USMLE Surgery Management P2 190 QCM

1) A previously healthy 20-year-old man is admitted to the hospital with acute onset of left-sided chest pain. Electrocardiographic findings are normal, but CXR shows a 40% left pneumothorax. Appropriate treatment consists of which of the following procedures?
. Observation
. Barium swallow
. Thoracotomy
. Tube thoracostomy
. Thoracostomy and intubation
2) A 22-year-old professional basketball player falls on his outstretched hand during a scrimmage game. He has mild swelling at the wrist and tenderness to palpation in the anatomic snuffbox. No fracture is visible on multiple radiographs of the wrist and hand. Which of the following is the most appropriate management of this patient?
. anti-inflammatory medication and application of ice
. Elastic wrist support, analgesics, and restricted activity for 1–2 weeks
. Presumptive diagnosis of a scaphoid fracture, with application of a wrist splint, and repeat x-rays in 10–14 days
. Presumptive diagnosis of a scaphoid fracture, with application of a short-arm cast including the thumb
. Presumptive diagnosis of a scaphoid fracture, application of a short-arm cast including the thumb, and removal of the cast, with repeat x-rays in 10–14 days
3) After suitable calculations have been made using the modified Parkland formula, a 70-kg man with extensive third-degree burns is receiving Ringer's lactate at the calculated rate, which happens to be 750 mL/hr. The infusion was started within 30 minutes of the time when the burn occurred. Over the next 3 hours, his urinary output is recorded as 15 mL, 22 mL, and 18 mL. It is verified that the Foley catheter is open and draining freely. The urine is dark yellow, without blood, and has a specific gravity of 1040 and a sodium concentration of 10mEq/L. The patient's blood pressure is 100/70 mm Hg, his pulse is 98/min, and his central venous pressure is 2 cm H2O. On the basis of these findings, which of the following is the most appropriate next step in management?
. Diuretics should be given
. Fluid administration should continue at the present rate
. The rate of fluid administration should be decreased
. The rate of fluid administration should be increased
. Treatment is needed for renal failure
4) A 32-year-old woman in the 2nd month of pregnancy is found to have a 5-cm mass in the upper outer quadrant of her left breast. Mammogram shows no other lesions, and core biopsy reveals infiltrating ductal carcinoma. Which of the following would be the best course of action at this time?
. Chemotherapy now, deferring surgery until after delivery
. Radiation therapy now, deferring surgery until after delivery
. Lumpectomy and axillary sampling, followed in 6 weeks by radiotherapy
. Modified radical mastectomy now, deferring systemic therapy until later
. Immediate therapeutic abortion and palliative breast surgery
5) In the course of a robbery, a young woman is stabbed repeatedly. On arrival at the emergency department, she is shivering and asks for a blanket and a drink of water; she is noted to be pale and perspiring. Her blood pressure is 72/50 mm Hg and her pulse is 130/min. Her neck and forehead veins are large and distended. A quick initial survey reveals entry wounds in her left chest and upper abdomen. She has bilateral breath sounds and a scaphoid, nontender abdomen. As IV infusions of Ringer's lactate are started, her systolic blood pressure drops further to 40 mm Hg, no distal pulses can be felt, and she loses consciousness. Her central venous pressure at that time is 28 cm H2O. Which of the following is the most appropriate next step in management?
. Chest x-ray to direct further therapy
. Bilateral chest tubes
. Diagnostic peritoneal lavage
. Evacuation of the pericardial sac
. Crash laparotomy in the emergency department to clamp the aorta
6) A 37-year-old woman undergoes a lumpectomy and axillary dissection for a 3-cm infiltrating ductal carcinoma, diagnosed by core biopsies, located on the upper outer quadrant of her left breast. The pathology report of the surgical specimen is received 3 days after the operation. It indicates that all margins around the tumor are clear, and that 4 of 17 axillary lymph nodes have metastatic tumor. The tumor is reported to be estrogen and progesterone receptor negative. Which of the following should further therapy most likely include?
. Antiestrogen medication (tamoxifen)
. Conversion to modified radical mastectomy
. Radiation to the remaining left breast
. Radiation to the remaining left breast and systemic chemotherapy
. Radiation to both breasts and tamoxifen
7) A 45-year-old man with alcoholic cirrhosis is bleeding from a duodenal ulcer. He has required 6 units of blood over the past 8 hours, and all conservative measures to stop the bleeding, including irrigation with cold saline, IV vasopressin, and endoscopic use of the laser have failed. He is being considered for surgical intervention. Laboratory studies done at the time of admission, when he had received only one unit of blood, showed a bilirubin of 4.5 mg/dL, a prothrombin time of 22 seconds, and a serum albumin of 1.8 g/dL. He was mentally clear when he came in, but has since then developed encephalopathy and is now in a coma. Which of the following best describes his operative risk?
. Acceptable as he now is
. Amenable to improvement if he receives vitamin K
. Amenable to improvement if he is given albumin
. Prohibitive unless he is dialyzed to normalize his bilirubin
. Prohibitive regardless of attempts to improve his condition
8) A 22-year-old convenience store clerk is shot once with a .38 caliber revolver. The entry wound is in the left midclavicular line, 2 inches below the nipple. There is no exit wound. He is hemodynamically stable. A chest x-ray film shows a small pneumothorax on the left, and demonstrates the bullet to be lodged in the left paraspinal muscles. In addition to the appropriate treatment for the pneumothorax, which of the following will this patient most likely need?
. Barium swallow
. Bronchoscopy
. Extraction of the bullet via local back exploration
. Extraction of the bullet via left thoracotomy
. Exploratory laparotomy
9) A middle-aged homeless man is brought to the emergency department because of very severe pain in his forearm. He had passed out after drinking a bottle of cheap wine, and then slept on a park bench for an indeterminate time, probably more than 12 hours. Shortly after he woke up and began to walk, the pain began. There are no signs of trauma, but the muscles in his forearm are very firm and tender to palpation and passive motion of his fingers and wrist elicits excruciating pain. Pulses at the wrist are normal. Which of the following is the most appropriate next step in management?
. Analgesics and observation
. Immobilization in a sling
. Immobilization in a plaster cast
. Emergency embolectomy
. Emergency fasciotomy
10) A 66-year-old man with diabetes and generalized arteriosclerotic occlusive disease notices a gradual loss of erectile function over several years. Initially, he can get erections, but they do not last long enough. Later, he notices a decrease in the quality of his erections, and more recently he becomes, by his own criteria, completely impotent. He has occasional, brief nocturnal erections, but "he can never get an erection when he needs one." Which of the following is the most appropriate initial step in management?
. Psychotherapy
. Pharmacologic therapy
. Erectile nerve reconstruction
. Implantable penile prosthesis
. Pudendal artery revascularization
11) A 54-year-old woman has a severe ureteral colic. An intravenous pyelogram shows a 7-mm ureteral stone at the ureteropelvic junction. She has a normal coagulation profile. Which of the following would most likely be the best therapy in this case?
. Plenty of fluids and analgesics and await spontaneous passage
. Extracorporeal shock wave lithotripsy (ESWL)
. Endoscopic retrograde basket extraction
. Endoscopic retrograde laser vaporization of the stone
. Open surgical removal
12) A 31-year-old woman smashes her car against a bridge abutment. She sustains multiple injuries, including upper and lower extremity fractures. She is fully awake and alert, and she reports that she was not wearing a seat belt and distinctly remembers hitting her abdomen against the steering wheel. Her blood pressure is 135/75 mm Hg, and her pulse is 88/min. Physical examination shows that she has a rigid, tender abdomen, with guarding and rebound in all four quadrants. She has no bowel sounds. Which of the following would be the most appropriate step in evaluating potential intra-abdominal injuries?
. Continued clinical observation
. CT scan of the abdomen
. Sonogram of the abdomen
. Diagnostic peritoneal lavage
. Exploratory laparotomy
13) A 72-year-old man has a 3-mm ureteral stone impacted at the ureterovesical junction. He has been having mild ureteral colicky pain for about 12 hours, and he has been given fluids and analgesics in the expectation that he will spontaneously pass the stone. He then has shaking chills, and spikes a temperature of 40C (104F). When seen shortly thereafter, he has flank pain and looks quite ill. Which of the following is the most appropriate next step in management?
. Addition of IV antibiotics to the current therapeutic regimen
. Crushing and extraction of the stone via cystoscopy
. Extracorporeal shock wave lithotripsy and parenteral antibiotics
. Immediate insertion of a suprapubic catheter into the bladder
. IV antibiotics and immediate decompression of the urinary tract above the stone
14) A 72-year-old man is scheduled to have elective sigmoid resection for diverticular disease. He has a history of heart disease, and had a documented myocardial infarction 2 years ago. He currently does not have angina, but he lives a sedentary life because "he gets out of breath" if he exerts himself. During the physical examination, it is noted that he has jugular venous distention. He has hemoglobin of 12 g/dL. If surgery is indeed needed, which of the following should most likely be done prior to the operation?
. Evaluate the patient as a candidate for coronary revascularization
. Place the patient on intensive respiratory therapy
. Order a transfusion to increase the patient's haemoglobin to 14 g/dL
. Treat the patient for congestive heart failure
. If at all possible, wait 6 months before performing surgery
15) A group of illegal immigrants is smuggled across the border in a closed metal truck in the middle of summer. When apprised by radio that the border patrol is on their trail, the smugglers abandon their charges in the middle of the desert, in the locked truck, with little water to drink. The victims are found and rescued 5 days later. One of them is brought to the emergency department, awake and alert, with obvious clinical signs of severe dehydration and a serum sodium concentration of 155mEq/L. Which of the following would be the best choice and rate of IV fluid administration?
. 5 L of 5% dextrose in water (D5W) over 2-3 days
. 5 L of D5W over 5-10 hours
. 5 L of 5% dextrose in half normal saline (D5 1/2 NS) over 5-10 hours
. 10 L of D5 1/2 NS over 5-10 hours
. 10 L of normal saline over 2-3 days
16) A 55-year-old woman has been known for years to have mitral valve prolapse. She has now developed exertional dyspnea, orthopnea, and atrial fibrillation. She has an apical, high-pitched, holosystolic heart murmur that radiates to the axilla and back. Because of her deterioration, surgery has been recommended. Which of the following is the most appropriate procedure?
. Aortic valve replacement
. Mitral commissurotomy
. Mitral valve annuloplasty
. Mitral valve replacement
. Both aortic and mitral valve replacement
17) A 23-year-old woman seeks help for exquisite pain with defecation and blood streaks on the outside of her stools, which she has been having for several weeks. Because of the pain, she has avoided having bowel movements, and when she finally did the stools were hard and even more painful. When seen, she has no fever or leukocytosis. Physical examination has to be done under spinal anesthesia, because the patient was so afraid of the pain that she initially refused even inspection of the area. The examination confirms the suspected diagnosis, and she is placed on stool softeners and appropriate topical agents, but without success. She is willing to undergo more aggressive treatment. Which of the following is the most appropriate next step?
. Excision of the lesion
. Fistulotomy
. Incision and drainage
. Lateral internal sphincterotomy
. Rubber band ligation
18) An exploratory laparotomy for multiple intra-abdominal injuries has lasted 3 and a half hours. Multiple blood transfusions have been given, and several liters of Ringer's lactate have been infused. When the surgeons are ready to close the abdomen, they find that the abdominal wall edges cannot be pulled together without undue tension. Both the belly wall and the abdominal contents seem to be swollen. Which of the following is the most appropriate management in this situation?
. Approximate the skin only, using towel clips
. Close the abdomen with heavy retention sutures
. Give diuretics and close the abdomen in the usual way
. Leave the abdomen and its contents open to the air
. Provide temporary bowel coverage with an absorbable mesh
19) A 52-year-old nurse seeks medical retirement because of a "heart condition." She complains of disabling attacks of tachycardia and palpitations. The physical examination and ECG studies confirm that indeed her pulse is between 100 and 105/min at all times, and she is in and out of atrial fibrillation. It is also noted that she is fidgety and constantly moving, and various examiners remark that she arrives for tests lightly dressed when it is rather cold outside. Thyroid function studies show elevated free thyroxine (T4) and undetectable levels of thyroid stimulating hormone (TSH). Her thyroid gland is not clinically enlarged or tender. Which of the following is the most appropriate next step in diagnosis?
. Fine needle aspiration cytology of the thyroid gland
. MRI of the pituitary area
. Radioactive iodine uptake
. Serum levels of C peptide
. Serum levels of tri-iodo-thyronine (T3)
20) A 24-year-old woman is admitted to the hospital for a broken femur. The patient was in a motor vehicle accident 20 hours ago and was brought to the hospital by EMS. On the scene, she was found belted in her car in the driver’s seat, and her only documented injury was the leg fracture. She had no loss of consciousness or altered mental status. On arrival to the hospital, radiographs confirmed a fracture of her femur. She was stabilized overnight and scheduled for surgery the next day. Which of the following is the major surgical risk for this patient?
. Air embolism
. Cerebrovascular accident
. Fat embolism
. Osteomyelitis
. Permanent disability
21) A young man sustains a gunshot wound to the base of his neck. He was shot point blank with a .38 caliber revolver. The entrance wound is above the left clavicle, below the level of the cricoid cartilage, and just lateral to the sternomastoid muscle. The exit wound is just above the spinous process of the right scapula. He has normal breath sounds on both sides, is awake and alert, is talking with a normal tone of voice, is neurologically intact, and is hemodynamically stable. Portable x-ray films of the neck and chest taken in the emergency department show some air in the tissues of the lower neck, but are otherwise non-diagnostic. Which of the following is the most appropriate next step in management?
. Observation for several hours
. CT scan of the lower neck and upper chest
. Angiogram, esophagogram, esophagoscopy, and bronchoscopy prior to surgical exploration
. Immediate surgical exploration of the lower neck through a collar incision
. Immediate surgical exploration of the upper chest through a median sternotomy
22) A 31-year-old male immigrant from India is found on a routine physical examination to have a single, 2-cm nodule in the right lobe of his thyroid gland. The mass is firm, moves up and down with swallowing, and is not tender. The skin of his face and neck is pitted with multiple scars, which suggest smallpox; however, he explains that the scars are due to very severe acne that he had as a youngster, for which he eventually received external beam radiation therapy at the age of 14. His thyroid function tests are normal, and fine needle aspiration (FNA) cytology of the mass is read by the pathologist as "indeterminate." Which of the following is the most appropriate next step in management?
. No further care is needed
. Thyroid function tests should be repeated yearly
. Thyroid scan and sonogram are needed
. FNA should be repeated until it can be read as benign or malignant
. Thyroid lobectomy
23) A 9-month-old infant is brought in by her parents because she has an umbilical hernia. Physical examination shows an umbilical defect about 1 cm in diameter, with a small bulge when the girl cries. The hernial contents can be easily reduced. The hernia is not painful, and the girl is otherwise asymptomatic. Which of the following is the most appropriate next step in management?
. No therapy unless the hernia persists beyond the age of 2 years
. Repeated injections of sclerosing agents
. Elective laparoscopic surgical repair
. Elective open surgical repair
. Urgent surgical repair
24) A 53-year-old male is brought to the emergency department after being involved in a motor vehicle accident (MVA) as an unrestrained driver. He was found unresponsive at the scene and was intubated by paramedics. He has received 1L of normal saline over the last 20 minutes. His blood pressure in the emergency department is 70/30 mmHg, and his heart rate is 100/min. On physical examination, he responds to strong vocal and tactile stimuli by opening his eyes. His pupils are equal and reactive to light. On exam, there are multiple bruises over the anterior chest and upper abdomen. The trachea is midline. A Swan-Ganz catheter reveals a pulmonary capillary wedge pressure of 12 mmHg. Rapid infusion of 1L of normal saline increases the pulmonary capillary wedge pressure to 17 mmHg, with a blood pressure of 75/30 mmHg and heart rate of 103/min. Which of the following is the best treatment for this patient?
. Anticoagulation
. High-rate IV fluids
. Inotropic agents
. Pericardiocentesis
. Chest tube
25) A 63-year-old male presents to the urgent care center with a four hour history of abdominal pain which he describes as severe, diffuse and constant. He has had one episode of non-bloody vomiting since the pain started. His past medical history is significant for coronary artery disease, diabetes, hypertension, chronic atrial fibrillation and chronic kidney disease. His current medications are lisinopril, digoxin, warfarin, metoprolol, and simvastatin and insulin glargine. On physical examination, his blood pressure is 130/70 mmHg and his heart rate is 100/min and irregular. Physical examination reveals an overweight male in moderate distress. His abdomen is diffusely tender to palpation with positive rebound tenderness. His laboratory findings are as follows: Hemoglobin 9.5 mg/dl, WBC count 7,500/mm3, Platelets 90,000/mm3, Sodium 137 mEq/L, Potassium4.5 mEq/L, Chloride 101 mEq/L, Bicarbonate 22 mEq/L, Glucose 210 mg/dl, Creatinine 1.8 mg/dl, INR 2.1, Blood digoxin level therapeutic. An upright abdominal x-ray shows free air under the diaphragm. Which of the following is the best initial treatment for this patient?
. Packed red blood cell transfusion
. Platelet transfusion
. Vitamin K
. Desmopressin
. Fresh frozen plasma
26) A 62-year-old female is hospitalized with epigastric pain and vomiting. Her past medical history includes mild COPD, congestive heart failure, diabetes mellitus and a stroke that occurred 2 years ago. Her current medications are insulin glargine and aspirin. Her blood pressure is 110/70 and her heart rate is 76/min. Comprehensive work-up is suggestive of acute calculous cholecystitis, and a cholecystectomy is planned. Which of the following would reduce postoperative mortality in this patient?
. Vancomycin
. Enalapril
. Metoprolol
. Verapamil
. Metformin
27) A 50-year-old postman presents with a six-month history of left calf pain that is brought on by walking and is relieved by rest. The patient reports no other symptoms. He has smoked cigarettes for the past 25 years, but does not drink alcohol or use illicit drugs. On physical examination, he has a blood pressure of 158/92 mm Hg and a pulse of 88 beats per minute. The heart and lung examinations are normal. A bruit is heard over the left femoral artery. Popliteal, dorsalis pedis and posterior tibial pulses are palpable bilaterally. The electrocardiogram shows normal sinus rhythm and Q-waves in II, Ill, and aVF. Which of the following is the best next step in management?
. Reassurance
. Ankle-brachial pressure index measurement
. Duplex scan of arteries of lower limbs
. Contrast arteriography
. Endovascular stent placement
28) An 85-year-old male is placed on mechanical ventilation after a complicated elective hernia repair. After five days of endotracheal intubation with mechanical ventilation, the ratio of the rate of carbon dioxide produced to the rate of oxygen uptake is 1.05. What is the best explanation for these findings?
. Sepsis
. High-protein tube feeding
. Carbohydrate excess in the diet
. High inspired oxygen fraction
. Pulmonary atelectasis
29) A 42-year-old man develops right calf pain one week after having a left hemi-colectomy. On physical examination, there is moderate right ankle edema and right calf pain with dorsiflexion of the right foot. Duplex ultrasonography shows a clot in the right superficial femoral vein. Which of the following is the most appropriate initial treatment?
. Aspirin
. Heparin
. Streptokinase
. Warfarin
. Tissue plasminogen activator
30) A 73-year-old male who is a nursing home resident underwent a laparotomy for intestinal obstruction. He has advanced dementia. On the 8th postoperative day, he complains of pain and swelling on the left angle of his jaw. His temperature is 38.90 C ( 102.00 F), blood pressure is 150/80 mm Hg, pulse is 90/min, and respirations are 16/min. Examination shows swelling, erythema, and tenderness in the region of the left parotid gland. Laboratory studies show a white blood cell count of 15,600/mm. Which of the following measures would most likely have prevented this complication?
. Incentive spirometry
. Adequate fluid intake and oral hygiene
. Avoiding antibiotics
. Tetanus toxoid
. Polysaccharide vaccine
31) A 23-year-old male is brought to the emergency department from the scene of a motor vehicle accident. He appears distressed and complains of severe abdominal pain and distention. Urgent laparotomy reveals splenic laceration, and splenectomy is performed. There are no post-operative complications. The patient has no significant past medical history. He drinks alcohol occasionally but denies smoking cigarettes or using illicit drugs. He works as a computer programmer in a small office. Which of the following vaccines is recommended in this patient?
. Hepatitis A
. Hepatitis B
. Meningococcal
. Pertussis
. Salmonella
32) A 68-year-old male undergoes colon resection surgery for diverticulosis. In the 24 hours following the surgery, he passes a total of 300 ml of urine. His past medical history is significant for coronary artery disease, right knee osteoarthritis and moderate chronic obstructive pulmonary disease. On physical examination, his blood pressure is 110/70 mm Hg and his heart rate is 90/min. His lungs are clearto auscultation and his abdomen is soft and non-distended. His current labs are given below: Hemoglobin 9.5 mg/dl, WBC count 13,000/mm3, Platelet count 160,000/mm3, Sodium 138 mg/dl, Potassium 5.1 mg/dl, Glucose 108 mg/dl, Creatinine 2.3 mg/dl, BUN 82 mg/dl, His indwelling bladder catheter is changed but no residual urine is drained. Which of the following is the best next step in managing this patient?
. Furosemide
. Bolus of IV fluids
. Mannitol
. Low-dose dopamine infusion
. Intravenous pyelography
33) A 65-year-old diabetic male comes to the physician because of pain in his calf muscles. His pain increases with walking. He also has end stage renal disease, hyperlipidemia and hypertension. His temperature is 36.7C (98F), blood pressure is 150/96 mm Hg, pulse is 80/min and respirations are 16/min. Examination shows skin atrophy, shiny skin and loss of hair on both legs below the knee. Which of the following would be most appropriate next step in management?
. Prescribe amitriptyline for his pain
. Obtain Doppler ultrasound examination
. Obtain resting and post-exercise systolic blood pressures in the ankle and arm
. Segmental volume plethysmography
. Obtain MRI of the spine
34) A 63-year-old obese female undergoes an elective cholecystectomy after two episodes of acute calculous cholecystitis. Three days after surgery, her blood pressure is 150/100 mmHg, her heart rate is 90/min, and her arterial oxygen saturation is 91% on room air. She is afebrile. Which of the following would most likely increase her functional residual lung capacity?
. Inhaled albuterol
. Sequential compression devices to her lower extremities
. Elevation of the head of the bed
. Decreasing the dose of her postoperative opioids
. Postoperative benzodiazepines
35) A 28-year-old woman with sickle cell anemia presents to the urgent care clinic complaining of 12 hours of right upper quadrant pain. She has had similar pain previously, usually after eating fatty foods. However, past episodes have always resolved within one to two hours. On examination, her temperature is 38.3C and she has right upper quadrant pain with a positive Murphy's sign. Abdominal ultrasound reveals gallstones, a thickened gallbladder wall, and a normal common bile duct. Her alkaline phosphatase level is normal. What is the most appropriate next step in the management of this patient?
. Conservative management and elective cholecystectomy
. Endoscopic retrograde cholangiography
. Emergent cholecystectomy
. HIDA scan
. Percutaneous transhepatic drainage
36) A 35-year-old man is brought to the emergency department after suffering a deep laceration from a rusted piece of barbed wire that was hidden in the grass. Examination shows a 6 cm laceration on the lateral leg that is contaminated with dirt and soil. The laceration is bleeding. The patient reports having received a complete set of childhood vaccinations. His last tetanus immunization was at age 23. Which of the following is the most appropriate next step in the management of this patient?
. Clean the wound, no need for vaccination
. Administer tetanus toxoid
. Administer tetanus immunoglobulin
. Administer tetanus toxoid and immunoglobulin
. Clean the wound, and use antibiotic
37) A 59-year-old man comes to the physician because of postprandial abdominal cramps, weakness, light-headedness, and diaphoresis. The symptoms begin 25-30 minutes after eating. He had a partial gastrectomy for intractable peptic ulcer disease two weeks ago. He takes no medications. His temperature is 36.7C (98F), blood pressure is 130/65 mmHg, pulse is 80/min, and respirations are 18/min. Which of the following is the most appropriate next step in management?
. Dietary modification
. Endoscopy
. Barium swallow
. Octreotide
. Reconstructive operation
38) A 37-year-old male is brought to the emergency department immediately after being smashed in a hydraulic press at a local factory. He is alert and oriented. Despite 10mg of IV morphine given by the paramedics, he is crying with pain. His blood pressure is 110/70 mm Hg, pulse is 110/min, and respirations are 18/min. apparently, his left humeral shaft is fractured and the left arm is severely deformed being bent medially 90 degrees. Left radial artery pulse sensation and muscle strength in the left forearm are decreased compared to the right side. His right leg is shortened and externally rotated. Deformity of the right thigh is noted. Pedal pulses are symmetric. He has pain in the left anterior chest on antero-posterior sternal compression, but breath sounds are normal. Physical examination otherwise shows no abnormalities. The paramedics have placed 2 peripheral intravenous lines and immobilized the fractured limbs. Which of the following is the most appropriate next step in management?
. X-ray of the left arm, right leg and chest
. Repeat 10 mg morphine
. Induction of general anesthesia for operative reduction of the fractures
. Gentle traction of the left forearm to attempt alignment of the fragments of the humerus
. Gentle traction of the right leg to attempt alignment of the fragments of the femur
39) 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 38.70 C (101.70 F), blood pressure 120/76 mm Hg, pulse 11 0/min and respirations 26/min. His condition worsened over the next several hours and required oro-tracheal 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?
. Stat chest x-ray
. Arterial blood gas analysis
. Pericardiocentesis
. Needle thoracostomy
. Intravenous fluids and dopamine
40) A 36-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He is in obvious distress. His blood pressure is 80/30 mm Hg, pulse is 140/min and respirations are 23/min. Examination reveals collapsed neck veins. Breath sounds are present bilaterally, heart sounds are normal and the trachea is midline. He is semiconscious and his pupils are bilaterally reactive. There is no obvious head injury. Abdominal examination shows distention with tenderness in all four quadrants with guarding and rigidity. After initial resuscitation including control of his airway, breathing and circulation, which of the following is the most appropriate next step in management?
. Diagnostic laparoscopy
. Chest x-ray
. CT of the abdomen
. Exploratory laparotomy
. Diagnostic peritoneal lavage
41) 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 28/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. You also note significant swelling over the right femur. Which of the following is the most appropriate next step in the management of this patient?
. Intubation and mechanical ventilation
. 100% oxygen via face mask
. Immediate thoracotomy
. Chest tube placement
. Intravenous fluid resuscitation
42) A 46-year-old man comes to the physician because of a two day history of worsening abdominal discomfort and persistent vomiting. He has not had a bowel movement or passed flatus for 3 days. He had an appendectomy for appendicitis 20 years ago. Examination shows a distended abdomen that is tympanic on percussion. High-pitched bowel sounds and splashing are heard on auscultation. The abdomen is diffusely tender on palpation without rebound or guarding. An x-ray film of the abdomen shows distended small bowel loops with air-fluid levels; no gas is seen in the colon. IV rehydration is started. Which of the following is the most appropriate next step in management?
. Emergency laparotomy
. Barium enema under fluoroscopic control
. Nasogastric suction and intravenous fluids
. Administer bethanechol
. Start total parenteral nutrition
43) A 25-year-old man comes to the physician because of a mass in his mouth. He has just noticed this mass and has had no trauma to his oral cavity. He does not use tobacco, alcohol or drugs. He has had no weight loss. Physical examination shows a large mass located on the hard palate of the mouth. On palpation, the mass is immobile, fleshy with bony surroundings and measures 3x 3 cm. Which of the following is the most appropriate next step in management?
. Reassurance
. Biopsy
. Surgery
. Radiation
. Antifungal treatment
44) A 22-year-old man is brought to the emergency department after falling from a motorbike. He has right wrist pain. His temperature is 37.1C (98.6F), blood pressure is 110/70 mm Hg, pulse is 80/min, and respirations are 17/min. He is well oriented and cooperative. His pupils are bilaterally reactive. Physical examination shows no signs of trauma except for marked tenderness in the right anatomical snuff box. An x-ray film of the wrist joint shows a radiolucent line across the waist of the right scaphoid bone. Which of the following is the most next step management?
. Open reduction and internal fixation of scaphoid bone
. Percutaneous fixation of scaphoid bone
. Send the patient home with analgesics and repeat X ray after 15 days
. Cast immobilization for 6-12 weeks
. Advise rest, ice, compression and elevation for wrist joint
45) A 23-year-old man is brought to the emergency department after being hit in the neck with a dull instrument. He has neck pain and stiffness. Vital signs are stable. Neurological examination shows no abnormalities. An astute medicine resident decides to order an angiogram of the neck vessels to rule out carotid artery injury. Diagnostic angiography shows an intimal flap in the left internal carotid artery just above the carotid bifurcation. Which of the following is the most appropriate next step in management?
. Neck exploration and repair
. Observation
. Heparin
. Aspirin
. Ligation of carotid artery
46) A 35-year-old woman is being evaluated after having a screening mammography. A 3 x 3 cm speculated mass with coarse calcifications is seen in the upper outer quadrant of her right breast. She has no complaints. She has a history of bilateral reduction mammoplasty for mammary hyperplasia 12 years ago. She has no family history of medical problems. Breast examination shows her right nipple is slightly retracted. A fixed mass is palpated in the upper outer quadrant of the right breast. Ultrasonography of the breast shows a hypo-echoic mass. Multiple core biopsy samples show foamy macrophages and fat globules. Which of the following is the most appropriate course of action?
. Instruction for regular clinical breast examination and follow-up mammography
. Radiation therapy of the right breast
. MRI of the breast
. Simple mastectomy
. Segmental excision and axillary node dissection followed by radiation therapy
47) A 76-year-old woman comes to the emergency department because of left lower quadrant (LLQ) abdominal pain and fever. She takes acetaminophen for arthritis and docusate for constipation. A CT scan of the abdomen showed perisigmoid stranding suggestive of inflammation and sigmoid diverticulosis. She was started on intravenous ciprofloxacin and metronidazole; however, she had only mild improvement and is persistently febrile. Examination shows persistent LLQ tenderness to deep palpation. A repeat CT scan now shows a 5 x 6 cm mass in the left iliac fossa. Laboratory studies show: Hemoglobin 13.0 g/L, Platelets 360,000/mm3, Leukocyte count 16,500/mm3. Which of the following is the most appropriate next step in management?
. Add a cephalosporin to the current antibiotic regimen
. CT guided percutaneous drainage
. Laparoscopic drainage
. Laparotomy for drainage and debridement
. Continue current antibiotics for another 4 weeks
48) A 44-year-old obese male is brought to the ER after a motor vehicle accident. His cervical spine is immobilized. He is alert and able to speak in complete sentences. He complains of abdominal pain. At the scene of the accident, his blood pressure is 90/60 mm Hg and pulse is 120/min. Lungs are clearto auscultation. Ecchymosis is present over the abdominal wall in distribution of the seat belt. Bowel sounds are decreased. Neck veins are collapsed. After receiving one liter of intravenous fluids, his blood pressure remains at 90/60 mmHg. A focused assessment with sonography for trauma is inconclusive due to the poor image quality. Which of the following is the most appropriate next step in management of this patient?
. CT scan of the abdomen
. Plain X-ray films of the abdomen
. Diagnostic peritoneal lavage
. Immediate laparotomy
. X-ray of the chest
49) A 62-year-old man comes to the emergency department because of severe abdominal pain. He states that he suddenly felt weak, diaphoretic, and had no energy. He is a smoker and has hypertension. His blood pressure on initial examination was 110/70 mm Hg. Physical examination shows a diffusely tender abdomen. During CT scan he becomes pale and drowsy. CT scan is shown below: Repeat examination shows a man with anxiety and a blood pressure of 80/50 mm Hg and pulse of 110/min Which of the following is the most appropriate next step in management?
 
1
. Exploratory abdominal surgery
. Obtain ultrasound
. Check amylase and lipase
. Laparoscopy
. Drain fluid from the abdomen
50) A 60-year-old man undergoes a laparotomy for intestinal obstruction secondary to postoperative adhesions. He has a history of diabetes mellitus, type 2, and hypertension. He underwent a cholecystectomy two years ago. His takes insulin, hydrochlorothiazide, enalapril, and pravastatin. On postoperative day number five, he has intense pain around the wound. His temperature is 38.3C (101F), blood pressure is 120/76 mm Hg, pulse is 100/min, and respirations are 16/min. Examination of the wound shows a cloudy-gray discharge and crepitus; sensation at the edges of the wound is decreased. Which of the following is the most appropriate next step in management?
. Surgical exploration
. Anti-staphylococcal antibiotics
. Culture the discharge
. Improve glycemic control
. Observation
51) 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?
. CT chest for pneumothorax
. Nerve conduction studies
. Angiogram
. Open reduction of the clavicle
. Closed reduction with figure of eight brace
52) A 16-year-old male is brought to the emergency department after falling off a bicycle and hitting the ground with his head. He briefly lost consciousness, but had no seizures. He has a mild headache but has no nausea or vomiting. Vital signs are stable. Examination shows no neurological deficit or any signs of fracture. Which of the following is the most appropriate next step in management?
. Discharge the patient home if a skull radiograph is normal and ask him to return if he develops any unusual symptoms.
. Discharge the patient home and ask him to return if he develops any unusual symptoms.
. Admit the patient; do the imaging study; serial neurological exams every 2 hours.
. Admit the patient and observe for neurological signs every 4 hours.
. Discharge the patient home if CT scan of head is normal and ask him to return if he develops any unusual symptoms.
53) A 46-year-old male is brought to the ER because of coffee ground emesis. He has a history of chronic hepatitis C and alcohol abuse. His temperature is 36.6C (97.9F), blood pressure is 120/70 mm Hg, pulse is 90/min and respirations are 14/min. He is oriented to time, place and person but somewhat sleepy. A flapping tremor is noted. His abdomen is soft, non-tender, and mildly-distended; liver and spleen are palpated below the costal margins; shifting dullness is present. Nasogastric tube aspiration shows bright red blood that was easily cleared with saline lavage. Endoscopy shows a fresh ulcer with a small adherent clot located high on the lesser curvature near the gastroesophageal junction. Non bleeding esophageal and gastric varices are also seen. Laboratory studies show: Hemoglobin 10.2 g/L, MCV 105 fl, Platelets 105,000/mm3, Leukocyte count 4,500/mm3, Prothrombin time 17 sec, Aspartate aminotransferase (SGOT) 78 U/L, Alanine aminotransferase (SGPT) 50 U/L, Which of the following is the most appropriate next step in management?
. Sclerotherapy of the varices
. Porto-systemic shunt
. Esophageal and proximal gastric devascularization and splenectomy
. Gastric resection, selective vagotomy and pyloroplasty
. Conservative medical management
54) A 3-year-old girl is 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?
. Refer the child to an orthopedic surgeon for possible supracondylar fracture of humerus
. Report the case to child protection agency
. Gentle passive elbow flexion and forearm supination
. Closed reduction and casting of forearm and arm
. Do a skeletal survey of the child
55) 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 37C (98.6F), 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?
. Immediate surgical repair of urethra
. Foley catheterization
. Retrograde urethrogram
. Diuretic to increase the urine output
. Retrograde cystogram with post-void films
56) A 42-year-old woman is brought to the emergency department after being involved in a motor vehicle collision. On arrival she is unconscious with bilaterally round and reactive pupils. Her temperature is 37C (98.6F), blood pressure is 70/20 mm Hg, pulse is 11 0/min and respirations are 22/min. There is a low jugular venous pulse. She does not respond to vocal commands but responds to pain with all 4 limbs. She is not vocalizing. Lung auscultation is unremarkable. Abdominal examination shows a distended abdomen with absent bowel sounds and some bruising. She is intubated and is rapidly infused with 2L of lactated Ringer's solution. Her blood pressure is now 80/30 mm Hg and her pulse is 118/min. Which of the following is the most appropriate next step in management?
. X-ray of abdomen
. CT scan of head
. Exploratory laparotomy
. Lateral x-ray of spine
. Chest x-ray
57) A 34-year-old woman is brought to the emergency department after being hit by a motorbike. Examination shows a 3 cm x 2 cm laceration on the left calf. The wound is dirty and the underlying fascia can be seen. She has had four doses of tetanus toxoid in her life; the last dose was 7-years ago. In addition to wound debridement and surgical management, which of the following is the most appropriate course of action to protect her from developing tetanus?
. Nothing more is required as the patient is already vaccinated
. Give her tetanus immunoglobulin
. Give her tetanus toxoid
. Give her both tetanus immunoglobulin and tetanus toxoid
. Observe the patient and give her tetanus immunoglobulin and tetanus toxoid if she develops any signs of tetanus
58) 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?
. Surgical exploration of penis
. Retrograde urethrogram followed by surgical exploration of penis
. Foley's catheterization
. Antibiotics, analgesics and anti-inflammatory and follow up in 24 hours
. Do a circumcision
59) 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 36C (96.8F), 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?
. Presence of left shoulder pain
. Presence of free fluid in the abdomen
. Presence of a rib fracture on chest x-ray
. Unvaccinated status of the patient
. Hemodynamic stability and hematocrit values
60) 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 36.9C (98.6F), 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?
. Closed treatment in a spica cast
. Internal fixation of the fracture
. Closed reduction and external fixation
. Lower limb skeletal traction
. Perform a primary arthroplasty
61) 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 38.3C (101.9F). 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?
. Appendectomy
. Laparoscopy
. CT of abdomen
. Colonoscopy
. AP and lateral lumbar films
62) 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?
. Fast track ultrasound
. CT scan of abdomen
. Abdominal angiogram
. Laparotomy
. Resuscitate and re-evaluate
63) 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?
. Open intramedullary nailing of the femur
. External fixation of the fracture
. Place a plaster cast
. Internal fixation of the fracture with plates and screw
. Closed intramedullary fixation of the femoral shaft
64) 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?
. Hematocrit less than 35%
. Blood loss greater than 1500ml
. Evidence of hypoxia
. Lactic acidosis
. Fracture of femur
65) 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?
. Insertion via right jugular vein
. ECG monitoring
. Free aspiration of blood after final catheter placement
. Cardiac ultrasound after placement
. Chest x-ray confirmation of catheter tip location after placement
66) 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?
. Aspiration and microscopic examination of the hip joint synovial fluid
. Conservative management with rest and analgesics
. Closed reduction of the hip joint
. Immediate osteotomy of the femoral neck
. External fixation of the hip joint with pins
67) 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 38.5C (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?
. Incision and drainage
. Recommend mammogram
. Antibiotics and lactation suppression with bromocriptine
. Antibiotics, analgesics and continue breast feeding
. Antibiotics, analgesics and nursing only from unaffected breast
68) 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?
. Give wound care instructions and send the patient home with analgesics
. Admit the patient and do a skeletal survey
. Give wound care instructions and advise the mother that she should keep the temperature of the water heater below 140 F to avoid such injuries in future
. Ask the mother if the child is being abused
. Advise the mother of the suspected abuse, but do not notify authorities because this is a violation of patient confidentiality
69) 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 38.7C (101.6F), 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?
. External drainage of the cystic lesion
. Continue conservative management
. Obtain echocardiogram to evaluate for endocarditis
. Obtain Ca 19-9 level for pancreatic cancer
. Perform lumbar puncture to rule out meningitis
70) 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 37.6C (99.8F), 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?
. Physiotherapy and respiratory exercises
. Begin broad-spectrum antibiotics
. Perfusion/ventilation scintigraphy
. Administer bronchodilators and steroids
. Check serial cardiac enzymes
71) 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?
. Exploratory laparotomy
. Nasogastric suction with parenteral nutrition
. Bowel rest and antibiotics
. Endoscopic removal of the hematoma
. MRI of the abdomen
72) A 55-year-old man comes to the emergency department because of severe right-sided chest pain. His temperature is 37.8C (100.4F), 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?
. To achieve a tidal volume of 500 ml with intubation
. To use only intravenous colloids
. To ensure appropriate analgesia
. To provide mechanical stabilization to the chest wall
. To give prophylactic antibiotics
73) 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 39.4C (103F), 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?
. Immediate surgery
. IV hydration, erythromycin and metronidazole
. IV hydration, tetracycline and metronidazole
. IV hydration and cefotetan
. Ciprofloxacin and vancomycin
74) 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?
. Place the amputated finger in a plastic bag with water and bring it along with the patient to the emergency department
. Place the amputated finger in a plastic bag with alcohol; place the bag on a bed of ice and bring it along with the patient to the emergency department
. Place the amputated finger in saline moistened gauze in a plastic bag: place the bag on a bed of ice and bring it along with the patient to the emergency department
. Place the amputated finger in antiseptic solution and bring it along with the patient to the emergency department
. Place the amputated finger on a bed of ice and bring it along with the patient to the emergency department
75) 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 37C (98.6F), 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?
. Endotracheal intubation with 100% oxygen
. Administration of 100 % oxygen with facemask
. Administration of 50% dextrose
. Administration of thiamine
. Administration of intravenous morphine
76) 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?
 
2
. Place chest tube
. Bronchoscopy
. Start antibiotics
. Barium swallow
. Angiogram
77) 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?
. Bone scan
. MRI of the foot
. Rest and analgesics
. Plaster cast
. Surgical intervention
78) A 34-year-old male is brought to the emergency department by the paramedics after a gun-shot injury. His temperature is 37C (98.8F), 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?
. Place a chest tube
. Do a diagnostic peritoneal lavage
. Pericardiocentesis
. Do an exploratory laparotomy
. Do a thoracotomy
79) 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 36.5C (97.6F), 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, Platelets223,000/mm3, Leukocyte count14,500/mm3, Serum sodium,134mEq /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?
. Add intravenous sodium bicarbonate
. Add intravenous pancreatic protease inhibitor
. Colonoscopic decompression
. Administer intramuscular carbachol to treat ileus
. Obtain a right upper quadrant ultrasound
80) A 72-year-old man underwent bypass grafting for severe coronary artery disease. On the 1st postoperative day, his temperature is 36.6C (97.9F), 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 timeb30sec. Which of the following will this patient most likely require?
. Aspirin therapy
. Thoracotomy for debridement and drainage; antibiotic therapy
. Thoracotomy for hemostasis
. Pericardial puncture and aspirin therapy
. Antibiotic therapy alone
81) 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?
. Immediate surgery
. CT scan of the spine
. Intravenous steroids
. MRI of the spine
. Watchful observation
82) 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?
. Laparoscopy
. Laparotomy
. X-ray films of the abdomen and pelvis
. CT scan of the abdomen
. Diagnostic peritoneal lavage
83) 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?
. Aspiration of fluid
. Surgical intervention
. Ultrasound examination
. Reassurance and observation
. Check 24-hour urinary protein excretion
84) 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?
. Recommend mammogram to be done as soon as possible
. Prescribe oral contraceptives and reassure her
. Reassure and reexamine her in six weeks
. Send the aspirated fluid for cytologic analysis
. Recommend ultrasound evaluation of the aspirated cyst
85) 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 37.1C (98.8F), 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?
. Give her intravenous steroids
. Giver her subcutaneous epinephrine
. Give her intravenous anti-histamines
. Look for the stinger and carefully remove it
. Give her oral steroids
86) 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?
. Chemoradiation
. External beam radiation therapy
. Intracavitary radiation therapy
. Surgical resection
. Surgical resection followed by adjuvant chemoradiation
87) 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?
. Evaluation of the cervical spine.
. Blind nasopharyngeal intubation with cervical in-line stabilization.
. Oropharyngeal intubation with cervical in-line stabilization.
. Emergency tracheostomy.
. Emergency cricothyroidotomy.
88) 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?
. Superficial parotidectomy with preservation of the facial nerve
. Superficial parotidectomy with resection of the facial nerve
. Total parotidectomy with preservation of the facial nerve
. Total parotidectomy with resection of the facial nerve
. Enucleation of the adenoma
89) 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?
. Expectant management with close follow-up of platelet counts
. Immediate platelet transfusion to increase platelet counts to greater than 50,000/μL
. Glucocorticoid therapy
. Intravenous immunoglobulin (IVIG) therapy
. Referral to surgery for laparoscopic splenectomy
90) 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 adeno-carcinoma 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?
. No further intervention at this time; follow-up every 6 months for 2 years
. Chemotherapy alone
. Neoadjuvant chemotherapy followed by right hemicolectomy
. Ileocecectomy
. Right hemicolectomy
91) 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?
. Medical treatment with sublingual nitroglycerin, nitrates, or calcium-channel blockers
. Repeated bougie dilations
. Injections of botulinum toxin directly into the lower esophageal sphincter
. Dilation with a Gruntzig-type (volume-limited, pressure-control) balloon
. Surgical esophagomyotomy
92) 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?
. Total proctocolectomy with end ileostomy
. Total proctocolectomy with ileal pouch-anal anastomosis and diverting ileostomy
. Total proctocolectomy with ileal pouch-anal anastomosis, anal mucosectomy, and diverting ileostomy
. Total abdominal colectomy with ileal-rectal anastomosis
. Total abdominal colectomy with end ileostomy and very low Hartmann
93) 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?
. Antibiotic therapy alone
. CT-guided aspiration with repeat imaging in 2 to 3 days
. Antibiotics and CT-guided aspiration with repeat imaging in 2 to 3 days
. Antibiotics and percutaneous catheter drainage
. Surgical internal drainage of the fluid collection with a cyst-gastrostomy or Roux-en-Y cyst-jejunostomy
94) 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?
 
3
. Distal pancreatectomy
. Serial CT scans with resection if the lesion increases significantly in size
. Internal drainage with Roux-en-Y cyst-jejunostomy
. Percutaneous drainage of the fluid-filled lesion
. Endoscopic retrograde cholangiopancreatography (ERCP) with pancreatic stent placement
95) A 55-year-old man comes to the emergency department because of severe right-sided chest pain. His temperature is 37.8°C (100F), 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?
. To achieve a tidal volume of 500 ml with intubation
. To use only intravenous colloids
. To ensure appropriate analgesia
. To provide mechanical stabilization to the chest wall
. To give prophylactic antibiotics
96) 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?
. Antibiotic therapy
. Incision and drainage
. Incision and drainage followed by complete excision after resolution of the inflammation and infection
. Partial excision followed by clinical observation
. Immediate excision followed by postoperative antibiotic therapy for 1 week
97) 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?
. Excision of the cyst
. Excision of the cyst and the central portion of the hyoid bone
. Excision of the cyst, the central portion of the hyoid bone, and the tract to the base of the tongue
. Excision of the cyst, the central portion of the hyoid bone, and the tract to the base of the tongue, with sampling of central cervical lymph nodes
. Excision of the cyst, the central portion of the hyoid bone, and the tract to the base of the tongue, with biopsy of the thyroid gland
98) 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?
. Radiation therapy alone
. Partial glossectomy
. Partial glossectomy and cervical lymph node sampling
. Partial glossectomy and bilateral neck dissections
. Partial glossectomy followed by chemoradiation
99) 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?
. Simple closure with omental patch
. Truncal vagotomy and pyloroplasty
. Truncal vagotomy and antrectomy
. Highly selective vagotomy with omental patch
. Hemigastrectomy
100) 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?
. Treatment with a long-acting somatostatin analog
. Dietary advice and counseling that symptoms will probably abate within 3 months of surgery
. Dietary advice and counseling that symptoms will probably not abate but are not dangerous
. Workup for neuroendocrine tumor (eg, carcinoid)
. Preparation for revision to Roux-en-Y gastrojejunostomy
101) 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?
. Administration of intravenous octreotide
. Administration of a β-blocker (eg, propranolol)
. Measurement of prothrombin time and transfusion with cryoglobulin if elevated
. Empiric transfusion of platelets given splenomegaly
. Gastric and esophageal balloon tamponade (Sengstaken-Blakemore tube)
102) 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 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?
. Orthotopic liver transplantation
. Transection and reanastomosis of the distal esophagus
. Distal splenorenal shunt
. End-to-side portocaval shunt
. Transjugular intrahepatic portosystemic shunt (TIPS)
103) 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 6 week trial of medical therapy, the ulcer is unchanged. Which of the following is the best next step in his management?
. Repeat trial of medical therapy
. Local excision of the ulcer
. Highly selective vagotomy
. Partial gastrectomy with vagotomy and Billroth I reconstruction
. Vagotomy and pyloroplasty
104) 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?
. A diverting ileostomy should be performed and further imaging obtained
. Right hemicolectomy
. Right hemicolectomy with local resection of the liver metastasis
. Closure of the abdomen followed by chemotherapy
. Right hemicolectomy with postoperative radiation therapy to the liver
105) 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?
. Ileocolectomy
. Cholecystectomy
. Ileotomy and extraction
. Nasogastric (NG) tube decompression
. Intravenous antibiotics
106) 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, 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?
. Stat chest x-ray
. Arterial blood gas analysis
. Pericardiocentesis
. Needle thoracostomy
. Intravenous fluids and dopamine
107) 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?
. Administer analgesics and recommend rest
. Obtain an ultrasonogram of the wrist
. Place a thumb spica cast and repeat the radiography in 7- 10 days
. Obtain a DEXA scan to screen for osteoporosis
. Administer a steroid injection
108) 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?
. No further workup is needed. Reevaluate the mass after a course of antibiotics for 2 weeks.
. Fine-needle aspiration (FNA).
. Core needle biopsy.
. Incisional biopsy.
. Excisional biopsy.
109) 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?
. Expectant management with sigmoid resection if symptoms recur
. Cystoscopy to evaluate for a fistula
. Sigmoid resection with end colostomy and rectal pouch (Hartmann procedure)
. Sigmoid resection with primary anastomosis
. Long-term suppressive antibiotic therapy
110) 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?
. Avoidance of fatty foods and reexamination in 6 months.
. Ultrasound examination should be repeated immediately, since the falsenegative rate for ultrasound in detecting gallstones is 10% to 15%.
. Treatment with ursodeoxycholic acid.
. CCK-HIDA scan should be performed to evaluate for biliary dyskinesia.
. Laparoscopic cholecystectomy for acalculous cholecystitis.
111) 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?
. Aspiration of the gallbladder with cytologic examination of the bile
. Observation with repeat ultrasound examinations to evaluate for increase in polyp size
. Laparoscopic cholecystectomy
. Open cholecystectomy with frozen section
. In bloc resection of the gallbladder, wedge resection of the liver, and portal lymphadenectomy
112) 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?
. Treatment with antiamebic drugs
. Percutaneous drainage of the fluid collection
. Marsupialization of the fluid collection
. Surgical drainage of the fluid collection
. Liver resection
113) 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?
. Observation for now and follow-up in surgery clinic in 6 months
. Observation for now and follow-up in surgery clinic if she develops further symptoms
. Elective surgical repair of hernia
. Emergent surgical repair of hernia
. Emergent surgical repair of hernia with exploratory laparotomy to evaluate the small bowel
114) 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?
. Angiography with administration of intra-arterial papaverine
. Emergent laparotomy with left hemicolectomy and transverse colostomy
. Aortomesenteric by pass
. Exploratory laparotomy with thrombectomy of the inferior mesenteric artery
. Expectant management
115) 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?
. Cessation of oral contraceptives and serial CT scans
. Intra-arterial embolization of the hepatic adenoma
. Embolization of the right portal vein
. Resection of the hepatic adenoma
. Systemic chemotherapy
116) 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?
. No further treatment is necessary
. Wedge resection of the lesion
. Formal left hepatectomy
. Intra-arterial embolization of the lesion
. Radiofrequency ablation of the liver lesion
117) 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?
. Transjugular intrahepatic portosystemic shunt
. Surgical portocaval shunt
. Surgical mesocaval shunt
. Splenectomy
. Placement of a Sengstaken-Blakemore tube
118) 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?
. Close the abdomen after culturing the exudate.
. Perform a standard appendectomy.
. Resect the involved terminal ileum.
. Perform an ileocolic resection.
. Perform an ileocolostomy to bypass the involved terminal ileum.
119) A 32-year-old woman undergoes a cholecystectomy for acute cholecystitis and is discharged home on the sixth postoperative day. She returns to the clinic 8 months after the operation for a routine visit and is noted by the surgeon to be jaundiced. Laboratory values on readmission show total bilirubin 5.6 mg/dL, direct bilirubin 4.8 mg/dL, alkaline phosphatase 250 IU (normal 21-91 IU), serum glutamic oxaloacetic transaminase (SGOT) 52 kU (normal 10-40 kU), and serum glutamic pyruvic transaminase (SGPT) 51 kU (normal 10-40 kU). An ultrasonogram shows dilated intrahepatic ducts. The patient undergoes the transhepatic cholangiogram seen here. Which of the following is the most appropriate next management step?
 
4
. Choledochoplasty with insertion of a T tube
. End-to-end choledochocholedochal anastomosis
. Roux-en-Y hepatico-jejunostomy
. Percutaneous transhepatic dilatation
. Choledochoduodenostomy
120) 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?
. Reexcision of the biopsy site with wider margins
. Abdominoperineal rectosigmoid resection
. Anterior resection of the rectum
. External radiation therapy to the rectum
. No further therapy
121) 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?
. Diet modification to include frequent meals
. Long-acting somatostatin analogue octreotide
. Simple excision of the tumor
. Total pancreatectomy
. Chemotherapy and radiation
122) 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?
. Abdominoperineal resection
. Wide local resection with bilateral inguinal node dissection
. Local radiation therapy
. Systemic chemotherapy
. Combined radiation therapy and chemotherapy
123) 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?
. Colonoscopic decompression and rectal tube placement
. Saline enemas and digital disimpaction of fecal matter from the rectum
. Colon resection and proximal colostomy
. Oral administration of metronidazole and checking a Clostridium difficile titer
. Evaluation of an electrocardiogram and obtaining an angiogram to evaluate for colonic mesenteric ischemia
124) 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 5l/min 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?
. Chest tube placement in the fifth intercostal space in the left midaxillary line
. Chest x-ray to confirm pneumothorax
. Endotracheal intubation to establish an adequate airway
. Imaging to exclude cervical spine injury
. Needle insertion into the second intercostal space in the left midclavicular line
125) 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?
. Intestinal obstruction
. Enterovesical fistula
. Ileum-ascending colon fistula
. Enterovaginal fistula
. Free perforation
126) 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?
. Decompression of the large bowel via colonoscopy
. Placement of the NG tube and administration of low-dose cholinergic drugs
. Administration of a gentle saline enema and encouragement of ambulation
. Operative decompression with transverse colostomy
. Right hemicolectomy
127) 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?
. Percutaneous catheter drainage.
. Medical treatment with albendazole.
. Medical treatment with steroids.
. Medical treatment with metronidazole.
. Total pericystectomy.
128) 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?
. Large sliding esophageal hiatal hernia
. Paraesophageal hiatal hernia
. Traction diverticulum of esophagus
. Schatzki ring of distal esophagus
. Esophageal web
129) A 65-year-old man who is hospitalized with pancreatic carcinoma develops abdominal distention and obstipation. The following abdominal radiograph is obtained. Which of the following is the most appropriate initial management of this patient?
 
 
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. Urgent colostomy or cecostomy
. Discontinuation of anticholinergic medications and narcotics and correction of metabolic disorders
. Digital disimpaction of fecal mass in the rectum
. Diagnostic and therapeutic colonoscopy
. Detorsion of volvulus and colopexy or resection
130) 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?
. Correction of coagulopathy, adequate biliary drainage, and close monitoring
. Transarterial embolization (TAE)
. Percutaneous transhepatic biliary drainage (PTBD)
. Ligation of bleeding vessels
. Hepatic resection
131) An upper GI series is performed on a 71-year-old woman who presented with several months of chest pain that occurs when she is eating. The film shown here is obtained. Investigation reveals a microcytic anemia and erosive gastritis on upper endoscopy. Which of the following is the most appropriate initial management of this patient?
 
6
. Cessation of smoking, decreased caffeine intake, and avoidance of large meals before lying down
. Antacids
. Histamine-2 blocker
. Proton-pump inhibitor
. Surgical treatment
132) 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?
. Pancreaticoduodenectomy
. Pancreaticoduodenectomy with reconstruction of the superior mesenteric artery
. Total pancreatectomy
. Total pancreatectomy with reconstruction of the superior mesenteric artery
. Chemoradiation therapy
133) 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?
. Right hemicolectomy
. Right hemicolectomy and chemotherapy
. Chemotherapy only
. Radiation only
. No further treatment
134) 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?
. Computed tomography scan of the abdomen
. Computed tomography scan of the head
. Diagnostic peritoneal lavage
. Immediate laparotomy
. Plain x-ray films of the abdomen
135) A 35-year-old woman presents with abdominal pain and jaundice. Subsequent ERCP reveals the congenital cystic anomaly of her biliary system illustrated in the film shown here. Which of the following is the most appropriate treatment?
 
 
7
. Cholecystectomy with resection of the extrahepatic biliary tract and Roux-en-Y hepaticojejunostomy
. Internal drainage via choledochoduodenostomy
. Internal drainage via choledochocystojejunostomy
. Percutaneous transhepatic biliary drainage
. Liver transplantation
136) 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?
. Endoscopic retrograde cholangiopancreatography (ERCP)
. Placement of a cholecystostomy tube
. Laparoscopic cholecystectomy
. Open cholecystectomy
. Emergent operation and decompression of the common bile duct with a T tube
137) 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?
. Tube cholecystostomy
. Open cholecystectomy
. Laparoscopic cholecystectomy
. Intravenous antibiotics followed by elective cholecystectomy
. Lithotripsy followed by long-term bile acid therapy
138) After a weekend drinking binge, a 45-year-old man presents to the hospital with abdominal pain, nausea, and vomiting. On physical examination, the patient is noted to have tenderness to palpation in the epigastrium. Laboratory tests reveal an amylase of 25,000 U/dL (normal < 180U/dL). The patient is medically managed and sent home after 1 week. A CT scan done 4 weeks later is pictured here. Currently the patient is asymptomatic. Which of the following is the most appropriate initial management of this patient?
 
8
. Distal pancreatectomy
. Percutaneous catheter drainage
. Endoscopic drainage
. Surgical drainage
. No intervention is warranted at this time
139) 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?
. Wedge resection of the lesion
. Wedge resection of the lesion with truncal vagotomy
. Wedge resection of the lesion with highly selective vagotomy
. Wedge resection of the lesion with truncal vagotomy and antrectomy
. Subtotal gastrectomy
140) 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?
. Diverting colostomy only
. Posterior sagittal anorectoplasty only
. Posterior sagittal anorectoplasty with diverting colostomy
. Perineal operation only
. Perineal operation with diverting colostomy
141) A 36-hour-old infant presents with bilious vomiting and an increasingly distended abdomen. At exploration, the segment pictured here is found as the point of obstruction. What is the best next step in management?
 
9
. Gentle, persistent traction on the specimen
. Enteroenterostomy
. Small bowel resection with exteriorization of the ends
. Small bowel resection with anastomosis
. Lysis of Ladd band
142) 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?
Appendectomy
Appendectomy followed by a colonoscopy
Appendectomy followed by a PET scan
Right hemicolectomy
Total proctocolectomy
143) 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?
. Observation
. Discontinuation of oral contraceptive pills
. Percutaneous biopsy of the lesion to confirm the diagnosis
. Resection of the hemangioma
. Liver transplantation
144) A 57-year-old woman presents with adenocarcinoma of the right colon. Laboratory evaluation demonstrates an elevation of carcinoembryonic antigen (CEA) to 123ng/mL. Which of the following is the most appropriate use of CEA testing in patients with colorectal cancer?
. As a screening test for colorectal cancer
. To determine which patients should receive adjuvant therapy
. To determine which patients should receive neoadjuvant therapy
. To monitor for postoperative recurrence
. To monitor for preoperative metastatic disease
145) 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?
. Angiography with embolization
. Balloon tamponade
. Exploratory laparotomy, gastrotomy, and oversewing of the tear
. Systemic vasopressin infusion
. Expectant management
146) 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?
. Placement of a left chest tube
. Thoracotomy
. Laparotomy
. Esophagogastroscopy
. Diagnostic peritoneal lavage
147) 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?
. Discharge him home without any other workup.
. Discharge him home if his amylase level is normal.
. Discharge him home if his abdominal plain films are negative for the presence of free air.
. Discharge him home if an abdominal computed tomography (CT) scan is negative.
. Observe him regardless of negative test results.
148) 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?
. Strapping the chest with adhesive tape
. Admission to the hospital and treatment with oral analgesia
. Tube thoracostomy
. Placement of an epidural for pain management
. Surgical fixation of the fractured ribs
149) 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?
. Repair of the popliteal vein with simple closure
. Repair of the popliteal vein with saphenous vein patch
. Repair of the popliteal vein with a synthetic interposition graft
. Ligation of the popliteal vein
. Amputation of the right lower extremity above the knee
150) 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?
. Local exploration of the wound
. Left tube thoracostomy
. Diagnostic laparoscopy
. CT scan of the abdomen
. Echocardiography
151) 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?
. Choledochoduodenostomy
. Loop choledochojejunostomy
. Primary end-to-end anastomosis of the transected bile duct
. Roux-en-Y choledochojejunostomy
. Bridging of the injury with a T tube
152) 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?
. Expanding hematoma
. Dysphagia
. Dysphonia
. Pneumothorax
. Hemoptysis
153) 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?
. Gastrojejunostomy
. Nasogastric suction and observation
. Duodenal resection
. TPN (total parental nutrition) to increase the size of the retroperitoneal fat pad
. Duodenojejunostomy
154) 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?
. Antiplatelet therapy
. Systemic anticoagulation with heparin
. Neck exploration and left carotid artery repair
. Neck exploration and left intra-extracranial bypass
. Angiography and left carotid artery stenting
155) 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?
. Change in level of consciousness
. Ipsilateral (side of hemorrhage) pupillary dilation
. Contralateral pupillary dilation
. Hemiparesis
. Hypertension
156) 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?
. Elevation of the head of the bed
. Saline-furosemide (Lasix) infusion
. Mannitol infusion
. Intravenous dexamethasone (Decadron)
. Hyperventilation
157) 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?
. Intubation, mechanical ventilation, and positive end-expiratory pressure
. Stabilization of the chest wall with sandbags
. Stabilization with towel clips
. Immediate operative stabilization
. Pain control, chest physiotherapy, and close observation
158) 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?
. Begin an immediate exchange transfusion.
. Transfer the patient to a hyperbaric oxygen chamber.
. Begin bicarbonate infusion and give 250 mg acetazolamide (Diamox) intravenously.
. Administer 100% oxygen by mask.
. Perform flexible bronchoscopy with further therapy determined by findings.
159) 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?
. Injuries are generally more superficial than those from thermal burns.
. Intravenous fluid replacement is based on the percentage of body surface area burned.
. Electric burns often result in a transient traumatic optic neuropathy.
. Evaluation for fracture of the other extremities and visceral injury is indicated.
. Cardiac conduction abnormalities are unlikely.
160) 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?
. Measurement of ankle-brachial indices
. Angiography of the right lower extremity
. Prophylactic below-knee 4-compartment fasciotomies
. Surgical exploration of the right popliteal artery
. Observation with serial pulse checks
161) 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?
. Admission and observation
. Peritoneal lavage
. Exploratory thoracotomy
. Exploratory celiotomy
. Local wound exploration
162) 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?
. A colostomy should be performed regardless of the patient’s hemodynamic status to decrease the risk of an intraabdominal infection.
. Primary repair should be performed, but only in the absence of hemodynamic instability.
. Primary repair should be performed with placement of an intra-abdominal drain next to the repair.
. Primary repair should be performed and intravenous antibiotics administered for 14 days.
. The patient should undergo a 2-stage procedure with resection of the injured portion and reanastomosis 48 hours later when clinically stabilized.
163) 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?
. A Whipple procedure
. Gastrojejunostomy
. Vagotomy and gastrojejunostomy
. Partial resection of the annular pancreas
. Duodenostomy
164) 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?
. Diagnostic air enema with subsequent observation and serial abdominal examinations
. Hydrostatic reduction with air enema
. Diagnostic laparoscopy with laparoscopic reduction
. Exploratory laparotomy with bowel resection
. Decompressive colonoscopy with placement of a rectal tube
165) A 34-year-old prostitute with a history of long-term intravenous drug use is admitted with a 48-hour history of pain in her left arm. She is tachycardic to 130 and her systolic blood pressure is 80 mm Hg. Physical examination is remarkable for crepitus surrounding needle track marks in the antecubital space with a serous exudate. The plain x-ray of the arm is shown here. Which of the following is the most appropriate next step in her management?
. Treatment with penicillin G and close observation
. MRI of the arm
. CT scan of the arm
. Surgical exploration and debridement
. Hyperbaric oxygen therapy
166) 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?
. The patient should be taken to the operating room immediately to evaluate for a significant arterial injury.
. A neurosurgical consult should be obtained and somatosensory evoked potential monitoring performed.
. A fasciotomy should be performed prophylactically in the emergency room.
. A duplex examination should be obtained to rule out a venous injury.
. The patient should be observed for at least 6 hours and then reexamined for changes in the physical examination.
167) 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?
. Resumption of normal daily activity excluding sports
. Exploration and suture of the laceration
. Exploration and wedge resection of the left kidney
. Nephrostomy
. Strict bed rest with serial hemoglobin levels
168) 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?
. Drainage alone
. Roux-en-Y pancreaticojejunostomy
. Pancreaticoduodenectomy
. Frey procedure
. Distal pancreatectomy
169) 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?
. Observation with serial abdominal exams
. Diagnostic peritoneal lavage
. Plain film of the abdomen with a lead apron as a shield
. Focused assessment with sonography for trauma (FAST) examination of the abdomen
. MRI of the abdomen
170) 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?
. No further workup is indicated prior to closure of the abdominal wall defect.
. A Silastic silo should be placed with immediate reduction of the viscera into the abdominal cavity.
. Broad-spectrum intravenous antibiotics should be administered prophylactically.
. Topical antimicrobial solutions should be administered prophylactically.
. Enteral feeds for nutritional support should be initiated early prior to operative management.
171) 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?
. Pneumoperitoneum
. Ascites
. Portal venous gas
. Ileus
. Pneumatosis intestinalis
172) 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?
. Administration of oral polyethylene glycol
. Bowel rest with nasogastric tube decompression and broad-spectrum intravenous antibiotics
. Contrast enema
. Surgical evacuation of the luminal meconium
. Resection of the dilated terminal ileum
173) 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 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?
. Increased peak airway pressure
. Increased cardiac output
. Decreased systemic vascular resistance
. Decreased plasma renin and aldosterone
. Increased cerebral perfusion pressure
174) 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?
. Insulin for glucose control
. Morphine for pain relief
. Perioperative antibiotics
. Metoclopramide for nausea
. Absence of bile storage reservoir
175) 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?
. Intravenous lorazepam
. Intravenous naloxone
. Intravenous phenytoin
. 50% dextrose with thiamine
. 100% oxygen with facemask
176) 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?
. Incision and drainage
. Recommend mammogram
. Antibiotics and lactation suppression with bromocriptine
. Antibiotics, analgesics and continue breast feeding
. Antibiotics, analgesics and nursing only from unaffected breast
177) 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?
. Aspirin
. Heparin
. Streptokinase
. Warfarin
. Tissue plasminogen activator
178) 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?
. Angiography
. Diagnostic peritoneal lavage
. Focused ultrasonography
. Laparoscopy
. Laparotomy
179) 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?
. Lumpectomy and axillary node dissection followed by radiation therapy
. MRI of the breast
. Radiation therapy of the right breast
. Routine follow-up and no intervention
. Simple mastectomy
180) 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?
. Albuterol inhalers
. Prophylactic antibiotics
. Incentive spirometry
. Continuous positive airway pressure
. Intercostal nerve blocks for pain control
181) 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?
. Bladder catheterization
. Femoral line placement
. Intravenous atropine
. Intravenous lorazepam
. Nasogastric tube placement
182) 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/mm3, Platelet count 512,000/mm3, Creatinine 1.7 mg/dl, CPK 430 U/L.Which of the following will this patient most likely require?
. Anticoagulation and electrical cardioversion
. Broad-spectrum antibiotics alone
. Nonsteroidal anti-inflammatory agents alone
. Pericardial puncture and nonsteroidal anti-inflammatory agents
. Surgical debridement and antibiotic therapy
183) 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?
. Admit the patient and observe for neurologic signs every 2 hours for a total of 6-8 hours
. Admit the patient, order a CT scan of the head, and observe for neurologic signs every 2 hours
. Discharge the patient home and ask him to return if he develops any new symptoms
. Discharge the patient home if a skull radiograph is normal and ask him to return if he develops any new symptoms
. Discharge the patient home if a CT scan of the head is norn1al and ask him to return if he develops any new symptoms
184) 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?
. Aspiration and microscopic examination of the hip joint synovial fluid
. Closed reduction of the hip joint
. Conservative management with rest and analgesics
. Immediate osteotomy of the femoral neck
. Surgical pinning of the fen1oral head
185) 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?
. Place the amputated finger in a plastic bag with water and bring it along with the patient to the emergency department
. Place the amputated finger in a plastic bag with alcohol; place the bag on a bed of ice and bring it along with the patient to the emergency department
. Place the amputated finger in saline moistened gauze in a plastic bag; place the bag on a bed of ice and bring it along with the patient to the emergency department
. Place the amputated finger in antiseptic solution and bring it along with the patient to the emergency department
. Place the amputated finger on a bed of ice and bring it along with the patient to the emergency department
186) 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?
. Increase the dose of her analgesics and discharge her
. Do an angiography to assess arterial blood flow
. Do an escharotomy
. Look for a missed fracture of the right upper limb
. Elevation of the limb
187) 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?
. Repeat the endoscopy
. Order water-soluble contrast esophagram
. Check serum amylase and lipase levels
. Wait until the pathologic diagnosis is ready
. Perform thoracocentesis
188) 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?
. Refer the child to an orthopedic surgeon for possible supracondylar fracture of humerus
. Report the case to child protection agency
. Gentle passive elbow flexion and forearm supination
. Closed reduction and casting of forearm and arm
. Do a skeletal survey of the child
189) 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?
 
11
. Chest tube placement
. Computed tomography scan of the chest and abdomen
. Flexible bronchoscopy
. Intravenous antibiotics
. Reassurance and outpatient follow-up
190) 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/mm3, Leukocyte count 14,500/mm3, 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?
. Add intravenous sodium bicarbonate
. Add intravenous pancreatic protease inhibitor
. Perform colonoscopic decompression
. Administer intramuscular carbachol to treat ileus
. Obtain a right upper quadrant ultrasound
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