Surgery USMLE (401-522)

401. 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?

402. A 65-year-old woman presents to the physician’s office for evaluation of an abnormal screening mammogram. She denies any breast masses, nipple discharge, pain, or skin changes. Past history is pertinent for hypertension. Family history is positive for postmenopausal breast cancer in a sister. She has a normal breast examination and no axillary adenopathy. The remainder of her examination is unremarkable. An MLO view of the right breast is shown in Figure 6-6a along with a magnification view of the craniocaudal (CC) film (Figure 6-6b). Which of the following is the most likely diagnosis?

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

Cervical dysphagia is related to the size of the diverticulum.

Pharyngoesophageal diverticula are of the pulsion type.

Pharyngoesophageal diverticula are true diverticula.

Pharyngoesophageal diverticula are congenital in origin.

Upper esophageal sphincter function is usually normal.

404. 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?

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

Growth hormone therapy

Cerebral angiography with tumor embolization

Transsphenoidal decompression of the optic nerve and optic chiasm

Surgical resection

Radiotherapy

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

High-dose IV penicillin G and broadspectrum antibiotics

High-dose IV penicillin G, broadspectrum antibiotics, and local wound care with unroofing of bullae and culture of wound drainage

High-dose IV penicillin G, broadspectrum antibiotics, with surgical debridement only if and when there is no improvement with antibiotics

Radical surgical debridement

High-dose IV penicillin G, broadspectrum antibiotics, radical surgical debridement, and hyperbaric oxygen therapy

407. A 36-year-old woman whose mother has just undergone treatment for breast cancer is asking about how this affects her and what can be done to lessen her chances of having the disease. Which of the following has the lowest risk factor for breast cancer?

Dietary fat intake

Paternal relative with breast cancer 1 (BRCA1) mutation

Excessive estrogen exposure—early menarche, late menopause, nulliparity

Previous biopsy with atypical hyperplasia

Exposure to ionizing radiation

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

Admit to telemetry for 24-hour monitoring

Admit to the regular ward with serial ECGs for 24 hours

Emergent cardiac catheterization

Immediate operative plating of the sternal fracture

Discharge to home with nonsteroidal anti-inflammatory agents for the sternal fracture

405. A 76-year-old man is undergoing an abdominoperineal resection for rectal cancer. During the surgery, unexpected severe bleeding is encountered, and the patient is hypotensive on and off for almost an hour. The anesthesiologist notes ST depression and T-wave flattening on the ECG monitor. Which of the following is the most likely diagnosis and the expected mortality?

Intraoperative air embolus, 100%

Myocardial infarction, 5% to 10%

Myocardial infarction, 50% to 90%

Pulmonary embolus, 5% to 10%

Pulmonary embolus, 50% to 90%

410. 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 weeks 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?

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

Systemic chemotherapy

Intra-arterial chemotherapy through the hepatic artery

Surgical resection

Radiation therapy to the liver

Repeat imaging studies in 3 months to determine the growth rate of the disease

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

413. A 60-year-old man is admitted to the coronary care unit with a large anterior wall myocardial infarction. On his second hospital day, he begins to complain of the sudden onset of numbness in his right foot and an inability to move his right foot. On physical examination, the right femoral, popliteal, and pedal pulses are no longer palpable. The left lower extremity is normal. Which of the following is the most appropriate management of this patient?

Duplex imaging of the right lower extremity arteries

CT angiogram of the right lower extremity

CT angiogram of bilateral lower extremities

Embolectomy of the right femoral artery

Embolectomy of the right femoral artery with exploration of the contralateral femoral artery

A 60-year-old man is found on a routine physical examination to have a 3-cm pulsatile mass in the right popliteal fossa. X-ray of the right of the right lower extremity is shown below. Which of the following is the most appropriate management of this patient?

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

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

Splenectomy

Platelet transfusion when peripheral platelet count drops below 50,000/mL

Systemic steroids

Chemotherapy

Expectant, with intervention only if the patient develops significant clinical bleeding.

417. 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?

Serum glucose level > 50 mg/dL, elevated serum insulin levels, elevated C-peptide levels

Serum glucose level > 50 mg/dL, elevated serum insulin levels, decreased C-peptide levels

Serum glucose level < 50 mg/dL, elevated serum insulin levels, elevated C-peptide levels

Serum glucose level < 50 mg/dL, elevated serum insulin levels, decreased C-peptide levels

Serum glucose level < 50 mg/dL, decreased serum insulin levels, decreased C-peptide levels

418. A 70-year-old woman undergoes a cardiac catheterization for exertional chest pain. Her pain continues to worsen and she is interested in having either surgery or percutaneous coronary intervention (PCI). Which of the following would be an indication for her to undergo either coronary artery bypass grafting or PCI?

Two-vessel coronary disease with proximal left anterior descending artery stenosis and depressed left ventricular ejection fraction

Isolated left main stenosis, no diabetes, and normal left ventricular ejection fraction Isolated left main stenosis and diabetes

Left main stenosis and additional coronary artery disease with depressed left ventricular ejection fraction.

Three-vessel coronary artery disease and diabetes

419. Six months ago at the time of lumpectomy for breast cancer, a 60-year-old female attorney quit a 30-year smoking habit of 2 packs per day. She had the chest radiograph shown here as part of her routine follow-up examination. Based on her age and history of smoking, you are concerned for either a new primary lung or metastatic breast malignancy. Which of the following is the most appropriate next step in the management of this lesion?

Follow-up CT scan in 3 months

Magnetic resonance imaging of bilateral breasts to evaluate for recurrence of the breast cancer

Transthoracic fine-needle aspiration of the lesion

Mediastinoscopy

Thoracotomy with lobectomy

420. A 72-year-old woman has a red, swollen breast. She states that the condition has been present for at least several weeks, perhaps a month or two. She has no pain or fever. The skin over the area looks like orange peel. The area is not warm to the touch, but on physical examination there is a fullness to the entire breast, with no discrete mass. Which of the following is the most likely diagnosis?

Chronic cystic mastitis

Inflammatory cancer of the breast

Normal menopausal involutionary changes

Pyogenic breast abscess

Tuberculous or fungal breast abscess

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

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

423. A 14-year-old black girl has her right breast removed because of a large mass. The tumor weighs 1400 g and has a bulging, very firm, lobulated surface with a whorl-like pattern, as illustrated here. Which of the following is the most likely diagnosis?

424. A 58-year-old man presents with tachycardia, fever, confusion, and vomiting. Workup reveals markedly elevated (triiodothyronine) T 3 and (thyroxine) T4 levels. He is diagnosed as having a thyroid storm. Which of the following is the most appropriate next step in the management of this patient?

Emergent subtotal thyroidectomy

Emergent total thyroidectomy

Emergent hemodialysis

Administration of fluid, antithyroid drugs, β-blockers, iodine solution, and steroids

Emergent radiation therapy to the neck

425. 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?

Plasma renin activity and plasma aldosterone concentration

Urine electrolytes

Plasma cortisol level

Overnight low-dose dexamethasone suppression test

Twenty-four-hour urinary aldosterone level

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

Carpal navicular fracture; thumb spica cast

De Quervain tenosynovitis; steroid injections

Displaced scaphoid fracture; open reduction and internal fixation

Ligamentous injury; Ace bandage and analgesics

No fracture; reassurance

427. A 55-year-old-woman presents to the physician’s office for evaluation of mammographic findings on a screening mammogram. She denies any breast masses, nipple discharge, pain, or skin changes. Past history is pertinent for insulin-dependent diabetes. Family history is positive for postmenopausal breast cancer in her mother. She has a normal breast examination and no axillary adenopathy. A mediolateral oblique (MLO) view of the right breast is shown Which of the following is the most appropriate next step in management?

Observation, with repeat mammogram in 6–12 months

Ultrasound

Biopsy

Lumpectomy, radiation therapy, and sentinel lymph node (SLN) biopsy

Total mastectomy

428. A 51-year-old woman presents to the physician’s office with a 2-month history of a right breast blood tinged nipple discharge. Past history is unremarkable. Family history is positive for postmenopausal breast cancer in a maternal grandmother. Examination reveals no palpable masses or regional adenopathy, but a serous discharge is easily elicited from a single duct in the right breast. Bilateral mammograms show no abnormalities. Cytology from the discharge was not diagnostic. A ductogram was ordered, and the results are shown: Which of the following is the most likely diagnosis?

429. An 18-year-old football player is seen in the emergency ward with severe knee pain incurred after being hit by a tackler while running. Which of the following findings on physical examination is most sensitive for an anterior cruciate ligament injury?

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

Intravenous (IV) antibiotics and cast or splint placement

IV antibiotics and internal or external fixation

Early irrigation and debridement, IV antibiotics, and cast or splint placement

Early irrigation and debridement, IV antibiotics, and internal or external fixation

Early irrigation and debridement, IV antibiotics, compartment decompression, and internal or external fixation

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

Discuss the surgical options in case cancer is found

Do a mammogram to ascertain whether biopsy is needed

Do a mammogram to find any other lesions that might also need to be addressed

First wait for two menstrual cycles to see whether there is spontaneous resolution.

Obtain a fine-needle aspirate and go no further if no malignant cells are found

432. A 55-year-old woman presents with a 6-cm right thyroid mass and palpable cervical lymphadenopathy. Fine-needle aspiration (FNA) of one of the lymph nodes demonstrates the presence of calcified clumps of sloughed cells. Which of the following best describes the management of this thyroid disorder?

The patient should be screened for pancreatic endocrine neoplasms and hypercalcemia.

The patient should undergo total thyroidectomy with modified radical neck dissection.

The patient should undergo total thyroidectomy with frozen section intraoperatively, with modified radical neck dissection reserved for patients with extra-capsular invasion.

The patient should undergo right thyroid lobectomy followed by iodine 131 (131I) therapy.

The patient should undergo right thyroid lobectomy.

433. A 45-year-old woman is found to have suspicious appearing calcifications in the right breast on a screening mammogram. Stereotactic biopsy of the calcifications shows lobular carcinoma in situ (LCIS). On examination both breasts are dense without palpable masses. The neck and bilateral axilla are negative for lymphadenopathy. Which of the following is the most appropriate management of this patient?

Frequent self-breast examinations and yearly screening mammograms

Chemotherapy

Radiation

Right total mastectomy with sentinel lymph node biopsy

Bilateral modified radical mastectomy

434. A30-year-old man presents with sudden onset of severe epigastric pain 6 hours ago. Examination reveals a low-grade fever, tender abdomen throughout, with rigidity of the abdominal usculature. Abdominal roentgenograms show pneumoperitoneum. Select the most likely diagnosis.

435. A 40-year-old woman presents to the emergency room with a 3-day history of worsening abdominal pain, with nausea and vomiting. Examination reveals a low-grade fever and abdominal tenderness in the right upper quadrant with guarding, especially during inspiration. Laboratory findings include a mild leukocytosis and a slightly elevated bilirubin. Select the most likely diagnosis.

436. A 3-year-old boy presents to the physician’s office with an asymptomatic neck mass located in the midline, just below the level of the thyroid cartilage. The mass moves with deglutition and on protrusion of the tongue. Which one is the most likely diagnosis?

437. While playing with his children, a 44-year-old man falls and lands on his right shoulder. There is immediate pain and deformity. In an uncomplicated dislocation of the glenohumeral joint, the humeral head usually dislocates primarily in which of the following directions?

438. A 29-year-old construction worker fell 15 ft from a roof and broke his right humerus, as depicted in the accompanying radiograph. Given his injury, which of the following nerves is most at risk?

439. In a failed suicide gesture, a depressed student severs her radial nerve at the wrist. Which of the following is her expected disability?

Loss of ability to extend the wrist

Loss of ability to flex the wrist

Wasting of the intrinsic muscles of the hand

Sensory loss over the thenar pad and the thumb web

Palmar insensitivity

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

Local wound irrigation, closure of the soft-tissue defect, closed reduction, and immobilization in a long-leg cast

Local wound irrigation with antibiotic solution, closed reduction, and immobilization in a long-leg cast, with continued local wound care through an anterior cast window

Tetanus prophylaxis, intravenous (IV) antibiotics, and operative wound irrigation and debridement, with application of an external fixation device

Tetanus prophylaxis, IV antibiotics, operative wound irrigation with closure of the soft-tissue defect, closed reduction, and immobilization in a long-leg cast

Tetanus prophylaxis, IV antibiotics, long leg splint for immobilization, and operative intervention during elective surgical schedule

441. 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?

442. A 60-year-old otherwise healthy woman presents to her physician with a 3-week history of severe headaches. A contrast CT scan reveals a small, circular, hypodense lesion with ringlike contrast enhancement. Which of the following is the most likely diagnosis?

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

Immediate surgical elevation of the skull fracture

Delayed surgical elevation of the skull fracture

Immediate dural repair

Elevation of the head of the bed and placement of a lumbar drain

Antibiotic therapy for sinusitis

444. A 39-year-old man presents to his physician with the complaint of loss of peripheral vision. Which of the following findings are demonstrated by the subsequent magnetic resonance imaging (MRI) scan, shown here?

445. A 50-year-old woman presents to the physician’s office for evaluation of a right neck mass. The mass has been present for 3 years and is painless. On examination, a nontender, firm, 2.5-cm mass is noted slightly below and posterior to the angle of the mandible on the right. Which one is the most likely diagnosis?

446. A 35-year-old woman presents to the physician’s office for evaluation of a left neck mass discovered 1 month ago on a routine physical examination. On examination, the mass measures 2 cm and is located anterolateral to the larynx and trachea. It is nontender and moves with swallowing. Past history is pertinent for a 15 pack-year smoking history and occasional alcohol intake. Which one is the most likely diagnosis?

447. A 55-year-old man presents to the physician’s office with complaints of hoarseness and left neck fullness for the past month. On examination, a firm, movable, left submandibular mass is noted. Past history is pertinent for a 30 packyear smoking history with occasional alcohol intake. Which one is the most likely diagnosis?

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

Intermittent thin or milky discharge can be physiologic.

Expressible nipple discharge is an indication for open biopsy.

Absence of a mass on mammogram rules out malignancy.

Galactorrhea is indicative of an underlying malignancy.

Pathologic discharge is usually bilateral.

449. A 52-year-old woman presents with hypertension, obesity, and new skin striae. You are concerned about possible Cushing syndrome. Which of the following is the most common cause of Cushing syndrome?

Adrenocortical hyperplasia

Adrenocorticotropic hormone (ACTH)–producing pituitary tumor

Primary adrenal neoplasms

Ectopic adrenocorticotropic hormone (ACTH)–secreting carcinoid tumor

Pharmacologic glucocorticoid use

450. A 76-year-old woman presents with acute onset of persistent back pain and hypotension. A CT scan is obtained (shown below), and the patient is taken emergently to the operating room. Three days after surgery she complains of abdominal pain and bloody mucus per rectum. Which of the following is the most likely diagnosis?

451. 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?

452. A 50-year-old man presents to the emergency department for increasing abdominal distention and jaundice over the last 4–6 weeks. Examination reveals mild jaundice, spider angiomas, and ascites. Enlarged veins are noted around the umbilicus. Which one is the most likely diagnosis?

453. A 75-year-old man is brought to the emergency department by his family for evaluation of jaundice. He complains of pruritus of 2 weeks’ duration and a recent 10-lb weight loss. On examination, he is deeply jaundiced and has a nontender, globular mass in the right upper quadrant of the abdomen that moves with respiration. Which one is the most likely diagnosis?

454. A 75-year-old woman is brought to the emergency department from the nursing home for jaundice and mental confusion. The nursing home notes state that she has become less responsive and has developed jaundice over the last 2 weeks. Past history is pertinent for hypertension, diabetes, and prior colon resection for cancer at age 55. Examination reveals mild jaundice with vital signs of temperature 101.5°F, pulse rate 110/min, and BP 100/60 mmHg. She does not respond to verbal commands, but withdraws to pain. Abdominal examination reveals tenderness in the epigastrium and right upper quadrant. Which one is the most likely diagnosis?

455. An 18-year-old man is admitted to the ER following a motorcycle accident. He is alert and fully oriented, but witnesses to the accident report an interval of unresponsiveness following the injury. Skull films disclose a fracture of the left temporal bone. Following x-ray, the patient suddenly loses consciousness and dilation of the left pupil is noted. Which of the following is the most likely diagnosis?

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

Repeat the head CT scan with intravenous contrast.

Perform an angiogram of the aorta and lumbar branches for immediate embolization of the injured vessel.

Perform a 4-vessel cerebral angiogram.

Administer a dose of mannitol.

Consult neurosurgery for immediate ventriculostomy.

457. A trauma patient with a closed-head injury is being monitored in the neurosurgical intensive care unit (ICU). His ICP measurement is seen to rise precipitously. An acute increase in ICP is characterized by which of the following clinical findings?

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

Colonoscopic decompression

Cyclosporine

Abdominal colectomy and ileostomy and Hartmann’s procedure

Proctocolectomy with ileal pouch-anal anastomosis

Abdominal colectomy with ileorectal anastomosis

459. A term infant is born at a small community hospital by cesarean section for failure to progress. The infant is noted to have the following abnormality at birth. Which of the following is the most likely diagnosis?

460. After being injured by a bull on his mother’s farm, a young man is placed in a cast for a supracondylar fracture of his humerus. A few hours later he begins to experience intense pain, swelling, and weakness in the ipsilateral hand. Pulses are normal in bilateral upper extremities. Which of the following is the most appropriate initial management of this patient?

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

462. A 45-year-old man presents to the physician’s office for evaluation of a posterior neck mass. The mass has been present for years, but has slowly enlarged over the last 2 years. Examination reveals a subcutaneous mass that is soft, nontender, and movable. Which one is the most likely diagnosis?

463. A 6-year-old boy presents to the emergency department with a cough, sore throat, and malaise of 4 days’ duration. Examination reveals a temperature of 101.5°F, erythematous pharynx, and a tender right neck mass with overlying erythema. Which one is the most likely diagnosis?

464. An 18-month-old girl is brought to the physician’s office for evaluation of left neck mass. Examination reveals a 2-cm soft, nontender, fluctuant mass in the left lateral neck. This is located at the anterior border of the sternomastoid, midway between the mastoid and clavicle. Which one is the most likely diagnosis?

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

No further therapy is indicated.

Chemotherapy.

External beam radiotherapy.

Radioiodine ablation.

Chemotherapy, external beam radiotherapy, and radioiodine ablation.

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

External beam radiation to the neck.

Multidrug chemotherapy.

TSH suppression by thyroid hormone.

Prophylactic neck dissection is indicated along with a total thyroidectomy.

Thyroid lobectomy.

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

Cover the wound with a regular dressing and get a chest x-ray

Cover the wound with Vaseline gauze, taped on three sides

Endotracheal intubation

Insert a chest tube at the right pleural base

Insert an 18-gauge needle into the right pleural space at the second intercostal space

468. A term infant is born at a small community hospital by cesarean section for failure to progress. The infant is noted to have the following abnormality at birth. Which of the following is the most likely diagnosis? Which of the following is the most appropriate initial management?

IV antibiotics alone

Emergency surgery for reduction

Monitor for spontaneous closure, with surgical intervention for persistent fascial defect

IV fluids, IV antibiotics, warm occlusive dressing, and transfer to a center with a pediatric surgeon

Elective umbilical exploration

469. A 2-year-old child presents with a 2-day history of painless rectal bleeding. On examination, the child is pale with tachycardia. The abdomen is nondistended and nontender. There is dark blood on rectal examination. The child has the following imaging study (see Figure 6-2). Which of the following is the most appropriate management?

470. A 55-year-old-woman presents to the physician’s office for evaluation of mammographic findings on a screening mammogram. She denies any breast masses, nipple discharge, pain, or skin changes. Past history is pertinent for insulin-dependent diabetes. Family history is positive for postmenopausal breast cancer in her mother. She has a normal breast examination and no axillary adenopathy. A mediolateral oblique (MLO) view of the right breast is shown: Which of the following is the most likely diagnosis?

Milk of calcium

Lobular carcinoma in situ (LCIS) with or without an invasive component

Ductal carcinoma in situ (DCIS) with or without an invasive component

Involuting fibroadenoma

Phyllodes tumor

471. A 6-year-old boy is brought into the emergency room by his mother for walking with a limp for several weeks. On examination, the patient has tenderness over his right thigh without evidence of external trauma. An x-ray of the pelvis shows a right femoral head that is small and denser than normal. Which of the following is the most likely diagnosis?

472. 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?

473. A 40-year-old previously healthy man presents with sudden onset of severe abdominal pain that radiates from the right loin (flank) to groin. This pain is associated with nausea, sweating, and urinary urgency. He is distressed and restless, but an abdominal examination is normal. Which of the following is the most appropriate next step in management?

Insertion of a urethral catheter

IV fluid hydration, IV analgesics, and nonenhanced computed tomography (CT) scan

IV fluid hydration, IV analgesics, and arrangements for lithotripsy

Cystoscopy and retrograde pyelogram

Urine culture, followed by initiation of antibiotic therapy

474. 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?

Insertion of a subclavian venous catheter and initiation of central IV hyperalimentation

Wait for extubation and improvement of neurologic status, allowing institution of an oral caloric intake

Early institution of NG or nasojejunal tube feeding with an elemental formulation

Wait for resolution of the associated gastrointestinal ileus, followed by delayed initiation of NG tube feeding with a complex hypercaloric formulation

Peripheral IV hyperalimentation

475. 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?

Do nothing, this is a normal anatomic variant

Inquire if the father is an albino, and do appropriate genetic counseling

Seek an ophthalmologic consultation for suspected congenital cataract

Seek an emergency ophthalmologic consultation for possible retinoblastoma

Treat the child with antibacterial eye drops and re-check in 2 weeks

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

Wide local excision with a rim of normal tissue

Lumpectomy and axillary lymphadenectomy

Modified radical mastectomy

Excision and postoperative radiotherapy

Excision, postoperative radiotherapy, and systemic chemotherapy

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

Right thyroid lobectomy

Subtotal thyroidectomy

Total thyroidectomy

Total thyroidectomy with lymph node dissection

131I radioactive ablation of the thyroid gland

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

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

480. During the performance of a supraclavicular node biopsy under local anesthesia, a hissing sound is suddenly heard, and the patient suddenly dies. At the time of the catastrophic event, the target node was under traction, and the final cut was being made blindly behind it to free it up completely. The patient, an otherwise healthy 24-year-old man, was inhaling at that moment. Which of the following most likely caused this patient's death?

481. A 42-year-old man presents with a solitary lung lesion. At the time of operation on this patient, a firm, rubbery lesion in the periphery of the lung is discovered. It is sectioned in the operating room to reveal tissue that looks like cartilage and smooth muscle. Which of the following is the most likely diagnosis?

482. A 45-year-old woman presents with dysphagia, regurgitation of undigested food, and weight loss. She had x-rays shown here as part of her workup. Upper endoscopy reveals no evidence of malignancy and esophageal motility studies show incomplete lower esophageal sphincter relaxation. Which of the following is the next best step in the treatment of this patient?

Laparoscopic myotomy of the lower esophageal sphincter (Heller)

Laparoscopic posterior 180° (Toupet) fundoplication

Laparoscopic anterior 180° (Dor) fundoplication

Laparoscopic 360° (Nissen) fundoplication

Transhiatal esophagectomy

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

484. 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?

485. A 70-year-old man is admitted to the ICU after repair of an abdominal aortic aneurysm. He has a prior history of hypertension and mild congestive heart failure, which were adequately controlled with digoxin and diuretics. To facilitate perioperative management, a Swan-Ganz (multilumen pulmonary artery) catheter was inserted in the operating room. During the first few hours postoperatively, the patient is noted to have a blood pressure of 140/70 mmHg, heart rate of 110/min, flat neck veins, a pulmonary arterial wedge pressure of 9 mmHg, and poor urine output. Several hours after this intervention a bolus of IV crystalloid, the patient is reassessed. The blood pressure is 150/85 mmHg, heart rate is 90/min, neck veins are distended, and the pulmonary arterial wedge pressure is 17 mmHg. Urine output is still low in volume. At this point, management should be which of the following?

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

487. 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?

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

Serum levels of alpha-fetoprotein and beta human chorionic gonadotrophin

Percutaneous biopsy of the testicular mass

Incisional biopsy of the testicular mass through a scrotal incision

Excisional biopsy of the testicular mass through a scrotal incision

Radical inguinal orchiectomy

489. A 10-year-old boy presents to the emergency room with pain in the left testicle. The pain was acute in onset and began 1 hour ago. On physical examination, he is noted to have a high-riding, firm, and markedly tender left testis. The right testicle is normal. Urinalysis is unremarkable. Which of the following is the most appropriate management of this patient?

Manual detorsion of the left testicle with external rotation toward the thigh; orchiopexy if the condition recurs

Manual detorsion of the left testicle with internal rotation toward the thigh; orchiopexy if the condition recurs

Orchiopexy of the left testicle

Orchiopexy of bilateral testicles

Orchiectomy of the left testicle

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

Immediate percutaneous nephrostomy

Immediate placement of a Foley catheter through the urethra into the bladder to align and stent the injured portions

Immediate reconstruction of the ruptured urethra after initial stabilization of the patient

Immediate exploration of the pelvis for control of hemorrhage from pelvic fracture and drainage of pelvic hematoma

Immediate placement of a suprapubic cystostomy tube

491. A 55-year-old man presents with fever and pain in the perineal region. Upon further questioning he also complains of frequency, urgency, dysuria, and a decreased urinary stream. On physical examination his abdomen is soft, nondistended, and nontender. Digital rectal examination demonstrates exquisite tenderness on the anterior aspect. Laboratory examination reveals leukocytosis and findings on urinalysis are consistent with a bacterial infection. Which of the following is the most likely diagnosis?

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

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

494. A 10-month-old infant presents to the emergency department with a 24-hour history of low-grade fever and anorexia. The parents report several episodes in which the child has been suddenly inconsolable and crying, followed by periods of lethargy. He has had nonbilious vomiting and several loose stools. On examination, the infant is pale and mildly dehydrated. His abdomen is soft and nondistended, with fullness to palpation in the right upper quadrant. The child passed another stool in the emergency department (see Figure 6-14). Which of the following is the most likely diagnosis?

495. 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?

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

Addition of vasopressors along with the inotropes

Transfusion of packed red blood cells

Return to the operating room for exploration of the mediastinum

Placement of an intraaortic balloon pump

Infusion of streptokinase into the mediastinal chest tube

497. An 89-year-old man has lost 30 lb over the past 2 years. He reports that food frequently sticks when he swallows. He also complains of a chronic cough. Barium swallow is shown here. What is the best treatment option for this patient?

Placement of an esophageal stent

Diverticuloplasty

Excision of the diverticulum

Excision of the diverticulum and administration of a promotility agent

Excision of the diverticulum and cricopharyngeal myotomy

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

Irrigation and debridement of the wound

Irrigation and debridement of the wound; tetanus toxoid and tetanus immune globulin

Irrigation and debridement of the wound; tetanus toxoid

Irrigation and debridement of the wound; IV antibiotics

Tetanus toxoid and IV antibiotics

499. A 6-year-old boy presents to the emergency department with a painful, markedly swollen elbow. While ice-skating, he fell with his arm outstretched. Radiographs of the elbow demonstrate a displaced, supracondylar fracture of the humerus. On examination, there is pain on passive flexion at the wrist and a decreased radial pulse, with diminished capillary refill in the hand. Which of the following is the most appropriate management of this injury?

Admission to hospital for close observation, with immobilization of the elbow at 90° of flexion

Closed reduction with percutaneous pinning under general anesthesia

Open reduction and pinning under general anesthesia

Open reduction with pinning, and exploration of the brachial artery

Open reduction with pinning, exploration of the brachial artery, and decompression fasciotomy of the forearm fascial compartments

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

Oxygen by mask, analgesics, and no specific intervention

Intubation and use of a respirator

Insertion of a chest tube in the right second intercostal space

Insertion of a chest tube at the right base

Exploratory thoracotomy

501. A 35-year-old woman with a history of previous right thyroidectomy for a benign thyroid nodule now undergoes completion thyroidectomy for a suspicious thyroid mass. Several hours postoperatively, she develops progressive swelling under the incision, stridor, and difficulty breathing. Orotracheal intubation is successful. Which of the following is the most appropriate next step?

Fiberoptic laryngoscopy to rule out bilateral vocal cord paralysis

Administration of intravenous calcium

Administration of broad-spectrum antibiotics and debridement of the wound

Wound exploration

Administration of high-dose steroids and antihistamines

502. A 62-year-old woman presents with invasive ductal carcinoma of the right breast. Which of the following findings would still allow her to receive breast conservation surgery (partial mastectomy)?

Diffuse suspicious microcalcifications throughout the breast

Multifocal disease

Previous treatment of a breast cancer with lumpectomy and radiation

Large tumor relative to breast size

Persistently positive margins after multiple reexcisions of the breast cancer

503. In a 6-month-old previously healthy male infant, an abnormality is revealed during a routine diaper change, as illustrated in Figure 6-19. The parents have noted this finding on and off on several occasions over the last month. On each occasion, the child has been feeding well, and is content and playful. Which of the following is the most likely diagnosis?

504. In a 6-month-old previously healthy male infant, an abnormality is revealed during a routine diaper change, as illustrated in Figure 6-19. The parents have noted this finding on and off on several occasions over the last month. On each occasion, the child has been feeding well, and is content and playful. Which of the following is the most appropriate management at this time?

Antibiotics

Reassurance to the parents that the abnormality will resolve without intervention

Referral to the emergency department for immediate surgical consultation

Referral for elective surgical repair

Scrotal support

505. A young mother complains of pain along the radial side of the wrist and the first dorsal compartment. She relates that the pain is often caused by the position of wrist flexion and simultaneous thumb extension that she assumes to carry the head of her baby. On physical examination, the pain is reproduced by asking her to hold her thumb inside her closed fist, and then forcing the wrist into ulnar deviation. Which of the following is the most likely diagnosis?

Acute and chronic bursitis

Carpal tunnel syndrome

Hairline unrecognized fracture of the carpal navicular (scaphoid) bone

Palmar fascial contracture (Dupuytren's contracture)

Tenosynovitis of the abductor or extensor tendons of the thumb (De Quervain's tenosynovitis)

506. A 60-year-old man seeks medical attention because of recurrent urinary tract infections. The patient also reports a history of increasing difficulty in urination (decreased flow, straining, and hesitancy) over the last several months. A prostate-specific antigen (PSA) level is mildly elevated and a prostate biopsy proves benign. Which of the following is the most appropriate initial management of this patient with benign prostatic hyperplasia (BPH)?

α-Adrenergic blocker

5-alpha reductase inhibitor

α-Adrenergic blocker and 5-alpha reductase inhibitor

Transurethral resection of the prostate (TURP)

Open prostatectomy

507. 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?

Placement of an external stent through the proximal ureteral stump with delayed reconstruction

Ipsilateral nephrectomy

Placement of a catheter from the distal ureter through an abdominal wall stab wound

Placement of a closed-suction drain adjacent to the injury

Bringing the proximal ureter up to the skin as a ureterostomy

508. An 83-year-old woman presents to a mammographic facility for a screening mammogram. The technician notices a mass in the lateral right breast. The patient denies any breast pain, nipple discharge, skin changes, or breast trauma. A right breast CC view is shown in Figure 6-7. Which of the following is the most appropriate next step in management?

509. A 25-year-old unhelmeted man involved in a motorcycle collision has multiple cerebral contusions on head computed tomographic (CT) scan. He is agitated but hemodynamically stable, with a heart rate of 80 beats per minute and a mean arterial pressure (MAP) of 90 mm Hg. An intracranial pressure monitor is placed, and the initial ICP reading is 30 mm Hg. Which of the following is the most appropriate in the management of his traumatic brain injury (TBI) over the next few days?

Hyperventilation to maintain a cerebral PCO2 of 25 to 30 mm Hg

Administration of neosynephrine to increase his MAP and, consequently, his cerebral perfusion pressure (CPP)

Administration of mannitol (1 g/kg) to reduce his ICP

Placement of the patient in Trendelenburg position to increase cerebral perfusion

Avoidance of all sedating drugs in the first 24 to 48 hours in order to accurately assess his neurologic status

510. A 10-day-old infant presenting with bilious vomiting, paucity of gas on plain radiographs, and duodenal obstruction on UGI contrast study (Figures 6-15 and 6-16). Which one is the most likely diagnostic?

511. A neonate with bile-stained vomiting, abdominal distention, dilated loops of bowel on plain radiographs, and a small-caliber colon on contrast enema (Figure 6-17) Which one is the most likely diagnostic?

512. A 50-year-old woman complains of headaches and lateralizing weakness. A CT scan of the brain reveals an irregular mass in the right cerebral hemisphere. A biopsy documents that this is a glioblastoma. Which of the following is the best treatment strategy for potential cure?

Chemotherapy with temozolomide alone

Combination chemotherapy with carmustin, cisplatin, and temozolomide

External beam radiation alone

Surgical resection alone

Combined surgical resection, external beam radiation, and chemotherapy with temozolomide

513. 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?

514. A 67-year-old man has had an indolent, unhealing ulcer at the heel of the right foot for several weeks. The patient began wearing a new pair of shoes shortly before the ulcer started and noticed a blister as the first anomaly at the site where the ulcer eventually developed. He indicates that neither the blister nor the ulcer ever gave him any pain. The ulcer is 3.5 cm in diameter, the ulcer base looks dirty, and there is hardly any granulation tissue. The skin around the ulcer looks normal. The patient has no sensation to pin prick anywhere in that foot. Peripheral pulses are weak but palpable. He is obese and has varicose veins, high cholesterol, and poorly controlled type 2 diabetes mellitus. Which of the following most accurately characterizes the ulcer?

Diabetic ulcer due to trauma, neuropathy, and microvascular disease

Ischemic ulcer due to arteriosclerosis

Ischemic ulcer due to embolization

Neoplastic in nature, probably squamous cell carcinoma

Stasis ulcer due to venous insufficiency

515. An 85-year-old man presents to the emergency room with an acute onset of midepigastric pain, nausea, vomiting, and hiccups starting 2 days ago. He is unable to keep any food down. Past history is pertinent for a long-standing hiatal hernia, hypertension, and diet-controlled diabetes. Examination reveals vital signs of pulse rate 82/min, BP 100/52 mmHg, respiratory rate 16/min, and temperature 97.2°F. The patient is in no acute distress, but has epigastric tenderness without guarding. Laboratory analysis revealed a hematocrit of 46 and a normal white blood cell (WBC) count. A chest x-ray is shown in Figure 6-5a. A fluoroscopically guided NG tube was placed using contrast, and his stomach was decompressed. After adequate fluid and electrolyte resuscitation, an upper gastrointestinal (UGI) contrast study was obtained and is shown in 6-5b. Which of the following is the most appropriate next step in management?

Laparotomy or laparoscopy and operative repair

Continued NG tube decompression and initiation of total parenteral nutrition (TPN)

Thoracotomy or thoracoscopy and operative repair

Endotracheal intubation and initiation of ventilatory support

Upper endoscopy

516. A 40-year-old previously healthy man presents with sudden onset of severe abdominal pain that radiates from the right loin (flank) to groin. This pain is associated with nausea, sweating, and urinary urgency. He is distressed and restless, but an abdominal examination is normal. Which of the following is the most likely diagnosis?

517. 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?

518. 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?

Fluid resuscitation with 2 L of isotonic crystalloid

Needle decompression of the left chest, followed by insertion of a chest tube

Portable chest x-ray

Immediate intubation and assisted ventilation

Emergency department thoracotomy

519. 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 likely diagnosis?

520. A 21-year-old previously healthy woman presents with abdominal pain of 48-hour duration. The pain was initially periumbilical and on progression became localized in the right lower quadrant. The woman had nausea and an appetite. She denied dysuria. Her last menstrual period was 2 weeks earlier. On examination, she was febrile (temperature 38.2°C), and was found to have localized tenderness in the right lower quadrant with guarding. Rectal examination was normal. Laboratory examination demonstrated mild leukocytosis. Select the most likely diagnosis.

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

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

Sympathectomy without any delay

Debridement of devitalized tissues

Slow rewarming at room temperature

Slow rewarming with dry heat

Rapid rewarming in warm water

{"name":"Surgery USMLE (401-522)", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"401. 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?, 402. A 65-year-old woman presents to the physician’s office for evaluation of an abnormal screening mammogram. She denies any breast masses, nipple discharge, pain, or skin changes. Past history is pertinent for hypertension. Family history is positive for postmenopausal breast cancer in a sister. She has a normal breast examination and no axillary adenopathy. The remainder of her examination is unremarkable. An MLO view of the right breast is shown in Figure 6-6a along with a magnification view of the craniocaudal (CC) film (Figure 6-6b). Which of the following is the most likely diagnosis?, 403. A 49-year-old woman presents to her physician with dysphagia, regurgitation of undigested food eaten hours earlier, and coughing over the last 6 months. She was hospitalized 1 month ago for aspiration pneumonia and successfully treated with antibiotics. Examination reveals a thin-appearing woman with normal vital signs and unremarkable chest, heart, and abdominal examination. A UGI contrast study is performed and reveals a pharyngoesophageal (Zenker’s) diverticulum. Which of the following statements is true regarding Zenker’s diverticula?","img":"https://cdn.poll-maker.com/17-694507/untitled.png?sz=1200"}