Pg 2070-2101

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?
Doppler studies
Venogram
Arteriogram
Embolectomy
Surgical exploration
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?
Metronidazole
Long-term IV antibiotics
ERCP and biliary drainage
Percutaneous drainage of the liver abscess
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?
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
Tape the wound securely, bind the abdomen, and avoid events that would suddenly increase his intra-abdominal pressure
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?
Central line via subclavian puncture
Hypodermoclysis
Intraosseous cannulation in the proximal tibia
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?
Lumpectomy only
Lumpectomy with axillary sampling and post-op radiation
Total mastectomy only
Modified radical mastectomy (including axillary sampling)
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?
Closed reduction and casting
Skeletal traction
Open reduction and internal fixation
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?
Age-associated detrusor overactivity
Alzheimer disease
Normal pressure hydrocephalus
Previous surgery
Prostatic hyperplasia
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?
Obtain an urgent head MRI to evaluate for herniation
Administer IV mannitol
Perform endotracheal intubation and hyperventilation
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 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 early administration of fresh-frozen plasma and platelets prior to return of 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 has had pneumonia is excluded as a donor
He is not a suitable donor because of his age
Patients on respirators cannot donate organs
The harvesting team should evaluate him as a potential donor
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?
Surgical debridement of the wound with skin grafting
Local wound care with silver sulfadiazine
Topical corticosteroids
Systemic steroids and immunosuppressants
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?
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 packed red blood cells to a hematocrit goal of 30%
Transfuse whole blood to a goal hematocrit of 30%
25) A 24-year-old woman is brought to the emergency department after being stabbed by her boyfriend. The examining physician notes a 1.5 cm puncture wound lateral to her sternum. She has a blood pressure of 70/min palpable, distended neck veins, and muffled heart sounds. Which of the following is the most appropriate next step in management?
Cardiac surgery consult
Echocardiogram
Chest x-ray film
Chest tube placement
Pericardiocentesis
26) A 60-kg, 53-year-old man with no significant medical problems undergoes lysis of adhesions for a small-bowel obstruction. Postoperatively, he has high nasogastric output and low urine output. What is the most appropriate management of his fluids?
Infusion of D5 0.45% normal saline at 100 mL/h
Infusion of D5 0.9% normal saline at 100 mL/h
Infusion of D5 lactated Ringer at 100 mL/h
Replacement of nasogastric tube losses with lactated Ringer in addition to maintenance fluids
Replacement of nasogastric tube losses with 0.45% normal saline with 20 mEq/L of potassium chloride in addition to maintenance fluids
27) Four days after surgical evacuation of an acute subdural hematoma, a 44-year-old man becomes mildly lethargic and develops asterixis. He has received 2400 mL of 5% dextrose in water intravenously each day since surgery, and he appears well hydrated. Pertinent laboratory values are as follows:Serum electrolytes (mEq/L): Na+ 118, K+ 3.4, Cl− 82, HCO3− 24Serum osmolality: 242 mOsm/LUrine sodium: 47 mEq/LUrine osmolality: 486 mOsm/LWhich of the following is the best treatment of his hyponatremia?
Insulin infusion to keep his glucose level less than 110 mg/dL
Slow infusion of 3% normal saline until neurologic symptoms are improved
Rapid infusion of 3% normal saline to correct the sodium to normal
Desmopressin (DDAVP) administration
Administration of a loop diuretic
28) A 22-year-old woman has a known family history of breast cancer Mammography every 6 months starting at age 35in her first-degree relatives. She undergoes genetic testing and is found to be a BRCA1 mutation carrier. She does not currently desire bilateral prophylactic mastectomy. Which of the following is the next best option to manage her risk for breast cancer?
Mammography every 6 months starting at age 25
Mammography every 6 months starting at age 35
Mammography every 12 months starting at age 25
Mammography every 12 months starting at age 35
Tamoxifen for chemoprevention
29) A 30-year-old woman comes to the physician 6 hours after falling on her outstretched right hand. She has pain and limitation of movement in her wrist, but denies sensations of tingling or numbness. The right wrist is mildly swollen, and its range of passive motion is limited compared with the left side. Palpation elicits maximal tenderness in the area of the anatomic snuffbox, between the tendons of the extensor pollicis longus and abductor pollicis muscles. Ulnar and radial pulses are normal, and Tinel's and Phalen's tests are negative. Further examination rules out signs of nerve or vascular damage. Plain x-ray films performed in the anteriorposterior, lateral, and oblique views fail to show any evidence of fractures. At this time, which of die following is the most appropriate next step in management?
Bone scanning
MRI examination of the wrist
Treatment for wrist sprain
Treatment for scaphoid fracture
Angiography Pulmonaire
30) A 72-year-old woman undergoes a partial colectomy for adenocarcinoma of the sigmoid colon. She receives appropriate antibiotic coverage and low-dose heparin prophylaxis. On the 5th hospital day, the patient begins complaining of right chest pain, difficulty in breathing, and dry cough. Her temperature is 37.9C (100.2F), blood pressure is 134/78 mm Hg, pulse is 115/min and regular, and respirations are 20/rnin. Examination shows crackles in the right chest, but no tenderness or edema in the legs. A chest x-ray film reveals areas of opacification in the right lung. ECG reveals sinus tachycardia with nonspecific ST changes. Laboratory studies show: Arterial blood gas analysis- PaO2 74 mm Hg- PaCO2 37 mm Hg- pH 7.35- Blood/serumHematocrit 40%- Leukocytes 8300/mm3- Lactate dehydrogenase 350 U/L- Fibrin Ddimer 600 ng/mL (normal upper limit 500 ng/mL)Which of the following is the most appropriate step in diagnosis?
Bronchoalveolar lavage
Contrast venography
Pulmonary angiography
Ultrasonography of the lower extremities
Ventilation-perfusion lung scanning
31) A 65-year-old man complains of blood in his urine for the past 2 months. He has had no similar episodes in the past. He is otherwise healthy and denies abdominal pain, any trauma, fever, chills, anorexia, or dysuria. He reports having a good urinary stream and no nocturia or dribbling. He is not sexually active. He has no other medical problems and is not taking any medications. His vital signs are stable. Lung, heart, abdominal, and groin examination are unremarkable. Rectal exam reveals a nontender prostate with no masses or enlargement- Urinalysis reveals packed red cells, a few white cells, and no casts. Which of the following is the most appropriate management?
Prescribe levofloxacin
Schedule a prostatic biopsy
Schedule a renal angiogram
Schedule a cystoscopy
Schedule a pelvic CT scan
32) A 30-year-old woman in her last trimester of pregnancy suddenly develops massive swelling of the left lower extremity. Which of the following would be the most appropriate workup and treatment at this time?
Venography and heparin
Duplex ultrasonography and heparin
Duplex ultrasonography, heparin, and vena caval filter
Duplex ultrasonography, heparin, warfarin (Coumadin)
Impedance plethysmography, warfarin
33) A 20-year-old woman with a family history of von Willebrand disease is found to have an activated partial thromboplastin time (aPTT) of 78 (normal = 32) on routine testing prior to cholecystectomy. Further investigation reveals a prothrombin time (PT) of 13 (normal = 12), a platelet count of 350,000/mm3, and an abnormal bleeding time. Which of the following should be administered in the perioperative period?
Factor VIII
Platelets
Vitamin K
Aminocaproic acid
Desmopressin (DDAVP)
34) A pedestrian is hit by a car. Physical examination shows the leg to be angulated midpoint between the knee and the ankle. X-ray films confirm fractures of the shaft of the tibia and fibula. Satisfactory alignment is achieved by external manipulation, and a long leg cast applied. In the ensuing 8 hours, the patient complains of increasing pain. When the cast is removed, the pain persists, the muscle compartments feel tight, and there is excruciating pain with passive extension of the toes. Which of the following is the most appropriate next step in management?
Re-casting with a looser cast
Nerve block prior to re-casting
Arteriogram
Fasciotomy
Open reduction and internal fixation
35) A 75-year-old thin cachectic woman undergoes a tracheostomy for failure to wean from the ventilator. One week later, she develops significant bleeding from the tracheostomy. Which of the following would be an appropriate initial step in the management of this problem?
Remove the tracheostomy and place pressure over the wound
Deflate the balloon cuff on the tracheostomy
Attempt to reintubate the patient with an endotracheal tube
Upsize the tracheostomy
Perform fiberoptic evaluation immediately
37) A 35-year-old woman has dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, cough, and hemoptysis. The symptoms have been slowly progressive for about 5 years. She looks thin and cachectic, and has atrial fibrillation and a low-pitched, rumbling diastolic apical heart murmur. At age 15, she had rheumatic fever. Surgery has been recommended. Which of the following is the most appropriate management?
Closure of the ventricular septal defect
Mitral annuloplasty to tighten an incompetent mitral valve
Mitral commissurotomy to open a stenotic mitral valve
Prosthetic replacement of the aortic valve
Prosthetic replacement of the mitral valve
38) A 59-year-old man is planning to undergo a coronary artery bypass. He has osteoarthritis and consumes nonsteroidal anti-inflammatory drugs (NSAIDs) for the pain. Which of the following is the most appropriate treatment prior to surgery to minimize his risk of bleeding from his NSAID use?
Begin vitamin K 1 week prior to surgery
Give FFP few hours before surgery
Stop the NSAIDs 1 week prior to surgery
Stop the NSAIDs 3 to 4 days prior to surgery
Stop the NSAIDs the day before surgery.
39) A 63-year-old man undergoes a partial gastrectomy with Billroth II reconstruction for intractable peptic ulcer disease. He presents several months postoperatively with a megaloblastic anemia. Which of the following is the best treatment for this surgical complication?
Transfusion with 1 unit of packed red blood cells
Oral iron supplementation
Oral vitamin B12 supplementation
Intravenous vitamin B12 (cyanocobalamin) supplementation
Oral folate supplementation
40) A 52-year-old woman undergoes a sigmoid resection with primary anastomosis for recurrent diverticulitis. She returns to the emergency room 10 days later with left flank pain and decreased urine output; laboratory examination is significant for a white blood cell (WBC) count of 20,000/mm3. She undergoes a CT scan that demonstrates new left hydronephrosis, but no evidence of an intra-abdominal abscess. Which of the following is the most appropriate next step in management?
Intravenous pyelogram
Intravenous antibiotics and repeat CT in 1 week
Administration of intravenous methylene blue
No further management if urinalysis is negative for hematuria
Immediate reexploration
41) A 63-year-old man with history of poorly controlled diabetes presents with right leg swelling and pain. The patient denies trauma to the leg and reports it was normal yesterday. Examination of the right lower extremity is significant for extreme tenderness to palpation, erythema, and edema extending up to the knee. X ray of the right leg shows tissue swelling without gas or osteomyelitis. The patient’s vital signs are normal and he is started on broad-spectrum IV antibiotics and insulin. An hour later the patient’s heart rate increases to 125 beats per minute and the erythema has progressed to the thigh with new blister formation on the leg. Which of the following is the most appropriate next step in management?
Repeat x-ray of the right lower extremity
CT scan of the right lower extremity
MRI of the right lower extremity
Bone scan of the right lower extremity
Immediate surgical intervention with incision and direct visualization of potentially infected tissue
42) A 25-year-old man is brought to the emergency room after sustaining burns during a fire in his apartment. He has blistering and erythema of his face, left upper extremity, and chest. He also has circumferential frank charring of his right upper extremity with decreased capillary refill. He is agitated, hypotensive, and tachycardic. Which of the following is the most appropriate initial management of his wounds?
Topical antibiotics should be applied to the burn wounds
Excision of facial and hand burns
Escharotomy of the right upper extremity
Excision of all third-degree burns
Split-thickness skin grafts over the areas of third-degree burns
43) A 55-year-old woman who has end-stage liver disease is referred to a hepatologist for evaluation. Which of the following would prevent her from being a transplantation candidate?
Use of alcohol 3 months ago
Two 2-cm hepatocellular carcinomas (HCCs) in the right lobe of the liver
A 4-cm hepatocellular carcinoma in the right lobe of the liver
Development of hepatorenal syndrome requiring hemodialysis
History of breast cancer 5 years ago with no evidence of disease currently
44) A 12-year-old boy with a femur fracture after a motor vehicle collision undergoes operative repair. After induction of anesthesia, he develops a fever of 40°C (104°F), shaking rigors, and blood-tinged urine. Which of the following is the best treatment option?
Alkalinization of the urine, administration of mannitol, and continuation with the procedure
Administration of dantrolene sodium and continuation with the procedure
Administration of dantrolene sodium and termination of the procedure
Administration of intravenous steroids and an antihistamine agent with continuation of the procedure
Administration of intravenous steroids and an antihistamine agent with termination of the procedure
45) A 24-year-old Jehovah’s Witness who was in a high-speed motorcycle collision undergoes emergent splenectomy. His estimated blood loss was 1500 mL. Which of the following strategy should be employed for his resuscitation?
Vasopressors should be primarily utilized for maintenance of his blood pressure
Synthetic colloids should be administered as the primary resuscitation fluid in a 3:1 ratio to replace the volume of blood lost.
0.9% normal saline should be administered in a 1:1 ratio to replace the volume of blood lost
0.45% normal saline should be administered in a 3:1 ratio to replace the volume of blood lost
Lactated Ringer solution should be administered in a ratio of 3:1 to replace the blood lost
 
 
47) A 60-year-old woman with no previous medical problems undergoes a total colectomy with diverting ileostomy for a cecal perforation secondary to a sigmoid stricture. Postoperatively, she has 2 L of ileostomy output per day. Her heart rate is 110 beats per minute, her respiratory rate is 24 breaths per minute, and her oxygen saturation is 98% on 2-L nasal cannula (NC). Her hemoglobin levels have been stable postoperatively at 9.0 mg/dL. Her other laboratory values on postoperative day 6 are as follows:Na+: 128K+: 3.0Cl−: 102HCO3-: 20Which of the following statements is the best strategy for correcting her acid–base disorder?
Her maintenance fluids should be changed to 0.9% normal saline with 20 mEq/L of potassium chloride
She should be intubated to correct her tachypnea and prevent respiratory alkalosis
She should be transfused 2 units of packed red blood cells
She should be treated with fluid replacement and stool-bulking agents
She should undergo immediate dialysis
48) A 39-year-old man is undergoing resuscitation with blood products for an upper GI bleed. He is suspected of having a hemolytic transfusion reaction. Which of the following is appropriate in the management of this patient?
Removal of nonessential foreign body irritants, for example, Foley catheter
Fluid restriction
0.1 M HCl infusion
Steroids
Fluids and mannitol
49) A 70-kg woman is to undergo nail removal from her right ring finger in the ambulatory surgery clinic. Which of the following is the most appropriate option for local anesthesia?
Digital block with 1% lidocaine without epinephrine up to 4.5 mg/kg
Digital block with 1% lidocaine with epinephrine up to 4.5 mg/kg
Digital block with 1% lidocaine with epinephrine up to 7 mg/kg
Local injection around the nail bed with 1% lidocaine with epinephrine up to 4.5 mg/kg
Local injection around the nail bed with 1% lidocaine with epinephrine up to 7 mg/kg/mL
50) A 58-year-old woman with multiple comorbidities and previous cardiac surgery is in a high-speed motor vehicle collision. She is intubated for airway protection. Because of hemodynamic instability, a central venous catheter is placed in the right subclavian vein. While the surgeon is securing the catheter, the cap becomes displaced and air enters the catheter. Suddenly, the patient becomes tachycardic and hypotensive. What is the best next maneuver?
Decompression of the right chest with a needle in the second intercostal space
Placement of a right chest tube
Withdrawal of the central venous catheter several centimeters
Placement of the patient in a left lateral decubitus Trendelenburg position
Bilateral “clamshell” thoracotomy with aortic cross-clamping
51) A 72-year-old chronic smoker with severe chronic obstructive pulmonary disease (COPD) is found to have a central hilar mass on chest x-ray. Bronchoscopy and biopsies establish a diagnosis of squamous cell carcinoma of the lung. Pulmonary function studies show that he has a FEVj of 1100 mL, and a ventilation-perfusion scan indicates that 60% of his pulmonary function comes from the affected lung. Which of the following is the most appropriate next step in management?
CT scan of the upper abdomen to rule out liver metastasis
Mediastinoscopy to biopsy carinal nodes
Radiation and chemotherapy
Palliative pneumonectomy
Pneumonectomy with hope of cure
52) An 11-year-old girl presents to your office because of a family history of medullary carcinoma of the thyroid. Physical examination is normal. Which of the following tests should you perform?
. Urine vanillylmandelic acid (VMA) level
Serum insulin level
Serum gastrin level
Serum glucagon level
Serum somatostatin level
53) A 37-year-old woman has developed a 6-cm mass on her anterior thigh over the past 10 months. The mass appears to be fixed to the underlying muscle, but the overlying skin is movable. Which of the following is the most appropriate next step in her management?
Above-knee amputation
Excisional biopsy
Incisional biopsy
Bone scan
Abdominal CT scan
54) A 50-year-old man is incidentally discovered to have a low-grade mucosa-associated lymphoid tissue (MALT) lymphoma on biopsy of the stomach during esophagogastroduodenoscopy for dyspepsia. CT scans of the chest, abdomen, and pelvis demonstrate no evidence of enlarged regional lymph nodes or distant metastases. Which of the following is the initial treatment of choice?
Total gastrectomy with esophagojejunostomy
Total gastrectomy with esophagojejunostomy and adjuvant chemotherapy
Chemotherapy
Steroids
Antibiotics
55) A 29-year-old woman on oral contraceptives presents with abdominal pain. A computed tomography (CT) scan of the abdomen demonstrates a large hematoma of the right liver with the suggestion of an underlying liver lesion. Her hemoglobin is 6, and she is transfused 2 units of packed red blood cells and 2 units of fresh frozen plasma. Two hours after starting the transfusion, she develops respiratory distress and requires intubation. She is not volume overloaded clinically, but her chest x-ray shows bilateral pulmonary infiltrates. Which of the following is the management strategy of choice?
Continue the transfusion and administer an antihistamine
Stop the transfusion and administer a diuretic
Stop the transfusion, perform bronchoscopy, and start broad-spectrum empiric antibiotics
Stop the transfusion and continue supportive respiratory care
Stop the transfusion and send a Coombs test
56) A 68-year-old hypertensive man undergoes successful repair of a ruptured abdominal aortic aneurysm. He receives 9 L Ringer lactate solution and 4 units of whole blood during the operation. Two hours after transfer to the surgical intensive care unit, the following hemodynamic parameters are obtained: systemic blood pressure (BP) 90/60 mm Hg, pulse 110 beats per minute, central venous pressure (CVP) 7 mm Hg, pulmonary artery pressure 28/10 mm Hg, pulmonary capillary wedge pressure (PCWP) 8 mm Hg, cardiac output 1.9 L/min, systemic vascular resistance 1400 (dynes)/cm5 (normal is 900-1300), PaO2 140 mm Hg (FiO2: 0.45), urine output 15 mL/h (specific gravity: 1.029), and hematocrit 35%. Given this data, which of the following is the most appropriate next step in management?
Administration of a diuretic to increase urine output
Administration of a vasopressor agent to increase systemic blood pressure
Administration of a fluid challenge to increase urine output
Administration of a vasodilating agent to decrease elevated systemic vascular resistance
A period of observation to obtain more data
57) A 71-year-old man returns from the operating room (OR) after undergoing a triple coronary bypass. His initial cardiac index is 2.8 L/ (min•m2). Heart rate is then noted to be 55 beats per minute, BP is 110/80 mm Hg, wedge pressure is 15, and his cardiac index has dropped to 1.6 L/(min•m2). He has a normal left ventricle. Which of the following maneuvers will increase his cardiac output?
Increase his peripheral vascular resistance
Increase his CVP
Increase his heart rate to 90 by electrical pacing
Increase his blood viscosity
Increase his inspired O2 concentration
58) Eight days after a difficult hemigastrectomy and gastroduodenostomy for gastric ulcer, a patient begins to leak 2-3 L of greenish fluid per day through the right corner of his bilateral subcostal surgical incision. He is afebrile and has no clinical signs of an acute abdomen. At surgery, a feeding catheter jejunostomy was placed, through which the patient has been receiving 3 L/day of elemental diet with a caloric content of 1 cal per mL, and 1 g nitrogen per 100 cal. The nursing staffs have rigged a very effective collection device for the fluid that is leaking through the wound, and the skin around the site is well protected. Which of the following is the most appropriate next step in management?
No changes in the present therapeutic plan
Addition of 2-3 L per day of IV Ringer's lactate
Immediate discontinuation of the jejunal feeding, and replacement by 5 L/day of IV 5% dextrosehalf normal saline
Surgical drainage of the operative area
Surgical reconstruction of die gastroduodenostomy
59) Six hours after undergoing laparoscopic bilateral inguinal hernia repairs, a 62-year-old man complains of suprapubic discomfort and fullness. He feels the need to void but has not been able to do so since the operation. There is a palpable suprapubic mass that is dull to percussion. Palpation of that mass exacerbates the symptoms. Which of the following is the most appropriate next step in management?
Abdominal x-ray films to ascertain the nature of the mass
Increased rate of IV fluid administration
Loop diuretics
In and out bladder catheterization
Placement of indwelling Foley catheter
60) An 18-year-old previously healthy man is placed on intravenous heparin after having a pulmonary embolism (PE) after exploratory laparotomy for a small-bowel injury following a motor vehicle collision. Five days later, his platelet count is 90,000/μL and continues to fall over the next several days. The patient’s serum is positive for antibodies to the heparin-platelet factor complexes. Which of the following is the most appropriate next step management?
Cessation of all anticoagulation therapy
Cessation of heparin and immediate institution of high-dose warfarin therapy
Cessation of heparin and institution of low-molecular-weight heparin
Cessation of heparin and institution of lepirudin
Cessation of heparin and transfusion with platelets
61) A 62-year-old woman undergoes a pancreaticoduodenectomy for a pancreatic head cancer. A jejunostomy is placed to facilitate nutritional repletion as she is expected to have a prolonged recovery. What is the best method for delivering postoperative nutrition?
Institution of enteral feeding via the jejunostomy tube after return of bowel function as evidenced by passage of flatus or a bowel movement
Institution of enteral feeding via the jejunostomy tube within 24 hours postoperatively
Institution of supplemental enteral feeding via the jejunostomy tube only if oral intake is inadequate after return of bowel function
Institution of a combination of immediate trophic (15 mL/h) enteral feeds via the jejunostomy tube and parenteral nutrition to provide total nutritional support
Complete nutritional support with total parenteral nutrition
62) A 65-year-old woman has a life-threatening pulmonary embolus 5 days following removal of a uterine malignancy. She is immediately heparinized and maintained in good therapeutic range for the next 3 days, then passes gross blood from her vagina and develops tachycardia, hypotension, and oliguria. Following resuscitation, an abdominal CT scan reveals a major retroperitoneal hematoma. Which of the following is the best next step in management?
Immediately reverse heparin by a calculated dose of protamine and place a vena caval filter (eg, a Greenfield filter).
Reverse heparin with protamine, explore and evacuate the hematoma, and ligate the vena cava below the renal veins.
Switch to low-dose heparin.
Stop heparin and observe closely
Stop heparin, give fresh-frozen plasma (FFP), and begin warfarin therapy
63) A 24-year-old woman presents with lethargy, anorexia, tachypnea, and weakness. Laboratory studies reveal a BUN of 150 mg/dL, serum creatinine of 16 mg/dL, and potassium of 6.2 mEq/L. Chest xray shows increased pulmonary vascularity and a dilated heart. Which of the following is the most appropriate management of this patient?
Emergency kidney transplantation
Creation and immediate use of a forearm arteriovenous fistula
Placement of a catheter in the internal jugular vein and initiation of hemodialysis
A 100-g protein/day diet
Renal biopsy
64) A 56-year-old woman is undergoing a cadaveric renal transplant. After revascularization of the transplanted kidney, the transplanted renal parenchyma becomes swollen and blue. The surgeon suspects hyperacute rejection. What is the treatment of choice for this patient?
There is no therapy for hyperacute rejection
Systemic anticoagulation
Catheter-directed anticoagulation into the renal artery
Intravenous steroids
Intravenous steroids and cyclosporine
65) A 41-year-old man underwent successful living-related kidney transplantation 1 year ago with good results. Preoperatively, he was noted to have an elevated calcium level; post-transplantation, he continues to have elevated calcium levels and associated symptoms. Which of the following is the most appropriate next step in management?
99mTc sestamibi scanning
Ultrasound of the neck
CT scan of the neck and mediastinum
Total parathyroidectomy with autotransplantation of a portion of a gland into the forearm
Measurement of urinary calcium levels
66) A young man is shot in the upper part of the neck with a .22 caliber revolver. Inspection of the entrance and exit wounds indicates that the trajectory of the bullet is all above die level of the angle of the mandible, but below the skull. He is fully conscious and neurologically intact. A steady trickle of blood flows from both wounds, and it does not seem to respond to local pressure. He is hemodynamically stable. Which of the following is the most appropriate next step in diagnosis?
Continued clinical observation
Barium swallow
Arteriogram
Endoscopy
Surgical exploration
67) A 21-year-old college student undergoes surgery to remove a small cyst in his palm at the base of his third digit. He receives an axillary regional block prior to die procedure but still has discomfort postoperatively. Injection of anesmetic in which of the following sites may be used to treat his pain?
Between the palmaris longus and flexor digitorum tendons
Into die anatomic snuff box
Near the spiral groove of the humerus
Posterior to the brachioradialis muscle
Posterior to the elbow, between the olecranon and the medial epicondyle
68) A 62-year-old man is suffering from arrhythmias on the night of his triple coronary bypass. Potassium has been administered. His urine output is 20 to 30 mL/h. Serum potassium level is 6.2. Which of the following medications counteracts the effects of potassium without reducing the serum potassium level?
Sodium polystyrene sulfonate (Kayexalate)
Sodium bicarbonate
50% dextrose
Calcium gluconate
Insulin
69) An in-hospital workup of a 78-year-old hypertensive, mildly asthmatic man who is receiving chemotherapy for colon cancer reveals symptomatic gallstones. Preoperative laboratory results are notable for a hematocrit of 24% and urinalysis with 18 to 25 WBCs and gram-negative bacteria. On call to the operating room, the patient receives intravenous penicillin. His abdomen is shaved in the operating room. An open cholecystectomy is performed and, despite a lack of indications, the common bile duct is explored. The wound is closed primarily with a Penrose drain exiting a separate stab wound. On postoperative day 3, the patient develops a wound infection. Which of the following changes in the care of this patient could have decreased the chance of a postoperative wound infection?
Increasing the length of the preoperative hospital stay to prophylactically treat the asthma with steroids
Treating the urinary infection prior to surgery
Shaving the abdomen the night prior to surgery
Continuing the prophylactic antibiotics for 3 postoperative days
Using a closed drainage system brought out through the operative incision
70) A 72-year-old man with diabetes, renal insufficiency, and coronary artery disease presents in septic shock from emphysematous cholecystitis. His oxygen saturation is 100% on 6-L nasal cannula and his hemoglobin is 7.2 mg/dL. His mixed venous oxygen saturation is 58%. Which of the following treatment options will improve his oxygen delivery the most?
Increase his inspired oxygen concentration
Transfer him to a hyperbaric chamber
Administer ferrous sulfate
Administer an erythropoietic agent
Transfuse two units of packed red blood cells 7
71) A 47-year-old man with hypertensive nephropathy develops fever, graft tenderness, and oliguria 4 weeks following cadaveric renal transplantation. Serum creatinine is 3.1 mg/dL. A renal ultrasound reveals mild edema of the renal papillae but normal flow in both the renal artery and the renal vein. Nuclear scan demonstrates sluggish uptake and excretion. Which of the following is the most appropriate next step?
Performing an angiogram
Decreasing steroid and cyclosporine dose
Beginning intravenous antibiotics
Performing renal biopsy, steroid boost, and immunoglobulin therapy
Beginning FK 506
72) A kidney transplant recipient presents with severe acute rejection that does not respond to steroid treatment. Administration of which of the following agents is the best step in her management?
Cyclosporine
Tacrolimus
Azathioprine
Muromonab-CD3
Sirolimus
73) A 30-year-old man is scheduled for a laparoscopic cholecystectomy for biliary colic. He reports a family history of prolonged paralysis during general anesthesia. Which of the following medications should be avoided during his procedure?
Succinylcholine
Vecuronium
Pancuronium
Halothane
Etomidate
74) A 63-year-old man with multiple rib fractures and a pulmonary contusion requires prolonged intubation. He is unable to be weaned from the ventilator and is on a volume control mode. He has a tracheostomy and a percutaneous gastrotomy in place through which he is being fed. The surgeon orders a respiratory quotient (RQ), which is the ratio of the rate of carbon dioxide production over the rate of oxygen uptake. The RQ is 1. Based on this information, which of the following is the next step in his management?
Decrease the inspired concentration of oxygen
Decrease the rate on the ventilator
Increase the rate on the ventilator
Decrease the carbohydrates in his enteral feeds
Increase the total number of calories in his enteral feeds
75) A 28-year-old medical student seeks your attention because of a testicular mass. Biopsy is consistent with pure seminoma. There is no evidence of enlarged retroperitoneal lymph nodes on CT scan. Which of the following is the best treatment strategy for this patient?
Orchiectomy alone
Orchiectomy followed by chemotherapy
Orchiectomy with retroperitoneal lymph node dissection
Orchiectomy with retroperitoneal lymph node dissection followed by external beam radiation
Orchiectomy followed by external beam radiation to the retroperitoneal lymph nodes
76) Following a boating injury in an industrial-use river, a patient begins to display fever, tachycardia, and a rapidly expanding area of erythema, blistering, and drainage from a flank wound. An x-ray shows gas in the soft tissues. Which of the following measures is most appropriate?
Administration of an antifungal agent
Administration of antitoxin
Wide debridement
Administration of hyperbaric O2
Early closure of tissue defect
77) Following pelvic gynecologic surgery, a 34-year-old woman becomes dyspneic, her peripheral arterial O2 saturation falls from 94% to 81%, and her measured PaO2 is 52 on a 100% non-rebreather mask. She is hemodynamically stable. A CT angiogram is consistent with a right lower lobe pulmonary embolus. Which of the following is the next step in her management?
Systemic anticoagulation with heparin infusion
Systemic anticoagulation with warfarin
Placement of an inferior vena cava filter
Thrombolytic therapy
Open pulmonary embolectomy
78) A 53-year-old woman presents with bright red blood per rectum, increased abdominal distention, and weight loss. She is found to have a large fungating mass 8 cm from the anal verge. No other lesions are identified. Biopsy is consistent with invasive rectal adenocarcinoma. Endorectal ultrasound shows invasion of the tumor into the perirectal fat and multiple enlarged lymph nodes. CT scans of the chest, abdomen, and pelvis do not show any metastases. She would like to preserve her sphincter if possible. Which of the following is the best treatment option for this patient given her preferences?
Abdominoperineal resection
Neoadjuvant chemoradiation followed by low anterior resection
Neoadjuvant chemoradiation followed by abdominoperineal resection
Transanal excision followed by adjuvant chemoradiation
Neoadjuvant chemoradiation followed by transanal excision
79) A 35-year-old woman presents with a right breast mass. You perform a thorough history and physical examination as well as a core biopsy of the right breast mass. In which of the following circumstances would a sentinel lymph node biopsy be indicated?
The core biopsy is consistent with ductal carcinoma in situ without comedo necrosis for which the patient desires partial mastectomy only.
The core biopsy is consistent with ductal carcinoma and the patient has a positive pregnancy test.
The core biopsy is consistent with ductal carcinoma and the patient desires partial mastectomy
The core biopsy is consistent with ductal carcinoma and the patient has palpable axillary lymph nodes.
The core biopsy is consistent with ductal carcinoma and the patient has a bone scan suspicious for metastasis
80) A 70-year-old man is concerned when his dentist finds a white patch on his oral mucosa during a routine examination. Proper management should include which of the following?
Excisional biopsy of all lesions
Application of topical antibiotics
Low-dose radiation therapy
Strict oral hygiene and avoidance of alcohol and tobacco
Application of topical chemotherapeutic agents
81) A 40-year-old woman undergoes an incisional biopsy of a pigmented lesion on her right thigh. Pathologic examination reveals malignant melanoma with a thickness of 3 mm. Findings on examination of the groin is normal. Which of the following is the most appropriate next step in her management?
Wide local excision of the melanoma with a 1-cm margin from the tumor, followed by radiation to the groin
Wide local excision of the melanoma with a 1-cm margin from the tumor and sentinel lymph node biopsy
Wide local excision of the melanoma with a 1-cm margin from the tumor and groin lymph node dissection
Wide local excision of the melanoma with a 2-cm margin from the tumor and sentinel lymph node biopsy
Wide local excision of the melanoma with a 2-cm margin from the tumor and groin lymph node dissection
82) A 49-year-old woman undergoes surgical resection of a malignancy. The family asks about the prognosis. The histopathology is available for review. For which of the following malignancies does histologic grade best correlate with prognosis?
Lung cancer
Melanoma
Colonic adenocarcinoma
Hepatocellular carcinoma
Soft tissue sarcoma
83) A 61-year-old man undergoes upper endoscopy for evaluation of weight loss and is identified to have a submucosal mass in the stomach. Biopsy is consistent with a gastrointestinal stromal tumor (GIST). Workup reveals the presence of liver metastases. Which of the following is the best initial treatment for this patient?
Tyrosine kinase inhibitor (Imatinib)
Monoclonal antibody against interleukin-2 receptor (Daclizumab)
Monoclonal antibody against tumor necrosis factor α (Infliximab)
Monoclonal antibody against vascular endothelial growth factor A (Bevacizumab)
Monoclonal antibody against epidermal growth factor receptor (Cetuximab)
84) A 57-year-old woman develops bony metastases 1 year after right modified radical mastectomy for breast cancer. The tumor was estrogen receptor-negative, progesterone receptor-negative and Her2/neu positive. Which of the following agents is indicated for treatment of her metastatic disease?
Antiestrogen (Tamoxifen)
Selective estrogen receptor modulator (Raloxifene)
Monoclonal antibody (Trastuzumab)
Aromatase inhibitor (Anastrozole)
5-fluorouracil
85) A 44-year-old woman has a 2-cm firm palpable mass in the upper outer quadrant of her right breast. The mass is freely movable, and her breast is of normal, rather generous size. There are no palpable axillary nodes. Mammogram shows no other lesions. A core biopsy establishes a diagnosis of infiltrating ductal carcinoma. She has no neurologic or skeletal symptoms, and a chest x-ray film and liver enzymes are normal. She understands that systemic therapy may eventually be needed once the full extent of her disease is known. Although she wants the best chance for cure, she is very concerned about cosmetic deformity and wants to know what can be done about the breast itself. Which of the following is the most appropriate management?
Radiation and chemotherapy without breast surgery
Lumpectomy, axillary sampling, and postoperative radiation
Simple total subcutaneous mastectomy with implants
Modified radical mastectomy with immediate rectus abdominis flap reconstruction
Radical mastectomy and postoperative radiation, with delayed reconstruction
86) A 26-year-old, drug-addicted man develops congestive heart failure over a period of a few days. He is febrile, has a loud, diastolic murmur at the right second intercostal space, and has a blood pressure of 120/20 mmHg. A physical examination performed a few weeks ago, when he attempted to enroll in a detoxification program, was completely normal. His blood pressure at that time was 120/80 mm Hg, and no murmurs were noted. In addition to long-term antibiotic therapy, which of the following is the most appropriate next step in management
Closure of the ventricular septal defect with a pericardial patch
Elective aortic valve repair if he develops a systolic gradient of 50 mm Hg
Emergency aortic valve replacement
Emergency mitral valve repair
Emergency pulmonic valve replacement
87) During a bar brawl, a 19-year-old man sustains a 4-in laceration on his left arm from glass and presents to the emergency room the following morning, 10 hours later. He is neurovascularly intact and the wound is deep, extending down to fascia. Which of the following is the most appropriate management of the wound?
Closure of the skin only and administration of oral antibiotics for 1 week
Closure of the skin and subcutaneous tissue and administration of oral antibiotics for 1 week
. A single dose of intravenous antibiotics and closure of the skin only
A single dose of intravenous antibiotics and closure of the skin and subcutaneous tissue
Local wound care without wound closure or antibiotics
88) A 59-year-old woman undergoes an exploratory laparotomy for peritonitis and is found to have perforated diverticulitis. She undergoes a sigmoid resection with an end colostomy. She is administered a third-generation cephalosporin within 1 hour prior to the incision and the antibiotic is continued postoperatively. One week later, she develops an intra-abdominal abscess, which is percutaneously drained. Bacteroides fragilis is isolated from the cultures. Which of the following statements regarding her perioperative antibiotic regimen is most accurate?
The preoperative dose of antibiotics should have been given closer to the time of incision
The patient should have received several doses of antibiotics prior to laparotomy
The patient should have received a first-generation cephalosporin
The patient did not have adequate gram-negative coverage
The patient did not have adequate anaerobic coverage
89) While playing football, a college student injures his shoulder. He comes in with his arm held close to his body, complaining of pain over the clavicle, rather than the shoulder joint. Physical examination shows a normal shoulder, but there is point tenderness at the junction of the middle and distal thirds of the clavicle. Gentle pressure elicits a gritty feeling of bone crunching on bone. He has normal pulses on that arm. After appropriate x-ray studies are performed, which of the following is the most appropriate initial step in management?
Analgesics only
Immobilization by a figure-eight device
Immobilization by hanging cast
Arteriogram of the subclavian vessels
Open reduction and internal fixation
90) A 50-year-old man complains of loss of libido and impotence after starting treatment with leuprolide for prostatic hyperplasia. An alpha-blocker and finasteride have also been tried, but with similar adverse effects. So far, the patient has not experienced any episodes of urinary tract infection or hematuria, but he is excessively bothered by his symptoms without any medication. Digital rectal examination shows mild prostatic enlargement. At this time, his prostate-specific antigen (PSA) is 4.5 ng/mL, and his creatinine is 0.7 mg/dL. Dipstick examination shows no hematuria. Which of the following is the most appropriate alternative to his current pharmacologic treatment?
Watchful waiting
Megestrol acetate
Transurethral incision of the prostate (TUIP)
Transurethral resection of the prostate (TURP)
Open prostatectomy
91) A 65-year-old man sustains a 50% TBSA burn while burning trash in the backyard. The patient is resuscitated with lactated Ringer (LR) solution using the Parkland formula and a weight of 80 kg. What is the rate of LR given in the first 8 hours?
100 mL/h
500 mL/h
1000 mL/h
5000 mL/h
10,000 mL/h
92) A 67-year-old man presents to his primary care physician with a 1-cm skin lesion on his left forearm. On examination, it has a waxy appearance with rolled pearly borders surrounding a central ulcer. Which of the following is the most appropriate management of this patient?
Mohs surgery
Curettage of the lesion
Electrodesiccation of the lesion
Laser vaporization of the lesion
Surgical excision
93) A 39-year-old woman with a known history of von Willebrand disease has a ventral hernia after a previous cesarean section and desires to undergo elective repair. Which of the following should be administered preoperatively?
High-purity factor VIII: C concentrates
Low-molecular-weight dextran
Fresh-frozen plasma (FFP)
Cryoprecipitate
Whole blood
94) You are the physician on call for the extracorporeal membrane oxygenation (ECMO) service. There are 5 calls today, but only one machine and one technologist available. Which of the following patients is the most appropriate recipient of this service?
A 1-day-old, full-term, anencephalic 4-kg boy suffering from meconium aspiration syndrome and hypoxia
A 75-year-old man with Alzheimer disease, severe pneumonia, and elevated pulmonary arterial pressure
A neonate with a diagnosis of severe pulmonary hypoplasia who is in respiratory failure
A 5-year-old girl with rhabdomyosarcoma metastatic to the lungs
A 3-day-old boy preoperative for a congenital diaphragmatic hernia
95) A 45-year-old man shows up in the emergency department with a pale, pulseless, paresthetic, painful, and paralytic right lower extremity. The process began suddenly 2 hours ago. On examination, no pulses are apparent in the right lower extremity. Pulse at the wrist is 95/min and grossly irregular. Treatment would likely be based on which of the following?
Dacron prosthetic vascular conduits
Fogarty balloon tipped catheters
Heparin and dicumarol
Saphenous vein bypasses
Selective sympathetic blocks medical
96) A neonate does not pass any meconium during the first day of life. On day 2 he is brought for evaluation because of repeated green vomiting and progressive abdominal distention. X-ray films of the abdomen show multiple dilated loops of small bowel and no gas in the colon. A contrast enema shows a normally positioned microcolon, and the contrast material refluxes freely into the small bowel, filling some of the more distal distended loops. Exploratory laparotomy is done. There is no malrotation, the small bowel does not have any atretic or obstructed segments, and there is no inspissated meconium in it. Which of the following is most appropriate next step in management?
Diverting ileostomy
Diverting ileostomy and appendectomy
Transverse loop colostomy
Total colectomy
Total proctocolectomy and permanent ileostomy
97) A 62-year-old woman with a history of coronary artery disease presents with a pancreatic head tumor and undergoes a pancreaticoduodenectomy. Postoperatively, she develops a leak from the pancreaticojejunostomy anastomosis and becomes septic. A Swan-Ganz catheter is placed, which demonstrates an increased cardiac output and decreased systemic vascular resistance. She also develops acute renal failure and oliguria. Which of the following is an indication to start dopamine?
To increase splanchnic flow
To increase coronary flow
To decrease heart rate
To lower peripheral vascular resistance
To inhibit catecholamine release
98) A 49-year-old man who underwent liver transplantation 5 years ago for alcoholic cirrhosis presents with a gradually increasing bilirubin level. He undergoes a liver biopsy, which demonstrates a paucity of bile ducts. Which of the following is his best option for treatment?
Increase his immunosuppression
Administration of a monoclonal antibody against T cells
Exploratory laparotomy with hepatic arterial reconstruction
Exploratory laparotomy with thrombectomy of the portal vein
Retransplantation
99) An otherwise healthy 24-year-old man presents in the emergency department with very severe pain of recent onset in his right scrotum. The pain is constant and began about 3 hours prior to his arrival. Physical examination shows a temperature of 39.4C (103F) but is otherwise unremarkable, except for the scrotal area. The testis on the affected side is in the normal position; however, it appears to be swollen and is exquisitely tender to palpation. The cord above the testis is equally painful and tender. Urinalysis shows pyuria. Which of the following is the most appropriate next step in management?
Antiviral medication started within the hour
Scrotal sonogram and antibiotics
Cystoscopy and bladder irrigation
Trans-scrotal biopsy and appropriate resection
Emergency surgery and bilateral orchiopexy
100) A 25-year-old man is found on a pre-employment chest x-ray film to have a 3-cm peripheral coin lesion. The patient has never smoked, and a chest x-ray film that he had 2 years ago when he enrolled in graduate school had been normal. Prompted by this finding, he undergoes a more thorough physical examination, which discloses the presence of a firm, 2-cm testicular mass of which he was not previously aware. There are also palpable inguinal nodes on the same side. Which of the following is the most appropriate next step in management?
Supportive symptomatic palliative care
Bronchoscopy and biopsy of the lung mass
Trans-scrotal incisional biopsy of the testicular mass
Trans-scrotal orchiectomy and sampling of inguinal nodes
Radical orchiectomy by the inguinal route
101) A 25-year-old man is shot with a .22-caliber revolver. The entrance wound is in the anterior, lateral aspect of his thigh, and the bullet is seen on x-ray films to be embedded in the muscles posterolateral to the femur. The emergency department physician cleans the wound thoroughly. Which of the following is the most appropriate next step in management?
Tetanus prophylaxis
Doppler studies
Arteriogram
Cal exploration of the femoral vessels
Surgical removal of the embedded bullet
102) A 25-year-old man presents with a painless, hard, 3-cm testicular mass that he discovered serendipitously while taking a shower. Physical examination confirms that the mass arises from the testicle itself, is not part of the epididymis, and is solid rather than a fluid collection. The rest of the physical examination is unremarkable. Which of the following would be the most appropriate next step?
Serum levels of alpha-fetoprotein and beta human chorionic gonadotropin
Trans-scrotal needle biopsy of the mass
Trans-scrotal incisional biopsy at the edge of the mass
Trans-scrotal orchiectomy
Radical inguinal orchiectomy
103) A 53-year-old woman sustains multiple injuries in a head-on automobile collision. She was driving the car and wearing a seat belt. At the moment of impact, she was held in place by the belt, but she hit the windshield with her face, the dashboard with her arms, and the steering wheel with her abdomen. Initial survey reveals closed fractures in both upper extremities, facial lacerations, and abdominal bruises. She is breathing well and is neurologically intact, but she is complaining of severe abdominal pain. Her blood pressure is 75/55 mm Hg, pulse is 110/min, and central venous pressure is zero. Physical examination of the abdomen shows tenderness, guarding, and rebound tenderness on all quadrants. There is no evidence of pelvic fracture. Which of the following would be the most appropriate study to evaluate her abdominal injuries?
Sonogram of the abdomen
Flat and upright x-ray films of the abdomen
CT scan of the abdomen
Diagnostic peritoneal lavage
Exploratory laparotomy
104) A 42-year-old man sustains a gunshot wound to the abdomen and is in shock. Multiple units of packed red blood cells are transfused in an effort to resuscitate him. He complains of numbness around his mouth and displays carpopedal spasm. An electrocardiogram demonstrates a prolonged QT interval. Which of the following is the most appropriate treatment?
Intravenous bicarbonate
Intravenous potassium
Intravenous calcium
Intravenous digoxin
Intravenous parathyroid hormone
105) A 39-year-old woman is involved in a head-on, highspeed automobile collision. She arrives at the emergency department in a deep coma, with bilaterally fixed dilated pupils. She has normal blood pressure and pulse rate. CT scan of the head shows diffuse blurring of the gray-white interface and multiple small punctate hemorrhages. There is no single large hematoma or displacement of the midline structures. Extension of the CT to include the neck shows no cervical spine fractures. Which of the following is the most appropriate initial step in management?
Improvement of cerebral perfusion by infusion of large amounts of TV fluids
Improvement of cerebral perfusion by the use of systemic vasodilators
Preservation of neurologic function by the use of hyperbaric oxygen
Prevention of further damage due to development of increased intracranial pressure
Surgical evacuation of the multiple punctate hemorrhages
106) An 82-year-old man develops severe abdominal distention, nausea, vomiting, and colicky abdominal pain. He has not passed any gas or stools for the past 12 hours. His vital signs are normal, and his pulse is regular. He has a distended, tympanitic abdomen, with hyperactive, highpitched bowel sounds. There are no signs of peritoneal irritation. Rectal examination is negative for masses or occult blood, and trie rectal vault is empty. Abdominal xray films show distended loops of small and large bowel, as well as a very large round gas shadow that is located in the right upper quadrant and tapers toward the left lower quadrant in the shape of a parrot's beak. The patient has never had any abdominal surgery, and he does not have any palpable hernias. Which of the following is the most appropriate next step in management?
Nasogastric suction, IV fluids, and observation
Repeated enemas and laxatives
Emergency celiac and mesenteric arteriogram
Proctosigmoidoscopy
Emergency exploratory laparotomy
107) A 42-year-old woman drops a hot iron on her lap while doing the laundry. She comes in with the shape of the iron clearly delineated on her upper thigh. The area is white, dry, leathery, and anesthetic. Which of the following is the most appropriate next step in management?
Application of mafenide acetate
Application of silver sulfadiazine
Use of triple antibiotic ointment
Repeated debridement and wet to dry dressings
Immediate excision and grafting
108) A 73-year-old woman with a long history of heavy smoking undergoes femoral artery-popliteal artery bypass for rest pain in her left leg. Because of serious underlying respiratory insufficiency, she continues to require ventilatory support for 4 days after her operation. As soon as her endotracheal tube is removed, she begins complaining of vague upper abdominal pain. She has daily fever spikes of 39°C (102.2°F) and a leukocyte count of 18,000/mL. An upper abdominal ultrasonogram reveals a dilated gallbladder, but no stones are seen. A presumptive diagnosis of acalculous cholecystitis is made. Which of the following is the next best step in her treatment?
Nasogastric suction and broad-spectrum antibiotics
Immediate cholecystectomy with operative cholangiogram
Percutaneous drainage of the gallbladder
Endoscopic retrograde cholangiopancreatography (ERCP) to visualize and drain the common bile duct
Provocation of cholecystokinin release by cautious feeding of the patient
109) A 29-year-old woman presents with a 6-month history of erythema and edema of the right breast with palpable axillary lymphadenopathy. A punch biopsy of the skin reveals neoplastic cells in the dermal lymphatics. Which of the following is the best next step in her management?
A course of nafcillin to treat the overlying cellulitis and then neoadjuvant chemotherapy for breast cancer
Modified radical mastectomy followed by adjuvant chemotherapy
Modified radical mastectomy followed by hormonal therapy
Combined modality chemotherapy and radiation therapy to the right breast with surgery reserved for residual disease
Combined modality therapy with chemotherapy, surgery, and radiation
110) A 35-year-old woman presents with a lump in the left breast. Her family history is negative for breast cancer. On examination the mass is rubbery, mobile, and nontender to palpation. There are no overlying skin changes and the axilla is negative for lymphadenopathy. An ultrasound demonstrates a simple 1-cm cyst in the area of the palpable mass in the left breast. Which of the following represents the most appropriate management of this patient?
Reassurance and re-examination
Immediate excisional biopsy
Aspiration of the cyst with cytologic analysis
Fluoroscopically guided needle localization biopsy
Mammography and reevaluation of options with new information
 
 
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