Practice test 1 Flashcards
3w after undergoing arteriography through the R groin for eval of progressive L calf claudication, a 64yo man is noted to have a palpable thrill and continuous machinery murmur at the arteriography site. exam shows decreased pedal pulses on the R. Pulses had been normal prior to the procedure. the arteriogram si shown. which of the following is most predictive of developent of heart failure in this pt?
a. degree of edema in the LE
b. groin compression causing bradycardia
c. presence of pallor with elevation and dependent rubor
d. presence of pseudoaneurysm
e. size of abnormality
E
b/c leaking lots of blood into space
12yo girl is brought to the ED 30min after falling off a second floor balcony. on arrival, her pulse is 105, RR 22, and BP 105/77. the chest is clear to auscultation. the abdomen is soft and nontender. an xray of the chest shows no abnormalities. which of the following is the most appropriate next step in diagnosis? a. xray of the cervical spine b. xray of the abdomen and pelvis c. cystography d. ultrasonography e. CT scan of the abdomen f. CT scan of the chest G. peritoneal lavage h. arteriography
A
fall from a a tall height. likely damage to spine
An unconscious 27yo man is brought to the ED immediately after being involved in a MVA. he was the unrestrained driver of a vehicle that struck a tree. at the scene, he was unconscious. he was not breathing spontaneously and was intubated and mechanically ventilated. on arrival, his Glasgow oma score is 9/15. he breathes spontaneously when mechanical ventilation is discontinued. his temp is 98.6F, pulse 124 RR 16 and palpable systolic BP is 100mmHg. exam shows copious bleeding from a laceration over the scalp. there is a pool of blood around his head. there is an obvious fracture of L humerus. breath sounds are heard b/l. the abdomen is soft. the pelvis is stable. in addition to IV administration of crystalloid solutiaon, which of the following is the most appropriate next step in management?
A. direct pressure to the bleeding laceration
b. CT scan of the abdomen.
C. IV administration of a vasopressor
d. transfusion of type-specific packed RBCs
e. closed reduction of the fracture
A
b/c BP is soft
19yo man is brought to the ED 15min after his motorcycle collided head-on with a truck. no loss of conscioussness at the scene is reported. on arrival, he is agitated but oriented to person, place and time. he resopnds to verbal commands. supplemental O2 and IV fluids are adminstered. his pulse is 115, RR 18, and BP 110/70. there are multiple abrasions over the forehead, chest, abdomen, and R LE. the pupils are equal and reactive to light. the trachea is midline, and breath sounds are equal b/l. heart sounds are normal. the abdomen is mildly distended, soft and diffusely tender. his Hgb conc is 11.8, and leukocyte count is 14,000. urinary catheterization yields clear urine. X rays of the cervical spine and pelvis show no abnormalities. an xray of the chest shows a moderate amt of free intra-abdominal air under the diaphragm. which of the following is the most appropriate next step in management? a. lateral decubitus xray. b. CT scan of the abdomen C. upper GI endoscopy D. diagnostic peritoneal lavage e. laparotomy.
E
62 yo woman comes to the physician for a routine health maintenance exam. she feels well. Menarche was at the age of 13y, and menopause occurred 19y ago. she has no family hx of breast dz. examination shows a 2x2cm mass in the upper outer quadrant of the L breast. Mammography of the L breast shows calcifications in the upper outer quadrant. a biopsy of the breast mass shows invasive estrogen receptor-positive carcinoma with positive margins. which of the following is the most appropriate next step in management?
a. observation only
b. cytotoxin and doxorubicin therapy
c. tamoxifen therapy
d. radiation therapy
e. reexcision of the biopsy site
D
invasive with positive margins
a25 yo construction worker has had fever and a painful, swollen R hand for 2d. his temp is 102.2F. The dorsum of the hand is swollen, erythematous and tender. there is a small traumati laceration on the dorsum of hte hand with a beefy-red expanding margin and red streks extending up the arm. the axillary lymph nodes are palpable and tender. which of the following is the most likely pathogen?
a. bacteroides fragilis
b. clostridium difficile
c. clostridium perfringens
d. clostridium tetani
e. enterobacter cloacae
f. enterococcus faecalis
g. escherichia coli
h. staphylococcus epidermidis
i. . streptococcus pneumoniae
j. streotococcus pyogenes (group a)
J
Skin infection - Strep or Staph. pyogenes - for nec fasc
not C perfringens b/c no diarrhea
a previously healthy 37yo woman comes to the physician b/c of a 2mo history of intermittent, RUQ abdominal pain that usually occurs after meals. he has not had fever, chills, vomiting, nausea, weight loss, or change in bowel movements. she takes no medications. her temp is 98.6F, pulse is 68, RR are 16, and BP is 110/70. exam shows no jaundice or scleral icterus. abdominal exam shows no abnormalities. her leukocyte count is 5000. results of LFTs are within the reference ranges. abd ultrasonography shows a thickened gallbladder wall, cholelithiasis, and a 4.2cm hepatic mass int he R lobe. an abdominal CT scan shows the mass to be 4.2x3.5cm with a central scar. which of the following is the most appropriate next step in treatment?
a. measurement of serum alpha-fetoprotein concentration
b. hepatitis B virus etiology
c. radionuclide liver scan
d. MRI of liver
e. fine-needle aspiration biopsy of the mass
f. no further testing is indicated.
F
focal nodular hyperplasia ==> these do not have malignant potential
don’t need to do anything about them
a12 yo boy has had weakness, pallor, and black, shiny stools for 5d. he has had no abdominal pain or other symptoms. laboratory studes show: Hct 26% MCV 70 MCHC 22% An abdominal scintigram, using technitium 99m pertechnetate, shows uptake in the RLQ separate from the activity in the stomach, kidney and bladder. which of the following is the most likely diagnosis? a. henoch-schonlein purpura b. ileocecal intussusception c. juvenile colonic polyp d. meckel diverticulum e. ulcerative colitis
D
TC99m is the diagnostic test for Meckel’s
a 42yo construction worker is brought to the ED 20min after falling 30ft from a scaffold. en route to the hospital, he received 1L of lactated Ringer solution. on arrival, he is awake and alert & has severe abdominal and leg pain. he can move all extremities. his temp is 98.6F, pulse is 110, RR are 16, and BP is 120/70. examination shows ecchymoses over the L forehead and lower abdomen. there is obvious deformity of the L LE. there is no neck tenderness. cardiopulmonary exam shows no abnormalities. the lower abdomen is slightly distended and exquisitely eder. there is no blood at the urethral meatus. rectal examination shows no abnormalities. insertion of a urinary catheter yields 30ml of grossly bloody fluid. an additional 1.5L of lactated Ringer solution is administered, and the L LE is placed in traction. 30 min later, his pulase is 95/min, and BP is 140/80. no additional urine has drained from the cathter. which of the following is the most likely cause of this pt’s anuria.
a. acute tubular necrosis
b. hypovolemia
c. rupture of the bladder
d. SIADH (vasopressin)
e. transection of the urethra
C
grossly bloody urine –> damage somewhere along the urinary tract –> from kidney - ureters - bladder - urethra
42yo woman, G3P3 comes to the physician b/c of a 3mo history of intermittent bloody discharge from her R nipple. her mother died of breast CA at the age of 60y. on exam, bloody discharge can be expressed with pressure on the R areola. no masses are palpable. palpation of the L breast and axilla shows no abnormalities. mammography shows normal findings. which of the following is the most likely diagnosis?
a. breast abscess
b. breast Ca
c. cystosarcoma phylodes
d. galactocele
e. hematoma
f. inflamatory carcinoma of the breast
g. intraductal papilloma
h. sebaceous cyst
G
U/L bloody discharge
intraductal papilloma is the most common cause (esp. 35-50yo).
an 87yo woman is brought to the ED from a skilled nusring care facility b/c of 6 episodes of loose brown stools daily during the past week. there is no visible blood or mucus in the stool, and she has not had fever or abd pain. 5y ago, she sustained a cerebral infarction and has residual left hemiparesis. she has atrial fibrillation and multiple compression fractures from osteoporosis. her medications include warfarin, digoxin,and famotidine. 1 mo ago, she began taking acetaminophen with codeine for her most recent compression fracture. her temp is 98.8, pulse 80 and irregular, RR 16 and BP 130/75. abd examination shows mild tenderness in the LLQ. bowel sounds are normal. rectal exam shows normal tone with hard stool in the vault. test of the stool for occult blood is negative. an abd xray shows copious stool throughout the bowel. there is no evidence of free air or obstruction. which of the following is the most appropriate next step in management?
a. elevation of the head of the bed during sleep
b. elimination of milk from the diet
c. elimination of spicy food from the diet
d. enemas
e. esophagogstroduodenoscopy
f. left hemicolectomy
g. low fat diet
h. mesenteric angiography
i. omeprazole therapy
j. recommendation to increase her milk consumption
k. stress management
l. total proctocolectomy
m. U/S of the abdomen
n. upper GI series
D
she has hard stool + diarrhea around it.
do the easiest, least morbid thing.
37yo woman comes to the physician b/c of a 3 mo history of neck swelling and tightness in her throat. seh has not had weakness, weight change, or heat / cold intolerance. exam shows a diffusely enlarged & firm thyroid gland. there is no modularity. serum TSH, T3, and T4 conc. are within normal limits. serum studies show circulating Antibodies against thyroid peroxidase and thyroglobulin. what is the most likely diagnosis?
a. anapalstic thyroid carcinoma
b. chronic lymphocytic thyroiditis (Hashimoto disease)
c. graves disease
d. papillary carcinoma of the thyroid gland
e. subacute thyroiditis
B
these are for Hashimoto’s
65yo woman is brought to the ED 1h after she fell. she has R wrist pain. her last visit to a physician was 10y ago. exam shows swelling and tenderness of the R wrist. an xray of the wrist shows no fracture, but subperiosteal bone resorption is noted in the distal phalanges. her serum Ca conc. is 12.4, and serum creatinine conc. is 1.2 . which fo the following conc. is most likely to be decreased in this pt?
a. 1,25-dihydroxycholecalciferol
b. magnesium
c. parathyroid hormone
d. phosphorus
e. vit C
D
most common cause of hypercalcemia in an “outpt” –> hyperparathyroidism - though more likely in younger men. However, would lead to high PTH, Ca, with low phosphorus. would also cause osteoporosis b/c so much Ca in drawn into blood.
OR could be chronic renal disease, leading to high Cr, high Ca, with low phosphorus AND low PTH. (secondary hyperparathyroidism)
- either way - low phosphorus
a previously healthy 52yo woman comes to the ED b/c of a 2d hx of abdominal cramps & vomiting. she has not passed stool or flaatus during this period. she has no hx of similar sxs. she underwent an abd hysterectomy 10y ago. her temp is 99.8F. pulse is 110 and Bp 140/70. the lungs are clear to auscultation and percussion. abd examination shows distension and mild tenderness but no peritoneal signs. BS are active. lab studies show Hct 42% leuk 11,500 Na 140 Cl 101 K 3.6 HCOe 28 uera nitrogen 40 glucose 110 creatinine 1.7 which of the following is the most likely diagnosis? a. acute cholecystitis b. colon cancer c. complete SBO d. ileus secondary to renal failure e .perforated viscus
C
constipation + obstipation
+ likely some degree of dehydration leading to AKI
4d after admission to the hospital for treatment of metastatic breast Ca with chemotherapy, a 42yo woman has increased pain of extremities and ribs. she has a history of HTN and renal insufficiency. she underwent b/l mastectomy 4y ago. she is currently takinga ceatminophen with codeine (2 tablets 4 x daily), and amitriptyline (50mg at bedtime) with no relief of pain. she sleeps well but awakens early b/c of pain. her appetite is good. her pulse is 100 and regular, RR 20, BP 100/80. the pupils are round and reactive. there is tenderness to palpation of the chest wall and vertebrae. she is alert and oriented but winces in painwhen she moves. she says that she does not feel depression but occasionally wishes that she would not wake up. she is hopeful tthat she will get better. her mood is reserved, but she smiles when she discusses her children. lab studies are pending. which of the following is the appropriate next step in management?
a. carbamazepine therapy
b. clonazepam therapy
c. oxycodone therapy
d. paroxetine therapy
e. valproic acid therapy
f. regional nerve blockade
C
no relief of pain. she has metastatic cancer. give her morphine
63 yo man has had dysphagia and chest pain during meals for 4 mo. he has a 6y hx of GE reflux. he has limited his intake to liquids for 3w b/c he regurgitates solid food. which of the following is the most likely cause of his sxs?
a. disordered neuromuscular transmission in the esophagus.
b. disordered neuromuscular transmission in the oropharynx
c. failure of oropharyngeal propulsion
d. paraesophageal hiatal hernia
e. stricture of the distal esophagus
E
anatomic stricture –> that allows fluids but not solids through
an obese 72yo man is brought to the ED 15 min after he collapsed at home. his wife reports that he has had upper abd pain, nausea, and vomiting for the past 24h. he has HTN and coronary artery disease. he is diaphoretic. his temp is 97.7, pulse is 115 and irregularly irregular, RR 22 and palpable systolic BP is 80. there is no jugular venous distension. the lungs are clear to auscultation. no murmurs or gallops are heard. the abdomen is tender and rigid. pulm artery catheterization shows:
cardiac index 1.2mmHg (n=2.5-4.2)
mean pulmonary arterial pressure 5mmHg (N=9-16)
pulmonary capillary wedge pressure 1mmHg (N=5-16)
systemic vascular resistance 1929 (N=770-1500)
a. anaphylactic
b. cardiogenic
c. hypovolemic
d. neurogenic
e. septic
C
abd perf? likely from SBO or ulcer.
abd pain and nausea for a whole day –> NOT MI or cardiac problem
increased SVR
57yo man comes to the physician b/c of persistent increasingly severe L sided chest pain for 1 mo. he works as an industrial engineer. exam shows absent breath sounds and dullness to percussion over the lower portion of the L hemithorax. an xray of the chest shows a L sided pleural effusion w/ an extensive peripheral soft tissue density. thoracentesis shows bloody, mitotic figures and areas of cuboidal epithelial cells. exposure to which of the following agents is the most likely cause of his condition?
a. asbestos
b. nickel
c. talc
d. tobacco
e. toluene diisocyanate
A
Cancer. Mesothelioma
further out at the edge
==> mitotic figures & cuboidal epithelial cells.
RF of lung cancer
- smoking
- asbestos
(? talc)
a 67yo man is brought to the physician bc of severe pain in the R foot for 6h. on exam, the R foot is pale and cool, and pedal pulses are nor palpable. he can wiggle his toes. exam of the L foot shows no abnormalities. there are b/l femoral pulses and pulsatile masses in the popliteal fossae. which of the following is the most appropriate next step in diagnosis?
a. cardiolipin antibody assay
b. measurement of transcutaneous O2 tension in the feet
c. measurement of serum antithrombin III concentration
d. impedance plesthysmography
e. arteriography with runoff
f. venography of the R LE.
E
emboli / claudication
87 yo woman brought to the ED from a skilled nursing care facility b/c of a change in mental status during the past 12h. she has severe dementia, Alzheimer type and is unable to give a history. she is currently taking donepezil, atenolol, digoxin, lisinopril, sertraline, docusate, psyllium, and aspirin. on arrival, she is agitated and does not respond to verbal stimuli. her temp is 100.4F, pulse is 92, RR24, and Bp 148/86. the lungs are clear to auscutation. the abdomen is distended. there is diffuse guarding with no rebound. test of the stool for occult blood is negative. her Hct is 34%, leuk count is 9500, and plt is 267,000. an xray of the abdomen is shown with dilation ofthe colon at the very inferior of the abdomen/pelvis which of the following is the most appropriate next step in management?
a. serial measurement of cardiac enzyme activities
b. CT scan of the abdomen
c. discontinuation fo sertraline
d. sigmoidoscopy-guided placement of the rectal tube
e. exploratory laparotomy
D
constipation
need to disimpact
