USMLE chirc management 1

1) A 22-year-old man is stabbed in the right chest with a 5-cm-long knife blade. On arrival at the emergency department, he is wide awake and alert. He is speaking with a normal tone of voice but complaining of shortness of breath. The right hemithorax is hyperresonant to percussion and has no breath sounds; the rest of the initial survey is negative. His blood pressure is 110/75 mm Hg, pulse is 86/min, and venous pressure is 3cm H2O. Pulse oximetry shows a saturation of 85%. Which of the following is the most appropriate next step in patient care?

2) A one-year-old boy is brought to the emergency department with scalds on both the buttocks and thighs. His mother states that the child was burned because she accidentally drew a bath for the child with water that was too hot. She states the injury occurred 2 days ago. On examination, the child is irritable. Second-degree burns are noted on the buttocks, genitalia, waist, proximal thighs and feet. There is an abrupt demarcation between the burned and unaffected skin. A faint yellow patch of discoloration is noted on the left thorax with a slight violaceous hue. The child has not yet had his 1-year vaccinations. Which of the following is the most appropriate next step in management?

3) A 47-year old woman comes to the clinic because of worsening left breast swelling and pain. She had mastitis when she nursed her first child 20 years ago. She has not seen a doctor since that time. She is afebrile. Breast examination shows the left breast is enlarged with a 7 x 6 cm area of edema and erythema. A poorly localized mass without fluctuation is palpated in that area. Scant non-bloody discharge is noted on the nipple, and several large axillary nodes are palpated. Which of the following is the most appropriate next step in management?

4) A man involved in a high-speed, head-on automobile collision arrives at the emergency department in a deep coma. His pupils react poorly to light but are of equal size. An airway is placed, and the patient is sent for CT scan of the head with extension to the neck. The study shows no cervical spine fractures, but does reveal a small, crescent-shaped hematoma on the right side, with no deviation of the midline structures. Which of the following is the most appropriate next step in management?

5) A 19-year-oldgangmemberisshotintheabdomenwith a .38 caliber revolver. The entry wound is in the epigastrium, to the left of the midline. The bullet is lodged in the psoas muscle on the right. He is hemodynamically stable, and the abdomen is moderately tender. Which of the following is the most appropriate next step in diagnosis?

6) Five days after an uneventful cholecystectomy, an asymptomatic middle-aged woman is found to have a serum sodium level of 125 mEq/L. Which of the following is the most appropriate management strategy for this patient?

7) A 33-year-old woman is undergoing a diagnostic work-up because she appears to have Cushing syndrome. She has elevated levels of cortisol, which are not suppressed when she is given high-dose dexamethasone. ACTH levels are greater than 200 pg/ mL. A chest x-ray film shows a central, 3-cm round mass on the hilum of the right lung. Bronchoscopy and biopsies confirm a diagnosis of small cell carcinoma of the lung. Which of the following is the preferred treatment for this woman?

8) A multiple trauma patient receives 14 units of packed red cells and several liters of Ringer's lactate solution during a laparotomy for multiple intra-abdominal injuries. The surgeons note that blood is oozing from all dissected raw surfaces, as well as from his TV line sites. His core temperature is normal. Which of the following is the most appropriate next step in management?

9) A patient with a nonobstructing carcinoma of the sigmoid colon is being prepared for elective resection. Which of the following reduces the risk of postoperative infectious complications?

10) A young man is shot with a .45 caliber revolver, point blank in the lower abdomen, just above the pubis. The entrance wound is at the midline, and there is no exit wound. X-ray films show the bullet embedded in the sacral promontory, to the right of the midline. Digital rectal examination and proctoscopic examination are negative, but he has gross hematuria. He is hemodynamically stable. Which of the following is the most appropriate next step in management?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

28) A 22-year-old woman has a known family history of breast cancer in 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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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 Her- 2/neu positive. Which of the following agents is indicated for treatment of her metastatic disease?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

112) Following significant head trauma, a 34-year-old woman undergoes a CT scan that demonstrates bilateral frontal lobe contusions of the brain. There is no midline shift. She has a GCS of 14. Which of the following is the best initial management of this patient?

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?

114) A 45-year-old man with poorly controlled hypertension presents with severe chest pain radiating to his back. An ECG demonstrates no significant abnormalities. A CT scan of the chest and abdomen is obtained, which demonstrates a descending thoracic aortic dissection extending from distal to the left sub-clavian take off down to above the iliac bifurcation. A Foley catheter is placed, and urine output is 30 to 40cc/h. His feet are warm, with less than 2-second capillary refill. Which of the following is the most appropriate initial management?

115) A stockbroker in his mid-40s presents with complaints of episodes of severe, often incapacitating chest pain on swallowing. Diagnostic studies on the esophagus yield the following results: endoscopic examination and biopsy mild inflammation distally; manometry—prolonged high-amplitude contractions from the arch of the aorta distally, lower esophageal sphincter (LES) pressure 20 mm Hg with relaxation on swallowing; barium swallow 2 cm epiphrenic diverticulum. Which of the following is the best management option for this patient?

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?

118) A 55-year-old man with recent onset of atrial fibrillation presents with a cold, numb, pulseless left lower extremity. He is immediately taken to the operating room for an embolectomy of the left popliteal artery. Which additional procedure should be performed along with the embolectomy?

120) A 35-year-old woman presents to the clinic for a discussion on breast cancer risk. Her family history is pertinent for a grandmother who died of breast cancer at age 53, a mother who died of premenopausal breast cancer, and one of three sisters with breast cancer diagnosed at age 42. The sister with breast cancer underwent genetic testing and was found to have a BRCA1 mutation. Subsequently, the 35-year-old woman underwent genetic testing and was found to be a carrier of the same deleterious BRCA1 mutation. Which of the following ranges represents the lifetime risk for breast cancer that should be quoted for this patient?

121) A 35-year-old woman presents to the clinic for a discussion on breast cancer risk. Her family history is pertinent for a grandmother who died of breast cancer at age 53, a mother who died of premenopausal breast cancer, and one of three sisters with breast cancer diagnosed at age 42. The sister with breast cancer underwent genetic testing and was found to have a BRCA1 mutation. Subsequently, the 35-year-old woman underwent genetic testing and was found to be a carrier of the same deleterious BRCA1 mutation.For this patient, which of the following strategies represents an accepted management option for her high-risk status?

122) A 38-year-old woman presents to the physician because of right upper quadrant pain associated with nausea and vomiting for the past 12 hours. She has had similar pain previously, usually precipitated after the ingestion of fatty foods. However, past episodes have always resolved within one to two hours. She has type 2 diabetes mellitus, hypertriglyceridemia, and hypercholesterolemia. Her current medications include metformin, fenofibrate, and a statin. Her temperature is 38.3° C (101° F), blood pressure is 130/70 mm Hg, pulse is 98/min, and respirations are 20/min. Her BMI is 32 kg/m2. Examination shows right upper quadrant tenderness. Abdominal ultrasound reveals gallstones, a thickened gallbladder wall with edema, and a normal common bile duct. Her alkaline phosphatase level is normal. Which of the following is the most appropriate next step in the management of this patient?

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?

124) In this patient, a benign gastric ulcer was found, and he was placed on a proton-pump inhibitor and triple antibiotics for Helicobacter pylori. He returns to the physician’s office 3 months later with similar complaints and, on re-evaluation, the gastric ulcer was found to persist. Which of the following is the most appropriate next step in management?

126) A 75-year-old woman with history of angina is admitted to the hospital for syncope. Examination of the patient reveals a systolic murmur best heard at the base of the heart that radiates into the carotid arteries. Electrocardiogram (ECG) is notable for left ventricular hypertrophy with evidence of left atrial enlargement. ECG reveals an aortic valve area of 0.7 cm2. What is the most appropriate next step in her management?

127) A pediatrician's office gets a phone call from a frantic mother. Her 7-year-old daughter was playing under the sink and accidentally spilled Liquid Plumber (a strong, corrosive alkaline drain cleaner) all over her arms and legs. The nurse on the phone can hear the girl screaming in the background. Which of the following are the most appropriate instructions to give the mother?

128) A 59-year-old man sustains blunt trauma in an automobile accident, resulting in multiple intraabdominal injuries. Surgery for the repair of these injuries takes several hours and requires multiple blood transfusions and infusions of Ringer's lactate. Before all the operative steps are completed, the patient develops a significant coagulopathy, a core body temperature less than 34 C (93.2 F), and refractory acidosis. The anesthesiologists are administering fresh frozen plasma and platelet packs. Which of the following is the most appropriate next step in management for the surgeon?

129) A previously healthy 19-year-old man presents to the emergency department with a penetrating wound to the right neck. There were reports of bleeding at the scene. The patient is talking, complaining of pain at the injury site and pain with swallowing. On examination, he has a normal respiratory rate, clear air entry on auscultation, blood pressure of 120/70 mmHg, and heart rate of 95 beats/min. There is a penetrating right neck wound in zone 2 (between the clavicle and the lower part of the mandible), with a surrounding hematoma. On probing, there is violation of the platysma. Which of the following is the best next step in the management of this patient?

130) A 45-year-old man is brought to the emergency department after being involved in an automobile crash. He is alert and oriented, with a normal neurologic examination. His respiratory rate is 20/min, with clear lungs, pulse rate of 120/min, and blood pressure of 80/40 mmHg. On examination, he is noted to have a distended abdomen, with decreased bowel sounds, and a fracture of the right ankle. IV access is established, and the patient receives a rapid infusion of 2 L of saline, without changes to pulse rate or blood pressure. Which of the following is the most appropriate next step in his management?

132) Two days after admission to the hospital for a myocardial infarction, a 65-year-old man complains of severe, unremitting midabdominal pain. His cardiac index is 1.6. Physical examination is remarkable for an absence of peritoneal irritation or distention despite the patient’s persistent complaint of severe pain. Serum lactate is 9 mmol/L (normal is < 3 mmol/L). Which of the following is the most appropriate next step in this patient’s management?

133) A 55-year-old man comes to the emergency department because of severe retrosternal chest pain that suddenly started a few hours ago. He has been having some chest pain and epigastric burning for the past few days but says that the current pain is different. His other medical problems include nonischemic cardiomyopathy for which he takes furosemide, carvedilol, spironolactone, lisinopril, and potassium chloride. He also has HIV infection but has chosen not to take any medication related to this diagnosis. His temperature is 38.9° C (102° F), blood pressure is 110/65 mm Hg, pulse is 110/min, and respirations are 22/min. Examination shows that he is in obvious distress secondary to pain. His lungs are clear to auscultation. The remainder of the examination shows no abnormalities. His ECG is within normal limits. Chest x-ray shows a widened mediastinum and some mediastinal air. Which of the following is the most appropriate next step in the management of this patient?

134) A 36-year-old woman presents with palpitations, anxiety, and hypertension. Workup reveals a pheochromocytoma. Which of the following is the best approach to optimizing the patient preoperatively?

135) A 35-year-old woman is involved in a motor vehicle crash, sustaining a severe pelvic fracture, with disruption of the pelvic ring. In the trauma resuscitation room, she is confused and tachypneic, with a blood pressure of 90 mmHg systolic and a heart rate of 130/min. Laboratory investigations include serum electrolyte analysis, revealing a sodium of 139, a chloride of 103, and a bicarbonate of 14 meq/L. Which of the following is the most appropriate management of this acid-based derangement?

136) A 33-year-old pregnant woman notices a persistent, painless lump in the left breast. On examination the left breast has a single mobile mass without evidence of skin changes or lymphadenopathy in the neck or axilla. An ultrasound demonstrates a solid, 1-cm mass in the upper outer quadrant of the breast. A core-needle biopsy shows invasive ductal carcinoma. The patient is in her first trimester of pregnancy. Which of the following is the most appropriate management of this patient?

137) A 40-year-old woman presents with a rash involving the nipple-areola complex for the last month with associated itching. On physical examination there is crusting and ulceration of the nipple with surrounding erythema involving the areola and surrounding skin, no palpable breast masses, and no cervical or axillary lymphadenopathy. Which of the following is the most appropriate next step in the management of this patient?

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?

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?

140) An elderly woman with osteoporosis falls on her outstretched hand. She comes in with a deformed and painful wrist that looks like a dinner fork. X-ray films show a dorsally displaced, dorsally angulated fracture of the distal radius. There is also an associated fracture of the ulnar styloid. A neurologic examination is normal. Which of the following is the most appropriate management?

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?

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?

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?

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?

146) A 65-year-old man presents to the emergency department with sudden onset of pain and weakness of the left lower extremity of 2-hour duration. Past history reveals chronic atrial fibrillation following a myocardial infarction 12 months ago. On examination, he is found to have a cool, pale left lower extremity with decreased strength and absent popliteal and pedal pulses. The opposite leg has a normal appearance with palpable pulses. Which of the following is the treatment of choice for this patient?

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?

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?

149) A 64-year-old woman complains of right calf pain and swelling. She recently underwent an uncomplicated left hemicolectomy for diverticular disease. A duplex ultrasound confirms the presence of deep vein thrombosis (DVT) of the calf. Which of the following is the most appropriate initial management of this patient?

152) A 45-year-old woman presents with a 7-cm renal cell carcinoma with radiologic evidence of abdominal lymph node involvement with no distant metastases. Which of the following is the most appropriate management of this patient?

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?

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?

155) A patient with mild skin pigmentation is admitted emergently to your service because of sudden abdominal pain, fever, and a rigid abdomen. Her blood work indicates a marked leukocytosis, a blood sugar of 55 mg/dL, a sodium value of 119 mEq/dL, and a potassium value of 6.2 mEq/dL. Her blood pressure is 88/58-mmHg. She undergoes an exploratory laparotomy. Which of the following is the definitive treatment for her primary condition?

157) A 45-year-old woman presents with left-sided weakness. A CT scan of the head demonstrates a well-circumscribed mass abutting the skull in the right hemisphere. Workup of the mass reveals a meningioma. Which of the following is the best next step in treatment?

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?

159) An 18-year-old high school senior develops peripheral vision abnormalities. A CT scan of the brain reveals a cystic suprasellar mass with some calcification noted. Clinically, this is compatible with a craniopharyngioma. What is the best next step in treatment?

160) A 65-year-old diabetic man presents to the emergency department with a history of a penetrating wound to his buttock by a wooden stump while working in his garden 24 hours earlier. On examination, he is febrile, the tissue around the wound is violaceous in color, and several bullae and crepitus are noted in the buttock. The drainage from the wound is foul smelling, watery, and grayish in appearance. The optimal treatment for this patient would include which of the following?

161) A 26-year-old man is brought to the emergency room after being extricated from the driver’s seat of a car involved in a head-on collision. He has a sternal fracture and is complaining of chest pain. He is hemodynamically stable and his electrocardiogram (ECG) is normal. Which of the following is the most appropriate management strategy for this patient?

162) The imaging studies demonstrate three lesions in the right hepatic lobe suspicious for metastatic disease, each measuring 3–4 cm in diameter. There was no evidence of extrahepatic disease. Which of the following is the most appropriate next step in management?

163) In your discussion with the patient regarding the risks and benefits of the different management options listed above, which of the following values should you quote regarding the expected 5-year survival rate following curative surgical resection?

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?

166) A 46-year-old woman, who had always been in good health, comes in because of the sudden onset of very severe back and leg pain that she experienced 2 hours ago when attempting to lift a heavy object. She says that she felt "a bolt of lightning" running down the back of her leg, and she still has very severe pain that prevents her from walking or moving. The pain is exacerbated by coughing, sneezing, or straining. She keeps the affected leg flexed; straight leg rising gives her excruciating pain. She has good sphincter tone and intact sensation in the perineum. Once the diagnosis is confirmed with the appropriate studies, which of the following will be the most appropriate treatment?

167) During diagnostic evaluation, a 14-year-old girl with menorrhagia, frequent nosebleeds, and iron deficiency anaemia is found to have a low platelet count with a normal coagulation profile. Bone marrow biopsy reveals abundant megakaryocytes. On abdominal examination, no organomegaly is noted. Which of the following is the most appropriate initial therapy for this patient?

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?

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?

170) A 39-year-old woman presents to the physician’s office for evaluation of a palpable nodule in the neck of 2 years’ duration. Her past history is pertinent for Hashimoto’s disease diagnosed 5 years ago, for which she takes thyroid hormone. She has a history of low-dose chest irradiation for an enlarged thymus gland during infancy. On examination, a 2.5-cm nodule is palpable in the left lobe of the thyroid and is firm and non-tender. Which of the following is the most appropriate next step in her management?

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?

172) A 35-year-old man falls on an outstretched hand and comes in complaining of wrist pain. He relates that he was not able to break the fall, and that the heel of his hand took the brunt of his full weight as it hit the pavement. On physical examination, he is distinctly tender to palpation over the anatomic snuff box. Anteroposterior and lateral x-rays are negative. Which of the following are the most likely diagnosis and most appropriate next step in management?

174) A 34-year-old man is extricated from an automobile after a motor vehicle collision. The patient has an obvious deformity of his right thigh consistent with a femur fracture. Upon closer examination of the right thigh, there is bone visible through an open wound. Which of the following is the most appropriate management of his open femur fracture?

175) A 43-year-old woman comes in because of a breast mass. Two days ago, she noticed a lump on selfexamination. She has a 2-cm, firm, nontender mass in the left breast, which is movable from the chest wall, but not movable within the breast. She has no prior history of breast disease, but she is well read and well informed, and she specifically requests that a biopsy be done with a mammotome. Before proceeding, which of the following is the most appropriate initial step?

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?

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?

178) A 32-year-old, previously healthy man is a victim of a drive-by shooting, sustaining a gunshot wound to the left lower extremity. The entrance wound is located over the medial aspect of the calf, with an exit wound over the anterior pretibial region. Neurovascular examination of the extremity is normal. There is associated soft-tissue injury from the blast effect and a severely comminuted tibial fracture demonstrated on radiographs. Appropriate management of this injury includes which of the following?

179) A 16-year-old adolescent boy sustains head trauma in a motor vehicle collision. He has a GCS of 15 and an obvious depressed skull fracture with 1cm displacement. During his hospital stay, he notices clear fluid draining from his nose. What is the best management strategy for this patient?

180) A 41-year-old woman has noted bilateral thin serous discharge from her breasts. There seems to be no mass associated with it. Which of the following statements would be appropriate to tell the patient?

181) A 42-year-old woman presents to the ER with the worst headache of her life. A noncontrast CT scan of the head is negative for lesions or hemorrhage. She then undergoes a lumbar puncture, which appears bloody. All 4 tubes collected have red blood cell counts greater than 100,000/mL. Which of the following steps is the most appropriate management of this patient?

182) A 16-year-old girl with a history of ulcerative colitis managed with steroid therapy presents to the emergency department with a 36-hour history of nausea, crampy abdominal pain, and severe bloody diarrhea. On examination, the patient is febrile and pale, with a blood pressure of 90/60 mmHg and heart rate of 130 beats/min. Her abdomen is distended and diffusely tender. A complete blood count (CBC) demonstrates a leukocytosis with a left shift. The patient receives IV fluid resuscitation and nasogastric (NG) tube decompression. We inject high-dose IV steroids and broad-spectrum antibiotics. After 48 hours, there is no clinical improvement. Which of the following is the most appropriate next step in management?

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?

184) A 39-year-old man presents with an isolated fracture of the tibia after being hit on the leg with a car. The patient is stable and a radiograph of the leg shows a tibial shaft fracture with severe dislocation. Which of the following is the most appropriate management of the fracture?

185) A 63-year-old woman notices lumps on both sides of her neck. A fine-needle aspirate is nondiagnostic, and she undergoes total thyroidectomy. Final pathology reveals a 2-cm Hürthle cell carcinoma. Which of the following is the most appropriate postsurgical management of this patient?

186) A 51-year-old man presents with a 2-cm left thyroid nodule. Thyroid scan shows a cold lesion. FNA cytology demonstrates follicular cells. Which of the following is the most appropriate initial treatment of this patient?

187) A 25-year-old man is stabbed once in the right chest. The entrance wound is on the midaxillary line, at the level of the fifth intercostal space. He arrives at the emergency department moderately short of breath, but he is fully awake and alert, is talking with a normal tone of voice, and has no distended veins visible in his neck or forehead. His blood pressure is 130/75 mm Hg, and his pulse is 82/min. Physical examination of the chest shows the wound, which is not visibly "sucking air," and demonstrates no breath sounds at all on the right side, which is tympanitic to percussion. There is no evidence of mediastinal displacement. Which of the following would be the most appropriate next step in management?

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?

191) Incisional biopsy of a breast mass in a 35-year-old woman demonstrates cystosarcoma phyllodes at the time of frozen section. Which of the following is the most appropriate management strategy for this lesion?

192) A 36-year-old woman, 20 weeks pregnant, presents with a 1.5-cm right thyroid mass. FNA is consistent with a papillary neoplasm. The mass is cold on scan and solid on ultrasound. Which of the following methods of treatment is contra-indicated in this patient?

193) A 45-year-old man presents to the physician’s office complaining of dysphagia and retrosternal pressure and pain of 2-year duration. The symptoms have worsened over the last 3 months. He has a 30 pack-year smoking history and drinks beer on weekends. Vital signs include a BP of 150/90 mmHg, pulse rate of 90/min, and respiratory rate of 12/min, with a normal temperature. Examination reveals a thin man with a normal heart, lung, and abdomen examination. An esophagogram reveals a 6-cm, smooth, concave defect in the mid-esophagus with sharp borders. Esophagoscopy reveals intact overlying mucosa and a mobile tumor. Which of the following is the most appropriate next step?

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?

195) During diagnostic evaluation, a 14-year-old girl with menorrhagia, frequent nosebleeds, and irondeficiency anemia is found to have a low platelet count with a normal coagulation profile. Bone marrow biopsy reveals abundant megakaryocytes. On abdominal examination, no organomegaly is noted. The patient has a satisfactory response to the initial therapeutic intervention, but over 6–12 months’ time, the response is less dramatic and shorter in duration. There are signs and symptoms of increasing side effects from therapy. The next step in management should be to recommend which of the following?

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?

197) A 19-year-old previously healthy man is an unbelted driver of a motor vehicle involved in a frontend collision. On arrival in the emergency department, the patient is noted to have stridor, with marked respiratory distress, and an oxygen saturation of 88% despite 100% oxygen by mask. He has obvious extensive facial injuries, a flail chest, and poor chest expansion. Bag-mask-valve ventilation is ineffective. Which of the following is the most appropriate next step in management?

198) A 32-year-old man presents with an asymptomatic mass in his right testicle. On examination, the mass cannot be transilluminated. Ultrasound shows a solid mass in the right testicle. Which of the following is the most accurate method in obtaining a diagnosis of testicular cancer?

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?

200) A pedestrian is hit by a speeding car. Radiologic studies obtained in the emergency room, including a retrograde urethrogram (RUG), are consistent with a pelvic fracture with a rupture of the urethra superior to the urogenital diaphragm. Which of the following is the most appropriate next step in this patient’s management?

201) A previously healthy 45-year-old man presents with a 9-month history of a slow-growing, painless right neck mass. He is a nonsmoker and has no significant past medical history. On examination, there is a nontender, discrete, 3-cm mass over the angle of the right mandible. Facial muscle function and sensation are normal. An oropharyngeal examination is normal. Which of the following is the best next step in the management of this patient?

202) A 63-year-old man underwent a 3-vessel coronary artery bypass graft (CABG) 5 hours ago. Initially, his mediastinal chest tube output was 300 mL blood/h, but an hour ago, there was no further evidence of bleeding from the tube. His mean arterial pressure has fallen, and several fluid boluses were administered. His central venous pressure (CVP) is elevated to 20 mm Hg, and he has required the addition of inotropes. Which of the following is the best management strategy?

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?

204) A 23-year-old man presents to the emergency department with a soft-tissue injury to the left lower extremity. The injury was sustained 8 hours earlier in a motorcycle accident on a gravel road. On examination, the patient has a 7-cm deep laceration to the calf, with visible road debris. He had full tetanus immunization as a child and a tetanus booster immunization at age 15. Appropriate management of this injury would include which of the following?

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?

206) A 25-year-old man is stabbed in the right chest. He comes in fully awake and alert, and, in a normal tone of voice, he states that he feels short of breath. His vital signs are normal and stable. On physical examination, he has no breath sounds at the right base, and only faint breath sounds at the apex. He is dull to percussion over the right base. A chest x-ray film confirms that he has a hemothorax on that side. Which of the following is the most appropriate next step in management?

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?

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)?

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?

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?

214) A 49-year-old woman presents to her physician with dysphagia, regurgitation of undigested food eaten hours earlier, and coughing over the last 6 months. She was hospitalized 1 month ago for aspiration pneumonia and successfully treated with antibiotics. Examination reveals a thin-appearing woman with normal vital signs and unremarkable chest, heart, and abdominal examination. A UGI contrast study is performed and reveals a pharyngoesophageal (Zenker’s) diverticulum. Which of the following is the most important aspect of treatment?

215) A 40-year-old alcoholic is brought to the emergency department with frostbite to both lower extremities. His core body temperature is 36°C. Which of the following is the most appropriate initial treatment for the patient’s thermal injury?

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?

217) A 65-year-old man presents to the emergency department with sudden onset of pain and weakness of the left lower extremity of 2-hour duration. Past history reveals chronic atrial fibrillation following a myocardial infarction 12 months ago. On examination, he is found to have a cool, pale left lower extremity with decreased strength and absent popliteal and pedal pulses. The opposite leg has a normal appearance with palpable pulses. Following successful treatment for an embolus to the left femoral artery with no evidence of a reperfusion injury (anticoagulation with heparin and thromboembolecctomy), which of the following long-term treatments would most likely decrease the chance of recurrent embolus?

218) A 63-year-old man has a chylothorax that after 2 weeks of conservative therapy appears to be persistent. The chest tube output is approximately 600 mL/day. Appropriate management at this time includes which of the following procedures?

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?

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?

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?

222) A 63-year-old woman with chronic obstructive pulmonary disease (COPD) presents with a severalweek history of fever, night sweats, weight loss, and cough. Her CXR is noted to have a density in the left upper lobe with a relatively thin-walled cavity. Bronchoscopy and computed tomographic (CT) scan are suggestive of a lung abscess rather than a malignant process. Which of the following is the most appropriate initial management of this patient?

223) A 4-year-old previously healthy girl presents to the emergency department with a 24-hour history of rectal bleeding and dizziness. She has no other gastrointestinal symptoms. On examination, she appears pale. Her heart rate is 140 beats/min, and she has a 20 mmHg postural drop in systolic blood pressure. The child’s abdomen is nondistended and nontender, and fresh blood and clots are in the rectal vault on rectal examination. Definitive management of this child should include which of the following?

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?

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?

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?

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?

229) A 49-year-old woman has a firm, 2-cm mass in the right breast that has been present for 3 months. Mammogram has been read as "cannot rule out cancer," but it cannot diagnose cancer either. A fineneedle aspiration of the mass (FNA) and cytology do not identify any malignant cells. Which of the following is the most appropriate next step in management?

230) A 60-year-old man sees a urologist for what he describes as bloody urine. A urine sample is positive for cytologic evidence of malignancy. Cystoscopy confirms the presence of superficial transitional cell carcinoma. Which of the following is the recommended treatment for stage A (superficial and submucosal) transitional cell carcinoma of the bladder?

231) A 36-year-old man presents to the emergency room with renal colic. His vital signs are normal and a urinalysis shows microscopic hematuria. A radiograph reveals a 1.5-cm stone. Which of the following is the most appropriate management of this patient?

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?

233) A 55-year-old man presents to the emergency department with left lower quadrant abdominal pain. The pain has been present for 1 week, but has increased in intensity over the last 2 days associated with nausea, constipation, and dysuria. Past history is unremarkable. Examination reveals a temperature of 101°F, pulse rate of 95/min, BP of 130/70 mmHg, and normal heart and lung examinations. Abdominal examination reveals fullness and marked tenderness in the left lower quadrant, with voluntary guarding and decreased bowel sounds. Laboratory tests reveal a WBC count of 18,000 with a left shift and 20–50 WBCs in the urinalysis. A CT scan of the abdomen reveals a thickened sigmoid colon with pericolonic inflammation. He is admitted to the hospital for treatment. We find this patient has diverticulitis. Which of the following is the most appropriate management of this patient?

234) A 39-year-old woman completed her last course of postoperative adjuvant chemotherapy for breast cancer 6 months ago. She now comes to the clinic complaining of constant back pain for about 3 weeks. She is tender to palpation over two well-circumscribed areas in the thoracic and lumbar spine. Which of the following is the most appropriate next step in management?

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?

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?

237) A man who weighs 65 kg sustains second and third degree burns over both of his lower extremities when his pants catch on fire. When examined shortly thereafter, it is ascertained that virtually all of the skin from both groins to the tip of the toes, front and back, has been burned. According to the modified Parkland formula, which of the following is the approximate total amount of IV fluid that he can be expected to require during the first 24 hours post-burn?

238) A 65-year-old man presents to the emergency department with sudden onset of pain and weakness of the left lower extremity of 2-hour duration. Past history reveals chronic atrial fibrillation following a myocardial infarction 12 months ago. On examination, he is found to have a cool, pale left lower extremity with decreased strength and absent popliteal and pedal pulses. The opposite leg has a normal appearance with palpable pulses. Which of the following is the most appropriate first step in management of this patient?

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?

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?

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?

242) A 71-year-old woman with a 40-year smoking history is noted to have a peripheral nodule in her left upper lobe on chest x-ray. Workup is consistent with small cell lung cancer with ipsilateral mediastinal lymph node involvement but no extrathoracic disease. What is the best treatment option for this patient?

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?

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?

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?

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?

247) A 64-year-old man with a history of a triple coronary artery bypasses 2 years ago presents with peripheral arterial occlusive disease. His only medication is a thiazide diuretic. Which of the following medications would be most appropriate in the medical management of his atherosclerosis?

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?