Deck 2: In-patient Facilities

Question 1

A 68-year-old woman is admitted to the hospital due to shortness of breath and lower extremity swelling for the past 6 weeks.  Her medical history includes hypertension, hypothyroidism, type 2 diabetes mellitus, hyperlipidemia, obstructive sleep apnea, and stage II chronic kidney disease.  The patient had a transient ischemic attack with right carotid endarterectomy 8 years ago.  Home medications include aspirin, levothyroxine, hydrochlorothiazide, lisinopril, atorvastatin, and glipizide.  She has never used tobacco.
Temperature is 37.2 C (99 F), blood pressure is 122/80 mm Hg, pulse is 84/min, and respirations are 22/min.  Pulse oximetry is 92% on 3 L oxygen via nasal cannula.  Jugular venous pressure is elevated at 12 cm H₂O.  Lung examination reveals decreased breath sounds at the bases with bibasilar rales up to the lower one-third of the chest.  Cardiac examination reveals a normal S1 and S2 and an audible S4 over the cardiac apex.  There is a 1/6 holosystolic murmur heard over the cardiac apex.  The patient has 3+ lower extremity edema up to her knees.  The remainder of her physical examination is within normal limits.
Laboratory results are as follows:
ECG results are shown in the exhibit.
Initial chest x-ray reveals cardiomegaly and bilateral pulmonary vascular congestion, along with small, bilateral pleural effusions.
A transthoracic echocardiogram shows normal left ventricular size and a left ventricular ejection fraction of 65%.  Moderate, concentric left ventricular hypertrophy is present.  The left atrium is moderately dilated.  A central jet of mild mitral regurgitation is present.  Pulmonary artery systolic pressure is estimated at 45 mm Hg.
Which of the following is the most appropriate next step in management of this patient?

A)Optimal volume control
B)Pulmonary function tests
C)Right heart catheterization
D)Treatment with angiotensin II receptor blockers
E)Treatment with beta blockers

Answer 1

Optimal volume control

Question 2

A 78-year-old man is brought to the emergency department with severe abdominal pain over the last 6 hours.  He has vomited twice since the onset of symptoms.  Six months ago, he was diagnosed with severe aortic stenosis with an estimated aortic valve area of 0.8 cm² and has been followed clinically.  The patient's left ventricular ejection fraction was normal.  He also has chronic kidney disease with baseline estimated glomerular filtration rate of 50 mL/min.
His temperature is 38.3 C (101 F), blood pressure is 102/65 mm Hg, and pulse is 122/min and regular.  Lungs are clear on auscultation.  A 3/6 mid-systolic murmur is heard at the right upper sternal border with radiation to the carotids.  The carotid pulse is delayed.  The abdomen is mildly distended and diffusely tender with prominent rebound tenderness.  The extremities are warm.  Upright chest x-ray shows free air under the diaphragm.
He receives intravenous fluids and antibiotics.
Which of the following is the best initial management for this patient?

A)Abdominal surgery with invasive hemodynamic monitoring
B)Aortic balloon valvuloplasty
C)Dobutamine echocardiography
D)Left heart catheterization
E)Pain control and supportive care

Answer 2

A
Explanation:
This patient has signs of intra-abdominal perforation (free air under the diaphragm) with generalized peritonitis and should be referred for emergency exploratory laparotomy.  The presence of aortic stenosis (AS) is associated with an increased (10%-30%) risk of perioperative cardiac complications in patients undergoing noncardiac surgery.  The risk is higher in those with severe AS.  Such patients have an increased risk of developing hypotension, myocardial infarction, heart failure, arrhythmias, and death in the perioperative period.  Patients with moderate-to-severe AS also have an increased risk of bleeding due to acquired von Willebrand syndrome.  However, regardless of the risk and AS severity, patients requiring emergency life-saving procedures should proceed with surgery with invasive hemodynamic monitoring to ensure adequate intravascular volume, preload, and systemic vascular resistance.
(Choice B)  Patients with severe symptomatic AS should have aortic valve replacement prior to elective noncardiac surgery.  Balloon aortic valvuloplasty is not recommended due to the risk of restenosis and adverse outcomes.  However, patients requiring emergency noncardiac surgery should proceed with surgery without further delay.
(Choice C)  Dobutamine echocardiography has no role in the preoperative evaluation of patients with severe AS.
(Choice D)  Left heart catheterization, along with coronary angiography, can provide additional risk stratification in patients with severe AS and known coronary artery disease, angina, or heart failure prior to elective noncardiac surgery.
(Choice E)  This patient has clinical signs of peritonitis and intra-abdominal perforation and needs emergency surgery.  Pain control and supportive care alone are not adequate.
Educational objective:
Severe aortic stenosis is a major clinical predictor of adverse perioperative outcomes in patients undergoing noncardiac surgery.  Patients with severe aortic stenosis who require emergency surgery should proceed with surgery, with the addition of invasive hemodynamic monitoring to ensure adequate intravascular volume, preload, and systemic vascular resistance.
__________
References:
Aortic stenosis: an underestimated risk factor for perioperative complications in patients undergoing noncardiac surgery.
(http://www.ncbi.nlm.nih.gov/pubmed/14706659)

Question 3

A study evaluates the role of MRI in assessing the potential for myocardial recovery after reperfusion.  A total of 185 patients undergoing coronary bypass surgery were evaluated by MRI for delayed gadolinium enhancement, indicative of myocardial scar tissue and therefore no viability.  Subsequently, the patients were followed for improvement in myocardial contractility after surgery.  The following results were obtained.

Which of the following best describes the specificity of MRI in assessing for scar tissue?

A)82/85
B)92/100
C)92/95
D)82/90
E)100/185

Answer 3

A
Explanation:

Specificity, sometimes called the true negative rate, is the proportion of patients who have a negative test result among all those who truly do not have the disease of interest.  The formula to calculate specificity is TN / (TN + FP), where TN denotes true negatives (ie, patients who test negative and do not have the disease) and FP denotes false positives (ie, patients who test positive but do not have the disease).  The sum (TN + FP) represents all patients who do not have the disease of interest (negative condition).
According to the table, 85 patients did not have myocardial scar tissue (ie, negative condition) given that they recovered their myocardial contractility following surgery.  Out of these 85 patients, 82 (ie, TN) were correctly identified by delayed gadolinium enhancement on MRI (ie, negative test result in a patient without the condition).  This means that the specificity of MRI was 82/85 = 96.5% when used to assess scar tissue.  Out of these 85 patients, 3 had a positive test result even though they did not have scar tissue; these represent false positives.  The specificity is complementary to the false positive rate, which is 3/85 or about 3.5% in this case.
(Choice B)  The calculation 92/100 = 92% gives the sensitivity of the test.  Sensitivity is the proportion of true positives (TP) among all those who have the disease.
(Choice C)  The calculation 92/95 = 97% gives the positive predictive value (PPV) of the test.  The PPV is the proportion of positive test results that are true positives.  It answers the question: Given a positive test result, what is the probability that a patient has the disease?
(Choice D)  The calculation 82/90 = 91% gives the negative predictive value (NPV) of the test.  The NPV is the proportion of negative test results that are true negatives.  It answers the question: Given a negative test result, what is the probability that a patient does not have the disease?
(Choice E)  The calculation 100/185 = 54% represents the prevalence of myocardial scar tissue among the patients who took part in the study.
Educational objective:
Specificity is the proportion of true negatives among all those who do not have the disease.  The formula to calculate specificity is True Negatives / (True Negatives + False Positives).  Specificity and sensitivity are intrinsic characteristics of the test and are not affected by prevalence, unlike the positive and negative predictive values.
__________

Question 4

A 62-year-old woman comes to the emergency department with a 2-week history of palpitations and mild shortness of breath.  The patient has a history of hypertension and type 2 diabetes mellitus.  She is a lifetime nonsmoker and has no family history of heart disease.  Blood pressure is 144/70 mm Hg and pulse is 145/min and irregular.  Oxygen saturation is 95% on room air.  Lung examination reveals minimal rales at both bases.  There are no heart murmurs.
ECG shows atrial fibrillation with rapid ventricular response.  Transthoracic echocardiogram shows mild left atrial dilation and a diffusely hypokinetic left ventricle with an ejection fraction of 40%.  Chemistry panel, serial troponin I, and TSH levels are normal.
The patient is treated with metoprolol and anticoagulation.  On the third day of hospitalization, despite increasing doses of metoprolol, she still has palpitations.  Blood pressure is 128/67 mm Hg, and pulse is 122/min and irregular.
Which of the following is the best next step in management of this patient?

A)Cardiac catheterization
B)Flecainide
C)Myocardial perfusion imaging
D)Sotalol
E)Transesophageal echocardiography

Question 5

A 42-year-old woman is evaluated for palpitations.  She describes them as an occasional "fluttering in the chest" that is sometimes precipitated by emotion.  Her lifestyle is sedentary, but she has had no shortness of breath, cough, or lower extremity swelling and no history of bleeding.  The patient emigrated from Mexico when she was 6 years old.  She is a lifetime nonsmoker and does not drink alcohol.
Blood pressure is 135/85 mm Hg.  ECG shows a normal sinus rhythm with a heart rate of 65/min.
Resting transthoracic echocardiogram shows moderate left atrial dilation, mitral stenosis with a valve area of 1.5 cm², pliable leaflets with minimal calcification, mild mitral regurgitation, normal right ventricle size, and an estimated pulmonary artery systolic pressure of 25 mm Hg.  Two episodes of atrial fibrillation lasting 20 minutes each are seen on 24-hour Holter monitoring.
What is the best next step in management of this patient?

A)Anticoagulation with rivaroxaban
B)Anticoagulation with warfarin
C)Low-dose aspirin
D)Risk assessment using CHA₂DS₂VASc score
E)Transesophageal echocardiography

Question 6

A 76-year-old woman comes to the emergency department due to fatigue, nausea, and abdominal pain for the past 2 weeks.  She feels weak and has not been eating much.  She also has "black spots" in her vision when she watches television.  Medical history includes hypertension, type 2 diabetes mellitus, persistent atrial fibrillation, myocardial infarction with coronary artery bypass grafting 10 years ago, and ischemic cardiomyopathy with an ejection fraction of 30%.  The patient was hospitalized 6 months ago with an episode of decompensated heart failure but has had no recent illnesses.  Medications include aspirin, furosemide, valsartan, carvedilol, atorvastatin, spironolactone, digoxin, warfarin, and insulin.
Temperature is 36.7 C (98 F), blood pressure is 120/74 mm Hg, and pulse is 50/min.  Mucous membranes are dry and the neck veins are flat.  The lungs are clear to auscultation.  Heart sounds are regular with a faint ejection systolic murmur present over the aortic area.  The abdomen is soft with mild, diffuse tenderness over the epigastric area with deep palpation.  Neurologic examination is unremarkable.
Laboratory results are as follows:
ECG shows a regular narrow-complex rhythm at 48/min, no P waves, and occasional ventricular premature beats.  While in the emergency department, the patient also has an asymptomatic 9-beat run of nonsustained ventricular tachycardia that resolves spontaneously.
Which of the following is the best treatment for this patient?

A)Calcium gluconate
B)Digoxin-specific antibody (Fab) fragments
C)Insulin and dextrose
D)Intravenous amiodarone
E)Intravenous glucagon

Question 7

A 31-year-old farmer is hospitalized with a severe reaction to a bee (Hymenoptera) sting.  He developed respiratory distress requiring endotracheal intubation in the field.  He was treated with epinephrine and corticosteroids with rapid recovery.  The patient has no prior similar incidents and no allergies.  He is given an epinephrine autoinjector and instructed on its use.
Which of the following is the most important part of discharge planning in this patient?

A)Antihistamine therapy
B)Prolonged course of corticosteroids
C)Referral for immunotherapy
D)Serum total immunoglobulin E levels
E)Serum tryptase levels

Question 8

A 72-year-old veteran is admitted to the hospital due to worsening abdominal pain and distension for the past 4 weeks.  He recently moved back to his home town to be close to his family.  The patient was admitted to the hospital approximately 6 months ago with leg swelling and "fluid in his belly," and a large-volume paracentesis was performed for symptomatic relief.
The patient has a history of hypertension, hyperlipidemia, atrial fibrillation, myocardial infarction, and coronary artery bypass grafting 5 years ago.  He also has a history of Hodgkin lymphoma treated with chemotherapy and radiation therapy 20 years ago.  He quit smoking 30 years ago but drinks 1 or 2 glasses of wine almost every day and hard liquor occasionally.  Medications include aspirin, atenolol, pravastatin, valsartan, warfarin, and over-the-counter vitamin supplements.
The patient's temperature is 37.2 C (99 F), blood pressure is 110/60 mm Hg, pulse is 88/min, and respirations are 22/min.  Pulse oximetry is 92% on room air.  Two spider angiomata are seen on the upper chest.  Jugular venous pressure is elevated at 16 cm H₂O.  The lungs are clear to auscultation.  Cardiac examination reveals irregular heart sounds with no significant murmur or rub.  His abdomen is soft with ascites on palpation.  There is 2+ pitting lower-extremity edema bilaterally up to the mid-thighs.
Laboratory results are as follows:

ECG shows atrial fibrillation and low-voltage QRS complexes in the precordial leads.
Which of the following would help most in establishing this patient's diagnosis?

A)Abdominal ultrasound
B)Echocardiography
C)Kidney biopsy
D)Liver biopsy
E)V/Q scan of the lungs

Question 9

A 63-year-old man is scheduled for coronary artery bypass surgery.  He underwent cardiac catheterization for a 2-month history of effort-limiting angina and was found to have left main coronary artery stenosis.  One year ago, the patient underwent drug-eluting stent placement in the right coronary artery.  The patient's other medical problems include type 2 diabetes mellitus and obesity.  His current medications are low-dose aspirin, clopidogrel, rosuvastatin, metoprolol, and basal-bolus insulin therapy.
Vital signs are within normal limits except for BMI of 35 kg/m².  Cardiopulmonary examination is unremarkable.
ECG shows sinus rhythm with normal intervals, minimal voltage criteria for left ventricular hypertrophy, and no pathologic Q waves.  The patient's most recent echocardiogram showed a left ventricular ejection fraction of 50% with no regional wall motion or valvular abnormalities.
Which of the following is the most appropriate management of this patient's antiplatelet medication before surgery?

A)Continue both antiplatelet agents
B)Start enoxaparin and discontinue aspirin and clopidogrel the day before surgery
C)Stop aspirin and clopidogrel 5 days before surgery
D)Stop only aspirin 5 days before surgery
E)Stop only clopidogrel 5 days before surgery

Question 10

A 53-year-old woman is hospitalized with acute inferior ST elevation myocardial infarction.  She did not undergo a revascularization procedure due to delayed presentation.  The patient has a distant history of deep vein thrombosis and is a factor V Leiden carrier.  Echocardiogram shows inferior and inferolateral wall akinesis with left ventricular ejection fraction of 45%.  Before discharge on day 3, she develops severe shortness of breath and is evaluated urgently.
Blood pressure is 84/60 mm Hg and pulse is 112/min and regular.  The apical impulse is hyperdynamic and there is a faint early systolic murmur heard at the apex.  There is no precordial thrill.  Bilateral crackles are heard on lung auscultation.  The extremities are cold and clammy.
ECG shows sinus tachycardia with Q waves in leads II, III, and aVF.
Which of the following is the most likely diagnosis?

A)Acute myocardial ischemia
B)Left ventricular free wall rupture
C)Mitral regurgitation
D)Pulmonary embolism
E)Ventricular septal rupture

Question 11

A 55-year-old construction worker is brought to the emergency department 2 hours after awakening with severe left chest discomfort.  He appears diaphoretic and uncomfortable.  He has no other medical problems and has not seen a physician in 5 years.
His blood pressure is 152/88 mm Hg and pulse is 92/min.  Examination shows clear lung fields, normal first and second heart sounds, and the presence of a fourth heart sound.  His initial EKG shows sinus rhythm with a 3-mm ST-segment elevation in leads V1-V4.
The hospital does not have a cardiac catheterization laboratory and the closest hospital with angioplasty capabilities is 2 hours away.  The patient is given a single bolus dose of tenecteplase over 10 seconds.  His chest discomfort subsides completely, and a repeat EKG 30 minutes after injection shows near-complete resolution of the ST-segment elevation.
Which of the following is the best next step in managing this patient?

A)Admit to telemetry floor
B)Admit to intensive care unit
C)Transfer to angioplasty-capable hospital immediately
D)Transfer to angioplasty-capable hospital after 24 hours of observation
E)Transfer to angioplasty-capable hospital only if patient has recurrent chest pain

Question 12

A 74-year-old man with type 2 diabetes is admitted to the cardiac care unit after an episode of substernal chest pain.  He has no history of coronary artery disease.  He was hospitalized two years ago for lower gastrointestinal bleeding and one year ago for community-acquired pneumonia.  He has non-specific ECG changes, and his initial troponin I level is 1.3 ng/mL.  Cardiac catheterization is performed showing 95% proximal left anterior descending artery stenosis and 85% proximal right coronary artery stenosis.  No intervention is performed and coronary artery bypass surgery is planned for the following day.
Five hours after the catheterization procedure, the patient complains of generalized weakness and back pain.  He appears to be diaphoretic and clammy.  His blood pressure is 77/55 mm Hg and pulse is 122/min and regular.  His neck veins are flat.  Heart sounds are normal and the chest is clear to auscultation.  The site of arterial puncture at his groin is mildly tender without subcutaneous hematoma.  He receives 1 liter of normal saline with symptomatic improvement.  Repeat blood pressure is 92/60 mm Hg and pulse is 96/min.  His ECG is unchanged from the previous one.
Which of the following is the best next step in managing this patient?

A)Obtain CT scan of the abdomen and pelvis without contrast
B)Obtain CT scan of the chest with contrast
C)Obtain emergent transthoracic echocardiogram
D)Place nasogastric tube
E)Proceed to coronary artery bypass surgery immediately

Question 13

A 60-year-old man is hospitalized for acute pancreatitis.  He reports swelling and tenderness in his jaw that appeared 6 months ago.  He has no medical problems, takes no medications, and does not use tobacco, alcohol, or illicit drugs.  There is no history of trauma to the abdomen.  He does not have dry eyes or dry mouth.  On admission, ultrasound of the abdomen shows no gallstones.  CT of the abdomen reveals a 3x4-cm solid mass in the mid-portion of his pancreas with some surrounding edema.  Chest CT reveals bilateral hilar adenopathy.  He is started on intravenous fluids, opioids for pain control, and nothing by mouth, and his abdominal pain resolves.
On examination, he is well-nourished and appears comfortable.  His blood pressure is 133/78 mm Hg, pulse is 90/min, and oxygen saturation is 98% on room air.  There is bilateral enlargement of his parotid glands and some enlargement of his lacrimal glands.  The remainder of his examination is within normal limits.
Laboratory results are as follows:

Serum chemistry and fasting lipid panels, liver function tests, urinalysis, and erythrocyte sedimentation rate are all within normal limits.  HIV testing is negative.
Which of the following conditions is the most likely cause of this patient's presentation?

A)IgG4-related disorder
B)Large B cell lymphoma
C)Occult alcoholism
D)Pancreatic carcinoma
E)Sjögren's syndrome

Question 14

A 48-year-old man is evaluated in the surgical intensive care unit for tachycardia and hypotension.  He underwent a hemicolectomy due to a perforated colonic diverticulum yesterday.  The patient has a history of hyperlipidemia but no known history of heart disease.  His current medications include piperacillin/tazobactam, famotidine, and benzodiazepines and opioids for sedation.
The patient is intubated and the ventilator is in the assist control mode.  His temperature is 39.4 C (103 F), blood pressure is 86/55 mm Hg, and pulse is 142/min.  Oxygen saturation is 99% on 40% FiO₂.
Examination shows flat neck veins and tachycardia with an irregular rhythm.  Breath sounds are heard bilaterally without wheezes or rhonchi.  The abdomen is soft but diffusely tender and the incision is clean.  The stoma is pink without any fluid output in the bag.  The patient's extremities are warm with 2+ pulses and no peripheral edema.  His urine output is 10 mL/hr.
Laboratory results are as follows:

ECG shows atrial fibrillation with rapid ventricular response.  There are no significant ST-segment or T wave changes.
Which of the following would be the most appropriate next step in management of this patient?

A)Electrical cardioversion
B)Intravenous (IV) digoxin
C)IV metoprolol
D)IV normal saline
E)Norepinephrine drip

Question 15

A 55-year-old construction worker is brought to the emergency department with sudden onset of diaphoresis and severe chest discomfort.  His symptoms woke him up 3 hours earlier.  On arrival, his blood pressure is 98/60 mm Hg, pulse is 86/min, and oxygen saturation is 98% on 3 L oxygen by nasal cannula.  He has persistent chest discomfort, and his skin is cold and clammy.  Neck veins are mildly distended.  Lung fields are clear and cardiac examination is unremarkable.  His initial EKG reveals 3-mm ST segment elevation in leads II, III, and aVF.
He is referred for emergency cardiac catheterization and is found to have an acute occlusion of the proximal right coronary artery.  There is mild, diffuse coronary atherosclerosis present in the left coronary circulation.  Left ventriculography reveals mild hypokinesis of the inferior wall with an LV ejection fraction of 55%.  He undergoes primary percutaneous coronary intervention with a bare metal stent and has TIMI II flow restored at the end of the procedure.  He is started on aspirin, prasugrel, atorvastatin, and intravenous eptifibatide and is transferred to the coronary care unit.
Thirty minutes later, his blood pressure drops to 80/54 mm Hg.  He has minimal residual chest discomfort but no other symptoms.  His physical examination is unchanged.  An urgent EKG shows minimal, less than 1 mm, persistent ST-segment elevation along with small Q waves in inferior leads.
Which of the following is the next best step in management of this patient?

A)Call for a pericardiocentesis tray
B)500-mL bolus of normal saline
C)Intra-aortic balloon pump insertion
D)Start dobutamine infusion
E)Stat CT scan of abdomen and pelvis

Question 16

A 72-year-old woman with a history of hypertension and coronary artery disease was admitted to the hospital 2 months ago with dizziness and palpitations.  The patient was diagnosed with persistent atrial fibrillation but has been doing well since.  She takes 20-minute walks on most days of the week for exercise with no chest pain or shortness of breath.
The patient had coronary artery bypass graft surgery 7 years ago for stable angina and also has gastroesophageal reflux disease, right knee osteoarthritis, and chronic constipation.  Her current medications include aspirin, metoprolol, digoxin, simvastatin, warfarin, and valsartan.  She also takes antacids frequently for heartburn and upper abdominal discomfort.
Her blood pressure is 146/80 mm Hg, and pulse is 76/min and irregularly irregular.  BMI is 31 kg/m².  A faint ejection-type systolic murmur is heard at the right upper sternal border.  Her peripheral pulses are 2+ and there is trace edema in the leg with the vein harvest scar.
Laboratory results are as follows:

Her last echocardiogram showed normal left ventricular systolic function and mild mitral regurgitation.
Compared to warfarin, dabigatran has a lower risk of which of the following?

A)Congestive heart failure
B)Dyspepsia
C)Intracranial bleeding
D)Pericarditis
E)Recurrent myocardial infarction

Question 17

A 26-year-old primigravid woman at 36 weeks gestation is admitted to the hospital because of vaginal bleeding and lower abdominal pain.  Her other medical problems include selective IgA deficiency, allergic rhinitis, and recurrent sinusitis.  Her anti-IgA antibody screening is positive.
Evaluation reveals placental abruption.  She is scheduled to undergo urgent cesarean section and requires blood transfusion.
Which of the following should be administered to this patient?

A)Blood product desensitization therapy
B)Irradiated red cells
C)Leukoreduced red cells
D)Normal packed red cells
E)Washed red cells

Question 18

A 75-year-old man comes to the emergency department with 6 hours of intermittent chest pain.  He has no nausea, vomiting, syncope, shortness of breath, or diaphoresis.  His medical problems include type 2 diabetes mellitus, hypertension, and hyperlipidemia.
The patient's blood pressure is 142/78 mm Hg and pulse is 82/min.  Cardiac and pulmonary examinations are within normal limits.
Electrocardiogram shows normal sinus rhythm with 1.5-mm horizontal ST-segment depression in leads II, III, and aVF.  Initial troponin I level is 2.2 ng/mL (normal <0.012 ng/mL).
The patient receives antiplatelet agents, nitroglycerin, and anticoagulation.  He reports complete resolution of symptoms.
Which of the following is the best next step in management of this patient?

A)Cardiac catheterization within 90 minutes
B)Cardiac catheterization within 24 hours
C)Coronary calcium score
D)Medical therapy and discharge if no recurrence of chest pain
E)Medical therapy and stress test before discharge

Question 19

A 52-year-old woman is undergoing screening colonoscopy and receives midazolam for sedation.  Shortly after the procedure is started, she becomes tachycardic and hypertensive.  Blood pressure is 240/140 mm Hg, pulse is 180/min, and respirations are 22/min.  Oxygen saturation is 92% on 4 L by nasal cannula.  ECG shows atrial fibrillation with rapid ventricular response.  Fine crackles are heard at the lung bases.
The procedure is aborted and the patient is admitted to the cardiac care unit for further management.  Medical history is significant for chronic lower back pain, anxiety disorder, and chronic headaches.  Medications include acetaminophen as needed for pain.  She has had no previous surgeries.
The following day, she feels fine and wishes to go home.  Blood pressure is 112/70 mm Hg, and pulse is 78/min and regular.  ECG shows normal sinus rhythm with nonspecific ST-segment and T-wave changes.  Complete blood count, serum chemistries, and TSH are unremarkable.  Transthoracic echocardiogram shows mild left atrial enlargement and mild mitral regurgitation.  Left ventricular systolic function is normal.
Which of the following is the best next step in management of this patient?

A)Chronic anticoagulation
B)Electrophysiology study for an accessory pathway
C)Opioid abuse screening
D)Pheochromocytoma workup
E)"Pill-in-the-pocket" flecainide therapy

Question 20

An 84-year-old man comes to the emergency department due to a week-long history of dizziness, lightheadedness, and shortness of breath.  His symptoms occur at any time but are worse with exertion.  He has had no chest pain, palpitations, or syncope.  Medical history includes hypertension, hypercholesterolemia, and benign prostatic hyperplasia.  His medications are aspirin, lisinopril, atorvastatin, and tamsulosin.
Temperature is 36.7 C (98 F), blood pressure is 120/60 mm Hg, pulse is 36/min, and respirations are 16/min.  On examination, the patient appears in no acute distress and has no symptoms.  Other than a slow pulse rate, physical examination shows no abnormalities.
Initial laboratory studies, including complete metabolic panel, thyroid function tests, and cardiac markers, are within normal limits.
ECG is shown in the exhibit.
A transthoracic echocardiogram shows normal right and left ventricular size and function with an ejection fraction of 60%, along with mild mitral and tricuspid regurgitation.
Which of the following is the best next step in management of this patient?

A)24-hour ECG monitoring
B)Intravenous atropine
C)Intravenous dobutamine
D)Permanent pacemaker
E)Transcutaneous pacing

Question 21

A 52-year-old man comes to the physician because of weight loss and constipation for the past 3 months.  He has no abdominal pain, vomiting, or black stools.  He has smoked 1 pack of cigarettes daily for 20 years.
His vital signs are within normal limits.  Examination shows no abnormalities.  Test of the stool for occult blood is positive.
Laboratory results are as follows:

He undergoes a colonoscopy that shows a nonobstructive mass in the rectum 10 cm from the anal verge.  Biopsy during colonoscopy shows moderately differentiated adenocarcinoma.  MR imaging shows tumor invading through the muscularis propria into perirectal tissues.  CT scan of the chest, abdomen, and pelvis  shows no lymph node enlargement or evidence of metastatic disease.
Which of the following is the most appropriate treatment for this patient?

A)Chemoradiation followed by surgery and chemotherapy
B)Surgery followed by chemotherapy
C)Surgery followed by radiation
D)Surgery only

Question 22

A 38-year-old man admitted with severe, acute alcoholic pancreatitis is evaluated in the intensive care unit for persistent fever.  The patient is intubated and on mechanical ventilation.  He is receiving nasojejunal tube feeding and intravenous crystalloids.
His temperature is 38.3 C (101 F), blood pressure is 90/60 mm Hg, pulse is 104/min, and respirations are 18/min.  Respiratory secretions are scant.  Breath sounds are decreased at the lung bases.  There is epigastric tenderness on deep palpation and mild abdominal distension.  2+ presacral edema is present.  A peripherally inserted central catheter in the right arm shows no surrounding skin redness or discharge.
Laboratory results are as follows:

Chest x-ray reveals bilateral, small pleural effusions.  A contrast-enhanced abdominal CT scan reveals 40% pancreatic necrosis and moderate-size fluid collections in the retroperitoneum around the pancreas.  The gallbladder has some sludge, the common bile duct measures 5 mm, and no intrahepatic ductal dilation is seen.
Which of the following is the best next step in managing this patient?

A)Ceftriaxone and vancomycin
B)Endoscopic retrograde cholangiopancreatography
C)Open necrosectomy
D)Parenteral nutrition
E)Percutaneous CT-guided aspiration

Question 23

A 56-year-old man comes to the emergency department with retrosternal chest pain that began when he was cleaning his backyard a few hours ago.  His medical problems include type 2 diabetes mellitus, hypertension, hypercholesterolemia, and obesity.  Three weeks ago, his hemoglobin A1C was 9.6% and glyburide was added.  He has no overt chronic complications of diabetes.  His medications include metformin, glyburide, ramipril, amlodipine, simvastatin, and low-dose aspirin.
His blood pressure is 140/80 mm Hg, pulse is 70/min, and body mass index is 38 kg/m².  The patient appears a little apprehensive, but the examination otherwise shows no abnormalities.
Electrocardiogram shows normal sinus rhythm and non-specific ST-T changes in the lateral chest leads.  The initial levels of cardiac troponin I are normal.  Chemistry profile is normal except for blood glucose of 266 mg/dL.  Chest x-ray is unremarkable.
The patient is admitted to a telemetry bed for monitoring, and serial cardiac enzymes are ordered.  He is allowed to eat a diabetic diet.  Finger-stick blood glucose measurement before meals and bedtime is ordered.
Which of the following is the best way to manage this patient's diabetes mellitus during hospitalization?

A)Continue his home regimen and start a long-acting basal insulin
B)Continue his home regimen and start a sliding scale of short-acting insulin
C)Stop oral diabetic agents and start a basal-bolus regimen
D)Stop oral diabetic agents and start intravenous insulin infusion
E)Stop oral diabetic agents and start a sliding scale of short-acting insulin

Question 24

A 48-year-old woman is admitted to the hospital from the emergency department due to fatigue and confusion.  She had been well until 2 months prior to admission when she began to feel tired and lost her appetite.  Over the next several weeks, the patient experienced nausea, constipation, and weight loss.  Recently, she has also had difficulty concentrating at work, and on the day of admission her daughter visited her at home and found her confused.  The patient has had no fever, chills, or depression.  Medical history is notable for rheumatoid arthritis, which was previously treated with methotrexate but has been quiescent in the absence of therapy for several years.  She is an ex-smoker with a 30-pack-year smoking history.  Her mother died of lung cancer at age 50.
Blood pressure is 138/78 mm Hg and pulse is 89/min.  Mucous membranes appear dry.  There is no lymph node enlargement.  Breast examination is unremarkable.  The lungs are clear to auscultation.  The spleen is not palpable.  There are no skin rashes.
Laboratory results are as follows:
Serum calcium was normal 6 months ago.  Which of the following is the most likely cause of this patient's hypercalcemia?

A)Bone metastases
B)Parathyroid hormone
C)Parathyroid hormone-related peptide
D)Renal tubular dysfunction
E)Vitamin D metabolite

Question 25

A 22-year-old woman is brought to the emergency department with confusion after a tonic-clonic seizure.  She has no prior history of seizures, headaches, or recent febrile illness.  The patient has suffered from recurrent nosebleeds for years with several visits to urgent care clinics for nasal packing.  She takes no medications.
The patient's blood pressure is 134/85 mm Hg and pulse is 98/min.  She has no meningeal signs and moves all her extremities.  Deep-tendon reflexes are 2+ bilaterally.
Laboratory results are as follows:

Additional physical examination findings are shown in the photograph below.

Which of the following is the most likely diagnosis?

A)Hereditary hemorrhagic telangiectasia
B)Hypersensitivity vasculitis
C)Peutz-Jeghers syndrome
D)Tuberous sclerosis
E)von Willebrand disease

Question 26

A 55-year-old man with known hepatic cirrhosis due to hepatitis C and alcohol abuse is brought to the emergency department with lethargy.  His wife states that the patient has been confused for the past 2 days.  He has not had any fevers, recent abdominal pain, or vomiting.  He eats a regular diet and has no constipation or diarrhea.  He was diagnosed with liver cirrhosis 2 years ago and quit drinking alcohol at that time.  One year ago, he underwent upper GI endoscopy and was diagnosed with non-bleeding grade 2 esophageal varices.  Since then, he has been maintained on propranolol.  In addition, he had a large-volume paracentesis 5 months ago and has been taking spironolactone and furosemide.  His wife states that he has been compliant with his medications.
His temperature is 36.7 C (98 F), blood pressure is 99/54 mm Hg, and pulse is 92/min and regular.  Oxygen saturation is 97% on room air.  Abdominal examination shows a distended but non-tender abdomen.  There is shifting dullness and a fluid thrill is present.  Rectal examination shows brown stool, which is negative for occult blood.  There is 2+ pretibial edema.  The patient is oriented to person only and has asterixis.
Laboratory results are as follows:

Urine toxicology screen is negative.  Chest x-ray is unremarkable.  Urinalysis is negative for infection.  Blood and urine cultures are obtained.  CT scan of the head shows mild cerebral atrophy, but no masses or bleeding.
Which of the following is the most appropriate next step in management?

A)Perform lumbar puncture
B)Start oral rifaximin
C)Pass nasogastric tube and perform gastric lavage
D)Perform upper GI endoscopy
E)Perform diagnostic paracentesis

Question 27

A 30-year-old woman with ulcerative colitis treated with mesalamine is hospitalized for nausea, abdominal pain, and diarrhea.  She has had 8-10 bloody bowel movements every day for the past week with associated tenesmus, anorexia, and a 2-kg (4.4-lb) weight loss.  The patient reports no recent travel, antibiotic use, or eating anything unusual.  She does not use tobacco, alcohol, or illicit drugs.
Temperature is 37 C (98.6 F), blood pressure is 110/70 mm Hg, pulse is 92/min, and respirations are 16/min.  Examination shows a mildly distended abdomen.  There is mild diffuse tenderness but no involuntary guarding or rebound tenderness.  Bowel sounds are present in all quadrants.  Stool is positive for occult blood.
Laboratory results are as follows:
Abdominal and upright chest radiographs are unremarkable with no free air or severe colonic dilatation.  Stool testing for Clostridium difficile is negative and stool cultures are sent.
Which of the following is the most appropriate next step in management of this patient?

A)Anti-tumor necrosis factor therapy
B)Colonoscopy with biopsy
C)CT scan of the abdomen and pelvis
D)Empiric antibiotics until culture results are available
E)Systemic glucocorticoids

Question 28

A 32-year-old African American man is admitted to the hospital due to dizziness.  For the past 2 weeks he has had decreased appetite, nausea, dry cough, constipation, and excessive urination.  He has had no fever or night sweats and was in good health prior to these symptoms.  The patient has no other medical problems and takes no medications.  He has 10-pack-year history of smoking.  He admits to drinking a few beers on weekends but does not use illicit drugs.
His blood pressure is 110/70 mm Hg and pulse is 110/min.  Lung examination shows normal breath sounds.  The remainder of the examination is normal.
Laboratory results are as follows:

Chest x-ray is shown below.

In addition to intravenous fluids, which of the following medications is most appropriate for this patient?

A)Calcitonin
B)Cinacalcet
C)Furosemide
D)Prednisone
E)Zoledronate

Question 29

A 75-year-old man with ischemic cardiomyopathy is hospitalized with acute decompensated heart failure.  His left ventricular ejection fraction is 10% and he has not been compliant with his medications.
His blood pressure is 134/78 mm Hg, pulse is 68/min, respirations are 20/min, and oxygen saturation is 96% on 2-liters O2 by nasal cannula.  His BMI is 24 kg/m².
The patient's symptoms improve with intravenous furosemide therapy and he appears comfortable at rest on supplemental oxygen.  During the night, the nurse notes frequent episodes of desaturation accompanied by short runs of nonsustained ventricular tachycardia.
Which of the following is the most likely diagnosis?

A)Central sleep apnea
B)Hyponatremia
C)Metabolic acidosis
D)Neuromuscular disease
E)Obstructive lung disease

Question 30

A 78-year-old man is evaluated for gallstones.  The patient has a history of benign prostate hyperplasia and was admitted to the hospital earlier today with lower abdominal discomfort and difficulty voiding.  Evaluation revealed a distended urinary bladder and serum creatinine of 1.3 mg/dL.  A urinary catheter was placed, draining 400 mL of cloudy urine.  He was started on empiric antibiotics and an alpha-adrenergic antagonist.  Abdominal ultrasonography revealed no hydronephrosis, but 2 large gallstones were seen with no gallbladder wall thickening or dilation of the common bile duct.  The patient has had intermittent abdominal bloating and mild nausea in the past but reports no fever, chills, pain in the right upper quadrant, or jaundice.  Other medical problems include hypertension and type 2 diabetes mellitus.
Temperature is 36.6 C (98 F), blood pressure is 144/83 mm Hg, and pulse is 78/min.  BMI is 44 kg/m².  Physical examination reveals mild suprapubic and epigastric tenderness on deep palpation, which does not accentuate on inspiration.  There is no rebound tenderness.
Laboratory results are as follows:
Which of the following is the best next step in management of this patient's gallstones?

A)Begin ursodeoxycholic acid therapy
B)Obtain MR cholangiography
C)Offer cholecystectomy
D)Perform hepatobiliary cholescintigraphy (HIDA scan)
E)Provide reassurance with no further intervention

Question 31

A 24-year-old African American man complains of abdominal pain while vacationing in the mountains with his parents.  They arrived after 2 days of driving.  Thirty-six hours after arrival, the patient experienced upper abdominal pain and nausea.  The pain has increased and is localized to the left side of his abdomen.  It is sharp, constant, and increased by deep inspiration.  He also feels pain on the top of his left shoulder.  He vomited a small amount of clear material once.  The patient has no history of similar episodes.  He considers himself to be in good health with no known medical problems.  He does not use tobacco or illicit drugs but drinks 1-2 beers on weekends.
On examination, he looks mildly uncomfortable.  His temperature is 37.8 C (100.5 F), pulse is 90/min, and respirations are 24/min.  Pulse oximetry is 96% on ambient air.  He appears to be splinting his left chest.  No rales or rhonchi are heard.  He has pain on palpation in the left upper quadrant without rebound tenderness.  There is no lower-extremity swelling or tenderness.  There are no skin rashes.
Laboratory results are as follows:

Chest x-ray reveals blunting of the left costophrenic angle.
Which of the following studies would best reveal the underlying cause of this patient's condition?

A)Duplex ultrasound of legs
B)Hemoglobin electrophoresis
C)Serum antiphospholipid antibodies
D)Serum lipase levels
E)Transthoracic echocardiogram

Question 32

A 64-year-old man hospitalized with acute myocardial infarction 3 days ago has chest pain that is worse on deep inspiration and radiates to the trapezius ridge.  He underwent cardiac catheterization on admission and was found to have occlusion of the distal left anterior descending artery that could not be revascularized.  He was treated with low-dose aspirin, clopidogrel, atorvastatin, metoprolol, and valsartan.
Physical examination shows a friction rub at the lower left sternal border.
Echocardiogram shows apical hypokinesis, left ventricular ejection fraction of 50%, and trivial pericardial effusion.
Which of the following is the best management for this patient?

A)Discontinue aspirin and clopidogrel
B)Increase aspirin to higher dose
C)Start heparin infusion
D)Treat with ibuprofen
E)Treat with low-dose prednisone

Question 33

A 29-year-old woman undergoes thyroidectomy for Graves' disease with ophthalmopathy.  She was treated with antithyroid drugs and beta-blockers preoperatively.  Physical examination and laboratory results prior to surgery were unremarkable.  Her ophthalmopathy was characterized as moderate with no corneal involvement or visual loss.
The patient has no immediate surgical complications.  Twenty-four hours after extubation, she reports feeling anxious and is irritable.  She has paresthesias of her hands and around her lips.  Six hours later, shortly after a nursing shift change, she complains of trouble breathing and has a high-pitched inspiratory sound.  A quick inspection of her neck bandages reveals no hemorrhage.
What is the most likely cause of her dyspnea?

A)Acute lung injury
B)Bilateral recurrent laryngeal nerve injury
C)Hypocalcemia
D)Tracheomalacia
E)Wound hematoma

Question 34

A 44-year-old woman is brought to the emergency department with 2 days of abdominal pain.  She has had worsening upper abdominal pain associated with nausea and multiple episodes of non-bloody vomiting.  She also reports subjective fevers and chills.  The patient's past medical history is notable for hypertension.  She drinks alcohol socially and does not use tobacco or recreational drugs.  Her last drink was a week ago.
Temperature is 38.4 C (101.2 F), blood pressure is 116/60 mm Hg, pulse is 112/min, and respirations are 18/min.  BMI is 34 kg/m².  Mucous membranes are dry and there is mild scleral icterus.  There is tenderness in the mid-epigastrium and right upper quadrant without rebound or guarding.  Rectal examination is notable for brown guaiac-negative stool.
Laboratory results are as follows:

CT scan of the abdomen shows diffuse pancreatic enlargement and heterogenous attenuation with peripancreatic inflammation.  The liver appears normal.  The gallbladder has multiple small gallstones with surrounding gallbladder wall edema.  The common bile duct is dilated and measures 12 mm.
The patient is made NPO and is started on analgesics, intravenous hydration, and empiric intravenous antibiotics.
Which of the following is the most appropriate next step in management of this patient?

A)Continue current management and observe closely
B)CT-guided percutaneous pancreatic aspiration
C)Endoscopic retrograde cholangiopancreatography
D)Hepatobiliary iminodiacetic acid (HIDA) scan
E)Surgical evaluation for cholecystectomy

Question 35

A 79-year-old nursing home resident is admitted to the hospital for nausea, vomiting, and abdominal distension.  He has had little oral intake over the last 48 hours.  This morning, workers at his facility noticed that his abdomen was distended.  The patient's medical history is remarkable for advanced dementia, coronary artery disease, hypertension, cerebrovascular accident, atrial fibrillation with rapid ventricular response, chronic low back pain, and gastroesophageal reflux disease.  Medications include aspirin, furosemide, hydrocodone with acetaminophen, metoprolol, calcium, vitamin D, simvastatin, and omeprazole.  He was hospitalized for a myocardial infarction 3 months ago.
The patient's temperature is 36.7 C (98 F), blood pressure is 131/78 mm Hg, pulse is 98/min, and respirations are 18/min.  Pulse oximetry shows an oxygen saturation of 98% on room air.  BMI is 22 kg/m².  Lungs are clear to auscultation.  The abdomen is distended and nontender.  Bowel sounds are present with increased tympany to percussion throughout.
Laboratory results are as follows:
Abdominal radiograph reveals marked dilation of the cecum, right hemicolon, and transverse colon with a maximal colonic diameter of 11.3 cm.  Abdominal CT scan confirms colonic dilation with no evidence of mechanical obstruction or bowel wall thickening.
Intravenous fluids are administered along with potassium and magnesium supplementation.
Which of the following is the best initial management for this patient?

A)Intravenous metoclopramide
B)Intravenous neostigmine
C)Percutaneous tube cecostomy
D)Serial abdominal examinations
E)Subcutaneous methylnaltrexone

Question 36

A 23-year-old woman with a 12-year history of type 1 diabetes mellitus is hospitalized with diabetic ketoacidosis.  On admission, her blood pressure is 80/60 mm Hg, pulse is 120/min, and respirations are 28/min.  She weighs 60 kg (132 lb).  Her oropharynx is very dry.  Abdominal examination shows diffuse tenderness without guarding or hepatosplenomegaly.  The remainder of her physical examination is within normal limits.
Her clinical status improves significantly with intravenous (IV) fluids and insulin.  In the first 2 hours, she receives 2 liters of isotonic saline (NS), and this is later changed to 1/2 NS with potassium chloride (KCl) at 250 mL/hr.  The patient is also receiving IV regular insulin infusion.  Her blood glucose declines steadily to 188 mg/dL after 6 hours of treatment.  She states that she is feeling better but still feels very nauseous.
Laboratory results are as follows:

Which of the following is the most appropriate fluid management for this patient?

A)Continue 1/2 NS without KCl
B)Continue current treatment
C)Switch IV fluids to D5% 1/2 NS with KCl
D)Switch IV fluids to D5% 1/2 NS without KCl

Question 37

An 80-year-old man is hospitalized because of an acute exacerbation of chronic obstructive pulmonary disease.  He is started on high-dose systemic steroids, bronchodilator nebulization, and antibiotics.  He initially receives non-invasive positive pressure ventilation for 12 hours.  On the third day of hospitalization, his breathing improves but he complains of "fluttering in his chest."  He denies chest pain or dizziness.  He had similar symptoms in the past that were transient and occurred mostly at night.  His other medical problems include type 2 diabetes mellitus, hypertension, hypercholesterolemia, chronic kidney disease, and osteoarthritis.
On examination, he appears comfortable.  His temperature is 36.7 C (98 F), blood pressure is 110/60 mm Hg, pulse is 124/min, and respirations are 20/min.  The patient's pulse oximetry is 96% on 2 liters of oxygen.  His jugular venous pressure is normal.  Lung auscultation reveals mild bilateral wheezing and prolonged expiration.  He has no hepatomegaly, peripheral edema, or thyromegaly.
/_
/_Laboratory results are as follows:

ECG reveals atrial fibrillation with rapid ventricular response.
Which of the following would be the most helpful in diagnosing this patient's thyroid disorder?

A)Radioactive iodine uptake and scan
B)Repeat thyroid function tests in few days
C)Reverse triiodothyronine (rT3) levels
D)Thyroid ultrasound
E)Triiodothyronine (T3) levels

Question 38

A 60-year-old man with alcoholism is admitted after being found unresponsive in the street.  No other history is available.
His temperature is 37.1 C (98.8 F), blood pressure is 130/86 mm Hg, pulse is 110/min and regular, and respirations are 20/min.  On examination, the patient is disheveled and appears chronically ill.  He has decreased muscle mass and no subcutaneous fat.  He responds to painful stimuli and has slurred speech.  Carpal spasm was noted in the hand of the arm in which his blood pressure was taken.  Mucous membranes are dry and there is no moisture in the axillae.  He has nystagmus on end lateral gaze of both eyes.  No other focal neurologic findings are present.
Laboratory results are as follows:

Intravenous thiamine and fluids consisting of 3 L normal saline/5% dextrose containing 40 mEq of potassium are administered over 4 hours.  Electrolytes are re-measured with the following results:

Which of the following is the most likely cause of this patient's hypokalemia?

A)Beta-adrenergic stimulation
B)Hypomagnesemia
C)Primary hyperaldosteronism
D)Refeeding syndrome
E)Renal tubular acidosis

Question 39

An 88-year-old nursing home resident is admitted to the hospital for fever and confusion.  She was recently discharged after an episode of aspiration pneumonia, which entailed a prolonged and complicated hospitalization course.  She has lost 20 lbs (9 kg) over the past 6 months.  She suffers from dementia and requires constant assistance with her activities of daily living.  She frequently does not recognize her caregivers and is regularly found to be incontinent of urine and stool.  Her other medical problems include hypertension, atrial fibrillation, type 2 diabetes mellitus, and mild residual left-sided hemiparesis from a previous ischemic stroke.
Her temperature is 38.3 C (101 F), blood pressure is 144/87 mm Hg, pulse is 92/min, and oxygen saturation is 92% on 2 L/min O₂ via nasal canula.  Her BMI is 18.5 kg/m².  Examination reveals dry mucous membranes.  Coarse rhonchi are heard over the right lower lung.  She has a stage 3 coccygeal pressure ulcer.
Blood cultures are sent and she is started on broad-spectrum antibiotics.  Her daughter inquires about nutritional support because her mother is losing weight and "needs to get stronger to fight this infection."
Which of the following statements would best address the daughter's concerns?

A)Percutaneous gastrostomy (PEG) tube placement prevents aspiration and recurrent pneumonia
B)PEG tube placement does not seem to prolong life in patients with advanced dementia
C)PEG tube placement offers an advantage in managing and preventing pressure ulcers in patients with advanced dementia
D)A high-calorie liquid diet with avoidance of solid foods would improve her nutritional status and may prevent aspiration
E)Appetite stimulants would address her weight loss issue

Question 40

A 66-year-old woman is admitted to the hospital with a 3-week history of worsening shortness of breath and palpitations.  She has had severe dyspnea with minimal exertion.  The patient has also experienced bilateral leg swelling and insomnia but no dizziness or chest pain.  Medical history is notable for hypertension, type 2 diabetes mellitus, atrial fibrillation, heart failure, and hypercholesterolemia.  Current medications are warfarin, amiodarone, metoprolol, metformin, atorvastatin, and lisinopril.  Family history is unremarkable.  The patient does not use tobacco, alcohol, or illicit drugs.
Blood pressure is 120/66 mm Hg and pulse is 120/min and irregular.  On physical examination, there is mild lid lag but no proptosis.  Visual field examination is normal.  Neck examination shows elevated jugular venous pressure.  The thyroid is irregular, enlarged, and nontender, and the left thyroid lobe is larger than the right.  Crackles are heard in both lung bases.  There is trace pedal edema and no pretibial myxedema.
Laboratory results are as follows:
Radioactive iodine uptake at 24 hours shows patchy uptake at 5% (normal: 10%-30%).
Which of the following is the most likely cause of the thyroid dysfunction in this patient?

A)Drug-induced thyrotoxicosis
B)Euthyroid sick syndrome
C)Graves disease
D)Subacute thyroiditis
E)Toxic nodule

Question 41

A 63-year-old man with diabetes is hospitalized with right foot methicillin-resistant Staphylococcus aureus osteomyelitis complicated by sepsis and respiratory failure.  He spends 3 days in the intensive care unit on mechanical ventilation but is now extubated and has resumed eating.  He has generalized weakness, mild cough, and foot pain.  The patient has no chest pain, abdominal pain, bleeding, or diarrhea.  He has no prior history of pneumonia, heart failure, or coagulopathy.  His current medications include intravenous vancomycin, subcutaneous heparin, short- and long-acting subcutaneous insulin, and omeprazole.  His vital signs are within normal limits.
Laboratory values show hemoglobin of 12.2 g/dL, creatinine of 1.4 mg/dL, and albumin of 2.5 mg/dL.  Coagulation profile is unremarkable.
Which of the following should be strongly considered when transferring this patient to the medical floor?

A)Discontinuing omeprazole
B)Starting an albumin infusion
C)Starting oral diabetic medications
D)Switching from intravenous vancomycin to oral rifampin
E)Switching from pharmacologic to mechanical thromboprophylaxis

Question 42

A 22-year-old woman is evaluated for fever, diarrhea, and skin rash.  The patient was admitted 10 days ago after a motor vehicle collision resulted in a splenic laceration.  She underwent an emergency splenectomy and received multiple units of emergency-release type O-negative blood perioperatively.  Postoperatively, she received the pneumococcal vaccine but not the meningococcal vaccine as it had been given 2 years ago.  The patient had been recovering well with no issues until 2 days ago when she developed a nonpruritic skin rash on her trunk that progressed to involve the face and extremities.  She has also had fevers as high as 38.8 C (102 F) and profuse, watery diarrhea.  The patient has a history of Hodgkin disease and received her most recent dose of chemotherapy 3 weeks ago.
New findings on the physical examination compared to 2 days ago include a diffuse maculopapular skin rash sparing the palms and soles and mild, nontender hepatomegaly.
Laboratory test results are as follows:
Stool Clostridium difficile testing is negative.
Which of the following would have been most effective in preventing this patient's current condition?

A)Cytomegalovirus screening of the donor blood
B)Repeat meningococcal vaccination
C)Transfusion of ABO-compatible erythrocytes
D)Transfusion of washed erythrocytes
E)Use of irradiated blood products

Question 43

A 54-year-old man comes to the emergency department with pain and swelling of his right leg.  He injured his leg 2 days ago while playing soccer and noticed the swelling the next day.  His medical history is significant for hypertension and chronic kidney disease.  His medications include amlodipine, lisinopril, and clonidine.  He has not been hospitalized previously.
Laboratory results are as follows:

Ultrasound examination shows deep venous thrombosis of the right lower extremity extending to the superficial femoral vein.  The patient is hospitalized and started on heparin infusion and oral warfarin.
On the second day of hospitalization, his platelet count is 130,000/mm³ and International Normalized Ratio is 1.1.  He reports no additional symptoms and the remainder of his laboratory workup is unremarkable.  Leg pain and swelling are decreased.
Which of the following is the best next step in management of this patient?

A)Continue heparin infusion and check for heparin-PF4 antibodies
B)Continue heparin infusion and observe
C)Stop heparin infusion and check for heparin-PF4 antibodies
D)Stop heparin infusion, check for heparin-PF4 antibodies, and start argatroban

Question 44

A 61-year-old man with a history of coronary artery disease, hypertension, and chronic obstructive pulmonary disease is evaluated for persistent fever in the cardiac intensive care unit.  He underwent coronary artery bypass grafting (CABG) six days ago.  He has been receiving mechanical ventilation, and is unable to be weaned off the ventilator.  Four days after his surgery, he developed fever, increased oxygen requirements, and abundant secretions from the endotracheal tube.  He was started on intravenous piperacillin-tazobactam.
His current temperature is 38.9 C (102 F), blood pressure is 124/84 mm Hg, pulse is 96/min, respirations are 18/min, and oxygen saturation is 90% on 60% FiO₂ and 5 mm Hg of PEEP.
Laboratory results are as follows:

Chest x-ray shows a dense right lower lobe infiltrate.  Blood cultures sent two days ago return negative.
Which of the following is the best additional therapy for this patient?

A)Azithromycin
B)Daptomycin
C)Linezolid
D)Tigecycline
E)Trimethoprim-sulfamethoxazole

Question 45

An 81-year-old woman is seen for a preoperative assessment prior to hip surgery.  The patient presented yesterday evening after tripping while walking and falling from a standing height.  She had no head trauma or loss of consciousness, but she injured her left hip.  Evaluation revealed a left femoral neck fracture, and surgical repair is planned.  Her other medical problems include hypertension, paroxysmal atrial fibrillation, and mild dementia.  The patient takes donepezil, dabigatran, and metoprolol.  She did not receive dabigatran last night or this morning in the hospital.  The patient cannot recall if she took her medications yesterday morning or the day before, and her daughter was unable to determine this from the number of pills remaining in her mother's medication bottles.
Vital signs are within normal limits.  Physical examination is notable for bruising and tenderness of the left hip.
Blood cell counts and serum chemistry studies are within normal limits.  Other laboratory findings are as follows:
Which of the following is the most appropriate recommendation regarding surgery and anticoagulation use in this patient?

A)Administer 4-factor prothrombin complex concentrate and proceed with surgery
B)Administer idarucizumab and proceed with surgery
C)Delay surgery for 72 hours to completely eliminate dabigatran
D)Obtain plasma anti-factor Xa activity levels
E)Proceed with surgery now with no further intervention

Question 46

A 61-year-old man comes to the emergency department due to 20 minutes of slurred speech while eating lunch at work.  Two months ago, he had an episode of blurry vision in his right eye.  The patient has a history of hyperlipidemia and hypertension and takes amlodipine and hydrochlorothiazide.  He is an active smoker with a 35-pack-year history.
Blood pressure is 155/90 mm Hg and pulse is 78/min.  Oxygen saturation is 94% on room air.  BMI is 31 kg/m².  The lungs are clear to auscultation.  The spleen tip is palpable on inspiration.  There is trace bilateral pedal edema.
Laboratory results are as follows:
Which of the following is the most likely additional finding in this patient?

A)Hematuria
B)Low serum erythropoietin
C)Philadelphia chromosome
D)Prolonged nocturnal desaturations
E)Vitamin B₁₂ deficiency

Question 47

A 22-year-old hospitalized woman is evaluated for thrombocytopenia.  Three days ago, she was hospitalized due to lower abdominal pain, vaginal bleeding, and fever.  She was diagnosed with a septic abortion, was initiated on cefotetan and doxycycline, and underwent dilation and curettage.  Platelet count at admission was 154,000/mm³; yesterday it was noted to be 89,000/mm³, with a further decrease on this morning's results.  She has had no epistaxis or visible blood in the urine or stool but has had mild headache and fatigue.  The patient has no known medical problems and no history of blood disorders.
Vital signs are normal.  Physical examination shows scattered ecchymoses but is otherwise unremarkable, including benign abdominal and pelvic examinations.
Complete laboratory results from today are as follows:
Direct Coombs test is negative.  Peripheral blood smear shows decreased platelets, polychromatophilic red blood cells, and multiple schistocytes with no platelet clumping.
Which of the following is the most likely cause of this patient's thrombocytopenia?

A)Antiphospholipid antibody syndrome
B)Disseminated intravascular coagulation
C)Drug-induced immune thrombocytopenia
D)Idiopathic thrombocytopenic purpura
E)Thrombotic thrombocytopenic purpura

Question 48

An 86-year-old nursing home resident is hospitalized because of fever for the past two days.  His medical problems include cerebrovascular accident, decubitus ulcer, benign prostatic hyperplasia, urinary incontinence, hypertension, and type 2 diabetes mellitus.
Upon admission, his temperature is 38.9 C (102 F), blood pressure is 88/54 mm Hg, pulse is 98/min, and respirations are 18/min.  After 2 liters of intravenous normal saline, his blood pressure is 109/68 mm Hg and his pulse is 82/min.  Examination reveals decreased breath sounds and crackles at the right lung base.  He has a chronic Foley catheter in place that drains clear urine.  His decubitus ulcer looks clean.  He denies any urinary discomfort and there is no suprapubic or costovertebral tenderness.  His leukocyte count is 15,400 cells/µL and his serum creatinine level is 0.9 mg/dL.  A chest x-ray reveals a right lower lobe infiltrate.
The patient is started on intravenous antibiotics.  Over the subsequent 48 hours, he improves and becomes afebrile.  A urine culture from admission grows Candida albicans.  Blood cultures show no growth.
Which of the following is the best next step in management?

A)Begin intravenous caspofungin
B)Begin oral fluconazole
C)Change the urinary catheter
D)Irrigate the bladder with antifungal solution
E)Repeat urine cultures

Question 49

A 55-year-old woman was hospitalized 2 days ago for initiation of chemotherapy.  The patient was recently found to have a leukocyte count of 117,000/mm³, and a bone marrow biopsy confirmed the diagnosis of acute myeloid leukemia.  She has been receiving combination chemotherapy for the past 2 days and has had nausea and several episodes of vomiting.  The patient has also been receiving normal saline infusion at 100 mL/hr, rasburicase, and as-needed ondansetron since admission.  She has no other medical problems and does not use tobacco, alcohol, or illicit drugs.
Blood pressure is 140/90 mm Hg, pulse is 100/min, and respirations are 18/min.  The patient has conjunctival pallor and scattered petechiae.  Urine output is approximately 50 mL/hr.
Laboratory results are as follows:
Which of the following is the most appropriate course of action?

A)Discontinue rasburicase and prepare for hemodialysis
B)Discontinue rasburicase and start allopurinol
C)Increase normal saline for goal urine output >80-100 mL/hr
D)Initiate oral phosphate and potassium binders
E)Initiate sodium bicarbonate to promote urine alkalinization to pH >6.5-7

Question 50

An 83-year-old man with mild cognitive impairment is transported from an assisted living facility with a 2-day history of abdominal pain and decreased oral intake.  He has no vomiting, fever, or urinary symptoms.  He underwent coronary artery bypass grafting 6 years ago.  The patient also had a stent placed in his superficial femoral artery 3 years ago for claudication due to peripheral artery disease.
His temperature is 37.3° C (99.2° F), blood pressure is 127/77 mm Hg, and pulse is 102/min.  He appears uncomfortable.  Examination shows dry membranes.  The abdomen is distended, diffusely tender, and tympanic to percussion.  There is no rebound tenderness or rigidity.
Laboratory results are as follows:

Contrast abdominal imaging, shown below, reveals a large, air-filled sigmoid colon with absence of air in the rectum.

Which of the following is the best next step in managing this patient?

A)Flexible sigmoidoscopy
B)Nasogastric suction and broad-spectrum antibiotics
C)Oral lactulose
D)Sodium phosphate enema
E)Surgery

Question 51

A 34-year-old man comes to the emergency department due to 2 days of fever, chills, and drenching sweats.  He has had no sore throat, cough, shortness of breath, chest pain, or dysuria.  The patient has a history of Crohn disease and recently underwent abdominal surgery to remove a bowel stricture.  The postoperative course was complicated by an enterocutaneous fistula, which has been treated over the past 6 weeks with antitumor necrosis factor therapy.  This treatment has reduced the amount of drainage from the fistula.  He has had no recent abdominal pain or diarrhea.  The patient takes nothing by mouth and receives daily total parenteral nutrition.  He has no other medical problems and does not use tobacco, alcohol, or illicit drugs.
Temperature is 38.3 C (101 F), blood pressure is 110/60 mm Hg, pulse is 112/min, and respirations are 18/min.  The patient is ill-appearing and diaphoretic.  The lungs are clear to auscultation.  Cardiac examination reveals tachycardia but is otherwise unremarkable.  The abdomen is soft and nontender with clear discharge from the infraumbilical fistula site.  The right upper arm peripherally inserted central catheter site has no erythema or tenderness.
Leukocyte count is 18,000/mm³, and serum creatinine is 0.9 mg/dL.  Chest x-ray reveals no infiltrates.  Urinalysis is normal.  Blood cultures are obtained, and empiric broad-spectrum intravenous antibiotics are initiated.
Within the next 24 hours, both sets of blood cultures grow budding yeast.
Which of the following is the most appropriate next step in management of this patient?

A)Change the catheter via guidewire and begin intravenous fluconazole
B)Keep the catheter and begin intravenous liposomal amphotericin B
C)Remove the catheter and await species identification of the yeast
D)Remove the catheter and begin intravenous caspofungin
E)Repeat blood cultures and continue broad-spectrum antibiotics

Question 52

A 68-year-old woman admitted for community-acquired pneumonia 4 days ago is evaluated in the hospital for new-onset jaundice.  During morning rounds today, it is noted that she has yellowish discoloration of both eyes.  The patient has no abdominal pain, nausea, or prior history of liver disease, but she has a history of hypertension.  She does not use tobacco, alcohol, or illicit drugs.  Her current medications include azithromycin, ceftriaxone, lisinopril, and acetaminophen as needed.
Her temperature is 36.7 C (98 F), blood pressure is 120/70 mm Hg, and pulse is 72 /min.  The patient's pulse oximetry shows 96% on 2 liters oxygen.  Examination reveals scleral icterus, rales in the right lower lobe, and normal heart sounds without murmurs.  The abdomen is soft and nontender with no organomegaly.
Laboratory results are as follows:

Acute viral hepatitis serologies are negative.  Abdominal ultrasound reveals normal liver size and echotexture, a thin-walled nondistended gallbladder, no gallstones or biliary sludge, and a normal common bile duct.
Which of the following is the best next step in management of this patient?

A)Acetaminophen level
B)Change antibiotics
C)Cholescintigraphy (HIDA scan)
D)Liver biopsy
E)MR cholangiopancreatography

Question 53

A 67-year-old man is hospitalized with cough, shortness of breath, orthopnea, and ankle swelling.  He is treated with intravenous diuretics.  He was diagnosed with non-ST segment elevation myocardial infarction 3 weeks ago and had a right coronary artery stent placed.  On discharge, the patient's left ventricular ejection fraction was 40%.  On the sixth day of his current hospitalization, he feels better but still complains of some shortness of breath.  His platelet count is 62,000/µL, down from 210,000/µL on admission.
The other laboratory results are as follows:
Subcutaneous injections of unfractionated heparin for deep venous thrombosis prophylaxis are stopped and the nurses are instructed not to use heparin flushes.  Appropriate laboratory workup is sent.
Which of the following should be used for preventing thromboembolism in this patient?

A)Ambulation as tolerated only
B)Argatroban
C)Compression stockings only
D)Enoxaparin
E)Warfarin

Question 54

A 72-year-old man is evaluated for refractory constipation.  He recently had an episode of stool impaction requiring manual disimpaction and is now passing flatus and small amounts of hard stool.  He has no abdominal pain, vomiting, or hematochezia.  The patient is receiving palliative care for stage IV lung cancer with multiple skeletal metastases and has adequate pain control with a fentanyl patch and oral immediate-release morphine.  His other medications include a fiber supplement, senna-docusate combination, and oral lactulose.
Examination shows a frail-looking, cachectic man.  Bowel sounds are normal.  His abdomen is soft, nondistended, and nontender.
Which of the following is the most appropriate next step in managing this patient's constipation?

A)Add methylnaltrexone therapy
B)Administer mineral oil enema
C)Change morphine to hydromorphone
D)Discontinue fentanyl patch
E)Start misoprostol therapy

Question 55

A 55-year-old man with chronic alcohol abuse underwent right-sided hemicolectomy for complicated diverticulitis 10 days ago.  During his hospitalization, he developed abdominal wall hematomas at subcutaneous heparin injection sites.  His preoperative laboratory blood work showed a hemoglobin of 5.4 g/dL, platelets of 87,000/µL, and normal coagulation parameters.  The patient received 8 units of packed red blood cells during the perioperative period.  His hospital course has been complicated by an abdominal wound infection and alcohol withdrawal symptoms.
His temperature is 38.1 C (100.6 F), blood pressure is 98/56 mm Hg, and pulse is 108/min.  His body mass index is 18 kg/m².  The lungs are clear to auscultation and no murmurs are appreciated.  The incision site is erythematous and tender.  The patient has a palpable spleen tip.  There is no evidence of active mucosal bleeding.  His mental status is normal.
Laboratory results are as follows:

Factor V and VIII levels are normal, and factor VII level is decreased.
Which of the following is the most likely cause of this patient's coagulopathy?

A)Antiphospholipid antibodies
B)Disseminated intravascular coagulation
C)Folic acid deficiency
D)Liver failure
E)Vitamin K deficiency

Question 56

A 40-year-old man with known HIV infection is admitted to the hospital with right arm weakness and difficulty with speech.  He was diagnosed with HIV infection eight years ago.  He has not been adherent with either anti-retroviral treatment or trimethoprim-sulfamethoxazole prophylaxis therapy for several months prior to admission.  His most recent CD4 count obtained 12 months ago was 150/µL.  He does not smoke, drink alcohol, or use intravenous drugs.
His BMI is 26 kg/m².  After a thorough evaluation, a diagnosis of central nervous system toxoplasmosis was established.  He was given intravenous fluids and therapy was initiated with sulfadiazine and pyrimethamine.
Which of the following additional medications should be given to this patient?

A)Filgrastim
B)Leucovorin
C)Ondansetron
D)Phenytoin
E)Trimethoprim-sulfamethoxazole

Question 57

An 80-year-old man fell at home and sustained a hip fracture.  On the day after repair, physical therapy team members notice that the patient's post-operative hemoglobin is 8.6 g/dL.  They recommend a blood transfusion, which may allow the patient greater participation in rehabilitation and a more rapid recovery.
The patient's admitting ECG showed evidence of an old inferior myocardial infarction.  At that time, his pre-operative hemoglobin was 11.5 g/dL.  Two years ago, he experienced pedal edema and dyspnea with exertion requiring diuretics for presumed mild congestive heart failure.
The patient is currently resting comfortably and has no chest pain or pressure, dyspnea, or fatigue.  His blood pressure is 130/84 mm Hg and pulse is 84/min and regular.  Oxygen saturation is 97% on room air.  Jugular venous pressure is normal.  The lungs are clear to auscultation.  There is a grade 2/6 systolic murmur along the upper left sternal border.  There is trace pedal edema bilaterally to the shin.
Repeat hemoglobin is 8.5 g/dL and mean corpuscular volume is 89 fL.
Which of the following is the most appropriate step in management of this patient's low hemoglobin?

A)Erythropoietin and iron
B)No treatment at this time
C)One unit packed red blood cells only
D)Transfusion as required to keep hemoglobin above 10 g/dL
E)Transfusion as required to keep hemoglobin above 12 g/dL

Question 58

A 49-year-old man with end-stage renal disease is hospitalized because of fever and malaise for the past 2 days.  His other medical problems include hypertension and type 2 diabetes mellitus.  His renal failure is attributed to uncontrolled hypertension and progressive diabetic nephropathy.  He has had several hemodialysis access failures due to infection and thrombosis issues.
His temperature is 38.9 C (102 F), blood pressure is 124/60 mm Hg, pulse is 88/min, and respirations are 18/min.  Examination shows a tunneled hemodialysis catheter in the right chest which was placed four weeks ago.  There is no drainage, erythema, or tenderness over the catheter entry or tunnel site.  Lungs are clear to auscultation and there are no cardiac murmurs.  The remainder of the examination shows no abnormalities.
His chest x-ray shows no infiltrates.  Blood cultures are sent and he is started on broad-spectrum antibiotics.
Which of the following positive culture results would necessitate immediate catheter removal?

A)Escherichia coli sensitive to cephalosporins
B)Enterococcus faecalis sensitive to vancomycin
C)Pseudomonas aeruginosa sensitive to piperacillin-tazobactam
D)Streptococcus anginosus sensitive to penicillin
E)Staphylococcus epidermidis sensitive to vancomycin

Question 59

A 62-year-old man comes to the hospital due to 2 days of bilateral lower extremity swelling and throbbing pain.  Two weeks ago he was admitted to a different hospital with a non-ST elevation myocardial infarction.  He initially received aspirin, metoprolol, nitrates, heparin, a statin, and a glycoprotein IIb/IIIa inhibitor.  Cardiac catheterization showed 3-vessel coronary artery disease and a left ventricular ejection fraction of 40%.  The patient underwent on-pump coronary artery bypass grafting.  His postoperative course was uncomplicated, and he was discharged home with a normal blood count and serum creatinine levels.  He also has a history of hypertension, hyperlipidemia, and type 2 diabetes mellitus.  His current medications include aspirin, metoprolol, lisinopril, atorvastatin, metformin, insulin, and fish oil.  The patient does not use tobacco, alcohol, or illicit drugs.
Blood pressure is 135/70 mm Hg, pulse is 78/min, and oxygen saturation is 98% on room air.  Physical examination reveals clear lungs, normal heart sounds, and bilateral pitting edema.  There is no jugular venous distension.  The sternotomy scar is clean, dry, and intact.  The remainder of the examination is unremarkable.
Laboratory results are as follows:
Lower extremity ultrasound reveals extensive, bilateral deep venous thrombosis extending into the superficial femoral veins.
Which of the following is the most appropriate next step in management of this patient?

A)Initiate direct thrombin inhibitor
B)Initiate low-molecular-weight heparin and place an inferior vena cava filter
C)Initiate low-molecular-weight heparin only
D)Obtain serum fibrinogen level and fibrinogen split products
E)Send blood for hypercoagulable workup and initiate low-molecular-weight heparin

Question 60

A 74-year-old man recovering from recent ischemic stroke develops right ankle and calf swelling.  He has mild, persistent right-sided hemiplegia and has been receiving daily physical therapy for the last week.  Compression ultrasonography confirms right-sided popliteal vein thrombosis.  The patient is started on a therapeutic dose of enoxaparin twice daily.
When is it appropriate for this patient to resume mobilization and physical therapy?

A)3-5 days after starting anticoagulation
B)After inferior vena cava filter placement
C)After transition to oral anticoagulant
D)After ultrasound confirms resolution of the thrombus
E)Within 24 hours of starting enoxaparin

Question 61

A 79-year-old man is found poorly responsive in his apartment by a neighbor in the middle of July.  The apartment is not air conditioned and the last few days have been extremely hot.  The patient's neighbors state that he lives alone and appeared fully functional in their interactions with him.  No additional medical history is available.
On physical examination, he appears obtunded and responds slowly to commands.  His temperature is 42.2° C (108° F), blood pressure is 90/60 mm Hg, pulse is 104/min, and respirations are 16/min.  The patient's pulse oximetry shows 96% on room air.  Mucous membranes are dry.  His neck is supple, and jugular veins are flat in the supine position.  Cardiopulmonary examination is within normal limits.  There are no skin rashes.  Deep tendon reflexes are 2+ and symmetrical.  There is no muscular rigidity.
An electrocardiogram demonstrates sinus rhythm with nonspecific ST-segment changes.  A chest film shows no significant abnormalities.  Laboratory workup is pending.
In addition to volume resuscitation, which of the following is the best initial therapy for this patient?

A)Alcohol sponge baths
B)Aspirin suppositories
C)Dantrolene
D)Evaporative cooling
E)Immersion in ice water

Question 62

A 43-year-old woman is seen in the hospital following a laparoscopic cholecystectomy.  The patient had no significant operative complications but was observed overnight due to nausea during recovery from anesthesia.  The nausea has resolved and she is tolerating a regular diet.  The patient reports continuous moderate incisional pain with occasional spikes of increased pain with movement.  Medical history is unremarkable and she takes no chronic medications.  She does not use tobacco, alcohol, or illicit drugs.
Vital signs are normal.  Examination shows intact abdominal incisions with normal bowel sounds and no significant abdominal tenderness.  The remainder of the examination is normal.
Which of the following is the most appropriate prescription for home pain control for this patient?

A)3-day supply of hydrocodone plus acetaminophen
B)7-day supply of codeine plus acetaminophen
C)7-day supply of oxycodone
D)14-day supply of tramadol
E)Low-dose fentanyl patch

Question 63

There has been a continuous increase in the number of urinary tract infections among residents of a local long-term care facility over the last 5 years.  Due to comorbidities, many residents are incontinent of urine and have indwelling urinary catheters.
Which of the following measures will most likely decrease the frequency of urinary tract infections in these patients?

A)Acidification of the urine
B)Administration of systemic prophylactic antibiotics
C)Changing of indwelling catheters weekly
D)Removal of indwelling catheters
E)Weekly bladder mucosal washes with antibiotic mixtures

Question 64

A 72-year-old woman is sent to the hospital after 2 days of agitation and combative behavior.  The patient has Alzheimer dementia and lives in a skilled nursing facility.  The nursing staff at the facility report that she is calm at baseline and spends most of her time in bed or in a wheelchair.  She is normally minimally interactive with staff members but reportedly brightens when her son comes to visit.  The patient has a history of generalized anxiety disorder but is currently not taking any medications for it.
In the emergency department, the patient is anxious and agitated.  She is disoriented to place and time and frequently tries to get out of bed.  She intermittently mumbles to herself and accuses the nurse of stealing her handbag.  Urinalysis is both leukocyte esterase and nitrite positive and contains 100 white blood cells/high-power field.  A urine culture has been sent to the laboratory.
In addition to empiric antibiotics for urinary tract infection, which of the following is the most appropriate management for this patient?

A)Administer intravenous haloperidol
B)Administer intravenous lorazepam
C)Apply soft restraints
D)Have a family member or sitter at bedside
E)Keep the patient in a dark, quiet room

Question 65

An 84-year-old man with a long history of obesity, diabetes, and peripheral artery disease is hospitalized for an extensive gangrenous ulcer on his right foot.  A surgical consultant recommends urgent below-the-knee amputation as a life-saving procedure.  The patient refuses, saying, "I've had a long life.  Most of my friends are dead and all I have left are memories."  He does not want to undergo any type of surgical procedure and prefers to be treated with medications only.  His primary care provider is uncomfortable with this decision as the patient seems forgetful.
On evaluation and record review, there is no evidence of delirium or psychosis.  The patient is sad about the death of several friends over the past year.  His appetite is normal and he reports no changes in sleep.  He is able to provide a summary of his medical condition and acknowledges that refusing surgery may result in his death.  His score on a Montreal Cognitive Assessment is 24/30.
Which of the following is the most appropriate course of action?

A)Initiate treatment for depression and reassess the patient's capacity
B)Initiate treatment with a cholinesterase inhibitor and reassess the patient's capacity
C)Obtain a psychiatric consult to evaluate the patient's capacity
D)Respect the patient's decision and treat nonsurgically
E)Seek an appropriate family member for discussion and a surrogate decision

Question 66

A 40-year-old woman is seen 48 hours after an uncomplicated repeat caesarean delivery at 39 weeks gestation.  She reports sudden-onset shortness of breath and a nonproductive cough.  The patient has no fever, chills, nausea, vomiting, or chest pain.  Her prenatal course was uncomplicated.  She has no chronic medical conditions.  The patient's previous pregnancy was uncomplicated; she had a term caesarean delivery for breech presentation.
On examination, the patient appears distressed.  Blood pressure is 196/112 mm Hg, pulse is 120/min, and respirations are 32/min.  Pulse oximetry is 86% on room air.  Auscultation of the lungs shows diffuse inspiratory crackles bilaterally.  Jugular venous pressure is normal.  Cardiac sounds are normal and there are no murmurs or additional sounds.  Abdominal examination is normal.  There is 2+ pedal edema to the bilateral mid-calves.
Laboratory results are as follows:
Chest x-ray reveals bilateral diffuse alveolar infiltrates.  ECG shows sinus tachycardia and upsloping ST-segment depressions in the inferior lateral leads.
Which of the following is the most likely diagnosis in this patient?

A)Acute coronary syndrome
B)Amniotic fluid embolism
C)Aspiration of gastric contents
D)Peripartum cardiomyopathy
E)Preeclampsia

Question 67

An 81-year-old man is transferred from a skilled nursing facility to the hospital due to lethargy and poor oral intake over the last 24 hours.  For the past 2 days, he has had increased urinary frequency and dysuria.  A urinalysis showed evidence of urinary tract infection, and he was started on oral ciprofloxacin.  He was recently hospitalized with acute ischemic stroke, and his hospital course was complicated by pneumonia requiring intravenous antibiotics.  He also had an episode of urinary retention requiring Foley catheter placement for 5 days.  His other medical problems include mild cognitive impairment, hypertension, and type 2 diabetes mellitus.  He has no known drug allergies.
His temperature is 38.9° C (102° F), blood pressure is 92/58 mm Hg, and pulse is 112/min.  Lungs are clear to auscultation.  His extremities are warm and well perfused.
Foley catheter placement yields 230 mL of cloudy urine.
Laboratory results are as follows:

Urine culture obtained at the nursing facility 2 days earlier showed extended spectrum beta-lactamase-producing Klebsiella.
Which of the following is the best initial antibiotic regimen for this patient?

A)Aztreonam
B)Ceftriaxone
C)Daptomycin
D)Levofloxacin
E)Meropenem

Question 68

A 75-year-old woman with stage 4 breast cancer with brain metastases is admitted to hospice with a life expectancy of 2-4 weeks.  She responded poorly to her last chemotherapy treatment and decided with her family that palliative care was best.  Although her pain is fairly well controlled, the patient has very poor appetite, little energy, and sleeps for most of the day.  She often does not get up for meals and has lost 3.6 kg (8 lb) in the past week.  During a family visit, the daughter notices that the patient is quieter than usual and appears very depressed; she says, "She barely responds to us anymore and just cries softly."
Physical examination is unchanged.  The patient is alert and oriented.  When the physician asks the patient about her mood she says, "Of course I am depressed given my situation.  I'm just so hopeless and tired."
In addition to providing support, which of the following is the most appropriate next step in management of this patient?

A)Administer electroconvulsive therapy
B)Prescribe escitalopram
C)Prescribe methylphenidate
D)Prescribe mirtazapine
E)Reassure that the behavior is a normal grief reaction

Question 69

A 63-year-old man with recent elective right inguinal hernia repair comes to the emergency department with pain and swelling of the right thigh.  The pain began the night before and he could not sleep well despite taking oxycodone and acetaminophen.  The patient has mild hypertension and type 2 diabetes requiring daily long-acting insulin.  He also suffers from resistant fungal infection of the toenails.
His temperature is 38.4° C (101° F), blood pressure is 110/72 mm Hg, and pulse is 124/min and regular.  His lungs are clear to auscultation.  A faint systolic murmur is heard at the base.  His abdomen is soft and nontender.  The surgical incision looks clean with minimal amount of gray discharge.  The right inner thigh has a large area of erythema and swelling that is very tender on superficial palpation.  Several small vesicles containing pink fluid with surrounding purpura are also present.
Laboratory results are as follows:

Which of the following is the best next step in management of this patient?

A)Duplex ultrasound of the lower extremities
B)Intravenous penicillin G and metronidazole
C)Surgical consultation
D)Transesophageal echocardiogram
E)Valacyclovir

Question 70

A 69-year-old man is admitted to the hospital due to 2 days of high fevers, chills, headache, nausea, and diarrhea.  He has also had intermittent abdominal pain associated with 4 nonbloody bowel movements over the past 24 hours.  The patient has a history of rheumatoid arthritis and takes infliximab and hydroxychloroquine.  He lives with his wife in Florida and has had no sick contacts or recent travel outside of the state.  He is the primary caretaker of a domesticated bird.
Temperature is 39.4 C (103 F), blood pressure is 118/80 mm Hg, pulse is 112/min, and respirations are 16/min.  The patient is ill-appearing.  Pulmonary examination is normal.  Bowel sounds are hyperactive, and the abdomen is soft and mildly tender.  Neurological examination shows no focal abnormalities.
Laboratory results are as follows:
Chest x-ray reveals no focal infiltrate.  Intravenous empiric antibiotics and fluids are administered.  Blood cultures sent on admission grow Gram-positive rods in all 4 bottles after 12 hours.
Which of the following is the most likely etiology of this patient's illness?

A)Consumption of infected food
B)Direct contact with infected respiratory secretions
C)Exposure to antibiotics
D)Exposure to bird feces
E)Overgrowth of endemic intestinal flora

Question 71

A 36-year-old man is brought to the emergency department after waking up with dyspnea, nonproductive cough, fever, and malaise.  He had been feeling well prior to these symptoms and has no chronic medical problems.  The patient and his wife are on vacation in Florida and are staying in an "old and dusty" rental house.  Last night they went to a bar and then relaxed in a hot tub.
Temperature is 38.9 C (102 F), blood pressure is 144/89 mm Hg, and pulse is 104/min.  Pulse oximetry is 89% on room air.  Chest examination reveals bilateral fine crackles.  There are no skin rashes.
Laboratory results are as follows:
Liver function tests are normal.  Chest x-ray reveals mildly increased interstitial markings in the middle and lower lung fields bilaterally.
Which of the following is most likely responsible for this patient's current symptoms?

A)Chlamydia psittaci
B)Nontuberculous mycobacteria
C)Pseudomonas aeruginosa
D)Staphylococcus aureus
E)Streptococcus pneumoniae

Question 72

A 46-year-old woman is seen in the emergency department for severe headache accompanied by nausea since she awoke this morning.  She was diagnosed with hypertension 7 years ago and took medications for 2 years.  The patient stopped the medications and did not follow up with doctors as she felt fine.  She has a history of remote but not active intravenous drug use.  She is a current smoker with a 25-pack-year history.
Her temperature is 37.8° C (100.1° F), blood pressure is 176/105 mm Hg, and pulse is 100/min.  She appears lethargic with mild neck stiffness.  Cardiac auscultation shows an apical 2/6 holosystolic murmur.  Lungs are clear to auscultation bilaterally.  Deep abdominal palpation shows bilateral firm flank masses.  There is no peripheral edema or skin rash.  There is no focal muscle weakness or cranial nerve deficit.
ECG shows sinus tachycardia with left ventricular hypertrophy and secondary ST-segment and T-wave changes.
Laboratory results are as follows:

Which of the following is the most likely cause of this patient's headache?

A)Brain metastasis
B)Hypertensive encephalopathy
C)Non-communicating hydrocephalus
D)Subarachnoid hemorrhage
E)Viral encephalitis

Question 73

A 25-year-old man sustained a head injury during a motor vehicle accident.  He is currently comatose and intubated in the intensive care unit.  He has no significant medical problems except for mild asthma.  His urine drug screen was negative; however, his blood alcohol level was above the legal limit.  He works as a bartender and frequently binges on hard liquor and beer.  A non-contrast head CT at the time of admission revealed a hyperdense, extra-axial, space-occupying, right-sided lesion, which was subsequently drained.  He was sedated with a propofol infusion, but it was discontinued 12 hours ago.
His temperature is 37 C (98.6 F), pulse is 80/min, blood pressure is 130/85 mm Hg, and respirations are 18/min.  He is currently on volume assist-control ventilation with an FiO₂ of 40%, tidal volume of 500 cc, and PEEP of 5 cm H₂O.  He is not triggering the ventilator.  The general physical examination is unremarkable except for a hemi-craniectomy along the right side of the head.  He is comatose on neurological examination.  Cranial nerve and motor responses are absent.
His arterial blood gas analysis shows a pH of 7.42, PaCO₂ of 36 mm Hg, and PaO₂ of 101 mm Hg.
Which of the following is essential in establishing the diagnosis of brain death in this patient?

A)Atropine response testing
B)Bedside apnea testing
C)Cerebral blood flow testing
D)EEG with electrocerebral inactivity protocol
E)No further testing is needed

Question 74

A 66-year-old woman is hospitalized for the worst headache of her life.  CT scan of the head without contrast shows diffuse subarachnoid hemorrhage with intraventricular extension and hydrocephalus.  Because of the patient's deteriorating mental status and agitation, her trachea is cannulated and a central venous catheter is placed.
Which of the following is the most effective strategy to decrease this patient's risk for developing catheter-related infection?

A)Chlorhexidine baths
B)Internal jugular catheter placement versus subclavian site
C)Prophylactic systemic antibiotics
D)Routine catheter replacement every 3 days
E)Triple-lumen versus single-lumen placement

Question 75

A 46-year-old man comes to the emergency department complaining of severe headache for the last 3 hours.  He took ibuprofen without much relief.  He suffers from tension headaches but says that this headache is nothing like those.  He feels nauseated and wants to move to a quiet, dark room.
His temperature is 36.5 C (97.7 F), blood pressure is 160/90 mm Hg, and pulse is 108/min.  Examination shows pain and mild stiffness with neck flexion.  There are no cranial nerve deficits or muscle weakness.
A noncontrast head computed tomography scan reveals subarachnoid hemorrhage with no evidence of hydrocephalus.  The patient is admitted to the intensive care unit.  A few hours later, he complains of increasing headache and has 2 episodes of vomiting.  Soon after, he develops cardiac arrest with pulseless electrical activity.
Which of the following interventions would have been the most effective in preventing this outcome?

A)Anti-fibrinolytic therapy
B)Endovascular therapy
C)Hemodilution and hypervolemia
D)Nimodipine
E)Ventricular drain placement

Question 76

A 56-year-old man with a past medical history of hypertension and diabetes mellitus is hospitalized after sustaining a mild concussion following a motor vehicle accident.  His daily medications include aspirin, metformin, and lisinopril.  He has smoked one pack of cigarettes daily for 20 years.  He does not drink alcohol.  He is married and works as an accountant.  His family history is significant for coronary artery disease and diabetes mellitus.
His blood pressure is 143/95 mm Hg and pulse is 90/min with regular rhythm.  His general physical and neurological examinations are unremarkable.
An MRI of the brain without contrast reveals a chronic infarct in the right basal ganglia without any evidence of intracranial bleeding.
This patient is at the highest risk for which of the following?

A)Dementia
B)Migraine headaches
C)Multiple sclerosis
D)Normal pressure hydrocephalus
E)Seizure disorder

Question 77

A 23-year-old woman with known type 1 diabetes mellitus and systemic lupus erythematosus is admitted with low-grade fever, nausea, and headache.  She takes prednisone, hydroxychloroquine, and multiple daily injections of insulin.  She also uses decongestants for seasonal allergies and omeprazole for acid reflux disease.
Initial laboratory results are as follows:

Lumbar puncture shows protein of 23 mg/dL and no white blood cells.  Chest x-ray is normal.  Urinalysis shows no evidence of infection.  The patient is treated with IV fluids and insulin infusion.  On the second day of hospitalization, she complains of worsening headache and blurry vision.  On physical examination, she appears mildly lethargic.  There is right-sided periorbital swelling and tenderness over the maxilla.  There is no lymph node enlargement and the neck is supple.  Chest examination is unremarkable.  The abdomen is soft and nontender.  There are no skin rashes.
Repeat laboratory results are as follows:

This patient would most likely require which of the following?

A)Anti-pseudomonal antibiotics
B)MR angiography of the neck
C)Repeat lumbar puncture
D)Surgical treatment
E)Transesophageal echocardiography

Question 78

A 55-year-old man comes to the physician with an intensely pruritic rash under his left arm.  He has used an old prescription of 1% triamcinolone cream for the past 2 weeks without relief and believes that the rash is expanding.  The patient was diagnosed with Sjögren's syndrome 6 months ago when he developed dry eyes, dry mouth, and positive anti-SS-A and anti-SS-B antibodies.  Labial salivary gland biopsy at that time showed lymphocytic infiltration of salivary glands, confirming the diagnosis.  He was treated with hydroxychloroquine, topical moisturizing eye drops, and artificial saliva.  His other medical problems include type 2 diabetes mellitus, which has been well controlled with metformin.  Physical examination findings are shown in the image below.

Complete blood count and comprehensive metabolic panel are unremarkable.  His hemoglobin A1C is 6.1%.
After confirming the diagnosis, which of the following is the most appropriate next step in management of this patient?

A)Increase dose of oral hydroxychloroquine
B)Increase potency of topical steroids
C)Topical calcipotriene
D)Topical clotrimazole
E)Topical tacrolimus

Question 79

A 53-year-old woman is brought to the emergency department due to severe headaches, vomiting, and muscle weakness.  The patient's medical problems include hypertension and obesity.  Her body mass index is 34.2 kg/m².  Temperature is 38 C (100.4 F), blood pressure is 185/105 mm Hg, pulse is 110/min, and respirations are 24/min.  Pulse oximetry is 99% on room air.  The patient is oriented to person and place only, and has a throbbing headache and paralysis of her left side.
CT head scan without contrast reveals a right hemisphere hemorrhagic stroke.
What is the best next step in preventing deep-vein thrombosis in this patient?

A)Below-knee-high elastic compression stockings
B)D-dimer surveillance
C)Intermittent pneumatic compression device
D)Low-molecular-weight heparin
E)Thigh-high graduated compression stockings

Question 80

A 35-year-old woman comes to the emergency department with progressively worsening dyspnea and generalized weakness.  She has had a month of double vision and difficulty swallowing that are significantly worse toward the end of the day.  Over the past 2 weeks, she has had difficulty raising her arms above her head and walking up and down stairs.  The patient has no headache, speech difficulty, muscle aches, numbness, or paresthesias.  She also has no rash, insect bites, recent travel, or illness.
On physical examination, the patient has fatigable horizontal binocular diplopia in the primary position and bilateral ptosis.  Strength is 4 on a scale of 5 in the proximal muscles of the upper and lower extremities.  Sensory examination and reflex testing are unremarkable.
Complete blood count, comprehensive metabolic panel, and chest x-ray are normal.  Vital capacity obtained at the bedside is 500 mL.  The patient's respiratory status decompensates, requiring endotracheal intubation and admission to the intensive care unit.
Which of the following therapies is the most appropriate for rapidly improving this patient's current condition?

A)High-dose methylprednisolone
B)Methotrexate
C)Plasma exchange
D)Pyridostigmine
E)Rituximab