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HIV

A 27-year-old primigravid woman comes to the physician for her first prenatal visit 10 weeks after a home pregnancy test was positive. She feels well, and her pregnancy has been uncomplicated. She previously used an oral contraceptive but discontinued it 3 months ago. She has no history of sexually transmitted diseases. She is sexually active in a monogamous relationship with a male partner who is the father. She has had five lifetime sexual partners. She has a pet cat. Examination shows a uterus consistent in size with a 10-week gestation. Testing for which of the following infectious conditions is the most appropriate recommendation for this patient?

D

Withdraw from the study now

An investigator would like to decrease the incidence of type 2 diabetes mellitus among adult patients with risk factors including obesity, decreased physical activity, and family history of diabetes mellitus. A total of 200 men and women aged 30 to 64 years will be enrolled in a regular exercise program for 6 months. A nurse reviews the details of the study with each participant, and each participant signs an informed consent form. One month after the study begins, one of the participants asks to drop out of the study. Which of the following represents the most appropriate next step by this study participant?

E

Measurement of postvoid residual volume

A 70-year-old man comes to the clinic because of a 3-day history of fatigue, dark urine, decreased urine output, mild pain with urination, and a low-grade fever. He has gout, hypertension, and osteoarthritis. His medications are allopurinol, hydrochlorothiazide, and acetaminophen. Temperature is 37.9°C (100.2°F), pulse is 88/min, respirations are 24/min, and blood pressure is 160/95 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 97%. Jugular venous pressure is 7 cm H2O (N=5–9). Cardiopulmonary examination shows no abnormalities. Which of the following is the most appropriate next step in management?

C

Vancomycin

A 52-year-old woman comes to the physician because of a 2-day history of severe pain and markedly decreased range of motion in her right elbow. She has rheumatoid arthritis in her elbows, wrists, and hands. She reports episodes of moderate pain approximately four times yearly. Previous treatment with naproxen, methotrexate, and hydroxychloroquine has provided moderate relief. Treatment with prednisone was begun after her most recent episode 9 weeks ago. She has not had generalized fatigue or muscle aches. She has no other history of serious illness. Her other medications are naproxen, prednisone, and omeprazole. Temperature is 38.4°C (101.1°F), pulse is 90/min, respirations are 12/min, and blood pressure is 110/76 mm Hg. Range of motion of the wrists and ankles is decreased; the right elbow is more severely limited by pain than the left elbow. There is warmth, tenderness, erythema, and edema of the right elbow. Fine-needle aspiration of the right elbow is performed. Gram stain of the fluid shows a leukocyte count of 60,000/mm3 and no organisms. Which of the following is the most appropriate pharmacotherapy?

E

5

Abstract:Objective:In patients with cirrhosis and acute bleeding esophageal varices, how do endoscopic sclerotherapy and emergency portacaval shuntcompare for control of bleeding and survival?MethodsDesign: Randomized controlled trial (San Diego Bleeding Esophageal Varices Study). ClinicalTrials.gov NCT00690027.Allocation: Concealed.Blinding: Blinded (gastroenterologist who evaluated patients for portal-systemic encephalopathy).Follow-up period: Up to 17 years.Setting: University of California San Diego Medical Center.Patients: 211 patients (mean age 49 years, 77% men) with acute bleeding esophageal varices resulting from cirrhosis, who required a transfusion of ≥ 2 units of blood and, for patients transferred from other hospitals, observation of upper gastrointestinal bleeding within 48 hours of transfer. Exclusion criterion was > 1 previous session of endoscopic sclerotherapy.Intervention: Endoscopic sclerotherapy (n = 106) or emergency portacaval shunt (n = 105). Emergency portacaval shunt comprised a direct side-to-side or direct end-to-side portacaval shunt done within 8 hours of initial contact.Outcomes: Control of bleeding at > 30 days, survival, readmissions for variceal or nonvariceal bleeding requiring transfusion of packed red blood cells, and recurrent portal-systemic encephalopathy.Patient follow-up: 100% (minimum follow-up until death or 9.4 years).Main results15-year survival was lower with endoscopic sclerotherapy than with emergency portacaval shunt (10/106 vs 48/105, relative benefit reduction 79%, 95% CI 62 to 89; number needed to harm 3, CI 2 to 4). Other main results are shown in the Table.Endoscopic sclerotherapy (EST) vs emergency portacaval shunt (EPCS) in patients with cirrhosis and acute bleeding esophageal varicesOutcomes | Child-Pugh risk class | EST | EPCS | P value | ————————————————————————————————————Control of bleeding at > 30 days* | | 20% | 100% | <.001 | Median survival (years) | A | 4.62 | 10.43 | .003. | | B | 2.61 | 6.19 | <.001 | |. C | 0.58 | 5.30 | .005. |Mean number of readmissions for variceal bleeding requiring packed red blood cell transfusion | | 6.8 | 0.4 | <.001 | Recurrent portal-systemic encephalopathy† | | 35% | 15% | < .001 |———————————————————————————————————*Excluding indeterminate deaths at 14 days from nonbleeding causes.†In patients who survived 30 days and left hospital.———————————————————————————————————ConclusionIn patients with cirrhosis and acute bleeding esophageal varices, emergency portacaval shunt was better than endoscopic sclerotherapy for control of bleeding, recurrent encephalopathy, and survival.Sources of funding: National Institutes of Health and Surgical Education and Research Foundation.Structured abstract based on: Orloff MJ, Isenberg JI, Wheeler HO, et al. Randomized trial of emergency endoscopic sclerotherapy versus emergency portacaval shunt for acutely bleeding esophageal varices in cirrhosis. J Am Coll Surg.2009;209:25-40. 19651060A 52-year-old man with hepatic cirrhosis comes to the emergency department because of a 3-hour history ofvomiting blood. Esophagogastroduodenoscopy confirms actively bleeding esophageal varices. Based on the abstractshown, the physician is considering an emergency portacaval shunt (EPCS) procedure rather than endoscopicsclerotherapy (EST). According to the results in the abstract, approximately how many patients must be treated withEPCS rather than EST to prevent one case of recurrent portal-systemic encephalopathy?

C

EPCS is available only at specialty centers

Abstract:Objective:In patients with cirrhosis and acute bleeding esophageal varices, how do endoscopic sclerotherapy and emergency portacaval shuntcompare for control of bleeding and survival?MethodsDesign: Randomized controlled trial (San Diego Bleeding Esophageal Varices Study). ClinicalTrials.gov NCT00690027.Allocation: Concealed.Blinding: Blinded (gastroenterologist who evaluated patients for portal-systemic encephalopathy).Follow-up period: Up to 17 years.Setting: University of California San Diego Medical Center.Patients: 211 patients (mean age 49 years, 77% men) with acute bleeding esophageal varices resulting from cirrhosis, who required a transfusion of ≥ 2 units of blood and, for patients transferred from other hospitals, observation of upper gastrointestinal bleeding within 48 hours of transfer. Exclusion criterion was > 1 previous session of endoscopic sclerotherapy.Intervention: Endoscopic sclerotherapy (n = 106) or emergency portacaval shunt (n = 105). Emergency portacaval shunt comprised a direct side-to-side or direct end-to-side portacaval shunt done within 8 hours of initial contact.Outcomes: Control of bleeding at > 30 days, survival, readmissions for variceal or nonvariceal bleeding requiring transfusion of packed red blood cells, and recurrent portal-systemic encephalopathy.Patient follow-up: 100% (minimum follow-up until death or 9.4 years).Main results15-year survival was lower with endoscopic sclerotherapy than with emergency portacaval shunt (10/106 vs 48/105, relative benefit reduction 79%, 95% CI 62 to 89; number needed to harm 3, CI 2 to 4). Other main results are shown in the Table.Endoscopic sclerotherapy (EST) vs emergency portacaval shunt (EPCS) in patients with cirrhosis and acute bleeding esophageal varicesOutcomes | Child-Pugh risk class | EST | EPCS | P value | ————————————————————————————————————Control of bleeding at > 30 days* | | 20% | 100% | <.001 | Median survival (years) | A | 4.62 | 10.43 | .003. | | B | 2.61 | 6.19 | <.001 | |. C | 0.58 | 5.30 | .005. |Mean number of readmissions for variceal bleeding requiring packed red blood cell transfusion | | 6.8 | 0.4 | <.001 | Recurrent portal-systemic encephalopathy† | | 35% | 15% | < .001 |———————————————————————————————————*Excluding indeterminate deaths at 14 days from nonbleeding causes.†In patients who survived 30 days and left hospital.———————————————————————————————————ConclusionIn patients with cirrhosis and acute bleeding esophageal varices, emergency portacaval shunt was better than endoscopic sclerotherapy for control of bleeding, recurrent encephalopathy, and survival.Sources of funding: National Institutes of Health and Surgical Education and Research Foundation.Structured abstract based on: Orloff MJ, Isenberg JI, Wheeler HO, et al. Randomized trial of emergency endoscopic sclerotherapy versus emergency portacaval shunt for acutely bleeding esophageal varices in cirrhosis. J Am Coll Surg.2009;209:25-40. 19651060Which of the following most strongly limits the generalizability of this study's findings?

B

EPCS is more effective than EST in decreasing hospital readmissions for variceal bleeding requiring

Abstract:Objective:In patients with cirrhosis and acute bleeding esophageal varices, how do endoscopic sclerotherapy and emergency portacaval shuntcompare for control of bleeding and survival?MethodsDesign: Randomized controlled trial (San Diego Bleeding Esophageal Varices Study). ClinicalTrials.gov NCT00690027.Allocation: Concealed.Blinding: Blinded (gastroenterologist who evaluated patients for portal-systemic encephalopathy).Follow-up period: Up to 17 years.Setting: University of California San Diego Medical Center.Patients: 211 patients (mean age 49 years, 77% men) with acute bleeding esophageal varices resulting from cirrhosis, who required a transfusion of ≥ 2 units of blood and, for patients transferred from other hospitals, observation of upper gastrointestinal bleeding within 48 hours of transfer. Exclusion criterion was > 1 previous session of endoscopic sclerotherapy.Intervention: Endoscopic sclerotherapy (n = 106) or emergency portacaval shunt (n = 105). Emergency portacaval shunt comprised a direct side-to-side or direct end-to-side portacaval shunt done within 8 hours of initial contact.Outcomes: Control of bleeding at > 30 days, survival, readmissions for variceal or nonvariceal bleeding requiring transfusion of packed red blood cells, and recurrent portal-systemic encephalopathy.Patient follow-up: 100% (minimum follow-up until death or 9.4 years).Main results15-year survival was lower with endoscopic sclerotherapy than with emergency portacaval shunt (10/106 vs 48/105, relative benefit reduction 79%, 95% CI 62 to 89; number needed to harm 3, CI 2 to 4). Other main results are shown in the Table.Endoscopic sclerotherapy (EST) vs emergency portacaval shunt (EPCS) in patients with cirrhosis and acute bleeding esophageal varicesOutcomes | Child-Pugh risk class | EST | EPCS | P value | ————————————————————————————————————Control of bleeding at > 30 days* | | 20% | 100% | <.001 | Median survival (years) | A | 4.62 | 10.43 | .003. | | B | 2.61 | 6.19 | <.001 | |. C | 0.58 | 5.30 | .005. |Mean number of readmissions for variceal bleeding requiring packed red blood cell transfusion | | 6.8 | 0.4 | <.001 | Recurrent portal-systemic encephalopathy† | | 35% | 15% | < .001 |———————————————————————————————————*Excluding indeterminate deaths at 14 days from nonbleeding causes.†In patients who survived 30 days and left hospital.———————————————————————————————————ConclusionIn patients with cirrhosis and acute bleeding esophageal varices, emergency portacaval shunt was better than endoscopic sclerotherapy for control of bleeding, recurrent encephalopathy, and survival.Sources of funding: National Institutes of Health and Surgical Education and Research Foundation.Structured abstract based on: Orloff MJ, Isenberg JI, Wheeler HO, et al. Randomized trial of emergency endoscopic sclerotherapy versus emergency portacaval shunt for acutely bleeding esophageal varices in cirrhosis. J Am Coll Surg.2009;209:25-40. 19651060Which of the following conclusions is most appropriate based on the results presented in the table?

B

Cardiovascular disease

A 42-year-old man comes to the office as a new patient. Three weeks ago, he was hospitalized for treatment of community-acquired pneumonia and diagnosed with HIV infection. He has no other history of serious illness and takes no medications. Vital signs are within normal limits. Examination shows no abnormalities. CD4+ T-lymphocyte count is 490/mm³, and plasma HIV viral load is 45,000 copies/mL. Results of other laboratory studies are within the reference ranges. Test results for syphilis and hepatitis B and C are negative. The patient agrees to begin antiretroviral therapy. He asks what his long-term prognosis will be. With adherence to the medication regimen, this patient is at greatest risk of death from which of the following?

A

Education on sleep hygiene

A 40-year-old divorced woman comes to the office because of a 1-year history of difficulty sleeping. She says she sometimes does not fall asleep before 2 AM and does not feel rested at 6:30 AM when she has to get up and get her children ready for school. Sometimes she wakes after 1 to 2 hours of sleep and cannot fall back to sleep. On these occasions, she typically gets up for about 30 minutes, does some housework, and smokes a cigarette. She smokes one pack of cigarettes every three to four days. She works in a customer service call center and says she enjoys helping people resolve their problems. She now finds her job much harder and less enjoyable because she feels tired and sleepy. She says she would take a nap if she could, but she picks her children up as soon as she leaves work and spends the evening doing homework with them, making their dinner, and preparing lunches for the following day. By 9 PM, the children are in bed so she eats her own dinner and does some housework. She says that after 9 PM is when she smokes most of her cigarettes. She has not had depressed mood, excessive worry, or change in weight. Vital signs are within normal limits. Examination shows dark circles under the eyes and injected conjunctivae. Which of the following is the most appropriate initial step in management?

A

Measurement of cerebrospinal fluid 14-3-3 protein concentration

A 58-year-old woman is brought to the office by her husband because of a 6-week history of increasing confusion. Her husband says that, initially, she had difficulty doing “normal” things, such as preparing meals. Since then, she has become progressively less able to care for herself or even use a telephone. During this time, she also has had increased anxiety and restlessness. She has type 2 diabetes mellitus well controlled with an oral hypoglycemic agent. She is alert and appears anxious. She is oriented to person but not to place or time. She startles when the door to the examination room is slammed shut. Her temperature is 36.8°C (98.2°F), pulse is 78/min and regular, and blood pressure is 132/94 mm Hg. Physical examination shows no other abnormalities. On neurologic examination, she can repeat three objects immediately but is unable to recall them after 3 minutes. She is unable to copy a drawing of a cube. Results of a complete blood count and serum electrolyte concentrations are within the reference ranges. Her serum glucose concentration is 155 mg/dL. CT scan of the head shows no abnormalities. Which of the following is the most appropriate next step in diagnosis?

B

Submerge the feet in a moderately warm whirlpool

A 38-year-old woman is brought to the emergency department by paramedics 90 minutes after she fell through ice into a stream while hiking. She was stuck in the ice until emergency responders rescued her. On arrival, she has severe pain in her feet. She has no history of serious illness and takes no medications. Temperature is 34.8°C (94.6°F); other vital signs are within normal limits. Examination shows blue discoloration over the toes bilaterally, and the feet are cold to touch. Which of the following is the most appropriate next step in management?

C

Prednisone therapy

A 52-year-old woman comes to the emergency department because of a 1-day history of bleeding gums and moderate pain in her knees. She first noticed the gum bleeding while brushing her teeth this morning; she has been unable to stop the bleeding. She has systemic lupus erythematosus with inflammatory arthritis and Raynaud disease. Medications are tramadol and hydroxychloroquine. Vital signs are within normal limits. Examination shows bleeding, friable gums. There are multiple ecchymoses and petechiae over the upper extremities. Cardiac and abdominal examinations show no abnormalities. The knees are cool to the touch; there are effusions, and range of motion is limited by pain. Neurologic examination shows no focal findings. Laboratory studies show:Hemoglobin = 11 g/dLHematocrit = 33%Erythrocyte count = 4.2 × 10¹²/LMean corpuscular volume = 90 μm³Leukocyte count = 9000/mm³Segmented neutrophils = 60%Bands = 3%Eosinophils = 2%Basophils = 1%Lymphocytes = 30%Monocytes = 4%Platelet count = 20,000/mm³Serum Creatinine = 0.9 mg/dL Ferritin 1= 0 ng/mLWhich of the following is the most appropriate next step in management?

D

Myocarditis

A 13-year-old boy is brought to the emergency department because of a 3-day history of progressive fatigue, shortness of breath, and difficulty walking up stairs. He had been well until 1 week ago, when he developed rhinorrhea, cough, and a sore throat. These symptoms resolved spontaneously 2 days ago. He has no history of serious illness and takes no medications. On arrival, he is pale and in moderate respiratory distress. Pulse is 120/min, respirations are 25/min, and blood pressure is 80/40 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 91%. On pulmonary examination, crackles are heard throughout the lung fields. On cardiac examination, a gallop is heard. S1 is soft. A grade 2/6, high-pitched holosystolic murmur is heard best at the apex. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis?

B

Volvulus

A 10-day-old female newborn is brought to the emergency department because of a 2-day history of bilious vomiting. She was born at term following an uncomplicated pregnancy and spontaneous vaginal delivery. She was 50.8 cm (20 in) in length and weighed 3260 g (7 lb 3 oz) at birth. Examination following delivery showed no abnormalities, and she was discharged at the age of 2 days. She is exclusively breast-fed. She appears ill. Today, she is 50.8 cm (20 in) in length and weighs 3062 g (6 lb 12 oz). Temperature is 38.3°C (100.9°F), pulse is 180/min, and respirations are 52/min. The abdomen is distended; the patient cries on palpation of the abdomen. Which of the following is the most likely diagnosis?

E

Absence of resource stewardship

An 85-year-old man with severe dementia, Alzheimer type, is admitted to the hospital because of a nonhealing ulceron his right second toe. He lives in a nursing care facility and has been bedridden for the past 3 years. He has type 2diabetes mellitus, hypertension, and peripheral vascular disease. His medications are metformin, amlodipine, andaspirin. Noninvasive vascular studies of the lower extremities show marked bilateral vascular disease. Subsequentperipheral angiography shows severe stenoses of the right superficial femoral and the left common iliac arteries. Thepatient undergoes uncomplicated placement of two sequential vascular stents in the superficial femoral artery andplacement of an additional stent in the left common iliac artery. The type of stents used was recently approved bythe US Food and Drug Administration and has been heavily marketed as a long-lasting solution to restenosis. Eachstent costs the hospital $15,000. Alternatives to this approach include amputation of the toe, balloon angioplasty,and use of less expensive stents. Which of the following best describes the public policy implications of thisscenario?

A

Assessment of medical decision-making capacity

A 62-year-old woman with myasthenia gravis comes to the office because of a 2-week history of falling. She saysher legs "give out" once daily; she falls to the ground but does not hit her head. She took pyridostigmine until2 weeks ago when she decided that it no longer worked. Respirations are 30/min. Examination shows a hypophonicnasal voice and ptosis bilaterally. Muscle strength is 2/5 in all extremities. The patient is told that she is in imminentdanger of respiratory compromise and that she should be admitted to the hospital. She says she knows her breathingcould pose a problem, but she hates hospitals and does not want to undergo more tests or therapy. She asks if shecan have a prescription for her former medication and if she can go home. Which of the following is the mostappropriate next step in management?

A

Vitamin B1 (thiamine)

A 55-year-old man is brought to the emergency department by paramedics 45 minutes after his daughter found himunresponsive in his apartment. Paramedics initiated intravenous fluid warming and resuscitation at the scene. Thepatient has major depressive disorder, hypertension, and alcoholism. His medications are chlordiazepoxide,fluoxetine, and lisinopril. On arrival, he is arousable but confused. Temperature is 34.0°C (93.2°F), pulse is 64/min,respirations are 14/min, and blood pressure is 94/62 mm Hg. Physical examination shows no sign of trauma orprolonged immobilization. On mental status examination, he is oriented to person but not to place or time. Hisspeech is verbose and nonsensical. Serum glucose concentration is 44 mg/dL, and blood alcohol concentration is312 mg/dL. Urine toxicology screening is positive for alcohol and benzodiazepines. The most appropriate next stepin management is administration of which of the following?

E

Testicular torsion

A 16-year-old boy is brought to the emergency department because of a 6-hour history of severe right-sided scrotalpain. He has not had penile discharge, fever, abdominal pain, vomiting, or diarrhea. He has no history of similar painor any trauma to the region. He is sexually active with one female partner and uses condoms inconsistently. Vitalsigns are within normal limits. Abdominal examination shows no abnormalities. Genitourinary examination showsmoderate edema and diffuse tenderness to palpation of the right scrotum; there is mild erythema. Lifting the righttesticle does not relieve the pain. The left testicle is lower than the right testicle. Cremasteric reflex is present on theleft and absent on the right. Which of the following is the most likely diagnosis?

B

Serum creatine kinase activity

A 64-year-old man comes to the clinic because of a 2-week history of severe pain and generalized muscle weakness.He has hypercholesteremia and hypertension. Three months ago, he had a myocardial infarction. At that time, hebegan atorvastatin therapy. Other medications are clopidogrel, lisinopril, and amiodarone. He is 178 cm (5 ft 10 in)tall and weighs 82 kg (180 lb); BMI is 26 kg/m²Pulse is 80/min and blood pressure is 125/67 mm Hg. Musclestrength is 4/5 on abduction of the shoulders and flexion of the hips. Deep tendon reflexes are 2+ throughout. Noother abnormalities are noted. Measurement of which of the following is the most appropriate initial step indiagnosis?

E

Cleanse the site and apply ice

A 23-year-old man who is on active duty in the US Army comes to the clinic 1 hour after sustaining a bee sting tohis right cheek. The patient reports continued pain at the site of the sting, but he has not had shortness of breath,throat tightness, loss of vision, or other neurologic symptoms. Medical history is unremarkable. He takes nomedications. The patient has no known allergies. He is 178 cm (5 ft 10 in) tall and weighs 64 kg (140 lb); BMI is 20kg/m². Temperature is 37.0°C (98.6°F), pulse is 86/min, respirations are 10/min, and blood pressure is120/70 mm Hg. Examination of the right cheek shows an erythematous, swollen area of induration surrounding acentral clear area with the stinger in situ. The swelling encroaches on the lower aspect of the patient's right orbit,which appears puffy and mildly dusky. After the stinger is removed, which of the following is the most appropriatenext step in management?

C

Electroconvulsive therapy

A 32-year-old man is brought to the emergency department after being found by his wife in their bedroom with agun in his hands. His wife reports that the patient “has not been himself” since their son was stillborn 6 months ago.She says that during the past month, he hardly has slept and has not showered or shaved; he sits in the dark andrefuses to eat. He began fluoxetine therapy 3 months ago, but his symptoms have continued to worsen. He appearsdisheveled. He is 175 cm (5 ft 9 in) tall and weighs 52 kg (115 lb); BMI is 17 kg/m². His pulse is 90/min, and bloodpressure is 100/60 mm Hg. Physical examination shows decreased skin turgor and dry mucous membranes. When asked about his mood, he says, “I don’t know.” He has a tearful affect. He responds to most questions with one-word answers in a soft voice. He says he hears a voice telling him that he is a failure and says he wants to join his son in heaven. He refuses to answer questions about suicide. After removing all firearms from the patient’s house and admitting him to a psychiatric facility, which of the following is the most appropriate next step in management?

A

Hepatitis C

A 60-year-old woman comes to the office as a new patient. She recently moved to the area. She feels well. She hashypertension treated with amlodipine and asthma well controlled with inhaled fluticasone and inhaled albuterol asneeded. According to the medical records she brought with her, a mammography 6 months ago showed noabnormalities, results of laboratory studies 1 year ago were within the reference ranges, and colonoscopy 5 years agoshowed no abnormalities. Her past three Pap smears have shown no abnormalities; the most recent Pap smear was1 year ago. Her mother has type 2 diabetes mellitus, and her maternal aunt had breast cancer at the age of 55 years.The patient does not smoke cigarettes. She drinks two glasses of wine weekly. She works as a nurse. She has beenmonogamous with her husband for 30 years. Pulse is 76/min, respirations are 16/min, and blood pressure is132/86 mm Hg. Examination shows no abnormalities. Screening for which of the following is the most appropriatenext step in management?

E

Use of a nonpenicillin antibiotic to treat the pharyngitis

A 12-year-old girl is brought to the physician for a follow-up examination 8 days after starting a course of oralpenicillin for streptococcal pharyngitis. Temperature is 38.6°C (101.5°F). Examination shows an erythematousmorbilliform rash, urticaria, mild swelling of the hands and feet, arthralgias, and lymphadenopathy. Leukocyte countis 13,000/mm³ (62% segmented neutrophils, 10% eosinophils, and 28% lymphocytes). Urinalysis shows 2+ protein.Which of the following is most appropriate to prevent recurrence of these symptoms if the patient is diagnosed withstreptococcal pharyngitis again?

D

Encourage questions from all team members

A 45-year-old woman is hospitalized for management of Staphylococcus aureus endocarditis with persistentbacteremia. The patient is discussed during interdisciplinary rounds, which includes physicians, nurses, pharmacists,and social workers. During rounds, a pharmacy student notices that the patient missed two doses of her scheduledantibiotic last week but is unsure why. The physician and nurse are unaware of these missed doses, and the studentdoes not mention her observation. Which of the following measures is most likely to improve communication withinthis interdisciplinary health care team?

B

Serum lipid studies

A 37-year-old man comes to the physician for a routine health maintenance examination. He has no history ofserious illness and takes no medications. He does not smoke cigarettes, and he exercises four times weekly. Hismother died of colon cancer at the age of 76 years. He is 183 cm (6 ft 0 in) tall and weighs 100 kg (220 lb); BMI is30 kg/m². Pulse is 68/min and blood pressure is 138/74 mm Hg. The remainder of the examination shows noabnormalities. Which of the following is the most appropriate next step?

D

CT scan of the abdomen

A 35-year-old woman is evaluated for a persistent fever 4 days after admission to the hospital for treatment ofpyelonephritis. She has type 2 diabetes mellitus poorly controlled with insulin. She has received ciprofloxacin sinceadmission. Results of initial blood cultures are pending. Temperature is 40.0°C (104.0°F), pulse is 110/min,respirations are 20/min, and blood pressure is 100/60 mm Hg. Examination shows marked right costovertebral angletenderness. Which of the following is the most appropriate next step in management?

C

Begin a continuous infusion of norepinephrine

A 23-year-old man is being evaluated in the intensive care unit because of steadily decreasing blood pressure sincehe was admitted 2 hours ago for treatment of septic shock caused by pneumonia. Medical history is remarkable forcystic fibrosis and severe obstructive lung disease. In the emergency department, the patient was intubated, had threeperipheral intravenous catheters placed, and was treated empirically with broad-spectrum antibiotics,bronchodilators, a continuous infusion of propofol and fentanyl, and 4 L of 0.9% saline. Immediately afteradministration of fluids, the patient's pulse was 105/min and blood pressure was 100/50 mm Hg. The patient is 173cm (5 ft 8 in) tall and weighs 59 kg (130 lb); BMI is 20 kg/m². Pulse is 135/min and blood pressure is 79/43 mm Hg.Auscultation of the lungs discloses diffuse rhonchi and inspiratory crackles with low-pitched bilateral expiratorywheezes. Cardiac examination discloses no murmurs, rubs, or gallops. Bedside ultrasonography of the abdomenshows the inferior vena cava is 1.8 cm in diameter with minimum respirophasic collapsibility, and cardiacultrasonography shows that the left ventricular ejection fraction is approximately 0.65. Results of laboratory studiesobtained on admission and now are shown:On Admission, the White Blood Cell count is 21,000/mm³ and Blood Lactic acid is 5.2 mg/dL. Now the patient's White Blood Cell count is 19,000/mm³ and Blood Lactic acid is 4.0 mg/dLWhich of the following is the most appropriate next step in management?

D

Gestational diabetes

A 32-year-old nulligravid woman comes to the office for counseling prior to conception. Menses occur at irregular40- and 60-day intervals. She has impaired glucose tolerance controlled by diet. She takes no medications. She is165 cm (5 ft 5 cm) tall and weighs 84 kg (185 lb); BMI is 31 kg/m². Vital signs are within normal limits.Examination shows no abnormalities. Her fasting serum glucose concentration is 120 mg/dL. This patient is atgreatest risk for developing which of the following?

A

Inform the parents that the physician cannot deceive the patient

A 17-year-old girl is brought to the physician by her parents because they are concerned she is using illicit drugs.They report that, “she just isn’t herself anymore.” She has no history of serious illness and takes no medications. Sheis upset about being “tricked” to come to the doctor. Physical examination shows no abnormalities. On mental statusexamination, she has an angry mood and anxious affect. The patient’s parents privately request a toxicologyscreening for their daughter but ask that she be told that her blood will be taken to “check her thyroid gland.” Afterdiscussing the parents’ wish for secrecy, which of the following is the most appropriate next step in management?

D

Acute kidney injury

A 52-year-old woman with type 2 diabetes mellitus comes to the office for a follow-up examination. Two weeksago, she was treated with amoxicillin for a urinary tract infection. At that time, her blood pressure was 165/98 mmHg, and serum creatinine concentration was 1.2 mg/dL; lisinopril therapy was also begun. During the past week, shehas had increased swelling of the lower extremities and shortness of breath. Her dysuria has resolved. She appearsanxious. Temperature is 36.8°C (98.2°F), pulse is 110/min, respirations are 20/min, and blood pressure is 185/105mm Hg. Diffuse bilateral crackles are heard on pulmonary examination. An S3 gallop is heard. There is 3+ pittingbilateral pretibial edema. The laboratory studies showed that the levels for Serum Urea nitrogen is 45 mg/dL and Serum Creatinine is 4 mg/dL. As for the urine, its specific gravity is 1.010, no blood, and has moderate numbers of Hyaline casts.Which of the following is the most likely diagnosis?

C

Osteogenesis imperfecta

A 15-year-old girl is brought to the emergency department by her father because of a 2-hour history of right leg painthat began after she fell from her bicycle. Medical history is remarkable for bilateral hearing loss, a fracture of thehumerus at age 8 years, and multiple rib fractures. She takes no medications. Family history is remarkable forkyphoscoliosis, hearing loss, and early onset osteoporosis in her mother; the mother died from complications relatedto a hip fracture at age 44 years. The patient is a refugee who has recently immigrated. The patient appears to be indistress. She is below the 5th percentile for height, at the 70th percentile for weight, and above the 95th percentilefor BMI. Her temperature is 37.0°C (98.6°F), pulse is 118/min, respirations are 12/min, and blood pressure is130/68 mm Hg. Examination shows kyphosis and hypermobile joints of the hands, wrists, and feet. Examination ofthe right lower extremity shows superficial abrasions and ecchymoses; there is tenderness to palpation andmovement of the extremity. Which of the following is the most likely underlying diagnosis?

C

“How do you think he will react?”

A 22-year-old primigravid woman at 10 weeks’ gestation comes to the emergency department (ED) because of a 3-day history of persistent vomiting. She is treated with intravenous hydration, pyridoxine, and doxylamine. As theresident physician prepares the patient for discharge, he asks who will be picking her up from the ED. She says herhusband will be arriving soon and asks if the hospital staff can refer to her symptoms as a “stomach flu.” She doesnot want anyone to mention to her husband that she is pregnant because the pregnancy resulted from an oralcontraceptive failure and “he is not expecting this.” Which of the following is the most appropriate next question toask this patient?

B

Aortic embolism

Five days after admission to the hospital for management of an ST-elevation myocardial infarction, a 59-year-oldman has the sudden onset of severe abdominal and bilateral lower extremity pain, cyanosis of the lower body, andparesthesias. On hospital days 1 and 2, he received vasopressor and inotropic therapy. On hospital day 2,echocardiography showed extensive anterolateral akinesis of the left ventricle. He has no history of serious illness.His medications are metoprolol, lisinopril, simvastatin, and dalteparin. He appears to be in acute distress. Pulse is105/min and regular, respirations are 24/min, and blood pressure is 80/60 mm Hg. Examination shows lower bodycyanosis to the level of the costal margins. Crackles are heard over the lower lung fields bilaterally. Distant heartsounds but no murmurs are heard. The abdomen is nondistended and nontender. Pulses are 1+ in the upperextremities and absent in the lower extremities. Muscle strength is 3/5 in the lower extremities. Sensation to touchand temperature is decreased over the lower extremities. ECG shows sinus tachycardia. Which of the following isthe most likely explanation for this patient’s clinical findings?

B

High-resolution CT scan of the chest

A 75-year-old man comes to the clinic because of a 2-year history of progressive shortness of breath. He also hashad an occasional dry cough for the past 6 months. He has not had chest pain, palpitations, or swelling of his legs.Medical history is unremarkable, and the patient takes no medications. He has smoked one pack of cigarettes dailyfor 57 years. He does not drink alcoholic beverages. Vital signs are temperature 37.0°C (98.6°F), pulse 92/min,respirations 18/min, and blood pressure 122/76 mm Hg. Pulse oximetry on room air shows an oxygen saturation of89%. The patient has mild dyspnea when he speaks. Auscultation of the lungs discloses fine and dry crackles in thebases of both lungs. Cardiac examination discloses a normal S1 and S2. No extra heart sounds are heard. Jugularvenous pulsation is measured at 2 cm above the sternal angle with the head of the bed elevated at 30 degrees.Examination of the extremities shows clubbing of the digits of both hands. Results of complete blood count, serumchemistry profile, and urinalysis are within the reference ranges. Chest x-ray shows scattered reticular opacities inboth lung bases. There is no hilar lymphadenopathy. Which of the following is the most appropriate next step inevaluation?

B

K⁺ Decreased Cl⁻ decreased HCO³⁻ increased

A previously healthy 20-year-old woman, who is a sophomore in college, is brought to the emergency departmentby her roommates because of an 8-hour history of weakness and vomiting blood and a 2-day history of dizziness.She has no history of similar symptoms. She says she overeats in response to the stress of her classes. She inducesvomiting after consuming a significant amount of food because she feels "too full" and "out of control." She nowvomits almost daily. She feels she is slightly overweight. She is physically active and exercises moderately two tothree times weekly. She does not use laxatives or diuretics. She has many friends and enjoys going out socially. Shetakes no medications. She drinks three to four beers on weekends and does not use illicit drugs. She appearsuncomfortable and is tearful and mildly diaphoretic. She is 157 cm (5 ft 2 in) tall and weighs 59 kg (130 lb); BMI is24 kg/m². Temperature is 37.5°C (99.5°F), pulse is 115/min and regular, and blood pressure is 100/68 mm Hg.Examination shows tender parotid glands bilaterally and poor dentition. Results of laboratory studies are most likelyto show which of the following in this patient?

B

Cystoscopy

A 58-year-old man comes to the clinic for a follow-up examination 3 months after beginning warfarin therapy fordeep venous thrombosis. He noted blood in his urine 1 week ago but has not seen any since that time. He has not hadpain, fever, or increased urinary frequency. He has not sustained any recent trauma. His prothrombin time and INRhave been within the therapeutic ranges during his previous measurements. He has hypertension and benignprostatic hyperplasia. Medications are warfarin and hydrochlorothiazide. He smoked one pack of cigarettes daily for40 years but quit when diagnosed with deep venous thrombosis. Temperature is 35.9°C (96.6°F), pulse is 88/min,respirations are 18/min, and blood pressure is 135/87 mm Hg. The prostate is moderately enlarged; no nodules arenoted.Laboratory studies showed that the Prothrombin time is 19 sec (INR=2.5), serum Urea nitrogen is 18 mg/dL, serum Creatinine is 1 mg/dL, and Prostate-specific antigen is 3.8 ng/mL (N<4).The laboratory result on urine showed the following: blood is 3+, protein is 1+, RBC is too numerous to count, WBC is 2/hpf, no casts, and negative for Nitrites and Leukocyte esterase.In addition to a CT scan of the abdomen, which of the following is the most appropriate next step in management?

C

Operative reduction and internal fixation

A 32-year-old woman is brought to the emergency department immediately after being involved in a motor vehiclecollision. She was the unrestrained driver. On arrival, she says she has severe pain in her right groin. Onexamination, any movement of the right hip produces pain. An x-ray of the pelvis shows a completely displacedfracture of the femoral neck. In addition to intravenous morphine, which of the following is the most appropriatemanagement?

E

Antihypertensive therapy

A 57-year-old man comes to the physician 1 week after he had a 45-minute episode of slurred speech andclumsiness of his right hand. The episode occurred during his daily walk; the symptoms resolved during the next 24hours. He has no history of similar symptoms. He has a 20-year history of hypertension and a 15-year history ofhypercholesterolemia controlled with a low-cholesterol diet and daily exercise. He takes no medications. He hassmoked one pack of cigarettes daily for 40 years and drinks one to two glasses of wine nightly with dinner. He isalert and fully oriented. He is 178 cm (5 ft 10 in) tall and weighs 86 kg (190 lb); BMI is 27 kg/m². His temperature is37.0°C (98.6°F), pulse is 88/min, respirations are 10/min, and blood pressure is 170/90 mm Hg. Examination,including neurologic examination, shows no other abnormalities. Daily enteric-coated aspirin therapy is begun.Which of the following is the most appropriate next step to decrease this patient’s risk for subsequent cerebralinfarction?

D

Influenza A virus

A 27-year-old primigravid woman at 21 weeks’ gestation comes to the emergency department because of a 2-dayhistory of moderate headache, shortness of breath, nausea, vomiting, muscle aches, and malaise. She also has hadcough occasionally productive of sputum. Pregnancy had been uncomplicated. She has no history of serious illness,and her only medication is a prenatal vitamin. She immigrated to the USA from India 6 months ago. Temperature is38.3°C (100.9°F), pulse is 100/min, respirations are 18/min, and blood pressure is 100/60 mm Hg. On examination,breath sounds are decreased at the right lung base. Fundal height is 22 cm. Fetal heart rate is 160/min. Chest x-rayshows right-sided interstitial infiltrates. Which of the following is the most likely infectious agent?

B

Learning disorder

A 7-year-old boy is brought to the physician because of a 1-year history of poor performance in school. His parentssay that he is bright, has many friends, and seems to want to do well in school. His teachers report that he seemsfrustrated with his own progress and his inability to meet the expectations of his parents. Speech fluency andarticulation and motor skills are appropriate for age. Physical examination shows no abnormalities. When asked toread during the examination, he has significant difficulty sounding out words he is unfamiliar with. Visual acuitytest and audiometry show no abnormalities. Which of the following is the most likely diagnosis?

D

Otitis externa

A 23-year-old woman who is an active-duty enlisted airman in the US Air Force comes to the base clinic because ofa 4-week history of an itchy sensation in her right ear. She has not had ringing in her ears or hearing loss. She worksas a fuel specialist and at first attributed her symptom to the earplugs she uses when she is on the flight line. Thesymptom has not improved despite the patient's wearing headphones instead of the earplugs during the past 2 weeks.She has no history of serious illness and takes no medications. Vital signs are within normal limits. Duringexamination, pulling of the right pinna inferiorly to examine the ear canal produces pain. The right ear canal appearserythematous and edematous. The tympanic membrane cannot be fully visualized because of the presence ofcerumen. Examination of the left ear shows no abnormalities. Which of the following is the most likely diagnosis?

C

Ibuprofen and decongestant therapy

A 34-year-old woman who is on active duty in the US Army comes to the military urgent care clinic because of a 4-day history of headache, purulent nasal discharge, and left facial pain. She has not had fever or chills. She haschronic bilateral knee pain, which she attributes to multiple parachute jumps while she was assigned to an airborneunit 7 years ago. The knee pain is exacerbated by long-distance running on pavement. Her only medication isoccasional ibuprofen for the knee pain. The patient has no known medication allergies. Temperature is 37.1°C(98.8°F), pulse is 60/min, respirations are 14/min, and blood pressure is 122/80 mm Hg. Cervical lymph nodes arenot palpable. There is tenderness to palpation over the left maxillary sinus. Nasal examination shows inflamedturbinates and purulent discharge. The patient needs to blow her nose twice during the examination. Bilateralotoscopic examination discloses no abnormalities. Examination of the oropharynx shows scant purulent dischargeposteriorly. The remainder of the examination discloses no abnormalities. Which of the following is the mostappropriate next step in management?

C

Tracheal collapse

A 16-year-old boy with VATER syndrome is brought to the physician because of 2-week history of harsh cough thatbegan with a common cold. He receives no medications. Temperature is 37°C (98.6°F), pulse is 70/min, respirationsare 20/min, and blood pressure is 112/64 mm Hg. Examination shows a harsh vibratory sound in the mid anteriorchest with forced expiration. A systolic murmur is heard best at the lower left sternal border. There is mild scoliosis.Spirometry shows an FVC of 2.54 L (78% of predicted) and a slow vital capacity of 2.88 L (85% of predicted). Aflow volume loop shows scooping on the expiratory limb. Which of the following is the most likely cause of thediscrepancy between this patient’s forced and slow vital capacity measurements?

D

Instruct the surgeon to take a temporary leave of absence and undergo a medical evaluation

A chief medical officer at a hospital has received several reports that one of her colleagues, a 64-year-old malesurgeon, has “not been acting like himself” recently. An administrative assistant says that during the past 6 months,the surgeon’s dictations have become hard to follow and appear to be missing information; previously, they werecomprehensive and easy to transcribe. The assistant adds that after the surgeon missed three meetings in a rowduring the past 2 months, he asked her to send him a text message 5 minutes before the next meeting to let himknow its location. Previously, he was always in attendance and on time for meetings. A senior resident also hasnoted unusual behavior by the surgeon; the resident says that while on rounds 3 days ago, the surgeon listedincorrect indications for a specific surgical procedure. A scrub nurse reported that the surgeon used unsterilepractices three times during a 2-hour procedure today. The chief medical officer meets with the surgeon and askshim about these reported incidents. The surgeon says that “nothing is wrong” and the people who reported him areangry with him for various reasons and “are trying to stir up trouble.” Which of the following is the most appropriateaction for the chief medical officer to take?

D

MRI of the brain

A 33-year-old woman is admitted to the hospital because of visual field loss following a 48-hour history of acute eyepain. She also has a 3-week history of numbness and a feeling of "heaviness" in both legs. She has no history ofserious illness and takes no medications. Six weeks ago, she returned from a hiking expedition in the northeasternUSA; she has no recent history of international travel. Vital signs are within normal limits. Muscle strength is 5/5 inthe upper extremities, 3/5 in the hip flexors and knee extensors, and 4/5 in the knee flexors and ankle dorsiflexors.Patellar and ankle reflexes are 3+ bilaterally, and there is nonsustained ankle clonus bilaterally. Sensation topinprick is absent throughout the lower extremities. Ophthalmologic examination discloses optic neuritis andreconfirms the visual field loss. Which of the following studies is most likely to confirm the diagnosis?

E

No additional diagnostic studies are indicated

A 68-year-old woman comes to the office because she is concerned about developing Alzheimer disease. She saysshe has had increasing difficulty recalling names of people and objects during the past 6 months. She has not haddifficulty with her activities of daily living, finances, or shopping. She teaches part-time at a local communitycollege. She has no history of serious illness and takes no medications. She does not smoke cigarettes. She drinksone 5-oz glass of wine daily. Her mother developed dementia, Alzheimer type, in her mid 70s. Physical andneurologic examinations of the patient show no abnormalities. On cognitive testing, she has delayed recall of threeof five words. She is able to perform serial sevens, knows similarities, is fully oriented, and has intact executive,visuospatial, and attention abilities. Which of the following is the most appropriate next step in management?

E

Discontinue paroxetine and duloxetine

A 55-year-old man with major depressive disorder is brought to the emergency department 1 1/2 hours after he wasfound by his brother in his home acting strangely. On arrival, he is babbling incoherently and cannot answerquestions. There are two empty pill bottles in his pockets; one is for paroxetine and the other is for duloxetine. He isrestless, diaphoretic, and says he has a severe headache. Temperature is 38.5°C (101.3°F), pulse is 130/min, andblood pressure is 145/105 mm Hg. The pupils are 8 mm and reactive to light. Deep tendon reflexes are 4+ andsymmetric in all extremities. There is spontaneous myoclonus in the upper extremities. Results of laboratory studies,including a complete blood count, serum electrolyte concentrations, creatine phosphokinase activity, and thyroidfunction tests, are within the reference ranges. After admitting the patient to the hospital for observation andsupportive care, what are you going to give or change in terms of pharmacotherapy?

D

Determine whether the patient has had thoughts of harming others

A 32-year-old man comes to the office for a follow-up examination 2 months after he was diagnosed withhypertension. He arrives late for the appointment, stating that he had to make sure no one followed him here becausesome "drug dealers" are after him. He insists that he be seen in an examination room with no windows. He says he is"fine" but is reluctant to answer questions because "doctors hold everything against me." He doubts his diagnosisand says, "Doctors and drug companies are in cahoots trying to get my money." He refuses to speak with the officemanager about his bill because he thinks "she looks at me funny and makes nasty remarks about me behind myback." He says he has no history of psychiatric illness; his medical record indicates that he has made similarstatements during the past 7 years concerning doctors and office staff but he always refused to elaborate on hisstatements. His medications are metoprolol and hydrochlorothiazide. He does not drink alcohol or use illicit drugs.Vital signs are within normal limits. Physical and neurologic examinations show no abnormalities. Results ofscreening laboratory studies are within the reference ranges. Which of the following is the most appropriate nextstep in management?

E

Vulvar carcinoma

An 87-year-old woman, gravida 2, para 2, is brought to the emergency department from a skilled nursing carefacility because of profuse vaginal bleeding for 2 days. At the age of 41 years, she underwent a cold knife conebiopsy for cervical dysplasia. Annual follow-up Pap smears until the age of 65 years showed no abnormalities. Sheis in moderate distress. Temperature is 36.1°C (97.0°F), pulse is 84/min, respirations are 30/min, and blood pressureis 140/90 mm Hg. Abdominal examination shows mild distention and tenderness; no masses are palpated. Pelvicexamination shows a large verrucous lesion on the perineum partially covering the anal verge. Speculumexamination shows atrophic changes on the vagina and cervix. Which of the following is the most likely explanationfor these findings?

E

Ultrasonography of the thyroid gland

A 47-year-old woman comes to the office for a routine health maintenance examination. She feels well and has nohistory of serious illness. Examination shows a 2-cm, soft, nontender nodule in the right lobe of the thyroid gland.There is no lymphadenopathy. Her serum thyroid-stimulating hormone concentration is within the reference range.Which of the following is the most appropriate initial step in management?

E

Zidovudine (AZT)

A 1-hour-old male newborn is examined in the hospital nursery. He was born at term to a 22-year-old woman,gravida 1, para 1, with HIV infection. The mother took antiretroviral therapy throughout her pregnancy, and her HIVviral load was consistently <1000 copies/mL. She received intravenous zidovudine (AZT) during labor. Thepatient’s Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. He is at the 50th percentile for length, weight,and head circumference. He appears well. Examination shows no abnormalities. In addition to administration of thehepatitis B vaccine, which of the following is the most appropriate pharmacotherapy for this newborn?

E

Cabergoline therapy

A 25-year-old woman comes to the office because she has not had a menstrual period for 6 months. Previously,menses occurred at regular 28-day intervals. She has not had blurred or double vision. She has no history of seriousillness and takes no medications. Temperature is 37.0°C (98.6°F), pulse is 72/min, and blood pressure is108/60 mm Hg. The pupils are equal and reactive to light; extraocular muscles are intact. Funduscopic examinationshows no abnormalities. Visual field testing shows bitemporal hemianopia. Milky discharge can be expressed fromthe nipples. Pelvic examination shows no abnormalities. Serum studies show a thyroid-stimulating hormoneconcentration of 2.0 μU/mL and a prolactin concentration of 100 ng/mL. A urine pregnancy test is negative. MRI ofthe pituitary gland shows a 1.2 × 1.5-cm mass compressing the optic chiasm. Which of the following is the mostappropriate next step in management?

B

X-ray of the abdomen

A 2-week-old boy is evaluated in the neonatal intensive care unit because of temperature instability and decreasedactivity. He was born by cesarean delivery at 30 weeks’ gestation because of premature rupture of membranes. Since birth, he has been fed breast milk by orogastric tube. He was feeding and growing appropriately until today, whenhis axillary temperature was 36.5°C (97.7°F) and he had decreased activity. During the past 4 hours, gastric residuehas been noted in the orogastric tube when it is aspirated prior to feedings. Temperature is now 37.0°C (98.6°F),pulse is 160/min, respirations are 50/min, and blood pressure is 70/40 mm Hg. The anterior fontanel is soft.Cardiopulmonary examination shows no abnormalities. The abdomen is mildly distended, and there is mildtenderness to palpation diffusely; there are no masses. Bowel sounds are decreased. There is a small amount ofblood-streaked stool in the diaper. The remainder of the examination shows no abnormalities. Leukocyte count is18,000/mm³ (N=5000–34,000) (80% segmented neutrophils, 5% bands, 10% lymphocytes, and 5% monocytes), andplatelet count is 100,000/mm³. Blood culture results are pending. Which of the following is most likely to confirm the diagnosis?

E

The suburban hospital violated the Emergency Medical Treatment and Active Labor Act (EMTALA)

A 13-month-old boy is brought to a small rural emergency department (ED) near his family's community because of an erythematous, edematous mass in his perianal area that is hot to touch. He has no history of serious illness and receives no medications. Growth and development are appropriate for age. Vaccinations are up-to-date. He is at the 50th percentile for length and weight. Temperature is 39.4°C (103.0°F), pulse is 160/min, and respirations are 36/min. Examination shows fluctuance and exquisite tenderness to palpation of the perianal mass. Oral acetaminophen and a dose of oral cephalexin are administered, and the parents are told that their child’s case is beyond the capabilities of the hospital. They are referred to the nearest hospital with a pediatric service, a suburban hospital 50 miles away. The suburban hospital is contacted regarding the referral and a pediatric surgeon accepts transfer of the patient. When the patient is brought to the ED of the suburban hospital, a triage nurse obtains his oral temperature of 37.7°C (99.8°F) and pulse of 126/min. The nurse notes that the family has no health insurance and states that the case is beyond the capabilities of the hospital. The nurse recommends taking the patient to the ED of a downtown university hospital 4 miles away. The parents follow this recommendation, and the patient undergoes incision and drainage of the abscess at the downtown hospital later that day. Which of the following is the most accurate characterization of this patient's pattern of care?

E

Video EEG monitoring

A 25-year-old woman is brought to the emergency department by paramedics because of a seizure that began 45minutes ago at home. Intravenous antiepileptic therapy begun en route to the hospital has not stopped her seizure.Her parents report that she initially began crying, then fell to the floor and exhibited asymmetric kicking andthrashing of all extremities. Fifteen years ago, she was diagnosed with a seizure disorder. Her seizures had been wellcontrolled with oral antiepileptic therapy until this morning. Today, while the physician is in the patient’s room, themovements of her extremities gradually subside. The patient then sits up and asks the physician what happened. Sheis fully oriented. Vital signs are within normal limits. Examination shows no evidence of tongue biting, urinaryincontinence, or other abnormalities. Which of the following is most likely to confirm this patient’s diagnosis?

E

Ibuprofen therapy

A 32-year-old woman comes to the emergency department because of a 1-day history of sharp, right-sided chest pain that worsens with coughing and sneezing. Four days ago, she had a mild sore throat and runny nose followed by nonproductive cough 1 day later. Over-the-counter decongestant and aspirin mildly relieved the symptoms. She has not had shortness of breath, blood-tinged sputum, fever, or chills. She has a long-standing history of recurrent aphthous ulcers. Her only medication is an oral contraceptive. Temperature is 37.2°C (99.0°F), pulse is 65/min, and respirations are 14/min. Pulse oximetry on room air shows an oxygen saturation of 99%. Splinting is observed over the right hemithorax with deep breathing. On cardiac examination, no abnormalities are heard. The remainder of the examination shows no abnormalities. Chest x-ray shows no abnormalities. Which of the following is the most appropriate next step in management?

D

Hypothalamic hypogonadism

A 30-year-old nulligravid woman, who is a military veteran, comes to the office because she has not had a menstrual period for the past year. She has not had nausea, vomiting, or night sweats. Menses previously occurred at regular 28-day intervals. She is sexually active with one male partner and uses condoms consistently. Three weeks ago, she returned from a 1-year deployment in the Middle East, where she worked as an army combat medic. She resumed work as a teacher 2 weeks ago. She appears tearful but otherwise in no distress. Temperature is 37.1°C (98.7°F), pulse is 88/min, respirations are 16/min, and blood pressure is 116/72 mm Hg. Physical examination, including pelvic examination, shows no abnormalities. Serum studies show: Thyroid-stimulating hormone: 2 μU/mL Follicle-stimulating hormone: 7 mIU/mL Luteinizing hormone: 10 mIU/mL Prolactin: 10 ng/mL β-hCG: negative Which of the following is the most likely cause of this patient’s amenorrhea?

B

Follicle-stimulating hormone

A 45-year-old woman comes to the office because she has not had a menstrual period for 1 year. Menses previously occurred at regular 30-day intervals. She feels well, has no history of serious illness, and takes no medications. She has smoked one-half pack of cigarettes daily for 20 years. She is sexually active with one male partner and uses condoms consistently. She is 163 cm (5 ft 4 in) tall and weighs 63 kg (140 lb); BMI is 24 kg/m². Vital signs are within normal limits. Physical examination, including pelvic examination, shows no abnormalities. Measurement of which of the following serum concentrations is most likely to confirm the diagnosis?

B

Oral prophylactic penicillin therapy

A 2-month-old girl is brought to the office by her mother for a routine examination. Newborn screening electrophoresis showed hemoglobin FS. The mother says her daughter has not had fever or pallor. The patient is feeding well and gaining weight appropriately. She receives no medications. She appears well. She is at the 35th percentile for length and weight. Temperature is 37.0°C (98.6°F), pulse is 158/min, and respirations are 28/min. Examination shows no abnormalities. All routine immunizations are administered. In addition to routine anticipatory guidance about feeding and development, the mother is instructed to observe the patient for pallor and fever and to palpate for an enlarged spleen. Which of the following is most appropriate to prevent complications in this patient?

E

Ultrasonography of the abdomen

A 3-week-old boy is brought to the physician by his mother because of a 5-day history of yellow eyes and skin and white stools. Pregnancy and delivery were uncomplicated. The patient's temperature is 37.1°C (98.8°F), pulse is 160/min, respirations are 40/min, and blood pressure is 85/50 mm Hg. Examination shows diffuse jaundice. Cardiopulmonary examination shows no abnormalities. The abdomen is nontender. The liver edge is palpated 4 cm below the right costal margin. The spleen tip is palpated 3 cm below the left costal margin. Laboratory studies show: Leukocyte count: 10,000/mm³ Serum Bilirubin, total: 16 mg/dL Direct: 12 mg/dL AST: 800 U/L ALT: 500 U/L Amylase: 100 U/L Which of the following is the most appropriate next step in diagnosis?

B

Discontinuation of lisinopril

A 52-year-old woman comes to the physician for a follow-up examination. She received the diagnosis of hypertension 3 weeks ago, and lisinopril therapy was begun at that time. She has had a constant, nonproductive, hacking cough for 2 weeks but has not had any other problems. She has no history of serious illness and takes no other medications. She does not smoke. She drinks one to two glasses of wine daily. She does aerobic exercise for 30 minutes four to five times weekly. Her blood pressure has decreased from 164/92 mm Hg 3 weeks ago to 140/84 mm Hg today. Lungs are clear to auscultation. Which of the following is the most appropriate next step in management of this patient's cough?

D

Neonatal respiratory depression

A 27-year-old primigravid woman at 41 weeks' gestation is admitted to the hospital for induction of labor. She hasreceived cervical ripening agents and is now receiving oxytocin. The cervix is 9 cm dilated and 100% effaced; thevertex is at 0 station. Fetal monitoring shows contractions every 3 minutes and a reassuring heart rate. She requestspain medication. Which of the following is the most likely adverse effect of an intravenous opioid in this patient?

E

Polysomnography

A 7-year-old girl is brought to the clinic by her father because of behavior problems at school since she started second grade 6 months ago. Her teacher is concerned because she cannot sit still or complete tasks and is not learning at the same pace as her classmates. Psychoeducational testing shows normal intelligence. The father says his daughter’s behavior problems have worsened since last year. She snores at night and wets the bed several nights weekly. She has no history of serious illness and receives no medications. She has been at the 25th percentile for height and weight for the past 3 years. Pulse is 105/min and regular, respirations are 22/min, and blood pressure is 105/65 mm Hg. The tonsils are 3+. Cardiopulmonary and abdominal examinations show no abnormalities. On neurologic examination, cranial nerves are intact. Deep tendon reflexes are 2+ in all extremities. Finger-nose testing shows no abnormalities. Romberg sign is absent. Her gait is normal. Which of the following is the most appropriate next step in diagnosis?

D

Proceed with the blood transfusion while obtaining an emergency telephone court order

An 8-year-old boy is brought to the emergency department (ED) by ambulance 45 minutes after he was struck by a car while riding his bicycle. He did not lose consciousness but has multiple rib fractures with depression of the left anterior chest wall. His parents have been notified and are on their way to the hospital. On the patient's arrival to the ED, his temperature is 37.2°C (99.0°F), pulse is 180/min, respirations are 36/min, and blood pressure is 65/30 mm Hg. The abdomen is distended with exquisite tenderness to palpation. A rapid intravenous infusion of 0.9% saline is begun. CT scans are quickly obtained and show a disrupted spleen and an abdominal cavity filled with free fluid. The parents arrive at the hospital and are informed that their son needs an emergency laparotomy and splenectomy to control the internal bleeding. A saline infusion is continued to support the patient's blood pressure. The parents provide consent to proceed with the operation but refuse to consent to transfusion of blood or blood products, regardless of consequences, because of their religious beliefs. As the patient is transferred to the operating room, his pulse is 210/min and blood pressure is 50/20 mm Hg. Hemoglobin concentration is 3.8 g/dL. The surgeon agrees with the anesthesiologist that the patient will die without transfusion of blood and plasma. Which of the following is the most appropriate action?

C

Intravenous alprostadil (prostaglandin E₁)

A female newborn has the onset of tachypnea 4 hours after birth. She was delivered at term to a 24-year-old woman following an uncomplicated pregnancy and delivery. Apgar scores were 9 and 9 at 1 and 5 minutes, respectively. Her parents had refused prenatal screening. The patient's temperature is 37.2°C (99.0°F), pulse is 150/min, respirations are 60/min, and blood pressure is 55/35 mm Hg. On cardiac examination, a single, loud S₂ is heard. The liver edge is palpated 3 cm below the right costal margin. Capillary refill time is 6 seconds. Peripheral pulses are difficult to palpate in all extremities. Arterial blood gas analysis on room air shows: pH: 7.24 PCO₂: 35 mm Hg (N=27–40) PO₂: 68 mm Hg HCO₃⁻: 15 mEq/L Chest x-ray shows increased pulmonary haziness and vascular markings suggestive of bilateral pulmonary edema. The most appropriate next step in management is administration of which of the following?

C

Diltiazem

A 43-year-old woman comes to the office for a follow-up examination 1 week after she was discharged from the hospital following an overnight admission for an episode of crushing, aching chest pain. The pain was located behind her sternum and radiated to her left jaw and shoulder. She also had shortness of breath, palpitations, and nausea. Initial ECG obtained on admission showed ST-segment depressions in leads V₃ through V₆. Nitroglycerin was administered, and the chest pain resolved. Follow-up serial ECGs disclosed no abnormalities and serum troponin concentrations were within the reference ranges. Cardiac catheterization obtained the next morning showed no substantial narrowing of the coronary arteries. At discharge, the patient declined medication to prevent recurrence of pain. The patient reports that since discharge, she has had two episodes of chest discomfort lasting 2 to 4 minutes, similar in location and quality to the pain precipitating her hospitalization. Medical history otherwise is unremarkable and she takes no routine medications. Vital signs are within normal limits. Physical examination discloses no abnormalities. Which of the following is the most appropriate pharmacotherapy to prescribe at this time?

A

Alcohol use disorder

A 35-year-old woman is brought to the emergency department by police after they found her wandering the streets and appearing intoxicated. On arrival, she is tremulous and appears distressed. She says she moved out of her abusive boyfriend’s apartment 1 week ago because she was afraid he would kill her. She has no financial or emotional family support. She worked at a grocery store until 1 month ago when she was fired for missing four shifts during the course of 1 week. During the past week, she has slept less than 4 hours nightly because she has slept on the streets or in shelters. She has panic disorder treated with fluoxetine. She takes no other medications. Ten years ago, she underwent 6 months of psychotherapy for dependent personality disorder. During the past year, she has drunk four or more glasses of wine and other alcoholic beverages nightly. She tried to quit drinking alcohol twice during the past year but was unsuccessful. Her last alcoholic drink was 24 hours ago. Pulse is 90/min and blood pressure is 140/90 mm Hg. Physical examination shows resting hand tremors and delayed reflexes. Mental status examination shows slurred speech. She has an irritable mood and anxious affect. Blood alcohol concentration is 140 mg/dL. Which of the following is the strongest predisposing risk factor for suicide in this patient?

B

Administer intravenous morphine

A 76-year-old woman, who is receiving home hospice care because of end-stage metastatic lung cancer diagnosed 1 month ago, is examined at home at the request of her family because of a 3-hour history of labored breathing despite receiving 100% oxygen at 5 L/min via face mask. Pulse is 92/min, respirations are 18/min, and blood pressure is 105/62 mm Hg. Pulse oximetry on 100% oxygen via face mask shows an oxygen saturation of 85%. The patient appears cachectic and is in mild distress, showing increased work of breathing with prominent sternocleidomastoid muscles and intermittent agonal respirations. Which of the following is the most appropriate next step in management?

A

Medullary thyroid carcinoma

A 42-year-old woman comes to the physician because of a 1-month history of moderate constant abdominal pain. She was evaluated in the emergency department 6 weeks ago for renal calculi and was told that her serum calcium concentration was increased. She has labile hypertension treated with hydrochlorothiazide and enalapril. Two brothers have hyperparathyroidism, and one sister has an adrenal tumor. The patient's temperature is 37.0°C (98.6°F), pulse is 80/min, respirations are 12/min, and blood pressure is 182/98 mm Hg. Funduscopic examination shows arteriovenous nicking. There is mild, diffuse tenderness to palpation of the abdomen. The remainder of the examination shows no abnormalities. Serum calcium concentration is 13.2 mg/dL. Urine metanephrine concentration is 4000 μg/24 h (N=140–785). This patient is most likely at risk for which of the following conditions?

D

Lymph node biopsy

A 26-year-old woman with common variable immunodeficiency comes to the office because of a 2-month history of night sweats. She also has had a 10-kg (22-lb) weight loss during the past 3 months despite no change in appetite. She has a 15-year history of recurrent sinusitis and otitis media. Her only medication is intravenous immune globulin. She is 163 cm (5 ft 4 in) tall and weighs 54 kg (120 lb); BMI is 21 kg/m². Vital signs are within normal limits. Examination shows cervical and epitrochlear lymphadenopathy. Which of the following is the most appropriate next step in management?

A

Skeletal survey

A 9-month-old boy is brought to the office by his mother because of a 6-hour history of persistent fussiness and decreased appetite. Two weeks ago, he was diagnosed with an upper respiratory tract infection. The symptoms have since resolved. He lives with his parents and a pet lizard. His diet consists of cow milk-based formula, baby food, and some solid foods. He has no history of serious illness and receives no medications. Immunizations are up-to-date. Today, he is inconsolable. He is at the 50th percentile for length and weight. Examination shows multiple flaccid bullae on an erythematous base over the buttocks. The mother says she had no knowledge of these findings. Which of the following is the most appropriate next step in management?

E

Ultrasonography of the right upper abdominal quadrant

A 62-year-old woman is admitted to the hospital because of an 8-hour history of severe right upper abdominal pain, nausea, and fever that began after she ate fried fish and potatoes. During the past 3 years, she has had 12 episodes of similar pain after meals, but it has not lasted as long or been as severe as this episode. She has hypertension, hyperlipidemia, and alcohol use disorder. Her medications are amlodipine, benazepril, and simvastatin. She drinks one 12-oz beer daily. She is 163 cm (5 ft 4 in) tall and weighs 86 kg (190 lb); BMI is 33 kg/m². Temperature is 38.5°C (101.3°F), pulse is 120/min, respirations are 28/min, and blood pressure is 100/68 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 98%. On abdominal examination, there is diffuse tenderness to palpation, rebound, and guarding. Bowel sounds are decreased. Laboratory studies show: Hematocrit: 35% Leukocyte count: 16,000/mm³ Serum Ca²⁺: 7.9 mg/dL Urea nitrogen: 26 mg/dL Glucose: 200 mg/dL Creatinine: 2 mg/dL Triglycerides: 180 mg/dL AST: 162 U/L ALT: 98 U/L Amylase: 682 U/L Lipase: 515 U/L (N=14–280) Serum electrolyte concentrations and lactate dehydrogenase activities are within the reference ranges. Which of the Following is the most appropriate next step in diagnosis?

E

Titrated oxygen therapy

A 63-year-old man with chronic obstructive pulmonary disease comes to the urgent treatment center because of a 4- day history of worsening shortness of breath. Use of his albuterol rescue inhaler has provided no improvement in his symptoms. Medical history otherwise is unremarkable. Additional medications are formoterol, budesonide, and tiotropium. The patient smoked two packs of cigarettes daily for 45 years but currently smokes only three to four cigarettes daily and says he is trying hard to quit. He appears anxious. He is 175 cm (5 ft 9 in) tall and weighs 100 kg (220 lb); BMI is 33 kg/m². Temperature is 37.2°C (99.0°F), pulse is 96/min, respirations are 26/min, and blood pressure is 128/76 mm Hg. Pulse oximetry on room air discloses an oxygen saturation of 85%. Mild cyanosis is noted, but there is no clubbing or edema of the extremities. Auscultation of the lungs discloses diffuse expiratory wheezes. Cardiac examination discloses distant but regular heart sounds. Results of arterial blood gas analysis on room air are shown: PO2: 48 mm Hg PCO2: 55 mm Hg pH: 7.36 After an albuterol nebulizer treatment is administered, the patient reports feeling somewhat better but says he is feeling "jittery" and is starting to have a mild tremor. In addition to providing smoking cessation counseling and prescribing antibiotic and corticosteroid therapy, which of the following is the most appropriate next step in management?

F

Adenocarcinoma of the colon

A 49-year-old man returns to the office for follow-up 2 weeks after he was evaluated for a 4-month history of intermittent diarrhea associated with cramping abdominal pain, urgency, and fecal incontinence. Since the onset of these symptoms, he has had four to five bowel movements daily that contain blood and mucus. Endoscopy done 1 week ago showed erythematous, inflamed mucosa of the rectum and sigmoid colon; there were no abnormalities of the ileum. He also had an episode of uveitis treated with intraocular corticosteroids 3 months ago. He takes no routine medications. He is 185 cm (6 ft 1 in) tall and weighs 77 kg (170 lb); BMI is 22 kg/m². Vital signs are temperature 37.3°C (99.2°F), pulse 88/min, respirations 18/min, and blood pressure 128/80 mm Hg. Skin examination shows raised, tender nodules that are 2 to 3 cm in diameter on the anterior surfaces of both lower extremities. Palpation of the abdomen discloses mild tenderness. Rectal examination discloses no fissures or ulcers. Test of the stool for occult blood is trace positive. This patient should be counseled that he is at greatest risk for which of the following?

A

Decreased uptake of glucose by insulin-sensitive tissues

A 27-year-old man is examined in the intensive care unit 1 day after he sustained a closed head injury, liver laceration, and pelvic fracture in a motor vehicle collision. He is intubated and mechanically ventilated. He is receiving intravenous midazolam and 5% dextrose in lactated Ringer solution. Temperature is 37.8°C (100.0°F), pulse is 95/min, and blood pressure is 100/70 mm Hg. Cardiopulmonary examination shows no abnormalities. The abdomen is soft. He withdraws appropriately to painful stimuli. Laboratory studies show: Hematocrit: 28% Leukocyte count: 13,000/mm³ Serum Na⁺: 138 mEq/L K⁺: 3.5 mEq/L Cl⁻: 102 mEq/L HCO₃⁻: 24 mEq/L Urea nitrogen: 20 mg/dL Glucose: 220 mg/dL Creatinine: 1 mg/dL Which of the following is the most likely mechanism of these laboratory findings?

A

Discharge the patient with a plan for home health care and physical therapy

A 72-year-old woman is evaluated in the acute rehabilitation facility where she has been receiving physical therapy since sustaining a stroke 2 weeks ago that resulted in moderate left hemiparesis. A swallowing study obtained on admission to the facility showed no abnormalities and she has been progressing well with her rehabilitation. She is able to walk with the aid of a walker and assistant, has no speech impairment, and tolerates a regular diet. Medical history also is notable for well-controlled hypertension and hyperlipidemia. Medications are lisinopril, simvastatin, and daily aspirin. Temperature is 37.0°C (98.6°F), pulse is 72/min and regular, respirations are 12/min, and blood pressure is 130/80 mm Hg. Cardiopulmonary examination shows no abnormalities. Cranial nerves are intact. Muscle strength in the extremities is 4/5 on the left and 5/5 on the right. Sensation is intact bilaterally. Standardized assessment of cognitive function shows no abnormalities. For the past 2 days, the patient has insisted that she is well enough to go home despite not being fully cleared to do so by her physical therapist and physiatrist, who want her to stay for 1 more week to try to advance from the walker to a cane. The patient lives with her daughter, son-in-law, and grandson, and has a bedroom on the main floor of the house with no need to use stairs. The daughter works as a stay-at-home mother. Which of the following is the most appropriate next step in management?

A

Hyperaldosteronism

A 46-year-old woman comes to the office for an annual health maintenance examination. She reports a 6-week history of fatigue, which she attributes to working full time and caring for her three children. Her blood pressure has been consistently high as measured at home with her husband's automated cuff, with many readings greater than 150/90 mm Hg. Medical history is unremarkable and routine preventive screenings, including mammography and Pap smear, have shown no abnormalities. Her only medications are a daily multivitamin and ibuprofen as needed. She is 165 cm (5 ft 5 in) tall and weighs 72 kg (158 lb); BMI is 26 kg/m². Pulse is 84/min, and blood pressure is 152/98 mm Hg. Physical examination shows trace edema of the ankles but no other abnormalities. Results of serum studies are shown: Urea nitrogen: 12 mg/dL Creatinine: 0.9 mg/dL Na⁺: 141 mEq/L K⁺: 3.1 mEq/L Cl⁻: 100 mEq/L HCO₃⁻: 23 mEq/L Which of the following is the most likely explanation for this patient's increased blood pressure?

C

Necrotizing fasciitis

A 50-year-old woman is brought to the emergency department because of a 3-day history of severely painful lesions over her right leg and temperatures to 38.7°C (101.7°F). She has a 12-year history of type 2 diabetes mellitus. Her only medication is insulin. On arrival, temperature is 39.3°C (102.8°F). Examination of the right lower extremity shows exquisite tenderness to palpation, edema, and warmth. The extremity appears shiny and diffusely erythematous without sharp margins. The subcutaneous tissue is firm, and there are areas of notable skin breakdown with bullae containing thick purple fluid. Examination of the left lower extremity shows no abnormalities. Which of the following is the most likely diagnosis?

F

Using a respirator at work

A 37-year-old woman comes to the office for a routine health maintenance examination. For the past 6 years, she has worked in a paper mill factory that uses liquid chlorine to bleach the paper. The patient is concerned about her exposure to toxic substances. Vital signs are within normal limits. Examination shows no abnormalities. Which of the following is the most appropriate recommendation to address this patient's concerns?

D

Spironolactone

A 57-year-old man with alcohol use disorder comes to the emergency department because of a 3-day history of worsening abdominal pain and distention. Medical history is remarkable for alcoholic cirrhosis, hypertension, hyperlipidemia, and a laparoscopic cholecystectomy 10 years ago. The patient also has had several previous hospital admissions for similar episodes of abdominal pain and distention. The patient takes no medications but has been prescribed medications for hypertension in the past. He recently participated in an alcohol rehabilitation program but began drinking alcohol again 1 week ago. During the past 5 days, he has drunk 1 L of vodka daily. Pulse is 100/min, respirations are 16/min, and blood pressure is 165/85 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 100%. The patient appears jaundiced. Cardiopulmonary examination discloses no abnormalities. The abdomen is large, distended, and tense; a fluid wave is present. Palpation of the abdomen discloses a 2-cm–wide reducible umbilical hernia and diffuse tenderness without guarding. There is no tenderness to percussion. In addition to large-volume paracentesis and furosemide therapy, initiation of which of the following pharmacotherapies is most appropriate?

D

Gemfibrozil therapy

A 48-year-old man is admitted to the hospital 2 hours after the onset of severe abdominal pain, nausea, and vomiting. The pain radiates to the back but improves when he bends forward. He has no history of serious illness and takes no medications. He does not smoke cigarettes. He drinks two 12-oz beers weekly. He appears restless. He is 173 cm (5 ft 8 in) tall and weighs 90 kg (198 lb); BMI is 30 kg/m² . Temperature is 38.0°C (100.4°F), pulse is 110/min, respirations are 20/min, and blood pressure is 110/60 mm Hg. On pulmonary examination, decreased breath sounds are heard at the lung bases; there is dullness to percussion. Abdominal examination shows distention and severe tenderness to palpation of the epigastrium and left upper quadrant. Laboratory studies show:Hemoglobin: 13.5 g/dLSerum Urea nitrogen: 30 mg/dL Glucose: 120 mg/dL Creatinine: 1.2 mg/dL Cholesterol: 300 mg/dL Triglycerides: 1500 mg/dL Total bilirubin: 1.1 mg/dL Amylase: 300 U/LAdministration of intravenous fluids and analgesics is begun. The patient’s abdominal pain, nausea, and vomiting decrease. Which of the following is the most appropriate next step in management? Choose one among the choices below.

C

Vitamin B₁ (thiamine)

A 57-year-old man is admitted to the hospital 30 minutes after he was found wandering in the streets. Fingerstick blood glucose concentration obtained by paramedics prior to transport was 68 mg/dL. The patient's medical history is unknown. Temperature is 35.8°C (96.5°F), pulse is 80/min, respirations are 16/min, and blood pressure is 106/70 mm Hg. The patient appears disheveled and is not oriented to person, place, or time. Physical examination shows mild conjunctival icterus. Cardiopulmonary examination discloses no abnormalities. Abdominal examination discloses a small fluid wave. There is palmar erythema and 1+ pitting edema of the lower extremities. Gait is broad based and ataxic. The patient is unable to cooperate with ocular or neurologic examinations. ECG shows a regular sinus rhythm and no acute abnormalities. Results of toxicology screening are pending. The most appropriate initial step in management is to administer which of the following?

B

Develop an institutional policy with standardized orders for DVT prophylaxis

Three days after an operation for uterine cancer, a hospitalized 67-year-old woman develops edema of the right lower extremity. Doppler ultrasonography shows a deep venous thrombosis (DVT). Review of the patient's record indicates that no DVT prophylaxis was initiated perioperatively. Which of the following is the best approach to prevent a similar adverse event in the future?

B

Absolute risk reduction is 1%

A clinical trial is performed to assess the efficacy of aspirin in decreasing the risk for myocardial infarction. Twenty-two thousand male physicians with no history of coronary artery disease are randomly assigned to receive aspirin (325 mg/d) or a placebo. After following the subjects for 5 years, results show that the incidence of myocardial infarction is 1.2% in the aspirin group and 2.2% in the placebo group. The reduction in incidence is statistically significant. Which of the following is the most accurate interpretation of these results?

A

Ask the surgeon to continue the operation only after the discrepancy is resolved

An 18-year-old man is being prepared to undergo left temporal craniotomy for meningioma. General anesthesia has been administered. The surgeon reviews the patient's most recent MRI findings, which are hanging on a view box in the operating room, and prepares to clip the hair from the patient's right scalp. The circulating nurse is concerned because the signed operative consent form indicates a left temporal craniotomy. Which of the following is the most appropriate course of action for the circulating nurse?

C

Application of positive end-expiratory pressure

A 52-year-old man is brought to the emergency department because of a 2-day history of severe, progressive shortness of breath associated with exacerbation of his chronic cough. He has a 6-week history of pneumonia, which has responded slowly to treatment. Prior to the onset of his current symptoms, he had minimally productive cough and mild shortness of breath after walking one or two blocks. He also has had a low-grade fever for 6 days. He has no other history of serious illness. Current medications are erythromycin and an over-the-counter cough suppressant. He has smoked one pack of cigarettes daily for 20 years. On arrival, he appears ill. He is diaphoretic and in severe respiratory distress. Temperature is 38.1°C (100.6°F), pulse is 110/min, respirations are 36/min and shallow, and blood pressure is 70/50 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 83%. Examination shows perioral cyanosis. There is no jugular venous distention. Diffuse crackles and wheezes are heard throughout the lungs. Heart sounds are normal. While a blood sample is being taken, the patient's blood pressure decreases, and he stops breathing. He is intubated, and mechanical ventilation is begun. Laboratory studies show: Hematocrit: 42% Leukocyte count: 16,000/mm³ Segmented neutrophils: 85% Lymphocytes: 15% Platelet count: 200,000/mm³ Arterial blood gas analysis on an FIO2 of 1.0 shows: pH: 7.35 PCO₂: 42 mm Hg PO₂: 55 mm Hg Chest x-ray shows diffuse alveolar infiltrates bilaterally and no cardiomegaly. Following intravenous administration of fluids, his blood pressure increases to 118/80 mm Hg. Which of the following is the most appropriate next step in management?

E

Cardiac monitoring

A 14-year-old boy is brought to the emergency department by his parents 30 minutes after the sudden onset of confusion, sweating, and pallor. He has enuresis treated with imipramine. His parents refilled his prescription for imipramine 3 days ago and noted today that the bottle is empty. On arrival, the patient is awake but confused. Temperature is 37.0°C (98.6°F), pulse is 80/min, respirations are 8/min, and blood pressure is 100/60 mm Hg. Examination shows dilated pupils and flushed skin. In addition to ensuring an adequate airway and establishing intravenous access, which of the following is the most appropriate initial step in management?

A

Duplex ultrasonography of the abdomen

A 65-year-old man with mild hypertension comes to the veterans’ administration outpatient clinic because he is concerned about having an abdominal aortic aneurysm. He says he feels well. His medications are metoprolol and lisinopril. His older brother, who was "seemingly in good health," recently underwent emergency repair of a ruptured abdominal aortic aneurysm that had not been diagnosed previously. The patient retired from the military 15 years ago. He smoked one-half pack of cigarettes daily for 20 years but quit 20 years ago. He is 183 cm (6 ft 0 in) tall and weighs 84 kg (185 lb); BMI is 25 kg/m². Pulse is 72/min and regular, and blood pressure is 140/85 mm Hg. Abdominal examination shows no organomegaly or tenderness to palpation. The aortic pulsation is estimated at 3 cm in width. A midepigastric bruit is heard. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in diagnosis?

C

Serum protein electrophoresis

A 57-year-old man comes to the physician because of a 1-month history of fatigue and moderate low back pain. He also has had a mildly decreased appetite resulting in a 1.8-kg (4-lb) weight loss during this period. He has a 1-week history of headache. He has had no fever, sweating, or chills. He has hypertension well controlled with triamterene-hydrochlorothiazide. Other medications include 81-mg aspirin, ibuprofen, and a daily multivitamin. He appears tired. Examination shows slightly pale conjunctivae. A grade 2/6 systolic flow murmur is heard best at the lower left sternal border. The remainder of the examination shows no abnormalities. Test of the stool for occult blood is negative. Laboratory studies show: Hematocrit: 32% Mean corpuscular volume: 102 μm³ Leukocyte count :9200/mm³ Segmented neutrophils: 66% Bands: 3% Lymphocytes: 31% Platelet count: 325,000/mm3 Red cell distribution width: 15.6% (N=13%–15%) Serum Ca²⁺: 10.8 mg/dL Urea nitrogen: 18 mg/dL Glucose: 108 mg/dL Creatinine: 1.5 mg/dL Albumin: 3 g/dL X-rays of the lumbosacral spine show mild osteopenia. Which of the following is the most appropriate next step in diagnosis?

A

Osteoporosis

A 38-year-old woman, gravida 1, para 1, comes to the office because she has been unable to conceive for the past year. She and her husband have had unprotected sexual intercourse three times weekly during this time. They have a 6-year-old daughter. During the past year, menses have occurred at irregular 90- to 120-day intervals. Her last menstrual period was 2 months ago. Menses previously occurred at regular 30-day intervals. She used an oral contraceptive for 4 years after the birth of her daughter but discontinued it 14 months ago. She has no history of serious illness and takes no medications. The patient appears well. She is 163 cm (5 ft 4 in) tall and weighs 63 kg (140 lb); BMI is 24 kg/m². Vital signs are within normal limits. Examination shows no abnormalities. Results of serum studies are shown: Thyroid-stimulating hormone: 3 μU/mL Follicle-stimulating hormone: 100 mIU/mL Prolactin: 10 ng/mL β-hCG: negative This patient’s diagnosis puts her at risk for which of the following?

D

von Willebrand disease

A 27-year-old man comes to the physician because of a 1-month history of progressive fatigue and episodes of moderate abdominal pain. He has a 4-year history of recurrent nosebleeds that have increased in frequency despite undergoing cauterization of the nasal mucosa 6 months ago. He takes no medications. His sister has anemia associated with recurrent nosebleeds and heavy menstrual periods; she also had postpartum hemorrhage that required transfusion. The patient's vital signs are within normal limits. Examination shows pallor; no other abnormalities are noted. Laboratory studies show: Hemoglobin: 7.1 g/dL Erythrocyte count: 2.1 million/mm³ Leukocyte count: 13,500/mm³ Platelet count: 250,000/mm³ Prothrombin time: 12 sec (INR=1) Partial thromboplastin time: 45 sec Which of the following is the most likely diagnosis?

E

Generalized anxiety disorder

A 37-year-old woman comes to the office for a follow-up examination 3 weeks after testing confirmed a mass in her left breast to be benign. She says that despite the test results, she has had anxiety, insomnia, and a preoccupation with cancer since noticing the lump. Two weeks ago, she had a 20-minute episode of markedly intense anxiety characterized by heart palpitations and the fear that she was dying. She says she has always been a tense, nervous person and is uncomfortable in social situations. She says she frequently worries and is fearful of the future and apprehensive of dying. She has no other history of panic episodes, traumatic events, or serious illness and takes no medications. She does not drink alcohol or use illicit drugs. Physical examination shows a 2-cm mass in the left breast. On mental status examination, she is cooperative but worried. Her thought processes are linear, and content focuses on possible negative eventualities. Which of the following is the most likely diagnosis?

B

Cefotaxime

A 55-year-old man comes to the emergency department because of a 6-hour history of diffuse abdominal pain and subjective fever. His most recent bowel movement 4 hours ago was loose but not bloody. He reports no chills or urinary symptoms. Medical history is remarkable for gastroesophageal reflux disease and alcoholic cirrhosis. Medications are furosemide, spironolactone, lactulose, and pantoprazole. The patient appears uncomfortable. Temperature is 37.8°C (100.0°F), pulse is 88/min, respirations are 14/min, and blood pressure is 104/66 mm Hg. Physical examination shows conjunctival icterus and abdominal distention. Bowel sounds are normal. There is moderate diffuse abdominal tenderness with mild guarding but no rebound tenderness. Results of laboratory studies are shown: Serum ALT: 70 U/L AST: 85 U/L Alkaline phosphatase: 66 U/L Total bilirubin: 3.5 mg/dL Creatinine: 0.6 mg/dL Blood Hematocrit: 39% Hemoglobin: 13.0 g/dL Leukocyte count: 11,300/mm³ Platelet count: 66,000/mm³ Partial thromboplastin time: 39 seconds Prothrombin time: 17.2 seconds Abdominal paracentesis is done, and analysis of the ascitic fluid shows a segmented neutrophil cell count of 288 cells/mm³. Results of blood and ascitic fluid cultures are pending. Which of the following is the most appropriate pharmacotherapy at this time?

A

Vitamin D

A 45-year-old man is brought to the emergency department because of moderate chest pain after a generalized tonic-clonic seizure 30 minutes ago. He has seizure disorder for which he has taken carbamazepine and phenobarbital for the past 20 years. X-ray of the chest shows generalized osteopenia with several rib fractures. Which of the following is the most likely nutritional deficiency?

E

Ketorolac 0.5% solution, 1 drop in right eye, four times daily

A 32-year-old man comes to the office because of a 2-day history of redness of the right eye. He has not had sensitivity to light or the sensation of a foreign body in the eye. He has no history of serious illness and takes no medications. Examination of the right eye shows erythema and clear discharge. Examination of the left eye shows no abnormalities. The physician prescribes ketorolac ophthalmic solution. Which of the following is the most appropriate way for the physician to write the prescription?

A

Pubic Hair Development: Normal; Breast Development: normal

A 14-year-old girl is brought to the physician by her mother for a well-child examination. Vital signs are within normal limits. On breast examination, the areolae are 3 cm in diameter and form a secondary mound bilaterally. Cardiopulmonary and abdominal examinations show no abnormalities. Pelvic examination shows dark, curly, coarse hair that spreads sparsely over the pubic area but not over the thighs. Which of the following is the most accurate assessment of this patient's development?

D

Subdermal contraceptive implant

A healthy 19-year-old woman comes to the clinic requesting advice regarding contraception. Menses occur at regular 28-day intervals with heavy flow. She is sexually active and has had three lifetime male partners. She has smoked one-half pack of cigarettes daily for 2 years. She lives in a college dormitory and says that she often does not sleep in her own room and has trouble remembering to take medications regularly. Her only medication is a daily multivitamin. She is 163 cm (5 ft 4 in) tall and weighs 58 kg (128 lb); BMI is 22 kg/m². Vital signs are within normal limits. Physical examination shows no abnormalities. Which of the following is the most appropriate recommendation regarding contraception for this patient?

D

Tubo-ovarian abscess

A previously healthy 17-year-old girl comes to the emergency department because of a 3-day history of moderateright lower quadrant pain, fever, and loss of appetite. She has not had abnormal vaginal discharge. Four months ago,she was treated with oral antibiotics for cystitis. She currently takes no medications. Menses occur at regular 28-dayintervals. Her last menstrual period was 10 days ago. She has been sexually active with two male partners during thepast 6 months and uses condoms inconsistently. Temperature is 38.5°C (101.3°F), pulse is 105/min, respirations are14/min, and blood pressure is 127/82 mm Hg. Abdominal examination shows tenderness to palpation of the lowerquadrants with rebound in the right lower quadrant; there is no distention. Bowel sounds are decreased. Pelvicexamination shows blood-tinged discharge from the cervical os and cervical motion tenderness. There is a 5-cmmass in the right adnexal region. Which of the following is the most likely diagnosis?

E

Gonadectomy

A 15-year-old girl is brought to the office because she has never had a menstrual period. She has no history ofserious illness and receives no medications. Growth and development are appropriate for age. Breast developmentbegan at the age of 10 years. She has never been sexually active. She is at the 90th percentile for height, 75thpercentile for weight, and 69th percentile for BMI. Sexual maturity rating is 4 for breast development. Pelvicexamination shows a normal-appearing vagina; the cervix and uterus cannot be palpated. Her serum testosteroneconcentration is 340 ng/dL (N=5–40). Serum concentrations of luteinizing hormone, follicle-stimulating hormone,thyroid-stimulating hormone, 17α-hydroxyprogesterone, and prolactin are within the reference ranges. Serum β-hCGtesting is negative. Pelvic ultrasonography shows no uterus. Her karyotype is 46,XY. Which of the following is themost appropriate next step in management?

B

Hydrochlorothiazide

A 50-year-old man returns to the office for a follow-up examination. During the past 2 months, he has had increased blood pressure readings during several checks at the office and at home. He says he has felt well. He has major depressive disorder and gout. Medications are fluoxetine and allopurinol. His maternal grandfather had congestive heart failure and the patient's older brother has hypertension. The patient has smoked one-half pack of cigarettes daily for 32 years. He is 180 cm (5 ft 11 in) tall and weighs 95 kg (210 lb); BMI is 29 kg/m². Pulse is 70/min and blood pressure is 152/90 mm Hg. Physical examination discloses no abnormalities. Which of the following medications is contraindicated in this patient?

C