12-17-2011, 08:36 AM
18. A 50-year-old woman has had progressive dyspnea over the past 2 weeks and constant, sharp chest pain for 4 days. The pain is localized to the center of the chest and is worse while supine. She underwent a right, modified radical mastectomy and adjuvant chemotherapy for breast cancer 3 years ago. She has a history of hypothyroidism treated with thyroid replacement therapy. She has smoked one pack of cigarettes daily for 30 years and drinks two ounces of alcohol daily. She is dyspneic and diaphoretic. Her temperature is 37.2 C (99 F), blood pressure is 90/70 mm Hg with a pulsus paradoxus of 20 mm Hg, pulse is 110/min, and respirations are 28/min. Examination shows jugular venous distention to the angle of the mandible. The liver span is 14 cm with 4 cm of shifting abdominal dullness. Arterial blood gas analysis on room air shows a pH of 7.50, PCO2 of 30 mm Hg, and PO2 of 70 mm Hg. An x-ray film of the chest shows an enlarged cardiac silhouette with a globular configuration. An ECG shows sinus tachycardia with nonspecific ST-segment changes diffusely. Which of the following is the most appropriate next step in management?
A ) Echocardiography
B ) CT scan of the abdomen
C ) Ventilation-perfusion lung scans
D ) Bronchoscopy
E ) Paracentesis
28.
A 37-year-old man is brought to the emergency department 6 hours after the onset of constant, increasingly severe abdominal pain and nausea. His symptoms awoke him from sleep, and he has vomited once since that time. He has no history of similar symptoms, and he does not take any medications or use alcohol or illicit drugs. Family history is noncontributory. He is in acute distress and lying in the fetal position. Any movement exacerbates the pain. His temperature is 37.8 C (100 F), blood pressure is 108/68 mm Hg, pulse is 112/min, and respirations are 24/min. The lungs are clear to percussion and auscultation. Examination shows a rigid abdomen; bowel sounds are absent. Laboratory studies show:
Hemoglobin 14 g/dL
Leukocyte count 18,200/mm3
Platelet count 150,000/mm3
Serum
Urea nitrogen (BUN) 34 mg/dL
Creatinine 1.9 mg/dL
Total bilirubin 1.2 mg/dL
An x-ray film of the chest shows a small amount of free air under the left diaphragm. Administration of antibiotics and fluids is begun. Which of the following is the most appropriate next step in management?
A) Barium swallow
B) CT scan of the abdomen
C) Intravenous administration of an H2-receptor blocking agent
D) Upper endoscopy
E) Laparotomy
A ) Echocardiography
B ) CT scan of the abdomen
C ) Ventilation-perfusion lung scans
D ) Bronchoscopy
E ) Paracentesis
28.
A 37-year-old man is brought to the emergency department 6 hours after the onset of constant, increasingly severe abdominal pain and nausea. His symptoms awoke him from sleep, and he has vomited once since that time. He has no history of similar symptoms, and he does not take any medications or use alcohol or illicit drugs. Family history is noncontributory. He is in acute distress and lying in the fetal position. Any movement exacerbates the pain. His temperature is 37.8 C (100 F), blood pressure is 108/68 mm Hg, pulse is 112/min, and respirations are 24/min. The lungs are clear to percussion and auscultation. Examination shows a rigid abdomen; bowel sounds are absent. Laboratory studies show:
Hemoglobin 14 g/dL
Leukocyte count 18,200/mm3
Platelet count 150,000/mm3
Serum
Urea nitrogen (BUN) 34 mg/dL
Creatinine 1.9 mg/dL
Total bilirubin 1.2 mg/dL
An x-ray film of the chest shows a small amount of free air under the left diaphragm. Administration of antibiotics and fluids is begun. Which of the following is the most appropriate next step in management?
A) Barium swallow
B) CT scan of the abdomen
C) Intravenous administration of an H2-receptor blocking agent
D) Upper endoscopy
E) Laparotomy