Step 2 NBME Questions

Behcet's disease

*Inflammatory disorder which affects multiple parts of the body. Symptoms -painful mouth sores -painful genital sores -inflammation of parts of the eye -arthritis. *The sores typically last a few days. *Less commonly there may be inflammation of the brain or spinal cord, blood clots, aneurysms, or blindness. Often the symptoms come and go.

How to fix nursemaid's elbow?

1. Hyperpronation 2. Supination with extension, then flexion

An asymptomatic 47-year-old woman comes to the physician for a routine health maintenance examination. She has no history of rheumatic fever. She takes no medications. Her pulse is 70./min. and blood pressure is l50./`60 mm Hg. A grade 2/`6 decrescendo murmur that begins after S2 is heard at the left sternal border. Which ofthe following is the most likely diagnosis? O A) Aortic valve insufficiency O B) Aortic valve stenosis O C) mtral valve regurgitation O D) mitral valve stenosis O E) Tricuspid valve regurgitation

Aortic regurgitation -even though heard at L sternal border -early diastolic -decrescendo All others besides mitral valve stenosis are SYSTOLIC MURMURS

A 25-year-old woman comes to the physician because of shortness of breath, marked malaise, weakness, and fatigue for 4 hours. She felt well until 24 hours ago when she developed muscle soreness after an unusually strenuous physical workout; she took ibuprofen for the pain 1 hour before her symptoms began. She has a history of frequent migraines that have been prevented by taking metoprolol (twice daily) over the past month. Her blood pressure is 100/70 mm Hg. Examination shows facial flushing and mild periorbital edema. Multiple wheezes are heard throughout the lung fields. Avoidance of which of the following substances is most likely to prevent recurrence of a similar episode? A. Acetaminophen B. Aspirin C. Meperidine D. Prednisone E. Propoxyphene

AERD *Avoid aspirin

A 67.year-old African American woman comes to the physician for an annual health maintenance examination. Menopause occurred at the age of 44 years. She has hypothyroidism treated with thyroid replacement therapy. She has smoked one pack of cigarettes daily for 45 years. She is 157 cm (5 ft 2 in) tall and weighs 51 kg (112 Ib): BMI is 21 kgim2. Examination shows no abnormalities. which of the following factors decreases this patient’s risk for osteoporosis? o A) African American race 0 B) Cigarette smoking 0 C) Early menopause 0 D) Thin body habitus 0 E) Thyroid replacement therapy

African american woman has high bone mineral density compared to caucasian and asian women ..comparitively low risk of osteoporosis

32 yo F ER- 2 day hx of vomiting, diarrhea, right sided pelvic pain. LMP was 3 weeks ago. Temp 102.2 F, HR 100, resp 20, BP 120/70. RLQ tenderness with rebound on abd exam with decreased bowel sounds. Pelvic exam shows right adnexal tenderness. Pregnancy test is negative. Labs: Hb 12, leukocyte ct 15,000, segmented neutrophils 80%, bands 10%, lymphocytes 5%, monocytes 5%. U/S shows no adnexal mass. Dx? A. Adnexal torsion B. Appendicites C. Bowel obstruction D. Corpus luteum cyst E. Degenerating leiomyoma uteri F. Ovarian cancer G. Ovarian hyperstimulation syndrome H. Tubo-ovarian abscess I. Urinary tract infection

Appendicitis no history of ovarian mass, LMP3 weeks ago, Mcburneys point, leukocytosis etc

A 77 year old woman is admitted to the hospital because of a 24 hour history of watery diarrhea and nausea. During this period she has vomited four times, has been unable to eat or drink and has had decreased urination. She has not had fever. Two days ago she had visited her grandson, who has similar sx. The pt has htn, type 2 diabetes, chronic renal insufficiency, and hyperlipidemia. Current medications are insulin, HCTZ, atorvastatin, lisinopril and ASA. Temperature is 99.3, pulse is 110/min, respirations are 22/min, and blood pressure is 100/60. Examination shows dry mucous membranes. The abdomen is soft and nontender. The remainder of the exam shows no abnormalities. Lab studies: Hct 42% Serum: Na 132 K 8.2 Cl 99 HC03 18 Urea nitrogen 95 Glucose 199 Creatinine 6.4 ECG shows peaked T waves and a QRS interval of 0.16 msec. Which of the following is the most appropriate initial step in management? A) Administer bicarb B) Administer calcium gluconate C) administer insulin and 50% dextrose in water D) administer sodium polystyrene sulfonate (kayexalate) E) schedule dialysis

CALCIUM GLUCONATE = CARDIOPROTECTIVE! -NOT BICARB!!! mostly for acidemia

A 62-year-old woman with hypertension comes to the physician for a follow-up examination. Her hypertension was well controlled until 1 year ago; during the past year, her blood pressure has ranged between 160/100 mm Hg and 180/120 mm Hg. Treatment with maximal doses of an ACE inhibitor, a diuretic, and a 6-adrenergic blocking agent for 10 months has not controlled her hypertension. She has a 2-year history of increasing leg pain with walking that improves with rest; she is otherwise asymptomatic. Her last menstrual period was 7 years ago. She smoked one to two packs of cigarettes dai ly for 40 years but quit 1 year ago. Her exercise capacity has improved during the past year. She is 152 cm (5 ft) tall and weighs 48 kg (105 lb); BMI is 21 kg/m . Her pulse is 85/min and regular, and blood pressure is 160/100 mm Hg in the right arm, 175/105 mm Hg in the left arm, and 155/90 mm Hg in the right leg. Cardiac examination shows a nondisplaced point of maximal impulse: there is an S4 but no murmurs, heaves, or thrills. Abdominal examination shows no abnormalities. Pulses are 2+ in the upper extremities; the femoral and dorsalis pedis pulses are 1+ bilaterally. Serum studies show a potassium concentration of 4.5 mEq/L urea nitrogen concentration of 20 mg/dL. and creatinine concentration of 1.2 mg/dL Which of the following is the most likely cause of this patient's hypertension? O A) Atherosclerotic renal artery stenosis O B) Coarctation of the aorta O C) Fibromuscular hyperplasia of the renal artery O D) Polycystic kidney disease O E) Primary hyperaldosteronism

Atherosclerotic renal artery stenosis -BP of 155/90 mm Hg in the right leg is also due to atherosclerotic change. -in coarctation BP in leg would b much lower than 155/90 *in coarctation--- pressure in RIGHT arm is more than the left because of back-up!!!

87 yo man with 1 yr h/o of difficulty starting urinary stream and post void dribbling. nocturia. 30 yrs of DM, orthostatic hypotension. lisinopril and glyburide-current meds. BP 140/80 whil supine, 100/60 while standing, large prostate on examination, most appropriate med for pts urinary symptoms? amlodipine doxazocin finasteride metoprolol oxybutinin

BPH -don't use doxazosin because already has orthostatic hypotension, a-blockers would worsen --> FINASTERIDE

a previously healthy 67 year old man has had an ching burning snsation in the distal lower extremities for 3 weeks, the symptoms are exacerbated by walking and relieved by elevation of the feet. The cetatarsalphalangeal joints and ankles are warm swolle, tender and erythematoud. There is clubbing of the fingers and toes. which of the following is the most likely diagnosis? a) bronchogenic carcinoma b) hyperparathyroidism c) hypoparathyroidism d) medullary thyroid carcinoma e) non-hodgkin lymphoma (WRONG)

Bronchogenic carcinoma -Clubbing

A 25-year-old woman comes to the physician because of a 1-month history of severe headaches. During this period, she has missed several days of work because ofthe pain. She has a 10-year history of intermittent headaches that are responsive to treatment with naproxen. She has major depressive disorder treated with fluoxetine. She appears uncomfortable. She is 160 cm (5 ft 3 in) tall and weighs 50 kg (110 lb); BMI is 20 kg/m Funduscopic examination shows bilateral papilledema. The pupils are 5 mm and reactive to light. The remainder ofthe neurologic examination shows no abnormalities. An MRIofthe brain is shown. Which of the following is the most likely cause of these findings? O A) Idiopathic intracranial hypertension o B) Impaired resorption of cerebrospinal fluid (CSF) O C) Infection ofthe CSF O D) Obstruction ofthe ventricular system O E) Overproduction of CSF

CHOROID PLEXUS PAPILLOMA -uncommon, benign (WHO grade I) neuroepithelial intraventricular tumour which can occur in both the paediatric (more common) and adult population. Symptoms -found in fourth ventricle in adults and in the lateral ventricles in the pediatric population. -solid vascular tumour with vivid FROND-LIKE pattern enhancement -In a quarter of cases, speckled calcifications are present.

57 yr old woman with 2 wk progressive jaundice and 11 pound weight loss. She has had dark urine and pale stools during this period. No serious illness and no meds. T 99, pulse 80, and bp 120/80. Exam shows severe jaundice. Gallbladder is palpated in RUQ and urine dipstick is positive for bilirubin. US shows dilated gallbladder and dilated intrahepatic and extrahepatic biliary ducts; there are no calculi. What is the most appropriate next step in diagnosis? -endoscopic US -CT of abdomen -FNA of pancreas -lap choly -surgical exploration of common bile duct

CT abdomen to see if there's pancreatic cancer. -palpable GB Jaundine(directe hyperbilirubinemia...bilirubin in urine) wt loss Hx U/S suggestive of cholestasis.( dilated GB n dilated Intrahepatic n extrahepatic biliary ducts)

A previously healthy 4-year-old boy is brought to the physician because of increasing left ear pain for 2 weeks. His temperature is 38.5°C (101.3°F). Examination of the left ear shows an erythematous, bulging tympanic membrane and an edematous auditory canal with a small amount of mucopurulent discharge. The ear appears to be displaced laterally, and there is moderate tenderness in the area behind the ear. Examination of the right ear shows no abnormalities. A 1-cm, freely mobile, nontender mass is palpated over the left anterior neck. Examination of the pharynx shows no abnormalities. Which of the following is the most appropriate next step in management? A. Monospot test B. Tympanography C. CT scan of the temporal bone D. Hydrocortisone/polymyxin/neomycin ear drops E. Oral amoxicillin therapy

CT scan of temporal bone --> check for MASTOIDITIS!!

a 15 month old girl is brought to the physician because of a 3 month history of poor weight gain and foul-smelling, greasy, loose stools. She was hospitalized for bacterial pneumonia at the age of 1 tear. Her diet consists of cow's milk and table food. She is at the 25th percentile for length and 10th percentile for weight. Hct 32% leukocyte count 11,100 seg 55% lympho 40% mono 5% plt 325,000 Na 140 Cl 100 K 3.8 Hco3 22 BUN 10 glucose 80 Cr 0.4 Total protein 6 albumin 3.6 72-hour fecal fat 1.8g/24h (N a. absence of bowel wall ganglion cells b. absence of small bowel villi c. bowel ischemia d. decrerased bilirubin conjugation e. decreased pancreatic enzyme secretion f. dilation of intestinal lymphtic vessels g. hypertrophy of pyloric sphincter h. increeased cilirunin production i. increased bowel motility j. osmotic diarrhea k. secretory diarrhea

CYSTIC FIBROSIS!!! -decreased pancreatic enzyme secretion!!!

A 15 year old girl is brought to the physician because of a 1 week history of vaginal discharge and 2 day history of sore throat and recurrent candidal infections of the skin and mucous membranes since childhood. She has a 2 year history of type 1 diabetes mellitus and thyroiditis. Medications include insulin and levothyroxine. Exam shows oral candidiasis. Pelvic exam shows to have thick white and budding yeasts. Which of the following is the most likely mechanism of her recurrent candidal infections? A) Autoimmune destruction of thymus B) Blunting of inflammatory response from complement deficiency C) Deficiency of anticandidal antibodies D) Impaired cell-mediated immunity E) Inability of macrophage to present candidal infection

Chronic mucocutaneous candidiasis? -absent in vitro T-cell proliferation in response to Candida antigens

A 33 year old woman comes for follow up examination one week after a pap smear shows a high grade squamous intraeptithelial lesion.examinations shows no abnoramlities.Which of the following is the most accurate next step in the menagment 1.repeat pap smear 2.trichloroaceticacid therapy 3.colposcopic directed biopsy 4.cone biopsy of the cervix 5.cryosurgery of the cervix

Colposcopic directed biopsy!!! *Cone biopsy and LEEP more of treatments *Cone biopsy indications 1. The abnormal tissue cannot be seen with colposcopy but was found in cells collected from a biopsy of the cervical canal, or the abnormal tissue seen with colposcopy extends high into the cervical canal. A cone biopsy is done to remove and examine the abnormal tissue. 2. The abnormal cells found on a Pap test cannot be seen with colposcopy or found in cells collected from a cervical biopsy. The cone biopsy may be used to diagnose the cause of the abnormal cell changes and remove the abnormal tissue at the same time. 3. Cervical cancer is suspected based on Pap test results, colposcopy, and cervical biopsy. A cone biopsy can determine the extent, depth, and severity of the cancerous tissue and can guide treatment decisions.

A 10-month old infant is brought to the emergency department because of laboured breathing for 1 hour. She has cough, coryza and fever for 18 hours. Her temperature is 39°C (102.2°F) , pulse is 120/min, respirations are 54/min, and blood pressure is 82/60 mm Hg. Pulse oximetry shows an oxygen saturation if 92%. Bilateral wheezes and basilar crackles are heard. A) Allergen-induced bronchospasm B) Barotrauma-related alveolar disease C) Cardiac-induced pulmonary edema D) Chemical irritant pneumonitis E) Community acquired viral disease F) Contagiously spread bacterial infection G) Osmotically generated fluid shift H) Toxin-mediated capillary leak

Community-acquired viral disease RSV BRONCHIOLITIS!!! -cough -inflammation of mucus membranes of nose -wheezing

A 15-year-old boy is brought to the physician because of headaches for 3 months. The headaches occur most often in the morning and are associated with vomiting. Over the past month, he also has had increasing visual difficulty. During this period, he has had a 4.5-kg (10-lb) weight gain, and his school performance has declined. He is also concerned that his pubertal development has been slower than his friends. Growth charts are shown. Genital development is Tanner stage 2. Funduscopic examination shows mild papilledema. Which of the following is the most likely diagnosis? A. Adrenal insufficiency B. Craniopharyngioma C. Gonadal dysgenesis D. Medulloblastoma E. Migraines F. Primary hypothyroidism

Craniopharyngioma symptoms: -headaches (occassionally with nausea and vomiting) -hydrocephalus -visual field defects (classical - bitemporal hemianopsia) -growth failure (below age 20) -endocrine dysfunction - obesity, lethargy *Most common pituitary tumor in children Histology - arises from remnants of the Rathke's duct, benign (mostly, however ) Treatment - Surgical resection and endocrine therapy for endocrine disturbances

24 yo M, MVA with head trauma arrives comatose. He is intubated and mechanically ventilated. Vitals: HR 52/min, BP 160/94, temp 96 F. Roving eye movements. Corneal & pupillary reflexes normal. Spontaneous extention of legs and flexion of arms. DTRs are 3+ bilaterally. He is given 80 mL of 0.45% saline & urine output of 900 mL. Babinski +ve bilaterally. Labs: Na+ 147, Glucose 124, osmolality 294, urine specific gravity 1.001. CT scan: subarachnoid hemorrage & contusions. Cause of increased urine output? a. diabetes insipidus b. hypernatremia c. SIADH d. traumatic nephropathy e. DM2

Diabetes insipidus = excessive urine output *SIADH = hypotremia, less urine output!!

A 52-year-old woman comes to the physician because of tremors in her hands for 4 months. She only fills teacups halfway to avoid spilling, and she has difficulty lifting a spoonful of soup to her mouth without spilling it. Her children noticed tremors of her head 5 years ago. She has no history of serious illness and takes no medications. She is 168 cm (5 ft 6 in) tall and weighs 56 kg (123 lb); BMI is 20 kg/m2. Her temperature is 37°C (98.6°F), pulse is 80/min, respirations are 12/min, and blood pressure is 110/70 mm Hg. Examination shows a tremor of the outstretched hands bilaterally; the amplitude of the tremor increases with finger-nose testing. The tremor resolves at rest. Muscle strength and tone are intact, and her gait is normal. Which of the following is the most appropriate pharmacotherapy? A)Carbamazepine B)Diazepam C)Fluoxetine D)Levodopa-carbidopa E)Propranolol

ESSENTIAL TREMOR -worse with sustained posture (outstretched arms), movement, anxiety --> PROPRANOLOL

A 3 month old infant has had tachypnea and tachycardia for 10 days; during this period he has been feeding poorly. A grade 3/6 systolic murmur and a grade 2/6, apical mid-diastolic murmur are heard. An x-ray of the chest shows cardiomegaly with increased pulmonary vascular markings. Echocardiography shows a large ventricular septal defect. Whch of the following is the most likely cause of these symptoms A)Excessive Pulmonary blood flow B) Mitral Valve obstruction C) reduced left ventricular contractibility D) Reduced right ventricular preload E) Right Ventricular pressure overload

Excessive pulmonary blood flow -more mixing of blood --> more goes back into pulmonary circuit -increased pulmonary vascular markings

47 yr woman has lump in breast and mammography shows irregular borders but no calcifications? next step? reexamination FNA mastectomy radiation and chemo

FNA -easier for most MDs -core needle usually needs radiologist's help (but may be better if don't want to seed the rest of breast?) -Mammography is primarily for screening.If it is abnormal, you should try to confirm ur findings, just like u would do colposcopy if you find an abnormal pap smear.Mastectomy and radiation plus chemo seems too agressive for at this stage.

A previously healthy 2 year old girl is brought to the ER department by her parents 60 mins after she had a 2 min episode of generalized shaking. During the episode, she was unresponsive, and her eyes were rolled back in her head. On arrival, she is awake and cooperative. Her temperature is 39.8 deg C (103.6 deg F), pulse is 130, respirations are 12, and blood pressure is 90/70. Exam shows an erythematous, bulging right tympanic membrane. The neck is supple. Neurologic examination shows no focal findings. Serum electrolyte concentrations are within normal limits. Which of the following is the most appropriate next step in management? A) CT scan of the head B) Oral antibiotic therapy C) Mastoidectomy D) IV phenobarbital therapy E) Lumbar puncture

Febrile seizure for otitis media --> oral abx therapy *Meningitis less likely because neck supple

A 22 yr old woman with asthma comes to the physician for a follow up examination. She feels well. She has been treated for six acute episodes of wheezing and nonproductive cought during the past yr, her last episode was 1 month ago. Her symptoms are exacerbated when she is outside during the spring and fall. Current medications include an albuterol inhaler and echinacea. She has smoked one half pack of cigarettes daily for 5yrs and does not drink alcohol. She is employed in a jewelry factory. Her temperature is 37.2C (99F), pulse is 80/min, respirations are 12/min, and BP is 120/80. Examination and an xray of the chest show no abnormalities. In addition to counselling about smoking cessations, which of the following measures is most likely to reduce the frequency of asthma exacerbations? A) Change in work environment B) Desensitization to animal dander C) Fluticasone inhaler therapy D) Haemophilus influenzae type b vaccine E) Influenza vaccine F) 23 valent pneumococcal vaccine

Fluticasone therapy -long-acting steroids to reduce incidence of asthma flare-ups

A 16-year-old girl comes to the physician because of painful genital lesions for 2 days. Over the past 6 months, she has been sexually active with five male partners; she last had sexual intercourse 2 weeks ago. As far as she knows, her sexual partners have not had similar symptoms. Examination shows two 3 x3-mm ulcerated lesions on the anteri or vagi nal vault. She currently has a new boyfri end with whom she has not had sexual i ntercourse and would li ke to know the best way to prevent transmi ssi on of her infection. Which of the following is the most appropriate strategyto prevent transmission? o A) Use of condoms when lesions are present O B) Consistent condom use O C) Acyclovir therapy for the patient far 7 days O D) Penicillin therapy for the patient for 3 weeks O E) Prophylactic acyclovir t

HSV? (vs chanchroid) --> Consistent condom use

A hospitalized 22-year-old woman with acute myelogenous leukemia undergoes evaluation prior to discharge. She has received induction chemotherapy and transfusions via a subcutaneous central venous catheter for the past 4 weeks. Two days ago, results of a complete blood count and bone marrow biopsy showed no abnormalities. Examination shows well-healed skin over the catheter. The remainder of the examination shows no abnormalities. The physician reviews the patient's discharge plan with her and her parents. Which of the following is the most appropriate recommendation to avoid complications related to the catheter? A) Avoiding bathing in a shower or bathtub B) Hand washing with an antibacterial soap prior to contact with the catheter C) Placement of a new sterile dressing at the site of access D) Topical application of mupirocin at the site of access E) Oral penicillin therapy

Hand washing with an antibacterial soap prior to contact with the catheter

47yo man comes to ED 2 hrs after onset of severe neck pain that began while he was lifting a heavy tool at his construction job. The pain is exacerbated when he turns his neck or coughs and now radiates over his right shoulder and arm. He has a 3 year hx of intermittent neck pain that's relieved by ibuprofen use. He is in severe distress. When asked to turn his head, he turns it slowly to avoid pain. Muscle strength is 4/5 in the elbow flexor and wrist extensor muscles on the right. DTRs are decreased in the right biceps and brachioradialis muscles. What's the most likely cause of these findings? a). central cord syndrome b). compression of the lower brachial plexus c). compression of the musculocutaneous nerve d). compression of the upper brachial plexus e). herniated disc at C5-6

Herniated disk at C5-6 A) central cord syndrome they have LL weakness but its more in UL adding to that sensory findings are bilateral & urinary retention. B) Lower brachial plexus dont supply the elbow flexor (mainly biceps ) & there must be sensory as well on C8 & T1. C) Musculocutaneous nerve doesnt supply the wrist extensors (supplied by radial). D) Upper plexus doesnt supply Radial also . E) in herniated Disc , pain will be aggravated by cough or movement , also the dermatomes affected corresponds with the lesion .

A 47 year old man comes to the physician for a follow up exam after being diagnosed with stage 1 hypertension 5 months ago. A 3 month trial of diet modification and exercise failed to control his blood pressure and hydrochlorothiazide therapy was begun. Over the past month, he has felt fatigued. Examination shows no abnormalities. Which of the following is the most likely cause of the patient's symptoms? A) Hyperglycemia B) Hyperlipidemia C) Hypocalcemia D) Hypokalemia E) Hyponatremia

Hypokalemia -body is more sensitive for k metabolism while hyponatremia and hyperglycemia takes some time before being symptomatic. -Moderate hypokalemia (2.5- 3): muscular weakness, myalgia, and muscle cramps

A 27-year-old man comes to the emergency department because of a 12-hour history of vomiting and mild, intermittent, nonradiating abdominal pain. He has passed flatus, and his last bowel movement was today. He underwent exploratory laparotomy secondary to a gunshot wound 6 years ago. His temperature is 37°C (98.6°F), pulse is 102/min, and blood pressure is 120/75 mm Hg. The lungs are clear to auscultation. The abdomen is soft, distended, and nontender. There is no flank tenderness. Bowel sounds are hyperactive. Rectal examination shows no abnormalities; test of the stool for occult blood is negative. His leukocyte count is 6900/mm3. Urinalysis is within normal limits. X-rays of the abdomen show dilated loops of small bowel and air-fluid levels; there is gas in the ascending colon and rectum. Which of the following is the most appropriate next step in management? A)Tap water enema B)Lactulose therapy C)Colonoscopic decompression D)Nasogastric tube decompression E)Exploratory laparotomy

Incomplete SBO -wait to see if worsens/resolves on its own --> Supportive care (NG tube decompression) + observation

23yo man comes to the doctor bc of a 2 day hx of abdominal pain. Initially, the pain was diffuse and colicky, but over the past 24 hrs, it has become sharp and has localized to the RLQ. He has had nausea and vomited 3 times. His last bowel movement was 2 days ago. His temp is 38.1, pulse 95, BP 130/75. Lungs are clear. Heart sounds are normal. Abdominal exam shows RLQ tenderness with guarding. What's the underlying mechanism of the shift in location of this patient's pain? a). arterial occlusion b). inflammation to the parietal peritoneum c). progressive increase in intraluminal pressure d). transmigration of bacteria thru the visceral wall e). visceral perforation

Inflammation to the parietal peritoneum -NOT progressive increase in intraluminal pressure

43 - A 77-year-old woman is brought to the emergency department by paramedics 1 hour after the sudden onset of right-sided weakness and difficulty speaking. Her son found her at home after he became concerned because he did not get his usual morning phone call. She has a history of hypertension and hypercholesterolemia treated with a β-adrenergic blocking agent and a lipid-lowering agent. Her pulse is 72/min, and blood pressure is 160/90 mm Hg. During examination, she is only able to give single-word answers with many paraphasic errors. She has good comprehension. Examination shows normal visual fields. There is weakness of the right side of the mouth. Muscle strength of the right upper extremity is 2/5. There is mild weakness of flexion of the right hip; muscle strength of the right lower extremity is otherwise normal. Sensation to pinprick is decreased over the right upper extremity. Deep tendon reflexes are more brisk on the right side than the left, and Babinski sign is present on the right. Which of the following arteries is most likely to be occluded? A) Basilar B) Left anterior cerebral C) Left internal carotid D) Left middle cerebral E) Left ophthalmic F) Left posterior cerebral G) Right anterior cerebral H) Right internal carotid I) Right middle cerebral J) Right ophthalmic K) Right posterior cerebral

L MCA -facial deficits -motor deficits -BROCA, WERNICKE"S APHASIA!!! *ICA stroke symptoms -AMAUROSIS FUGAX!!! -motor symptoms on part of that side of body (arms, legs, face, etc) -sensory symptoms on part of that side of body (arms, legs, face, etc) -personality symptoms

What is trismus?

LOCKJAW!!!

77 yr old woman with lesion on left arm for past 2 months. She underwent MRM of the left breast for breast cancer 20 years ago complicated by chronic edema of left upper extremity. Exam of left upper extremity shows two 4 mm, raised, hard, purple lesions just above the left elbow. The entire left upper extremity is edematous. Which if the most likely diagnosis? -hemangioma -liposarcoma -lymphangiosarcoma -melanoma -recurrent breast carcinoma

Lymphangiosarcoma *Modified radical mastectomy leads to chronic lymphedema --> could be complicated with LYMPHANGIOSARCOMA or HEMANGIOSARCOMA

A 67-year-old man with alcoholism comes to the physician for a routine examination. He has a 15-year history of poorly controlled hypertension; he takes hydrochlorothiazide and admits that he is not compliant with his drug regimen. His blood pressure is 170/102 mm Hg, unchanged from his last three office visits. Funduscopic examination shows arteriovenous nicking and tortuosity of the arteries. This patient is at greatest risk for which of the following? a) Glaucoma b) Myocardial infarction c) Pulmonary hypertension d) Subarachnoid hemorrhage e) aortic aneurysm

MI -malignant HTN *cardiovascular disease = #1 killer

. 37yo M with 3-day history of diarrhea. Six to eight watery stools daily that occasionally contain streaks of blood. Family does not have similar symptoms. No travel. Two weeks ago, he completed course of oral ciprofloxacin for acute prostatitis. CBC normal. Stool for leukocytes and clostridium difficile toxin is positive. Next step? -Metronidazole -Vancomycin

Metronidazole! -In cases when the WBC is <15k, oral metronidazole is the correct answer. Remember that in patient's with WBC >20k, lactacte >2.2, toxic megacolon and/or severe ileus, the patient will need emergent surgery -Oral vancomycin is reserved for more severe cases, particularly when WBC > 15k and creatinine is >1.5x the patient's baseline.

A 72 year old woman comes to the physician because of 1 3 month history of bilateral knee pain with weight bearing. Use of maximum doses of over the counter naproxen over the past 6 weeks has partially relieved the pain. She has a history of stable exertional angina and moderate shortness of breath with exertion that have not changed during this period. She has HTN, coronary artery disease, congestive heart failure, and osteoporosis. Medications include atenolol, oral nitrates, furosemide, and potassium supplements. Her pulse is 62.min, and blood pressure is 115/70 mmHg. Examination shows jugular venous distention to 2 cm above the sternal angle with the pt sitting at a 30-degree angle. The lungs are clear to auscultation. Cardiac examination shows no gapplps or murmurs. She has trace pedal edema. There is crepitus of both knees and bony prominences at the proximal tibial bones bilaterally. Serm studies show a potassium concentration of 5.1 mEq/L, urea nitrogen concetration of 47 mg/dl(baseline of 20), and creatine of 2.2mg/dL(baseline of 1). Which of the following medications is the most likely cause of the abnormal lab findings? a. atenolol b. furosemide c. naproxen d. nitrates e. porassium supplements

Naproxen -Intrinsic renal damage? -AIN? -Renal papillary necrosis (Sickle cell, Acute pyelo, Analgesics, DM)

A previously healthy 10y/o girl is taken to the doctor cause of a 2day hx of a slightly itchy rash that has spread from her face to her chest, arms, and legs. One week ago, she had a 2 day hx of low-grade fever, headache, and malaise. She has not had a sore throat. She appears well. Her temperature is 37.3°C (99.1°F). A photograph of the face is shown. The rash over the chest and upper and lower extremities is symmetric, maculopapular, reticular, erythematous, and nonconfluent. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in pharmacotherapy? A. Acyclovir B. Amoxicillin C. Doxycycline D. Prednisone E. No pharmacotherapy is indicated at this time

No pharm indicated at this time -steroids only needed in acute exacerbations -this isn't life-threatening/severe

A previously healthy 18-year-old woman comes to the physician because of a lump in her neck that she first noticed 1 month ago. She is otherwise asymptomatic. Examination shows a 3- cm left supraclavicular lymph node that is firm and rubbery. The spleen is palpated 3 cm below the left costal margin. The remainder of the examination shows no abnormalities. Laboratory studies are most likely to show which of the following: A)Decreased serum potassium concentration B) Increased erythrocyte count C) Increased serum calcium concentration D) Increased serum lactate dehydrogenase activity E) Increased serum thyroid-stimulating hormone concentration

Non-Hodgkin's lymphoma --> increased LDH Hodgkin's lymphoma --> PTHrP secretion --> increased Ca2+

A 42-year old woman comes to the physician because of progressive shortness of breath during the past 6 months. She now has to r est three or four times when climbing one flight of stairs. Shew has smoked one pack of cigarettes daily for 26 years. She has a chronic nonproductive cough and has wheezing controlled with an albuterol inhaler two to three times weekly. During the past year, he BMI has increased from 45kg/sq.m to 52kg/sq.m. Her temperature is 37°C (98.6°F), pulse is 95/min, respirations are 24/min and shallow, and blood pressure is 140/90 mm Hg. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is distended. There is 1+ edema of the ankles. Arterial blood gas analysis on room air shows: pH 7.37 Pco2 48 mm Hg Po2 62 mm Hg o2 saturation 92% Her FEV1 is 75% of predicted, and total lung capacity is 50% of predicted. Which of the following is the most likely diagnosis? A) Chronic obstructive pulmonary disease B) Congestive heart failure C) Interstitial pneumonia D) Recurrent pulmonary embolism E) Restrictive lung disease

Obesity --> RESTRICTIVE LUNG DISEASE -TLC decreased!

13yo boy with 3-month history of left knee pain that is exacerbated by vigorous exercise. Occasional pain in his right knee. 50th percentile for height and weight. T 37 C. Tenderness at left tibial tubercle. a. Bone scan b. MRI of left knee c. Antibiotics d. NSAiD e. Knee immobilisation f. Joint aspiration

Osgood-Schlatter --> patellar ligament (connected to tibial tubercle) inflammed -resolves without formal treatment NSAIDS!!

a 37 year-old man comes to physician because of a 6 weeks history of the rash shown. He has had three episodes of a similar rash over the past 5 years that had resolved with treatment. With sun exposure, the rash becomes lighter than his tanned skin. Exam shows no other abnormalities. Which of the following is the most appropriate pharmocotherapy? a. oral cephalexin b. oral prednisone c. selenium sulfide shampoo d. topical mupirocin e. topical triamcinolone f. no pharmacotherapy indicated

Pityriasis versicolor -both hypo and hyperpigmented spots -lipid degradation of melanocytes!! --> selenium sulfide shampoo

47 yo M with 2 yr hx of increasing left knee pain. Initially pain was only felt when playing basketball or running, but now he has pain all the time. During the last 6 months his pain has been waking him up at night. Pain is worse with walking or prolonged standing. He used to take part in sports 2-3x weely but now has stopped participating due to pain. When he was 16 he fractured his left proximal tibia while playing football for at which point he underwent open reduction and internal fixation. Says he occasionally has swelling of knee but has not had any locking or catching. There is a varus deformity of left knee on exam. Anterior and posterior drawer tests are are negative. Explanation for these findings? a. nonunion of his prior fracture b. patella tendinitis (INCORRECT) c. post traumatic arthritis d. tear of anterior cruciate ligament e. tear of medial meniscus

Post-traumatic arthritis *Patellar tendinitis -Jumper's knee (patellar tendinopathy, patellar tendinosis, patellar tendinitis) commonly occurs in athletes who are involved in jumping sports such as basketball and volleyball. Patients report anterior knee pain, often with an aching quality. The symptom onset is insidious.

A 67-year-old man comes to the physician for a follow-up examination. Three years ago, he underwent radical resection of a T3 N0 M0 epidermoid carcinoma of the floor of his mouth and supraomohyoid dissection of his neck. He currently takes no medications. He smoked three packs of cigarettes daily for 40 years but stopped 3 years ago. Vital signs are within normal limits. Examination shows well-healed surgical scars. There are no signs of local recurrence. An x-ray of the chest shows a 3-cm mass in the medial upper lobe of the right lung. Which of the following is the most likely cause of these findings? A. Bronchioalveolar carcinoma of the lung B. Metastatic carcinoma C. Obstructive pneumonia D. Primary squamous cell carcinoma of the lung E. Sarcoidosis

Primary squamous cell carcinoma of the lung: -only 2 CA of the lung are medially placed, squamous cell and small cell and both are mainly due to smoking -The logic, I use to remember it is that the smoke enters the lung parenchyma medially thus this part of the lung will receive higher dose of smoke so has higher risk to develop those 2 cancers. T- size, extent of primary tumor N- #lymph nodes involved M- metastases *Bronchioalveolar carcinoma of the lung: peripheric, more common in non smoker *Metastatic carcinoma: no history of lymphadenopathy; histology doesn't indicate this *Obstructive pneumonia: Clinical history doesn't correspond, no mention of fever. *Sarcoidosis: no hiliar adenopathy

Felty syndrome

RA + splenomegaly + neutropenia

6 month old boy, chronic constipation since the age of 1 week. Current Rx with rectal stimulation, glycerin suppositories, and 4 ounces of prune juice produces string-like stool every 4 days. No vomiting. Growth and development are appropriate for age. Abdominal exam shows distension, no tenderness. Rectal exam, no palpable stool in ampulla. What is next step in mangement? a. switch to lactose-free formula b. test of stool for botulism toxin (INCORRECT) c. stool culture d. measurement of serum TSH concentration e. rectal manometry f. upper GI series

Rectal manometry -Failure to pass Meconium in a neonate is Hirshprung dz until proven otherwise, do Manometry

A previously healthy 14-year-old girl is brought to the physician because of a 2-day history of fever and pain and swelling of the right knee. She remembers injuring the knee while playing soccer lastweek, but she was able to finish the game. She has no history of rash or joint pain. Her sister has inflammatory bowel disease. The patient's temperature is 39 C (102.2 F), blood pressure is 110/80 mm Hg, pulse is 95/min, and respirations are 20/min. Examination of the right knee shows swelling, tenderness, warmth, and erythema; range of motion is limited by pain. Which of the following is the most likely causal organism? A) E. coli B) Hemophilus influenza B C) N. meningitidis D) Staph aureus E) Staph epidermis F) Strep pneumo G) Strep pyogenes (group A)

S. aureus!! etiology of septic arthritis: -staph aureus 40 percent -streptococcus 30 percent -gram negative 20 percent

A 32-year-old man with AIDS comes to the emergency department because of a 1-week history of temperatures to 40°C (104°F) and cough productive of small amounts of clear sputum. Current medications include trimethoprim-sulfamethoxazole and three antiretroviral agents. His temperature is 39.7°C (103.5°F), pulse is 100/min, respirations are 20/min, and blood pressure is 126/60 mm Hg. There is no lymphadenopathy or edema. Moist crackles are heard over the right lung base. Cardiac examination shows no abnormalities. An x-ray of the chest shows an infiltrate in the right lower lobe. Which of the following is the most likely causal organism? A)Aspergillus fumigatus B)Candida albicans C)Pneumocystis jiroveci (formerly P. carinii) D)Rhodococcus equi E)Streptococcus pneumoniae

S. pneumo

Previously healthy 37yo woman, left leg pain x2 days, on OCP and calcium supplement. Left distal extremity has subQ palpable, hard, cord-like structure within a 6 x 1 cm warm, erythematous area just proximal to ankle. Also has scattered varicose veins in both lower extremities. Best next step in mgmt? A. application of warm compresses B. use of compression stockings C. oral dicloxacillin tx D. oral prednisone tx E. subQ enoxaparin tx

SUPERFICIAL THROMBOPHLEBITIS!! -thrombosis and inflammation of superficial veins *Symptoms -painful induration with erythema -linear or branching configuration --> forming CORDS!!! -cord persists even when leg elevated!! -same risk factors as DVT (OCPs, etc) Tx -compression stockings (if in legs) -NSAIDs for pain

A 16-year-old boy is brought to the physician because of a 3-day history of right knee pain associated with redness and swelling. There is no history of trauma.he is at the 50th percentile for height and weight. His temperature is 38.6°C (101.5°F). Examination shows ery thema. swelling, and tenderness of the right knee ,and range of motion is limited. select the most appropriate next step in management: o A) Radionuclide bone scan O B) MRI of the affected knee O C) Antibiotic therapy O D) Nonsteroidal anti-inflammatory drug therapy o E) Knee immobilization O F) Joint aspiration

Septic arthritis --> JOINT ASPIRATION 1. Joint aspiration (get synovial fluid for culture) 2. Empiric abx treatment 3. Narrow abx when cultures come back

A 72 year old skilled nursing care facility with dementia came with 2 days of fever ,confusion generalized weakness.Symptoms began following irrigation of his urinary catheter,which was not draining well.he has COPD and osteoarthritis.He appears lethargic.Temp 36.2 ,pulse 110 , BP 90/50.Neck is supple.Heberden nodes in his hands. Breath sounds decrease with no dullness. HCt 50 WBC15400 neut 74% bands 4 lympho 22 Na + 134 K+ 4.2 Cl- 86 HCO3- 24 urea 12 creatinine 1.1 ECG shows sinus tachycardia with flattening of ST_T segments.What s the explanation for his hypotension A-decrease cardiac contractility b-decrease SVR c- deficiency of mineralocorticoids d-impaired vagal reflexes e-impaired venous return

Septic shock --> decreased SVR -don't double-guess yourself!!!

How to workup Entamoeba?

Serum antibody titer for Entamoeba Histolytica!!!

37 yr old with 12 hours of vomiting, abd cramping and swelling. He has had constipation for 4 days. Diagnosed with Crohns 7 years ago. His symptoms of diarrhea and pain have been well controlled with mesalalmine for past 3 years. His t 96.8, pulse 98 regular, BP 110/70. Exam shows diffusely distended, tympanitic abdomen and visible peristalsis. High pitched bowel sounds are heart. Rectal exam shows no stool in rectal vault. Xray shows SBO. Which is the most likely cause? -colon cancer -ileocecal fistula -small bowel adhesions -small bowel fibrotic stricture -small bowel intussusception

Small bowel fibrotic stricture -more likely in Crohn's -no history of surgery (adhesions)

A Male newborn has bilateral clubfoot deformity.He was born at term following an uncomplicated pregnancu and delivery.He did not move his lower extremities immediately after birth,and did not cry when he recieved a needlestick in his heel.On examination,he is vigorous and moves his upper extremities but not his lower extremities.The bladder is palpable and full.which of the following is the most likely diagnosis? A.CP B.Congenital Hip dysplasia C.GBS D.muscular dystrophy E.Spinal dysraphism

Spinal dysraphisim = tethered cord syndrome Lesions, hairy patches, dimples, or fatty tumours on the lower back Foot and spinal deformities[2] Weakness in the legs[2] Change in or abnormal gait including awkwardness while running or wearing the tips or side of one shoe[2] Low back pain[2] Scoliosis[2] Urinary irregularities (incontinence or retention)[2] C/v-- newborn with hair patch on his back, cannot move his lower legs, bowel/bladder dysfunction ,no sensation in Lower ext, In child-- same vignette with scoliosis, lower ext weakness, severe back pain radiating into legs,motor delay, asymmetric lower ext growth Diagnosis ? spinal dysraphism (tethered cord syndrome) C/v--2 yo child with abnormal unsteady gait, decreased muscle mass , spasticity and increased lower ext reflexes,scissor walking ( knees come in and cross while walking) ,h/o recurrent seizures, learning disability and mentally retarded Dx? --cerebral palsy

Tx for aldosteronoma?

Spironolactone!!! CCB Glucocorticoids ACE/ARB

An otherwise healthy 37 y/o man comes to the physician because of a 3-month history of low back pain. Use of NSAID has provided moderate relief. Forward flexion of the spine is normal and does not produce pain, hyperextension of the spine increase the pain. Muscle strength in the lower extremities is 5/5; sensation and reflexes are normal. A lateral X-ray of the lumbar spine is hsown. Which of the following is most likely diagnosis? A. Compression fracture B. intervertebral disc space infection C osteitis deformans (Paget disease) D. Osteoporosis E. spondylolisthesis

Spondylolisthesis -worse with hyperextension -more common in young patients Compression fracture only gives severe back pain, more commonly seen in patients with osteroporosis or lytic lesions from metastatic or primary tumors, but this patient is healthy and young.

A previously healthy 7.year-old girl is brought to the physician because of a 2-week history of fever, intermittent rash, and joint pain and swelIing She had three similar episodes dunng the past 2 years. She appears ill Her temperature is 394°C (1029°F), pulse is 108/mni, respirations are 20;min, and blood pressure is 100/70 mm Hg. Examination shows a generalized pink macular rash over the trunk and upper and lower extremities There are several warm, swollen interphalangeal joints, range of motion is decreased This patient most likely has which of the following abnormalities in the synovium? O A) Calcium deposits O B) Gram-positive bacteria O C) Leukocvtes O D) Malignant cells 0 E) Urate crystals

Still's disease- autoinflammatory disease 1. high fever 2. Joint inflammation 3. Salmon colored rash (trunk and extr) that comes and goes but does not itch Other symptoms -internal organ enlargement -pericarditis -pleuritis -high WBC without infection, high ESR, CRP *(-) RF and ANA ab. *Leukocyte migration occurs in the synovium due to local production of inflamm mediators, cytokines and chemokines.

A hospitalized 37-year-old woman has the sudden onset of fever 7 days after undergoing splenectomy for immune thrombocvtopenic purpura. She has had moderate abdominal pain and mild left shoulder pain for 2 days Her hemoglobin concentration has ranged from 9.5 gâ€dL to 10 g/dL since the operation Current medications include hydrocodonie and docusate Her temperature is 39 1°C (102 4°F) Abdominal examination shows mild distention and diffuse tenderness without rebound, rigidity, or guarding Bowel sounds are absent Laboratory studies show: Hemoglobin 98 g/dL Leukocyte count 21,3oo1mm3 Segmented neutrophils 50% Bands 17% Eosinophils 3% Lymphocytes 25% Monocytes 5% Platelet count 105,000/mm3 Serum amylase 124 U/L A chest x-ray shows a left pleural effusion. Which of the following is the most likely cause of these findings? O A) Aspiration O B) Gastric perforation O C) Pancreatitis O D) Pneumonia 0 E) Subphrenic abscess

Subphrenic abscess

A 4-year-old boy is brought to the physician because of scalp lesions that have been increasing in size during the past week. He went for a nature walk with his day-care class 10 days ago. Examination shows scattered papules with some scaly areas on the scalp; the surrounding hair is broken near the base with mild alopecia. Which of the following is most likely to have prevented this condition? a) Avoidance of wooded areas b) Avoidance of sharing hats c) Use of insect repellent d) Use of sunscreen

Tinea capitus -single or multiple patches of hair loss, sometimes with a 'black dot' pattern -broken-off hairs -inflammation, scaling, pustules, itching --> avoid sharing hats

87 yo nursing home resident, with fever for 1 day. She has urinary incontinence for which a catheter was placed 2 weeks ago. Hx of Alzheimers dementia and cannot verbally communicate. Has moist and pink mucous membranes. Vitals: HR 86/min, BP 120/74, resp 14/min, temp 100 F. Urinanalysis: cloudy brown, pH 8.8, blood 2+, Glucose -ve, protein 2+, RBC: too numerous to count, WBC 20-25, Nitrites 3+, Leukocyte esterase 3+, bacteria: many. Gram -ve bacilli on gram stain. Measure most likely to prevent patient's current condition? a. use of incontinence briefs instead of catheter b. changing catheter daily (INCORRECT) c. cleaning urethral orifice with povidone iodide daily d. flushing the catheter with antibiotic solution daily e. oral antibiotic prophylaxis f. oral oxybutynin therapy

Use of incontinence briefs (dipends) instead of catheter

A 32-year-old worman, gravida 2, para 1, at 40 weeks' gestation is brought to the emergency department by her husband because she has been confused for 45 minnutes. Her husband says that she has been in labor for 3 days at home, and she has recieved all her prenatal care from an alternative provider. This morning the caregiver gave the patient a natural product to chew to induce contractions. She began to have strong, regular,, painful contractions, and after 6 hours, she suddenly lost conciousness. On arrival, she is obtuned. her pulse is 140/min, and palabalbe systolic blood pressure is 60 mm Hg. Abdominal examination shows distention and rigidity and a 25-cm, irregular mobile mass in the upper right quadrant. The cervic is 3 cm dilated and 50% effacted; no presenting fetal part can be palpated. which of the following is most likely cause of thse findings? A) Coagulopathy B) endomyometritis C) methamphetamine use D) uterine atony E) uterine Rupture

Uterine rupture -shock -irregular mobile mass in RUQ = fetus -no presenting fetal part palpated = regression of fetal station?

An 82-year-old widower comes to the physician because of a 1-month history of sudden forgetfulness. Previously, he had noticed mild memory impairment and had difficulty managing his checkbook; he has had to ask his daughter for help. He thinks that his deficits have become more severe during the past month and reports occasionally getting lost and having to ask for directions. He has hypertension treated with hydrochlorothiazide. He does not drink alcohol. He is 170 cm (5 ft 7 in) tall and weighs 83 kg (182 lb); BMI is 29 kg/m2. His pulse is 78/min, respirations are 18/min, and blood pressure is 145/95 mm Hg. Muscle strength in the left upper and lower extremities is 3/5. Babinski sign is present on the left. Neurologic examination shows no other focal findings. He is able to recall one of three objects after 5 minutes. Long-term memory is intact. His Mini-Mental State Examination score is 23/30. Which of the following is the most likely diagnosis? a) Huntington disease b) Lewy body dementia c) Multi-infarct (vascular) dementia d) Pick disease

Vascular dementia -history of HTN -sudden onset memory loss -UMN findings *Pick disease -abrupt mood changes. -compulsive or inappropriate behavior. -depression-like symptoms, such as disinterest in daily activities. -withdrawal from social interaction. -difficulty keeping a job. -poor social skills. -poor personal hygiene. -repetitive behavior.

A 47-year-old worman comes to the physician for a routine health maintenance examination. She has a 2-year history of venous insufficiency and notes daily swelling of her ankles that worsesn in the evening. She takes no medications. Her pulse is 80/min, and BP is 160/100 mm Hg. Cardiopulmonary examination shows no abnormalities. Examination of the lower extermities show 2+ edema and increased pigmentation. WHich of the following antihypertensie drugs would most likely exacerbate this patient's swelling? A) Atenolol B) Clonidine C) Lisniopril D) Losartan E) Nifedipine

Woman has venous insufficiency, NOT ANGIOEDEMA!! Nifedipine -CCB --> vasodilator -don't want to dilate vessels even more

Workup for gastric perf?

XR of chest and abdomen --> see free air under diaphragm!

A previously healthy 32yo woman comes to the doctor bc of a 2 day hx of fever and an area of swelling and redness on her right forearm. Six hrs ago, she noticed red streaks extending from her forearm to her elbow. She has not raveled, and there is no history of trauma. Her temp is 37.8. Epitrochlear lymph nodes are enlarged. Exam of the distal radial aspect of the right upper extremity shows an 8 x 13 cm warm, erythematous area of edema that is tender to palpation; there is a warm, tender red streak extending from this area to the elbow. What's the most likely causal organism? a). Haemophilus influenza b). Beta-hemolytic streptococcus c). Pseudomonas aeruginosa d). Salmonella choleraesuis e). Staphylococcus epidermidis

b-hemolytic strep (GAS) -Red streak is LYMPHANGITIS most commonly associated with Group A Strep *inflamed lymphatic vessels appear as several thin, red, tender lines on the slightly edematous skin progressing towards the regional lymph nodes which are enlarged and tender (lymphadenitis). Lymphangitis usually is caused by streptococci and staphylococci.

Six hours after undergoing a surgical excision of the distal colon for cancer, a 77 year old man has decreased urine output. His urine output has been 10 mL/h during the past 3 hours. During the 4-hour operation, he lost 500 mL of blood and underwent transfusion of 1 unit of packed red blood cells. His initial postoperative course was uncomplicated. Two years ago, he had a myocardial infarction and underwent coronary artery bypass grafting. He has a 10 year history of hypertension well controlled with atenolol. Current medications include morphine and labetalol. He currently appears pale and diaphoretic. His temperature is 37 deg C (98.6 deg F), pulse is 85, respirations are 14/min, and blood pressure is 90/60. Pulse oximetry is 2L/min of oxygen via nasal cannula shows an oxygen saturation of 89%. Cardiopulmonary examination shows no abnormalities. The abdomen is nondistended with mild tenderness over the incision. His hematocrit is 24%, serum sodium concentration is 140 mEq/L, and serum creatinine concentration is 2.1 mg/dL. The patient switched to administration of 100% oxygen by non-rebreathing face mask. The most appropriate next step in management is administration of which of the following? A) Bumetanide B) 5% dextrose in water C) Fresh frozen plasma D) Furosemide E) Packed red blood cells F) 0.45% saline

pRBCs -Hb 8 --> close to 7 -rarely give half saline