USMLE CHIR DIAGNOSIS 2

1) A 25-year-old previously healthy man is scheduled for elective inguinal hernia repair under general anesthesia. After induction of anesthesia and initial inguinal incision, the patient develops tachycardia, muscle rigidity, fever of 38.5°C, and elevated end-tidal carbon dioxide. Which of the following is the most likely diagnosis?

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

3) A 56-year-old woman has been treated for 3 years for wheezing on exertion, which was diagnosed as asthma. Chest radiograph, shown here, reveals a midline mass compressing the trachea. Which of the following is the most likely diagnosis?

5) A 25-year-old man was admitted to the ICU with severe head injury with a basal skull fracture. Eighteen hours after the injury, he developed polyuria. Urine osmolality was 150 mOsm/Land serum osmolality was 350 mOsm/L. IV fluids were stopped, and 1 hour later urine output and urine osmolality remained unchanged. Five units of vasopressin were administered intravenously, and urine osmolality increased to 300mOsm/L. Select the most likely diagnosis of the patients with polyuria?

6) A 70-year-old man was admitted to the ICU with severe pancreatitis. During his ICU course, he underwent several CT scans with IV contrast and was also treated with an aminoglycoside for a urinary tract infection. The patient required a prolonged course of TPN, and developed Candida sepsis treated with amphotericin. He subsequently developed polyuria with urine osmolality of 250mOsm/L and serum osmolality of 350 mOsm/L. After receiving 5 units of vasopressin intravenously, there is no change in urine osmolality or urine output. Select the most likely diagnosis of the patients with polyuria?

7) A 42-year-old man describes intermittent episodes of severe, crushing chest pain that extends to the back and the jaw and last anywhere from a few seconds to several minutes. Many times the pain is accompanied by dysphagia and triggered by the ingestion of very cold or very hot liquids. However, sometimes the pain occurs for no apparent reason. There is no history of regurgitation, and, although the problem has been present for many years, there has been no progression of the symptoms. Repeated ECGs and cardiac enzymes have always been negative. Barium swallow shows an area of "corkscrew" appearance. Manometry shows that about one half of wet swallows produce repetitive simultaneous esophageal contractions of the esophageal body, and that the lower esophageal sphincter has normal pressures and exhibits normal relaxation. Which of the following is the most likely diagnosis?

8) A 29-year-old man presents to the ER with persistent vomiting and abdominal pain for the last 24 hours. The pain is crampy, diffuse, and has been getting worse. He had a normal bowel movement two days ago and denies diarrhea. The emesis appears green without blood or coffee grounds. He has not eaten since the onset of the pain due to nausea. On exam, his temperature is 36.8° C (98.2° F}, pulse is 91/min, and blood pressure is 116/75 mmHg while sitting and 94/65 mmHg while standing. His abdomen is distended with hyperactive bowel sounds. Percussion reveals tympany and he is diffusely tender to palpation. There is no rebound tenderness or guarding. Laboratory studies reveal:WBC count 9,600/mm3Hematocrit 45%Sodium 147 mEq/LPotassium 3.1 mEq/LCreatinine 1.0 mg/dLAST 20 U/LALT 12 U/LBilirubin 0.8 mg/dLWhich of the following historical findings would you most expect in this patient?

9) A 63-year-old obese female undergoes an elective cholecystectomy after two episodes of acute calculous cholecystitis. Three days after surgery, her blood pressure is 150/100 mmHg, her heart rate is 90/min, and her arterial oxygen saturation is 91 % on room air. She is afebrile. Which of the following would most likely increase her functional residual lung capacity?

10) A 62-year-old woman had an abdominal hysterectomy and salpingo-oophorectomy 3 days ago. She had an indwelling bladder catheter during the procedure, which was removed in the recovery room. She has been voiding at will since then. She also had compression pneumatic stockings on both lower extremities during the operation. She began ambulation on the 1st postoperative day, and has been as active as possible under the circumstances, including faithful adherence to a prescribed program of incentive spirometry. On the evening of the 3rd postoperative day, she spikes a fever, with a temperature to 39.4C (103F). Which of the following is the most likely source of the fever?

11) A 44-year-old male is found unresponsive and hypotensive at the scene of a high-speed motor vehicle accident. He is intubated and immediately rushed to the emergency department. The passenger in his car is pronounced dead at the scene. Physical examination in the ED shows large bruises over the entire chest wall and collapsed neck veins bilaterally. Lung exam reveals decreased breath sounds on the left side. Chest x-ray shows a large left hemothorax and a widened, rightward deviating mediastinum. The most likely diagnosis is?

12) An 85-year-old male is placed on mechanical ventilation after a complicated elective hernia repair. After five days of endotracheal intubation with mechanical ventilation, the ratio of the rate of carbon dioxide produced to the rate of oxygen uptake is 1.05. What is the best explanation for these findings?

13) A 75-year-old woman is admitted to the hospital from a nursing home for abdominal pain and pneumonia. She was noted to be short of breath with increasing cough for 2 days before admission. Treatment, consisting of supplemental oxygen, IV antibiotics, and pulmonary toilet, is instituted, with improvement within 2 days. On the third hospital day, her abdominal pain worsens. Examination reveals a mildly distended abdomen with bowel sounds but no signs of peritonitis. Remainder of examination reveals a tender bulge in the medial left thigh below the inguinal ligament. Gentle pressure causes more pain but does not change the size or shape of the bulge. Abdominal films show a nonspecific bowel gas pattern. Laboratory analysis shows a WBC of 13,000, decreased from 18,000 at the time of admission. Which of the following is the most likely diagnosis?

14) A 66-year-old woman picks up a bag of groceries out of the supermarket cart to place it in the trunk of her car. As she does so, she feels sharp, sudden pain in the middle of her arm, and her humerus suddenly breaks. She arrives at the emergency department cradling her arm; the deformity leaves no doubt that the bone is broken. Which of the following is the most likely reason for the fracture?

15) An 18-year-old male comes to the physician's office because of dull aching and fullness of the scrotum. Examination shows soft left-sided scrotal swelling; transillumination testing is negative. The scrotal swelling increases when the patient performs the Valsalva maneuver. The physical examination is otherwise unremarkable. Which of the following is the most likely cause of his condition?

16) A 72-year-old man underwent surgical repair of an aneurysm of the infrarenal aorta. He received perioperative prophylaxis with a second-generation cephalosporin antibiotic. On the first postoperative day he complains of progressive abdominal pain and bloody diarrhea. His temperature is 38.5° C (101° F), blood pressure is 110/65 mm Hg, pulse is 110/min and respirations are 22/min. His abdomen is mildly distended and tender to palpation. The tenderness is mostly in the left lower quadrant without rebound. Femoral pulses are full and symmetric. His white blood cell count is 12,000/mm3. Which of the following is the most likely diagnosis?

17) A 32-year-old male comes to the emergency department because of a 3 day history of increasing lower abdominal pain, mild diarrhea and rectal pain on defecation. Ten days ago he had right lower quadrant (RLQ) pain for about 24 hours that resolved spontaneously. Since then, he has had malaise and low-grade fever. His temperature is 38.7°C (101.6°F), blood pressure is 150/90 mm Hg, pulse is 11 0/min and respirations are 15/min. Examination shows lower abdominal tenderness without rebound. No masses are palpable, and bowel sounds are decreased. Rectal examination shows a very tender, boggy and fluctuant bulging mass on palpation with the tip of the finger anteriorly. Laboratory studies show:Complete blood count Hemoglobin14.0 g/LPlatelets270,000/mm3Leukocyte count15,500/mm3His current condition is most likely a complication of?

18) A 44-year-old man complains of vague right upper abdominal discomfort that he has had for about 1 month. He describes no other symptoms, and, except for enucleation of one eye at age 21 "for a tumor," he has been in excellent health all his life. He exercises regularly and neither smoke nor drinks. The only findings on physical examination include the artificial eye and a tender, enlarged, and nodular liver. CT scan of the upper abdomen demonstrates multiple masses within the liver. Which of the following will most likely be found on biopsy of these masses?

19) A previously healthy, intoxicated, 19-year-old man is driving a car without using a seat belt. He crashes the car into the back of a parked truck. In the process he slams his abdomen into the steering wheel and ruptures his spleen. Which of the following is the most important problem associated with this type of injury?

20) A 27-year-old immigrant from El Salvador has a 14 × 12 × 9 cm mass in her left breast. It has been present for 7 years and has slowly grown to its present size. The mass is firm, nontender, rubbery, and completely movable, and it is not attached to the overlying skin or the chest wall. There are no palpable axillary nodes or skin ulceration. Which of the following is the most likely diagnosis?

21) A 63-year-old man, who weighs 65 kg, is in his 2nd postoperative day after an abdominoperineal resection for cancer of the rectum. An indwelling Foley catheter was left in place after surgery. The nurses are concerned because, even though his vital signs have been stable, his urinary output in the past 2 hours has been zero. In the preceding 3 hours, they had collected 56 mL, 73 mL, and 61 mL. Which of the following is the most likely diagnosis?

22) A 55-year-old woman falls in the shower and hurts her right shoulder. She shows up in the emergency department with her arm held close to her body, but the forearm rotated outward as if she were going to shake hands. She is in pain and will not move the arm from that position. Her shoulder looks "square" in comparison with the rounded unhurt opposite side, and there is numbness in a small area of her shoulder over the deltoid muscle. Which of the following is the most likely diagnosis?

23) A 68-year-old man is brought to the emergency department with excruciating back pain that began suddenly 45 minutes ago. The pain is constant and is not exacerbated by sneezing or coughing. He is diaphoretic and has a systolic blood pressure of 90 mm Hg. There is an 8 cm pulsatile mass deep in his epigastrium, above the umbilicus. A chest x-ray film is unremarkable. Two years ago, he was diagnosed with prostatic cancer and was treated with orchiectomy and radiation. At that time, his blood pressure was normal, and he had a 6-cm, asymptomatic abdominal aortic aneurysm for which he declined treatment. Which of the following is the most likely diagnosis?

24) An out-of-shape, recently divorced, 42-year-old man is trying to impress a young woman by challenging her to a game of tennis. In the middle of the game, a loud "pop" (like a gunshot) is heard, and the man falls to the ground clutching his ankle. He limps off the court with pain and swelling in the back of the lower leg. Although he can still weakly plantar-flex his foot, he seeks medical help the next day because of persistent pain, swelling, and limping. He can put weight on that foot with no exacerbation of the pain, but the motion of taking a step is painful. Which of the following would be the most likely finding on physical examination?

25) A 27-year-old man sustained penetrating injuries of the chest and abdomen when he was repeatedly stabbed with a long ice-pick. At the time of admission, he had a right pneumothorax, for which a chest tube was placed prior to undergoing a general anesthetic for exploratory laparotomy. The operation revealed no intraabdominal injuries and was terminated sooner than had been anticipated. The patient remained intubated, waiting for the anesthetic to wear off. Because he was not moving enough air, he was placed on a respirator. Then, he suddenly went into cardiac arrest and died. All through this time he had been hemodynamically stable, and never had any signs of hypotension or arrhythmias. Which of the following was the most likely cause of the cardiac arrest?

26) A 13-year-old, obese boy complains of persistent knee pain for several weeks. The family brings him in because he has been limping. He sits in the examining table with the sole of the foot on the affected side pointing to the other leg. Physical examination is normal for the knee, but shows limited hip motion. As the hip is flexed, the leg goes into external rotation and cannot be rotated internally. Which of the following is the most likely diagnosis?

27) A 72-year-old man comes in complaining of persistent and nagging low back pain that he has had for several weeks. The pain seems to be increasing in intensity, is worse at night, is unrelieved by rest or positional changes, and is not exacerbated by coughing, sneezing, or straining to have a bowel movement. He is a chronic smoker, and for the past 3 months has had persistent cough with occasional bloody streaked sputum, as well as a 20-pound weight loss. On physical examination, he is distinctly tender to palpation at a particular spot over his lower thoracic spine. Which of the following is the most likely diagnosis?

28) The unrestrained front-seat passenger in a car that crashed at high speed arrives at the emergency department with signs of moderate respiratory distress. Physical examination shows no breath sounds at all on the left hemithorax. Percussion is unremarkable, and his vital signs are normal. A chest x-ray film shows a collapsed left lung and multiple air-fluid levels filling the left pleural cavity. A nasogastric tube that had been placed prior to taking the film shows the tube reaching the upper abdomen and then curling up into the left chest. Which of the following is the most likely diagnosis?

29) A 67-year-old man shows up in the emergency department because he has not been able to void for the past 12 hours. He feels the need to, but he cannot do it. He gives a history that, for several years now, he has been getting up four or five times a night to urinate. It would take him a considerable time to get the urinary stream going, and the stream lacked force and often ended in a dribble. Because of a cold, 2 days ago he began taking an antihistamine, taking a decongestant, and drinking plenty of fluids. Physical examination shows a palpable, smooth, round mass arising from the pubis and reaching about half way toward the umbilicus. The mass is dull to percussion, and pushing on it accentuates the feeling of needing to void. Rectal examination reveals a large, boggy, non-tender prostate gland without nodules. This a classic presentation for which of the following acute conditions?

30) Several months after sustaining a crushing injury to his arm, a patient complains bitterly about constant, burning, agonizing pain in that arm, that does not respond to the usual analgesic medications. The pain in his arm is aggravated by the slightest stimulation of the area, such as rubbing from the shirt sleeves. The arm is cold, cyanotic, and moist, but it is not swollen. Pulses at the wrist are normal, and neurologic function of the three major nerves is intact. Which of the following is most appropriate to provide diagnostic confirmation of the nature of the problem and eventual therapy?

31) A 57-year-old alcoholic man is being treated for acute hemorrhagic pancreatitis. He was in the intensive care unit for 1 week, where he required chest tubes for pleural effusions and was on a respirator for several days. Eventually, he improved sufficiently to be transferred to the floor. Three days after leaving the unit, and about 2 weeks after the onset of the disease, he spikes a fever and develops leukocytosis. Which of the following developments do these recent findings most likely suggest?

32) A 33-year-old woman is involved in a high-speed automobile collision. She arrives at the emergency department gasping for breath. Her lips are cyanotic and she has flaring nostrils. There are bruises over both sides of the chest, and tenderness suggestive of multiple rib fractures. Her blood pressure is 60/45 mm Hg, pulse is 160/min and feeble and central venous pressure is 25 cm H2O. Her neck and forehead veins are distended. She is diaphoretic and has a hint of subcutaneous emphysema in the lower neck and upper chest. Her left hemithorax has no breath sounds and is hyper resonant to percussion. The trachea is deviated to the right, as are the heart sounds. Which of the following is the most likely diagnosis?

33) A 32-year-old male is rushed to the emergency room after a motor vehicle accident. He was driving 55 mph when he suddenly lost control of his vehicle and hit a tree. He was wearing a seat belt. On physical examination, the patient appears scared and complains of moderate chest and abdominal discomfort. His voice is soft. His blood pressure is 190/ 100 mmHg and his heart rate is 100/min. The pupils are symmetric and reactive to light and the trachea is midline. You note bruising over the chest and upper abdomen. No penetrating injuries are evident. Which of the following injuries is most likely in this patient?

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

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

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

37) A 74-year-old male is undergoing elective abdominal aortic aneurysm repair. He is given two units of packed red blood cells during the surgery. He develops fever and chills one hour after finishing the surgery and transfusion. He received one dose of prophylactic antibiotics before surgery. He had coronary bypass grafting two months ago. His temperature is 38.5C (101.3F), blood pressure is 130/76 mm Hg, pulse is 90/min and respirations are 16/min. Physical examination shows a mildly tender wound; there is no redness. The lungs are clearto auscultation. He has a Foley catheter and right subclavian central venous access, each placed at the time of surgery. Which of the following is the most likely cause of his fever?

38) A 55-year-old male comes to the physician's office because of chronic pain in his buttock, hip and thigh muscles. The aching pain is present in both legs and usually is associated with walking. He has multiple medical problems and takes several medications. He has a 30 pack year smoking history. His temperature is 36.7C (98F), blood pressure is 150/88 mm Hg, pulse is 80/min and respirations are 16/min. Examination shows decreased femoral, popliteal and dorsalis pedis pulses in both legs. Which of the following additional complaints is most likely in this patient?

39) A 23-year-old male is brought to the emergency department after a motor vehicle accident. He was an unrestrained driver. He was found unresponsive at the scene of the accident, and was intubated by the paramedics. He has received 2L of normal saline over the last 20 minutes. His blood pressure is 80/40 mmHg, and heart rate is 120/min. He responds to strong vocal and tactile stimuli by opening his eyes. His pupils are equal and reactive to light. His neck veins are distended. There are multiple bruises involving the anterior chest and upper abdomen. His chest x-ray shows a small, left-sided pleural effusion and normal cardiac contours. Which of the following is the most likely diagnosis?

40) A 65-year-old male comes to the ER because of sudden onset severe pain in his right leg. He says he has never previously had pain in his leg and denies any recent trauma, fever or chills. He recently suffered an acute anterior wall myocardial infarction that resulted in cardiogenic shock and is currently undergoing cardiac rehabilitation. His other medical problems include hypertension, diabetes and hyperlipidemia. His temperature is 36.7C (98F), blood pressure is 110/70 mm Hg, pulse is 90/min (regular) and respirations are 16/min. His lungs are clear to auscultation. His heart rate is regular with no murmurs. Below the knee the right leg is cool to touch and appears pale. The dorsalis pedis pulse is not palpable while the popliteal pulses are full. Pulses are normal in the contralateral extremity. Neurologic examination shows numbness over the dorsum of the leg and foot. Which of the following is the most likely cause of his symptoms?

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

42) A 62-year-old man is brought to the emergency department after being involved in a motor vehicle collision where he suffered serious burns. On physical examination there are second degree burns covering both upper extremities and third degree burns over the anterior aspects of both lower extremities. On day three of his hospitalization, the patient develops tachycardia and decreased urine output. His blood pressure is 90/60 mmHg, pulse is 120/min, temperature is 95°F (35°C), and respirations are 26/min. Laboratory analysis reveals: Blood glucose 230 mg/dL, WBC 16,000/mm3, Platelets 80,000/mm3. Which of the following is the best explanation for this patient's current condition?

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

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

45) A 32-year-old female presents with intermittent blood staining of her bra from her left breast. She has not felt any lumps on either breast. Physical examination shows no breast mass or axillary lymphadenopathy. Ultrasonogram of the breast is within normal limits. Which of the following is the most likely diagnosis?

46) A 31-year-old male presents to your office with pain and swelling over his coccyx. He has never had symptoms like this before. His past medical history is significant for an appendectomy two years ago and acute pyelonephritis one year ago. Which of the following is the most likely diagnosis?

47) An 18-year-old male comes to the physician's office because of dull aching and fullness of the scrotum. Examination shows soft testicular swelling; transillumination testing is negative. The scrotal swelling increases when the patient performs the Valsalva maneuver. The physical examination is otherwise unremarkable. Which of the following is the most likely cause of his condition?

48) A 12-year-old boy is brought to the emergency department after being involved in a motor vehicle collision. He is in no distress and is admitted for observation. Two hours after admission, he develops tachypnea and tachycardia. His temperature is 36.7C (98F), blood pressure is 110/66 mm Hg, pulse is 110/min, and respirations are 22/min. Examination shows bruises on the right side of the chest, but palpation of the ribs does not elicit pain or suspicion for rib fractures. Breath sounds are decreased on the right side. ABG on 6 liters of oxygen shows PO2 of 60 mm Hg, PCO2 of 32 mm Hg, and pH of 7.42. An x-ray film of the chest shows a patchy irregular alveolar infiltrate in the right middle and lower lobes. Which of the following is the most likely diagnosis?

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

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

51) A 54-year-old female with a 30 pack-year smoking history undergoes cholecystectomy after an episode of biliary pancreatitis. On the third postoperative day, she complains of discomfort in the upper abdomen. Though she is breathing comfortably, her oxygen saturation is 90%, compared with 98% yesterday. Her blood pressure is 130/80 mmHg, heart rate is 90/min, respiratory rate is 20/min, and temperature is 98F (36C). Arterial blood gas analysis reveals the following: pH = 7.44, p02 =64 mmHg, pC02 =34 mmHg, which of the following most likely explains the observed findings?

52) A 35-year-old male presents with complaints of muscle weakness and sensory loss in his upper extremities. His medical history is significant for involvement in a motor vehicle accident seven years ago in which he sustained a whiplash cervical spine injury. Physical examination today reveals moderate wasting of the small hand muscles and impaired pain and temperature sensation in the bilateral upper extremities. Light touch, vibration, and position senses are all intact. Which of the following is the most likely diagnosis?

53) A 45-year-old male presents to his physician with persistent nausea and vomiting of partially digested food for the past month. He has also lost 5 lbs of weight during this period of time. His appetite is good but he feels full after a few bites. His past medical history is significant for a one-year history of type 2 diabetes and a suicide attempt 6 months ago in which he ingested acid. He drinks alcohol and smokes one pack of cigarettes daily. His temperature is 36.80C (98.20 F), blood pressure is 110/65 mm Hg, pulse is 110/min, and respirations are 16/min. Mucous membranes are dry. Examination shows succussion splash on the epigastrium. Which of the following is the most likely diagnosis?

54) A 34-year-old male undergoes successful laparotomy for a gun-shot wound. He received 5 units of packed red blood cells during the surgery. He has been receiving incentive spirometry and ampicillin/sulbactam. However, he developed a fever of 38.7C (101.7F) on the sixth postoperative day. His blood pressure is 120/76 mm Hg, pulse is 97/min and respirations are 14/min. Examination shows an alert, pleasant male in no acute distress. The oropharynx is clear. The lungs and heart are clear to auscultation. The abdomen is soft and non-tender, and the wound has no discharge. He has a right femoral triple lumen catheter and Foley catheter in place. Extremities have no swelling or redness. Two days later, four bottles of blood cultures grew coagulase negative Staphylococcus. Which of the following is the most likely cause of his fever?

55) An overweight 12-year-old boy presents with left knee pain that has been going on intermittently for the past three months. Physical activity, especially stair climbing, exacerbates the pain. The boy's mother also points out that he has been limping recently. On physical examination, his anterior left hip is moderately tender to palpation, and when he is asked to stand on his left leg, the right half of his pelvis tilts downward. Which of the following best explains this finding?

56) A 23-year-old woman comes to the physician because of a 4-week history of a whistling noise during respiration. She underwent a difficult rhinoplasty a few months ago. The noise is getting louder and is annoying. Which of the following is the most likely diagnosis?

57) A 46-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He is unresponsive. His injuries include a basilar skull fracture, brain contusion, fractures of ribs 7-10, hemopneumothorax on the right and a pelvic fracture. After placement of a chest tube and pelvis fixation, his condition stabilized. On the fifth day of his hospital stay, he is still unresponsive with a Glasgow Coma Scale of 8. He is breathing spontaneously. Examination shows an abnormal facial reaction to abdominal palpation. Pain appears to be elicited by palpation in right upper quadrant. Bowel sounds are diminished. Rectal examination shows no abnormalities. Nasogastric tube aspiration shows retention of gastric contents. An abdominal CT scan shows gaseous distention of the small and large bowels without airfluid levels. The gall bladder is distended and pericholecystic fluid is present. Stones are not seen. Which of the following is the most likely diagnosis?

58) A 77-year-old woman is brought to the emergency department because of sudden-onset intense diffuse abdominal pain followed by vomiting. Her past medical history is significant for chronic uncontrolled hypertension, cerebrovascular accident, diabetes and hyperlipidemia. She takes multiple medications. She does not use tobacco, alcohol or drugs. Her temperature is 38.30 C (1010 F), blood pressure is 180/100 mm Hg, pulse is 110/min and irregular and her respirations are 22/min. She is in severe distress. Lungs are clear to auscultation. Abdominal examination shows severe pain to palpation and nearly absent bowel sounds. There is rigidity and rebound. Rectal examination shows heme-positive stools. EKG shows absent P waves, irregular rhythm and inverted T waves. There are no previous EKGs for comparison. An x-ray film of the chest shows cardiomegaly. Laboratory studies show: Hematocrit 49%, Leukocyte count 77,500/mm3, Troponin I normal. What is the most likely diagnosis?

59) A 35-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He is unconscious. His blood pressure is 100/50 mm Hg, pulse is 100/min, and respirations are 19/min. Examination shows bilaterally reactive and non-dilated pupils. He does not follow commands and makes inappropriate sounds. A CT scan of the head shows numerous minute punctuate hemorrhages with blurring of the gray-white matter interface. Which of the following is the most likely diagnosis?

60) A 65-year-old man with cervical spondylosis secondary to degenerative changes in the cervical spine was admitted after being involved in a motor vehicle accident. He regained consciousness after 5 minutes. After regaining consciousness, he had complete weakness in both upper extremities but was able to move his lower extremities. Vital signs are stable. Plain x-ray films of the cervical spine show no abnormalities except those consistent with mild degenerative changes. Which of the following is the most likely diagnosis?

61) A 54-year-old alcoholic man comes to the emergency department because of dysphagia, drooling and a fever. He has been sick for two days and has not been able to eat. His mouth is swollen and feels hot. Examination shows a pale, febrile man who is drooling. There is redness around the entire mouth extending into the floor of the mouth. A tender, symmetric and indurated swelling with palpable crepitus is present in the submandibular area. Laboratory study shows an elevated W BC count. Which of the following is the most likely source of the oral cavity infection?

62) A 69-year-old man is evaluated after undergoing an elective repair of a rapidly expanding abdominal aortic aneurysm. The surgical procedure was complicated by a significant amount of blood loss and required multiple transfusions. In the postoperative recovery room, he had weakness in both lower extremities and developed urinary retention. Neurologic examination shows spastic paraplegia and loss of pain sensation over the lower extremities; vibratory sensation is intact. Upper extremity examination shows no abnormalities. Which of the following is the most likely pathophysiologic mechanism of the neurologic dysfunction?

63) A 24-year-old woman comes to the physician because of a one-week history of increasing pain in the right leg. She is an active dancer and practices 4-5 hours a day. One week ago, she felt a dull aching pain in the right middle leg; the pain has been increasing since and is particularly bad when she dances. The pain is interfering with her dancing sessions. She is afebrile and her other vital signs are within normal limits. Examination shows point tenderness over the midpoint of the right leg; there are no abnormalities of the skin overlying the tender point. Knee and ankle examinations show no abnormalities. An x-ray of the lower leg shows no abnormalities. ESR is within normal limits. Which of the following is the most likely cause of her pain?

64) A 32-year-old male comes to the emergency department because of a 3 day history of increasing lower abdominal pain, mild diarrhea and rectal pain on defecation. Ten days ago he had right lower quadrant (RLQ) pain for about 24 hours that resolved spontaneously. Since then, he has had malaise and low-grade fever. His temperature is 38.70C (101.60F), blood pressure is 150/90 mm Hg, pulse is 110/min and respirations are 15/min. Examination shows lower abdominal tenderness without rebound. No masses are palpable, and bowel sounds are decreased. Rectal examination shows a very tender, boggy and fluctuant bulging on palpation with the tip of the finger anteriorly. Laboratory studies show: Complete blood count: Hemoglobin 14.0 g/L, Platelets 270,000/mm3, Leukocyte count 15,500/mm3, His current condition is most likely a complication of?

65) A 70-year-old male rushed to the emergency department because of bright red bleeding per rectum. He says his commode is full of blood and has never experienced any bleeding before. He has a history of constipation. He takes daily aspirin for prevention of stroke and hydrochlorothiazide for high blood pressure. His temperature is 36.50C (97.80F), blood pressure is 100/60 mm Hg, pulse is 120/min and respirations are 20/min. He is not hypoxic. Abdomen is soft, non-distended and non-tender; no masses or organomegaly are palpated; bowel sounds are normal. Rectal examination shows bright red blood and an enlarged prostate. Nasogastric tube aspirate shows non-bilious stomach contents without blood. An x-ray of the abdomen shows no abnormalities. Which of the following is the most likely cause of his bleeding?

66) An 11-year-old boy is brought to the emergency department for evaluation of an injury from jumping off a 10 ft wall, 2 days ago. He had some pain in his feet immediately following the jump, but was able to walk. The past 2 days, he has had increasing pain in his right foot with walking. He has no pain at rest. He has some "crunching" in the right foot. Physical examination shows the foot appears normal with the exception of suffusion on the plantar surface. Passive motion of the second toe and passive dorsiflexion of the foot produces pain in the middle of the foot. Which of the following is the most likely diagnosis?

67) An 18-year-old woman at 9 weeks' gestation is brought to the emergency department because of an open fracture of the tibia and fibula. She is hemodynamically stabilized and referred to the orthopedic department. She is scheduled for internal fixation of the tibia for the following day. However, before the surgery she develops severe dyspnea and confusion. Her temperature is 37.70C (99.90F), blood pressure is 110/70 mm Hg, pulse is 110/min, and respirations are 22/min. Examination shows numerous nonpalpable petechiae in the upper part of the body. Which of the following is the most likely diagnosis?

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

69) A 7-year-old child is brought to the emergency department after being involved in a highway motor vehicle collision. He had blunt trauma to his abdomen. Vital signs are stable, except for a respiratory rate of 30 per minute. Physical examination shows bruising of the upper abdomen, abdominal distention, and tenderness. He is in moderate respiratory distress; breath sounds are decreased on the left side. Chest tube placement shows no blood or air in the pleural cavity. An x-ray film of the chest shows an elevated left hemidiaphragm. Laboratory studies show hemoglobin and hematocrit within normal limits. Which of the following is the most likely diagnosis?

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

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

72) A 35-year-old black man is brought to the emergency department after a motorcycle accident. He hit the street with the side of his head. He was found unconscious when the emergency medical team arrived. However, on the way to the emergency department he regains consciousness. Upon arrival he is confused and complains of a headache. His temperature is 36.9C (98.5F), blood pressure is 100/60 mm Hg, pulse is 110/min, and respirations are 22/min. Examination shows a dilated pupil on the right side, with some weakness of the left arm and leg. CT scan of the head shows a biconvex hematoma on the right side of the head. Which of the following is the most likely diagnosis?

73) A 54-year-old man is brought to the emergency department 1 0 minutes after being involved in a motor vehicle collision. On arrival, he is breathing spontaneously, is non-cyanotic and has no signs of external injury. His temperature is 37C (98.6F), blood pressure is 104/50 mm Hg, pulse is 122/min and respirations are 16/min. Examination shows bilateral round and reactive pupils of 4 mm. He is making some incomprehensible sounds. He responds to his name by opening his eyes and on applying supraorbital pressure he extends his left extremity and grasps your hand with his right hand. What is the Glasgow coma scale (GCS) in this patient?

74) A four-year-old boy is brought to the physician because of discomfort in the left hip and left knee that is causing him to limp. Examination shows normal knee joints bilaterally, but there is marked limitation of internal rotation and abduction of the left hip. His temperature is 37.1 C (98.6F), blood pressure is 90/60 mm Hg, pulse is 80/min and respirations are 16/min. Laboratory studies including complete blood count and basic metabolic profile show no abnormalities. Which of the following is the most likely diagnosis?

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

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

77) A 34-year-old man comes to the physician after being involved in a street fight. He has a painful and swollen left arm. Neurovascular examination shows no abnormalities. An x-ray film of the arm shows a fracture of the midshaft of the humerus. Closed reduction of the facture is done and the arm is kept in a hanging cast. One hour later he has numbness of the left wrist and marked limitation of extension at the wrist. Which of the following is the most likely diagnosis?

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

79) A 32-year-old man comes to the emergency room (ER) because of acute onset left flank pain, hematuria and vomiting. His pain is relieved with ketorolac in the ER. He has a history of abdominal pain due to Crohn disease, but that pain was always in the rightlower quadrant and was never this severe. His temperature is 36.8C (98.2F), blood pressure is 120/65 mm Hg, pulse is 110/min and respirations are 16/min. Chest auscultation is clear. Abdomen is soft and mildly tender over the left flank. He has no rebound or rigidity. Bowel sounds are decreased. A laparotomy scar is present in right lower quadrant. Which of the following is the most likely cause of his symptoms?

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

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

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

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

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

87) A 72-year-old man underwent surgical repair of an aneurysm of the infrarenal aorta. He received perioperative prophylaxis with a second-generation cephalosporin antibiotic. On the first postoperative day he complains of progressive abdominal pain and bloody diarrhea. His temperature is 38.5C (101F), blood pressure is 110/65 mm Hg, pulse is 110/min and respirations are 22/min. His abdomen is mildly distended and tender to palpation. The tenderness is mostly in the left lower quadrant without rebound. Femoral pulses are full and symmetric. His white blood cell count is 12,000/mm3. Which of the following is the most likely diagnosis?

88) A 51-year-old male with a history of alcoholic pancreatitis presented to the hospital because of sudden onset severe retrosternal and upper abdominal pain. He has been vomiting for the past few hours after consuming alcohol. His temperature is 38.1C (100.9F), blood pressure is 140/90 mm Hg, pulse is 120/min and respirations are 30/min. Examination shows palpable crepitus in the suprasternal notch. Lungs are clear to auscultation. The abdomen is tender to palpation mostly in the epigastrium. Which of the following is the most likely cause of his current condition?

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

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

92) A 22-year-old primigravida woman at 33 weeks gestation is brought to the emergency department after a tonic clonic seizure. On arrival, she also has visual disturbances and a headache. She is given magnesium sulfate and hydralazine. She soon regains consciousness but cannot move her right arm; however, she can move her fingers. Her temperature is 37.2C (99F), blood pressure is 160/100 mm Hg, pulse is 110/min and respirations are 20/min. Examination shows her arm extended along the chest and internally rotated. There is no sensory loss on the arm, but there is an inability to externally rotate the shoulder. Deep tendon reflexes (DTR) are intact. Which of the following is the most likely cause of her inability to move her hand?

93) A 15-year-old boy is brought to the physician because of a 15-day history of painful swelling of the right knee. The swelling and redness were immediate after hitting his knee on the door, but have not subsided after 15 days of ibuprofen. He states the pain is increasing. He has no other complaints. His temperature is 37.1C (98.9F), blood pressure is 110/75 mm Hg, pulse is 80/min, and respirations are 22/min. Laboratory studies show a normal ESR and elevated serum alkaline phosphatase. Examination shows the skin is warm and non-tender. An x-ray film of the femur and the knee joint shows an osteolytic lesion of the distal femur along with periosteal inflammation. Which of the following is the most likely diagnosis?

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

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

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

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

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

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

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

103) An 18-year-old woman at 9 weeks' gestation is brought to the emergency department because of an open fracture of the tibia and fibula. She is hemodynamically stabilized and referred to the orthopedic department. She is scheduled for internal fixation of the tibia for the following day. However, before the surgery she develops severe dyspnea and confusion. Her temperature is 37.7° C (99.9° F), blood pressure is 110/70 mmHg, pulse is 11 O/min, and respirations are 22/min. Examination shows numerous non-palpable petechiae in the upper part of the body. Which of the following is the most likely diagnosis?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

134) A 32-year-old man comes to the emergency room (ER) because of acute onset left flank pain, hematuria and vomiting. His pain is relieved with analgesics in the ER. He has a history of abdominal pain due to Crohn disease, but that pain was always in the right lower quadrant and was never this severe. His temperature is 36.8°C (98.2°F), blood pressure is 120/65 mm Hg, pulse is 110/min and respirations are 16/min. Chest auscultation is clear. Abdomen is soft and mildly tender over the left flank. He has no rebound or rigidity. Bowel sounds are decreased. A laparotomy scar is present in right lower quadrant. Which of the following is the most likely cause of his symptoms?

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

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

137) A 65-year-old male is being evaluated for hip pain. The pain has been present for several months and is constant. He denies any weight loss or loss of appetite. His past medical history is significant only for high blood pressure. His temperature is 37.2°C (98.9°F), blood pressure is 150/88 mm Hg, pulse is 80/min and respirations are 12/min. Physical examination is unremarkable. Laboratory studies show: Alkaline phosphatase Elevated, Gamma glutamyl transferase Normal, Serum calcium Normal, 25, (OH)2 vitamin D Normal. Bone scan shows increased uptake in several spots. This patient is at the highest risk of developing?

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