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Question 1 of 33
1. Question
A 35-year-old man is brought to the emergency department after cutting his finger with a rusty knife while doing yard work. It is a deep cut, and his wife had immediately applied a pressure dressing to stop the bleeding. His immunization status is unknown. The patient last saw his doctor about 10 years ago, and cannot recall if he received all of his childhood vaccinations. He has a deep laceration on the palmar aspect of his right middle finger. Cleaning of the wound and other wound-care measures are initiated. Which of the following is the best next step in management of this patient?
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Question 2 of 33
2. Question
The following vignette applies to the next 2 items. The items in the set must be answered in sequential order. Once you click Proceed to Next Item, you will not be able to add or change an answer.
A 62-year-old man comes to the office due to a nodule on the back of his neck. The patient first noticed the lesion several months ago, and it has been slowly enlarging. He reports no pain or itching, but the lesion often rubs against the collar of his shirt and causes irritation. Medical history also includes hypertension, diabetes mellitus, and atrial fibrillation. Skin examination reveals a 1.5-cm lesion as seen in the exhibit.
Item 1 of 2
Which of the following is the best next step in management of this patient?
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Question 3 of 33
3. Question
Item 2 of 2
Biopsy reveals basal cell carcinoma with nodular features. Which of the following is the best next step in management of this patient?
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Question 4 of 33
4. Question
A 22-year-old woman is hospitalized after a car accident. She sustained a hip fracture, fracture of several ribs, and a blunt abdominal injury that required a laparotomy. The laparotomy revealed a liver laceration and extensive hemoperitoneum. In the early postoperative period, the patient is noted to have hyperactive deep tendon reflexes. Which of the following electrolyte abnormalities may be responsible for this condition?
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Question 5 of 33
5. Question
A 62-year-old woman comes to the emergency department due to dysuria, urinary frequency, and flank pain for 2 days. Medical history is significant for hypertension, atrial fibrillation, and recurrent urinary tract infections. Temperature is 38.5 C (101.3 F), pulse is 102/min and irregular, and blood pressure is 132/82 mm Hg. Physical examination shows left costovertebral angle tenderness. Laboratory results are as follows:
Complete blood count
Hemoglobin
11.2 g/dL
Leukocytes
15,000/mm3
Urinalysis
Blood
moderate
Glucose
negative
Leukocyte esterase
positive
Nitrites
positive
Red blood cells
20-30/hpf
White blood cells
20-30/hpf
Ultrasonography of the abdomen reveals a 3.5-cm, irregularly shaped stone occupying most of the left renal pelvis. Urine culture would most likely grow which of the following organisms?
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Question 6 of 33
6. Question
A 21-year-old man is brought to the emergency department after being found unconscious following a house fire. The patient was intubated at the scene due to his mental status. He was last seen in his usual state of health the previous day. The patient has a history of opioid use disorder and depression. Temperature is 37.8 C (100 F), blood pressure is 90/60 mm Hg, and pulse is 55/min. Pulse oximetry shows 100% on 100% FiO2 via endotracheal tube. The patient is unresponsive to painful stimuli. There are no signs of head trauma. Mucous membranes are dry; nasal hairs are singed. Cardiopulmonary examination is normal. Skin examination shows superficial partial-thickness burns covering <5% of his body. Laboratory results are as follows:
Arterial blood gases
pH
7.07
PaO2
110 mm Hg
PaCO2
24 mm Hg
Serum chemistry
Bicarbonate
8 mEq/L
Lactic acid, venous blood
22 mg/dL
Glucose
100 mg/dL
Which of the following antidotes should be administered to the patient at this time?
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Question 7 of 33
7. Question
A 66-year-old hospitalized man is evaluated after an episode of generalized tonic-clonic seizure. The patient has no previous history of seizure. He underwent right hemicolectomy for cecal adenocarcinoma the previous day. Postoperatively, the patient had hypotensive episodes, which responded to fluid resuscitation. He has been receiving intravenous infusion of 5% dextrose with 0.45% saline. He is also receiving morphine via a patient-controlled device. On physical examination, he is postictal. Temperature is 36.7 C (98 F), blood pressure is 112/60 mm Hg, pulse is 68/min, and respirations are 12/min. Pulse oximetry shows 96% on room air. Laboratory results are as follows:
Sodium
114 mEq/L
Potassium
4.2 mEq/L
Chloride
90 mEq/L
Bicarbonate
22 mEq/L
Blood urea nitrogen
24 mg/dL
Creatinine
0.9 mg/dL
Calcium
9.4 mg/dL
Glucose
120 mg/dL
Which of the following is the most appropriate next step in management of this patient?
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Question 8 of 33
8. Question
A 72-year-old man comes to the office because of a skin lesion on his hand that first appeared 6 months ago. The lesion does not itch or cause pain. The patient has had similar lesions on his face; some spontaneously resolved, and some were successfully treated with topical liquid nitrogen therapy. Skin examination reveals a 1.3-cm lesion, as shown in the exhibit; it is nontender. Which of the following is the most appropriate next step in management of this patient?
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Question 9 of 33
9. Question
A 76-year-old man is brought to the emergency department due to severe hip pain following a ground-level fall. Medical history is significant for long-standing hypertension, for which he takes chlorthalidone. The patient drinks an alcoholic beverage with dinner on most nights. He smoked 2-3 cigarettes weekly for 30 years until age 65. Blood pressure is 136/76 mm Hg and pulse is 72/min. BMI is 34 kg/m2. Serum calcium, phosphorus, and alkaline phosphatase levels are normal. X-ray of the hip reveals osteopenia and a femoral neck fracture. Which of the following is the strongest predisposing factor for this patient’s condition?
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Question 10 of 33
10. Question
A 56-year-old man comes to the clinic for follow-up. The patient has a history of end-stage renal disease due to hypertensive nephropathy and underwent renal transplantation 2 weeks ago. The surgery had no complications and he had good initial graft function. The patient has no other medical conditions. His immunosuppression medications include prednisone, tacrolimus, and mycophenolate sodium. The patient does not use tobacco, alcohol, or illicit drugs. Vital signs are normal. BMI is 31.8 kg/m2. Physical examination shows a healing lower abdominal surgical scar with no erythema or drainage. Fasting serum chemistry reveals the following:
Sodium
136 mEq/L
Potassium
4.6 mEq/L
Chloride
102 mEq/L
Bicarbonate
22 mEq/L
Blood urea nitrogen
14 mg/dL
Creatinine
1.4 mg/dL
Glucose
102 mg/dL
Calcium
9.8 mg/dL
Which of the following is this patient at greatest risk of developing within the next several months?
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Question 11 of 33
11. Question
A 59-year-old man comes to the office complaining of a vague upper abdominal discomfort. The pain has been present for most of the past 3 months but has never been severe enough to make him seek immediate medical attention. The discomfort is not associated with eating or performing any activities. He has no other medical problems. His blood pressure is 120/60 mm Hg, pulse is 84/min, and respirations are 14/min. Abdominal examination reveals the presence of multiple scars from previous surgical procedures around the epigastric area. A 3 x 5-cm, oblong-shaped, firm, and deeply seated mass is palpable in the epigastric area. There is no tenderness on direct palpation of the mass and surrounding epigastric area. The patient says that he previously had similar “things” in the same area “but they were taken out.” Which of the following is the most likely diagnosis?
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Question 12 of 33
12. Question
A 24-year-old man is carried into the emergency department by friends after a fight in the street. During the fight, the patient was struck in the head with a knife, which became firmly implanted in his skull. His blood pressure is 106/72 mm Hg, pulse is 118/min, and respirations are 14/min. Pulse oximetry shows 93% on room air. His Glasgow Coma Scale score is 8. He opens his eyes to pain, and his speech is incomprehensible. Compressing the fingernail bed causes him to withdraw his hand. The estimated length of the knife is 14 cm, 3 cm of which have penetrated his skull. There is no other evidence of injury on his body. Which of the following is the most important next step in management of this patient?
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Question 13 of 33
13. Question
An 18-year-old high school senior is brought to the emergency room after she was involved in a motor vehicle accident. Upon her arrival to the emergency room, she is minimally responsive, and there is evidence of bleeding from the right side of her head. Her vital signs are as follows: temperature 37.6C (99.6F), blood pressure 182/98 mmHg, heart rate 52 per minute and respiratory rate 6 per minute. Her oxygen saturation is 96% on two liters of oxygen. Her breath smells of alcohol. Physical examination reveals a right pupillary size of 7 mm with minimal response to light. The left pupil is 3 mm with normal pupillary light reflex. The right eye is deviated outwards and downwards. There is bilateral papilledema on funduscopic examination. While in the ER, the patient had an episode of generalized body extension, with adduction and pronation of her upper extremities. There is no evidence of any thoracic or abdominal injuries. Which of the following is the most appropriate next step in the management of this patient?
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Question 14 of 33
14. Question
A 34-year-old woman, gravida 2 para 1, is evaluated for hospital discharge 8 hours after surgery. She came to the emergency room this morning with hypotension, tachycardia, and vaginal bleeding and was diagnosed with a ruptured ectopic pregnancy for which she underwent a laparoscopic right salpingectomy. The patient’s only prior surgery was a cesarean section. Two units of packed red blood cells were transfused in the emergency department and another two in the operating room due to acute blood loss anemia; she also received 2 L of normal saline. A Foley catheter was placed immediately prior to surgery and removed before the patient awakened from anesthesia, after an intraoperative urine output of 200 mL was noted. There were no complications. However, the patient has been unable to pass flatus or void since the procedure. She has mild nausea but no fever, dizziness, weakness, or vomiting. Light vaginal bleeding is present. Blood pressure is 140/90 mm Hg and pulse is 98/min. The abdomen is soft and mildly distended with suprapubic tenderness but no rebound or guarding. Tympany is present under the right costal margin. The incisions are closed and the primary dressings are clean, dry, and intact. Which of the following is the most likely cause of this patient’s current condition?
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Question 15 of 33
15. Question
A 70-year-old man presents to the emergency department due to right-sided arm and leg weakness that occurred several hours ago. The episode lasted 15 minutes and resolved spontaneously. He had a similar episode of right arm weakness two days ago. He was diagnosed with hypercholesterolemia on routine check-up three months ago, and has been treated with pravastatin. He does not smoke or consume alcohol. His blood pressure is 140/90 mmHg and his heart rate is 70/min. Doppler studies shows 89% stenosis in his left carotid artery and 40% stenosis in his right carotid artery. He undergoes left carotid endarterectomy. The surgery goes well and he recovers from the anesthesia without any complications. In the recovery room, upon protrusion of the tongue, the tongue deviates to the left. Which of the following structures is most likely damaged?
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Question 16 of 33
16. Question
A 42-year-old, previously healthy man comes to the office for evaluation of an enlarging mole. The mole has been on his forearm for several years but has rapidly increased in size over the past 4 months. Physical examination shows an 8-mm raised lesion with variegated pigmentation and ill-defined borders on the right forearm. An excisional biopsy is performed. During the procedure, local anesthesia is achieved with an infiltrating injection of lidocaine mixed with epinephrine. Which of the following is the most likely reason for adding epinephrine to the injection?
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Question 17 of 33
17. Question
A 22-year-old white male who underwent a laparotomy two weeks ago for a perforated appendix, develops a swinging fever, dry cough, and pain in his right shoulder-tip. His temperature is 38.9 C (102 F), blood pressure is 120/76 mmHg, pulse is 110/min, and respirations are 20/min. Examination shows tenderness over the 8th to 11th rib. Abdominal and rectal examinations are within normal limits. The WBC count is 14,000/micro-L, with 6% bands. Which of the following is the best diagnostic test for this patient?
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Question 18 of 33
18. Question
A 37-year-old man is brought to the emergency department with left eye pain after a metal shard entered his eye at work 30 minutes ago. The patient reports pain, tearing, and blurred vision in that eye. He has no medical conditions and takes no medications daily. Blood pressure is 140/80 mm Hg, pulse is 115/min, and respirations are 20/min. On examination, the patient appears uncomfortable, with constant tearing from the left eye. There are no obvious foreign bodies on inspection, but on penlight examination, the left pupil is shaped like a teardrop. Visual acuity is decreased in the left eye. Which of the following is the best next step in management of this patient?
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Question 19 of 33
19. Question
A 69-year-old woman underwent thyroidectomy due to thyroid cancer. The surgery was uncomplicated. Three hours afterward, the patient developed slurred speech and right-sided weakness. Temperature is 36.3 C (97.3 F), blood pressure is 140/86 mm Hg, pulse is 90/min, and respirations are 18/min. On examination, the patient is alert and awake, but her speech is incomprehensible. Strength is 2/5 in both right upper and lower extremities. Sensations are decreased on the right side of the body. The dressing covering the operative site on the neck is dry. There is no stridor. The extremities are warm with normal capillary refill time. Neurologic examination prior to the surgery showed no abnormalities. Serum glucose and calcium concentration are normal. Which of the following is the most appropriate next step in management of this patient?
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Question 20 of 33
20. Question
A 48-year-old man comes to the office for intractable lower extremity bone pain. He has end-stage renal disease due to focal segmental glomerulosclerosis and has been on hemodialysis 3 times a week for the past 4 years. Approximately 3 months ago, adjustments in his medications and hemodialysis regimens were made after the patient was found to have high serum calcium, phosphorus, and parathyroid hormone levels; however, these adjustments did not lead to any significant improvements in laboratory values. Temperature is 36.9 C (98.4 F), blood pressure is 190/100 mm Hg, and pulse is 88/min. Oral examination shows pallor of the mucous membranes. Lungs have decreased sounds at both bases. Cardiovascular examination shows a 2/6 systolic ejection murmur at the left upper sternal border and a palpable thrill over an arteriovenous fistula in the left forearm. Laboratory results are as follows:
Serum calcium
11.6 mg/dL
Serum phosphorus
8.7 mg/dL
Parathyroid hormone
1,200 pg/mL
Bone alkaline phosphatase
155 mcg/L (normal: <20 mcg/L)
25-hydroxyvitamin D
32 ng/mL (normal: 30-50 ng/mL)
Chest x-ray reveals cardiomegaly with calcification of the ascending aorta. Which of the following treatments would be most beneficial for this patient’s current condition?
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Question 21 of 33
21. Question
A 35-year-old man comes to the office due to recurrent kidney stones. The patient had his first stone 5 years ago and has since had 2 episodes of acute renal colic; the most recent episode was 4 weeks ago. Stone composition is 85% calcium oxalate and 15% calcium phosphate. The patient has been following all dietary recommendations for stone prevention. His father also had kidney stones. Vitals signs are normal. Complete physical examination shows no abnormalities. Laboratory results are as follows:
Serum chemistry
Bicarbonate
26 mEq/L
Creatinine
0.8 mg/dL
Calcium
9.2 mg/dL
Uric acid
4 mg/dL
Results of 24-hour urine collection analysis are as follows:
Calcium
340 mg (normal: <300)
Citrate
670 mg (normal: 300-1100)
Oxalate
20 mg (normal: <40)
Uric acid
590 mg (normal: 250-750)
A first-line pharmacotherapy is prescribed to prevent stone recurrence. Which of the following is the most likely mechanism of action of this drug?
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Question 22 of 33
22. Question
A 52-year-old man is in the hospital burn unit 3 days after sustaining severe burns to 35% of his body surface area in a house fire. The patient remains intubated due to inhalational injury and has been undergoing staged excision and grafting of his burns. There has been no clinical evidence of infection, but the patient has been persistently febrile, hypertensive, tachycardiac, and hyperglycemic. Treatment with oxandrolone, a synthetic testosterone analogue, is considered. The beneficial effect of this treatment is most likely related to its effect on which of the following processes?
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Question 23 of 33
23. Question
A 65-year-old woman with a medical history significant for tobacco use, hypertension, and laparoscopic cholecystectomy is brought to the operating room for a lumbar discectomy. She is placed in the prone position. General anesthesia is induced with propofol and rocuronium, and the patient is intubated without complications. Anesthesia is maintained with sevoflurane. Five minutes later, prior to incision, the ventilator sounds an alarm. Peak pressures have increased to >40 mm Hg, and end-tidal CO2 has decreased from 30 to 20 mm Hg. Blood pressure is 90/60 mm Hg and pulse is 114/min. On examination, the patient is sedated and paralyzed. Heart sounds are rapid and regular. Bilateral wheezing is noted on auscultation of the lungs. What is the next step in management?
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Question 24 of 33
24. Question
A 7-year-old boy is brought to the emergency department due to a dog bite to the face. The father states the patient approached their dog, who was sleeping, and the dog suddenly snapped and bit him near the right eye. The dog’s vaccines are up to date. The patient has no medical conditions, and his vaccines are up to date. Vital signs are normal. On examination, there are 2 puncture wounds on the lateral forehead. The right eyelid is swollen, and there is a small, horizontal laceration of the lateral aspect of the right upper eyelid; there is fatty tissue protruding at the base of the wound. The pupils are symmetric and reactive to light, and the extraocular movements are intact. Visual acuity is normal. Which of the following structures is most likely injured as a result of the eyelid laceration in this patient?
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Question 25 of 33
25. Question
A 69-year-old man with a history of Parkinson disease is brought to the emergency department due to difficulty walking, falls, and urinary incontinence for a day. For the past 5 days, he has not been feeling well and has had back pain. His other medical conditions include osteoporosis and type 2 diabetes mellitus. He takes carbidopa-levodopa, metformin, and calcium carbonate/vitamin D. Temperature is 38.3 C (100.9 F), blood pressure is 110/78 mm Hg, and pulse is 80/min. On examination, there is tenderness over the T12 vertebra. Lower extremity muscle strength is 3/5 and deep tendon reflexes are 3+. He has mild generalized stiffness and resting tremor. Lungs are clear to auscultation. Bladder distension is present. Laboratory studies are as follows:
Complete blood count
Hemoglobin
11.8 g/dL
Platelets
240,000/mm3
Leukocytes
15,000/mm3
Urinalysis
Leukocyte esterase
negative
Nitrites
negative
Bacteria
few
White blood cells
1-2/hpf
Red blood cells
1-2/hpf
X-ray of the spine reveals osteoporosis and an old compression fracture at L2. What is the most appropriate next step in management of this patient?
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Question 26 of 33
26. Question
A 69-year-old man is brought to the emergency department due to left-sided weakness and facial droop that began an hour ago while he was eating breakfast. Medical history includes a previous transient ischemic attack. The patient takes aspirin. Temperature is 37.2 C (99 F), blood pressure is 150/80 mm Hg, pulse is 88/min, and respirations are 14/min. The patient is awake and alert. Left-sided hemiparesis is present, and he neglects his left side during examination. Noncontrast CT scan of the head reveals no evidence of hemorrhage, and intravenous tissue plasminogen activator is administered. Thirty minutes later, the patient reports a severe headache and begins vomiting. Blood pressure is 175/100 mm Hg, and pulse is 94/min. Repeat noncontrast CT scan of the head reveals hemorrhage within the right cerebral cortex. The patient’s initial complete blood count and coagulation studies, obtained shortly after arrival, were within normal limits. Which of the following is the best reversal agent for this patient?
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Question 27 of 33
27. Question
A 7-year-old boy is brought to the emergency department by paramedics after being attacked by a dog. Approximately an hour ago, the boy was playing in a park near his house when he tried to separate 2 stray dogs that were fighting. The dogs assaulted the patient, dragged him to the ground, and bit him multiple times on the upper extremities and face. His parents were able to drive the dogs away. The boy is otherwise healthy and up to date on immunizations. Temperature is 37.1 C (98.8 F) and pulse is 138/min. The child is inconsolable; intravenous morphine and midazolam are administered to allow examination of his wounds. Multiple, deep bite wounds are found on the dorsal forearms bilaterally. There is also a 6-cm, macerated wound overlying the left mandible extending to the left ear. The upper extremity wounds are actively bleeding and contain specks of dirt and grass. Pressure is applied, and hemostasis of all wounds is achieved. The wounds are copiously irrigated and cleaned, and rabies prophylaxis is initiated. The mother asks about tetanus and says, “Please do everything you can for him! My husband was bitten by a dog last year and received several shots for tetanus.” Which of the following is the most appropriate response?
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Question 28 of 33
28. Question
A 46-year-old man with type 2 diabetes mellitus is scheduled for cardiac catheterization in 2 days for undiagnosed, episodic chest pain. For 15 days, the patient has had retrosternal chest pain radiating to his arm, and it is becoming more frequent. He went to the emergency department 7 days ago due to chest pain. The patient was admitted for overnight observation but left against medical advice. Three sets of cardiac enzymes tests were negative, and his ECG showed nonspecific ST-T changes. He has a history of hypertension, a 6-year history of diabetes mellitus, and does not check his blood glucose levels regularly. Medications include metformin and lisinopril. At his last emergency department visit, laboratory results (chemistry profile and complete blood count) were normal, and he was started on low-dose aspirin. He has a long smoking history, and uses alcohol occasionally. The patient has a strong family history of premature coronary artery disease. Today, blood pressure is 127/70 mm Hg and pulse is 66/min. BMI is 30 kg/m2. The remainder of the examination is within normal limits. Which of the following is the best next step in management of this patient?
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Question 29 of 33
29. Question
A 46-year-old woman comes to the emergency department due to 2 days of left flank pain, nausea, and vomiting. She reports several episodes of non-bloody emesis and poor oral intake but has had no fever, chills, diarrhea, or dysuria. Her pain is partially relieved with over-the-counter ibuprofen. The patient states that her symptoms are similar to a prior renal calculus 3 years ago. She has no chronic medical conditions and takes no other medications. Temperature is 37.3 C (99.1 F), blood pressure is 108/66 mm Hg, and pulse is 110/min. On physical examination, the patient appears in moderate pain. The abdomen is soft with mild left costovertebral angle tenderness. Laboratory results are as follows:
Complete blood count
Hemoglobin
14.8 g/dL
Hematocrit
48%
Platelets
380,000/mm3
Leukocytes
13,000/mm3 (80% neutrophils)
Serum chemistry
Sodium
134 mEq/L
Potassium
3.2 mEq/L
Chloride
104 mEq/L
Bicarbonate
26 mEq/L
Blood urea nitrogen
52 mg/dL
Creatinine
1.9 mg/dL
Urinalysis
Specific gravity
1.030
Protein
none
White blood cells
5-10/hpf
Red blood cells
many/hpf
Crystals
calcium oxalate
Noncontrast CT scan of the abdomen and pelvis reveals a normal sized right kidney without hydronephrosis; left-sided hydronephrosis and hydroureter with an 8-mm mid-ureter calculus are present. Which of the following best explains this patient’s acute kidney injury?
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Question 30 of 33
30. Question
A 45-year-old woman with a history of chronic menorrhagia is hospitalized for an elective hysterectomy. Her preoperative hemoglobin is 7 g/dL. She is transfused with 2 units of packed red blood cells. Two hours after starting the transfusion, the patient reports chills and malaise. Her temperature is 38.8 C (102 F), blood pressure is 120/76 mm Hg, pulse is 100/min, and respirations are 18/min. The transfusion is stopped, and she receives acetaminophen. Direct antiglobulin test and plasma free hemoglobin level are negative. Urinalysis is within normal limits. The reaction resolves 6 hours after the transfusion began. Which of the following actions could have prevented this reaction?
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Question 31 of 33
31. Question
A 60-year-old man is brought to the emergency department after being rescued from a burning apartment complex, where he was found unconscious inside the building. He was intubated and received crystalloid resuscitation. Initial assessment shows partial- and full-thickness burns covering approximately 85% of his total body surface area. The patient is identified by a medical bracelet. Hospital records show a history of schizophrenia, epilepsy, and hypertension; the patient lives alone, relies on disability income, and appears to have little social support. The next of kin is contacted to discuss treatment options. Which of the following is the strongest indication for considering hospice care in this patient?
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Question 32 of 33
32. Question
A 6-year-old boy is brought to the emergency department by his parents due to a dog bite. Approximately 16 hours ago, the patient was playing with the family dog in their backyard when the dog bit his left hand. The parents immediately washed the wound with soap and water and applied topical antibiotic ointment. When the child woke up this morning, he had increased pain exacerbated by making a fist. The dog is up to date with recommended immunizations. The boy has no medical issues and is current with his immunizations. Vital signs are within normal limits. On physical examination, a 2-cm × 1-cm ragged laceration is seen on the dorsal left hand. There is minimal amount of serous drainage from the wound, and no redness or streaking is seen. Full range of motion is present. The wound is copiously irrigated with normal saline. X-ray of the hand is normal. Which of the following is the best next step in management of this patient?
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Question 33 of 33
33. Question
A 26-year-old woman comes to the office for postoperative follow-up. She has Graves disease and has taken methimazole for 4 years, but due to her desire to become pregnant, she underwent total thyroidectomy 2 weeks ago. Methimazole was stopped and levothyroxine initiated after the operation. The patient has had no neck pain, dyspnea, or voice changes since the procedure but for the past several days has felt fatigued, irritable, and depressed. She also has had intermittent paresthesia in both hands and both feet. Medical history is otherwise unremarkable, and the patient does not use tobacco, alcohol, or recreational drugs. Which of the following examination findings is most likely in this patient?
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