(EXAM) DES 2016-2017 : 2040-2299 (Rabid Wolverine) 1

135) A 36-year-old male presents with firm, non-tender swelling of his right cheek. He tells you that he had similar swelling at that site two years ago and was diagnosed with a tumor, which was subsequently removed without complication. Examination reveals fullness of the pre-auricular space on the right side. Repeat surgery in this patient is most likely to result in which of the following complications?
. Facial droop
. Hoarseness
. Tic douloureux
. Tongue palsy
. Jaw asymmetry
136) A 39-year-old paleontologist complains of right-sided hip pain that makes it very difficult for him to lie on his right side while sleeping. He localizes the pain to the outer surface of his thigh. He was recently diagnosed with hypertension and hyperlipidemia. He takes hydrochlorothiazide and atorvastatin. He has smoked one pack of cigarettes daily for 15 years. He does not use alcohol or illicit drugs. Which of the following is the most likely cause of his pain?
. Trochanteric bursitis
. Slipped femoral epiphysis
. Paget's disease
. Peripheral vascular disease
. Hip osteoarthritis
137) A 65-year-old male is being evaluated for hip pain. The pain has been present for several months and is constant. He denies any weight loss or loss of appetite. His past medical history is significant only for high blood pressure. His temperature is 37.2°C (98.9°F), blood pressure is 150/88 mm Hg, pulse is 80/min and respirations are 12/min. Physical examination is unremarkable. Laboratory studies show: Alkaline phosphatase Elevated, Gamma glutamyl transferase Normal, Serum calcium Normal, 25, (OH)2 vitamin D Normal. Bone scan shows increased uptake in several spots. This patient is at the highest risk of developing?
. Hearing loss
. Subarachnoid hemorrhage
. Carpal tunnel syndrome
. Renal cell carcinoma
. Pulmonary hemorrhage
138) A 25-year-old motorcyclist is brought to the emergency department after being involved in a collision with an automobile. On arrival he is in obvious pain. He expresses an urge to void, but is unable to do so. Genital examination shows blood at the urethral meatus and a scrotal hematoma. Rectal examination reveals a high-riding prostate. Abdominal examination is suggestive of a distended bladder. Which of the following is the most likely diagnosis?
. Urethral injury
. Intraperitoneal bladder rupture
. Extraperitoneal bladder injury
. Fracture of penis
. Renal injury
1) A 50-year-old patient presents with symptomatic nephrolithiasis. He reports that he underwent a jejunoileal bypass for morbid obesity when he was 39. Which of the following is a complication of jejunoileal bypass?
. Hyperoxaluria
. Pseudohyperparathyroidism
. Hyperuric aciduria
. Hungry bone syndrome
. Sporadic unicameral bone cysts
2) A 75-year-old man slips and falls at home, hitting his right chest wall against the kitchen counter. He has an area of exquisite pain to direct palpation over the seventh rib, at the level of the anterior axillary line. A chest x-ray film confirms the presence of a rib fracture, with no other abnormal findings. Which of the following is the most appropriate initial step in management?
Intercostal nerve block to minimize pain Open
Supplemental oxygen to compensate for hypoventilation
Systemic narcotic analgesics
Binding of the chest to limit motion
Open reduction and internal fixation to accelerate healing
3) A 71-year-old woman is brought to the physician by her distressed daughter. The daughter relates that, 3 days ago, her mother began to complain of right upper quadrant abdominal pain. She did not want to eat and "took to her bed sick." The daughter recalls that she complained of chills, nausea, and some vomiting. Physical examination reveals an obtunded, hypotensive, and obviously very sick elderly woman. She has impressive pain to deep palpation in the right upper quadrant, along with muscle guarding and rebound. Her temperature is 40C (104F), and laboratory analysis shows a white cell count of 22,000/mm3 with multiple immature forms, a bilirubin of 5 mg/dL and alkaline phosphatase of 840 U/L. The serum amylase is normal. An emergency sonogram shows multiple stones in the gallbladder, normal thickness of the gallbladder wall without pericholecystic fluid, dilated intrahepatic ducts, and common duct with a diameter of 2.1 cm. The sonographer cannot identify stones in the common duct. In addition to IV fluids and antibiotics, which of the following is the most appropriate next step in management?
. Emergency decompression of the common duct
. Elective cholecystectomy
. Emergency cholecystectomyv
. Emergency surgical exploration of the common duct
. Emergency transhepatic cholecystostomy
4) A 54-year-old man, who 5 years ago underwent a laparotomy for a gunshot wound to the abdomen, is admitted to the hospital because of protracted vomiting and progressive abdominal distention. The symptoms began 5 days earlier, and since then he has not had a bowel movement or passed any gas. At the time of hospitalization, he has hyperactive bowel sounds and some abdominal discomfort, but does not have an acute abdomen. His abdominal x-ray films show dilated loops of small bowel, multiple air-fluid levels, and no free air under the diaphragms. He is placed on nasogastric suction and IV fluids. After 6 hours, he develops fever, leukocytosis, abdominal tenderness, and rebound tenderness, and his abdomen is silent. Which of the following is the most appropriate next step in management?
. Emergency exploratory laparotomy
. Add antibiotics
. Barium tag and serial abdominal x-ray films
. CT scan of the abdomen
. Upper gastrointestinal endoscopy and introduction of a long intestinal tube
5) A 3-year-old boy is brought to the emergency room after spilling bleach onto his lower extremities. He is diagnosed with a chemical burn and all involved clothing are removed. In addition to resuscitation, which of the following is the most appropriate initial management of this patient?
. Lavage of the burn wound with large volumes of water.
. Treatment of the burn wound with antimicrobial agents.
. Neutralize the burn wound with weak acids.
. Wound debridement in the operating room.
. Treatment of the burn wound with calcium gluconate gel.
6) Following a weekend of snowmobiling, a 42-year-old man comes to the emergency department with pain, numbness, and discoloration of his right forefoot. You diagnose frostbite. Which of the following is the proper initial treatment?
. Immersion of the affected part in water at 40 C-44 C (104 F-111.2 F)
. Debridement of the affected part followed by silver sulfadiazine dressings
. Administration of corticosteroids
. Administration of vasodilators
. Rewarming of the affected part at room temperature
7) A 40-year-old woman complains of mild, intermittent pain and paresthesias in her right wrist. She reports the pain is worse at night and with driving. On physical examination hyperflexion of the right wrist reproduces the paresthesia. With regard to her diagnosis, which of the following is the most appropriate initial treatment?
. Wrist splint worn at nighttime
. Ice pack to the affected wrist at nighttime
. Heat pad to the affected wrist at nighttime
. Surgical treatment with division of the flexor retinaculum
Surgical treatment with division of the extensor retinaculum
8) A 19-year-old man receives un-cross-matched blood during resuscitation after a gunshot wound to the abdomen. He develops fever, tachycardia, and oliguria during the transfusion and is diagnosed as having a hemolytic reaction. Which of the following is the most appropriate next step in the management of this patient?
. Stopping the transfusion immediately
. Administration of a loop diuretic such as furosemide
. Treating anuria with fluid and potassium replacement
. Acidifying the urine to prevent hemoglobin precipitation in the renal tubules
. Removing foreign bodies, such as Foley catheters, which may cause hemorrhagic complications
9) A 64-year-old man with history of severe emphysema is admitted for hematemesis. The bleeding ceases soon after admission, but the patient becomes confused and agitated. Arterial blood gases are as follows: pH 7.23; PO2 42 mm Hg; PCO2 75 mm Hg. Which of the following is the best initial therapy for this patient?
. Intubate the patient
. Correct hypoxemia with high-flow nasal O2
. Correct acidosis with sodium bicarbonate
. Administer 10 mg intravenous dexamethasone
. Administer 2 mg intravenous Ativan
10) A 16-year-old adolescent boy with a history of severe hemophilia A is undergoing an elective inguinal hernia repair. Which of the following is the best option for preventing or treating a bleeding complication in the setting of this disease?
. Combination of ε-aminocaproic acid and desmopressin
. Fresh-frozen plasma
. Combination of desmopressin and fresh-frozen plasma
. DDAVP
. Factor IX concentrate
11) A 23-year-old woman undergoes total thyroidectomy for carcinoma of the thyroid gland. On the second postoperative day, she begins to complain of a tingling sensation in her hands. She appears quite anxious and later complains of muscle cramps. Which of the following is the most appropriate initial management strategy?
. Continuous infusion of calcium gluconate
. 10 mL of 10% magnesium sulfate intravenously
. Oral vitamin D
. 100 μg oral Synthroid
. Oral calcium gluconate
12) A 24-year-old firefighter sustains 30% total body surface area (TBSA) burns to his torso, face, and extremities. His wounds are treated topically with silver nitrate. Which of the following complications is associated with use of this agent?
. Hyponatremia
. Hypernatremia
. Metabolic acidosis
. Hyperchloremia
. Neutropenia
13) A 22-year-old man sustains severe blunt trauma to the back. He notes that he cannot move his lower extremities. He is hypotensive and bradycardic. Which of the following is the best initial management of the patient?
. Intravenous fluid bolus
. Administration of phenylephrine
. Administration of dopamine
. Administration of epinephrine
. Placement of a transcutaneous pacer
14) A 14-year-old boy presents in the emergency department with very severe pain of sudden onset in his right testicle. There is no history of either trauma or recent mumps. He is afebrile, and a urinalysis shows no pyuria. The testis is swollen, exquisitely painful, high in the scrotum, and riding in a horizontal position. The cord above the testis is not tender. Which of the following is the most appropriate next step in management?
Emergency surgery
Testicular biopsy
IV antibiotics
Ice packs, analgesics, and careful observation
Sonogram of the testicle
15) A 59-year-old man with a history of myocardial infarction 2 years ago undergoes an uneventful aortobifemoral bypass graft for aortoiliac occlusive disease. Six hours later he develops ST segment depression, and a 12-lead electrocardiogram (ECG) shows anterolateral ischemia. His hemodynamic parameters are as follows: systemic BP 70/40 mm Hg, pulse 100 beats per minute, CVP 18 mm Hg, PCWP 25 mm Hg, cardiac output 1.5 L/min, and systemic vascular resistance 1000 (dynes)/cm5. Which of the following is the single best pharmacologic intervention for this patient?
. Dobutamine
. Sublingual nitroglycerin
. Intravenous nitroglycerin
. A short-acting β-blocker
. Sodium nitroprusside
16) A 56-year-old man undergoes a left upper lobectomy. An epidural catheter is inserted for postoperative pain relief. Ninety minutes after the first dose of epidural morphine, the patient complains of itching and becomes increasingly somnolent. Blood-gas measurement reveals the following: pH 7.24, PaCO2 58, PaO2 100, and HCO3− 28. Which of the following is the most appropriate initial therapy for this patient?
. Intravenous naloxone
. Endotracheal intubation
. Intramuscular diphenhydramine (Benadryl)
. Epidural naloxone
. Alternative analgesia
17) A cirrhotic patient with abnormal coagulation studies due to hepatic synthetic dysfunction requires an urgent cholecystectomy. A transfusion of FFP is planned to minimize the risk of bleeding due to surgery. What is the optimal timing of this transfusion?
. On call to surgery
. The day before surgery
. The night before surgery
. Intraoperatively
. In the recovery room
18) Ten days after an exploratory laparotomy and lysis of adhesions, a patient, who previously underwent a low anterior resection for rectal cancer followed by postoperative chemoradiation, is noted to have succus draining from the wound. She appears to have adequate source control—she is afebrile with a normal white blood count. The output from the fistula is approximately 150 cc per day. Which of the following factors is most likely to prevent closure of the enterocutaneous fistula?
. Previous radiation
. Previous chemotherapy
. Recent surgery
. History of malignancy
. More than 100-cc output per day
19) A 45-year-old woman undergoes an uneventful laparoscopic cholecystectomy for which she receives 1 dose of cephalosporin. One week later, she returns to the emergency room with fever, nausea, and copious diarrhea and is suspected of having pseudomembranous colitis. She is afebrile and has no peritoneal signs on abdominal examination. She has a mild leukocytosis with a left shift. Which of the following is the appropriate initial management strategy?
. Administration of oral metronidazole
. Administration of an antidiarrheal agent
. Exploratory laparotomy with left hemi-colectomy and colostomy
. Exploratory laparotomy with subtotal abdominal colectomy and ileostomy
. Administration of intravenous vancomycin
20) An 18-year-old woman develops urticaria and wheezing after an injection of intravenous contrast for an abdominal CT scan. Her blood pressure is 120/60 mm Hg, heart rate is 155 beats per minute and respiratory rate is 30 breaths per minute. Which of the following is the most appropriate immediate therapy?
. Epinephrine
. Intubation
. β-Blockers
. Iodine
. Fluid challenge
21) A patient involved in a high-speed automobile collision arrives in the emergency department unconscious, with multiple facial fractures; brisk bleeding into his nose, mouth, and throat; and gurgly, irregular, noisy breathing. Which of the following would be the best method to secure an airway in this patient?
Cricothyroidotomy done in the emergency department
Nasotracheal intubation with visualization of the cords
Orotracheal intubation with rapid anesthetic induction
Percutaneous transtracheal ventilation
Emergency tracheostomy done in the emergency department
22) A 22-year-old woman is involved in a major motor vehicle accident and receives a tracheostomy during her hospitalization. Five days after placement of the tracheostomy she has some minor bleeding around the tracheostomy site. Which of the following is the most appropriate immediate therapy?
. Bronchoscopic evaluation of the trachea in the operating room.
. Removal of tracheostomy at bedside.
. Exchange the tracheostomy at bedside.
. Exchange the tracheostomy in the operating room.
. Bronchoscopic evaluation of the trachea at bedside.
23) A 33-year-old woman is brought to the emergency room from the scene of a severe motor vehicle accident. She is combative, confused, uncooperative, and appear dusky and dyspneic. Which of the following is the most appropriate management of her airway?
. Intubation should be performed as soon as possible (in the emergency room) if the patient is unstable.
. Awake endotracheal intubation is indicated in patients with penetrating ocular injury.
. Steroids have been shown to be of value in the treatment of aspiration of acidic gastric secretions.
. The stomach may be assumed to be empty only if a history is obtained indicating no ingestion of food or liquid during the prior 8 hours.
. Cricothyroidotomy is contraindicated in the presence of maxillofacial injuries.
24) A 42-year-old man who was in a house fire is transferred to your burn unit. He has singed nose hairs and facial burns. Direct laryngoscopy in the emergency room demonstrates pharyngeal edema and mucosal sloughing. He has 60% total body surface area burns. Which of the following is the next step in the management of this patient?
. Intubation
. Hyperbaric oxygen
. Intravenous steroids
. Inhaled steroids
. Bronchoscopy
25) A 24-year-old man presents in septic shock from an empyema. He is febrile to 103°F, tachycardic in the 120s, and hypotensive to the 90s. His oxygen saturation is 98% on 2-L oxygen. His white blood cell count is 25,000/mL and creatinine is 0.8 mg/dL. His blood pressure does not respond to fluid administration despite a CVP of 15. Which of the following therapies is indicated in managing this patient?
. Norepinephrine
. Intubation
. Recombinant human activated protein C
. Epinephrine
. Dobutamine
26) Shortly after the administration of an inhalational anesthetic and succinylcholine for intubation prior to an elective inguinal hernia repair in a 10-year-old boy, he becomes markedly febrile, displays a tachycardia of 160, and his urine changes color to a dark red. Which of the following is the most appropriate treatment at this time?
. Hyperventilate with 100% O2.
. Complete the procedure but pretreat with dantrolene prior to future elective surgery.
. Administer inhalational anesthetic agents.
. Administer succinylcholine.
. Acidify the urine to prevent myoglobin precipitation in the renal tubules.
27) A 37-year-old woman is brought to the surgical floor after undergoing a routine vaginal hysterectomy that morning. She had been fasting since midnight the night prior to her surgery. She has no past medical history except for uterine fibroids and takes only oral contraceptive pills regularly. During the procedure, she was reported to lose approximately 300 mL of blood. On the floor, she appears well but complains of some fatigue. Her blood pressure is 110/60 mm Hg, and her pulse is 100/min. She is not taking food or water yet because of persistent nausea and vomiting postoperatively. Which of the following is the most appropriate next step in management?
Administer IV crystalloid
No further intervention
Administer IV 25% albumin (colloid)
Transfuse packed red blood cells
Re-explore the patient under anesthesia for possible bleeding
28) A 22-year-old woman is brought to the emergency department after a motorcycle accident in which she sustained severe crush injuries of her lower extremities. In the field, her Glasgow Coma Score was 14. She is awake and alert on arrival after having been given morphine for pain control. Any details of her past medical history are unknown. Initial examination shows a blood pressure of 140/80 mm Hg and pulse of 100/min. Her oxygen saturation on room air is 95% by pulse oximeter. An ECG is obtained and shows very large, peaked T-waves in leads V1-V6. Which of the following is the most appropriate initial step in patient care?
Administer IV calcium gluconate
Administer oral sodium polystyrene sulfonate (Kayexalate)
Administer IV bicarbonate
Administer IV insulin and dextrose
Initiate urgent hemodialysis
29) A 32-year-old man undergoes a distal pancreatectomy, splenectomy, and partial colectomy for a gunshot wound to the left upper quadrant of the abdomen. One week later he develops a shaking chill in conjunction with a temperature spike of 39.4°C (103°F). His blood pressure is 70/40 mm Hg, pulse is 140 beats per minute and respiratory rate is 45 breaths per minute. He is transferred to the intensive care unit (ICU), where he is intubated and a Swan-Ganz catheter is placed. Which of the following is consistent with the expected initial Swan-Ganz catheter readings?
. An increase in cardiac output
. An increase in peripheral vascular resistance
. An increase in pulmonary artery pressure
. An increase in PCWP
. An increase in central venous pressure
30) A 72-year-old man has multiple injuries and an altered sensorium after a high-speed motor vehicle collision. He is intubated for his decreased mental status. During intubation, a large amount of gastric contents are noted in the posterior pharynx and he aspirates. Which of the following is the appropriate initial treatment?
. Bronchoscopy for aspiration of particulate matter
. Steroids
. Prophylactic antibiotics
. Inhaled nitric oxide
. High positive end-expiratory pressure
31) A 50-year-old woman with a history of essential hypertension presents to the emergency department with sudden onset of a severe headache, nausea and vomiting, and photophobia. On examination, her BP is 160/100 mmHg. She is mildly confused and has nuchal rigidity, without focal neurologic signs. Once the diagnosis has been confirmed, Rupture cerebral aneurysm, which of the following is the next most important step in patient management?
. Urgent surgical intervention with aneurysm clipping
. Admission to the ICU, close monitoring, and aggressive treatment of hypertension
. Admission to the ICU, close monitoring, and IV antibiotics
. Serial lumbar punctures to drain cerebrospinal fluid (CSF)
. Anticoagulation and antiplatelet therapy.
32) A 22-year-old gang member arrives in the emergency department with multiple gunshot wounds to the chest and abdomen. He has labored breathing and is cyanotic, diaphoretic, cold, and shivering. He is wide awake, and in a normal tone of voice he tells everyone that he is going to die. An initial survey reveals a blood pressure of 60/40 mm Hg. His pulse is 150/min and barely perceptible. He is in obvious respiratory distress and has big distended veins in his neck and forehead. His trachea is deviated to the left, and the right side of his chest is hyperresonant to percussion, with no breath sounds. Which of the following is the most appropriate initial step in management?
. A 16-gauge needle inserted in the second right intercostal space
. Emergency blood gases
. Immediate chest x-ray films
. Awake endotracheal intubation
. Pericardiocentesis
33) On the 5th postoperative day after abdominal surgery, a patient has been draining copious amounts of clear pink fluid from his midline laparotomy wound. A medical student removes the dressing, confirms that it is soaked, and sees a normal-appearing fresh wound with a row of skin staples in place. The student asks the patient to sit up so he can get out of bed and be helped to the treatment room for a more thorough examination. When the patient complies, the wound opens widely, and a handful of small bowel suddenly rushes out. Which of the following is the most appropriate management at this time?
. Cover the bowel with sterile dressings soaked in warm saline and rush the patient to the operating room
. Cover the bowel with dry sterile dressings and schedule urgent surgical closure
. Irrigate the bowel with cold antiseptic solutions while awaiting urgent surgical closure
. Take the patient to the treatment room and suture the skin edges together
. Wearing sterile gloves, push the bowel back in and tape the wound securely
34) Several days following esophagectomy, a patient complains of dyspnea and chest tightness. A large pleural effusion is noted on chest radiograph, and thoracentesis yields milky fluid consistent with chyle. Which of the following is the most appropriate initial management of this patient?
. Tube thoracostomy and low-fat diet
. Immediate operation to repair the thoracic duct
. Immediate operation to ligate the thoracic duct
. Observation and low-fat diet
. Observation and antibiotics
35) A 16-year-old girl with a history of ulcerative colitis managed with steroid therapy presents to the emergency department with a 36-hour history of nausea, crampy abdominal pain, and severe bloody diarrhea. On examination, the patient is febrile and pale, with a blood pressure of 90/60 mmHg and heart rate of 130 beats/min. Her abdomen is distended and diffusely tender. A complete blood count (CBC) demonstrates a leukocytosis with a left shift. The patient receives IV fluid resuscitation and nasogastric (NG) tube decompression. Further therapeutic interventions should include which one of the following?
. high-dose IV steroids and broad-spectrum antibiotics
. Colonoscopic decompression
. 6-mercaptopurine
. azathioprine
. Opioid antidiarrheals
36) A severely traumatized woman is seen in the emergency room (ER) with decreased mental status. Prior to intubation, she does not open her eyes, withdraws with all of her extremities, and makes incomprehensible sounds. What is her Glasgow coma scale score?
. 7
. 3
. 4
. 5
. 6
37) A 25-year-old woman was involved in a motor vehicle crash and sustained a significant closed-head injury, a pulmonary contusion, and a pelvic fracture. She is unresponsive and is ventilated in the intensive care unit (ICU). Which of the following is the best initial approach to the management of this patient’s nutritional needs?
. Early institution of NG or nasojejunal tube feeding with an elemental formulation
. Insertion of a subclavian venous catheter and initiation of central IV hyperalimentation
. Wait for extubation and improvement of neurologic status, allowing institution of an oral caloric intake
. Wait for resolution of the associated gastrointestinal ileus, followed by delayed initiation of NG tube feeding with a complex hypercaloric formulation
. peripheral IV hyperalimentation
38) A young mother is at the pediatrician's office for a routine well-baby visit for her 18-month-old son. It is immediately noticed that one of the baby's pupils is white, while the other one is black. When asked about it, the mother relates that she saw that curious situation for the first time 1 week ago, but since the baby was otherwise asymptomatic, she did not think it merited special attention. Which of the following is the most appropriate course of action?
. Seek an emergency ophthalmologic consultation for possible retinoblastoma
. Do nothing, this is a normal anatomic variant
. Inquire if the father is an albino, and do appropriate genetic counseling
. Seek an ophthalmologic consultation for suspected congenital cataract
. Treat the child with antibacterial eye drops and re-check in 2 weeks
39) A 70-year-old man is admitted to the ICU after repair of an abdominal aortic aneurysm. He has a prior history of hypertension and mild congestive heart failure, which were adequately controlled with digoxin and diuretics. To facilitate perioperative management, a Swan-Ganz (multilumen pulmonary artery) catheter was inserted in the operating room. During the first few hours postoperatively, the patient is noted to have a blood pressure of 140/70 mmHg, heart rate of 110/min, flat neck veins, a pulmonary arterial wedge pressure of 9 mmHg, and poor urine output. Which of the following is the most appropriate next step in management of this patient?
. A bolus of IV crystalloid
. IV furosemide
. A dopamine infusion
. A nitroprusside infusion
. IV digoxin administration
40) The left ureter is partially transected (50% of circumference) during the course of a difficult operation on an unstable, critically ill patient. Which of the following would be the most appropriate management of this injury given the patient’s unstable condition?
. Placement of an external stent through the proximal ureteral stump with delayed reconstruction
. Ipsilateral nephrectomy
. Placement of a catheter from the distal ureter through an abdominal wall stab wound
. Placement of a closed-suction drain adjacent to the injury
. Bringing the proximal ureter up to the skin as a ureterostomy
41) A 65-year-old man presents to the emergency department with an abrupt onset of excruciating chest pain 1 hour ago. The pain is localized to the anterior chest, but radiates to the back and neck. On examination, the patient is afebrile, with a BP of 210/110 mmHg, pulse rate of 95/min, and a respiratory rate of 12/min. He appears pale and sweaty. Unequal carotid, radial, and femoral pulses are noted. An electrocardiogram (ECG) shows nonspecific ST-T segment changes. Chest x-ray shows a slightly widened mediastinum and normal lung field. Which of the following is the first step in management of this patient?
. Control of hypertension
. Treatment with thrombolytic agents
. Systemic anticoagulation
. Placement of an intra-aortic balloon pump
. Immediate operation
42) A 26-year-old previously healthy man was pinned under a crane at a construction site. After a prolonged extrication, he was brought to the emergency department, immobilized on a back board and receiving 100% oxygen by mask. He is alert and complaining of chest pain with respiratory effort. On examination, he is found to have an oxygen saturation of 90% by pulse oximetry, shallow respirations at a respiratory rate of 35/min, heart rate of 120 beats/min, and a blood pressure of 85/60 mmHg. The trachea is deviated to the right. There is tenderness and crepitation over the left chest wall, asymmetric chest wall movement, and decreased air entry over the left lung field. Which of the following is the most appropriate next step in the initial evaluation and management of this patient?
. Needle decompression of the left chest, followed by insertion of a chest tube
. Fluid resuscitation with 2 L of isotonic crystalloid
. Portable chest x-ray
. Immediate intubation and assisted ventilation
. Emergency department thoracotomy
43) A 13-year-old boy is brought to the emergency department at midnight with a 4-hour history of right scrotal pain that was sudden in onset and associated with nausea and one episode of vomiting. On examination, he is in obvious distress. He has mild right lower abdominal tenderness, and high-riding, tender right testes. CBC and urinalysis are normal. Which of the following is the most appropriate next step in management?
. Urgent surgical exploration
. Admit the patient to the hospital and place him on bed rest
. Analgesics and a scrotal support
. Antibiotic therapy
. Schedule a testicular isotope scan
44) A 75-year-old man is brought to the emergency department for severe pain in the left flank and back of 1 hour duration. He has a prior history of a myocardial infarction and coronary artery bypass grafting 8 years ago. On examination, he is found to have a BP of 80/50 mmHg, pulse rate of 110/min, respiratory rate of 15/min, and a pulsatile, tenderabdominal mass. He has had two large-bore IV lines placed by the paramedics. He is alert and oriented, and gives consent for surgery. Which of the following is the most appropriate next step in management of this patient?
. Immediate transfer to the operating room with concomitant resuscitation and laparotomy
. Immediate consultation with cardiology to assess cardiac risk for surgery, followed by transfer to the operating room
. Resuscitation in the emergency department with IV fluids, transfer to radiology for a CT scan to assess for the location and degree of rupture, followed by transfer to the operating room
. Resuscitation in the emergency department with IV fluids to achieve a systolic BP greater than 100, followed by transfer to the operating room
. Resuscitation in the emergency department with IV fluids, transfer to radiology for immediate aortic angiogram for assessment of the location of the rupture, followed by transfer to the operating room
45) A 14-year-old boy dives into the shallow end of a swimming pool and hits his head against the bottom. When he is rescued, he shows a complete lack of neurologic function below the neck. He is still breathing on his own, but he cannot move or feel his arms and legs. The paramedics carefully immobilize his neck for transportation to the hospital, and they alert the emergency department to his impending arrival. Once there, which of the following would most likely have an immediate benefit for this patient?
. IV high-dose corticosteroids
. Hyperbaric oxygenation
. IV antibiotics
. Massive diuresis induced by loop diuretics.
. Surgical decompression of the cord
46) A 61-year-old man comes in because of colicky abdominal pain and vomiting of 3 days' duration. On physical examination, he is moderately distended and has high pitched hyperactive bowel sounds and a 5-cm tender groin mass. On direct questioning, he explains that he has had that bulge for many years, but has always been able to "push it back in" when he lies down. For the past 3 days, however, he has been unable to do so. He has a temperature of 38.9C (102F) and a white blood cell count of 12,500/mm3. Which of the following is the most appropriate management at this time?
. Urgent surgical intervention
. A sonogram of the mass
. A trial of nasogastric suction and IV fluids for a few days
. Insertion of a long rectal tube via sigmoidoscopy
. Manual reduction of the hernia, followed by a period of observation
47) In a rollover car accident, a 42-year-old woman is thrown from the car. The car subsequently lands on her and crushes her. On physical examination in the emergency department, it is determined that she has a pelvic fracture, which is confirmed by portable x-rays done as she is being resuscitated. Her initial blood pressure is 50/30 mm Hg, and her pulse is 160/min and barely perceptible. Thirty minutes later, after 2 L Ringer's lactate and 2 U packed cells have been infused, her pressure is only 70/50 mm Hg, and her pulse is 130/min. A sonogram done in the emergency department shows no intra-abdominal bleeding, and a diagnostic peritoneal lavage confirms that there is no blood in the abdomen (the recovered fluid is pink, but not grossly bloody). Rectal and vaginal exams show no injuries to those organs. There is no blood in her urine. Which of the following is the most appropriate next step in management?
. External fixation of the pelvis
. Packing of the vagina and rectum
. Angiographic embolization of torn veins
. Open reduction and internal fixation of the pelvis
. Exploratory laparotomy with pelvic dissection and hemostasis
48) A 34-year-old man is brought to the emergency department after being rescued from a burning building. His temperature is 36.90C (98.60 F), blood pressure is 90/60 mm Hg, pulse is 100/min and respirations are 28/min. Examination shows second and third degree burns over 15% of his body. His oropharynx shows erythema and scattered blisters. His lungs are clear to auscultation and his abdomen is soft and nondistended. His blood carboxyhemoglobin concentration is 20%. Which of the following is the best management for this patient?
Endotracheal intubation
High-dose corticosteroids
Broad-spectrum antibiotics
Fluid restriction
Acetylcysteine inhalation
49) A 28-year-old man is brought to the emergency department 4 hours after being involved in a motor vehicle collision. His blood pressure is 90/50 mm Hg, pulse is 120/min and respirations are 30/min. Examination shows a stuporous man with bruises over his extremities and upper abdomen. His trachea is midline and his neck veins are flat. His abdomen is moderately distended but non-tender. Immediately after being intubated and placed on mechanical ventilation he goes into cardiac arrest. Which of the following could have prevented cardiac arrest in this patient?
. Volume resuscitation
. High initial tidal volume
. Positive end-expiratory pressure
. Chest tube placement
. Pain management
50) A 28-year-old male is brought to the emergency department after being an unrestrained passenger in a motor vehicle collision. In the ambulance on his way to the hospital, he receives 2 liters of normal saline intravenously and 5 Umin of oxygen by nasal cannula. On physical examination, his blood pressure is 100/70 mmHg, heart rate is 120/min, and respiratory rate is 40/min. He is agitated and moves all four extremities spontaneously. His pupils are symmetric and reactive to light. His neck veins are distended, and his trachea is deviated to the right. Which of the following is the best initial management for this patient?
. Needle insertion into the second intercostal space in the left mid-clavicular line
. Immediate chest x-ray to confirm pneumothorax
. Immediate ultrasound exam to confirm pleural fluid accumulation
. Immediate endotracheal intubation to establish an adequate airway
. X-ray series to exclude cervical spine injury
51) A 62-year-old man presents to the emergency department (ED) with one hour of severe epigastric pain. He has been having some epigastric pain exacerbated by eating for the last several days. He feels nauseous, and has vomited once since the pain began. His past medical history is significant for hypertension, diabetes, hyperlipidemia, and coronary artery disease. He underwent coronary bypass surgery one year back. His current medications are simvastatin, aspirin, clopidogrel, metoprolol, enalapril and metformin. His blood pressure is 140/ 100 mmHg, and heart rate is 65/min. His ECG is normal. Chest x-ray findings are shown on the slide below. Which of the following is the best step in the management of this patient?
 
 
preDES
 
 
 
 
. Immediate surgical evaluation
. Abdominal CT scan
. Mesenteric angiography
. Nothing by mouth (NPO) and gastric suction
. Transthoracic echocardiography
52) A 23-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He has multiple organ injuries and is listed in critical condition. Physical examination shows an open wound in the right lower extremity and significant blood loss. He is in hypovolemic shock. Which of the following is the first parameter to change in hypovolemic shock?
. Pulse rate
. Systolic blood pressure
. Respiratory rate
. Level of consciousness
. Skin vasoconstriction
53) A 25-year-old man is brought to the emergency department after falling 12m (40ft) from a ladder. He is unconscious. Examination shows obvious head and neck injuries, and a fractured forearm. He is totally apneic. Which of the following would be the best method to establish an immediate definitive airway in this patient?
. Orotracheal intubation
. Nasotracheal intubation
. Needle cricothyroidectomy
. Intubation over a fiberoptic bronchoscope
. Surgical tracheostomy
54) A 35-year-old previously healthy male comes to the emergency department because of a 4-hour history of severe abdominal pain. The pain had initially started in the periumbilical area but has now shifted to the right lower quadrant. He also felt nauseated and vomited twice. He has had no previous surgeries. His temperature is 38.9C (102F), blood pressure is 125/80 mm Hg, pulse is 100/min and respirations are 20/min. Examination shows tenderness in the right lower quadrant. Palpation of the left lower quadrant produces pain in the right lower quadrant. Urinalysis is negative. Which of the following is the most appropriate next step in management?
. Immediate surgery
. Ultrasound of the abdomen
. CT scan of the abdomen
. Conservative management
. Colonoscopy
55) A 22-year-old man involved in a motor vehicle collision undergoes a prolonged operation to repair a left femur fracture and femoral artery injury. During the first night after surgery he has pain in the left leg. Despite adequate narcotics, his pain is unremitting; the pain is worse with passive leg movement. Examination shows a pale and swollen leg that is tender to the touch; pulses are palpable. Which of the following is the most appropriate next step in management?
. Go back to the operating room
. Increase the dose of narcotics
. Elevate the leg and place ice packs
. Get an x-ray to make sure the femur fracture is not displaced
. Go to ICU
56) A 4-year-old boy is brought into the emergency room by his parents for difficulty in breathing and swallowing. On physical examination the child is febrile, tachycardic, and tachypneic. He is anxious, drooling, and becomes increasingly exhausted while struggling to breathe. A lateral cervical spine radiograph is shown here. Which of the following is the most appropriate management of this patient?
 
 
Last but not least
. Immediate endotracheal intubation in the operating room
. Examine the larynx at bedside
. IV antibiotics and admission to the floor
. Immediate endotracheal intubation in the emergency room
. Immediate tracheostomy in the operating room
57) A 27-year-old man sustains a single gunshot wound to the left thigh. In the ER, he is noted to have a large hematoma of his medial thigh. He complains of paresthesias in his left foot. On examination, there are weak pulses palpable distal to the injury and the patient is unable to move his foot. Which of the following is the most appropriate initial management of this patient?
. Immediate exploration and repair in the operating room
. Angiography
. Fasciotomy of the anterior compartment of the calf
. Observation for resolution of spasm
. Local wound exploration at the bedside
58) A 25-year-old woman arrives in the ER following an automobile accident. She is acutely dyspneic with a respiratory rate of 60 breaths per minute. Breath sounds are markedly diminished on the right side. Which of the following is the best first step in the management of this patient?
. Decompress the right pleural space.
. Take a chest x-ray.
. Draw arterial blood for blood-gas determination.
. Perform pericardiocentesis.
. Administer intravenous fluids.
59) A 75-year-old man with a history of coronary artery disease, hypertension, and diabetes mellitus undergoes a right hemicolectomy for colon cancer. On the second postoperative day, he complains of shortness of breath and chest pain. He becomes hypotensive with depressed mental status and is immediately transferred to the intensive care unit. After intubation and placement on mechanical ventilation, an echocardiogram confirms cardiogenic shock. A central venous catheter is placed that demonstrates a central venous pressure of 18 mm Hg. Which of the following is the most appropriate initial management strategy?
. Inotropic support
. Additional liter fluid bolus
. Mechanical circulatory support with intra-aortic balloon pump (IABP)
. Cardiac catheterization
. Heart transplant
60) A 27-year-old man presents to the ER after a high-speed motor vehicle collision with chest pain and marked respiratory distress. On physical examination, he is hypotensive with distended neck veins and absence of breath sounds in the left chest. Which of the following is the proper initial treatment?
. Chest decompression with a needle
. Intubation
. Chest x-ray
. Pericardiocentesis
. Emergent thoracotomy
61) A 20-year-old man presents after being punched in the right eye and assaulted to the head. On a facial CT scan, he is noted to have a blowout fracture of the right orbital floor. Which of the following findings mandates immediate surgical intervention?
. Inability to move the right eye upward
. A fracture 25% of the orbital floor
. 1 mm of enophthalmos
. Periorbital ecchymosis
. Traumatic optic neuropathy
62) A 33-year-old woman is seen in the ER with severe rectal bleeding. She has a history of ulcerative colitis. Her blood pressure is 78/56 mm Hg, her pulse is 144, and she is pale and clammy. Which of the following responses is likely to occur after administration of Ringer lactate solution?
. Improvement in hemodynamics by alleviating the deficit in the interstitial fluid compartment
. Increase in serum lactate concentration
. Impairment of liver function
. Increase in metabolic acidosis
. Increase in the need for blood transfusion
63) A 4-week-old male infant presents with projectile, nonbilious emesis. Ultrasound of the abdomen reveals a pyloric muscle thickness of 8 mm (normal 3-4 mm). Which of the following is the best initial management of this patient?
. Fluid hydration and correction of electrolyte abnormalities prior to operative management
. Urgent pyloromyotomy
. Urgent pyloroplasty
. Urgent gastroduodenostomy
. Administration of sodium bicarbonate to correct aciduria prior to operative management
64) A 1-month-old female infant presents with persistent jaundice. A serum direct bilirubin is 4.0 mg/dL and an ultrasound of the abdomen shows a shrunken gallbladder and inability to visualize the extrahepatic bile ducts. Which of the following is the most appropriate initial management of this patient?
. Exploratory laparotomy
. NPO and total parenteral nutrition
. Oral choleretic bile salts
. Methylprednisolone
. IV antibiotics
65) A full-term male newborn experiences respiratory distress immediately after birth. A prenatal sonogram was read as normal. An emergency radiograph is shown here. The patient is intubated and placed on 100% O2. Arterial blood gases reveal pH 7.24, PO2 60 kPa, and PCO2 52 kPa. The baby has sternal retractions and a scaphoid abdomen. Which of the following should be performed in the management of this patient?
 
 
Last but not least
. Mechanical ventilation with low tidal volumes
. Administration of intravenous steroids
. Placement of bilateral tube thoracostomies
. Immediate thoracotomy with lung resection
. Immediate laparotomy with repair of the diaphragm
66) A 10-year-old girl is the unrestrained backseat passenger in a high-speed motor vehicle collision. She is intubated in the field for unresponsiveness and on presentation to the ER, her heart rate is 160 beats per minute, and her blood pressure is 60/35 mm Hg. She weighs 30 kg. Which of the following is the most appropriate recommendation for her fluid resuscitation?
. Bolus 600 cc of normal saline initially followed by a repeat bolus. Transfuse if no response
. Bolus 1 L of normal saline initially.
. Bolus 1 L of 5% albumin initially.
. Transfuse 300 cc of packed RBCs initially
. Bolus 600 cc of normal saline initially. Transfuse if no response.
67) A 21-year-old woman sustains a stab wound to the middle of the chest. Upon arrival to the ER she has equal breath sounds, blood pressure of 85/46 mm Hg, distended neck veins, and pulsus paradoxus. Which of the following is the most appropriate management of this patient?
. Emergent pericardiocentesis or subxiphoid pericardial drainage under local anesthesia in the operating room
. Emergent intubation and mechanical ventilation in the ER
. Emergent pericardiocentesis in the ER
. Emergent thoracotomy in the ER
. Emergent pericardiocentesis or subxiphoid pericardial drainage after anesthetic induction in the operating room
68)A 58-year-old man presents to the ER after falling 10 ft from a ladder. Examination reveals stablevital signs, no evidence of respiratory distress, and multiple right-sided rib fractures. Chest x-ray shows a hemothorax on the right side and a right tube thoracostomy is performed in the ER. Approximately 700 mL of blood is immediately drained with placement of the thoracostomy tube. Over the next 4 hours he continues to drain 300 mL/h after the original evacuation. Which of the following is the definitive treatment for this patient?
. Thoracotomy in the operating room
. Platelets
. Fresh-frozen plasma
. Second tube thoracostomy
. Thoracotomy in the ER
69)A 25-year-old man is brought to the emergency department by ambulance after falling from a ladderfor 12 m (40 ft). He was placed on a backboard for spinal stabilization. Intravenous access was obtained en route, and infusion of crystalloids was initiated. The patient is comatose on arrival to the emergency department. Examination shows facial lacerations, a depressed skull fracture, and a forearm fracture. In the emergency department, his blood pressure is 92/45 mm Hg, pulse is 127/min, and respirations are 6/min. His pulse oximetry shows 86% on 40% facemask oxygen. Which of the following is the most appropriate next step in management?
. Orotracheal intubation
. Laryngeal mask placement and manual bagging
. Nasotracheal intubation
. Needle cricothyroidotomy
. Surgical tracheostomy
70)A 62-year-old man presents to the emergency department (ED) with one hour of severe epigastricpain. He has been having some epigastric pain exacerbated by eating for the last several days. He feels nauseated, and has vomited once since the pain began. His past medical history is significant for hypertension, diabetes, hyperlipidemia, and coronary artery disease. He underwent coronary bypass surgery one year back. His current medications are simvastatin, aspirin, clopidogrel, metoprolol, enalapril and metformin. His blood pressure is 140/100 mmHg, and heart rate is 65/min. His ECG is normal. Chest x-ray findings are shown on the slide below. Which of the following is the best step in the management of this patient?
 
 
Last but not least
. Immediate surgical evaluation
. Transthoracic echocardiography
. Nothing by mouth (NPO) and gastric suction . Mesenteric angiography . Abdominal CT scan . Immediate
. Mesenteric angiography
. Immediate surgical evaluation
71) A 42-year-old man is found unconscious at the scene of a motor vehicle collision. He is rushed to the emergency department, where his blood pressure is found to be 70/40 mm Hg and his respirations are 32/min. On physical examination, his trachea is deviated to the left and his breath sounds are decreased on the right side. His neck veins are distended bilaterally. The abdomen is soft and non-distended. There is significant swelling of the right thigh. Which of the following is the most appropriate next step in the management of this patient?
. Needle thoracostomy
. Bedside echocardiography
. CT scan of the chest with contrast
. Intubation and mechanical ventilation
. Two large bore IV lines and fluid resuscitation
72) A 54-year-old man is brought to the emergency department 10 minutes after being involved in a motor vehicle accident. He was an unrestrained driver and hit a car while speeding on the highway. On arrival to the emergency department, he is spontaneously breathing and noncyanotic. His temperature is 37°C (98.6°F), blood pressure is 104/50 mm Hg, pulse is 122/min, and respirations are 16/min. Examination shows facial lacerations and multiple ecchymoses on the anterior chest and abdomen. He appears obtunded. Which of the following is a component of the Glasgow coma scale (GCS) assessment for this patient?
. Eye opening
. Capillary refill
. Deep tendon reflexes
. Gag reflex
. Pupillary reaction
1) A 22-year-old man is stabbed in the right chest with a 5-cm-long knife blade. On arrival at the emergency department, he is wide awake and alert. He is speaking with a normal tone of voice but complaining of shortness of breath. The right hemithorax is hyperresonant to percussion and has no breath sounds; the rest of the initial survey is negative. His blood pressure is 110/75 mm Hg, pulse is 86/min, and venous pressure is 3cm H2O. Pulse oximetry shows a saturation of 85%. Which of the following is the most appropriate next step in patient care?
Chest x-ray and insertion of a chest tube
Infusion of 2 L Ringer's lactate
Securing an airway by orotracheal intubation
Immediate insertion of a needle into the right pleural space
Sonographically guided evacuation of the pericardial sac
2) A one-year-old boy is brought to the emergency department with scalds on both the buttocks and thighs. His mother states that the child was burned because she accidentally drew a bath for the child with water that was too hot. She states the injury occurred 2 days ago. On examination, the child is irritable. Second-degree burns are noted on the buttocks, genitalia, waist, proximal thighs and feet. There is an abrupt demarcation between the burned and unaffected skin. A faint yellow patch of discoloration is noted on the left thorax with a slight violaceous hue. The child has not yet had his 1-year vaccinations. Which of the following is the most appropriate next step in management?
. Admit the patient and do a skeletal survey
. Give wound care instructions and send the patient home with analgesics
. Give wound care instructions and advise the mother that she should keep the temperature of the water heater below 140 F to avoid such injuries in future
. Ask the mother if the child is being abused
. Advise the mother of the suspected abuse, but do not notify authorities because this is a violation of patient confidentiality
3) A 47-year old woman comes to the clinic because of worsening left breast swelling and pain. She had mastitis when she nursed her first child 20 years ago. She has not seen a doctor since that time. She is afebrile. Breast examination shows the left breast is enlarged with a 7 x 6 cm area of edema and erythema. A poorly localized mass without fluctuation is palpated in that area. Scant non-bloody discharge is noted on the nipple, and several large axillary nodes are palpated. Which of the following is the most appropriate next step in management?
. Biopsy for histology and treatment depending on the findings of the histology
. Antibiotic active against Streptococci and Staphylococci
. Culture of the discharge and treatment depending on the findings of the culture
. Drainage, culture of the drained exudate and treatment depending on the findings of the culture
. Biopsy for culture and treatment depending on the findings of the culture
4) A man involved in a high-speed, head-on automobile collision arrives at the emergency department in a deep coma. His pupils react poorly to light but are of equal size. An airway is placed, and the patient is sent for CT scan of the head with extension to the neck. The study shows no cervical spine fractures, but does reveal a small, crescent-shaped hematoma on the right side, with no deviation of the midline structures. Which of the following is the most appropriate next step in management?
Hyperventilation, diuretics, and fluid restriction
High-dose steroids
Systemic vasodilators and alpha blockers
Surgical evacuation of his epidural hematoma
Surgical evacuation of his subdural hematoma
5) A 19-year-oldgangmemberisshotintheabdomenwith a .38 caliber revolver. The entry wound is in the epigastrium, to the left of the midline. The bullet is lodged in the psoas muscle on the right. He is hemodynamically stable, and the abdomen is moderately tender. Which of the following is the most appropriate next step in diagnosis?
Exploratory laparotomy
Close clinical observation
Emergency ultrasound
CT scan of the abdomen
Diagnostic peritoneal lavage
 
6) Five days after an uneventful cholecystectomy, an asymptomatic middle-aged woman is found to have a serum sodium level of 125 mEq/L. Which of the following is the most appropriate management strategy for this patient?
. Restriction of free water
. Administration of hypertonic saline solution
. Plasma ultrafiltration
. Hemodialysis
. Aggressive diuresis with furosemide
7) A 33-year-old woman is undergoing a diagnostic work-up because she appears to have Cushing syndrome. She has elevated levels of cortisol, which are not suppressed when she is given high-dose dexamethasone. ACTH levels are greater than 200 pg/ mL. A chest x-ray film shows a central, 3-cm round mass on the hilum of the right lung. Bronchoscopy and biopsies confirm a diagnosis of small cell carcinoma of the lung. Which of the following is the preferred treatment for this woman?
. Radiation and chemotherapy directed at the lung cancer
. Bilateral adrenalectomy
. General support only
. Pneumonectomy . Radiation and
. Trans-sphenoidal hypophysectomy and pulmonary lobectomy
8) A multiple trauma patient receives 14 units of packed red cells and several liters of Ringer's lactate solution during a laparotomy for multiple intra-abdominal injuries. The surgeons note that blood is oozing from all dissected raw surfaces, as well as from his TV line sites. His core temperature is normal. Which of the following is the most appropriate next step in management?
Empiric administration of fresh frozen plasma and platelet packs
Proceed with surgery and give blood transfusions as needed
Obtain a stat coagulation profile to guide specific therapy
Abort the operation and close the abdomen with towel clips
Leave the abdomen open and covered with mesh until coagulation parameters can be corrected
9) A patient with a nonobstructing carcinoma of the sigmoid colon is being prepared for elective resection. Which of the following reduces the risk of postoperative infectious complications?
. A single preoperative parenteral dose of antibiotic effective against aerobes and anaerobes
. Avoidance of oral antibiotics to prevent emergence of Clostridium difficile
. Postoperative administration for 48 hours of parenteral antibiotics effective against aerobes and anaerobes
. Postoperative administration of parenteral antibiotics effective against aerobes and anaerobes until the patient’s intravenous lines and all other drains are removed
. Redosing of antibiotics in the operating room if the case lasts for more than 2 hours
10) A young man is shot with a .45 caliber revolver, point blank in the lower abdomen, just above the pubis. The entrance wound is at the midline, and there is no exit wound. X-ray films show the bullet embedded in the sacral promontory, to the right of the midline. Digital rectal examination and proctoscopic examination are negative, but he has gross hematuria. He is hemodynamically stable. Which of the following is the most appropriate next step in management?
. Exploratory laparotomy
. CT scan of the abdomen
. Intravenous pyelogram
. Retrograde cystogram
. Diagnostic peritoneal lavage
11) A 25-year-old man is shot with a .22 caliber revolver. The entrance wound is in the anteromedial aspect of his upper thigh, and the exit wound is about 3 inches lower, in the posterolateral aspect of the thigh. He has a large, expanding hematoma in the upper inner thigh. There are no palpable pulses in the foot. The bone is intact by physical examination and x-ray films. Which of the following is the most appropriate next step in management?
. Surgical exploration
. Doppler studies
. Venogram
. Arteriogram
. Embolectomy
12) A 44-year-old woman is recovering from a mild episode of acute ascending cholangitis secondary to choledocholithiasis. When seen initially, she had a spiking fever, leukocytosis, and a very high alkaline phosphatase; however, all these findings subsided rapidly after she was placed on IV antibiotics. A sonogram of the right upper quadrant on the day of admission showed the presence of gallstones in the gallbladder, but the diameter of the biliary ducts was normal. It was assumed that she had passed a common duct stone, and plans to do an endoscopic retrograde cholangiopancreatogram (ERCP) were canceled. While awaiting elective cholecystectomy, she again developed a fever and leukocytosis, and her liver function tests showed minimal elevation of her bilirubin (to 2.5 mg/dL) and alkaline phosphatase (to 115 U/L). A repeat sonogram shows no changes in her biliary ducts, but now there is a 6-cm abscess in the right lobe of the liver. Which of the following is the most appropriate treatment for this new development?
. Percutaneous drainage of the liver abscess
. Metronidazole
. Long-term IV antibiotics
. ERCP and biliary drainage
. Open surgical resection of the right lobe of the liver
13) On the 5th postoperative day, it is noticed that large amounts of clear, pink, salmon-colored fluid are soaking the wound dressings of a patient who had a negative exploratory laparotomy for a stab wound of the abdomen. The laparotomy was done through a midline supraumbilical and infraumbilical incision. When seen by the surgical staff, the patient is lying in bed in the supine position, with the dressings removed. In the dim light of his hospital room, the incision appears intact and not particularly red or inflamed, but there are indeed traces of the clear pink fluid on his skin. He has no specific complaints. He is still NPO and on IV fluids, but has already been passing gas per rectum, and plans had been made to feed him today. The abdomen is not distended, and he has normal bowel sounds. He is afebrile. Which of the following is the most appropriate next step in management?
. Tape the wound securely, bind the abdomen, and avoid events that would suddenly increase his intra-abdominal pressure
. Culture the pink fluid and start empiric antibiotic therapy
. Gently probe the wound at several points until pus is found and drained
. Help the patient out of bed and have him walk to the examining room for proper inspection of the wound
. Stop plans for oral feedings and start total parenteral nutrition
14) A 2-year-old child has been shot in the arm in a drive-by shooting. His brachial artery was partially transected, and there was copious bleeding. The EMTs control the site of bleeding by local pressure, and the child is no longer losing blood; however, he is hypotensive and tachycardic. IV fluid resuscitation is urgently needed, but several attempts at starting peripheral IV lines have been unsuccessful. Which of the following would be the best alternative route in this situation?
. Intraosseous cannulation in the proximal tibia
. Central line via subclavian puncture
. Hypodermoclysis
. Percutaneous femoral vein cannulation
. Saphenous vein cut-down
15) A 62-year-old woman has a 4-cm, hard mass under the nipple and areola of her rather small left breast. The mass occupies most of the breast, but the breast is freely movable from the chest wall. There is no dimpling or ulceration of the skin over the mass, and careful palpation of the axilla is completely negative. A core biopsy of the breast mass has established a diagnosis of infiltrating ductal carcinoma, and the mammogram showed no other lesions in that breast or the other one. A chest x-ray film and liver function tests are normal. She has no symptoms suggestive of brain or bone metastasis. Which of the following should be offered to this woman?
. Modified radical mastectomy (including axillary sampling)
. Lumpectomy only
. Lumpectomy with axillary sampling and post-op radiation
. Total mastectomy only
. Radical mastectomy (including complete axillary dissection
16) While running to catch a bus, and old man twists his ankle and falls on his inverted foot. Anteroposterior (AP), lateral, and mortise x-ray films show displaced fractures of both malleoli. Which of the following would be the preferred form of treatment?
. Open reduction and internal fixation
. Closed reduction and casting
. Skeletal traction
Replacement with a metal prosthesis
. Fusion of the ankle joint
17) Renal ultrasound and intravenous pyelography (IVP) in a 65-year-old man evaluated for urinary incontinence reveal bilateral hydronephrosis. Which of the following is the most likely condition leading to this complication?
Prostatic hyperplasia
Age-associated detrusor overactivity
Alzheimer disease
Normal pressure hydrocephalus
Previous surgery
18) A 57-year-old man is undergoing a femoral-popliteal bypass of his right lower extremity because of severe peripheral vascular disease. This patient has a longstanding history of claudication and shortness of breath. He had a myocardial infarction 3 years ago and has had progressive limitation of his exercise capacity because of his peripheral vascular disease. He has not had any risk stratification after his infarction. Two weeks ago, he underwent a lower extremity arterial study that showed severe diffuse disease of his right leg arterial system. The patient is brought to the operating room, and, during the procedure, his right lower extremity is made bloodless by application of a thigh tourniquet for 1.5 hours. The surgeons complete their bypass and are preparing to restore blood flow. Which of the following is an expected consequence of this maneuver?
Decrease in blood pressure
Increase in cardiac output
Increase in preload
Increase in venous return
Sinus bradycardia
19) A 52-year-old man with gastric outlet obstruction secondary to a duodenal ulcer presents with hypochloremic, hypokalemic metabolic alkalosis. Which of the following is the most appropriate therapy for this patient?
. Infusion of 0.9% NaCl with supplemental KCl until clinical signs of volume depletion are eliminated
. Infusion of isotonic (0.15 N) HCl via a central venous catheter
. Clamping the nasogastric tube to prevent further acid losses
. Administration of acetazolamide to promote renal excretion of bicarbonate
. Intubation and controlled hypoventilation on a volume-cycled ventilator to further increase PCO2
20) A 31 -year-old man is brought to the emergency department after a motor vehicle accident. He sustained a severe head injury and, on arrival to the emergency department, has a Glasgow coma score of 8. His blood pressure is stable, and an urgent CT scan of the head reveals a large subdural bleed with evidence of a midline shift and cerebellar tonsillar compression. The patient is breathing spontaneously without any respiratory assistance and is not intubated. Which of the following is the most appropriate next step in management?
Perform endotracheal intubation and hyperventilation
Obtain an urgent head MRI to evaluate for herniation
Administer IV mannitol
Induce a barbiturate coma
Initiate immediate surgical decompression
21) A victim of blunt abdominal trauma has splenic and liver lacerations as well as an unstable pelvic fracture. He is hypotensive and tachycardic with a heart rate of 150 despite receiving 2 L of crystalloid en route to the hospital. He was intubated prior to arrival due to declining mental status. He is taken emergently to the operating room for exploratory laparotomy and external fixation of his pelvic fracture. Which of the following is the best resuscitative strategy?
. Infusion of packed red blood cells and early administration of fresh-frozen plasma and platelets prior to return of laboratory values
. Infusion of another liter of crystalloid
. Infusion of 500 mL of 5% albumin
. Infusion of packed red blood cells followed by fresh-frozen plasma and platelets as indicated by the PT and platelet counts on laboratory values
. Infusion of packed red blood cells and vitamin K
22) A 62-year-old man who had a motorcycle accident has been in a coma for several weeks. He is on a respirator, has had pneumonia on and off, has been on pressors, and shows no signs of neurologic improvement. The family inquires about brain death and possible organ donation. An independent neurologic evaluation confirms that the patient is brain dead. What advice should be given to his family? Anyone who
The harvesting team should evaluate him as a potential donor
Anyone who has had pneumonia is excluded as a donor
He is not a suitable donor because of his ag
Patients on respirators cannot donate organs
The use of pressors precludes organ donation
23) A 35-year-old man with new diagnosis of Crohn disease presents with rapidly enlarging painful ulcerations on the lower extremities. Cultures of the lesion are negative, and skin biopsy reveals no evidence of malignancy. Which of the following is the most appropriate treatment option?
. Systemic steroids and immunosuppressants
. Surgical debridement of the wound with skin grafting
. Local wound care with silver sulfadiazine
. Topical corticosteroids
. Saphenous vein stripping and compressive stockings
24) A 23-year-old man is admitted to the hospital after being struck by a motor vehicle. The patient sustained a compound fracture of his left femur in the accident and has had moderate blood loss. He was admitted to the hospital, has been stabilized over the past few days, and is now preparing for physical therapy. His hematocrit is 24%. The man feels weak and fatigued and easily gets short of breath with mild exertion. Which of the following is the most appropriate next step in management?
Transfuse packed red blood cells to a hematocrit goal of 30%
Continue with physical therapy; no transfusion is indicated
Discontinue physical therapy until the patient recovers more of his strength
Transfuse fresh frozen plasma to a hematocrit goal of 30%
Transfuse whole blood to a goal hematocrit of 30%
 
 
{"name":"(EXAM) DES 2016-2017 : 2040-2299 (Rabid Wolverine) 1", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"135) A 36-year-old male presents with firm, non-tender swelling of his right cheek. He tells you that he had similar swelling at that site two years ago and was diagnosed with a tumor, which was subsequently removed without complication. Examination reveals fullness of the pre-auricular space on the right side. Repeat surgery in this patient is most likely to result in which of the following complications?, 136) A 39-year-old paleontologist complains of right-sided hip pain that makes it very difficult for him to lie on his right side while sleeping. He localizes the pain to the outer surface of his thigh. He was recently diagnosed with hypertension and hyperlipidemia. He takes hydrochlorothiazide and atorvastatin. He has smoked one pack of cigarettes daily for 15 years. He does not use alcohol or illicit drugs. Which of the following is the most likely cause of his pain?, 137) A 65-year-old male is being evaluated for hip pain. The pain has been present for several months and is constant. He denies any weight loss or loss of appetite. His past medical history is significant only for high blood pressure. His temperature is 37.2°C (98.9°F), blood pressure is 150\/88 mm Hg, pulse is 80\/min and respirations are 12\/min. Physical examination is unremarkable. Laboratory studies show: Alkaline phosphatase Elevated, Gamma glutamyl transferase Normal, Serum calcium Normal, 25, (OH)2 vitamin D Normal. Bone scan shows increased uptake in several spots. This patient is at the highest risk of developing?","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
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