08-27-2014, 09:29 AM
6.
A 26-year-old woman comes to the emergency department because of nausea and copious watery diarrhea on awakening this morning. She has not vomited. Her 3-year-old child and husband are both well. They have shared all meals during the past 3 days. Medical history is unremarkable. The patient is 168 cm (5 ft 6 in) tall and weighs 68 kg (150 lb); BMI is 24 kg/m2. Vital signs while the patient lies in a supine position are temperature 37.0°C (98.6°F), pulse 95/min, respirations 16/min, and blood pressure 120/80 mm Hg. When the patient sits up, she says she feels faint; her pulse rises to 105/min, and blood pressure decreases to 110/65 mm Hg. The abdomen is not tender to palpation and has hyperactive sounds. Leukocyte count is 7600/mm3. Plain x-ray of the abdomen shows gas throughout the small and large intestines, and air-fluid levels in the small intestine. One liter of lactated Ringer solution is administered intravenously. Serum electrolyte concentrations are obtained and results are pending. While waiting for the results, the patient has two watery bowel movements. She now says that she no longer feels nauseated. Which of the following is the most appropriate next step?
A) Administer amoxicillin
B) Initiate oral fluid hydration
C) Obtain consultation with a surgeon
D) Obtain CT scan of the abdomen
E) Obtain cultures of the stool
7.
A 70-year-old man is brought to the emergency department by his son because of a 2-day history of right upper quadrant abdominal pain, chills, and confusion. He has vomited twice during this time despite decreased food intake. He has hypertension controlled with hydrochlorothiazide. Medical and surgical history is otherwise unremarkable. Vital signs are temperature 40.2°C (104.4°F), pulse 110/min, respirations 18/min, and blood pressure 100/60 mm Hg. The patient appears seriously ill without evidence of jaundice. Abdominal examination discloses tenderness to palpation over the liver without guarding. Results of laboratory studies are shown:
Serum ………………………………….. Blood
Amylase 350 U/L ……………...........…… WBC 16,500/mm3 with prominent immature forms
Bilirubin, total 2.1 mg/dL ………………. Neutrophils, segmented 42%
Neutrophils, band 25%
Serum urea nitrogen and creatinine concentrations are within the reference ranges, as are results of liver function tests. Ultrasonography of the abdomen shows multiple stones in the gallbladder and a common bile duct measuring 9 mm in diameter. Intravenous fluids and a broad-spectrum antibiotic are administered. Which of the following is the most appropriate next step?
A) Cholecystectomy
B) Cholecystostomy
C) CT scan of the abdomen
D) Endoscopic retrograde cholangiopancreatography
E) HIDA scan
8.
A 6-year-old boy with autistic disorder is brought to the emergency department by his parents 20 minutes after his right arm got caught in a truck door. The arm is swollen and bruised and the patient is in moderate pain. His parents appear to be concerned about his injury. Vital signs are temperature 37.0°C (98.6°F), pulse 110/min, and respirations 24/min. Physical examination discloses contusion on the dorsal and ventral surfaces of the right forearm; no open lacerations are present. The arm is tender to palpation. X-rays of the right forearm show no fracture, but significant soft tissue swelling is noted. Which of the following is the most likely serious complication of this patient's condition?
A) Compartment syndrome
B) Hematoma formation
C) Median nerve palsy
D) Secondary infection
E) Volkmann contracture
9.
A 68-year-old woman comes to the emergency department via ambulance at the recommendation of her primary care physician because of an abnormal ECG obtained 2 hours ago. The patient says she has not been feeling well for the past 7 to 10 days. She has had generalized weakness, fatigue, and nausea and is "just not herself." Medical history is remarkable for diabetes mellitus and hypertension. She refuses to take any medications. She says she watches her diet and is healthy. Vital signs are temperature 37.0°C (98.6°F), pulse 86/min, respirations 18/min, and blood pressure 160/90 mm Hg. The patient appears ill. Auscultation of the chest discloses no abnormalities. Abdomen is soft and nontender with normoactive bowel sounds. ECG is shown.
http://i42.photobucket.com/albums/e338/G...dbe24d.png
Which of the following is the most likely explanation for the ECG findings?
A) Acute myocardial infarction
B) Hypothyroidism
C) Pericarditis
D) Pulmonary embolism
E) Renal failure
10.
A 19-year-old African American man is brought to the emergency department by ambulance after he collapsed while playing basketball 45 minutes ago. The emergency medical technician reports that the patient had a transient loss of consciousness, during which time he fell to the floor and landed on his right side. The patient is now alert and oriented to time and place. He states that he has been in excellent health, does not take medication, and has not used illicit drugs or abused alcohol. The patient is 208 cm (6 ft 10 in) tall and he weighs 88 kg (195 lb); BMI is 20.4 kg/m2. Vital signs now are temperature 37.0°C (98.6°F), pulse 86/min, respirations 20/min, and blood pressure 142/92 mm Hg. The patient appears well-developed and has long, thin arms and legs. There is diffuse tenderness over the right lateral rib cage. His father, who was also tall, died 1 year ago from a dissecting aortic aneurysm. Which of the following additional findings on physical examination would best support the diagnosis?
A) Ectopia lentis
B) Exophthalmos
C) Focal alopecia
D) Micrognathia
E) Ulnar deviation of the fingers
A 26-year-old woman comes to the emergency department because of nausea and copious watery diarrhea on awakening this morning. She has not vomited. Her 3-year-old child and husband are both well. They have shared all meals during the past 3 days. Medical history is unremarkable. The patient is 168 cm (5 ft 6 in) tall and weighs 68 kg (150 lb); BMI is 24 kg/m2. Vital signs while the patient lies in a supine position are temperature 37.0°C (98.6°F), pulse 95/min, respirations 16/min, and blood pressure 120/80 mm Hg. When the patient sits up, she says she feels faint; her pulse rises to 105/min, and blood pressure decreases to 110/65 mm Hg. The abdomen is not tender to palpation and has hyperactive sounds. Leukocyte count is 7600/mm3. Plain x-ray of the abdomen shows gas throughout the small and large intestines, and air-fluid levels in the small intestine. One liter of lactated Ringer solution is administered intravenously. Serum electrolyte concentrations are obtained and results are pending. While waiting for the results, the patient has two watery bowel movements. She now says that she no longer feels nauseated. Which of the following is the most appropriate next step?
A) Administer amoxicillin
B) Initiate oral fluid hydration
C) Obtain consultation with a surgeon
D) Obtain CT scan of the abdomen
E) Obtain cultures of the stool
7.
A 70-year-old man is brought to the emergency department by his son because of a 2-day history of right upper quadrant abdominal pain, chills, and confusion. He has vomited twice during this time despite decreased food intake. He has hypertension controlled with hydrochlorothiazide. Medical and surgical history is otherwise unremarkable. Vital signs are temperature 40.2°C (104.4°F), pulse 110/min, respirations 18/min, and blood pressure 100/60 mm Hg. The patient appears seriously ill without evidence of jaundice. Abdominal examination discloses tenderness to palpation over the liver without guarding. Results of laboratory studies are shown:
Serum ………………………………….. Blood
Amylase 350 U/L ……………...........…… WBC 16,500/mm3 with prominent immature forms
Bilirubin, total 2.1 mg/dL ………………. Neutrophils, segmented 42%
Neutrophils, band 25%
Serum urea nitrogen and creatinine concentrations are within the reference ranges, as are results of liver function tests. Ultrasonography of the abdomen shows multiple stones in the gallbladder and a common bile duct measuring 9 mm in diameter. Intravenous fluids and a broad-spectrum antibiotic are administered. Which of the following is the most appropriate next step?
A) Cholecystectomy
B) Cholecystostomy
C) CT scan of the abdomen
D) Endoscopic retrograde cholangiopancreatography
E) HIDA scan
8.
A 6-year-old boy with autistic disorder is brought to the emergency department by his parents 20 minutes after his right arm got caught in a truck door. The arm is swollen and bruised and the patient is in moderate pain. His parents appear to be concerned about his injury. Vital signs are temperature 37.0°C (98.6°F), pulse 110/min, and respirations 24/min. Physical examination discloses contusion on the dorsal and ventral surfaces of the right forearm; no open lacerations are present. The arm is tender to palpation. X-rays of the right forearm show no fracture, but significant soft tissue swelling is noted. Which of the following is the most likely serious complication of this patient's condition?
A) Compartment syndrome
B) Hematoma formation
C) Median nerve palsy
D) Secondary infection
E) Volkmann contracture
9.
A 68-year-old woman comes to the emergency department via ambulance at the recommendation of her primary care physician because of an abnormal ECG obtained 2 hours ago. The patient says she has not been feeling well for the past 7 to 10 days. She has had generalized weakness, fatigue, and nausea and is "just not herself." Medical history is remarkable for diabetes mellitus and hypertension. She refuses to take any medications. She says she watches her diet and is healthy. Vital signs are temperature 37.0°C (98.6°F), pulse 86/min, respirations 18/min, and blood pressure 160/90 mm Hg. The patient appears ill. Auscultation of the chest discloses no abnormalities. Abdomen is soft and nontender with normoactive bowel sounds. ECG is shown.
http://i42.photobucket.com/albums/e338/G...dbe24d.png
Which of the following is the most likely explanation for the ECG findings?
A) Acute myocardial infarction
B) Hypothyroidism
C) Pericarditis
D) Pulmonary embolism
E) Renal failure
10.
A 19-year-old African American man is brought to the emergency department by ambulance after he collapsed while playing basketball 45 minutes ago. The emergency medical technician reports that the patient had a transient loss of consciousness, during which time he fell to the floor and landed on his right side. The patient is now alert and oriented to time and place. He states that he has been in excellent health, does not take medication, and has not used illicit drugs or abused alcohol. The patient is 208 cm (6 ft 10 in) tall and he weighs 88 kg (195 lb); BMI is 20.4 kg/m2. Vital signs now are temperature 37.0°C (98.6°F), pulse 86/min, respirations 20/min, and blood pressure 142/92 mm Hg. The patient appears well-developed and has long, thin arms and legs. There is diffuse tenderness over the right lateral rib cage. His father, who was also tall, died 1 year ago from a dissecting aortic aneurysm. Which of the following additional findings on physical examination would best support the diagnosis?
A) Ectopia lentis
B) Exophthalmos
C) Focal alopecia
D) Micrognathia
E) Ulnar deviation of the fingers
