Items 818 through 819

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A 57-year-old man develops acute shortness of breath shortly after a 12-h automobile ride. The patient consults his internist, and findings on physical examination are normal except for tachypnea and tachycardia. An electrocardiogram reveals sinus tachycardia but is otherwise normal.

8-18. Which of the following is correct?

a. A definitive diagnosis can be made by history alone b. The patient should be admitted to the hospital, and if there is no contraindication to anticoagulation, intravenous heparin should be started pending further testing c. Normal findings upon examination of the lower extremities are extremely unusual in this clinical setting d. Early treatment has little effect on overall mortality

8-19. The most important next step in the diagnosis of the patient above would be a. Pulmonary angiogram b. Ventilation-perfusion scan c. D-dimer assay d. Venous ultrasound

8-20. A newborn infant has mild cyanosis, diaphoresis, poor peripheral pulses, hepatomegaly, and car-diomegaly. Respiratory rate is 60 breaths/min, and heart rate is 250 beats/min. The child most likely has congestive heart failure caused by a. A large atrial septal defect and valvular pulmonic stenosis b. A ventricular septal defect and transposition of the great vessels c. Total anomalous pulmonary venous return d. Hypoplastic left heart syndrome e. Paroxysmal atrial tachycardia

8-21. A 70-year-old man complains of the sudden onset of visual loss in his right eye accompanied by a headache. He has a history of hypertension and diabetes mellitus. On physical examination, visual acuity in the left eye is 20/20 while visual acuity in the right eye is 20/90. Fun-duscopic exam shows the right disc to be pale and swollen with some hemorrhages. Which of the following is the most likely diagnosis?

a. Diabetic retinopathy b. Retinal vein occlusion c. Retinal artery occlusion d. Ischemic optic neuropathy e. Hypertensive retinopathy f. Retinal detachment

8-22. A 53-year-old postmeno-pausal woman, gravida 3, para 3, presents for evaluation of troublesome urinary leakage of 6 wk duration. Of the following choices, which is the most appropriate first step in this patient's evaluation?

a. Urinalysis and culture b. Urethral pressure profiles c. Intravenous pyelogram d. Cystourethrogram e. Urethrocystoscopy

8-23. A 50-year-old woman is evaluated for hypertension. Her blood pressure is 130/98 mm Hg. She complains of polyuria and mild muscle weakness. She is on no diuretics or other blood pressure medication. On physical exam the PMI is displaced to the 6th intercostal space. There is no sign of congestive heart failure and no edema. Laboratory values are as follows:

Na+: 147 meq/dL K+: 2.3 meq/dL Cl-: 112 meq/dL HCO3: 27 meq/dL

The patient is on no other medication. She does not eat licorice. The first step in diagnosis is a. 24-h urine for cortisol b. Urinary metanephrine c. Plasma resin and aldosterone d. Renal angiogram

8-24. A 10-year-old boy with sickle cell disease presents with headache, anorexia, and fever. He complains of pain in the right tibia and local inflammation is noted. Osteomyelitis is diagnosed. The most likely etiologic agent is a. Listeria b. Salmonella c. Shigella d. Cryptosporidium e. Campylobacter

8-25. An 8-year-old is accidentally hit in the abdomen by a baseball bat. After several minutes of discomfort, he seems to be fine. Over the ensuing 24 h, however, he develops a fever, abdominal pain radiating to the back, and persistent vomiting. On examination, the child appears quite uncomfortable. The abdomen is tender with decreased bowel sounds throughout, but especially painful with guarding in the mid-epigastric region. The test likely to confirm your suspicions is a. Serum amylase b. Complete blood count with differential and platelets c. Serum total and direct bilirubin levels d. Abdominal radiograph e. Electrolyte panel

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