Ichigo USLME Med Management P3

4) A 6-year-old, African-American boy presents with fever and pain in his extremities for the last several hours. The pain is unrelated to movement or posture. His pulse is 102/min, blood pressure is 110/70 mm Hg, temperature is 38°C (100.4°F), and respirations are 18/min. Physical examination reveals pallor, jaundice, and splenomegaly. Both lower legs are tender to palpation. Lab tests show the following: Hematocrit 20%, WBC count 13,000/micro-L, Platelet count 180,000/miro-L, Bilirubin 5.0 mg/dL, Direct bilirubin 1.2 mg/dL, Reticulocyte count 11%. Peripheral blood smear shows sickle shaped cells. Hemoglobin electrophoresis confirms the diagnosis of sickle cell anemia. After treating the child with analgesia, hydration, and oxygen therapy, the painful episode subsides. Which of the following measures should be employed to prevent aplastic crisis in this child?

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

8) A 34-year-old woman comes to the ER because of right lower leg swelling, redness, and pain. She has no significant past medical history and does not use any medications. Her mother has a history of pulmonary embolism. Her temperature is 36.7°C (98°F), pulse is 80/min, respirations are 16/min, and blood pressure is 120/76 mmHg. Examination shows tenderness to palpation in the right calf. Compressive ultrasonogram shows a deep vein thrombosis of the right leg. Further evaluation reveals an elevated plasma homocysteine level. She is started on heparin and warfarin therapy. What other additional therapy is indicated in this patient?

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

17) A 55-year-old Caucasian male is hospitalized after a massive hemorrhage from a duodenal ulcer. The hemorrhage was stopped with endoscopic manipulation. Two litters of Ringer lactate were infused and two units of packed red blood cells (RBC) ordered. Ten minutes after the transfusion of packed RBC had been started; the patient was complaining of tremor and feeling 'chilly.' His temperature is 39.4° C (103° F), blood pressure is 120/76 mmHg, pulse is 100/min, and respirations are 24/min. The transfusion was stopped, and acetaminophen was given. Direct antiglobulin test and plasma free hemoglobin level are negative. Urinalysis is normal. The reaction abated three hours after the transfusion had started. Which of the following actions could have prevented the reaction described?

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

26) A 72-year-old Hispanic man comes to the clinic with complains of mild headache, and lethargy for the past several days. He complains of cough for the past 12 years, the cough has been bothering him more lately. The cough is mucoid, he has noticed blood in it once in a while. He has smoked 1 pack/day for 29 years. His vitals are, Temperature 37.0°C (98.6°F); BP 120/84 mm Hg; PR 78/min; RR 24/min. On examination of lungs, adventitious sounds are heard over all the lobes and scant crackles at the base. Laboratory studies show: WBC 7,600/mm3, Hemoglobin 13.6, Hematocrit 40%, Platelets 214,000mm3, Sodium 130 mEq/L, Potassium 3.6 mEq/L, Bicarbonate 18 mEq/L, Blood urea nitrogen 16 mg/dl, Creatinine 0.6 mg/dl, Glucose 95 mg/dl, Serum osmolality 260 mOsm/kg (normal 280), Urine osmolality 310 mOsm/kg. A chest x-ray shows a 2-centimeter left upper lobe mass and mediastinal adenopathy. What will be the next best step in management of this patient?

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

41) An 18-year-old young man comes to your clinic with complaints of fatigue, malaise, fever, and sore throat for the past few days. His temperature is 38.8°C (101°F), pulse is 90/min, respirations are 18/min, and blood pressure is 135/70 mm Hg. Physical examination reveals cervical lymphadenopathy, pharyngeal hyperemia, and splenomegaly. Complete blood count shows leukocytosis with predominant atypical lymphocytes. The heterophile antibody test is positive. When you ask if he has any questions, he replies with, "Well, I'm a rugby player in school, so I need to know when I can start playing again." What is the most appropriate advice for this patient?

43) 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?

50) A 32-year-old man from Arkansas presents to physician with a two-day history of fever, headache, malaise, and myalgias. His family says that he seems slightly confused. He recalls having a tick bite two weeks ago after walking through the woods. His temperature is 39°C (102°F), pulse is 90/min, and blood pressure is 125/80 mm Hg. Neck is supple and there is no lymphadenopathy noted. Oropharynx is clear. Chest auscultation is unremarkable. Abdomen is soft and non-tender. There is no rash evident. Neurologic examination is nonfocal. Laboratory testing shows: Complete blood count:Hemoglobin 14.0 g/L, MCV 88 fL, Platelets 78,000/mm3, Leukocyte count 2,500/mm3, Neutrophils 56%, Eosinophils 1%, Lymphocytes 33%, Monocytes 10%. Liver studies:Total protein, serum 6.5 g/dL, Total bilirubin 1.0 mg/dL, Direct bilirubin 0.8 mg/dL, Alkaline phosphatase 110 U/L, Aspartate aminotransferase (SGOT) 98 U/L, Alanine aminotransferase (SGPT) 105 U/L. What is the most appropriate next step in the management of this patient?

56) A 5-year-old Hispanic girl is brought to the emergency department (ED) due to a cat bite on her right upper extremity. She was bitten after rambunctiously playing for several minutes with the cat, which had just been given to her as a birthday gift. Her most recent booster tetanus vaccine was one year ago. Her temperature is 36.7°C (98°F), blood pressure is 108/70 mm Hg, pulse is 107/min, and respirations are 21/min. Physical examination reveals a deep puncture wound on the volar aspect of her right forearm. Before going to the ED, her mother cleaned the wound with hydrogen peroxide. There is no visible debris in the wound, and little bleeding is evident. Neurovascular function is intact. Her wound is cleaned in the ED with Betadine and lavaged with saline solution. What is the best next step in managing this girl's care?

57) A 57-year-old male comes to your office in the middle of January. He complains of a 4-day history of a nonproductive cough and coryza. He also has vague muscle aches and a mild headache. He denies any shortness of breath or chest pain. His past medical history is significant for hyperlipidemia and impaired glucose tolerance. He takes aspirin and simvastatin 40 mg at bedtime. He has no known drug allergies. His medical records show that he did not show up for his scheduled annual influenza vaccine this year. His temperature is 38.5°C (101.3°F), blood pressure is 135/80 mm Hg, and pulse is 88/min. Physical examination shows conjunctival redness and an erythematous oropharynx. The tympanic membranes are clear. The heart sounds are audible with no added murmurs, rubs or gallops. His breath sounds are vesicular in quality and equal bilaterally. Which of the following is the most appropriate next step in management?

58) A 60-year-old Caucasian woman undergoes elective coronary artery bypass surgery and aortic valve replacement. Her postoperative course is complicated by acute renal failure, atrial fibrillation, and pulmonary edema. On the third postoperative day, extubation is attempted but not tolerated, thus warranting reintubation. On the fifth postoperative day, she develops a fever to 38.9°C (102°F). Her pulse is 110-120/min and irregular, respirations are 36/min, and blood pressure is 110/65 mmHg. Her chest x-ray shows right middle and lower lobe infiltrates. WBC count is elevated with bandemia. Gram stain of her sputum shows gram-negative rods. She is given intravenous ceftriaxone; however, she deteriorates over the next 24 hours. Which of the following is the most appropriate next step in the management of this patient?

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

61) A 74-year-old man residing in a nursing home develops symptoms of high fever, diarrhea, chest pain, and nonproductive cough. His temperature is 40°C, blood pressure 120/80 mm Hg, respiration 24/min, and oxygen saturation 90%. He has bibasilar crackles, normal heart sounds, and a soft nontender abdomen. His CXR reveals bilateral lower lobe infiltrates. He is not able to provide any sputum, and the urine is positive for legionella antigen. Which of the following is the most appropriate antibiotic choice?

62) A 28-year-old female presents to her internist with a 2-day history of low-grade fever and lower abdominal pain. She denies nausea, vomiting, or diarrhea. On physical examination, there is temperature of 38.3°C (100.9°F) and bilateral lower quadrant tenderness, without point or rebound tenderness. Bowel sounds are normal. On pelvic examination, an exudate is present and there is tenderness on motion of the cervix. Her white blood cell count is 15,000/μL and urinalysis shows no red or white blood cells. Serum β-hCG is undetectable. Which of the following is the best next step in managemen

67) A businesswoman needs to make frequent trips to South America, but every time she is there, she develops traveler’s diarrhea, which requires her to change her business schedule. To prevent future episodes during business trips, she is inquiring about prophylaxis methods. Which of the following is the most helpful advice for her?

69) A 35-year-old previously healthy male develops cough with purulent sputum over several days. On presentation to the emergency room, he is lethargic. Temperature is 39°C, pulse 110, and blood pressure 100/70. He has rales and dullness to percussion at the left base. There is no rash. Flexion of the patient’s neck when supine results in spontaneous flexion of hip and knee. Neurologic examination is otherwise normal. There is no papilledema. A lumbar puncture is performed in the emergency room. The cerebrospinal fluid (CSF) shows 8000 leukocytes/μL, 90% of which are polys. Glucose is 30 mg/dL with a peripheral glucose of 80 mg/dL. CSF protein is elevated to 200 mg/dL. A CSF Gram stain shows gram-positive diplococci. Which of the following is the correct treatment option?

72) A 23-year-old woman visits your office because of headache, malaise, anorexia, pain in both sides of her jaw, and discomfort in both lower abdominal quadrants. Physical examination reveals enlarged parotid glands; bilateral lower quadrant abdominal tenderness; a temperature of 38.7°C; and a pulse rate of 92/min. Serologic testing (IgM) confirms the diagnosis of mumps. Which of the following is the most appropriate treatment for this condition?

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

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

80) 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?

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

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

89) 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?

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

94) A 50-year-old diabetic woman presents for follow-up of her hypertension. Her blood pressure is 152/96 in the office today and she brings in readings from home that are consistently in the same range over the past month. Her current medications are amlodipine 5 mg daily and hydrochlorothiazide 25 mg daily. The diuretic was added when she developed peripheral edema on the amlodipine; now she has only trace peripheral edema. A spot urine specimen shows 280 μg of albumin per mg creatinine (microalbuminuria is present if this value is between 30 and 300 μg/mg). What would be the best next therapeutic step in this patient?

95) A 64-year-old woman develops severe diarrhea 2 weeks after finishing antibiotics for pneumonia. She has also noticed decreased urine output despite drinking lots of fluids. On examination, she has a postural drop in her blood pressure, the JVP is low, and the abdomen is soft but diffusely tender. Despite giving 4 L of normal saline, her urine output remains low. The urinalysis is positive for heme-granular casts and the urine sodium is 42mEq/L. Which of the following medications should be held during the recovery phase of this woman’s ARF?

100) A 60-year-old man is brought in by ambulance and is unable to speak. The EMS personnel tell you that a neighbor informed them he has had a stroke in the past. There are no family members present. His serum sodium is 118 mEq/L. Which of the following is the most helpful first step in the assessment of this patient’s hyponatremia?

101) A 39-year-old woman is admitted to the gynecology service for hysterectomy for symptomatic uterine fibroids. Postoperatively the patient develops an ileus accompanied by severe nausea and vomiting; ondansetron is piggybacked into an IV of D5 ½ normal saline running at 125 cc/h. On the second postoperative day the patient becomes drowsy and displays a few myoclonic jerks. Stat labs reveal Na 118, K 3.2, Cl 88, HCO3 22, BUN 3, and creatinine 0.9. Urine studies for Na and osmolality are sent to the lab. What is the most appropriate next step?

104) A 43-year-old female with history of hepatitis C, alcohol use and cirrhosis is admitted to the hospital for severe vomiting for the last 2 days. Her temperature is 36.7°C (98.2°F), pulse is 90/min, respirations are 14/min and blood pressure is 100/70 mmHg supine. Her lungs are clear to auscultation. She has mild epigastric tenderness, but there is no abdominal distention. Extremities have no edema. Her laboratory profile shows: Blood PH 7.49, PaO2 100 mmHg, PaCO2 41 mm Hg, HCO3- 30 mEq/L, Sodium 138 mEq/L, Potassium 3.0 mEq/L, Chloride 95 mEq/L. Which of the following is the most appropriate treatment for the patient's alkalosis?

120) A 32-year-old Caucasian male comes to the emergency department due to progressive ascending paralysis, which began 18 hours ago. He initially noticed paresthesias in his lower limbs, followed by a sense of fatigue and weakness. He denies any history of headache, fever, and recent infection or illness. His blood pressure is 120/80 mm Hg, pulse is 80/min, respirations are 16/min, and temperature is 37.3°C (99.2°F). The physical examination reveals intact cranial nerves, absent deep tendon reflexes, and a normal sensory exam. Laboratory studies reveal a normal WBC count. No abnormalities are noted on CSF examination. While evaluating the patient in the hospital, he quickly deteriorates. What is the most appropriate next step in the management of this patient?

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

139) A 65-year-old male comes to the emergency department because of a sudden, painless loss of vision in his right eye that occured a half an hour ago. Five hours ago, he experienced a similar but transient loss of vision in the same eye, which lasted for five minutes. He has hypertension, diabetes, hypercholesterolemia, and peripheral vascular disease. He had an anterior wall myocardial infarction six years ago. His medications include glyburide, captopril, atenolol, simvastatin and aspirin. His temperature is 36.7°C (98.0°F), respirations are 16/min, pulse is 88/min, and blood pressure is 146/88 mmHg. Examination of the right eye reveals visual acuity of 20/60 and subtle retinal whitening. A right carotid bruit is heard. Which of the following is the most appropriate next step in the management of this patient?

141) A 72-year-old man presents with right eye pain for 1 day. The patient has a history of diabetes, hypertension, and “some type of eye problem.” He does not recall the name of his eye problem or the name of his ophthalmic medication. However, he does remember that the eye drop has a yellow cap. Which class of ophthalmic medication is the patient taking?

142) A 45-year-old woman presents with right eye pain and redness for 1 day. She has photophobia and watery discharge from the eye. She does not wear glasses or contact lenses and has no prior eye problems. On examination, the patient’s visual acuity is 20/20 in the left eye and 20/70 in the right eye. She has conjunctival injection around the cornea and clear watery discharge. On slit-lamp examination, the lids, lashes, and anterior chamber are normal. When fluorescein is applied, a branching, white-colored epithelial defect is seen. The remainder of the head examination is normal and the patient has no cutaneous lesions. Which of the following is the most appropriate treatment for this patient?

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

159) A 68-year-old female comes to the Emergency Room with increased shortness of breath and cough for 12 hours. She has a history of chronic obstructive pulmonary disease for the past 14 years and has been oxygen dependent for two years. Twelve hours ago, she felt unable to get her breath. She took two extra nebulizer treatments and used her as-needed inhaler with no relief of symptoms. She denies any fever, chills, sweating, nausea or vomiting, and hemoptysis. She rarely uses alcohol, but had smoked two packs/day for 45 years. She quit smoking about six years ago. Her medications include ipratropium, albuterol, multivitamins, and oxygen 2 liters/min by nasal cannula. She is a thin, frail female in moderate distress. Her temperature is 36.7°C (98°F), blood pressure is 110/65 mmHg, pulse is 110/min, and respirations are 28/min. Pulse oximetry shows 84% on 2 liters oxygen by nasal cannula. The patient is given oxygen, methyl prednisolone, aerosolized ipratropium, and albuterol; however, the patient remains dyspneic and bedridden. ABGs are ordered and the results show: pH 7.32, PCO2 60 mmHg, and PO2 52 mmHg on 4-liters O2. What is the next best step in the management of this patient?

162) A 64-year-old male presents to the physician's office with increasing shortness of breath. He denies orthopnoea, paroxysmal nocturnal dyspnea, or chest pain. He was hospitalized for pneumonia four years ago but has otherwise been healthy. He has smoked one pack of cigarettes daily for the past 30 years. He does not take any medications. His temperature is 37.2°C (98.9°F), blood pressure is 124/76 mm Hg, pulse is 82/min and respirations are 16/min. Pulse oximetry reveals an oxygen saturation of 88%. On chest auscultation, breath sounds are diminished throughout, and the expiratory phase is prolonged. Heart sounds are regular and there are no murmurs or gallops. There is no peripheral edema or jugular venous distention. Laboratory studies show a hematocrit of 56% and WBC count of 6,700/mm3. Which of the following interventions will have the maximum impact on this patient's survival?

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

164) A 36-year-old female presented to the emergency room with fever and a productive cough. The physician on call suspected community acquired pneumonia and prescribed azithromycin for 5 days. After 5 days of treatment, she comes to your office with no improvement of her symptoms and complains of worsening foul smelling sputum. Further inquiry reveals that she had undergone an upper GI endoscopy 8 days ago for a long history of heartburn and suspected peptic ulcer disease. She also reports a history of manic-type bipolar disorder. In your office she has a blood pressure of 130/80 mm Hg, her pulse is 108/min, temperature is 38.7°C (101.6°F) and respirations are 26/min. Chest x-ray showed a right upper lobe infiltrate. Which of the following additional therapies would be most helpful for this patient's condition?

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

166) A 65-year-old male with oxygen-dependent chronic obstructive pulmonary disease, chronic atrial fibrillation, and depression comes into the Emergency Room, with symptoms of increased dyspnea and worsening cough pattern. His recent history had been significant for a gradual worsening of his baseline lung disease over the past month, which had been treated by his outpatient doctor with increased frequency of inhaled beta-agonist and azithromycin. This morning he had a severe shortness of breath that was unresponsive to "stacked" home nebulizer treatments. The ER physician notes that the patient is in moderate severe respiratory distress. His temperature is 37.2°C (99°F), blood pressure is 150/90 mmHg, pulse is 110/min, and respirations are 28/min. Accessory muscle use was noted. Lung exam shows diffuse rhonchi and wheezing. A pulse oximetry revealed an oxygen saturation of 80% on room air. His chest x-ray showed no new infiltrates. His WBC count is 7,000/cmm with normal differential. The ER physician had given nebulization, and the patient is on 5-liters of oxygen. Which of the following should also be considered in this patient?

168) A 50-year-old female comes into your office complaining of four-month history of dry cough. She denies dyspnea or hemoptysis. Past medical history is significant for hypertension, diabetes, and gout. Her current medications include enalapril, metformin, hydrochlorothia zide, and allopurinol. She does not smoke or consume alcohol. Her vital signs are BP 130/80 mmHg, HR 80/min, T 36.7°C (98°F) and RR 16/min. Physical examination is within normal limits. The best next step in the management of this patient is:

179) A 35-year-old homeless man presents to the emergency department with chief complaints of a cough and fever. He is intoxicated. He admits to drinking about a fifth of vodka every day and confirms a history of delirium tremens and blackouts. X-ray of the chest is significant for an air-fluid level in the superior segment of the right lower lobe. Which of the following is the most appropriate first-line agent for treating this patient’s condition?

185) A 22-year-old woman with mild persistent asthma comes to the primary care clinic after an emergency department visit 2 days ago for an acute asthma exacerbation. She notes an in- crease in frequency of wheezing and shortness of breath for the past 4 months, with daily symptoms, and has been symptomatic for at least 2 nights per week. She has also had three emergency department visits during the same period. Her current asthma medications include montelukast (leukotriene inhibitor) daily and an albuterol inhaler as needed. The patient’s peak flow is 75% of predicted. Which of the following is the most appropriate next step in management?

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

191) A 1-year-old child with cerebral palsy secondary to perinatal asphyxia presents to her general pediatrician for a well-child visit. She was delivered at 37 weeks’ gestation by emergency cesarean section for a tight nuchal chord. The patient has severe spastic quadriparesis that is limiting her movements. She also has mental retardation and is unable to speak. She has received physical and occupational therapy since early infancy; however, her parents are concerned by her lack of improvement. Which of the following is the best choice for treatment of spasticity in this child?

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

194) A 23-year-old man is seen in the emergency department for sudden onset, right-sided pleuritic chest pain that developed 30 minutes ago while he was watching television. The patient also complains of difficulty breathing. He has no prior medical history, denies smoking and intravenous drug use, and does not take any medications. His temperature is 37.3°C (99.1°F), blood pressure is 130/82 mm Hg, pulse is 92/ min and regular, respiratory rate is 20/min and shallow, and oxygen saturation is 98% on room air. His body mass index is 18 kg/m². Diminished breath sounds, hyperresonance, and decreased tactile fremitus are prominent in the right lung field. The trachea is midline. X-ray of the chest shows a 10% pneumothorax on the right. Which of the following is the most appropriate initial management?

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

206) A middle-aged married couple brings their 10-year-old daughter to the pediatrician because "she just is too tired to play nowadays and sleeps all the time." The parents say that their daughter is winded with minimal exertion. Further inquiry reveals that for the past two weeks, the girl has had bleeding gums when she brushes her teeth. Physical examination demonstrates pallor and hepatosplenomegaly. An extensive workup indicates that the girl is suffering from acute lymphoblastic leukemia, and her parents are informed that chemotherapy will be necessary. The parents firmly refuse to comply with this treatment plan, however, because they are convinced that the side effects will be too severe. Despite a lengthy discussion about the benefits of treatment and the likely consequences for their daughter if therapy is withheld, the girl’s parents insist upon taking her home. What is the most appropriate next step?

209) A 20-year-old female college student is brought to the emergency department by police at 2:30 am after she was caught attempting to enter the White House. She is highly agitated and is pacing around the examination room. Upon further questioning, she states that she just flew in from Texas to meet with the president because she has a "foolproof plan for eliminating terrorism worldwide in just seven days." She adds that she has barely slept for the past ten nights because she has been working intensively on this plan. She speaks very quickly, but periodically stops to angrily shout, "I'm going to sue all of you for interfering with my right to meet with the president." The evaluation has to be stopped because she demands that she be allowed to leave. Family history is significant for major depression in her mother. Vital signs are temperature 37.0°C (98.6°F), blood pressure 148/84 mmHg, pulse 98/min, and respiratory rate 22/min. Which of the following medications should be administered to this patient immediately?

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

216) As the on-call surgery resident, you are paged to see a patient on the ward who is having seizures. The patient is a 35-year-old male who underwent a cholecystectomy yesterday. His surgery was uneventful and the man appeared to be doing well until an hour ago when he developed altered sensorium. Upon arriving on the floor, you discover the patient to be confused and agitated. His vital signs include a temperature of 38°C (100.4°F), blood pressure of 134/86 mm Hg, pulse of 110/min, and respirations of 18/min. The man is diaphoretic and has tremors. His wound incisions show no evidence of inflammation, and biliary drainage appears adequate. A review of his medical record indicates his medical history to be unremarkable except for mild esophagitis. He smokes a pack of cigarettes per day and drinks 6-10 beers per night. His medications include folic acid, thiamine, and omepra zole. Laboratory results include the following: CBC: Hb 14.1 g/dL, Leukocyte count 7,100/cmm. Serum Chemistry: Sodium 137 mEq/L, Potassium 4.0 mEq/L, Chloride 101 mEq/L, Bicarbonates 24 mEq/L, BUN 12 mg/dL, Creatinine 1.0 mg/dL, Glucose 104 mg/dL. Arterial Blood Gas: PH 7.40, PO2 94 mm Hg, PCO2 40 mm Hg. Which of the following should be initiated immediately in this patient?

220) A 16-year-old female presents to her pediatrician's office for a routine examination. She is wearing a sweater despite the warm weather, and admits she often feels cold. She states that she has otherwise been feeling fine, except for having difficulty losing weight. She wants to lose about 10 lbs (4.5 kg) because she believes she is "too fat." She has been on a strict diet and exercises two hours daily. She is also requesting a pregnancy test because she has not had a menstrual period for the past three months. Past medical history is significant for a supracondylar fracture of her right humerus at the age of seven. She is alert, cooperative, and in no apparent distress. Vital signs are temperature 36.2°C (97.2°F), blood pressure 88/58 mmHg, pulse 56/min, and respiratory rate 16/min. Her height is 5'5" (165 cm) and weight is 90 lbs (40.9 kg). What is the most appropriate next step in the management of her symptoms?

225) A 19-year-old college student presents for a first visit because she is concerned about her "abnormal behavior." She says that she worries excessively about her door being locked and that she wakes several times throughout the night to confirm that the door is properly locked. She finds these thoughts distressing. Although she agrees that her fears are not rational, she feels unable to stop from acting on them. This frequent waking grossly impairs her sleep and as a result, she is finding it increasingly difficult to perform well academically. She has no history of psychiatric conditions, but her mother was recently diagnosed with trichotillomania. Vital signs include a temperature of 37.0°C (98.6°F), blood pressure of 118/84rnrnHg, pulse of 76/min, and respirations of 12/min. Physical examination is unremarkable. Which of the following medications would be the most appropriate treatment for her condition?

231) A 42-year-old Caucasian man presents to the emergency department complaining of a two-day history of fever to 40°C (104°F), headache, and vomiting. Physical examination reveals petechiae and purpura on his trunk and lower extremities. Examination of his cerebrospinal fluid is consistent with bacterial meningitis. The patient is told of his diagnosis and the need for antibiotics and hospitalization is discussed. The patient refuses to be admitted to the hospital, however, and insists upon being treated at home. What is the most appropriate next step?

234) A 24-year-old man with chronic schizophrenia is brought to the emergency room after his parents found him in his bed and were unable to communicate with him. On examination, the man is confused and disoriented. He has severe muscle rigidity and a temperature of 39.4°C (103°F). His blood pressure is elevated, and he has a leucocytosis. Which of the following is the best first step in the pharmacologic treatment of this man?

239) A 22-year-old college student calls his psychiatrist because for the past week, after cramming hard for finals, his thoughts have been racing and he is irritable. The psychiatrist notes that the patient’s speech is pressured as well. The patient has been stable for the past 6 months on 500 mg of valproate twice a day. Which of the following is the most appropriate first step in the management of this patient’s symptoms?

240) A 38-year-old woman with bipolar disorder has been stable on lithium for the past 2 years. She comes to her psychiatrist’s office in tears after a 2-week history of a depressed mood, poor concentration, loss of appetite, and passive suicidal ideation. Which of the following is the most appropriate next step in the management of this patient?

241) A 42-year-old woman sees her physician because she has been depressed for the past 4 months. She also notes that she has gained 20 lb without trying to. She notes that she does not take pleasure in the activities that she once enjoyed and seems fatigued most of the time. These symptoms have caused the patient to withdraw from many of the social functions that she once enjoyed. The physician diagnoses the patient with hypothyroidism and starts her on thyroid supplementation. Six weeks later, the patient’s thyroid hormone levels have normalized, but she still reports feeling depressed. Which of the following is the most appropriate next step in the management of this patient?

247) A 35-year-old female presents to your office complaining of knee pain. She has a long history of rheumatoid arthritis affecting her hand and knee joints. The stiffness and pain has persisted over the last several months and has responded poorly to NSAIDs. Over the last two days the pain in her right knee has been interfering with her sleep. She had an episode of chills this morning. Her blood pressure is 120/70 mmHg, pulse is 90/min, temperature is 38.7°C (102°F) and respiratory rate is 18/min. Physical examination reveals swelling in the joints of her hand and wrist. The right knee is red and swollen; active and passive range of motion at the right knee is limited due to pain. This patient's current condition can be best treated with which of the following?

248) A 68-year-old African-American woman presents to the ER in acute distress. She complains of a sudden onset of complete visual loss in her right eye. Her vision had been blurry for the past few days and acutely worsened one hour ago. She also describes right-sided headaches of two months duration for which she has taken ibuprofen without relief. She has no nausea or vomiting. She has diabetes, hypertension, and degenerative joint disease. Her temperature is 37.2°C (98.9°F) and blood pressure is 146/86 mmHg. Examination reveals complete loss of vision in the right eye. Her pupils are 4 mm bilaterally. Fundoscopy shows a swollen pale disc with blurred margins. A bruit is heard in the right subclavicular area. Motor and sensory examination is within normal limits. Which of the following is the most appropriate next step in management?

250) A 55-year-old man presents to his physician with 6 months of mild intermittent pain in both knees. The pain is aggravated by walking and weight bearing, and is partially relieved by rest. He also complains of morning stiffness that lasts for 10 minutes. He does not smoke but drinks alcohol occasionally. His BMI is 25 Kg/m2, temperature is 37°C (98.6°F), pulse is 75/min, and blood pressure is 130/80 mmHg. Examination reveals crepitus over both knee joints. Which of the following is the most appropriate initial treatment for this patient?

264) A 20-year-old woman has developed low-grade fever, a malar rash, and arthralgias of the hands over several months. High titers of anti-DNA antibodies are noted, and complement levels are low. The patient’s white blood cell count is 3000/μL, and platelet count is 90,000/μL. The patient is on no medications and has no signs of active infection. Which of the following statements is correct?