DES C_Management (5) Prepared : CHILLY

A 30-year-old man presents to the resuscitation bay with gunshot wounds in the anterior and posterior left chest. Although in distress and dyspneic, the patient is cooperative. He has a patent airway and is moving all extremities. His pulse is 120/min, blood pressure is 120/90 mm Hg, and respiratory rate is 30/min. He has bounding distal pulses, and no other injuries are identified on secondary examination. X-ray of the chest reveals fluid in the pleural space, and a left chest tube thoracostomy yields 600 mL of bright red fluid. Over the next hour 750 mL of blood is collected. What is the most appropriate next step in management?

A 30-year-old woman comes to the physician 6 hours after falling on her outstretched right hand. She has pain and limitation of movement in her wrist, but denies sensations of tingling or numbness. The right wrist is mildly swollen, and its range of passive motion is limited compared with the left side. Palpation elicits maximal tenderness in the area of the anatomic snuffbox, between the tendons of the extensor pollicis longus and abductor pollicis muscles. Ulnar and radial pulses are normal, and Tinel's and Phalen's tests are negative. Further examination rules out signs of nerve or vascular damage. Plain x-ray films performed in the anteriorposterior, lateral, and oblique views fail to show any evidence of fractures. At this time, which of die following is the most appropriate next step in management?

A 30-year-old woman in her last trimester of pregnancy suddenly develops massive swelling of the left lower extremity. Which of the following would be the most appropriate workup and treatment at this time?

A 30-year-old woman with a genetic disorder characterized by a deficiency of phenylalanine hydroxylase is planning a first pregnancy. Her physician explains the increased risk of mental retardation, as well congenital heart disease, in the infant. Which of the following should also be recommended?

A 30-year-old woman, gravida 2, para 1, at 37 weeks gestation is brought to the emergency department because of acute onset intense uterine contractions and vaginal bleeding. She has been followed closely for pre-eclampsia since her 32nd week of gestation. Her temperature is 37.0 C (98.7F), blood pressure is 140/86mmHg, pulse is 92/min and respirations are 18/min. Physical examination shows uterine tenderness and hyperactivity and moderate vaginal bleeding. Pelvic examination shows an effaced and 3cm dilated cervix. Ultrasonography shows a fundic placenta and a fetus in the cephalic position. Fetal heart tracing shows 140/min with good long-term and beat-to-beat variability. After initial resuscitation the bleeding is stopped Which of the following is the most appropriate next step in management?

A 30-year-old woman, gravida 3, para 2, at 32 weeks gestation comes to the physician because of a decrease in fetal movements. She has felt few fetal kicks the past 20 hours. Her prenatal course, prenatal tests and fetal growth have been normal. She has chronic hypertension and is now taking methyldopa and labetalol. Her previous pregnancies were uncomplicated and both delivered vaginally. She does not use tobacco, alcohol or drugs. Fetal heart tones are heard by Doppler. Non-stress test is reactive. Which of the following is the most appropriate next step in management?

A 31 -year-old man is brought to the emergency department after a motor vehicle accident. He sustained a severe head injury and, on arrival to the emergency department, has a Glasgow coma score of 8. His blood pressure is stable, and an urgent CT scan of the head reveals a large subdural bleed with evidence of a midline shift and cerebellar tonsillar compression. The patient is breathing spontaneously without any respiratory assistance and is not intubated. Which of the following is the most appropriate next step in management?

A 31-year-old African American man presents with dyspnea on exertion. He also has fever and red tender rash on his shins. Physical examination reveals fine inspiratory crackles in both lower lung lobes and tender erythematous nodules on his legs. CXR shows bilateral hilar adenopathy and reticulonodular changes in both lungs. Transbronchial biopsy reveals noncaseating granulomas. Which of the following is the most appropriate next step in management?

A 31-year-old African-American woman is diagnosed with uterine fibroids. Which of the following types of fibroids is most likely to interfere with conception and pregnancy?

A 31-year-old Caucasian male complains of joint pains. He describes right knee pain, right heel pain and lowback pain. He was recently treated for urethral discharge at an outside clinic. He has no history of trauma or illicit drug use. He is afebrile, and his vital signs are stable. His right knee is swollen, tender and warm to touch; tenderness is also present over the Achilles tendon. Oral examination shows mouth ulcers. Synovial fluid analysis from the right knee shows a white blood cell count of 10,000/mm3 with many polymorphonuclear leukocytes but a negative Gram stain. Which of the following is the most appropriate initial pharmacotherapy for this patient?

A 31-year-old man is brought to the ER following an automobile accident in which his chest struck the steering wheel. Examination reveals stable vital signs and no evidence of respiratory distress, but the patient exhibits multiple palpable rib fractures and paradoxical movement of the right side of the chest. Chest x-ray shows no evidence of pneumothorax or hemothorax. Which of the following is the most appropriate initial management of this patient?

A 31-year-old man who works for a moving company presents to the ED because he thinks he was having a heart attack. He does not smoke, and jogs 3 days a week. His father died of a heart attack in his sixties. He describes a gradual onset of chest pain that is worse with activity and resolves when he is at rest. His HR is 68 beats per minute, BP is 120/70 mmHg, and RR is 14 breaths per minute. On examination, his lungs are clear and there is no cardiac murmur. You palpate tenderness over the left sternal border at the third and fourth ribs. An ECG reveals sinus rhythm at a rate of 65. A chest radiograph shows no infiltrates or pneumothorax. Which of the following is the most appropriate next step in management?

A 31-year-old woman comes to the physician for follow-up after an abnormal Pap test and cervical biopsy. The patient's Pap test showed a high-grade squamous intraepithelial lesion (HGSIL). This was followed by colposcopy and biopsy of the cervix. The biopsy specimen also demonstrated HGSIL. The patient was counseled to undergo a loop electrosurgical excision procedure (LEEP). Which of the following represents the potential long-term complications from this procedure?

A 31-year-old woman comes to your office seeking advice about birth control. She had her third child 3 months ago and does not wish to get pregnant in the near future. Her medical history is significant for HIV infection with a CD4 count of 500 cells/mm3 and a viral load of 2000 copies/mL. She also has migraine headaches with an aura that she has had since the age of 14 years. She has never had surgery. She takes no medications and has no known drug allergies. She has a family history significant for breast, endometrial, and ovarian cancers. Her physical examination, including breast and pelvic examination, is normal. Which of the following conditions represents a contraindication to the combined oral contraceptive pill for this patient?

A 31-year-old woman smashes her car against a bridge abutment. She sustains multiple injuries, including upper and lower extremity fractures. She is fully awake and alert, and she reports that she was not wearing a seat belt and distinctly remembers hitting her abdomen against the steering wheel. Her blood pressure is 135/75 mm Hg, and her pulse is 88/min. Physical examination shows that she has a rigid, tender abdomen, with guarding and rebound in all four quadrants. She has no bowel sounds. Which of the following would be the most appropriate step in evaluating potential intra-abdominal injuries?

A 31-year-old woman, gravida 1, para 0, at 36-weeks' gestation with twins comes to the physician for a prenatal visit. The patient has had no contractions, bleeding from the vagina, or loss of fluid, and the babies are moving well. An ultrasound that was performed today shows that the presenting fetus is vertex and the non-presenting fetus is breech. Both fetuses are appropriately grown and greater than 2000 g. The patient wants to know if she should have a vaginal or cesarean delivery. Which of the following is the proper counseling for this patient?

A 31-year-old, HIV-positive woman, gravida 3, para 2, at 32-weeks' gestation comes to the physician for a prenatal visit. Her prenatal course is significant for the fact that she has taken zidovudine throughout the pregnancy. Otherwise, her prenatal course has been unremarkable. She has no history of mental illness. She states that she has been weighing the benefits and risks of cesarean delivery in preventing transmission of the virus to her baby. After much deliberation, she has decided that she does not want a cesarean delivery and would like to attempt a vaginal delivery. Which of the following is the most appropriate next step in management?

A 32-year-old Caucasian female presents to your office for a routine check-up. Her past medical history is significant for generalized seizures controlled with chronic phenytoin therapy. The last seizure was six months ago. She does not smoke or consume alcohol. Physical examination is insignificant, except mild pallor. Laboratory values are: Hb 10.8 g/dL, MCV 105 fl, Platelet count 180,000/cmm, Leukocyte count 7,500/cmm, Segmented neutrophils 68%, Bands 1%, Eosinophils 1%, Lymphocytes 24%, Monocytes 6%. Which of the following supplementations could have prevented this patient's anemia?

A 32-year-old female is crying as she approaches the office. She has had severe, unbearable pain in her face for the past five days. She describes the pain as knife-like, comes in paroxysms, occurs 10-20 times a day, and lasts a few seconds. She does not know what precipitates the attacks, but she has been unable to sleep, eat or go to work because of her symptoms. She has tried numerous pain medications, but nothing seems to relieve the pain. She denies any history of trauma, medication use or recent surgery. Vital signs are within normal limits. Physical examination is within normal limits. Which of the following agents will best benefit this patient?

A 32-year-old female presents for her yearly examination. She has been smoking one pack of cigarettes a day for the past 12 years. She wants to stop, and you make some recommendations to her. Which of the following is true regarding smoking cessation in women?

A 32-year-old G2P0101 presents to labor and delivery at 34 weeks of gestation, complaining of regular uterine contractions about every 5 minutes for the past several hours. She has also noticed the passage of a clear fluid per vagina. A nurse places the patient on an external fetal monitor and calls you to evaluate her status. The external fetal monitor demonstrates a reactive fetal heart rate tracing, with regular uterine contractions occurring about every 3 to 4 minutes. On sterile speculum examination, the cervix is visually closed. A sample of pooled amniotic fluid seen in the vaginal vault is fern and nitrazine-positive. The patient has a temperature of 38.8C, pulse 102 beats per minute, blood pressure 100/60 mm Hg, and her fundus is tender to deep palpation. Her admission blood work comes back indicating a WBC of 19,000. The patient is very concerned because she had previously delivered a baby at 35 weeks who suffered from respiratory distress syndrome (RDS). You perform a bedside sonogram, which indicates oligohydramnios and a fetus whose size is appropriate for gestational age and with a cephalic presentation. Which of the following is the most appropriate next step in the management of this patient?

A 32-year-old G2P1001 at 20 weeks gestational age presents to the emergency room complaining of constipation and abdominal pain for the past 24 hours. The patient also admits to bouts of nausea and emesis since eating a very spicy meal at a new Thai restaurant the evening before. She denies a history of any medical problems. During her last pregnancy, the patient underwent an elective cesarean section at term to deliver a fetus in the breech presentation. The emergency room doctor who examines her pages you and reports that the patient has a low-grade fever of 37.7C (100F), with a normal pulse and blood pressure. She is minimally tender to deep palpation with hypoactive bowel sounds. She has no rebound tenderness. The patient has a WBC of 13,000, and electrolytes are normal. Which of the following is the most appropriate next step in the management of this patient?

A 32-year-old G3P2 at 39 weeks gestation with an epidural has been pushing for 30 minutes with good descent. The presenting fetal head is left occiput anterior with less than 45 degree of rotation with a station of +3 of 5. The fetal heart rate has been in the 90s for the past 5 minutes and the delivery is expedited with forceps. Which of the following best describes the type of forceps delivery performed?

A 32-year-old G3P3 woman is postoperative day 5 after an emergent cesarean section due to fetal distress. The patient progressed rapidly through passive labor without incident, but after her membranes were ruptured manually, a fetal scalp probe was placed in the active phase secondary to several runs of mid-late decelerations. Cesarean section was ultimately performed after 2 hours of active labor secondary to fetal distress. The patient presents now with a fever to 38.7C (101.7F) and uterine tenderness. Laboratory tests reveal a WBC count of 14,000/mm3, with 70% neutrophils and 4% bands. Which of the following is the most appropriate treatment?

A 32-year-old Hispanic woman presents to the emergency department complaining of heavy vaginal bleeding. Her temperature is 37 C (98.6 F), blood pressure is 80/50 mm Hg, pulse is 110/min, and respirations are 18/min. Her abdomen is soft, non-tender and non-distended. Her pelvic examination reveals approximately 200 mL of clotted blood in the vagina, an open cervical os with tissue protruding from it, and a 10-week-sized, non-tender uterus. Leukocyte count is 9000/mm3, hematocrit is 22%, and platelet count is 275,000/mm3. Quantitative hCG is 100,000mIU/L (normal: 5-200,000mIU/L). Pelvic ultrasound shows echogenic material within the uterine cavity consistent with blood or tissue, no adnexal masses, and no free fluid. No viable pregnancy is seen. Which of the following is the most appropriate next step in management?

A 32-year-old man presents to his primary care physician complaining of diffuse muscle weakness, dry and puffy skin, and patchy areas of hair loss on his scalp. He also notes numbness around his mouth and a tingling sensation in his hands and feet. He has a history of seizure disorder, and has been taking carbamazepine for the past 5 years. On physical examination he has dry skin and coarse, brittle hair with patchy alopecia. Tapping his right cheek causes contraction of the muscles at the corner of his mouth, nose, and eye on the right side. Which of the following could best have prevented the development of the patient’s current problem?

A 32-year-old man presents to the emergency department with pain and swelling in the right leg. He was recently hospitalized for a right lower extremity deep venous thrombosis and discharged on warfarin. Today his INR is 1.12. Ultrasound reveals a right popliteal vein thrombosis extending into the deep femoral vein. What is the best initial management step for this patient?

A 32-year-old man presents with an asymptomatic mass in his right testicle. On examination, the mass cannot be transilluminated. Ultrasound shows a solid mass in the right testicle. Which of the following is the most accurate method in obtaining a diagnosis of testicular cancer?

A 32-year-old man with a 3-year history of ulcerative colitis (UC) presents for discussion for surgical intervention. The patient is otherwise healthy and does not have evidence of rectal dysplasia. Which of the following is the most appropriate elective operation for this patient?

A 32-year-old multiparous African-American woman comes for her initial prenatal visit at 14 weeks' gestation. She complains of the recent appearance of facial hair and acne. The beta-HCG level is consistent with gestational age. Examination shows hirsutism. Ultrasonogram shows an intrauterine gestation consistent with dates and bilateral solid nodular masses in both ovaries. Which of the following is the most appropriate next step in management?

A 32-year-old nulliparous woman at 38 weeks' gestation comes to the labor and delivery ward with regular painful contractions after a gush of fluid two hours ago. Her temperature is 98.6 F (37 C). She is found to have gross rupture of membranes and to have a cervix that is 6 centimeters dilated. The fetus is in breech position. The patient is then brought to the operating room for cesarean delivery. Which of the following represents the correct procedure for antibiotic administration?

A 32-year-old white woman complains of abdominal pain off and on since the age of 17. She notices abdominal bloating relieved by defecation as well as alternating diarrhea and constipation. She has no weight loss, GI bleeding, or nocturnal diarrhea. On examination, she has slight LLQ tenderness and gaseous abdominal distension. Laboratory studies, including CBC, are normal. Which of the following is the most appropriate initial approach?

A 32-year-old woman comes to the hospital for an elective repeat cesarean delivery. Four years ago she had a primary cesarean delivery for a nonreassuring fetal heart rate tracing. Two years ago she chose to have an elective repeat cesarean delivery rather than attempt a vaginal birth after cesarean (VBAC). Her prenatal course was uncomplicated except that she has mitral valve prolapse. An echocardiograph demonstrated the mitral valve prolapse, but no other structural cardiac disease. Which of the following is the correct management of this patient?

A 32-year-old woman comes to the physician because of amenorrhea. She had menarche at age 13 and has had normal periods since then. However, her last menstrual period was 8 months ago. She also complains of an occasional milky nipple discharge. She has no medical problems and takes no medications. She is particularly concerned because she would like to become pregnant as soon as possible. Examination shows a whitish nipple discharge bilaterally, but the rest of the examination is unremarkable. Urine human chorionic gonadotropin (hCG) is negative. Thyroid stimulating hormone (TSH) is normal. Prolactin is elevated. Head MRI scan is unremarkable. Which of the following is the most appropriate pharmacotherapy?

A 32-year-old woman comes to the physician because of recurrent painful outbreaks on her labia and vagina. Her first outbreak was six years ago. At that time she developed what she thought was a bad "flu" with malaise and a fever, along with a painful rash on her labia. This initial outbreak resolved, but since then she has had approximately 8 -10 outbreaks each year. Each outbreak is preceded by burning in her perineal area. A few days later she develops vesicles, then shallow, painful ulcers that resolve in about 10 days. Which of the following is the most appropriate pharmacotherapy?

A 32-year-old woman comes to your office for re-evaluation of her birth control method. She wants her intrauterine device (IUD) removed because it is causing her pelvic pain. She wants to be placed on oral contraceptive pills (OCPs). She has had hypertension for the past five years controlled with hydrochlorothiazide and atenolol. She has a family history of diabetes mellitus and ovarian carcinoma. Her body mass index (BMI) is 34 kg/m2. Physical examination is unremarkable. If she starts taking oral contraceptive pills, which of the following statement is most correct?

A 32-year-old woman has a CXR screening, and a 1.5-cm mass is noted in the right lower lobe. She is a nonsmoker. Bronchoscopy shows a mass in the right lower lobe orifice, covered with mucosa. Biopsy indicates this is compatible with a carcinoid tumor. Imaging suggests ipsilateral mediastinal lymph node involvement but no extrathoracic disease. Which of the following is the most appropriate treatment plan?

A 32-year-old woman in the 2nd month of pregnancy is found to have a 5-cm mass in the upper outer quadrant of her left breast. Mammogram shows no other lesions, and core biopsy reveals infiltrating ductal carcinoma. Which of the following would be the best course of action at this time?

A 32-year-old woman undergoes an uncomplicated appendectomy for acute appendicitis. The pathology report notes the presence of a 1-cm carcinoid tumor in the tip of the appendix. Which of the following is the most appropriate management of this patient?

A 32-year-old woman who is 40 weeks pregnant comes to the maternity unit in active labor. She states that she has painful genital blisters and ulcers, which she has experienced intermittently in the past. Pelvic examination reveals exquisitely tender vesicles and ulcers on her labia and vagina consistent with an active genital herpes infection. She is advised by the obstetrician that she should undergo a primary cesarean section delivery because of the increased risk of fetal infection via passage through an infected birth canal. She is mentally competent and tells the obstetrician that she refuses to have a cesarean section because her mother died during a surgical procedure. Although the doctor explains the risks of a vaginal delivery, she still refuses. The obstetrician should do which of the following?

A 32-year-old woman who is one week postpartum presents with dull pain in her left leg for the past three days. She denies any history of trauma, fever or chills. Her pregnancy and delivery were uncomplicated, and her past medical history is unremarkable. She does not use tobacco, alcohol or illicit drugs. Her temperature is 37.2C (98.9 F) and blood pressure is 120/76 mm Hg. Physical examination reveals a swollen, tender, and mildly erythematous left leg. Doppler ultrasonogram reveals a thrombus in the superficial part of the femoral vein of the left leg. Which of the following is the most appropriate next step in management?

A 32-year-old woman, gravida 2, para 2, comes to the physician for follow-up of an abnormal Pap test. One month ago, her Pap test showed a high-grade squamous intraepithelial lesion (HGSIL). Colposcopy demonstrated acetowhite epithelium at 2 o'clock. A biopsy taken of this area demonstrated HGSIL. Endocervical curettage (ECC) was negative. The patient has no other medical problems, has never had cervical dysplasia, and takes no medications. Which of the following is the most appropriate next step in management?

A 32-year-old woman, gravida 3, para 0, at 29 weeks' gestation comes to the physician for a prenatal visit. She has no complaints. She had a prophylactic cerclage placed at 12 weeks' gestation because of her history of two consecutive 20-week losses. These spontaneous abortions were both characterized by painless cervical dilation, with the membranes found bulging into the vagina on examination. Ultrasound now demonstrates her cervix to be long and closed with no evidence of funneling. Which of the following is the most appropriate time to remove the cerclage from this patient?

A 32-year-old woman, gravida 3, para 2, at 14 weeks' gestation comes to the physician for a prenatal visit. She has some mild nausea, but otherwise no complaints. She has no significant medical problems and has never had surgery. She takes no medications and has no known drug allergies. She is concerned for two reasons. First, the "flu season" is coming, and she seems to get sick every year. Second, a child at her son's daycare center recently broke out with welts and was sent home. Which of the following vaccinations should this patient most likely be given?

A 32-year-old woman, gravida 3, para 2, at 30 weeks gestation comes to the hospital because of new onset painful, regular uterine contractions that began 5 hours ago. Her pregnancy has been uncomplicated. Her second pregnancy was complicated by preterm labor at 28 weeks gestation. She has no discharge, leakage of fluid or bleeding from the vagina; she has no dysuria or urgency. Her temperature is 37.0C (98.7F), blood pressure is 125/70 mmHg, pulse is 80/min and respirations are 18/min. Pelvic examination shows a soft, partially effaced and posterior cervix dilated to 2cm. A Nitrazine test is negative. Nonstress test shows a reassuring fetal heart pattern and uterine contractions occurring every 7 minutes. Which of the following is the most appropriate next step in management?

A 32-year-old woman, gravida 4, para 3, at 39 weeks' gestation comes the labor and delivery ward with painful contractions. Her prenatal course was unremarkable. Examination shows that her cervix is 5 cm dilated, 100% effaced and the fetal heart rate is in the 130s and reactive. She is given meperidine for pain control. She progresses rapidly and less than 2 hours later she delivers a 7-pound, 6-ounce (3,345g) male fetus. The one-minute APGAR score is 1 and the infant is making little respiratory effort. Which of the following is the most appropriate next step in management?

A 32-year-old women presents to the emergency room complaining of severe lower abdominal pain. She says she was diagnosed with pelvic inflammatory disease by her gynecologist last month, but did not take the medicine that she was prescribed because it made her throw up. She has had fevers on and off for the past 2 weeks. In the emergency room, the patient has a temperature of 38.3C (101F). Her abdomen is diffusely tender, but more so in the lower quadrants. She has diminished bowel sounds. On bimanual pelvic examination, bilateral adnexal masses are palpated. The patient is sent to the ultrasound department, and a transvaginal pelvic ultrasound demonstrates bilateral tubo-ovarian abscesses. Which of the following is the most appropriate next step in the management of this patient?

A 32-year-old, gravida 3, para 2 woman at 35 weeks gestation comes to the hospital because of regular and painful uterine contractions occurring every 5 - 6 minutes. She also has continuous leakage of clear fluid from her vagina that started 10 hours earlier. She has chronic hypertension and was prescribed methyldopa throughout pregnancy but has been noncompliant. She also has a history of drug abuse and has missed two previous antenatal appointments. Her temperature is 37.0C (98.7F), blood pressure is 160/100 mmHg, pulse is 80/min and respirations are 16/min. Sterile speculum examination shows pooling of amniotic fluid in the vagina; the cervix is 80% effaced and 3cm dilated. Ultrasound shows a small for gestational age fetus in the vertex presentation with a decreased amniotic fluid index. Fetal heart monitoring shows repetitive late decelerations. Uterine contractions are now occurring every 4 minutes. Which of the following is the most appropriate next step in management?

A 32-year-old, HIV-positive, primigravid woman comes to the physician for a prenatal visit at 30 weeks. Her prenatal course has been notable for her use of zidovudine (ZDV) during the pregnancy. Her viral load has remained greater than 1000 copies per milliliter of plasma throughout the pregnancy. She has no other medical problems and has never had surgery. Examination is appropriate for a 30-week gestation. She wishes to do everything possible to prevent the transmission of HIV to her baby. Which of the following is the most appropriate next step in management?

A 32-year-old, previously healthy man is a victim of a drive-by shooting, sustaining a gunshot wound to the left lower extremity. The entrance wound is located over the medial aspect of the calf, with an exit wound over the anterior pretibial region. Neurovascular examination of the extremity is normal. There is associated soft-tissue injury from the blast effect and a severely comminuted tibial fracture demonstrated on radiographs. Appropriate management of this injury includes which of the following?

A 33-year-old businessman with an unremarkable past medical history presents to you complaining of fatigue and some weight loss over the past three months. He awakens at 4:00 am each morning and is unable to fall back asleep. He also mentions that he used to enjoy playing golf twice per week, but now has little interest. Although he used to excel at work, he now finds himself losing interest and "spacing out" at times. He denies considering suicide. His TSH is normal. He is diagnosed with major depression and prescribed fluoxetine, and is asked to return for a follow-up appointment in two weeks. At the return visit, he states that his symptoms have not worsened, but have not improved either. He says, "I don't feel like the medication is doing anything." What is the most appropriate next step in the management of this patient's condition?

A 33-year-old computer programmer was diagnosed with ulcerative colitis last year. He had a colonoscopy and biopsy that showed pancolitis, after which no further work-up was done. This is his first visit to a physician in 6 months. He takes aminosalicylates and is in remission, without any symptoms. He is a member of the Ulcerative Colitis Support Group, which recently sent him a letter that said he should be screened for colon cancer. His vital signs are stable. Physical examination reveals mild tenderness on deep palpation of the lower abdomen. What is the best advice for him regarding his concerns?

A 33-year-old G1P1 woman presents to her gynecologist for a Pap smear. It has been several years since she last saw a physician. She is not currently sexually active, but takes oral contraceptives. Her vaginal examination is normal, but her Pap smear shows moderate-grade cervical intraepithelial neoplasia. The patient undergoes colposcopy and biopsies, which confirm the diagnosis. What is the most appropriate management of this patient?

A 33-year-old man presents with a 1-day history of localized, small swelling along the margin of the upper eyelid. He feels pain, which does not seem to come from the conjunctival surface. He has a 10-pack year smoking history. He occasionally drinks alcohol. He is sexually active, and does not use condoms regularly. He is worried about the swelling. What is the best next step in the management of this patient?

A 33-year-old pregnant woman notices a persistent, painless lump in the left breast. On examination the left breast has a single mobile mass without evidence of skin changes or lymphadenopathy in the neck or axilla. An ultrasound demonstrates a solid, 1-cm mass in the upper outer quadrant of the breast. A core-needle biopsy shows invasive ductal carcinoma. The patient is in her first trimester of pregnancy. Which of the following is the most appropriate management of this patient?

A 33-year-old primigravid woman at 18 weeks' gestation comes to the physician for a prenatal visit. Her prenatal course has been uncomplicated thus far. She has no complaints. She has had no loss of fluid, bleeding, or contractions. She has hypothyroidism, for which she takes thyroid hormone replacement. The patient states that a friend of hers recently had a preterm delivery. The patient is quite concerned about preterm delivery and wants to know whether home uterine activity monitoring (HUAM) is recommended. Which of the following is the most appropriate response?

A 33-year-old woman is found to have a palpable thyroid nodule during a routine medical checkup. A sonogram confirms the presence of a solid, 1.5-cm nodule in the right lobe of the thyroid gland. Fine needle aspirate cytology (FNA) is reported as "follicular tumor, otherwise unspecified." At surgery, a frozen section is read as follicular carcinoma. With the neck open, the surgeon can feel for enlarged jugular and peritracheal lymph nodes, and finds none. Which of the following is the most appropriate treatment?

A 33-year-old woman is undergoing a diagnostic work-up because she appears to have Cushing syndrome. She has elevated levels of cortisol, which are not suppressed when she is given high-dose dexamethasone. ACTH levels are greater than 200 pg/ mL. A chest x-ray film shows a central, 3-cm round mass on the hilum of the right lung. Bronchoscopy and biopsies confirm a diagnosis of small cell carcinoma of the lung. Which of the following is the preferred treatment for this woman?

A 33-year-old woman is very depressed about her recurrent pregnancy loss. She has had four pregnancies that all have ended in spontaneous abortion before 8 weeks. Her past medical history is otherwise unremarkable. She has never had surgery. She takes acetaminophen occasionally for headaches, but otherwise uses no medications and has no known drug allergies. Physical examination is normal. Laboratory evaluation demonstrates that she is positive for lupus anticoagulant and that she is positive for anticardiolipin IgG. These results are again positive 8 weeks later. Which of the following is the most appropriate management of this patient during her next pregnancy?

A 33-year-old woman, gravida 1, para 0, comes for a routine prenatal visit. According to her history, she is at 18-weeks gestation. Her family history is significant for Down syndrome on her maternal side. She does not use tobacco, alcohol or drugs. Vital signs are normal, and physical examination is unremarkable. Initial laboratory studies show a decreased maternal serum alpha-fetoprotein (MSAFP). Which of the following is the most appropriate next step in management?

A 34-year-old Caucasian female presents to the ER with a rash and pruritis. She says that she has had a sore throat for several days, and her friend gave her amoxicillin that turned out to be out dated. The rash developed about 30 minutes after she took the drug. Her blood pressure is 110/70 mmHg and heart rate is 80/min. Physical examination reveals wide spread urticaria and excoriations. Pharyngeal mucosa and tonsils are hyperemic, and tender lymph nodes are palpated in the submandibular area. Lungs are clear on auscultation. Which of the following is the best next step in the management of this patient?

A 34-year-old Caucasian male presents to the office with a 4-week history of diarrhea. He just returned from a trip to South America, where he developed foul-smelling stools, abdominal cramps and bloating. A three-day course of ciprofloxacin did not relieve his symptoms. His vital signs are within normal limits. Physical examination shows no abnormalities. Which of the following is the most appropriate next step in management?

A 34-year-old G1P1 with a history of pulmonary embolism presents to your office to discuss contraception. Her cycles are regular. She has a history of pelvic inflammatory disease last year, for which she was hospitalized. She has currently been sexually active with the same partner for the past year. She wants to use condoms and a spermicide. You counsel her on the risks and benefits. Which of the following statements is true regarding spermicides found in vaginal foams, creams, and suppositories?

A 34-year-old G2P1 at 31 weeks gestation with a known placenta previa is admitted to the hospital for vaginal bleeding. The patient continues to bleed heavily and you observe persistent late decelerations on the fetal heart monitor with loss of variability in the baseline. Her blood pressure and pulse are normal. You explain to the patient that she needs to be delivered. The patient is delivered by cesarean section under general anesthesia. The baby and placenta are easily delivered, but the uterus is noted to be boggy and atonic despite intravenous infusion of Pitocin. Which of the following is contraindicated in this patient for the treatment of uterine atony?

A 34-year-old G2P1 at 31 weeks gestation with a known placenta previa presents to the hospital with vaginal bleeding. On assessment, she has normal vital signs and the fetal heart rate tracing is 140 beats per minute with accelerations and no decelerations. No uterine contractions are demonstrated on external tocometer. Heavy vaginal bleeding is noted. Which of the following is the best next step in the management of this patient?

A 34-year-old male calls his primary care physician's office, requesting an urgent appointment to discuss a personal problem. The receptionist informs him that the physician is preparing to leave as it is near closing time, but that an appointment is available for early the next morning. The patient declines the offer of an appointment and hangs up. Fifteen minutes later, as the physician is locking the office up, the patient arrives and insists on being seen immediately. He breathlessly says that he has "some kind of red rash" on his penis, which has him very worried. He asks again to be examined now. What is the most appropriate response?

A 34-year-old male is brought to the emergency department by the paramedics after a gun-shot injury. His temperature is 37C (98.8F), blood pressure is 110/60 mm Hg, pulse is 96/min and respirations are 18/min. Examination shows a gunshot entry wound in the left 6th intercostal space anteriorly just lateral to the mid-clavicular line, and an exit wound in left 7th intercostal space posteriorly. After completing the primary survey by attending to airway, breathing and circulation, which of the following is the most appropriate next step in management?

A 34-year-old male presents to his physician's office for a routine health maintenance examination. He has a five-year history of bronchial asthma for which he uses an albuterol inhaler. He says that he uses the inhaler an average of two times per week during the day. In addition, he states that his asthma symptoms wake him from sleep approximately 3-4 times per month. He does not use tobacco, alcohol or illicit drugs. His family history is significant for asthma in his grandfather. Physical examination is unremarkable. Which of the following is the most appropriate next step in his management?

A 34-year-old male presents with palpitations for the past 4 hours without associated chest pain, shortness of breath, fevers, or chills. His medical history is significant for Wolff-Parkinson-White syndrome for the past ten years and three prior episodes of supraventricular tachycardia. He does not smoke cigarettes, and drinks alcohol on social occasions. He does report having had five cans of beer while at a party last night. On examination, his blood pressure is 120/80 mmHg and his pulse is irregularly irregular. EKG shows atrial fibrillation with a rate of 160/min. What is the best next step in the management of this patient?

A 34-year-old male with a history of mitral valve prolapse and mitral regurgitation presents with one week of intermittent fevers and increasing fatigue. He was punched in the face during a street fight two weeks ago. On admission he receives empiric intravenous vancomycin and gentamicin. Three days later, three out of four blood cultures grow Streptococcus viridans highly sensitive to penicillin. Which of the following is the best next step in managing this patient?

A 34-year-old man comes to the emergency department because of severe pain in his penis. He was having sex with his wife on top when he had sudden onset severe pain in the penis at the height of orgasm. Swelling of the penis and deviation of the penile shaft to the right followed the pain. Examination shows a man in severe distress. The penis is uncircumcised, grossly swollen and deviated to the right. There is no blood at the urethral meatus. Which of the following is the most appropriate next step in management?

A 34-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He has severe abdominal and left shoulder pain. His temperature is 36C (96.8F), blood pressure is 100/60 mm Hg, pulse is 110/min and respirations are 23/min. Examination shows tenderness in the left upper quadrant of the abdomen. An x-ray film of the chest shows fractures of the left 7th, 8th and 9th ribs. A CT scan of the abdomen is suggestive of splenic injury with some free fluid in the abdomen. He has not been vaccinated for H. Influenza or S. pneumoniae. Which of the following is the most important determinant for surgical versus non-surgical management in this patient?

A 34-year-old man is extricated from an automobile after a motor vehicle collision. The patient has an obvious deformity of his right thigh consistent with a femur fracture. Upon closer examination of the right thigh, there is bone visible through an open wound. Which of the following is the most appropriate management of his open femur fracture?