Chir diagnostic 1

2) A 68-year-old man is brought to the emergency department following a high-speed automobile accident. He is alert and complains of chest pain and mild back pain. His blood pressure is 80/60 mm Hg. Chest x-ray shows a widened mediastinum, tracheal deviation, bronchial displacement, and loss of the aortic knob. Which of the following is the most likely diagnosis?

6) An 81-year-old man with Alzheimer disease who lives in a nursing home undergoes surgery for a fractured femoral neck. On the 5th postoperative day, it is noted that his abdomen is grossly distended and tense, but not tender. He has occasional bowel sounds. The rectal vault is empty on digital examination, and there is no evidence of occult blood. X-ray films show a few distended loops of small bowel and a much distended colon. The cecum measures 9 cm in diameter, and the gas pattern of distention extends throughout the entire large bowel, including the sigmoid and rectum. No stool is seen in the films. Other than the abdominal distention, and the ravages of his mental disease, he does not appear to be ill. Vital signs are normal for his age. Which of the following is the most likely diagnosis?

7) A 55-year-old, HIV-positive man has a fungating mass growing out of the anus. He can feel it when he wipes himself after having a bowel movement, but it is not painful. For the past 6 months, he has noticed blood on the toilet paper, and from time to time there has also been blood coating the outside of the stools. He has lost weight, and he looks emaciated and ill. On physical examination, the mass is easily visible. It measures 3.5 cm in diameter, is fixed to surrounding tissues, and appears to grow out of the anal canal. He also has rock-hard, enlarged lymph nodes on both groins, some of them as large as 2 cm in diameter. Which of the following is the most likely diagnosis?

12) A 65-year-old man undergoes a low anterior resection for rectal cancer. On the fifth day in hospital, his physical examination shows a temperature of 39°C (102°F), blood pressure of 150/90 mm Hg, pulse of 110 beats per minute and regular, and respiratory rate of 28 breaths per minute. A computed tomography (CT) scan of the abdomen reveals an abscess in the pelvis. Which of the following most accurately describes his present condition?

13) A 24-year-old man comes to the physician 24 hours after sustaining an injury to the right knee while playing soccer. He can walk, but he limps on the right side. He reports that he was hit by another player on the lateral side of his right knee, but did not feel a snap or pop at the time of the accident. On examination, the right knee appears normal, but palpation elicits tenderness along the medial aspect of the joint line. Increased laxity is observed when a valgus stress is applied to the knee flexed at 30 degrees, but not when the knee is in full extension. Lachman's test and posterior drawer tests are negative. Which of the following is the most likely diagnosis?

14) A 35-year-old man had a splenectomy 8 days ago, following a motor vehicle accident. He is now complaining of left shoulder pain. His temperature is 39.0C (102.2F), blood pressure is 110/80 mm Hg, pulse is 110/min, and respirations are 30 min and shallow, Physical examination shows clear lungs with equal breath sounds bilaterally and mild tenderness to palpation in the left upper quadrant with a well- healing midline laparotomy incision. Laboratory studies show: Hemoglobin 15 g/dL, Hematocrit 45%, Leukocyte counts 15,000/mm3.A chest x-ray film shows no infiltrates or effusions. Which of the following is the most likely diagnosis?

15) A 27-year-old man is shot point blank with a .22-caliber revolver. The entrance wound is in the anterior chest wall, just to the left of the sternal border, at the level of the 4th intercostal space. There is no exit wound. He is diaphoretic, cold, shivering, and anxious, and is asking for a blanket and a drink of water. His blood pressure is 65/40 mm Hg, and his pulse is 145/min and barely perceptible. He has large, distended veins in his neck and forehead. He is breathing adequately and has bilateral breath sounds. He is neurologically intact. Which of the following is the most likely diagnosis?

21) A 55-year-old woman requires an abdominoperineal operation for rectal cancer. She has a history of stable angina. Which of the following clinical markers is most likely to predict a cardiac event during her noncardiac surgery and should prompt further cardiac workup prior to her operation?

22) An 18-year-old man was traveling at a high speed when his car slammed into a wall. He is brought into the emergency department by ambulance. His blood pressure is 60/40 mmHg, pulse is 115/min and weak, respirations are 18/min, and central venous pressure is 2 cmH2O. He is responsive only to painful stimuli. Breath sounds are equal bilaterally, and cardiac auscultation reveals only tachycardia. The abdomen is soft, nondistended, and nontender with active bowel sounds. A chest x-ray film shows a widened mediastinum. Which of the following is the most likely diagnosis?

25) A 71-year-old man develops dysphagia for both solids and liquids and weight loss of 60 lb over the past 6 months. He undergoes endoscopy, demonstrating a distal esophageal lesion, and biopsies are consistent with squamous cell carcinoma. He is scheduled for neoadjuvant chemoradiation followed by an esophagectomy. Preoperatively he is started on total parenteral nutrition, given his severe malnutrition reflected by an albumin of less than 1. Which of the following is most likely to be a concern initially in starting total parenteral nutrition in this patient?

27) An elderly diabetic woman with chronic steroid-dependent bronchospasm has an ileocolectomy for a perforated cecum. She is taken to the ICU intubated and is maintained on broad-spectrum antibiotics, renal dose dopamine, and a rapid steroid taper. On postoperative day 2, she develops a fever of 39.2°C (102.5°F), hypotension, lethargy, and laboratory values remarkable for hypoglycemia and hyperkalemia. Which of the following is the most likely explanation for her deterioration?

28) On postoperative day 5, an otherwise healthy 55-year-old man recovering from a partial hepatectomy is noted to have a fever of 38.6°C (101.5°F). Which of the following is the most common nosocomial infection postoperatively?

30) Acute renal failure occurs following aortic angiography in a 72-year-old man. His weight has been rising, his lungs show rales at both bases, and he is dyspneic. His fractional excretion of sodium is greater than 1. He has eosinophilia on his peripheral smear, an elevated erythrocyte sedimentation rate, and proteinuria with microscopic hematuria. Which of the following is the most likely cause of his renal failure?

33) A patient develops a fever and tachycardia during a blood transfusion after a redo coronary artery bypass procedure. The nurse subsequently discovers that there was a mix-up in the cross-match because of a labeling error. Which of the following is diagnostic in a patient with an immediate hemolytic reaction secondary to a blood transfusion?

34) An obese 50-year-old woman undergoes a laparoscopic cholecystectomy. In the recovery room, she is found to be hypotensive and tachycardic. Her arterial blood gases reveal a pH of 7.29, PaO2 of 60 mm Hg, and PaCO2 of 54 mm Hg. Which of the following is the most likely cause of this patient’s problem?

35) Approximately 6 weeks following a kidney transplant, a 59-year-old woman develops fever, malaise, and myalgias and is found to have a cytomegalovirus (CMV) infection. Which of the following is a potential sequela of CMV infection?

36) A 24-year-old woman develops moderate, generalized abdominal pain of sudden onset and shortly thereafter faints. At the time of evaluation in the emergency department, she has regained consciousness, is pale, and has a blood pressure of 95/70 mm Hg and a faint pulse rate of 90/min. The abdomen is mildly distended and tender, with normal bowel sounds. Her hemoglobin is 7 g/dL. There is no history of trauma, but it is suspected that she might be bleeding into her abdomen, and a diagnostic peritoneal lavage is performed. The study shows that there is free blood in the peritoneal cavity. She denies the possibility of pregnancy because she has been on birth control pills since the age of 14 and has never missed taking them. Pelvic examination is normal, and a pregnancy test is negative. At laparotomy, the surgeons are likely to find which of the following?

37) A 42-year-old man is undergoing chemotherapy after resection of a cecal adenocarcinoma with positive lymph nodes. You are asked to see him regarding a potential surgical complication. Which of the following potentially operable complications is a common occurrence among patients receiving systemic chemotherapy?

38) A 30-year-old previously healthy man presents with refractory hypertension on four medications. Urinalysis is positive for metanephrines. He was adopted as an infant and therefore does not know his family history. Which of the following inherited syndromes is not associated with this disease?

40) A 22-year-old healthy African-American woman presents with a recurrent growth on her right thigh. She has a childhood history of a third-degree scald burn to the same area that did not require skin grafting. The growth was completely removed 2 years ago. On physical examination there is a 5 cm × 2 cm, raised, irregularly shaped purple lesion with a smooth top. Which of the following is the most likely diagnosis?

45) A 71-year-old man is involved in a minor automobile accident on the road between Guadalajara and Lake Chapala in Mexico. The man is an American citizen who at the age of 65 years retired to a lakeside home in that area. Although he is asymptomatic, he decides to return to the United States to be "thoroughly checked." He is admitted to a veteran's hospital in south Texas, where he undergoes a CT scan of his abdomen. There are no signs of traumatic injuries, but the scan reveals the presence of four simple, thin walled cystic structures, approximately 1 cm in diameter, scattered throughout both lobes of his liver. They have no septations. There are no cysts in the kidneys or pancreas. The man is completely asymptomatic and afebrile. Liver function tests are normal, as is his white blood count and differential. Which of the following is the most likely diagnosis?

46) A 78-year-old man comes to the physician because of a bloody urethral discharge for 3 days. He has had increasing frequency of urination and hesitancy for the past 2 years, but these symptoms have never been severe enough to require medical attention. Digital rectal examination reveals a slightly enlarged and firm prostate. Expressed prostatic secretions are negative for bacteria and leukocytes. Collection of clean-catch urine in separate aliquots reveals initial hematuria, with blood present in the first 5 mL. Which of the following is the most likely diagnosis?

49) A 14-year-old girl has a firm, movable, rubbery mass in her left breast. The mass was first noticed 6 months ago and has since grown to about 6 cm in diameter. Which of the following is the most likely diagnosis?

52) A 53-year-old man is brought to the emergency department by his wife because of headache and visual changes. Approximately 3 hours ago, he had the acute onset of an extremely severe posterior headache that was non-radiating but was associated with nausea and vomiting. This headache subsided, but over the past hour he has developed mild neck stiffness and pain on flexion of his neck. The patient is not cooperative, so no additional history is known; however, his wife states that he was feeling well until recently and has no allergies. The patient appears moderately uncomfortable and is complaining of the worst headache he has ever experienced. Which of the following is the most likely cause for his symptoms?

54) A 6-year-old boy has insidious development of limping with decreased motion in one hip. He complains occasionally of knee pain on that side. He walks into the office with an antalgic gait. Examination of the knee is normal, but passive motion of the hip is guarded. The child is afebrile, and the parents indicate that his gait and level of activity were completely normal all his life until this recent problem. He has not had a recent febrile illness. Which of the following is the most likely diagnosis?

56) A 51-year-old man is undergoing abdominal surgery and becomes hypotensive while under general anesthesia. The patient had been doing well during most of the procedure but now has a blood pressure of 80/40 mm Hg. His past medical history is significant for coronary artery disease and diabetes mellitus. A pulmonary artery catheter placed prior to the procedure gives the following data: Central venous pressure 10 mmHg, Pulmonary artery pressure 60/30 mmHg, Pulmonary capillary occlusion 24 mm Hgpressure Cardiac output 2.3 L/min. Which of the following is the most likely diagnosis?

60) A previously healthy 28-year-old woman develops significant postpartum hemorrhage, with a rapid drop in hematocrit to 18%. Despite aggressive IV fluid resuscitation, the patient has a persistent tachycardia, labile systolic blood pressure, and poor urine output. Ongoing resuscitation includes emergency transfusion with 2 units of O-negative packed red blood cells. During transfusion of the second unit, the patient develops chills, fever, vomiting, and hypertension. These symptoms are most likely the result of which of the following?

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

71) A 35-year-old woman is involved in a motor vehicle crash, sustaining a severe pelvic fracture, with disruption of the pelvic ring. In the trauma resuscitation room, she is confused and tachypneic, with a blood pressure of 90 mmHg systolic and a heart rate of 130/min. Laboratory investigations include serum electrolyte analysis, revealing a sodium of 139, a chloride of 103, and a bicarbonate of 14 meq/L. This patient demonstrates which of the following?

75) A 54-year-old man presents to the emergency department on transfer from another hospital at the request of the family. He was admitted to the outside hospital 2 weeks ago with abdominal pain, nausea, vomiting, and fever. He was treated with antibiotics, NG tube decompression, and TPN without significant improvement. He developed jaundice 2 days ago. His past history is pertinent for a 40 pack- year smoking history, chronic alcohol abuse, and diabetes. Examination reveals a mildly jaundiced patient with vital signs of temperature 100°F, pulse rate 95/min, and BP 110/60 mmHg. Cardiac examination is unremarkable, lung examination reveals decreased breath sounds at the bases bilaterally, and abdominal examination reveals fullness in the epigastrium with tenderness and voluntary guarding. Which one is the most likely diagnosis?

78) A 5-week-old infant presents with a 1-week history of progressive nonbilious emesis, associated with a 24-hour history of decreased urine output. The infant continues to be active and eager to feed. On examination, the infant has a sunken fontanels and decreased skin turgor. The abdomen is scaphoid, and with a test feed, there is a visible peristaltic wave in the epigastrium. The diagnosis is best confirmed by which of the following?

83) A 63-year-old man is seen because of facial swelling and cyanosis, especially when he bends over. There are large, dilated subcutaneous veins on his upper chest. His jugular veins are prominent even while he is upright. Which of the following conditions is the most likely cause of these findings?

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

85) A 65-year-old woman has had pain in her right shoulder and has been treated with analgesics without relief. The CXR reveals a mass in the apex of the right chest. A transthoracic needle biopsy documents carcinoma. Superior pulmonary sulcus carcinomas (Pancoast tumors) are bronchogenic carcinomas that typically produce which of the following clinical features?

89) A 56-year-old man develops slow, progressive paralysis of the facial nerve on one side. It took several weeks for the full-blown paralysis to become obvious, and it has been present now for 3 months. It affects both the forehead and the lower face. He has no pain anywhere, and no palpable masses by physical examination. Which of the following is the most likely diagnosis?

92) The unrestrained front-seat passenger in a car that crashes sustains closed comminuted fractures of both femoral shafts. Shortly after admission, he develops a blood pressure of 80/50 mm Hg, a pulse rate of 110/min, and a venous pressure of zero. He becomes pale, cold, and clammy, but the rest of his physical examination and x-ray films of the chest and pelvis are unremarkable. A sonogram of the abdomen done in the emergency department is likewise negative. Which of the following is the most likely reason for the low blood pressure?

97) 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 likely diagnosis?

110) 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?

115) 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?

117) 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?

118) 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?

121) 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?

125) 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?

126) 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?

127) 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?

128) 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?

129) 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?

139) A 25-year-old woman presents to the emergency room complaining of redness and pain in her right foot up to the level of the midcalf. She reports that her right lower extremity has been swollen for at least 15 years, but her left leg has been normal. On physical examination, she has a temperature of 39°C (102.2°F) and the right lower extremity is nontender with nonpitting edema from the groin down to the foot. There is cellulitis of the right foot without ulcers or skin discoloration. The left leg is normal. Which of the following is the most likely underlying problem?

140) A blond, blue-eyed, 69-year-old sailor has a non-healing, indolent, 1.5-cm ulcer on the lower lip, arising from the vermilion border. The ulcer has been present and growing for the past 8 months. He is a pipe smoker, but has no history of alcohol or drug abuse. Physical examination shows "weather-beaten" facial skin, but no other ulcers. There are no enlarged lymph nodes in his neck. Which of the following is the most likely diagnosis?