NBME 13 – Block 2

A randomized clinical trial is conducted to assess the risks and benefits of surgery compared with pharmacotherapy for the treatment of symptomatic high-grade carotid artery stenosis. A total of 3000 patients are randomly assigned to undergo surgery or receive pharmacotherapy. After excluding the 98 patients who died during surgery, the investigators found that surgery is associated with a 48% reduction in stroke. Which of the following raises the most concern regarding the validity of this conclusion?

A 25-year-old man is being observed in the emergency department after he was evacuated from a mountainous area while backpacking alone during a snowstorm. The wilderness search team found him 2 days after he lost his way. The patient was wearing wet clothing, and he was cold, confused, and hallucinating. Initial vital signs were pulse 40/min, respirations 8/min, and blood pressure 80/50 mm Hg. Inclement weather delayed helicopter access for 6 hours. Field treatment included removal of wet clothing, warming with layers of dry clothing and sleeping bags, and later administration of warm liquids. On arrival at the emergency department, the patient was alert, fully oriented, and shivering. Vital signs were core temperature 36.1°C (97.0°F), pulse 68/min, respirations 14/min, and blood pressure 100/70 mm Hg. The patient’s feet were cold to the touch and mildly erythematous from ankle to midfoot. There were mixed erythematous and pale areas distally, as well as mild edema. There were several small blisters filled with bloody fluid over the proximal toes. Sensation was poor in both feet. No gangrene was present. The patient’s feet were immersed in water with a temperature of 42.0°C to 44.0°C. Now, 6 hours later the patient reports severe pain in his feet. The feet are hyperemic to midfoot, with numbness to the ankles. Distally, his feet are pale and have more dark blebs. The patient is worried about his feet and asks what will happen. At this time it is most appropriate to tell him which of the following?

A 37-year-old woman comes to the emergency department because of fever and shortness of breath for 4 days. She has a history of intravenous drug use. Her temperature is 39°C (102.2°F), and blood pressure is 160/60 mm Hg. Examination shows splinter hemorrhages under several fingernails. A grade 2/6, high-pitched, decrescendo diastolic murmur is heard at the third left intercostal space. Which of the following is the most likely cause of these findings?

A meta-analysis is conducted of five randomized, blinded, placebo-controlled clinical trials to assess the effectiveness of prophylactic antibiotic use prior to IUD insertion. The number of participants in each trial ranges from 22 to 58. Trials V and W use oral doxycycline. Trials X, Y, and Z use oral clindamycin. The outcome of all trials is the development of postprocedural infection. The results are shown in the graph. On the basis of these data, which of the following is the most accurate conclusion regarding prophylactic antibiotic use prior to IUD insertion?

An 82-year-old woman is disoriented 6 hours after undergoing a total abdominal hysterectomy and bilateral salpingo-oophorectomy under general anesthesia for endometrial cancer. She was placed on patient-controlled analgesia with hydromorphone postoperatively. Nine years ago, she underwent lumpectomy and axillary dissection followed by radiation therapy for stage I breast cancer. Other medical history includes hypothyroidism, hypertension, and hypercholesterolemia. Her pulse is 72/min, respirations are 7/min, and blood pressure is 127/62 mm Hg. During the examination, the patient stops breathing. The physician calls the rapid response (Code Blue) team. Intravenous administration of naloxone is begun; the patient’s condition improves, and her respirations increase to 22/min. Which of the following is the most appropriate course of action by the hospital staff?

A 72-year-old man comes to the physician because of a 4-year history of nonproductive chronic cough. The cough primarily occurs during eating or drinking; he has frequently coughed up undigested food and pills. He has not had nausea or vomiting or the sensation of food stuck in his throat. He has required admission to the hospital twice during the past 2 years for treatment of aspiration pneumonia. He has arthritis and hypercholesterolemia. His only medication is lovastatin. He does not smoke cigarettes or drink alcohol. Vital signs are within normal limits. During the examination, he is coughing continuously. Examination shows no abnormalities except for a grade 2/6 systolic murmur. Which of the following is the most likely diagnosis?

A 21-year-old woman comes to the physician because of a 1-day history of redness and itchiness of her right eye. When she awoke this morning, she had mild crusting over her eyelashes. She has not had fever, dry mouth, muscle aches, or rash. She has no allergies or history of serious illness. She takes no medications. She works in a preschool. Vital signs are within normal limits. Examination shows moderate, diffuse injection of the right conjunctiva. Which of the following is the most appropriate pharmacotherapy?

A 32-year-old woman is brought to the emergency department because of a 24-hour history of increasingly severe lower abdominal pain. She has been unable to eat anything for 12 hours because of nausea. She has been taking sulfasalazine for ulcerative colitis for 6 months. Her temperature is 38.2°C (100.8°F). Examination shows a distended, tympanitic abdomen. There is tenderness to palpation of the lower quadrants. Bowel sounds are decreased. An x-ray of the abdomen shows a dilated colon and gas in the bowel wall. Which of the following is the most appropriate next step in management?

A 32-year-old man comes to the office because of episodes of the sensation of a racing heart, sweating, difficulty breathing and swallowing, and the fear that he is dying. His symptoms began when he started a new job 4 weeks ago. He has had four episodes during the past 2 weeks. He says these episodes are similar to episodes he had 10 years ago. He has a history of alcohol use disorder but has been abstinent for 2 years. He has no other history of serious illness and takes no medications. His father and paternal grandfather had alcohol use disorder. The patient is calm and cooperative. Pulse is 74/min, respirations are 16/min, and blood pressure is 116/72 mm Hg. Physical examination shows no abnormalities. On mental status examination, he is engaging and says he has not felt depressed. His affect is reactive, and his thought process is goal directed. Serum studies show a thyroid-stimulating hormone concentration of 3 μU/mL and thyroxine (T4) concentration of 5 μg/dL. Which of the following is the most appropriate pharmacotherapy?

A 42-year-old woman is brought to the emergency department 30 minutes after the sudden onset of left-sided weakness and a moderate headache while exercising at the gym. She reports that the weakness occurred almost immediately after the sudden onset of pain in her right jaw that radiated to the right temple. She has no history of serious illness and takes no medications. She is awake and alert. Her temperature is 37°C (98.6°F), pulse is 90/min, and blood pressure is 150/90 mm Hg. Examination shows left homonymous hemianopia. The right pupil is 2 mm, and the left is 4 mm. Both pupils are reactive to light. There is partial ptosis of the right eye and drooping of the left lower aspect of the face. Muscle strength is 5/5 in the right extremities and 4/5 in the left extremities. Deep tendon reflexes are 2+ in the right extremities and 3+ in the left extremities. Babinski sign is absent on the right and present on the left. Which of the following is the most likely diagnosis?

A previously healthy 18-year-old primigravid woman at 22 weeks’ gestation comes to the physician because of a genital lesion for 2 days. She is sexually active with multiple partners, but she has no history of sexually transmitted diseases. Examination shows a 1.5-cm, painless, superficial ulcer on the left labium majus. There is nontender, firm inguinal lymphadenopathy. Serologic testing 8 weeks ago was negative for syphilis, Neisseria gonorrhoeae, and Chlamydia trachomatis. Which of the following is the most appropriate pharmacotherapy?

A 9-month-old boy is brought to the office by his parents for a well-child examination in late autumn. He was born at 34 weeks’ gestation via spontaneous vaginal delivery to a 24-year-old woman, gravida 2, para 2, following an uncomplicated pregnancy. Medical history is noncontributory, and he receives no medications. His growth and development have been appropriate for age, and required vaccinations are up-to-date as of his last well-child visit. The patient is 72 cm (28.5 in; 50th percentile) long and weighs 10 kg (22 lb; 75th percentile). Vital signs are within normal limits. Physical examination discloses no abnormalities. Which of the following is the most appropriate condition to vaccinate against at this time?

A 17-year-old girl comes to the office because of a 2-month history of increasingly severe pain below her left knee at rest and with exertion. She now has moderate difficulty walking because of the pain. She has no history of trauma or serious illness. She takes no medications. On examination, she is unable to bear her full weight on the left lower extremity. There is warmth and tenderness over the anterolateral aspect of the left proximal tibia. Peripheral pulses are 2+. There is no evidence of instability of the ligaments of the left knee. The remainder of the examination, including neurologic examination, shows no abnormalities. X-ray of the left knee is shown. Which of the following is the most appropriate next step in management?

A 25-year-old woman comes to the physician because of a 3-day history of low-grade fever, sore throat, generalized muscle aches, and fatigue. She also has had moderate neck pain radiating to her jaw and ears during this period. She has no history of serious illness and takes no medications. She is alert and in no distress. Her temperature is 38.2°C (100.8°F), pulse is 110/min, respirations are 16/min, and blood pressure is 120/80 mm Hg. The thyroid gland is diffusely tender and slightly enlarged. Examination of the head, ears, eyes, nose, and oropharynx shows no abnormalities. Serum studies show a thyroid-stimulating hormone concentration of 0.5 μU/mL and a thyroxine (T4) concentration of 16 μg/dL. A 131I thyroid scan shows decreased uptake. Which of the following is the most appropriate next step in management?

A 63-year-old man who has chronic obstructive pulmonary disease (COPD) returns to the office for a follow-up visit. His COPD has progressed during the past 3 years. He smoked cigarettes for 48 years but quit 1 year ago; he continues to have chronic cough, dyspnea on exertion, and episodes of wheezing. He says he often sleeps in his recliner so that his snoring and coughing will not bother his wife. Current medications include inhaled albuterol, budesonide, and ipratropium for the past 2 months. He received a pneumococcal polysaccharide vaccine, 23-valent, 2 years ago. He is a retired postal worker and is frustrated because he is no longer able to walk from the car to the poker room at the local community center to play cards with his friends. Today, pulse is 90/min and regular, and blood pressure is 130/78 mm Hg. He appears large and has a barrel-shaped chest. Breath sounds are decreased, and scattered wheezes are heard. No gallops or murmurs are heard on cardiac examination. Leukocyte count is 12,000/mm3 and hemoglobin concentration is 14 g/dL. After the patient receives nebulized albuterol, pulse oximetry on room air shows an oxygen saturation of 86%. Which of the following is the most important factor in this patient’s history and physical examination in determining his prognosis?

A 67-year-old woman comes to the physician because of a 5-day history of progressive shortness of breath with walking and climbing stairs. She has had fatigue for the past 2 weeks. She has not had any other symptoms. She has chronic obstructive pulmonary disease. Current medications include inhaled albuterol and ipratropium and oral prednisone. She smoked two packs of cigarettes daily for 40 years but stopped 5 years ago. Her pulse is 100/min, respirations are 24/min, and blood pressure is 110/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 93%. Examination shows pale conjunctivae. Breath sounds are decreased bilaterally. Heart sounds are distant. The spleen tip is palpated 5 cm below the left costal margin. The remainder of the examination shows no abnormalities. Laboratory studies show:

Which of the following is the most likely explanation for these findings?

A 57-year-old woman comes to the physician because of substernal chest discomfort since awakening 3 hours ago. She has not had injury or heavy exertion. She ate a greasy meal for dinner last night. She has not had any other symptoms. She has fibromyalgia, hyperlipidemia, and major depressive disorder. Current medications include ibuprofen, atorvastatin, and fluoxetine. She has never smoked and rarely drinks alcohol. She is in mild distress. Her pulse is 80/min and regular. Examination shows mild tenderness to palpation of the chest wall. Serum studies show:

An ECG shows a normal sinus rhythm and 1- to 2-mm ST-segment depression in leads V3 through V5. Which of the following is the most likely explanation for these findings?

A 27-year-old woman, gravida 2, para 1, at 18 weeks’ gestation comes to the physician for a routine prenatal visit. Her 5-year-old son recently received the diagnosis of erythema infectiosum (fifth disease). Examination shows no abnormalities. Which of the following is the most appropriate next step in management?

A 17-year-old girl comes to the office for contraceptive counseling. She requests a specific brand-name oral contraceptive because she heard from her friends that it works well and also helps control acne. The physician informs her that this particular drug has a higher co-payment and there are similar oral contraceptives that would provide the same benefits. The patient refuses any other oral contraceptive, and she says that she has a good job and can afford the more expensive one. Which of the following is the most appropriate response by the physician?

An 18-month-old boy from Afghanistan, who immigrated to the USA with his family 2 days ago, is brought to the emergency department by his mother because of a 6-hour history of fever and difficulty breathing. The mother says he previously was doing well. Medical history is unremarkable, and he has not had contact with anyone known to be ill. He receives no medications, and immunization status is unknown. He is sitting on his mother’s lap, leaning forward, and drooling. He appears to be in significant respiratory distress. Vital signs are temperature 39.0°C (102.2°F), pulse 120/min, respirations 40/min, and blood pressure 80/50 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 95%. Physical examination discloses stridor heard without auscultation. Which of the following is the most appropriate next step in management?

A 57-year-old man with pancreatic cancer is admitted to the hospital because of a 5-day history of moderate epigastric pain that has not responded to oral hydromorphone therapy. On admission, intravenous hydromorphone is begun. The nurse calls to report that 3 hours ago, she mistakenly administered 5 mg of hydromorphone instead of the prescribed 0.5 mg. The patient is sleeping comfortably and is easily aroused. His respirations are 12/min, and blood pressure is 120/78 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 98%. Examination shows no other abnormalities. In addition to reporting the incident to the patient safety committee, which of the following is the most appropriate next step in management?

A 16-month-old boy is brought to the physician by his mother for a follow-up examination. One month ago, he completed a course of antibiotic therapy for an ear infection. His mother reports he has a 2-day history of irritability, decreased appetite, and difficulty sleeping. He has been hospitalized for pneumonia twice during the past 9 months. He appears irritable. His temperature is 38.7°C (101.6°F), pulse is 96/min, respirations are 20/min, and blood pressure is 92/54 mm Hg. Skin examination shows no abnormalities. Examination of the right ear shows an erythematous, bulging tympanic membrane. Laboratory studies show a leukocyte count of 16,400/mm3 (74% segmented neutrophils, 17% lymphocytes, and 9% monocytes). Additional serum studies are most likely to show which of the following?

A 27-year-old man comes to the physician because of a 3-day history of fever and bloody diarrhea; episodes of diarrhea are preceded by abdominal pain. He has had no weight loss or rash. He takes no medications. His temperature is 37.8°C (100°F), pulse is 88/min, and blood pressure is 124/72 mm Hg. Abdominal examination shows diffuse tenderness with no rebound or guarding; bowel sounds are increased. Rectal examination shows no abnormalities; there is no blood or stool in the rectal vault. Which of the following is the most likely causal organism?

A 15-year-old boy is brought to the emergency department after football practice because of a 45-minute history of bright red blood in his urine. He has no history of serious illness and receives no medications. His pulse is 115/min, and blood pressure is 119/73 mm Hg; other vital signs are within normal limits. Examination shows no ecchymoses, suprapubic tenderness, or abdominal distention; there is moderate tenderness to palpation of the left flank. Which of the following is the most appropriate next step in diagnosis?

A 67-year-old man with squamous cell carcinoma of the lung comes to the office for follow-up examination 10 days after receiving his first dose of chemotherapy with carboplatin and etoposide followed by radiation therapy. He had nausea and vomiting for 2 to 3 days following the treatment. He now feels weak but well overall. Vital signs are within normal limits. Examination shows no new abnormalities. Results of laboratory studies are shown:

Which of the following is the most appropriate next step in management of this patient’s pancytopenia?

A 47-year-old man comes to the office because of a 6-month history of aching, burning pain in both legs. Initially, he had pain only after he walked for one-half mile, but now the pain occurs after he walks one-half block and resolves only after he rests for at least 1 minute. He says his symptoms interfere with his job as a construction worker on a large work site. He is able to ride an exercise bicycle without pain. He has hypertension, type 2 diabetes mellitus, and hypercholesterolemia. His medications are lisinopril, metformin, and atorvastatin. Two years ago, he underwent orchiectomy and retroperitoneal radiation therapy for testicular cancer. His blood pressure is 130/70 mm Hg; other vital signs are within normal limits. Examination shows absence of the left testis. Ankle brachial indices are 0.9 in both feet. Deep tendon reflexes are moderately decreased at the ankles. Sensation to pinprick is decreased over the feet. The remainder of the examination shows no abnormalities. An MRI of the lumbosacral spine shows narrowing of the spinal canal secondary to congenital stenosis and superimposed degenerative changes. Which of the following is the most appropriate next step in management?

A 23-year-old woman with epilepsy comes to the clinic because she and her husband would like to conceive during the next year. She began having generalized tonic-clonic seizures and absence seizures at the age of 11 years and has been taking valproic acid and ethosuximide twice daily since the age of 14 years. Her most recent seizure was 2 years ago; at that time, her dosage of valproic acid was increased. Her symptoms have been well controlled since then. She has no other history of serious illness and takes no other medications. She and her husband use condoms consistently. Examination shows no abnormalities. Without prophylaxis, which of the following anticonvulsant-mediated adverse effects is most likely to develop?

A 32-year-old woman comes to the physician for a follow-up examination to discuss test results regarding HIV infection. Laboratory studies 1 week ago showed:

The patient feels well and is asymptomatic. She is sexually active with multiple male partners; they use condoms inconsistently. Vital signs are within normal limits. Examination shows scattered enlarged lymph nodes in the neck and groin area. The most appropriate next step is prophylaxis against which of the following organisms?

A 72-year-old woman with hypertension comes to the office because of a 1-day history of episodes of shaking of her arms and legs. She has no other history of serious illness. Her only medication is hydrochlorothiazide. Her pulse is 74/min, and blood pressure is 128/82 mm Hg. Physical examination shows rhythmic, rapid, coarse shaking of all extremities, which the patient is able to suppress when asked to do so by the physician. There is no cogwheel rigidity, bradykinesia, or masked facies. Mental status examination shows a worried mood and constricted affect. She recalls two of three objects after 5 minutes. Which of the following is the most likely clinical course for this patient’s illness?

A 67-year-old woman comes to the physician because of a 6-month history of generalized itching and facial reddening and flushing. She has hypertension and hyperlipidemia. Medications are benazepril and lovastatin. She does not smoke cigarettes or use illicit drugs. She drinks alcohol only on social occasions. Her temperature is 36.5°C (97.7°F), pulse is 80/min, respirations are 12/min, and blood pressure is 145/90 mm Hg. Examination of the face shows a ruddy complexion and no rash. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The spleen tip is palpated 4 cm below the left costal margin and is nontender. There is no hepatomegaly. Laboratory studies show:

Additional studies are most likely to show which of the following?

A 15-year-old boy is brought to the emergency department 1 hour after the onset of severe abdominal pain. During the past 2 months, he has had several 30-minute episodes of mild abdominal pain after eating fatty foods. There is a family history of anemia. On arrival, the pain is resolving. His temperature is 37°C (98.6°F), pulse is 90/min, and blood pressure is 120/70 mm Hg. The spleen tip is palpated 2 cm below the left costal margin. Laboratory studies show:

A blood smear shows fragmented erythrocytes. Osmotic fragility testing is positive. Ultrasonography of the abdomen shows gallstones. Which of the following is the most appropriate next step in management?

A 3-year-old girl is brought to the office by her mother 2 days after she suddenly stopped talking. The mother says her daughter has not spoken since returning from a weekend visit at her father’s house. Previously, she spoke in short sentences. The patient’s parents are divorced, and her father has a new girlfriend who has a 4-year-old son. The patient has no history of serious illness and receives no medications. In the examination room, she looks at books and plays alone quietly. Vital signs are within normal limits. Physical examination shows no abnormalities. The patient looks in the direction of a dropped object that made a loud sound when it hit the ground. She nods or shakes her head in response to questions but does not answer open-ended questions. Which of the following is the most appropriate initial step in management?

A 23-year-old man comes to the office because of a 4-week history of an itchy rash on his torso. He is otherwise asymptomatic. He has no history of serious illness and takes no medications. Vital signs are within normal limits. A photograph of the torso is shown. Cardiopulmonary and abdominal examinations show no abnormalities. Which of the following is the most appropriate next step in management?

An 82-year-old woman is brought to the physician by her daughter because she has not had a bowel movement for 2 weeks and has had loss of appetite for 3 days. There is no history of rectal bleeding or change in stool color or caliber. One year ago, test of the stool for occult blood was negative. Examination shows a large, exophytic, cauliflower-like lesion between the vagina and rectum. Digital rectal examination shows fecal impaction. A biopsy specimen of the lesion is most likely to show which of the following?

An 80-year-old woman with hypertension and dementia, Alzheimer type, is brought to the emergency department by paramedics from the nursing care facility where she resides because of a 1-day history of vaginal bleeding. The patient is nonverbal. The staff member who accompanied the patient reports the patient fell 2 nights ago while moving from the shower chair to the bathtub. The bleeding was noted today while a nurse’s aide changed the patient’s absorbent pad this morning. Her medications are donepezil, amlodipine, and aspirin. She is 163 cm (5 ft 4 in) tall and weighs 48 kg (105 lb); BMI is 18 kg/m2. Vital signs and oxygen saturation are within normal limits. Examination shows ecchymoses over the upper extremities and thighs; the ecchymoses are more severe on the right thigh than the left. Genitourinary examination shows ecchymoses over the labia majora and torn labia minora at the 7 o’clock position with minimal bleeding. Her hemoglobin concentration is 12 g/dL and platelet count is 150,000/mm3. Which of the following is the most likely explanation for these findings?

A 67-year-old man comes to the physician for a second measurement of his blood pressure. He had a blood pressure of 165/105 mm Hg in his right arm 9 days ago. He takes no medications. He has smoked two packs of cigarettes daily for 35 years. Today, his blood pressure is 160/100 mm Hg in the right arm and 105/65 mm Hg in the left arm. The remainder of the examination shows no abnormalities. Which of the following is the most likely cause of these blood pressure findings?

A 68-year-old woman, gravida 2, para 2, comes to the clinic because of a 3-week history of progressive loss of urine control. She says that when she has the urge to void, she sometimes has urine loss before she reaches the bathroom. She now wears absorbent pads daily. She has hypertension well controlled with hydrochlorothiazide and enalapril and osteoarthritis treated with naproxen. Vital signs are within normal limits. Physical examination, including pelvic examination, shows no abnormalities. Which of the following is the most appropriate next step in management?

A 49-year-old woman comes to the physician because she has not had a menstrual period for 9 months. She has not had vaginal dryness or hot flashes. She has no history of serious illness or abnormal Pap smears. She has had a levonorgestrel IUD in place for 4 years. Her last visit to a physician was 3 years ago. She is 152 cm (5 ft) tall and weighs 54 kg (120 lb); BMI is 23 kg/m2. Her blood pressure is 145/95 mm Hg. Physical examination shows no other abnormalities. On pelvic examination, the IUD string cannot be seen at the cervical os. Which of the following is the most appropriate next step in management?

A 19-year-old man, who is a college freshman, comes to the student health center because of a 2-year history of intermittent headaches that have been occurring more frequently during the past 6 months and recently have caused him to miss several days of class. He says the headaches affect either the left or right side of his head, and begin with “sparkling lights” in his peripheral vision and sensitivity to light and sound. The headaches often are brought on by strong odors, hunger, and alcohol consumption. The headaches also are associated with nausea. The patient says he often tries to “sleep them off.” The headaches previously occurred once every few months, but now he has as many as four headaches monthly. Acetaminophen has provided no relief. He has no history of serious illness and takes no other medications. Vital signs are within normal limits. Neurologic examination discloses no abnormalities. Daily use of which of the following medications is most appropriate to recommend to prevent or decrease the frequency of this patient’s headaches?

A previously healthy 9-year-old boy is brought to the emergency department because of acute pain and swelling around the right elbow since sliding into home plate during a baseball game 30 minutes ago. On arrival, his arm is splinted in newspaper and wrapped with duct tape. He is in acute distress. Examination of the right upper extremity shows edema and severe tenderness around the elbow. There is a distal right humeral deformity. Radial pulses are decreased on the right. X-rays of the right upper extremity show a transverse fracture of the right distal humeral metaphysis with posterior displacement of the distal fragment. This patient is at greatest risk for which of the following sequelae?

A 17-year-old girl is brought to the physician by her mother because she is concerned that her daughter has never had a menstrual period. The mother reports that her own menarche occurred at the age of 13 years. The patient has no history of serious illness and takes no medications. She is in the 11th grade, receives grades of A’s and B’s, and sings in the school choir. She has never been sexually active. She is 173 cm (5 ft 8 in) tall and weighs 66 kg (145 lb); BMI is 22 kg/m2. Her blood pressure is 100/60 mm Hg. Breast development is sexual maturity rating (SMR) stage 5, and pubic hair development is SMR stage 2. Examination of the external genitalia shows no abnormalities. Insertion of a speculum into the vagina is difficult. The cervix cannot be visualized or palpated. The uterus is not palpable. Karyotype analysis shows a 46,XY chromosome. Which of the following is the most appropriate next step in management?

A 90-year-old woman, who lives alone, is brought to the emergency department after her family found her lying on the floor of her home. She did not have loss of consciousness. She has hypertension and type 2 diabetes mellitus. On arrival, her pulse is 60/min, respirations are 14/min, and blood pressure is 110/60 mm Hg. Examination shows an open fracture of the tibia. Antibiotic therapy is recommended with irrigation, debridement, and surgical stabilization of the tibia with an intramedullary nail. The patient insists that she will allow irrigation, debridement, and antibiotics but refuses the surgical stabilization and requests discharge to home as soon as possible. Her family provides documentation that the patient has appointed her son as her durable power of attorney. Which of the following is the most appropriate next step in management?

A 21-year-old man comes to the physician for an examination prior to employment. He feels well. He has no history of serious illness and takes no medications. He is in his first year of law school and sleeps 4 to 5 hours nightly; he reports feeling stressed frequently because of the demanding course load. He has smoked one pack of cigarettes daily for 2 years and drinks one beer daily. He is 178 cm (5 ft 10 in) tall and weighs 91 kg (200 lb); BMI is 29 kg/m2. His pulse is 80/min, and blood pressure is 140/100 mm Hg. Examination shows no abnormalities. Serum electrolyte concentrations are within the reference ranges. Urinalysis shows no abnormalities. In addition to a subsequent blood pressure measurement, which of the following is the most appropriate next step in diagnosis?

An 18-year-old man is brought to the emergency department 25 minutes after being involved in a motor vehicle collision. He was the unrestrained driver. He has shortness of breath and moderate left-sided chest pain. His temperature is 37.5°C (99.5°F), pulse is 110/min, respirations are 24/min, and blood pressure is 110/60 mm Hg. Examination of the chest shows numerous abrasions and tenderness on the left. Breath sounds are decreased on the left. Heart sounds are normal. Abdominal examination shows no abnormalities. Pulse oximetry on 40% oxygen by face mask shows an oxygen saturation of 92%. An x-ray of the chest shows a left pleural effusion. Which of the following is the most appropriate next step in management?