a supple neck with fullness in the left supraclavicular foss

Discussion in 'USMLE STEP 2 CS' started by Shabir., Jul 29, 2008.

  1. Shabir.

    Shabir. Guest

    A 67-year-old man is brought to the emergency department by his wife because of a 3-day history of progressive sleepiness. Over the past year, he has had intermittent night sweats and a 9-kg (20-Ib) weight loss with no change in appetite. He has a 2-year history of a nonproductive cough treated with inhaled nasal corticosteroid therapy. He has smoked two packs of cigarettes daily for 40 years and does not drink alcohol. He is somnolent and oriented to person but not to place or time. His temperature is 37.1 °C (98.8°F), pulse is 96/min, respirations are 16/min, and blood pressure is 120/85 mm Hg. Examination shows a supple neck with fullness in the left supraclavicular fossa. Breath sounds are decreased on the left. There is dullness to percussion at the left lung base. Neurologic examination shows no focal findings. Pulse oximetry on room air shows an oxygen saturation of 90%. A complete blood count is within the reference range, and serum calcium level is 14 mg/dL. Urinalysis shows a sodium level less than 5 mmol/L and a fractional sodium
    excretion less than 1%. An x-ray film of the chest shows a large left pleural effusion. The most appropriate next step in management is administration of which of the following?

    A) Intravenous bisphosphonate
    B) Intravenous 5% dextrose in 0.45% saline
    C) Intravenous 5% dextrose in water
    D) Intravenous 0.9% saline
    E) Oral loop diuretic

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