07-04-2016, 07:32 AM
A 62-year-old man is brought to the emergency department because of a 12-hour history of fever, fatigue, and severe pain in the toes of his left foot. He rates the pain as a 9 on a I O-point scale. He has not had abdominal pain. Six weeks ago, he was discharged from the hospital following antibiotic treatment for diverticulitis; at that time, he was prescribed a 14-day course of intravenous piperacillin and tazobactam to be administered at home via percutaneous intravenous catheter. He has hypertension treated with atenolol. His temperature is 38.9°C (102°F), pulse is 120/mm and regular, respirations are 22/mm, and blood pressure is 100/60 mm Hg. There is an
intravenous catheter in his medial right arm. A grade 2/6, decrescendo, diastolic murmur is heard best at the upper right sternal border. The abdomen is flat and nontender. There is no pedal edema. The second and third toes of the left foot are pale blue and tender. His leukocyte count is 17,000/mm 3(70% segmented neutrophils, 10% bands, and 20% lymphocytes). A blood culture is positive for Staphylococcus aureus. Echocardiography shows vegetations on the aortic valve. Which of the following is most likely to have prevented this complication?
A) Implantation of a port instead of a catheter for administration of piperacillin and tazobactam
B) Initiation of ampicillin and gentamicin therapy instead of piperacillin and tazobactam
C) Addition of fluconazole to the medication regimen for his diverticulitis
D) Removal of the percutaneous intravenous catheter after completion of piperacillin and tazobactam therapy
E) Administration of the pneumococcal polysaccharide vaccine, 23-valent, at discharge
Three weeks after undergoing arteriography through the right groin for
evaluation of progressive left calf claudication, a 64-year-old man is noted to have a palpable thrill and a continuous machinery murmur at the arteriography site. Examination shows decreased pedal pulses on
the right; pulses had been normal prior to the procedure. The arteriogram is shown. Which of the following factors is most predictive of the development of heart failure in this patient?
A) Degree of edema in the lower extremity
B) Groin compression causing bradycardia
C) Presence of pallor with elevation and dependent rubor
D) Presence of a pseudoaneurysm
E) Size of the abnormality
A 19-year-old man is brought to the emergency department 15 minutes after his motorcycle collided head-on with a truck. No loss of consciousness at the scene is reported. On arrival, he is agitated but oriented to person, place, and time. He responds to verbal commands. Supplemental oxygen and intravenous fluids are administered. His pulse is 115/mm, respirations are 18/mm, and blood pressure is 110/70 mm Hg. There are multiple abrasions over the forehead, chest, abdomen, and right lower extremity. The pupils are equal and reactive to light. The trachea is midline, and breath sounds are equal bilaterally. Heart sounds are normal. The abdomen is mildly distended, soft, and diffusely tender. His hemoglobin concentration is 11.8 g/dL, and leukocyte count is 14,000/mm3. Urinary
catheterization yields clear urine. X-rays of the cervical spine and pelvis show no abnormalities. An x-ray of the chest shows a moderate amount of free intra-abdominal air under the diaphragm. Which of the following is the most appropriate next step in management?
A) Lateral decubitus x-ray
B) CT scan of the abdomen
C) Upper gastrointestinal endoscopy
D) Diagnostic peritoneal lavage
E) Laparotomy
An 87-year-old woman is brought to the emergency department from a skilled nursing care facility because of six episodes of loose brown stools daily during the past week. There is no visible blood or mucus in the stool, and she has not had fever or abdominal pain. Five years ago, she sustained a cerebral infarction and has residual left hemiparesis. She has atrial fibrillation and multiple compression fractures from osteoporosis. Her medications include warfarin, digoxin, and famotidine. One month ago, she began taking acetaminophen with codeine for her most recent compression fracture. Her temperature is 37.1°C (98.8°F), pulse is 80/mm and irregular, respirations are 16/mm, and blood pressure is 130/75 mm Hg. Abdominal examination shows mild tenderness in the left lower quadrant. Bowel sounds are normal. Rectal examination shows normal tone with hard stool in the vault. Test of the stool for occult blood is negative. An abdominal x-ray shows copious stool throughout the bowel. There is no evidence of free air or obstruction. Which of the following is the most appropriate next step in management?
A) Elevation of the head of the bed during sleep
B) Elimination of milk from the diet
C) Elimination of spicy food from the diet
D) Enemas K) Stress management
E) Esophagogastroduodenoscopy
F) Left hemicolectomy
G) Low-fat diet
H) Mesenteric angiography
I) Omeprazole therapy
J) Recommendation to increase her milk consumption
L) Total proctocolectomy
M) Ultrasonography of the abdomen
N) Upper gastrointestinal series
A 27-year-old man comes to the emergency department 6 hours after being bitten during a fistfight. He has a 3 x 2-cm flap laceration on the dorsum of the right hand that extends into the subcutaneous fat. The surrounding tissues are contused. No tendons are exposed. The avulsed skin is cyanotic and insensate on a 1-cm margin. There is no bleeding. Which of the following is the most appropriate management?
A) Debridement and application of a sterile dressing to the open wound
B) Debridement and primary closure of the wound by mobilization of adjacent skin
C) Debridement and flap rotation to achieve tension-free primary closure of the wound
D) Debridement and split-thickness skin grafting to the soft-tissue defect
An otherwise healthy 47-year-old woman comes to the physician because of a 2-year history of increasingly severe heartburn. Current medications are cimetidine for the past 2 years and an over-the-counter antacid as needed; neither medication has relieved the symptoms. She has smoked one pack of cigarettes daily for 20 years and drinks three to four beers daily. She is 157 cm (5 ft 2 in) tall and weighs 59 kg (130 lb); BMI is 24 kg/rn2. Vital signs are within normal limits. Scattered wheezes are heard bilaterally. Cardiac and abdominal examinations show no abnormalities. Findings on ECG are normal. A chest x-ray shows an air-fluid level posterior to the cardiac silhouette. A barium swallow shows the proximal stomach herniating through the esophageal hiatus. Which of the following is
the most appropriate next step in diagnosis?
A) 24-Hour pH monitoring
B) Endoscopic ultrasonography
C) Esophageal manometry
D) Esophagogastroduodenoscopy
E) Thoracoscopy
A previously healthy 47-year-old man is admitted to the hospital because of a 3-day history of constant increasingly severe abdominal pain. A diagnosis of diverticulitis is made, and bowel rest and antibiotic treatment are recommended. The patient insists that he undergo an operation to relieve the pain. A second opinion is obtained from an independent physician who states that an operation is contraindicated, because it carries an unacceptable level of risk and will not improve the patient’s condition. After prolonged discussion with the patient and his wife, the patient continues to insist that he undergo an operation. Which of the following is the most appropriate course of action?
A) Ask the patient’s wife to formally refuse the operation on the patient’s behalf
B) Obtain a court order to refuse the operation
C) Obtain permission from the hospital ethics committee not to perform the operation
D) Proceed with the operation
E) Refuse to proceed with the operation
A 63-year-old man has had dysphagia and chest pain during meals for 4 months. He has a 6-year history of gastroesophageal reflux. He has limited his intake to liquids for 3 weeks because he regurgitates solid food. Which of the following is the most likely cause of his symptoms?
A) Disordered neuromuscular transmission in the esophagus
B) Disordered neuromuscular transmission in the oropharynx
C) Failure of oropharyngeal propulsion
D) Paraesophageal hiatal hernia
E) Stricture of the distal esophagus
Four days after admission to the hospital for treatment of metastatic breast cancer with chemotherapy, a 42-year-old woman has increased pain of the extremities and ribs. She has a history of hypertension and renal insufficiency. She underwent bilateral mastectomy 4 years ago. She is currently taking acetaminophen with codeine (two tablets four times daily) and amitriptyline (50 mg at bedtime) with no relief of pain. She sleeps well but awakens early because of pain. Her appetite is good. Her pulse is 100/mm and regular, respirations are 20/mm, and blood pressure is 100/80 mm Hg. The pupils are round and reactive. There is tenderness to palpation of the chest wall and vertebrae. She is alert and oriented but winces in pain when she moves. She says that she does not feel depressed but occasionally wishes that she would not wake up. She is hopeful that she will get better. Her mood is reserved, but she smiles when she discusses her children. Laboratory studies are pending. Which of the following is the most appropriate next step
in management?
A) Carbamazepine therapy
B) Clonazepam therapy
C) Oxycodone therapy
D) Paroxetine therapy
E) Valproic acid therapy
F) Regional nerve blockade
A previously healthy 37-year-old woman is brought to the emergency department immediately after her husband found her lying in bed in a deep stupor. She has no history of a seizure disorder, and she does not take any medications. Her temperature is 37.5°C (99.5°F), pulse is 54/mm, and blood pressure is 180/1 00 mm Hg. Examination shows a dense left hemiparesis and early decerebrate posturing. There is no evidence of trauma. Which of the following is the most likely diagnosis?
A) Arteriovenous malformation
B) Brain abscess
C) Meningioma
D) Ruptured intracerebral aneurysm
E) Thrombosed middle cerebral artery
intravenous catheter in his medial right arm. A grade 2/6, decrescendo, diastolic murmur is heard best at the upper right sternal border. The abdomen is flat and nontender. There is no pedal edema. The second and third toes of the left foot are pale blue and tender. His leukocyte count is 17,000/mm 3(70% segmented neutrophils, 10% bands, and 20% lymphocytes). A blood culture is positive for Staphylococcus aureus. Echocardiography shows vegetations on the aortic valve. Which of the following is most likely to have prevented this complication?
A) Implantation of a port instead of a catheter for administration of piperacillin and tazobactam
B) Initiation of ampicillin and gentamicin therapy instead of piperacillin and tazobactam
C) Addition of fluconazole to the medication regimen for his diverticulitis
D) Removal of the percutaneous intravenous catheter after completion of piperacillin and tazobactam therapy
E) Administration of the pneumococcal polysaccharide vaccine, 23-valent, at discharge
Three weeks after undergoing arteriography through the right groin for
evaluation of progressive left calf claudication, a 64-year-old man is noted to have a palpable thrill and a continuous machinery murmur at the arteriography site. Examination shows decreased pedal pulses on
the right; pulses had been normal prior to the procedure. The arteriogram is shown. Which of the following factors is most predictive of the development of heart failure in this patient?
A) Degree of edema in the lower extremity
B) Groin compression causing bradycardia
C) Presence of pallor with elevation and dependent rubor
D) Presence of a pseudoaneurysm
E) Size of the abnormality
A 19-year-old man is brought to the emergency department 15 minutes after his motorcycle collided head-on with a truck. No loss of consciousness at the scene is reported. On arrival, he is agitated but oriented to person, place, and time. He responds to verbal commands. Supplemental oxygen and intravenous fluids are administered. His pulse is 115/mm, respirations are 18/mm, and blood pressure is 110/70 mm Hg. There are multiple abrasions over the forehead, chest, abdomen, and right lower extremity. The pupils are equal and reactive to light. The trachea is midline, and breath sounds are equal bilaterally. Heart sounds are normal. The abdomen is mildly distended, soft, and diffusely tender. His hemoglobin concentration is 11.8 g/dL, and leukocyte count is 14,000/mm3. Urinary
catheterization yields clear urine. X-rays of the cervical spine and pelvis show no abnormalities. An x-ray of the chest shows a moderate amount of free intra-abdominal air under the diaphragm. Which of the following is the most appropriate next step in management?
A) Lateral decubitus x-ray
B) CT scan of the abdomen
C) Upper gastrointestinal endoscopy
D) Diagnostic peritoneal lavage
E) Laparotomy
An 87-year-old woman is brought to the emergency department from a skilled nursing care facility because of six episodes of loose brown stools daily during the past week. There is no visible blood or mucus in the stool, and she has not had fever or abdominal pain. Five years ago, she sustained a cerebral infarction and has residual left hemiparesis. She has atrial fibrillation and multiple compression fractures from osteoporosis. Her medications include warfarin, digoxin, and famotidine. One month ago, she began taking acetaminophen with codeine for her most recent compression fracture. Her temperature is 37.1°C (98.8°F), pulse is 80/mm and irregular, respirations are 16/mm, and blood pressure is 130/75 mm Hg. Abdominal examination shows mild tenderness in the left lower quadrant. Bowel sounds are normal. Rectal examination shows normal tone with hard stool in the vault. Test of the stool for occult blood is negative. An abdominal x-ray shows copious stool throughout the bowel. There is no evidence of free air or obstruction. Which of the following is the most appropriate next step in management?
A) Elevation of the head of the bed during sleep
B) Elimination of milk from the diet
C) Elimination of spicy food from the diet
D) Enemas K) Stress management
E) Esophagogastroduodenoscopy
F) Left hemicolectomy
G) Low-fat diet
H) Mesenteric angiography
I) Omeprazole therapy
J) Recommendation to increase her milk consumption
L) Total proctocolectomy
M) Ultrasonography of the abdomen
N) Upper gastrointestinal series
A 27-year-old man comes to the emergency department 6 hours after being bitten during a fistfight. He has a 3 x 2-cm flap laceration on the dorsum of the right hand that extends into the subcutaneous fat. The surrounding tissues are contused. No tendons are exposed. The avulsed skin is cyanotic and insensate on a 1-cm margin. There is no bleeding. Which of the following is the most appropriate management?
A) Debridement and application of a sterile dressing to the open wound
B) Debridement and primary closure of the wound by mobilization of adjacent skin
C) Debridement and flap rotation to achieve tension-free primary closure of the wound
D) Debridement and split-thickness skin grafting to the soft-tissue defect
An otherwise healthy 47-year-old woman comes to the physician because of a 2-year history of increasingly severe heartburn. Current medications are cimetidine for the past 2 years and an over-the-counter antacid as needed; neither medication has relieved the symptoms. She has smoked one pack of cigarettes daily for 20 years and drinks three to four beers daily. She is 157 cm (5 ft 2 in) tall and weighs 59 kg (130 lb); BMI is 24 kg/rn2. Vital signs are within normal limits. Scattered wheezes are heard bilaterally. Cardiac and abdominal examinations show no abnormalities. Findings on ECG are normal. A chest x-ray shows an air-fluid level posterior to the cardiac silhouette. A barium swallow shows the proximal stomach herniating through the esophageal hiatus. Which of the following is
the most appropriate next step in diagnosis?
A) 24-Hour pH monitoring
B) Endoscopic ultrasonography
C) Esophageal manometry
D) Esophagogastroduodenoscopy
E) Thoracoscopy
A previously healthy 47-year-old man is admitted to the hospital because of a 3-day history of constant increasingly severe abdominal pain. A diagnosis of diverticulitis is made, and bowel rest and antibiotic treatment are recommended. The patient insists that he undergo an operation to relieve the pain. A second opinion is obtained from an independent physician who states that an operation is contraindicated, because it carries an unacceptable level of risk and will not improve the patient’s condition. After prolonged discussion with the patient and his wife, the patient continues to insist that he undergo an operation. Which of the following is the most appropriate course of action?
A) Ask the patient’s wife to formally refuse the operation on the patient’s behalf
B) Obtain a court order to refuse the operation
C) Obtain permission from the hospital ethics committee not to perform the operation
D) Proceed with the operation
E) Refuse to proceed with the operation
A 63-year-old man has had dysphagia and chest pain during meals for 4 months. He has a 6-year history of gastroesophageal reflux. He has limited his intake to liquids for 3 weeks because he regurgitates solid food. Which of the following is the most likely cause of his symptoms?
A) Disordered neuromuscular transmission in the esophagus
B) Disordered neuromuscular transmission in the oropharynx
C) Failure of oropharyngeal propulsion
D) Paraesophageal hiatal hernia
E) Stricture of the distal esophagus
Four days after admission to the hospital for treatment of metastatic breast cancer with chemotherapy, a 42-year-old woman has increased pain of the extremities and ribs. She has a history of hypertension and renal insufficiency. She underwent bilateral mastectomy 4 years ago. She is currently taking acetaminophen with codeine (two tablets four times daily) and amitriptyline (50 mg at bedtime) with no relief of pain. She sleeps well but awakens early because of pain. Her appetite is good. Her pulse is 100/mm and regular, respirations are 20/mm, and blood pressure is 100/80 mm Hg. The pupils are round and reactive. There is tenderness to palpation of the chest wall and vertebrae. She is alert and oriented but winces in pain when she moves. She says that she does not feel depressed but occasionally wishes that she would not wake up. She is hopeful that she will get better. Her mood is reserved, but she smiles when she discusses her children. Laboratory studies are pending. Which of the following is the most appropriate next step
in management?
A) Carbamazepine therapy
B) Clonazepam therapy
C) Oxycodone therapy
D) Paroxetine therapy
E) Valproic acid therapy
F) Regional nerve blockade
A previously healthy 37-year-old woman is brought to the emergency department immediately after her husband found her lying in bed in a deep stupor. She has no history of a seizure disorder, and she does not take any medications. Her temperature is 37.5°C (99.5°F), pulse is 54/mm, and blood pressure is 180/1 00 mm Hg. Examination shows a dense left hemiparesis and early decerebrate posturing. There is no evidence of trauma. Which of the following is the most likely diagnosis?
A) Arteriovenous malformation
B) Brain abscess
C) Meningioma
D) Ruptured intracerebral aneurysm
E) Thrombosed middle cerebral artery