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345. Several days following esophagectomy, a patient complains of dyspnea and chest tightness. A large pleural effusion is noted on chest radiograph, and thoracentesis yields milky fluid consistent with chyle. Which of the following is the most appropriate initial management of this patient?

230. A 45-year-old man comes to the emergency department because of severe right flank pain that began abrupdy 3 hours ago. The pain comes in waves and radiates down to the ipsilateral testis. The patient is nauseated and extremely restless. His temperature is 37.0 C (98.6 F). Dipstick examination of urine is positive for hematuria. Urinary pH is 5.8. Which of die following is the most appropriate next step in diagnosis?

709. A 25-year-old male is brought to the trauma center by the paramedics after being involved in a road traffic accident that occurred 90 minutes ago. He was a front seat passenger in a 3-car accident. His initial blood pressure at the scene of the accident was 90/60 mm Hg and pulse was 126/min. The paramedics administered 2 liters of normal saline in the ambulance. In the ED, his blood pressure is 110/70 mm Hg and pulse is 90/min. His abdomen is tender in the left upper quadrant. Ultrasound shows fluid in the spleno-renal angle The most appropriate next step is to-

775. A 45-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He is conscious but in severe pain. His blood pressure is 90/60 mm Hg, pulse is 100/min and respirations are 17/min. Physical examination shows marked swelling and some bruising over the right thigh; the skin is intact. An x-ray film of the leg shows a fracture of the mid shaft of the femur. After hemodynamically stabilizing the patient, which of the following is the most appropriate next step in management?

663. A 62-year-old female is hospitalized with epigastric pain and vomiting. Her past medical history includes mild COPD, congestive heart failure, diabetes mellitus and a stroke that occurred 2 years ago. Her current medications are insulin glargine and aspirin. Her blood pressure is 110/70 and her heart rate is 76/min. Comprehensive work-up is suggestive of acute calculous cholecystitis, and a cholecystectomy is planned. Which of the following would reduce postoperative mortality in this patient?

632. 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?

288. A 35-year-old woman presents with a lump in the left breast. Her family history is negative for breast cancer. On examination the mass is rubbery, mobile, and nontender to palpation. There are no overlying skin changes and the axilla is negative for lymphadenopathy. An ultrasound demonstrates a simple 1-cm cyst in the area of the palpable mass in the left breast. Which of the following represents the most appropriate management of this patient?

588. A 64-year-old man with a history of a triple coronary artery bypass 2 years ago presents with peripheral arterial occlusive disease. His only medication is a thiazide diuretic. Which of the following medications would be most appropriate in the medical management of his atherosclerosis?

756. An otherwise healthy 17-year-old complains of swollen glands in his neck and groin for the past 6 months and an increasing cough over the previous 2 weeks. He also reports some fevers, especially at night, and possibly some weight loss. On examination, you notice that he has nontender cervical, supraclavicular, axillary, and inguinal nodes, no hepatosplenomegaly, and otherwise looks to be fairly healthy. Which of the following would be the appropriate next step?

601. A 6-month-old infant presents to the emergency department with the new onset of weak cry, decreased activity, and poor feeding. The mother also states that the infant has been constipated for the past 2 days. On physical examination, the infant has a very weak cry, poor muscle tone, and absent deep tendon reflexes. Which of the following is the most likely diagnosis?

952. A 16-year-old girl presents with lower abdominal pain and fever. On physical examination, a tender adnexal mass is felt. Further questioning in private reveals the following: she has a new sexual partner; her periods are irregular; she has a vaginal discharge. Which of the following is the most likely diagnosis?

435. A mother brings her 7-year-old son to the clinic because, over the past several days, his urine has become pink and bis eyes have looked puffy. About 2 weeks ago, he missed school because of fever and a sore throat. On examination, the boy's blood pressure is 130/85 mm Hg, his eyelids and scrotum appear puffy, and he has 1+ tibial edema. No rashes are noted. Which of the following is the most likely diagnosis?

786. A 15-year-old woman presents to your office for her first wellwoman examination while she is on summer break from school. She denies any medical problems or prior surgeries. She had chicken pox at age 4. Her menses started at the age of 12 and are regular. She has recently become sexually active with her 16-year-old boyfriend. She states that they use condoms for contraception. Her physical examination is normal. Which of the following vaccines is appropriate to administer to this patient?

400. A patient is seen on the first postoperative day after a difficult abdominal hysterectomy complicated by hemorrhage from the left uterine artery pedicle. Multiple sutures were placed into this area to control bleeding. Her estimated blood loss was 500 mL. The patient now has fever, left back pain, left costovertebral angle tenderness, and hematuria. Her vital signs are temperature 38.2C (100.8F), blood pressure 110/80 mm Hg, respiratory rate 18 breaths per minute, and pulse 102 beats per minute. Her postoperative hemoglobin dropped from 11.2 to 9.8, her white blood cell count is 9.5, and her creatinine rose from 0.6 mg/dL to 1.8 mg/dL. What is next best step in the management of this patient?

782. You are following up on the results of routine testing of a 68-year-old G4P3 for her well-woman examination. Her physical examination was normal for a postmenopausal woman. Her Pap smear revealed parabasal cells, her mammogram was normal, lipid profile was normal, and the urinalysis shows hematuria. Which of the following is the most appropriate next step in the management of this patient?

18) A 66-year-old man presents to the office for a well visit. He has no complaints and feels well. His wife has been complaining that his belly has been increasing in girth over the past year. His vital sign is stable. What is the best next step in the management of this patient?

161. A 56-year-old man is evaluated for chronic cough. It is present most of the time and is progressively getting worse over the past 3 years. With the cough he usually has white to yellow sputum that he has to expectorate. There is no history of wheezing, asthma, congestive heart failure (CHF), or acid reflux disease. He currently smokes one pack a day for the past 25 years. On examination, his chest is clear. CXR is normal and his forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) on spirometry are normal. Which of the following is the most likely diagnosis?

90. A 43-year-old moderately overweight woman presents to the emergency department complaining of two days of shortness of breath. Today, while climbing stairs, she had an episode of severe lightheadedness and near syncope. Her medical history is significant for a right calf deep venous thrombosis one year ago. She takes no medications currently. On physical examination, her blood pressure is 90/50 mmHg and her heart rate is 120/min and regular Imaging studies are most likely to reveal which of the following?

165. A 29-year-old woman complains of dysphagia with both solids and liquids, worse when she is eating quickly or is anxious. Manometry reveals normal basal esophageal sphincter pressure, with no relaxation of the sphincter on swallowing. Which of the following is the most appropriate next step in management?

24. A 78-year-old female is being evaluated for recent weight loss and fatigue. Laboratory tests reveal abnormal thyroid function. She begins treatment with a single agent, but soon after is hospitalized with new onset atrial fibrillation and hand tremor. Which of the following treatments had she most likely received?

137. A 22-year-old male, recently incarcerated and now homeless, has received one week of clarithromycin for low-grade fever and left upper-lobe pneumonia. He has not improved on antibiotics, with persistent cough productive of purulent sputum and flecks of blood. Repeat chest x-ray suggests a small cavity in the left upper lobe. Which of the following statements is correct?

1. An 82-year-old woman presents 1-hour after the sudden onset of moderate-to-severe epigastric pain. The pain radiates to her back, both scapulae, and both arms. She has been nauseated and vomited three times in the past hour. Her past medical history is remarkable for peptic ulcer disease 10-years ago, cholelithiasis for the past 6-years, and stable angina pectoris for the past 3-years. She has had occasional episodes of biliary colic and two bouts of acute cholecystitis which were treated conservatively. Her temperature is 36.8C (98.2F), blood pressure is 120/70 mm Hg, pulse is 90/min, and respirations are 14/min. The lungs are clear to auscultation. Abdominal examination shows a soft abdomen with mild tenderness to palpation in the epigastrium. Murphy's sign is negative. Which of the following studies should be done first?

99. A 36-year-old man presents to your office for a routine pre-employment physical. He has no complaints except for occasional morning headaches. His father died suddenly at the age of 54. The patient's blood pressure is 175/103 mmHg in the right arm and 180/105 in the left arm. His heart rate is 82/min. His lungs are clear bilaterally and his heart sounds are normal. Bilateral, non-tender, upper abdominal masses are palpated on exam. His hemoglobin level is 15.2 g/dl and creatinine concentration is 0.8 mg/dl. Which of the following is most likely to diagnose this patient's condition?

106. A 64-year-old man presents with symptoms of malaise, shortness of breath, edema, and no urine output for 24 hours. His past medical history is not significant, and his only medication is daily aspirin. On examination his JVP is 4 cm, heart sounds are normal, lungs are clear, and the abdomen is soft. A Foley catheter is inserted into his bladder for 200 cc of urine, which is sent for urinalysis. His urine output still remains low. Which of the following is the most appropriate initial diagnostic test?

103. A 32-year-old woman comes to the emergency department complaining of sudden onset shortness of breath accompanied by a non-productive cough and left-sided chest discomfort that increases on inspiration. She denies subjective fever, coughing up blood, wheezing, palpitations, leg pain, and swelling of the lower extremities or any recent travel. Past medical history is significant for an appendectomy at age 15. Her medications include birth control pills and over- the-counter vitamins. She is a known carrier of sickle cell trait. Her father, age 65, has had diabetes for 20 years; mother, age 58, has coronary artery disease. She has never been pregnant, drinks alcohol socially and does not smoke. Her temperature is 99 F (38C), blood pressure is 110/70 mmHg, pulse 130/min and respirations are 33/min. Pulse oximetry shows an oxygen saturation of 85% on 6 liters of oxygen. Her BMI is 30 kg/m2. She is alert and cooperative without cyanosis or jaundice. Her lungs are clear to auscultation. Her abdomen is soft, nondistended and non-tender. Which of the following is the best test to confirm this patient's diagnosis?

197. A 33-year-old woman, otherwise perfectly well, presents with recurrent episodes of hemopty- sis. She has no fever, weight loss, cough, or sputum production. Her physical examination is entirely normal. Her CXR, biochemisty, CBC, and coagulation profile are also normal. Which of the following is the most appropriate initial diagnostic test?

92. A 25-year-old female presents to your office complaining of exertional dyspnea and fatigue. Her past medical history is insignificant. She does not smoke or consume alcohol. Her blood pressure is 110/70 mmHg and heart rate is 90/min. Physical examination reveals pale conjunctiva. The laboratory values are: ESR 15 mm/hr Hemoglobin 7.5 g/dL MCV 70 fl MCHC 29% Leukocyte count 7,000/cmm Segmented Neutrophils 55% Bands 3% Eosinophils 3% Basophils 0% Lymphocytes 32% Monocytes 7% What is the best next step in the management of this patient?

61.A 45-year-old man complains of sudden pain and swelling in his left first metatarsophalangeal joint. He is undergoing high dose induction chemotherapy for acute leukemia. Joint fluid aspiration reveals negative birefringent crystals and elevated white cell count. Which of the following prophylactic measures would most likely have prevented this condition?

85.A 27-year-old male presents to the physician's office because of pain on the medial side of the tibia just below the knee. The pain does not radiate and is continuous. He relates the onset of his pain to falling on the ground while playing football two weeks ago. He denies fever, malaise and weight loss. His past medical history is not significant. On examination, a well-defined area of tenderness is present on the upper tibia below the medial knee joint. There is no redness, warmth or swelling. His gait is normal. A valgus stress test has no effect on his pain. X-ray of the knee and tibia shows no abnormalities. Which of the following is the most likely cause of his current symptoms?

63. A 24-year-old man comes to the physician 24 hours after sustaining an injury to the right knee while playing soccer. He can walk, but he limps on the right side. He reports that he was hit by another player on the lateral side of his right knee, but did not feel a snap or pop at the time of the accident. On examination, the right knee appears normal, but palpation elicits tenderness along the medial aspect of the joint line. Increased laxity is observed when a valgus stress is applied to the knee flexed at 30 degrees, but not when the knee is in full extension. Lachman's test and posterior drawer tests are negative. Which of the following is the most likely diagnosis?

7.A 36-year-old male AIDS patient comes in due to a painful red eye. He complains of pain, discharge and redness in his left eye for the past 10 days. On physical examination, you notice redness in his left eye as well as multiple skin lesions on his face, left eyelid, inner thighs, penis and pubis. The lesions are painless, pale, shiny, dome-shaped papules with a central umbilication measuring 2-5mm in diameter. These lesions were not present on his previous visit. His CD4 count thirty days ago was 100/uL. What is the most likely etiology of this patient's skin lesions?

158. A 33-year-old Russian male reports concern over recurrent episodes of a "pounding" and "racing" heart over the last several months. He says his symptoms are worst while lying supine and while lying on his left side. On physical examination, his blood pressure is 150/55 mmHg and heart rate is 73/min. Which of the following is most likely responsible for his symptoms?

116. A 53-year-old male presents to your office with a two-day history of right calf pain and swelling. He describes the pain as constant and states that it is exacerbated by knee flexion. He has a history of past IV drug abuse, endocarditis, and stroke. He is currently wheelchair-bound secondary to stroke- related left-sided hemiparesis. On physical examination, his blood pressure is 140/90 mmHg and his heart rate is 100/min. There is no jugular venous distention or hepatojugular reflux. His chest is clear to auscultation but his abdomen is enlarged with shifting dullness and a fluid wave, suggestive of ascites. His liver is palpable 3 cm below the right costal margin. His spleen is also palpable. On examination of his lower extremities, you note right-sided calf swelling and tenderness. Which of the following is the most likely cause of this patient's ascites?

106. A 24-year-old male experiences syncope while shoveling snow. He regained consciousness within one minute. He has been having some shortness of breath and chest pains recently, mostly related to exercise. He denies any illicit drug use. His temperature is 37.2 C (98.9 F), and blood pressure is 126/76 mm Hg, pulse is 76/min and respirations are 14/min. Physical examination shows a well-built male in no apparent distress. Lungs are clear. A crescendo-decrescendo systolic murmur is heard along the left sternal border without carotid radiation. Chest X-ray is normal. Which of the following is the most likely cause of his syncopal episode?

49. A 32-year-old male complains of progressive weakness and exertional dyspnea. His past medical history is significant for a knife injury to the right thigh two months ago. He has been arrested several times for robbery. He consumes alcohol regularly, and smokes crack occasionally. His younger brother died of cystic fibrosis. His blood pressure is 160/60 mmHg, and heart rate is 100/min. His extremities are warm and flushed. Carotid upstroke is brisk. The point of maximal impulse is displaced to the left, and a soft, holosystolic murmur is heard over the cardiac apex. The murmur does not change with the Valsalva maneuver. Which of the following is the most likely cause of this patient's symptoms?

. A 60-year-old male is brought to ER by his son because he had an episode of syncope. He was watching TV in an arm-chair when suddenly lost his consciousness without any warning sign. He had several clonic jerks while unconscious He never had such an episode before. His past medical history is significant for acute myocardial infarction six months ago and well-controlled hypertension. His current medications include captopril metoprolol hydrochlorothiazide, clopidogrel and aspirin. His blood pressure is 130/85 mmHg and heat rate is 80/min with frequent ectopic beat. Physical examination revealed mild holosystolic apical murmur radiating to the axilla. Which of the following is the most probable pathophysiologic mechanism for his syncopal episode?

92. A 64-year-old diabetic with a long history of uncontrolled hypertension is admitted for chest pain. ECG reveals elevated ST segments in the anterior wall leads. Cardiac enzymes are elevated and the patient is admitted to the ICU for supportive care. He receives low molecular weight heparin and is placed on a nitroglycerin drip. He continues to have chest pain and requires intravenous morphine. Three days later, the patient is transferred to the floor and he remains on bed rest. During the night the nurse on call informs you that the patient has a cold leg. On examination, the left leg is cold and there are no distal pulses. There is minimal swelling and the leg appears mottled. Emergency vascular surgery consult was placed and the appropriate treatment was given Which of the following should also be considered in this patient?

31. A 70-year-old man is brought to the Emergency Room because he lost his consciousness while working in the garden. He says that he had several episodes of near-syncope on exertion recently. His past medical history is insignificant He is not taking any medications. His blood pressure is 110/85 mmHg and heat rate is 80/min. Point of maximal impulse is increased in intensity. Cardiac auscultation reveals ejection type systolic murmur at the base of the heat with radiation to the carotid arteries. ECG demonstrates left ventricular hypertrophy, and secondary ST segment and T wave change. What is the most probable cause of this patient's condition?

190. A 56-year-old white male presents to his primary care physician for follow-up evaluation of high blood pressure noted on each of three prior visits over a period of 6 months (systolic blood pressure ranging 140-145, diastolic blood pressure ranging 90-96 mm Hg). He has smoked a pack of cigarettes per day for the past 20 years and takes 5-6 drinks of alcohol daily. He has no other medical problems and takes no medications. There is no family history of diabetes mellitus, coronary artery disease, hyperlipidemia or hypertension. On physical examination today, his blood pressure is 146/97 mm Hg and pulse is 80/min. The remainder of the exam is unremarkable. Which of the following nonpharmacologic interventions would be expected to have the greatest impact on his high blood pressure?

300. A 57-year-old man complains of chest palpitations and light-headedness for the past hour. Five years ago he underwent a cardiac catheterization with coronary artery stent placement. He smokes half a pack of cigarettes daily and drinks a glass of wine at dinner. His HR is 140 beats per minute, BP is 115/70 mm Hg, and oxygen saturation is 99% on room air. An ECG reveals a wide complex tachycardia at a rate of 140 that is regular in rhythm. An ECG from 6 months ago shows a sinus rhythm at a rate of 80. Which of the following is the most appropriate medication to treat this dysrhythmia?

299. A 62-year-old woman presents to the ED with general weakness, shortness of breath, and substernal chest pain that radiates to her left shoulder. Her BP is 155/80 mm Hg, HR is 92 beats per minute, and RR is 16 breaths per minute. You suspect that she is having an acute MI. Which of the following therapeutic agents has been shown to independently reduce mortality in the setting of an acute MI?

A 47-year-old obese female comes to the office for the evaluation of recent episodes of mood instability. Her mood varies between sad and irritable. She denies any other symptoms, except for some mild forgetfulness. She tearfully shares that she is convinced that she is going to die, as her father also developed similar symptoms around the same age and died subsequently. On physical examination, writhing movements of the extremities are prominent. This patient's clinical presentation is most consistent with:

A 79-year-old woman is brought to the emergency department due to a suspected cerebrovascular accident on her right side. She complains of diffuse paresthesias and tingling in her right hand. She did not lose consciousness. The physical examination reveals normal speech, symmetric deep tendon reflexes (2/4 on both upper extremities, 2/4 both patellar reflexes, and 0/4 both Achilles reflexes), a cold right hand, and undetectable arterial radial pulse. Tinel and Phalen's signs are negative. The rest of the examination is normal. What is the most appropriate next step in the management of this patient?

A 62-year-old Caucasian woman complains of difficulty remembering important dates and appointments. She also describes poor concentration, daytime sleepiness and easy fatigability. She is concerned about her forgetfulness because her mother suffered from recurrent strokes and had severe memory loss. Her father died of chronic leukemia. Her daughter's recent job loss has caused her a lot of stress. She does not smoke or consume alcohol. Her appetite is decreased but she has gained 4 pounds over the last three months. She visited an otolaryngologist for hoarseness of recent onset. She takes over- the-counter laxatives for constipation and occasional aspirin for knee pain. She denies any other medication use. Which of the following is the most likely diagnosis in this patient?

A 63-year-old man presents to the emergency department with a 6-hour history of slurred speech and right hand weakness. His past medical history is significant for chronic hypertension and a myocardial infarction 2 years ago. His current medications include enalapril and aspirin. He smokes 2 packs of cigarettes daily and consumes alcohol occasionally. His blood pressure is 165/95 mmHg, pulse is 80/min, and respirations are 14/min. Physical examination reveals right hand weakness and mild motor aphasia without sensory abnormalities Which of the following is the most probable cause of this patient's condition?

50. A 36-year-old male comes to your office complaining of progressive fatigability. His past medical history is significant for infiltrative pulmonary tuberculosis diagnosed two months ago. His current treatment includes isoniazid, rifampin, ethambutol, and pyrazinamide. Laboratory values are: Hemoglobin 8 g/dl MCV 77 fl MCHC 30% ESR 17 mm/hr Serum iron 170 micro-g/dl (N 50- 150 micro-g/dl ) Total iron binding capacity (TIBC) 280 micro-g/dl (N 300-360 micro-g/dl) Microscopy reveals two populations of red blood cells (RBC) - hypochromic and normochromic. What is the next best step in the management of this patient?

121. A 45-year-old white male comes to the emergency room with "all sorts of things going wrong with him", for the last few months. He has a severe headache, chest and abdominal pain. He is sweating profusely. He has lost weight recently, has diarrhea and palpitations. He is feeling hot all the time. Vital signs reveal BP: 190/100mm of Hg; PR 124/min; RR 18/min; Temperature 37.7 C (99.8F). On physical examination he has enlarged cervical lymph nodes. Examination of the thyroid reveals multiple thyroid nodules. FNA biopsy reveals thyroid C-cell hyperplasia. Which of the following can also be found on laboratory results?

122. A 54-year-old male had undergone an emergency colonic resection following an extensive ischemic colitis. The surgery was uneventful. The patient has been on peperacillin and tazobactam (Zosyn) for the past five days. He was NPO (nothing by mouth) for the past five days. He has a significant alcoholic history. On postoperative day six, he developed bleeding from the venipuncture site. His temperature is 36.7 C (98 F), blood pressure is 120/76 mmHg, pulse is 80/min, and respirations are 16/min. Lab results are: Hb 11.5g/dL MCV 88 fl Platelet count 160,000/cmm Leukocyte count 7,500/cmm Segmented neutrophils 68% Bands 1% Eosinophils 1% Lymphocytes 24% Monocytes 6% Prothrombin time 20 sec (INR=1.9) Partial thromboplastin time 45 sec His family history is insignificant. Which of the following is the most likely cause of his condition?

89. A 62-year-old woman presents complaining of recurrent cough productive of yellow sputum. She was seen several weeks ago for similar complaints and was effectively treated with a course of azithromycin. Today she expresses frustration that she seems to keep getting sick with the same infection. On review of systems, the patient also reports recent-onset back pain for which she has been taking acetaminophen. Her past medical history is otherwise insignificant. She has never smoked cigarettes, and drinks alcohol only on rare social occasions. Physical examination reveals conjunctival pallor, a few scattered rales in the lungs bilaterally, and tenderness over the lumbar vertebrae. Laboratory analyses reveal: Hemoglobin 8.4 g/dL Leukocyte count 5,500/mm3 Blood urea nitrogen 34 mg/dL Creatinine 2.0 mg/dL Calcium 10.9 mg/dL Albumin 3.8 g/dL Total protein 9.5 g/dL This patient is at increased risk for recurrent infections because of which of the following abnormalities?

12. A 54-year-old Caucasian man presents to his family physician's office complaining of several months of increased fatigability. He eats meat occasionally and drinks two to three cans of beer on weekends. Physical examination reveals pale conjunctivae and hyperdynamic carotid pulses. His blood hemoglobin level is 7.7 mg/dl, WBC count is 4,500/mm3, and platelet count is 170,000/mm3 Folic acid therapy is initiated. Four weeks later the patient's hemoglobin level is 9.1 mg/dl, but he complains of new tingling in his toes. Which of the following is a likely cause of this patient's current symptoms?

113. A mother brings her 7-year-old son in for evaluation of bleeding gums. She reports that he brushes his teeth regularly and visits a dentist twice per year. The boy also complains of easy fatigability and a pounding sensation in his ears. On physical examination, he is at the 5th percentile for height and the 25th percentile for weight for his age. You note several areas of hypopigmentation on his skin. Laboratory findings include: Hemoglobin 7.8 mg/dl RBC count 3.0 x 1012/L MCV 112fl Platelet count 40,000/mm3 This patient's condition is most likely caused by:

48. A 79-year-old woman presents to your office complaining of an intermittent skin rash over the last several months. She denies fever, headache, and recent weight loss. Her past medical history is significant for diet-controlled diabetes and right knee osteoarthritis treated with acetaminophen. Physical examination reveals several dark purple ecchymotic areas over the dorsum of both arms. Her abdomen is soft and non-tender. The liver span is 8 cm and the spleen is not palpable. Laboratory studies reveal: Hematocrit 47% WBC count 5,800/mm3 Platelet count 220,000/mm3 Serum creatinine 0.8 mg/dL\ Fibrinogen 350 mg/dL Prothrombin time 10 sec INR 1.0 Partial thromboplastin time 25 sec Which of the following is the most likely cause of this patient's complaint?

A 45-year-old man presents with two days of bilateral hand pain that is most severe in his wrists. Physical examination reveals bilateral wrist tenderness, thickening of the distal fingers, and convex nail beds. There is nicotine staining of the right index and middle fingers. He states that he has been smoking 2 packs of cigarettes a day for the past 25 years. Chest examination reveals decreased breath sounds and a prolonged expiratory phase. The patient relates the pain's onset to a data entry job he recently started. He notes that his boss believes he is fabricating his pain to get off work. His job records reveal numerous sick leaves. Which of the following is the most appropriate course of action?

A 54-year-old man is being evaluated for shortness of breath. Examination shows dullness to percussion and increased breath sounds, particularly during expiration, in the right lower lobe. Cardiac examination reveals regular rate and rhythm with normal S1 and S2. There is no murmur. Moderate peripheral edema is present. Which of the following is the most likely cause of his shortness of breath?

A 63-year-old male complains of cough and nocturnal wheezing. The cough is mostly non-productive but can sometimes relieve chest tightness if a small amount of yellow sputum is produced. His past medical history is significant for a hospitalization for a 'chest infection' two years ago. His appetite is good but he lost 5 pounds over the last several months. He has smoked one pack of cigarettes per day for the past 40 years. He drinks 2-3 cans of beer per day on the weekends. His mother suffered from diabetes mellitus and his father died of a stroke. On physical examination, his blood pressure is 140/80 mmHg and his heart rate is 80/min. There is chest hyperinflation and scattered expiratory wheezes on auscultation. The patient expires through pursed lips. His fingers demonstrate prominent clubbing. This patient's clubbing is most likely related to:

A 66-year-old man has progressive shortness of breath due to COPD. He is currently able to do his activities of daily living, but has trouble walking more than one block. His physical examination reveals hyperinflation, increased resonance to percussion, and bilateral expiratory wheezes. He is on appropriate medical therapy for his stage of COPD. Which of the following is also indicated in the management of this condition?

31. A 70-year-old man presents to the emergency department with a 12-hour history of inability to void. He also complains of nocturia and problems with initiating micturition for the past few weeks. He denies fever, weakness, numbness, dysuria or hematuria. He does not use tobacco, alcohol, or drugs. Neurological examination shows no abnormalities, except absent Achilles tendon reflexes bilaterally. Straight catheterization of the bladder produces 600 ml of urine. Further evaluation will most likely show which of the following?

148.A 59-year-old female is hospitalized due to lower gastrointestinal bleeding. Her past medical history includes diabetes mellitus, hypertension, chronic obstructive pulmonary disease, cor pulmonale and recurrent urinary tract infections. Her condition initially stabilized with fluid resuscitation and blood transfusions, but she subsequently developed an acute renal failure. Her urine output has been between 300 and 400 ml per day for the last couple of days. On the 1Oth day of her hospitalization she is lethargic. Serum analysis reveals: Hemoglobin 10.2 g/dl Hematocrit 30% WBC 14,300/mm3 Blood glucose 93 mg/dl BUN 141 mg/dl Creatinine 4.1 mg/dl Sodium 133 mEq/L Potassium 5.0 mEq/L pH 7.15 pO2 90 mmHg pCO2 60 mmHg HCO3 18 mEq/L Which of the following is the most likely cause of her lethargy?

63. A 62-year-old woman presents to your office complaining of urinary frequency and burning during urination. She denies fever, chills, nausea, back pain or abdominal pain. Her past medical history is significant for a long history of diabetes mellitus and hypertension. She does not use tobacco or consume alcohol. Her blood pressure is 160/100 mmHg and her heart rate is 70/min. Her hematocrit is 43% and her WBC count is 8,500/mm3 Urinalysis reveals the following: Glucose negative Ketones negative Nitrates positive Protein 2+ WBC 20-25/hpf RBC 3-5/hpf She is given a three-day course of levofloxacin. Urinalysis two weeks later reveals 2+ protein but no nitrates, WBCs, or RBCs. Which of the following is most likely responsible for her persistent urinalysis abnormality?

21. 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 mm Hg, temperature is 37.2C (99F), 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?

18. A 60-year-old Caucasian male is brought to the emergency department by his daughter due to a 2-day history of confusion and lethargy. According to his daughter, he had been complaining of fatigue, anorexia, polyuria and constipation for the last several weeks. He smokes two packs of cigarettes daily, and consumes alcohol occasionally. His blood pressure is 130/90 mmHg and heart rate is 90/min. Physical examination reveals a somnolent patient who is not oriented in time. His lab values are: Serum Na 140 mEq/L Serum K 4.0 mEq/L Serum chloride 100 mEq/L Serum bicarbonate 22 mEq/L Serum creatinine 1.6 mg/dl Serum calcium 13.4 mg/dl Serum phosphorus 2.2 mg/dl Blood glucose 1 00 mg/dl Alkaline phosphatase 80 U/L Chest x-ray demonstrates a right middle lobe mass and perihilar adenopathy. What is the most probable cause of this patient's symptoms?

16. A 17-year-old white female comes to the office for the evaluation of fatigue which has been present for the past 4 months. Her past medical history is insignificant. She denies the use of any drugs. Her pulse is 74/min, blood pressure is 110/70 mm Hg, and temperature is 36.7C (98.0F). Physical examination shows scars on the dorsum of her hands and dental erosions. Laboratory studies show: Plasma sodium 139 mEq/L Serum potassium 2.3 mEq/L Bicarbonate 40 mEq/L Urine chloride concentration is 15 mEq/L (Normal = 80-250 mEq/L). Based on these findings, what is the most likely diagnosis?

43. A 35-year-old male presents with complaints of weakness and fatigue of one year's duration. He is anorexic and has lost interest in all his activities. He also complains of cold intolerance and constipation. His blood pressure is 98/72 mm Hg, temperature is 37.1C (99F), respirations are 14/min, and pulse is 50/min. His skin is dry and rough, nails are brittle, and hair is thin. There is no hyperpigmentation of the skin. Delayed deep tendon reflexes are noted on neurological examination. Lab studies show: Hemoglobin 10.2 g/dL WBC count 5,000/micro-L Neutrophils 45% Monocytes 5% Eosinophils 10% Basophils 1% Lymphocytes 40% Serum sodium 135 mEq/L Serum potassium 4.0 mEq/L Which of the following is most consistent with this patient's findings?

54. A 54-year-old male with a history of chronic alcoholism is admitted to the hospital with hematemesis and abdominal distension. Upper gastrointestinal endoscopy reveals the presence of esophageal varices. Continued workup of his condition results in a diagnosis of cirrhosis of the liver. He is treated appropriately and strongly counseled about the need to abstain from alcohol. He is then discharged home. After discharge, he begins to work as a full-time volunteer for a non-profit organization that assists patients with alcoholic cirrhosis. Which of the following defense mechanisms is this man using?

72. A 31-year-old woman voices her anger at the increasing number of immigrants who compete for job opportunities in her chosen field of computer science. She observes that many of her friends in the local community are also experiencing difficulty in securing appealing employment because of the influx of immigrants. This woman volunteers in her spare time to provide vocational guidance to new immigrant families in the community. Which of the following psychological defense mechanisms is she demonstrating?

49. A 37-year-old obese man returns to his doctor for a follow-up visit. One month ago, he was diagnosed with type II diabetes mellitus and was started on metformin. His fasting glucose is 122 mg/dl, and his blood pressure is 145/85 mm Hg. The patient looks rather dejected and admits it has been difficult to come to terms with his diagnosis. He has tried to exercise, watch his diet, and quit smoking as was suggested, but lately he has been feeling unmotivated and without energy. He admits to feeling sad and guilty about his weight, but is not sure he will be able to do anything about it. He continues to smoke despite attempts to cut back, and has been spending much of the day in bed watching television or sleeping. He has withdrawn from friends and family and took the last two weeks off from work, as he did not feel "up to going." Which of the following would be the best medication to prescribe at this time?

6. A mother brings her 16-year- old daughter to the ER after she had two episodes of coffee ground emesis. The mother reports that for the past two weeks, the teen has not been acting like herself; she has been especially isolated and has had a poor appetite and poor sleep. Her medical history is significant for anemia, for which she takes iron sulfate and folic acid. She also takes acetaminophen for occasional back pain. Presently, the patient's blood pressure is 110/70 mmHg and heart rate is 120/min. Which of the following is most likely to establish the diagnosis?

28. A 34-year-old homeless male is brought to the ER in a confused state. He complains of flank pain. His past medical history is unknown. His temperature is 36.8C (98.2F), blood pressure is 110/60 mm Hg, pulse is 110/min and respirations are 22/min. His appearance is disheveled. Pupils are equal, 4 mm in size and reactive to light. Funduscopic examination is within normal limits. Lungs have crackles at both bases. Mild costovertebral angle tenderness is present. Foley catheter is placed and urine appears red. Laboratory studies show: Serum sodium 136 mEq/L Serum potassium 3.5 mEq/L Chloride 93 mEq/L Bicarbonate 6 mEq/L Blood urea nitrogen (BUN) 34 mg/dl, Serum creatinine 2.8 mg/dl Blood glucose 80 mg/dl Calcium 6.5 mg/dl S erum ketones negative Plasma lactate 2.4 mEq/L Which of the following is the most appropriate next step in management?

71.A 64-year-old male recovering from an upper respiratory infection develops malaise and productive cough. Two days later he presents to the emergency department with confusion and severe dyspnea. He reports coughing up copious amounts of yellowish sputum streaked with blood today. On physical examination, his temperature is 40C (104F), blood pressure is 150/90 mm Hg, pulse is 110/min, and respirations are 24/min. Chest x-ray reveals infiltrates in the lung midfields bilaterally as well as multiple thinwalled cavities. What is the most likely cause of this patient's condition?

73.A 35-year-old man presents to the office with a two-week history of low-grade fever and progressive weakness. He has "a heart murmur detected a long time ago." He denies illicit drug use. Physical examination reveals splinter hemorrhages, small petechiae on the palatal mucosa, and an audible murmur. His ESR is 60/min. Urinalysis reveals microscopic hematuria and 1+proteinuria. Which of the following valvular dysfunctions is most likely to be detected?

420. A previously healthy 21-year-old woman has a profuse, malodorous vaginal discharge. Examination shows a greenish gray "frothy" discharge with a "fishy" odor and petechial lesions on the cervix. There is no cervical motion tenderness. Her temperature is 37.5 C (99.4 F), blood pressure is 120/80 mm Hg, pulse is 60/min, and respirations are 16/min. Microscopic evaluation of the discharge is most likely to show which of the following?

103. A 26-year-old woman in the third trimester of her first pregnancy develops persistent headaches and swelling of her legs and face. Early during her pregnancy, a physical examination was unremarkable; however, now her blood pressure is 170/105 mm Hg and urinalysis reveals slight proteinuria. Which of the following is the most likely diagnosis?

714. A 32-year-old G5 delivers a stillborn fetus at 34 weeks. The placenta is noted to be much larger than normal. The fetus appeared hydropic and had petechiae over much of the skin. What is the most likely causative agent?

716. A 20-year-old woman who works as a kindergarten teacher presents for her routine visit at 32 weeks. Her fundal height measures 40 cm. An ultrasound reveals polyhydramnios, an appropriately grown fetus with ascites and scalp edema. The patient denies any recent illnesses, but some of the children at her school have been sick recently. What is the most likely cause of the fetal findings?

346. A 2-week-old infant presents with hepatosplenomegaly and a thick, purulent, bloody nasal discharge. Coppery, oval, maculopapular skin lesions are present in an acral distribution. The neurologic examination is normal, including head circumference. Which of the following is the most likely cause of this congenital infection?

712. A 25-year-old G3 at 39 weeks delivers a small-for-gestational-age infant with chorioretinitis, intracranial calcifications, jaundice, hepatosplenomegaly, and anemia. The infant displays poor feeding and tone in the nursery. The patient denies eating any raw or undercooked meat and does not have any cats living at home with her. She works as a nurse in the pediatric intensive care unit at the local hospital. What is the most likely causative agent?

713. A 23-year-old G1 with a history of a flulike illness, fever, myalgias, and lymphadenopathy during her early third trimester delivers a growth-restricted infant with seizures, intracranial calcifications, hepatosplenomegaly, jaundice, and anemia. What is the most likely causative agent?

437. A healthy 42-year-old G2P1001 presents to labor and delivery at 30 weeks gestation complaining of a small amount of bright red blood per vagina which occurred shortly after intercourse. It started off as spotting and then progressed to a light bleeding. By the time the patient arrived at labor and delivery, the bleeding had completely resolved. The patient denies any regular uterine contractions, but admits to occasional abdominal cramping. She reports no pregnancy complications and a normal ultrasound done at 14 weeks of gestation. Her obstetrical history is significant for a previous low transverse cesarean section at term. Which of the following can be ruled out as a cause for her vaginal bleeding?

112. A 22-year-old woman comes to your office at 10 weeks gestation for her first prenatal visit. Her obstetrical history is significant for a spontaneous abortion at 12 weeks gestation one year ago. She states that her mother has hypothyroidism, and she asks you to order thyroid function tests for her. She denies any symptoms, and her physical examination is unremarkable. Ultrasound reveals an intrauterine gestation with normal fetal cardiac activity. Which of the following results is most likely to be expected in this patient?

92. A 24-year-old woman asks her physician about the possibility of genetic screening for BRCA1 mutations. Her mother died of breast carcinoma at age 44, and a sister had a diagnosis of in situ ductal carcinoma at age 38. Which of the following is the most appropriate advice to give this woman?

156. A 19-year-old female comes to the physician because of left lower quadrant pain for 2 months. She states that she first noticed the pain 2 months ago but now it seems to be growing worse. She has had no changes in bowel or bladder function. She has no fevers or chills and no nausea, vomiting, or diarrhea. The pain is intermittent and sometimes feels like a dull pressure. Pelvic examination is significant for a left adnexal mass that is mildly tender. Urine hCG is negative. Pelvic ultrasound shows a 6 cm complex left adnexal mass with features consistent with a benign cystic teratoma (dermoid). Which of the following is the most appropriate next step in management?

554. An 18-year-old college student, who has recently become sexually active, is seen for severe primary dysmenorrhea. She does not want to get pregnant, and has failed to obtain resolution with heating pads and mild analgesics. Which of the following medications is most appropriate for this patient?

4) A 52-year-old woman returns to the clinic for a followup appointment. She has had fatigue and anorexia for the past 6 months that, despite an extensive workup, including age-appropriate cancer screening, thyroid testing, routine blood studies, and psychiatric screening, has eluded a diagnosis. She now returns with the same complaints of fatigue and diminished appetite, but now is complaining also of lower abdominal bloating and pressure. Before these 6 months, she had been in excellent health. Her past medical history is unremarkable, though she does have an uncle who had diabetes and colon cancer, an aunt with breast cancer, and a mother who died of uterine cancer. Vital signs are within normal limits. Physical examination reveals a mildly distended, nontender abdomen that is increased in size since her last visit. Additionally, the pelvic examination reveals a possible nontender adnexal mass, though it is difficult to palpate. A CA-125 level is within normal limits. Which of the following is the most appropriate next diagnostic study?

11) A 60-year-old man comes to the emergency department with shortness of breath and a left-sided dull chest pain. He has had a low-grade fever for the past 3 days. He was treated recently for pneumonia with antibiotics, but says that he never quite returned to baseline. He has no other medical issues and has no allergies. He denies alcohol abuse or drug use. His temperature is 37.8 C (100.0 F), blood pressure is 120/80 mm Hg, and pulse is 70/min. Examination reveals decreased breath sounds on the left and deceased tactile fremitus. Chest x-ray is consistent with a large left-sided pleural effusion greater than 15 mm. A thoracentesis reveals turbid fluid with a white blood cell count of 70,000, red blood cell count of 20,000, LDH of 500 IU/L, and serum LDH of 600 IU/L (normal 50-150 IU/L). A repeat chest x-ray reveals pneumonia in the right upper lobe. Gram stain of the fluid obtained reveals multiple gram-positive diplococci. Pleural fluid pH is 7.1. Which of the following is the most appropriate initial management?

25) A 29-year-old G2P1001 with an IUP at 35 weeks' gestation presents to the ED for vaginal bleeding. The patient states that she woke up in a puddle of blood. She denies abdominal pain. She also denies other medical history, surgical history, and allergies. The patient is taking prenatal vitamins. Fetal movement: Present, Contractions: Absent, Vaginal bleeding: Present, Leakage of fluid: Absent. Physical examination: CVS: Normal, Lungs: Clear bilaterally, Abd: Gravid, nontender, nondistended, +BS, Ext: No edema bilaterally. What is the next step in the management of this patient?

72) A 27-year-old African American woman presents with several months of prolonged menstrual bleeding and increased volume of menstrual flow. She also has a sensation of heaviness in her abdomen. She denies abdominal pain, nausea, vomiting, diarrhea, and constipation. She fatigues easily. Vital sign: Physical examination: Gen: Awake, alert, oriented x3, no acute distress, CVS: Regular rate and rhythm, no murmurs, rubs, or gallops, Lungs: Clear to auscultation bilaterally, Abd: Soft, nontender, nondistended, + bowel sounds, Pelvis: Cervix appears normal, no cervical motion tenderness, no adnexal masses felt. What is the term for what this patient is experiencing?

78) A 5O-year-old woman with no PMH presents f or a routine physical examination. The patient states that she has been pregnant three times. She has two children who were born fullterm and delivered vaginally. She had one miscarriage. She has been with her husband for the past 23 years. The patient started her menstruation at 15 years old and is currently going through perimenopause. Her LMP was 3 months ago. The patient states that she last had a Pap smear 2 years ago. All of her Pap smears have been normal. Vital sign: BP, 120/80 mm Hg; P, 80 beats/min; R, 17 breaths/min; T, 98.7 F. Review of system: Denies any complaints. Physical examination: Thyroid: Normal to palpation, Breast: Symmetric, nontender, no lesions felt, no nipple inversion, Cervix: Appears normal, no lesions seen. Which of the following is the next best step in the management of this patient?

588. A 64-year-old man with a history of a triple coronary artery bypass 2 years ago presents with peripheral arterial occlusive disease. His only medication is a thiazide diuretic. Which of the following medications would be most appropriate in the medical management of his atherosclerosis?

13. A 50-year-old patient presents with symptomatic nephrolithiasis. He reports that he underwent a jejunoileal bypass for morbid obesity when he was 39. Which of the following is a complication of jejunoileal bypass?

51. A 40-year-old retired professional football player complains of the sudden onset of palpitations and shortness of breath 5 days after having knee replacement surgery. His pulse is 100/min and regular. Oxygen saturation is 90% room air. An ECG reveals sinus tachycardia. A chest x-ray film is unremarkable. Which of the following is the most appropriate next step in management?

For the first 6 hours following a long and difficult surgical repair of a 7-cm abdominal aortic aneurysm, a 70-year-old man has a total urinary output of 25 mL since the operation. Which of the following is the most appropriate diagnostic test to evaluate the cause of his oliguria?

An 18-year-old football player is seen in the emergency ward with severe knee pain incurred after being hit by a tackler while running. Which of the following findings on physical examination is most sensitive for an anterior cruciate ligament injury?

657. A 34-year-old immigrant from Mexico presents following an episode of massive hemoptysis. He describes bringing up large amounts of bright red, foamy sputum. He denies any recent trauma. On physical examination, the patient is agitated and has difficulty speaking. His blood pressure is 100/60 mmHg and his heart rate is 110/min. On physical examination, breath sounds are audible bilaterally. You immediately initiate intravenous infusion of crystalloid. Portable chest x-ray shows an opacity in the right upper lobe. Which of the following is the best next step in the management of this patient?

578. A pedestrian is hit by a car. The paramedics report that he was unconscious at the site, and he arrives at the emergency department in coma, strapped to a head board with sandbags on either side of his head. Initial survey shows stable vital signs, and his pupils are of equal size and reactive to light. He is rapidly intubated by the nasotracheal route over a flexible bronchoscope and then sent for CT scans of the head. As he is being positioned on the table, it is noted that there is a sizable hematoma behind his right ear and that clear fluid is dripping from the ear canal. Which of the following is most advisable, considering this new finding?

755. A 42-year-old woman is brought to the emergency department after being involved in a motor vehicle collision. On arrival she is unconscious with bilaterally round and reactive pupils. Her temperature is 370 C (98.60 F), blood pressure is 70/20 mm Hg, pulse is 11 0/min and respirations are 22/min. There is a low jugular venous pulse. She does not respond to vocal commands but responds to pain with all 4 limbs. She is not vocalizing. Lung auscultation is unremarkable. Abdominal examination shows a distended abdomen with absent bowel sounds and some bruising. She is intubated and is rapidly infused with 2L of lactated Ringer's solution. Her blood pressure is now 80/30 mm Hg and her pulse is 118/min. Which of the following is the most appropriate next step in management?

696. A 34-year-old unrestrained male driver is brought to the ER after a motor vehicle accident. His cervical spine is immobilized. At the scene of the accident, his blood pressure is 80/40 mm Hg and heart rate is 130/min. He is able to communicate and follows simple commands. Lungs are clear to auscultation. Abdominal wall ecchymosis is present. Abdomen is mildly distended. Bowel sounds are decreased. Neck veins are collapsed. After two liters of intravenous fluids, his blood pressure is 90/60 mmHg. Which of the following is the most appropriate next step in management of this patient?

716. A 46-year-old man comes to the physician because of a two day history of worsening abdominal discomfort and persistent vomiting. He has not had a bowel movement or passed flatus for 3 days. He had an appendectomy for appendicitis 20 years ago. Examination shows a distended abdomen that is tympanic on percussion. High-pitched bowel sounds and splashing are heard on auscultation. The abdomen is diffusely tender on palpation without rebound or guarding. An x-ray film of the abdomen shows distended small bowel loops with air-fluid levels; no gas is seen in the colon. IV rehydration is started. Which of the following is the most appropriate next step in management?

727. A 36-year-old forest worker is brought to the emergency department after being hit by a falling tree, 3 hours ago. He has pain in the left subscapular region. His temperature is 360C (96.90F), blood pressure is 120/76 mm Hg, pulse is 90/min, and respirations are 18/min. Physical examination shows aggravation of the pain in the left subscapular region with taking a deep breath and with anteroposterior and lateral chest compression. He has ecchymoses on the anterior and posterior chest and on the upper abdominal wall. His abdomen is vaguely tender to palpation in the left upper quadrant (LUQ) and he has left costovertebral angle (CVA) tenderness. Examination otherwise shows no abnormalities. An x-ray film of the chest shows posterior factures of the 8th, 9th and 1Oth ribs on the left. An x-ray film of the abdomen shows blunting of the left psoas shadow. Abdominal ultrasound shows no abnormalities. Laboratory studies show: Hb 15.3 g/dL Hematocrit 43% W BC 6,200/cmm Urinary sediment Many erythrocytes; W BC 4-5/hpf; oxalate crystals. Which of the following is the most appropriate next step in management?

668. A 27-year-old basketball player jumps to block a shot with his right hand. As his hand contacts the ball, he feels severe pain in his right shoulder. He presents to the emergency department with continuing shoulder pain. You note that he holds his right arm in slight external rotation, supporting its weight with his left hand. On physical examination, he resists internal rotation of his right arm. Which of the following nerves is most likely to be injured in this patient?

782. A 51-year-old male with a history of alcoholic pancreatitis presented to the hospital because of sudden onset severe retrosternal and upper abdominal pain. He has been vomiting for the past few hours after consuming alcohol. His temperature is 38.10 C (100.90 F), blood pressure is 140/90 mm Hg, pulse is 120/min and respirations are 30/min. Examination shows palpable crepitus in the suprasternal notch. Lungs are clear to auscultation. The abdomen is tender to palpation mostly in the epigastrium. Which of the following is the most likely cause of his current condition?

955. A 20-year-old man presents after being punched in the right eye and assaulted to the head. On a facial CT scan, he is noted to have a blowout fracture of the right orbital floor. Which of the following findings mandates immediate surgical intervention?

950. A 36-year-old man sustains a gunshot wound to the left buttock. He is hemodynamically stable. There is no exit wound, and an x-ray of the abdomen shows the bullet to be located in the right lower quadrant. Which of the following is most appropriate in the management of his suspected rectal injury?

963. An infant is born with a defect in the anterior abdominal cavity. Upon examination there are abdominal contents (small bowel and liver) protruding directly through the umbilical ring. Which of the following should be considered in the management of this condition?

157. A 24-year-old woman presents with lethargy, anorexia, tachypnea, and weakness. Laboratory studies reveal a BUN of 150 mg/dL, serum creatinine of 16 mg/dL, and potassium of 6.2 mEq/L. Chest x-ray shows increased pulmonary vascularity and a dilated heart. Which of the following is the most appropriate management of this patient?

223. A 26-year-old, drug-addicted man develops congestive heart failure over a period of a few days. He is febrile, has a loud, diastolic murmur at the right second intercostal space, and has a blood pressure of 120/20 mmHg. A physical examination performed a few weeks ago, when he attempted to enroll in a detoxification program, was completely normal. His blood pressure at that time was 120/80 mm Hg, and no murmurs were noted. In addition to long-term antibiotic therapy, which of the following is the most appropriate next step in management?

290. Following significant head trauma, a 34-year-old woman undergoes a CT scan that demonstrates bilateral frontal lobe contusions of the brain. There is no midline shift. She has a GCS of 14. Which of the following is the best initial management of this patient?

220. A 57-year-old woman develops bony metastases 1 year after right modified radical mastectomy for breast cancer. The tumor was estrogen receptor-negative, progesterone receptor- negative, and Her-2/neu positive. Which of the following agents is indicated for treatment of her metastatic disease?

268. A 72-year-old man has a 4-cm hard mass in the left supraclavicular area. The mass is movable and nontender and has been present and steadily growing for the past 3 months. On direct questioning the only additional findings include a 20-pound weight loss and a vague feeling of epigastric discomfort over the past 2 months. Physical examination shows evidence of the weight loss but no other significant findings in the abdominal examination. The supraclavicular mass is obvious, but no other masses can be felt anywhere else in the neck, axillas, or groins. There is occult blood in the stool, and his hemoglobin is 10.5 g/dL. Which of the following would a biopsy of the supraclavicular mass most likely reveal?

64. A 2 and a half-year-old child is brought to the office for the evaluation of easy bruising, nosebleeds, and decreased activity over the past week. He had an upper respiratory infection that was treated with an antibiotic 2 weeks ago. On examination, he is well-developed, seems well-nourished, anicteric, and pale. Pertinent findings include some small palpable posterior cervical lymph nodes, sinus tachycardia, a grade I/VI systolic ejection murmur, ecchymoses on his left shoulder and both lower extremities, and petechiae over his extremities and groin. There is no hepatosplenomegaly. The laboratory findings are as follows: Hemoglobin 7.9 g/dl Hematocrit 24% Platelet count 12, 000/mm3 WBC 3,000/mm3 Reticulocyte count 0.5% A bone marrow biopsy reveal a markedly hypocellular marrow with decreased megakaryocytes and precursors of the erythroid and myeloid cell lines. What is the most likely diagnosis?

135. A toddler is brought to the emergency department with burns on both of his buttocks. The areas are moist, have blisters, and are exquisitely painful to touch. The parents explain that the child accidentally pulled a pot of boiling water over himself. Which of the following is the most important step in management?

119. A 4-year-old previously healthy but unimmunized boy presents with sudden onset of high fever, inspiratory stridor, and refusal to drink. Of the following causes of inspiratory stridor, which best fits this clinical scenario?

229. An infant is born prematurely and is small for gestational age. At birth, the infant is obviously ill with jaundice, fever, hepatosplenomegaly, myocarditis, and rashes. Neurologic involvement is prominent, with hydrocephalus, intracranial calcifications, and seizures. The mother has a cat and continued to clean the cat's litter box during the pregnancy. Which of the following is the most likely causative agent?

468. A 9-month-old male is in for a well-child checkup. He is greater than 90th percentile for height, and he weighs 25 lbs. He no longer fits in his infant car seat, which is only recommended for use by children under 20 lbs. Which of the following is the safest car seat option for him?

You are seeing a 2-year-old child, brought by his father for a well-child examination. In providing age-appropriate anticipatory guidance, you should tell him which of the following?

An 8-year-old boy presents to the pediatrician's office with a headache for the past 3 weeks. His mother also states that he has been more tired and has had frequent nose bleeding for the past month. On physical examination, his height and weight are both below the 5th percentile for his age. His blood pressure is 152/86 mm Hg in all four extremities. His pulse is 74/min, and respirations are 16/min. His heart examination is normal with no murmur. His peripheral pulses are strong and symmetric. Urinalysis and serum electrolytes are ordered. Which of the following is the most appropriate next step in diagnosis?

551. A 14-year-old high school student arrives to your clinic for well-child care. In reviewing his records you determine that his most recent immunization for tetanus was at 4 years of age. Which of the following should you recommend?

A 2-year-old boy is brought to the office due to recurrent skin and soft tissue infections. When he was 2- months-old, he had a perianal furuncle that was incised and drained because it was unresponsive to oral antibiotics. At 7 months of age, he had a left inguinal Klebsiella pneumoniae lymphadenitis. His other past infections include a left calf cellulitis that grew Serratia marcescens and a left inguinal abscess that grew Staphylococcus epidermidis. On examination, he has hepatosplenomegaly, and enlarged axillary and inguinal lymph nodes. The screening tests for humoral, cell-mediated, and complement-mediated immunity are normal. The nitroblue tetra zolium (NBT) slide test is abnormal. What is the most likely diagnosis?

590. A 17-year-old boy is brought to the emergency department by his parents with the complaint of coughing up blood. He is stabilized, and his hemoglobin and hematocrit levels are 11 mg/dL and 33%, respectively. During his hospitalization, he is noted to have systolic blood pressure persistently greater than 130 mm Hg and diastolic blood pressure greater than 90 mm Hg. His urinalysis is remarkable for hematuria and proteinuria. You are suspicious the patient has which of the following?

A 6-month-old infant is taken to the emergency department because he had a seizure. Physical examination demonstrates premature closure of cranial sutures and markedly bowed legs. Laboratory studies demonstrate low serum phosphate levels, with normal vitamin D and parathyroid hormone levels. Urinalysis shows high phosphate levels, but no increased excretion of glucose, amino acids, or protein. The child's maternal grandfather had crippling bone disease, and his mother has mild bowing of the legs. Which of the following is most likely diagnosis?

901. A 20-year-old female is brought to the Emergency Room by her college roommate who states that the patient vomited all night. The patient complains of a sore throat and says she has not eaten for the last two days. She admits to a "sugar problem" and quit taking her medication because she has not been eating. Examination reveals an ill-appearing woman. Her temperature is 37.9 C (100.2 F), blood pressure is 118/78 mm Hg, pulse is 160/min, and respirations are 30/min. The patient's lips and mucous membranes are dry. There is a fruity odor noted to the patient's breath. The lung and cardiac examination are unremarkable except for mild tachypnea and tachycardia. Laboratory analysis shows: Sodium......................130 mEq/L Potassium..................6.1 mEq/L Chloride....................100 mEq/L Bicarbonate...............8 mEq/L Urea nitrogen............10 mg/dL Creatinine.................1.0 mg/dL Glucose....................680 mg/dL pH...........................7.15 pCO2.......................30 mm Hg pO2.........................85 mm Hg Urinalysis is positive for ketones. Which of the following is the most appropriate initial step in management?

915. A 14-month-old male infant presents to the emergency room with a chief complaint of high grade fever with no response to antipyretic therapy. This illness started suddenly with the abrupt onset of fever early yesterday morning. He then developed a severe cough and increased work of breathing. The mother reports that he is frequently ill. He was hospitalized 2 months ago for pneumococcal pneumonia. On examination: PR: 145/min; RR: 55/min; BP 100/60mm Hg; oxygen saturation 91%; weight 7 kg (154 lbs). He is listless, tired, and small for age. Both ear canals contain purulent drainage. An immunologic work-up is done and found to have markedly elevated IgM, undetectable IgG and IgA with diminished total B- lymphocytes and neutrophils. Which of the following is the most likely diagnosis?

962. A 4-year-old child is observed to hold his eyelids open with his fingers and to close one eye periodically, especially in the evening. He has some trouble swallowing his food. He usually appears sad, although he laughs often enough. He can throw a ball, and he runs well. Which of the following is most likely to aid in the diagnosis?

297. A 13-year-old girl presents with lethargy, fever, severe headache, and a stiff neck. On examination, a unilateral fixed, dilated pupil and papilledema are noted. Which of the following is the most appropriate initial step in managing this patient?