USMLE CHIR EMERGENCY AND TEST

1) A 50-year-old patient presents with symptomatic nephrolithiasis. He reports that he underwent a jejunoileal bypass for morbid obesity when he was 39. Which of the following is a complication of jejunoileal bypass?

2) A 75-year-old man slips and falls at home, hitting his right chest wall against the kitchen counter. He has an area of exquisite pain to direct palpation over the seventh rib, at the level of the anterior axillary line. A chest x-ray film confirms the presence of a rib fracture, with no other abnormal findings. Which of the following is the most appropriate initial step in management?

3) A 71-year-old woman is brought to the physician by her distressed daughter. The daughter relates that, 3 days ago, her mother began to complain of right upper quadrant abdominal pain. She did not want to eat and "took to her bed sick." The daughter recalls that she complained of chills, nausea, and some vomiting. Physical examination reveals an obtunded, hypotensive, and obviously very sick elderly woman. She has impressive pain to deep palpation in the right upper quadrant, along with muscle guarding and rebound. Her temperature is 40C (104F), and laboratory analysis shows a white cell count of 22,000/mm3 with multiple immature forms, a bilirubin of 5 mg/dL and alkaline phosphatase of 840 U/L. The serum amylase is normal. An emergency sonogram shows multiple stones in the gallbladder, normal thickness of the gallbladder wall without pericholecystic fluid, dilated intrahepatic ducts, and common duct with a diameter of 2.1 cm. The sonographer cannot identify stones in the common duct. In addition to IV fluids and antibiotics, which of the following is the most appropriate next step in management?

4) A 54-year-old man, who 5 years ago underwent a laparotomy for a gunshot wound to the abdomen, is admitted to the hospital because of protracted vomiting and progressive abdominal distention. The symptoms began 5 days earlier, and since then he has not had a bowel movement or passed any gas. At the time of hospitalization, he has hyperactive bowel sounds and some abdominal discomfort, but does not have an acute abdomen. His abdominal x-ray films show dilated loops of small bowel, multiple airfluid levels, and no free air under the diaphragms. He is placed on nasogastric suction and IV fluids. After 6 hours, he develops fever, leukocytosis, abdominal tenderness, and rebound tenderness, and his abdomen is silent. Which of the following is the most appropriate next step in management?

5) A 3-year-old boy is brought to the emergency room after spilling bleach onto his lower extremities. He is diagnosed with a chemical burn and all involved clothing are removed. In addition to resuscitation, which of the following is the most appropriate initial management of this patient?

6) Following a weekend of snowmobiling, a 42-year-old man comes to the emergency department with pain, numbness, and discoloration of his right forefoot. You diagnose frostbite. Which of the following is the proper initial treatment?

7) A 40-year-old woman complains of mild, intermittent pain and paresthesias in her right wrist. She reports the pain is worse at night and with driving. On physical examination hyperflexion of the right wrist reproduces the paresthesia. With regard to her diagnosis, which of the following is the most appropriate initial treatment?

8) A 19-year-old man receives un-cross-matched blood during resuscitation after a gunshot wound to the abdomen. He develops fever, tachycardia, and oliguria during the transfusion and is diagnosed as having a hemolytic reaction. Which of the following is the most appropriate next step in the management of this patient?

9) A 64-year-old man with history of severe emphysema is admitted for hematemesis. The bleeding ceases soon after admission, but the patient becomes confused and agitated. Arterial blood gases are as follows: pH 7.23; PO2 42 mm Hg; PCO2 75 mm Hg. Which of the following is the best initial therapy for this patient?

10) A 16-year-old adolescent boy with a history of severe hemophilia A is undergoing an elective inguinal hernia repair. Which of the following is the best option for preventing or treating a bleeding complication in the setting of this disease?

11) A 23-year-old woman undergoes total thyroidectomy for carcinoma of the thyroid gland. On the second postoperative day, she begins to complain of a tingling sensation in her hands. She appears quite anxious and later complains of muscle cramps. Which of the following is the most appropriate initial management strategy?

12) A 24-year-old firefighter sustains 30% total body surface area (TBSA) burns to his torso, face, and extremities. His wounds are treated topically with silver nitrate. Which of the following complications is associated with use of this agent?

13) A 22-year-old man sustains severe blunt trauma to the back. He notes that he cannot move his lower extremities. He is hypotensive and bradycardic. Which of the following is the best initial management of the patient?

14) A 14-year-old boy presents in the emergency department with very severe pain of sudden onset in his right testicle. There is no history of either trauma or recent mumps. He is afebrile, and a urinalysis shows no pyuria. The testis is swollen, exquisitely painful, high in the scrotum, and riding in a horizontal position. The cord above the testis is not tender. Which of the following is the most appropriate next step in management?

15) A 59-year-old man with a history of myocardial infarction 2 years ago undergoes an uneventful aortobifemoral bypass graft for aortoiliac occlusive disease. Six hours later he develops ST segment depression, and a 12-lead electrocardiogram (ECG) shows anterolateral ischemia. His hemodynamic parameters are as follows: systemic BP 70/40 mm Hg, pulse 100 beats per minute, CVP 18 mm Hg, PCWP 25 mm Hg, cardiac output 1.5 L/min, and systemic vascular resistance 1000 (dynes)/cm5. Which of the following is the single best pharmacologic intervention for this patient?

16) A 56-year-old man undergoes a left upper lobectomy. An epidural catheter is inserted for postoperative pain relief. Ninety minutes after the first dose of epidural morphine, the patient complains of itching and becomes increasingly somnolent. Blood-gas measurement reveals the following: pH 7.24, PaCO2 58, PaO2 100, and HCO3− 28. Which of the following is the most appropriate initial therapy for this patient?

17) A cirrhotic patient with abnormal coagulation studies due to hepatic synthetic dysfunction requires an urgent cholecystectomy. A transfusion of FFP is planned to minimize the risk of bleeding due to surgery. What is the optimal timing of this transfusion?

18) Ten days after an exploratory laparotomy and lysis of adhesions, a patient, who previously underwent a low anterior resection for rectal cancer followed by postoperative chemoradiation, is noted to have succus draining from the wound. She appears to have adequate source control—she is afebrile with a normal white blood count. The output from the fistula is approximately 150 cc per day. Which of the following factors is most likely to prevent closure of the enterocutaneous fistula?

19) A 45-year-old woman undergoes an uneventful laparoscopic cholecystectomy for which she receives 1 dose of cephalosporin. One week later, she returns to the emergency room with fever, nausea, and copious diarrhea and is suspected of having pseudomembranous colitis. She is afebrile and has no peritoneal signs on abdominal examination. She has a mild leukocytosis with a left shift. Which of the following is the appropriate initial management strategy?

20) An 18-year-old woman develops urticaria and wheezing after an injection of intravenous contrast for an abdominal CT scan. Her blood pressure is 120/60 mm Hg, heart rate is 155 beats per minute and respiratory rate is 30 breaths per minute. Which of the following is the most appropriate immediate therapy?

21) A patient involved in a high-speed automobile collision arrives in the emergency department unconscious, with multiple facial fractures; brisk bleeding into his nose, mouth, and throat; and gurgly, irregular, noisy breathing. Which of the following would be the best method to secure an airway in this patient?

22) A 22-year-old woman is involved in a major motor vehicle accident and receives a tracheostomy during her hospitalization. Five days after placement of the tracheostomy she has some minor bleeding around the tracheostomy site. Which of the following is the most appropriate immediate therapy?

23) A 33-year-old woman is brought to the emergency room from the scene of a severe motor vehicle accident. She is combative, confused, uncooperative, and appear dusky and dyspneic. Which of the following is the most appropriate management of her airway?

24) A 42-year-old man who was in a house fire is transferred to your burn unit. He has singed nose hairs and facial burns. Direct laryngoscopy in the emergency room demonstrates pharyngeal edema and mucosal sloughing. He has 60% total body surface area burns. Which of the following is the next step in the management of this patient?

25) A 24-year-old man presents in septic shock from an empyema. He is febrile to 103°F, tachycardic in the 120s, and hypotensive to the 90s. His oxygen saturation is 98% on 2-L oxygen. His white blood cell count is 25,000/mL and creatinine is 0.8 mg/dL. His blood pressure does not respond to fluid administration despite a CVP of 15. Which of the following therapies is indicated in managing this patient?

26) Shortly after the administration of an inhalational anesthetic and succinylcholine for intubation prior to an elective inguinal hernia repair in a 10-year-old boy, he becomes markedly febrile, displays a tachycardia of 160, and his urine changes color to a dark red. Which of the following is the most appropriate treatment at this time?

27) A 37-year-old woman is brought to the surgical floor after undergoing a routine vaginal hysterectomy that morning. She had been fasting since midnight the night prior to her surgery. She has no past medical history except for uterine fibroids and takes only oral contraceptive pills regularly. During the procedure, she was reported to lose approximately 300 mL of blood. On the floor, she appears well but complains of some fatigue. Her blood pressure is 110/60 mm Hg, and her pulse is 100/min. She is not taking food or water yet because of persistent nausea and vomiting postoperatively. Which of the following is the most appropriate next step in management?

28) A 22-year-old woman is brought to the emergency department after a motorcycle accident in which she sustained severe crush injuries of her lower extremities. In the field, her Glasgow Coma Score was 14. She is awake and alert on arrival after having been given morphine for pain control. Any details of her past medical history are unknown. Initial examination shows a blood pressure of 140/80 mm Hg and pulse of 100/min. Her oxygen saturation on room air is 95% by pulse oximeter. An ECG is obtained and shows very large, peaked T-waves in leads V1-V6. Which of the following is the most appropriate initial step in patient care?

29) A 32-year-old man undergoes a distal pancreatectomy, splenectomy, and partial colectomy for a gunshot wound to the left upper quadrant of the abdomen. One week later he develops a shaking chill in conjunction with a temperature spike of 39.4°C (103°F). His blood pressure is 70/40 mm Hg, pulse is 140 beats per minute and respiratory rate is 45 breaths per minute. He is transferred to the intensive care unit (ICU), where he is intubated and a Swan-Ganz catheter is placed. Which of the following is consistent with the expected initial Swan-Ganz catheter readings?

30) A 72-year-old man has multiple injuries and an altered sensorium after a high-speed motor vehicle collision. He is intubated for his decreased mental status. During intubation, a large amount of gastric contents are noted in the posterior pharynx and he aspirates. Which of the following is the appropriate initial treatment?

31) A 50-year-old woman with a history of essential hypertension presents to the emergency department with sudden onset of a severe headache, nausea and vomiting, and photophobia. On examination, her BP is 160/100 mmHg. She is mildly confused and has nuchal rigidity, without focal neurologic signs. Once the diagnosis has been confirmed, Rupture cerebral aneurysm, which of the following is the next most important step in patient management?

32) A 22-year-old gang member arrives in the emergency department with multiple gunshot wounds to the chest and abdomen. He has labored breathing and is cyanotic, diaphoretic, cold, and shivering. He is wide awake, and in a normal tone of voice he tells everyone that he is going to die. An initial survey reveals a blood pressure of 60/40 mm Hg. His pulse is 150/min and barely perceptible. He is in obvious respiratory distress and has big distended veins in his neck and forehead. His trachea is deviated to the left, and the right side of his chest is hyperresonant to percussion, with no breath sounds. Which of the following is the most appropriate initial step in management?

33) On the 5th postoperative day after abdominal surgery, a patient has been draining copious amounts of clear pink fluid from his midline laparotomy wound. A medical student removes the dressing, confirms that it is soaked, and sees a normal-appearing fresh wound with a row of skin staples in place. The student asks the patient to sit up so he can get out of bed and be helped to the treatment room for a more thorough examination. When the patient complies, the wound opens widely, and a handful of small bowel suddenly rushes out. Which of the following is the most appropriate management at this time?

34) Several days following esophagectomy, a patient complains of dyspnea and chest tightness. A large pleural effusion is noted on chest radiograph, and thoracentesis yields milky fluid consistent with chyle. Which of the following is the most appropriate initial management of this patient?

35) A 16-year-old girl with a history of ulcerative colitis managed with steroid therapy presents to the emergency department with a 36-hour history of nausea, crampy abdominal pain, and severe bloody diarrhea. On examination, the patient is febrile and pale, with a blood pressure of 90/60 mmHg and heart rate of 130 beats/min. Her abdomen is distended and diffusely tender. A complete blood count (CBC) demonstrates a leukocytosis with a left shift. The patient receives IV fluid resuscitation and nasogastric (NG) tube decompression. Further therapeutic interventions should include which one of the following?

36) A severely traumatized woman is seen in the emergency room (ER) with decreased mental status. Prior to intubation, she does not open her eyes, withdraws with all of her extremities, and makes incomprehensible sounds. What is her Glasgow coma scale score?

37) A 25-year-old woman was involved in a motor vehicle crash and sustained a significant closed-head injury, a pulmonary contusion, and a pelvic fracture. She is unresponsive and is ventilated in the intensive care unit (ICU). Which of the following is the best initial approach to the management of this patient’s nutritional needs?

38) A young mother is at the pediatrician's office for a routine well-baby visit for her 18-month-old son. It is immediately noticed that one of the baby's pupils is white, while the other one is black. When asked about it, the mother relates that she saw that curious situation for the first time 1 week ago, but since the baby was otherwise asymptomatic, she did not think it merited special attention. Which of the following is the most appropriate course of action?

39) A 70-year-old man is admitted to the ICU after repair of an abdominal aortic aneurysm. He has a prior history of hypertension and mild congestive heart failure, which were adequately controlled with digoxin and diuretics. To facilitate perioperative management, a Swan-Ganz (multilumen pulmonary artery) catheter was inserted in the operating room. During the first few hours postoperatively, the patient is noted to have a blood pressure of 140/70 mmHg, heart rate of 110/min, flat neck veins, a pulmonary arterial wedge pressure of 9 mmHg, and poor urine output. Which of the following is the most appropriate next step in management of this patient?

40) The left ureter is partially transected (50% of circumference) during the course of a difficult operation on an unstable, critically ill patient. Which of the following would be the most appropriate management of this injury given the patient’s unstable condition?

41) A 65-year-old man presents to the emergency department with an abrupt onset of excruciating chest pain 1 hour ago. The pain is localized to the anterior chest, but radiates to the back and neck. On examination, the patient is afebrile, with a BP of 210/110 mmHg, pulse rate of 95/min, and a respiratory rate of 12/min. He appears pale and sweaty. Unequal carotid, radial, and femoral pulses are noted. An electrocardiogram (ECG) shows nonspecific ST-T segment changes. Chest x-ray shows a slightly widened mediastinum and normal lung field. Which of the following is the first step in management of this patient?

42) A 26-year-old previously healthy man was pinned under a crane at a construction site. After a prolonged extrication, he was brought to the emergency department, immobilized on a back board and receiving 100% oxygen by mask. He is alert and complaining of chest pain with respiratory effort. On examination, he is found to have an oxygen saturation of 90% by pulse oximetry, shallow respirations at a respiratory rate of 35/min, heart rate of 120 beats/min, and a blood pressure of 85/60 mmHg. The trachea is deviated to the right. There is tenderness and crepitation over the left chest wall, asymmetric chest wall movement, and decreased air entry over the left lung field. Which of the following is the most appropriate next step in the initial evaluation and management of this patient?

43) A 13-year-old boy is brought to the emergency department at midnight with a 4-hour history of right scrotal pain that was sudden in onset and associated with nausea and one episode of vomiting. On examination, he is in obvious distress. He has mild right lower abdominal tenderness, and high-riding, tender right testes. CBC and urinalysis are normal. Which of the following is the most appropriate next step in management?

44) A 75-year-old man is brought to the emergency department for severe pain in the left flank and back of 1 hour duration. He has a prior history of a myocardial infarction and coronary artery bypass grafting 8 years ago. On examination, he is found to have a BP of 80/50 mmHg, pulse rate of 110/min, respiratory rate of 15/min, and a pulsatile, tenderabdominal mass. He has had two large-bore IV lines placed by the paramedics. He is alert and oriented, and gives consent for surgery. Which of the following is the most appropriate next step in management of this patient?

45) A 14-year-old boy dives into the shallow end of a swimming pool and hits his head against the bottom. When he is rescued, he shows a complete lack of neurologic function below the neck. He is still breathing on his own, but he cannot move or feel his arms and legs. The paramedics carefully immobilize his neck for transportation to the hospital, and they alert the emergency department to his impending arrival. Once there, which of the following would most likely have an immediate benefit for this patient?

46) A 61-year-old man comes in because of colicky abdominal pain and vomiting of 3 days' duration. On physical examination, he is moderately distended and has high pitched hyperactive bowel sounds and a 5-cm tender groin mass. On direct questioning, he explains that he has had that bulge for many years, but has always been able to "push it back in" when he lies down. For the past 3 days, however, he has been unable to do so. He has a temperature of 38.9C (102F) and a white blood cell count of 12,500/mm3. Which of the following is the most appropriate management at this time?

47) In a rollover car accident, a 42-year-old woman is thrown from the car. The car subsequently lands on her and crushes her. On physical examination in the emergency department, it is determined that she has a pelvic fracture, which is confirmed by portable x-rays done as she is being resuscitated. Her initial blood pressure is 50/30 mm Hg, and her pulse is 160/min and barely perceptible. Thirty minutes later, after 2 L Ringer's lactate and 2 U packed cells have been infused, her pressure is only 70/50 mm Hg, and her pulse is 130/min. A sonogram done in the emergency department shows no intra-abdominal bleeding, and a diagnostic peritoneal lavage confirms that there is no blood in the abdomen (the recovered fluid is pink, but not grossly bloody). Rectal and vaginal exams show no injuries to those organs. There is no blood in her urine. Which of the following is the most appropriate next step in management?

48) A 34-year-old man is brought to the emergency department after being rescued from a burning building. His temperature is 36.90C (98.60 F), blood pressure is 90/60 mm Hg, pulse is 100/min and respirations are 28/min. Examination shows second and third degree burns over 15% of his body. His oropharynx shows erythema and scattered blisters. His lungs are clear to auscultation and his abdomen is soft and nondistended. His blood carboxyhemoglobin concentration is 20%. Which of the following is the best management for this patient?

49) A 28-year-old man is brought to the emergency department 4 hours after being involved in a motor vehicle collision. His blood pressure is 90/50 mm Hg, pulse is 120/min and respirations are 30/min. Examination shows a stuporous man with bruises over his extremities and upper abdomen. His trachea is midline and his neck veins are flat. His abdomen is moderately distended but non-tender. Immediately after being intubated and placed on mechanical ventilation he goes into cardiac arrest. Which of the following could have prevented cardiac arrest in this patient?

50) A 28-year-old male is brought to the emergency department after being an unrestrained passenger in a motor vehicle collision. In the ambulance on his way to the hospital, he receives 2 liters of normal saline intravenously and 5 Umin of oxygen by nasal cannula. On physical examination, his blood pressure is 100/70 mmHg, heart rate is 120/min, and respiratory rate is 40/min. He is agitated and moves all four extremities spontaneously. His pupils are symmetric and reactive to light. His neck veins are distended, and his trachea is deviated to the right. Which of the following is the best initial management for this patient?

52) A 23-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He has multiple organ injuries and is listed in critical condition. Physical examination shows an open wound in the right lower extremity and significant blood loss. He is in hypovolemic shock. Which of the following is the first parameter to change in hypovolemic shock?

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

54) A 35-year-old previously healthy male comes to the emergency department because of a 4-hour history of severe abdominal pain. The pain had initially started in the periumbilical area but has now shifted to the right lower quadrant. He also felt nauseated and vomited twice. He has had no previous surgeries. His temperature is 38.9C (102F), blood pressure is 125/80 mm Hg, pulse is 100/min and respirations are 20/min. Examination shows tenderness in the right lower quadrant. Palpation of the left lower quadrant produces pain in the right lower quadrant. Urinalysis is negative. Which of the following is the most appropriate next step in management?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

1) An otherwise healthy 28-year-old man comes to his physician because of painless enlargement of the right testis. He began to feel a sensation of heaviness in the right hemiscrotum approximately 6 months ago. Physical examination reveals diffuse enlargement of the right testis, but it is difficult to determine whether this is due to an intratesticular or extratesticular lesion. Which of the following is the most appropriate next step in diagnosis?

2) Following surgery a patient develops oliguria. You believe the oliguria is due to hypovolemia, but you seek corroborative data before increasing intravenous fluids. Which of the following values supports the diagnosis of hypovolemia?

3) A 53-year-old woman comes to the physician because of a "lump" in her neck. She says that her masseuse noticed it 1 month ago. There is no associated pain, pressure, or hoarseness. She feels fine and has no other complaints. She has no history of radiation exposure. Examination reveals a palpable thyroid nodule that is approximately 3 cm. Which of the following is the most appropriate next step in diagnosis?

4) A 75-year-old man with a history of myocardial infarction 2 years ago, peripheral vascular disease with symptoms of claudication after walking half a block, hypertension, and diabetes presents with a large ventral hernia. He wishes to have the hernia repaired. Which of the following is the most appropriate next step in his preoperative workup?

5) A 7-year-old boy passes a large, bloody bowel movement. He is hemodynamically stable, and he has hemoglobin of 14 g/dL. Nasogastric aspiration yields clear, greenish fluid. Physical examination, including anoscopy, is unremarkable. Which of the following is the most appropriate next diagnostic test?

6) A 46-year-old woman was applying her make-up while also drinking her morning cup of coffee. She noticed in the mirror that a round, 2-cm mass would move up and down in the lower part of her neck whenever she swallowed. Her physician confirms that she has a single, firm, thyroid nodule in the right lobe. There are no other abnormalities in the history or physical examination. Her pulse is 82/min and regular. Thyroid stimulating hormone (TSH) is within normal limits. Which of the following is the most appropriate next step in management?

7) A 69-year-old man who smokes and drinks and has rotten teeth, has a hard, fixed, 4-cm mass in his left neck. The mass is just medial to and in front of the sternomastoid muscle, at the level of the upper notch of the thyroid cartilage. It has been there for at least 6 months, and it is growing. Which of the following is the most appropriate next step in diagnosis?

8) A 24-year-old woman sustains multiple injuries in a car accident, including a pelvic fracture. She is hemodynamically stable. Initial assessment shows no vaginal or rectal injuries; however, when a Foley catheter is inserted, bloody urine is recovered. Which of the following would be the best way to evaluate her urologic injury?

9) A 40-year-old retired professional football player complains of the sudden onset of palpitations and shortness of breath 5 days after having knee replacement surgery. His pulse is 100/min and regular. Oxygen saturation is 90% room air. An ECG reveals sinus tachycardia. A chest x-ray film is unremarkable. Which of the following is the most appropriate next step in management?

10) A 19-year-old man is involved in a motorcycle accident in which he sustains a closed fracture of his right femur and a pelvic fracture. In addition to the obvious deformity in his leg, physical examination is remarkable for the presence of a scrotal hematoma and blood at the meatus. There is no blood in the rectal exam, but the prostate cannot be felt. The patient states that he feels the need to void, but cannot do it. Which of the following is the most appropriate next step in diagnosis?

11) In the first postoperative day after an open abdominal procedure, a patient develops a temperature of 38.9 C (102 F). He is encouraged to ambulate, cough, and breathe deeply, but he is noncompliant. On the second day, he is still febrile. Incentive spirometry and postural drainage are instituted, but his participation is less than enthusiastic. He lies in bed all day and hardly moves. By the third day, he is still spiking fevers in the same range, although efforts to improve his ventilation continue, resolution of his problem will most likely require which of the following?

12) A 54-year-old man sees you because of a growth on his lower lip. He smokes tobacco, has a fair complexion, and works outdoors. The biopsy report confirms a carcinoma. Which of the following is the most common diagnosis for tumors involving the lips?

13) A 42-year-old man is diagnosed with an osteosarcoma. His family history is significant for a 37-yearold sister with breast cancer and an uncle with adrenocortical carcinoma. His family physician suspects that he may have Li-Fraumeni syndrome and suggests genetic testing. Which of the following genes is most likely to be mutated if he has the syndrome?

14) A 68-year-old man is admitted to the coronary care unit with an acute myocardial infarction. His postinfarction course is marked by congestive heart failure and intermittent hypotension. On the fourth day in hospital, he develops severe midabdominal pain. On physical examination, blood pressure is 90/60 mm Hg and pulse is 110 beats per minute and regular; the abdomen is soft with mild generalized tenderness and distention. Bowel sounds are hypoactive; stool Hematest is positive. Which of the following is the most appropriate next step in this patient’s management?

15) A 62-year-old woman has an eczematoid lesion in the areola of her right breast that has been present for 3 months. She has self-medicated with skin lotions and over-the-counter steroid ointments, but the area has not improved. On physical examination, the nipple is inverted, the skin of the areola is reddish and desquamated, and the entire area feels firm, with no discrete mass demarcated from the rest of the breast. Which of the following is the most appropriate next step in management?

16) A 74-year-old man presents with sudden onset of extremely severe, tearing precordial chest pain that radiates to the back and migrates downward shortly after its onset. As far as the man can tell, there was no precipitating event. He is seen within an hour and is in obvious distress. He is afebrile, but his blood pressure is 220/110 mm Hg and his pulses in the upper extremities are unequal at 102/min. Chest x-ray shows a wide mediastinum. Which of the following could best establish the diagnosis?

17) A 25-year-old man is shot with a .22 caliber revolver. The entrance wound is in the anteromedial aspect of his upper thigh, 5 cm below the groin crease. The exit wound is in the posterolateral aspect of the thigh, half way between the greater trochanter and the knee. He has palpable pulses in the dorsum of his foot and in the posterior tibial artery behind the malleolus. The popliteal pulse is reported normal by one examiner, but cannot be felt by another. There is no hematoma under the entrance wound, and blood is oozing from both wounds but not at an alarming rate. He is hemodynamically stable. Neurologic examination of the leg is normal. X-ray films show the femur to be intact. In addition to local wound care and the appropriate tetanus prophylaxis, which of the following is the most appropriate next step in management?

18) A 62-year-old man with alcoholic cirrhosis of the Uver and ascites presents with generalized abdominal pain that started 12 hours ago. He now has moderate tenderness over the entire abdomen, with minimal guarding and equivocal rebound. Bowel sounds are diminished but present. He has a temperature of 38.4 C (101.2 F) and a leukocyte count of 11,000/mm3. Although he used to be a heavy drinker, he has not touched a drop of alcohol for the past 7 years. Except for the presence of ascites, upright and flat x-ray films of the abdomen are unremarkable. Which of the following is the most appropriate next step in diagnosis?

19) A 56-year-old man presents with progressive jaundice that he first noted 6 weeks ago. The patient has lost about 20 pounds over the past 2 months and he has persistent, nagging pain deep into his epigastrium and upper back. Except for the obvious jaundice and the signs of weight loss, physical examination is remarkable only for the presence of a vaguely palpable, nontender mass under the liver edge. His hemoglobin is 14 g/dL, and there is no occult blood in the stool. Total bilirubin is 22 mg/dL, with 16 mg/dL direct (conjugated) fraction. The transaminases are minimally elevated, whereas the alkaline phosphatase is about 8 times the upper limit of normal. A sonogram shows dilated intrahepatic ducts, dilated extrahepatic ducts, and a much distended, thinwalled gallbladder without stones. Which of the following is the most appropriate next step in diagnosis?

20) A 35-year-old man who has had type 1 diabetes for many years undergoes a pancreas transplant with enteric drainage (connection of the donor duodenum to the recipient jejunum). Postoperatively, he has increased pain near his pancreas transplant. Which of the following should be performed to confirm a diagnosis of rejection?

21) A 27-year-old man was assaulted and stabbed on the left side of the chest between the areola and the sternum. He is hemodynamically unstable with jugular venous distention, distant heart sounds, and hypotension. Which of the following findings would be consistent with a diagnosis of hemodynamically significant cardiac tamponade?

22) A 49-year-old man crashes his car against a bridge abutment at high speed. On arrival at the emergency department, he is breathing well, but he has multiple bruises over the chest, and there is a specific spot at about the middle of the sternum that is exquisitely painful to touch. Gentle palpation of that area elicits a gritty feeling of bone grating on bone. He distinctly recalls hitting the steering wheel with his chest and is certain that he hurt that particular spot in that manner. Anteroposterior and lateral chest x-ray films confirm that he has a sternal fracture. The films do not show any mediastinal widening or mediastinal air, and both lung fields are clear. His vital signs are normal, and he does not have subcutaneous emphysema. Which of the following studies is most likely to show evidence of additional injuries?

23) A hypertensive 47-year-old man is proposed for kidney transplantation. He is anemic but is otherwise functional. Which of the following would preclude renal transplantation?

24) A 53-year-old man presents with constipation and a 20-lb weight loss over the course of 6 months. Colonoscopy reveals a fungating mass in the sigmoid colon; biopsy is consistent with adenocarcinoma. His metastatic workup is negative. A CEA level is obtained and is 4-fold greater than normal. Which of the following is the appropriate use of this test?

25) A 62-year-old, right-handed man has transient episodes of paralysis of the right arm and inability to express himself. There is no associated headache. The episodes have sudden onset, last about 5-10 minutes, and leave no neurologic sequela. The patient is overweight and sedentary. He smokes one pack of cigarettes per day and has high cholesterol, but he is not hypertensive. The only abnormality in the physical examination is a bruit over the left carotid bifurcation. Which of the following is the most appropriate initial step in diagnosis?

26) Eight hours after undergoing a transnasal, transsphenoidal resection of a prolactinoma, a young lady becomes lethargic, confused, and eventually comatose. Review of the record shows that her urinary output since surgery has averaged 600 mL/hr, while her intake of IV fluids (5% dextrose in 0.45% saline) has been 100 mL/hr. Her blood pressure is 110/75 mm Hg, and her pulse is 88/min. Which of the following would most likely yield the correct diagnosis?

27) A 65-year-old man who had a 25-lb weight loss over the previous 6 months is diagnosed with adenocarcinoma of the distal esophagus. He undergoes a transhiatal esophagectomy complicated by a cervical leak. He is receiving enteral feeds through a jejunostomy tube. After a week, his physicians wish to assess his nutritional resuscitation. Which of the following is the most accurate measure of adequacy of his nutritional support?

28) A 56-year-old man presents to his urologist for continued evaluation of hypertension and hematuria. The patient has a 10-year history of hypertension and recent onset of painless hematuria for which he sought the attention of an urologist 3 months ago. On detailed questioning, the man states that he has been having severe headaches that are refractory to narcotic analgesics. Three days ago, a renal ultrasound was obtained that demonstrated bilaterally enlarged kidneys with multiple cysts. Which of the following is the most appropriate next step in diagnosis?

29) A 25-year-old woman with end-stage renal disease is exploring the benefits of renal transplantation. Which of the following is an advantage of dialysis over renal transplantation?

30) A 48-year-old man with alcoholic cirrhosis has several episodes of massive hematemesis. Upper gastrointestinal endoscopy confirms that he is bleeding from esophageal varices. Sclerosing injections fail to control the bleeding. After the patient has been transfused 7 units of packed red cells, he is subjected to an emergency side-to-side portacaval shunt. At the time of surgery he has a serum albumin level of 3.1 g/dL, a total bilirubin of 1,7 mg/dL, and a prothrombin time (PT) 2 seconds above the control After surgery, the bleeding stops, and the patient wakes up briefly from the anesthetic but then lapses into a coma. The reason for his neurologic deterioration would most likely be revealed by a laboratory determination of which of the following?

31) A 57-year-old man is returned to the post-surgical recovery unit after an open cholecystectomy. The patient had an uneventful, but prolonged, operative course in a very cold operating room. His past medical history is unremarkable. The only attempt at patient warming was raising the ambient temperature of the room. His urine output since arrival in the post-anesthesia care unit (PACU) has been 5 mL/hr. Which of the following is most likely to confirm the diagnosis?

32) A 12-year-old boy is in a motor vehicle collision in which the car caught fire. He sustains significant inhalation injury and a circumferential burn without fractures or other soft tissue trauma to his left lower extremity during extrication from the burning vehicle. He is intubated and aggressively resuscitated in the intensive care unit. Which of the following is the most appropriate method of assessing for compartment syndrome of the left lower extremity?

33) A 45-year-old man comes to the emergency department because of severe right flank pain that began abrupdy 3 hours ago. The pain comes in waves and radiates down to the ipsilateral testis. The patient is nauseated and extremely restless. His temperature is 37.0C (98.6F). Dipstick examination of urine is positive for hematuria. Urinary pH is 5.8. Which of die following is the most appropriate next step in diagnosis?

34) An edentulous 72-year-old man with a 50-year history of cigarette smoking presents with a nontender, hard mass in the lateral neck. Which of the following is the best diagnostic test for establishing a diagnosis of malignancy?

35) A 38-year-old immigrant from Latin America sustained a third-degree burn in the lateral aspect of her lower leg when she was 14. The burn was untreated. Ever since the incident, she has had shallow ulcerations at the scar site that heal and break down all the time. In the past few months she has developed an indolent, dirty-looking, deeper ulcer at the site, with "heaped up" tissue growth around the edges. The ulcer is steadily growing and showing no signs of healing. Which of the following is the most appropriate next step in diagnosis?

36) A 69-year-old man, who smokes and drinks heavily, complains of an earache on his left side. The earache has been present for 6 weeks and is not getting any better despite systemic antibiotics and ear drops. On physical examination, he is found to have very poor oral hygiene, only a few remaining stumps of rotten teeth, and big tonsils that are hard to see because he gags easily. Otoscopic examination shows a perfectly normal right tympanic membrane, although the left is distorted by what appears to be a serous otitis media. Tuning fork testing shows conductive hearing loss on the left but equal bone conduction on both sides. He is afebrile. Which of the following will most likely confirm the diagnosis?

37) A 31-year-old man is brought by helicopter to the trauma center after a motor vehicle accident in which he sustained massive lower extremity crush injury. The patient is alert and awake but in tremendous pain. His blood pressure is 140/80 mm Hg, and his pulse is 110/min. There is copious ongoing blood loss from the sites of injury. Urgent laboratory data will most likely show which of the following electrolyte abnormalities?

38) A window cleaner falls from a third-story scaffold and lands on his feet. Physical examination and xrays show comminuted fractures of both calcaneus. He is tender to palpation over multiple bruises and abrasions in other parts of his trunk and extremities, but he has normal vital signs and a normal neurologic exam. Given the mechanism of injury, which of the following is the most appropriate next step in diagnosis?

39) On the second postoperative day after an abdomino-perineal resection for cancer of the rectum, a 72-yearold man complains of severe retrosternal pain. The pain is crushing in nature and radiates to the left arm. He also becomes short of breath and tachycardic. Except for his fresh surgical wounds and postoperative discomfort, physical examination is unremarkable. He does not have distended neck veins. Which of the following is the most appropriate next step in diagnosis?

40) A young man is brought to the emergency department following a head-on collision at 30 miles per hour. He is awake and alert. Other than a forehead laceration, physical examination is normal and laboratory values are within normal limits. Chest x-ray films are unremarkable. Which of the following is the most appropriate next step in diagnosis?

41) A 52-year-old woman in renal failure is listed as a transplant candidate. In order to assess the propriety of the transplant, which of the following combinations represents how a cross-match is performed?

42) A 65-year-old man comes to the physician for a health maintenance examination. Which of the following screening methods would allow the highest detection rate of prostatic carcinoma in early stages?

43) A patient with severe neurological devastation after head trauma has a prolonged course in the intensive care unit. He has been mechanically ventilated for his entire hospital stay. Which of the following clinical findings is diagnostic of a ventilator-associated pneumonia?

44) A 40-year-old obese woman, mother of five children, presents with progressive jaundice that she first noticed 4 weeks ago. She has a total bilirubin of 22 mg/dL, with 16 mg/dL direct (conjugated) and 6 mg/dL indirect (unconjugated). Her transaminases (AST and ALT) are minimally elevated, but her alkaline phosphatase is about 6 times the upper limit of normal. She has no anemia or occult blood in the stools. She has a history of multiple episodes of colicky right upper quadrant abdominal pain, brought about by the ingestion of fatty food; the last episode occurred a few days before her jaundice was first noted. She currently has no pain and is afebrile. A sonogram of her upper abdomen shows a contracted gallbladder full of stones, as well as dilated intrahepatic and extrahepatic biliary ducts; however, no stone can be identified in die common duct. Which of the following is the most appropriate next step in diagnosis?

45) A 34-year-old woman is admitted to the hospital because of septic shock secondary to a urinary tract infection. In the intensive care unit, she receives intravenous fluids and antibiotics. Her initial ECG shows sinus tachycardia but is otherwise unremarkable. Chest x-ray shows no abnormalities. An internal jugular vein catheter is placed on the right side using ultrasound guidance to locate the vein. The patient is properly draped, and the skin is cleaned with chlorhexidine solution. Blood is freely aspirated from all ports after insertion. Vital signs are stable, and oxygenation is maintained. Which of the following is the most appropriate next step in managing this patient?

46) A 23-year-old man known to have neurofibromatosis, type 1 (von Recklinghausen's disease), presents with a left lower quadrant abdominal mass and signs of neurologic deficits in his left leg. In the ensuing workup, it is determined that he has higher than normal values of catabolites of epinephrine and norepinephrine in a 24-hour urinary collection. He is currently normotensive. Before invasive steps are taken to biopsy and eventually remove his left lower quadrant abdominal mass, which of the following is the most appropriate next step in management?

47) A car is involved in a head-on collision. The driver, who is sober and wearing his seat belt, explains that he clearly saw his drunk, unrestrained front seat passenger hit the windshield with his face and the dashboard with his knees. Examination of the passenger indeed shows multiple facial lacerations, but because of his intoxication he cannot explain where else he might be hurting. He is neurologically intact, and his cervical spine x-ray films are normal. Additional injury, representing a potential orthopedic emergency, is not obvious but is suspected. Therefore, an x-ray film of which of the following areas should most likely be obtained?

48) A 68-year-old man presents to the physician’s office complaining of progressive dysphagia over the last 3 months associated with mild chest discomfort. He reports a 15-lb weight loss, a 30 pack-year smoking history, and occasional alcohol intake. The physical examination, including vital signs, is unremarkable. A chest x-ray was normal, and a barium esophagogram shows an irregular filling defect in the distal third of the esophagus with distortion and narrowing of the lumen. Which of the following is the most appropriate next step in management?

50) A 68-year-old man is diagnosed with lung cancer. In preparation for pulmonary resection he undergoes pulmonary function tests. Which of the following results indicate a favorable prognosis?

51) A 55-year-old man presents to the emergency department at 5 a.m. Complaining of vomiting blood. After binge drinking last night, the patient began to vomit repeatedly. After a number of episodes, the patient noted blood in the vomitus, followed by a melanotic stool 5 hours later. His past history is pertinent for ethanol abuse and a 40 pack-year smoking history. Vital signs reveal a BP of 100/60 mmHg, pulse rate of 95/min, respiratory rate of 12/min, and temperature of 97°F. Examination reveals a thin man with normal chest, cardiac, and abdominal findings. Rectal examination reveals heme-positive stool. Laboratory data show normal electrolytes and a hematocrit of 30. A chest x-ray is unremarkable. Volume resuscitation, gastric lavage, and NG tube decompression are initiated. Which of the following is the most appropriate diagnostic test?

52) A 70-year-old man with a 50 pack-year history of smoking presents with a 6-week history of intermittent, painless, gross hematuria and urinary frequency. There are no masses palpable on abdominal examination, and rectal examination is normal. Urinalysis confirms the presence of hematuria, and urine culture is negative. Which of the following is the most appropriate initial diagnostic evaluation of this patient?

53) A 70-year-old man with a 50 pack-year history of smoking presents with a 6-week history of intermittent, painless, gross hematuria and urinary frequency. There are no masses palpable on abdominal examination, and rectal examination is normal. Urinalysis confirms the presence of hematuria, and urine culture is negative. The initial diagnostic evaluation does not reveal any abnormalities. Which of the following is the best next step in the diagnostic workup?

55) A 56-year-old woman presents to the physician’s office with complaints of a new left breast mass. She denies any pain, nipple discharge, or skin dimpling. She has a prior history of breast cysts 5 years ago, treated by aspiration at that time. Her last mammogram was at age 53. Past history is pertinent for a 30 pack-year smoking history, prior total abdominal hysterectomy bilateral salpingo-oophorectomy (TAH-BSO) at age 54 for leiomyomas, and current use of hormone replacement therapy (HRT). Family history is negative for breast disease. Examination reveals a firm, welldefined, mobile, 1.5-cm nodule in the upper outer quadrant of the left breast without any regional lymphadenopathy. Which of the following is the most appropriate next step in management?

56) A 54-year-old African American man, with a history of smoking and drinking, describes progressive dysphagia that began 3 months ago. He first noticed difficulty swallowing meat; it then progressed to other solid foods, then to soft foods, and now to liquids as well. He locates the place where the food "sticks" at the lower end of the sternum. He has lost 30 pounds. Which of the following is the most appropriate first step in diagnosis?

58) A 75-year-old man is found by his internist to have an asymptomatic carotid bruit. Which of the following is the most appropriate next test?

59) A 55-year-old woman presents with a 6-month history of weight loss, abdominal cramps, and intermittent non-bloody diarrhea. On examination, her abdomen is mildly distended and there is a palpable mass in the right lower quadrant. Stool cultures yield normal fecal flora. CT scan with oral contrast demonstrates an inflammatory mass in the right lower quadrant, with thickening of the terminal ileum and ileocecal valve. Which of the following is the best diagnostic test to confirm the diagnosis?

60) For the first 6 hours following a long and difficult surgical repair of a 7-cm abdominal aortic aneurysm, a 70-year-old man has a total urinary output of 25 mL since the operation. Which of the following is the most appropriate diagnostic test to evaluate the cause of his oliguria?

61) A 66-year-old man presents with progressive jaundice, which he first noticed 6 weeks ago. He has a total bilirubin of 22 mg/dL, with a direct (conjugated) bilirubin of 16 mg/dL. His transaminases are minimally elevated, whereas his alkaline phosphatase is about six times the upper limit of normal. A sonogram shows dilated intrahepatic ducts, dilated extrahepatic ducts, and a much distended, thinwalled gallbladder without stones. Which of the following is the most appropriate next step in diagnosis?

62) A 52-year-old woman sees her physician with complaints of fatigue, headache, flank pain, hematuria, and abdominal pain. She undergoes a sestamibi scan that demonstrates persistent uptake in the right superior parathyroid gland at 2 hours. Which of the following laboratory values is most suggestive of her diagnosis?

63) A 55-year-old man presents to the physician’s office complaining of upper abdominal pain of 2 months’ duration. The pain is described as gnawing, localized to the upper midline, and associated with nausea. The pain is exacerbated by food, and there is an associated 20-lb weight loss over 2 months. His past history is pertinent for a 30 pack-year smoking history, occasional alcohol intake, and a prior history of a benign gastric ulcer 5 years ago. Physical examination reveals normal vital signs, mild epigastric pain with deep palpation, and mildly hemepositive stool. An evaluation for recurrence of a gastric ulcer is recommended. Which of the following tests is the most reliable method for diagnosing a gastric ulcer?

64) A middle-aged homeless man is brought to the ER by EMS for altered mental status, seizures, and vomiting. On physical examination he has no fever, neck stiffness, or evidence of head trauma. He does, however, have multiple dental caries and a focal neurologic deficit. Which of the following is the best next step in the patient’s workup?

65) A 30-year-old man presents to the emergency department with sudden onset of severe epigastric pain and vomiting 3 hours ago. He reports a 6-month history of chronic epigastric pain occurring nearly every day and relieved by antacids. On examination, he appears sweaty and avoids movement. Vital signs reveal a temperature of 100°F, BP of 100/60 mmHg, pulse rate of 110/min, and respiratory rate of 12/min. The remainder of his examination reveals diminished bowel sounds and a markedly tender and rigid abdomen. A chest x-ray and abdominal films reveal pneumoperitoneum. Which of the following is the most appropriate next diagnostic test?

66) A 65-year-old man presents to the physician’s office for his yearly examination. His past history is pertinent for a 40 pack-year smoking history and colon cancer 3 years ago for which he underwent a sigmoid colectomy. The most recent colonoscopic follow-up 3 months ago was negative. His physical examination is normal. Laboratory results show a normal CBC and electrolytes, markedly elevated cholesterol, and a CEA of 12 compared to values of less than 5 obtained every 6 months since colectomy. A repeat CEA 4 week later was 15, and liver function tests revealed a minimally elevated alkaline phosphatase, with normal transaminases and bilirubin. Which of the following is the most appropriate next diagnostic test in this patient?

67) A 34-year-old woman has recurrent fainting spells induced by fasting. She also reports palpitations, trembling, diaphoresis, and confusion prior to the syncopal episodes. She has relief of symptoms with the administration of glucose. Which of the following findings is most consistent with the diagnosis of an insulinoma?

68) A 34-year-old woman presents with hypertension, generalized weakness, and polyuria. Her electrolyte panel is significant for hypokalemia. Which of the following is the best initial test given her presentation and laboratory findings?

69) A 65-year-old man presents with acute onset of pain, swelling, and erythema of the left knee. He denies previous episodes or trauma to the knee. The differential diagnosis includes septic arthritis and gout. Which of the following is the best study to differentiate between gout and septic arthritis?

70) A 14-year-old boy slides down a banister and crashes into a large ornamental knob at its base, thereby injuring his scrotal contents. He presents in the emergency department with acute testicular pain and a scrotal hematoma the size of a grapefruit. He is able to void normally, and his urine does not contain blood. A rectal examination is unremarkable. Findings from which of the following tests will most likely determine further therapy?

71) A 44-year-old woman has a palpable nodule in the right lobe of her thyroid gland. The nodule measures 2 cm and is firm. The rest of the thyroid gland cannot be felt and is not tender. She also describes losing weight in spite of a ravenous appetite, palpitations, and heat intolerance. She is thin, fidgety, and constantly moving, with moist skin and a pulse of 105/min. She has no exophthalmos or pretibial edema. Her TSH is reported as much lower than normal, and she has elevated levels of free T4. Which of the following is the most appropriate next step in diagnosis?

72) A 72-year-old man undergoes an aortobifemoral graft for symptomatic aortoiliac occlusive disease. The inferior mesenteric artery (IMA) is ligated at its aortic attachment. Twenty-four hours after surgery the patient has abdominal distention, fever, and bloody diarrhea. Which of the following is the most appropriate diagnostic study for this patient?

73) A 50-year-old salesman is on a yacht with a client when he has a severe vomiting and retching spell punctuated by a sharp substernal pain. He arrives in your emergency room 4 hours later and has a chest film in which the left descending aorta is outlined by air density. Which of the following is the most appropriate next step in his workup?

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

76) A 66-year-old woman presents with severe right lower extremity claudication. Surgery is considered, but her hypertension, smoking, and diabetes puts her at risk for associated coronary heart disease. What test is most predictive of postoperative ischemic cardiac events following surgery?

77) A 5-week-old infant presents with a 1-week history of progressive nonbilious emesis, associated with a 24-hour history of decreased urine output. The infant continues to be active and eager to feed. On examination, the infant has a sunken fontanels and decreased skin turgor. The abdomen is scaphoid, and with a test feed, there is a visible peristaltic wave in the epigastrium. Electrolytes and a urinalysis are evaluated. Which of the following laboratory findings are most likely to be seen in this patient?

78) A 77-year-old man becomes "senile" over a period of 3 or 4 weeks. He used to be active and managed all of his financial affairs. Now, he stares at the wall, barely talks, and sleeps most of the day. His daughter recalls that he fell from a horse about a week before the mental changes began. Which of the following would a CT scan of his head most likely show?

79) A 50-year-old man presents with intractable peptic ulcer disease, severe esophagitis, and abdominal pain. Which of the following is most consistent with the diagnosis of Zollinger-Ellison syndrome?

80) A postoperative patient with swelling and pain in his right calf is suspected of having a deep venous thrombosis. Prior to initiating treatment with anticoagulants, he requires a confirmatory examination. Which of the following is a limitation of the duplex ultrasound in evaluating a DVT?

81) A 75-year-old man is brought to the emergency department for severe pain in the left flank and back of 1 hour duration. He has a prior history of a myocardial infarction and coronary artery bypass grafting 8 years ago. On examination, he is found to have a BP of 80/50 mmHg, pulse rate of 110/min, respiratory rate of 15/min, and a pulsatile, tenderabdominal mass. He has had two large-bore IV lines placed by the paramedics. He is alert and oriented, and gives consent for surgery. On postoperative day 3, the patient develops dark-colored diarrhea but remains normotensive, on full mechanical ventilation, and is awake. Laboratory analysis reveals normal electrolytes, blood urea nitrogen (BUN), and creatinine; hematocrit of 30; and WBC of 15,000. Which is the most appropriate next step in management?

82) A pedestrian is hit by a car. The paramedics report that he was unconscious at the site, and he arrives at the emergency department in coma, strapped to a head board with sandbags on either side of his head. Initial survey shows stable vital signs, and his pupils are of equal size and reactive to light. He is rapidly intubated by the nasotracheal route over a flexible bronchoscope and then sent for CT scans of the head. As he is being positioned on the table, it is noted that there is a sizable hematoma behind his right ear and that clear fluid is dripping from the ear canal. Which of the following is most advisable, considering this new finding?

83) A 76-year-old man is admitted to the coronary care unit after an episode of substernal chest pain. His other medical problems include hypertension, hyperlipidemia, and type 2 diabetes mellitus. He has a history of a diverticular bleed 2 years ago. After initial workup, cardiac catheterization is performed and shows 50% left main coronary artery stenosis, 90% proximal left anterior descending artery stenosis, and 65% right coronary artery stenosis. Antiplatelet agents are stopped, and the patient is continued on a heparin drip in preparation for coronary artery bypass surgery the next day. Five hours after the catheterization, his blood pressure is 75/60 mm Hg and pulse is 120/min and regular. He complains of some generalized weakness and back pain but denies chest pain, shortness of breath, nausea, and abdominal discomfort. He appears to be diaphoretic and clammy. Neck veins are flat. Heart sounds are normal, and the chest is clear to auscultation. The groin site for arterial puncture is mildly tender, without subcutaneous hematoma. He receives 1000 ml of normal saline, with symptomatic improvement. His blood pressure is 96/60 mm Hg and pulse is 85/min. His ECG seems to be unchanged. Which of the following is the most appropriate next step in managing this patient?

84) A 65-year-old woman presents to the physician’s office for a second opinion on the management options for recently diagnosed breast cancer. She presents with a 2.5-cm mass in the upper outer quadrant of the left breast associated with a palpable axillary node suspicious for metastatic disease. The remainder of her examination is normal. Mammography demonstrates the cancer and shows no other suspicious lesions in either breast. Chest x-ray, bone scan, and blood test panel, including liver function tests, are normal. Family history is positive for breast cancer diagnosed in her sister at age 65. Past history is unremarkable. The first physician recommended modified radical mastectomy. The patient has read about SLN biopsy. She avidly wants to avoid the risk of lymphedema that her sister must endure. She asks the question “Am I a candidate for a SLN biopsy instead of a complete axillary dissection?” Which of the following is the most appropriate answer to her question?

85) A 4-year-old boy is seen 1 hour after ingestion of a lye drain cleaner. No oropharyngeal burns are noted. The CXR is normal, but the patient continues to complain of significant chest pain. Which of the following is the most appropriate next step in his management?

86) A 71-year-old West Texas farmer of Irish ancestry has a nonhealing, indolent, punched out, cleanlooking 2-cm ulcer over the left temple. The ulcer has been slowly growing over the past 3 years. There are no enlarged lymph nodes in the head and neck. Which of the following would best dictate proper management?

87) Ten days after undergoing liver transplantation, a patient's levels of gamma-glutamyl transferase (GGT), alkaline phosphatase, and bilirubin begin to rise. Which of the following is the most appropriate next step in diagnosis?

88) A 62-year-old man reports an episode of gross, painless hematuria. There is no history of trauma, and further questioning determines that he had total hematuria, rather than initial or terminal hematuria. The man does not smoke and has had no other symptoms referable to the urinary tract. He has no known allergies. Physical examination, including rectal examination, is unremarkable. His serum creatinine is 0.8 mg/dL, and, except for the presence of many red cells, his urinalysis is normal and shows no red cell casts. His hematocrit is 46%. Which of the following is the most appropriate initial step in the workup?

89) A 54-year-old obese man gives a history of burning retrosternal pain and heartburn that is brought about by bending over, wearing a tight belt, or lying flat in bed at night. He gets symptomatic relief from over-the-counter antiacids or H2 blockers, but has never been formally studied or treated. The problem has been present for many years and seems to be progressing. Which of the following is the most appropriate next step in management?

90) A pedestrian is hit by a car and knocked unconscious. Within a few minutes, he starts to move around and moan. When the ambulance arrives, he is moving all four extremities and mumbling that his neck hurts. Shortly thereafter, he lapses again into a deep coma. In the emergency department, it is noted that his left pupil is fixed and dilated, and he has clear fluid dripping from the left ear. The trauma team intubates him nasally over a fiberoptic bronchoscope and does a quick initial survey that reveals no other obvious injuries. He is hemodynamically stable. Which of the following is the most appropriate next step in management?

91) A 68-year-old woman presents with an obviously incarcerated umbilical hernia. She has gross abdominal distention, is clinically dehydrated, and reports persistent fecaloid vomiting for the past 3 days. Although tired, weak, and thirsty, she is awake and alert and her sensorium is not particularly affected. Laboratory analysis reveals a serum sodium concentration of 118mEq/L. Which of the following is the most likely physiologic explanation for the serum sodium?

92) The unrestrained front-seat passenger in a car that crashes at high speed is brought to the emergency department by paramedics. At the site of injury, the patient was unconscious and had gurgly respiratory sounds, and the EMTs successfully accomplished blind nasotracheal intubation. The initial survey in the emergency department shows normal vital signs, multiple facial lacerations, and an unresponsive, comatose patient with fixed dilated pupils. Preparations are made to do a CT scan of the head. It is imperative that which of the following should be obtained as well?

93) A 59-year-old man is referred for evaluation because he has been fainting at his job, where he operates heavy machinery. He is pale and gaunt, but otherwise his physical examination is remarkable only for 4+ occult bloods in the stool. Laboratory studies show haemoglobin of 5gm/dL with microcytosis, as well as decreased levels of serum iron and increased iron binding capacity. Which of the following will most likely establish the diagnosis?

94) A 42-year-old woman hit her breast with a broom handle while doing housework. She noticed a lump in that area at the time, and 1 week later the lump was still present. She then sought medical advice. On physical examination, she has a 3-cm, hard mass deep inside the affected breast and some superficial ecchymosis over the area. Which of the following is the most appropriate next step, or steps, in management?

95) On the 7th postoperative day after the pinning of a broken hip, a 76-year-old man suddenly develops severe pleuritic chest pain and shortness of breath. When examined, he is found to be anxious, diaphoretic, and tachycardic, with a blood pressure of 140/85 mm Hg. He has prominent distended veins in his neck and forehead. Blood gases show hypoxemia and hypocapnia. His chest x-ray film is unremarkable. The nurses have placed him on supplemental oxygen by face mask. Which of the following is the most appropriate next step in management?

96) A 44-year-old woman complains bitterly of severe headache that has been present for several weeks and has not responded to the usual over-the-counter headache remedies. She locates the headache to the center of her head. It is pretty much constant but is worse in the mornings. She has no other neurologic signs or symptoms. She has had "tension headaches" in the past, but she says that those were located in the back of her head and felt different from the present pain. She is currently under considerable stress because she has been unemployed since undergoing modified radical mastectomy for T3, N1, M0 breast cancer 2 years ago. She had several courses of post-operative chemotherapy, which she eventually discontinued because of the side effects. Which of the following is the most appropriate next step in diagnosis?

97) A 59-year-old black man has a rock-hard, discrete, 1.5-cm nodule that is felt in his prostate during a routine physical examination. He is completely asymptomatic, and his prostatic specific antigen (PSA) done 3 months ago was normal for his age. His last rectal examination was performed a year earlier and was unremarkable. Which of the following will best establish the diagnosis?

98) A 34-year-old immigrant from Mexico presents following an episode of massive hemoptysis. He describes bringing up large amounts of bright red, foamy sputum. He denies any recent trauma. On physical examination, the patient is agitated and has difficulty speaking. His blood pressure is 100/60 mmHg and his heart rate is 110/min. On physical examination, breath sounds are audible bilaterally. You immediately initiate intravenous infusion of crystalloid. Portable chest x-ray shows opacity in the right upper lobe. Which of the following is the best next step in the management of this patient?

99) A 53-year-old male presents to the emergency room complaining of chest pain localized to the left chest wall and following a linear pattern along the fifth intercostal space. His past medical history is significant for polycystic kidney disease and hypertension. His current medications are metoprolol and amlodipine. He has a ten pack-year smoking history but quit 14 years ago. He consumes alcohol occasionally. His blood pressure is 160/90 mmHg and his heart rate is 90/min. Physical examination is noncontributory. His laboratory findings are as follows: Sodium 142 mEq/L, Potassium 4.2 mEq/L, Hemoglobin 9.5 mg/dl, WBC 10,000/mm3, Creatinine 1 .9 mg/dl, BUN 28 mg/dl. Chest x-ray reveals a solitary round lesion in the left upper lung field that measures 2 cm in diameter. It does not about the pleura. Which of the following is the best next step in managing this patient?

100) A 34-year-old man complains of severe abdominal pain. He describes the pain as "sharp" and "unbearable." It is located in the lower left abdomen and radiates to the perineum. He has vomited twice since the pain began. He denies dysuria. On exam, he is afebrile. He cannot lie still on the examination table due to his discomfort. Mucus membranes appear slightly dry. Lungs are clear to auscultation. Heart sounds are normal and there are no murmurs or gallops. His abdomen is soft and non-tender to palpation. Inspection and palpation of his genitalia is unrevealing. Extremities have no cyanosis, clubbing, or edema. Which of the following is the best test to diagnose this patient's condition?

101) A 34-year-old unrestrained male driver is brought to the ER after a motor vehicle accident. His cervical spine is immobilized. At the scene of the accident, his blood pressure is 80/40 mm Hg and heart rate is 130/min. He is able to communicate and follows simple commands. 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 90/60 mmHg. Which of the following is the most appropriate next step in management of this patient?

102) A 42-year-old man comes to the physician because of a 3-month history of substernal chest pain after every meal. He has chronic alcoholism and a long history of heartburn. Upper endoscopy shows mucosal irregularity and ulceration of the squamocolumnar junction above the lower esophageal sphincter (LES). Multiple biopsies were taken. 4 hours later he is complaining of worsening substernal pain radiating to the back, left chest pain, and shortness of breath. His temperature is 37.10C (98.90F), blood pressure is 110/70 mm Hg, pulse is 140/min, and respirations are 34/min. An x-ray film of the chest shows minimal left pleural effusion. Which of the following is the most appropriate next step in management?

103) A 65-year-old man comes to the physician four years after suffering a burn injury to his entire right leg. One area of the leg never healed and has now started increasing in size. He has constant pain and drainage from the site of the lesion. Several topical creams and antibiotics have not helped. Biopsy of the lesion is attempted. Which of the following is most likely be identified on biopsy?

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

105) A 50-year-old man comes to the physician because of a 2-day history of constipation and not passing flatus. For the last 3 days he has been having intermittent, but worsening, right lower quadrant (RLQ) pain. He has vomited several times today and feels nauseated. Examination shows a distended abdomen with tenderness in the RLQ; there is no rebound; there are no masses or hernias; bowel sounds are absent. Rectal examination shows an enlarged prostate. An upright x-ray film of the abdomen shows gas distributed throughout the small and large bowel, and some fluid levels. After nasogastric tube placement and hydration, his temperature is 36.50C (97.60F), blood pressure is 140/80 mm Hg, pulse is 57/min, and respirations are 12/min. Laboratory studies show: RBC count 4.5 million, WBC 7,400, Na 140, K 3.5, Cl 100, BUN 15 mg/dl, Creatinine 1.0 mg/dl, Urine pH 5.5, Urine sediment: 2 W BC and 15 RBC/high power field, and needle-shaped crystals are present. Which of the following is the most appropriate next step in management?

106) A 25-year-old male is brought to the trauma center by the paramedics after being involved in a road traffic accident that occurred 90 minutes ago. He was a front seat passenger in a 3-car accident. His initial blood pressure at the scene of the accident was 90/60 mm Hg and pulse was 126/min. The paramedics administered 2 liters of normal saline in the ambulance. In the ED, his blood pressure is 110/70 mm Hg and pulse is 90/min. His abdomen is tender in the left upper quadrant. Ultrasound shows fluid in the spleno-renal angle. The most appropriate next step is?

107) A 62-year-old man complains of right knee pain. He says that the pain started two days ago and has been limiting his daily activities. He required 2 grams of acetaminophen in order to sleep through the previous night. He has a long history of rheumatoid arthritis treated with daily low-dose prednisone. Physical examination reveals swelling, limited flexion, and tenderness to palpation of the right knee. Synovial fluid aspiration is performed. Which of the following synovial fluid characteristics would warrant immediate surgical intervention?

108) A 38-year-old woman comes to the emergency department because of the sudden onset of severe abdominal pain. The pain started one hour ago in the epigastrium but now it is mostly localized to the lower abdomen. She has some nausea but denies any vomiting. Her last menstrual period (LMP) was 25 days ago. Her temperature is 36.8C (98.1F), blood pressure is 160/90 mm Hg, pulse is 110/min, and respirations are 25/min. The abdomen is tender on palpation with prominent guarding and positive rebound. There is no shifting dullness, and bowel sounds are absent. Laboratory studies show: Hb 13.1 g/dl, Hct 43%, WBC 10,900/mm3. Which of the following is the most appropriate next step in management?

108) A 38-year-old woman comes to the emergency department because of the sudden onset of severe abdominal pain. The pain started one hour ago in the epigastrium but now it is mostly localized to the lower abdomen. She has some nausea but denies any vomiting. Her last menstrual period (LMP) was 25 days ago. Her temperature is 36.8C (98.1F), blood pressure is 160/90 mm Hg, pulse is 110/min, and respirations are 25/min. The abdomen is tender on palpation with prominent guarding and positive rebound. There is no shifting dullness, and bowel sounds are absent. Laboratory studies show: Hb 13.1 g/dl, Hct 43%, WBC 10,900/mm3. Which of the following is the most appropriate next step in management?

109) A 36-year-old forest worker is brought to the emergency department after being hit by a falling tree, 3 hours ago. He has pain in the left subscapular region. His temperature is 36C (96.9F), blood pressure is 120/76 mm Hg, pulse is 90/min, and respirations are 18/min. Physical examination shows aggravation of the pain in the left subscapular region with taking a deep breath and with anteroposterior and lateral chest compression. He has ecchymoses on the anterior and posterior chest and on the upper abdominal wall. His abdomen is vaguely tender to palpation in the left upper quadrant (LUQ) and he has left costovertebral angle (CVA) tenderness. Examination otherwise shows no abnormalities. An x-ray film of the chest shows posterior factures of the 8th, 9th and 1Oth ribs on the left. An x-ray film of the abdomen shows blunting of the left psoas shadow. Abdominal ultrasound shows no abnormalities. Laboratory studies show: Hb 15.3 g/dL, Hematocrit 43%, WBC 6,200/mm3, Urinary sediment Many erythrocytes; WBC 4-5/hpf; oxalate crystals. Which of the following is the most appropriate next step in management?

110) A 35-year-old woman presents to the physician's office after she palpated a lump in her right breast. She has no other complaints. She has not seen a doctor for 10 years. She regularly performs breast self-exams after menses. She has no significant past medical history. Her mother died of breast cancer at the age of 40. Breast examination shows a 1 x 1 cm, rubbery, firm, freely mobile round mass in the upper, outer quadrant of the right breast; no axillary lymph nodes are palpable. Which of the following is the most appropriate next step in management?

111) A 45-year-old male comes to the hospital because of severe retrosternal chest pain that started suddenly a few hours ago. He says that he has been having mild chest pain for the past few days, but that this pain is completely different. His past medical history is significant for nonischemic cardiomyopathy for which he takes furosemide, carvedilol, spironolactone, lisinopril and potassium chloride. He also has HIV infection but is not taking any edications related to this diagnosis by his own choice. On physical examination, his temperature is 38.9C (102F), blood pressure is 110/65 mm Hg, pulse is 110/min, and respirations are 22/min. He is in obvious distress secondary to pain. His lungs are clearto auscultation and the remainder of his physical examination is unremarkable. His EKG is within normal limits. Chest X-ray shows a widened mediastinum and mediastinal air. W hich of the following is the most appropriate next step in the management of this patient?

112) A 78-year-old man with Alzheimer's disease was brought to the ER because of bright red bleeding per rectum. He has chronic constipation and is being treated with bisacodyl. On admission, his temperature was 36.6C (97.9F), blood pressure was 130/80 mm Hg with no orthostatic change, pulse was 90/min and respirations were 14/min. Nasogastric tube drainage showed normal stomach contents without blood. His bleeding stopped a few hours after dmission, and he remained hemodynamically stable during that time. Colonoscopy showed extensive diverticulosis but no active bleeding source. Later that night he started bleeding again, and he is now hypotensive with a BP of 100/70 mm Hg. Packed red cells and intravenous fluid are started. Which of the following is the most appropriate next step in management?

113) A 44-year-old unrestrained male driver is brought to the ER after a motor vehicle accident. Cervical spine is immobilized. His breathing is normal. At the scene of the accident, his blood pressure is 70/30 mm Hg. After receiving two liters of intravenous fluid, his blood pressure is 80/40 mmHg. Neck veins are collapsed. Lungs are clear to auscultation. Abdomen is mildly distended. There is no obvious source of external bleeding. No intraperitoneal blood or solid organ damage is seen on ultrasonogram or diagnostic peritoneal lavage. Imaging studies reveal a pelvic fracture and fracture of the right fourth rib. Which of the following is the most appropriate next step in management?

114) A full-term, female infant is born to a 26-year-old, primigravid mother via C-section secondary to breech position. The mother has lived in New York City for the past 5 years. She denies the use of any drugs, alcohol or cigarettes during her pregnancy. She denies having any sexually transmitted infections. Her lead levels were within the normal range throughout her pregnancy. Prenatal ultrasound done at 30 weeks gestation showed normal anatomy of the fetus. The Apgar scores at 1 and 5 minutes are 7 and 9, respectively. There are some bluish-brown spots located on the infant's lumbosacral area. Flexion and abduction of the lower extremities reveal a palpable clunk. The rest of the physical examination is normal. Which of the following is the best next step in the management of this patient?

115) A 36-year-old woman is brought to the emergency department after she jumped from the second floor of a burning building. On arrival examination shows an unconscious woman with blood coming from her nose and with an open tibial fracture of left leg. Her eyes are closed and her pupils are equal and responsive bilaterally. She makes muffled sounds and responds to pain by opening the eyes and moving all the limbs. After the initial resuscitation, which of the following is the most appropriate next step in management?

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

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

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

119) A 42-year-old man is brought to the emergency department after a motor vehicle accident. He was a restrained driver and hit a car from behind on a highway. He drank one glass of wine before driving. He occasionally uses cocaine. His medical problems include mild intermittent asthma and peptic ulcer disease. On initial evaluation, his blood pressure is 112/92 mm Hg and pulse is 96/min. His pulse oximetry shows 95% on room air. Examination shows bruises on the anterior chest wall and abdominal wall. X-rays reveal a fracture of the eighth left rib but no pneumothorax or pleural effusion. Cervical Cspine series are negative. An ultrasound does not show free intraperitoneal fluid. An ECG shows normal sinus rhythm with no ST-segment or T-wave changes. He is treated with intravenous fluids and analgesics. Eight hours later, he complains of epigastric discomfort, left shoulder pain, and mild nausea. His blood pressure is 97/62 mm Hg and pulse is 112/min. His pulse oximetry shows 96% on room air. Which of the following is most likely to diagnose this patient's current condition?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

136) 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?

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

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

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

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

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