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A 74-year-old man who had a stroke 2 years ago is admitted to the hospital from the nursing care facility because of a 4-day history of reduced urinary output, and worsening abdominal pain, nausea, and lethargy. The stroke had resulted in right-sided hemiparesis and difficulties with speech and swallowing. Medical history is also significant for hypertension. The patient has been hospitalized twice during the past 3 months for pneumonias that did not respond to oral antibiotic therapy in the nursing facility. He underwent bladder catheterization during each of the recent hospitalizations for a total of 6 days to monitor urine output. The catheter was removed prior to each discharge. Bladder catheterization attempts during the past several days in response to his current symptoms have been unsuccessful. Now on admission, the patient appears agitated and confused. Vital signs are temperature 36.9°C (98.4°F), pulse 110/min, respirations 24/min, and blood pressure 160/100 mm Hg. Physical examination discloses jugular venous distention, 8 cm at 45 degrees. Lungs are clear to auscultation. Auscultation of the heart discloses regular tachycardia with no gallops. There is fullness and tenderness to palpation of the low central abdomen but no rebound or guarding. Examination of the extremities shows 1+ pedal edema bilaterally. The prostate is normal in size and has no palpable nodules or tenderness. Results of laboratory studies are shown:SerumUrea nitrogen - 73 mg/dLCreatinine - 4.2 mg/dLCalcium - 8.6 mg/dLNa⁺ - 134 mEq/LK⁺ - 5.6 mEq/LCl⁻ - 100 mEq/LHCO3⁻ - 20 mEq/LMg2⁺ - 2.0 mEq/LGlucose - 126 mg/dLPhosphorus - 4.8 mEq/L Blood Hematocrit - 32%Hemoglobin - 10.6 g/dLWBC - 8200/mm³Platelet count - 359,000/mm³Ultrasonography shows distention of the bladder and bilateral hydronephrosis. ECG shows sinus tachycardia. Which of the following is the most appropriate next step?

Placement of a suprapubic catheter

D

A 47-year-old man comes to the emergency department because of a 3-day history of increasing pain, tenderness, and swelling near the fingernail of his right index finger. He rates the pain as an 8 on a 10-point scale. He has not had fever or chills, and he has not sustained any trauma to the finger. Medical history is unremarkable and the patient takes no medications. He appears generally well and is not in distress. Vital signs are temperature 37.1°C (98.8°F), pulse 72/min, respirations 14/min, and blood pressure 120/80 mm Hg. Physical examination of the right hand discloses swelling, erythema, warmth, and tenderness of the periungual region of the right index finger. There is a mildly fluctuant area near the nail edge. The remainder of the physical examination discloses no abnormalities. Which of the following is the most appropriate next step in management?

Incision and drainage

A

A 12-year-old girl with type 1 diabetes mellitus is brought to the emergency department by her parents because of a 2-day history of nausea, vomiting, and decreased oral intake. Medications are insulin glargine and insulin aspart. She decreased her insulin dose at the onset of symptoms but her condition has since worsened and she now is unable to consume solids or liquids without subsequent vomiting. She reports feeling dizzy on standing. Medical history is otherwise unremarkable. She is at the 50th percentile for height, weight, and BMI. Vital signs are temperature 37.8°C (100.1°F), pulse 118/min, respirations 27/min, and blood pressure 85/47 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 99%. Physical examination discloses dry mucous membranes, delayed capillary refill time, and poor skin turgor. Palpation of the abdomen discloses diffuse tenderness with no rebound or guarding. The remainder of the physical examination discloses no abnormalities. Results of laboratory studies obtained on arrival are shown:SerumUrea nitrogen - 28 mg/dLCreatinine - 1.2 mg/dL Na⁺ - 126 mEq/LK⁺ - 4.3 mEq/LCl⁻ - 95 mEq/LHCO3⁻ - 9 mEq/L Glucose - 563 mg/dLArterial blood gas values on room air HCO3⁻ 10 mEq/L Partial Pressure of Oxygen - 98 mm Hg Partial Pressure of Carbon Dioxide - 22 mm Hg pH - 7.20Boluses of intravenous 0.9% saline are administered and an infusion of insulin is initiated. Three hours later the patient becomes somnolent and develops a headache. She has had one episode of emesis and one episode of incontinence. Her urine output has been 30 mL/h. Results of follow-up serum laboratory studies are shown: Urea nitrogen - 24 mg/dLCreatinine - 1.1 mg/dLNa⁺ - 127 mEq/LK⁺ - 3.7 mEq/LCl⁻ - 98 mEq/LHCO3⁻ - 11 mEq/LGlucose - 287 mg/dLWhich of the following is the most appropriate intravenous pharmacotherapy?

Mannitol

E

A 54-year-old woman, gravida 2, para 2, comes to the office because of a 4-month history of hot flushes that awaken her from sleep on most nights. She also reports increased irritability during this time. She has not had fever, shortness of breath, or cough. She says her appetite has been good and her weight has been stable. Medical history is remarkable for hysterectomy done 5 years ago for symptomatic leiomyomata uteri. The patient takes calcium and vitamin D supplements. She has never smoked cigarettes. She drinks one glass of wine 1 night weekly. She is 165 cm (5 ft 5 in) tall and weighs 48 kg (106 lb); BMI is 18 kg/m². Vital signs are temperature 37.0°C (98.6°F), pulse 66/min, respirations 12/min, and blood pressure 108/64 mm Hg. Physical examination discloses no abnormalities. Screening PPD skin test shows 15 mm of induration. Chest x-ray shows densities consistent with granulomata. Which of the following pharmacotherapies is most likely to alleviate this patient's symptoms?

Conjugated estrogen

B

A 55-year-old woman, gravida 1, para 1, comes to the office because she is concerned that she has continued to have regular menses while her friends of the same age have gone through menopause. She reports having her usual premenstrual breast tenderness and menstrual cramping. She has not had change in flow, intermenstrual spotting, hot flushes, or night sweats. Medical history is unremarkable. She takes no medications. She does not smoke cigarettes. She drinks one glass of wine each evening. Her last menstrual period occurred 3 weeks ago. Screening mammogram obtained 1 year ago and all previous Pap smears, including her most recent Pap smear 2 years ago, have shown no abnormalities. Her 50-year-old sister also has not gone through menopause. The patient does not exercise. She is 157 cm (5 ft 2 in) tall and weighs 80 kg (176 lb); BMI is 32 kg/m². Vital signs are normal. Physical examination discloses adiposity of the abdomen. Pelvic examination discloses pink and rugose vaginal walls and a small uterus. The remainder of the physical examination discloses no abnormalities. Which of the following is the most appropriate next step to address the patient's continued menstruation?

Provide reassurance that she is simply still premenopausal

D

A 25-year-old man comes to the emergency department because he developed chest pain and shortness of breath 1 hour ago, shortly after snorting cocaine for the first time. He rates the chest pain as a 7 on a 10-point scale and notes that the pain is radiating down his left arm. Medical history is unremarkable and the patient takes no medications or any other illicit drugs. He is 178 cm (5 ft 10 in) tall and weighs 70 kg (154 lb); BMI is 22 kg/m². The patient is diaphoretic. Vital signs are temperature 37.5°C (99.5°F), pulse 110/min, respirations 16/min, and blood pressure 200/100 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 95%. Pupils are equal, round, and reactive to light and accommodation. Lungs are clear to auscultation and percussion. Auscultation of the heart discloses an audible S1 and S2. There is no edema, cyanosis, or clubbing of the digits. The patient is fully oriented. He is treated with supplemental oxygen, a 325-mg aspirin tablet, and intravenous nitroglycerin and lorazepam. Despite therapy, he continues to have chest pain and shortness of breath. ECG shows sinus tachycardia with no ST-segment or T-wave abnormalities. Which of the following is the most appropriate additional pharmacotherapy to initiate at this time?

Phentolamine

D

A 70-year-old man, who was admitted to the hospital 3 days ago for treatment of pneumonia, has now developed diarrhea and severe lower abdominal cramping. The patient has passed watery and yellow stools every 2 hours for the past 12 hours. Since admission, the patient has been treated with intravenous levofloxacin therapy and albuterol/ipratropium nebulizers every 4 hours, with only mild improvement of his respiratory symptoms. Medical history is also significant for hypertension, type 2 diabetes mellitus, and hyperlipidemia. Routine medications include rosiglitazone, amlodipine, and atorvastatin. He has smoked one pack of cigarettes daily for the past 50 years. BMI is 20 kg/m2. Vital signs are temperature 36.7°C (98.0°F), pulse 102/min, respirations 16/min, and blood pressure 100/50 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 93%. Physical examination discloses dry mucous membranes and cracked lips. Lungs are clear to auscultation bilaterally. Cardiac examination discloses a tachycardic but regular rhythm. Abdomen is diffusely tender to palpation with no distention, rebound, or guarding. Test of the stool for occult blood is negative. Results of serum laboratory studies are shown:Urea nitrogen - 30 mg/dLCreatinine - 1.5 mg/dLCalcium - 8.2 mg/dLNa⁺ - 150 mEq/L K⁺ - 3.7 mEq/LCl⁻ - 115 mEq/LHCO3⁻ - 22 mEq/LGlucose - 120 mg/dLStool culture is obtained. Intravenous infusion of which of the following substances is the most appropriate next step?

0.9% Saline

D

A 3-week-old male infant is brought to the office by his mother because of a 2-day history of white lesions in the mouth. The infant was born at term via uncomplicated spontaneous vaginal delivery; he has been breast-feeding well and is urinating and having bowel movements normally. At birth, he weighed 3289 g (7 lb 4 oz; 30th percentile). Today, he weighs 3629 kg (8 lb; 25th percentile). He appears adequately hydrated. Vital signs are normal. Physical examination discloses white patches on the tongue and buccal mucosa that do not come off when gently scraped with a tongue blade. Which of the following is the most appropriate pharmacotherapy?

Nystatin

C

A 55-year-old man is brought to the emergency department by his wife because he told her he did not want to live anymore. During the past 6 weeks, he has experienced fatigue, loss of interest in usual activities, a 7-kg (15-lb) weight loss, and insomnia. He has no history of serious medical or psychiatric illness. Vital signs are temperature 37.0°C (98.6°F), pulse 80/min, respirations 16/min, and blood pressure 140/82 mm Hg. Physical examination discloses no abnormalities. Beck Depression Inventory score is 35 (severely depressed). He says he feels guilty that his investments have not done well and that he has ruined his family finances. He reports he hears voices at night telling him he has sinned. In addition to olanzapine, which of the following is the best treatment option for this patient?

Fluoxetine

B

A 78-year-old man, who underwent coronary angiography with stent placement 8 years ago, comes to the office for a routine health maintenance examination. The patient reports no new symptoms except for shortness of breath and fatigue during exercise that began 3 months ago when he tried to increase the distance of his daily walk from 1 mile to 3 miles. He has not had orthopnea, paroxysmal nocturnal dyspnea, or chest pain. Additional medical history is significant for hypertension, coronary artery disease, dyslipidemia, and polymyalgia rheumatica. The patient also has a heart murmur that was discovered at an armed forces screening physical examination at age 18 years, but it did not prevent him from serving in the military. Medications are metoprolol, atorvastatin, lisinopril, omeprazole, and a low dose of prednisone every other day. The patient is active and manages a small farm. BMI is 26 kg/m². Vital signs are temperature 37.0°C (98.6°F), pulse 60/min, respirations 18/min, and blood pressure 124/61 mm Hg. Cardiac examination discloses a normal S1, pronounced S2, and a grade 2/6 late systolic murmur heard at the right upper parasternal border. Pulses are normal in contour. Results of laboratory studies are within the reference ranges. ECG shows no abnormalities. Which of the following is the most appropriate next step in management?

Order a transthoracic echocardiography

D

A 28-year-old man comes to the office because he would like to quit smoking cigarettes. He says, "I cannot go more than a day without cigarettes because I get so anxious and irritable. I even wake up at night to smoke." The patient began smoking cigarettes at age 12 years; he was smoking two packs of cigarettes daily by age 17 years, and he has not curtailed his use since that time. He does not drink alcoholic beverages or use illicit drugs. Medical history is remarkable for childhood febrile seizures. He takes no medications. Vital signs are normal. The patient is interested in using a nicotine patch and bupropion therapy because he says his friend found the treatments to be helpful. In combining these two therapies, this patient is at greatest risk for which of the following?

The patient is at no increased risk

E

A 25-year-old woman comes to the office because of a 24-hour history of right-sided facial weakness. Two days ago she developed mild aching behind the right ear, which resolved spontaneously. This morning, however, the entire right side of her face was drooping and she was unable to close her right eye. When she tried to drink coffee this morning, the liquid ran out the right side of her mouth. She has been otherwise healthy and she takes no medications. Vital signs are normal. Examination of the ears and oral mucosa shows no abnormalities. Cranial nerve examination shows moderate weakness of the right orbicularis oculi and oris, frontalis, buccinator, and platysma muscles. Sound is perceived as louder in the right ear. The remainder of the neurologic examination shows no abnormalities. Which of the following is the most accurate statement regarding this patient's prognosis for neurologic recovery?

She has an 80% chance of complete recovery within the next 12 months without treatment

C

A 20-year-old woman comes to the office because of a 2-day history of nasal congestion, runny nose, and nonproductive cough that has made it difficult for her to sleep. She has not had fever. Her brother with whom she resides also has similar symptoms. The patient's medical history is significant for mild persistent asthma for which she takes inhaled fluticasone- salmeterol twice daily and albuterol as needed. She has been using her albuterol more frequently during the past 2 days without much effect. During this time, her peak expiratory flow rates have been 70% to 80% of her baseline. Vital signs today are temperature 37.2°C (99.0°F), pulse 70/min, respirations 20/min, and blood pressure 110/70 mm Hg. Physical examination discloses inflamed nasal mucosa with clear discharge. The posterior oral pharynx is erythematous. Auscultation of the lungs discloses rare expiratory wheezes. Which of the following is the most appropriate pharmacotherapy for this patient's cough?

Prednisone

E

A 34-year-old woman, gravida 2, para 1, comes to the office at 26 weeks' gestation to establish prenatal care after obtaining health insurance coverage. She has gained 14 kg (31 lb) during this pregnancy. Her last pregnancy 4 years ago resulted in delivery of a 4564-g (10-lb 1-oz) male newborn. Today, the patient is 162 cm (5 ft 4 in) tall and weighs 99 kg (218 lb). Vital signs are normal. Physical examination discloses a fundal height of 30 cm. Fetal heart rate is 146/min. Prenatal laboratory studies and ultrasonography are ordered. This patient is most at risk for which of the following?

Gestational diabetes

A

A 39-year-old woman, gravida 6, para 5, is admitted to the hospital at 39 weeks' gestation for a scheduled induction of labor for delivery of twins. Her prior pregnancies were uncomplicated. Her current pregnancy has been complicated by well- controlled gestational diabetes. Vital signs are temperature 36.7°C (98.1°F), pulse 80/min, respirations 16/min, and blood pressure 134/84 mm Hg. Uterine size is consistent with a 36-week gestation. The fetuses are estimated to weigh 1814 g (4 lb) each. The patient delivers healthy twins. After the delivery of the placenta, examination discloses decreased uterine tone, increased bleeding, and increased hypotension. Which of the following is the most appropriate initial pharmacotherapy?

Oxytocin

E

A 32-year-old woman comes to the emergency department because of a 3-day history of worsening fever, dry cough, and shortness of breath. She also has had abdominal discomfort, diarrhea, and nausea, but she has not vomited. She returned home from a business trip to a midwestern city 2 days ago. She has had no known contact with any ill individuals. She had been generally healthy and medical history is unremarkable. She takes no medications. Her last menstrual period was 6 weeks ago and she thinks she might be pregnant. She does not smoke cigarettes, drink alcoholic beverages, or use illicit drugs. She is married and uses no contraception. She appears well developed and well nourished but is short of breath and lethargic. Vital signs are temperature 38.3°C (101.0°F), pulse 104/min, respirations 28/min, and blood pressure 100/60 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 92%. Auscultation of the chest discloses crackles at the right lung base, tachycardia, a normal S1 and S2, and no other abnormalities. Abdominal examination discloses no abnormalities. Petechiae are present over both lower extremities. Results of laboratory studies are shown:Serum ALT - 80 U/LAST - 63 U/LUrea nitrogen - 14 mg/dLCreatinine - 1.7 mg/dLNa⁺ - 130 mEq/LK⁺ - 3.9 mEq/LCl⁻ - 104 mEq/LHCO3⁻ - 16 mEq/LIron, total - 18 μg/dLIron binding capacity, total - 428 μg/dL (N=250–350)Iron saturation - 5% (N=20–50)β-hCG - PositiveBloodHematocrit - 30.3%Hemoglobin - 10.2 g/dL WBC - 11,300/mm³MCV - 76 μm³ Platelet count - 104,000/mm³Red cell distribution width - 16% (N=11.5–14.5)Which of the following is the most appropriate intravenous pharmacotherapy at this time?

Cefuroxime and azithromycin

B

A 72-year-old man is admitted to the intensive care unit for pain management and observation of ventricular ectopy 4 hours after undergoing uncomplicated left total knee replacement. He is receiving fentanyl via systemic patient-controlled analgesic pump for pain management. Medical history is remarkable for coronary artery disease, for which he takes atorvastatin, furosemide, carvedilol, lisinopril, and 81-mg aspirin. Baseline echocardiogram showed an ejection fraction of 0.20. Vital signs now are temperature 38.0°C (100.4°F), pulse 90/min, respirations 16/min, and blood pressure 130/90 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Physical examination discloses no unexpected abnormalities. Which of the following regimens for prophylaxis of deep venous thrombosis will likely be most beneficial in this patient?

Subcutaneous enoxaparin

D

A 45-year-old man comes to the emergency department because of a 1-month history of fatigue, generalized muscle weakness, and a 4-kg (8-lb) weight loss. He also reports a loss of appetite and nausea without vomiting during the past 2 weeks. Medical history is unremarkable and he takes no medications. He does not smoke cigarettes or drink alcoholic beverages. He is 180 cm (5 ft 11 in) tall and weighs 70 kg (155 lb); BMI is 22 kg/m². Vital signs are temperature 36.4°C (97.5°F), pulse 100/min, respirations 20/min, and blood pressure 88/50 mm Hg. Physical examination shows bronze darkening of the elbows, on the creases of his hands, and around the areolae of his nipples. Muscle strength is 4.5/5 in all extremities. The remainder of the physical examination shows no abnormalities. Results of laboratory studies are shown:SerumNa⁺ 128 mEq/L K⁺ 5.2 mEq/L Cl⁻ 95 mEq/L HCO3⁻ 20 mEq/LBloodHemoglobin 12 g/dL WBC 3500/mm³In addition to administering intravenous fluids, which of the following is the most appropriate pharmacotherapy?

Hydrocortisone

C

A 45-year-old man comes to the office because of severe pain of the right foot that awoke him from sleep last night. He says the pain kept him awake for the rest of the night. Walking has been difficult due to the pain, which he rates as a 9 on a 10- point scale. He reports no recent trauma. Medical history is remarkable for hypertension, type 2 diabetes mellitus, and asthma. Medications include hydrochlorothiazide, metformin, atorvastatin, and an albuterol inhaler. He is allergic to penicillin. He does not smoke cigarettes, but he has drunk three to four glasses of red wine daily for the past 5 years. Family history is significant for arthritis in his father. He is 168 cm (5 ft 6 in) tall and weighs 111 kg (245 lb); BMI is 40 kg/m². Vital signs are temperature 37.9°C (100.2°F), pulse 100/min, respirations 16/min, and blood pressure 160/100 mm Hg. Examination of the right foot discloses erythema and increased warmth over the first toe extending over the dorsum of the foot. The involved area is very tender and the patient resists movement of his toes. There is moderate swelling of the first metatarsophalangeal joint. The remainder of the physical examination discloses no abnormalities. Results of laboratory studies are shown:SerumUrea nitrogen - 15 mg/dLCreatinine - 1.0 mg/dLBloodHemoglobin - 16 mg/dL WBC - 12,500/mm³Examination of joint aspirate shows a leukocyte count of 50,000/mm³; no organisms are seen on Gram stain. Which of the following is the most appropriate pharmacotherapy to treat this patient's acute condition?

Indomethacin

D

A 2-year-old boy is brought to the emergency department by his babysitter because of a 30-minute history of respiratory distress. The babysitter reports that she has cared for the patient on numerous occasions during the past year. The child's parents are currently out of town for business but will return later tonight. The babysitter says, "He has had a runny nose since I started babysitting yesterday, but this afternoon he awoke from a nap with a barking sound and he was breathing real heavy." She does not know the child's prior health history, nor does she know if the boy takes any medications on a regular basis. The child looks tired and sits upright on the babysitter's lap. He is obviously comfortable with his caregiver. Vital signs are temperature 38.7°C (101.7°F), pulse 110/min, respirations 28/min and labored, and blood pressure 85/50 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 89%. Physical examination discloses inspiratory stridor. Neck is supple, tympanic membranes are normal, and there is a profuse nasal discharge. Examination of the pharynx discloses no abnormalities. Auscultation of the chest discloses equal air entry on both sides and no crackles. The remainder of the examination shows no abnormalities. Treatment with 40% oxygen via venturi mask and intravenous fluids is initiated. Despite continued supplemental oxygen and hydration, the child remains tachypneic and stridorous at rest. Oxygen saturation is now 93%. In addition to administering racemic epinephrine by nebulizer, which of the following is the most appropriate next step?

Oral dexamethasone therapy

D

A 30-year-old man comes to the office because of an itchy and painful facial rash that has worsened since he first noticed it 1 day ago. He has no other symptoms and says he otherwise has been generally healthy. Medical history is unremarkable and he takes no medications. He does not use any substances. He is unmarried and is not currently in a romantic relationship but has been sexually active with multiple female partners during the past year. Vital signs are within normal limits. Physical examination shows an erythematous macular rash with several 1- to 2-mm raised vesicles that do not cross the midline over the left forehead and periorbital area. There are no other abnormalities. Acyclovir therapy is initiated. Which of the following is the most appropriate next step?

Serum HIV antibody test

B

A 31-year-old man with a 5-year history of HIV infection comes to the office because of anal pain, particularly on defecation, for the past 4 months. He says he has seen spots of blood on the toilet tissue but has not had any other noticeable bleeding. He reports no change in bowel habits and has not had recent fever, chills, or rectal drainage. He says he and his partner engage in anal-receptive intercourse. His most recent CD4+ T-lymphocyte count 2 months ago was 350/mm³; HIV viral load at that time was undetectable. He currently is being treated with antiretroviral therapy. He has had no opportunistic infections. Medical history is also significant for syphilis and genital herpes treated with penicillin and acyclovir, respectively. He does not smoke cigarettes or drink alcoholic beverages. Vital signs are normal. Physical examination shows small bilateral inguinal lymph nodes, but respiratory, cardiac, and abdominal examinations disclose no abnormalities. There are several tender fleshy lesions around the perianal area. Rectal examination produces tenderness, but there is no rectal discharge. Test of the stool for occult blood is trace positive. Which of the following is the most appropriate pharmacotherapy at this time?

Imiquimod

B