Medicine 5 Flashcard
Which of the following patients has the lowest clinical probability for the diagnosis of pulmonary embolism?
A 39-year-old man who smokes cigarettes occasionally and underwent an uncomplicated appendectomy 2 months ago
A 27-year-old man complains of chest palpitations and lightheadedness for the past hour. He has no past medical history and is not taking any medications. He drinks a beer occasionally on the weekend and does not smoke cigarettes. His HR is 180 beats per minute, BP is 110/65 mm Hg, and oxygen saturation is 99% on room air. An ECG reveals a HR of 180 beats per minute with a QRS complex of 90 msec with a regular rhythm. There are no discernable P waves. Which of the following is the most appropriate medication to treat this dysrhythmia?
Adenosine
While eating dinner, a 55-year-old man suddenly feels a piece of steak "get stuck" in his stomach. In the ED, he complains of dysphagia, is drooling, and occasionally retches. On examination, his BP is 130/80 mm Hg, HR is 75 beats per minute, RR is 15 breaths per minute, and oxygen saturation is 99% on room air. He appears in no respiratory distress. Chest x-ray is negative for air under the diaphragm. Which of the following is the most appropriate next step in management?
Administer 1-mg glucagon intravenously while arranging for endoscopy.
A 31-year-old man who works for a moving company presents to the ED because he thought he was having a heart attack. He does not smoke, and jogs 3 days a week. His father died of a heart attack in his sixties. He describes a gradual onset of chest pain that is worse with activity and resolves when he is at rest. His HR is 68 beats per minute, BP is 120/70 mm Hg, and RR is 14 breaths per minute. On examination, his lungs are clear and there is no cardiac murmur. You palpate tenderness over the left sternal border at the third and fourth rib. An ECG reveals sinus rhythm at a rate of 65. A chest radiograph shows no infiltrates or pneumothorax. Which of the following is the most appropriate next step in management?
Administer ibuprofen and reassure the patient that he is not having a heart attack.
A 63-year-old insurance agent is brought to the ED by paramedics for shortness of breath and a RR of 31 breaths per minute. The patient denies chest pain, fever, vomiting, or diarrhea. His wife says he ran out of his "water pill" 1 week ago. His BP is 185/90 mm Hg, HR is 101 beats per minute, oxygen saturation is 90% on room air, and temperature is 98.9°F. There are crackles midway up both lung fields and 2+ pitting edema midway up his legs. An ECG shows sinus tachycardia. The patient is sitting up and able to speak to you. After placing the patient on a monitor and inserting an IV, which of the following is the most appropriate next step in management?
Administer oxygen via non-rebreather, furosemide, nitroglycerin, and consider noninvasive respiratory therapy.
A 27-year-old woman presents to the ED complaining of an intensely pruritic rash all over her body, abdominal cramping, and chest tightness. She states that 1 hour ago she was at dinner and accidentally ate some shrimp. She has a known anaphylactic allergy to shrimp. Her BP is 115/75 mm Hg, HR is 95 beats per minute, temperature is 98.9°F, RR is 20 breaths per minute, and oxygen saturation is 97% on room air. She appears anxious, and her skin is flushed with urticarial lesions. Auscultation of her lungs reveals scattered wheezes with decreased air entry. Which of the following is the most appropriate next step in management?
Administer oxygen via non-rebreather, place a large-bore IV, begin IV fluids, administer methylprednisolone and diphenhydramine intravenously, and give subcutaneous epinephrine.
A 35-year-old HIV-infected homosexual man presents with fever, pain of the right upper quadrant, and a CT of the liver that shows a 10-cm, oval hypoechoic cyst in the right lobe. An ELISA assay detects the presence of antibodies to Entamoeba histolytica; cysts from the same organism are found in a stool specimen. Which of the following is the most appropriate next step in management?
Administration of metronidazole
A 57-year-old man complains of chest palpitations and lightheadedness for the past hour. Five years ago he underwent a cardiac catheterization with coronary artery stent placement. He smokes half a pack of cigarettes daily, and drinks a glass of wine at dinner. His HR is 140 beats per minute, BP is 115/70 mm Hg, and oxygen saturation is 99% on room air. An ECG reveals a wide complex tachycardia at a rate of 140 that is regular in rhythm. An ECG from 6 months ago shows a sinus rhythm at a rate of 80. Which of the following is the most appropriate medication to treat this dysrhythmia?
Amiodarone
A 62-year-old man presents to the ED with gradual dyspnea over the last few weeks. He reports that he is a daily smoker and has not seen a physician in years. Upon physical examination, there are decreased breath sounds on the right as compared to the left. A chest radiograph indicates blunting of the right costophrenic angle with a fluid line. A thoracentesis is performed. Given this patient's history, which of the following most likely describes his effusion?
Exudative effusion
A 29-year-old woman presents to the ED for hyperventilation. Her initial vitals include an RR of 28 breaths per minute with an oxygen saturation of 100% on room air. She is able to speak in full sentences and tells you that she cannot breathe and that her hands and feet are cramping up. She denies any trauma, past medical history, or illicit drug use. Chest auscultation reveals clear breath sounds bilaterally. A subsequent chest radiograph is normal. Upon reevaluation, the patient reports that she is breathing better. Her vitals include an RR of 12 breaths per minute with an oxygen saturation of 100% on room air. Which of the following conditions is most likely the etiology of this patient's symptoms?
Anxiety attack
A 75-year-old man goes out to shovel snow from his driveway. After 5 minutes of shoveling, he feels short of breath, chest pain, and then passes out. He awakens minutes later to his wife shaking him. In the ED, he denies chest pain or dyspnea. His BP is 160/85 mm Hg, HR is 71 beats per minute, and oxygen saturation is 97% on room air. On examination, you hear a harsh systolic ejection murmur. An ECG reveals a sinus rhythm with left ventricular hypertrophy. Which of the following is the most likely diagnosis?
Aortic stenosis
Four days after he and his friends were killing muskrats along a rural creek, a boy becomes ill with headache, fever, and a macular rash. On examination, axillary adenopathy is noted, but otherwise the examination is normal. Which of the following tests would be most helpful in proving that this boy has tularemia?
Aspiration and culture of an axillary lymph node
A 62-year-old woman presents to the ED with general weakness, shortness of breath, and substernal chest pain that radiates to her left shoulder. Her BP is 155/80 mm Hg, HR is 92 beats per minute, and RR is 16 breaths per minute. You suspect that she is having an acute MI. Which of the following therapeutic agents has been shown to independently reduce mortality in the setting of an acute MI?
Aspirin
A 32-year-old man is brought into the ED by EMS with fever, shortness of breath, and stridor. The patient was treated yesterday in the ED for a viral syndrome. His BP is 90/50 mm Hg, HR is 110 beats per minute, temperature is 101.2°F, and his RR is 28 breaths per minute. A chest radiograph reveals a widened mediastinum. The patient is endotracheally intubated, given a 2-L bolus of normal saline, and started on antibiotics. His BP improves to 110/70 mm Hg and he is transferred to the intensive care unit ICU. You see a friend that accompanied the patient to the hospital and ask him some questions. You find out that the patient is a drum maker and works with animal hides. What is the most likely organism that is responsible for the patient's presentation?
Bacillus anthracis
A 12-year-old girl presents with painful epitrochlear lymphadenopathy associated with low-grade fever and malaise. The patient has a cat and also gave a history of a papillary lesion in the left forearm about 1 week or 10 days ago. The most likely etiologic agent in this situation is
Bartonella henselae
A 43-year-old undomiciled man is brought to the ED after being found intoxicated on the street. He is currently rousable and expresses a request to be left alone. Initial vitals include a HR of 92 beats per minute, a BP of 125/80 mm Hg, and an RR of 14 breaths per minute with an oxygen saturation of 93% on room air. His rectal temperature is 101.2°F. A chest radiograph shows infiltrates involving the right-lower lobe. Given this clinical presentation, what initial antibiotic coverage is most appropriate for this patient?
Broad-spectrum with anaerobic coverage
A 51-year-old woman presents to the ED after 5 consecutive days of crushing substernal chest pressure that woke her up from sleep in the morning. The pain resolves spontaneously after 20 to 30 minutes. She is an avid rock climber and jogs 5 miles daily. She has never smoked cigarettes and has no family history of coronary disease. In the ED, she experiences another episode of chest pain. An ECG reveals ST-segment elevations and cardiac biomarkers are negative. The pain is relieved with sublingual nitroglycerin. She is admitted to the hospital and diagnostic testing reveals minimal coronary atherosclerotic disease. Which of the following is the most appropriate medication to treat this patient's condition
Calcium channel blocker CCB.
A previously healthy 28-year-old man describes several episodes of fever, myalgia, and headache that have been followed by abdominal pain and diarrhea. He has experienced up to 10 bowel movements per day. Physical examination is unremarkable. Laboratory findings are notable only for a slightly elevated leukocyte count and an elevated erythrocyte sedimentation rate. Wright's stain of a fecal sample reveals the presence of neutrophils. Colonoscopy reveals is inflamed mucosa. Biopsy of an affected area discloses mucosal infiltration with neutrophils, monocytes, and eosinophils; epithelial damage, including loss of mucus; glandular degeneration; and crypt abscesses. The patient notes that several months ago he was at a church barbecue where several people contracted a diarrhea1 illness. While this patient could have inflammatory bowel disease, which of the following pathogens is most likely to be responsible for his illness?
Campylobacter
A tall, thin 18-year-old man presents to the ED with acute onset of dyspnea while at rest. The patient reports sitting at his desk when he felt a sharp pain on the right side of his chest that worsened with inspiration. His past medical history is significant for peptic ulcer disease. He reports taking a 2-hour plane trip a month ago. His initial vitals include a HR of 100 beats per minute, a BP of 120/60 mm Hg, an RR of 16 breaths per minute, and an oxygen saturation of 97% on room air. On physical examination, you note decreased breath sounds on the right side. Which of the following tests should be performed next?
Chest radiograph
A 56-year-old woman with a history of ovarian cancer presents to the ED with acute onset of right-sided chest pain, shortness of breath, and dyspnea. Her BP is 131/75 mm Hg, HR is 101 beats per minute, respirations are 18 breaths per minute, and oxygen saturation is 97% on room air. You suspect this patient has a pulmonary embolism PE. Which of the following tests is most likely to be abnormal?
D-dimer
A 42-year-old man presents to the ED via ambulance after activating EMS for dyspnea. He is currently on an oxygen face mask and was administered one nebulized treatment of a β2-agonist by the paramedics. His initial vitals include an RR of 16 breaths per minute with an oxygen saturation of 96% on room air. The patient appears to be in mild distress with some intercostal retractions. Upon chest auscultation, there are minimal wheezes localized over bilateral lower lung fields. The patient's symptoms completely resolve after two more nebulizer treatments. Which of the following medications, in addition to a rescue β2-agonist inhaler, should be prescribed for outpatient use?
Corticosteroids
A 22-year-old college student went to the health clinic complaining of a fever over the last 5 days, fatigue, myalgias, and a bout of vomiting and diarrhea. The clinic doctor diagnosed him with acute gastroenteritis and told him to drink more fluids. Three days later, the student presents to the ED complaining of substernal chest pain that is constant. He also feels short of breath. His temperature is 100.9°F, HR is 119 beats per minute, BP is 120/75 mm Hg, and RR is 18 breaths per minute. An ECG is performed revealing sinus tachycardia. A chest radiograph is unremarkable. Laboratory tests are normal except for slightly elevated WBCs. Which of the following is the most common cause of this patient's diagnosis?
Coxsackie B virus
A 30-year-old man is brought to the ED by emergency medical service EMS. in respiratory distress. His initial vitals include a HR of 109 beats per minute, a BP of 180/90 mm Hg, and an RR of 20 breaths per minute with an oxygen saturation of 92% on room air. A chest x-ray shows a bilateral diffuse infiltrative process. A subsequent toxicologic screen is positive. Which of the following agents is most likely responsible for this patient's presentation?
Crack cocaine
A 29-year-old tall, thin man presents to the ED after feeling short of breath for 2 days. In the ED, he is in no acute distress. His BP is 115/70 mm Hg, HR is 81 beats per minute, RR is 16 breaths per minute, and oxygen saturation is 98% on room air. Cardiac, lung, and abdominal examinations are normal. An ECG reveals sinus rhythm at a rate of 79. A chest radiograph shows a small right-sided less than 10% of the hemithorax. spontaneous pneumothorax. A repeat chest x-ray 6 hours later reveals a decreased pneumothorax. Which of the following is the most appropriate next step in management?
Discharge the patient with follow-up in 24 hours
An 81-year-old woman presents to the ED with acute onset of shortness of breath just before arrival. She refuses to answer questions for the interview, but repeatedly states that she is feeling short of breath. Her initial vitals include a HR of 89 beats per minute, a BP of 168/76 mm Hg, and an RR of 18 breaths per minute with an oxygen saturation of 89% on room air. A portable chest x-ray appears normal. Her physical examination is unremarkable, except for a systolic ejection murmur. Intravenous IV. access is successfully obtained. After placing the patient on oxygen and a monitor, which of the following should be performed first?
ECG
A 72-year-old man presents to the ED with worsening dyspnea. His initial vitals include a HR of 93 beats per minute, BP of 110/50 mm Hg, and RR of 20 breaths per minute with an oxygen saturation of 88% on room air. The patient appears thin and anxious. He is using accessory muscles to breathe. Despite distant breath sounds, you hear end-expiratory rhonchi and a prolonged expiratory phase. An ECG shows peaked P waves in leads II, III, and aVF. Given this patient's history and physical examination, which of the following conditions does this patient most likely have?
Emphysema
A 42-year-old man found vomiting in the street is brought to the ED by emergency medical services EMS.. He has a known history of alcohol abuse with multiple presentations for intoxication. Today, the patient complains of acute onset, persistent chest pain associated with dysphagia, and pain upon flexing his neck. His BP is 115/70 mm Hg, HR is 101 beats per minute, RR is 18 breaths per minute, and oxygen saturation is 97% on room air. As you listen to his heart, you hear a crunching sounD. His abdomen is soft with mild epigastric tenderness. The ECG is sinus tachycardia without ST-T-wave abnormalities. On chest x-ray, you note lateral displacement of the left mediastinal pleural. What is the most likely diagnosis?
Esophageal perforation
A 65-year-old retired banker who spends the summer on Nantucket Island off the Massachusetts coast returned to his home in Boston early in September. He noted the gradual onset of a febrile illness with chills, sweats, myalgias, and yellow eyes. His doctor palpated the spleen and noted a macrocytic anemia, hyperbilirubinemia, and a high serum level of lactic dehydrogenase on laboratory examination. Which of the following would be the most helpful diagnostic procedure at this point?
Examination of erythrocytes on blood film
An 82-year-old woman becomes acutely short of breath while at rest on the rehabilitation unit. She is brought into the ED with an oxygen saturation of 86% on room air and in acute respiratory distress. Her initial ECG is within normal limits and unchanged from a recent previous examination. Her initial chest x-ray is also negativE. Upon chest auscultation, there are equal bilateral breath sounds with some scattered rhonchi. Her nurse tells you that 2 days ago she underwent internal fixation of a right-femur fracture and has been on anticoagulant therapy. Given the history and presentation of this patient, what is the most likely etiology of her symptoms?
Fat embolism
A 38-year-old woman has undergone allogeneic bone marrow transplantation for acute myelogenous leukemia in second remission from a matched unrelated donor; she now develops pneumonia proven to be due to cytomegalovirus. The patient is placed on ganciclovir, but the pneumonia progresses. Which of the following drugs may potentially be effective in this situation?
Foscarnet
A 71-year-old man is playing cards with some friends when he starts to feel a pain in the left side of his chest. His fingers in the left hand become numb and he feels short of breath. His wife calls the ambulance and he is brought to the hospital. In the ED, an ECG is performed. Which of the following best describes the order of ECG changes seen in an MI?
Hyperacute T wave, ST-segment elevation, Q wave
A 29-year-old man is brought to the ED by EMS for a syncopal episode that occurred during a basketball game. A friend states that the patient just dropped to the ground shortly after scoring a basket on a fast-break. On examination, you note a prominent systolic ejection murmur along the left sternal border and at the apex. An ECG reveals left ventricular hypertrophy, left atrial enlargement, and septal Q waves. You suspect the diagnosis and ask the patient to perform the Valsalva maneuver while you auscultate his heart. Which of the following is most likely to occur to the intensity of the murmur with this maneuver?
Increase
A 65-year-old Greek woman visiting her children in New York City complains of upper abdominal pain. The patient is brought to the family physician, who notices icteric sclera and a mass in the right upper quadrant. CT reveals a 10-cm multiloculated cyst with mural calcification that is compressing the common bile duct. Which of the following statements is correct concerning this clinical situation?
Infection was probably caused by exposure to infected dogs.
A 73-year-old previously healthy man is hospitalized because of the acute onset of dysuria, urinary frequency, fever, and shaking chills. His temperature is 39.5 C or 103.1 F., blood pressure is 100/60 mmHg, pulse is 140 beats per minute, and respiratory rate is 30 breaths per minute. Which of the following interventions would be the most important in the treatment of this acute illness?
Initiation of antibiotic therapy
A 26-year-old woman presents to the ED with an acute onset of dyspnea after falling down a few steps. The patient denies any loss of consciousness and reports feeling short of breath. Her initial chest x-ray appears normal; however she continues to be symptomatic with stable vital signs. Which of the following procedures should be performed next?
Inspiratory and expiratory chest radiographs
A 54-year-old undomiciled woman presents to the ED with severe cough, general malaise, and subjective fevers for the last week. She also describes coughing up "chicken livers" during this time and reports that her symptoms are getting progressively worse. Her initial vitals include a HR of 100 beats per minute, a BP of 145/66 mm Hg, temperature of 99.9 °F, and an RR of 16 breaths per minute with an oxygen saturation of 95% on room air. She states that she has a history of alcohol abuse, but denies taking any medications or illicit drugs. A chest radiograph shows a lobar pneumonia. Given this patient's clinical presentation, which of the following is this patient at most risk for contracting?
Klebsiella pneumoniae
As you evaluate a patient with shortness of breath, you appreciate decreased breath sounds at the left-lung base. You suspect the patient has a small pleural effusion. Which of the following views of the chest is this small pleural effusion most likely to be detected?
Lateral decubitus left-side down
A 67-year-old man is brought to the ED in respiratory distress. His initial vitals include a HR of 112 beats per minute, a BP of 145/88 mm Hg, and an RR of 18 breaths per minute with an oxygen saturation of 92% on room air. He is also febrile at 102°F. After obtaining IV access, placing the patient on a monitor, and administering oxygen via nasal cannula, a chest radiograph is performed and shows patchy alveolar infiltrates with consolidation in the lower lobes. On review of systems, the patient tells you that he had five to six watery bowel movements a day for the last 2 days with a few bouts of emesis. Which of the following infectious etiologies is most likely responsible for the patient's presentation?
Legionella pneumophila
A 55-year-old woman with a past medical history of diabetes walks into the emergency department ED stating that her tongue and lips feel like they are swollen. During the history, she tells you that her doctor just started her on a new blood pressure BP medication. Her only other medication is a baby aspirin. Her vitals at triage are: BP 130/70 mm Hg, heart rate HR 85 beats per minute, respiratory rate RR 16 breaths per minute, oxygen saturation 99% on room air, and temperature 98.7°F. On physical examination, you detect mild lip and tongue swelling. Over the next hour, you notice that not only are her tongue and lips getting more swollen, but her face is starting to swell, too. What is the most likely inciting agent?
Lisinopril
Four months after having undergone a siblingdonor renal allograft, a 38-year-old man is has done well and has had no evidence of graft rejection or major problems stemming from his chronic immunosuppressive therapy cyclosporine and prednisone. He now develops a fever to 39 C or 102 F., headache, and a stiff neck. MRI of the brain with gadolinium enhancement reveals no abnormalities. The most likely cause of the patient's current clinical problem is infection with
Listeria monocytogenes
A 58-year-old man presents to the ED with progressive dyspnea over the course of 1 week. Upon arrival, he is able to speak in full sentences and states that he stopped taking all of his medications recently. Initial vitals include a HR of 92 beats per minute, a BP of 180/100 mm Hg, and an RR of 16 breaths per minute with an oxygen saturation of 94% on room air. Upon physical examination, the patient has bibasilar crackles, jugular venous distention, and pedal edema. Which of the following medication regimens was the patient most likely on?
Loop diuretic, β-blocker, and angiotensin-converting enzyme ACE inhibitor
A 79-year-old man was being commemorated at an awards dinner for his 50 years of service at the local bank. While eating a steak dinner, he felt food get stuck in his stomach. He drank a glass of water, but shortly thereafter vomited the water up. He is a bit anxious and decides to come to the ED for further evaluation. His BP is 155/70 mm Hg, HR is 98 beats per minute, RR is 18 breaths per minute, and oxygen saturation is 99% on room air. What is the most common area for an esophageal foreign body to lodge in an adult?
Lower esophageal sphincter
A 40-year-old Canadian who operates a tropical fish store sees his physician because of a nonhealing ulcer on his left arm. He is afebrile and gives no history of night sweats, weight loss, or other constitutional symptoms. Biopsy of the lesion shows granulomatous inflammation and rare acid-fast organisms. A tuberculin test is negative. This man most likely has an infection caused by
M. marinum
A 47-year-old man with a history of hypertension presents to the ED complaining of continuous left-sided chest pain that began while snorting cocaine 1 hour ago. The patient states he never experienced chest pain in the past when using cocaine His BP is 170/90 mm Hg, HR is 101 beats per minute, RR is 18 breaths per minute, and oxygen saturation is 98% on room air. The patient states that the only medication he takes is alprazolam to "calm his nerves." Which of the following medications is contraindicated in this patient?
Metoprolol
A 22-year-old woman is brought to the ED by paramedics who state that they found the patient hunched over on a park bench barely breathing. The patient is rousable only to painful stimuli. Her initial vitals include a HR of 78 beats per minute, a BP of 125/58 mm Hg, and a respiratory rate of 6 breaths per minute with an oxygen saturation of 94% on 2-L nasal cannula. Upon physical examination, the patient has clear breath sounds bilaterally and no signs of trauma. Her pupils are 2 mm bilaterally and reactive to light. Which of the following agents may be used to restore this patient's respirations?
Naloxone
An 18-year-old sexually active woman from the innercity presents with fever, pleuritic pain of the right upper quadrant, and lower abdominal pain. Pelvic examination reveals mucopurulent cervicitis and tenderness after the production of cervical motion. The right upper quadrant, uterine fundus, and adnexa are slightly tender. The white blood cell count and erythrocyte sedimentation rate are elevated, but the results of the remainder of the laboratory examination, including liver function tests, are normal. Which of the following agents is the most likely cause of this clinical syndrome?
Neisseria gonorrhoeae
A 55-year-old man presents to the ED at 2:00 AM with left-sided chest pain that radiates down his left arm. He takes a β-blocker for hypertension, a proton-pump inhibitor for gastroesophageal reflux disease, and an antilipid agent for high cholesterol. He also took sildenafil the previous night for erectile dysfunction. His BP is 130/70 mm Hg and HR is 77 beats per minute. Which of the following medication is contraindicated in this patient?
Nitroglycerin
A 61-year-old woman with a history of congestive heart failure CHF. is at a family picnic when she starts complaining of shortness of breath. Her daughter brings her to the ED where she is found to have an oxygen saturation of 85% on room air with rales halfway up both of her lung fields. Her BP is 185/90 mm Hg and pulse rate is 101 beats per minute. On examination, her jugular venous pressure JVP is 6 cm above the sternal angle. There is lower extremity pitting edema. Which of the following is the most appropriate first-line medication to lower cardiac preload?
Nitroglycerin
A 76-year-old man presents to the ED in acute respiratory distress, gasping for breath while on face mask. Paramedics state that he was found on a bench outside of his apartment in respiratory distress. Initial vitals include a HR of 90 beats per minute, a BP of 170/90 mm Hg, and an RR of 33 breaths per minute with an oxygen saturation of 90%. Upon physical examination, the patient is coughing up pink, frothy sputum, has rales two-thirds of the way up both lung fields, and has pitting edema of his lower extremities. A chest radiograph reveals bilateral perihilar infiltrates, an enlarged cardiac silhouette, and a small right-sided pleural effusion. After obtaining IV access and placing the patient on a monitor, which of the following medical interventions is most appropriate?
Nitroglycerin and a loop diuretic
A 32-year-old woman presents to the ED with a persistent fever of 101°F over the last 3 days. The patient states that she used to work as a convenience store clerk but was fired 2 weeks ago. Since then, she has been using drugs intravenously daily. Cardiac examination reveals a heart murmur. Her abdomen is soft and nontender with an enlarged spleen. Chest radiograph reveals multiple patchy infiltrates in both lung fields. Laboratory results reveal white blood cells WBC 14,000/μL with 91% neutrophils, hematocrit 33%, and platelets 250/μL. An ECG reveals sinus rhythm with first-degree heart block. Which of the following is the most appropriate next step in management?
Obtain four sets of blood cultures, order a transthoracic echocardiogram TTE and start antibiotic treatment.
A 50-year-old woman emigrated from El Salvador 10 years ago and currently resides in Washington, DC. She complains of shortness of breath. Chest x-ray reveals biventricular cardiac enlargement. An echocardiographic study shows biventricular enlargement, thin ventricular walls, and an apical aneurysm. The patient has no history of alcohol abuse, thyroid disease, risk factors for atherosclerotic heart disease, or family history of hemochromatosis. In considering a potential etiology for the patient's current problem, which of the following statements is correct?
Other manifestations of infection could include involvement of the gastrointestinal tract.
A 42-year-old man underwent allogeneic bone marrow transplantation from an unrelated donor for acute myeloid leukemia in second remission. He develops hepatomegaly and fever 3 months after the infusion of the allogeneic cells. Radiographic imaging of the abdomen reveals extensive intraabdominal lymphadenopathy as well as an enlarged liver, which appears to be diffusely infiltrated. There is no ascites noted. Which of the following is the likely mechanism for the patient's current deterioration?
Overgrowth of EBV-infected lymphocytes
A 30-year-old obese woman with no significant past medical history presents to the ED complaining of shortness of breath and coughing up blood-streaked sputum. The patient states that she traveled to Moscow a month ago. Upon returning to the United States, the patient developed a persistent cough associated with dyspna. She was seen by a pulmonologist, who diagnosed her with bronchitis and prescribed an inhaler. However, over the following weeks, the patient's symptoms worsened, and she developed pleuritic chest pain. In the ED, she lets you know that she smokes half a pack per day. Her vitals include a temperature of 99°F, BP of 105/65 mm Hg, HR of 124 beats per minute, RR of 22 breaths per minute, and an oxygen saturation of 94% on room air. Physical examination is noncontributory, except for rales at the left-mid lung. Her ECG reveals sinus tachycardia with large R waves in V1 to V3 and inverted T waves. Given this patient's history and presentation, what is the most likely etiology of her symptoms?
PE
A 55-year-old man presents to the ED with chest pain and shortness of breath. His BP is 170/80 mm Hg, HR is 89 beats per minute, and oxygen saturation is 90% on room air. Physical examination reveals crackles midway up both lung fields and a new holosystolic murmur that is loudest at the apex and radiates to the left axilla. ECG reveals ST elevations in the inferior leads. Chest radiograph shows pulmonary edema with a normalsized cardiac silhouette. Which of the following is the most likely cause of the cardiac murmur?
Papillary muscle rupture
An 18-year-old man pictured in Plate F presents because of unsightly facial inflammation. Which of the following statements is correct?
Patients on systemic retinoic acid may experience very dry skin and hypertriglyceridemia
A 49-year-old woman presents to the ED with difficulty breathing after a morning jog. Her initial vitals include a HR of 60 beats per minute, a BP of 120/55 mm Hg, and an RR of 20 breaths per minute with an oxygen saturation of 94% on room air. Upon physical examination, the patient appears to be in mild distress with audible wheezing. She is able to speak in partial sentences and states that she occasionally uses an inhaler. Given this patient's history and physical examination, which of the following measures should be taken next?
Peak expiratory flow
While discussing a case presentation with a medical student, a nearby patient who just returned from getting an ankle radiograph done yells out in pain. You walk over to him and ask what is wrong. He states that since returning from the radiology suite, his automatic implantable cardioverter defibrillator AICD. is discharging. You hook him up to the monitor and note that his rhythm is sinus. You observe a third shock while the patient is in sinus rhythm. Which of the following is the most appropriate next step in management?
Place a magnet over the AICD generator to inactivate it and thereby prevent further shocks.
A 45-year-old woman presents to the ED immediately after landing at the airport from a transatlantic flight. She states that a few moments after landing she felt short of breath and felt pain in her chest when she took a deep breath. Her only medications are oral contraceptive pills and levothyroxine. She is a social drinker and smokes cigarettes occasionally. Her BP is 130/75 mm Hg, HR is 98 beats per minute, temperature is 98.9F, RR is 20 breaths per minute, and oxygen saturation is 97% on room air. You send her for a duplex ultrasound of her legs, which is positive for deep vein thrombosis. What is the most appropriate management for this patient?
Place patient on a monitor, provide supplemental oxygen, and administer unfractionated heparin.
A 59-year-old man presents to the emergency department ED complaining of new onset chest pain that radiates to his left arm. He has a history of hypertension, hypercholesterolemia, and a 20-pack-year smoking history. His electrocardiogram ECG. is remarkable for T-wave inversions in the lateral leads. Which of the following is the most appropriate next step in management?
Place the patient on a cardiac monitor, administer oxygen, and give aspirin.
An 81-year-old diabetic woman with a history of atrial fibrillation is transferred to your emergency department ED from the local nursing home. The note from the facility states that the patient is complaining of abdominal pain, having already vomited once. Her vital signs in the ED are temperature 100.1°F, blood pressure BP 105/75 mm Hg, heart rate HR. 95 beats per minute, and respiratory rate RR 18 breaths per minute. You examine the patient and focus on her abdomen. Considering that the patient has not stopped moaning in pain since arriving to the ED, you are surprised to find that her abdomen is soft on palpation. You decide to order an abdominal radiographic series. Which of the findings on plain abdominal film is strongly suggestive of mesenteric infarction?
Pneumatosis intestinalis
A 32-year-old woman presents to the ED with a 1-month history of general malaise, mild cough, and subjective fevers. She states that she is human immunodeficiency virus HIV. positive and her last CD4 count, 6 months ago, was 220. She is not on antiretroviral therapy or any other medications. Initial vitals include a HR of 88 beats per minute, a BP of 130/60 mm Hg, and an RR of 12 breaths per minute with an oxygen saturation of 91% on room air. Her chest radiograph shows bilateral diffuse interstitial infiltrates. Subsequent laboratory tests are unremarkable except for an elevated lactate dehydrogenase level. Given this patient's history and physical examination, which of the following is the most likely organism responsible for her clinical presentation?
Pneumocystis jiroveci
A 59-year-old man presents to the ED with left-sided chest pain and shortness of breath that began 2 hours prior to arrival. He states the pain is pressure-like and radiates down his left arm. He is diaphoretic. His BP is 160/80 mm Hg, HR 86 beats per minute, and RR 15 breaths per minute. ECG reveals 2-mm ST-segment elevation in leads I, aVL, V3 to V6. Which of the following is an absolute contraindication to receiving thrombolytic therapy?
Previous hemorrhagic stroke
A 60-year-old insulin-dependent man with diabetes mellitus has had purulent drainage from his left ear for 1 week. Suddenly, fever, increased pain, and vertigo develop. The most likely causative agent is
Pseudomonas
A 71-year-old woman presents to the ED after a reported mechanical fall 2 days ago. Her initial vitals include a HR of 55 beats per minute, a BP of 110/60 mm Hg, an RR of 14 breaths per minute, and an oxygen saturation of 96% on room air. The patient does not appear to be taking deep breaths. Her physical examination is significant for decreased breath sounds bilaterally and tenderness to palpation along the right side of her chest. After initial stabilization, which of the following is the diagnostic test of choice for this patient's condition?
Rib radiographs
A 25-year-old homosexual man presents with a diffuse maculopapular rash over his trunk, head, neck, palms, and soles. Generalized lymphadenopathy is also present. He has a history of 4 weeks of anal pain. Which of the following tests is likely to identify the etiologic agent?
Serum rapid plasma reagin RPR.
A 68-year-old woman with recently diagnosed uterine cancer is brought to the ED by her daughter. The patient complains of acute onset right-sided chest pain that is sharp in character and worse with inspiration. Her BP is 135/85 mm Hg, HR 107 beats per minute, RR 20 breaths per minute, and oxygen saturation 97% on room air. Physical examination reveals a swollen and tender right calf. ECG is sinus tachycardia. Which of the following is the most appropriate next step in management?
Start heparin therapy prior to diagnostic study
A 46-year-old alcoholic man presents to the ED with cough, fever, and rigors for 2 days. He describes his sputum as rust-colored. His vital signs are: temperature 101.1 ˚F, HR 94, BP 125/75 mm Hg, RR 20, and pulse oxygen of 97% on room air. Auscultation reveals crackles in the left-lower lobe. Chest radiograph is significant for a left-lower lobar infiltrate. Which of the following organism is the most common cause of community acquired bacterial pneumonia?
Streptococcus pneumoniae
A 35-year-old man is seen 6 months after a cadaveric renal allograft. The patient has been on azathioprine and prednisone since that procedure. He has felt poorly for the past week with fever to 38.6 C or 101.5 F, anorexia, and a cough productive of thick sputum. Chest x-ray reveals a left lower lobe 5 cm. nodule with central cavitation. Examination of the sputum reveals long, crooked, branching, beaded gram-positive filaments. The most appropriate initial therapy would include the administration of which of the following antibiotics?
Sulfisoxazole
A 67-year-old woman is brought to the ED by paramedics complaining of dyspnea, fatigue, and palpitations. Her BP is 80/50 mm Hg, heart is 139 beats per minute, and RR is 20 breaths per minute. Her skin is cool and she is diaphoretic. Her lung examination reveals bilateral crackles and she is beginning to have chest pain. Her ECG shows a narrow complex irregular rhythm with a rate in the 140s. Which of the following is the most appropriate immediate treatment for this patient?
Synchronized cardioversion
A 36-year-old woman presents to the ED with sudden onset of leftsided chest pain and mild shortness of breath that began the night before. She was able to fall asleep without difficulty but woke up in the morning with persistent pain that is worsened upon taking a deep breath. She walked up the stairs at home and became very short of breath, which made her come to the ED. Two weeks ago, she took a 7-hour flight from Europe and since then has left-sided calf pain and swelling. What is the most common ECG finding for this patient's presentation?
Tachycardia or nonspecific ST-T-wave changes
A 28-year-old Egyptian farmer presents with left flank pain. Ultrasonography reveals enlargement of the left ureter and hydronephrosis of the left kidney. Cystoscopy reveals a mass extending from the left ureter into the bladder. Parasitic ova 150 by 50 mm are noted in the urine and in a biopsy of the ureteral mass. Which of the following statements is correct?
The patient is suffering from schistosomiasis.
A 32-year-old firefighter presents to the ED in acute respiratory distress. He was taken to the ED shortly after extinguishing a large fire in a warehouse. His initial vitals include a HR of 90 beats per minute, a BP of 120/55 mm Hg, and an RR of 18 breaths per minute with an oxygen saturation of 98% on 2-L nasal cannula. An ECG shows a first-degree heart block. Upon physical examination, there are diffuse rhonchi bilaterally. The patient is covered in soot and the hairs in his nares are singed. Given this clinical presentation, which of the following may be responsible for this patient's respiratory distress?
Thermal burns
A 26-year-old man from Cape Cod sees his physician because of a 3-week history of an expanding, slightly burning ring of redness as shown in Plate C that first surrounded a red papule on the posterior neck. He complains of headaches, generalized muscle aches, anorexia, and malaise. On examination, he is noted to be febrile [38.3 C or 101 F.]; his rash is slightly raised and slightly tender and displays central clearing but no scaling, even after vigorous scraping. Which of the following vectors has been strongly associated with the type of rash described above?
Tick
A 65-year-old man with a history of chronic hypertension presents to the ED with sudden-onset tearing chest pain that radiates to his jaw. His BP is 205/110 mm Hg, HR is 90 beats per minute, RR is 20 breaths per minute, and oxygen saturation is 97% on room air. He appears apprehensive. On cardiac examination you hear a diastolic murmur at the right sternal border. A chest x-ray reveals a widened mediastinum. Which of the following is the preferred study of choice to diagnose this patient's condition?
Transesophageal echocardiography TEE.
A 61-year-old woman with a history of diabetes and hypertension is brought to the ED by her daughter. The patient states that she started feeling short of breath approximately 12 hours ago and then noticed a tingling sensation in the middle of her chest and became diaphoretic. An ECG reveals ST-depression in leads II, III, and aVF. You believe that the patient had a non-ST-elevation MI. Which of the following cardiac markers begins to rise within 3 to 6 hours of chest pain onset, peaks at 12 to 24 hours, and returns to baseline in 7 to 10 days?
Troponin I
While playing a match of tennis, a 56-year-old man with a medical history significant only for acid reflux disease starts to feel substernal chest pain that radiates into his left arm and shortness of breath. His pain feels better after drinking antacid, but since it is not completely resolved, his partner calls 911. Upon arrival, EMS administers aspirin and sublingual nitroglycerin. After 20 minutes, the man's symptoms resolve. He is brought to the ED for further evaluation where his ECG shows sinus rhythm without any ischemic abnormalities. You order a chest radiograph and send his blood work to the laboratory for analysis. Which of the following statements regarding the diagnosis of acute MI is most accurate?
Troponin may not reach peak levels for at least 12 hours.
As you palpate the right upper quadrant RUQ of a 38-year-old woman's abdomen, you notice that she stops her inspiration for a brief moment. During the history, the patient states that over the last 2 days she gets pain in her RUQ that radiates to her back shortly after eating. Her vitals include a temperature of 100.4°F, HR of 95 beats per minute, BP of 130/75 mm Hg, RR of 16 breaths per minute. What is the initial diagnostic modality of choice for this disorder?
Ultrasonography
A 22-year-old man presents to the ED with a history consistent with an acute MI. His ECG reveals ST elevations and his cardiac biomarkers are positive. He has been smoking half a pack of cigarettes per day for the last 3 months. He drinks alcohol when hanging out with his friends. His grandfather died of a heart attack at 80 years of age. The patient does not have hypertension or diabetes mellitus and takes no prescription medications. A recent cholesterol check revealed normal levels of total cholesterol, lowdensity lipoprotein LDL, and high-density lipoprotein HDL.Which of the following is the most likely explanation for his presentation?
Undisclosed cocaine use
A 55-year-old man with hypertension and a one-pack-per-day smoking history presents to the ED complaining of three episodes of severe heavy chest pain this morning that radiated to his left shoulder. In the past, he experienced chest discomfort after walking 20 minutes that resolved with rest. The episodes of chest pain this morning occurred while he was reading the newspaper. His BP is 155/80 mm Hg, HR 76 beats per minute, RR 15 breaths per minute. He does not have chest pain in the ED. An ECG reveals sinus rhythm with a rate of 72. A troponin I is negative. Which of the following best describes this patient's diagnosis?
Unstable angina
A husband and wife present to the ED with 1 day of subjective fever, vomiting, watery diarrhea, and abdominal cramps. They were at a restaurant a day before for dinner and both ate the seafood special, which consisted of raw shellfish. In the ED, they are both tachycardic with temperatures of 99.8°F and 99.6°F for him and her, respectively. Which of the following is responsible for the majority of acute episodes of diarrhea?
Viruses
A 21-year-old woman presents to the ED complaining of lightheadedness. Her symptoms appeared 45 minutes ago. She has no other symptoms and is not on any medications. She has a medical history of mitral valve prolapse. Her HR is 170 beats per minute and BP is 105/55 mm Hg. Physical examination is unremarkable. After administering the appropriate medication, her HR slows down and her symptoms resolve. You repeat a 12-lead ECG that shows a rate of 89 beats per minute with a regular rhythm. The PR interval measures 100 msec and there is a slurred upstroke of the QRS complex. Based on this information, which of the following is the most likely diagnosis?
Wolff-Parkinson-White WPW. syndrome
A 23-year-old woman who will be doing Peace Corps work in Bolivia has had all her routine immunizations and has been vaccinated against hepatitis A and B. Which of the following is the most reasonable recommendation for prophylaxis against common infectious diseases in the country of her destination?
Yellow fever vaccine plus mefloquine
A 62-year-old gardener who has chronic lymphocytic leukemia develops lymphangitis and a painless, nodular lesion on his wrist. Subsequently, he becomes severely ill with cavitary right-upper-lobe pneumonia; Sporothrix schenckii is isolateD. He should be treated with
amphotericin B
A 10-year-old boy is seen in a rural Arizona clinic because of prostration, fever of 40 C or 104 F., and severe headache. Examination is negative for rash, stiff neck, joint tenderness, and chest and abdominal abnormalities. However, several tender, enlarged lymph nodes are palpated in the left axilla, which is very edematous. The test most likely to be of greatest help in the immediate management of this boy would be
aspiration and Gram stains of an axillary lymph node
A 35-year-old patient undergoing initial therapy for acute myeloid leukemia has tolerated the chemotherapy well. However, 6 days after the initiation of chemotherapy and 10 days after the insertion of an indwelling transthoracic intravenous device Hickman catheter., he develops a fever. Examination is negative except for erythema and tenderness at the insertion site and along the subcutaneous tunnel. Blood cultures and chest x-ray are negative. The most appropriate course of action at this point is to
remove the line
A 10-year-old boy presents with an abnormal appearing face. The boy lives in Rhode Island and has been playing outside a good deal this summer. He has been feeling poorly for a week with complaints of muscle aches and headache. His mother has noticed that her son has a low-grade fever and an oval rash on the back measuring about 10 cm in diameter. Physical examination reveals evidence of the oral erythema on the posterior thorax and evidence of right facial droop. Routine laboratory studies are unremarkable. A lumbar puncture reveals an opening pressure of 80 mmHg, total protein of 0.46 g/L 46 mg/dL, and glucose of 5.0 mmol/L 90 mg/dL with 10 white cells, all of which are lymphocytes. The most specific diagnostic study would be
blood culture for Borrelia
A 35-year-old Samoan presents with recurrent fever, headache, photophobia, and painful lymphangitis in the left leg. The best way to diagnose filariasis caused by Wuchereria bancrofti is
demonstration of microfilariae in blood taken between 9 P.M. and 2 A. M.
For the past 2 days, a 24-year-old woman has had fever and pain in the left wrist, right ankle, and left knee. Nine painful skin lesions are present on the distal extremities, predominantly about the joints as shown in Plate B. The most likely diagnosis is
gonococcemia
A 35-year-old man with a history of abrasion of the right hand presents with acute pain in the right shoulder. His physical examination reveals a temperature of 39.5 C or 103 F. and rigor, and he appears to be quite ill. There is dusky erythema and edema of the right shoulder and right upper extremity with marked tenderness. Within a few hours the patient is unresponsive and is found to be hypotensive. Laboratory evaluation reveals an elevated serum, creatinine, thrombocytopenia, and elevated hepatic transaminases. The soft tissues in the left upper extremity have begun to necrose. Blood culture, obtained at the time of initial presentation, has already turned positive. The organism that is most likely to be responsible for this clinical syndrome is
group A streptococci
A 22-year-old gay man from New Orleans presents with a 2-week history of fever, anorexia, and progressive diffuse lymphadenopathy. Physical findings reveal an emaciated young man who has several tongue ulcers. Hepatomegaly is noted. Laboratory examination reveals pancytopenia, an elevated alkaline phosphatase, and hyperkalemia. A chest radiograph reveals a miliary pattern of diffuse infiltration. A tongue biopsy reveals the presence of hyphae that bear both large and small spores. The correct diagnosis is
histoplasmosis
A 53-year-old black man who received a renal allograft 7 months ago is now receiving azathioprine and prednisone. He presents to the hospital 1 week after developing fever, night sweats, and anorexia. He also complains of coughing and chest pain. Chest film reveals biapical infiltrates with an apparent cavity in the left upper lobe. Auramine-rhodamine staining reveals the presence of microorganisms consistent with tubercle bacilli. The patient's creatinine is 106 mol/L 1.2 mg/dL. The treatment of choice at this time would be
isoniazid, rifampin, pyrazinamide, and ethambutol
A 60-year-old man from North Carolina presents with a fever and progressive confusion. His wife reports that he experienced 1 week of fever, headache, and malaise before the more profound neurologic condition occurred. Just prior to the presentation at the hospital he had a generalized seizure. The IgM capture enzyme immunoassay of the patient's CSF was positive for the eastern equine encephalitis virus. An MRI would most likely reveal
lesions in the basal ganglia
A 24-year-old man is concerned because of the appearance of several light brown spots on his trunk Plate D. The lesions limited to the chest, back, abdomen, and upper arms. are flat and sharply marginated and have a fine scale that is easily scraped off. The most appropriate diagnostic study is
microscopic examination of potassium hydroxide treated scrapings
A 67-year-old man presents with a history of headache for 5 days and 2 days of swelling of the right part of the forehead and right eye see Plate E. A Tzanck preparation of the lesion reveals multinucleate giant cells on Giemsa stain. The patient was admitted to the hospital and begun on intravenous acyclovir. The most important next step would be
ophthalmologic consultation
A 70-year-old man with a history of heavy smoking and moderately severe chronic obstructive pulmonary disease COPD has been feeling poorly. He reports cough, chills, pleuritic chest pain, and low-grade fever. Chest xray reveals a small dense infiltrate in the right lower lobe. Gram's stain of the patient's sputum reveals numerous gram-negative cocci, many of which occur in pairs. The most appropriate therapy would be
penicillin/clavulanic acid
A 35-year-old intravenous drug abuser with HIV infection is being managed with combination antiretroviral therapy. The patient was doing well on his current medical regimen, which consists of lamivudine and saquinavir as well as methodone, TMP/SMZ, and fluconazole. Although he has been stable clinically of late, efavirenz has recently been added to his medical regimen in an attempt to decrease a rising viral load. After 1 week of therapy with efavirenz, the patient develops abdominal cramps, malaise, sweats, and anxiety. The most likely reason for the patient's symptoms is
reduced plasma methadone concentration.
A 43-year-old nurse whose job requires frequent hand washing has noted a small erosive skin lesion between the third interdigital web of the right hand Plate A. The best therapy for this condition would be
topical clotrimazole
A 22-year-old female intravenous drug abuser and admitted prostitute is seen in the emergency room with a complaint of vaginal discharge. She is afebrile and has no complaint or physical findings except that she has yellow mucopurulent discharge emanating from the cervical os. Gram's stain of the discharge reveals polymorphonuclear leukocytes, but organisms are not seen. The patient has no primary care doctor. The most appropriate action at this time is to
treat for both chlamydial and gonorrheal infection with cefixime, 400 mg PO, plus azithromycin, 1 g PO
A 25-year-old intravenous drug abuser with fever has blood cultures obtained, and 24 h later a report from the microbiology laboratory indicates the presence of gram-positive cocci in clusters. The identification of the organism and sensitivities are pending. The most appropriate antibiotic choice would be
vancomycin
A 24-year-old woman is brought to the ED after being found on a nearby street hunched over and in mild respiratory distress. Upon arrival, she is tachypneic at 24 breaths per minute with an oxygen saturation of 97% on face mask oxygen administration. Upon physical examination, the patient appears to be in mild distress with supraclavicular retractions. Scattered wheezing is heard throughout bilateral lung fields. Which of the following medications should be administered first?
β2-Agonist nebulizer treatment
