CK- NBME 11 – Block 4

A previously healthy 22-year-old man comes to the emergency department because of a 1-day history of burning and tingling around his mouth and in his arms and legs. During this time, cold water has felt “burning hot” when he washes his hands, and cool beverages have felt hot in his mouth. Two days ago, he ate grouper and mussels at a restaurant. One hour after eating, he had nausea, vomiting, and diarrhea, which lasted 24 hours and resolved spontaneously. He takes no medications. Vital signs are within normal limits. Muscle strength is 5/5 throughout. Deep tendon reflexes are absent throughout. Babinski sign is absent. Sensation is intact. Which of the following is the most likely diagnosis?

 A 37-year-old woman is brought to the emergency department because of a 3-day history of progressive shortness of breath, cough productive of rust-colored sputum, and temperatures to 38.9°C (102°F). Four years ago, she underwent splenectomy for injuries sustained during a motor vehicle collision. Her temperature is 39°C (102.2°F), pulse is 120/min, respirations are 22/min, and blood pressure is 105/60 mm Hg. Examination shows no jugular venous distention. On pulmonary examination, there are diffuse inspiratory wheezes and crackles heard at the right lung base. Cardiac examination shows no abnormalities. The extremities are cyanotic, and there is no edema. Arterial blood gas analysis on 2 L/min of oxygen by nasal cannula shows:

pH: 7.39

Pco₂: 38 mm Hg

Po₂: 41 mm Hg

HCO₃⁻: 22 mEq/L

O₂ saturation: 79%

A chest x-ray is shown. Which of the following is the most likely diagnosis?

A 24-year-old woman comes to the physician because of a 2-day history of moderate pain and swelling of her left ankle that began when she stepped in a hole while running. She says she continued running for 20 minutes afterward but stopped because she twisted the ankle again. Use of ice, bandages, and crutches has provided moderate relief. She has no history of previous ankle injury or serious illness. She takes ibuprofen as needed for pain. Vital signs are within normal limits. Dorsalis pedis pulses are 2+ bilaterally. The left anterior talofibular and calcaneofibular ligaments are tender to palpation; there is no bony tenderness to palpation of the forefoot, hindfoot, or ankle bilaterally. Anterior drawer test is 0 in the right ankle and 2+ in the left. Talar tilt test is 0 in the right ankle and 1 + in the left. The patient is able to dorsiflex and plantar flex both feet and ankles and flex and extend all toes. Sensation to light touch is intact over the lower extremities. Which of the following is the most appropriate next step in management to prevent morbidity in this patient?

A 42-year-old woman is admitted to the hospital 2 hours after the onset of pain and numbness in her left arm; she is having difficulty moving her arm. Two weeks ago, she was diagnosed with right popliteal venous thrombosis, and treatment with heparin and warfarin was begun. The left upper extremity is pale and cool; sensation to touch is decreased in a glove distribution distal to the mid forearm. Strength of the intrinsic muscles of the left hand is 2/5. Her prothrombin time is 14 sec (INR=1.3). An uncomplicated brachial embolectomy is performed. Which of the following is most likely to confirm the diagnosis?

A 71-year-old woman comes to the physician for a follow-up examination. She has chronic obstructive pulmonary disease, hypertension, and osteoporosis. She quit smoking 15 years ago. She is currently able to walk two blocks without shortness of breath, which is her baseline. Current medications include albuterol, alendronate, beclomethasone, chlorthalidone, and lisinopril. Her blood pressure is 135/80 mm Hg. Physical examination shows no abnormalities. The lungs are clear. Screening mammography 18 months ago showed no abnormalities. She has no history of abnormal mammograms and there is no family history of breast cancer. She asks whether she should continue to receive annual mammography to screen for breast cancer. Which of the following is the most appropriate recommendation by the physician?

A 19-year-old patient, gravida 1, para 1, is examined 1 hour after spontaneous vaginal delivery of a healthy male newborn at term. Pregnancy was uncomplicated. The patient dropped out of high school during the second trimester. The newborn’s father is 19 years of age and is incarcerated for possession of an illicit drug. The patient says the men in her family have histories of aggression, substance abuse, arrests, and incarcerations. She is concerned that her child will follow a similar path. The patient has no history of serious illness. Her only medication is a prenatal vitamin. She does not smoke cigarettes, drink alcohol, or use illicit drugs. Examination shows no abnormalities. Which of the following is the most appropriate next step in management?

A 55-year-old man comes to the office because of a 3-month history of episodes of mild, intermittent, mid chest pain. He says that the episodes occur 3 days weekly and last 2 to 3 minutes. The pain has not increased since his episodes began, and it is relieved by rest and use of antacids. He has not had shortness of breath, nausea, wheezing, or light-headedness. He has hypertension and asthma. His medications are lisinopril, hydrochlorothiazide, and albuterol. He does not smoke cigarettes. He drinks four glasses of wine on weekends. He works as an automobile mechanic. His pulse is 78/min, respirations are 16/min, and blood pressure is 142/84 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 97%. Cardiopulmonary examination shows no abnormalities. An ECG shows a normal sinus rhythm and no ST-T wave changes. Which of the following is the most appropriate next step in diagnosis?

Four days after admission to the hospital for management of cellulitis of the right lower extremity, a 70-year-old woman has an increased serum creatinine concentration. She has type 2 diabetes mellitus. Her medications are glipizide and a multivitamin; she also has received intravenous nafcillin since admission. She is retired from the military. Vital signs are within normal limits. Examination of the trunk shows no abnormalities. There is edema, erythema, and warmth of the right lower extremity. Examination of the left lower extremity shows no abnormalities. On admission, her serum creatinine concentration was 0.9 mg/dL. Today, laboratory studies show:

Hemoglobin: 11 g/dL

Hemoglobin A1c: 7.5%

Leukocyte count: 15,000/mm³

Segmented neutrophils: 75%

Bands: 1%

Eosinophils: 8%

Lymphocytes: 14%

Monocytes: 2%

Serum:

K⁺: 5 mEq/L

Urea nitrogen: 60 mg/dL

Creatinine: 2.3 mg/dL

Phosphorus: 4.3 mg/dL

Albumin: 2 g/dL

Cholesterol: 250 mg/dL

Urine:

pH: 6.00

Protein: trace

RBC: 10/hpf

WBC: 20–50/hpf

RBC casts: 0/lpf

WBC casts: 0/lpf

Serum complement concentrations are within the reference ranges. Which of the following is the most likely diagnosis?

A 29-year-old woman with systemic lupus erythematosus comes to the office because of a 5-day history of moderate pain in the right elbow, left knee, and left foot. There is no recent history of trauma. She has no history of sexually transmitted disease or other serious illness. Menses occur at regular 28-day intervals; her last menstrual period ended 2 days ago. Her only medication is methotrexate. She is sexually active with two male partners and uses condoms inconsistently. She is 173 cm (5 ft 8 in) tall and weighs 84 kg (185 lb); BMI is 28 kg/m2. Her temperature is 38.5°C (101.3°F); other vital signs are within normal limits. A photograph of the left foot is shown. Examination of the skin shows no other abnormalities. Analysis of synovial fluid shows a leukocyte count of 50,000/mm3. Cultures of blood and synovial fluid grow no organisms. Which of the following is the most likely diagnosis?

A 7-month-old boy is brought to the office by his mother because of a 1 -day history of fussiness. His mother says several children at the patient’s day-care center have been sick during the past week. He has had no change in appetite. His immunizations are up-to-date. He has no history of serious illness and receives no medications. He is at the 10th percentile for length, 15th percentile for weight, and 50th percentile for head circumference. His temperature is 37.2°C (99.0°F), pulse is 110/min, and respirations are 32/min. Pulse oximetry on room air shows an oxygen saturation of 97%. There are mild intercostal retractions. On pulmonary examination, mild wheezes are heard throughout the lung fields. The remainder of the examination shows no abnormalities. There is no change in examination findings after administration of nebulized albuterol. Which of the following is the most appropriate next step in management?

A 64-year-old woman comes to the office because of an enlarging, painless mass in her left cheek that she first noticed 2 months ago. She says the mass has doubled in size during this time. She has not sustained any trauma to the area. She was diagnosed with chronic obstructive pulmonary disease 2 years ago. She takes no medications. She has smoked one pack of cigarettes daily for 50 years. Her pulse is 96/min, respirations are 16/min, and blood pressure is 136/90 mm Hg. The left cheek at the mandibular angle is larger than the right; a 2 x 2-cm mass fixed to the underlying tissue is palpated. There is no lymphadenopathy. Ultrasonography shows a 2 * 2-cm mass in the superficial left parotid gland. Which of the following is the most appropriate next step in diagnosis?

A 62-year-old man, who is recovering in the coronary care unit following an acute ST-segment elevation anterior wall myocardial infarction 4 days ago, is being evaluated for the sudden onset of dyspnea and diaphoresis. At the time of admission, tissue plasminogen activator therapy was initiated, and the patient’s recovery had been uncomplicated. Medical history otherwise is unremarkable, and he takes no routine medications. Vital signs are temperature 37°C (98.6°F), pulse 128/min, respirations 36/min, and blood pressure 82/58 mm Hg. Pulse oximetry on 100% oxygen via nonrebreather face mask shows an oxygen saturation of 89%. Jugular venous pressure is 8 cm H20 (N=5-9). Auscultation of the lungs discloses diffuse crackles halfway up the back. Cardiac examination discloses a hyperdynamic precordium and a grade 3/6 holosystolic murmur that was not present on previous examinations. There is no clubbing, cyanosis, or edema of the extremities. Based on these findings, the patient’s condition is most likely attributable to which of the following?

A 17-year-old girl comes to the office for an examination required for sports participation. Medical history is unremarkable, and she takes no medications. She is 165 cm (5 ft 5 in) tall and weighs 54 kg (120 lb); BMI is 20 kg/m2. At her last visit 1 year ago, BMI was 23 kg/m2. The patient says she lost the weight by “eating healthy and exercising.” She adds, “I would like to lose a little more weight.” She began a vegetarian diet 6 weeks ago. Vital signs are normal with a pulse of 64/min; however, her pulse 1 year ago was 80/min. The remainder of the physical examination discloses no abnormalities. Which of the following is the most appropriate next step in management?

A 52-year-old man is brought to the emergency department by police 30 minutes after being found wandering in the park. On arrival, he appears confused and agitated. He is tremulous. He is 1 80 cm (5 ft 11 in) tall and weighs 59 kg (130 lb); BMI is 18 kg/m2. His temperature is 37.8°C (100°F), pulse is 100/min, respirations are 16/min, and blood pressure is 150/90 mm Hg. Examination shows telangiectasias over the face and upper and lower extremities. The liver edge is palpated 4 cm below the right costal margin. Muscle bulk is decreased throughout; deep tendon reflexes are 3+ throughout. Babinski sign is absent. His gait is ataxic. On mental status examination, he refuses to answer any questions. Laboratory studies show:

Serum:

Na⁺: 135 mEq/L

K⁺: 3.5 mEq/L

Cl⁻: 93 mEq/L

Glucose: 100 mg/dL

AST: 90 U/L

ALT: 65 U/L

Blood alcohol: 90 mg/dL

Urine:

Positive for Δ⁹-tetrahydrocannabinol

Intravenous administration of which of the following is the most appropriate next step in management to prevent Wernicke encephalopathy in this patient?

A 35-year-old man with Crohn disease returns to the clinic for follow-up 4 months after undergoing uncomplicated surgical repair of an enterovesical fistula. Medical history otherwise is unremarkable. Trials of 5-aminosalicylic acid, azathioprine, and prednisone prescribed since diagnosis 2 years ago have not controlled his Crohn disease; his only current medication is a daily multivitamin. He has smoked one pack of cigarettes daily for 15 years and occasionally drinks alcoholic beverages. The patient is 180 cm (5 ft 11 in) tall and weighs 68 kg (150 lb); BMI is 21 kg/m2. Temperature is 37.2°C (99.0°F), pulse is 85/min and regular, respirations are 16/min, and blood pressure is 114/68 mm Hg. Lungs are clear to auscultation. Cardiac examination discloses a grade 1/6 systolic ejection murmur heard best at the upper right sternal border. Abdominal examination shows a well-healed surgical scar. Bowel sounds are normal. There is no tenderness to palpation or percussion of the abdomen. Infliximab therapy is initiated. Which of the following studies is most appropriate to obtain at follow-up examination in 1 month?

A researcher conducts a randomized controlled trial of a new drug to treat chronic hepatitis B infection. A total of 400 patients are needed in order to detect a 10% difference in remission rates between the study drug and standard treatment groups. The researcher sets an α level of 0.05 and a β level of 0.20. A total of 500 patients are enrolled in the study, and 480 complete it. Patients are monitored for adverse events and for remission of the disease. The results are shown:

Which of the following is the most likely cause of the lack of difference in the adverse event rate?

A 13-year-old boy is brought to the office because of a 2-week history of a painless mass in the right thigh. He noticed the mass after a teammate hit him in the same area during a soccer game. He has not had weight loss, fatigue, or fever. He has no history of serious illness and takes no medications. Vital signs are within normal limits. Cardiopulmonary examination shows no abnormalities. Examination of the anterior aspect of the right thigh shows a 5-cm firm, nontender mass. Range of motion of the right knee is full and does not produce pain. Femoral and distal pulses are palpable. Sensation is intact. MRI of the right thigh shows a soft-tissue mass in the anterior compartment that is not adjacent to major arteries or nerves. An incisional biopsy specimen shows moderate-grade fibrosarcoma. Which of the following studies is the most appropriate next step in management?

A 17-year-old boy comes to the urgent treatment center because of a 4-day history of abdominal pain, loss of appetite, nausea, chills, and fever, which has responded to acetaminophen. He has not had headache, ear pain, or sore throat. He is able to tolerate fluids, but eating solid food increases his abdominal pain. Medical history is remarkable for seasonal allergies and lactose intolerance. His only routine medication is as-needed loratadine. He does not drink alcoholic beverages or use illicit drugs. He is monogamous with his girlfriend and engages in oral sex only. He returned home from a trip to Mexico with his family 3 weeks ago. Temperature is 37.8°C (100.0°F), pulse is 86/min, respirations are 14/min, and blood pressure is 100/60 mm Hg. The patient appears jaundiced. There is abdominal tenderness in the right upper quadrant without rebound or guarding. Murphy sign is absent. Results of which of the following serologic studies are most likely to confirm the diagnosis?

Screening for colon cancer is started in patients at the age of 45 years instead of at the age of 50 years. Which of the following is the most likely effect on the predictive values?

A 42-year-old man comes to the physician because of a 1-year history of chronic nosebleeds. He also had an episode of hematuria 3 months ago. His older brother has similar bleeding problems. Examination shows no abnormalities. Laboratory studies show:

Hemoglobin: 13.7 g/dL

Leukocyte count: 8000/mm³

Platelet count: 280,000/mm³

Bleeding time: 15 min

Prothrombin time: 11 sec (INR = 1.0)

Partial thromboplastin time: 45 sec

Test of the stool for occult blood is positive. Urinalysis shows no abnormalities. Which of the following is the most likely diagnosis?

A 23-year-old woman comes to the physician because of a 2-day history of several small, painful lesions over the vulva. She has no history of medical or gynecologic illness. She has a history of six lifetime sexual partners and became sexually active with her current partner 6 weeks ago; she uses condoms inconsistently. Examination shows ulcerations over the external genitalia that are tender to touch. She is concerned that she might have a sexually transmitted disease and that this might endanger future pregnancies. This patient should be advised that she is at increased risk for which of the following pregnancy outcomes?

A 62-year-old woman comes to the physician because of a 6-month history of increasing pain in her right thumb, especially with use. She now has difficulty with daily activities such as opening jars. She is right-handed. Ten years ago, she received the diagnosis of breast cancer and underwent mastectomy followed by chemotherapy. Evaluation 2 years ago showed no evidence of recurrence. She has type 2 diabetes mellitus controlled with metformin. Examination shows severe tenderness to palpation at the base of the right thumb. Muscle strength is 3/5 on abduction of the thumb due to pain. Sensation to pinprick is intact over the thumb. Which of the following is the most likely diagnosis?

A 42-year-old woman comes to the physician because of a 1-year history of increased drinking and difficulty swallowing because of a dry mouth. She also has noticed swelling of her cheeks and has had more dental cavities than usual during this period. She has no history of serious illness. She takes no medications. Vital signs are within normal limits. Examination shows enlarged parotid glands; slightly red eyes; and dry, cracked lips. Which of the following is the most appropriate next step in management?

A randomized controlled trial shows that a new fecal occult blood test (FOBT) leads to an 80% decrease in the relative risk for death due to colorectal cancer. Which of the following additional information is most useful in understanding the impact of this test?

 A 4-month-old boy is brought to the office by his mother because of a 1 -month history of feeding problems. The mother says her son often vomits after feeding and hiccups frequently. She also notes that he sometimes arches his back after feeding and appears to be in pain. The infant’s diet consists primarily of cow milk-based formula, with occasional infant cereal and fruits. He is fed six times daily. Medical history is unremarkable and he takes no medications. Vaccinations are up-to-date. The patient is at the 10th percentile for length, weight, and head circumference. Vital signs are normal. Physical examination discloses no abnormalities. Which of the following is the most likely preliminary diagnosis?

A 62-year-old woman is brought to the physician by her children 1 week after they noticed a large lesion on her right shoulder. She has lived alone since her husband died 6 months ago, and her family has recently become concerned that she is not caring for herself adequately. She says she thinks she has had the lesion for 1 year and that it has been increasing in size. She underwent renal transplantation 5 years ago and has taken prednisone and cyclosporine since then. She underwent radiation therapy on her face for treatment of acne as a teenager. Her sister died of skin cancer 3 years ago at the age of 65 years. The patient has smoked one pack of cigarettes daily for 45 years. She was employed as a landscaper for 25 years. She appears disheveled and is poorly groomed. Examination shows a 5-cm lesion on the posterior right shoulder. A photograph of the patient’s back is shown. Which of the following is the most likely cause of the lesion?

A 27 year old primigravid woman at 20 weeks gestation comes to the physician for her first prenatal visit. Examination shows a uterus consistent in size with a 10 week gestation. Laboratory studies show:

Hemoglobin: 10.5 g/dL

Mean corpuscular hemoglobin: 27.8 pg/cell

Mean corpuscular hemoglobin concentration: 29% Hb/cell

Mean corpuscular volume: 75 µm³

Leukocyte count: 10,000/mm³

Platelet count: 174,000/mm³

Which of the following is the most likely diagnosis?

A previously healthy 4-year-old boy is brought to the physician because of a 3-day history of fever, cough, and runny nose. He has not had wheezing, vomiting, or diarrhea. He is at the 75th percentile for height and 10th percentile for weight. His temperature is 37.5°C (99.5°F). The skin is warm and pink. Capillary refill time is 2 seconds. Examination shows clear rhinorrhea. Breath sounds are normal. Cardiac examination is shown. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis?

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A 6-year-old girl with a history of delayed motor and language development is brought to the physician by her parents because of three episodes of “staring off” during the past 5 weeks. During the episodes, she turns her head to the left, extends her left arm, and does not respond to questions; each episode lasts 2 minutes. After the episode, she is confused and wants to sleep. She was born at term following an uncomplicated pregnancy and spontaneous vaginal delivery. Examination shows no dysmorphic features. There are a few hypopigmented macules over the abdomen and lower extremities. Language development is at the level of a 3-year-old child. An MRI of the brain is shown. Which of the following is the most likely diagnosis?

A study is conducted to determine the efficacy of cervical cerclage to prevent preterm birth. Pregnant patients at 16 weeks’ gestation are enrolled, and their cervical length is measured transvaginally by ultrasonography. If cervical length is found to be less than 25 mm, the patient is offered cerclage or bed rest. Patients are observed until delivery, and outcome data are collected. Which of the following is the best description of this type of study?

A 67-year-old woman, gravida 5, para 5, is admitted to the hospital because of a 6-month history of increasingly severe abdominal pain and distention and difficulty eating. During the past 2 weeks, she has had increased abdominal girth. She also has had a 4-day history of nausea and vomiting. Ten years ago, she had breast cancer treated with bilateral mastectomy; she took tamoxifen therapy for 6 years. Her pulse is 68/min, respirations are 20/min, and blood pressure is 124/72 mm Hg. Breath sounds are decreased at the lung bases. The abdomen is distended, tense, and tender; there is a fluid shift. The genitalia are normal. On bimanual examination, a midline pelvic mass is palpated and several 1-cm nodules are palpated along the rectovaginal septum. Laboratory studies show:

Hemoglobin: 10.2 g/dL

Serum urea nitrogen: 10 mg/dL

Serum creatinine: 1 mg/dL

CA 125: 2270 U/mL (normal <35)

Following surgical removal of the masses, which of the following is the most appropriate next step in management?

A previously healthy 32-year-old woman comes to the physician because of a 3-month history of intermittent milky discharge from her breasts. During the past year, menses have occurred at irregular 15- to 32-day intervals. She takes no medications. Her mother and sister were diagnosed with pituitary tumors at the ages of 50 and 44 years, respectively; they also have increased serum calcium concentrations. The patient’s temperature is 36.9°C (98.4°F), pulse is 90/min and regular, respirations are 14/min, and blood pressure is 156/70 mm Hg. On examination, milky discharge is expressed from both breasts. The remainder of the examination, including funduscopic examination and visual field testing, shows no abnormalities. Serum studies show:

Na⁺: 140 mEq/L

K⁺: 3.9 mEq/L

Cl⁻: 109 mEq/L

Ca²⁺: 12.4 mg/dL

Urea nitrogen: 30 mg/dL

Glucose: 90 mg/dL

Creatinine: 1.2 mg/dL

Total protein: 9 g/dL

Albumin: 4.8 g/dL

Phosphorus: 2 mg/dL

Intact parathyroid hormone: 90 pg/mL (normal 10–65)

Prolactin: 140 ng/mL

β-hCG: <5 mIU/mL

In addition to bromocriptine therapy, which of the following is the most appropriate next step in management?

A 67-year-old man is brought to the emergency department because of a 20-minute history of palpitations, dizziness, and fatigue. He has hypertension controlled with hydrochlorothiazide and lisinopril. His pulse is 110/min and irregular, respirations are 18/min, and blood pressure is 126/70 mm Hg. Examination shows no other abnormalities. An ECG shows atrial fibrillation. Which of the following is the most appropriate next step in management?

An 82-year-old woman is brought to the emergency department 30 minutes after collapsing at a shopping center. She was intubated at the scene. On admission, she is comatose and requires mechanical ventilation. Her pulse is 120/min, respirations are 12/min, and blood pressure is 90/60 mm Hg. She does not respond to painful stimuli. Thirty minutes later, her granddaughter comes to the hospital and shows the physician an advance directive signed by the patient requesting no intubation or “artificial means to prolong life.” Which of the following is the most appropriate next step in management?

An 18-year-old woman comes to the physician because of a 3-day history of fatigue and yellow eyes. She has a history of mild anemia but is otherwise healthy. Her 16-year-old brother also has mild anemia. Her temperature is 36.7°C (98°F), pulse is 82/min, respirations are 14/min, and blood pressure is 105/60 mm Hg. There is scleral icterus. Examination shows multiple, 1-cm, cervical lymph nodes that are mildly tender.

Hemoglobin: 8.6 g/dL

Mean corpuscular hemoglobin concentration: 38% Hb/cell

Reticulocyte count: 8%

Serum total bilirubin: 3 mg/dL

A direct antiglobulin (Coombs) test is negative. A blood smear is shown. Which of the following is most likely to have prevented this patient’s current symptoms?

 An 8-year-old boy is brought to the physician 1 hour after the sudden onset of facial swelling. He has had an upper respiratory tract infection and sore throat for the past 2 days. He has a history of six similar episodes since birth requiring hospitalization; two of the episodes required endotracheal intubation. All episodes presented the same except for one episode of facial swelling that began after he fell and cut his lip. He has no known allergies. His father, several paternal aunts, and some paternal cousins have had similar episodes. He appears anxious, and his voice is hoarse. His axillary temperature is 36.9°C (98.4°F), pulse is 110/min, respirations are 28/min, and blood pressure is 120/84 mm Hg. Examination shows edema of the lips and tongue; there is no tenderness, erythema, pain, or itching. Mild inspiratory stridor is heard. Which of the following serum studies is most likely to be abnormal?

A 62-year-old man is brought to the emergency department 4 hours after the sudden onset of vomiting and severe abdominal pain. During the past year, he has had mild, intermittent epigastric pain, which is relieved with antacid use. He has no history of serious illness. He has smoked one and one-half packs of cigarettes daily for 35 years. He drinks one to two alcoholic beverages daily. He appears diaphoretic and is in acute distress. His temperature is 38.4°C (101.1 °F), pulse is 100/min, respirations are 18/min, and blood pressure is 115/75 mm Hg. The abdomen is rigid and tympanitic to percussion over the liver. There is severe diffuse tenderness. Bowel sounds are absent. Which of the following is the most appropriate next step in diagnosis?

 A 6-year-old boy is brought to the physician by his parents because of a 3-day history of progressive pain, swelling, and redness around his right eye. The swelling began on his right upper eyelid and has now spread to the whole eye. He says that it hurts when he moves his eyes. He also has had fever and headache during this period. He has a 2-week history of cough and nasal congestion. He takes no medications. Immunizations are up-to-date. His temperature is 38.1°C (100.6°F), pulse is 110/min, respirations are 22/min, and blood pressure is 130/70 mm Hg. Examination shows exophthalmos of the right eye; the upper and lower eyelids are erythematous and edematous. The erythema does not extend beyond the superior orbital rim. He cannot fully abduct his right eye on lateral gaze. The remainder of the examination shows no abnormalities. A CT scan of the head is shown. Which of the following is the most likely diagnosis?

A 47-year-old woman comes to the physician for a routine health maintenance examination. She has a 2-year history of venous insufficiency and notes daily swelling of her ankles that worsens in the evening. She takes no medications. Her pulse is 80/min, and blood pressure is 160/100 mm Hg. Cardiopulmonary examination shows no abnormalities. Examination of the lower extremities shows 2+ edema and increased pigmentation. Which of the following antihypertensive drugs would most likely exacerbate this patient’s swelling?

An asymptomatic 37-year-old woman comes to the physician for a routine health maintenance examination. She has a history of asthma exacerbated by nonsteroidal anti-inflammatory drugs. She has smoked two packs of cigarettes daily for 20 years. Her current medications include inhaled isoetharine and an oral contraceptive. She is 152 cm (5 ft) tall and weighs 50 kg (110 lb); BMI is 22 kg/m2. Her blood pressure is 140/88 mm Hg. Examination shows no abnormalities. Which of the following is the most appropriate recommendation to prevent stroke in this patient?

A 62-year-old woman, gravida 2, para 2, comes to the physician because of loss of urine that has become progressively worse during the past 3 months. She has a 5-year history of occasional incontinence after feeling a strong urge to void; treatment with oxybutynin has provided no relief of her symptoms. She has type 2 diabetes mellitus and hypertension. Current medications include metformin, insulin, and metoprolol. Vital signs are within normal limits. Abdominal examination shows no abnormalities. The external genitalia, vagina, and cervix appear normal. The uterus and adnexa are normal to palpation. There is loss of a large amount of urine with mild pressure on Valsalva maneuver. Her postvoid residual volume is 500 ml_. Urinalysis shows no abnormalities. Which of the following is the most likely diagnosis?

A 62-year-old man comes to the physician because of a 1-year history of progressive shortness of breath. He has moderate difficulty breathing at rest and has wheezing after walking 20 feet. He has a chronic cough productive of white sputum that occurred intermittently for 10 years and then started to occur daily 1 year ago. He has not had any other symptoms. He has no other history of serious medical conditions and takes no medications. He has smoked one pack of cigarettes daily for 47 years. His temperature is 37.1°C (98.7°F), pulse is 76/min, respirations are 28/min, and blood pressure is 130/70 mm Hg while sitting. Pulse oximetry on room air shows an oxygen saturation of 92%. Examination shows no jugular venous distention. Expiratory wheezes are heard bilaterally. Cardiac examination shows no abnormalities. Carotid and femoral pulses are 2+. There is no peripheral edema. Spirometry shows a decreased FEV1 and FEV1/FVC ratio. An ECG shows no abnormalities. A chest x-ray shows an increased anteroposterior diameter. The physician counsels the patient about beginning a smoking cessation program. Which of the following is the most appropriate next step in management?

A previously healthy 2-year-old girl is brought to the emergency department by her parents 60 minutes after she had a 2-minute episode of generalized shaking. During the episode, she was unresponsive, and her eyes were rolled back in her head. On arrival, she is awake and cooperative. Her temperature is 39.8°C (103.6°F), pulse is 130/min, respirations are 12/min, and blood pressure is 90/70 mm Hg. Examination shows an erythematous, bulging right tympanic membrane. The neck is supple. Neurologic examination shows no focal findings. Serum electrolyte concentrations are within normal limits. Which of the following is the most appropriate next step in management?

A 27-year-old man is brought to the emergency department by police after being found somnolent in an alley. On arrival, he is agitated and confused. When staff approach him, he shouts and tries to get off the stretcher. He appears disheveled. He is malodorous and diaphoretic. He rambles unintelligibly on questioning and persistently picks at his clothes. His pulse is 110/min, and blood pressure is 160/90 mm Hg. Pupils are equal and reactive. He has a mild tremor of both hands. Urine toxicology screening is negative. Which of the following is the most likely cause of this patient’s symptoms?

A 16-year-old boy comes to the physician for a routine follow-up examination. He has a 10-year history of type 1 diabetes mellitus. During the past 9 months, he has not been compliant with his treatment; he has been missing insulin injections and has not been monitoring his blood glucose concentrations. He has been admitted to the hospital four times during the past 3 years for diabetic ketoacidosis; his hemoglobin A1c during each hospital stay was greater than 10%. His pulse is 68/min, and blood pressure is 122/85 mm Hg. Examination shows lipoatrophy at the abdominal injection sites. Funduscopic examination shows no abnormalities. Which of the following is the most appropriate next step?

A 5-year-old boy is brought to the emergency department 20 minutes after being stung by a bee on his right arm at summer camp. The site immediately became red, swollen, and hot, and an itchy rash developed and quickly spread to his chest. He has not had shortness of breath, rapid breathing, wheezing, or swelling of his other extremities. On arrival, he appears slightly anxious but is not in acute distress. His temperature is 37°C (98.6°F), pulse is 98/min, respirations are 28/min, and blood pressure is 90/65 mm Hg. Examination shows moist mucous membranes. A 3-cm area of erythematous induration surrounds the site of the sting, and the right upper arm is diffusely edematous. There is an urticarial rash on the right upper arm and chest. The lungs are clear to auscultation. Which of the following measures is most likely to decrease this patient’s risk for similar reactions in the future?

A 7-year-old girl is brought to the physician 3 days after her mother noticed a rash on her face. The patient has no other symptoms and has no history of similar skin lesions or recent trauma to the face. She feels well. Her temperature is 37°C (98.6°F). A photograph of the rash is shown. Examination shows no other abnormalities. Which of the following is the most appropriate initial treatment?

Four weeks after a flu-like illness, a 40-year-old man develops progressive dyspnea on exertion. Examination shows jugular venous distention, bilateral pulmonary crackles, a diffuse apical impulse, an apical S3, and bilateral pedal edema. Which of the following is the most likely cause?

A 52-year-old woman comes to the physician for a routine health maintenance examination. One year ago, she was started on daily hormone replacement therapy (estradiol and medroxyprogesterone) to treat severe vasomotor symptoms. But she has been taking the medroxyprogesterone intermittently because of severe depression and mood changes when taking it. Menses had stopped for the first 6 months on the original regimen, but since she changed her regimen, she has had vaginal spotting two to three times monthly. Which of the following is the most appropriate next step in management?

A 77-year-old man is brought to the physician by his family because of a 10-week history of decreased appetite that has resulted in a 10.4-kg (23-lb) weight loss. During this time, he also has had a persistent, nonproductive cough, intermittent nausea, and constipation. He reports that he has been sleeping 10 hours daily but does not feel rested. His family states that he had an upper respiratory tract infection prior to the weight loss and that he never “bounced back” from the infection. He had smoked one to two packs of cigarettes daily for 60 years but has recently cut back to one to two cigarettes daily because he no longer enjoys the taste. He appears tired and cachectic. He is 175 cm (5 ft 9 in) tall and weighs 58 kg (129 lb); BMI is 19 kg/m2. His temperature is 36°C (96.8°F), pulse is 86/min, and blood pressure is 120/78 mm Hg. The lungs are clear to auscultation. Abdominal examination shows no tenderness and mild distention. There is trace pedal edema. On mental status examination, he has a sad mood and constricted affect. His speech is slow. He is oriented to person, place, and time. He cannot perform serial sevens. An x-ray of the chest shows no abnormalities. An x-ray of the abdomen shows copious stool. Which of the following is the most appropriate next step in management?