USMLE_Management VI
USMLE Management Quiz VI
Test your medical knowledge with our comprehensive quiz designed for healthcare professionals preparing for the USMLE. This quiz features a variety of clinical scenarios that challenge your decision-making skills and knowledge of medical management in high-stakes situations.
- 100 Multiple Choice Questions
- Focused on USMLE Management Topics
- Immediate Feedback on Answers
A 31-year-old man from Florida presents to the ED complaining of severe pain that starts in his left flank and radiates to his testicle. The pain lasts for about 1 hour and then improves. He had similar pain last week that resolved spontaneously. He noted some blood in his urine this morning. His BP is 145/75 mm Hg, HR is 90 beats per minute, temperature is 98.9°F, and his RR is 24 breaths per minute. His abdomen is soft and nontender. As you examine the patient, he vomits and has trouble lying still in his stretcher. Which of the following is the most appropriate next step in management?
. Call surgery consult to evaluate the patient for appendicitis
. Order an abdominal CT
. Start intravenous (IV) fluids and administer an IV nonsteroidal anti-inflammatory drug (NSAID) and antiemetic
. Perform an ultrasound to evaluate for an abdominal aortic aneurysm (AAA)
. Perform an ultrasound to evaluate for testicular torsion
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?
. Intubation, mechanical ventilation, and positive end-expiratory pressure
. Stabilization of the chest wall with sandbags
. Stabilization with towel clips
. Immediate operative stabilization
. Pain control, chest physiotherapy, and close observation
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?
Administer aspirin and send for a troponin
Administer aspirin, clopidogrel, and heparin, and admit for acute coronary syndrome (ACS)
Administer ibuprofen and reassure the patient that he is not having a heart attack
Inject corticosteroid into the costochondral joint to reduce inflammation
Observe the patient for 6 hours
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?
. Abscess and chronic pelvic inflammatory disease
. Cervical incompetence and cervical stenosis
. Constipation and fecal incontinence
. Hernia and intraperitoneal adhesions
. Urinary incontinence and urinary retention
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?
. Family history of breast cancer
. Family history of endometrial cancer
. Family history of ovarian cancer
. Human immunodeficiency virus infection
. Migraine with aura
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?
. Continued clinical observation
. CT scan of the abdomen
. Sonogram of the abdomen
. Diagnostic peritoneal lavage
. Exploratory laparotomy
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?
. Both vaginal delivery and cesarean delivery are acceptable.
. Cesarean delivery is mandated because the fetuses are > 2000g.
. Cesarean delivery is mandated because the second twin is breech.
. Vaginal delivery is mandated because the fetuses are > 2000g.
. Vaginal delivery is mandated because the first twin is vertex.
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?
. Contact psychiatry to evaluate the patient
. Contact the hospital lawyers to get a court order for cesarean delivery
. Perform cesarean delivery at 38 weeks
. Perform cesarean delivery once the patient is in labor
. Respect the patient's decision and perform the vaginal delivery
A 32-year-old alcoholic man, recently emigrated from Mexico, presents with right upper quadrant pain and fevers for 2 weeks. CT scan of the abdomen demonstrates a non–rim-enhancing fluid collection in the periphery of the right lobe of the liver. The patient’s serology is positive for antibodies to Entamoeba histolytica. Which of the following is the best initial management option for this patient?
. Treatment with antiamebic drugs
. Percutaneous drainage of the fluid collection
. Marsupialization of the fluid collection
. Surgical drainage of the fluid collection
. Liver resection
A 32-year-old alcoholic with end-stage liver disease has been admitted to the hospital 3 times for bleeding esophageal varices. He has undergone banding and sclerotherapy previously. He admits to currently drinking 6 packs of beer per day. On his abdominal examination, he has a fluid wave. Which of the following is the best option for long-term management of this patient’s esophageal varices?
. Orthotopic liver transplantation
. Transection and reanastomosis of the distal esophagus
. Distal splenorenal shunt
. End-to-side portocaval shunt
. Transjugular intrahepatic portosystemic shunt (TIPS)
A 32-year-old anxious-appearing male is wheeled into the emergency room with the sudden onset of excruciating left-sided chest pain. His temperature is 37.2°C (99°F), blood pressure is 160/88 mmHg, pulse is 125/min, regular and respirations are 20/min. Physical examination is normal, except for multiple venous track marks on his extremities and atrophic nasal mucosa. An EKG is done which shows ST depression and T wave inversion in leads V1-V6. Cardiac enzymes including CK-MB and Troponin Tare not elevated. Which of the following is the most appropriate next step in the management of this patient?
. Cardiac catheterization
. Administer metoprolol
. Administer thrombolytics
. Close observation
. Intravenous diazepam
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?
. Folic acid
. Vitamin B12
. Iron
. Vitamin B6
. Vitamin B1
A 32-year-old Caucasian male comes to the emergency department due to progressive ascending paralysis, which began 18 hours ago. He initially noticed paresthesias in his lower limbs, followed by a sense of fatigue and weakness. He denies any history of headache, fever, and recent infection or illness. His blood pressure is 120/80 mm Hg, pulse is 80/min, respirations are 16/min, and temperature is 37.3°C (99.2°F). The physical examination reveals intact cranial nerves, absent deep tendon reflexes, and a normal sensory exam. Laboratory studies reveal a normal WBC count. No abnormalities are noted on CSF examination. While evaluating the patient in the hospital, he quickly deteriorates. What is the most appropriate next step in the management of this patient?
. IV immunoglobulin and plasmapheresis
. Administer botulinum antitoxin
. IV methylprednisolone
. Meticulous search for a tick
. MRI of the spine
A 32-year-old Caucasian male is admitted to the hospital due to a 1-week history of progressive paralysis of his upper and lower extremities. He had a flu-like illness 3 weeks ago, followed by paresthesias in his fingertips and toes. The weakness initially started in his lower extremities. He denies any changes in bowel and bladder functions. His blood pressure (supine) is 130/70mm Hg, heart rate is 82/min, respirations are 18/min, and temperature is 36.9°C (98.5°F). Physical examination reveals bilateral facial paralysis, orthostatic hypotension, areflexia in all four extremities, and distal paresthesias. His CSF analysis shows: Total WBC 10/cmm, Protein 120 mg/dl, Glucose 70 mg/dl, Gram stains No organisms. What is the most appropriate next step in the management of this patient?
. Intravenous methyl prednisolone
. Intravenous immunoglobulin therapy
. Intravenous acyclovir therapy
. Botulinum antitoxin
. Intravenous ceftriaxone and ampicillin
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?
. Levodopa
. Methotrexate
. Carbamazepine
. Lithium
. Morphine
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?
. Ninety percent of those who stop smoking relapse within 3 months.
. Nicotine replacement in the form of chewing gum or transdermal patches has not been shown to be effective in smoking cessation programs.
. Smokers do not benefit from repeated warnings from their doctor to stop smoking.
. Stopping cold turkey is the only way to successfully achieve smoking cessation.
. No matter how long one has been smoking, smoking cessation appears to improve the health of the lungs.
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?
. Administer betamethasone
. Administer tocolytics
. Place a cervical cerclage
. Administer antibiotics
. Perform emergent cesarean section
A 32-year-old G2P1 woman at 16 weeks gestation presents to her obstetrician complaining of fatigue, anxiety, and palpitations. She says she has been feeling warm, even in her air-conditioned home, and has been having three or four loose stools per day, as compared to one or two prior to her pregnancy. She has a temperature of 37.1°C (98.9°F), heart rate of 105/min, and blood pressure of 128/76 mmHg. Neck examination reveals mild diffuse enlargement of the thyroid gland with no lymphadenopathy. Relevant laboratory findings include a total triiodothyronine level of 400 ng/dL, free thyroxine of 6.8 ng/dL, and thyroid-stimulating hormone of 0.01 μU/mL (normal: 0.4–4 μU/L). Results of a thyroid- stimulating hormonereceptor antibody test are positive. Which of the following is the most appropriate therapy for this patient?
High-dose iodine therapy
Methimazole
Propylthiouracil
Radioiodine ablation
Surgical resection
A 32-year-old G2P1 woman at 35 weeks’ gestation presents to her obstetrician for a routine prenatal check-up. The mother has been previously diagnosed with mild preeclampsia, which the obstetrician has chosen to manage expectantly. During the visit, a biophysical profile is performed and the amniotic fluid index is found to be < 5 cm, indicating the development of oligohydramnios. The biophysical profile is otherwise normal, with a total score of 8/10 and reassuring fetal heart tracings. How should oligohydramnios be managed in this patient?
Administration of betamethasone, then cesarean section in 24 hours
Amnioinfusion with normal saline solution
Biweekly fetal biophysical profiles
Emergent cesarean section
No change in management is necessary
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?
. The history and physical examination are consistent with constipation, which is commonly associated with pregnancy; the patient should be discharged with reassurance and instructions to give herself a soapsuds enema and follow a high-fiber diet with laxative use as needed
. The patient should be prepped for the operating room immediately to have an emergent appendectomy
. The patient should be reassured that her symptoms are a result of the spicy meal consumed the evening before and should be given Pepto-Bismol to alleviate the symptoms
. The patient should be sent to radiology for an upright abdominal x-ray
. Intravenous antiemetics should be ordered to treat the patient’s hyperemesis gravidarum
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?
. Outlet forceps
. Low forceps
. Midforceps
. High forceps
. Rotational forceps
A 32-year-old G3P2 woman at 35 weeks’ gestation has a past medical history significant for hypertension. She was well-controlled on hydrochlorothiazide and lisinopril as an outpatient, but these drugs were discontinued when she found out that she was pregnant. Her blood pressure has been relatively well controlled in the 120–130 mm Hg systolic range without medication, and urinalysis has consistently been negative for proteinuria at each of her prenatal visits. She presents now to the obstetric clinic with a blood pressure of 142/84 mmHg. A 24hour urine specimen yields 0.35 g of proteinuria. Which of the following is the most appropriate next step?
Administer oral furosemide
Prepare for emergent delivery
Restart the patient’s prepregnancy antihypertensive regimen
Restricted activity and close monitoring as an outpatient following initial inpatient evaluation
Start hydralazine
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?
Ampicillin and gentamicin
Cefotaxime and levofloxacin
Clindamycin and gentamicin
Imipenem
Metronidazole and doxycycline
A 32-year-old G3P3 woman presents to her obstetrician for help conceiving. She states her menstrual cycles have not been regular since the birth of her third child 3 years ago. Furthermore, although she readily became pregnant with her other three children, she has failed to become pregnant despite trying over the past 2 years. She has no significant past medical history and takes only prenatal vitamins. Although she says she has not been ill lately, she reports feeling “tired and cold all the time.” She also reports she has had trouble sleeping over the past several months. Her physical examination is normal. Laboratory tests show: WBC count: 9000/mm3; Hemoglobin: 8.0 g/dL; Platelet count: 300,000/mm3; Hematocrit: 40%; Thyroid-stimulating hormone level: 0.5 μU/mL; Free thyroxine: 2.0 ng/dL; Luteinizing hormone: 0.5 mU/mL; Follicle-stimulating hormone: 0.5 mU/mL. Which of the following will this woman likely need to take to conceive?
Clomiphene
Levothyroxine
Prednisone
Progesterone
Propylthiouracil
A 32-year-old generally healthy woman presents to the office for a routine preemployment physical. She uses a vaginal ring for birth control. Her LMP was 2 weeks ago. She has been pregnant three times and has had two full-term births via normal spontaneous vaginal delivery. She had one spontaneous miscarriage at 10 weeks' gestation. She is only sexually active with her husband. She has a family history of breast cancer in her mother. Her mother had breast cancer at age 40 years and again at age 56 years. Her aunt also had breast cancer at an early age. Her last Pap smear, including human papillomavirus (HPV) was negative last year. BP, 120/80 mm Hg; P, 75 beats/min; R, 14 breaths/min; T, 98.4°F. Physical examination: Gen: Awake, alert, oriented x3, CVS: S1S2+ RRR no m/r/g, Lungs: Clear to auscultation bilaterally, Breast: No breast mass felt. What should be done as a part of the evaluation?
. Gonorrhea screening
. Chlamydia screening
. BRCA gene testing
. Mammography
. Pap-smear
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?
Discharge to home
Culdocentesis
Dilation and evacuation
Laparoscopy
Laparotomy
A 32-year-old Italian-American man presents to your office for a routine check-up. He works as a business executive and admits to being under a lot of stress recently. He drinks alcohol occasionally and smokes one pack of cigarettes per day. Laboratory analyses reveal: Hemoglobin 10.1 mg/dl, RBC count 4.0 x 10^12/L, MCV 70fl, WBC count 5,500/mm3, Platelets 170,000/mm3, Serum calcium 10.1 mg/dl, Serum potassium 4.5 meq/L, Serum sodium 135 meq/L. Serial fecal occult blood tests are negative. A peripheral blood smear reveals the following: Which of the following is the best treatment for this patient?
. Iron
. Folic acid
. Cobalamin
. Reassurance
. Erythropoietin
A 32-year-old man from Arkansas presents to physician with a two-day history of fever, headache, malaise, and myalgias. His family says that he seems slightly confused. He recalls having a tick bite two weeks ago after walking through the woods. His temperature is 39°C (102°F), pulse is 90/min, and blood pressure is 125/80 mm Hg. Neck is supple and there is no lymphadenopathy noted. Oropharynx is clear. Chest auscultation is unremarkable. Abdomen is soft and non-tender. There is no rash evident. Neurologic examination is nonfocal. Laboratory testing shows: Complete blood count:Hemoglobin 14.0 g/L, MCV 88 fL, Platelets 78,000/mm3, Leukocyte count 2,500/mm3, Neutrophils 56%, Eosinophils 1%, Lymphocytes 33%, Monocytes 10%. Liver studies:Total protein, serum 6.5 g/dL, Total bilirubin 1.0 mg/dL, Direct bilirubin 0.8 mg/dL, Alkaline phosphatase 110 U/L, Aspartate aminotransferase (SGOT) 98 U/L, Alanine aminotransferase (SGPT) 105 U/L. What is the most appropriate next step in the management of this patient?
. Doxycycline
. Chloramphenicol
. Erythromycin
. Ceftriaxone
. Hepatitis serology
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?
Magnesium supplementation
Parathyroidectomy
Thyroid hormone
Vitamin C supplementation
Vitamin D supplementation
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?
. Increase warfarin dose for goal INR > 2.0
. Start intravenous unfractionated heparin
. Initiate thrombolytic therapy
. Place inferior vena cava filter
. Discontinue warfarin and reassure
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?
. Serum levels of alpha-fetoprotein and beta human chorionic gonadotrophin
. Percutaneous biopsy of the testicular mass
. Incisional biopsy of the testicular mass through a scrotal incision
. Excisional biopsy of the testicular mass through a scrotal incision
. Radical inguinal orchiectomy
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?
. Total proctocolectomy with end ileostomy
. Total proctocolectomy with ileal pouch-anal anastomosis and diverting ileostomy
. Total proctocolectomy with ileal pouch-anal anastomosis, anal mucosectomy, and diverting ileostomy
. Total abdominal colectomy with ileal-rectal anastomosis
. Total abdominal colectomy with end ileostomy and very low Hartmann
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?
. Suction evacuation of uterus
. Exploratory laparotomy
. Ultrasound guided aspiration of the mass
. Diagnostic laparoscopy
. Reassurance and follow-up with ultrasonogram
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?
. Administer intravenous antibiotics 30 minutes prior to the procedure
. Administer intravenous antibiotics after the cord is clamped
. Administer intravenous antibiotics immediately after the procedure
. Administer intravenous antibiotics for 24 hours after the procedure
. Administer oral antibiotics for 1 week following the procedure
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?
. Recommend increased dietary fiber, antispasmodics as needed, and follow-up examination in 2 months
. Refer to gastroenterologist for colonoscopy
. Obtain antiendomysial antibodies
. Order UGI series with small bowel follow-through
. Order small bowel biopsy
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?
. Administer intravenous antibiotics 30 minutes prior to the procedure
. Administer intravenous antibiotics immediately after the procedure
. Administer intravenous antibiotics for 24 hours after the procedure
. Administer oral antibiotics 6 hours after the procedure
. No antibiotics are needed
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?
. Bromocriptine
. Dicloxacillin
. Magnesium sulfate
. Oral contraceptive pill (OCP)
. Thyroxine
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?
. Daily oral acyclovir
. Daily oral estrogen
. Daily topical estrogen
. Daily oral ferrous sulfate
. Daily oral penicillin
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?
. She is at risk of endometrial cancer
. Her hypertension may worsen
. She will develop benign breast disease
. She will become diabetic
. She is at risk of ovarian cancer
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?
. Right lower lobectomy and mediastinal lymph node dissection
. Right lower lobectomy and mediastinal lymph node dissection followed by adjuvant chemotherapy
. Neoadjuvant chemotherapy followed by right lower lobectomy and mediastinal lymph node dissection
. Neoadjuvant chemoradiation followed by right lower lobectomy and mediastinal lymph node dissection
. Chemoradiation
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?
. Chemotherapy now, deferring surgery until after delivery
. Radiation therapy now, deferring surgery until after delivery
. Lumpectomy and axillary sampling, followed in 6 weeks by radiotherapy
. Modified radical mastectomy now, deferring systemic therapy until later
. Immediate therapeutic abortion and palliative breast surgery
A 32-year-old woman presents to the emergency department for left lower quadrant abdominal pain for thepast2 days. The patient states the pain is 8 of10 on the pain scale, non-radiating, and started off intermittent. The pain is now constant. She denies vomiting, diarrhea, and constipation but has nausea intermittently. Her last menstrual period was around 3 or 4 weeks ago. She has one sexual partner, and they have been trying to get pregnant. BP, 140/90 mm Hg; P, 90 beats/min; R, 15 breaths/min; T, 98.4°F. Review of system: Negative except for above. PE: Abd: Soft, tender in the left lower quadrant on palpation, + bowel sounds. Which of the following is the next step in the management of this patient?
. Beta-human chorionic gonadotropin (BHCG)
. Computed tomography (CT) scan of the abdomen and pelvis
. Complete blood count (CBC)
. Transvaginal ultrasonography (US)
. MRI
A 32-year-old woman presents to your office for her well-woman examination. She is also worried because she has not been able to achieve orgasm with her new partner, with whom she has had a relationship for the past 3 months. She had three prior sexual partners and achieved orgasm with them. She is taking a combined oral contraceptive pill for birth control and an antihypertensive medication for chronic hypertension. She has also been on fluoxetine for depression for the past 2 years. She smokes one pack per day and drinks one drink per week. She had a cervical cone biopsy for severe cervical dysplasia 6 months ago. Which of the following is the most likely cause of her sexual dysfunction?
. Clonidine
. Contraceptive pill
. Disruption of cervical nerve pathways
. Fluoxetine
. Nicotine
A 32-year-old woman presents to your office with dysuria, urinary frequency, and urinary urgency for 24 hours. She is healthy but is allergic to sulfa drugs. Urinalysis shows large blood, leukocytes, and nitrites in her urine. Which of the following medications is the best to treat this patient’s condition?
. Dicloxacillin
. Bactrim
. Nitrofurantoin
. Azithromycin
. Flagyl
A 32-year-old woman undergoes a cholecystectomy for acute cholecystitis and is discharged home on the sixth postoperative day. She returns to the clinic 8 months after the operation for a routine visit and is noted by the surgeon to be jaundiced. Laboratory values on readmission show total bilirubin 5.6 mg/dL, direct bilirubin 4.8 mg/dL, alkaline phosphatase 250 IU (normal 21-91 IU), serum glutamic oxaloacetic transaminase (SGOT) 52 kU (normal 10-40 kU), and serum glutamic pyruvic transaminase (SGPT) 51 kU (normal 10-40 kU). An ultrasonogram shows dilated intrahepatic ducts. The patient undergoes the transhepatic cholangiogram seen here. Which of the following is the most appropriate next management step?
. Choledochoplasty with insertion of a T tube
. End-to-end choledochocholedochal anastomosis
. Roux-en-Y hepatico-jejunostomy
. Percutaneous transhepatic dilatation
. Choledochoduodenostomy
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?
. Right hemicolectomy
. Right hemicolectomy and chemotherapy
. Chemotherapy only
. Radiation only
. No further treatment
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?
Allow a vaginal delivery
Obtain a court order to perform the cesarean delivery
Perform the cesarean section without her consent
Obtain the consent of the husband to perform the cesarean delivery
Refer her to another physician
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?
. Reassurance and ibuprofen
. Anticoagulation with heparin
. Inferior vena cava filter
. Thrombolytic therapy
. Antistaphylococcal antibiotics
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 37.2 C (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 femoral vein of the left leg. Which of the following is the most appropriate next step in management?
. Reassurance and ibuprofen
. Anticoagulation with heparin
. Inferior vena cava filter
. Thrombolytic therapy
. Antistaphylococcal antibiotics
A 32-year-old woman with a history of diabetes presents with an IUP at 5 weeks. She has been taking metformin, glyburide, and lisinopril. Her glucose has been well controlled on these medications. Vital sign: BP, 120/80 mm Hg; P, 75 beats/min; R, 12 breaths/min; T, 98°F (37 C). She denies leakage of fluid, denies contractions, denies fetal movement, denies vaginal bleeding, and denies abdominal pain. What is the next best step in the management?
. Switch the patient to insulin
. Continue metformin but discontinue glyburide
. Continue both metformin and glyburide
. Stop both metformin and glyburide and change to acarbose
. Stop both metformin and glyburide and start rosiglitazone
A 32-year-old woman, gravida 1, para 0, with a history of infertility, underwent ovulation induction resulting in a twin pregnancy, now at 31 weeks’ gestation. An early obstetric sonogram at 7 weeks’ gestation showed dichorionic placentation. She has a positive group B –hemolytic streptococcus vaginal culture. Because of epigastric pain, vaginal bleeding, and uterine contractions, she is evaluated at the maternity unit. An obstetric sonogram shows twin A to be a female fetus in breech presentation and twin B to be a male fetus in transverse lie with the back down. The sonogram also shows a marginal anterior placenta previa. Her initial vital signs are as follows: temperature, 37.2C (99.0F); pulse, 95/min; respiration, 18/min; blood pressure, 165/115 mm Hg. Her urine dipstick test shows 2 glucose and 3 albumin. Which of the following is a contraindication to tocolysis in this case?
Multiple gestation
Marginal placenta previa
Severe preeclampsia
Early gestational age
Positive group B -hemolytic streptococcus vaginal culture
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?
. Repeat Pap test in 1 year
. Repeat Pap test in 6 months
. Repeat colposcopy in 6 months
. Loop electrode excision procedure (LEEP)
. Hysterectomy
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?
. 30-32 weeks
. 32-34 weeks
. 34-36 weeks
. 36-38 weeks
. 38-40 weeks
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?
. Influenza
. Measles
. Mumps
. Rubella
. Varicella
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?
. Tocolysis
. Amnioinfusion
. Reassure and discharge home
. Augment delivery
. Cervical cerclage
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 37.0 C (98.7 F), 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 2 cm. A Nitrazine test is negative. Non-stress 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?
. Tocolysis
. Amnioinfusion
. Reassure and discharge home
. Augment delivery
. Cervical cerclage
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?
. Blood transfusion
. Glucose
. Naloxone
. Penicillin
. Sodium bicarbonate
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?
. Admit the patient for emergent laparoscopic drainage of the abscesses.
. Call interventional radiology to perform CT-guided percutaneous drainage of the abscesses.
. Send the patient home and arrange for intravenous antibiotics to be administered by a home health agency.
. Admit the patient for intravenous antibiotic therapy.
. Admit the patient for exploratory laparotomy, TAH/BSO.
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?
. Augmentation of labor
. Tocolysis
. Cesarean section
. Betamethasone IM
. Expectant 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?
. Offer elective cesarean section after amniocentesis to determine lung maturity
. Offer elective cesarean section at 38 weeks
. Offer elective cesarean section at 34 weeks
. Recommend forceps-assisted vaginal delivery
. Recommend vaginal delivery
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?
. Local wound irrigation, closure of the soft-tissue defect, closed reduction, and immobilization in a long-leg cast
. Local wound irrigation with antibiotic solution, closed reduction, and immobilization in a long-leg cast, with continued local wound care through an anterior cast window
. Tetanus prophylaxis, intravenous (IV) antibiotics, and operative wound irrigation and debridement, with application of an external fixation device
. Tetanus prophylaxis, IV antibiotics, operative wound irrigation with closure of the soft-tissue defect, closed reduction, and immobilization in a long-leg cast
. Tetanus prophylaxis, IV antibiotics, long leg splint for immobilization, and operative intervention during elective surgical schedule
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?
. Continue with fluoxetine at the same dose
. Increase the dose of fluoxetine
. Discontinue fluoxetine and begin sertraline
. Discontinue fluoxetine and begin amitriptyline
. Continue fluoxetine and add amitriptyline
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?
. He has an increased risk of colon cancer and he should have prophylactic colectomy
. He has an increased risk of colon cancer and he should have colonoscopy every year
. He has an increased risk of colon cancer and he should have periodic colonoscopy eight years later
. Since he does not have any signs and symptoms, he has no increased risk and doesn't need any surveillance
. He has an increased risk of colon cancer, and he should have a biopsy
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?
Continued annual Pap smears
Loop electrosurgical excision procedure
Radiation therapy
Serial colposcopies every 3–4 months
Total abdominal hysterectomy
A 33-year-old male is admitted to the hospital after an episode of tonic-clonic seizures. He is a known IV drug abuser. He admits 'shooting' cocaine and heroin prior to the seizure. He has never had seizures before. Fallowing the seizure, he complains of muscle pain but otherwise feels normal. His temperature is 37.2°C (98.9°F) and his blood pressure is 156/90 mm Hg. Laboratory analyses reveal the following: CPK 11,200 U/ml, AST 545 U/L, ALT 560U/L, Troponin T normal, Anti-HAV antibodies negative, HBsAg negative, Anti-HBsAg negative, Anti-HCV antibodies positive. He reports that a recent HIV test was negative. Which of the following is the best management for this patient?
. Fluid restriction
. Metoprolol
. Hepatitis B vaccination
. Life-long phenytoin therapy
. No intervention
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?
. Use warm compresses
. Incision and drainage
. Incision and curettage
. Take biopsy of the lesion
. Oral Penicillin
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?
. Termination of the pregnancy followed by modified radical mastectomy
. Immediate administration of chemotherapy followed by modified radical mastectomy after delivery of the baby
. Administration of radiation in the third trimester followed by modified radical mastectomy after delivery of the baby
. Total mastectomy with sentinel lymph node biopsy
. Modified radical mastectomy
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?
. HUAM has been proven to cause preterm birth
. HUAM has been proven to prevent preterm birth
. HUAM has not been proven to prevent preterm birth
. HUAM should be started immediately
. HUAM should be started at 35 weeks
A 33-year-old white female complains of repeated episodes of fever, malaise, chills, breathlessness and dry cough over the past 6 months. She says that each episode starts suddenly and lasts for several days. She otherwise has no significant past medical history and does not take any medications. There is no family history of lung disorders. She does not smoke cigarettes or drink alcohol. She has never been abroad, and has had no sick contacts. She breeds budgerigars (a small Australian parrot) as a hobby. Chest x-ray shows diffuse generalized haziness in both lower lung fields. Pulmonary function tests reveal reduced lung volumes and an FEV1/FVC ratio of 87%. PPD test is negative. Serology shows antibodies to budgerigar antigens. What is the best treatment for this disease?
. Inhaled beclomethasone
. Oral prednisolone
. Inhaled cromolyn
. Avoid exposure to birds
. Reassurance
A 33-year-old woman at 10 weeks presents for her first prenatal examination. Routine labs are drawn and her hepatitis B surface antigen is positive. Liver function tests are normal and her hepatitis B core and surface antibody tests are negative. Which of the following is the best way to prevent neonatal infection?
. Provide immune globulin to the mother.
. Provide hepatitis B vaccine to the mother.
. Perform a cesarean delivery at term.
. Provide hepatitis B vaccine to the neonate.
. Provide immune globulin and the hepatitis B vaccine to the neonate.
A 33-year-old woman comes to the clinic at 16 weeks’ gestation with no complaints. This is her second pregnancy. During the first pregnancy she delivered an 8.5 lb. infant. The patient reports hydramnios during that pregnancy. She has no prior medical history and is on no medications. On physical examination, she has a firm uterus. Which of the following is the appropriate management of this patient?
. Genetic amniocentesis
. Glucose testing
. Maternal serum alpha-fetoprotein
. Pelvic Ultrasound
. Triple screen test
A 33-year-old woman comes to the physician because she has not had a menstrual period for 6 months. Prior to this she had a normal period every 29 days that lasted for 4 days. She has noted some weight gain in the past few months. She has a history of hepatitis A infection 6 years ago and had an appendectomy at age 12. She takes no medications and has no allergies to medications. Her father died of acute pancreatitis 3 years ago. Her mother is alive and well with no medical problems. Which of the following is the most appropriate next step in diagnosis?
Amylase
FSH
P-hCG
Liver function tests
TSH
A 33-year-old woman is 12 weeks pregnant with her third pregnancy. Her prior two pregnancies were uncomplicated and resulted in two normal spontaneous vaginal deliveries. It has been 7 years since her last delivery, and 4 years ago she was diagnosed with chronic hypertension. She was managed on an ACE-inhibitor but discontinued all medication when she started trying to conceive 6 months ago. She is doing well during the pregnancy except for some mild nausea and rare vomiting. Her physical examination is within normal limits for a woman at 12 weeks’ gestation. Her current blood pressure is 100/60 mmHg. At which of the following blood pressures should antihypertensive therapy be initiated in this patient?
. 100/60 mm Hg
. 110/70 mm Hg
. 120/80 mm Hg
. 140/90 mm Hg
. 150/111 mm Hg
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?
. Enucleation of the tumor
. Right thyroid lobectomy
. Total thyroidectomy
. Total thyroidectomy plus postoperative radioactive iodine
. Total thyroidectomy, radical neck dissection, and postoperative radioactive iodine
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?
. Bilateral adrenalectomy
. General support only
. Pneumonectomy
. Radiation and chemotherapy directed at the lung cancer
. Trans-sphenoidal hypophysectomy and pulmonary lobectomy
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?
. Daily heparin
. Daily heparin and low dose aspirin
. Daily low dose aspirin
. Paternal leukocyte immunization
. Paternal leukocyte immunization and intravenous immune globulin
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?
. Amniocentesis
. Chorionic villus sampling
. Ultrasonogram
. Cordocentesis
. Urinary estradiol levels
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?
. Continue amoxicillin therapy with non-outdated drug
. Administer adrenalin immediately
. Prescribe steroids
. Prescribe antihistamines
. Schedule for dialysis
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?
. Schedule colonoscopy
. Obtain CT scan of the abdomen
. Prescribe oral metronidazole
. Prescribe another course of ciprofloxacin
. Prescribe oral ampicillin
A 34-year-old G1P0 woman at 29 weeks’ gestation presents to the emergency department complaining of 2 hours of vaginal bleeding. The bleeding recently stopped, but she was diagnosed earlier with placenta previa by ultrasound. She denies any abdominal pain, cramping, or contractions associated with the bleeding. Her temperature is 36.8C (98.2F), blood pressure is 118/72 mm Hg, pulse is 75/min, and respiratory rate is 13/min. She reports she is Rh positive, her hemoglobin is 11.1 g/dL, and coagulation tests, fibrinogen, and D-dimer levels are all normal. On examination her gravid abdomen is non-tender. Fetal heart monitoring is reassuring, with a heart rate of 155/min, variable accelerations, and no decelerations. Two large-bore peripheral intravenous lines are inserted and two units of blood are typed and crossed. What is the most appropriate next step in management?
Admit to the antenatal unit for bed rest and betamethasone
Admit to the antenatal unit for bed rest and blood transfusion
Admit to the antenatal unit for bed rest and treatment with RhO(D) immune globulin
Emergent cesarean section
Outpatient expectant 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?
. The active agent in these spermicides is nonoxynol-9.
. The active agent in these spermicides is levonorgestrel.
. Effectiveness is higher in younger users.
. Effectiveness is higher than that of the diaphragm.
. These agents are associated with an increased incidence of congenital malformations.
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?
. Methylergonovine (Methergine) administered intramuscularly
. Prostaglandin F2α (Hemabate) suppositories
. Misoprostol (Cytotec) suppositories
. Terbutaline administered intravenously
. Prostaglandin E2 suppositories
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?
. Administer intramuscular terbutaline
. Administer methylergonovine
. Admit and stabilize the patient
. Perform cesarean delivery
. Induce labor
A 34-year-old G2P1001 with an IUP at 38 weeks' gestation presents to labor and delivery for contractions. The patient states that she has had gestational diabetes that was diet controlled throughout her pregnancy. She states that she has had routine prenatal care. Vital sign: BP, 125/88 mm Hg; P, 95 beats/min; R, 12 breaths/min; T, 98.6°F. Contractions: Present, Fetal movement: Present. Physical examination: Gen: Awake, alert, oriented x3, mild pain distress, CVS: S1S2+ RRR no m/r/g, Vaginal bleeding: Absent, Leakage offluid: Present, Lungs: CTA bilaterally, Abd: Gravid, contractions present, Ext: 1+ edema bilaterally. Cervical Examination: 7 cm, 100% effaced, -1 station. Fetal Heart Monitoring: Reassuring, good variability, accelerations are present, no decelerations. What is the next step in the management of this patient?
. Complete blood count (CBC)
. Finger stick
. HgbAlC
. Administer insulin drip
. Administer Ampicillin
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?
."It is extremely inappropriate on your part to come here despite my request that you make an appointment."
. "All right, we should look at your rash now. Come inside."
. "Your rash can most certainly wait until tomorrow."
. "Didn't I already inform you that it is closing time?''
. 'Although I understand your concern, we should address the issue tomorrow since it is not an emergency."
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?
. Place a chest tube
. Do a diagnostic peritoneal lavage
. Pericardiocentesis
. Do an exploratory laparotomy
. Do a thoracotomy
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?
. Add long-acting beta-2 agonist inhaler
. Add inhaled corticosteroids
. Add oral theophylline
. Add oral prednisone
. Continue current medical regimen
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?
. Digoxin
. Verapamil
. Lidocaine
. Procainamide
. Adenosine
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?
. Continue current regimen
. Switch antibiotics to IV ceftriaxone
. Switch antibiotics to IV aminoglycosides
. Switch antibiotics to oral penicillin V
. Switch antibiotics to oral amoxicillin/clavulanate
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?
. Surgical exploration of penis
. Retrograde urethrogram followed by surgical exploration of penis
. Foley's catheterization
. Antibiotics, analgesics and anti-inflammatory and follow up in 24 hours
. Do a circumcision
A 34-year-old man is being evaluated for possible end-stage renal disease. He has a long history of diabetes, type 1. He previously developed chronic renal insufficiency despite being on enalapril and insulin. His renal function is getting worse day by day. A nephrologist is currently managing his renal condition. Which of the following long-term treatments would give the best survival rate for this patient?
. Hemodialysis
. Peritoneal dialysis
. Renal transplantation from a cadaver
. Renal transplantation from a living related donor
. Renal transplantation from a living unrelated donor
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?
. Presence of left shoulder pain
. Presence of free fluid in the abdomen
. Presence of a rib fracture on chest x-ray
. Unvaccinated status of the patient
. Hemodynamic stability and hematocrit values
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?
. Intravenous (IV) antibiotics and cast or splint placement
. IV antibiotics and internal or external fixation
. Early irrigation and debridement, IV antibiotics, and cast or splint placement
. Early irrigation and debridement, IV antibiotics, and internal or external fixation
. Early irrigation and debridement, IV antibiotics, compartment decompression, and internal or external fixation
A 34-year-old man is traveling in Southeast Asia on business. He is staying in Western-style hotels and eating food in large restaurants. He has not eaten from street vendors. One week after arrival, he develops symptoms of anorexia, nausea, and abdominal cramps followed by the sudden onset of watery diarrhea. He has no fever or chills and there is no blood or pus in the stools. Which of the following is the most appropriate therapy for his condition?
Amoxicillin
Symptomatic therapy with loperamide
Doxycycline
Oral rehydration only
Specific antitoxin
A 34-year-old man presents with substernal discomfort. The symptoms are worse after meals, particularly a heavy evening meal, and are sometimes associated with hot/sour fluid in the back of the throat and nocturnal awakening. The patient denies difficulty swallowing, pain on swallowing, or weight loss. The symptoms have been present for 6 weeks; the patient has gained 20 lb in the past 2 years. Which of the following is the most appropriate initial approach?
. Therapeutic trial of ranitidine
. Exercise test with thallium imaging
. Esophagogastroduodenoscopy
. CT scan of the chest
. Coronary angiography
A 34-year-old obese female returns to the physician's office for a follow-up appointment at 16 weeks gestation. She was diagnosed with gestational diabetes at 12 weeks gestation and since then has been following dietary recommendations. She eats a balanced diabetic diet three times a day and avoids snacks. Her fasting blood sugars for the past two weeks have been in between 120 to 150 mg/dl. Her temperature is 37.0C (98.7F), blood pressure is 130/88 mmHg, pulse is 76/min and respirations are 14/min. Physical examination is unremarkable. Which of the following is the most appropriate therapy for this patient?
. Chlorpropamide
. Tolbutamide
. Insulin
. Exenatide
. Continue dietary therapy
A 34-year-old primigravid woman at 30 weeks' gestation comes to the physician with regular contractions every 6 minutes. Her prenatal course was significant for type 1 diabetes, which she has had for 10 years. Over the course of 1 hour, she continues to contract, and her cervix advances from closed and long to a fingertip of dilation with some effacement. The patient is started on magnesium sulfate, penicillin, and betamethasone. Which of the following is the most likely side effect from the administration of corticosteroids to this patient?
. Decreased childhood intelligence
. Increased maternal insulin requirement
. Maternal infection
. Neonatal adrenal suppression
. Neonatal infection
A 34-year-old prostitute with a history of long-term intravenous drug use is admitted with a 48-hour history of pain in her left arm. She is tachycardic to 130 and her systolic blood pressure is 80 mm Hg. Physical examination is remarkable for crepitus surrounding needle track marks in the antecubital space with a serous exudate. The plain x-ray of the arm is shown here. Which of the following is the most appropriate next step in her management?
. Treatment with penicillin G and close observation
. MRI of the arm
. CT scan of the arm
. Surgical exploration and debridement
. Hyperbaric oxygen therapy
A 34-year-old unrestrained male driver is brought to the ER after a motor vehicle accident. His cervical spine is immobilized. He is stuporous. At the scene of the accident, his blood pressure is 70/30 mm Hg and heart rate is 130/min. Lungs are clear to auscultation. Abdominal wall ecchymosis is present. Abdomen is mildly distended. Bowel sounds are decreased. Neck veins are collapsed. After two liters of intravenous fluids, his blood pressure is 80/40 mmHg. A focused assessment with sonography for trauma shows blood in the peritoneal cavity but no obvious solid organ injury. Which of the following is the most appropriate next step in management?
. Laparoscopy
. Laparotomy
. X-ray films of the abdomen and pelvis
. CT scan of the abdomen
. Diagnostic peritoneal lavage
A 34-year-old woman comes the physician because of lower abdominal cramping. The cramping started 2 days ago. Examination is unremarkable except for a pelvic examination that reveals a 10-week sized uterus. Urine hCG is positive, and pelvic ultrasound reveals a 10-week intrauterine pregnancy with a fetal heart rate of 160. The patient states that she is not sure whether to keep the pregnancy. Which of the following is the most appropriate next step in management?
. Counsel the patient or refer to an appropriate counselor
. Notify the patient's parents
. Notify the patient's partner
. Schedule a termination of pregnancy
. Tell the patient that she is likely to have a miscarriage
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