USMLE_Management X

A 50-year-old diabetic woman presents for follow-up of her hypertension. Her blood pressure is 152/96 in the office today and she brings in readings from home that are consistently in the same range over the past month. Her current medications are amlodipine 5 mg daily and hydrochlorothiazide 25 mg daily. The diuretic was added when she developed peripheral edema on the amlodipine; now she has only trace peripheral edema. A spot urine specimen shows 280 μg of albumin per mg creatinine (microalbuminuria is present if this value is between 30 and 300 μg/mg). What would be the best next therapeutic step in this patient?

A 50-year-old female comes into your office complaining of four-month history of dry cough. She denies dyspnea or hemoptysis. Past medical history is significant for hypertension, diabetes, and gout. Her current medications include enalapril, metformin, hydrochlorothia zide, and allopurinol. She does not smoke or consume alcohol. Her vital signs are BP 130/80 mmHg, HR 80/min, T 36.7°C (98°F) and RR 16/min. Physical examination is within normal limits. The best next step in the management of this patient is:

A 50-year-old female is 5 ft 7 in tall and weighs 185 lb. There is a family history of diabetes mellitus. Fasting blood glucose (FBG) is 160 mg/dL and 155 mg/dL on two occasions. HgA1c is 7.8%. You educate the patient on medical nutrition therapy. She returns for reevaluation in 8 weeks. She states she has followed diet and exercise recommendations but her FBG remains between 130 and 140 and HgA1C is 7.3%. She is asymptomatic, and physical examination shows no abnormalities. Which of the following is the treatment of choice?

A 50-year-old male patient comes to the office because he is concerned about the marked tremors of his hands. His tremors disappear with voluntary activity and worsen with emotional stress. He finds it mild difficult to initiate movements. He does not have a family history of tremors. Physical examination reveals tremors that occur at a frequency of 3-4 cycles/sec. There is rigidity of his limb musculature. His gait and posture is minimally disturbed. His higher mental functions are intact. Which of the following is the most appropriate treatment for this patient?

A 50-year-old man comes to the emergency department due to a sudden onset of severe, colicky pain in the right flank. He was admitted twice in the past for similar complaints; he was managed conservatively and sent home on both occasions. He has no other medical problems. He does not use tobacco, alcohol or drugs. His vital signs are stable. He is given IV fluids and narcotics. Laboratory studies show: Hb 14.5 g/dL, WBC 13,000/cmm; no bands, Platelets 300,000/cmm, BUN 16 mg/dl, Serum Creatinine 0.8 mg/dl. CT scan of the abdomen without contrast shows renal calculi. Which of the following is the best advice for the prevention of future stones in this patient?

A 50-year-old man comes to the emergency department due to acute onset respiratory difficulty. He also has periorbital, circumoral and facial edema. Two weeks ago, he experienced chest pain, profuse sweating and anxiety, and was subsequently admitted to the cardiac intensive care unit. At that time, his ECG showed ST segment elevation and Q waves in the inferior leads. He was taken to the catheterization lab and had an angioplasty with stent done for 100% occlusion of the right coronary artery. He was discharged with the following medications: aspirin, clopidogrel, metoprolol, enalapril, simvastatin and isosorbide mononitrate. In the ED, his pulse is 102/min, blood pressure is 110/70 mmHg, respirations are 24/min and temperature is 36.8°C (98.4°F). Which of the following is most likely responsible for his present symptoms?

A 50-year-old man complains of loss of libido and impotence after starting treatment with leuprolide for prostatic hyperplasia. An alpha-blocker and finasteride have also been tried, but with similar adverse effects. So far, the patient has not experienced any episodes of urinary tract infection or hematuria, but he is excessively bothered by his symptoms without any medication. Digital rectal examination shows mild prostatic enlargement. At this time, his prostate-specific antigen (PSA) is 4.5 ng/mL, and his creatinine is 0.7 mg/dL. Dipstick examination shows no hematuria. Which of the following is the most appropriate alternative to his current pharmacologic treatment?

A 50-year-old man is admitted to the hospital with a UGI bleed from acute erosive gastritis, secondary to chronic nonsteroidal anti-inflammatory use. His hematocrit is 28%. With fluid resuscitation, his blood pressure normalizes, but he has a persistent hyperdynamic precordium, tachycardia, and flow murmur on auscultation. He complains of shortness of breath on ambulation. An ECG shows depressed ST-T segments. Which of the following is the next appropriate step in management?

A 50-year-old man is incidentally discovered to have a low-grade mucosa-associated lymphoid tissue (MALT) lymphoma on biopsy of the stomach during esophagogastroduodenoscopy for dyspepsia. CT scans of the chest, abdomen, and pelvis demonstrate no evidence of enlarged regional lymph nodes or distant metastases. Which of the following is the initial treatment of choice?

A 50-year-old postman presents with a six-month history of left calf pain that is brought on by walking and is relieved by rest. The patient reports no other symptoms. He has smoked cigarettes for the past 25 years, but does not drink alcohol or use illicit drugs. On physical examination, he has a blood pressure of 158/92 mm Hg and a pulse of 88 beats per minute. The heart and lung examinations are normal. A bruit is heard over the left femoral artery. Popliteal, dorsalis pedis and posterior tibial pulses are palpable bilaterally. The electrocardiogram shows normal sinus rhythm and Q-waves in II, Ill, and aVF. Which of the following is the best next step in management?

A 50-year-old woman complains of headaches and lateralizing weakness. A CT scan of the brain reveals an irregular mass in the right cerebral hemisphere. A biopsy documents that this is a glioblastoma. Which of the following is the best treatment strategy for potential cure?

A 50-year-old woman presents to your office complaining of severe insomnia, hot flashes, and mood swings. She also states that her mother had a hip fracture at 65 years of age. She is afraid of developing osteoporosis and having a similar incident. Her last menstrual period was six months ago. Her past medical history is significant for hypothyroidism diagnosed seven years ago. She takes L-thyroxine and the dose of the hormone has been stable for the last several years. Her blood pressure is 120/70 mmHg and her heart rate is 75/min. Serum TSH level is normal. You consider estrogen replacement therapy for this patient. Which of the following is most likely concerning estrogen replacement therapy in this patient?

A 51-year-old man presenting to the clinic for routine examination mentions that he has not been able to get over the flu. Further questioning clarifies that he has had a nonproductive cough for the past 3–4 months and is unable to sustain his normal walking pace for prolonged periods. He reports feeling more fatigued than he recalls feeling last year. His medical history is significant for hypertension, alcoholism, and obesity. His blood pressure is well controlled on losartan and hydrochlorothiazide. He has no known drug allergies. His mother died of complications of type 2 diabetes mellitus. His father had a fatal myocardial infarction at age 56 years. The patient smokes half a pack of cigarettes per day and has done so for the past 7 years. He has worked all his adult life as an accountant and has no known exposures to asbestos or organic dusts. His blood pressure is 134/96 mm Hg, heart rate is 78/min, respiratory rate is 16/min, temperature is 37°C (98.6°F), and oxygen saturation is 94% on room air. Lung examination reveals bilateral inspiratory crackles in the lung bases. High-resolution CT shows patchy areas of ground glass, reticular abnormalities, and traction bronchiectasis. Laboratory findings are normal except for an elevated erythrocyte sedimentation rate of 54 mm/hr. What is the recommended treatment for this patient’s cough?

A 51-year-old man presents with a 2-cm left thyroid nodule. Thyroid scan shows a cold lesion. FNA cytology demonstrates follicular cells. Which of the following is the most appropriate initial treatment of this patient?

A 51-year-old woman G3P3 presents to your office with a 6-month history of amenorrhea. She complains of debilitating hot flushes that awaken her at night; she wakes up the next day feeling exhausted and irritable. She tells you she has tried herbal supplements for her hot flushes, but nothing has worked. She is interested in beginning hormone replacement therapy (HRT), but is hesitant to do so because of its possible risks and side effects. The patient is very healthy. She denies any medical problems and is not taking any medication except calcium supplements. She has a family history of osteoporosis. Her height is 5 ft 5 in and her weight is 115 lb. In counseling the patient regarding the risks and benefits of hormone replacement therapy, you should tell her that HRT (estrogen and progesterone) has been associated with which of the following?

A 51-year-old woman presents to the ED after 5 consecutive days of crushing substernal chest pressure that woke her up from sleep in the morning. The pain resolves spontaneously after 20 to 30 minutes. She is an avid rock climber and jogs 5 miles daily. She has never smoked cigarettes and has no family history of coronary disease. In the ED, she experiences another episode of chest pain. An ECG reveals ST-segment elevations and cardiac biomarkers are negative. The pain is relieved with sublingual nitroglycerin. She is admitted to the hospital and diagnostic testing reveals minimal coronary atherosclerotic disease. Which of the following is the most appropriate medication to treat this patient’s condition?

A 52-year-old Caucasian male comes to the office for the evaluation of tremors. He has been having tremors in both hands and head over the past several months. He does not experience any tremors at rest, or any problem with his legs. He has a history of alcohol abuse. He is currently not on any medication. His father had essential tremors, and his paternal uncle has Parkinsonism. The physical examination reveals tremors, which increase in amplitude when he tries to reach for an object. Which of the following is the most appropriate next step in the management of this patient?

A 52-year-old man complains of frequent chest pain. The pain typically occurs at night and is described as retrosternal and burning in quality. He leads a sedentary lifestyle but does not smoke or drink alcohol. His past medical history includes a chronic cough and occasional hoarseness. He does not take any medications. His BMI is 28.5 kg/m2 ECG stress testing reveals 1 mm ST segment depression in the inferior leads at 90% of predicted maximal heart rate. He did not experience chest pain during the stress test. Which of the following is most likely to relieve this patient's chest pain?

A 52-year-old man develops sudden-onset shortness of breath on postoperative day 4 after a hemicolectomy for colon cancer. His surgery went well with no operative complications. He reports no cough, sputum, or pleuritic chest pain. His blood pressure is 155/90 mm Hg, pulse 100/min, temperature 37.8°C, lungs are clear, and heart sounds normal. He has bilateral pedal edema, but no discomfort in his legs. His CXR and ECG are normal. A chest CT with contrast reveals a thrombus in his right upper lobe artery. Which of the following statements concerning the management of this condition is most likely correct?

A 52-year-old man is pinned against a loading dock. The patient has a fractured femur, a pelvic fracture, a tender abdomen, and no pulses in the right foot with minimal tissue damage to the right leg. Angiography discloses a popliteal artery injury with obstruction. At surgery, the popliteal vein is also transected. His blood pressure is 85/60 mm Hg. Which of the following is the best management strategy for his vascular injuries?

A 52-year-old man presents to his primary care physician’s office for routine care. He has hypertension, hypercholesterolemia, and type 2 diabetes mellitus, and has smoked one pack of cigarettes per day for the past 30 years. Medications include hydrochlorothiazide, atorvastatin, and glipizide. There is a family history of myocardial infarction in the maternal grandfather at age 60. The patient has undergone screening for colon and prostate cancer. Physical examination reveals a pleasant, obese man who is 175 cm (5􀆝9􀆎) tall and weighs 108 kg (238 lb). His blood pressure is 155/81 mmHg, heart rate is 78/min, respiratory rate is 14/min, and temperature is 36.8°C (98.3°F). What one action would most reduce the patient’s stroke risk?

A 52-year-old man with Burkitt lymphoma is admitted to the hospital for chemotherapy. He is started on chemotherapy without incident. Two days into his hospitalization, he develops new peaked T-waves on his ECG. Laboratory analysis reveals a serum potassium concentration of 6.2 mEq/L, and the patient is given one ampule of calcium gluconate emergently. His renal function is within normal limits. Which of the following additional interventions will most rapidly correct his hyperkalemia?

A 52-year-old man with gastric outlet obstruction secondary to a duodenal ulcer presents with hypochloremic, hypokalemic metabolic alkalosis. Which of the following is the most appropriate therapy for this patient?

A 52-year-old nurse seeks medical retirement because of a "heart condition." She complains of disabling attacks of tachycardia and palpitations. The physical examination and ECG studies confirm that indeed her pulse is between 100 and 105/min at all times, and she is in and out of atrial fibrillation. It is also noted that she is fidgety and constantly moving, and various examiners remark that she arrives for tests lightly dressed when it is rather cold outside. Thyroid function studies show elevated free thyroxine (T4) and undetectable levels of thyroid stimulating hormone (TSH). Her thyroid gland is not clinically enlarged or tender. Which of the following is the most appropriate next step in diagnosis?

A 52-year-old obese male presents with complaints of episodes of daytime sleepiness that prove irresistible. He reports feeling very refreshed and energized upon awakening from these "naps." A detailed history reveals he also frequently experiences a complete loss of muscle tone, especially when he laughs suddenly or feels a surge of intense emotion. Of particular concern to this patient is that he occasionally finds himself unable to move upon waking, and says he feels temporarily "frozen." His previous diagnoses include gout and external hemorrhoids. His family history is noncontributory. He does not smoke cigarettes or drink alcohol and denies recreational drug use. Physical examination reveals no abnormalities. Which of the following is the most appropriate treatment for this patient?

A 52-year-old postmenopausal woman who was diagnosed with advanced ovarian cancer presents to the clinic to discuss her treatment options. She has had a CT of the abdominalpelvic region that showed extensive disease extending from her left ovary and involving her uterus along with large pelvic nodes. What is the best treatment for this patient?

A 52-year-old woman comes to clinic complaining of a persistent urinary tract infection. She tells you that she has had a burning, almost scalding sensation when she urinates. These symptoms have lasted months. Additionally, she has suffered from intermittent urinary incontinence for the last year, which has tended to correlate with the symptoms. Her primary care physician has treated her with trials of oral trimethoprim-sulfamethoxazole and levofloxacin, but she has had no improvement in her symptoms. She denies any fevers, flank pain, discharge, or recent sexual activity, though she notes that she is having severe hot flashes. Physical examination reveals a thin, friable vaginal mucosa with multiple small punctate hemorrhages. Which of the following is the most appropriate treatment?

A 52-year-old woman has terminal cervical cancer with extensive pelvic invasion, and requires strong opiate analgesia to control severe pain. Intermittent nausea and vomiting have precluded the use of oral agents. She was on fentanyl patches but she developed allergic skin reactions to the adhesive and now requests to be switched to parenteral medication. Because of prior chemotherapy treatments she has no available venous access, but she is willing to have her family administer intramuscular injections. Assuming equianalgesic dosages, which of the following would be the most appropriate pharmacotherapy?

A 52-year-old woman is experiencing abdominal discomfort after meals as well as early in the morning. There is no weight loss or constitutional symptoms, and she has tried antacids but experienced minimal relief. Upper endoscopy reveals a duodenal ulcer and the biopsy is negative for malignancy. Which of the following is the most appropriate next step in management?

A 52-year-old woman undergoes a sigmoid resection with primary anastomosis for recurrent diverticulitis. She returns to the emergency room 10 days later with left flank pain and decreased urine output; laboratory examination is significant for a white blood cell (WBC) count of 20,000/mm3. She undergoes a CT scan that demonstrates new left hydronephrosis, but no evidence of an intra-abdominal abscess. Which of the following is the most appropriate next step in management?

A 52-year-old woman with a past medical history of hypertension presents for a lump in her breast. The patient noticed that her left breast was becoming slightly deformed and appears swollen on one side. The patient states that she first realized it when she was getting dressed about a month ago. She thought that it would go away on its own, but it seems to be growing. She is very concerned. BP, 136/82; P, 73 beats/min; R, 18 breaths/min; T, 98.6°F. Review of system: Denies weight loss, pain in the breast, nipple discharge, and erythema of the breast, Denies chest pain, shortness of breath, and abdominal pain. Physical examination: Gen: Awake, alert, oriented x3, no acute distress, Breasts: Asymmetric. Left breast slightly larger than right, with mass on left upper outer quadrant of breast. Thickening of skin in the same area. Palpation significant for a 2 in x 3 in mass in the left upper outer quadrant, nontender, nonmobile. The right breast is unremarkable. Which of the following the next step in the management of this patient?

A 52-year-old woman with cirrhosis presents with increasing abdominal distension. Her treatment regimen was amended three days ago, when furosemide was added to spironolactone and sodium/water restriction. However, her distension persists, and today she is very somnolent and has passed very little urine. Her past medical history is remarkable for chronic hepatitis type B, cirrhosis, encephalopathy, and 2 bleeding episodes from esophageal varices; the bleeding was controlled with sclerotherapy. Her temperature is 36.5°C (97.6°F), blood pressure is 90/60 mm Hg, pulse is 80/min, and respirations are 18/min. Abdominal examination shows distension, shifting dullness, and no tenderness; bowel sounds are present. Laboratory studies show: Hemoglobin 11.0 g/L, Leukocyte count 3,500/mm3, Serum sodium 125 mEq/L, Serum potassium 5.5 mEq/L, Chloride 103 mEq/L, Blood urea nitrogen 60 mg/dL, Serum creatinine 1.8 mg/dL, Prothrombin time 18 sec, Partial thromboplastin time 35 sec. Urinalysis shows no abnormalities. Ultrasound of the kidney is unremarkable. Which of the following is the most appropriate next step in management?

A 53-year-old Caucasian male is admitted to the hospital with a 2-week history of fatigue and decreased exercise tolerance. He says he can hardly climb two flights of stairs without getting dyspneic. He denies palpitations or chest pain. His past medical history is insignificant, and a routine check-up 6 months ago was normal. He admits two episodes of binge drinking during the last month, but says that he 'got it under control'. He is currently not taking any medications. His blood pressure is 150/90 mmHg and heart rate is 130/min, irregular. Lungs are clear on auscultation. ECG does not reveal P waves. Echocardiography shows significant left ventricular dilation with an ejection fraction of 35% and mitral regurgitation (1+). Which of the following intervention will most likely improve the left ventricular function in this patient?

A 53-year-old Caucasian woman comes to the physician for a routine health maintenance examination. Recently, she noticed a mild hand tremor while performing some fine tasks, like pouring out the tea. She says that the tremor disappears for a while after drinking a glass of wine. Her past medical history is insignificant. Her blood pressure is 160/90 mmHg and heart rate is 80/min. Physical examination is insignificant. Which of the following medications is the best choice to treat this patient's hypertension?

A 53-year-old male is brought to the emergency department after being involved in a motor vehicle accident (MVA) as an unrestrained driver. He was found unresponsive at the scene and was intubated by paramedics. He has received 1L of normal saline over the last 20 minutes. His blood pressure in the emergency department is 70/30 mmHg, and his heart rate is 100/min. On physical examination, he responds to strong vocal and tactile stimuli by opening his eyes. His pupils are equal and reactive to light. On exam, there are multiple bruises over the anterior chest and upper abdomen. The trachea is midline. A Swan-Ganz catheter reveals a pulmonary capillary wedge pressure of 12 mmHg. Rapid infusion of 1L of normal saline increases the pulmonary capillary wedge pressure to 17 mmHg, with a blood pressure of 75/30 mmHg and heart rate of 103/min. Which of the following is the best treatment for this patient?

A 53-year-old man presents to the emergency room with left lower quadrant pain, fever, and vomiting. CT scan of the abdomen and pelvis reveals a thickened sigmoid colon with inflamed diverticula and a 7-cm by 8-cm rim-enhancing fluid collection in the pelvis. After percutaneous drainage and treatment with antibiotics, the pain and fluid collection resolve. He returns as an outpatient to clinic 1 month later. He undergoes a colonoscopy, which demonstrates only diverticula in the sigmoid colon. Which of the following is the most appropriate next step in this patient’s management?

A 53-year-old man with a long respiratory history is admitted to the hospital because of increasing shortness of breath and sputum production. He is started on antibiotics and inhaled bronchodilators and anticholinergic agents. The next day he is found in his room confused and sleepy. A PCO2 determination reveals severe hypercarbia (PCO2 70 mmHg). Which of the following explanations regarding his elevated PCO2 is correct?

A 53-year-old woman presents to the physician's office with a 3-week history of burning, substernal chest pain that usually comes on with exertion and is relieved with rest. The pain does not radiate to the arms or jaw. Her past medical history is significant for bronchial asthma, type 2 diabetes, hypercholesterolemia, and hypertension. A diagnosis of stable angina is suspected, and the patient is scheduled for an exercise EKG stress test. Which of her medications should be withheld 24 hours before the test?

A 53-year-old woman presents with bright red blood per rectum, increased abdominal distention, and weight loss. She is found to have a large fungating mass 8 cm from the anal verge. No other lesions are identified. Biopsy is consistent with invasive rectal adenocarcinoma. Endorectal ultrasound shows invasion of the tumor into the perirectal fat and multiple enlarged lymph nodes. CT scans of the chest, abdomen, and pelvis do not show any metastases. She would like to preserve her sphincter if possible. Which of the following is the best treatment option for this patient given her preferences?

A 53-year-old woman presents with complaints of weakness, anorexia, malaise, constipation, and back pain. While being evaluated, she becomes somewhat lethargic. Laboratory studies include a normal chest x-ray, serum albumin 3.2 mg/dL, serum calcium 14 mg/dL, serum phosphorus 2.6 mg/dL, serum chloride 108 mg/dL, blood urea nitrogen (BUN) 32 mg/dL, and creatinine 2.0 mg/dL. Which of the following is the most appropriate initial management?

A 53-year-old woman suffers from long-standing obesity complicated by DJD of the knees, making it difficult for her to exercise. Recently her fasting blood glucose values have been 148 mg/dL and 155 mg/dL; you tell her that she has developed type 2 diabetes. She wonders if diet will allow her to avoid medications. In addition, her daughter also suffers from obesity and has impaired fasting glucose, and the patient wonders about the management of her prediabetes. Which of the following is a correct statement based on the American Diabetes Association 2008 guidelines regarding nutrition recommendations and interventions for diabetes?

A 53-year-old woman sustains multiple injuries in a head-on automobile collision. She was driving the car and wearing a seat belt. At the moment of impact, she was held in place by the belt, but she hit the windshield with her face, the dashboard with her arms, and the steering wheel with her abdomen. Initial survey reveals closed fractures in both upper extremities, facial lacerations, and abdominal bruises. She is breathing well and is neurologically intact, but she is complaining of severe abdominal pain. Her blood pressure is 75/55 mm Hg, pulse is 110/min, and central venous pressure is zero. Physical examination of the abdomen shows tenderness, guarding, and rebound tenderness on all quadrants. There is no evidence of pelvic fracture. Which of the following would be the most appropriate study to evaluate her abdominal injuries?

A 54-year-old Caucasian female is complaining of hot flashes, vaginal dryness and irritability. Her symptoms started about a year ago, and have been gradually getting worse. She has not had a menstrual period for 12 months. She currently smokes 1 pack of cigarettes daily and drinks a glass of wine occasionally. The cardiorespiratory examination is unremarkable. Inspection of her vagina reveals dryness and atrophy. She asks about the risks and benefits of combination hormone replacement therapy (HRT). Which of the following is NOT an appropriate statement to make regarding this treatment modality?

A 54-year-old female comes to the physician because of involuntary loss of urine. She states "Doc, whenever I laugh, cough, or sneeze, I am unable to hold my urine. I am afraid to leave the house." She has no involuntary loss of urine while sleeping. She had a hysterectomy four years ago. She has had no trauma to her head or back. She has no other medical problems and takes no medications. Physical examination shows a relaxed anterior vaginal wall. Neurological examination shows no abnormalities. A cotton-tipped swab test reveals a urethral straining angle of 45 degrees when intra-abdominal pressure is increased. Urinalysis shows no abnormalities. Which of the following is most beneficial long-term management for this patient?

A 54-year-old male presents to the office with several months history of hand tremors that are unresponsive to over-the-counter medication. The tremors always become worse when he is in public places. Sometimes, the hand tremors are so bad that he is unable to grasp. He denies trauma, fever, loss of muscle function or any prior stroke. His past medical history is significant for vague abdominal pains, the cause of which was never found. He is given some medication. A month later, he comes back and says, "The tremor is gone, but now I have colicky abdominal pain, confusion, headaches, hallucinations and dizziness." What is the drug that caused this patient's new symptoms?

A 54-year-old male with a past medical history of type 2 diabetes mellitus comes to the emergency department complaining of shortness of breath. His blood pressure is 146/92 mmHg, respiratory rate is 26/min, and oxygen saturation is 87% on room air. Cardiac auscultation over the apex shown S3. Based on the physical findings, which of the following is the best initial therapy for this patient?

A 54-year-old man complains that his eyes are yellow. His bilirubin is elevated. His physical examination is unremarkable. A CT of the abdomen shows a small mass in the head of the pancreas encasing the superior mesenteric artery. Cytology from the ERCP is positive for cancer. Which of the following is the most appropriate treatment for this patient?

A 54-year-old man presents to the emergency department with severe chest pain that radiates to his back. The pain is 9 of 10, increasing in intensity, and constant and is described as a tearing sensation. It began earlier this morning and has progressively gotten worse. He denies shortness of breath but does state he feels dizzy and lightheaded. His vital signs: BP 200/100 mm Hg, P 101 beats/min, afebrile. What is the best next step in the management of this patient?

A 54-year-old man presents with sudden onset of massive, painless, recurrent hematemesis. Upper endoscopy is performed and reveals bleeding from a lesion in the proximal stomach that is characterized as an abnormally large artery surrounded by normal-appearing gastric mucosa. Endoscopic modalities fail to stop the bleeding. Which of the following is the most appropriate surgical management of this patient?

A 54-year-old man sees a physician complaining of a depressed mood and inability to sleep for the past 3 weeks. He tells the physician that in the past when he has had similar episodes, he was placed on a monoamine oxidase inhibitor, which proved effective. The physician diagnoses the patient with major depression and agrees to use an MAOI. Which of the following foods must be completely avoided by this patient while on this medication?

A 54-year-old woman comes to the clinic because of a forceful hyperextension injury to her hand after falling down. She complains of pain and swelling of the right wrist and pain associated with movement. She has no other complaints. She has no other medical conditions and takes no medication. Her blood pressure is 110/60 mm Hg, pulse is 84/min, and respirations are 12/min. Examination shows maximal tenderness in the anatomic snuffbox and pain with radial deviation of the wrist. The rest of the examination shows no other injuries. X-ray imaging of the wrist in multiple views does not reveal a fracture. Which of the following is the most appropriate next step in management?

A 54-year-old woman comes to the physician because of hot flashes. She states that her hot flashes have been steadily worsening over the past year since she had a total abdominal hysterectomy and bilateral salpingo-oophorectomy for menometrorrhagia. Pathology from the surgery showed low grade endometrial hyperplasia. She has no medical problems and takes no medications. Her family history is unremarkable except for a strong family history of osteoporosis. She states that the hot flashes have become absolutely debilitating for her and she wants to take something that will give her the best chance of stopping them. Which of the following is the most appropriate pharmacotherapy?

A 54-year-old woman comes to the physician's office complaining of chronic, bilateral knee and hip pain. The pain increases with activity and is relieved by rest. She denies fever, chills or weight loss. The review of systems is unremarkable. She currently weighs 80 kg (180 lb) and is 146 cm (59 in) tall. Her knee joints are tender but there is no warmth, erythema or effusion. X-rays show narrow joint space, subchondral bone cysts, and bony spurs in both knees. Which of the following interventions would provide the greatest long-term benefit to this patient?

A 54-year-old woman has a severe ureteral colic. An intravenous pyelogram shows a 7-mm ureteral stone at the ureteropelvic junction. She has a normal coagulation profile. Which of the following would most likely be the best therapy in this case?

A 54-year-old woman presents for a routine physical. She has no complaints. She has no history of hypertension, diabetes, hypercholesterolemia, or heart disease, and she does not use tobacco, alcohol or drugs. On physical examination, her pulse is irregular. There are no murmurs. Her lungs are clear to auscultation and her legs are free of edema. An EKG shows atrial fibrillation with a heart rate of 72 beats per minute. An echocardiogram is unremarkable except for evidence of atrial fibrillation. What is the most appropriate management of this patient?

A 54-year-old woman presents to her physician for an opinion regarding additional therapy following curative resection of recently diagnosed colon cancer. She underwent uncomplicated sigmoid resection for invasive colon cancer 4 weeks ago. The pathology revealed carcinoma invading into, but not through, the muscularis propria, with one of eight positive mesenteric nodes. There was no evidence of liver metastases at the time of operation. Preoperative chest x-ray and CT scan of the abdomen showed no evidence of distant disease. Preoperative carcinoembryonic antigen (CEA) level was normal. Past history is positive for diabetes and mild hypertension. Examination is unremarkable except for a healing abdominal incision. Which of the following is the most appropriate recommendation regarding adjuvant therapy?

A 54-year-old woman undergoes a laparotomy because of a pelvic mass. At exploratory laparotomy, a unilateral ovarian neoplasm is discovered that is accompanied by a large omental metastasis. Frozen section diagnosis confirms metastatic serous cystadenocarcinoma. Which of the following is the most appropriate intraoperative course of action?

A 55-year-old African-American male comes to the office for a routine follow-up visit. His past medical history is significant for type 2 diabetes mellitus (DM), hypertension for the last 5 years, and an acute myocardial infarction 2 years ago. His mother died of a heart attack at the age of 72 years, and his father died in a motor vehicle accident at the age of 42 years. He has no siblings. He is currently on glyburide, captopril and baby aspirin. He is very compliant with his diet and medication. His glycemic control was very good until a few months ago, when he noticed that his blood sugar levels were running high. This morning, his finger stick reading was 200 mg/dL. He weighs 188 lbs and is 5'8" tall. His physical examination is otherwise unremarkable. His blood work done three days ago showed blood urea nitrogen of 14 mg/dL and a creatinine level of 1.0 mg/dL. His HBA1c one month ago was 8.0%. Which of the following is the most appropriate next step in management?

A 55-year-old Caucasian male is hospitalized after a massive hemorrhage from a duodenal ulcer. The hemorrhage was stopped with endoscopic manipulation. Two litters of Ringer lactate were infused and two units of packed red blood cells (RBC) ordered. Ten minutes after the transfusion of packed RBC had been started; the patient was complaining of tremor and feeling 'chilly.' His temperature is 39.4° C (103° F), blood pressure is 120/76 mmHg, pulse is 100/min, and respirations are 24/min. The transfusion was stopped, and acetaminophen was given. Direct antiglobulin test and plasma free hemoglobin level are negative. Urinalysis is normal. The reaction abated three hours after the transfusion had started. Which of the following actions could have prevented the reaction described?

A 55-year-old Caucasian male presents to your office for a routine check-up. His past medical history is significant for gout, hypertension, and hypercholesterolemia. His current medications include enalapril and pravastatin. He does not smoke or consume alcohol. His blood pressure is 156/94 mmHg and heart rate is 80/min. Physical examination reveals that the patient is moderately overweight (BMI = 27 kg/m2) with increased waist-to-hip ratio. You consider adding hydrochlorothiazide to the treatment regimen to improve the control of hypertension. Which of the following metabolic effects do you expect to emerge after this correction?

A 55-year-old chronic smoker comes to you because of worsening shortness of breath. He says that he has had lung problems due to smoking for the past five years. He has hypertension controlled with hydrochlorothiazide, and type 2 diabetes mellitus, controlled with diet. He has smoked two packs of cigarettes daily for 25 years. Physical examination shows bilateral decrease in breath sounds with prolonged expiration and wheezing in both the lung fields. He is hypoxic on room air. An x-ray film of the chest shows hyperinflation of both lung fields. His pulmonary function tests showed moderate obstructive disease, with very little bronchodilator response. The patient is started on bronchodilators. He is being considered for home oxygen therapy. Which of the following is a criterion for initiating home oxygen in such patients?

A 55-year-old female presents to the office with a one-week history of left-sided ear pain and itchiness. The pain is especially bothersome at night, and is exacerbated by chewing. She denies any hearing loss. Her past medical history is significant for hypertension, type 2 diabetes mellitus, hyperlipidemia, and gout. Current medications include lisinopril, allopurinol, and metformin. She has missed her last two appointments with her primary care physician. Her temperature is 38.3°C (101°F), blood pressure is 140/90 mmHg, and pulse is 98/min. On examination, there is granulation tissue in the left ear canal with a scant amount of discharge. Which of the following is the best initial treatment for this patient?

A 55-year-old male presents to your office with a 6-month history of periodic substernal pressure. He experiences this pressure while walking uphill or climbing two flights of stairs. His past medical history is insignificant. He smokes 1 pack a day and consumes alcohol occasionally. His blood pressure is 160/90 mmHg and heart rate is 75/min. Resting ECG is normal. You suspect stable angina and order an ECG stress test that reveals horizontal ST segment depression in leads II, III, and aVF at submaximal heart rate. What is the best medication to treat this patient's condition?

A 55-year-old male with a history of rheumatoid arthritis and rheumatoid lung disease is admitted to the hospital with palpitations. His restrictive lung disease is of moderate severity, requiring use of 2 liters of oxygen by nasal cannula at all times. He has no known history of coronary artery disease, hypertension or diabetes. On physical examination, his blood pressure is 110/70 mmHg and heart rate is 120 and irregular. EKG shows atrial fibrillation with a rapid ventricular rate. Which of the following medications should be avoided in this patient?

A 55-year-old man comes to the emergency department because of severe retrosternal chest pain that suddenly started a few hours ago. He has been having some chest pain and epigastric burning for the past few days but says that the current pain is different. His other medical problems include nonischemic cardiomyopathy for which he takes furosemide, carvedilol, spironolactone, lisinopril, and potassium chloride. He also has HIV infection but has chosen not to take any medication related to this diagnosis. His temperature is 38.9° C (102° F), blood pressure is 110/65 mm Hg, pulse is 110/min, and respirations are 22/min. Examination shows that he is in obvious distress secondary to pain. His lungs are clear to auscultation. The remainder of the examination shows no abnormalities. His ECG is within normal limits. Chest x-ray shows a widened mediastinum and some mediastinal air. Which of the following is the most appropriate next step in the management of this patient?

A 55-year-old man comes to the emergency department because of severe right-sided chest pain. His temperature is 37.8°C (100F), blood pressure is 138/88 mm Hg, pulse is 88/min and respirations are 19/min and shallow. Examination shows decreased respiratory movements on the right side of the chest and tenderness on palpation over the right mid-chest. An x-ray film of the chest shows a fracture of the right 6th rib. Which of the following is the most important goal in management of the rib fracture in this patient?

A 55-year-old man comes to the emergency department because of severe right-sided chest pain. His temperature is 37.8C (100.4F), blood pressure is 138/88 mm Hg, pulse is 88/min and respirations are 19/min and shallow. Examination shows decreased respiratory movements on the right side of the chest and tenderness on palpation over the right mid-chest. An x-ray film of the chest shows a fracture of the right 6th rib. Which of the following is the most important goal in management of the rib fracture in this patient?

A 55-year-old man complains of chronic intermittent epigastric pain. A gastroscopy demonstrates a 2-cm prepyloric ulcer. Biopsy of the ulcer yields no malignant tissue. After a 6 week trial of medical therapy, the ulcer is unchanged. Which of the following is the best next step in his management?

A 55-year-old man has undergone renal transplantation due to end-stage renal failure. His postoperative course was uncomplicated. He is currently taking prednisone and cyclosporine. He is afebrile and his pulse is 80/min, respirations are 14/min, and blood pressure is 130/65 mm Hg. Physical examination is unremarkable. Which of the following should be added to his current medication regimen to prevent opportunistic infections?

A 55-year-old man is brought to the ED by his family. They state that he has been vomiting large amounts of bright red blood. The patient is an alcoholic with cirrhotic liver disease and a history of portal hypertension and esophageal varices. His vitals on arrival are HR 110 beats per minute, BP 80/55 mm Hg, RR 22 breaths per minute, and temperature 99°F. The patient appears pale and is in moderate distress. Which of the following is an inappropriate option in the initial management of a hypotensive patient with a history of known esophageal varices presenting with hematemesis?

A 55-year-old man presents to his physician with 6 months of mild intermittent pain in both knees. The pain is aggravated by walking and weight bearing, and is partially relieved by rest. He also complains of morning stiffness that lasts for 10 minutes. He does not smoke but drinks alcohol occasionally. His BMI is 25 Kg/m2, temperature is 37°C (98.6°F), pulse is 75/min, and blood pressure is 130/80 mmHg. Examination reveals crepitus over both knee joints. Which of the following is the most appropriate initial treatment for this patient?

A 55-year-old man presents to the ED at 2:00 AM with left-sided chest pain that radiates down his left arm. He takes a β-blocker for hypertension, a proton pump inhibitor for gastroesophageal reflux disease, and an antilipid agent for high cholesterol. He also took sildenafil the previous night for erectile dysfunction. His BP is 130/70 mmHg and HR is 77 beats per minute. Which of the following medications is contraindicated in this patient?

A 55-year-old man presents to the emergency department with left lower quadrant abdominal pain. The pain has been present for 1 week, but has increased in intensity over the last 2 days associated with nausea, constipation, and dysuria. Past history is unremarkable. Examination reveals a temperature of 101°F, pulse rate of 95/min, BP of 130/70 mmHg, and normal heart and lung examinations. Abdominal examination reveals fullness and marked tenderness in the left lower quadrant, with voluntary guarding and decreased bowel sounds. Laboratory tests reveal a WBC count of 18,000 with a left shift and 20–50 WBCs in the urinalysis. A CT scan of the abdomen reveals a thickened sigmoid colon with pericolonic inflammation. He is admitted to the hospital for treatment. We find this patient has diverticulitis. Which of the following is the most appropriate management of this patient?

A 55-year-old man presents to the physician’s office for his yearly physical examination. He is asymptomatic. Past history is pertinent for hypertension. Family history is positive for breast cancer in his mother at age 70 and colon cancer in his father at age 65. His examination is unremarkable except for guiac positive stool. Barium enema shows a sigmoid colon polyp. Colonoscopy confirms a 3-cm pedunculated polyp in the sigmoid colon, and snare polypectomy is performed. Pathologic examination reveals an adenomatous polyp with a focus of invasive carcinoma in the head, with a 4-mm resection margin and no tumor noted in the stalk. Which of the following is the most appropriate next step in management?

A 55-year-old man who is extremely obese reports weakness, sweating, tachycardia, confusion, and headache whenever he fasts for more than a few hours. He has prompt relief of symptoms when he eats. Labarotory examination reveals an inappropriately high level of serum insulin during the episodes of fasting. Which of the following is the most appropriate treatment for this condition?

A 55-year-old man with psoriasis has been troubled by long-standing destructive arthritis involving the hands, wrists, shoulders, knees, and ankles. Hand films demonstrate pencil-in-cup deformities. He has been treated with naproxen 500 mg bid, sulfasalazine 1 g bid, prednisone 5 mg qd, and methotrexate 17.5 mg once a week without substantive improvement. Which of the following treatments is most likely to provide long-term benefit?

A 55-year-old man with recent onset of atrial fibrillation presents with a cold, numb, pulseless left lower extremity. He is immediately taken to the operating room for an embolectomy of the left popliteal artery. Which additional procedure should be performed along with the embolectomy?

A 55-year-old obese male presents to his physician for a routine annual physical examination. A review of systems is insignificant, except for constipation which has been present for several years. He does not have major medical problems and is not on any prescription or over-the-counter medications. He has smoked one and- a-half packs of cigarettes daily for 30 years. He drinks 4 oz of alcohol daily. Physical examination is unremarkable. As part of the routine screening, a colonoscopy is performed, which shows multiple diverticuli at the sigmoid colon. He is concerned about the diverticulosis. Which of the following is the most appropriate next step in the management of this patient's diverticulosis?

A 55-year-old patient presents to you after a 3-day hospital stay for gradually increasing shortness of breath and leg swelling while away on a business trip. He was told that he had congestive heart failure, but is asymptomatic now, with normal vital signs and physical examination. An echocardiogram shows an estimated ejection fraction of 38%. The patient likes to keep medications to a minimum. He is currently on aspirin and simvastatin. Which would be the most appropriate additional treatment?

A 55-year-old white male presents to the Emergency Room with a four-hour history of chest pain. The pain is substernal and radiates to the left arm. He has a history of hypertension, diabetes, and hypercholesterolemia. His temperature is 36.7°C (98°F), blood pressure is 110/65 mmHg, pulse is 110/min, and respirations are 18/min. ECG is recorded and reveals ST segment elevation in the anterior leads and several ventricular premature beats (VPBs). What would the administration of lidocaine to such a patient most likely result in?

A 55-year-old woman comes to the physician because of hot flashes. She first noted them about 9 months ago, and since then they have been worsening. She states that the flashes come on at various times throughout the day, but that they are especially intense at night. She had her last menstrual period approximately 5 months ago. Her medical history is significant for a pulmonary embolus at the age of 36 and severe depression. She takes fluoxetine for depression and has no allergies to medications but smokes one pack of cigarettes per day. Physical examination is unremarkable, including a normal pelvic examination. Which of the following is the most appropriate pharmacotherapy for this patient?

A 55-year-old woman has a palpable 2 cm mass in her left breast. She had found the mass on self-examination, but she says that she had not done self-breast exam for at least six months before she did this one. Physical examination confirms the presence of the lesion, which is hard, movable, and not painful. A mammogram confirms the presence of an opacity in that area, but it does not have any of the radiological characteristics of a breast cancer. The radiologist also does a sonogram, and comes up with the same opinion, I.e., that neither study is suggestive for cancer. Fine needle aspirate is read as negative. Which of the following is the most appropriate next step in management?

A 55-year-old woman has been known for years to have mitral valve prolapse. She has now developed exertional dyspnea, orthopnea, and atrial fibrillation. She has an apical, high-pitched, holosystolic heart murmur that radiates to the axilla and back. Because of her deterioration, surgery has been recommended. Which of the following is the most appropriate procedure?

A 55-year-old woman is brought to the emergency department by fi re and rescue personnel because of intractable back and thigh pain for the past 3 hours. Upon presentation she says that the pain is 9 of 10 in severity and localized to her lower back. She lives with her sister, and she has no primary care physician. She denies any complaints aside from fatigue, which she attributes to her multiple jobs and caring for her sister’s children. She has a pulse of 110/min, blood pressure of 140/88 mm Hg, respiratory rate of 20/min, and temperature of 37.8C (100.1F). On physical examination she is exquisitely tender over the L2–3 area of the spine. She also has point tenderness over the anterior right thigh. Sensation is intact over the lower extremities bilaterally and she has 5/5 strength in the lower extremities bilaterally. Breast examination reveals a retracted nipple and dimpling of the right breast. What will likely represent the mainstay of treatment for this patient’s symptoms?

A 55-year-old woman presents with a 6-cm right thyroid mass and palpable cervical lymphadenopathy. Fine-needle aspiration (FNA) of one of the lymph nodes demonstrates the presence of calcified clumps of sloughed cells. Which of the following best describes the management of this thyroid disorder?

A 55-year-old woman presents with a 6-month history of weight loss, abdominal cramps, and intermittent nonbloody diarrhea. On examination, her abdomen is mildly distended and there is a palpable mass in the right lower quadrant. Stool cultures yield normal fecal flora. CT scan with oral contrast demonstrates an inflammatory mass in the right lower quadrant, with thickening of the terminal ileum and ileocecal valve.Initial management should include which of the following?

A 55-year-old woman presents with a slow-growing painless mass on the right side of the neck. A fine-needle aspiration of the nodule shows a well-differentiated papillary carcinoma. A complete neck ultrasound demonstrates a 1-cm nodule in the right thyroid without masses in the contralateral lobe or lymph node metastasis in the central and lateral neck compartments. With regards to this patient, which of the following is associated with a poor prognosis?

A 55-year-old woman who has end-stage liver disease is referred to a hepatologist for evaluation. Which of the following would prevent her from being a transplantation candidate?

A 56-year-old chronic alcoholic has a 1-year history of ascites. He is admitted with a 2-day history of diffuse abdominal pain and fever. Examination reveals scleral icterus, spider angiomas, a distended abdomen with shifting dullness, and diffuse abdominal tenderness. Paracentesis reveals slightly cloudy ascitic fluid with an ascitic fluid PMN cell count of 1000/μL. Which of the following statements about treatment is true?

A 56-year-old male is admitted to the ICU for the management of hepatic encephalopathy. He is a known alcoholic. He is started on oral neomycin, lactulose, and a low-protein, high-carbohydrate diet. His blood pressure is 116/78 mm Hg, pulse is 78/min, temperature is 37.5°C (99.5°F), and respirations are 18/min. His labs reveal the following: Hb 10.2 g/dl, WBC 7,400/cmm, Hct 27%, Platelets 4 2,000/mm3, PT 18 sec, INR 2.02, PTT 31 sec. He has no evidence of active bleeding. Which of the following should be administered to this patient at this time?

A 56-year-old man complains of fatigue and occasional palpitations. He has a 20-year history of diabetes mellitus and takes daily insulin therapy. He receives hemodialysis three times a week for end-stage renal disease. He was recently started on erythropoietin therapy for anemia (his pretreatment hemoglobin was 8.0 mg/dl). Physical examination at this visit reveals pale conjunctiva. Repeat laboratory studies show: Hemoglobin 9.2 mg/dl, MCV 77 fl, MCHC 30 g/dl, WBC count 7,000/mm3, Platelets 150,000/mm3, Hemoglobin A1c 7.5%, ESR 15 mm/hr. Which of the following is likely to be helpful in improving this patient's symptoms?

A 56-year-old man develops oliguria three days after having a kidney transplantation. His postoperative course was uncomplicated. His blood pressure is 160/100 mm Hg and heart rate is 90/min. Palpation of the transplant reveals mild tenderness. Laboratory studies show: Serum sodium 145 mEq/L, Serum potassium 5.5 mEq/L, Serum calcium 8.6 mg/dl, Serum creatinine 3.2 mg/dl, BUN 30 mg/dl. His serum cyclosporine level is normal. Renal ultrasonography does not detect dilatation of the calyces. Biopsy of the transplant shows heavy lymphocyte infiltration and vascular involvement with swelling of the intima. Which of the following is the most appropriate next step in management?

A 56-year-old man presents with hypertension and peripheral edema. He is otherwise healthy and takes no medications. Family history reveals that his father and a brother have kidney disease. His father was on hemo-dialysis before his death at age 68 of a stroke. Physical examination reveals BP 174/96 mm Hg and AV nicking on funduscopic examination. He has a soft S4 gallop. Bilateral flank masses measuring 16 cm in length are palpable. Urinalysis shows 15 to 20 RBC/hpf and trace protein but is otherwise normal; his serum creatinine is 2.4 mg/dL. Which is the most likely long-term complication of his condition?