Clinical Medicine Comprehensive questions

Which of the following statements regarding breast cancer screening is true?

Most abnormalities found on routine mammography are not breast cancer.

A 48-year-old woman presents for an annual examination. She has had a supracervical hysterectomy and Pap smears with HPV cotesting every 5 years since her 20s and all were normal. She read on the Internet that women who have had a hysterectomy no longer require Pap smears. Which of the following would be your advice?

"You should continue to have Pap smears with HPV cotesting every 5 years since your hysterectomy does not exclude you from routine screening recommendation in your age group."

The drugs donepezil, rivastigmine, and galantamine are used in AD to try to raise the availability of which transmitter in the brain?

Acetylcholine

A 67-year-old woman has diabetes and mild hypertension. She is noted to have diabetic retinopathy, and she states that she cannot feel her legs. She has recurrent episodes of light-headedness when she gets up in the morning. She comes in now because she fainted this morning. Which of the following is the most likely cause of her syncope?

Autonomic neuropathy

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

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.

A 34-year-old woman is being seen in the urgent care center for "feeling ill." She was diagnosed with hyperthyroidism 6 months ago, but she has not taken her medications for 5 days. After the history and physical examination, the provider is suspicious of possible thyroid storm. Which of the following features would best distinguish hyperthyroidism from thyroid storm?

C Fever and delirium

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 (valve replacement is usually necessary in IV drug users)

A father brings to the clinic his 6-year-old son who currently is undergoing induction chemotherapy for ALL. The school will not allow the child to register until his immunizations are up to date. Which of the following is the best course of action?

Call the school nurse or principal to inform him or her that this child should not receive immunizations while he is taking chemotherapy.

Penicillins inhibit which of the following bacterial processes/compounds?

Cell-wall synthesis

A 22-year-old woman presents with fatigue, arthralgias, and a nagging dry cough for the past 6 weeks, but no shortness of breath. On physical examination, her lungs are clear to auscultation, and she has bilateral pretibial tender erythematous raised nodules. Which of the following is your best next step?

Chest radiograph: The patient has clinical features suggestive of sarcoidosis given the new cough, arthralgias, and description of erythema nodosum. The initial, most cost-effective study is a chest radiograph.

A 45-year-old African American man is noted to have blood pressures of 145/90 mm Hg and 150/96 mm Hg on two separate occasions. He has no other medical problems and no signs or symptoms suggestive of secondary hypertension. Which of the following is the best initial therapy for this patient?

Chlorthalidone

A 66-year-old Caucasian woman has an average BP of 155/70 mm Hg despite appropriate lifestyle modification efforts. Her only other medical problems are osteopenia, kidney stones, and mild depression. Her last lipid panel revealed a total cholesterol of 160 mg/dL, high-density lipoprotein of 40 mg/dL, and low-density lipoprotein of 90 mg/dL. Which of the following would be the most appropriate treatment at this time?

Chlorthalidone

A previously healthy 42-year-old overweight woman presents to the emergency department complaining of sudden, right upper abdominal pain that "comes and goes," lasting approximately 45 minutes after eating at a fast-food restaurant. The patient has vomited twice since the pain started, and any attempt to eat worsens the pain. She is sexually active with one male partner, uses condoms regularly, and denies drug use. Which of the following is the most likely cause?

Cholelithiasis (Acute right upper abdominal pain occurring after a fatty meal ("fast food") and producing nausea/vomiting is most suggestive of biliary colic due to gallstones.)

A 45-year-old man presents with 3 days of watery diarrhea and abdominal cramping. He has no sick contacts and has not traveled recently. He is not currently taking any medications, but he was prescribed amoxicillin 2 weeks ago for a sinus infection. Which of the following tests is most likely to identify the cause of his diarrhea?

Clostridium difficile toxin immunoassay: ny antibiotic can cause C. difficile colitis, clindamycin, cephalosporins, and penicillins are the most commonly implicated.

65-year-old man reports a lifelong history of IBS with alternating bouts of constipation and diarrhea. He denies blood in the stool, unintentional weight loss, fevers, or nighttime symptoms that awaken him. He now reports that his symptoms have worsened over the last several months. He has never had a colonoscopy. Which of the following is the recommend initial step in management?

Colonoscopy

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 52-year-old man comes into the outpatient clinic for an annual "checkup." He is in good health and has a relatively unremarkable family history. He has never smoked cigarettes. For which of the following disorders should a screening test be performed?

Colorectal cancer: Colorectal cancer screening has a grade A recommendation by the USPSTF and is routinely offered or provided to all adults older than 50 years.

A mother arrives at the clinic with her 4-year-old daughter, who began complaining of right knee pain 2 weeks ago. The patient is limping slightly, is fatigued, and has had a fever of 100.4 °F (38 °C) over the past week. Which of the following laboratory tests is most important?

Complete blood count (CBC) with differential and platelets (his child has symptoms consistent with both juvenile idiopathic arthritis (JIA) and leukemia. The CBC with differential and platelets is the best initial screening test.)

A 62-year-old man is evaluated for a 7-month history of progressive dyspnea and lower extremity swelling. His medical history is significant for lymphoma treated with chest irradiation 15 years ago and currently in remission. He does not smoke or drink alcohol. On physical exam, vital signs are stable. There is jugular venous distension and jugular venous engorgement with inspiration. Cardiac exam discloses a prominent early diastolic sound but no murmurs or gallops. Lung exam reveals normal breath sounds. Abdominal examination reveals ascites, and lower extremities show 3+ pitting edema. ECG shows normal sinus rhythm with nonspecific diffuse ST-T changes. Urinalysis is normal. Chest radiography shows calcifications around the heart and clear lung fields.

Constrictive pericarditis

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 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?

D Place an indwelling Foley catheter.

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

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: Chronic GI blood loss leads to low ferritin levels, reflecting diminished iron stores; elevated TIBC; and low iron saturation

A 42-year-old woman is noted to have Type II diabetes for 20 years. She is noted to have hypertension with BP in the 150/94 range. The urinalysis shows mild proteinuria. Which of the following drugs would be the best to treat the hypertension in this individual?

Enalapril: ACE inhibitors, such as enalapril, have been shown to reduce the progressive loss of renal function that is often seen in diabetic patients.

A 45-year-old man is diagnosed with essential hypertension based on two blood pressures of 150/100 and 156/102 mm Hg during two separate visits. He has no other medical problems. Which of the following would most likely provide prognostic information regarding this patient?

End-organ effects from hypertension

You are called to evaluate a 19-year-old woman who was just intubated for uncontrolled seizure activity following a drug overdose. Her chest x-ray shows complete opacification of the left chest with a shift of the mediastinum also to the left. She is 5′2″ and weighs 60 kg. The front teeth are at the 32 cm mark on the ETT. Examination reveals normal breath sounds and definite expansion of the right chest, but no breath sounds and no expansion of the left chest are noted. What is the most likely etiology for this finding?

Endotracheal tube placement in the right main stem bronchus

A 40-year-old man travels to South America and develops watery diarrhea 1 day after coming back to the United States. He had been in good health previously. Which of the following is the most likely etiology of the symptoms

Escherichia coli: most common etiology for traveler's diarrhea

A 22-year-old woman is pregnant at 14 weeks' gestation. She denies vaginal bleeding or prior medical problems. Her BP is 100/60 mm Hg, HR is 90 beats per minute, and RR is 14 breaths/min. Her hemoglobin level is 9 g/dL. She is counseled that the most likely cause of the low hemoglobin level is due to iron deficiency. She asks why she could have iron deficiency when she is no longer menstruating. Which of the following is the best explanation?

Expanded blood volume and transport to the fetus

The mother of a 15-year-old girl recently diagnosed with infectious mononucleosis calls for more information. She reports that her daughter, although tired, seems comfortable and is recovering nicely. She remembers that her 20-year-old son had "mono" when he was 10 years old, and he received an oral medicine. She requests the same medication for her daughter. Which of the following is the most appropriate course of action?

Explain that medications are not routinely used in EBV infection

A 17-year-old boy has left shoulder and left upper quadrant abdominal tenderness and vomiting. He reports having "mono" last month but says he is completely recovered. He was playing flag football with friends when the pain started an hour ago. On examination, his heart rate is 150 beats per minute and blood pressure is 80/50 mm Hg. He is pale and weak and seems disoriented. He has diffuse rebound abdominal tenderness. Emergent management includes which of the following?

Fluid resuscitation and blood transfusion

A 32-year-old woman with a known history of sickle cell anemia presents to the emergency department for the fifth time this year, complaining of diffuse abdominal pain and severe bilateral lower extremity pain typical of her previous pain crises. Normally, she takes hydrocodone/acetaminophen every 8 hours, but for the past day she has required doses every 4 hours without relief. Which of the following therapies would most likely decrease her number of sickle cell crises?

Hydroxyurea: may decrease the incidence of sickle cell crises by increasing levels of hemoglobin F.

Which one of these abnormalities on the neurologic examination would be unusual in a patient with mild AD?

Hyperreflexia with positive Babinski signs

A 21-year-old woman presents for her first Pap smear. She completed the HPV vaccine series by age 19. Assuming that her examination and Pap smear results are normal, when would you recommend that she return for a follow-up Pap smear?

In 3 years, as the Pap smear was normal

A 56-year-old man is admitted to the hospital for chest pain of 2-hour duration. His heart rate is 42 bpm, with sinus bradycardia on ECG, as well as ST-segment elevation in leads II, III, and aVF. Which of the following is the most likely diagnosis?

Inferior wall infarction

Which of the following is the best treatment for a 39-year-old woman with fever of 103 °F, nausea, flank pain, and more than 105 CFU/mL of E. coli in a urine culture?

Intravenous and then oral levofloxacin for 14 dayS

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: stabilize the cardiac membranes and reduce the risk of arrhythmia

Which of the following ECG changes makes the determination of acute MI the most difficult?

LBBB

A 21-year-old man with known asthma has been placed on a regimen consisting of inhaled corticosteroids and intermittent (short-acting) beta-2-agonist. He is being seen in the office with a new complaint of nocturnal awakenings secondary to cough and occasional wheezing. These episodes occur three to four times per week. Six months ago, his pulmonary function testing revealed an FEV1 of 80% of predicted, and FEV1/FVC of 70% of predicted. Which of the following is the best next step?

Long-acting beta-2-agonists (LABAs)

In the patient described in question 10.5, which of the following is the treatment of choice for his diarrhea?

Metronidazole

A 4-year-old boy is brought to your office by his mother for evaluation of a rash on his face that his mother first noticed one day previously. His mother comments that it looks like somebody "slapped him." The mother reports that he has had a cold for the last couple of days. The child's physical examination is unremarkable except for an erythematous macular rash over both cheeks and a temperature of 102 °F (38.9 °C). The mother admits that the child is behind on his immunization schedule. Which of the following is the most likely cause?

Parvovirus B19

Which of the following is the most likely organism responsible in Question 58.3?

Parvovirus B19: In children with sickle cell anemia, aplastic crisis is most commonly associated with parvovirus B19

The patient described in Question 10.1 is hospitalized, but there is a delay in initiating treatment. You are called to the bedside because he has become hypotensive with a systolic blood pressure of 85/68 mm Hg, a heart rate of 122 bpm, and pulsus paradoxus. A repeat ECG is unchanged from admission. Which of the following is the most appropriate immediate intervention?

Perform echocardiographic-guided pericardiocentesis.

A 59-year-old diabetic woman had suffered an acute anterior wall MI. Five days later, she gets into an argument with her husband and complains of chest pain. Her initial ECG shows no ischemic changes, but serum cardiac troponin I levels are drawn and return mildly elevated at this time. Which of the following is the best next step?

Perform serial ECGs and obtain CK-MB. (Diabetic patients can have myocardial ischemia or infarction with atypical or absent symptoms)

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 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: This patient should undergo splenectomy for refractory ITP. Thus, she will be at risk for infections by encapsulated organisms such as Streptococcus pneumoniae and will benefit from the pneumococcal vaccine

An 18-year-old woman is brought to the emergency center because she fainted at a rock concert. She apparently recovered spontaneously, did not exhibit any seizure activity, and has no medical history. Her heart rate is 90 bpm, and blood pressure is 110/70 mm Hg. The neurologic examination is normal. A pregnancy test is negative, and an ECG shows normal sinus rhythm. Which of the following is the most appropriate management?

Reassure the patient and discharge home.

A 45-year-old man has hypertension. A thiazide diuretic agent had been prescribed with continued elevated blood pressure. The inclusion of spironolactone to the thiazide diuretic is done to achieve which of the following?

Reduce K+ loss

A 54-year-old woman is brought into the emergency department (ED) after a motor vehicle collision. The patient was driving when she lost control, hit a tree, and suffered trauma to her head. A noncontrast computed tomography (CT) scan of the brain is performed. A homogeneous high-density signal is noted outside of the right parietal region and appears to be crescent-shaped. Which of the following is the most likely diagnosis?

SDH

A 55-year-old woman presents to your office for follow-up. She was discharged from the hospital 1 week ago following an acute MI. She has quit smoking since that time and vows to stay off cigarettes forever. Her lipid levels are total cholesterol 240 mg/dL, HDL 50 mg/dL, LDL-C 160 mg/dL, and triglycerides 150 mg/dL. In addition to initiation of TLCs, which of the following is the most appropriate management at this time?

Start on a statin

A 20-year-old woman is found to be anemic (10 g/dL) on routine laboratory tests. She is otherwise healthy, with review of systems notable only for heavy menses. Iron studies are as follows: decreased MCV, decreased ferritin, increased TIBC, and increased RDW. Which of the following is the best next step?

Start oral ferrous sulfate 325 mg twice daily

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 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

68-year-old male with hypertension presents for annual examination. On review of systems he reports urinary hesitancy and nocturia. Your examination reveals a nontender but enlarged prostate without nodules. On review of his blood pressure logs and clinic readings he is averaging values of 150/80 mm Hg. Which of the following medications would offer treatment of the hypertension and prostatic symptoms?

Terazosin

A 45-year-old African American woman presents for a routine examination. You notice a 9-mm diameter lesion on the palm of her right hand that is dark black and slightly raised and has a notched border. When asked about it, she says that it has been present for about a year and is growing. A friend told her not to be concerned because, "Black people don't get skin cancer." Which of the following is your advice?

This lesion is suspicious for a primary melanoma and needs further evaluation immediately.

Tx of PE if evidence of right HF or hemodynamic intability (SBP <90)

Thrombolysis or embolectomy (alteplase or reteplase)

A 55-year-old woman presents with a 5-year history of gradual loss of function. The patient's daughter has been researching on the Internet and suspects PD. Which of the following signs is most suggestive of PD rather than the other neurodegenerative diseases?

Unilateral resting tremor

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 (prerenal urinary sodium usually less than 20%)

Which of the various modalities of diagnostic interventions listed in the answer choices would directly determine the possible basis for the findings on this patient's physical examination?

audiology referral

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 22-year-old college student with fever, headache, photophobia, and CSF with 25 white blood cells per high-power field, but no red blood cells or xanthochromia

meningitis

What postexposure prophylaxis (if any) should the student described in Question 26.1 receive?

reassurance

During the winter, a young day care worker develops watery diarrhea. Which of the following is the most likely etiology of the symptoms?

rotavrius: common etiology for watery diarrhea, especially in the winter. It is very common in children. Given this patient's employment in a day care

Which pathophysiologic entity should be investigated (and "ruled out") prior to entertaining other more long-term chronic diagnoses, given the clinical presentation of this patient discussed earlier?

sensory impairment

Which one of the following patients should be promptly referred for endoscopy?

A 65-year-old man with new onset of epigastric pain and weight loss

Which one of the following patients presenting with chest pain is at the highest risk for an acute MI?

A 67-year-old man with a history of a prior angioplasty, with chest pain radiating to the neck and complaint of diaphoresis

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 6-year-old boy with a history of sickle cell anemia is brought to the emergency department by his parents because of the boy's 4 days of fatigue. The patient is up to date on all his immunizations. His home medications include penicillin and folic acid. His temperature is 99.3 °F, blood pressure is 102/70 mm Hg, heart rate is 116 bpm, respiratory rate is 22 breaths/min, and oxygen saturation shows 96% on room air. On physical examination, he appears pale, but he has normal chest, respiratory, and abdominal examinations. His white blood cell count is 7000/mm3, hemoglobin is 6.5 g/dL, platelet count is 27,000/mm3, and reticulocyte count is 0.2%. Which of the following is the most likely diagnosis?

Aplastic crisis: in sickle cell patients, aplastic crisis can result from a temporary stop in red blood cell production, characterized by a very low hemoglobin and reticulocyte count less than 1%

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? A

Cardiogenic shock

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: bc symptomatic and stenosis >70%

A 74-year-old man with no prior medical problems faints while shaving. He has a quick recovery and has no neurologic deficits. His blood sugar level is normal, and an ECG shows a normal sinus rhythm. Which of the following is the most useful diagnostic test of his probable condition?

Carotid massage

Which of the following asymptomatic patients would most benefit from treatment of the finding of more than 105 CFU/mL of Escherichia coli on urine culture?

A 33-year-old pregnant woman

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?

A Diastolic dysfunction (HF with preserved EF)

A 48-year-old Caucasian man with type 2 diabetes has had persistent BP readings of 150/95 mm Hg for the past 6 months. Current medications include glyburide and metformin. His last hemoglobin A1c was 7.9%, and the patient has a BMI of 24 kg/m2. On physical examination, position sense is intact but a peripheral neuropathy is detected in a stocking-and-glove pattern. Vibratory sensation is decreased bilaterally on both lower extremities. Eye examination shows mild papilledema but no cotton wool spots. When questioned, he says that he still occasionally sneaks a cookie after dinner and drinks alcohol nightly. Which of the following is the most appropriate treatment for him?

ACE inhibitor alone

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 37-year-old woman was being followed by her primary provider for symptomatic gallstones, which were confirmed on ultrasonography. She was placed on a low-fat diet and was doing well for the past 3 months. However, today, she presents to the emergency center with severe RUQ pain and nausea. On examination, her temperature is 102.3 °F, heart rate 100 bpm, and blood pressure 120/70 mm Hg. Her abdominal examination reveals marked RUQ tenderness and guarding. There is no rebound tenderness. Which of the following is the most likely diagnosis?

Acute cholecystitis (Acute cholecystitis)

A 14-year-old girl was sideswiped by a car while she was riding her bicycle. She was not wearing a helmet and struck the pavement with her head, losing consciousness for about 45 seconds. Afterward, the patient was awake and alert and returned home to rest. The parents noted that later she became drowsy, slurred her words, and after a few minutes had some weakness of the arms. On examination, the patient is lethargic and does not have any evidence of nuchal rigidity. The parents report that the patient's best friend had the "flu" 1 week ago. Which of the following is the most likely diagnosis?

Acute epidural hemorrhage (EDH)

A 1-month-old boy has a fever of 102.7 °F (39.3 °C), is irritable, has diarrhea, and has not been eating well. On examination, he has an immobile, dull, and red TM that has pus behind it. Which of the following is the most appropriate course of action?

Admission to the hospital with complete sepsis evaluation

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 (3rd gen cephalosporin and macrolide)

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:should be considered in a patient who develops COPD at a young age; this condition is also associated with liver dysfunction and can cause cirrhosis (another cause of COPD)

A 61-year-old man is diagnosed with mild PD. In discussion about therapy, you review the medication rationale and also the side effects associated with the medications. Which of the following medications is most likely to be able to help relieve his mild symptoms of PD without increasing risk of dyskinesias?

Amantadine

A 36-year-old man is noted to have a bothersome "mole" that on biopsy reveals malignant melanoma. The pathologist comments that this histology is a very rare type of melanoma and usually escapes diagnosis until a more advanced stage. Which of the following is the most likely diagnosis?

Amelanotic melanoma (because of the lack of pigmentation, it often goes undiagnosed until it is more invasive and has progressed to an advanced stage.)

Ototoxicity and nephrotoxicity are characteristic adverse effects of which of the following?

Aminoglycosides

Abnormal processing of which of these proteins is felt to be particularly important in the pathophysiology of AD?

Amyloid precursor protein

Which of the following counseling strategies is most likely to enhance your patients' smoking cessation rates?

Ask about smoking cessation at each encounter.

A 59-year-old male smoker complains of severe retrosternal squeezing chest pain of 30 minutes' duration. The paramedics have given sublingual nitroglycerin and oxygen by nasal cannula. His blood pressure is 110/70 mm Hg, and heart rate is 90 bpm on arrival to the Emergency Department. The ECG is normal. Which of the following is the best next step?

Aspirin

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 62-year-old man is being seen in the office for establishment of care. He reports that he had an acute myocardial infarction (MI) 1 year previously and lost his insurance and has not been able to take any medications since his heart attack. He smokes half a pack a day, which is less than the 1 pack per day previously. On examination, his blood pressure is 110/60 mm Hg. The cardiac examination is normal, and there is no jugular vein distension or pedal edema. His LDL-C is 105 mg/dL, HDL cholesterol is 28 mg/dL, and total cholesterol is 170 mg/dL. According to the NICE guidelines, what medication therapy should be initiated at this time? A

Atorvastatin

A 49-year-old man is admitted to the intensive care unit with a diagnosis of an inferior myocardial infarction. His heart rate is 35 bpm, and blood pressure is 90/50 mm Hg. His ECG shows a Mobitz type I heart block. Which of the following is the best next step?

Atropine

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

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?

B Intravenous fluid replacement

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? A

Begin adjusted dose warfarin therapy. (Patients between 65 and 75 years old, who score 1 point may use aspirin or warfarin, but warfarin therapy is preferred when bleeding risk is low)

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: he patient has uremia, hyperkalemia, and (likely) uremic pericarditis (harsh systolic and diastolic sounds of friction rub), which may progress to life-threatening cardiac tamponade

A 34-year-old woman contemplating pregnancy is diagnosed with stage 1 hypertension, and after an evaluation she is noted to have no complications. Which of the following antihypertensive classes may be appropriate for this individual?

Beta adrenergic blockers (Labetalol, which is a beta blocking agent, is widely used in pregnant women and is considered safe for the fetus.)

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 re

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 31-year-old man with a history of diabetes mellitus and sickle cell anemia presents to the emergency department with 2 days of cough, chest pain, and difficulty breathing. His temperature is 100.7 °F, blood pressure is 112/65 mm Hg, heart rate is 117 bpm, respiratory rate is 22 breaths/min, and pulse oximetry shows 94% on room air. White blood cell count is 13,000/mm3, and hemoglobin is 9.9 g/dL (baseline of 10.1 g/dL). Chest x-ray reveals a right lower lobe opacity. Blood and sputum cultures are collected. Which of the following is the most appropriate empiric antibiotic therapy for this patient?

Cefotaxime and azithromycin

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 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: JVD and lower extremity edema are suggestive of cor pulmonale, which is right heart failure due to chronically elevated pressures in the pulmonary circulation

A 43-year-old man is admitted to the hospital with a diagnosis of acute pancreatitis. His family shares that he is a heavy user of alcohol. He is given intravenous hydration and is placed NPO. Which of the following findings is the highest predictor of mortality?

Disorientation, with Glasgow Coma Scale score of 10

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: Vitamin B12 stores last for nearly 10 years; therefore, a dietary change of several months would more likely cause folate deficiency. Folate is found in green leafy vegetables

A 34-year-old woman of Mediterranean descent is found to have mild anemia on prenatal screening CBC. She denies any shortness of breath, fatigue, or blood in stool. Family history is notable for a brother who requires frequent blood transfusions. A CBC demonstrates microcytic, hypochromic anemia with high serum iron, normal RDW, normal ferritin, and low reticulocytes. Hemoglobin electrophoresis is normal. Which of the following is the best next diagnostic step?

DNA testing: Thalassemia usually leads to a microcytic anemia with uniform red cell size (normal RDW) and excess iron stores. The patient's asymptomatic anemia, ethnicity, and family member with transfusion-dependent anemia are consistent with alpha-thalassemia minor. Alpha-thalassemia minor can have normal hemoglobin electrophoresis, and diagnosis requires DNA sequencing

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

Match the following laboratory pictures (A-D) of patients with anemia: A 67-year-old man presents with dizziness and a positive stool guaiac test.

Decreased ferritin; decreased MCV; decreased serum iron level

A 30-year-old woman is noted to have blood pressures in the 160/100 mm Hg range. She also has increased obesity, especially around her abdomen, which also shows some striae. She has been bruising very easily and has increased hair growth on her face and chest. Which of the following most likely to reveal the diagnosis?

Dexamethasone suppression test and serum cortisol: patient has Cushing syndrome, which can be diagnosed with a dexamethasone suppression test and serum cortisol.

A 68-year-old man with a history of end-stage renal disease is admitted to the hospital for chest pain. On examination, a pericardial friction rub is noted. His ECG shows diffuse ST-segment elevation. Which of the following is the best definitive treatment?

Dialysis

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: The anion gap is calculated by the following formula: Anion Gap = [Na+] - [Cl-+ HCO3]. In this case, the patient's anion gap = 138 - (105 + 23) = 10, which is normal (recall normal anion gap is 10-12). Diarrhea leads to bicarbonate loss and usually does not affect the anion gap

A 47-year-old woman reports a 10-year history of intermittent abdominal pain and constipation alternating with diarrhea. She has no weight loss, fever, or alarm features on history or examination. Which of the following agents can be used for treatment of mild-to-moderate abdominal pain associated with IBS?

Dicyclomine

A 65-year-old man is being seen in the office for shortness of breath of 1 day's duration. He has smoked 1.5 packs of cigarettes per day for 35 years. On examination, he is cachectic and breathes with pursed lips. His chest is barrel-shaped, and the AP diameter is enlarged. Which of the following is the most likely physical examination finding in this patient?

Diffuse expiratory wheezing

A 33-year-old man is complaining of the room spinning. Which of the following tests is used to diagnose BPPV

Dix-Hallpike maneuver

A 7-year-old boy is brought to a hospital in Charlotte, North Carolina, with a fever of 104 °F (40 °C). A maculopapular rash is seen on his wrists and ankles, but the palms and soles are spared. His laboratory results show leukopenia, hyponatremia, and elevated liver transaminases. His parents say that he was on a camping trip 1 week ago, but they vigorously used insect repellants and filtered all of their water. His father came in contact with poison oak, but the boy denies any pruritus. Which of the following is the best treatment for this patient's rash?

Doxycycline

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.

A 3-year-old boy is noted to have a stiff neck, fever, and photophobia. He and his family recently emigrated from a remote village in Central America. The mother reports that the child has not received any preventive care. Which of the following is most likely to be found on Gram stain of CSF?

Gram-negative coccobacilli: 3-year-old child likely has a bacterial meningitis caused by Haemophilus influenzae type b, which is the most common etiology of nonvaccinated children. The history of emigrating from a remote village in Central America makes it likely that the vaccination was not received

A 67-year-old man with coronary artery disease, dyslipidemia, and eczema comes to you complaining of lower back pain and left leg pain. The pain is worse when he stands for long periods of time but improves when he bends forward to push his shopping cart around the grocery store. He indicates that his feet "burn" and "ache" after walking different distances every day. His lower extremity neuromuscular examination is unremarkable. Which of the following is the most appropriate treatment for this patient?

Epidural corticosteroid injection: history is classic for spinal stenosis. Patients often find relief by sitting or stooping, as these positions tend to lead to spinal flexion rather than extension

A 70-year-old woman presents for evaluation of a lesion on her left cheek. It has been present for several months. It is slowly enlarging and bleeds if she scratches it. On examination, you find a 7-mm diameter, pearly appearing papule with visible telangiectasias on the surface. Which of the following is the appropriate management of this lesion?

Excision

Two weeks after a viral syndrome, a 2-year-old boy develops bruising and generalized petechiae that is more prominent over the legs. He has neither hepatosplenomegaly nor lymph node enlargement. Laboratory testing reveals a normal hemoglobin, hematocrit, and WBC count and differential. The platelet count is 15,000/mm3. Which of the following is the most likely diagnosis?

ITP

Which of the following is the most likely explanation for multiple drug resistance to antibiotics that spreads from one type of bacteria to another?

Gene transfer

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) (most common primary brain cancer in adults)

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? A

Graves disease

A 58-year-old Caucasian woman presents complaining of low back pain 4 weeks after a fall. She has no history of fever, unexplained weight loss, diabetes, or cancer. Her past medical history is significant for moderate persistent asthma and nicotine dependence. She had a hysterectomy for uterine fibroids at age 40. Which of the following aspects of the patient's history should prompt further evaluation of her pain?

History of corticosteroid use: patient's history is suspicious for a vertebral compression fracture that could be secondary to osteoporosis caused in part by corticosteroid use in a postmenopausal woman

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 33-year-old man is diagnosed with essential hypertension. He is started on a blood pressure medication, and after 6 weeks, he notes fatigue, rash over his face, joint aches, and effusions. A serum antinuclear antibody (ANA) test is positive. Which of the following is the most likely agent?

Hydralazine: Hydralazine is associated with a lupus-like presentation, with photosensitivity, malar rash, joint pain, and sometimes pericardial effusion or pleural effusion.

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 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.

A 36-year-old woman has severe burning chest pain that radiates to her neck. The pain occurs particularly after meals, especially when she lies down, and is not precipitated by exertion. She is admitted for observation. Serial ECG and troponin I levels are normal. Which of the following is the best next step?

Initiation of a proton pump inhibitor

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 45-year-old man was brought to the emergency department after vomiting bright red blood. He has a blood pressure of 88/46 mm Hg and heart rate of 120 bpm. Which of the following is the best next step?

Intravenous fluid resuscitation and preparation for a transfusion B Administration of a PPI

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 34-year-old man is being seen in the office for follow-up for epigastric pain and suspected PUD. Serum antibodies are positive for H. pylori. Which of the following is the most accurate statement regarding this infection?

It is a cause of both duodenal and gastric ulcers.

A teenage boy arrives for a checkup. His friend was recently diagnosed with mononucleosis. He is worried he will contract it. Which of the following is true regarding transmission of EBV?

It requires close contact with saliva (ie, kissing or drinking from the same cup)

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: The clinical presentation of paresthesia and CBC findings are consistent with macrocytic anemia due to B12 deficiency. Pernicious anemia (lack of intrinsic factor) is the most common cause; recall that intrinsic factor is critical to binding vitamin B12 and absorption by the terminal ileum.

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: typically presents with diffuse myalgias, abdominal pain, diarrhea, and severe pneumonia. Tobacco dependence increases susceptibility to Legionella as wel

A 73-year-old woman presents to the office due to concern about several tan-colored moles on her arms, face, and ears that have progressively grown over the past 6 months. Upon further examination, the moles are determined to be between 6 and 8 mm with very irregular borders. The clinician decides to obtain an excisional biopsy. Which of the following skin lesions should the provider be most suspicious of based on the history and physical examination?

Lentigo maligna melanoma

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?

Rhythm control with amiodarone

A mother brings her 3-year-old son with Down syndrome to the clinic because his gums have been bleeding for 1 week. She reports that he has been less energetic than usual. Examination reveals that the child has an oral temperature of 100 °F (37.8 °C), pallor, splenomegaly, gingival bleeding, and bruises on the lower extremities. Which of the following is most likely?

Leukemia

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.

22-year-old woman is a college student who has been increasingly stressed with coursework this semester. She has been using over-the-counter antacids more days out of the week than not for an upset stomach. She typically has two to three bowel movements per week but recently has only been having one or two hard bowel movements a week. She reports no blood in the stool. She feels immediate relief after passage of stool and flatulence, but she often feels like her bowel movements are incomplete. She has tried several diets eliminating foods that create GI symptoms and has increased her exercise regimen from once a week to daily without improvement. Which of the following therapies is recommended in IBS-C to improve motility, abdominal pain, spontaneous bowel movements, and IBS-related global function?

Linaclotide (used in adults to treat irritable bowel syndrome with constipation (IBS-C; a condition that causes stomach pain or cramps, bloating)

A 65-year-old veteran complains of increasing difficulty understanding conversations, especially in crowded settings. The audiologist identifies the patient as having high-frequency, symmetric, and progressive sensory presbycusis. Which of the following best explains the pathophysiology of the patient's symptoms?

Loss of sensory hair cells along the cochlear basilar membrane

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

A 35-year-old man is being evaluated for resting tremor, rigidity, and difficulty with balance. In reviewing the medications, you suspect drug-induced parkinsonism. Which of the following medications would be most likely to be responsible?

Metoclopramide: dopamine receptor blocking agents (prochlorperazine and metoclopramide), dopamine depleting agents (reserpine, tetrabenazine), and atypical antipsychotic agents

A 62-year-old woman presents for a routine physical examination. She is asymptomatic and is not taking any medications. Her BP is found to be 145/85 mm Hg on two readings, and her BMI is 29 kg/m2. Review of her chart reveals that her BP was 143/84 mm Hg on a visit 4 months ago for a urinary tract infection. Which of the following is the most accurate statement regarding her BP?

She is at risk for needing pharmacologic treatment for hypertension.

Which of the following is most accurate?

More than one condition is often responsible for causing chronic cough in a given patient.

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: leads to a reddish appearance and positive urine dipstick reaction for blood, but microscopic analysis of the urine likely will demonstrate no red cells.

Three days after beginning oral amoxicillin therapy for OM, a 4-year-old boy has continued fever, ear pain, and swelling with redness behind his ear. His ear lobe is pushed superiorly and laterally; he has tenderness posterior to the ear. He seems to be doing well otherwise. Which of the following is the most appropriate course of action?

Myringotomy and parenteral antibiotics (pt has mastoiditis)

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 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 45-year-old man with no significant past medical history presents with severe back pain after lifting heavy boxes at work 2 days ago. Other than his back pain, his review of symptoms is negative. His pain is exacerbated by coughing and sneezing. The pain radiates from his lower back down his right posterior thigh to his great toe when you perform both a straight leg raise and the contralateral leg raise tests. His strength, sensation, and reflexes are intact and symmetrical. Which of the following is the recommended first step in the evaluation of this patient?

No imaging indicated: patient has signs and symptoms of a herniated disk

A 27-year-old man in graduate school is evaluated for intermittent abdominal pain and frequent loose stools. He has no fevers, weight loss, bloody stools, or symptoms that wake him up at night. His family history is negative for colorectal cancer and IBD. He is diagnosed with IBS-D and asks about getting a colonoscopy to support his diagnosis. Although not indicated as part of his workup, a colonoscopy in this patient would likely show which of the following?

Normal colonic mucosa: Irritable bowel syndrome is a functional disorder with no identifiable organic cause. C

In a suicide attempt, an 18-year-old woman took 4 g of acetaminophen, approximately 8 hours previously. On examination, she is drowsy but oriented and answers questions appropriately. Her blood pressure is 120/70 mm Hg and heart rate is 90 bpm. She is anicteric. Her heart, lung, and abdominal examinations are normal. Her acetaminophen level is 30 mcg/mL. Which of the following is the best next step to be performed for this patient?

Observation

You are in a small town practicing pediatrics and have been asked to see a 2-year-old boy in consultation. His general practice doctor admitted him to the hospital 2 days ago because of 3 days of fever. He has generalized lymphadenopathy but is otherwise well. Results of Monospot, human immunodeficiency virus (HIV) testing, and cytomegalovirus (CMV) antigen tests are negative; his liver function test values are mildly elevated. His physician diagnosed the boy's 7-year-old sibling with "mono" the month prior. You should suggest which of the following?

Obtain EBV viral capsid antigens (VCA) IgG and IgM, EBV early antigen (EA), and EBV nuclear antigen (NA) tests.

A 35-year-old woman comes to your office worried that she might have IBS, which she heard about from her colleagues at work. She reports abdominal pain and diarrhea for 3 months. She also reports observing several bloody stools. She is worried about the impact that frequently having to use the bathroom is having on her job as an attorney. Her physical examination is unremarkable except for a guaiac-positive test after a rectal examination. When reviewing her medical records, you notice that she has lost 15 pounds since she last saw you 4 months ago. Which of the following is an appropriate next step? A

Obtain a colonoscopy.

A 42-year-old woman presents to the emergency department (ED) with a 1-day history of fever, neck stiffness, and severe headache. Her examination reveals a widespread maculopapular rash. Which of the following is the most appropriate next step in management?

Obtain a complete blood count (CBC) with differential, blood cultures, comprehensive metabolic panel (CMP), and international normalized ratio (INR), and begin intravenous (IV) penicillin G or ampicillin.

A 5-year-old girl developed high fever, ear pain, and vomiting a week ago. She was diagnosed with OM and started on amoxicillin-clavulanate. On the third day of this medication, she continued with findings of OM, fever, and pain. She received ceftriaxone intramuscularly and switched to oral cefuroxime. Now, 48 hours later, she has fever, pain, and no improvement in her OM; otherwise, she is doing well. Which of the following is the most logical next step in her management?

Tympanocentesis and culture of middle ear fluid

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. This patient has CKD with volume overload, as evidenced by symptoms of shortness of breath, weight gain, the presence of an S3, crackles, and moderate JVD. Because oxygenation is the most important first priority, respiratory status should be addressed first. Pt has pulmonary edema

A 45-year-old man was admitted for acute pancreatitis, thought to be a result of blunt abdominal trauma. After 3 months, he still has epigastric pain but is able to eat solid food. His amylase level is elevated at 260 IU/L. Which of the following is the most likely diagnosis?

Pancreatic pseudocyst (clinical presentation of abdominal pain and mass and persistent hyperamylasemia in a patient with prior pancreatitis. T)

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 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: Bilateral, diffuse infiltrates are more likely to be seen in patients with pneumonia caused by atypical agents, such as Mycoplasma,

A 50-year-old man is evaluated in the ICU 1 hour after a motor vehicle accident where he was the unrestrained passenger. On examination the patient is confused, agitated, and diaphoretic. Vital signs are as follows: BP 76/50 mm Hg, HR 140 beats/minute, RR 32 breaths/minute, and Sao2 by pulse oximetry of 72% on room air. Chest x-ray shows multiple rib fractures with an associated right pneumothorax. RSI is initiated with an 8-mm ETT and a right-sided chest tube is inserted. The patient is started on a pressure support of +10 mm Hg with 0 PEEP and Fio2 of 100%. Additional chest x-rays and blood gas determinations are pending. Which of the following is the most reliable confirmation of proper tracheal placement of the ETT?

Positive color changes on a CO2 monitor attached to the endotracheal tube

A patient with which of the following conditions requires antimicrobial prophylaxis before dental surgery?

Previous infective endocarditis

A 25-year-old medical student is stuck with a hollow needle during a procedure performed on a patient known to have hepatitis B and C viral infections, but who is HIV negative. The student's baseline laboratory studies include serology: HBsAg negative, anti-HBsAb positive, and anti-HBc IgG negative. Which of the following regarding this medical student's hepatitis status is true?

Prior vaccination with hepatitis B vaccine (vaccinated against the hepatitis B virus, which induces anti-HBs IgG antibody, and is thought to be protective)

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 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 72-year-old woman slipped and fell down the concrete steps outside of her office building, hitting her face and head on the ground. She was taken to the emergency department and noted to have multiple lacerations and contusions to the face, chest, and right arm but no fractures. She was initially confused but then became more alert and could follow directions. Her neurologic exam was normal, and her Glasgow Coma Scale (GCS) score was 15/15. No focal neurologic deficits were noted. A noncontrast CT study of the head showed no bleeding or fractures. She was discharged home after being observed for 12 hours. Two weeks later, she is brought back to the emergency department for confusion and disorientation. She knows her first name but cannot verbalize her last name, the place, or the date/time. Her short-term memory is also markedly impaired. Which of the following is the most likely diagnosis?

SDH: several weeks later, the patient developed decreased cognitive function, which is classic for a subacute or chronic SDH

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? A

Sarcoidosis: can present with cough, dyspnea, and hilar adenopathy on chest x-ray. In approximately 10% of cases, sarcoidosis can cause elevated calcium levels through the production of 1,25-vitamin D that occurs in the macrophages of the granulomas. This can also be seen in granulomas caused by tuberculosis and in lymphoma.

A 25-year-old woman complains of pain in her PIP and metacarpophalangeal joints and reports a recent positive antinuclear antibody (ANA) laboratory test. Which of the following clinical features would not be consistent with a diagnosis of SLE?

Sclerodactyly

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 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): Type 4 = abnormal aldosterone production or response (usually hyperkalemia and non-anion gap acidosis)

Several friends develop vomiting and diarrhea 6 hours after eating food at a private party. They describe the diarrhea as watery and nonbloody. Which of the following is the most likely etiology of the symptoms?

Staphylococcus aureus: consistent with food poisoning. This is most likely due to S. aureus toxin, which usually causes vomiting and diarrhea within a few hours of food ingestion because the toxin is preformed in the food.

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: sudden onset of severe headache with diminution in level of consciousness is classic

A 6-year-old girl is brought to your office by her mother because of a rash first noticed a week ago. Her mother reports that several children in her child's school have chicken pox, but that her child has received all of her immunizations, including two doses of the varicella vaccine. You observe the child actively playing with the toys in the waiting room before both the mother and child are brought back to the examination room. The child has a temperature of 100.4 °F (38 °C), a pulse of 90 beats/min, a blood pressure of 100/70 mm Hg, and a respiratory rate of 20 breaths/min. The physical examination is unremarkable except for about 20 vesicles on erythematous bases sparsely scattered on the child's trunk and limbs. Which of the following is the most appropriate treatment?

Supportive care

At a routine checkup, a 6-year-old boy is found to have a BP of 150/90 mm Hg. Repeated BP readings are consistently elevated. The child was delivered at 36 weeks by normal spontaneous vaginal delivery with no complications. All major milestones were met on time, and he currently is enrolled in first grade. The child has been healthy up until this point. Which of the following are the most appropriate diagnosis and therapeutic step?

The child most likely has renal parenchymal disease and should have a urinalysis and renal ultrasound ordered.: The most common cause of hypertension (in kids) is renal parenchymal disease, and a urinalysis, urine culture, and renal ultrasonography should be ordered for all children presenting with hypertension.

An 18-year-old adolescent young man is brought to the emergency department from his college dorm by his roommate. The patient is confused and cannot give a history. He has a temperature of 104 °F (40 °C), pulse of 110 beats/min, blood pressure of 90/60 mm Hg, and respiratory rate of 24 breaths/min. His head cannot be moved because of severe nuchal rigidity. Multiple petechiae are observed on his buttocks and legs. After initiation of treatment for the patient, what is the most appropriate advice to give to this patient's roommate?

The patient should take rifampin for prophylaxis: most likely diagnosis is meningitis and meningococcemia caused by N. meningitidis. The patient is severely affected and is in septic shock. All people in close contact with the patient should receive ciprofloxacin or rifampin prophylaxis

A 48-year-old man is being seen for follow-up from an elevated cholesterol level at a health screening, which is recorded as 250 mg/dL. He denies significant medical history and has no symptoms. Which of the following tests is the most important further evaluation of this patient's condition?

Thyroid-stimulating hormone level (Hypothyroidism is a potential cause of secondary dyslipidemia. A TSH level is a reasonable test to perform in this setting in a patient with an elevated cholesterol level.)

A 54-year-old man is evaluated in the emergency department for a 2-day history of worsening dyspnea. He has had intermittent pleuritic chest pain for the past 7 days. On physical exam, temperature is 37.7°C (99.9°F), blood pressure is 84/46, pulse rate is 130/min, and respiratory rate is 28/min. Oxygen saturation is 91% on room air. Cardiac examination reveals muffled heart sounds. Lung auscultation discloses normal breath sounds. A 12-lead ECG shows sinus tachycardia with diffuse low voltage. A bedside echocardiogram shows a large pericardial effusion with right atrial and ventricular diastolic collapse with a normal left ventricular systolic function.

Urgent pericardiocentesis

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?

Valve replacement: The symptoms of aortic stenosis classically progress through angina, syncope, and, finally, HF, which has the worst prognosis for survival

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: Vertigo and dizziness can be seen in vertebrobasilar insufficiency.

18-year-old woman eats raw seafood and 2 days later develops fever, abdominal cramping, and watery diarrhea. She is being seen in the emergency center for dizziness and lightheadedness. She describes the diarrhea as profuse and continues even if she is not eating or drinking foods. Which of the following is the most likely etiology of the symptoms?

Vibrio species

A confused 21-year-old man is brought in by emergency medical services (EMS) to the ED. He has a severe headache and fever. His neurologic examination is notable for a Kernig sign and hyperreflexia. LP reveals a protein of 72 mg/dL, glucose of 84 mg/dL (serum glucose of 100 mg/dL), and 235 white blood cells (WBCs)/mm3 with 60% lymphocytes; cultures and Gram stain are pending. These cerebrospinal fluid (CSF) studies are most consistent with which of the following?

Viral meningitis. The finding of an elevated CSF protein, normal glucose, and predominance of lymphocytes is consistent with a viral meningitis.

An 11-month-old boy presents with fever, ear pain, and purulent discharge from both eyes. On examination, bilateral, erythematous, bulging TMs and purulent conjunctivitis are noted. Based on his symptoms and examination, amoxicillin-clavulanate is prescribed. The mother asks what she could do to prevent future ear infections. Which of the following is not one of the current recommendations to reduce the incidence of otitis media?

Xylitol

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 (alcohol abuse is a common cause of folate defieicny)

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: inhibition of osteoclastic bone reabsorption

9.3 A 34-year-old woman presents to the emergency department with a 3-day history of pleuritic chest pain. She has had a recent flulike episode a week ago. On physical exam her temperature is 37.8°C (100.0°F), blood pressure is 114/54, pulse rate is 110/min, and respiration rate is 24/min. Cardiac exam reveals a pericardial friction rub. Lung exam discloses normal breath sounds. A 12-lead ECG shows sinus tachycardia and diffuse concave upward ST segment elevation. A chest radiograph shows an enlarged cardiac silhouette but no infiltrates. The first set of cardiac enzymes is negative.

cardiac echocardiogram

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 b

depression

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 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 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: Tight glycemic control can prevent the microvascular complications of diabetes, such as diabetic nephropathy, though it has not been shown to decrease significantly the occurrence of macrovascular complications of diabetes, such as coronary artery disease or peripheral vascular disease.

A 31-year-old woman with a long history of intermittent severe unilateral throbbing headache lasting hours to days associated with nausea and photophobia, but no preceding symptoms and no visual disturbance, occurring once or twice per month

migraine

Match the following laboratory pictures (A-D) of patients with anemia: A 68-year-old man has an incidental finding of anemia while in the hospital for alcohol abuse.

normal MMA, decreased serum folate level (normal MMA rules out a concomitant B12 deficiency)

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 32-year-old G2 P1 woman is pregnant at 12 weeks' gestation. She is being seen for her prenatal visit. As you examine her, you note some bruises on her arms and neck area. She looks down at the floor and is tearful when you ask about these bruises. She confides that her husband has been violent toward her. Which of the following factors is associated with an increased risk of intimate partner violence in this patient?

pregnancy

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

A 50-year-old man is being seen in the office for follow-up of severe rheumatoid arthritis. He declines taking medications except for a daily multivitamin with iron. His laboratory examination results include a hemoglobin level of 9.8 g/dL. The colonoscopy this year was normal. Which of the following lab findings would most likely to be seen on laboratory workup of his anemia?

the patient has an inflammatory condition (rheumatoid arthritis) that would cause an anemia of chronic disease. The typical parameters with chronic inflammation would be a normocytic (normal to slightly low MCV), normal to high serum ferritin level (due to inability to mobilize iron), and low serum iron levels (due to lack of iron in circulation)

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?

vena cava filter