possible surgical removal of stone

. Observe in ED for another 6 hours to see if stone passes

. Discharge with antibiotics and pain medicine

. Discharge patient with instructions to consume large amounts of water

. Discharge patient with antibiotics, pain medicine, and instructions to drink large amounts of water and cranberry juice

A 30-year-old man presents to the emergency department with sudden onset of severe epigastric pain and vomiting 3 hours ago. He reports a 6-month history of chronic epigastric pain occurring nearly every day and relieved by antacids. On examination, he appears sweaty and avoids movement. Vital signs reveal a temperature of 100°F, BP of 100/60 mmHg, pulse rate of 110/min, and respiratory rate of 12/min. The remainder of his examination reveals diminished bowel sounds and a markedly tender and rigid abdomen. A chest x-ray and abdominal films reveal pneumoperitoneum. Which of the following is the most appropriate next step in management?

. Immediate laparotomy

. Nonoperative management with NG decompression and antibiotics

. Fluid resuscitation

. Administration of H2 blockers

. Placement of a central venous line

A 30-year-old man presents to the resuscitation bay with gunshot wounds in the anterior and posterior left chest. Although in distress and dyspneic, the patient is cooperative. He has a patent airway and is moving all extremities. His pulse is 120/min, blood pressure is 120/90 mm Hg, and respiratory rate is 30/min. He has bounding distal pulses, and no other injuries are identified on secondary examination. X-ray of the chest reveals fluid in the pleural space, and a left chest tube thoracostomy yields 600 mL of bright red fluid. Over the next hour 750 mL of blood is collected. What is the most appropriate next step in management?

Autotransfuse with the collected blood and continue to observe closely

Insert another chest tube

Left thoracotomy

Remove the chest tube and suture the incision closed

Thoracentesis

A 30-year-old obese G3P2 woman is in active labor at 41 weeks’ gestation. She has no significant past medical history, and had an uncomplicated pregnancy with appropriate prenatal evaluation. The patient ruptured membranes spontaneously 30 minutes ago. Contractions occur regularly every 2–3 minutes. Early decelerations are noted on the fetal heart rate monitor with each of the past five contractions. Which is the most appropriate next step in management?

Change the maternal position

No further management is required

Place a fetal scalp probe

Prepare for emergent cesarean delivery

Start an amnioinfusion of saline

A 30-year-old obese white female comes to the physician with a six months history of oligomenorrhea. She never had this problem before. She has no galactorrhea. She has gained significant weight over the past two years despite a regular exercise program. She has also experienced hair loss during this time. She has had regular Pap smears since the age of 20; pap smears have shown no abnormalities. She takes no medications. She does not use tobacco, alcohol, or drugs. Her mother has a history of endometrial carcinoma and her grandmother had a history of ovarian carcinoma. Physical examination shows male pattern baldness. Abdominal and pelvic examination shows no abnormalities. A urine pregnancy test is negative. Serum prolactin level and thyroid function tests are normal. Which of the following is the most appropriate next step in management?

A 30-year-old school teacher presents with a three-day history of fever, chills, and sore throat. He also complains of difficulty swallowing that started yesterday. He denies any cough, chest pain, or difficulty breathing. He is married and denies any new sexual encounters. His temperature is 39°C (102.2°F), blood pressure is 118/76 mmHg, pulse is 102/min, and respirations are 19/min. On examination, his voice is muffled. Enlarged, tender cervical lymph nodes are palpated on the left, and his uvula is deviated to the right. What is the most appropriate treatment for this patient?

A 30-year-old white, HIV-infected male from Ohio presents with low-grade fever, anorexia and weight loss of 3.6kg (Bib) for the past 3 weeks. His baseline PPD test was negative. His pulse is 87/min, blood pressure is 126/76 mm Hg, temperature is 38.3°C (101°F), and respirations are 18/min. Examination shows oropharyngeal ulcers and hepatosplenomegaly. Lab testing shows: Hematocrit 36%, Platelet count 50,000/microL, WBC count 3,100/microL. Blood culture establishes the diagnosis of histoplasmosis. What is the most appropriate next step in the management of this patient?

. IV amphotericin B followed by lifelong treatment with itraconazole

. IV amphotericin B till the cultures become negative

. Itraconazole till the cultures become negative

. IV amphotericin B plus itraconazole till the cultures become negative

. Lifelong treatment with itraconazole

A 30-year-old woman comes to the physician 6 hours after falling on her outstretched right hand. She has pain and limitation of movement in her wrist, but denies sensations of tingling or numbness. The right wrist is mildly swollen, and its range of passive motion is limited compared with the left side. Palpation elicits maximal tenderness in the area of the anatomic snuffbox, between the tendons of the extensor pollicis longus and abductor pollicis muscles. Ulnar and radial pulses are normal, and Tinel's and Phalen's tests are negative. Further examination rules out signs of nerve or vascular damage. Plain x-ray films performed in the anteriorposterior, lateral, and oblique views fail to show any evidence of fractures. At this time, which of die following is the most appropriate next step in management?

A 30-year-old woman comes to the physician due to the recent onset of occipital headaches. She has taken acetaminophen several times, but the pain returns. She has no fever or visual problems. She has not had similar episodes in the past. She has no history of serious illness. Her temperature is 36.1°C (98°F), blood pressure is 160/90 mm Hg, pulse is 88/min, and respirations are 16/min. Physical examination shows a rightsided renal bruit Which of the following is the most appropriate treatment for this patient's condition?

A 30-year-old woman in her last trimester of pregnancy suddenly develops massive swelling of the left lower extremity. Which of the following would be the most appropriate workup and treatment at this time?

. Venography and heparin

. Duplex ultrasonography and heparin

. Duplex ultrasonography, heparin, and vena caval filter

. Duplex ultrasonography, heparin, warfarin (Coumadin)

. Impedance plethysmography, warfarin

A 30-year-old woman with a genetic disorder characterized by a deficiency of phenylalanine hydroxylase is planning a first pregnancy. Her physician explains the increased risk of mental retardation, as well congenital heart disease, in the infant. Which of the following should also be recommended?

Low phenylalanine diet should be initiated before conception

Dietary supplementation with glycine is recommended

Dietary supplementation with L-carnitine is recommended

There is no need for diet control if phenylalanine levels are mildly elevated

Vitamin B6 should be administered to the neonate on delivery

A 30-year-old woman, gravida 2, para 1, at 37 weeks gestation is brought to the emergency department because of acute onset intense uterine contractions and vaginal bleeding. She has been followed closely for pre-eclampsia since her 32nd week of gestation. Her temperature is 37.0°C (98.7°F), blood pressure is 140/86mmHg, pulse is 92/min and respirations are 18/min. Physical examination shows uterine tenderness and hyperactivity and moderate vaginal bleeding. Pelvic examination shows an effaced and 3cm dilated cervix. Ultrasonography shows a fundic placenta and a fetus in the cephalic position. Fetal heart tracing shows 140/min with good long-term and beat-to beat variability. After initial resuscitation the bleeding is stopped. Which of the following is the most appropriate next step in management?

. Vaginal delivery with augmentation of labor, if necessary

. Emergency cesarean section

. Perform tocolysis and schedule cesarean section within 48 hours

. Forceps delivery

. Conservative management at home

A 30-year-old woman, gravida 2, para 1, at 37 weeks gestation is brought to the emergency department because of acute onset intense uterine contractions and vaginal bleeding. She has been followed closely for pre-eclampsia since her 32nd week of gestation. Her temperature is 37.0 C (98.7F), blood pressure is 140/86mmHg, pulse is 92/min and respirations are 18/min. Physical examination shows uterine tenderness and hyperactivity and moderate vaginal bleeding. Pelvic examination shows an effaced and 3cm dilated cervix. Ultrasonography shows a fundic placenta and a fetus in the cephalic position. Fetal heart tracing shows 140/min with good long-term and beat-to-beat variability. After initial resuscitation the bleeding is stopped Which of the following is the most appropriate next step in management?

. Vaginal delivery with augmentation of labor, if necessary

. Emergency cesarean section

. Perform tocolysis and schedule cesarean section within 48 hours

. Forceps delivery

. Conservative management at home

A 30-year-old woman, gravida 3, para 2, at 32 weeks gestation comes to the physician because of a decrease in fetal movements. She has felt few fetal kicks the past 20 hours. Her prenatal course, prenatal tests and fetal growth have been normal. She has chronic hypertension and is now taking methyldopa and labetalol. Her previous pregnancies were uncomplicated and both delivered vaginally. She does not use tobacco, alcohol or drugs. Fetal heart tones are heard by Doppler. Non-stress test is reactive. Which of the following is the most appropriate next step in management?

A 31 -year-old man is brought to the emergency department after a motor vehicle accident. He sustained a severe head injury and, on arrival to the emergency department, has a Glasgow coma score of 8. His blood pressure is stable, and an urgent CT scan of the head reveals a large subdural bleed with evidence of a midline shift and cerebellar tonsillar compression. The patient is breathing spontaneously without any respiratory assistance and is not intubated. Which of the following is the most appropriate next step in management?

Obtain an urgent head MRI to evaluate for herniation

Administer IV mannitol

Perform endotracheal intubation and hyperventilation

Induce a barbiturate coma

Initiate immediate surgical decompression

A 31-year-old African American man presents with dyspnea on exertion. He also has fever and red tender rash on his shins. Physical examination reveals fine inspiratory crackles in both lower lung lobes and tender erythematous nodules on his legs. CXR shows bilateral hilar adenopathy and reticulonodular changes in both lungs. Transbronchial biopsy reveals noncaseating granulomas. Which of the following is the most appropriate next step in management?

A 31-year-old African-American woman is diagnosed with uterine fibroids. Which of the following types of fibroids is most likely to interfere with conception and pregnancy?

A 31-year-old Caucasian male complains of joint pains. He describes right knee pain, right heel pain and lowback pain. He was recently treated for urethral discharge at an outside clinic. He has no history of trauma or illicit drug use. He is afebrile, and his vital signs are stable. His right knee is swollen, tender and warm to touch; tenderness is also present over the Achilles tendon. Oral examination shows mouth ulcers. Synovial fluid analysis from the right knee shows a white blood cell count of 10,000/mm3 with many polymorphonuclear leukocytes but a negative Gram stain. Which of the following is the most appropriate initial pharmacotherapy for this patient?

A 31-year-old G3P2 woman at 37 weeks’ gestation presents to the labor and delivery floor after 2 hours of contractions of increasing frequency and intensity. An epidural anesthetic is requested on admission and placed. The patient continues to have contractions for the next 15 hours, during which time her membranes rupture spontaneously. Vaginal examination at that time reveals a cervix that is soft, 3 cm dilated, in an anterior position, and 80% effaced. The fetal head is at the -1 station. Fetal heart tracings reveal a baseline heart rate of 156/min, with variable accelerations and no significant decelerations. Which of the following is the best next step in management?

Apply intravaginal prostaglandin E2

Attempt forceps-facilitated delivery

Begin an infusion of oxytocin

Increase the rate of intravenous fluids to hydrate the patient

Proceed to cesarean section

A 31-year-old kindergarten teacher presents to the ED complaining of acute-onset substernal chest pain that is sharp in nature and radiates to her back. The pain is worse when she is lying down on the stretcher and improves when she sits up. She smokes cigarettes occasionally and was told she has borderline diabetes. She denies any recent surgeries or long travel. Her BP is 145/85 mmHg, HR is 99 beats per minute, RR is 18 breaths per minute, and temperature is 100.6°F. Examination of her chest reveals clear lungs and a friction rub. Her abdomen is soft and nontender to palpation. Her legs are not swollen. Chest radiography and echocardiography are unremarkable. Her ECG is shown below. Which of the following is the most appropriate next step in management?

. Anticoagulate and CT scan to evaluate for a PE

. Prescribe a NSAID and discharge the patient

. Aspirin, heparin, clopidogrel, and admit for ACS

. Administer thrombolytics if the pain persists

. Prescribe antibiotics and discharge the patient

A 31-year-old male immigrant from India is found on a routine physical examination to have a single, 2-cm nodule in the right lobe of his thyroid gland. The mass is firm, moves up and down with swallowing, and is not tender. The skin of his face and neck is pitted with multiple scars, which suggest smallpox; however, he explains that the scars are due to very severe acne that he had as a youngster, for which he eventually received external beam radiation therapy at the age of 14. His thyroid function tests are normal, and fine needle aspiration (FNA) cytology of the mass is read by the pathologist as "indeterminate." Which of the following is the most appropriate next step in management?

. No further care is needed

. Thyroid function tests should be repeated yearly

. Thyroid scan and sonogram are needed

. FNA should be repeated until it can be read as benign or malignant

. Thyroid lobectomy

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