04-13-2016, 10:04 PM
A 52-year-old woman comes to the physician because of a 2-month history of pain and swelling of her knees. She says she also has had stiffness of her knees, which is worse in the morning. During the past month, she has had progressive, generalized fatigue. On examination, the knees are warm, swollen, and tender. Any attempt at passive movement of the knees produces pain. Her hemoglobin concentration is 10 g/dL, leukocyte count is 10,000/mm3, and erythrocyte sedimentation rate is 50 mm/h. X-rays of the knees show osteopenia and subcartilaginous cysts around the joints. The joint spaces are intact. Which of the following is the most appropriate pharmacotherapy?
A
)
Oral alendronate
B
)
Oral colchicine
C
)
Oral ibuprofen
wrong D
)
Intra-articular injection of methylprednisolone
E
)
Intravenous cefazolin
Immediately after an episode of massive hematemesis, a 50-year-old man feels faint, cold, and sweaty. His pulse is 130/min, and blood pressure is 80/40 mm Hg; hematocrit is 40%. Which of the following is the most appropriate next step in patient care?
A
)
Rapid infusion of 5% dextrose in water
B
)
Rapid infusion of 0.9% isotonic saline
C
)
Insertion of a pulmonary artery catheter via the subclavian vein
wrong D
)
Gastric lavage with ice-cold saline until bleeding stops
E
)
Emergency esophagogastroduodenoscopy
A 27-year-old African American woman comes to the physician because of a 1-week history of a tight sensation in her chest and a nonproductive cough. The cough occurs most frequently at night after she goes to bed. She says she received breathing treatments in the emergency department for acute shortness of breath twice during the past 3 months and was told to stop smoking. She has a long-standing history of frequent upper respiratory tract infections. She currently takes no medications. She has smoked one pack of cigarettes daily for 10 years. Vital signs are within normal limits. End-expiratory wheezes are heard bilaterally. The remainder of the examination shows no abnormalities. A chest x-ray shows no abnormalities. Which of the following is the most likely underlying cause of this patient's symptoms?
A
)
Activation of mast cells
B
)
Embolism of intravascular thrombi
wrong C
)
Loss of elastin in the lung matrix
D
)
Necrotizing pulmonary vasculitis
E
)
Noncaseating granulomatous inflammation
A 27-year-old African American woman comes to the physician because of a 1-week history of a tight sensation in her chest and a nonproductive cough. The cough occurs most frequently at night after she goes to bed. She says she received breathing treatments in the emergency department for acute shortness of breath twice during the past 3 months and was told to stop smoking. She has a long-standing history of frequent upper respiratory tract infections. She currently takes no medications. She has smoked one pack of cigarettes daily for 10 years. Vital signs are within normal limits. End-expiratory wheezes are heard bilaterally. The remainder of the examination shows no abnormalities. A chest x-ray shows no abnormalities. Which of the following is the most likely underlying cause of this patient's symptoms?
A
)
Activation of mast cells
wrong B
)
Embolism of intravascular thrombi
C
)
Loss of elastin in the lung matrix
D
)
Necrotizing pulmonary vasculitis
E
)
Noncaseating granulomatous inflammation
Immediately after undergoing an upper gastrointestinal endoscopy and dilatation for achalasia, a 32-year-old woman has moderate substernal and midback pain. She has no history of serious illness. Her temperature is 37°C (98.6°F), pulse is 90/min, respirations are 22/min, and blood pressure is 110/80 mm Hg. The lungs are clear to auscultation. The abdomen is soft and nondistended. Esophagography shows a small leak of contrast from the distal esophagus into the left chest. In addition to intravenous antibiotic therapy, which of the following is the most appropriate next step in management?
A
)
Placement of an intraluminal esophageal stent
wrong B
)
Placement of a left chest tube
C
)
Nissen fundoplication
D
)
Esophagogastrectomy
E
)
Operative repair of the esophageal injury
A 74-year-old woman has a myocardial infarction and is admitted to the intensive care unit. Her blood pressure has decreased from 148/74 mm Hg to 80/62 mm Hg. She is confused and has cool clammy skin. Arterial blood gas analysis is most likely to show which of the following?
A
)
Hypoxemia with normal pH
B
)
Primary metabolic acidosis
wrong C
)
Primary metabolic alkalosis
D
)
Primary respiratory acidosis
E
)
Primary respiratory alkalosis
A previously healthy 21-year-old man comes to the emergency department 2 weeks after the onset of mild cough and runny nose. During the past 3 days, the cough has worsened with episodes so intense that he has vomited. The cough is productive of thick green sputum. He feels well between coughing episodes. He has not had fever, chest pain, or shortness of breath. He takes no medications. He is a college student. His temperature is 37.3°C (99.2°F), pulse is 70/min, respirations are 14/min, and blood pressure is 115/65 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 98%. Pulmonary examination shows no abnormalities. Which of the following is the most likely diagnosis?
wrong A
)
Influenza
B
)
Legionnaires disease
C
)
Pertussis
D
)
Psittacosis
E
)
Q fever
A 73-year-old man with hypertension is brought to the emergency department by paramedics 1 hour after the onset of moderate chest pain and difficulty breathing. Aspirin was administered en route to the hospital. He takes no other medications. On arrival, he is diaphoretic. His temperature is 37.2°C (98.9°F), pulse is 185/min and thready, respirations are 30/min, and blood pressure is 85/45 mm Hg. Pulse oximetry on 100% oxygen by face mask shows an oxygen saturation of 92%. Breath sounds are heard bilaterally. Cardiac examination shows a regular rhythm. A rhythm strip shows a wide complex tachycardia. Which of the following is the most appropriate initial step in management?
A
)
Administration of esmolol
B
)
Administration of nitroglycerin by intravenous drip
wrong C
)
Intravenous administration of morphine
D
)
Endotracheal intubation
E
)
Synchronized cardioversion
A 72-year-old woman is brought to the emergency department because of a 1-month history of progressive shortness of breath and fatigue. She has had no chest pain. There is no history of heart or pulmonary disease. She is in moderate respiratory distress. Her temperature is 37°C (98.6°F), pulse is 100/min, respirations are 22/min, and blood pressure is 135/85 mm Hg. Examination shows jugular venous distention. Crackles are heard halfway up both lungs. A grade 2/6, systolic ejection murmur is heard along the left sternal border. There is an S3. She has 2+ edema of the lower extremities. Rectal examination shows dark stool; test for occult blood is positive. Laboratory studies show:
Hemoglobin 5 g/dL
Leukocyte count 9000/mm3
Serum
Na+ 140 mEq/L
K+ 4 mEq/L
Cl− 105 mEq/L
HCO3− 25 mEq/L
Urea nitrogen 28 mg/dL
Glucose 120 mg/dL
Creatinine 1.2 mg/dL
Urine protein 1+
An x-ray of the chest shows a mildly enlarged cardiac silhouette with pulmonary vascular congestion. An ECG shows nonspecific ST-segment changes. Echocardiography shows trace mitral regurgitation and an ejection fraction of 70%; there are no wall motion abnormalities. Which of the following is the most likely cause of these findings?
A
)
High-output heart failure
wrong B
)
Left ventricular diastolic dysfunction
C
)
Left ventricular systolic dysfunction
D
)
Nephrotic syndrome
E
)
Valvular heart disease
An 82-year-old man has been mechanically ventilated in the hospital for the past 48 hours because of an exacerbation of chronic obstructive pulmonary disease. He has passed no urine since removal of a urinary catheter 12 hours ago. Current medications include intravenous methylprednisolone and albuterol, ipratropium, and fluticasone by inhalation. Which of the following is the most likely diagnosis?
A
)
Acute interstitial nephritis
B
)
Acute urethral obstruction
C
)
Contrast-induced nephropathy
D
)
End-stage renal disease
E
)
Hepatorenal syndrome
F
)
Ischemic acute tubular necrosis
wrong G
)
Myoglobinuric acute renal failure (rhabdomyolysis)
H
)
Prerenal azotemia
A previously healthy 22-year-old woman comes to the physician because of a 2-day history of fever, chills, and left flank pain. She also has had nausea and vomited four times during this period. Her temperature is 38.9°C (102°F), pulse is 110/min, and blood pressure is 90/60 mm Hg. The abdomen is soft with tenderness to percussion over the left flank. The remainder of the examination shows no abnormalities. Laboratory studies show:
Hematocrit 39%
Leukocyte count 22,000/mm3
Urine
RBC 10–20/hpf
WBC 20–50/hpf
Which of the following is the most appropriate pharmacotherapy?
A
)
Oral amoxicillin
B
)
Oral azithromycin
wrong C
)
Intravenous amoxicillin
D
)
Intravenous ceftriaxone
E
)
Intravenous metronidazole
A previously healthy 27-year-old woman comes to the physician because of swelling of her face and legs for 2 weeks. As the day progresses, her facial swelling resolves, but her legs become increasingly swollen. Her pulse is 64/min and regular, and blood pressure is 110/70 mm Hg. Cardiopulmonary examination shows no abnormalities. There is 1+ presacral edema and 2+ edema of the lower extremities. Her prothrombin time is 12 seconds (INR=1.1), and serum albumin concentration is 2.3 g/dL. Which of the following is the most likely cause of this patient's edema?
A
)
Cellulitis
wrong G
)
Malnutrition
B
)
Cirrhosis
H
)
Nephrotic syndrome
C
)
Congestive heart failure
I
)
Postphlebitic syndrome
D
)
Deep venous thrombosis
J
)
Pulmonary hypertension
E
)
Lymphangitis
K
)
Stasis dermatitis
F
)
Lymphedema
L
)
Varicose veins
A 64-year-old woman with a 4-year history of type 2 diabetes mellitus controlled with insulin comes to the emergency department because of exertional chest pressure for 3 weeks. The first episode occurred while she was walking upstairs and was relieved by 5 minutes of rest. The second episode occurred 1 week ago while she was mowing the lawn and was relieved after 10 minutes of rest. She had two episodes yesterday, each lasting 15 minutes; both occurred with exertion and were accompanied by shortness of breath and nausea. Today she had a 10-minute episode starting while she was in the shower and another while she was walking into the emergency department. Examination and an ECG show no abnormalities. Which of the following is the most appropriate next step in management?
A
)
Self-monitoring of blood glucose concentration during the next episode of chest pain
B
)
Dipyridamole-thallium-201 scintigraphy
wrong C
)
Exercise stress test within 24 hours
D
)
Antianginal drug therapy now and an exercise stress test in 5 days
E
)
Admit the patient to the hospital
A 68-year-old man is brought to the emergency department because of severe substernal chest pain for 2 hours and severe shortness of breath for 30 minutes. He has a history of type 2 diabetes mellitus treated with an oral hypoglycemic agent and hypertension treated with a diuretic. His temperature is 37.5°C (99.5°F), pulse is 104/min, respirations are 28/min, and blood pressure is 100/78 mm Hg. Jugular venous pressure is increased. Bilateral crackles are heard throughout all lung fields. An S3 and S4 gallop are heard. Pulse oximetry on room air shows an oxygen saturation of 88%. An x-ray of the chest shows bilateral perihilar infiltrates and a slightly enlarged cardiac silhouette. An ECG shows ST-segment elevation and T-wave inversion in leads V2 through V6. Which of the following is the most likely diagnosis?
wrong A
)
Acute pericarditis
B
)
Myocardial infarction
C
)
Pericardial tamponade
D
)
Pneumonia
E
)
Pulmonary embolism
A 47-year-old woman is brought to the emergency department because of a 1-day history of temperatures to 39.4°C (103°F) and shortness of breath and a 6-hour history of chest pain exacerbated by cough or inspiration. Three days ago, she started treatment with erythromycin for fever and cough productive of yellow sputum, but she discontinued the medication 24 hours later because of nausea and vomiting. She has autoimmune hepatitis that has been in remission for 3 years. She appears lethargic. Her temperature is 39°C (102.2°F), pulse is 120/min, respirations are 32/min, and blood pressure is 110/70 mm Hg. There is dullness to percussion over the left hemithorax two thirds of the way up from the lung bases. Breath sounds are decreased at the left base. Cardiac examination shows a hyperdynamic precordium with no rubs, gallops, or murmurs. Thoracentesis is performed. Laboratory studies show:
Hematocrit 40%
Leukocyte count 20,000/mm3
Segmented neutrophils 80%
Bands 15%
Lymphocytes 5%
Pleural fluid
Leukocyte count 50,000/mm3
pH 7.11
Glucose 20 mg/dL
Total protein 4 g/dL
Lactate dehydrogenase 400 U/L
Which of the following is the most appropriate next step in management?
A
)
Admission to the coronary care unit
B
)
Chest tube placement
wrong C
)
Instillation of talc in the pleural space
D
)
Intravenous corticosteroid therapy
E
)
Intravenous heparin therapy
F
)
Oral naproxen therapy
G
)
Pericardiocentesis
H
)
Surgical repair
A 65-year-old man has a positive test of the stool for occult blood during a routine examination. He has no personal or family history of gastrointestinal disorders. Which of the following is the most appropriate next step in evaluation?
A
)
Repeat test of the stool for occult blood in 6 weeks
B
)
Measurement of serum carcinoembryonic antigen (CEA) concentration
C
)
CT scan of the abdomen
wrong D
)
Flexible sigmoidoscopy
E
)
Colonoscopy