Access Med
A third-year medical student has been reading about the dangers of excessive anticoagulation and bleeding potential. He reviews the charts of several patients with AF currently taking warfarin. Which of the following patients is best suited to discontinue anticoagulation?
A 45-year-old man who has normal echocardiographic findings and no history of heart disease or hypertension, but a family history of hyperlipidemia
A 75-year-old man is noted to have chest pain with exertion and has been passing out recently. On examination, he is noted to have a harsh systolic murmur. Which of the following is the best therapy for his condition?
A 75-year-old man is noted to have chest pain with exertion and has been passing out recently. On examination, he is noted to have a harsh systolic murmur. Which of the following is the best therapy for his condition?
A 45-year-old woman with type 2 diabetes presents to the clinic for follow-up. She states that over the past year, she has decreased vision in the left eye. She also has had some occasional chest pain for the past 2 months. On examination, the blood pressure is 145/92 mm Hg. The cardiac and lung examinations are normal. Laboratory tests show the urinalysis reveals 1+ proteinuria. Serum laboratory tests reveal a baseline Cr of 1.6 mg/dL, a low-density lipoprotein (LDL) cholesterol level of 135 mg/dL. Which of the following is the best medication to start the patient on at this time?
ACE inhibitor
A 55-year-old man is noted to have moderately severe HF with impaired systolic function. Which of the following drugs would most likely lower his risk of mortality?
ACE inhibitors
A 28-year-old woman presents to the emergency department with complaints of excessive bleeding from her gums and petechiae. She is otherwise healthy and takes no medications. She smokes half a pack of cigarettes daily and occasionally drinks beer. Her temperature is 99.1 °F, BP is 110/81 mm Hg, HR is 85 bpm, and respiratory rate (RR) is 12 breaths/min. On physical examination, she has bleeding from her gums and petechiae on her bilateral lower extremities. Her CBC shows a white blood cell (WBC) count of 87,000/mm3, a hemoglobin of 8.9 g/dL, and a platelet count of 22,000/mm3. Which of the following is the most likely etiology of her low platelet count?
Acute leukemia
A 68-year-old man is found to have an incidental finding of anemia while hospitalized with pneumonia. His physical examination is normal except for crackles in the left lower lobe. Serum laboratory examinations reveal a normal MMA and a decreased serum folate level. Which of the following is the best next step?
Administer CAGE questionnaire
An 85-year-old nursing home resident with a medical history of diastolic heart failure, hypertension, diabetes mellitus, and dementia requiring assistance in all activities of daily life presents with a 3-day history of fever and nonbloody, productive cough. Her mental status was found to be more altered than usual. On admission, her vital signs show the following: temperature of 39 °C, BP 105/70 mm Hg, heart rate 93 bpm, RR 32 breaths/min, and SpO2 94% on room air. Chest x-ray reveals a right middle lobe consolidation. Which of the following is the best medical treatment of the patient?
Admit to the floor and start intravenous azithromycin and ceftriaxone.
Which one of the following recommendations is accurate regarding the current USPSTF recommendation for osteoporosis screening in the elderly?
All women with strong risk factors, regardless of age, should be screened for osteoporosis.
A 38-year-old woman presents with progressively worsening dyspnea and cough. She has never smoked cigarettes, has no known passive smoke exposure, and does not have any occupational exposure to chemicals. She has a family history of cirrhosis. Pulmonary function testing shows obstructive lung disease that does not respond to bronchodilators, and a complete metabolic panel demonstrates elevation of alanine aminotransferase (ALT) and aspartate aminotransferase (AST). Which of the following is the most likely etiology?
Alpha-1 antitrypsin deficiency
Which of the following counseling strategies is most likely to enhance your patients' smoking cessation rates?
Ask about smoking cessation at each encounter.
In the United States, which of the following is most likely to have caused the HF in the patient described in Question 4.1?
Atherosclerosis
A 30-year-old woman who is 12 weeks' postpartum is noted to have adrenal insufficiency and a very distinct tan, although she hardly ventures outside. Which of the following is the most likely etiology?
Autoimmune adrenal destruction
A 45-year-old woman complains of recurring episodes of vertigo. Her spells last 10 to 15 seconds and occur mostly when rolling out of bed (and once when changing a light bulb). She denies hearing loss or tinnitus. Her physical examination is normal except for rotatory nystagmus when she is lying with the right ear down. What is the most likely diagnosis?
BPPV
Ms N is a widowed 80-year-old woman who comes to your office for a yearly physical examination. She is doing well and has no complaints. A routine ECG is performed and reveals atrial fibrillation with a heart rate of 75 bpm. Blood pressure is similar to her last visit, which is 128/76 mm Hg. She does not have a history of diabetes, heart failure, or stroke. Her current medications include mirtazapine for treatment of depression. What is the appropriate management of this patient?
Begin adjusted dose warfarin therapy.
A 49-year-old man with a long-standing history of chronic renal failure as a consequence of diabetic nephropathy is brought to the emergency room for nausea, lethargy, and confusion. His physical examination is significant for an elevated jugular venous pressure, clear lung fields, and harsh systolic and diastolic sounds heard over the precordium. Serum chemistries reveal K 5.1 mEq/L, CO2 17 mEq/L, BUN 145 mg/dL, and creatinine 9.8 mg/dL. Which of the following is the most appropriate next step in therapy?
Begin hemodialysis urgently
A 62-year-old asymptomatic woman is noted to have multiple myeloma and hypercalcemia but no bone lesions or end-organ damage. Which of the following therapies is useful for immediate treatment of the hypercalcemia?
Bisphosphonates
A 40-year-old man with rheumatoid arthritis presents to the postop unit after an irrigation and debridement of a methicillin-resistant Staphylococcus aureus (MRSA)-positive septic joint. His blood pressure is 84/60 mm Hg, rectal temperature is 101.5 °F, and his heart rate is 95 bpm. Total blood loss from the surgery was 500 mL. The anesthesia staff give him a bolus 2 L of normal saline with dopamine and norepinephrine for pressors. His blood pressure elevates to 89/61 mm Hg. You are called to the postop unit to assess the situation. Which of the following is the best decision?
Bolus hydrocortisone due to possible steroid dependence.
Which of the following statements regarding available treatments for smoking cessation is accurate?
Bupropion can be used in combination with nicotine supplements.
A pregnant woman who smokes one pack of cigarettes a day asks for your advice regarding smoking cessation while she is pregnant. Which of the following statements is most appropriate?
Bupropion is pregnancy category C and relatively safe in pregnancy.
A 60-year-old man is diagnosed with moderately severe COPD. He admits to a long history of cigarette smoking and is still currently smoking one pack per day. In counseling him about the benefits of smoking cessation, which of the following statements is most accurate?
By quitting, his current pulmonary function will be unchanged, but the rate of pulmonary function decline will slow.
A 57-year-old man is brought into the emergency center for shortness of breath and light-headedness. He is found to have a blood pressure of 68/50 mm Hg and heart rate of 140 bpm. His jugular venous pulses are elevated. The lungs have inspiratory crackles on examination. All four extremities are cold and clammy. Which of the following is the most likely etiology for this patient's condition?
Cardiogenic shock
A 24-year-old intravenous drug user is admitted to the hospital with 4 weeks of fever. He has three blood cultures positive for growth of Candida species. After 2 days in the hospital, he develops a cold, blue right great toe. Which of the following is the appropriate next step?
Cardiovascular surgery consultation for aortic valve replacement.
A previously healthy 75-year-old man is being seen in the office for an episode of weakness that he reports occurred 2 weeks previously. He states that he had weakness of the left arm and left leg that lasted for 4 hours and slowly resolved over the rest of day. His arm and leg also felt "heavy" and had some numbness. He denies having similar episodes in the past. On physical examination, his BP is 140/90 mm Hg. He is found to have a right carotid bruit on auscultation. A duplex ultrasound demonstrates a 75% stenosis of the right carotid artery. Which of the following is the best therapy for this patient at this time?
Carotid endarterectomy
A 35-year-old morbidly obese woman patient is being evaluated in the emergency center from an outlying clinic. She was seen 8 days ago for headache, fever of 102 °F, nonproductive cough, and myalgias, for which she was diagnosed with influenza and prescribed oseltamavir for 5 days. She felt better after taking the medication initially but now feels she is getting worse. She is sent to the emergency department for expedited evaluation. She states that she has had night sweats, chills, shortness of breath, and cough productive of yellowish-green sputum for 3 days. Today, her vital signs show a temperature of 104 °F, with a respiratory rate of 30 breaths/min, heart rate of 100 bpm, and pulse oximetry of 93% on room air. Assuming admission for pneumonia, which of the following is the best empiric antibiotic treatment for this patient?
Ceftriaxone with vancomycin
A 65-year-old man with a history of rheumatoid arthritis is found to have a microcytic anemia. He had a colonoscopy 1 year ago that was normal, and a stool guaiac is negative. Which of the following is the most likely cause of his anemia?
Chronic disease
A 68-year-old man was hospitalized with persistent fever and a new heart murmur and diagnosed with Streptococcus bovis endocarditis of the mitral valve. After receiving 10 days of intravenous antimicrobial therapy, he is noted to be afebrile and with symptoms resolved. At this time, which of the following is the most important next step?
Colonoscopy to look for mucosal lesions.
A 59-year-old man with a known history of COPD presents with worsening dyspnea. On examination, he is afebrile. His breath sounds are decreased bilaterally. He is noted to have jugular venous distension (JVD) and 2+ pitting edema of the lower extremities. Which of the following is the most likely cause of his increasing dyspnea?
Cor pulmonale
A 49-year-old sedentary man has made an appointment because his best friend died of a myocardial infarction at age 50. He asks your advice about exercise and weight loss to prevent cardiovascular disease. In counseling him, which of the following statements regarding exercise is most accurate?
Counseling patients has not been shown to increase the number of patients who exercise.
A 48-year-old woman is noted to have AF with a ventricular rate of 140 bpm. She is feeling dizzy and dyspneic, with a systolic blood pressure of 75/48 mm Hg. Which of the following is the most appropriate next step?
DC cardioversion
A 56-year-old woman is being seen in the office for a history of shortness of breath that has worsened over the past month. She admits to a 60 pack-year smoking history. She complains of fatigue and dyspnea with minimal exertion and a productive cough each morning. Pulmonary function testing is ordered. Which of the following is the most likely finding in this patient?
Decreased FEV1/FVC
A 67-year-old man presents with dizziness and a positive stool guaiac test.
Decreased ferritin; decreased MCV; decreased serum iron level
A 24-year-old man who has sex with men presents for his yearly health maintenance examination. He wants to be "tested for everything" but is completely asymptomatic. His BMI is 22 kg/m2, blood pressure is 125/76 mm Hg, and he has no significant medical history. According to the USPSTF, for which of the following should this man be screened?
Depression
A 36-year-old woman is brought into the emergency department for lethargy. She is unable to respond to commands but does open her eyes to painful stimuli. On examination, her HR is 110 bpm, BP is 90/60 mm Hg, and respiratory rate (RR) is 24 breaths/min. An arterial blood gas reveals a pH of 7.28, pco2 of 28 mm Hg, po2 of 90 mm Hg, and HCO3 of 22 mEq/L. Serum electrolytes reveal Na+ 138 mEq/L, K+ 3.8 mEq/L, Cl- 105 mEq/L, and HCO3 of 23 mEq/L. Which of the following is the most likely diagnosis that led to this patient's condition?
Diarrhea
A 55-year-old man is noted to have HF and states that he is comfortable at rest but becomes dyspneic when he walks to the bathroom. On echocardiography, he is noted to have an EF of 50%. Which of the following is the most accurate description of this patient's condition?
Diastolic dysfunction (HF with preserved EF)
A 28-year-old woman has been told she has rheumatic heart disease, specifically mitral stenosis. Which of the following murmurs is most likely present?
Diastolic rumble at apex of the heart
A 58-year-old man presents to his provider for follow-up of his hypertension and hyperlipidemia. He also reports chest pain and feeling short of breath after climbing two flights of stairs or walking three to four blocks. The symptoms resolve after several minutes of rest. Which of the following drugs would not be indicated as a first-line agent in the treatment of this patient's condition?
Doxazosin
A 39-year-old man develops a moderate free-flowing pleural effusion following a left lower lobe pneumonia. Thoracentesis reveals straw-colored fluid with gram-positive diplococci on Gram stain, pH 6.9, glucose 32 mg/dL, and LDH 1890. Which of the following is the best next step?
Drain the effusion via tube thoracostomy.
An 8-year-old boy is brought into the pediatrician's office for fatigue, pain of the joints, and red-brown colored urine of 2 days. On examination, the blood pressure is 140/92 mm Hg, and heart rate is 90 beats per minute. He has facial swelling and pedal edema. The heart, lung, and abdominal examinations are normal. His mother states that about 3 weeks ago he had a sore throat and fever. Which of the following laboratory findings would most likely be present?
Elevated ASO titers
A 25-year-old man with a history of a duodenal ulcer is being seen in the office for follow-up. He does not complain of abdominal pain and does not report any bloody stool or melena. His blood pressure (BP) is 120/80 mm Hg, heart rate (HR) is 80 beats per minute, and respiratory rate (RR) is 12 breaths/min. His hemoglobin level is 10 g/dL. Which of the following most likely will be seen on laboratory investigation?
Elevated TIBC
A 39-year-old man is noted to have a DVT without any known risk factors. He notes that his brother also developed a PE at age 45, and his mother developed a "clot in the leg" when she was in her 30s. Which of the following is the most likely inherited disorder in this patient?
Factor V Leiden mutation
A 56-year-old man presents to his provider with symptoms consistent with allergic rhinitis. His past medical history is positive for benign prostatic hyperplasia. He continues to work in a warehouse as a forklift operator. Which of the following medications should be used to treat this patient?
Fexofenadine
A 35-year-old man who is mildly obese has undertaken a strict fad diet for 3 months. He previously had been healthy but now complains of fatigue. His hemoglobin level is 10 g/dL, and his MCV is 105 fL. Which of the following is the most likely etiology of his anemia?
Folate deficiency
A 66-year-old man is taken to the emergency department due to new-onset seizures. He reports a severe headache over the past month and morning nausea and vomiting. He also has had some difficulty with walking and balance. On CT imaging, there is a 4-cm mass noted in the right parietal lobe of the brain. Which of the following is the most likely cell type of this brain mass?
Glioblastoma multiforme (GBM)
A 39-year-old woman with hypertension and type 2 diabetes has been noted to have progressively worsening renal insufficiency. Which of the following measures is most important in the prevention of ESRD?
Glycemic control
A 22-year-old man complains of acute hemoptysis over the past week. He denies smoking, fever, or preexisting lung disease. His blood pressure is 130/70 mm Hg, and his physical examination, including lung examination, is normal. His urinalysis shows microscopic hematuria and RBC casts. Which of the following is the most likely etiology?
Goodpasture disease (antiglomerular basement membrane)
A 44-year-old woman is being seen in the office for a 2-month history of progressive anxiety, nervousness, and tremor. She also says she has heat intolerance. On exam, her HR is 110 bpm and BP is 130/80 mm Hg. Her thyroid gland is diffusely enlarged and nontender, and an audible bruit is present. Her serum TSH level is 0.01 mIU/L (normal 0.35-5.0). Which of the following is the most likely diagnosis?
Graves disease
A 65-year-old man with a history of prosthetic aortic valve, hypertension, and osteoarthritis is hospitalized for an elective knee replacement surgery. The patient is a nonsmoker but drinks one or two glasses of wine on the weekends. His admission CBC shows a WBC count of 8000/mm3, hemoglobin of 9.2 g/dL, and a platelet count of 250,000/mm3. Medications started on admission include acetaminophen, heparin prophylaxis, lisinopril, and pantoprazole. The patient's hospital course was complicated by acute kidney injury and postsurgery ileus. Five days after his knee surgery, laboratory tests are significant for a platelet count of 62,000/mm3. Which of the following is the most likely cause of the thrombocytopenia?
Heparin
A third-year medical student is researching various recommendations for the care of the geriatric patient. Which of the following statements is most accurate?
Herpes zoster vaccination is recommended for all adults over the age of 50.
A 59-year-old woman has been placed on warfarin after being found to have chronic AF. She is noted to have an INR of 5.8, is asymptomatic, and has no overt bleeding. Which of the following is the best management for this patient?
Hold warfarin.
A 64-year-old man sees you in the office because of a cough he has had for the past 4 days and a fever that started last night. He is short of breath and has significant malaise. He is a nonsmoker and has no history of lung disease. His medical history is significant for type 2 diabetes mellitus, which is well managed with medications and diet. A physical examination reveals an alert and mildly ill-appearing man who is speaking in complete sentences. His temperature is 38.1 °C (100.6 °F), pulse rate 95 beats/min, respiratory rate 22 breaths/min, blood pressure 115/70 mm Hg, and oxygen saturation 97% on room air. His heart has a regular rhythm, and respirations appear unlabored. He has rhonchi in the left lower lung field but has good air movement overall. A chest radiograph reveals a left lower lobe infiltrate. Which one of the following is the most appropriate setting for the management of this patient's pneumonia?
Home with close monitoring
A 30-year-old woman takes oral prednisone 15 mg/d for systemic lupus erythematosus, which is largely in remission. She is admitted to the hospital for a cholecystectomy. Which of the following is the most important intervention for her?
Hydrocortisone intravenously before surgery and every 6 hours for 24 hours
A 12-year-old girl is brought to the emergency department because of a severe sore throat, muffled voice, drooling, and fatigue. She has been sick for the past 3 days and is unable to eat because of painful swallowing. The parents deny any history of recurrent pharyngitis. The patient still manages to open her mouth, and you are able to see an abscess at the upper pole of the right tonsil with deviation of the uvula toward the midline. Examination of the neck reveals enlarged and tender lymph nodes. Which of the following is the most appropriate management?
Incision and drainage of the abscess
A 68-year-old patient with known COPD has been having frequent exacerbations of his COPD. Pulmonary function testing shows a FEV1 of 40% predicted (normal = 80% to 120%). His SaO2 by pulse oximetry is 91%. Which of the following medication regimens is the most appropriate at this time?
Inhaled fluticasone twice daily, inhaled tiotropium twice daily, and inhaled albuterol as needed
A 45-year-old man is brought into the emergency center for severe abdominal pain and light-headedness. His wife states that the patient has had lower abdominal pain for 2 days but did not want to see a doctor. He is noted to have a blood pressure of 80/40 mm Hg, heart rate of 142 bpm, and temperature of 102 °F. His abdomen is tender with guarding and rebound, particularly in the right lower quadrant. Acute appendicitis is diagnosed. Three liters of 0.9% saline are infused, and IV antibiotics are administered as he is prepared for surgery. After the saline, his blood pressure is 70/42 mm Hg. Which of the following is the most appropriate next step?
Initiate norepinephrine IV infusion.
An 80-year-old woman is brought to the emergency department with altered mental status and fever. She is awake and cooperative but is not oriented to time or place. Her blood pressure is normal, her pulse is normal, and her temperature is 101 °F. She is found to have pneumonia. Laboratory testing reveals a sodium level of 130 mEq/L but otherwise normal electrolytes. Which of the following is the most appropriate treatment?
Intravenous antibiotic and fluid restriction
A 65-year-old dialysis patient is found to have a serum potassium level of 6.8 mEq/L, which is verified on a stat repeat level. An ECG shows peaked T waves and a widened QRS complex. What is the first intervention that should be made at this point?
Intravenous calcium
An 11-year-old girl is being seen in the pediatric emergency department for near syncope. She is being followed for type 1 diabetes and is not very adherent to her medications or diet. Her current BP is 90/60 mm Hg, HR is 120 bpm, RR is 26 breaths/min, and temperature is afebrile. Based on an arterial blood gas with a pH of 7.23 and a serum glucose level of 550 mg/dL, she is diagnosed with DKA. Which of the following is the most important first step in the treatment of this patient?
Intravenous fluid replacement
A 66-year-old man with known metastatic squamous cell carcinoma of the esophagus is brought to the emergency department for increasing lethargy and confusion. He is clinically dehydrated, his serum calcium level is 14 mg/dL, and his creatinine level is 2.5 mg/dL, though 1 month ago it was 0.9 mg/dL. Which therapy for his hypercalcemia should be instituted first?
Intravenous normal saline
A 54-year-old woman is being evaluated in the emergency center with shortness of breath of 12 hours' duration. She also has significant vaginal bleeding of 1 month's duration. On examination, she is found to have significant pallor of her sclera and skin. Speculum examination showed a large necrotic and exophytic mass of the cervix. The hemoglobin level is 7 g/dL. Her left leg is swollen and markedly different from her right leg. Doppler investigation reveals a DVT of the left leg. Which of the following is the best treatment for the thrombus?
Intravenous unfractionated heparin
A 58-year-old woman comes to your office complaining of fatigue. She has also noticed a burning sensation in her feet over the past 6 months. A CBC shows anemia with an increased MCV. Which of the following is the most likely cause of her anemia?
Lack of intrinsic factor
Which of the following ECG changes makes the determination of acute MI the most difficult?
Left bundle branch block
A 65-year-old man with a medical history of uncontrolled hypertension, mild biventricular systolic heart failure, and a 40 pack-year smoking history presents to the emergency room with 1 week of worsening cough, fever, and dyspnea at rest. His symptoms also include diffuse myalgia, abdominal pain, nonbloody diarrhea, and a rapidly worsening nonproductive cough. He denies alcohol or drug history and endorses being married to his wife for 40 years. On admission, his vital signs are: temperature of 38 °C, blood pressure (BP) 160/82 mm Hg, heart rate 89 beats per minute (bpm), respiratory rate (RR) 25 breaths/min, and SpO2 (oxygen saturation as measured by pulse oximetry) is 94% on room air. Which of the most likely organisms is the etiology of his illness?
Legionella pneumophila
An 18-year-old man is being seen the emergency center for nausea, vomiting, lightheadedness, and fatigue. He is a known type 1 diabetic and states that he has been taking his insulin as scheduled. On examination, his BP is 80/40 mm Hg, temperature is 101 °F, HR is 120 bpm, and RR is 30 breaths/min. He has some adenopathy of the cervical area. Laboratory test values show an arterial pH of 7.20, po2 of 100 mm Hg, pco2 of 28 mm Hg, and HCO3 of 12 mEq/L. His serum glucose level is 400 mg/dL. Which of the following is the most accurate statement regarding this patient's likely potassium status?
Likely to have a total body potassium deficit regardless of the serum level.
A 69-year-old man is being seen in the emergency center for gradually worsening dyspnea and a nagging cough over the past 3 months. He denied feeling warm or having fever. The chest radiograph shows a right-sided pleural effusion. A diagnostic thoracentesis reveals gross blood in the fluid. Which of the following is the most likely diagnosis?
Malignancy in the pleural space
A 48-year-old man presents for follow-up of an elevated calcium level of 12.3 mg/dL found on routine screening laboratory tests at his last health maintenance visit. He takes no medications other than an occasional antihistamine for allergies. He recently started smoking a half-pack of cigarettes per day. He was prompted to attend to today's health maintenance visit by his wife, who claims that he has become forgetful, has a decreased appetite, and has had a 10-lb weight loss over the past 2 months. As part of his follow-up laboratory tests, you obtain a serum PTH, which comes back within the normal range. Which of the following is the next step in diagnosis?
Measurement of urinary calcium excretion
Which of the following statements regarding breast cancer screening is true?
Most abnormalities found on routine mammography are not breast cancer
One year ago, a 24-year-old woman had an episode of diplopia of 2 weeks' duration. The symptoms resolved completely. Currently, she complains of left arm weakness but no headache. Which of the following is the most likely diagnosis?
Multiple sclerosis
An 18-year-old marathon runner has been training during the summer. He is brought to the emergency department disoriented after collapsing on the track. His temperature is 102 °F. A Foley catheter is placed and reveals reddish urine with 3+ blood on dipstick and no cells seen microscopically. Which of the following is the most likely explanation for his urine?
Myoglobinuria
A 40-year-old woman has recurring 30-minute episodes of disabling vertigo. The episodes are accompanied by roaring tinnitus, aural pressure, and low-frequency hearing loss. Her physical examination is normal. What is the most likely diagnosis?
Ménière disease
A 68-year-old man has an incidental finding of anemia while in the hospital for alcohol abuse.
Normal MMA; decreased serum folate level
A 56-year-old man with a medical history of hypertension, chronic kidney disease stage III, gout, and alcohol dependence is brought in by emergency medical services after being found down on the ground. He smells strongly of ethanol and has a prior history of delirium tremens based on previous medical records. He is admitted to the ICU with concern for alcohol withdrawal. His vitals on admission are: temperature 37 °C, BP 110/74 mm Hg, heart rate 77 bpm, RR 12 breaths/min, and SpO2 of 94% on room air. Due to concern for inability to protect his airway, he is intubated in the emergency room. The next day, he shows significant clinical improvement and is extubated. Later that day, he goes into withdrawal with altered mental status, and aspirates while eating. What is the next best step in management?
Obtain chest x-rays and continue to monitor for symptoms.
A 30-year-old man has both mild persistent asthma and chronic environmental allergies. Which of the following medications is indicated for the management of this patient's conditions?
Oral montelukast (leukotriene modifier)
A 56-year-old man with known CKD presents to the emergency center with a 3-day history of shortness of breath and rapid weight gain. On examination of the heart, you are able to auscultate an S3 heart sound and hear crackles at the lung bases. You also see moderate JVD. The oxygen saturation is 90% on room air. Which of the following is your next step in evaluation?
Order a chest x-ray.
A 30-year-old woman with no past medical history presents with a productive cough of 2 weeks' duration. She states she also has had a runny nose, body aches, congestion, and fevers for the past week. In the office, she is normotensive, with a normal pulse and a temperature of 101.2 °F. Her physical examination is significant for sinus tenderness, boggy nasal turbinates, and crackles in the left lower lobe lung fields. Which of the following is the best initial step in management?
Order chest x-ray to rule out possible pneumonia
On routine blood work performed for a life insurance application, a 48-year-old premenopausal woman was found to have a calcium level of 12 mg/dL (normal 8.8-10.4 mg/dL) and a phosphate level of 2 mg/dL (normal 3.0-4.5 mg/dL). She is not anemic and has no symptoms. Her medical history is significant for osteoporosis, which was discovered on a dual-energy x-ray absorptiometry (DEXA) scan performed last year. Which of the following is the most likely cause of her hypercalcemia?
Parathyroid adenoma
A 64-year-old woman with a history of hypertension and angina pectoris presents with chest pain for the last 3 hours. She describes the pain as "sharp"; it is worse when she inhales deeply, and it is not relieved by sublingual nitroglycerin. The pain improves if she sits up and leans forward. Her ECG shows ST elevation in most leads. Cardiac enzymes are negative. Which of the following is the most likely diagnosis in this patient?
Pericarditis
A 72-year-old man with a long history of hypertension presents to the emergency department complaining of not being able to urinate for the last 36 hours. He also has a 1-day history of nausea, vomiting, and abdominal pain. He states that his urinary stream has been decreasing over the past 2 years. On examination, the abdomen is firm and tender, and the prostate is enlarged. His serum Cr level is 3.4 mg/dL. Which of the following is the best next step?
Place an indwelling Foley catheter.
A 55-year-old man with HF presents to the emergency department with a 1-week history of dyspnea on exertion and swelling in both ankles. He has had no fever or cough. Chest radiography shows bilateral pleural effusions. Which of the following is the most likely pleural fluid characteristic if thoracentesis is performed?
Pleural fluid LDH 39, LDH ratio 0.2, protein ratio 0.1
A 30-year-old woman with ITP comes to her outpatient hematology office for a routine follow-up. She reports that despite taking maximum corticosteroid doses, she still has a platelet count of 20,000/mm3 and frequent bleeding episodes. Which of the following should she receive before her splenectomy?
Pneumococcal vaccine
A 17-year-old adolescent male presents to the emergency department with a temperature of 101 °F (38.3 °C), a deep nonproductive cough, and generalized malaise for 3 days. He does not recall being around any particular sick contacts but is around many people in his afterschool job and at school. He states that he never had the chicken pox and is unaware of what immunizations he received as a child. He was diagnosed at age 12 with leukemia but has since been healthy. He is worried that his cancer may no longer be in remission. A chest x-ray reveals bilateral, diffuse infiltrates. Which of the following is the most likely cause of illness?
Pneumonia caused by M. pneumonia
A patient with which of the following conditions requires antimicrobial prophylaxis before dental surgery?
Previous infective endocarditis
A 45-year-old woman is noted to have dizziness, a pounding feeling in her chest, and fatigue of 3 hours' duration. On examination, she is noted to have a blood pressure of 110/70 mm Hg and a heart rate of 180 bpm. On ECG, she has AF, and a prior baseline ECG showed delta waves. The emergency department provider counsels the patient regarding cardioversion, but the patient declines. Which of the following is the best therapy for her condition?
Procainamide
A 58-year-old woman is being seen in the office for her first evaluation of hyperthyroidism. On examination, she is found to have a diffusely slightly enlarged thyroid gland that is nontender. She has exophthalmos, tremor, and brisk deep tendon reflexes. Serum TSH is 0.03 mIU/L (normal 0.35-5.0). Which of the following is the best therapy for this patient?
Radioactive iodine ablation
A 5-year-old boy is brought to the clinic with cough, congestion, runny nose, and low-grade fever for the past 3 days. He has been treated with acetaminophen for fever and given honey for his cough. He has been eating well and has been active at home. On examination, his temperature is 99.7 °F, and his vital signs are otherwise normal. He is active, playful, and smiles during the encounter. You note that his right tympanic membrane is red and bulging, but the left tympanic membrane is normal. His examination is otherwise normal. At this time, the best step in management is which of the following?
Reassurance with a follow-up visit if not improving in the next 10 days
A 63-year-old woman with a history of cervical cancer treated with a hysterectomy and pelvic irradiation now presents with acute oliguric renal failure. On physical examination, she has normal jugular venous pressure, is normotensive without orthostasis, and has a benign abdominal examination. Her urinalysis shows a specific gravity of 1.010, with no cells or casts on microscopy. Urinary FENa is 2%, and the Na level is 35 mEq/L. Which of the following is the best next step?
Renal ultrasound
A 22-year-old woman presents with a worsening cough over 6 weeks that did not improve with a course of antibiotics or antitussives. Her serum calcium level is found to be 12.5 mg/dL, and a chest x-ray reveals bilateral hilar lymphadenopathy. She has erythema nodosum on her legs. Which of the following is the most likely diagnosis?
Sarcoidosis
A 56-year-old woman with history of hypertension, diabetes, and newly diagnosed polycystic kidney disease presents for follow-up for hypertension. Routine laboratory work shows elevated calcium of 13 mg/dL and an elevated phosphate level. The patient denies weight loss, is taking only metoprolol for her blood pressure, and denies recent history of immobilization. Given these findings, which etiology of hypercalcemia would you be most concerned about in this patient?
Secondary hyperparathyroidism due to renal disease
A 50-year-old man has been treated for rheumatoid arthritis for many years. He currently is taking corticosteroids for the disease. On examination, he has stigmata of rheumatoid arthritis and some fullness on his left upper abdomen. His platelet count is slightly low at 105,000/mm3. His WBC count is 3100/mm3 with neutropenia, and hemoglobin level is 9 g/dL. Which of the following is the most likely etiology of the thrombocytopenia?
Splenic sequestration
A 62-year-old man who works at an automobile assembly line has noticed that he feels pain, fatigue, and numbness in his right arm while working for the last several months. This morning at work, he noticed vertigo, then light-headedness, then lost consciousness for a few seconds. The BP in his right arm is 30 mm Hg lower than that in his left arm. What is the most likely diagnosis?
Stenosis of right subclavian artery due to atherosclerosis
A 42-year-old man with polycystic kidney disease who complained of a sudden onset of severe headache and then lost consciousness
Subarachnoid hemorrhage
Which of the following therapies is most likely to provide the greatest benefit to a patient with chronic stable emphysema and a resting oxygen saturation of 86%?
Supplemental oxygen used continuously
A 7-month-old infant is brought by her mother to an outpatient clinic because of a 2-day history of fever, copious nasal secretions, and wheezing. The mother volunteers that the baby has been healthy and has not had these symptoms in the past. The infant's temperature is noted to be 100.7 °F (38.1 °C), her respiratory rate is 50 breaths/min, and her pulse oximetry is 95% on room air. Physical examination reveals no signs of dehydration, but wheezing is heard on bilateral lung fields on auscultation. The infant shows no improvement after three treatments with nebulized albuterol. Which of the following is the recommended treatment?
Supportive care with hydration and humidified oxygen
A 35-year-old woman presents with calf tenderness and acute dyspnea. The arterial blood gas reveals a partial pressure of oxygen (Po2) of 76 mm Hg. Which of the following is the most common physical examination finding of PE?
Tachypnea
62-year-old man with recently diagnosed chronic obstructive pulmonary disease presents to your office in November for a routine examination. He has not had any immunizations in more than 10 years. Which of the following immunizations would be most appropriate for this individual?
Tdap, pneumococcal, and influenza
A 5-year-old child is brought into the office due to the mother's concern about difficulty breathing. On examination, the child appears toxic and has a high fever, cough productive of thick mucopurulent expectorant, and stridor with wheezing. The child is up to date regarding immunizations. Which of the following are the most likely condition and causative organism requiring antibiotic therapy?
Tracheitis due to S. aureus
A 13-year-old girl presents with fever and sore throat of 48 hours' duration. She has a temperature of 101 °F in the office and is tachycardic, with a pulse of 118 beats/min. Her physical examination is positive for tender, enlarged left cervical lymphadenopathy and tachycardia. Her pharynx is erythematous with tonsillar enlargement or exudate. She has had no cough. What is the best step in management?
Treat empirically with antibiotics
A 59-year-old man with a long history of diabetes with chronic renal insufficiency due to diabetic nephropathy is seen in clinic for routine laboratory work. He is asymptomatic, but his glucose is elevated at 258 mg/dL. His other chemistries are as follows: sodium 135 mEq/L, potassium 5.4 mEq/L, chloride 108 mEq/L, and bicarbonate 18 mEq/L. His creatinine is stable at 2.1 mg/dL. Which of the following is the most likely cause of this patient's acidemia?
Type 4 renal tubular acidosis (RTA)
A 62-year-old diabetic man underwent an abdominal aortic aneurysm repair 2 days ago. He is being treated with gentamicin for a urinary tract infection. His urine output has fallen to 300 mL over 24 hours, and his serum creatinine has risen from 1.1 mg/dL on admission to 1.9 mg/dL. Which of the following laboratory values would be most consistent with a prerenal etiology of his renal insufficiency?
Urinary sodium level of 10 mEq/L
A 67-year-old woman is being seen in the office for the acute onset of dizziness. She says she was sitting on the couch watching TV when the episode came on, and the room was spinning. She feels nauseous. Her history includes a stroke 2 years ago that left some right-sided weakness. Which of the following arteries is most likely to be affected in today's presentation?
Vertebrobasilar
A 68-year-old white female presents to the ED with palpitations that started several hours ago. On physical examination she has an irregular heart beat with a rate of 75 to 90 bpm and a thready pulse. ECG shows atrial fibrillation. Her past medical history is significant for Type 2 diabetes diagnosed 10 years ago and a cholecystectomy last year. What therapy improves survival in patients with chronic atrial fibrillation?
amiodarone
