Ichigo USLME Med Management P2

2) 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?

7) A 64-year-old woman presents with diffuse hair loss. She says that her hair is “coming out by the handfuls” after shampooing. She was treated for severe community-acquired pneumonia 2 months ago but has regained her strength and is exercising regularly. She is taking no medications. Examination reveals diffuse hair loss. Several hairs can be removed by gentle tugging. The scalp is normal without scale or erythema. Her general examination is unremarkable; in particular, her vital signs are normal, she has no pallor or inflammatory synovitis, and her reflexes are normal with a normal relaxation phase. What is the best next step in her management?

13) A 60-year-old male comes to the office due to edema of his face and ankles of two weeks duration. He denies any chest pain or breathlessness. He is a known diabetic for the past 15 years. His diabetes is being managed with exercise, dietary modification and glyburide. His glycosylated hemoglobin (HbA1C) level one month ago was 7.5%. His temperature is 37.0°C (98.6°F), pulse is 75/min, blood pressure is 146/87 mmHg, and respirations are 15/min. Examination is unremarkable, except for bilateral pitting edema around the ankles and periorbital edema. Lab results show: Serum sodium 140 mEq/L, Potassium 4.3 mEq/L, Bicarbonate 20 mEq/L, Blood glucose120 mg/dL, Blood urea nitrogen 37 mg/dL, Serum creatinine 24 mg/dL, Total cholesterol 300 mg/dl. EKG is normal. 24 hour urine collection shows 3.7 g protein/day. To alter the course of this patient's diabeticnephropathy, what is the most appropriate next step in management?

14) A 40-year-old white female presents with complaints of heat intolerance, sweating and palpitations. She also reports menstrual irregularities, increased appetite and diarrhea. She has had these symptoms for the past 4 Months. Her pulse is 102/min and regular, blood pressure is 116/80 mmHg, temperature is 37.2°C (99°F), and respirations are 14/min. Physical examination reveals a non-tender, diffuse swelling in front of her neck; it moves upwards with deglutition. Her TSH level is 0.05 mU/L. Free T4 and T3 levels are increased. Radioactive iodine uptake at 24 hours is significantly increased. Pregnancy test is negative. Which of the following is the most appropriate long-term treatment modality for this patient?

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

17) A 60-year-old female presents with transient loss of consciousness. She appears lethargic and confused. She also complains of hemoptysis and weight loss of 10 lbs (4.5kg) over a period of 2 months. She has smoked one pack of cigarettes daily for the last 40 years. Her temperature is 37.0°C (98.6°F), pulse is 75/min, blood pressure is 110/70 mmHg, and respirations are 16/min. Her mucus membranes are moist. There is no jugular venous distention. Her neurological examination is non-focal, and cardiovascular examination is unrevealing. There is no ankle edema or ascites. Serum studies show: Sodium 115 mEq/L, Potassium 3.7 mEq/L, Bicarbonate 22 mEq/L, Blood glucose 100 mg/dL, BUN 10.0 mg/dL. Serum osmolality is 250 mOsm/Kg, and urine osmolality is 500 mOsm/Kg. Urine sodium concentration is 40 mEq/L. Chest x-ray shows a mass in the right hilar region. What is the most appropriate next step in the management of this patient?

18) A 40-year-old African American female comes to the office for a routine medical check-up. She has no complaints. She has twenty pack-year smoking history but she stopped smoking one year ago. Her mother and one maternal uncle have diabetes. Her height is 5'7" inches, and weight is 150 lbs. Her blood pressure is 122/80 mmHg, pulse is 80/min, respirations are 14/min and temperature is 37°C (98°F). She agrees to have diabetes mellitus screening. Her plasma glucose level after an overnight fast is 130 mg/dL. What is the most appropriate next step in the management of this patient?

19) A 22-year-old female presents with complaints of heat intolerance, sweating and palpitations. She also reports menstrual irregularities, increased appetite and diarrhea. Her pulse is 102/min and regular, blood pressure is 116/80 mmHg, temperature is 37.2°C (99°F), and respirations are 14/min. Physical examination reveals a diffusely enlarged, nontender thyroid gland. TSH level is 0.05 mU/L. Free T4 and T3 levels are elevated. Radioactive iodine uptake at 24 hours is 50 percent. Thyroid stimulating immunoglobulins are present. She is started on propylthiouracil 300 mg daily in three divided doses. After two weeks, she returns and complains of a sore throat. Her pulse is 98/min and regular, temperature is 38.6°C (101.5°F), blood pressure is 115/76 mmHg, and respirations are 15/min. The soft palate, pharynx, and tonsils are red and swollen. What is the most appropriate next step in the management of this patient?

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

27) A 60-year-old asymptomatic man presents to your office for a routine check-up. He has a 10-year history of type 2 DM, and a 12-year history of hypertension. His current medications include low-dose glyburide and a low-dose thiazide diuretic. His blood pressure is 140/90 mmHg and heart rate is 65/min. Physical examination shows a soft ejection systolic murmur at the base of the heart. Ophthalmoscopic evaluation reveals no abnormalities. ECG recorded 6 months ago showed left ventricular hypertrophy and non-specific ST segment and T-wave abnormalities. His recent fasting glucose level was in the range of 120 to 150 mg/dl, and HbA1c was 7.1 % (normal< 6%). 24-hour urine collection reveals microalbuminuria. Which of the following is the best measure to slow end-organ damage in this patient?

28) A 21-year-old man with type 1 diabetes mellitus presents to the emergency department with complaints of abdominal pain, nausea and vomiting. His temperature is 36.0°C (97.0°F), pulse is 110/min, blood pressure is 102/60 mmHg, and respirations are 26/min. Lungs are clear to auscultation. Abdomen is soft, non-tender and non-distended. Chemistry panel shows: Sodium 130 mEq/L, Potassium 5.2 mEq/L, Chloride 90 mEq/L, Bicarbonate 10 mEq/L, Blood glucose 450 mg/dl. Which of the following is the most appropriate next step in management?

29) A 40-year-old female patient is brought to the office by her husband due to altered mental status and confusion of recent onset. According to her husband, she has been complaining of intense thirst, craving for ice water, and experiencing increased urination for the past few days. Her only medication is lithium for bipolar depression. Her temperature is 39.0°C (102.5°F), pulse is 102/min, blood pressure is 90/60 mmHg, and respirations are 15/min. Physical examination reveals a disoriented patient with dry skin and mucous membranes. Blood chemistry panel reveals: Sodium 156 mEq/L, Potassium 4.1 mEq/L, Bicarbonate 26 mEq/L, Blood glucose 102 mg/dl, BUN 27 mg/dl. Serum osmolality is 328 mOsm/kg, and urine osmolality is 180mOsm/Kg. What is the most appropriate next step in the management of this patient?

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

36) A 37-year-old white female presents with galactorrhea and amenorrhea for the past 7 months. She denies any headaches, visual problems, vaginal dryness or dyspareunia. She is married, has two children, and remarks that her family is "complete." She does not use tobacco, alcohol or drugs. Her blood pressure is 120/80 mmHg, pulse is 72/min, temperature is 36.7°C (98.6°F) and respirations are 14/min. Visual field testing is within normal limits. Pregnancy test is negative. Her serum prolactin level is 150ng/ml. Pituitary MRI shows a 6mm pituitary adenoma. Which of the following is the most appropriate next step in the management of this patient?

37) 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?

38) A 30-year-old Caucasian female comes to the physician's office because of polyuria and polydipsia of recent onset. She has no other medical problems. She does not use tobacco, alcohol or drugs. She has no known drug allergies. Her mother has diabetes. Her temperature is 36.7°C (98°F), pulse is 75/min, blood pressure is 110/70 mmHg, and respirations are 15/min. The initial lab results are: Hb 12.7 g/dl, WBC 5,000 /cmm, Platelets 380,000/cmm, Blood glucose 90 mg/dl, Serum sodium 142 mEq/L, Serum potassium 4.0 mEq/L, Bicarbonate 26 mEq/L, BUN 15 mg/dl, Serum creatinine 0.9 mg/dl, Serum uric acid 9 mg/dl, Serum osmolality 295 mOsm/kg, Urine osmolality 160 mOsm/kg. After 12 hours of water deprivation, lab testing reveals:Serum sodium 151 mEq/L, Serum potassium 4.2 mEq/L, Bicarbonate 26 mEq/L, Serum osmolality 300 mOsm/kg, Urine osmolality 186 mOsm/kg. One hour after the subcutaneous administration of arginine vasopressin, the urine osmolality is 400mosm/kg. Which of the following is the most appropriate treatment for this patient?

41) Your patient is a 48-year-old Hispanic male with a 4-year history of diabetes mellitus type 2. He is currently utilizing NPH insulin/Regular insulin 40/20 units prior to breakfast and 20/10 units prior to supper. His supper time has become variable due to a new job and ranges from 5 to 8 PM. In reviewing his glucose diary, you note some very low readings (40-60 mg/dL) during the past few weeks at 3 AM. When he awakens to urinate, he feels sweaty or jittery so has been checking a fingerstick blood glucose. Morning glucose levels following these episodes are always higher (200-250) than his average fasting glucose level (120-150). Which change in his insulin regimen is most likely to resolve this patient’s early AM hypoglycemic episodes?

42) 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 hormone-receptor antibody test are positive. Which of the following is the most appropriate therapy for this patient?

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

45) A 42-year-old woman presents to her physician with complaints of fever (38.2°C [100.8°F]) and mild-to-moderate anterior neck pain. On examination the physician finds her to be tachycardic and sweating, and to have an exquisitely tender thyroid gland. Her blood work shows a depressed thyroid-stimulating hormone level and increased free thyroxine. Which of the following is the most appropriate treatment at this time?

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

48) A 28-year-old patient with known Addison’s disease presents with abdominal pain and is hypotensive to a systolic pressure of 88 mmHg. He has a 2-week history of progressively worse nonproductive dry cough, sore throat, malaise, and headache. He has not checked his temperature at home but complains of constant chills. Which of the following is the best initial management?

49) A generally healthy 74-year-old woman who recently moved into the area visits the physician’s office for her first well-visit. She states that her previous doctor had been treating her with propylthiouracil (PTU) for subclinical hyperthyroidism, but that her prescription ran out several months ago. Laboratory studies reveal that her free thyroxine and triiodothyronine levels are normal, but her thyroid-stimulating hormone is depressed. PTU therapy is most important in this patient to prevent the development of which disorder?

50) You recently evaluated a 28-year-old woman who presented with complaints of shakiness and heat intolerance. The patient plans to have children and is currently using no contraception. On examination you noted tachycardia with an HR of 102, a fine tremor, a diffuse goiter, and proptosis. You now have the laboratory results and note a TSH < 0.001, elevated total T4 of 17.8, and increased T3 uptake. Radionuclide uptake by the thyroid gland is elevated. You tell her that she has Graves’ disease. What is the best treatment plan for this patient?

51) A 61-year-old obese man with a history of chronic alcohol abuse is diagnosed with type 2 DM. In addition to diet modification and exercise, his physician recommends he begin therapy with a hyperglycemic agent. Several days after starting therapy, his wife comes home from work and finds him sitting on the couch staring into space and breathing rapidly. When she speaks to him, she finds he is quite confused, and immediately takes him to the emergency department. Arterial blood gas analysis shows: pH: 7.2, HCO −: 19 mEq/L. Partial carbon dioxide pressure: 32 mmHg Partial oxygen pressure: 80 mmHg Lactate: 6 mmol/L. Which of the following drugs is most likely responsible for this patient’s symptoms?

52) A 56-year-old woman presents to the outpatient clinic for a routine visit. On physical examination a 1-cm nodule is palpated in her thyroid. Her physical examination is otherwise unremarkable. Her heart rate is 70/min and regular, blood pressure is 126/82 mmHg, and temperature is 36.7°C (98.0°F). Which of the following is a poor prognostic indicator for the thyroid nodule?

53) 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?

55) A 7-year-old boy is brought to your office with a sore throat, decreased appetite, and nausea. His past medical history is insignificant. All of his vaccinations are up-to-date. He has no known allergies. His temperature is 39.0°C (102.5°F), blood pressure is 110/70 mmHg, pulse is 104/min, and respirations are 16/min. On examination, the pharynx and tonsils are red, swollen, and have white exudates on their surface. There is also bilateral tender cervical lymphadenopathy. The rapid diagnostic test for streptococcal antigen is positive. What is the most appropriate next step in management?

57) A 30-year-old school teacher presents with a three-day history of fever, chills, and sore throat. He also complains of difficulty swallowing that started yesterday. He denies any cough, chest pain, or difficulty breathing. He is married and denies any new sexual encounters. His temperature is 39°C (102.2°F), blood pressure is 118/76 mmHg, pulse is 102/min, and respirations are 19/min. On examination, his voice is muffled. Enlarged, tender cervical lymph nodes are palpated on the left, and his uvula is deviated to the right. What is the most appropriate treatment for this patient?

62) A 56-year-old woman with cirrhosis presents with a 2-week history of increasing abdominal distension. She has mild encephalopathy and esophageal varices without bleeding. Her cirrhosis is due to chronic hepatitis type B. She has a past history of ascites treated successfully with conservative management. She is currently on sodium, water and protein restriction, maximal doses of spironolactone and furosemide, and lactulose. Her temperature is 36.6°C (97.9°F), blood pressure is 120/70 mmHg, pulse is 80/min, and respirations are 30/min. She has a flapping tremor and labored breathing. Abdominal examination shows marked abdominal distension. An x-ray film of the chest is unremarkable. Abdominal ultrasound shows peritoneal fluid and splenomegaly, liver hyperechogenicity and nodularity, and portal vein width of 16 mm; no masses are evident. Which of the following is the most appropriate next step in the management of this patient's ascites?

63) 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?

66) 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?

71) 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?

72) A 60-year-old man with known hepatitis C and a previous liver biopsy showing cirrhosis requests evaluation for possible liver transplantation. He has never received treatment for hepatitis C. Though previously a heavy user of alcohol, he has been abstinent for over 2 years. He has had 2 episodes of bleeding esophageal varices. He was hospitalized 6 months ago with acute hepatic encephalopathy. He has a 1 year history of ascites that has required repeated paracentesis despite treatment with diuretics. Medications are aldactone 100 mg daily and lactulose 30 cc 3 times daily. On examination he appears thin, with obvious scleral icterus, spider angiomas, palmar erythema, gynecomastia, a large amount ascites, and small testicles. There is no asterixis. Recent laboratory testing revealed the following: hemoglobin = 12.0 mg/dL (normal 13.5-15.0), MCV = 103 fL (normal 80-100), creatinine = 2.0 mg/dL (normal 0.7-1.2), bilirubin = 6.5 mg/dL (normal 0.1-1.2), AST = 25 U/L (normal < 40), ALT= 45 U/L (normal < 40), INR = 3.0 (normal 0.8-1.2). What is the next best step?

74) A 27-year-old female is found to have a positive hepatitis C antibody at the time of plasma donation. Physical examination is normal. Liver enzymes reveal ALT of 62 U/L (normal < 40), AST 65 U/L (normal < 40), bilirubin 1.2 mg/dL (normal), and alkaline phosphatase normal. Hepatitis C viral RNA is 100,000copies/mL. Hepatitis B surface antigen and HIV antibody are negative. Which of the following statements is true?

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

76) A 65-year-old man with a history of occasional painless rectal bleeding presents with 2 to 3 days of constant, dull RLQ pain. He also complains of fever, nausea, and decreased appetite. He had a colonoscopy 2 years ago that was significant for sigmoid and cecal diverticula but was otherwise normal. On physical examination he has RLQ tenderness with rebound and guarding. His vitals include HR of 95 beats per minute, BP of 130/85 mm Hg, and temperature of 101.3°F. The abdominal CT demonstrates the presence of sigmoid and cecal diverticula, inflammation of pericolic fat, thickening of the bowel wall, and a fluid-filled appendix. Which of the following is the most appropriate next step in management?

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

78) 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?

79) A 22-year-old man presents to the ED complaining of dysuria for 3 days. He states that he has never had this feeling before. He is currently sexually active and uses a condom most of the time. He denies hematuria but notes a yellowish discharge from his urethra. His BP is 120/75 mm Hg, HR is 60 beats per minute, and temperature is 98.9°F. You send a clean catch urinalysis to the laboratory that returns positive for leukocyte esterase and 15 white blood cells per high power field (WBCs/hpf). Which of the following is the most appropriate next step in management?

80) An 18-year-old woman presents to the ED complaining of acute onset of RLQ abdominal pain. She also describes the loss of appetite over the last 12 hours, but denies nausea and vomiting. Her BP is 124/77 mm Hg, HR is 110 beats per minute, temperature is 102.1°F, RR is 16 breaths per minute, and oxygen saturation is 100% on room air. Abdominal examination reveals lower abdominal tenderness bilaterally. On pelvic examination you elicit cervical motion tenderness and note cervical exudates. Her WBC is 20,500/μL and β-hCG is negative. Which of the following is the most appropriate next step in management?

81) A 30-year-old man presents to the ED complaining of sudden onset of abdominal bloating and back pain lasting for 2 days. The pain woke him up from sleep 2 nights ago. It radiates from his back to his abdomen and down toward his scrotum. He is in severe pain and is vomiting. His temperature is 101.2°F and HR is 107 beats per minute. A CT scan reveals a 9-mm obstructing stone of the left ureter with hydronephrosis. Urinalysis is positive for 2+ blood, 2+ leukocytes, 2+ nitrites, 40 to 50 WBCs, and many bacteria. You administer pain medicine, antiemetics, and antibiotics. Which of the following is the most appropriate next step in management?

82) A 24-year-old woman presents to the ED after being sexually assaulted. She is a college student with no past medical history. Her BP is 130/75 mm Hg, HR is 91 beats per minute, temperature is 98.6°F, and RR is 16 breaths per minute. On physical examination you observe vaginal trauma and scattered bruising and abrasions. Which of the following medications should be offered to the patient in this scenario?

83) A 43-year-old man presents to the ED complaining of progressively worsening abdominal pain over the past 2 days. The pain is constant and radiates to his back. He also describes nausea and vomiting and states he usually drinks six pack of beer daily, but has not had a drink for 2 days. His BP is 144/75 mm Hg, HR is 101 beats per minute, temperature is 99.8°F, and RR is 14 breaths per minute. He is lying on his side with his knees flexed. Examination shows voluntary guarding and tenderness to palpation of his epigastrium. Laboratory results reveal WBC 10,500/μL, hematocrit 51%, platelets 225/μL, and lipase 620 IU. An abdominal radiograph reveals a nonspecific bowel gas pattern. There is no free air under the diaphragm. Which of the following is the most appropriate next step in management?

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

88) A 39-year-old Japanese-American woman with insulin-dependent diabetes and asthma presents to her primary care physician complaining of trouble swallowing for the past few months. She explains that it started with solids, and then progressed to liquids. She states it now is hard even to swallow water and that she is often very thirsty. She says she has lost about 3.2 kg (7 lb), but says she is working out frequently. Her blood pressure is 118/76 mm Hg, pulse is 86/min, respiratory rate is 16/min, and temperature is 37.2°C (98.9°F). Laboratory tests show: Na+: 144 mEq/L, K+: 4.0 mEq/L, Cl−: 100 mEq/L, Carbon dioxide: 22 mmol/L Blood urea nitrogen: 18 mg/dL Creatinine: 1.0 mg/dL, Glucose: 88 mg/dL. Her hemoglobin A1c level, measured 3 months earlier, was 6.1%. A barium swallow is performed, which reveals a dilated esophagus, especially distally, that flares out near the lower esophageal junction. Still not completely sure of the diagnosis, esophageal manometry is performed, which reveals abnormal peristalsis and increased lower sphincter pressure. Which of the following is the most appropriate management?

89) 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?

90) A 59-year-old woman presents to the ED complaining of worsening lower abdominal pain over the previous 3 days. She describes feeling constipated recently and some burning when she urinates. Her BP is 135/75 mm Hg, HR is 89 beats per minute, temperature is 101.2°F, and her RR is 18 breaths per minute. Her abdomen is mildly distended, tender in the LLQ, and positive for rebound tenderness. CT scan is consistent with diverticulitis with a 7-cm abscess. Which of the following is the most appropriate management for this condition?

91) A 60-year-old man is brought to the ED complaining of generalized crampy abdominal pain that occurs in waves. He has been vomiting intermittently over the last 6 hours. His BP is 150/75 mm Hg, HR is 90 beats per minute, temperature is 99.8°F, and his RR is 16 breaths per minute. On abdominal examination you notice an old midline scar across the length of his abdomen that he states was from surgery after a gunshot wound as a teenager. The abdomen is distended with hyperactive bowel sounds and mild tenderness without rebound. An abdominal plain film confirms your diagnosis. Which of the following is the most appropriate next step in management?

93) A 68-year-old African-American man presents to his primary care physician for a check-up. He has not been to the physician’s office in over 15 years. He reports that he is fine but that his wife keeps telling him that he has to “go see the doctor.” He says he has never been sick, despite smoking three packs of cigarettes per day for over 40 years. He also says that he drinks 2–3 beers a night but never had a problem with that either. He’s as healthy “as a bull,” he says. His wife is in the room and says that he recently has had some problems swallowing food and that he is losing weight. He laughs and says, “I just need to chew more and eat more.” His vital signs are normal, as are his laboratory values. The physician is concerned and orders an endoscopy, which reveals a biopsy positive for squamous cell carcinoma of the esophagus. Which of the following most likely could have prevented this condition?

94) A full-term 6-day-old boy presents to a physician’s office for routine care. He is tolerating breast milk well. He is urinating, defecating, and sleeping normally. Physical examination reveals an alert new-born with mild eczema, good skin turgor, normal reflexes, and a musty odor. His newborn laboratory screen is notable for phenylketones in the urine. What is the best advice to give his parents regarding the boy’s diet?

97) A 62-year-old woman presents to her physician with complaints of heartburn, fatigue, and intermittent upper abdominal pain. The pain is often worse after meals and especially with spicy foods. She reports no recent nausea, vomiting, weight loss, dysphagia, or bright-red blood per rectum. However, her stools are darker than normal. Her last colonoscopy 2 years ago was unremarkable. Stool guaiac test result is positive. An initial complete blood cell count reveals: Hemoglobin: 10.1 g/dL, Hematocrit: 33.2%, Mean corpuscular volume: 74.6/mm³, Mean corpuscular hemoglobin concentration: 25.8%, WBC count: 9200/mm³ Platelet count: 176,000/mm³ Ferritin: 11 ng/mL. The patient undergoes upper endoscopy, which reveals erosive gastritis. She is started on omeprazole, 40 mg twice a day and oral iron sulfate supplementation, 325 mg three times a day with meals. Six months into treatment, abdominal pain and heartburn are resolved, but the patient still has fatigue and is pale. Repeat laboratory tests show: Hemoglobin: 9.9 g/dL, Hematocrit: 30.2%, Mean corpuscular volume: 74.2/mm³, Mean corpuscular hemoglobin concentration: 25.1% , WBC count: 9800/mm³ Platelet count: 198,000/mm³ Ferritin: 10 ng/mL. Repeat upper endoscopy is negative for bleeding and erosive gastritis. Stool guaiac test result is negative. Which of the following is the next best step in management?

99) You are called to the oncology floor to examine a 57-year-old female who is complaining of severe nausea and vomiting. Her other symptoms include some general malaise and a sore throat. She is receiving combination ABVD chemotherapy (Doxorubicin, Bleomycin, Prednisone, and Procarbazine). She was diagnosed with stage II Hodgkin's lymphoma 4 weeks ago. She tells you that she does not want to continue her therapy anymore since it is "making life even more miserable." She has lost 30 lbs (12.6kg) in a month. Her temperature is 38.5°C (101.3°F), pulse is 88/min, respirations are 18/min, and blood pressure is 109/68mm Hg. Her pulse oximetry reading in room air is 92%. Physical examination reveals a significantly cachectic patient with a dry mouth, enlarged cervical lymph nodes and hepatomegaly. How can this patient's vomiting be best managed?

103) A 21-year-old previously healthy man presents to your office for a routine check-up. He has no current complaints. He does not smoke or consume alcohol. His family history is significant for cystic fibrosis in his older brother. He is sexually active with one partner and uses condoms regularly. He visits a dentist twice per year. His temperature is 36.6°C (97.9°F), pulse is 78/min, respirations are 14/min, and blood pressure is 120/76 mmHg. Physical examination reveals several non-tender, rubbery cervical lymph nodes, each measuring approximately 1 cm in diameter. There is no hepatosplenomegaly. Which of the following is the best next step in management of this patient?