USMLE Surgery 1022 (761-1022 / Part 4) GD

761. A 32-year-old man comes to the emergency room (ER) because of acute onset left flank pain, hematuria and vomiting. His pain is relieved with ketorolac in the ER. He has a history of abdominal pain due to Crohn disease, but that pain was always in the rightlower quadrant and was never this severe. His temperature is 36.80 C (98.20 F), blood pressure is 120/65 mm Hg, pulse is 110/min and respirations are 16/min. Chest auscultation is clear. Abdomen is soft and mildly tender over the left flank. He has no rebound or rigidity. Bowel sounds are decreased. A laparotomy scar is present in right lower quadrant. Which of the following is the most likely cause of his symptoms?

762. A 54-year-old man comes to the physician because of edema of his right ankle. He reports heaviness and cramping in the same leg that is worse after a long day at work. The swelling is usually reduced significantly when he wakes up in the morning and worsens progressively throughout the day. He denies any other symptoms. He has no significant medical problems except hypertension, for which he takes atenolol. His temperature is 36.7C (98F), blood pressure is 120/76 mm Hg, pulse is 80/min and respirations are 16/min. JVP is normal. Lungs are clearto auscultation. There are no murmurs. There is no hepatosplenomegaly. Examination shows edema of the right ankle. Doppler examination of the leg shows no evidence of thrombosis W hich of the following is the most likely cause of his edema?

763. A 34-year-old man comes to the emergency department because of severe pain in his penis. He was having sex with his wife on top when he had sudden onset severe pain in the penis at the height of orgasm. Swelling of the penis and deviation of the penile shaft to the right followed the pain. Examination shows a man in severe distress. The penis is uncircumcised, grossly swollen and deviated to the right. There is no blood at the urethral meatus. Which of the following is the most appropriate next step in management?

764. A 30-year-old man comes to the physician because of a 2-week history of swelling and pain in the right knee. He first experienced pain when he twisted his leg while playing football 15 days ago. He felt something 'popping' in the knee at that time but ignored it. The pain and swelling has been increasing since, and he feels sudden pain with extension of his leg. Examination shows the right knee is swollen and tender along the medial side. Full extension of the right knee is not possible due to sudden pain during terminal extension. Snapping can be felt in the right knee on tibial torsion with the knee flexed at 90 degrees. An x-ray film of the knee joint shows no abnormalities. Which of the following is the most likely diagnosis?

765. A 34-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He has severe abdominal and left shoulder pain. His temperature is 360 C (96.80 F), blood pressure is 100/60 mm Hg, pulse is 110/min and respirations are 23/min. Examination shows tenderness in the left upper quadrant of the abdomen. An x-ray film of the chest shows fractures of the left 7th, 8th and 9th ribs. A CT scan of the abdomen is suggestive of splenic injury with some free fluid in the abdomen. He has not been vaccinated for H. Influenza or S. pneumoniae. Which of the following is the most important determinant for surgical versus non-surgical management in this patient?

766. A 45-year-old woman underwent elective surgery for an inguinal hernia. In the postoperative recovery room, she developed nausea, vomiting, and acute abdominal pain. She has a history of systemic lupus erythematosus, pernicious anemia, type- 1 diabetes, chronic low back pain, and uterine fibroids. Her preoperative medications include monthly vitamin B- 12 injections, insulin, prednisone, hydroxychloroquine, and acetaminophen. Her blood pressure is 70/40 mm Hg and heart rate is 110/min. Initial laboratory studies show a blood glucose of 50 mg/dl. Which of the following is the most likely cause of her condition?

767. A 46-year-old male is brought to the emergency department after falling on his head and back during a downhill bike race and losing consciousness for 1 minute. He has severe back and abdominal pain. AP and lateral skull films show no abnormalities. Lumbar films show anterior compression wedge fractures of the bodies of L1 and L2. A brace is placed. CT scan of the abdomen shows a mild retroperitoneal bleed and splenic laceration. During the hospitalization he was treated conservatively with analgesics and supportive measures. On hospital day 3, he started to have abdominal distention, pain and nausea. His last bowel movement was 4 days ago and he is not passing gas. His abdomen is distended, tympanic and mildly tender without rebound or guarding. Bowel sounds are absent. An x-ray film of the abdomen is shown ABOVE.Which of the following is the most likely diagnosis?

768. A 55-year-old male Asian immigrant presents to the physician because of recent-onset neck swelling. He also notes having several episodes of epistaxis lately. He has not sustained any trauma to the neck or nose. His past medical history is significant for syphilis and recurrent bacterial sinusitis. He drinks 2 beers daily and has a 30-pack year smoking history. He takes daily multivitamins with antioxidants. On physical examination, you note a mass in the posterior nasal cavity. Biopsy shows undifferentiated carcinoma. Which of the following is a risk factor for this cancer?

769. A 75-year-old woman is brought to the emergency department after falling early in the morning. She is unable to move her right leg and has severe pain in her right hip. Her temperature is 36.90 C (98.60 F), blood pressure is 90/50 mm Hg, pulse is 100/min and respirations are 16/min. Examination shows the right lower extremity is shortened and is externally rotated with marked limitation of hip movement on the right side. An x-ray of the hip shows a markedly displaced fracture of the neck of the right femur. After hemodynamically stabilizing the patient, which of the following is the most appropriate step in management?

770. A 12-year-old boy is brought to the emergency department after falling from a tree. Examination shows tenderness and swelling over the left lower arm. An x-ray film of the arm shows a fracture of the distal end of the humerus with proximal and posterior displacement of the distal fracture segment. Closed reduction of the fracture is performed. However, postoperatively the patient complains of increasing pain in the left arm and forearm. Twelve hours postoperatively his forearm is pale and cold. There is marked pain on passive extension of the fingers. Which of the following is the potential dreaded complication of this condition?

772. A 36-year-old male comes to the emergency department because of worsening right lower quadrant (RLQ) abdominal pain. One week ago he was started on cephalexin for furunculosis. He has had type I diabetes mellitus for 10 years and is on insulin. His temperature is 38.30 C (101.90 F). Examination shows multiple furuncles on the inner side of both thighs; most of them are in regression. Abdominal examination shows tenderness on deep palpation in RLQ without rebound or guarding; no masses are palpated; psoas sign is positive; bowel sounds are present. Rectal examination shows no abnormalities. Laboratory studies show: Hemoglobin 13.0 g/L Leukocyte count 17,500/mm3 Which of the following is the most appropriate next step in management?

773. A 68-year-old man comes to the emergency department because of sudden onset back pain. He has never had back pain before and denies any trauma. He does not feel well and feels "like he is going to die". His blood pressure is 70/40 mm Hg, pulse is 110/min and respirations are 20/min. On examination, the abdomen is tender to palpation and there is a large pulsatile mass. Which of the following is the most appropriate next step in management?

774. A 40-year-old female is brought to the emergency department following a motor vehicle accident in which she was the front seat passenger. She reports hitting her head against the windshield and hurting her right leg. She appears completely alert and oriented. Glasgow Coma Scale = 15/ 15. Her pupils are equal and reactive to light. There is a bruise over the right forehead, but no tenderness is present on palpation of the cranial bones. Examination of the right leg reveals a hematoma over the thigh. Knee extension on the right is markedly reduced when compared to the left. Sensory examination reveals decreased sensory perception to both sharp and dull stimuli over the right lower medial leg. All other dermatomes are intact. What nerve injury is most likely present in this patient?

775. A 45-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He is conscious but in severe pain. His blood pressure is 90/60 mm Hg, pulse is 100/min and respirations are 17/min. Physical examination shows marked swelling and some bruising over the right thigh; the skin is intact. An x-ray film of the leg shows a fracture of the mid shaft of the femur. After hemodynamically stabilizing the patient, which of the following is the most appropriate next step in management?

776. A 25-year-old man is brought to the emergency department after falling 12m (40ft) from a ladder. He is unconscious. Examination shows obvious head and neck injuries, and a fractured forearm. He is totally apneic. Which of the following would be the best method to establish an immediate definitive airway in this patient?

777. A 60-year-old male with a history of ischemic heart disease (IHD) is brought to the emergency department after a motor vehicle accident. On arrival, his blood pressure is 90/60 mm Hg, pulse is 110/min and respirations are 26/min. There are bruises on the left thigh, left side of the chest and tenderness over the same areas. He is started on intravenous normal saline. The presence of which of the following situations would require a blood transfusion in this patient?

778. A 73-year-old man comes to the physician because of right anterior thigh pain that is worse with walking. He has a history of stable angina, hypertension, hypercholesterolemia, and COPD with periodic exacerbations. He takes ipratropium, aspirin, metoprolol and pravastatin. He smokes 2 packs a day and drinks alcohol occasionally. Physical examination shows a small pulsatile mass in the right groin area. Which of the following is the most likely diagnosis?

779. A 34-year-old woman is admitted for septic shock secondary to a urinary tract infection. In the intensive care unit, she receives dopamine, intravenous fluids and antibiotics and requires central line placement for venous access. Which of the following is the most important safeguard to prevent respiratory and cardiac complications following central line placement?

780. A 72-year-old man underwent surgical repair of an aneurysm of the infrarenal aorta. He received perioperative prophylaxis with a second-generation cephalosporin antibiotic. On the first postoperative day he complains of progressive abdominal pain and bloody diarrhea. His temperature is 38.50C (1010F), blood pressure is 110/65 mm Hg, pulse is 110/min and respirations are 22/min. His abdomen is mildly distended and tender to palpation. The tenderness is mostly in the left lower quadrant without rebound. Femoral pulses are full and symmetric. His white blood cell count is 12,000/mm3. Which of the following is the most likely diagnosis?

781. A 35-year-old previously healthy male comes to the emergency department because of a 4-hour history of severe abdominal pain. The pain had initially started in the periumbilical area but has now shifted to the right lower quadrant. He also felt nauseated and vomited twice. He has had no previous surgeries. His temperature is 38.90 C (1020 F), blood pressure is 125/80 mm Hg, pulse is 100/min and respirations are 20/min. Examination shows tenderness in the right lower quadrant. Palpation of the left lower quadrant produces pain in the right lower quadrant. Urinalysis is negative. Which of the following is the most appropriate next step in management?

782. A 51-year-old male with a history of alcoholic pancreatitis presented to the hospital because of sudden onset severe retrosternal and upper abdominal pain. He has been vomiting for the past few hours after consuming alcohol. His temperature is 38.10 C (100.90 F), blood pressure is 140/90 mm Hg, pulse is 120/min and respirations are 30/min. Examination shows palpable crepitus in the suprasternal notch. Lungs are clear to auscultation. The abdomen is tender to palpation mostly in the epigastrium. Which of the following is the most likely cause of his current condition?

783. A 12-year-old male is brought to the physician because of a two week history of right groin pain and limping. He is at the 60th percentile for height and the 90th percentile for weight. He is afebrile and his other vital signs are within normal limits. Examination shows the range of motion of the right knee joint is within normal limits, but hip movements are restricted and the right foot points medially. There is marked external rotation of the right thigh on flexion of the hip. After confirming the diagnosis, which of the following is the most appropriate management?

784. A 24-year-old woman comes to the physician's office because of breast pain. She has a 2-month-old baby who she breastfeeds. Her temperature is 38.SC (101.9F). Examination shows a hard, red, tender and swollen area on her right breast. There is no fluctuance noted. Which of the following is the most appropriate next step in management?

785. A 23-year-old man comes to the emergency department because of a painful swollen left knee. The pain began after he twisted his leg while playing football. Examination shows a swollen left knee with marked tenderness of the medial side of the knee. When compared to the right knee, on valgus stressing the left knee shows exaggerated laxity at the joint line. Which of the following is the most appropriate next step to confirm the diagnosis?

786. 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?

787. A 46-year-old male was admitted with epigastric pain radiating to the back. He has a previous history of endocarditis from intravenous drug use and cellulitis of the arm. Serum lipase is elevated. He was admitted and treated conservatively. Two days later he started to have a fever. He is awake but slightly disoriented. His temperature is 38.70 C (101.60 F), blood pressure is 120/76 mm Hg, pulse is 110/min and respirations are 16/min. He is tremulous and says bugs are crawling on him. His blood cultures are positive for gram negative rods. Empiric antibiotic therapy is started. CT scan of the abdomen shows a new 6 x 6 cm cystic lesion attached to the pancreatic head. Laboratory results show: Hematocrit 44.0 g/L MCV 105fl Leukocyte count 18,500/mm3 Amylase 255 U/L Which of the following is the most appropriate next step in management?

789. A 40-year-old male developed shortness of breath during the postoperative recovery period. He had a large ventral hernia repair a few hours ago. He has no significant past medical history. He has never smoked. His temperature is 37.60 C (99.80 F), blood pressure is 100/60 mm Hg, pulse is 100/min and respirations are 30/min. Lungs are clear to auscultation except for a few rales at the bases. An x-ray film of the chest shows bibasilar atelectasis. Arterial blood analysis shows: pH 7.35 P02 70 mm Hg PC02 45 mm Hg HC03 28 mEq/L Which of the following is the most appropriate next step in management?

790. A 39-year-old paleontologist complains of right-sided hip pain that makes it very difficult for him to lay on his right side while sleeping. He localizes the pain to the outer surface of his thigh. Which of the following is the most likely cause of his pain?

791. A 12-year-old male is brought to the emergency department after direct blunt trauma to the upper abdomen. He has epigastric pain and repeated vomiting immediately after the trauma. He is afebrile and his other vital signs are stable. Barium examination shows duodenal obstruction. CT scan of the abdomen shows a duodenal hematoma and no other injuries are noted. Which of the following is the most appropriate next step in management?

792. A 55-year-old man comes to the emergency department because of severe right-sided chest pain. His temperature is 37.80 C (100.40 F), blood pressure is 138/88 mm Hg, pulse is 88/min and respirations are 19/min and shallow. Examination shows decreased respiratory movements on the right side of the chest and tenderness on palpation over the right mid-chest. An x-ray film of the chest shows a fracture of the right 6th rib. Which of the following is the most important goal in management of the rib fracture in this patient?

793. A 17-year-old man comes to the physician because a one-week history of fever and abdominal pain. This began with mid-abdominal pain and nausea one week ago, but he was able to continue his usual activities. However, during the past two days, the pain has become worse. It is now localized to the right iliac fossa and impairs walking. He has had two episodes of vomiting during the past several hours. His temperature is 39.40 C (1030 F), blood pressure is 110/70 mm Hg, pulse is 90/min, and respirations are 18/min. Examination shows a tender iliac fossa mass palpated on the right side; remaining abdominal examination shows no rigidity or guarding. Which of the following is the most appropriate next step in management?

794. A 34-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He was the restrained front passenger. He has had epigastric pain since the accident. He is hemodynamically stable and has no obvious injury or other complaints. An x-ray of the abdomen shows retroperitoneal air. Which of the following is the most appropriate test to confirm the diagnosis?

795. A 22-year-old football player comes to the physician because of difficulty in extending his right knee. This started one month ago after he twisted his knee while playing. There was mild swelling immediately; he took pain relievers which relieved both the pain and swelling. However, now the knee motion is limited and this is significantly restricting his physical activities. Physical examination shows no swelling of the knee. While passively flexed and extended, a popping sensation is noted under the examiner's finger (which is placed at the right knee). Which of the following is the most appropriate next step in management?

796. A 34-year-old male is involved in a high-speed highway motor vehicle collision. He is intubated by rescue workers at the accident scene. In the emergency department, the patient has decreased breath sounds on the right side, normal breath sounds on the left, and hypotension. A right-sided chest tube is placed. Physical examination reveals multiple bruises over the entire chest wall as well as subcutaneous emphysema. A few hours later, his chest x-ray shows an accumulation of air in the pleural space as well as pneumomediastinum. Which of the following is the most likely diagnosis?

797. A 23-year-old man is brought to the emergency department in an obtunded state following a gun-shot wound to the right upper quadrant of the abdomen. His systolic blood pressure is 60 mm Hg and unable to obtain diastolic blood pressure. His pulse is 136/min. Chest auscultation shows clear heart and breath sounds. The abdomen appears distended, and there is an obvious gun-shot wound on the right upper quadrant. The bowel sounds are decreased. Which of the following is the most appropriate next step in management?

798. While working on-site at a factory doing physical examinations for workers, a physician is suddenly called to help a worker who amputated his finger. Which of the following is the most appropriate next step in management in this situation?

799. A 35-year-old woman is brought to the emergency department after being rescued from a burning home by firefighters. She is confused, agitated and tachypneic. Her temperature is 370 C (98.60 F), blood pressure is 100/60 mm Hg, pulse is 130/min and respirations are 24/min. Physical examination shows no burns and her skin color is normal. Auscultation shows normal bilateral air entry with scattered wheezes. Neurological examination shows no abnormalities except some confusion. Abdominal examination shows a soft abdomen; bowel sounds are present. Which of the following is the best immediate treatment for her acute confusional state?

800. A 12-year-old boy is brought to the emergency department after being involved in a motor vehicle collision. He was in the rear seat and was thrown out of the car during the accident. He was immediately resuscitated, and the trauma work-up showed no abnormalities. His discharge was uneventful. Two months later he was seen in the emergency department because of vague chest pain and discomfort. Auscultation showed decreased air entry into the left lower base. An x-ray film of the chest is shown below. Which of the following is the most appropriate next step in management?

801. A 22-year-old primigravida woman at 33 weeks gestation is brought to the emergency department after a tonic clonic seizure. On arrival, she also has visual disturbances and a headache. She is given magnesium sulfate and hydralazine. She soon regains consciousness but cannot move her right arm; however, she can move her fingers. Her temperature is 37.20 C (990 F), blood pressure is 160/100 mm Hg, pulse is 110/min and respirations are 20/min. Examination shows her arm extended along the chest and internally rotated. There is no sensory loss on the arm, but there is an inability to externally rotate the shoulder. Deep tendon reflexes (DTR) are intact. Which of the following is the most likely cause of her inability to move her hand?

802. A 21-year-old female military recruit presented to the physician's office because of pain in her right foot. The pain started a few weeks ago and initially only occurred with activity, but now the pain is present even at rest. She has no history of obvious trauma. Examination shows swelling and warmth in the foot and point tenderness over the second metatarsal. Plain films of the foot show a hairline fracture of the shaft of the second metatarsal. Which of the following is the most appropriate next step in management?

803. A 15-year-old boy is brought to the physician because of a 15-day history of painful swelling of the right knee. The swelling and redness were immediate after hitting his knee on the door, but have not subsided after 15 days of ibuprofen. He states the pain is increasing. He has no other complaints. His temperature is 37.10C (98.90F), blood pressure is 110/75 mm Hg, pulse is 80/min, and respirations are 22/min. Laboratory studies show a normal ESR and elevated serum alkaline phosphatase. Examination shows the skin is warm and non-tender. An x-ray film of the femur and the knee joint shows an osteolytic lesion of the distal femur along with periosteal inflammation. Which of the following is the most likely diagnosis?

804. A 34-year-old male is brought to the emergency department by the paramedics after a gun-shot injury. His temperature is 370 C (98.80 F), blood pressure is 110/60 mm Hg, pulse is 96/min and respirations are 18/min. Examination shows a gunshot entry wound in the left 6th intercostal space anteriorly just lateral to the mid-clavicular line, and an exit wound in left 7th intercostal space posteriorly. After completing the primary survey by attending to airway, breathing and circulation, which of the following is the most appropriate next step in management?

805. A 46-year-old male comes to the emergency department because of an abrupt onset of worsening epigastric pain radiating to the back and vomiting. His temperature is 36.50 C (97.60 F), blood pressure is 100/70 mm of Hg, pulse is 100/min and respirations are 20/min. Examination shows a mildly distended abdomen that is very tender to palpation in the epigastric region without rebound; bowel sounds are absent; rectal examination shows no abnormalities. An x-ray film of the abdomen shows gaseous distention of the small bowel in the upper abdomen. CT with contrast shows diffuse hypodense enlargement of the pancreas and peripancreatic and perirenal fluid collections. Nasogastric suction, intravenous normal saline, analgesics and antibiotics are started. Laboratory studies show: Hemoglobin 15.0 g/L Platelets 223,000/mm3 Leukocyte count 14,500/mm3 Serum sodium 134 mEq /L Serum potassium 3.6 mEq/L Chloride 93 mEq/L Bicarbonate 29 mEq/L Blood urea nitrogen (BUN) 30 mg/dL Serum creatinine 0.8 mg/dL Calcium 10.3 mg/dL Blood glucose 168 mg/dL Total bilirubin 1.4 mg/dL Alkaline phosphatase 220 U/L Aspartate aminotransferase (SGOT) 88 U/L Alanine aminotransferase (SGPT) 155 U/L Lipase 523 U/L Which of the following is the most appropriate next step in management?

806. A 72-year-old man underwent bypass grafting for severe coronary artery disease. On the 1st postoperative day, his temperature is 36.60 C (97.90 F), blood pressure is 120/70 mm Hg, pulse is 80/min and respirations are 12/min. On postoperative day 10 he is complaining of worsening retrosternal pain despite continuing analgesia with morphine. He also has dyspnea at rest. His temperature currently is 37.90 C (100.10 F), blood pressure is 110/70 mm Hg, pulse is 100/min and respirations are 24/min. Examination shows clear heart sounds without murmurs or rubs. EKG shows no acute changes compared to the EKG on the 1st postoperative day. An x-ray film of the chest shows widening of the mediastinum. Echocardiography shows a small amount of pericardial fluid. Laboratory studies show: Hemoglobin 11 .0 g/L Platelets 120,000/mm3 Leukocy1e count 16,500/mm3 Neutrophils 86% Lymphocy1es 13% Prothrombin time 12 sec Partial thromboplastin time 30sec Which of the following will this patient most likely require?

807. A 24-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He has severe low back pain. Examination shows weakness and decreased pain and temperature sensation in both legs. Fine touch, vibration, pressure and proprioceptive sensations are intact. He is immobilized and his airway, breathing and circulation are restored. Which of the following is the most appropriate next step in management of his spinal injury?

808. A 34-year-old unrestrained male driver is brought to the ER after a motor vehicle accident. His cervical spine is immobilized. He is stuporous. At the scene of the accident, his blood pressure is 70/30 mm Hg and heart rate is 130/min. Lungs are clear to auscultation. Abdominal wall ecchymosis is present. Abdomen is mildly distended. Bowel sounds are decreased. Neck veins are collapsed. After two liters of intravenous fluids, his blood pressure is 80/40 mmHg. A focused assessment with sonography for trauma shows blood in the peritoneal cavity but no obvious solid organ injury. Which of the following is the most appropriate next step in management?

809. A newborn infant is found to have a scrotal mass. The mass is cystic and transilluminated with light. He is born without any other complications. The vital signs are with in normal limits. Other physical examination is unremarkable. Which of the following is the most appropriate next step in management?

810. A 37-year-old woman comes to the physician's office because of left breast discomfort. The discomfort has been there for several months, and she recently started having breast pain before menses. Yesterday she noticed a lump in her breast. She has no family history of breast cancer. She smokes one pack of cigarettes every day. She had a baseline mammogram at age 35, which showed no abnormalities. Examination shows a smooth, soft, mobile mass palpable in the upper outer quadrant of the left breast; some diffuse nodularity is present bilaterally. Vital signs are normal. Physical examination otherwise shows no abnormalities. Fine needle aspiration of the mass shows thin greenish, non-bloody fluid; the mass disappears completely after the aspiration. Which of the following is the most appropriate next step in management?

811. A 23-year-old woman is brought to the emergency department because of severe respiratory distress. She was stung by a bee one hour ago. Her temperature is 37.10 C (98.80 F), blood pressure is 80/50 mm Hg, pulse is 98/min and respirations are 20/min. Examination shows a conscious woman in severe respiratory distress with audible wheezing. Her skin is warm to palpation. Which of the following is the most appropriate next step in management?

812. A 14-year-old boy is brought to medical attention because of nasal fullness and bleeding. Inspection reveals enlarged cervical lymph nodes as well. Biopsy of a lymphnode confirms nasopharyngeal carcinoma. What is the best management strategy for this patient?

813. A young motorcycle driver is thrown against a concrete bridge abutment and sustains severe trauma about the face, with marked periorbital edema and ecchymosis as well as epistaxis. He is obtunded with rapid, shallow breathing. Which of the following is the next appropriate step in his workup and management?

814. A 48-year-old man with a strong history of cigarette use and heavy alcohol intake presents with an intraoral mass. Biopsy shows squamous cell cancer. Chest xray shows hyperinflated lungs but is otherwise normal. Which of the following is indicated as part of his staging workup?

815. Your patient presents with a complaint of a mass on her right cheek, which has been slowly enlarging. Biopsy shows a pleomorphic adenoma. Which is the next step in her management?

817. A 74-year-old woman is admitted with upper gastrointestinal (GI) bleeding. She is started on H 2 blockers, but experiences another bleeding episode. Endoscopy documents diffuse gastric ulcerations. Omeprazole is added to the H2 antagonists as a therapeutic approach to the management of acute gastric and duodenal ulcers. Which of the following is the mechanism of action of omeprazole?

818. A 35-year-old woman presents with frequent and multiple areas of cutaneous ecchymosis. Workup demonstrates a platelet count of 15,000/μL, evaluation of the bone marrow reveals a normal number of megakaryocytes, and ultrasound examination demonstrates a normal-sized spleen. Based on the exclusion of other causes of thrombocytopenia, she is given a diagnosis of immune (idiopathic) thrombocytopenic purpura (ITP). Which of the following is the most appropriate treatment upon diagnosis?

819. A 59-year-old woman presents with right lower quadrant pain, nausea, and vomiting. She undergoes an uncomplicated laparoscopic appendectomy. Postoperatively, the pathology reveals a 2.5-cm mucinous adenocarcinoma with lymphatic invasion. Staging workup, including colonoscopy, chest x-ray, and computed tomography (CT) scan of the abdomen and pelvis, is negative. Which of the following is the most appropriate next step in her management?

820. A 41-year-old man complains of regurgitation of saliva and of undigested food. An esophagram reveals a dilated oesophagus and a bird’s-beak deformity. Manometry shows a hypertensive lower esophageal sphincter with failure to relax with deglutition. Which of the following is the safest and most effective treatment of this condition?

821. A 32-year-old man with a 3-year history of ulcerative colitis (UC) presents for discussion for surgical intervention. The patient is otherwise healthy and does not have evidence of rectal dysplasia. Which of the following is the most appropriate elective operation for this patient?

822. A 39-year-old previously healthy male is hospitalized for 2 weeks with epigastric pain radiating to his back, nausea, and vomiting. Initial laboratory values revealed an elevated amylase level consistent with acute pancreatitis. Five weeks following discharge, he complains of early satiety, epigastric pain, and fevers. On presentation, his temperature is 38.9°C (102°F) and his heart rate is 120 beats per minute; his white blood cell (WBC) count is 24,000/mm3 and his amylase level is normal. He undergoes a CT scan demonstrating a 6 cm by 6 cm rim-enhancing fluid collection in the body of the pancreas. Which of the following would be the most definitive management of the fluid collection?

823. A previously healthy 79-year-old woman presents with early satiety and abdominal fullness. CT scan of the abdomen, pictured here, reveals a cystic lesion in the body and tail of the pancreas. CT-guided aspiration demonstrates an elevated carcinoembryonic antigen (CEA) level. Which of the following is the most appropriate treatment option for this patient?

824. A 35-year-old man is brought to the emergency department after he jumped from the fourth floor of a burning building. His temperature is 36.9° C (98.5° F), blood pressure is 90/40, pulse is 90/min, and respirations are 20/min. Examination shows a fracture of the right tibia. He is conscious and his pupils are bilaterally equal and reactive to light and accommodation. His neurological examination shows paraplegia, with loss of pain and temperature in both legs but normal proprioception. Upper extremities do not show any neurological deficits. Passive straight leg raising test is negative. A CT scan of the spine shows a burst fracture at the level of the fourth thoracic vertebra. Which of the following is the most likely diagnosis?

825. A 22-year-old man involved in a motor vehicle collision undergoes a prolonged operation to repair a left femur fracture and femoral artery injury. During the first night after surgery he has pain in the left leg. Despite adequate narcotics, his pain is unremitting; the pain is worse with passive leg movement. Examination shows a pale and swollen leg that is tender to the touch; pulses are palpable. Which of the following is the most appropriate next step in management?

826. A 42-year-old man is brought to the emergency department after a motor vehicle accident. He was a restrained driver and hit a car from behind on a highway. He drank one glass of wine before driving. He occasionally uses cocaine. His medical problems include mild intermittent asthma and peptic ulcer disease. On initial evaluation, his blood pressure is 11 2192 mm Hg and pulse is 96/min. His pulse oximetry shows 95% on room air. Examination shows bruises on the anterior chest wall and abdominal wall. X-rays reveal a fracture of the eighth left rib but no pneumothorax or pleural effusion. Cervical C-spine series are negative. An ultrasound does not show free intraperitoneal fluid. An ECG shows normal sinus rhythm with no ST-segment or T-wave changes. He is treated with intravenous fluids and analgesics. Eight hours later, he complains of epigastric discomfort, left shoulder pain, and mild nausea. His blood pressure is 97/62 mm Hg and pulse is 11 2/min. His pulse oximetry shows 96% on room air. Which of the following is most likely to diagnose this patient's current condition?

827. A 30-year-old man comes to the physician because of a 2-week history of swelling and pain in the right knee. He first experienced pain when he twisted his leg while playing football 15 days ago. He felt something 'popping' in the knee at that time but ignored it. The pain and swelling has been increasing since, and he feels sudden pain with extension of his leg. Examination shov1s the right knee is swollen and tender along the medial side. Full extension of the right knee is not possible due to sudden pain during terminal extension. Snapping can be felt in the right knee on tibial torsion with the knee flexed at 90 degrees. An x-ray film of the knee joint shows no abnormalities. Which of the following is the most likely diagnosis?

828. A 25-year-old male is brought to the emergency department following a motor vehicle accident in which he was the unrestrained driver. The emergency response team's reports indicate that his breath smelled of alcohol at the scene. En route to the hospital, the patient receives 2 liters of intravenous normal saline, and in the ED his blood pressure is 100/60 mmHg, heart rate is 120/min, and respiratory rate is 34/min. His neck veins are flat. You note multiple bruises overlying his anterior chest wall and upper abdomen. On inspiration, there is inward motion of the right side of his chest wall. His abdomen is soft and non-distended. He is put on positive pressure mechanical ventilation and his chest movements become symmetric. Which of the following is the most likely diagnosis?

829. A 55-year-old man comes to the emergency department because of severe right-sided chest pain. His temperature is 37.8° C (1000 F), blood pressure is 138/88 mm Hg, pulse is 88/min and respirations are 19/min and shallow. Examination shows decreased respiratory movements on the right side of the chest and tenderness on palpation over the right mid-chest. An x-ray film of the chest shows a fracture of the right 6th rib. Which of the following is the most important goal in management of the rib fracture in this patient?

830. A 5-year-old child presents with a small mass near the anterior border of the sternocleidomastoid muscle. The mass is associated with localized erythema and induration, and the child is febrile. Which of the following is the definitive treatment of this problem?

831. A 21-year-old woman asks you to evaluate a small painless lump in the midline of her neck that moves with swallowing. You make the clinical diagnosis of thyroglossal duct cyst. Which of the following is the most appropriate management of this patient?

832. A 60-year-old smoker is seen because of a 3-cm midline ulcerating mass that is visualized when he sticks out his tongue. Biopsy establishes that this is squamous cell carcinoma. Which of the following is the most appropriate treatment of his cancer?

833. A 56-year-old woman is referred to you about 3 months after a colostomy subsequent to a sigmoid resection for cancer. She complains that her stoma is not functioning properly. Which of the following is the most common serious complication of an end colostomy?

834. A 56-year-old previously healthy physician notices that his eyes are yellow and he has been losing weight. On physical examination the patient has jaundice and scleral icterus with a benign abdomen. Transcutaneous ultrasound of the abdomen demonstrates biliary ductal dilation without gallstones. Which of the following is the most appropriate next step in the workup of this patient?

835. A 45-year-old woman with history of heavy nonsteroidal anti-inflammatory drug ingestion presents with acute abdominal pain. She undergoes exploratory laparotomy 30 hours after onset of symptoms and is found to have a perforated duodenal ulcer. Which of the following is the procedure of choice to treat her perforation?

836. A 45-year-old man with a history of chronic peptic ulcer disease undergoes a truncal vagotomy and antrectomy with a Billroth II reconstruction for gastric outlet obstruction. Six weeks after surgery, he returns, complaining of postprandial weakness, sweating, light-headedness, crampy abdominal pain, and diarrhea. Which of the following would be the best initial management strategy?

837. A 60-year-old male patient with hepatitis C with a previous history of variceal bleeding is admitted to the hospital with hematemesis. His blood pressure is 80/60 mmHg, physical examination reveals splenomegaly and ascites, and initial hematocrit is 25%. Prior to endoscopy, which of the following is the best initial management of the patient?

838. A 32-year-old alcoholic with end-stage liver disease has been admitted to the hospital 3 times for bleeding esophageal varices. He has undergone banding and sclerotherapy previously. He admits to currently drinking a 6 packs of beer per day. On his abdominal examination, he has a fluid wave. Which of the following is the best option for long-term management of this patient’s esophageal varices?

839. A 55-year-old man complains of chronic intermittent epigastric pain. A gastroscopy demonstrates a 2-cm prepyloric ulcer. Biopsy of the ulcer yields no malignant tissue. After a 6weeks trial of medical therapy, the ulcer is unchanged. Which of the following is the best next step in his management?

840. A 45-year-old man was discovered to have a hepatic flexure colon cancer during a colonoscopy for anemia requiring transfusions. Upon exploration of his abdomen in the operating room, an unexpected discontinuous 3-cm metastasis is discovered in the edge of the right lobe of the liver. Preoperatively, the patient was counseled of this possibility and the surgical options. Which of the following is the most appropriate management of this patient?

841. A 42-year-old man with no history of use of NSAIDs presents with recurrent gastritis. The patient was diagnosed and treated for Helicobacter pylori 6 months ago. Which of the following tests provides the least invasive method to document eradication of the infection?

842. A 22-year-old college student notices a bulge in his right groin. It is accentuated with coughing, but is easily reducible. Which of the following hernias follows the path of the spermatic cord within the cremaster muscle?

843. An 80-year-old man with history of symptomatic cholelithiasis presents with signs and symptoms of a small-bowel obstruction. Which of the following findings would provide the most help in ascertaining the diagnosis?

844. A 42-year-old man has bouts of intermittent crampy abdominal pain and rectal bleeding. Colonoscopy is performed and demonstrates multiple hamartomatous polyps. The patient is successfully treated by removing as many polyps as possible with the aid of intraoperative endoscopy and polypectomy. Which of the following is the most likely diagnosis?

845. A 70-year-old woman has nausea, vomiting, abdominal distention, and episodic crampy midabdominal pain. She has no history of previous surgery but has a long history of cholelithiasis for which she has refused surgery. Her abdominal radiograph reveals a spherical density in the right lower quadrant. Which of the following is the definitive treatment for this patient’s bowel obstruction?

847. A 65-year-old male presented to the ER with increasing shortness of breath, fever and productive cough of 2 days duration. He has smoked for several years and has been on home oxygen. Chest x-ray showed right lower lobe consolidation. His vital signs on admission were temperature 38.7°C (101.7°F), blood pressure 120/76 mm Hg, and pulse 110/min and respirations 26/min. His condition worsened over the next several hours and required orotracheal intubation and mechanical ventilation. He was transferred to the intensive care unit. Placement of a central venous catheter in the right subclavian vein for IV access was attempted. After the line is successfully placed, the patient begins to deteriorate. Repeat vital signs are blood pressure 80/50 mm Hg and pulse 130/min. Examination shows absent breath sounds on the right side and distended neck veins. Which of the following is the most appropriate next step in management?

848. A 54-year-old woman comes to the clinic because of a forceful hyperextension injury to her hand after falling down. She complains of pain and swelling of the right wrist and pain associated with movement. She has no other complaints. She has no other medical conditions and takes no medication. Her blood pressure is 110/60 mm Hg, pulse is 84/min, and respirations are 12/min. Examination shows maximal tenderness in the anatomic snuffbox and pain with radial deviation of the wrist. The rest of the examination shows no other injuries. X-ray imaging of the wrist in multiple views does not reveal a fracture. Which of the following is the most appropriate next step in management?

849. An 18-year-old woman at 9 weeks' gestation is brought to the emergency department because of an open fracture of the tibia and fibula. She is hemodynamically stabilized and referred to the orthopedic department. She is scheduled for internal fixation of the tibia for the following day. However, before the surgery she develops severe dyspnea and confusion. Her temperature is 37.7° C (99.9° F), blood pressure is 110/70 mmHg, pulse is 110/min, and respirations are 22/min. Examination shows numerous non-palpable petechiae in the upper part of the body. Which of the following is the most likely diagnosis?

852. A 38-year-old woman who underwent total thyroidectomy for multinodular goiter 6 months ago presents with persistent hoarseness. Which of the following nerves was most likely injured during her operation?

854. A 58-year-old man is found to have a small mass in the right neck on a yearly physical examination. The patient reports that the mass has been slowly growing for the last few months and is not associated with pain or drainage. He has an otherwise negative review of systems. On examination there is a hard, mobile 2 cm mass along the mid-portion of the right sternocleidomastoid muscle. Which of the following is the most appropriate initial step in the workup of the neck mass?

855. A 53-year-old man presents to the emergency room with left lower quadrant pain, fever, and vomiting. CT scan of the abdomen and pelvis reveals a thickened sigmoid colon with inflamed diverticula and a 7-cm by 8-cm rim-enhancing fluid collection in the pelvis. After percutaneous drainage and treatment with antibiotics, the pain and fluid collection resolve. He returns as an outpatient to clinic 1 month later. He undergoes a colonoscopy, which demonstrates only diverticula in the sigmoid colon. Which of the following is the most appropriate next step in this patient’s management?

856. A 29-year-old woman complains of postprandial right upper quadrant pain and fatty food intolerance. Ultrasound examination reveals no evidence of gallstones or sludge. Upper endoscopy is normal, and all of her liver function tests are within normal limits. Which of the following represents the best management option?

857. A 47-year-old asymptomatic woman is incidentally found to have a 5-mm polyp and no stones in her gallbladder on ultrasound examination. Which of the following is the best management option?

858. A 48-year-old woman develops pain in the right lower quadrant while playing tennis. The pain progresses and the patient presents to the emergency room later that day with a low-grade fever, a WBC count of 13,000/mm3 and complaints of anorexia and nausea as well as persistent, sharp pain of the right lower quadrant. On examination, she is tender in the right lower quadrant with muscular spasm, and there is a suggestion of a mass effect. An ultrasound is ordered and shows an apparent mass in the abdominal wall. Which of the following is the most likely diagnosis?

859. A 32-year-old alcoholic man, recently emigrated from Mexico, presents with right upper quadrant pain and fevers for 2 weeks. CT scan of the abdomen demonstrates a non–rim-enhancing fluid collection in the periphery of the right lobe of the liver. The patient’s serology is positive for antibodies to Entamoeba histolytica. Which of the following is the best initial management option for this patient?

860. A 45-year-old executive experiences increasingly painful retrosternal heartburn, especially at night. He has been chewing antacid tablets. An esophagogram shows a hiatal hernia. In determining the proper treatment for a sliding hiatal hernia, which of the following is the most useful modality?

861. A 22-year-old woman is seen in a surgery clinic for a bulge in the right groin. She denies pain and is able to make the bulge disappear by lying down and putting steady pressure on the bulge. She has never experienced nausea or vomiting. On examination she has a reducible hernia below the inguinal ligament. Which of the following is the most appropriate management of this patient?

862. A 22-year-old woman presents with a painful fluctuant mass in the midline between the gluteal folds. She denies pain on rectal examination. Which of the following is the most likely diagnosis?

863. A 72-year-old man status post–coronary artery bypass graft (CABG) 5 years ago presents with hematochezia, abdominal pain, and fevers. Colonoscopy reveals patches of dusky-appearing mucosa at the splenic flexure without active bleeding. Which of the following is the most appropriate management of this patient?

864. A 62-year-old man has been diagnosed by endoscopic biopsy as having a sigmoid colon cancer. He is otherwise healthy and presents to your office for preoperative consultation. He asks a number of questions regarding removal of a portion of his colon. Which of the following is most likely to occur after a colon resection?

865. A 39-year-old woman with no significant past medical history and whose only medication is oral contraceptive pills (OCP) presents to the emergency room with right upper quadrant pain. CT scan demonstrates a 6-cm hepatic adenoma in the right lobe of the liver. Which of the following describes the definitive treatment of this lesion?

866. A 43-year-old man without symptoms is incidentally noted on CT scan to have a 4 cm lesion in the periphery of the left lobe of the liver. The lesion enhances on the arterial phase of the CT scan and has a central scar suggestive of focal nodular hyperplasia (FNH). Which of the following is the recommended treatment of this lesion?

867. A 57-year-old previously alcoholic man with a history of chronic pancreatitis presents with hematemesis. Endoscopy reveals isolated gastric varices in the absence of esophageal varices. His liver function tests are normal and he has no stigmata of end-stage liver disease. Ultrasound examination demonstrates normal portal flow but a thrombosed splenic vein. He undergoes banding, which is initially successful, but he subsequently rebleeds during the same hospitalization. Attempts tocontrol the bleeding endoscopically are unsuccessful. Which of the following is the most appropriate next step in management?

868. A previously healthy 15-year-old boy is brought to the emergency room with complaints of about 12 hours of progressive anorexia, nausea, and pain of the right lower quadrant. On physical examination, he is found to have a rectal temperature of 38.18°C (100.72°F) and direct and rebound abdominal tenderness localizing to McBurney point as well as involuntary guarding in the right lower quadrant. At operation through a McBurney-type incision, the appendix and cecum are found to be normal, but the surgeon is impressed by the marked edema of the terminal ileum, which also has an overlying fibrinopurulent exudate. Which of the following is the most appropriate next step?

870. After complete removal of a sessile polyp of 2.0 cm by 1.5 cm found 1 finger length above the anal mucocutaneous margin, the pathologist reports it to have been a villous adenoma that contained carcinoma in situ. Which of the following is the most appropriate next step in management?

871. A 62-year-old man has been noticing progressive difficulty swallowing, first solid food and now liquids as well. A barium study shows a ragged narrowing just below the carinal level. Endoscopic biopsy confirms squamous cell carcinoma. Which of the following provides the most accurate information regarding the T stage of an esophageal carcinoma?

872. A 53-year-old woman with a history of a vagotomy and antrectomy with Billroth II reconstruction for peptic ulcer disease presents with recurrent abdominal pain. An esophagogastroduodenoscopy (EGD) demonstrates that ulcer and serum gastrin levels are greater than 1000 pg/mL on three separate determinations (normal is 40-150). Which of the following is the best test for confirming a diagnosis of gastrinoma?

873. A 52-year-old man with a family history of multiple endocrine neoplasia type 1 (MEN1) has an elevated gastrin level and is suspected to have a gastrinoma. Which of the following is the most likely location for his tumor?

874. A 73-year-old woman presents to the emergency room complaining of severe epigastric pain radiating to her back, nausea, and vomiting. CT scan of the abdomen demonstrates inflammation and edema of the pancreas. A right upper quadrant ultrasound demonstrates the presence of gallstones in the gallbladder. Which of the following is an important prognostic sign in acute pancreatitis according to Ranson’s criteria?

875. A 55-year-old man who is extremely obese reports weakness, sweating, tachycardia, confusion, and headache whenever he fasts for more than a few hours. He has prompt relief of symptoms when he eats. Labarotory examination reveals an inappropriately high level of serum insulin during the episodes of fasting. Which of the following is the most appropriate treatment for this condition?

876. A 57-year-old woman sees blood on the toilet paper. Her doctor notes the presence of an excoriated bleeding 2.8-cm mass at the anus. Biopsy confirms the clinical suspicion of anal cancer. In planning the management of a 2.8-cm epidermoid carcinoma of the anus, which of the following is the best initial management strategy?

877. An 80-year-old man is admitted to the hospital complaining of nausea, abdominal pain, distention, and diarrhea. A cautiously performed transanal contrast study reveals an apple-core configuration in the rectosigmoid area. Which of the following is the most appropriate next step in his management?

878. A 40-year-old female is brought to the emergency department following a motor vehicle accident in which she was the front seat passenger. She reports hitting her head against the windshield and hurting her right leg. She appears completely alert and oriented. Glasgow Coma Scale =15/15. Her pupils are equal and reactive to light. There is a bruise over the right forehead, but no tenderness is present on palpation of the cranial bones. Examination of the right leg reveals a hematoma over the thigh. Knee extension on the right is markedly reduced when compared to the left. Sensory examination reveals decreased sensory perception to both sharp and dull stimuli over the medial side of the right lower thigh and leg. All other dermatomes are intact. What nerve injury is most likely present in this patient?

879. A 28-year-old man is brought to the emergency department after being an unrestrained passenger in a motor vehicle collision. In the ambulance on the way to the hospital, he receives 2 L normal saline intravenously and 5 Umin of oxygen by nasal cannula. His blood pressure is 80/42 mm Hg, pulse is 135/min, and respirations are 40/min. He is agitated and moves all 4 extremities spontaneously. His pupils are symmetric and reactive to light. Neck veins are distended, and his trachea is deviated to the right. Which of the following is the best initial management for this patient?

880. A 46-year-old woman who was recently diagnosed with Crohn disease asks about the need for surgery. Which of the following findings would be an indication for an immediate exploratory laparotomy?

882. A septuagenarian woman undergoes an uncomplicated resection of an abdominal aneurysm. Four days after surgery the patient presents with sudden onset of abdominal pain and distention. An abdominal radiograph demonstrates an air-filled, kidney-bean–shaped structure in the left upper quadrant. Which of the following is the most appropriate management at this time?

883. A 45-year-old man presents with right upper quadrant abdominal pain and fever. CT scan shows a large, calcified cystic mass in the right lobe of the liver. Echinococcus is suggested by the CT findings. Which of the following is the most appropriate management of echinococcal liver cysts?

884. A 28-year-old woman who is 15 weeks pregnant has new onset of nausea, vomiting, and right sided abdominal pain. She has been free of nausea since early in her first trimester. The pain has become worse over the past 6 hours. Which of the following is the most common non-obstetric surgical disease of the abdomen during pregnancy?

885. A 56-year-old woman has nonspecific complaints that include an abnormal sensation when swallowing. An esophagram is obtained. Which of the following is most likely to require surgical correction?

887. A 48-year-old man presents with jaundice, melena, and right upper quadrant abdominal pain after undergoing a percutaneous liver biopsy. Endoscopy shows blood coming from the ampulla of Vater. Which of the following is the most appropriate first line of therapy for major hemobilia?

888. A 30-year-old female patient who presents with diarrhea and abdominal discomfort is found at colonoscopy to have colitis confined to the transverse and descending colon. A biopsy is performed. Which of the following is a finding consistent with this patient’s diagnosis?

889. A 24-year-old man presents to the emergency room with abdominal pain and fever. CT scan of the abdomen reveals inflammation of the colon. He is referred to a gastroenterologist to be evaluated for inflammatory bowel disease (Crohn disease versus ulcerative colitis). Which of the following indications for surgery is more prevalent in patients with Crohn disease?

890. A 62-year-old man presents with a 3-month history of an enlarged lymph node in the left neck. He is a long-time smoker of cigarettes and denies fevers, night sweats, fatigue, or cough. On physical examination there is a 1.5 cm hard, fixed mass below the angle of the mandible in the left neck. Which of the following is the most likely cause of an enlarged lymph node in the neck?

892. A 54-year-old man complains that his eyes are yellow. His bilirubin is elevated. His physical examination is unremarkable. A CT of the abdomen shows a small mass in the head of the pancreas encasing the superior mesenteric artery. Cytology from the ERCP is positive for cancer. Which of the following is the most appropriate treatment for this patient?

893. A 28-year-old woman presents with hematochezia. She is admitted to the hospital and undergoes upper endoscopy that is negative for any lesions. Colonoscopy is performed and no bleeding sources are identified, although the gastroenterologist notes blood in the right colon and old blood coming from above the ileocecal valve. Which of the following is the test of choice in this patient?

894. A 32-year-old woman undergoes an uncomplicated appendectomy for acute appendicitis. The pathology report notes the presence of a 1-cm carcinoid tumor in the tip of the appendix. Which of the following is the most appropriate management of this patient?

895. A 44-year-old man is brought to the emergency department after a motor vehicle accident. His cervical spine is immobilized and 2 large-bore intravenous lines are placed. His breath smells of alcohol. The patient is lethargic but responds to commands appropriately. A 3-cm laceration is present on his forehead. Ecchymoses are seen on his back and over the abdominal wall in the distribution of the seat belt. The lungs are clear to auscultation. The trachea is midline and the neck veins are collapsed. Passive movement of the right hip is limited due to pain. At the scene of the accident, blood pressure was 90/60 mm Hg and pulse was 130/min. After receiving a 1 L bolus of intravenous fluids, the patient's blood pressure remains 90/60 mm Hg and his pulse is now 122/min. Portable chest x-ray shows no pneumothorax or pleural effusions. A bedside abdominal ultrasound is inconclusive for hemoperitoneum or intra-abdominal injury due to poor image quality. What is the most appropriate next step in management of this patient?

896. A 43-year-old mildly overweight female complains of periodic right knee swelling and pain with physical activity for the past three months. She says that this problem started while on a hiking trip three months ago, at which point she experienced a 'popping' sensation in her right knee. She recalls that her knee was swollen the next day, and responded to over-the-counter pain killers. Recently, she has been having to limit her physical activities due to knee pain. On physical examination, there is tenderness of the anterior and medial right knee joint. Which of the following is the most likely diagnosis?

897. A 53-year-old male is brought to the emergency room after a high-speed motor vehicle accident. He was an unrestrained driver and admits to consuming a moderate amount of alcohol before driving. In the ER, he complains of bilateral chest pain and left leg pain. His past medical history is significant for emphysema, diabetes mellitus and remote drug abuse. A traumatic fracture of the left femur is evident on physical examination. His initial arterial blood gas analysis shows a pH of 7.45, p02 of 81 mmHg and pC02 of 32 mmHg. His pulmonary capillary wedge pressure is 1OmmHg. After a 2000 ml IV fluid challenge, his p02 is 76 mmHg and his pulmonary capillary wedge pressure is 12 mmHg. Chest x-ray shows alveolar opacities over the right and left lower lobes. Hours after the accident, he complains of continued chest pain and shortness of breath. Which of the following diagnoses is most likely responsible for his shortness of breath?

899. A 36-year-old man is in your intensive care unit on mechanical ventilation following thoracotomy for a 24-hour-old esophageal perforation. His WBC is markedly elevated, and he is febrile, hypotensive, and coagulopathic. His NG tube fills with blood and continues to bleed. Which of the following findings on upper endoscopy would be most suspicious for stress gastritis?

900. A 35-year-old man presents with right upper quadrant pain, fever, jaundice, and shaking chills. Ultrasound of the abdomen demonstrates gallstones, normal gallbladder wall thickness, and common bile duct of 1.0 cm. The patient is admitted to the hospital and given IV fluids and antibiotics. He continues to be febrile with increasing WBCs. Which of the following is the most appropriate next step in this patient’s management?

901. An 88-year-old man with a history of end-stage renal failure, severe coronary artery disease, and brain metastases from lung cancer presents with acute cholecystitis. His family wants “everything done.” Which of the following is the best management option in this patient?

903. A 54-year-old man presents with sudden onset of massive, painless, recurrent hematemesis. Upper endoscopy is performed and reveals bleeding from a lesion in the proximal stomach that is characterized as an abnormally large artery surrounded by normal-appearing gastric mucosa. Endoscopic modalities fail to stop the bleeding. Which of the following is the most appropriate surgical management of this patient?

904. A 31-year-old male is brought to the emergency department after being involved in a motor vehicle collision as an unrestrained passenger. He was given 3L of normal saline in the ambulance on his way to the hospital and has been receiving 5L/min of oxygen by nasal cannula. He is agitated and moves all four extremities spontaneously. His blood pressure is 85/55 mmHg and his heart rate is 120/min. His respiratory rate is 30/min. His pupils are symmetric and reactive to light. His neck veins are flat and his trachea is shifted slightly to the right. Over the left hemithorax, breath sounds are absent and there is dullness to percussion. Which of the following diagnoses is most likely?

905. A 23-year-old woman comes to the physician because of right-sided foot pain. The pain started 5 weeks ago and is sharp and localized to the forefoot. She recalls no trauma or other inciting event but is an avid runner training for a long-distance race. The pain has been worsening over the past 1 week and prevents her from doing her daily running activities. She takes no medications. She is a vegetarian and does not drink soda. She does not use tobacco, alcohol, or illicit drugs. She is not sexually active, and her last menstrual period was 8 weeks ago. Her temperature is 37° C (98.6° F), blood pressure is 100/60 mm Hg, pulse is 68/min, and respirations are 12/min. Her body mass index is 15 kg/m2• Examination reveals tenderness to palpation along the first four metatarsal bones on the dorsal surface of the right foot, normal range of motion, and no erythema or bruising. Which of the following is the most likely diagnosis?

906. A neonate is examined in the nursery and found to have no anal orifice; only a small perineal fistulous opening is visualized. A complete workup is negative for any cardiac, esophageal, genitourinary, or musculoskeletal anomalies. Which of the following is the best next step in the management of this patient?

907. A 2-month-old boy is examined because he has been straining while passing stool and has a distended abdomen. He is very low on the growth chart for age. The primary care physician suspects that the boy has Hirschsprung disease. Which of the following findings on workup is diagnostic?

908. A newborn has a midline defect in the anterior abdominal wall. The parents ask what, if anything, should be done. Spontaneous closure of which of the following congenital abnormalities of the abdominal wall generally occurs by the age of 4?

909. A neonate is found to have an imperforate anus. As the pediatric surgeon you recommend studies to search for other anomalies. Which of the following is an associated abnormality?

911. During an appendectomy for acute appendicitis, a 4-cm mass is found in the midportion of the appendix. Frozen section reveals this lesion to be a carcinoid tumor. Which of the following is the most appropriate management of this patient?

912. A 45-year-old man is examined for a yearly executive physical. A mass is palpated in the rectum, and a biopsy suggests carcinoid. Which of the following findings is most likely to be associated with the carcinoid syndrome?

913. An ultrasound is performed on a patient with right upper quadrant pain. It demonstrates a large gallstone in the cystic duct but also a polypoid mass in the fundus. Which of the following is an indication for cholecystectomy for a polypoid gallbladder lesion?

914. An alcoholic man has been suffering excruciating pain from chronic pancreatitis recalcitrant to analgesics and splanchnic block. A surgeon recommends total pancreatectomy. A patient who has a total pancreatectomy might be expected to develop which of the following complications?

915. A 45-year-old woman has an incidental finding of a liver mass on a CT scan. Magnetic resonance imaging (MRI) is suggestive of a hemangioma. Which of the following is the most appropriate management strategy for this patient?

916. A 57-year-old woman presents with adenocarcinoma of the right colon. Laboratory evaluation demonstrates an elevation of carcinoembryonic antigen (CEA) to 123 ng/mL. Which of the following is the most appropriate use of CEA testing in patients with colorectal cancer?

917. A 61-year-old woman with a history of unstable angina complains of hematemesis after retching and vomiting following a night of binge drinking. Endoscopy reveals a longitudinal mucosal tear at the gastroesophageal junction, which is not actively bleeding. Which of the following is the next recommended step in the management of this patient?

918. A teenage boy falls from his bicycle and is run over by a truck. On arrival in the emergency room (ER), he is awake and alert and appears frightened but in no distress. The chest radiograph suggests an air-fluid level in the left lower lung field and the nasogastric tube seems to coil upward into the left chest. Which of the following is the next best step in his management?

919. A 10-year-old boy was the backseat belted passenger in a high-speed motor vehicle collision. On presentation to the ER, he is awake, alert, and hemodynamically stable. He is complaining of abdominal pain and has an ecchymosis on his anterior abdominal wall where the seatbelt was located. Which of the following is the best next step in his management?

920. A 65-year-old man who smokes cigarettes and has chronic obstructive pulmonary disease falls and fractures the third, fourth, and fifth ribs in the left anterolateral chest. Chest x-ray is otherwise normal. Which of the following would be the most appropriate next step in his management?

921. A 36-year-old man who was hit by a car presents to the ER with hypotension. On examination, he has tenderness and bruising over his left lateral chest below the nipple. An ultrasound examination is performed and reveals free fluid in the abdomen. What is the most likely organ to have been injured in this patient?

922. A 52-year-old man is pinned against a loading dock. The patient has a fractured femur, a pelvic fracture, a tender abdomen, and no pulses in the right foot with minimal tissue damage to the right leg. Angiography discloses a popliteal artery injury with obstruction. At surgery, the popliteal vein is also transected. His blood pressure is 85/60 mm Hg. Which of the following is the best management strategy for his vascular injuries?

923. A 27-year-old man sustains a single gunshot wound to the left thigh. In the ER, he is noted to have a large hematoma of his medial thigh. He complains of paresthesias in his left foot. On examination, there are weak pulses palpable distal to the injury and the patient is unable to move his foot. Which of the following is the most appropriate initial management of this patient?

924. A 25-year-old woman arrives in the ER following an automobile accident. She is acutely dyspneic with a respiratory rate of 60 breaths per minute. Breath sounds are markedly diminished on the right side. Which of the following is the best first step in the management of this patient?

925. A 17-year-old adolescent boy is stabbed in the left seventh intercostal space, midaxillary line. He presents to the ER with a heart rate of 86 beats per minute, blood pressure of 125/74 mm Hg, and oxygen saturation of 98%. Breath sounds are equal bilaterally. Which of the following is the most appropriate next step in his workup?

926. A 31-year-old biker is involved in a motor vehicle accident after attending a party where he drank a lot of soda drinks. He describes a direct blow to his lower abdomen and pelvis during the accident. He complains of diffuse abdominal pain that refers to his left shoulder. Which of the following injuries most likely accounts for this patient's current symptoms?

927. Your hospital is conducting an ongoing research study involving the hormonal response to trauma. Blood is drawn regularly (with Institutional Review Board [IRB] approval) for various studies. Which of the following values are likely to be seen after a healthy 36-year-old man is hit by a bus and sustains a ruptured spleen and a lacerated small bowel?

928. A 29-year-old man sustained a gunshot wound to the right upper quadrant. He is taken to the operating room and, after management of a liver injury, is found to have a complete transection of the common bile duct with significant tissue loss. Which of the following is the optimal surgical management of this patient’s injury?

929. You evaluate an 18-year-old man who sustained a right-sided cervical laceration during a gang fight. Your intern suggests nonoperative management and observation. Which of the following is a relative, rather than an absolute, indication for neck exploration?

930. Following blunt abdominal trauma, a 12-year-old girl develops upper abdominal pain, nausea, and vomiting. An upper gastrointestinal series reveals a total obstruction of the duodenum with a coiled spring appearance in the second and third portions. In the absence of other suspected injuries, which of the following is the most appropriate management of this patient?

931. A 45-year-old man presents after a high-speed motor vehicle collision. He has a seatbelt sign across his neck and chest with an ecchymosis over his left neck. He is hemodynamically stable and neurologically intact. A CT angiogram shows a left carotid dissection. In the absence of other significant injuries, what is the next step in his management?

932. An 18-year-old man was assaulted and sustained significant head and facial trauma. Which of the following is the most common initial manifestation of increased intracranial pressure?

933. A 28-year-old man is brought to the ER for a severe head injury after a fall. He was intubated in the field for his decreased level of consciousness. He is tachycardic and hypotensive. On examination, he is noted to have an obvious skull fracture and his right pupil is dilated. Which of the following is the most appropriate method for initially reducing his intracranial pressure?

934. A 45-year-old man was an unhelmeted motorcyclist involved in a high-speed collision. He was ejected from the motorcycle and was noted to be apneic at the scene. After being intubated, he was brought to the ER, where he is noted to have a left dilated pupil that responds only sluggishly. What is the pathophysiology of his dilated pupil?

935. A 31-year-old man is brought to the ER following an automobile accident in which his chest struck the steering wheel. Examination reveals stable vital signs and no evidence of respiratory distress, but the patient exhibits multiple palpable rib fractures and paradoxical movement of the right side of the chest. Chest x-ray shows no evidence of pneumothorax or hemothorax. Which of the following is the most appropriate initial management of this patient?

936. A 30-year-old man is stabbed in the arm. There is no evidence of vascular injury, but he cannot flex his three radial digits. Which of the following structures has he most likely injured?

937. Following a 2-hour firefighting episode, a 36-year-old fireman begins complaining of a throbbing headache, nausea, dizziness, and visual disturbances. He is taken to the ER, where his carboxyhemoglobin (COHb) level is found to be 31%. Which of the following is the most appropriate next step in his treatment?

938. A 75-year-old man with a history of coronary artery disease, hypertension, and diabetes mellitus undergoes a right hemicolectomy for colon cancer. On the second postoperative day, he complains of shortness of breath and chest pain. He becomes hypotensive with depressed mental status and is immediately transferred to the intensive care unit. After intubation and placement on mechanical ventilation, an echocardiogram confirms cardiogenic shock. A central venous catheter is placed that demonstrates a central venous pressure of 18 mm Hg. Which of the following is the most appropriate initial management strategy?

939. An 18-year-old man climbs up a utility pole to retrieve his younger brother’s kite. An electrical spark jumps from the wire to his metal belt buckle and burns hisabdominal wall, knocking him to the ground. Which of the following should guide your treatment of this patient?

940. A 22-year-old man is examined following a motor vehicle accident. He has a right knee dislocation which is reduced in the emergency room. He has palpable pedal pulses and is neurologically intact. Which of the following is an appropriate next step in his workup and management?

941. A 23-year-old, previously healthy man presents to the ER after sustaining a single gunshot wound to the left chest. The entrance wound is 3 cm inferior to the nipple and the exit wound is just below the scapula. A chest tube is placed that drains 400 mL of blood and continues to drain 50 to 75 mL/h during the initial resuscitation. Initial blood pressure of 70/0 mm Hg has responded to 2L crystalloid and is now 100/70 mm Hg. Abdominal examination is unremarkable. Chest x-ray reveals a reexpanded lung and no free air under the diaphragm. Which of the following is the best next step in his management?

942. A patient is brought to the ER after a motor vehicle accident. He is unconscious and has a deep scalp laceration and one dilated pupil. His heart rate is 120 beats per minute, blood pressure is 80/40 mm Hg, and respiratory rate is 35 breaths per minute. Despite rapid administration of 2 L normal saline, the patient’s vital signs do not change significantly. Which of the following is the most appropriate next step in the workup of his hypotension?

943. A 25-year-old man is involved in a gang shoot-out and sustains an abdominal gunshot wound from a .22 pistol. At laparotomy, it is discovered that the left transverse colon has incurred a through-and-through injury with minimal fecal soilage of the peritoneum. Which of the following is the most appropriate management of this patient?

944. A 1-year-old child has repeated episodes of vomiting and abdominal distention. An x-ray shows obstruction at the second portion of the duodenum. Laparotomy is performed and an annular pancreas is discovered. For a symptomatic partial duodenal obstruction secondary to an annular pancreas, which of the following is the operative treatment of choice?

945. Approximately 2 weeks after a viral respiratory illness, an 18-month-old child complains of abdominal pain and passes some bloody mucus per rectum. A long, thin mass is palpable in the right upper quadrant of the abdomen. No peritoneal signs are present. Intussusception is suspected. Which of the following is the most appropriate next step?

947. A 47-year-old man is extricated from an automobile after a motor vehicle accident. He is hypotensive with a systolic blood pressure of 80. The patient has a steering wheel bruise on the anterior chest. His electrocardiogram (ECG) shows some premature ventricular complexes, and his cardiac isoenzymes are elevated. Which of the following is the best next test for evaluation for a blunt cardiac injury?

949. A 70-year-old man presents to the ER with several fractures and a ruptured spleen after falling 20 ft. Which of the following will occur in response to the injury?

950. A 36-year-old man sustains a gunshot wound to the left buttock. He is hemodynamically stable. There is no exit wound, and an x-ray of the abdomen shows the bullet to be located in the right lower quadrant. Which of the following is most appropriate in the management of his suspected rectal injury?

951. A 27-year-old man presents to the ER after a high-speed motor vehicle collision with chest pain and marked respiratory distress. On physical examination, he is hypotensive with distended neck veins and absence of breath sounds in the left chest. Which of the following is the proper initial treatment?

952. A 48-year-old man sustains a gunshot wound to the right upper thigh just distal to the inguinal crease. He is immediately brought to the ER. Peripheral pulses are palpable in the foot, but the foot is pale, cool, and hypesthetic. The motor examination is normal. Which of the following statements is the most appropriate next step in the patient’s management?

953. A 62-year-old woman is seen after a 3-day history of fever, abdominal pain, nausea, and anorexia. She has not urinated for 24 hours. She has a history of previous abdominal surgery for inflammatory bowel disease. Her blood pressure is 85/64 mm Hg, and her pulse is 136. Her response to this physiologic state includes which of the following?

954. A 46-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He is unresponsive and his injuries include a basilar skull fracture, brain contusion, fractures of ribs 7-10, hemopneumothorax on the right, and a pelvic fracture. After placement of a chest tube and pelvis fixation, his condition stabilizes. On the fifth day of his hospital stay, he is still unresponsive with a Glasgow Coma Scale of 8 and spontaneous respirations. Examination shows an abnormal facial reaction with palpation of the right upper quadrant of the abdomen and diminished bowel sounds. Rectal examination shows no abnormalities. Nasogastric tube aspiration shows retention of gastric contents. An abdominal CT scan shows gaseous distention of the small and large bowels without air-fluid levels. The gall bladder is distended with pericholecystic fluid but no gallstones. Which of the following is the most likely diagnosis for this patient's abdominal findings?

955. A 20-year-old man presents after being punched in the right eye and assaulted to the head. On a facial CT scan, he is noted to have a blowout fracture of the right orbital floor. Which of the following findings mandates immediate surgical intervention?

956. A 33-year-old woman is seen in the ER with severe rectal bleeding. She has a history of ulcerative colitis. Her blood pressure is 78/56 mm Hg, her pulse is 144, and she is pale and clammy. Which of the following responses is likely to occur after administration of Ringer lactate solution?

957. An 18-year-old high school football player is kicked in the left flank. Three hours later he develops hematuria. His vital signs are stable. A CT scan demonstrates a grade II renal injury based on the Urologic Injury Scale of the American Association for the Surgery of Trauma. Which of the following is the most appropriate treatment for this patient?

958. A 32-year-old man is in a high-speed motorcycle collision and presents with an obvious pelvic fracture. On examination, he has a scrotal hematoma and blood at his urethral meatus. Which of the following is the most appropriate next step in his management?

959. A 17-year-old adolescent boy sustains a small-caliber gunshot wound to the mid-epigastrium with no obvious exit wound. His abdomen is very tender; he is taken to the operating room and the bullet appears to have tracked through the stomach, distal pancreas, and spleen. The duct appears to have been injured. Which of the following is the best strategy for the management of this patient’s pancreatic injury?

960. A 22-year-old woman who is 4 months pregnant presents after a motor vehicle collision complaining of abdominal pain and right leg pain. She has an obvious deformity of her right femur. She is hemodynamically stable. Which of the following is the best next step in her management?

962. A newborn infant born from a mother with polyhydramnios presents with excessive salivation along with coughing and choking with the first oral feeding. An xray of the abdomen shows gas in stomach and a nasogastric tube coiled in the esophagus. Which of the following is the most likely diagnosis?

963. An infant is born with a defect in the anterior abdominal cavity. Upon examination there are abdominal contents (small bowel and liver) protruding directly through the umbilical ring. Which of the following should be considered in the management of this condition?

964. A 2-week-old infant presents with sudden onset of bilious emesis. Plain films of the abdomen show evidence of an intestinal obstruction. An upper gastrointestinal (UGI) contrast series reveals a midgut volvulus with the site of obstruction at the third portion of the duodenum. Which of the following is the most likely diagnosis?

965. A 29-week-old previously healthy male infant presents with fevers, abdominal distention, feeding intolerance, and bloody stools at 3 weeks of age. The patient undergoes x-ray and ultrasound examination for possible necrotizing enterocolitis. Which of the following findings on imaging is an indication for surgical management?

966. A newborn presents with signs and symptoms of distal intestinal obstruction. Abdominal x-rays reveal dilated loops of small bowel, absence of air-fluid levels, and a mass of meconium within the right side of the abdomen mixed with gas to give a ground-glass appearance. Which of the following should be performed as the initial management of the patient?

967. A 4-week-old male infant presents with projectile, nonbilious emesis. Ultrasound of the abdomen reveals a pyloric muscle thickness of 8 mm (normal 3-4 mm). Which of the following is the best initial management of this patient?

968. A 1-month-old female infant presents with persistent jaundice. A serum direct bilirubin is 4.0 mg/dL and an ultrasound of the abdomen shows a shrunken gallbladder and inability to visualize the extrahepatic bile ducts. Which of the following is the most appropriate initial management of this patient?

970. A 22-year-old man undergoes an exploratory laparotomy after a gunshot wound to the abdomen. The patient has multiple injuries, including a significant liver laceration, multiple small-bowel and colon injuries, and an injury to the infrahepatic vena cava. The patient receives 35 units of packed RBCs, 15 L of crystalloid, 12 units of fresh-frozen plasma (FFP), and a 12 packs of platelets. The patient’s abdomen is packed closed and he is taken to the intensive care unit for further resuscitation. Which of the following warrants a decompressive laparotomy?

971. A 10-year-old girl is the unrestrained backseat passenger in a high-speed motor vehicle collision. She is intubated in the field for unresponsiveness and on presentation to the ER, her heart rate is 160 beats per minute, and her blood pressure is 60/35 mm Hg. She weighs 30 kg. Which of the following is the most appropriate recommendation for her fluid resuscitation?

972. A 21-year-old woman sustains a stab wound to the middle of the chest. Upon arrival to the ER she has equal breath sounds, blood pressure of 85/46 mm Hg, distended neck veins, and pulsus paradoxus. Which of the following is the most appropriate management of this patient?

973. A 58-year-old man presents to the ER after falling 10 ft from a ladder. Examination reveals stable vital signs, no evidence of respiratory distress, and multiple right-sided rib fractures. Chest x-ray shows a hemothorax on the right side and a right tube thoracostomy is performed in the ER. Approximately 700 mL of blood is immediately drained with placement of the thoracostomy tube. Over the next 4 hours he continues to drain 300 mL/h after the original evacuation. Which of the following is the definitive treatment for this patient?

974. A 65-year-old woman is involved in a motor vehicle collision and sustains multiple left-sided rib fractures. Upon presentation to the ER her vital signs are stable and she is in no respiratory distress. Chest x-ray reveals fractures of ribs 4 to 7 on the left side without evidence of hemothorax or pneumothorax. She is admitted for observation and a few hours later she develops shortness of breath. A repeat chest x-ray demonstrates a well-defined infiltrate in her left lung. What is the most likely diagnosis?

975. Following a head-on motor vehicle collision, a 21-year-old unrestrained passenger presents to the ER with dyspnea and respiratory distress. She is intubated and physical examination reveals subcutaneous emphysema and decreased breath sounds. Chest x-ray reveals cervical emphysema, pneumomediastinum, and a right-sided pneumothorax. What is the most likely diagnosis?

976. An intoxicated 22-year-old man is a restrained driver in a high-speed motor vehicle collision. Examination reveals normal vital signs, but the rest of the examination is unreliable secondary to the patient’s intoxicated state from alcohol. Which of the following sole findings on a CT scan of the abdomen and pelvis mandates an exploratory laparotomy?

977. A 23-year-old man arrives in the ER after a motor vehicle collision. Examination reveals an unstable pelvis and blood at the urethral meatus. Which of the following studies would most accurately identify a urethral injury?

978. A 2-year-old asymptomatic child is noted to have a systolic murmur, hypertension, and diminished femoral pulses. Which of the following should be performed as part of the preoperative workup and management of this child’s disorder?

979. A 35-week-term infant presents with cyanosis shortly after birth. His arterial oxygen saturation is only 30%. Which of the following is the most likely diagnosis?

980. A 42-year-old moderately obese female complains of abdominal discomfort two days after undergoing an elective cholecystectomy. Her past medical history is significant for hypertension, diabetes mellitus and hyperlipidemia. Her blood pressure is 132/90 mmHg and her heart rate is 76/min. Physical examination reveals a distended abdomen with decreased bowel sounds. Which of the following is most likely contributing to her current condition?

981. A 35-year-old woman is brought to the emergency department after being rescued from a burning building by firefighters. She had a brief tonic-clonic seizure en route to the hospital. Her past medical history is unknown. She is confused and mildly agitated. Her temperature is 37° C (98.6° F), blood pressure is 100/60 mm Hg, pulse is 115/min, and respirations are 24/min. Her oxygen saturation is 96% on room air. Physical examination shows no burns and her skin color is normal. There are symmetric breath sounds bilaterally with scattered end-expiratory wheezes. Neurological examination shows no abnormalities except some confusion. The abdomen is soft and non-tender. Which of the following is the best initial treatment for the patient?

982. A 24-year-old woman comes to the physician's office because of breast pain. She has a 2-month-old baby who she breastfeeds. Her temperature is 38.8° C (101.9° F). Examination shows a hard, red, tender and swollen area on her right breast. There is no fluctuance noted. Which of the following is the most appropriate next step in management?

983. A 22-year-old primi-gravida woman is brought to the emergency department during the 33rd week of pregnancy after a tonic-clonic seizure. She has no history of seizure disorder and has not had any complications during her pregnancy. She is given magnesium sulfate and hydralazine. One hour later, she is lethargic and complains of persistent blurry vision and headache. She also complains of muscle pain, sore joints, and inability to move her right arm. Her temperature is 37.2° C (99° F), blood pressure is 182/111 mm Hg, pulse is 112/min, and respirations are 16/min. She holds her right arm adducted and internally rotated. Examination shows no sensory loss but an inability to externally rotate the right arm. Deep tendon reflexes (DTRs) are intact bilaterally, and handgrip is preserved on both sides. Which of the following is the most likely cause of her arm weakness?

984. A 16-year-old boy was brought to the emergency department because of left shoulder and left hand pain after falling on his outstretched hand while playing soccer. He heard a crunching sound and had intense pain in his left shoulder area following the injury. Examination shows bruising around the clavicle area. He is holding his left arm with his right hand. There is a palpable gap in the middle of the clavicle. Auscultation shows a loud bruit just beneath the clavicle. An x-ray film of the left shoulder and chest shows the middle of the clavicle is fractured and displaced. Which of the following is the most appropriate next step in management?

985. A 60-year-old man comes to the clinic because of right calf pain. He has a history of chronic diverticular disease and has had multiple attacks of diverticulitis in the past. His most recent attack occurred 3 weeks ago, and he was treated with antibiotics and underwent left hemicolectomy. He had a stable postoperative course and was discharged from the hospital 1 week ago. He developed right calf pain 3 days ago, with swelling and difficulty bearing weight on his right leg. He currently takes no medication. He does not use tobacco, alcohol, or illicit drugs. His temperature is 36.8° C (98.2° F), blood pressure is 120/70 mm Hg, pulse is 92/min, and respirations are 14/min. Physical examination reveals the right calf slightly larger than the left calf, moderate right ankle edema, and right calf pain with dorsiflexion of the right foot. Duplex ultrasonography shows a clot in the right distal portion of the femoral vein. Which of the following is the most appropriate initial treatment?

986. A 78-year-old diabetic man has undergone surgical repair of a large abdominal aortic aneurysm. Postoperatively, he develops left lower quadrant abdominal pain followed by bloody diarrhea. He has a history of prostate cancer and received radiation therapy several years ago. He eats a low fiber diet. He quit smoking recently. Vital signs show a low grade fever. Examination shows tenderness in the left lower quadrant and rectal examination reveals blood in the stool. CT scan of the abdomen demonstrates thickening of the colon at the recto-sigmoid junction. On colonoscopy, ulcerations are seen in the same area while the colon above and below the lesions is completely normal. Which of the following is the most likely cause of his symptoms?

987. A 23-year-old man is brought to the emergency department in an obtunded state following a gun-shot wound to the right upper quadrant of the abdomen. His systolic blood pressure is 60 mm Hg and unable to obtain diastolic blood pressure. His pulse is 136/min. Chest auscultation shows clear heart and breath sounds. The abdomen appears distended, and there is an obvious gun-shot wound on the right upper quadrant. The bowel sounds are decreased. Which of the following is the most appropriate next step in management?

988. A 36-year-old woman presents to the physician's office after she palpated a lump in her right breast. She has no other complaints. She has not seen a doctor for 10years. She regularly performs breast self-exams after menses. She has no significant past medical history. Her mother died of breast cancer at the age of 40. Breast examination shows a 1 x 1 cm rubbery, firm, freely mobile, round mass in the upper, outer quadrant of the right breast. No axillary lymph nodes are palpable. Which of the following is the most appropriate next step in management?

989. A 35-year-old woman is being evaluated for a breast mass. She had a bilateral reduction mammoplasty for mammary hyperplasia 12 years ago. She has no family history of cancer. Breast examination shows a slightly retracted right nipple. A fixed mass is palpated in the upper outer quadrant of the right breast. Mammogram shows a 3 x 3-cm spiculated mass with coarse calcifications in the upper outer quadrant of the right breast. Ultrasonogram of the breast shows a hypoechoic mass. Multiple core biopsy samples show foamy macrophages and fat globules. Which of the following is the most appropriate course of action?

990. A 67-year-old male comes to the clinic for medical clearance prior to an elective abdominal aortic aneurysm repair. He denies any cough, shortness of breath or chest pain. He has coronary artery disease, diabetes and hypertension. He does not use tobacco, alcohol or drugs. His blood pressure is 120/76 mm Hg, pulse is 60/min, and respirations are 14/min. Examination shows no abnormalities, except prominent epigastric pulsations. Which of the following interventions would be most helpful in preventing postoperative pneumonia in this patient?

991. A 33-year-old male falls while riding his bicycle in the park, and presents to the emergency department. Physical examination reveals upper abdominal bruises. His abdomen is non-distended, soft, and mildly tender in the epigastrium. Abdominal CT scan does not reveal any abnormalities. The patient is sent home with analgesic medications. He returns one week later with fever, shaking chills, poor appetite and deep abdominal pain. Which of the following is most likely related to this patient's symptoms?

992. A 24-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He complains of severe back pain and abdominal discomfort. He was placed on a board in the field for spinal immobilization. His blood pressure is 111/78 mm Hg, pulse is 55/min and regular, and respirations are 16/min. Pulse oximetry shows 96% on room air. He is alert and fully oriented. There are several lacerations on the face and anterior chest. Air entry is bilaterally symmetric. There is weakness and decreased pain sensation in both legs. Proprioceptive sensation is preserved. Chest x-ray and CT scans of the abdomen and spine are performed. Which of the following is the most appropriate next step in managing this patient?

993. A 25-year-old man is brought to the emergency department by ambulance after falling from a ladder for 12 m (40 ft). He was placed on a backboard for spinal stabilization. Intravenous access was obtained en route, and infusion of crystalloids was initiated. The patient is comatose on arrival to the emergency department. Examination shows facial lacerations, a depressed skull fracture, and a forearm fracture. In the emergency department, his blood pressure is 92/45 mm Hg, pulse is 127/min, and respirations are 6/min. His pulse oximetry shows 86% on 40% facemask oxygen. Which of the following is the most appropriate next step in management?

994. A 78-year-old man with Alzheimer's disease was brought to the ER because of bright red bleeding per rectum. He has chronic constipation and is being treated with bisacodyl. On admission, his temperature was 36.6° C (97.9° F), blood pressure was 130/80 mm Hg with no orthostatic change, pulse was 90/min, and respirations were 14/min. Nasogastric tube drainage showed normal stomach contents and bile but no blood. His bleeding stopped a few hours after admission, and he remained hemodynamically stable during that time. Colonoscopy showed extensive diverticulosis but no active bleeding source. Later that night he started bleeding again from the rectum. Packed red cells and intravenous fluid are started. Which of the following is the most appropriate next step in management?

995. A 55-year-old man comes to the physician because of a 4-month history of an ulcer on the sole of his right foot. He has had no trauma and does not remember how he got the ulcer. He states the ulcer has been difficult to heal and readily gets infected. He has multiple medical problems. He does not use tobacco, alcohol or drugs. Examination shows the ulcer is located on the sole of his foot just below the head of the first metatarsal bone. His foot is warm and dry and appears slightly deformed. Dorsalis pedis pulses are present. Which of the following is the most likely cause of his condition?

996. A 72-year-old man undergoes coronary artery bypass graft (CABG) for severe coronary artery disease. He is extubated on the second postoperative day. His temperature is 36.6° C (97.9° F), blood pressure is 120/70 mm Hg, pulse is 80/min, and respirations are 12/min. On the third postoperative day, he complains of dyspnea and worsening retrosternal pain despite continuous analgesia with morphine. His temperature is 38.6° C (101.5° F), blood pressure is 112/52 mm Hg, pulse is 125/min and irregularly irregular, and respirations are 28/min. Examination shows normal heart sounds. A small amount of cloudy fluid is present in the sternal wound drain. His ECG shows atrial fibrillation with rapid ventricular response. An x-ray film of the chest shows widening of the mediastinum. Echocardiography reveals a small amount of pericardial fluid. Laboratory studies show : Hemoglobin 8.9 mg/dl WBC count 16,300/mm' Platelet count 512,000/mm Creatinine 1.7 mg/dl CPK 430 U/L Which of the following will this patient most likely require?

997. A 25-year-old man comes to the physician because of a mass in his mouth. He has had the lump for many years. He denies weight loss. He was in a motor vehicle accident several years ago and sustained a concussion of the brain. He does not use tobacco, alcohol, or illicit drugs. Physical examination shows a nontender 2 x 2-cm mass located on the hard palate of the mouth that is immobile and has a bony hard consistency. Which of the following is the most likely cause of this patient's oral finding?

998. A 43-year-old male complains of right shoulder pain and weakness after falling on his outstretched hands two days ago. He denies shoulder deformity. The physician passively abducts both his arms above his head and then asks him to bring his arms down slowly in an adducting motion. The right arm drops rapidly at the midpoint of its descent. What is the most likely diagnosis?

999. A 12-year-old boy is brought to the emergency department after falling from a tree. Examination shows tenderness and swelling over the left lower arm. An x-ray film of the arm shows a fracture of the distal end of the humerus with proximal and posterior displacement of the distal fracture segment. Closed reduction of the fracture is performed. However, postoperatively the patient complains of increasing pain in the left arm and forearm. Twelve hours post-operatively his forearm is pale and cold. There is marked pain on passive extension of the fingers. Which of the following is the potential dreaded complication of this condition?

1000. A 16-year-old boy is brought to the emergency department after falling off a bicycle and hitting his head on the ground. He briefly lost consciousness but had no seizures. He had two episodes of vomiting and complains of mild headache. His mother accompanies him and demands immediate evaluation. He has no other medical problems. His blood pressure is 121/67 mm Hg and pulse is 78/min. Examination shows a small bruise on his forehead but no bony abnormalities. The rest of the physical examination, including neurologic examination, shows no other abnormalities. Which of the following is the most appropriate next step in management?

1001. A 45-year-old policeman presents to your office complaining of tiredness and sleepiness. He says that his job seems tiring to him recently. It is difficult for him to get up in the morning and go to work. He goes to bed early because he feels tired and sleepy. Two months ago, he was investigating a case of mass murder. He slipped on the blood on the floor, fell and hit his head. He also describes recent abdominal pain that is constant and gnawing, interfering with his sleep. His appetite is poor, and he lost 15 pounds over the last month. Physical examination is significant only for tenderness and fullness in the epigastrium. Which of the following is the most likely diagnosis?

1003. A 12-year-old boy is brought to the physician because of right groin pain, knee pain, and limping. He has had these symptoms for the past 2 weeks. He is at the 90th percentile for weight and 60th percentile for height. He is afebrile, and his other vital signs are within normal limits. Examination shows that the range of motion of the right knee joint is within normal limits but hip movements are restricted and the right foot points outward. There is external rotation of the right thigh on flexion of the hip. After confirming the diagnosis, which of the following is the most appropriate management?

1004. A 42-year-old man is found unconscious at the scene of a motor vehicle collision. He is rushed to the emergency department, where his blood pressure is found to be 70/40 mm Hg and his respirations are 32/min. On physical examination, his trachea is deviated to the left and his breath sounds are decreased on the right side. His neck veins are distended bilaterally. The abdomen is soft and non-distended. There is significant swelling of the right thigh. Which of the following is the most appropriate next step in the management of this patient?

1005. A 32-year-old man comes to the emergency room (ER) because of acute onset left flank pain, hematuria and vomiting. His pain is relieved with analgesics in the ER. He has a history of abdominal pain due to Crohn disease, but that pain was always in the right lower quadrant and was never this severe. His temperature is 36.8°C (98.2°F), blood pressure is 120/65 mm Hg, pulse is 11 O/min and respirations are 16/min. Chest auscultation is clear. Abdomen is soft and mildly tender over the left flank. He has no rebound or rigidity. Bowel sounds are decreased. A laparotomy scar is present in right lower quadrant. Which of the following is the most likely cause of his symptoms?

1006. While working on-site at a factory doing physical examinations for workers, a physician is suddenly called to help a worker who amputated his finger. Which of the following is the most appropriate next step in management in this situation?

1007. A 36-year-old male presents with firm, non-tender swelling of his right cheek. He tells you that he had similar swelling at that site two years ago and was diagnosed with a tumor, which was subsequently removed without complication. Examination reveals fullness of the pre-auricular space on the right side. Repeat surgery in this patient is most likely to result in which of the following complications?

1008. A 39-year-old paleontologist complains of right-sided hip pain that makes it very difficult for him to lie on his right side while sleeping. He localizes the pain to the outer surface of his thigh. He was recently diagnosed with hypertension and hyperlipidemia. He takes hydrochlorothiazide and atorvastatin. He has smoked one pack of cigarettes daily for 15 years. He does not use alcohol or illicit drugs. Which of the following is the most likely cause of his pain?

1009. An 88-year-old male complains of severe right calf pain several hours after undergoing a right femoral artery embolectomy. He also complains of a burning sensation in his posterior right leg. He has a long history of atrial fibrillation and hypertension. His past medical history also includes stroke, bleeding duodenal ulcer, diabetes mellitus and diabetic nephropathy. On physical examination, his blood pressure is 160/70 mm Hg and his heart rate is 100 per minute and irregular. His right calf is swollen, tense and exquisitely tender; the pain is worsened by passive extension of the right knee. Dorsalis pedis and posterior tibial pulses are palpable in the bilateral lower extremities. Which of the following is the most likely cause of this patient's symptoms?

1010. A 29-year-old woman is brought to the emergency department after burning her right upper extremity in a cooking accident Examination shows a circumferential burn of the right upper extremity. She is given fluids, an analgesic and a wound dressing. On day three she develops severe deep tissue pain in the right limb with edema of the hand. Examination shows a circumferential eschar over the right arm. Her right radial and ulnar pulses are faint compared to the left and she has paresthesias in her right hand. Which of the following is the most appropriate next step in management?

1011. A 42-year-old man comes to the physician because of a 3-month history of burning substernal chest pain after every meal. His other medical problems include chronic alcoholism. Upper endoscopy shows mucosal irregularity and ulceration of the squamocolumnar junction above the lower esophageal sphincter. Multiple biopsies are taken. He complains of worsening substernal pain radiating to the back, left chest pain, and mild shortness of breath 4 hours later. His temperature is 37.1° C (98.9° F), blood pressure is 110/70 mm Hg, pulse is 120/min, and respirations are 34/min. A chest x-ray shows a small left pleural effusion that was not present on a chest radiograph taken 2 weeks ago. Which of the following is the most appropriate next step in management?

1012. A 65-year-old male is being evaluated for hip pain. The pain has been present for several months and is constant. He denies any weight loss or loss of appetite. His past medical history is significant only for high blood pressure. His temperature is 37.2° C (98.9° F), blood pressure is 150/88 mm Hg, pulse is 80/min and respirations are 12/min. Physical examination is unremarkable. Laboratory studies show: Alkaline phosphatase Elevated Gamma glutamyl transferase Normal Serum calcium Normal 2,5(OH)2 vitamin D Normal Bone scan shows increased uptake in several spots. This patient is at the highest risk of developing?

1013. A 36-year-old woman presents to the emergency department with severe epigastric pain and right shoulder pain of about two hours duration. She also reports having one episode of emesis. When asked about her diet, she explains that she unintentionally fasted yesterday and had a large meal two hours ago. Her past medical history is significant for frequent heartburn for which she takes ranitidine. Several hours after presenting, the patient's pain resolves completely. Which of the following best explains this episode?

1014. A 45-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He is unable to void. Examination shows blood at the urethral meatus and a scrotal hematoma. His temperature is 37° C (98.6° F), blood pressure is 100/50, pulse is 100/min and respirations are 16/min. Examination shows a high-riding prostate with no other signs of trauma. Which of the following is the most appropriate next step in management?

1015. A 3-year-old girl 1s brought to the emergency department because she is not moving her right arm. Her mother states that the child was perfectly normal in the morning. She remembers that she lifted the child with the child's right forearm and since then she has not been moving her right arm. Examination shows the right arm is held in pronation against the chest. The child avoids any movement of her right arm. Which of the following is the most appropriate next step in management?

1016. A 12-year-old boy comes to the emergency department complaining of vague left-sided chest discomfort. Two months ago, he was involved in a high-speed motor vehicle accident but sustained only minor injuries. He was observed in the emergency department overnight and discharged home. His past medical history is otherwise unremarkable. Vital signs are normal. Auscultation of the lungs shows decreased air entry into the left lower base. An x-ray of the chest is shown below.Which of the following is the most appropriate next step in management of this patient?

1017. A 23-year-old man comes to the emergency department because of a painful swollen left knee. The pain began after he twisted his leg while playing football. Examination shows a swollen left knee with marked tenderness of the medial side of the knee. When compared to the right knee, on valgus stressing the left knee shows exaggerated laxity at the joint line. Which of the following is the most appropriate next step to confirm the diagnosis?

1018. A 23-year-old male is brought to the emergency department following a motor vehicle accident (MVA) where he was the unrestrained driver. The patient was found unresponsive at the scene and was intubated by paramedics. He receives 2.5L of normal saline over the 20 minutes before he reaches the ED. His blood pressure there is 70/30 mmHg and his heart rate is 120/min. On physical examination, he responds to strong vocal and tactile stimuli by opening his eyes. His pupils are equal and reactive to light. There are multiple bruises over the anterior chest and upper abdomen. His neck veins are flat, trachea is midline and extremities are cold. Cardiac monitoring shows sinus tachycardia. Which of the following is the most likely cause of this patient's current condition?

1019. A 25-year-old motorcyclist is brought to the emergency department after being involved in a collision with an automobile. On arrival he is in obvious pain. He expresses an urge to void, but is unable to do so. Genital examination shows blood at the urethral meatus and a scrotal hematoma. Rectal examination reveals a high-riding prostate. Abdominal examination is suggestive of a distended bladder. Which of the following is the most likely diagnosis?

1020. A 36-year-old male comes to the emergency department because of worsening right lower quadrant (RLQ) abdominal pain. One week ago he was started on cephalexin for furunculosis. He has had type I diabetes mellitus for 1Oyears and is on insulin. His temperature is 38.83°C (101.9°F). Examination shows multiple furuncles on the inner side of both thighs; most of them are in regression. Abdominal examination shows tenderness on deep palpation in RLQ without rebound or guarding; no masses are palpated; psoas sign is positive; bowel sounds are present. Rectal examination shows no abnormalities. Laboratory studies show: Hemoglobin 13.0 g/L Leukocyte count 17,500/mm3 Which of the following is the most appropriate next step in management?

1021. A 54-year-old man is brought to the emergency department 10 minutes after being involved in a motor vehicle accident. He was an unrestrained driver and hit a car while speeding on the highway. On arrival to the emergency department, he is spontaneously breathing and noncyanotic. His temperature is 37°C (98.6°F), blood pressure is 104/50 mm Hg, pulse is 122/min, and respirations are 16/min. Examination shows facial lacerations and multiple ecchymoses on the anterior chest and abdomen. He appears obtunded. Which of the following is a component of the Glasgow coma scale (GCS) assessment for this patient?

1022. A 46-year-old man comes to the emergency department because of abrupt onset of epigastric pain radiating to the back and associated vomiting. He has had these symptoms for the past 1 day. The symptoms are progressively getting worse. He has no other medical problems or previous surgeries. He does not use tobacco, alcohol, or illicit drugs. His temperature is 36.5° C (97.6° F), blood pressure is 100/70 mm Hg, pulse is 100/min, and respirations are 20/min. Abdomen is mildly distended and very tender to palpation in the epigastric region; bowel sounds have decreased. There is no rebound tenderness or organomegaly. Rectal examination shows no abnormalities. Laboratory findings reveal: CBC Hb 15.0 g/dL Platelet count 223,000/mm Leukocyte count 14,500/mm Serum Chemistry Serum Na 134 mEq/L Serum K 3.6 mEq/L Chloride 93 mEq/L Bicarbonates 29 mEq/L BUN 30 mg/dL Serum creatinine 0.8 mg/dL Calcium 10.3 mg/dL Blood glucose 168 mg/dL LFT 1.4 mg/dL Total bilirubin Alkaline phosphatase 220 U/L Aspartate aminotransferase 88 U/L Alanine aminotransferase 155 U/L Lipase 523 U/L Abdominal x-ray shows gaseous distention of the small bowel in the upper abdomen. Computed tomography (CT) scan with contrast shows diffuse hypodense enlargement of the pancreas and peripancreatic and perirenal fluid collections. Nasogastric suction, intravenous normal saline, analgesics, and antibiotics are started. Which of the following is the most appropriate next step in management?