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Grand Canyon University > NRS 427V / NRS427V: Usmle step 3 Question and Answers 2020 ALL CORRECT ANSWERS

Usmle step 3 Question and Answers 2020 You are called emergently to the medical floor where a 66-year-old man was found to be minimally responsive. His past medical history is unclear but his arm band lists allergies to penicillin and sulfa medications. On arrival, chest compressions are being performed and 2 operators are mask ventilating the patient. Evaluation with an electrocardiogram reveals sinus tachycardia and the diagnosis of pulseless electrical activity is made. Volume is infused and compressions are continued. The patient remains apneic, so mask ventilation continues. During masking, the patient appears to regurgitate large volumes of gastric contents. The most appropriate immediate next step in the management of this patient is to A. cease mask ventilation and suction the mouth B. continue masking the patient C. insert a nasogastric tube D. intubate the trachea and suction the airway E. intubate the trachea and ventilate A 1-year-old child is brought to the clinic for a routine child health examination. His parents have been very compliant and have not missed any of his other health maintenance visits. He is a healthy child with no significant past medical history. Thus far, he has received the following vaccines (at the appropriate times): inactivated polio (IPV) 3 times, diphtheria/tetanus/acellular pertussis (DTaP) 3 times, hepatitis B (hep B) 3 times, haemophilus influenza type B (Hib) 3 times, and Pneumococcal conjugate (PCV) 3 times. At this time you should administer A. DTaP, Hib, MMR, varicella B. DTaP, IPV, varicella, PCV C. DTaP, MMR, varicella, PCV D. Hib, MMR, varicella, PCV E. IPV, Hib, MMR, PCV A 78-year-old woman is admitted to the hospital because of a fever, productive cough, and a chest x-ray demonstrating right lower lobe consolidation. Her past medical history is significant for seasonal allergies. She has been taking estrogen/progesterone replacement since menopause 19 years ago and occasional acetaminophen for headaches. The patient lives alone at her home and she does not drink alcohol or smoke. Review of systems is significant for weakness attributed to “old age". On the day prior to discharge, a repeat chest x-ray shows the pneumonia to be resolving. An incidental note is made of severe osteoporosis involving all of the bones visualized on the film. Vital signs are temperature 38.8 C (101.8 F), blood pressure 100/50 mm Hg, pulse 90/min, and respirations 10/min. Physical examination is significant only for decreased breath sounds at the right lung base. The patient is neurologically intact and wants to return home. Laboratory studies show a leukocyte count 15,000/mm3, hematocrit 28%, and platelets 150,000 mm3. The next step in the management of this patient is to A. discharge her and do a bone marrow biopsy as an outpatient B. discharge her and send her for a bone scan as an outpatient C. discharge her and order serum protein electrophoresis as an outpatient D. do a bone marrow biopsy before discharge E. order a bone scan and serum protein electrophoresis before discharge A 37-year-old woman with a history of intravenous drug use, hepatitis B, asthma, and acquired immunodeficiency syndrome (AIDS) is admitted to the hospital because of fever, night sweats, and malaise. Her last CD4 count was 1 month ago and measured 180/mm3. Vital signs are: temperature 38.5 C (101.3 F), blood pressure 145/76 mm Hg, and pulse 90/min. Physical examination is significant for a soft diastolic murmur heard best at the lower left sternal border. Auscultation of the lungs reveals diffuse rhonchi. The abdominal and neurologic exams are unremarkable. The next step in managing this patient is A. analysis and culture of spinal fluid B. a blood culture C. a CT of the head D. a urinalysis E. an x-ray of the chest F. an x-ray of the abdomen A 61-year old patient with a history of a duodenal ulcer, is admitted to the hospital for a scheduled right knee arthroplasty because of end-stage osteoarthritis. After an uneventful surgery and immediate postoperative course, the patient has an episode of 100 cc of bloody emesis. Vital signs are: temperature 37C (98.6 F), blood pressure 140/75 mm Hg, pulse 70/min, and respirations 10/min. Oxygen saturation measurement obtained while the patient is receiving supplemental oxygen of 2 L/min via nasal cannula is 99%. Physical examination is unremarkable. The hematocrit profile is: SQ746 After sending blood for type and cross match, an upper endoscopy is performed and fails to identify the source of bleeding. The most appropriate next step in the management of this patient is A. an angiography B. an endoscopy of lower gastrointestinal tract C. an enteroclysis D. a tagged red blood cell bleeding scan E. a transfusion of packed red blood cells A 49-year-old previously healthy man who is 9 days postop from a low anterior resection for organ-confined rectal cancer is experiencing a prolonged postoperative course. For the past 36 hours he has been having loose stools and emesis associated with meals. On rounds this morning he was noted to have abdominal distention. His temperature is 38.8 C (101.8 F), blood pressure is 114/71 mm Hg, pulse is 110/min, and respirations are 22/min. Abdominal examination reveals a distended abdomen with an intact staple line. There is erythema inferiorly, but no drainage is expressed. Bowel sounds are diffusely decreased and there is tenderness to palpation over the left lower quadrant. Rectal examination reveals a fluctuant mass on the left side. White blood cell count is 17,000/mm3. Clostridium difficile toxin is negative. Obstructive series shows a small amount of free air below the diaphragm and a bowel gas pattern consistent with ileus. The most likely underlying cause of his condition is A. nothing; it is a normal postoperative course B. a pelvic abscess C. a perforated viscus D. pneumonia E. pseudomembranous colitis F. a superficial wound infection Explanation: A 45-year-old woman is in the hospital following a major motor vehicle accident. She sustained fractures of her left femur and left tibia. She feels well after her open reduction and internal fixation of her fractures. On her third hospital day, she mentions that she has pain in her jaw. Since her hospitalization, she has had difficulty opening her mouth completely and when she does, she often hears a "popping" sound. Physical examination reveals moderate pain with palpation of the mastication muscles bilaterally. She is able to slowly open her mouth completely. There are no facial lacerations or bruising. At the time of admission, the patient had a CT of the head that was normal. The most appropriate step at this time is A. an arthrography of the temporomandibular joints B. a CT of the temporomandibular joints C. an MRI of the temporomandibular joints D. to recommend a soft diet to limit chewing E. to repeat the CT of the head You are called to the delivery room after a full-term male infant is born via cesarean section to a G2P1 mother. Under the radiant warmer, the baby is crying and has a heart rate of 90/min. There is some flexion of the extremities and he grimaces when the catheter is passed in the nostril. The baby's body is pink, but the extremities are blue. The baby's Apgar score at 1 minute is A. 5 B. 6 C. 7 D. 8 E. 9 A 16-year-old boy is admitted to the hospital for pneumonia. The patient reports that over the past 3 days he has had an increasing cough, productive of thick, green sputum and pleuritic chest pain. He has a history of cystic fibrosis and has been hospitalized for pneumonia 9 times in the past 3 years. He has never been intubated, but has required prolonged hospital stays at times in order to manage his infections. His medications include pancreatic enzymes and acetylcysteine nebulizers. The most appropriate management of this patient is to A. begin aggressive chest physiotherapy B. give him inhaled beta agonists C. enroll him in gene therapy trials D. evaluate him for lung transplantation E. obtain a sputum culture and await results for directed antibiotic therapy A 79-year-old man is admitted to the hospital for a gangrenous right foot. He has a long history of peripheral vascular disease, hypertension, hypercholesterolemia, coronary artery disease, and has suffered 2 strokes. The patient's daughter visited him at home today and noticed his foot was black. The patient is admitted to the hospital for a right, below-the-knee amputation. Over the next 48 hours the patient complains of increasing abdominal pain. His temperature is 39.8 C (103.6 F), blood pressure is 100/50 mm Hg, pulse is 120/min, and respirations are 22/min. Physical examination shows a diffusely tender and distended abdomen and his right foot is unchanged. Stat blood work is drawn and shows: SQ21 The diagnostic procedure most likely to establish the diagnosis is A. abdominal radiographs flat and upright B. chest films flat and upright C. CT scan of the abdomen D. exploratory laparotomy E. ultrasound of the abdomen A 42-year-old man comes to the emergency department with a history of a productive cough and hemoptysis. He is known to be HIV positive and admits to a history of intravenous drug abuse. In the emergency department, his temperature is 38.1 (100.6 F) with stable vital signs. He is admitted to the medical floor for the treatment of pneumonia. A chest x-ray and subsequent CT scan of the chest confirms a cavitary lesion in the right lung. He is started on antibiotics and sputum is sent for a Gram stain, acid-fast bacillus smear, cultures, and sensitivity. The acid-fast bacillus smear comes back positive. He now admits that he was diagnosed with pulmonary tuberculosis 4 years ago and was advised treatment with isoniazid (INH), rifampicin, pyrazinamide, and ethambutol, which he was supposed to take for 6 months. His compliancy in taking these medications is unclear. From the period of his admission to the emergency department and placement on respiratory isolation, several hospital employees were exposed to his respiratory secretions. A PPD test is given to all the exposed employees. Three employees with previously negative PPD test results, now have positive results.The most appropriate post exposure prophylaxis (PEP) plan for these employees is A. ethambutol and pyrazinamide therapy initially, then the addition of this regimen accordingly to the patient's sensitivity profile B. to hold postexposure prophylaxis until the patient's sensitivity profile is available and then choose a regimen C. INH for 6 months,and if PPD is still positive, an extension of the treatment for 12 months D. INH, rifampicin, pyrazinamide, and ethambutol for 6 months and recheck the PPD E. no postexposure prophylaxis is necessary A 48-year-old man is admitted to the hospital because of a 2-hour history of chest pain and shortness of breath that came on suddenly when he was shoveling snow from the walkway to his house. His electrocardiogram on admission showed ST elevation that started to descend as the T waves inverted and Q waves appeared. He is treated with streptokinase, aspirin, intravenous heparin, oxygen, nitroglycerin, metoprolol, and morphine. His chest pain resolves and he is settled into the cardiac care unit. As the days progress he is able to sit up, dangle his feet over the side of the bed, and begins to ambulate in his room. On hospital day 6, you go to examine him before he is discharged home. It is appropriate to advise the patient that A. beta-blockers will decrease his morbidity, not his mortality, following a myocardial infarction B. bed rest is necessary for 1 week C. maximal exercise stress testing should be performed in 2 days D. sexual activity can be resumed in 2 to 4 weeks E. supervised gradual aerobic program should be started in 2 months You are asked to see a baby in the newborn nursery. The baby is small for gestational age and has microcephaly. Physical examination shows hepatomegaly, a widened pulse pressure, a "machinery" heart murmur, and a purpuric skin rash. There is no red reflex in either eye. At this point, you are suspicious that the baby has a congenital infection caused by A. Cytomegalovirus B. rubella virus C. Toxoplasma gondii D. Treponema pallidum E. varicella-zoster virus Explanation: A 37-year-old very healthy and functional woman is scheduled to undergo a right total hip replacement after she suffered a femoral head fracture 2 days ago during a fall while climbing a flight of stairs. She has no significant past medical history and takes no routine medications. She is scheduled to have her operation in the morning and you are called as a medicine consult to make any appropriate recommendations. Postoperatively, this patient is at greatest risk for developing A. atrial fibrillation B. confusion C. a deep venous thrombosis D. a myocardial infarction E. a pulmonary embolism Explanation: A 19-year-old woman with a long psychiatric history is admitted to the hospital after taking an overdose of amitriptyline. In the emergency room, she underwent gastric lavage and received activated charcoal. Serum toxicology screen revealed an amitriptyline level of 900 ng/ml. On the floor, she is awake but lethargic. Her blood pressure is 110/70 mm Hg and pulse is 63/minute. An electrocardiogram shows normal sinus rhythm. She is placed on an infusion of sodium bicarbonate. Over the next three hours, she becomes more somnolent and her respiratory rate decreases to 7/min. Her pulse is weak and rapid and her blood pressure is 75/40 mm Hg. The electrocardiogram now shows a narrow complex tachycardia at 160 beats per minute. Pulse oximetry reads 95% oxygen saturation on 6 liters/min of supplemental oxygen by nasal cannula. Arterial blood gas shows: PH 7.32 PO2 83mmHg PCO2 58mmHg The first priority in caring for this patient is to A. administer quinidine, intravenously B. begin an esmolol drip, intravenously C. cardiovert the patient at 200 J D. intubate and hyperventilate the patient E. place a non-rebreathing mask with 100% supplemental oxygen You are seeing an 83-year-old woman for preoperative clearance prior to a total hip replacement. She has a long history of rheumatoid arthritis with pulmonary involvement. Her disease has, however, been well controlled over the last several years on methotrexate. She has no known allergies to any medications. She does not smoke or drink alcohol. She is active and walks a mile, 3 times a week. Her temperature is 37.7C (99.9 F), blood pressure is 110/56 mm Hg, pulse is 89/min, and respirations are 19/min. Her hands show degenerative changes consistent with long standing rheumatoid disease. Her lungs are clear to auscultation and her cardiac rhythm is regular. She has limited neck flexion-extension. A neurologic examination is unremarkable. A chest radiograph is unremarkable. An electrocardiogram shows a sinus rhythm with some non-specific ST and T wave abnormalities. During your discussion, the patient expresses a desire to have a general anesthetic. Based upon the available information, the next most reasonable imaging study to obtain is A. a cervical spine radiograph B. a chest CT C. a head CT D. a spine MRI E. an echocardiogram A 30-year old gravida 2, para 1 woman at 41 weeks and 5 days of gestation has been in active labor for over 30 hours. An epidural was successful placed at 5 cm of cervical dilation. Although the cervix has been dilated 10 cm for the past 8 hours, the fetus has descended the pelvis minimally. An obstetrical ultrasound obtained for estimation of fetal weight at 38-weeks gestation, showed a 4,000 g fetus. There are also obvious signs of non-reassuring fetal heart rate. The patient's sister had a cesarean hysterectomy, because of massive hemorrhage and the patient adamantly refuses a cesarean delivery, despite your efforts to assure her that this is the treatment of choice. Your best course of action is to A. consult with your hospital's ethics committee and then perform the cesarean delivery, if they agree with you B. document your recommendation and follow her request for no intervention C. obtain her husband's permission and proceed with the cesarean delivery D. obtain a court order to perform the cesarean delivery E. try to convince her family to change her mind Explanation: A 31-year-old woman with primary pulmonary hypertension is admitted to the hospital because of increasing shortness of breath, dyspnea on exertion, and increasing home oxygen requirements. The agent that will selectively decrease her pulmonary arterial pressures is A. hydralazine B. nifedipine C. nitrous oxide D. prostacyclin I E. sodium nitroprusside Explanation: A 45-year-old man with insulin dependent diabetes mellitus, peptic ulcer disease, hypercholesterolemia, and a motorcycle accident 10 weeks prior to this admission, has been on the telemetry floor for the last 3 days with shortness of breath and chest pain. His cardiac workup has been negative. An echocardiogram is pending. Vital signs have been stable with the exception of nightly low-grade fevers. There is no previous history of cardiopulmonary problems. During the accident he sustained multiple extremity fractures, and a pelvic fracture that required an external fixator for stabilization. The pin insertion sites for the external pelvis fixator became infected and the hardware was removed 10 days prior to this admission. He has 30 days of intravenous antibiotics remaining. On morning rounds, he complains of increased left wrist pain and swelling. He states that when he tries to hold his coffee cup the wrist pain increases. He denies any left hand or finger paresthesias. The left distal radius was fractured in the motorcycle accident. The left arm cast was removed 1 week ago after non-surgical management. He denies any new left wrist trauma. Physical examination reveals a left wrist with diffuse soft tissue swelling, that is fluctuant dorsally, with mild tenderness to palpation. Mild erythema and warmth are noted dorsally at the left wrist. Passive wrist flexion and extension exacerbates the wrist pain. The neurovascular examination is unremarkable in the left upper extremity. There is epitrochlear and axillary lymphadenopathy. The next best step in treating the left wrist pain, after x-rays are completed, is A. application of ice to the left wrist and elevation of the wrist. If the x-rays reveal any abnormalities then treat accordingly with a cast or splint and schedule orthopaedic follow up in 1 week B. aspiration of the fluctuant region of the left wrist; send the fluid for culture, sensitivity, and stat Gram stain; if the Gram stain is positive then plan for operative irrigation and debridement of the left wrist C. aspiration of the fluctuant region of the left wrist and the wrist joint. If the fluid has any color component to it, then plan for operative irrigation and debridement of the left wrist. Send the fluid for culture and sensitivity, a stat Gram stain, and ensure broad-spectrum antibiotic coverage D. if the x-rays are negative, then apply a resting splint to the left wrist; order occupational therapy to begin daily left wrist and hand therapy E. if the x-rays are negative, then aspirate the fluctuant region of the left wrist; send the fluid for a Gram stain, culture, and sensitivity; adjust the current intravenous antibiotic regimen pending the culture results A 35-year-old graduate student is in the hospital following a major motor vehicle accident. He was an unrestrained passenger in a car that was sideswiped by another vehicle traveling at 50 mph. The driver of the car that the patient was in was drunk and instantly killed. The patient suffered multiple fractures and blunt injuries to the abdomen. He is postoperative day two following a splenectomy and an open reduction internal fixation of a left femur fracture. He has had a normal postoperative course and is feeling well. Prior to discharging him to a rehabilitation facility, it is most important to A. encourage the patient to wear a seat belt when he is the driver B. encourage the patient to wear a seat belt when he is the driver or passenger C. question the patient regarding whether he was drinking alcohol prior to the accident D. recommend buying a car with airbags E. recommend buying a car with airbags and encourage him to wear a seat belt when he is the driver A 55-year-old man is in the intensive care unit for atrial fibrillation with rapid ventricular response. The patient was admitted from the emergency department after arrival with a blood pressure of 70/50 mm Hg with a heart rate of 180/min and irregular. After electrical cardioversion, the patient was started on digoxin and a beta blocking agent and admitted to the ICU. Frequent checks of the patient by the medical team throughout the night continue to show that the patient is in atrial fibrillation with a blood pressure averaging 115/60 mm Hg and a heart rate of 70-90/min. You are called to the patient's room by one of the floor nurses because the patient is complaining of chest pain. On arrival, the patient appears well but is sitting upright in bed, leaning forward, with his hand over his chest. His blood pressure remains at 110/50 mm Hg and his heart rate is irregular at 88/min. Auscultation of the chest reveals a rub over the left thorax with clear lungs. No murmurs or gallops are appreciated. While evaluating the patient, he becomes unresponsive. His radial pulse is barely palpable but is irregular at 110-140/min. Two other physicians are performing CPR and the patient has a stable and good airway. His jugular venous pulsations are visible at the angle of the mandible and his heart sounds are barely audible with a prominent rub. Lungs are clear with positive pressure mask breaths. The most appropriate next step is to A. attempt needle pericardiocentesis B. attempt needle thoracocentesis C. infusion of isotonic saline for blood pressure support D. synchronized cardioversion at 100 Joules E. unsynchronized cardioversion at 200 Joules A 53-year-old man is admitted to the hospital from the emergency department because of worsening confusion. He is brought in by a friend who reports that the patient has "liver disease", has been drinking lately, and has not been taking his medications. The friend tells you that he has gotten progressively more confused over the past few days. She only knows a vague history but thinks the patient has "cirrhosis". She does not think the patient has had a recent fall, even though he has not been without alcohol for any appreciable length of time. His temperature is 37.0 C (98.6 F), blood pressure is 120/70 mm Hg, and pulse is 100/min. He has deep scleral icterus and his skin is jaundiced. His lungs are clear, cardiac exam is normal, and he has a distended abdomen with shifting dullness. He is alert to person only and his neurological exam is normal with the exception of the inability to perform finger to nose touching and heel to shin maneuvers. He has asterixis. Laboratory studies show: SQ184 The most likely cause of his confusion is A. acute hyponatremia B. ascending cholangitis C. hepatic encephalopathy D. metabolic acidosis E. subdural hematoma Explanation: A 61-year-old woman is status post a right total hip replacement 3 hours ago. She underwent an uneventful replacement with hardware under spinal anesthesia. She is brought the postanesthesia care unit (PACU) sedated but alert and oriented to person, place, and time. Her past medical history is significant only for hypertension and gout for which she takes allopurinol and atenolol daily. On arrival to the PACU, she complains of some mild shortness of breath and chest pain. Over the past 3 hours, her shortness of breath significantly worsens and she has pleuritic chest pain on her right side. Her temperature is 37.0 C (98.6 F), blood pressure is 100/60 mm Hg, pulse is 128/min, and respirations are 32/min. She appears markedly dyspneic, but is alert and oriented to person, place, and time. Physical examination is remarkable for clear lung fields and jugular venous pulse visible at 12cm with the patient at 30 degrees elevation. There is no chest wall tenderness on palpation. The most appropriate immediate action is to A. administer a propranolol, intravenously B. administer morphine for pain control C. give the patient supplemental oxygen by face mask D. order a chest radiograph E. start warfarin therapy You are called to see a 45-year-old nursing home resident, who has been there since a motor vehicle accident that left him paralyzed from the neck down 2 months ago. He denies any active medical problems prior to his car accident 2 months ago. In the past month, he has noticed a rash on his back that is occasionally pruritic. He denies any systemic manifestations associated with the rash. He is confined to his bed and the nursing staff turns him to his side once per day by propping him back with multiple pillows. He has notable atrophy of all the extremities. Cutaneous examination reveals numerous non-folliculocentric inflammatory papules distributed over his posterior trunk. There is no involvement of the anterior trunk, extremities, face, or oral mucosa. The most appropriate management of this patient's condition is to A. prescribe oral minocycline B. prescribe a topical corticosteroid C. prescribe a topical tretinoin D. recommend a topical benzoyl peroxide E. tell the nurses to rotate the patient on his sides more frequently and keep his room at a cooler temperature You are the doctor on call in the well baby nursery at the community hospital. One of the nurses calls you to ask about one of your patients. The baby is now 30 hours old and was born full term via vaginal delivery to a healthy 28-year-old mother. There were no complications at the delivery and the baby has been feeding well. The nurse is concerned that the baby looks "yellow". You ask her to send for a bilirubin level. A few hours later she calls to tell you that the total bilirubin level has come back at 18 mg/dL with a direct bilirubin level of 0.6 mg/dL. The parents are now concerned about the baby's discoloration. The most appropriate next step is to A. reassure the mother that this is completely normal and no additional studies or treatment are indicated B. repeat the bilirubin level immediately as the result must be a lab error C. start phototherapy and repeat the bilirubin level in 6 hours D. transfer to the nearest neonatal intensive care unit for an exchange transfusion E. wait 6 hours and repeat the bilirubin level A 52-year-old woman is admitted to the hospital with shortness of breath, a productive cough with "yellowish sputum," fevers, and chills. She has a medical history significant for non-insulin dependent diabetes and depression for which she takes glyburide and sertraline. She has an allergy to penicillin, to which she gets severe hives. Her temperature is 38 C (100.4 F), blood pressure is 123/67 mmHg, pulse is 102/min, and respirations are 25/min. Her oxygen saturation on room air is 96%. Physical examination shows decreased breath sounds over the lower right lung field with dullness to percussion. A chest radiograph shows consolidation in her right lower lobe. The most appropriate next step is to A. obtain a sputum sample for Gram stain and culture B. obtain a surgery consult for an open lung biopsy C. order a CT scan of the chest D. order a ventilation-perfusion scan E. send her for bronchoalveolar lavage Explanation: A 3-day-old male infant in the neonatal unit has bilious vomiting for 24 hours. The child is inconsolable and will not feed. Vital signs are: temperature 38 C (100.4 F), pulse 110/min, blood pressure 80/50 mmHg, and respirations 20/min. Abdominal examination is unremarkable. A barium enema demonstrates the cecum to be in the left upper quadrant. There is no right lower quadrant mass on abdominal x-ray. Intravenous antibiotics and Ringer's solution are administered. The next step in treating this patient is A. bowel rest B. intussusception reduction with air C. intussusception reduction with contrast D. laparotomy E. repeat barium enema in 24 hours While in the hospital examining a patient with congestive heart failure, you run into a 30-year-old colleague who has just suffered a needle stick injury from a patient with known hepatitis B. She is very concerned about contracting the disease, because she has never been vaccinated against it. She is generally very healthy, takes a daily multivitamin, and an oral contraceptive agent. She smokes a few cigarettes a day, but denies any alcohol use. Her family history is significant for coronary disease and pancreatic carcinoma. Based upon the available information, you would advise her to A. check her hepatitis antibody titer and await results B. begin antiretroviral therapy immediately C. get the hepatitis B immune globulin (HBIG) D. get the hepatitis B vaccine E. get the hepatitis B vaccine and hepatitis B immune globulin (HBIG) A 78-year-old woman was admitted to the hospital with a new headache, visual changes, and jaw claudication. The nurse taking care of the patient calls you to say that no admission orders were written for this patient. You rush to the floor and review the chart and see that the laboratory studies that were ordered on admission, have returned and show an erythrocyte sedimentation rate of 97 mm/hr. You see that a temporal artery biopsy was done earlier today to rule out giant cell arteritis but nothing else has been ordered. Her symptoms are unchanged from admission. The next most appropriate action is to A. closely observe until the biopsy results are back B. initiate plasmapheresis C. start treatment with glatiramer D. start treatment with intravenous immunoglobulin E. start treatment with prednisone You are on call for the medical services and a nurse pages you to ask you to come speak with the family of one of the patient's. The patient is not your own, but one that you are cross covering for the evening. You know that the patient carries a new diagnosis of widely metastatic pancreatic cancer. On arrival to the floor, three members of the patient's family greet you. They are somewhat confrontational and are very insistent that their father not be told of his diagnosis. When you attempt to discuss with the family the reasons for this, they continue to demand that you agree and threaten to sue you and the hospital if you or any other members of the team inform their father, the patient, of his diagnosis. The most appropriate course of action at this time is to A. defer any discussion on the point until you talk with other members of the team B. tell the family that the patient will be told his diagnosis and they need to be more supportive of their father C. tell the family that the physician caring for the patient will talk with them in the morning D. tell the family that you will agree to their demands E. tell the family that your obligation is to the patient, not to them A 66-year-old man is postoperative day number 1 from his thoracic aortic aneurysm repair. He has a 6-year history of severe peripheral vascular disease and was diagnosed with a 4cm aortic aneurysm by computed tomography scan of his chest. The aneurysm had originated just distal to the left subclavian and extended just proximal to the celiac axis. The surgery went uneventfully and the patient was transported to the intensive care unit intubated with a spinal drain and cooling catheter. On arrival to the ICU his blood pressure was 150/90 mm Hg and he was given nitroprusside for pressure control. His blood pressure is now 70/palp and pluse is 130/min. His heart sounds are diminished. An electrocardiogram shows sinus tachycardia, with a beat-to-beat variability in the QRS amplitude. His extremities are cool to the touch. At this time the most likely diagnosis is A. acute rupture of a papillary muscle within the myocardium B. anaphylaxis C. cardiac tamponade D. neurogenic shock E. sepsis You are called to the labor floor in a community hospital because a 25-year-old patient of yours, who is 37 weeks pregnant, just presented to the triage area complaining of painful uterine contractions every 3 minutes lasting 90 seconds. Fetal well-being is assured via external fetal heart monitoring, and a sterile vaginal exam reveals a cervix that is 6-cm dilated. Her blood pressure is 90/50 mm Hg and urine dip is negative. You check her prenatal chart. She has had an uneventful normal pregnancy course, with prenatal care starting at 8 weeks. Prenatal labs were significant only for rubella non-immune and group B Streptococcus in a urine culture at 28 weeks. In addition to general intravenous hydration, the most appropriate management at this time is to administer A. ampicillin, intravenously B. magnesium sulfate, intravenously C. meperidine, intravenously D. oxytocin, intravenously E. Rubella vaccine A 59-year-old man with diabetes mellitus is admitted to the hospital because of a 4-day history of a cough with yellowish-brown sputum, fever, and chills. He tells you that he is allergic to penicillin, to which he gets severe urticaria. He reports a positive sick contact with a friend who was recently admitted with pneumonia. His temperature is 39 C (102.2 F), blood pressure is 123/67 mm Hg, pulse is 107/min, and respirations are 25/min. His room air oxygen saturation is 96%. Physical examination shows decreased breath sounds over his left lower lung field associated with dullness to percussion. A chest radiograph shows consolidation of the left lower lobe. A sputum Gram stain and culture shows Gram-positive cocci sensitive to cephalosporins and quinolones. A suitable treatment regimen given this data is to start the patient on A. ampicillin-sulbactam, intravenously B. cefuroxime, intravenously, if a penicillin skin test is negative C. cefuroxime, intravenously, if a penicillin skin test is positive D. gentamicin, intravenously E. vancomycin, orally A 61-year-old man underwent a total colectomy for ulcerative colitis 4 hours ago. He has a 15-year history of the disease and after a recent protracted flare that failed medical management, he was taken to the operating room for a colectomy. He received a lumbar epidural that was used for analgesia during his case and in the recovery room with good effect. You are called to see him on the floor for pain. The patient reports 9/10 pain on a visual-analog scale (VAS) and examination reveals that he has no appreciable sensory level from his epidural. The infusion drug is a mixture of 0.1% bupivacaine and hydromorphone and it is infusing at a maximal rate of 15cc/hour. The most appropriate management at this time is to A. bolus the catheter with the infusion mixture B. call the pain service C. discontinue the hydromorphone in the epidural mix and initiate patient controlled analgesia with morphine D. initiate intravenous morphine every 3 hours as needed E. maintain the hydromorphone in the epidural mixture and initiate patient controlled analgesia with morphine A 59-year-old woman with acute congestive heart failure is admitted to the intensive care unit. She was transferred from the medical floor where she was found to be in florid pulmonary edema with hypoxemia and respiratory distress. She was intubated by the anesthesia airway team at that time of transfer. She was transferred to the medical intensive care unit for aggressive diuresis and ventilator management. On arrival to the unit, it is determined that the patient will require frequent arterial blood samplings to monitor her ventilation status. A decision is made to place an indwelling arterial catheter for this purpose. The artery that carries with it the highest risk for complications when used for arterial cannulation is the A. brachial artery B. dorsalis pedis artery C. femoral artery D. radial artery E. ulnar artery A 52-year-old business executive is admitted to the hospital after coming to the emergency department following a transatlantic flight. He complained of increasing abdominal distension and discomfort. He lives in England and is currently on a business trip to New York City. He reports that he has had similar episodes twice in the past, one of which spontaneously resolved. During the second episode, he was admitted to a hospital and underwent "untwisting of a bowel loop by means of a tube in his back passage." His abdominal examination and abdominal x-ray are diagnostic of sigmoid volvulus, which is easily decompressed by a rectal tube. Now he is feeling much better and repeat abdominal x-rays have confirmed the disappearance of the volvulus. He requests to be discharged from the hospital so that he can complete his business transaction and fly back to London the following day. He promises to visit his surgeon at the earliest in England. The patient should be advised to A. go ahead with his plans B. seek a second opinion C. that he should not to fly without fixing his volvulus problem D. take a week rest before flying back E. undergo emergency surgery Six hours after a lumbar laminectomy for spinal stenosis, a 41-year-old man is complaining of pain. One month earlier he experienced pain with radicular signs and symptoms and was found by MRI to have L2 stenosis and cord impingement. He was taken to the operating room for successful laminectomy of L1-L3 segments. In the operating room the surgeons delivered intrathecal morphine for pain management. He did well in the recovery room, but on the floor, is complaining of pain. You are called to see the patient and he reports an 8/10 pain level on the visual-analog scale (VAS). The most appropriate management is to A. inject additional intrathecal morphine B. initiate intravenous morphine every 3 hours C. initiate intravenous morphine on an needed basis D. move the patient to a monitored bed and initiate intravenous morphine therapy E. tell him that he can have no additional pain medication A 23-year-old G1P0 is in the hospital after the delivery of a healthy baby girl 24 hours ago. She had an unassisted vaginal delivery after a prolonged induction of labor at 41-weeks gestational age. The placenta was expelled 10 minutes after delivery and it appeared to be intact. On the morning of the second hospitalization day, the patient reports heavy vaginal bleeding and minimal pain at the midline episiotomy site. Vital signs are: temperature 37.2 C (99.0 F), blood pressure 136/70 mm Hg, and pulse 90/min. Bimanual examination of the pelvis reveals a boggy uterus. The most appropriate initial management of this patient is A. hypogastric artery ligation B. selective arterial embolization C. uterine artery ligation D. uterine massage E. uterine packing A 42-year-old successful businessman comes to the office complaining of recent fevers reaching 38.3 C (102.8 F), a productive cough with brownish-colored sputum, and increasing dyspnea at rest. Physical examination reveals right-sided egophony on lung auscultation as well as dullness to percussion at the right base. A chest radiograph shows consolidation of the right middle lobe of the lung and a large pleural effusion. Decubitus chest films indicate that the effusion is loculated. A diagnostic thoracentesis is performed and reveals thick straw-colored pleural fluid. Culture results are pending, but chemical analysis of the pleural fluid shows: SQ335 A Gram stain of the pleural fluid indicates Gram-positive cocci. The patient is admitted to the hospital and started on intravenous antibiotics. The most appropriate next step in management is to A. arrange for immediate decortication B. do tube thoracostomy C. obtain a CT scan of the chest D. order a ventilation/perfusion scan E. schedule bronchial airway lavage You are called to see a patient with end-stage liver disease secondary to hepatitis C obtained from injection drug abuse. He reports that he has experienced increasing abdominal girth for the last 2 weeks. He also notes that his urine output has been minimal for the last 3 days, producing approximately 30 cc of urine each day. His temperature is 37 C (98.6 F), blood pressure is 95/60 mm Hg, pulse is 70/min, and respirations are 19/min. Physical examination reveals scleral icterus, huge abdominal distention with bulging flanks, and a fluid wave. His lower extremities have 2 edema. Laboratory studies show: Sodium 128 mEq/dL Potassium 4.8 mEq/dL Chloride 98 mEq/dL Bicarbonate 21 mEq/dL BUN 28 mg/dL Creatinine 3.2 mg/dL Urinalysis Color Clear Specific gravity 1.020 Osmolality 55 mOsmol/kg Leukocyte esterase Negative Nitrite Negative Protein Negative Blood Negative Microscopic Few hyaline casts Urine Sodium 4 mEq/L In an effort to increase urine output, you perform a therapeutic paracentesis and provide a fluid challenge with 500 ml normal saline. Urine output does not improve. He is "so sick of all of this" and wants to know what is the most effective treatment. He should be told that his condition can be most effectively managed with A. continued fluid resuscitation with normal saline B. intravenous albumin therapy C. liver transplantation D. renal dose dopamine therapy E. treatment with furosemide A 58-year-old man is admitted to the hospital directly from your office because of new-onset atrial fibrillation. He has no significant past medical history and does not take any medications. He is allergic to penicillin, to which he develops a rash. In the office, his blood pressure was 109/78 mmHg, pulse was 99/min, and respiratory rate was 22/min. An electrocardiogram demonstrated atrial fibrillation. Physical examination was remarkable for an irregularly irregular cardiac rhythm. While you are requesting further laboratory studies after arriving at his bedside the patient slumps over and becomes unresponsive. You immediately look to the continuous cardiac monitor and note that his heart rate is now 160/min and he is still in atrial fibrillation. His pulse is barely palpable. The most appropriate next step in management is to A. perform asynchronous cardioversion B. perform synchronous cardioversion C. order an immediate transesophageal echocardiogram D. schedule immediate cardiac catheterization E. schedule immediate placement of an intraaortic balloon pump A 21-year-old woman is admitted to the hospital because of a 3-day history of diarrhea and abdominal pain. Her bowel movements were loose, mucous-like and occasionally bloody. The patient reports no recent ingestions or any change in her diet. On further questioning, she reports that over the past few years she has occasionally had episodes such as these but that these have passed with a home remedy. She came to the hospital this time because her boyfriend was worried that she might be ill. On physical examination, the patient is thin and in no distress. Her abdominal examination shows diffuse tenderness to palpation but no rebound tenderness or guarding. The laboratory or diagnostic findings most supportive of the diagnosis of inflammatory bowel disease is A. elevated fecal fat content B. fecal Gram stain positive for organisms C. fecal gross blood D. fecal leukocytes E. positive fecal reducing substance test A 44-year-old man with metastatic liver cancer requires a central line for total parenteral nutrition. The patient was otherwise healthy until 3 months ago at which time he was diagnosed with liver cancer. A subsequent workup for metastatic disease disclosed that the tumor had already spread to his lungs, abdominal viscera, and brain. He is scheduled to begin chemotherapy and radiation therapy and will require nutritional support. The patient is given informed consent and the details of the procedure are discussed with him. A decision is made for a right subclavian line. The patient is positioned, prepped, and draped in a sterile manner and the skin is anesthetized with 1% lidocaine. During the procedure, the guidewire slips from your fingers and disappears through the lumen of the catheter. This patient is at greatest risk for A. atrial-septal perforation B. cardiac arrhythmia C. pneumothorax D. tricuspid valve damage E. ventricular perforation A 45-year-old woman with severe reflux disease secondary to a hiatal hernia is admitted to the hospital with flank pain from a kidney stone. An abdominal CT shows multiple stones in the right ureter and renal pelvis. On the floor, she is given intramuscular meperidine every 4 hours for pain control. Early in the morning the patient is found to be obtunded in moderate respiratory distress with some evidence of vomitus on her lips and bed shirt. She had been given 3 additional doses of meperidine for pain control in the past 5 hours. A chest radiograph will most likely show a A. diffuse bilateral airspace disease B. diffuse bilateral interstitial infiltrates C. right lower lobe opacification D. right pleural effusion E. widened mediastinum A 71-year-old man undergoes transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH) under spinal anesthesia. Towards the end of the resection the patient begins to complain of visual color changes. He is alert and oriented and his blood pressure and heart rate have been stable throughout the procedure. The procedure is aborted and the patient is taken to the recovery room. In the recovery room the patient's blood pressure is 160/110 mm Hg and pulse is 52/min. He is lethargic and confused. The most likely explanation for his symptoms is A. anemia B. hypercalcemia C. hyperkalemia D. hypermagnesemia E. hypernatremia F. hypocalcemia G. hypokalemia H. hypomagnesemia I. hyponatremia A 54-year-old man is admitted to the hospital because of a 30-minute history of substernal chest pain, difficulty breathing, and vomiting. His electrocardiogram on admission showed ST elevation in leads V4-V6, ST depression and inverted T waves in leads II, III, and aVF. Two hours later an electrocardiogram shows Q waves and laboratory studies show elevated troponin levels. His records indicate that he was treated with nitroglycerin, morphine, atenolol, oxygen, heparin, and aspirin. He tells you that he had a 5-minute "mini-stroke" 3 weeks before this incident, but he does not have any residual abnormalities. Today, he is complaining of sharp chest pain that increases when he is in the supine position. His temperature is 38.3 C (101.0 F), blood pressure is 110/70 mm Hg, and pulse is 85/min. An electrocardiogram shows ST elevations in leads V1-V6 and II, III, and aVF with diffuse PR interval depression. At this time the diagnosis is most likely to be A. acute pericarditis B. cardiac tamponade C. pulmonary embolism D. recurrent ischemia E. rupture of the intraventricular septum A 78-year-old nursing home resident is admitted to the hospital because of increasing left-sided abdominal pain for the past 48 hours. She has had several episodes of bloody diarrhea according to the nursing attendant at the nursing home. There was no associated fever or nausea or vomiting. On admission, her temperature is 37.3 C (99.1 F), blood pressure is 90/64 mm Hg, and pulse is 100/min. Her abdomen is soft and mildly distended without masses or organomegaly. There is moderate tenderness to palpation in the left lower quadrant, but no associated peritoneal signs. Rectal examination reveals guaiac-positive stool and no masses. A flexible sigmoidoscopic examination reveals patchy, depigmented mucosa. The most appropriate initial management of this patient is A. angiographic embolization of the inferior mesenteric artery B. intravenous fluid and bowel rest C. mesenteric angiogram D. sigmoid resection and colostomy E. subtotal colectomy A 45-year-old woman is admitted to the hospital after suffering an inhalational burn injury. She was found in her living room by a fire-rescue team. She presented to the hospital with laryngeal edema and was intubated in the emergency department. The patient is now in the intensive care unit and is mechanically ventilated and sedated. Her vital signs are stable; her body temperature is now 37 C (98.6 F). After discussion with the team, it is decided that the patient will need escharotomy and skin grafting procedures over the ensuing 3 days. The decision is made to keep the patient sedated and paralyzed. The drug that is contraindicated in this patient is A. cis-atracurium B. d-curare C. diazepam D. morphine E. succinylcholine A 71-year-old man is postoperative day number 12 from a heart transplant. The patient has a long-standing history of ischemic cardiomyopathy and successfully underwent a 5-hour transplant from a 22-year-old donor. During the procedure he was started on his immunosuppressive therapy that has continued. In the immediate postoperative period he did well. He was extubated on day number 1, had his pulmonary artery and radial arterial catheters removed on day number 3, and was transferred from the coronary care unit on day number 4 with excellent pain control. Over the past 3 days however, he has had increasing fever, lethargy, and mediastinal tenderness. The sternal wound appears mildly erythematous but nonsuppurative. On palpation, the incision site is tender. The most appropriate therapy is at this time is A. broad-spectrum antibiotics B. decreasing dose of immunosuppressive drugs C. initiate antifungal therapy D. surgical debridement E. there is no therapy indicated An 88-year-old man with a history of a 6.9 cm infrarenal abdominal aortic aneurysm is admitted to the hospital for elective aneurysm repair. His past medical history is significant for hypertension diagnosed 15 years ago, chronic bronchitis, and type II diabetes. His medications include albuterol, aspirin, atenolol, glyburide, metformin, and terazosin. Vital signs are: temperature 37.0 C (98.6 F), blood pressure 150/99 mm Hg, pulse 70/min, and respirations 8/min. The patient is awake, alert, and oriented to person, place, and time. The cardiac, lung, and abdominal examinations are normal. Rectal examination reveals an enlarged, nontender prostate without masses and the stool is heme-negative and brown. Laboratory studies show: SQ802 Before the surgery, the patient asks you about complications. He should be told that the major complication of this elective surgical procedure is A. cardiac tamponade B. delayed aneurysm rupture C. infection D. myocardial infarction E. mycotic aneurysm A 61-year-old man with a history of ulcerative colitis comes to the clinic with a 1-week history of abdominal distension and occasional nausea. He has also had intermittent constipation and diarrhea for the past 3 weeks. Physical examination reveals an obese male with a distended abdomen with normal bowel sounds. The abdomen is diffusely tender to touch. There is no rebound or hepatosplenomegaly. Rectal examination shows heme-negative stool. His hematocrit is 44% and leukocyte count is 7000/mm3. The most appropriate next step in the management of this patient is to A. do a flexible sigmoidoscopy B. insert a rectal tube C. order an abdominal radiograph D. prepare him for a total colectomy E. send him for a colonoscopy A 29-year-old man comes to the office because of a 6-month history of "bloating," and diffuse abdominal pain. He constantly feels like he has to loosen his belt, and he has gotten all the waists on his pants let out, despite no change in weight. He usually has 5-6 soft, non-bloody bowel movements throughout the day, but every few days he feels very constipated. His abdominal pain is often relieved by defecation. He does not think that he ever had a fever, does not take any medications, has no recent travel history, and is never awoken from sleep because of abdominal pain or the need to defecate. His temperature is 37.0 C (98.6 F). Physical examination and rectal examination are normal. Fecal occult blood testing is negative. You order a biochemical profile, thyroid function tests, complete blood count, and stool for ova and parasites. You perform a sigmoidoscopy and send him for a small bowel series, and a barium enema. He returns to the office after a 3-week lactose free diet to review the results of the studies, which were all unremarkable. At this time the most correct statement is: A. A high-fiber diet is the mainstay of treatment for this disorder B. His risk of colon cancer increases significantly after 10 years with this condition C. Microperforations, obstruction, peritonitis, fistula formation are complications of this condition D. Surgical resection is indicated if symptoms do not resolve with medical management E. Therapy with metronidazole should be initiated immediately A 37-year-old woman comes to the emergency department because of a 30-minute history of vomiting reddish-brown material. She informs you that she suffers from fibromyalgia syndrome and uses a number of "pain killers" to control her pain. Her blood pressure is 120/70 mm Hg and pulse is 110/min, no orthostasis. Physical examination is unremarkable. Her extremities are cool and her capillary refill is less than 2 seconds. A nasogastric tube is passed and returns 200 cc of coffee ground material that eventually clears with normal saline lavage. The patient is then sent for endoscopy. The most likely cause of this patient's gastrointestinal bleeding is A. esophageal varices B. esophagitis C. gastric neoplasm D. gastric ulcers E. Mallory Weiss tears A 54-year-old man with end-stage liver disease secondary to hepatitis C comes to the emergency department with fevers and mental status changes over the last 4 days. His wife reports that he has been compliant with his medications, which include furosemide, spironolactone, and lactulose up until today when he refused to take them. His temperature is 38.0 C (100.7 F), blood pressure is 100/70 mmHg, pulse is 103/min, and respirations are 19/min. Physical examination reveals a confused and slightly combative male with scleral icterus. His abdomen is distended with bulging flanks, shifting dullness, and a fluid wave. He has asterixis. There is no nuchal rigidity or photophobia. He is oriented to person but not place or time. The most appropriate next step in this patient's management is to A. determine his ammonia level B. order a CT scan of the head C. perform a lumbar puncture D. perform paracentesis E. send a urine culture and sensitivity A 67-year-old woman with peripheral vascular disease, bilateral leg claudication, and hypertension comes to the clinic because of nausea and severe, diffuse abdominal pain that she rates as 7/10 in intensity for the past 2 days. The pain is related to meals, particularly lunch. She has smoked a pack of cigarettes per day for the past 30 years. The patient has a temperature of 36.1 C/(97 F) with a pulse of 80/min and a blood pressure of 120/80 mm Hg. Abdominal examination demonstrates normal bowel sounds, no tenderness, and no hepatosplenomegaly. Laboratory studies reveal a leukocyte count of 4,000/mm3 and a hematocrit of 47%. You should be immediately suspicious of A. acute appendicitis B. acute cholecystitis C. malingering D. mesenteric ischemia E. ulcerative colitis A 39-year-old woman comes to the office because of "spasms" of abdominal pain and nausea over the past few hours. The pain, which is located in the right upper quadrant and radiates to the back, started a little while after she ate french fries at a fast food restaurant with her son. She has had similar episodes of pain in the past. Her temperature is 37.0 C (98.6 F), blood pressure is 120/80 mm Hg, pulse is 75/min, and respirations are 16/min. Physical examination shows mild right upper quadrant tenderness with no rebound or guarding. An ultrasound of the abdomen shows acoustic shadowing of opacities within the gallbladder lumen that change with the patient's position. Laboratory studies show a leukocyte count of 9,000/mm3. The most likely diagnosis is A. acute acalculous cholecystitis B. acute calculous cholecystitis C. acute cholangitis D. biliary colic E. primary sclerosing cholangitis A 55-year-old woman comes to the emergency department because of abdominal pain. She had just finished eating a steak dinner with her family when she suddenly experienced sharp, crampy pain in the upper right and middle of her abdomen. The pain has lasted for the past 3 hours and she is starting to feel nauseous. On physical examination, she is obese and in obvious discomfort. Her temperature is 38.8 C (101.8 F), blood pressure is 140/87 mm Hg, pulse is 90/min, and respirations are 16/min. Abdominal examination is significant for focal tenderness and guarding in her right upper quadrant. She is particularly tender when you palpate her right upper quadrant as she takes in a deep breath. The most appropriate next step in the evaluation of her abdominal pain is A. an abdominal x-ray B. a CT of the abdomen C. an endoscopic retrograde cholangiopancreatography (ERCP) D. serum liver function tests including bilirubin E. an ultrasonography of the abdomen A 17-year-old woman comes to the office complaining of a 3-month history of "crampy" abdominal pain along with alternating episodes of constipation and diarrhea. She reports that the pain has been worse recently since starting a new job, which she describes as "high stress." Pain also seems worse with eating fatty meals. Her temperature is 37.0 C (98.6F), blood pressure is 120/72 mm Hg, pulse is 63/min, and respirations are 10/min. Physical examination reveals a soft, non-tender, non-distended abdomen with normal bowel sounds and without organomegally. Her rectal exam reveals normal tone. The correct diagnosis would be supported by finding A. a biopsy with transmural intestinal inflammation B. fistula formation within the abdomen C. a history of bloody diarrhea D. a normal colonoscopy E. positive H. pylori antibody titers A 78-year-old woman comes to the geriatric clinic for a follow-up appointment. She was seen 3 weeks ago in the clinic for a routine appointment and was found to have a hematocrit of 28%. A rectal examination was positive for heme in the stool. Her only complaint is a long history of constipation. She has multiple medical problems including diabetes, hypertension, osteoarthritis, and a history of a myocardial infarction many years ago. To further evaluate her anemia, additional laboratory testing was initiated at that time. Since her last appointment, she had an outpatient barium enema and is now returning for the results of all her tests. An x-ray of the recto-sigmoid colon from the barium enema examination is shown. Serum laboratory tests are as follows: SQ785 Hg 9.8 g/dl Ferritin 10 ng/ml MCV 78 um3 At this time, the most appropriate next step is to A. admit the patient to the hospital for further evaluation B. do a colonoscopy C. encourage the patient to eat a high fiber diet D. order serum carcinoembryonic antigen (CEA-125) E. prescribe iron supplements A 52-year-old man, who recently transferred to the city, comes to the office for a first visit complaining of weight loss and frequent malodorous stools. He admits to abusing alcohol and reports that he has developed chronic pancreatitis from his alcoholism. For the past year, he has given up alcohol completely and has transferred his job to your city. He reports that he has lost 20 pounds over the past 3 months. In addition, he reports frequent, greasy, malodorous stools. He denies any recent alcohol consumption and any abdominal pain. Laboratory studies and a CT scan of the abdomen confirm the diagnosis of chronic pancreatitis. A 72-hour fecal fat collection confirms steatorrhea. The most appropriate treatment for this patient is A. endoscopic placement of pancreatic duct stent B. an enteric-coated pancreatic enzyme replacement tablet with meals and calcium-containing antacids C. a low-fat diet D. a non-enteric coated pancreatic enzyme replacement with H2 blockers E. octreotide You are evaluating a 72-year-old man brought to the emergency department in an altered mental status. He lives alone, but his neighbors informed paramedics that the patient was complaining of abdominal discomfort earlier in the day. Paramedics noted that there is evidence of vomiting at the bedside at the patient's home. The patient is wearing a wristband identifying him as an insulin-dependent diabetic. His temperature is 38.3 C (101 F), blood pressure is 106/60 mm Hg, pulse is 86/min, and oxygen saturation is 94% on room air. He is moaning in pain and is flexing his hips. His mucous membranes appear dry, and chest auscultation reveals coarse crepitations. Abdominal examination shows a distended, tender abdomen with guarding and hyperactive bowel sounds. His extremities are warm with diminished distal pulses. During the physical examination, particular attention should be given to his A. chest B. groin C. hips D. neurological status E. peripheral vasculature A 28-year-old white woman comes to the office with an 8-month history of weight loss, fatigue, and diarrhea. She states that she has stools approximately 6 times per day and there is blood present in the majority of them. She denies any personal or family history of previous gastrointestinal problems. Her temperature is 37.2 C (99.1 F), blood pressure is 120/80 mm Hg, and pulse is 110/min. Physical examination reveals present normoactive bowel sounds. Her abdomen is soft with diffuse tenderness without rebound or guarding. An office sigmoidoscopy reveals friable mucosa with multiple bleeding points and no areas of normal mucosa. A colonic mucosal biopsy is likely to show A. cobble stoning B. skip lesions C. superficial mucosal inflammation D. transmural inflammation E. villous atrophy A 73-year-old man with emphysema comes to the clinic with complaints of food getting stuck when he swallows, which has been getting progressively worse over the last 8 months. He denies problems swallowing liquids and thinks he has lost about 5 pounds. He used alcohol heavily for many years but quit drinking 10 years ago. He still smokes 1 pack of cigarettes per day and has done so since age 20. He uses albuterol, steroid inhalers and theophylline. His blood pressure is 123/73 mm Hg, pulse is 87/min, and respirations are 20/min. Physical examination reveals bilateral scattered wheezes in the lungs. A chest x-ray shows hyperexpansion and no nodules. The most appropriate next step in management is to A. order a barium esophagram B. order an esophageal manometry C. order an esophageal pH probe D. treat with omeprazole and follow up in 3 months E. treat with ranitidine and follow up in 3 months A 37-year-old woman comes to the office because of a "burning sensation" in the chest for the past 3 months. The "burning" typically begins in the "upper stomach and travels up to the neck." The symptoms worsen when she lies down to go to sleep. She is a chef at a local American restaurant, has 3 children, and has been married for 12 years. She "tries" to eat a healthy diet, but it is difficult because she is around food all day and night. She has no chronic medical conditions, takes no medications, and does not drink alcohol or caffeine-containing beverages. She recently quit smoking. Her temperature is 37.0 C (98.6 F), blood pressure is 120/80 mm Hg, pulse is 65/min, and respirations are 14/min. Physical examination is unremarkable. An electrocardiogram is unremarkable. A complete blood count and metabolic profile are normal. Serologic testing for H. pylori is negative. The most appropriate next step is to A. order ambulatory esophageal pH testing B. order an upper gastrointestinal barium radiograph C. recommend elevation of the head of bed and avoidance of food before bedtime D. schedule an upper endoscopy E. schedule esophageal manometry A 52-year-old man is brought to the emergency department by his wife because he has had "bright red blood pouring from his mouth" for the past 20 minutes. The wife tells you that he has a 4-year history of alcoholic cirrhosis and he continues to drink 1 or 2 beers per day. He also has hypertension and hypercholesterolemia. Two days prior to admission, he had an episode of hematemesis and this morning, had an additional episode. He is diaphoretic with a blood pressure of 80/50 mm Hg and pulse of 110/min. Physical examination shows scleral icterus and mild jaundice, a tense abdomen, and cool, moist extremities. The most appropriate immediate action is to A. begin large volume intravenous fluids B. insert a Minnesota tube C. perform an emergent portal-systemic surgical shunt D. provide intravenous pressors for blood pressure control E. send a blood bank sample for type and crossmatching A 2-year-old girl is brought to the emergency department because of the abrupt onset of spasms of severe, crampy abdominal pain. The mother says that she was "completely fine" earlier in the day. She picked her up from a "play date" at her friend's house, they picked up some fast food for dinner, and before she even started to eat, she became very irritable, and began complaining of pain. In the hospital bathroom, she had a bowel movement with mucus and blood. She is generally healthy and takes no medications. She is lying on the examination table wit

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