Chir 2

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
Surgical exploration of the femoral vessels
Surgical removal of the embedded bullet
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
111) A 55-year-old woman presents with a slow-growing painless mass on the right side of the neck. A fine-needle aspiration of the nodule shows a well-differentiated papillary carcinoma. A complete neck ultrasound demonstrates a 1-cm nodule in the right thyroid without masses in the contralateral lobe or lymph node metastasis in the central and lateral neck compartments. With regards to this patient, which of the following is associated with a poor prognosis?
. Age
. Sex
. Grade of tumor
. Size of tumor
. Lymph node status
113) A 50-year-old man is admitted to the hospital with a UGI bleed from acute erosive gastritis, secondary to chronic nonsteroidal anti-inflammatory use. His hematocrit is 28%. With fluid resuscitation, his blood pressure normalizes, but he has a persistent hyperdynamic precordium, tachycardia, and flow murmur on auscultation. He complains of shortness of breath on ambulation. An ECG shows depressed ST-T segments. Which of the following is the next appropriate step in management?
. Initiation of iron supplementation therapy
. Supplemental oxygen
. continued IV fluid resuscitation
. Initiation of a calcium channel blocker
. Blood transfusion
116) A 57-year-old man comes to the physician for a routine checkup. He complains of right-sided leg cramps accompanied by fatigue while walking. He also complains of occasional right thigh pain. He denies chest pain, syncope, nausea, and abdominal pain. His sexual performance has decreased over the past 1 year. His other medical problems include stage 3 chronic kidney disease, type 2 diabetes mellitus, hypertension, hyperlipidemia, gout, and gastroesophageal reflux disease. His blood pressure is 144/92 mm Hg, pulse is 67/min, and BMI is 29 kg/m2. Peripheral pulses are bilaterally palpable. There is a small ulcer at the base of the right great toe. The ankle-brachial index (ABI) is 1.0 (normal: 1.0 - 1.3). His laboratory values are significant for a serum creatinine level of 2.2 mg/dl and an HbA1c level of 7.5% but otherwise unremarkable. Which of the following is the most appropriate next step in managing this patient's leg pain?
. Aspirin, cilostazol, and verapamil
. CT angiography of the lower extremities
. Exercise testing with repeat ABI
. Tight glucose control and follow-up in 3 months
. Treatment for diabetic neuropathy
123) A 40-year-old, obese, white woman, mother of five children, gives a history of repeated episodes of right upper quadrant abdominal pain. The pain is brought about by the ingestion of fatty foods and is relieved by the administration of anticholinergic medications. The pain is colicky, radiates to the right shoulder and around to the back, and is accompanied by nausea and occasional vomiting. The patient has no pain at this time, but is anxious to avoid further episodes. She is afebrile, and physical examination is unremarkable. Which of the following is the most appropriate next step in management?
. Sonogram of the biliary tract and gallbladder
. Upper gastrointestinal series with barium
. Antibiotics, IV fluids, and nothing by mouth
. Endoscopic retrograde cholangiopancreatogram (ERCP)
. Exploratory surgery
138) A 54-year-old woman presents to her physician for an opinion regarding additional therapy following curative resection of recently diagnosed colon cancer. She underwent uncomplicated sigmoid resection for invasive colon cancer 4 weeks ago. The pathology revealed carcinoma invading into, but not through, the muscularis propria, with one of eight positive mesenteric nodes. There was no evidence of liver metastases at the time of operation. Preoperative chest x-ray and CT scan of the abdomen showed no evidence of distant disease. Preoperative carcinoembryonic antigen (CEA) level was normal. Past history is positive for diabetes and mild hypertension. Examination is unremarkable except for a healing abdominal incision. Which of the following is the most appropriate recommendation regarding adjuvant therapy?
. No therapy indicated
. 5-fluorouracil chemotherapy
. 5-fluorouracil chemotherapy with leucovorin
. doxorubicin (Adriamycin) chemotherapy
. Adriamycin chemotherapy with methotrexate and Cytoxam
139) A 55-year-old man presents to the physician’s office for his yearly physical examination. He is asymptomatic. Past history is pertinent for hypertension. Family history is positive for breast cancer in his mother at age 70 and colon cancer in his father at age 65. His examination is unremarkable except for guiac positive stool. Barium enema shows a sigmoid colon polyp. Colonoscopy confirms a 3-cm pedunculated polyp in the sigmoid colon, and snare polypectomy is performed. Pathologic examination reveals an adenomatous polyp with a focus of invasive carcinoma in the head, with a 4-mm resection margin and no tumor noted in the stalk. Which of the following is the most appropriate next step in management?
. CT scan
. Magnetic resonance imaging (MRI) scan
. Surgical resection of sigmoid
. observation
. Regular use of nonsteroidal antiinflammatory drugs (NSAIDs)
141) During endoscopic biopsy of a distal esophageal cancer, perforation of the esophagus is suspected when the patient complains of significant new substernal pain. An immediate chest film reveals air in the mediastinum. Which of the following is the most appropriate management of this patient?
. Placement of a nasogastric tube to the level of perforation, antibiotics, and close observation
. Spit fistula (cervical pharyngostomy) and gastrostomy
. Left thoracotomy, pleural patch oversewing of the perforation, and drainage of the mediastinum
. Left thoracotomy with esophagectomy
. Thoracotomy with chest tube drainage and esophageal exclusion
142) In preparation for an inguinal hernia repair, a 22-year-old man has a spinal anesthetic placed. The level of sensory block turns out to be much higher than had been planned, and shortly thereafter his blood pressure drops to 75/20 mm Hg. He looks warm and flushed, and his central venous pressure is near zero. Which of the following should be included in his therapy?
. Diuretics and fluid restriction
. Whole blood and clotting factors
. Inotropic agents and cardiac assist pump
. Vasoconstrictors and IV fluids
. Vasodilators and IV fluids
143) A 27-year-old woman seeks your advice regarding pain and numbness in the right arm and hand. She reports that it is exacerbated by raising her arm over her head. On examination, the right radial pulse disappears when the patient takes a deep breath and turns her head to the left. A provisional diagnosis is made. Which of the following is the most appropriate initial treatment for this patient?
. Physical rehabilitation
. Gabapentin to treat neuropathic pain
. Right first rib resection
. Thoracoscopic sympathectomy
. Upper thoracic discectomy
144) A 35-year-old man with a history of melanoma status post wide local excision with negative margins and lymph node dissection presents with 2, peripherallylocated pulmonary lesions seen on chest CT scan. Percutaneous biopsy of the lesion is consistent with metastatic melanoma. He has no evidence of recurrence or extrathoracic disease and is in good general health. Which of the following is the most appropriate management of this patient?
. Chemotherapy
. Radiation therapy
. Pulmonary metastasectomy
. Pulmonary metastasectomy followed by radiation therapy
Neoadjuvant radiation therapy followed by pulmonary metastasectomy
147) A 53-year-old woman presents with complaints of weakness, anorexia, malaise, constipation, and back pain. While being evaluated, she becomes somewhat lethargic. Laboratory studies include a normal chest x-ray, serum albumin 3.2 mg/dL, serum calcium 14 mg/dL, serum phosphorus 2.6 mg/dL, serum chloride 108 mg/dL, blood urea nitrogen (BUN) 32 mg/dL, and creatinine 2.0 mg/dL. Which of the following is the most appropriate initial management?
. Intravenous normal saline infusion
. Administration of thiazide diuretics
. Administration of intravenous phosphorus
. Use of mithramycin
. Neck exploration and parathyroidectomy
148) A 44-year-old homeless woman presents to the emergency department because she is "bleeding from the breast." Physical examination shows a huge, fungating, ulcerated mass that occupies the entire right breast and is firmly attached to the chest wall. The right axilla is full of hard masses that are not movable either. Core biopsies of the breast are read as highly undifferentiated infiltrating ductal carcinoma, and assay for estrogen and progesterone receptors are negative. Which of the following is the most appropriate next step in management?
. Local wound care, but no specific antineoplastic therapy
. Tamoxifen therapy
. Radiation and chemotherapy
. Palliative mastectomy
. Radical mastectomy with extended lymph node dissection
153) A 58-year-old man is found to have high serum prostate–specific antigen (PSA) concentration with a normal prostate examination. A biopsy of the prostate confirms low-grade carcinoma. The patient wishes to avoid therapy involving any risk for impotence. Which of the following is the most appropriate management of this patient?
. Observation
. Chemotherapy
. Prostatectomy
. Radiation therapy
. Hormonal therapy
154) A 28-year-old man with a past history of bilateral orchiopexy for cryptorchidism presents with a painless, unilateral right scrotal enlargement. On examination, there is a palpable right testicular mass and enlarged inguinal node. Scrotal ultrasonography demonstrates heterogeneity of the testis, with an associated hydrocele. A CT scan of the abdomen and pelvis demonstrated right-sided retroperitoneal adenopathy. CT scan of the chest is normal. Staging workup and surgery reveal a seminoma of the testicle, with positive inguinal and retroperitoneal nodes. Therapeutic management for this patient is which of the following?
. External beam radiotherapy
. Multidrug combination chemotherapy
. Combination radiotherapy and multidrug chemotherapy
. Clinical surveillance
. Laparotomy with pelvic and retroperitoneal node dissection
158) A 30-year-old man presents to the emergency department with sudden onset of severe epigastric pain and vomiting 3 hours ago. He reports a 6-month history of chronic epigastric pain occurring nearly every day and relieved by antacids. On examination, he appears sweaty and avoids movement. Vital signs reveal a temperature of 100°F, BP of 100/60 mmHg, pulse rate of 110/min, and respiratory rate of 12/min. The remainder of his examination reveals diminished bowel sounds and a markedly tender and rigid abdomen. A chest x-ray and abdominal films reveal pneumoperitoneum. Which of the following is the most appropriate next step in management?
. Immediate laparotomy
. Nonoperative management with NG decompression and antibiotics
. Fluid resuscitation
. Administration of H2 blockers
. Placement of a central venous line
164) A 60-year-old man is admitted to the coronary care unit with a large anterior wall myocardial infarction. On his second hospital day, he begins to complain of the sudden onset of numbness in his right foot and an inability to move his right foot. On physical examination, the right femoral, popliteal, and pedal pulses are no longer palpable. The left lower extremity is normal. Which of the following is the most appropriate management of this patient?
. Duplex imaging of the right lower extremity arteries
. CT angiogram of the right lower extremity
. CT angiogram of bilateral lower extremities
. Embolectomy of the right femoral artery
. Embolectomy of the right femoral artery with exploration of the contralateral femoral artery
168) A 70-year-old woman undergoes a cardiac catheterization for exertional chest pain. Her pain continues to worsen and she is interested in having either surgery or percutaneous coronary intervention (PCI). Which of the following would be an indication for her to undergo either coronary artery bypass grafting or PCI?
. Two-vessel coronary disease with proximal left anterior descending artery stenosis and depressed left ventricular ejection fraction
. Isolated left main stenosis, no diabetes, and normal left ventricular ejection fraction
. Isolated left main stenosis and diabetes
. Left main stenosis and additional coronary artery disease with depressed left ventricular ejection fraction.
. Three-vessel coronary artery disease and diabetes
169) Six months ago at the time of lumpectomy for breast cancer, a 60-year-old female attorney quit a 30-year smoking habit of 2 packs per day. She had the chest radiograph shown here as part of her routine follow-up examination. Based on her age and history of smoking, you are concerned for either a new primary lung or metastatic breast malignancy. Which of the following is the most appropriate next step in the management of this lesion?
. Follow-up CT scan in 3 months
. Magnetic resonance imaging of bilateral breasts to evaluate for recurrence of the breast cancer
. Transthoracic fine-needle aspiration of the lesion
. Mediastinoscopy
. Thoracotomy with lobectomy
171) A 58-year-old man presents with tachycardia, fever, confusion, and vomiting. Workup reveals markedly elevated (triiodothyronine) T 3 and (thyroxine) T4 levels. He is diagnosed as having a thyroid storm. Which of the following is the most appropriate next step in the management of this patient?
. Emergent subtotal thyroidectomy
. Emergent total thyroidectomy
. Emergent hemodialysis
. Administration of fluid, antithyroid drugs, β-blockers, iodine solution, and steroids
Emergent radiation therapy to the neck
176) A 55-year-old woman presents with a 6-cm right thyroid mass and palpable cervical lymphadenopathy. Fine-needle aspiration (FNA) of one of the lymph nodes demonstrates the presence of calcified clumps of sloughed cells. Which of the following best describes the management of this thyroid disorder?
. The patient should be screened for pancreatic endocrine neoplasms and hypercalcemia.
. The patient should undergo total thyroidectomy with modified radical neck dissection.
. The patient should undergo total thyroidectomy with frozen section intraoperative, with modified radical neck dissection reserved for patients with extra-capsular invasion.
. The patient should undergo right thyroid lobectomy followed by iodine 131 (131I) therapies.
. The patient should undergo right thyroid lobectomy.
177) A 45-year-old woman is found to have suspicious appearing calcifications in the right breast on a screening mammogram. Stereotactic biopsy of the calcifications shows lobular carcinoma in situ (LCIS). On examination both breasts are dense without palpable masses. The neck and bilateral axilla are negative for lymphadenopathy. Which of the following is the most appropriate management of this patient?
. Frequent self-breast examinations and yearly screening mammograms
. Chemotherapy
. Radiation
. Right total mastectomy with sentinel lymph node biopsy
. Bilateral modified radical mastectomy
183) After being injured by a bull on his mother’s farm, a young man is placed in a cast for a supracondylar fracture of his humerus. A few hours later he begins to experience intense pain, swelling, and weakness in the ipsilateral hand. Pulses are normal in bilateral upper extremities. Which of the following is the most appropriate initial management of this patient?
. Observation
. Repeat imaging of the humerus
. Elevation of the extremity
. Removal of the cast
. Surgical decompression (fasciotomy)
190) A 40-year-old previously healthy man presents with sudden onset of severe abdominal pain that radiates from the right loin (flank) to groin. This pain is associated with nausea, sweating, and urinary urgency. He is distressed and restless, but an abdominal examination is normal. Which of the following is the most appropriate next step in management?
. Insertion of a urethral catheter
. IV fluid hydration, IV analgesics, and nonenhanced computed tomography (CT) scan
. IV fluid hydration, IV analgesics, and arrangements for lithotripsy
. Cystoscopy and retrograde pyelogram
. Urine culture, followed by initiation of antibiotic therapy
194) A 45-year-old woman presents with dysphagia, regurgitation of undigested food, and weight loss. She had x-rays shown here as part of her workup. Upper endoscopy reveals no evidence of malignancy and esophageal motility studies show incomplete lower esophageal sphincter relaxation. Which of the following is the next best step in the treatment of this patient?
. Laparoscopic myotomy of the lower esophageal sphincter (Heller)
. Laparoscopic posterior 180 (Toupet) fundoplication
. Laparoscopic anterior 180 (Dor) fundoplication
. Laparoscopic 360 (Nissen) fundoplication
. Transhiatal esophagectomy
196) 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. Several hours after this intervention a bolus of IV crystalloid, the patient is reassessed. The blood pressure is 150/85 mmHg, heart rate is 90/min, neck veins are distended, and the pulmonary arterial wedge pressure is 17 mmHg. Urine output is still low in volume. At this point, management should be which of the following?
. IV furosemide
. A bolus of IV crystalloid
. A dopamine infusion
. A nitroprusside infusion
. IV digoxin administration
199) A 10-year-old boy presents to the emergency room with pain in the left testicle. The pain was acute in onset and began 1 hour ago. On physical examination, he is noted to have a high-riding, firm, and markedly tender left testis. The right testicle is normal. Urinalysis is unremarkable. Which of the following is the most appropriate management of this patient?
. Manual detorsion of the left testicle with external rotation toward the thigh; orchiopexy if the condition recurs
. Manual detorsion of the left testicle with internal rotation toward the thigh; orchiopexy if the condition recurs
. Orchiopexy of the left testicle
. Orchiopexy of bilateral testicles
. Orchiectomy of the left testicle
203) An 89-year-old man has lost 30 lb over the past 2 years. He reports that food frequently sticks when he swallows. He also complains of a chronic cough. Barium swallow is shown here. What is the best treatment option for this patient?
. Placement of an esophageal stent
. Diverticuloplasty
. Excision of the diverticulum
. Excision of the diverticulum and administration of a promotility agent
. Excision of the diverticulum and cricopharyngeal myotomy
205) A 6-year-old boy presents to the emergency department with a painful, markedly swollen elbow. While ice-skating, he fell with his arm outstretched. Radiographs of the elbow demonstrate a displaced, supracondylar fracture of the humerus. On examination, there is pain on passive flexion at the wrist and a decreased radial pulse, with diminished capillary refill in the hand. Which of the following is the most appropriate management of this injury?
Admission to hospital for close observation, with immobilization of the elbow at 90 of flexion
Closed reduction with percutaneous pinning under general anesthesia
Open reduction and pinning under general anesthesia
Open reduction with pinning, and exploration of the brachial artery
Open reduction with pinning, exploration of the brachial artery, and decompression fasciotomy of the forearm fascial compartments
207) A 35-year-old woman with a history of previous right thyroidectomy for a benign thyroid nodule now undergoes completion thyroidectomy for a suspicious thyroid mass. Several hours postoperatively, she develops progressive swelling under the incision, stridor, and difficulty breathing. Orotracheal intubation is successful. Which of the following is the most appropriate next step?
. Fiberoptic laryngoscopy to rule out bilateral vocal cord paralysis
. Administration of intravenous calcium
. Administration of broad-spectrum antibiotics and debridement of the wound
. Wound exploration
. Administration of high-dose steroids and antihistamines
209) A 60-year-old man seeks medical attention because of recurrent urinary tract infections. The patient also reports a history of increasing difficulty in urination (decreased flow, straining, and hesitancy) over the last several months. A prostate-specific antigen (PSA) level is mildly elevated and a prostate biopsy proves benign. Which of the following is the most appropriate initial management of this patient with benign prostatic hyperplasia (BPH)?
. α-Adrenergic blocker
. 5-alpha reductase inhibitor
. α-Adrenergic blocker and 5-alpha reductase inhibitor
. Transurethral resection of the prostate (TURP)
. Open prostatectomy
211) A 25-year-old unhelmeted man involved in a motorcycle collision has multiple cerebral contusions on head computed tomographic (CT) scan. He is agitated but hemodynamically stable, with a heart rate of 80 beats per minute and a mean arterial pressure (MAP) of 90 mm Hg. An intracranial pressure monitor is placed, and the initial ICP reading is 30 mm Hg. Which of the following is the most appropriate in the management of his traumatic brain injury (TBI) over the next few days?
. Hyperventilation to maintain a cerebral PCO2 of 25 to 30 mm Hg
. Administration of neosynephrine to increase his MAP and, consequently, his cerebral perfusion pressure (CPP)
. Administration of mannitol (1 g/kg) to reduce his ICP
. Placement of the patient in Trendelenburg position to increase cerebral perfusion
. Avoidance of all sedating drugs in the first 24 to 48 hours in order to accurately assess his neurologic status
212) A 50-year-old woman complains of headaches and lateralizing weakness. A CT scan of the brain reveals an irregular mass in the right cerebral hemisphere. A biopsy documents that this is a glioblastoma. Which of the following is the best treatment strategy for potential cure?
. Chemotherapy with temozolomide alone
. Combination chemotherapy with carmustin, cisplatin, and temozolomide
. External beam radiation alone
. Surgical resection alone
. Combined surgical resection, external beam radiation, and chemotherapy with temozolomide
216) A 35-year-old woman presents with a serum calcium level of 15.2 mg/dL and an elevated parathyroid hormone level. Following correction of the patient’s hypercalcemia with hydration and furosemide, which of the following is the best therapeutic approach?
. Administration of steroids
. Radiation treatment to the neck
. Neck exploration and resection of a parathyroid adenoma
. Neck exploration and resection of all 4 parathyroid glands
. Avoidance of sunlight, vitamin D, and calcium-containing dairy products
219) A 32-year-old woman has a CXR screening, and a 1.5-cm mass is noted in the right lower lobe. She is a nonsmoker. Bronchoscopy shows a mass in the right lower lobe orifice, covered with mucosa. Biopsy indicates this is compatible with a carcinoid tumor. Imaging suggests ipsilateral mediastinal lymph node involvement but no extrathoracic disease. Which of the following is the most appropriate treatment plan?
. Right lower lobectomy and mediastinal lymph node dissection
. Right lower lobectomy and mediastinal lymph node dissection followed by adjuvant chemotherapy
. Neoadjuvant chemotherapy followed by right lower lobectomy and mediastinal lymph node dissection
. Neoadjuvant chemoradiation followed by right lower lobectomy and mediastinal lymph node dissection
. Chemoradiation
220) A 55-year-old woman presents with a 6-month history of weight loss, abdominal cramps, and intermittent nonbloody diarrhea. On examination, her abdomen is mildly distended and there is a palpable mass in the right lower quadrant. Stool cultures yield normal fecal flora. CT scan with oral contrast demonstrates an inflammatory mass in the right lower quadrant, with thickening of the terminal ileum and ileocecal valve.Initial management should include which of the following?
. Antibiotics and IV fluids
. lactose-free diet
. antispasmodics
. Nutritional supplementation and systemic steroids
. laparotomy
221) A 33-year-old woman is found to have a palpable thyroid nodule during a routine medical checkup. A sonogram confirms the presence of a solid, 1.5-cm nodule in the right lobe of the thyroid gland. Fine needle aspirate cytology (FNA) is reported as "follicular tumor, otherwise unspecified." At surgery, a frozen section is read as follicular carcinoma. With the neck open, the surgeon can feel for enlarged jugular and peritracheal lymph nodes, and finds none. Which of the following is the most appropriate treatment?
. Enucleation of the tumor
. Right thyroid lobectomy
. Total thyroidectomy
. Total thyroidectomy plus postoperative radioactive iodine
. Total thyroidectomy, radical neck dissection, and postoperative radioactive iodine
224) A 29-year-old nonhelmeted motorcycle driver is involved in a single vehicular crash, resulting in a significant closed-head injury. He is intubated in the field and transported to a level 1 trauma center. On arrival, he is oxygenating well with assisted ventilation and has a normal blood pressure and moderate tachycardia. His Glasgow Coma Score is 7, and his pupils are equal and sluggishly reactive. After stabilization in the emergency department, the patient undergoes a CT scan of the head that demonstrates a small amount of subarachnoid blood and a right frontal lobe contusion with edema with no midline shift. CT scan of the abdomen is normal. The patient is transferred to the ICU. The optimal initial management of this patient’s intracranial pressure (ICP) would be which of the following?
. Fluid restriction, hyperventilation, and osmotic diuresis
. craniotomy
. Fluid restriction, hyperventilation, and ventriculostomy
. Hyperventilation and IV steroids
. normovolemia, normocarbia, sedation, and ventriculostomy
225) A 49-year-old obese man has become irritable, his face has changed to a round configuration, he has developed purplish lines on his flanks, and he is hypertensive. A 24-hour urine collection demonstrates elevated cortisol levels. This is confirmed with bedtime cortisol measurements of 700ng/mL. Which of the following findings is most consistent with the diagnosis of Cushing disease?
. Decreased ACTH levels
. Glucocorticoid use for the treatment of inflammatory disorders
. A 3-cm adrenal mass on computed tomography (CT) scan
. Suppression with high-dose dexamethasone suppression testing
. A 1-cm bronchogenic mass on magnetic resonance imaging (MRI)
226) A 70-year-old man presents with back pain and increasing difficulty with initiating a urinary stream. On rectal examination, he is found to have a hard, irregularly enlarged prostate. He has an elevated prostate-specific antigen (PSA), and osteoblastic lesions in the vertebral column and bones of the pelvis. A needle biopsy of the prostate shows well-differentiated adenocarcinoma. Which of the following is the treatment of choice?
. Radical prostatectomy
. Transurethral prostatectomy
. Cytotoxic chemotherapy
. Hormonal manipulation
. radiotherapy
228) A 5-week-old infant presents with a 1-week history of progressive nonbilious emesis, associated with a 24-hour history of decreased urine output. The infant continues to be active and eager to feed. On examination, the infant has a sunken fontanelle and decreased skin turgor. The abdomen is scaphoid, and with a test feed, there is a visible peristaltic wave in the epigastrium. Which of the following is the most appropriate next step in management of this infant?
. Immediate surgical exploration
. Send the child home with an oral electrolyte rehydration solution
. Change the infant’s formula and feeding regimen
. IV fluid resuscitation, followed by surgical intervention
. Initiate therapy with a prokinetic agent
232) An 8-month-old boy is seen by a pediatrician for the first time. The physician notes that there are no testes in the scrotum. Which of the following is the optimal management of bilateral undescended testicles in an infant?
. Immediate surgical placement into the scrotum
. Chorionic gonadotropin therapy for 1 month; operative placement into the scrotum before age 2 if descent has not occurred
. Observation until age 2; operative placement into the scrotum if descent has not occurred
. Observation until age 5; if no descent by then, plastic surgical scrotal prostheses before the child enters school
. No therapy; reassurance of the parent that full masculinization and normal spermatogenesis are likely even if the testicle does not fully descend
235) A 42-year-old woman returns to the clinic following an uneventful biopsy for a well-defined, mobile mass. The pathology report describes the mass as a fibro adenoma, but LCIS is identified in the breast parenchyma adjacent to the fibro adenoma and extending to the margin of resection. She has no current illnesses, is on no medications, and her family history is negative for breast cancer. Breast imaging studies show fatty breasts with no abnormal findings except for the fibro adenoma. Which of the following is the most appropriate management option?
. re-excision of the biopsy cavity to gain negative margins of resection
. Ipsilateral mastectomy
. Contralateral breast biopsy
. Observation including examinations and mammography
. Bilateral total mastectomies
236) A 59-year-old man is found to have a 6-cm thoracoabdominal aortic aneurysm which extends to above the renal arteries for which he desires repair, but he is concerned about the risk of paralysis postoperatively. Which of the following maneuvers should be employed to decrease the risk of paraplegia after repair?
. Infusion of a bolus of steroids immediately postoperatively with a continuous infusion for 24 hours
. Maintenance of intraoperative normothermia
. Clamping of the aorta proximal to the left subclavian artery
. Cerebrospinal fluid (CSF) drainage
. Extracorporeal membrane oxygenation
239) A 29-year-old woman with a history of difficulty becoming pregnant presents to her primary care physician and is diagnosed with Grave disease on iodine uptake scan; her thyrotropin (TSH) level is markedly suppressed and her free thyroxine (T4) level is elevated. She desires to conceive as soon as possible and elects to undergo thyroidectomy. After she is rendered euthyroid with medications preoperatively, which of the following management strategies should also be employed to reduce the risk of developing thyroid storm in the operating room?
. Drops of Lugol iodine solution daily beginning 10 days preoperatively.
. Preoperative treatment with phenoxybenzamine for 3 weeks.
. Preoperative treatment with propranolol for 1 week.
. Twenty-four hours of corticosteroids preoperatively.
. No other preoperative medication is required.
240) A 72-year-old woman with severe COPD who requires home oxygen is unable to ambulate inside her home without experiencing severe left hip pain. She was hospitalized 1 year ago for a viral pneumonia and was ventilator-dependent at that time for 6 weeks. On examination, her blood pressure is 165/80 mm Hg. She has weakly palpable bilateral femoral pulses. An angiogram demonstrates severe aortoiliac disease involving bilateral iliac vessels. Which of the following is the most appropriate vascular procedure for this patient?
. Femorofemoral bypass
. Axillofemoral bypass
. Femoropopliteal bypass
. Aortobifemoral bypass
. Common femoral and profunda femoral endarterectomise
241) A 52-year-old woman has terminal cervical cancer with extensive pelvic invasion, and requires strong opiate analgesia to control severe pain. Intermittent nausea and vomiting have precluded the use of oral agents. She was on fentanyl patches but she developed allergic skin reactions to the adhesive and now requests to be switched to parenteral medication. Because of prior chemotherapy treatments she has no available venous access, but she is willing to have her family administer intramuscular injections. Assuming equianalgesic dosages, which of the following would be the most appropriate pharmacotherapy?
. Codeine
. Hydromorphone (Dilaudid)
. Meperidine (Demerol)
. Methadone
. Morphine sulfate
243) A 42-year-old homeless man presents with a 3-week history of shortness of breath, fevers, and pleuritic chest pain. Chest x-ray (CXR) reveals a large left pleural effusion. Thoracentesis reveals thick, purulent-appearing fluid, which is found to have glucose less than 40 mg/dL and a pH of 6.5. A chest tube is placed, but the pleural effusion persists. Which of the following is the most appropriate management of this patient?
. Placement of a second chest tube at the bedside and antibiotic therapy
. Infusion of antibiotics via the chest tube
. Intravenous antibiotics for 6 weeks
. Thoracotomy with instillation of antibiotics into the pleural space
. Thoracotomy with decortication and antibiotic therapy
244) During a campaign appearance, a political candidate is shot point blank in the right chest with a .22 caliber revolver. The entrance wound is well above the nipple line, just under the third rib, at the level of the anterior axillary line. His motorcade brings him to the emergency department, but he makes it a point to walk in, holding his right chest with a bloody hand and waving for the news media. A chest x-ray shows a hemothorax on the right, and the bullet is seen to be embedded in the right paraspinous muscles. A chest tube is placed in the right pleural cavity, and 650 mL blood is recovered. Over the ensuing 4 hours, he continues to drain between 250 and 350 mL blood per hour. Which of the following is the most appropriate next step in management?
. Continued observation and appropriate blood replacement
. A second chest tube in a better position to drain the blood
. Thoracotomy and ligation of bleeding vessels
. Thoracotomy, ligation of bleeding vessels, and removal of the bullet
. Thoracotomy and pneumonectomy
245) A 65-year-old woman presents to the physician’s office for a second opinion on the management options for recently diagnosed breast cancer. She presents with a 2.5-cm mass in the upper outer quadrant of the left breast associated with a palpable axillary node suspicious for metastatic disease. The remainder of her examination is normal. Mammography demonstrates the cancer and shows no other suspicious lesions in either breast. Chest x-ray, bone scan, and blood test panel, including liver function tests, are normal. Family history is positive for breast cancer diagnosed in her sister at age 65. Past history is unremarkable. The first physician recommended modified radical mastectomy. Which of the following is the most appropriate management option for locoregional control yielding results equally effective as mastectomy?
. Radical mastectomy
. lumpectomy, irradiation, and axillary node dissection
. Lumpectomy and axillary node dissection
. Irradiation of the breast and axilla
. quadrantectomy, irradiation, and axillary node dissection
246) During a hunting trip, a young man is bitten by a coyote. The animal is captured and brought to the authorities alive. Which of the following is the most important criterion to determine the patient's need for rabies prophylaxis?
. The patient's history of previous immunizations
. The patient's clinical course over the next few weeks
. Observing the animal's behavior over the next few days
. Killing the animal and examining the brain
. The events that took place have already established the need to proceed with rabies immunization
249) A 62-year-old man has had gastroesophageal reflux disease diagnosed by pH monitoring, and present for several years. He has been less than totally compliant with medical management, which he follows when the pain is bad, but discontinues when he feels better. Endoscopy and biopsies show severe peptic esophagitis, with Barrett's esophagus and early dysplastic changes, but no overt carcinoma. Additional tests show good esophageal motility, with low pressure in the lower esophageal sphincter and normal gastric emptying. Which of the following is the most appropriate treatment at this time?
. Heller myotomy of the lower esophageal sphincter
. Laparoscopic Nissen fundoplication
Transhiatal total esophagectomy
Transthoracic resection of the lower esophagus
Vagotomy, pyloroplasty, and fundic gastric wrap
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