DES C_ParaClinic (7) Prepared : CHILLY

Following surgery a patient develops oliguria. You believe the oliguria is due to hypovolemia, but you seek corroborative data before increasing intravenous fluids. Which of the following values supports the diagnosis of hypovolemia?

For the first 6 hours following a long and difficult surgical repair of a 7-cm abdominal aortic aneurysm, a 70-year-old man has a total urinary output of 25 mL since the operation. Which of the following is the most appropriate diagnostic test to evaluate the cause of his oliguria?

In an adolescent presenting with pityriasis rosea, which of the following would be an appropriate blood test to order?

In the first postoperative day after an open abdominal procedure, a patient develops a temperature of 38.9 C (102 F). He is encouraged to ambulate, cough, and breathe deeply, but he is noncompliant. On the second day, he is still febrile. Incentive spirometry and postural drainage are instituted, but his participation is less than enthusiastic. He lies in bed all day and hardly moves. By the third day, he is still spiking fevers in the same range, although efforts to improve his ventilation continue, resolution of his problem will most likely require which of the following?

On postpartum day 2 after a vaginal delivery, a 32-year-old G2P2 develops acute shortness of breath and chest pain. Her vital signs are blood pressure 120/80 mm Hg, pulse 130 beats per minute, respiratory rate 32 breaths per minute, and temperature 37.6C (99.8F). She has new onset of cough. She appears to be in mild distress. Lung examination reveals clear bases with no rales or rhonchi. The chest pain is reproducible with deep inspiration. Cardiac examination reveals tachycardia with 2/6 systolic ejection murmur. Pulse oximetry reveals an oxygen saturation of 88% on room air and oxygen supplementation is initiated. Which of the following is the best diagnostic tool to confirm the diagnosis?

On the 7th postoperative day after the pinning of a broken hip, a 76-year-old man suddenly develops severe pleuritic chest pain and shortness of breath. When examined, he is found to be anxious, diaphoretic, and tachycardic, with a blood pressure of 140/85 mm Hg. He has prominent distended veins in his neck and forehead. Blood gases show hypoxemia and hypocapnia. His chest x-ray film is unremarkable. The nurses have placed him on supplemental oxygen by face mask. Which of the following is the most appropriate next step in management?

On the second postoperative day after an abdomino-perineal resection for cancer of the rectum, a 72-year-old man complains of severe retrosternal pain. The pain is crushing in nature and radiates to the left arm. He also becomes short of breath and tachycardic. Except for his fresh surgical wounds and postoperative discomfort, physical examination is unremarkable. He does not have distended neck veins. Which of the following is the most appropriate next step in diagnosis?

One of your obstetric patients presents to the office at 25 weeks complaining of severe left calf pain and swelling. The area of concern is slightly edematous, but no erythema is apparent. The patient demonstrates a positive Homans sign, and you are concerned that she may have a deep vein thrombosis. Which of the following diagnostic modalities should you order?

Ten days after undergoing liver transplantation, a patient's levels of gamma-glutamyl transferase (GGT), alkaline phosphatase, and bilirubin begin to rise. Which of the following is the most appropriate next step in diagnosis?

The 1-year-old brother of a child with known abetalipoproteinemia is evaluated by a pediatrician for the disease. The 1 -year-old has been exhibiting steatorrhea and ataxia. Which of the following would most strongly support the suspected diagnosis?

The parents of a 2-month-old baby boy are concerned about his risk of coronary artery disease because of the recent death of his 40-year-old maternal uncle from a myocardial infarction. Which of the following is the most appropriate management in this situation?

The unrestrained front-seat passenger in a car that crashes at high speed is brought to the emergency department by paramedics. At the site of injury, the patient was unconscious and had gurgly respiratory sounds, and the EMTs successfully accomplished blind nasotracheal intubation. The initial survey in the emergency department shows normal vital signs, multiple facial lacerations, and an unresponsive, comatose patient with fixed dilated pupils. Preparations are made to do a CT scan of the head. It is imperative that which of the following should be obtained as well?

Which feature of fibrocystic disease of the breast is associated with the greatest risk of developing breast cancer?

Which of the following is the most appropriate evaluative procedure for an otherwise normal 7-day-old boy with perineal hypospadias?

Within 8 hours after birth, an infant has "excessive salivation." Physical examination reveals that she has an imperforate anus, with a small fistula to the vagina. A small, soft nasogastric tube is inserted, and the infant is taken to x-ray. The film shows the tube coiled back on itself in the upper chest, and a normal gas pattern in the gastrointestinal tract. There are no apparent abnormalities of the radius or the vertebral bodies. Which of the following is the most appropriate next step in management?

You are asked by a colleague to evaluate a 5-year-old boy as a second opinion. He has a history of chronic and recurrent upper respiratory tract infections, several admissions to the hospital for pneumonia, and three surgeries for PE tubes for chronic otitis media. Of note is a right-sided heart on repeated radiographs. Convinced you know the diagnosis based on history alone, you confirm your diagnosis with a biopsy of the nasal mucosa. You expect to find which of the following?

You are asked to evaluate an infant born vaginally 3 hours previously to a mother whose only pregnancy complication was poorly controlled gestational diabetes. The nursing staff noticed that the infant was breathing abnormally. On examination, you find that the infant is cyanotic, has irregular, labored breathing, and has decreased breath sounds on the right side. You also note decreased tone in the right arm. You provide oxygen and order a stat portable chest radiograph, which is normal. Which of the following studies is most likely to confirm your diagnosis?

You are following up on the results of routine testing of a 68-year-old G4P3 for her well-woman examination. Her physical examination was normal for a postmenopausal woman. Her Pap smear revealed parabasal cells, her mammogram was normal, lipid profile was normal, and the urinalysis shows hematuria. Which of the following is the most appropriate next step in the management of this patient?

Your patient complains of decreased fetal movement at term. You recommend a modified BPP test. Nonstress testing (NST) in your office was reactive. The next part of the modified BPP is which of the following?

Your patient is a 23-year-old woman with primary infertility. She is 5 ft 4 in tall and weighs 210 lb. She has had periods every 2 to 3 months since starting her period at age 12. She has a problem with acne and hair growth on her chin. Her mother had the same problem at her age and now has adult-onset diabetes. On physical examination of the patient, you notice a few coarse, dark hairs on her chin and around her nipples. She has a normal appearing clitoris. Her ovaries and uterus are normal to palpation. Which of the following blood tests has no role in the evaluation of this patient?

A 58-year-old man with no prior cardiac history presents with retrosternal chest pain starting at rest and lasting 30 minutes. The pain radiates to the left arm and is associated with diaphoresis and dyspnea. His blood pressure is 150/90 mmHg, pulse 100/min, the heart sounds are normal, and the lungs are clear to auscultation. Which of the following is the next most appropriate investigation? CT scan—chest CXR cardiac troponin ECG myocardial perfusion imaging

A 58-year-old postmenopausal female presents to your office on suggestion from a urologist. She has passed 3 kidney stones within the past 3 years. She is taking no medications. Her basic laboratory work shows the following: Na: 139 mEq/L, K: 4.2 mEq/L, HCO3: 25 mEq/L, Cl: 101 mEq/L, BUN: 19 mg/dL, Creatinine: 1.1 mg/dL, Ca: 11.2 mg/dL. A repeat calcium level is 11.4 mg/dL; PO4 is 2.3 mmol/L (normal above 2.5). Which of the following tests will confirm the most likely diagnosis?

A 58-year-old woman has had bilateral hip and knee pain for the past several months. The pain is worse with activity and better with rest. Recently she has noticed swelling of the right knee. She reports morning stiffness of about 10-15minutes duration. She denies fever or weight loss. Her past medical history is significant for hypertension, type 2 diabetes, gastroesophageal reflux disease, and obstructive sleep apnea. She takes hydrochlorothiazide, lisinopril, omeprazole, insulin and aspirin. She does not use tobacco, alcohol or drugs. Her temperature is 37.2°C (98.9°F), and blood pressure is 146/86 mmHg. Examination shows a mild effusion, tenderness, and decreased range of motion of the right knee. Synovial fluid analysis reveals the following: Cell count 1100/ml, Gram stain negative, Crystals absent. Plain films of her knee joint would most likely reveal? . Punched out erosions with a rim of cortical bone . Periarticular osteopenia and joint margin erosions . Narrowing of joint space and osteophyte formation . Normal joint space with soft tissue swelling . Calcifications of cartilaginous structures

A 58-year-old woman presents to the emergency department with right subcostal heaviness, intermittent pain, food intolerance, and 13.2 lbs-weight loss (6kg) over the past 2 months. Her pain has been worsening for the past 2 days; it was initially localized to the right upper quadrant, but has now shifted to her back. Her past medical history is remarkable for appendicitis, which was complicated by perforation and peritonitis 20 years ago. Abdominal examination shows epigastric tenderness. There is a palpable mass below the right costal margin. Murphy's sign is negative. Abdominal ultrasound shows an enlarged gallbladder and dilation of the hepatic ducts. Laboratory studies show: WBC 11,000/cmm, Total bilirubin 2.4 mg/dl, Direct bilirubin 1.6 mg/dl, Alkaline phosphatase 310 U/L, Aspartate aminotransferase (SGOT) 87 U/L, Alanine aminotransferase (SGPT) 56 U/L, Amylase 140 U/L. Which of the following is the most appropriate next step in management? . Plain abdominal film . Endoscopic retrograde cholangiopancreatography . Percutaneous transhepatic cholangiography . CT scan of the abdomen . HIDA scan for cystic duct obstruction

A 59-year-old black man has a rock-hard, discrete, 1.5-cm nodule that is felt in his prostate during a routine physical examination. He is completely asymptomatic, and his prostatic specific antigen (PSA) done 3 months ago was normal for his age. His last rectal examination was performed a year earlier and was unremarkable. Which of the following will best establish the diagnosis? . Clinical follow-up during the ensuing year . Repeat determination of PSA . Transrectal needle biopsy of the mass . Transrectal sonogram of the prostate . Transurethral resection of the prostate

A 59-year-old man is referred for evaluation because he has been fainting at his job, where he operates heavy machinery. He is pale and gaunt, but otherwise his physical examination is remarkable only for 4+ occult bloods in the stool. Laboratory studies show haemoglobin of 5gm/dL with microcytosis, as well as decreased levels of serum iron and increased iron binding capacity. Which of the following will most likely establish the diagnosis?

A 59-year-old man presents for his routine colonoscopy and during his visit he has numerous large adenomas removed from his colon. Which of the following is the most effective strategy for follow-up of this patient?

A 6 month old male is brought in to the Emergency Room by his mother who states that when she picked him up from the baby-sitter he was not acting right. The baby-sitter stated that he was sleeping more and was fussy. On examination the baby is stuporous. His temperature is 37.8 C (99.9 F), pulse is 140/min, and respirations are 36/min. A 4 cm ecchymosis is noted on his right cheek. The remainder of the physical examination is unremarkable. The physician suspects possible physical abuse. He orders a CT scan of the head, skeletal survey, chemistry panel and complete blood count. Which of the following diagnostic tests should also be ordered?