DES C_ParaClinic (6) Prepared : CHILLY

A 70-year-old man with a 50 pack-year history of smoking presents with a 6-week history of intermittent, painless, gross hematuria and urinary frequency. There are no masses palpable on abdominal examination, and rectal examination is normal. Urinalysis confirms the presence of hematuria, and urine culture is negative. Which of the following is the most appropriate initial diagnostic evaluation of this patient?

A 70-year-old man with a 50 pack-year history of smoking presents with a 6-week history of intermittent, painless, gross hematuria and urinary frequency. There are no masses palpable on abdominal examination, and rectal examination is normal. Urinalysis confirms the presence of hematuria, and urine culture is negative. The initial diagnostic evaluation does not reveal any abnormalities. Which of the following is the best next step in the diagnostic workup?

A 70-year-old patient presents to the ER with a 3-hour history of intensive retrosternal chest pain that radiates to the interscapular area. He states that he has never experienced this pain before. His past medical history is significant for a 20-year history of hypertension and a 10-year history of diabetes mellitus, type 2. His current medications include enalapril and hydrochlorothiazide. He does not smoke or consume alcohol. His vital signs are BP 180/110 mmHg in the right arm and 178/110 mmHg in the left arm, PR 85/min and RR 18/min. The physical examination revealed an early decrescendo-type diastolic murmur at the left sternal border. The EKG is normal. Which of the following is the best next step in the management of this patient?

A 71-year-old man is playing cards with some friends when he starts to feel a pain in the left side of his chest. His fingers in the left hand become numb and he feels short of breath. His wife calls the ambulance and he is brought to the hospital. In the ED, an ECG is performed. Which of the following best describes the order of ECG changes seen in an MI?

A 71-year-old West Texas farmer of Irish ancestry has a nonhealing, indolent, punched out, clean-looking 2-cm ulcer over the left temple. The ulcer has been slowly growing over the past 3 years. There are no enlarged lymph nodes in the head and neck. Which of the following would best dictate proper management?

A 72-year-old man undergoes an aortobifemoral graft for symptomatic aortoiliac occlusive disease. The inferior mesenteric artery (IMA) is ligated at its aortic attachment. Twenty-four hours after surgery the patient has abdominal distention, fever, and bloody diarrhea. Which of the following is the most appropriate diagnostic study for this patient?

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

A 73-year-old female presents to your office with lower abdominal discomfort. Physical examination reveals an adnexal mass on the right side. This patient is most likely to have elevated levels of which of the following?

A 73-year-old man comes to his primary care physician for his yearly check-up. His medical history is significant for obesity, new onset diabetes mellitus, and a remote history of tobacco use. The patient has noticed that his stool has been darker for the past 3 months, although he has only seen gross blood in his stool once, a week ago. He also complains of recent fatigue and occasional light-headedness when standing up from sitting. On examination the patient has fecal occult blood and a hematocrit of 32%. Colonoscopy and upper gastrointestinal endoscopy reveal no obvious pathology. Which of the following is the best diagnostic test to locate this patient’s hemorrhage?

A 73-year-old man comes to the physician because of a one-year history of progressively worsening urinary urgency, hesitancy, nocturia, and weak urinary stream. He has no fever, abdominal pain, hematuria, malaise or weight loss. He takes atenolol for essential hypertension. He has no history of diabetes mellitus or ischemic heart disease. He does not use tobacco, alcohol, or drugs. Rectal examination shows a smooth, firm enlargement of the prostate with no induration or asymmetry. Neurological examination shows no abnormalities. Urinalysis shows no abnormalities. Laboratory studies show serum creatinine of 2.1 mg/dl. Which of the following is the most appropriate next step in management?

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

A 74-year-old man presents with sudden onset of extremely severe, tearing precordial chest pain that radiates to the back and migrates downward shortly after its onset. As far as the man can tell, there was no precipitating event. He is seen within an hour and is in obvious distress. He is afebrile, but his blood pressure is 220/110 mm Hg and his pulses in the upper extremities are unequal at 102/min. Chest x-ray shows a wide mediastinum. Which of the following could best establish the diagnosis?

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

A 75-year-old G2P2 presents to your gynecology office for a routine examination. She tells you that she does not have an internist and does not remember the last time she had a physical examination. She says she is very healthy and denies taking any medication, including hormone replacement therapy. She has no history of abnormal Pap smears. She is a nonsmoker and has an occasional cocktail with her dinner. She does not have any complaints. In addition, she denies any family history of cancer. The patient tells you that she is a widow and lives alone in an apartment in town. Her grown children have families of their own and live far away. She states that she is self-sufficient and spends her time visiting friends and volunteering at a local museum. Her blood pressure is 140/70 mm Hg. Her height is 5ft 4 in and she weighs 130 lb. Her physical examination is completely normal. Which of the following are the most appropriate screening tests to order for this patient?

A 75-year-old male comes to the office for the evaluation of a two-month history of intermittent right eye visual loss. Each episode is "painless, lasts a few seconds, and feels like a curtain coming over the eye." He denies any other symptoms. He has never had any trauma to his eye, and does not use any medications. His past medical history is significant for hypertension. He quit smoking 20 years ago, but had smoked for 25 years. On examination, the patient is alert and without neurologic findings. His blood work and chest x-ray are normal. What is the best next step in the management of this patient?

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

A 75-year-old man is found by his internist to have an asymptomatic carotid bruit. Which of the following is the most appropriate next test?

A 75-year-old man with a history of myocardial infarction 2 years ago, peripheral vascular disease with symptoms of claudication after walking half a block, hypertension, and diabetes presents with a large ventral hernia. He wishes to have the hernia repaired. Which of the following is the most appropriate next step in his preoperative workup?

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

A 75-year-old woman comes to the physician complaining of vulvar itch that has been worsening for the past 2 years. She has had no bleeding from the vagina since she underwent menopause at the age of 52. She smokes five cigarettes per day. On physical examination she has a raised, pigmented lesion on the right labia majora. The rest of her physical examination is unremarkable. Which of the following is the most appropriate next step in the management of this patient?

A 76-year-old Caucasian female is brought to the hospital with a one-hour history of confusion. Her husband says that she started to complain of occipital headaches two hours ago and took some acetaminophen; an hour later, he found her confused on the couch and called an ambulance. She has no recent history of fever, chills, ear pain, or upper respiratory infection. Her past medical history is significant for coronary artery disease, diabetes mellitus, hypertension and atrial fibrillation. She had triple vessel coronary artery bypass five years ago. Her current medications include warfarin, metoprolol, diltiazem and lisinopril, plus 25 units of long-acting insulin at bedtime. She lives with her husband and is independent in her activities of daily living. On examination, her blood pressure is 160/90 mmHg and her heart rate is 80/min and irregular. She is unable to follow simple commands or speak. She moves all four extremities. Deep tendon reflexes are symmetric and Babinski reflexes are downgoing bilaterally. Which of the following is the best next step in evaluating this patient?

A 76-year-old male with a history of mild dementia, hypertension and diabetes mellitus is brought to the emergency department by his daughter because of two days of confusion, disorientation and decreased oral intake. She says that he has been talking to people who are not there and wandering around the house in the middle of the night. His current medications are metoprolol, valsartan and metformin. On physical examination, his blood pressure is 100/60 mmHg and his heart rate is 70/min. Which of the following initial evaluations is most important for this patient?

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

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

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

A 77-year-old man becomes "senile" over a period of 3 or 4 weeks. He used to be active and managed all of his financial affairs. Now, he stares at the wall, barely talks, and sleeps most of the day. His daughter recalls that he fell from a horse about a week before the mental changes began. Which of the following would a CT scan of his head most likely show?

A 78-year-old man is seen in the doctor’s office for a nonproductive cough, 9-kg (20-lb) unintentional weight loss, and bilateral breast enlargement, all occurring within the past 6 months. He has smoked two packs per day for the past 40 years. His past medical history is otherwise unremarkable, and he takes no medications. His temperature is 36.7°C (98.1°F), blood pressure is 125/85 mm Hg, pulse is 68/ min and regular, respiratory rate is 15/min, and oxygen saturation is 99% on room air. There are crackles at the left lower lung field and a ridge of symmetric glandular tissue (1 cm in diameter) around the nipple-areolar complexes of both breasts. Complete blood cell count shows a WBC count of 6000/mm³ hemoglobin of 14.7 g/dL, and platelet count of 210,000/ mm³. All other laboratory results are normal. X-ray of the chest shows a focal 5-cm mass lesion in the left lower lung corroborated by CT scan. Which of the following is most likely histologic type of lung cancer present in this patient?

A 78-year-old man with Alzheimer's disease was brought to the ER because of bright red bleeding per rectum. He has chronic constipation and is being treated with bisacodyl. On admission, his temperature was 36.6°C (97.9°F), blood pressure was 130/80 mm Hg with no orthostatic change, pulse was 90/min, and respirations were 14/min. Nasogastric tube drainage showed normal stomach contents and bile but no blood. His bleeding stopped a few hours after admission, and he remained hemodynamically stable during that time. Colonoscopy showed extensive diverticulosis but no active bleeding source. Later that night he started bleeding again from the rectum. Packed red cells and intravenous fluid are started. Which of the following is the most appropriate next step in management?

A 78-year-old man with Alzheimer's disease was brought to the ER because of bright red bleeding per rectum. He has chronic constipation and is being treated with bisacodyl. On admission, his temperature was 36.6C (97.9F), blood pressure was 130/80 mm Hg with no orthostatic change, pulse was 90/min and respirations were 14/min. Nasogastric tube drainage showed normal stomach contents without blood. His bleeding stopped a few hours after dmission, and he remained hemodynamically stable during that time. Colonoscopy showed extensive diverticulosis but no active bleeding source. Later that night he started bleeding again, and he is now hypotensive with a BP of 100/70 mm Hg. Packed red cells and intravenous fluid are started. Which of the following is the most appropriate next step in management?

A 9-month-old child comes in for a routine visit. She has had several episodes of otitis media in the past, but no major illnesses or hospitalizations. Her mother is concerned because the child was previously happy and social around other people, but now cries if her mother is not in the room. The child constantly wants to be held by her mother and becomes upset if her mother walks into the next room. Her grandmother keeps her during the day, and she now cries when her mother leaves her in the morning. Developmentally, she is crawling and waves bye-bye. She does not yet respond to her name or say words. She previously babbled but stopped several months ago. When you hide a toy with your hand, she lifts your hand to look for the toy. Which of the following is the best next step in the management of this child?

A 9-month-old infant is brought to the pediatrician's office because his weight is persistently below the 10th percentile. His mother states that the infant seems to be hungry all the time and usually consumes 8-12 oz of formula every 2-3 hours in addition to some table food. He also has frequent, bulky, and malodorous stools. A malabsorption syndrome is suspected. The results of which of the following tests will most likely be abnormal?

A 9-year-old girl is brought to the clinic with complaints of fatigue, abdominal pain and low grade fever. Four days ago her mother noticed a red rash on the tops of her daughter's feet, which has now spread to her thighs and buttocks. The rash was initially small red dots, but has now become patches. Her daughter subsequently developed periumbilical, cramping, abdominal pain. Review of systems is positive only for a respiratory viral illness three weeks ago. Her temperature is 37.7 C (99.8 F), pulse is 96/min, and respirations are 18/min. Abdominal examination is remarkable for tenderness to palpation near the umbilicus, but the abdomen is otherwise soft, with no rebound or guarding, and no organomegaly. Raised, palpable purpuric lesions are present on the buttocks and thighs. The ankles are tender and edematous bilaterally. Complete blood count reveals a leukocyte count of 9,000/mm3. Her hemoglobin 12. 6 g/dL, and platelets are 325,000/mm3. Serum electrolytes are normal. Which of the following is her urinalysis most likely to reveal?

A car is involved in a head-on collision. The driver, who is sober and wearing his seat belt, explains that he clearly saw his drunk, unrestrained front seat passenger hit the windshield with his face and the dashboard with his knees. Examination of the passenger indeed shows multiple facial lacerations, but because of his intoxication he cannot explain where else he might be hurting. He is neurologically intact, and his cervical spine x-ray films are normal. Additional injury, representing a potential orthopedic emergency, is not obvious but is suspected. Therefore, an x-ray film of which of the following areas should most likely be obtained?

A Caucasian couple presents to your office for infertility evaluation. They are unable to conceive after 14 months of unprotected sex. The woman is 23 years of age. Her menstrual periods are regular, occurring every 26 days. She denies perimenstrual pain or pelvic discomfort. Her last menstrual period was six days ago. Her past medical history is insignificant, and bimanual examination is normal. The man is 27 years old. He is not taking any medications. Physical examination, including external genitals, is normal. What is the best next step in the management of this couple?

A concerned mother brings her 2-month-old daughter to the clinic because of constipation. The mother had appropriate prenatal care but decided to deliver her child at home with the help of a midwife. The child has not received any medical attention since birth. Examination reveals jaundice, an umbilical hernia, and poor muscle tone. Which of the following is the most appropriate diagnostic study?

A father brings his 3-year-old daughter to the emergency center after noting her to be pale and tired and with a subjective fever for several days. Her past history is significant for an upper respiratory infection 4 weeks prior, but she had been otherwise healthy. The father denies emesis or diarrhea, but does report his daughter has had leg pain over the previous week, waking her from sleep. He also reports that she has been bleeding from her gums after brushing her teeth. Examination reveals a listless pale child. She has diffuse lymphadenopathy with splenomegaly but no hepatomegaly. She has a few petechiae scattered across her face and abdomen and is mildly tender over her shins, but does not have associated erythema or joint swelling. A CBC reveals a leukocyte count of 8,000/µL with a hemoglobin of 4 g/dL and a platelet count of 7,000/µL. The automated differential reports an elevated number of atypical lymphocytes. Which of the following diagnostic studies is the most appropriate next step in the management of this child?

A father brings his 7-year-old boy to the office because "his eyes are getting yellow". The boy has no other complaints. However, he is feeling tired and does not feel like going to the next Steelers game. There is a history of diabetes and lung cancer in the family. His vitals are stable, but he has pallor, jaundice, and splenomegaly. His labs revel: WBC 10,000/cmm, Hemoglobin 10 gm/dl, Hematocrit 28%, RBC count 3.5 million, Platelets 240,000/cmm, Reticulocyte count 4%. RBC indices were as follows:MCV 90 fl, MCHC 38%, MCH 28 pg. Peripheral smear revealed anisocytosis, some spherocytosis, and polychromatophilia. Coomb's test was negative. LFTs showed: Albumin 5.2 g/dl, AST 47U/L, ALT 52U/L, Alkaline phosphatase 120 U/L, Total bilirubin 3.0 mg/dl, Direct bilirubin 0.2 mg/dl. What is the next step?

A four-week-old male infant is brought to the emergency department because of persistent vomiting immediately after feeding for the past several days. Examination shows an emaciated infant with dry mucus membranes. An olive-shaped mass is palpated in the right upper quadrant of the abdomen. Which of the following acid-base abnormalities is most likely in this patient? pH, PaCO2 (mm Hg), HCO3-(mEq/L)

A full-term infant is born after a normal pregnancy; delivery, however, is complicated by marginal placental separation. At 12 hours of age, the child, although appearing to be in good health, passes a bloody meconium stool. For determining the cause of the bleeding, which of the following diagnostic procedures should be performed first?

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

A healthy 20-year-old G1P0 presents for her first OB visit at 10 weeks gestational age. She denies any significant medical history both personally and in her family. Which of the following tests is not part of the recommended first trimester blood testing for this patient?

A healthy, 32-year-old, primigravid woman at 12 weeks of gestation comes to the physician for a routine prenatal visit. She has no complaints. She does not use tobacco or alcohol. She has blood group O, Rh(O)+, and her husband has blood group AB, Rh(O)+. She is concerned about the risk of alloimmunization because her mother had that problem during her second pregnancy. Although the child will have a different blood group from the patient, alloimmunization is of little concern due to which of the following?

A hypertensive 47-year-old man is proposed for kidney transplantation. He is anemic but is otherwise functional. Which of the following would preclude renal transplantation?

A male infant born at term is found to have bilateral colobomas, choanal atresia, ear anomalies, and cryptorchidism. There is no history maternal drug or alcohol abuse during pregnancy. There is no family history of similar congenital defects. Which of the following is the most appropriate initial test to exclude any associated abnormalities?

A neonate is markedly edematous and dies 1 hour after birth. A diagnosis of hydrops fetalis is made after the hematocrit on cord blood is demonstrated to be 5%. The erythrocytes in a smear from the cord blood are markedly hypochromatic. The mother is Rh positive and is known to have alpha-thalassemia trait. The thalassemia status of the father is unknown. Alpha-thalassemia is the suspected cause of the infant's hydrops. Which of the following hemoglobins would most likely be markedly elevated in this infant's blood if this diagnosis were correct?

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

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

A one-month-old infant is born with craniofacial anomalies. Further evaluation reveals a cognitive impairment, a 22q 11 microdeletion in his chromosomes, and a heart condition with a right-to-left shunt. The infant subsequently undergoes heart surgery. The surgeon notes that the patient's thymus is absent. The anesthesiologist observes prolonged QT intervals in the patient's ECG. What is the most important parameter that should be monitored throughout this surgery?

A patient comes to your office with her last menstrual period 4 weeks ago. She denies any symptoms such as nausea, fatigue, urinary frequency, or breast tenderness. She thinks that she may be pregnant because she has not had her period yet. She is very anxious to find out because she has a history of a previous ectopic pregnancy and wants to be sure to get early prenatal care. Which of the following actions is most appropriate at this time?

A patient in your practice calls you in a panic because her 14-year-old daughter has been bleeding heavily for the past 2 weeks and now feels a bit dizzy and light-headed. The daughter experienced menarche about 6 months ago, and since that time her periods have been irregular and very heavy. You instruct the mother to bring her daughter to the emergency room. When you see the daughter in the emergency room, you note that she appears very pale and fatigued. Her blood pressure and pulse are 110/60 mm Hg and 70 beats per minute, respectively. When you stand her up, her blood pressure remains stable, but her pulse increases to 100. While in the emergency room, you obtain a more detailed history. She denies any medical problems or prior surgeries and is not taking any medications. She reports that she has never been sexually active. On physical examinations, her abdomen is benign. She will not let you perform a speculum examination, but the bimanual examination is normal. She is 5ft 4in tall and weighs 95 lb. Which of the following blood tests is not indicated in the evaluation of this patient?

A patient is seen on the first postoperative day after a difficult abdominal hysterectomy complicated by hemorrhage from the left uterine artery pedicle. Multiple sutures were placed into this area to control bleeding. Her estimated blood loss was 500 mL. The patient now has fever, left back pain, left costovertebral angle tenderness, and hematuria. Her vital signs are temperature 38.2C (100.8F), blood pressure 110/80 mm Hg, respiratory rate 18 breaths per minute, and pulse 102 beats per minute. Her postoperative hemoglobin dropped from 11.2 to 9.8, her white blood cell count is 9.5, and her creatinine rose from 0.6 mg/dL to 1.8 mg/dL. What is next best step in the management of this patient?

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

A patient presents to you for evaluation of infertility. She is 26 years old and has never been pregnant. She and her husband have been trying to get pregnant for 2 years. Her husband had a semen analysis and was told that everything was normal. The patient has a history of endometriosis diagnosed by laparoscopy at age 17. At the time she was having severe pelvic pain and dysmenorrhea. After the surgery, the patient was told she had a few small implants of endometriosis on her ovaries and fallopian tubes and several others in the posterior cul-de-sac. She also had a left ovarian cyst, filmy adnexal adhesions, and several subcentimeter serosal fibroids. You have recommended that she have a hysterosalpingogram as part of her evaluation for infertility. Which of the patient’s following conditions can be diagnosed with a hysterosalpingogram?

A patient with benign prostatic hyperplasia has moderately severe symptoms and is started on finasteride. After six months of treatment with finasteride, his symptoms improve remarkably and his prostate has regressed in size. Which of the following histological patterns was most likely present at the time of initiation of treatment?

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

A pedestrian is hit by a car and knocked unconscious. Within a few minutes, he starts to move around and moan. When the ambulance arrives, he is moving all four extremities and mumbling that his neck hurts. Shortly thereafter, he lapses again into a deep coma. In the emergency department, it is noted that his left pupil is fixed and dilated, and he has clear fluid dripping from the left ear. The trauma team intubates him nasally over a fiberoptic bronchoscope and does a quick initial survey that reveals no other obvious injuries. He is hemodynamically stable. Which of the following is the most appropriate next step in management?

A pedestrian is hit by a car. The paramedics report that he was unconscious at the site, and he arrives at the emergency department in coma, strapped to a head board with sandbags on either side of his head. Initial survey shows stable vital signs, and his pupils are of equal size and reactive to light. He is rapidly intubated by the nasotracheal route over a flexible bronchoscope and then sent for CT scans of the head. As he is being positioned on the table, it is noted that there is a sizable hematoma behind his right ear and that clear fluid is dripping from the ear canal. Which of the following is most advisable, considering this new finding?

A postoperative patient with swelling and pain in his right calf is suspected of having a deep venous thrombosis. Prior to initiating treatment with anticoagulants, he requires a confirmatory examination. Which of the following is a limitation of the duplex ultrasound in evaluating a DVT?

A pregnant patient of yours goes to the emergency room at 20 weeks gestational age with complaints of hematuria and back pain. The emergency room physician orders an intravenous pyelogram (IVP) as part of a workup for a possible kidney stone. The radiologist indicates the absence of nephrolithiasis but reports the presence of bilateral hydronephrosis and hydroureter, which is greater on the right side than on the left. Which of the following statements is true regarding this IVP finding?

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

A premenopausal, 48-year-old woman undergoes a routine mammographic screening. Physical examination is normal. Mammography identifies a suspicious focus with clustered micro-calcifications located deeply in the lateral upper quadrant of the right breast. No abnormality can be detected in this area on breast examination. Which of the following is the most appropriate next step in diagnosis?

A previously healthy 15-month-old girl is brought to the emergency department after she had several episodes in which she lost consciousness after crying. Her parents state that the episodes always occur when the child gets frustrated or upset. She has no cyanosis or incontinence. The episodes last about 45 seconds each. After the episode, she is alert and appropriate. Physical examination is unremarkable. What is the next best step in the management of this patient?

A previously healthy 19-year-old female university student develops myalgia, headache, fever, and malaise. Blood tests reveal lymphocytosis, with 20% of the lymphocytes being atypical. She remains tired and unwell for 6 weeks, but repeated tests for heterophil antibody are negative. Which of the following is the most likely diagnosis?

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

A window cleaner falls from a third-story scaffold and lands on his feet. Physical examination and x-rays show comminuted fractures of both calcaneus. He is tender to palpation over multiple bruises and abrasions in other parts of his trunk and extremities, but he has normal vital signs and a normal neurologic exam. Given the mechanism of injury, which of the following is the most appropriate next step in diagnosis?

A young Hispanic couple brings their first child to their physician for a well-child examination. The child is a 3-month-old healthy-appearing infant, whose weight is at the 45th percentile of the normal growth curve. During examination, the physician observes an area of blue-black pigmentation over the buttocks. The parents say that it was present from the time of birth. Which of the following is the most appropriate next step in management?

A young man is brought to the emergency department following a head-on collision at 30 miles per hour. He is awake and alert. Other than a forehead laceration, physical examination is normal and laboratory values are within normal limits. Chest x-ray films are unremarkable. Which of the following is the most appropriate next step in diagnosis?

An 11-month-old boy is brought to the emergency department by his parents. The child has a fracture of the right femur. The father reports this was sustained as a result of falling out of the crib. The child is also noted to have bruises on his shoulders and back. The rest of his examination is unremarkable. Which of the following is the most appropriate next step in diagnosis?

An 11-month-old girl is brought by her mother to the office due to fever, fussiness, and irritability. The girl has a tendency to hold and pull on her left ear. For the past few days, she has had rhinorrhea and nasal congestion. Her medical history reveals nothing particular. Her temperature is 38.9C (102F). Otoscopic examination reveals a bulging, erythematous tympanic membrane with decreased mobility on air compression. What is the most likely organism responsible for the patient's condition?

An 18-month-old boy is brought to the clinic for a checkup. As part of his routine care, a serum lead level is obtained. It is 25 g/mL. Which of the following is the most appropriate next step in his management?

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

An 18-year-old woman comes to the physician for an annual examination. She has no complaints. She has been sexually active for the past 2 years. She uses the oral contraceptive pill for contraception. She has depression for which she takes fluoxetine. She takes no other medications and has no allergies to medications. Her family history is negative for cancer and cardiac disease. Examination is unremarkable. Which of the following screening tests should this patient most likely have?

An 18-year-old woman comes to your office because of abdominal pain. She states that the pain started yesterday afternoon and has been worsening. The pain is in the right lower quadrant and does not radiate. She rates it a 7 on a scale of 1 to 10. She has had some nausea but no vomiting. Nothing seems to improve or worsen the pain. She has a history of hypothyroidism for which she takes thyroid hormone replacement, and no other medical problems. She has never had surgery. She is allergic to penicillin. Physical examination is significant for right lower quadrant tenderness. Bimanual examination reveals right adnexal tenderness. Which of the following is the most appropriate next step in the diagnostic workup of this patient?

An 8-year-old boy is brought to the emergency department by his mother. Two weeks ago, he developed a low-grade fever followed by a persistent cough. He occasionally has severe paroxysms of cough that are precipitated by eating and do not resolve with antitussive medications. On physical examination, extensive subcutaneous emphysema over the anterior chest is noted. What is the most appropriate next step in the management of this patient?

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

An 8-year-old girl is brought to the pediatrician's office for evaluation of new onset swelling around the eyes. Physical examination reveals periorbital, sacral, and pretibial edema; her blood pressure is 96/64 mm Hg. The rest other physical examination is normal. Which of the following is the most appropriate initial diagnostic study?

An 8-year-old is accidentally hit in the abdomen by a baseball bat. After several minutes of discomfort, he seems to be fine. Over the ensuing 24 hours, however, he develops a fever, abdominal pain radiating to the back, and persistent vomiting. On examination, the child appears quite uncomfortable. The abdomen is tender, with decreased bowel sounds throughout, but especially painful in the midepigastric region with guarding. Which of the following tests is most likely to confirm the diagnosis?

An 81-year-old man is hospitalized for acute onset of shortness of breath and lower extremity edema. Although he lives by himself, it is very difficult for him to move around his apartment without experiencing fatigue. He has not seen his physician in years but was told in the past that he had high blood pressure. On physical examination his jugular venous pulse is palpated 9 cm above his sternal notch, inspiratory crackles are heard at his lung bases, and there is 3+ lower extremity edema. Which of the following will confirm the most likely diagnosis?

An 82-year-old woman is in the surgical intensive care unit after a carotid endarterectomy. She has been taking clindamycin and ciprofloxacin for the past 13 days. On postoperative day 2 the patient is febrile and tachycardic with a high WBC count and a low RBC count. She is also noted to be dehydrated and hypotensive. On physical examination she is distended and has abdominal tenderness with rebound and guarding. Barium enema reveals colonic dilatation of 8 cm. Stool is sent for Gram stain and analysis for fecal leukocytes, fecal occult blood, and Clostridium difficile toxin. Which of the following is most likely present in the stool sample?

An 82-year-old woman presents 1-hour after the sudden onset of moderate-to-severe epigastric pain. The pain radiates to her back, both scapulae, and both arms. She has been nauseated and vomited three times in the past hour. Her past medical history is remarkable for peptic ulcer disease 10-years ago, cholelithiasis for the past 6-years, and stable angina pectoris for the past 3-years. She has had occasional episodes of biliary colic and two bouts of acute cholecystitis which were treated conservatively. Her temperature is 36.8°C (98.2°F), blood pressure is 120/70 mmHg, pulse is 90/min, and respirations are 14/min. The lungs are clear to auscultation. Abdominal examination shows a soft abdomen with mild tenderness to palpation in the epigastrium. Murphy's sign is negative. Which of the following studies should be done first?

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

An 87-year-old female is brought to the emergency department for evaluation of altered mental status. Her medical history is significant for multi-infarct dementia, hypertension, stroke, coronary artery disease, severe degenerative joint disease, chronic atrial fibrillation, constipation and urinary incontinence. Her medications include aspirin, acetaminophen, atenolol, nitroglycerin, multivitamins, pravastatin, docusate, senna, digoxin and glucosamine. She lives in a local nursing home, and the people who brought her to the ED deny any history of new symptoms. Her blood pressure is 110/70 mmHg, pulse is 98/min, respirations are 16/min and temperature is 36.1°C (97°F). Physical examination reveals dry mucus membranes and decreased skin turgor. There are no new focal neurologic deficits. Which of the following is most likely to be present in this patient?

An edentulous 72-year-old man with a 50-year history of cigarette smoking presents with a nontender, hard mass in the lateral neck. Which of the following is the best diagnostic test for establishing a diagnosis of malignancy?

An elderly man presents to the emergency department with chest pain. He has a history of stable angina and recent onset diabetes mellitus, but now the chest pain comes on with less exertion and takes longer to go away. An ECG and cardiac enzymes are ordered. If this man has unstable angina, what are the expected findings on ECG and cardiac enzyme testing?

An elderly woman is brought to the emergency department (ED) by her husband in a semiconscious state. According to her husband, she had complained of feeling unwell "over the past day or so”, but he only became very concerned when he returned from work today and found her very drowsy and difficult to arouse. Her past medical history is significant for diabetes with diabetic nephropathy and hypothyroidism. Her medications include thyroxine, metformin, gliclazide and lisinopril. Her temperature is 37.3°C (99°F), blood pressure is 110/65 mmHg, and pulse is 90/min. GCS = 13/15 (Motor 6, Verbal4, Eye3). She is confused and not oriented to time or place, but is able to follow commands. Physical examination reveals dry mucous membranes and decreased skin turgor. Neurological examination reveals weakness in the left arm. The rest of the examination is unremarkable. Urinalysis shows: Blood negative, Glucose +++, Ketones negative, Protein +, Leukocyte esterase negative, Nitrites negative, WBC 10-20/HPF. Which of the following is the most appropriate next investigation to perform?

An infant has had repeated pneumonias and middle ear infections that began at about 5 months of age. At 1 year of age, serum electrophoresis demonstrated hypogammaglobulinemia. T cell function was normal. By 2 years of age, the child's infection rate has decreased, and repeat serum electrophoresis is normal. Which of the following immunoglobulins was likely decreased in this child during the period of increased susceptibility to infection?

An intoxicated 22-year-old man is a restrained driver in a high-speed motor vehicle collision. Examination reveals normal vital signs, but the rest of the examination is unreliable secondary to the patient’s intoxicated state from alcohol. Which of the following sole findings on a CT scan of the abdomen and pelvis mandates an exploratory laparotomy?

An intravenous pyelogram (IVP) shows hydronephrosis in the workup of a patient with cervical cancer otherwise confined to a cervix of normal size. This indicates which one of the following stages?

An obese Caucasian father brings his 1 0-year-old obese son to your office. The father states that he was recently diagnosed with high cholesterol levels and coronary artery disease. Even though his son is asymptomatic, he is worried about the obesity. Which of the following best explains the next best step in management?

An otherwise healthy 17-year-old complains of swollen glands in his neck and groin for the past 6 months and an increasing cough over the previous 2 weeks. He also reports some fevers, especially at night, and possibly some weight loss. On examination, you notice that he has nontender cervical, supraclavicular, axillary, and inguinal nodes, no hepatosplenomegaly, and otherwise looks to be fairly healthy. Which of the following would be the appropriate next step?

An otherwise healthy 28-year-old man comes to his physician because of painless enlargement of the right testis. He began to feel a sensation of heaviness in the right hemiscrotum approximately 6 months ago. Physical examination reveals diffuse enlargement of the right testis, but it is difficult to determine whether this is due to an intratesticular or extratesticular lesion. Which of the following is the most appropriate next step in diagnosis?

An otherwise healthy, 65-year-old woman comes to the physician because of bloody discharge from the right nipple for 2 weeks. On examination, no retraction, erosion, or other abnormal change is present. Palpation reveals an ill-defined, 1-cm nodule located deep in the right areola. Which of the following is the most appropriate next step in diagnosis?

As a city public health officer, you have been charged with the task of screening high-risk children for lead poisoning. Which of the following is the best screen for this purpose?

As you are walking across the hospital lobby, you stumble upon the arterial blood gas (ABG) results of a patient. The ABG (on room air) results are shown below: Blood pH 7.43, PaO2 100 mm Hg, PaCO2 25 mm Hg, HCO3- 16 mEq/L. Which of the following patients is most likely to have these laboratory values?

During a routine breast self-examination, a 35-year-old woman is concerned because her breasts feel “lumpy.” She consults you as her primary care physician. After performing an examination, you reassure her that no masses are present and that the “lumpiness” is due to fibrocystic changes. Which of the following pathologic findings is a type of nonproliferative fibrocystic change?

During a routine office visit, a 62-year-old male is found to have a pulsatile non-tender mass above his umbilicus. His medical history is significant for hypertension, chronic renal insufficiency, myocardial infarction, and peripheral vascular disease. He quit smoking 10 years ago. On physical examination, his blood pressure is 160/90 mmHg and pulse is 76/min. Laboratory analyses reveal a serum creatinine of 2.0 mg/dl. Which of the following is the most appropriate next step in evaluating this patient's abdominal mass?

During a routine return OB visit, an 18-year-old G1P0 patient at 23 weeks gestational age undergoes a urinalysis. The dipstick done by the nurse indicates the presence of trace glucosuria. All other parameters of the urine test are normal. Which of the following is the most likely etiology of the increased sugar detected in the urine?

During a routine yearly checkup, a 10-year-old boy is found to have 2+ proteinuria on urinalysis. Which of the following would be the most appropriate diagnostic test?

During routine ultrasound surveillance of a twin pregnancy, twin A weighs 1200 g and twin B weighs 750g. Hydramnios is noted around twin A, while twin B has oligohydramnios. Which statement concerning the ultrasound findings in this twin pregnancy is true?

Eight hours after undergoing a transnasal, transsphenoidal resection of a prolactinoma, a young lady becomes lethargic, confused, and eventually comatose. Review of the record shows that her urinary output since surgery has averaged 600 mL/hr, while her intake of IV fluids (5% dextrose in 0.45% saline) has been 100 mL/hr. Her blood pressure is 110/75 mm Hg, and her pulse is 88/min. Which of the following would most likely yield the correct diagnosis?

Following surgery a patient develops oliguria. You believe the oliguria is due to hypovolemia, but you seek corroborative data before increasing intravenous fluids. Which of the following values supports the diagnosis of hypovolemia?

For the first 6 hours following a long and difficult surgical repair of a 7-cm abdominal aortic aneurysm, a 70-year-old man has a total urinary output of 25 mL since the operation. Which of the following is the most appropriate diagnostic test to evaluate the cause of his oliguria?

For which of the following patients is an abdominal CT scan contraindicated?

Her son brings a 50-year-old female to the emergency room because she is confused and sweating a lot. She does not have any medical problems, except hypertension for which she takes hydrochlorothiazide. She is not taking any other medication. He tells you that his mother complained of profound weakness, and inability to stand, because of lightheadedness 3 hours ago. On examination, the patient is drowsy, confused, and appears sick. Her temperature 36.8°C (98.2° F) BP 153/83mm Hg PR 128/min. Her clothes are damp from perspiration. No other abnormalities are noted on physical examination. Initial laboratory studies show: Sodium 144 mEq/L, Potassium 3.6 mEq/L, Bicarbonate 26 mEq/L, Blood urea nitrogen: 12 mg/dl, Creatinine 0.6 mg/dl. You order a few more tests and on the basis of which you diagnose insulinoma. What set of following results leads to this diagnosis? (Serum Glucose, Insulin, C-Protein)

In an adolescent presenting with pityriasis rosea, which of the following would be an appropriate blood test to order?

In the first postoperative day after an open abdominal procedure, a patient develops a temperature of 38.9 C (102 F). He is encouraged to ambulate, cough, and breathe deeply, but he is noncompliant. On the second day, he is still febrile. Incentive spirometry and postural drainage are instituted, but his participation is less than enthusiastic. He lies in bed all day and hardly moves. By the third day, he is still spiking fevers in the same range, although efforts to improve his ventilation continue, resolution of his problem will most likely require which of the following?

On postpartum day 2 after a vaginal delivery, a 32-year-old G2P2 develops acute shortness of breath and chest pain. Her vital signs are blood pressure 120/80 mm Hg, pulse 130 beats per minute, respiratory rate 32 breaths per minute, and temperature 37.6C (99.8F). She has new onset of cough. She appears to be in mild distress. Lung examination reveals clear bases with no rales or rhonchi. The chest pain is reproducible with deep inspiration. Cardiac examination reveals tachycardia with 2/6 systolic ejection murmur. Pulse oximetry reveals an oxygen saturation of 88% on room air and oxygen supplementation is initiated. Which of the following is the best diagnostic tool to confirm the diagnosis?

On the 7th postoperative day after the pinning of a broken hip, a 76-year-old man suddenly develops severe pleuritic chest pain and shortness of breath. When examined, he is found to be anxious, diaphoretic, and tachycardic, with a blood pressure of 140/85 mm Hg. He has prominent distended veins in his neck and forehead. Blood gases show hypoxemia and hypocapnia. His chest x-ray film is unremarkable. The nurses have placed him on supplemental oxygen by face mask. Which of the following is the most appropriate next step in management?

On the second postoperative day after an abdomino-perineal resection for cancer of the rectum, a 72-year-old man complains of severe retrosternal pain. The pain is crushing in nature and radiates to the left arm. He also becomes short of breath and tachycardic. Except for his fresh surgical wounds and postoperative discomfort, physical examination is unremarkable. He does not have distended neck veins. Which of the following is the most appropriate next step in diagnosis?

One of your obstetric patients presents to the office at 25 weeks complaining of severe left calf pain and swelling. The area of concern is slightly edematous, but no erythema is apparent. The patient demonstrates a positive Homans sign, and you are concerned that she may have a deep vein thrombosis. Which of the following diagnostic modalities should you order?

Ten days after undergoing liver transplantation, a patient's levels of gamma-glutamyl transferase (GGT), alkaline phosphatase, and bilirubin begin to rise. Which of the following is the most appropriate next step in diagnosis?

The 1-year-old brother of a child with known abetalipoproteinemia is evaluated by a pediatrician for the disease. The 1 -year-old has been exhibiting steatorrhea and ataxia. Which of the following would most strongly support the suspected diagnosis?

The parents of a 2-month-old baby boy are concerned about his risk of coronary artery disease because of the recent death of his 40-year-old maternal uncle from a myocardial infarction. Which of the following is the most appropriate management in this situation?

The unrestrained front-seat passenger in a car that crashes at high speed is brought to the emergency department by paramedics. At the site of injury, the patient was unconscious and had gurgly respiratory sounds, and the EMTs successfully accomplished blind nasotracheal intubation. The initial survey in the emergency department shows normal vital signs, multiple facial lacerations, and an unresponsive, comatose patient with fixed dilated pupils. Preparations are made to do a CT scan of the head. It is imperative that which of the following should be obtained as well?

Which feature of fibrocystic disease of the breast is associated with the greatest risk of developing breast cancer?

Which of the following is the most appropriate evaluative procedure for an otherwise normal 7-day-old boy with perineal hypospadias?

Within 8 hours after birth, an infant has "excessive salivation." Physical examination reveals that she has an imperforate anus, with a small fistula to the vagina. A small, soft nasogastric tube is inserted, and the infant is taken to x-ray. The film shows the tube coiled back on itself in the upper chest, and a normal gas pattern in the gastrointestinal tract. There are no apparent abnormalities of the radius or the vertebral bodies. Which of the following is the most appropriate next step in management?

You are asked by a colleague to evaluate a 5-year-old boy as a second opinion. He has a history of chronic and recurrent upper respiratory tract infections, several admissions to the hospital for pneumonia, and three surgeries for PE tubes for chronic otitis media. Of note is a right-sided heart on repeated radiographs. Convinced you know the diagnosis based on history alone, you confirm your diagnosis with a biopsy of the nasal mucosa. You expect to find which of the following?