USMLE_Management IX

A 44-year-old man is brought to the emergency department after a motor vehicle accident. His cervical spine is immobilized and 2 large-bore intravenous lines are placed. His breath smells of alcohol. The patient is lethargic but responds to commands appropriately. A 3-cm laceration is present on his forehead. Ecchymoses are seen on his back and over the abdominal wall in the distribution of the seat belt. The lungs are clear to auscultation. The trachea is midline and the neck veins are collapsed. Passive movement of the right hip is limited due to pain. At the scene of the accident, blood pressure was 90/60 mm Hg and pulse was 130/min. After receiving a 1 L bolus of intravenous fluids, the patient's blood pressure remains 90/60 mm Hg and his pulse is now 122/min. Portable chest x-ray shows no pneumothorax or pleural effusions. A bedside abdominal ultrasound is inconclusive for hemoperitoneum or intra-abdominal injury due to poor image quality. What is the most appropriate next step in management of this patient?

A 44-year-old obese male is brought to the ER after a motor vehicle accident. His cervical spine is immobilized. He is alert and able to speak in complete sentences. He complains of abdominal pain. At the scene of the accident, his blood pressure is 90/60 mm Hg and pulse is 120/min. Lungs are clearto auscultation. Ecchymosis is present over the abdominal wall in distribution of the seat belt. Bowel sounds are decreased. Neck veins are collapsed. After receiving one liter of intravenous fluids, his blood pressure remains at 90/60 mmHg. A focused assessment with sonography for trauma is inconclusive due to the poor image quality. Which of the following is the most appropriate next step in management of this patient?

A 44-year-old renal transplant patient develops severe cough and shortness of breath on exertion. On examination, he appears dyspneic, respirations 24/min, pulse 110/min, and oxygen saturation 88%. His lungs are clear on auscultation and heart sounds are normal. CXR shows bilateral diffuse perihilar infiltrates. Bronchoscopy and bronchial brushings show clusters of cysts that stain with methenamine silver. Which of the following is the most appropriate next step in management?

A 44-year-old white male comes to the office and says, "I have had this persistent, upper abdominal pain for the past 2 months. My wife has peptic ulcer, and I think I also have an ulcer down there, so I take some of her medicines. At first, the medicines made the pain go away, but soon after the pain proved to be too tough for the medicines. I hardly want to eat anything now. Do you think all this is due to some reaction to those medicines?" Physical examination reveals mild tenderness in the epigastric region. Esophagogastroduodenoscopy reveals a mass in the pylorus, which the biopsy identifies as an infiltrating, low-grade, gastric mucosa-associated lymphoid tissue (MALT) lymphoma. Further work-up concludes that there are no regional lymph nodes involved. What is the best next step in the management of this patient?

A 44-year-old woman has a 2-cm firm palpable mass in the upper outer quadrant of her right breast. The mass is freely movable, and her breast is of normal, rather generous size. There are no palpable axillary nodes. Mammogram shows no other lesions. A core biopsy establishes a diagnosis of infiltrating ductal carcinoma. She has no neurologic or skeletal symptoms, and a chest x-ray film and liver enzymes are normal. She understands that systemic therapy may eventually be needed once the full extent of her disease is known. Although she wants the best chance for cure, she is very concerned about cosmetic deformity and wants to know what can be done about the breast itself. Which of the following is the most appropriate management?

A 44-year-old woman is recovering from a mild episode of acute ascending cholangitis secondary to choledocholithiasis. When seen initially, she had a spiking fever, leukocytosis, and a very high alkaline phosphatase; however, all these findings subsided rapidly after she was placed on IV antibiotics. A sonogram of the right upper quadrant on the day of admission showed the presence of gallstones in the gallbladder, but the diameter of the biliary ducts was normal. It was assumed that she had passed a common duct stone, and plans to do an endoscopic retrograde cholangiopancreatogram (ERCP) were canceled. While awaiting elective cholecystectomy, she again developed a fever and leukocytosis, and her liver function tests showed minimal elevation of her bilirubin (to 2.5 mg/dL) and alkaline phosphatase (to 115 U/L). A repeat sonogram shows no changes in her biliary ducts, but now there is a 6-cm abscess in the right lobe of the liver. Which of the following is the most appropriate treatment for this new development?

A 44-year-old woman presents for a follow-up visit regarding her severe depression. She has taken numerous antidepressants over the years with little symptomatic relief, and continues to spend the majority of her time in seclusion, experiencing intense feelings of worthlessness and despair. Her husband is deeply concerned about the impact her depression has had on their marriage and their two teenage children. He requests information about "all available options" to improve his wife's symptoms. The prospect of electroconvulsive therapy (ECT) is discussed, and the husband inquires about potential drawbacks to the procedure. Which of the following is a common side effect of electroconvulsive therapy?

A 45-year-old African-American woman who was diagnosed with PCOS in her early twenties presents to her gynecologist for her annual visit. One of her close friends has recently been diagnosed with ovarian cancer, so she is concerned about her own cancer risk. Menarche was at age 14 years, and she has yet to go through menopause. She has a healthy 19-year-old daughter. She has no family history of cancer. She does not smoke or drink and exercises regularly. Aside from a diagnosis of PCOS, she is otherwise in good health. Given her health history, which of the following statements is true?

A 45-year-old G2P2 female presents for annual examination. She reports regular menstrual cycles lasting 3 to 5 days. She exercises 5 times per week and reports no difficulty sleeping. Her weight is stable 140 lbs and she is 5 ft 8 in tall. Physical examination is unremarkable. Laboratory studies are normal with the exception of a TSH value of 6.6 mU/L (normal 0.4-4.0 mU/L). Which of the following represents the best option for management of this patient’s elevated TSH?

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?

A 45-year-old male patient comes to the physician's office for a routine check-up. He denies any symptoms and says he feels "perfectly healthy." He was diagnosed with hypertension and mixed hypercholesterolemia a year ago. He is currently taking hydrochlorothiazide, amiloride and simvastatin daily. He does not use tobacco, alcohol or drugs. His blood pressure today is 135/85 mm Hg. Physical examination shows no abnormalities. Routine blood results reveal the following: CBC: Hb 14.2g/dL, Ht 42%, MCV 86 fl, Platelet count 260,000/cmm, Leukocyte count 8,500/cmm, Neutrophils 70%, Eosinophils 1%, Lymphocytes 24%, Monocytes 5%. Serum: Serum Na 140 mEq/L, Serum K 5.7 mEq/L, Chloride 100 mEq/L, Bicarbonate 24 mEq/L, BUN 10 mg/dL, Serum Creatinine 1.1 mg/dL, Calcium 9.0 mg/dL, Blood Glucose 118 mg/dL, Total cholesterol 220 mg/dL, LDL cholesterol 130 mg/dL. The blood sample is checked and is not hemolysed. The EKG shows normal sinus rhythm. What is the most appropriate next step in the management of this patient?

A 45-year-old male presents to your clinic with complaints of pleuritic chest pain. He says he is a heavy smoker and has been having intermittent cough for the past 2 weeks. His blood work is normal and his chest x ray is clear. EKG reveals a normal sinus rhythm with a heart rate of 68. He does have a PR interval > 0.2 seconds. The next step in the management of his arrhythmia is:

A 45-year-old male with mild persistent asthma comes to you for a routine checkup. He is taking a low-dose beclomethasone inhaler daily and inhaled albuterol, as needed, for the last year. His past medical history is otherwise not significant. His family history is significant for diabetes mellitus type 2, hypertension and obesity. His blood pressure is 136/90 mmHg and his heart rate is 80/min. His BMI is 26 kg/m2. Which of the following is the most likely complication of chronic beclomethasone use in this patient?

A 45-year-old man complains of sudden pain and swelling in his left first metatarsophalangeal joint. He is undergoing high dose induction chemotherapy for acute leukemia. Joint fluid aspiration reveals negative birefringent crystals and elevated white cell count. Which of the following prophylactic measures would most likely have prevented this condition?

A 45-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He is conscious but in severe pain. His blood pressure is 90/60 mm Hg, pulse is 100/min and respirations are 17/min. Physical examination shows marked swelling and some bruising over the right thigh; the skin is intact. An x-ray film of the leg shows a fracture of the mid shaft of the femur. After hemodynamically stabilizing the patient, which of the following is the most appropriate next step in management?

A 45-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He is unable to void. Examination shows blood at the urethral meatus and a scrotal hematoma. His temperature is 37C (98.6F), blood pressure is 100/50, pulse is 100/min and respirations are 16/min. Examination shows a high-riding prostate with no other signs of trauma. Which of the following is the most appropriate next step in management?

A 45-year-old man is brought to the emergency department after being involved in an automobile crash. He is alert and oriented, with a normal neurologic examination. His respiratory rate is 20/min, with clear lungs, pulse rate of 120/min, and blood pressure of 80/40 mmHg. On examination, he is noted to have a distended abdomen, with decreased bowel sounds, and a fracture of the right ankle. IV access is established, and the patient receives a rapid infusion of 2 L of saline, without changes to pulse rate or blood pressure. Which of the following is the most appropriate next step in his management?

A 45-year-old man is brought to the emergency department following a serious motor vehicle collision. Despite heroic attempts to save him, the physician caring for him believes he is brain dead. Unfortunately, the patient does not have an advanced directive or durable medical power of attorney. What step is necessary in order to remove the patient from the ventilator?

A 45-year-old man presents after a high-speed motor vehicle collision. He has a seatbelt sign across his neck and chest with an ecchymosis over his left neck. He is hemodynamically stable and neurologically intact. A CT angiogram shows a left carotid dissection. In the absence of other significant injuries, what is the next step in his management?

A 45-year-old man presents to the physician’s office complaining of dysphagia and retrosternal pressure and pain of 2-year duration. The symptoms have worsened over the last 3 months. He has a 30 pack-year smoking history and drinks beer on weekends. Vital signs include a BP of 150/90 mmHg, pulse rate of 90/min, and respiratory rate of 12/min, with a normal temperature. Examination reveals a thin man with a normal heart, lung, and abdomen examination. An esophagogram reveals a 6-cm, smooth, concave defect in the mid-esophagus with sharp borders. Esophagoscopy reveals intact overlying mucosa and a mobile tumor. Which of the following is the most appropriate next step?

A 45-year-old man presents with right upper quadrant abdominal pain and fever. CT scan shows a large, calcified cystic mass in the right lobe of the liver. Echinococcus is suggested by the CT findings. Which of the following is the most appropriate management of echinococcal liver cysts?

A 45-year-old man shows up in the emergency department with a pale, pulseless, paresthetic, painful, and paralytic right lower extremity. The process began suddenly 2 hours ago. On examination, no pulses are apparent in the right lower extremity. Pulse at the wrist is 95/min and grossly irregular. Treatment would likely be based on which of the following?

A 45-year-old man was discovered to have a hepatic flexure colon cancer during a colonoscopy for anemia requiring transfusions. Upon exploration of his abdomen in the operating room, an unexpected discontinuous 3-cm metastasis is discovered in the edge of the right lobe of the liver. Preoperatively, the patient was counseled of this possibility and the surgical options. Which of the following is the most appropriate management of this patient?

A 45-year-old man with a history of chronic peptic ulcer disease undergoes a truncal vagotomy and antrectomy with a Billroth II reconstruction for gastric outlet obstruction. Six weeks after surgery, he returns, complaining of postprandial weakness, sweating, light-headedness, crampy abdominal pain, and diarrhea. Which of the following would be the best initial management strategy?

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?

A 45-year-old man with alcoholic cirrhosis is bleeding from a duodenal ulcer. He has required 6 units of blood over the past 8 hours, and all conservative measures to stop the bleeding, including irrigation with cold saline, IV vasopressin, and endoscopic use of the laser have failed. He is being considered for surgical intervention. Laboratory studies done at the time of admission, when he had received only one unit of blood, showed a bilirubin of 4.5 mg/dL, a prothrombin time of 22 seconds, and a serum albumin of 1.8 g/dL. He was mentally clear when he came in, but has since then developed encephalopathy and is now in a coma. Which of the following best describes his operative risk?

A 45-year-old man with known cirrhosis due to hepatitis C is admitted to the hospital for abdominal discomfort and confusion. Physical examination reveals a distended abdomen, leg edema, and deep yellow discoloration of the skin and sclerae. Bibasilar crackles are heard on chest auscultation. His serum sodium level is 127 mEq/L, potassium level is 2.9 mEq/L, and creatinine level is 1.3 mg/dl. On day 3 of his hospitalization, the serum creatinine is 4.2mg/dl. A urinalysis reveals: Protein negative, Glucose negative, WBC 4-5/hpf, RBC 0-1/hpf. Renal ultrasound is normal and the post-void residual urinary volume is less than 50 ml. He is given 2 L of normal saline intravenously with no change in his serum creatinine concentration. This patient's kidney dysfunction can be best corrected by which of the following?

A 45-year-old man with poorly controlled hypertension presents with severe chest pain radiating to his back. An ECG demonstrates no significant abnormalities. A CT scan of the chest and abdomen is obtained, which demonstrates a descending thoracic aortic dissection extending from distal to the left sub-clavian take off down to above the iliac bifurcation. A Foley catheter is placed, and urine output is 30 to 40cc/h. His feet are warm, with less than 2-second capillary refill. Which of the following is the most appropriate initial management?

A 45-year-old white man presents to your office complaining of daytime somnolence, increased fatigability, and morning headaches. He says that his wife complains that he snores loudly. He is not taking any medications and does not smoke or consume alcohol. His blood pressure is 145/90 mmHg and heart rate is 90/min. Physical examination reveals a well-nourished man with BMI = 31 kg/m2. What is the next best step in the management of this patient?

A 45-year-old woman has an incidental finding of a liver mass on a CT scan. Magnetic resonance imaging (MRI) is suggestive of a hemangioma. Which of the following is the most appropriate management strategy for this patient?

A 45-year-old woman is found to have suspicious appearing calcifications in the right breast on a screening mammogram. Stereotactic biopsy of the calcifications shows lobular carcinoma in situ (LCIS). On examination both breasts are dense without palpable masses. The neck and bilateral axilla are negative for lymphadenopathy. Which of the following is the most appropriate management of this patient?

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?

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

A 45-year-old woman presents to your office complaining of one week of fatigue and weakness in her shoulders and hips. She reports difficulty performing household tasks, climbing the stairs, or rising from a chair. She denies any facial weakness or blurry vision. She has a history of gastroesophageal reflux disease and takes over the counter ranitidine. Her family history is positive for breast cancer in her mother. Her vital signs are within normal limits and examination shows normal sensation and deep tendon reflexes. Strength is 4 out of 5 in the proximal muscles groups of the arms and legs, and there is no limitation in the range of motion. Other physical examination is within normal limits. The ESR is 80 mm/hour and her serum creatine kinase is elevated. The TSH is within normal limits. Which of the following is the best initial treatment for this patient?

A 45-year-old woman presents with a 7-cm renal cell carcinoma with radiologic evidence of abdominal lymph node involvement with no distant metastases. Which of the following is the most appropriate management of this patient?

A 45-year-old woman presents with dysphagia, regurgitation of undigested food, and weight loss. She had x-rays shown here as part of her workup. Upper endoscopy reveals no evidence of malignancy and esophageal motility studies show incomplete lower esophageal sphincter relaxation. Which of the following is the next best step in the treatment of this patient?

A 45-year-old woman presents with left-sided weakness. A CT scan of the head demonstrates a well-circumscribed mass abutting the skull in the right hemisphere. Workup of the mass reveals a meningioma. Which of the following is the best next step in treatment?

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?

A 45-year-old woman with cirrhosis secondary to autoimmune hepatitis is seeing her hepatologist for routine follow-up. She reports that she has been feeling relatively well lately, and complains only of mild fatigue. Her medical history is otherwise unremarkable. Her medications include lactulose, spironolactone, propranolol and furosemide. Her vital signs are stable and the remainder of her physical exam is consistent with compensated cirrhosis. Her laboratory values are given below: Sodium 132 mEq/L, Potassium 4.1 mEq/L, Chloride 100 mEq/L, Bicarbonate 24 mEq/L, Glucose 102 mg/dl, Creatinine 0.9 mg/dl, Calcium 7.4 mg/dl, Total protein 6.1 g/dl, Albumin 2.5 g/dl, Total bilirubin 2.1 mg/dl, AST 80 units/L, ALT 102 units/L. What is the most appropriate next step in the management of this patient's hypocalcemia?

A 45-year-old woman with history of heavy nonsteroidal anti-inflammatory drug ingestion presents with acute abdominal pain. She undergoes exploratory laparotomy 30 hours after onset of symptoms and is found to have a perforated duodenal ulcer. Which of the following is the procedure of choice to treat her perforation?

A 45-year-old woman with no PMH presents to the office for an increase in abdominal fullness and bloating, worsening over the past 3 or 4 months. The patient states that she feels nauseous all the time, although has not had any vomiting. She states because of the constant nausea, she has not been eating as much. She has had a 10-lb weight loss in the last 4 months. BP, 110/70 mm Hg; P, 97; R, 18; T, 98.6°F. ROS: Denies fever and chills, Weight loss has occurred (10 lb in 4 months), Denies chest pain, shortness of breath, and abdominal pain, Nausea is present with no vomiting, No diarrhea or constipation. PE: Gen: Awake, alert, oriented x3, Abd: Soft, nontender, distended bowel sounds are present, shifting dullness to percussion is present, Pelvic: Cervix normal, no cervical motion tenderness, right adnexal enlargement is present. Which of the following is the next step in the management of this patient?

A 45-year-old woman with previously documented urge incontinence continues to be symptomatic after following your advice for conservative self-treatment. Which of the following is the best next step in management?

A 46-year-old female is brought to the emergency department because of visual blurring and altered mental status. She was recently treated for gout. Physical examination shows moderate to severe splenomegaly and positive sternal tenderness. Laboratory studies reveal a WBC count of 120, 000/uL with left shifted myeloid series and basophilia. Bone marrow exam shows 3% blasts. Repeat CBC is ordered. The hematologist-on-call decides to start leukophereses emergently. What another drug should be given to this patient?

A 46-year-old male comes to the emergency department because of an abrupt onset of worsening epigastric pain radiating to the back and vomiting. His temperature is 36.5C (97.6F), blood pressure is 100/70 mm of Hg, pulse is 100/min and respirations are 20/min. Examination shows a mildly distended abdomen that is very tender to palpation in the epigastric region without rebound; bowel sounds are absent; rectal examination shows no abnormalities. An x-ray film of the abdomen shows gaseous distention of the small bowel in the upper abdomen. CT with contrast shows diffuse hypodense enlargement of the pancreas and peripancreatic and perirenal fluid collections. Nasogastric suction, intravenous normal saline, analgesics and antibiotics are started. Laboratory studies show: Hemoglobin 15.0 g/L, Platelets223,000/mm3, Leukocyte count14,500/mm3, Serum sodium,134mEq /L, Serum potassium 3.6 mEq/L, Chloride 93 mEq/L, Bicarbonate 29 mEq/L, Blood urea nitrogen (BUN) 30 mg/dL, Serum creatinine 0.8 mg/dL, Calcium 10.3 mg/dL, Blood glucose 168 mg/dL, Total bilirubin 1.4 mg/dL, Alkaline phosphatase 220 U/L, Aspartate aminotransferase (SGOT) 88 U/L, Alanine aminotransferase (SGPT) 155 U/L, Lipase 523 U/L. Which of the following is the most appropriate next step in management?

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

A 46-year-old male is brought to the ER because of coffee ground emesis. He has a history of chronic hepatitis C and alcohol abuse. His temperature is 36.6C (97.9F), blood pressure is 120/70 mm Hg, pulse is 90/min and respirations are 14/min. He is oriented to time, place and person but somewhat sleepy. A flapping tremor is noted. His abdomen is soft, non-tender, and mildly-distended; liver and spleen are palpated below the costal margins; shifting dullness is present. Nasogastric tube aspiration shows bright red blood that was easily cleared with saline lavage. Endoscopy shows a fresh ulcer with a small adherent clot located high on the lesser curvature near the gastroesophageal junction. Non bleeding esophageal and gastric varices are also seen. Laboratory studies show: Hemoglobin 10.2 g/L, MCV 105 fl, Platelets 105,000/mm3, Leukocyte count 4,500/mm3, Prothrombin time 17 sec, Aspartate aminotransferase (SGOT) 78 U/L, Alanine aminotransferase (SGPT) 50 U/L, Which of the following is the most appropriate next step in management?

A 46-year-old male is hospitalized with severe acute pancreatitis. Because of progressive respiratory difficulty, he is intubated and placed on mechanical ventilation. His weight is 70 kg (152 lb), blood pressure is 110/70 mmHg, and heart rate is 90/min. Chest x-ray shows patchy opacities bilaterally, consistent with pulmonary edema. His current ventilator settings are: assist control mode, respiratory rate of 12/min, tidal volume of 450 ml, FiO2 of 40%, and positive end-expiratory pressure (PEEP) of 5 cm H20. His blood gas readings are: pH 7.51, pCO2 22mmHg, pO2 121mmHg. Which of the following is the best next step in managing this patient?

A 46-year-old male was admitted with epigastric pain radiating to the back. He has a previous history of endocarditis from intravenous drug use and cellulitis of the arm. Serum lipase is elevated. He was admitted and treated conservatively. Two days later he started to have a fever. He is awake but slightly disoriented. His temperature is 38.7C (101.6F), blood pressure is 120/76 mm Hg, pulse is 110/min and respirations are 16/min. He is tremulous and says bugs are crawling on him. His blood cultures are positive for gram negative rods. Empiric antibiotic therapy is started. CT scan of the abdomen shows a new 6 x 6 cm cystic lesion attached to the pancreatic head. Laboratory results show: Hematocrit 44.0 g/L, MCV 105fl, Leukocyte count 18,500/mm3, Amylase 255 U/L. Which of the following is the most appropriate next step in management?

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

A 46-year-old man comes to the physician because of a two day history of worsening abdominal discomfort and persistent vomiting. He has not had a bowel movement or passed flatus for 3 days. He had an appendectomy for appendicitis 20 years ago. Examination shows a distended abdomen that is tympanic on percussion. High-pitched bowel sounds and splashing are heard on auscultation. The abdomen is diffusely tender on palpation without rebound or guarding. An x-ray film of the abdomen shows distended small bowel loops with air-fluid levels; no gas is seen in the colon. IV rehydration is started. Which of the following is the most appropriate next step in management?

A 46-year-old woman presents to your office complaining of something bulging from her vagina for the past year. It has been getting progressively more prominent. She has started to notice that she leaks urine with laughing and sneezing. She still has periods regularly every 26 days. She is married. Her husband had a vasectomy for contraception. After appropriate evaluation, you diagnose a second-degree cystocele. She has no uterine prolapse or rectocele. Which of the following is the best treatment plan to offer this patient?

A 46-year-old woman suffering from systemic lupus erythematosus (SLE) develops hematuria and proteinuria. She was diagnosed with SLE four years ago and has been treated with hydroxychloroquine. A renal biopsy is performed and shows diffuse proliferative glomerulonephritis. She is started on cyclophosphamide and prednisone and hydroxychloroquine is stopped. She continues these two medications for several weeks because of the low therapeutic response. This new therapeutic regimen puts her at an increased risk for which of the following conditions?

A 46-year-old woman who was recently diagnosed with Crohn disease asks about the need for surgery. Which of the following findings would be an indication for an immediate exploratory laparotomy?

A 46-year-old woman, who had always been in good health, comes in because of the sudden onset of very severe back and leg pain that she experienced 2 hours ago when attempting to lift a heavy object. She says that she felt "a bolt of lightning" running down the back of her leg, and she still has very severe pain that prevents her from walking or moving. The pain is exacerbated by coughing, sneezing, or straining. She keeps the affected leg flexed; straight leg rising gives her excruciating pain. She has good sphincter tone and intact sensation in the perineum. Once the diagnosis is confirmed with the appropriate studies, which of the following will be the most appropriate treatment?

A 47-year old woman comes to the clinic because of worsening left breast swelling and pain. She had mastitis when she nursed her first child 20 years ago. She has not seen a doctor since that time. She is afebrile. Breast examination shows the left breast is enlarged with a 7 x 6 cm area of edema and erythema. A poorly localized mass without fluctuation is palpated in that area. Scant non-bloody discharge is noted on the nipple, and several large axillary nodes are palpated. Which of the following is the most appropriate next step in management?

A 47-year-old asymptomatic woman is incidentally found to have a 5-mm polyp and no stones in her gallbladder on ultrasound examination. Which of the following is the best management option?

A 47-year-old Caucasian female presents with occasional episodes of nocturnal substernal chest pain that wakes her up during sleep. The pain episodes last 15-20 minutes and resolve spontaneously. She denies any illicit drug use. She leads a sedentary lifestyle but states that she can climb two flights of stairs without any discomfort. She has no history of hypertension or diabetes. Her pulse is 75/min and regular, blood pressure is 134/70 mmHg and respirations are 14/min. Extended ambulatory ECG monitoring reveals transient ST segment elevation in leads I, aVL, and V4-V6 during the episodes. Which of the following is the best treatment for this patient?

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?

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?

A 47-year-old man comes to the office for the evaluation of a sore over his right ear. His sore bleeds and oozes, and has remained open for 3 weeks. He thinks that it has been growing slowly over the past year. He works for the postal service (USPS), and is usually out all day delivering mail. He admits to smoking approximately 2 packs of cigarettes daily for the last 13 years. Physical examination reveals a punched out 1.5 cm ulcer on his right auricle. There are no enlarged lymph nodes. Full thickness biopsy reveals proliferating malignant cells which arise from the epidermis and extend into the dermis in lobules or strands. What is the best next step in the management of this patient?

A 47-year-old man with a history of hypertension presents to the ED complaining of continuous left-sided chest pain that began while snorting cocaine 1 hour ago. The patient states he never experienced chest pain in the past when using cocaine. His BP is 170/90 mmHg, HR is 101 beats per minute, RR is 18 breaths per minute, and oxygen saturation is 98% on room air. The patient states that the only medication he takes is alprazolam to “calm his nerves.” Which of the following medications is contraindicated in this patient?

A 47-year-old man with hypertensive nephropathy develops fever, graft tenderness, and oliguria 4 weeks following cadaveric renal transplantation. Serum creatinine is 3.1 mg/dL. A renal ultrasound reveals mild edema of the renal papillae but normal flow in both the renal artery and the renal vein. Nuclear scan demonstrates sluggish uptake and excretion. Which of the following is the most appropriate next step?

A 47-year-old woman comes to the physician for an annual examination. One year ago, she was diagnosed with endometrial carcinoma and underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy. She was found to have grade I, stage I, disease at that time. Over the past year, she has developed severe hot flashes that occur throughout the day and night and are worsening. She is also concerned because her mother and several of her aunts have severe osteoporosis. She wonders whether she can take estrogen replacement therapy. Which of the following is the most appropriate response?

A 47-year-old woman presents to your office complaining of two days of pain and itching over her left chest. Her medical history is significant for breast cancer for which she underwent a left-sided mastectomy six months ago. She has also been receiving chemotherapy and radiation. Physical examination reveals erythema around the mastectomy scar, with excoriations and occasional vesicles. Which of the following is the best treatment for her condition?

A 48-year-old Caucasian female is undergoing a routine work-up 9 months after radical mastectomy due to right-sided breast cancer. She has no present complaints, and says that she is 'full of energy'. Chest radiograph reveals an isolated pulmonary nodule, 2.0 cm in diameter, in the middle lobe of the right lung. CT confirms that the lesion is solitary with poorly defined margins, but completely within lung parenchyma. Bone scan is negative. CT abdomen and pelvis is normal. Transthoracic biopsy demonstrates adenocarcinoma with positive estrogen receptors (ER) and no HER-2/neu overexpression. Which of the following is the best management strategy for this patient?

A 48-year-old G2P2 presents for her well-woman examination. She had two uneventful vaginal deliveries. She had a vaginal hysterectomy for fibroids and menorrhagia. She denies any medical problems, but has not seen a doctor in 6 years. Her family history is significant for stroke, diabetes, and high blood pressure. On examination she is a pleasant female, stands 5 ft 3 in tall, and weighs 85 kg. Her blood pressure is 150/92 mm Hg, pulse 70 beats per minute, respiratory rate 14 breaths per minute, and temperature 37C (98.4F). Her breast, lung, cardiac, abdomen, and pelvic examinations are normal. The next appropriate step in the management of this patient’s blood pressure is which of the following?

A 48-year-old man presents with jaundice, melena, and right upper quadrant abdominal pain after undergoing a percutaneous liver biopsy. Endoscopy shows blood coming from the ampulla of Vater. Which of the following is the most appropriate first line of therapy for major hemobilia?

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

A 48-year-old man with a past medical history of hepatitis C and cirrhosis presents to the ED complaining of acute-onset abdominal pain and chills. His BP is 118/75 mm Hg, HR is 105 beats per minute, RR is 16 breaths per minute, temperature is 101.2°F rectally, and oxygen saturation is 97% on room air. His abdomen is distended, and diffusely tender. You decide to perform a paracentesis and retrieve 1 L of cloudy fluid. Laboratory analysis of the fluid shows a neutrophil count of 550 cells/mm 3. Which of the following is the most appropriate choice of treatment?

A 48-year-old woman complains of joint pain and morning stiffness for 4 months. Examination reveals swelling of the wrists and MCPs as well as tenderness and joint effusion in both knees. The rheumatoid factor is positive, antibodies to cyclic citrullinated protein are present, and subcutaneous nodules are noted on the extensor surfaces of the forearm. Which of the following statements is correct?

A 48-year-old woman consults with you regarding menopausal symptoms. Her periods have become less regular over the past 6 months. Her last period was 1 month ago. She started having hot flushes last year. They have been getting progressively more frequent. She has several hot flushes during the day, and she wakes up twice at night with them as well. She has done quite a lot of reading about perimenopause, menopause, and hormone replacement therapy. She is concerned about the risks of taking female hormones. She wants to know what she should expect in regard to her hot flushes if she does not take hormone replacement. You should tell her which of the following?

A 48-year-old woman presents to her gynecologist because of vaginal bleeding. She states that after a year of hot flashes and irregular cycles, she finally stopped menstruating 4 months ago. Two days ago she began having some vaginal bleeding that was very similar to her prior menses. She is concerned because she heard that the first sign of endometrial cancer in postmenopausal women is vaginal bleeding. She is an otherwise healthy woman with no medical problems. She exercises three times a week and takes multivitamins. She had three children when she was 29–35 years old. She used oral contraceptive pills for contraception from the time she was 18 until she got married at the age of 28. Which of the following is the most appropriate next step in managing this woman’s vaginal bleeding?

A 49-year-old man presents to the clinic for a health maintenance visit. He has a family history of type 2 DM. His medical history is significant for gastroesophageal reflux disease, for which he takes omeprazole and over-the-counter antacids. He smokes one pack of cigarettes per day and drinks an average of two beers per night. The patient’s body mass index is 32 kg/m². Which of the following most greatly reduce(s) the patient’s risk of future coronary artery disease, renal failure, and retinopathy?

A 49-year-old man presents to the ED with nausea, vomiting, and abdominal pain that began approximately 2 days ago. The patient states that he usually drinks a six pack of beer daily, but increased his drinking to 2 six packs daily over the last week because of pressures at work. He notes decreased appetite over the last 3 days and states he has not had anything to eat in 2 days. His BP is 125/75 mm Hg, HR is 105 beats per minute, and RR is 20 breaths per minute. You note generalized abdominal tenderness on examination. Laboratory results reveal the following: White blood cells (WBC) 9000/μL Sodium 131 mEq/L Hematocrit 48% Potassium 3.5 mEq/L Platelets 210/μL Chloride 101 mEq/L Aspartate transaminase (AST) 85 U/L Bicarbonate 10 mEq/L Alanine transaminase (ALT) 60 U/L Blood urea nitrogen (BUN) 9 mg/dL Alkaline phosphatase 75 U/L Creatinine 0.5 mg/dL Total bilirubin 0.5 mg/dL Glucose 190 mg/dL Lipase 40 IU Nitroprusside test weakly positive for ketones Which of the following is the mainstay of therapy for patients with thiscondition?

A 49-year-old man who underwent liver transplantation 5 years ago for alcoholic cirrhosis presents with a gradually increasing bilirubin level. He undergoes a liver biopsy, which demonstrates a paucity of bile ducts. Which of the following is his best option for treatment?

A 49-year-old obese man has become irritable, his face has changed to a round configuration, he has developed purplish lines on his flanks, and he is hypertensive. A 24-hour urine collection demonstrates elevated cortisol levels. This is confirmed with bedtime cortisol measurements of 700ng/mL. Which of the following findings is most consistent with the diagnosis of Cushing disease?

A 49-year-old woman has a firm, 2-cm mass in the right breast that has been present for 3 months. Mammogram has been read as "cannot rule out cancer," but it cannot diagnose cancer either. A fine-needle aspiration of the mass (FNA) and cytology do not identify any malignant cells. Which of the following is the most appropriate next step in management?

A 49-year-old woman presents to her physician with dysphagia, regurgitation of undigested food eaten hours earlier, and coughing over the last 6 months. She was hospitalized 1 month ago for aspiration pneumonia and successfully treated with antibiotics. Examination reveals a thin-appearing woman with normal vital signs and unremarkable chest, heart, and abdominal examination. A UGI contrast study is performed and reveals a pharyngoesophageal (Zenker’s) diverticulum. Which of the following is the most important aspect of treatment?

A 49-year-old woman presents to her physician’s office with a long-standing history of polydipsia, polyuria, central obesity, and hyperlipidemia. She is currently taking metformin, a sulfonylurea, and an angiotensin-converting enzyme (ACE) inhibitor. ACE inhibitors are most beneficial in preventing or slowing the progression of which of the following diabetic complications?

A 49-year-old woman undergoes surgical resection of a malignancy. The family asks about the prognosis. The histopathology is available for review. For which of the following malignancies does histologic grade best correlate with prognosis?

A 5-month-old child regularly regurgitates a large portion of her feeds. A pH probe study showed significant periods of low esophageal pH. The child has normal growth and no other significant past medical history. Which of the following is the best management at this point?

A 5-week-old infant presents with a 1-week history of progressive nonbilious emesis, associated with a 24-hour history of decreased urine output. The infant continues to be active and eager to feed. On examination, the infant has a sunken fontanelle and decreased skin turgor. The abdomen is scaphoid, and with a test feed, there is a visible peristaltic wave in the epigastrium. Which of the following is the most appropriate next step in management of this infant?

A 5-year-old African-American boy is brought to the office by his mother due to a painful right knee, fever and chills over the last 2 days. The child was diagnosed with pharyngitis 2 weeks ago, and was treated with a 10-day course of penicillin G. His temperature is 38.8 C (102F) and pulse rate is 102/min. On examination, his right knee joint is swollen and erythematous, with a decreased range of motion. The laboratory findings are significant for leukocytosis and an elevated ESR. X-rays of both the right hip and knee joints are normal. What is the most appropriate treatment for the patient's condition?

A 5-year-old boy is brought to an emergency room because of a painful, swollen knee joint. The boy had fallen while playing, and the joint had subsequently begun to swell. The mother reports that the boy was known to have hemophilia B. Replacement of which of the following is indicated?

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

A 5-year-old boy is brought to the office by his frustrated mother because, "he just can't seem to concentrate!" He has episodes that are characterized by frequent blinking and indifference to his surroundings. He does not remember anything after an episode. An episode does not last long, but he usually has 50-80 "daydreaming accidents" daily. His school performance has deteriorated lately, and his teacher has complained about his decreased concentration. Which of the following is the drug of choice for this patient's condition?

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

A 5-year-old boy is brought to the physician's office because of a cough. He has episodes of successive and rapid coughs, which seems like he is choking, followed by a deep and loud inspiratory sound. He has vomited a few times after these bursts of cough. His symptoms have been progressively worsening for the past week, and were preceded by congestion, serous rhinorrhea and sneezing. His past medical history is insignificant. His vital signs are stable. Lung auscultation is unremarkable. Which of the following is the most appropriate pharmacotherapy for this patient?

A 5-year-old boy suddenly begins coughing while eating peanuts. He is choking and gagging. When he is brought to the emergency department, but he is awake and is able to give his name. On physical examination, his vital signs are stable. On examination of the chest, inspiratory stridor and intercostal and suprasternal retractions are apparent. Which of the following is the most appropriate initial step in management?

A 5-year-old child presents with a small mass near the anterior border of the sternocleidomastoid muscle. The mass is associated with localized erythema and induration, and the child is febrile. Which of the following is the definitive treatment of this problem?

A 5-year-old child was hit in the right eye by a toy. He is rubbing at his eye, which is watering profusely. There is a small abrasion at the corner of the eye. He is mildly photophobic, but his pupils are equal, symmetric, and reactive to light and accommodation. His vision is normal. Which of the following is the most appropriate next step in the management of this patient?

A 5-year-old girl is brought to medical attention by her parents 12 hours after the onset of generalized tonicoclonic seizures. She never had similar episodes in the past. The girl is otherwise healthy. Her temperature is 37 C (98.6 F). Physical examination is unremarkable. There is no evidence that the girl had a fever at the onset of the convulsive episode. The parents fear that seizures may damage the child's brain and may eventually recur. Which of the following is the most appropriate next step in management?

A 5-year-old girl is diagnosed with Bordetella pertussis infection after an outbreak in the day-care center. She is prescribed erythromycin for 14 days. She lives with her parents and 13-year-old sister whose immunizations are up to date. What is the most appropriate way to limit the risk of infection in household contacts?

A 5-year-old girl without past history of UTI is in the hospital on antibiotics for Escherichia coli pyelonephritis. She is still febrile after 4 days of appropriate antibiotics. A renal ultrasound revealed no abscess, but a focal enlargement of one of the lobes of the right kidney. CT of the abdomen reveals a wedge shaped area in the right kidney distinct from the normal tissue with minimal contrast enhancement. Appropriate management of this patient includes which of the following interventions?

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?

A 5-year-old Mexican female child is brought to the office for the evaluation of a pruritic vulva for the past fifteen days. The pruritus is felt mostly during the night. Her 4-year-old cousin who visited them four weeks ago has a similar complaint. On examination, there is no vaginal discharge, but the vulva is erythematous. The rest of the physical examination is normal. What is the most appropriate next step in the management of this patient?

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

A 50-year-old Caucasian male returns to the clinic for the evaluation of his blood pressure control. He was diagnosed with essential hypertension one year ago. He claims compliance with his reduced salt intake diet. He is currently on a thiazide diuretic and a beta-blocker. His past medical history is significant for angina, which is always relieved with sublingual nitroglycerine, but he has not had an attack of angina in over a month. He has never had a myocardial infarction. He lives with his wife and two children. He quit smoking two years ago, but previously had a 25-pack year history. He drinks 4 bottles of wine per week. His blood pressure is 150/90 mm Hg. What is the best next step in management?