Management USMLE 12 (1503-1590)

In preparation for an inguinal hernia repair, a 22-year-old man has a spinal anesthetic placed. The level of sensory block turns out to be much higher than had been planned, and shortly thereafter his blood pressure drops to 75/20 mm Hg. He looks warm and flushed, and his central venous pressure is near zero. Which of the following should be included in his therapy?

In the course of a robbery, a young woman is stabbed repeatedly. On arrival at the emergency department, she is shivering and asks for a blanket and a drink of water; she is noted to be pale and perspiring. Her blood pressure is 72/50 mm Hg and her pulse is 130/min. Her neck and forehead veins are large and distended. A quick initial survey reveals entry wounds in her left chest and upper abdomen. She has bilateral breath sounds and a scaphoid, nontender abdomen. As IV infusions of Ringer's lactate are started, her systolic blood pressure drops further to 40 mm Hg, no distal pulses can be felt, and she loses consciousness. Her central venous pressure at that time is 28 cm H2O. Which of the following is the most appropriate next step in management?

Incisional biopsy of a breast mass in a 35-year-old woman demonstrates cystosarcoma phyllodes at the time of frozen section. Which of the following is the most appropriate management strategy for this lesion?

On the 5th postoperative day, it is noticed that large amounts of clear, pink, salmon-colored fluid are soaking the wound dressings of a patient who had a negative exploratory laparotomy for a stab wound of the abdomen. The laparotomy was done through a midline supraumbilical and infraumbilical incision. When seen by the surgical staff, the patient is lying in bed in the supine position, with the dressings removed. In the dim light of his hospital room, the incision appears intact and not particularly red or inflamed, but there are indeed traces of the clear pink fluid on his skin. He has no specific complaints. He is still NPO and on IV fluids, but has already been passing gas per rectum, and plans had been made to feed him today. The abdomen is not distended, and he has normal bowel sounds. He is afebrile. Which of the following is the most appropriate next step in management?

One of your patients with polycystic ovarian syndrome presents to the emergency room complaining of prolonged, heavy vaginal bleeding. She is 26 years old and has never been pregnant. She was taking birth control pills to regulate her periods until 4 months ago. She stopped taking them because she and her spouse want to try to get pregnant. She thought she might be pregnant because she had not had a period since her last one on the birth control pills 4 months ago. She started having vaginal bleeding 8 days ago. She has been doubling up on superabsorbant sanitary napkins 5 to 6 times daily since the bleeding began. On arrival at the emergency room, the patient has a supine blood pressure of 102/64 mm Hg with a pulse of 96 beats per minute. Upon standing, the patient feels light-headed. Her standing blood pressure is 108/66 mm Hg with a pulse of 126 beats per minute. While you wait for lab work to come back, you order intravenous hydration. After 2 hours, the patient is no longer orthostatic. Her pregnancy test comes back negative, and her Hct is 31%. She continues to have heavy bleeding. Which of the following is the best next step in the management of this patient?

The patient is a 25-year-old G1 P0 with an intrauterine pregnancy (IUP) at 24 weeks' gestation. She presents for her routine prenatal checkup. She has never had problems with blood pressure (BP). At her previous visit, her BP was 160/90 mm Hg. Now her vital sign: BP, 155/90 mm Hg; P, 85 beats/min; R, 12 breaths/min; T, 98F (37 C). She denies chest pain, denies shortness of breath, denies headache and blurry vision, denies abdominal pain and contractions, denies leakage of fluid, denies vaginal bleeding, fetal movement: present. Physical examination: cardiovascular: S1S2+ RRR no murmur, no rale, no gallop, lung: CTA bilaterally, extremities: 1+ edema, fundal height: 23 cm, fetal heart rate: 150s. What is the next step in the management of this patient?

While discussing a case presentation with a medical student, a nearby patient who just returned from getting an ankle radiograph done yells out in pain. You walk over to him and ask what is wrong. He states that since returning from the radiology suite, his automatic implantable cardioverter defibrillator (AICD) is discharging. You hook him up to the monitor and note that his rhythm is sinus. You observe a third shock while the patient is in sinus rhythm. Which of the following is the most appropriate next step in management?

While running to catch a bus, and old man twists his ankle and falls on his inverted foot. Anteroposterior (AP), lateral, and mortise x-ray films show displaced fractures of both malleoli. Which of the following would be the preferred form of treatment?

While working on-site at a factory doing physical examinations for workers, a physician is suddenly called to help a worker who amputated his finger. Which of the following is the most appropriate next step in management in this situation?

You are a physician in charge of patients who reside in a nursing home. Several of the patients have developed influenza-like symptoms, and the community is in the midst of influenza A outbreak. None of the nursing home residents have received the influenza vaccine. Which course of action is most appropriate?

You are asked to assist in the well-born nursery with neonatal care. Which of the following is a part of routine care in a healthy infant?

You are called to examine a newly delivered infant, who is 41 weeks gestation and a product of an uncomplicated pregnancy. Physical examination reveals a matted mass of edematous bowel loops protruding from the abdomen. There is no covering over the bowel loops. The umbilical cord appears normal. Which of the following is the best next step in the management of this patient?

You are discussing surgical options with a patient with symptomatic pelvic relaxation. Partial colpocleisis (Le Fort procedure) may be more appropriate than vaginal hysterectomy and anterior and posterior (A&P) repair for patients in which of the following circumstances?

You are making rounds on a 29-year-old G1P1 who underwent an uncomplicated vaginal delivery at term on the previous day. The patient is still very confused about whether she wants to breast-feed. She is a very busy lawyer and is planning on going back to work in 4 weeks, and she does not think that she has the time and dedication that breast-feeding requires. She asks you what you think is best for her to do. Which of the following is an accurate statement regarding breast-feeding?

You are treating a 31-year-old woman with danazol for endometriosis. You should warn the patient of potential side effects of prolonged treatment with the medication. When used in the treatment of endometriosis, which of the following changes should the patient expect?

You are volunteering with a dental colleague in a community indigent clinic. A nurse has prepared a list of patients who are scheduled for a dental procedure and may need antibiotic prophylaxis beforehand. Of the patients listed below, who would be most likely to benefit from antibiotic prophylaxis to prevent infective endocarditis?

You evaluate a 48-year-old man for chronic renal insufficiency. He has a history of hypertension, osteoarthritis, and gout. He currently has no complaints. His medical regimen includes lisinopril 40 mg daily, hydro-chlorothiazide 25 mg daily, allopurinol 300 mg daily, and acetaminophen for his joint pains. He does not smoke but drinks 8 oz of wine on a daily basis. Examination shows BP 146/86 mm Hg, pulse 76, a soft S4 gallop, and mild peripheral edema. There is no abdominal bruit. His UA reveals 1+ proteinuria and no cellular elements. Serum creatinine is 2.2 mg/dL and his estimated GFR from the MDRD formula is 42 mL/minute. What is the most important element is preventing progression of his renal disease?

You have been asked to evaluate a 42-year-old white male smoker who presented to the emergency department with sudden onset of crushing substernal chest pain, nausea, diaphoresis and shortness of breath. His initial ECG revealed ST segment elevation in the anterior-septal leads. Cardiac enzymes were normal. The patient underwent emergent cardiac catheterization, which revealed only a 25% stenosis of the left anterior descending (LAD) artery. No percutaneous intervention was performed. Which of the following interventions would most likely reduce his risk of similar episodes in the future?

You have just given a 10-year-old boy an injection of pollen extract as prescribed by his allergist. You are about to move on to the next patient when the boy starts to complain about nausea and a funny feeling in his chest. You note that his face is flushed and his voice sounds muffled and strained. Which of the following is the first priority in managing this episode of anaphylaxis?

Your patient presents with a complaint of a mass on her right cheek, which has been slowly enlarging. Biopsy shows a pleomorphic adenoma. Which is the next step in her management?