USMLE_Management III

A 22-year-old white obese female presents with headache for the last few weeks. Headache is worse at night and wakes her from sleep. Headache is pulsating in quality and is also associated with nausea and vomiting. She denies any weakness, sensory abnormalities or visual problems. She denies any history of trauma. She does not take any medication. Neurological examination is unremarkable. Fundoscopy shows papilledema. CT scan of head does not show any abnormality. Lumbar puncture is performed and CSF examination is normal except increased CSF pressure. Weight loss fails to control her symptoms. Which of the following is the most appropriate next step in the management of this patient?

A 22-year-old woman comes to the office for the evaluation of a breast mass which she discovered while taking a shower 2 months ago. She experiences severe pain in this mass during her menses. She looks very anxious because her 45-year-old friend was diagnosed with breast cancer last year, and who "now has all sorts of medicines that have made her lose her hair." She has no other problems. She has never been pregnant. She is an occasional smoker, and drinks 3-4 beers a week. There is no family history of breast cancer. Her vital signs are stable. Physical examination reveals a 4 x 5 x 6 cm firm, moveable, rubbery mass in her left breast. Ultrasound shows a cystic mass. Needle aspiration yields clear fluid, after which the mass disappears. What is the best approach in the management of this patient?

A 22-year-old woman comes to the physician because of a missed menstrual period. She has a complex past medical history. She has hypothyroidism, for which she takes thyroxine, she has an artificial heart valve, for which she takes Coumadin, and she recently started tetracycline for acne. She does not think that she is pregnant because she is currently on the oral contraceptive pill, but, if pregnant, she would keep the pregnancy. Physical examination, including pelvic examination, is unremarkable. Urine human chorionic gonadotropin (hCG) is positive. Which of the following medications should the patient continue to take during the pregnancy?

A 22-year-old woman comes to the physician for an annual examination. She has been sexually active since the age of 15 and has not had regular Pap smears or examinations. She is currently sexually active with multiple partners and intermittently uses condoms. She has no medical problems and takes no medications. Her examination is unremarkable. Her Pap smear is described as satisfactory but limited by the absence of endocervical cells. It is otherwise within normal limits. Which of the following is the most appropriate next step in management?

A 22-year-old woman comes to the physician seeking advice. Last night, while she was having sexual intercourse, the condom broke. She is very concerned that she may become pregnant and wants to know whether she can do anything at this point. She has no medical problems and has never had surgery. She takes ibuprofen for dysmenorrhea. She is allergic to sulfa drugs. On physical examination, she is anxious and intermittently sobbing. Her temperature is 37 C (98.6 F), blood pressure is 140/90 mm Hg, pulse is 98/min, and respirations are 24/min. The remainder of her physical examination is unremarkable. A urine pregnancy test is negative. Which of the following is the most appropriate pharmacotherapy?

A 22-year-old woman comes to the physician with her husband because of vaginal irritation and a malodorous vaginal discharge. Her symptoms started 4 days ago. She also notes pain with intercourse and dysuria. Pelvic examination reveals vaginal and cervical erythema and a copious greenish, frothy discharge. The pH of this discharge is 6.0. A wet preparation is done with normal saline, which shows numerous flagellated organisms that are slightly larger than the surrounding white blood cells. Which of the following is the most appropriate management?

A 22-year-old woman consults you for treatment of hirsutism. She is obese and has facial acne and hirsutism on her face and periareolar regions and a male escutcheon. Serum LH level is 35 mIU/mL and FSH is 9 mIU/mL. Androstenedione and testosterone levels are mildly elevated, but serum DHAS is normal. The patient does not wish to conceive at this time. Which of the following single agents is the most appropriate treatment of her condition?

A 22-year-old woman has a known family history of breast cancer in her first-degree relatives. She undergoes genetic testing and is found to be a BRCA1 mutation carrier. She does not currently desire bilateral prophylactic mastectomy. Which of the following is the next best option to manage her risk for breast cancer?

A 22-year-old woman has been seeing you for treatment of recurrent urinary tract infections over the past 6 months. She married 6 months ago and became sexually active at that time. She seems to become symptomatic shortly after having sexual intercourse. Which of the following is the most appropriate recommendation for this patient to help her with her problem?

A 22-year-old woman in labor progresses to 7 cm dilation, and then has no further progress. She therefore undergoes a primary cesarean section. Examination 2 days after the section shows a temperature of 39.1 C (102.4 F), blood pressure of 110/70 mm Hg, pulse of 90/min, and respirations of 14/min. Lungs are clear to auscultation bilaterally. Her abdomen is moderately tender. The incision is clean, dry, and intact, with no evidence of erythema. Pelvic examination demonstrates uterine tenderness. Which of the following is the most appropriate pharmacotherapy?

A 22-year-old woman is brought to the emergency department by her father because she is demonstrating "strange, disorganized behavior." Earlier that day, she had insisted that the television news anchorman was talking directly to her about the risks of "poison rays" from the moon. She was also apparently attempting to re-organize her bedroom closet when her father found her mumbling incoherently and counting the same pair of socks over and over. She is agitated when examined in the emergency department and the decision is made to admit her to the psychiatric ward. There, after a detailed interview, the diagnosis of schizophrenia is made. She is stabilized with antipsychotics and then discharged home. Her father asks what can be done to ease her return to everyday life and to decrease the likelihood of re-hospitalization. Which of the following measures would be most helpful in this regard?

A 22-year-old woman is seen in a surgery clinic for a bulge in the right groin. She denies pain and is able to make the bulge disappear by lying down and putting steady pressure on the bulge. She has never experienced nausea or vomiting. On examination she has a reducible hernia below the inguinal ligament. Which of the following is the most appropriate management of this patient?

A 22-year-old woman presents to the emergency department after she is bitten on her right arm by her neighbor's dog. She provoked the dog while it was eating. The dog is not immunized against rabies, but does not show any signs of rabies. Her right forearm shows a deep bite wound. Her last tetanus booster was 3 years ago. Her wound is cleaned with soap, water, and povidone-iodine solution. What is the most appropriate next step in the management of this patient?

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?

A 22-year-old woman who is 4 months pregnant presents after a motor vehicle collision complaining of abdominal pain and right leg pain. She has an obvious deformity of her right femur. She is hemodynamically stable. Which of the following is the best next step in her management?

A 22-year-old woman with cystic fibrosis is engaged to be married and asks you about childbearing. How should you advise her?

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 increase 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?

A 22-year-old woman, gravida 2, para 1, comes to the physician for her first prenatal visit She had a previous full-term, normal vaginal delivery 2 years ago. She has no medical problems and has never had surgery. She takes no medications and has no known drug allergies. Pelvic examination reveals a mucopurulent cervical discharge, no cervical motion tenderness, and an 8-week-sized, non-tender uterus. A cervical swab is performed. Two days later, the laboratory calls to notify the physician that the patient is positive for Chlamydia trachomatis. Which of the following is the most appropriate pharmacotherapy?

A 22-year-old woman, gravida 3, para 2, at 22 weeks' gestation comes to the physician because of an ulcer near her vagina. She noted this a few days ago and it has not improved. The ulcer is painless. The patient has no history of medical problems and takes no medications. She is allergic to penicillin. Examination is significant for a 22 week-sized uterus and a 1 cm, raised, nontender lesion on the distal portion of the vagina. A rapid plasma reagin (RPR) test is sent; the result is positive. A microhemagglutination assay for Treponema pallidum (MHA-TP) is also read as positive. Which of the following is the most appropriate management for this patient?

A 23-year-old female comes to your office to review her daily prescription medications. She had a positive pregnancy test three days ago despite strict contraception. Her last menstrual period was 5 weeks ago. She is on albuterol and beclomethasone inhalers for bronchial asthma, isotretinoin for acne, and lithium for bipolar disorder. Her bipolar disorder has been stable for the past several years. She does not use tobacco, alcohol, or drugs. Physical examination shows no abnormalities; vital signs are stable. Which of the following is the most appropriate advice for this patient?

A 23-year-old G1 at 38 weeks gestation presents in active labor at 6 cm dilated with ruptured membranes. On cervical examination the fetal nose, eyes, and lips can be palpated. The fetal heart rate tracing is 140 beats per minute with accelerations and no decelerations. The patient’s pelvis is adequate. Which of the following is the most appropriate management for this patient?

A 23-year-old G1P0 reports to your office for a routine OB visit at 28 weeks gestational age. Labs drawn at her prenatal visit 2 weeks ago reveal a 1-hour glucose test of 128, hemoglobin of 10.8, and a platelet count of 80,000. All her other labs were within normal limits. During the present visit, the patient has a blood pressure of 120/70 mm Hg. Her urine dip is negative for protein, glucose, and blood. The patient denies any complaints. The only medication she is currently taking is a prenatal vitamin. She does report a history of epistaxis on occasion, but no other bleeding. Which of the following medical treatments should you recommend to treat the thrombocytopenia?

A 23-year-old G2P2 requires a cesarean delivery for arrest of active phase. During labor she develops chorioamnionitis and is started on ampicillin and gentamicin. The antibiotics are continued after the cesarean delivery. On postoperative day 3, the patient remains febrile and symptomatic with uterine fundal tenderness. No masses are appreciated by pelvic examination. She is successfully breast-feeding and her breast examination is normal. Which antibiotic should be initiated to provide better coverage?

A 23-year-old G3P2002 presents for a routine obstetric (OB) visit at 34 weeks. She reports a history of genital herpes for 5 years. She reports that she has had only two outbreaks during the pregnancy, but is very concerned about the possibility of transmitting this infection to her baby. Which of the following statements is accurate regarding how this patient should be counseled?

A 23-year-old G3POA2 female presents to your clinic at an estimated 12 weeks of gestational age. She is a new patient and has come to your clinic to seek an elective abortion. She has had two elective abortions in the past because of unplanned pregnancy. She has no past medical history and takes no medications. Her physical examination is within normal limits and a limited ultrasound examination was able to detect fetal heart tones. You and your partners have a strict policy against performing abortions because some members of the group object to the procedure. You decide it would be best to stick to this policy; however, the patient becomes angry and tells you that she will sue you if you do not perform the procedure. What is the best response to this patient?

A 23-year-old gravida 3, para 2 is admitted to the hospital at 31 weeks' gestation with painful uterine contractions. Her cervix is initially 3 cm dilated. Magnesium sulfate is started. Over the next 5 hours she progresses to full dilation. After a 1-hour second stage, she delivers a 2013-g (4-lb, 7-oz) newborn. In the neonatal intensive care unit, the infant develops respiratory distress and pneumonia. Over the following days the infant develops septicemia. Preliminary blood cultures demonstrate gram-positive cocci in chains. Treatment with which of the following would most likely have prevented this neonatal outcome?

A 23-year-old male hospitalized for confusion and seizures is treated with intravenous high-dose acyclovir. On the third day of hospitalization, his serum creatinine level increases to 3.4 mg/dl from a baseline of 0.9 mg/dl at admission. The observed finding could have been potentially prevented by which of the following?

A 23-year-old male is brought to the emergency department from the scene of a motor vehicle accident. He appears distressed and complains of severe abdominal pain and distention. Urgent laparotomy reveals splenic laceration, and splenectomy is performed. There are no post-operative complications. The patient has no significant past medical history. He drinks alcohol occasionally but denies smoking cigarettes or using illicit drugs. He works as a computer programmer in a small office. Which of the following vaccines is recommended in this patient?

A 23-year-old man comes to the emergency department (ED) at 2:00 am due to severe pain all over his body for the past few hours. He was diagnosed with sickle cell anemia at 6 months of age, and has had previous episodes of unbearable pain in his chest, abdomen, thighs and lower back. He was hospitalized six times in the past twelve months. He does not have regular follow-up visits up with his physician, and comes to see him "only if required." His blood pressure is 110/80 mmHg, pulse is 80/min, respirations are 16/min and temperature is 37 C (98F). Adequate hydration and analgesics are administered in the ED. What is the best intervention to prevent his painful episodes?

A 23-year-old man is admitted to the hospital after being struck by a motor vehicle. The patient sustained a compound fracture of his left femur in the accident and has had moderate blood loss. He was admitted to the hospital, has been stabilized over the past few days, and is now preparing for physical therapy. His hematocrit is 24%. The man feels weak and fatigued and easily gets short of breath with mild exertion. Which of the following is the most appropriate next step in management?

A 23-year-old man is brought to the emergency department after being hit in the neck with a dull instrument. He has neck pain and stiffness. Vital signs are stable. Neurological examination shows no abnormalities. An astute medicine resident decides to order an angiogram of the neck vessels to rule out carotid artery injury. Diagnostic angiography shows an intimal flap in the left internal carotid artery just above the carotid bifurcation. Which of the following is the most appropriate next step in management?

A 23-year-old man is brought to the emergency department in an obtunded state following a gun-shot wound to the right upper quadrant of the abdomen. His systolic blood pressure is 60 mm Hg and unable to obtain diastolic blood pressure. His pulse is 136/min. Chest auscultation shows clear heart and breath sounds. The abdomen appears distended, and there is an obvious gun-shot wound on the right upper quadrant. The bowel sounds are decreased. Which of the following is the most appropriate next step in management?

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?

A 23-year-old man presents to the emergency department with a soft-tissue injury to the left lower extremity. The injury was sustained 8 hours earlier in a motorcycle accident on a gravel road. On examination, the patient has a 7-cm deep laceration to the calf, with visible road debris. He had full tetanus immunization as a child and a tetanus booster immunization at age 15. Appropriate management of this injury would include which of the following?

A 23-year-old married woman consults you because she and her husband have never consummated their marriage because she has severe pain with attempts at vaginal penetration. Her pelvic examination is normal except for involuntary tightening of her vaginal muscles when you attempt to insert a speculum. Which of the following conditions would best be treated with the use of vaginal dilators?

A 23-year-old primigravid female at 38 weeks' gestation was admitted to the delivery room for management of labor. She was in active labor for 4-hours during which her cervical dilation progressed from 3cm to 8cm, and descent progressed from - 1 to +1 station. Examination 6-hours later showed the same degree of dilation and descent. The fetal head is in the Left Occipita Anterior (LOA) position. An external tocometer is placed and reveals contractions 3 min apart, lasting 50 seconds each. Internal pelvic assessment shows prominent ischial spines. FetaI heart monitoring shows a baseline of 140 bpm with frequent accelerations. Prenatal ultrasound at 37-weeks showed a fetus of average size. Which of the following is the most appropriate next step in management?

A 23-year-old primigravid woman at 38 weeks gestation is admitted to the delivery room for management of labor. She has been in active labor for 4 hours, during which her cervical dilation has progressed from 3 cm to 8 cm and descent has progressed from the -1 to +1 station. Examination 6 hours later shows the same degree of dilation and descent. The fetal head is in the left occipitoanterior (LOA) position. An external tocometer reveals adequate contractions 3 minutes apart lasting 50 seconds each. Internal pelvic assessment reveals prominent ischial spines. Fetal heart monitoring shows a baseline of 140/min with frequent accelerations. Prenatal ultrasound at 37 weeks showed a fetus of average size. Which of the following is the most appropriate next step in management?

A 23-year-old primigravid woman at 9 weeks gestation presents to the emergency room because of generalized weakness and lightheadedness. For the past 4 weeks she has not been able to keep anything down and over the past week her nausea and vomiting have worsened. She has no fever, abdominal pain, diarrhea, headache, dysuria, polyuria, tremor, or heat intolerance. She does not use tobacco, alcohol or illicit drugs. Her temperature is 37.2 C (98.9 F); orthostatic vitals are as follows: BP 136/86 mm Hg and pulse 98/min supine, and 110/70 mm Hg and 115/min standing. Physical examination shows dry mucus membranes. The remainder of the examination is unremarkable. Laboratory studies show: Hematocrit: 50%, Platelets: 200,000/mm3, Serum sodium: 130 mEq/L, Serum potassium: 2.8 mEq/L, Chloride: 86 mEq/L, Bicarbonate: 30 mEq/L, Blood urea nitrogen (BUN): 30mEq/L, Serum creatinine: 1.6 mg/dl, Blood glucose: 98 mg/dl. Which of the following is the most appropriate next step in management?

A 23-year-old primigravid woman comes to your office for her first prenatal visit. She is working as an aerobics instructor and is concerned about the effect her exercise schedule might have on the pregnancy. She teaches 30 minutes daily in the morning and does not feel fatigued. She does not use tobacco, alcohol or drugs. Vital signs are normal and physical examination is unremarkable. Which of the following is the best advice to give this patient?

A 23-year-old white female presents with an acute onset of headache for the last eight hours. Her headache is severe, unilateral, pulsating in quality, associated with photophobia, worsens with physical activity, and does not respond to acetaminophen or ibuprofen. This is her 6th episode of similar headache over the last 2 months, and it is her first time to seek medical attention. Her neurological examination is unremarkable. Which of the following is the most appropriate next step in the management of this patient?

A 23-year-old woman comes to the physician because she thinks that she may be pregnant. She missed her last two periods and feels "different." A urine pregnancy test is positive and an ultrasound reveals a 12-week fetus. The patient is very concerned because she received the measles-mumps-rubella (MMR) vaccine four months ago and was told to wait 3 months before attempting conception. The pregnancy is desired. The patient asks if she should have a termination of pregnancy because she was vaccinated shortly before becoming pregnant. Which of the following is the most appropriate response?

A 23-year-old woman develops painful vulvar vesicles that contain intranuclear inclusions on cytologic examination. She is 22 weeks’ pregnant. Which of the following statements about genital herpes is correct?

A 23-year-old woman is brought to the emergency department because of severe respiratory distress. She was stung by a bee one hour ago. Her temperature is 37.1C (98.8F), blood pressure is 80/50 mm Hg, pulse is 98/min and respirations are 20/min. Examination shows a conscious woman in severe respiratory distress with audible wheezing. Her skin is warm to palpation. Which of the following is the most appropriate next step in management?

A 23-year-old woman presents for evaluation of a 7-month history of amenorrhea. Examination discloses bilateral galactorrhea and normal breast and pelvic examinations. Pregnancy test is negative. Which of the following classes of medication is a possible cause of her condition?

A 23-year-old woman presents for evaluation of infertility. For the past 12 months she has been having sexual intercourse without contraception but has not been able to conceive. Her history is significant for irregular periods for the past 2 years. She reports exercising intensely six days per week and acknowledges having a lot of stress at work. She smokes one pack of cigarettes daily. On physical examination, her vital signs are within normal limits. Her BMI is 18 kg/m2. Urine pregnancy test is negative. Laboratory studies show: Serum FSH: low, Serum LH: low, Serum prolactin: normal, Serum TSH: normal. Which of the following therapies would be most helpful for this patient's infertility?

A 23-year-old woman seeks help for exquisite pain with defecation and blood streaks on the outside of her stools, which she has been having for several weeks. Because of the pain, she has avoided having bowel movements, and when she finally did the stools were hard and even more painful. When seen, she has no fever or leukocytosis. Physical examination has to be done under spinal anesthesia, because the patient was so afraid of the pain that she initially refused even inspection of the area. The examination confirms the suspected diagnosis, and she is placed on stool softeners and appropriate topical agents, but without success. She is willing to undergo more aggressive treatment. Which of the following is the most appropriate next step?

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?

A 23-year-old woman was diagnosed with schizophrenia after a single episode of psychosis (hallucinations and delusions) that lasted 7 months. She was started on a small dose of olanzapine at the time of diagnosis, which resulted in the disappearance of all her psychotic symptoms. She has now been symptom free for the past 3 years. Which of the following treatment changes should be made first?

A 23-year-old woman who is 10 weeks pregnant with her first pregnancy is referred to you for smoking cessation. She has been smoking since the age of 21 and has never tried to quit. However, now that she is pregnant she would really like to quit. She has no symptoms of depression. Her past medical history is significant for asthma. She uses an inhaler occasionally for her asthma and takes no other medications. She has never had surgery and has no known drug allergies. Physical examination is normal for a patient at 10 weeks’ gestation. Which of the following is the most appropriate management for this patient?

A 23-year-old woman with an 18-year history of insulin-dependent diabetes is brought to the emergency department by her date, who became alarmed by her acute mental confusion and sudden-onset bizarre behavior. He explains that they spent the day at the beach, where she had been very active, playing volley ball and swimming, and that they missed lunch but were on their way to eat dinner when this sudden change in behavior occurred. He states over and over again that they had not been using drugs or drinking alcohol. The triage nurse notes perspiration, increased salivation, restlessness, and tachycardia. Which of the following is the most appropriate next step in the management of this patient?

A 23-year-old woman, gravida 2, para 1 at 26 weeks' gestation, comes to the physician because of fevers and pain in the middle of the back on the right side. Her fevers started 2 days ago, and the back pain began yesterday. Her temperature is 38.3 C (101 F), blood pressure is 110/70 mm Hg, pulse is 110/min, and respirations are 16/min. She has left costovertebral angle tenderness. Her abdomen is benign and gravid. Her laboratory values show leukocytes of 18,000/mm3. Urinalysis reveals white blood cells that are too numerous to count per high powered field. Which of the following is the most appropriate pharmacotherapy for this patient?

A 23-year-old woman, gravida 2, para 1, at 6 weeks' gestation comes to the emergency department because of lower abdominal pain and fevers. She states that her symptoms began 2 days ago and have steadily worsened since. Past medical history is significant for 2 episodes of gonorrhea and 1 episode of chlamydia. Temperature is 38.9 C (102.1 F), blood pressure is 110/76 mm Hg, pulse is 102/min, and respirations are 12/minute. Abdominal examination demonstrates significant lower abdominal tenderness. Pelvic examination shows a mucopurulent cervical discharge and bimanual examination reveals cervical motion tenderness and adnexal tenderness. Complete blood count shows leukocytes 18,000/mm3. Pelvic ultrasound shows a 6-week intrauterine gestation with no adnexal findings. Which of the following is the most appropriate management?

A 23-year-old, gravida 2, para 1 woman at 30 weeks gestation comes to the ER after she noticed a sudden gush of clear fluid coming from her vagina. She has had no uterine contractions or vaginal bleeding. Her pregnancy has been uncomplicated; she has had consistent prenatal care. Vital signs are normal. Sterile speculum examination shows the cervix is minimally effaced and 2cm dilated; there is pooling of clear fluid in the vaginal fornix, and when pressure is applied to the fundus, clear fluid comes out of the cervix. Emergency ultrasound shows a fetus of average size in the vertex presentation and an Amniotic Fluid Index (AFI) of 15. Nonstress test shows a baseline of 120 bpm and frequent accelerations. Amniotic fluid analysis shows lecithin/sphingomyelin ratio of 1.0. Which of the following is the most appropriate next step in management?

A 23-year-old, previously healthy man presents to the ER after sustaining a single gunshot wound to the left chest. The entrance wound is 3 cm inferior to the nipple and the exit wound is just below the scapula. A chest tube is placed that drains 400 mL of blood and continues to drain 50 to 75 mL/h during the initial resuscitation. Initial blood pressure of 70/0 mm Hg has responded to 2L crystalloid and is now 100/70 mm Hg. Abdominal examination is unremarkable. Chest x-ray reveals a reexpanded lung and no free air under the diaphragm. Which of the following is the best next step in his management?

A 24-year old woman comes to the physician because of burning with urination. She states that every time she urinates there is pain and that she has a feeling that she constantly needs to urinate even though only a little comes out. She has never had any similar symptoms before. She has no medical problems and no known drug allergies. Examination is unremarkable. Urinalysis demonstrates that the urine is positive for leukocyte esterase and nitrites. Which of the following is the most appropriate pharmacotherapy?

A 24-year-old African American female presents in the 35th week of an uncomplicated pregnancy with numbness and burning in her right palm. She says the sensation is so uncomfortable that it frequently makes it difficult to sleep Which of the following is the best initial treatment for this patient?

A 24-year-old female presents to you for the evaluation of acne. Further questioning, reveals that she also has had irregular periods for a long time. She is single and not sexually active. On examination, her BMI is 31 Kg/m2 and she has evidence of hirsutism. Further evaluation reveals increase in serum free testosterone and LH/FSH ratio of 2.4. Glucose tolerance testing reveals two-hour blood glucose of 155 mg/dl. Apart from prescribing oral contraceptive pills, which of the following is indicated in this patient?

A 24-year-old female veterinary assistant is referred to a psychiatrist for the presumptive diagnosis of dysthymia. She reports having a three-year history of low energy levels and gradual worsening in her ability to focus on her work. She feels "sad, hopeless," and experiences little pleasure. She denies any suicidal thoughts. She has never been on any psychotropic medications before, and denies any family history of psychiatric illness. She has gastroesophageal reflux disease, for which she takes omeprazole. She has no known allergies, and does not drink alcohol or smoke cigarettes. The psychiatrist decides to treat her dysthymia with bupropion. Which of the following is a contraindication to the use of bupropion?

A 24-year-old G1P0 woman at 31 weeks’ gestation presents to the emergency department with a 4-hour history of abdominal cramping and contractions. The contractions have been regularly spaced at 10 minutes, but seem to be increasing in intensity. She has had a small amount of vaginal discharge, but is unable to definitively say whether her water has broken. She has not had any vaginal bleeding. Her temperature is 36.8C (98.3F), blood pressure is 137/84 mm Hg, pulse is 87/min, and respiratory rate is 12/min. Physical examination reveals a non-tender abdomen with palpable contractions every 8 minutes. Which of the following is the best next step in management?

A 24-year-old G1P1 presents for her routine postpartum visit 6 weeks after an uncomplicated vaginal delivery. She states that she is having problems sleeping and is feeling depressed over the past 2 to 3 weeks. She reveals that she cries on most days and feels anxious about taking care of her newborn son. She denies any weight loss or gain, but states she doesn’t feel like eating or doing any of her normal activities. She denies suicidal or homicidal ideation. Which of the following is true regarding this patient’s condition?

A 24-year-old Jehovah’s Witness who was in a high-speed motorcycle collision undergoes emergent splenectomy. His estimated blood loss was 1500 mL. Which of the following strategy should be employed for his resuscitation?

A 24-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He complains of severe back pain and abdominal discomfort. He was placed on a board in the field for spinal immobilization. His blood pressure is 111/78 mm Hg, pulse is 55/min and regular, and respirations are 16/min. Pulse oximetry shows 96% on room air. He is alert and fully oriented. There are several lacerations on the face and anterior chest. Air entry is bilaterally symmetric. There is weakness and decreased pain sensation in both legs. Proprioceptive sensation is preserved. Chest x-ray and CT scans of the abdomen and spine are performed. Which of the following is the most appropriate next step in managing this patient?

A 24-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He has severe low back pain. Examination shows weakness and decreased pain and temperature sensation in both legs. Fine touch, vibration, pressure and proprioceptive sensations are intact. He is immobilized and his airway, breathing and circulation are restored. Which of the following is the most appropriate next step in management of his spinal injury?

A 24-year-old man is found to be HIV positive. He is asymptomatic. Physical examination is unremarkable. Laboratory tests show: CD4 count 400/micro-L, HIV viral load 9,000 copies/mL, VDRL negative, Toxoplasma serology negative, PPD test 6mm induration. His chest x-ray is unremarkable. What is the most appropriate next step in the management of this patient?

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?

A 24-year-old patient comes to the doctor because she has concerns regarding her sexuality. She states that for as long as she can remember she has been sexually attracted to other women. She was raised in a family where homosexuality is considered "unacceptable," so she has never discussed these feelings before. Now, however, she feels that she can no longer hide her feelings, but she is concerned that she will cause deep and irreparable harm to her relationship with her parents if she tells them. Which of the following is the most appropriate next step in the management of this patient?

A 24-year-old primigravid woman at 10 weeks gestation is brought to the emergency department because of vaginal bleeding. She has colicky pain in the suprapubic region radiating to her back. Her temperature is 37.0C (98.7F), blood pressure is 110/76 mm Hg, pulse is 84/min, and respirations are 14/min. Physical examination shows a dilated cervix and the products of conception are seen through it. Blood is sent to the laboratory for type and antibody screen. The patient is treated with dilation and curettage and all products of conception are evacuated. She is stabilized and transferred to the ward. Her laboratory results are as follows: Hematocrit: 32%; Leukocyte count: 8,000 cells/μL; Blood type: AB; Rh-negative; Anti-Rh antibody titer: 1:4. Which of the following is the most appropriate next step in management?

A 24-year-old primigravid woman at 10 weeks gestation is brought to the emergency department because of vaginal bleeding. She has colicky pain in the suprapubic region radiating to the back. Her temperature is 37.0 C (98.7F), blood pressure is 110/76 mmHg, pulse is 84/min and respirations are 14/min. Physical examination shows a dilated cervix and products of conception are seen through it. Blood for grouping and typing is sent. The patient is treated appropriately, and all products of conception are evacuated. She is stabilized and transferred to the ward. Laboratory studies there show: Hematocrit: 33%; WBC: 6,000/mm3; Blood type: AB; Rh negative; Antibody titer: 1:4. Which of the following is the most appropriate next step in management?

A 24-year-old primigravid woman at 28 weeks gestation comes to the physician because she has not felt her baby's movements for the past two weeks. Fetal heart tones are not heard by Doppler. Ultrasound shows absence of fetal cardiac activity. Fetal demise is diagnosed. Laboratory studies show: Serum fibrinogen level: 160 mg/dl (normal is 150 - 450 mg/dL), Platelets: 150, 000/mm3, Prothrombin time: 14 sec, Partial thromboplastin time: 28 sec, First trimester platelets were: 250,000/mm3. There are no signs of active bleeding. Which of the following is the most appropriate next step in management?

A 24-year-old primigravid woman at 35 weeks gestation comes to the emergency department with uterine contractions. She started these contractions six hours earlier, and they have not increased in intensity since then. The contractions started in the lower abdomen and are irregular. Her pregnancy has been uncomplicated. Her prenatal course, prenatal tests and fetal growth have been normal. She has no history of trauma. She does not use tobacco, alcohol or drugs. Vital signs are normal. Examination shows a firm, posterior and closed cervix. Ultrasonogram in the emergency department shows a gestational age of 35-weeks and the fetus in the vertex presentation. Fetal heart tones are heard. She feels better after mild sedation. Which of the following is the most appropriate next step in management?

A 24-year-old primigravid woman comes for her initial prenatal visit at 24 weeks' gestation. Her only complaint is low back pain. She has no significant past medical history, and she has had no complications of pregnancy thus far. She does not use tobacco, alcohol, or drugs. Her vital signs are within normal limits. Complete physical examination shows no abnormalities. During the interview she requests screening for diabetes because her friend was diagnosed with gestational diabetes at 26-weeks of gestation. Which of the following is the most appropriate screening procedure for this patient?

A 24-year-old primigravid woman comes to the physician because of recent onset amenorrhea. Her last menstrual period was 7 weeks ago, and she has had nausea for the past 2 weeks. A urine pregnancy test is positive. She is being evaluated for dysphagia, and one-week ago she had a barium swallow examination. She is concerned for the baby because of her recent exposure to radiation. Which of the following is the most appropriate next step in management?

A 24-year-old woman asks her physician about the possibility of genetic screening for BRCA1 mutations. Her mother died of breast carcinoma at age 44, and a sister had a diagnosis of in situ ductal carcinoma at age 38. Which of the following is the most appropriate advice to give this woman?

A 24-year-old woman comes to the physician's office because of breast pain. She has a 2-month-old baby who she breastfeeds. Her temperature is 38.5C (101.9F). Examination shows a hard, red, tender and swollen area on her right breast. There is no fluctuance noted. Which of the following is the most appropriate next step in management?

A 24-year-old woman comes to the physician's office because of breast pain. She has a 2-month-old baby who she breastfeeds. Her temperature is 38.8°C (101.9°F). Examination shows a hard, red, tender and swollen area on her right breast. There is no fluctuance noted. Which of the following is the most appropriate next step in management?

A 24-year-old woman comes to your office with vaginal spotting 2 weeks after a missed menstrual period. Her past medical history is significant for pelvic inflammatory disease. She has never had surgery. She takes no medications and is allergic to penicillin. Examination demonstrates scant blood in the vaginal vault and minimal right adnexal tenderness. Laboratory evaluation reveals a beta-hCG value of 1600 mIU/mL. Blood type is O positive. Hematocrit is 39%. Pelvic ultrasound demonstrates nothing in the uterus and a right adnexal mass consistent with ectopic pregnancy. The decision is made to proceed with intramuscular methotrexate for medical treatment of the ectopic pregnancy. Which of the following is the most likely side effect from this treatment?

A 24-year-old woman has fever, right upper quadrant pain, and lower abdominal pain. She reports having multiple sexual partners and does not use condoms. She has no medical history, does not take any medications, and has no drug allergies. Her temperature is 38.9 C (102.0 F). Her lungs are clear to auscultation. Abdomen examination is notable for right upper quadrant tenderness. Pelvic examination reveals mucopurulent drainage and tenderness with cervical motion. She also has adnexal tenderness. Her leukocyte count is 14,000/mm3. Liver function tests are normal. Abdominal imaging is normal. Urine pregnancy test is negative. Which of the following is the appropriate management?

A 24-year-old woman is admitted to the hospital for a broken femur. The patient was in a motor vehicle accident 20 hours ago and was brought to the hospital by EMS. On the scene, she was found belted in her car in the driver’s seat, and her only documented injury was the leg fracture. She had no loss of consciousness or altered mental status. On arrival to the hospital, radiographs confirmed a fracture of her femur. She was stabilized overnight and scheduled for surgery the next day. Which of the following is the major surgical risk for this patient?

A 24-year-old woman is brought to the emergency department after being stabbed by her boyfriend. The examining physician notes a 1.5 cm puncture wound lateral to her sternum. She has a blood pressure of 70/min palpable, distended neck veins, and muffled heart sounds. Which of the following is the most appropriate next step in management?

A 24-year-old woman lost her previous two pregnancies at approximately 20 weeks’ gestation, without having noted any contractions. She is currently at 15 weeks’ gestation and denies having uterine contractions. Her cervix is undilated and uneffaced. Which of the following is the most appropriate management of this patient?

A 24-year-old woman presents for her first prenatal visit at 12 weeks gestation. She was diagnosed with HIV two years ago, and her most recent CD4 count three months ago was 600cells/mm3. She does not use tobacco, alcohol, or illicit drugs. Physical examination is within normal limits. Which of the following is the single most important intervention for reducing maternal-fetal transmission of HIV infection?

. Elective cesarean section at 38 weeks gestation . Use of forceps to expedite delivery . Administering HIV immunoglobulin and vaccine to the neonate . Zidovudine treatment of the mother during pregnancy and of the neonate after birth . Reassurance

A 24-year-old woman presents to your office with a self-palpated breast lump. She discovered the mass 2 days ago while taking a shower and noted that it is mildly tender. Her menstrual periods are regular, occurring every 26 days. Her last menstrual period (LMP) was 3 weeks ago. Her past medical history is insignificant. She has no family history of breast cancer. Physical examination reveals a lump in the superior outer quadrant of the right breast without palpable lymphadenopathy. Which of the following is the most reasonable next step in the management of this patient?

A 24-year-old woman presents with lethargy, anorexia, tachypnea, and weakness. Laboratory studies reveal a BUN of 150 mg/dL, serum creatinine of 16 mg/dL, and potassium of 6.2 mEq/L. Chest x-ray shows increased pulmonary vascularity and a dilated heart. Which of the following is the most appropriate management of this patient?

A 24-year-old woman with chronic hypothyroidism presents to her gynecologist for her annual examination. She recently got married, and she and her husband would like to conceive. Her hypothyroidism is well controlled and stable on thyroxine, and she has no other medical conditions. She is healthy and does not smoke or drink alcohol. She would like to know if she should keep taking her thyroxine. Which of the following is the best advice to give this patient?

A 24-year-old woman, gravida 2, para 1, at 16 weeks' gestation comes to you for a routine prenatal visit. She has had mild constipation. She has had no nausea, vomiting, fever, burning urination, back pain, or other complaints. She has no history of urinary tract infections. She takes iron and folic acid supplements. She does not use tobacco, alcohol, or drugs. She is afebrile; her blood pressure is 124/74 mm Hg and pulse is 78/min. Examination shows a uterus consistent in size with a 16-week gestation. Physical examination shows no abnormalities. Urinalysis is within normal limits. A routine clean-catch urine culture grows greater than 100,000 colonies/ml of Escherichia coli. Which of the following is the most appropriate next step in management?

A 24-year-old woman, gravida 2, para 1, at 26 weeks' gestation comes to the physician complaining of aching and swelling in both legs. The aching of her legs is worst at night. She has no shortness of breath or chest pain. She has no past medical history. Her temperature is 36.9 C (98.2F), blood pressure is 110/70 mm Hg, and pulse is 78/min. Physical examination shows symmetrical pitting edema of both calves with no tenderness of either calf. Urinalysis shows no abnormalities. Which of the following is the most appropriate next step in management?

A 24-year-old woman, gravida 2, para 1, at 34 weeks' gestation comes for a routine prenatal visit. Her dates were confirmed by first trimester ultrasonogram. She has no painful uterine contractions. Her previous pregnancy was uncomplicated and ended with a normal vaginal delivery. Her vitals are stable and fetal heart tones are reassuring. Physical examination shows a closed cervix, vertex is palpable at the fundus, and the presenting part is not engaged. Which of the following is the appropriate next step in management?

A 24-year-old woman, gravida 2, para 2, comes to the physician for a yearly physical and birth control counseling. She is currently using the rhythm method of birth control, but has heard that this method has a high failure rate and would like to try a different method. Several of her friends use the intrauterine device (IUD), and she is wondering whether she could also use this method. Past medical history is significant for eczema. Past surgical history is significant for a right ovarian cystectomy 2 years ago. Past gynecologic history is significant for multiple episodes of Chlamydia cervicitis and two episodes of pelvic inflammatory disease (PID), the most recent episode occurring 1 year ago. She takes acetaminophen for occasional tension headaches. She is allergic to penicillin. She smokes onehalf pack of cigarettes per day. Physical examination is unremarkable. Which of the following would be the best recommendation for this patient regarding her birth control method?

A 24-year-old woman, gravida 3, para 2, comes to the physician for her first prenatal visit. Her last menstrual period was 8 weeks ago, and a home pregnancy test was positive. She states that this pregnancy, like her last two pregnancies, was unintended. She had been using condoms for birth control in all three instances. She had normal vaginal deliveries 2 and 4 years ago. Which of the following is the most likely reason for condom failure?

A 24-year-old woman, gravida 4, para 1, abortus 2, is at 28 weeks’ gestation by poor dates. She admits to intravenous (IV) drug use and having sex for drugs. She is unsure who the father of this pregnancy is. She has recently undergone treatment for syphilis identified by a positive venereal disease research laboratory (VDRL) test result and confirmed by a positive fluorescent treponemal antibody (FTA) test. On her last prenatal visit, she underwent human immunodeficiency virus (HIV) testing by enzyme-linked immunosorbent assay (ELISA), which was found to be positive and was confirmed with a positive Western blot assay. She inquires as to the significance of this finding for herself, as well as her baby. Which of the following statements best summarizes what you will say about her medical conditions?

A 24-year-old, gravida 0, para 0 woman comes to the physician because of an 8-week history of amenorrhea. She is sexually active and uses oral contraceptive pills for contraception. Her only other complaints are moderate fatigue and a decline in mood. She denies headaches, visual disturbances, and gastrointestinal symptoms. She has no other medical problems. She socially drinks alcohol and does not use tobacco or illicit drugs. She denies stress at home or work. She walks 1-2 miles every day. Her BMI is 24 kg/m2. Visual field test is within normal limits. Examination shows no hirsutism. Breast examination reveals a white, milky secretion upon expression of both nipples. Pelvic examination reveals a uterus of normal size. Initial investigations reveal a negative serum β-human chorionic gonadotropin (hCG) level. According to these findings, which of the following is the most appropriate next step in management?

A 25-year-old Caucasian woman, gravida 1, para 0, at 26 weeks' gestational age presents to her physician's office complaining of spotting from the vagina. She has no contractions and reports normal fetal movement. She denies any history of a bleeding disorder. Her temperature is 37.3 C (99.1 F), blood pressure is 100/60 mm Hg, pulse is 75/min, and respirations are 14/min. Her abdomen is gravid and benign, with a fundal height of 26 cm. A placenta previa is ruled out by ultrasound examination. Pelvic examination reveals some scant blood in the vagina, a closed os, and no uterine tenderness. Leukocyte count is 12,000/mm3, hematocrit is 33%, and platelet count is 140,000/mm3. Her blood type is A, Rh negative. Which of the following is the most appropriate pharmacotherapy?

A 25-year-old female comes to the physician because of abdominal bloating, headache, fatigue, weight gain, anxiety, and decreased libido. She experiences these symptoms seven to ten days before the start of each menstrual cycle. She has a past history of postpartum depression, but she denies any recent feelings of hopelessness or guilt. Physical examination shows no abnormalities. Complete blood count, serum chemistries and thyroid stimulating hormone levels are within normal limits. Which of the following is the most appropriate next step in management?

A 25-year-old G2 P1 woman at 12 weeks gestation comes to the physician because of foul smelling vaginal discharge. She is sexually active and reports no previous problems. Speculum examination reveals a grayish, foul smelling discharge, but no erythema or edema is noted on the vaginal walls or the vulva. There is no cervical or adnexal tenderness. A saline wet mount examination reveals numerous epithelial cells coated with bacteria. No white blood cells are seen. Which of the following is the most appropriate pharmacotherapy for this patient?

A 25-year-old G2P0 at 30 weeks gestation presents with the complaint of a new rash and itching on her abdomen over the last few weeks. She denies any constitutional symptoms or any new lotions, soaps, or detergents. On examination she is afebrile with a small, papular rash on her trunk and forearms. Excoriations from scratching are also noted. Which of the following is the recommended first-line treatment for this patient?

A 25-year-old G2P1 woman who is 36 weeks pregnant presents to her obstetrician complaining of restlessness and weakness for the past month. She says her boyfriend recently left her and their 2-year-old son, and she feels overwhelmed with this pregnancy. She denies feeling depressed but does report that she has trouble sleeping. She had an upper respiratory infection last month, “caught from my son,” and states she still has a sore throat. Laboratory tests show: WBC count: 8000/mm3; Hemoglobin: 11.0 g/dL; Hematocrit: 40%, Platelet count: 250,000/mm3; Thyroid-stimulating hormone: 0.5μU/mL; Free thyroxine: 4.0 ng/dL. Which of the following is the best next step in management?

A 25-year-old G3P2 at 39 weeks is admitted in labor at 5 cm dilated. The fetal heart rate tracing is reactive. Two hours later, she is reexamined and her cervix is unchanged at 5 cm dilated. An IUPC is placed and the patient is noted to have 280 Montevideo units (MUV) by the IUPC. After an additional 2 hours of labor, the patient is noted to still be 5 cm dilated. The fetal heart rate tracing remains reactive. Which of the following is the best next step in the management of this labor?

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