USMLE surgery 1022 (296-510 / Part 2) GD

A 45-year-old woman underwent elective surgery for an inguinal hernia. In the postoperative recovery room, she developed nausea, vomiting, and acute abdominal pain. She has a history of systemic lupus erythematosus, pernicious anemia, type-1 diabetes, chronic low back pain, and uterine fibroids. Her preoperative medications include monthly vitamin B-12 injections, insulin, prednisone, hydroxychloroquine, and acetaminophen. Her blood pressure is 70/40 mm Hg and heart rate is 110/min. Initial laboratory studies show a blood glucose of 50 mg/dl. Which of the following is the most likely cause of her condition?
Postoperative bleeding
Diabetic ketoacidosis
Intra-abdominal abscess
Intestinal obstruction
Adrenal insufficiency
A 57-year-old man comes to the physician for a routine checkup. He complains of right-sided leg cramps accompanied by fatigue while walking. He also complains of occasional right thigh pain. He denies chest pain, syncope, nausea, and abdominal pain. His sexual performance has decreased over the past 1 year. His other medical problems include stage 3 chronic kidney disease, type 2 diabetes mellitus, hypertension, hyperlipidemia, gout, and gastroesophageal reflux disease. His blood pressure is 144/92 mm Hg, pulse is 67/min, and BMI is 29 kg/m2. Peripheral pulses are bilaterally palpable. There is a small ulcer at the base of the right great toe. The ankle-brachia! index (ABI) is 1.0 (normal: 1.0 - 1.3). His laboratory values are significant for a serum creatinine level of 2.2 mg/dl and an HbA1c level of 7.5% but otherwise unremarkable. Which of the following is the most appropriate next step in managing this patient's leg pain?
Aspirin, cilostazol, and verapamil
CT angiography of the lower extremities
Exercise testing with repeat ABI
D. Tight glucose control and follow-up in 3 months
Treatment for diabetic neuropathy
A 34-year-old woman is admitted to the hospital because of septic shock secondary to a urinary tract infection. In the intensive care unit, she receives intravenous fluids and antibiotics. Her initial ECG shows sinus tachycardia but is otherwise unremarkable. Chest x-ray shows no abnormalities. An internal jugular vein catheter is placed on the right side using ultrasound guidance to locate the vein. The patient is properly draped, and the skin is cleaned with chlorhexidine solution. Blood is freely aspirated from all ports after insertion. Vital signs are stable, and oxygenation is maintained. Which of the following is the most appropriate next step in managing this patient?
Antibiotic installation into the catheter
Echocardiography
Heparin installation into the catheter
Portable chest x-ray
Repeat 12-lead ECG
A 45-year-old woman, who wears high-heeled, pointed shoes, complains of pain in the forefoot after prolonged standing or walking. Occasionally, she also experiences numbness, a burning sensation, and tingling in the area. Physical examination shows no obvious deformities and a very tender spot in the third interspace, between the third and fourth toes. There is no redness, limitation of motion, or signs of inflammation. Which of the following is the most likely diagnosis?
Gout
Hallux rigidus
Metatarsophalangeal articulation pain
Morton's neuroma
Plantar fasciitis
A 22-year-old gang member arrives in the emergency department with multiple gunshot wounds to the chest and abdomen. He has labored breathing and is cyanotic, diaphoretic, cold, and shivering. He is wide awake, and in a normal tone of voice he tells everyone that he is going to die. An initial survey reveals a blood pressure of 60/40 mm Hg. His pulse is 150/min and barely perceptible. He is in obvious respiratory distress and has big distended veins in his neck and forehead. His trachea is deviated to the left, and the right side of his chest is hyperresonant to percussion, with no breath sounds. Which of the following is the most appropriate initial step in management?
Emergency blood gases
Immediate chest x-ray films
Awake endotracheal intubation
A 16-gauge needle inserted in the second right intercostal space
Pericardiocentesis
A 62-year-old woman presents to the physician’s office with complaints of constipation. She has had constipation for the last 6 months, which has worsened over the last month, associated with mild bloating. She noted that her stool has become “pencil thin” in the last month, with occasional blood, but she continues to have bowel movements daily. Past history is unremarkable. Examination reveals normal vital signs and heart and lung examination. Abdominal examination reveals mild fullness, especially in the lower quadrants. Rectal examination shows no rectal masses, but the stool is hematest positive. A barium xray is obtained, and one view is shown in Figure 6-11. Which of the following is the most appropriate next step in management?
Proctoscopy and passage of a rectal tube
Proctoscopy and biopsy
Colonoscopy
Endoscopic dilation of the stricture
NPO, IV fluids, and antibiotics
A 45-year-old man presents to the physician’s office for evaluation of a skin lesion on his abdomen. He states that the lesion has been present for 1 year, but has recently enlarged over the last 2 months. The mass is nontender, and he is otherwise asymptomatic. Past history is unremarkable. Examination reveals a 3-cm, pigmented, irregular skin lesion located in the left lower quadrant of the abdomen, as shown in Figure 6-12. Heart, lung, and abdominal examination are normal. There are no palpable cervical, axillary, or inguinal lymph nodes. Chest x-ray and liver function tests are normal. Which of the following is the most likely diagnosis?
Squamous cell carcinoma
Basal cell carcinoma
Merkel cell carcinoma
Melanoma
Keratoacanthoma
A 55-year-old man with recent onset of atrial fibrillation presents with a cold, numb, pulseless left lower extremity. He is immediately taken to the operating room for an embolectomy of the left popliteal artery. Which additional procedure should be performed along with the embolectomy?
Electromyography (EMG) of the leg
Measurement of anterior compartment pressure in the leg
Fasciotomy of the anterior compartment in the leg
Fasciotomy of all the compartments in the leg
Application of a posterior splint to the leg
A 58-year-old man presents with pain in the left leg after walking more than one block that is relieved with rest. On physical examination, distal pulses are not palpable in the left foot and there is dry gangrene on the tip of his left fifth toe. An ankle-brachial index on the same side is 0.5. Which of the patient’s symptoms or signs of arterial insufficiency qualifies him for reconstructive arterial surgery of the left lower extremity?
Ankle-brachial index less than 0.7
Rest pain
Claudication
Absent palpable pulses
Toe gangrene
A 62-year-old man comes to the emergency department because of severe abdominal pain. He states that he suddenly felt weak, diaphoretic, and had no energy. He is a smoker and has hypertension. His blood pressure on initial examination was 110/70 mm Hg. Physical examination shows a diffusely tender abdomen. During CT scan he becomes pale and drowsy. CT scan is shown below. Repeat examination shows a man with anxiety and a blood pressure of 80/50 mm Hg and pulse of 110/min. Which of the following is the most appropriate next step in management?
Exploratory abdominal surgery
Obtain ultrasound
Check amylase and lipase
Laparoscopy
Drain fluid from the abdomen
An 84-year-old man is brought to the emergency department because of 1 hour of severe back pain. He also had syncope that lasted <1 minute. Before arriving at the hospital, he had an episode of gross hematuria, which he has never had before. He also complains of some shortness of breath. He denies chest pain, cough, nausea, vomiting, headache, and neck pain. His blood pressure is 72/55 mm Hg and pulse is 112/min and regular. His pulse oximetry shows 92% on room air. His ECG shows sinus tachycardia with prominent horizontal ST segment depression in the anterior chest leads. Which of the following is the most likely diagnosis?
Abdominal aortic aneurysm rupture
Acute mesenteric ischemia
Acute myocardial infarction
Massive pulmonary embolism
Nephrolithiasis with renal colic
A 23-year-old man known to have neurofibromatosis, type 1 (von Recklinghausen's disease), presents with a left lower quadrant abdominal mass and signs of neurologic deficits in his left leg. In the ensuing workup, it is determined that he has higher than normal values of catabolites of epinephrine and norepinephrine in a 24-hour urinary collection. He is currently normotensive. Before invasive steps are taken to biopsy and eventually remove his left lower quadrant abdominal mass, which of the following is the most appropriate next step in management?
CT scan of the head looking for meningiomas
MRI of his adrenal glands
MRI of the acoustic nerves
Radionuclide scans from the neck to the pelvis looking for extra-adrenal pheochromocytomas
Radiation therapy to the left lower quadrant abdominal mass
A car is involved in a head-on collision. The driver, who is sober and wearing his seat belt, explains that he clearly saw his drunk, unrestrained front seat passenger hit the windshield with his face and the dashboard with his knees. Examination of the passenger indeed shows multiple facial lacerations, but because of his intoxication he cannot explain where else he might be hurting. He is neurologically intact, and his cervical spine x-ray films are normal. Additional injury, representing a potential orthopedic emergency, is not obvious but is suspected. Therefore, an x-ray film of which of the following areas should most likely be obtained?
Both patellas
Both hips
The jaw
The lumbar spine
The skull
A 35-year-old woman presents to the clinic for a discussion on breast cancer risk. Her family history is pertinent for a grandmother who died of breast cancer at age 53, a mother who died of premenopausal breast cancer, and one of three sisters with breast cancer diagnosed at age 42. The sister with breast cancer underwent genetic testing and was found to have a BRCA1 mutation. Subsequently, the 35-year-old woman underwent genetic testing and was found to be a carrier of the same deleterious BRCA1 mutation. Which of the following ranges represents the lifetime risk for breast cancer that should be quoted for this patient?
0–30%
10–40%
20–50%
50–80%
70–100%
A 35-year-old woman presents to the clinic for a discussion on breast cancer risk. Her family history is pertinent for a grandmother who died of breast cancer at age 53, a mother who died of premenopausal breast cancer, and one of three sisters with breast cancer diagnosed at age 42. The sister with breast cancer underwent genetic testing and was found to have a BRCA1 mutation. Subsequently, the 35-year-old woman underwent genetic testing and was found to be a carrier of the same deleterious BRCA1 mutation. For this patient, which of the following strategies represent an accepted management option for her high-risk status?
Yearly self-breast examinations
Semiannual mammography
Bilateral breast irradiation
Prophylactic unilateral mastectomy
Chemoprevention with tamoxifen
A 38-year-old woman presents to the physician because of right upper quadrant pain associated with nausea and vomiting for the past 12 hours. She has had similar pain previously, usually precipitated after the ingestion of fatty foods. However, past episodes have always resolved within one to two hours. She has type 2 diabetes mellitus, hypertriglyceridemia, and hypercholesterolemia. Her current medications include metformin, fenofibrate, and a statin. Her temperature is 38.3° C (101° F), blood pressure is 130/70 mm Hg, pulse is 98/min, and respirations are 20/min. Her BMI is 32 kg/m2. Examination shows right upper quadrant tenderness. Abdominal ultrasound reveals gallstones, a thickened gallbladder wall with edema, and a normal common bile duct. Her alkaline phosphatase level is normal. Which of the following is the most appropriate next step in the management of this patient?
Cholecystectomy within 72 hours
Endoscopic retrograde cholangiography
Delayed cholecystectomy
HIDA scan
Percutaneous trans-hepatic drainage
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 36.7° C (98° F), blood pressure is 120/76 mm Hg, pulse is 80/min and respirations are 16/min. JVP is normaL Lungs are clear to 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. Which of the following is the most likely cause of his edema?
Lymphatic obstruction
Impaired cardiac contraction
Reduced diastolic filling of the heart
Increased urinary loss of protein
Venous valve incompetence
A 40-year-old, obese, white woman, mother of five children, gives a history of repeated episodes of right upper quadrant abdominal pain. The pain is brought about by the ingestion of fatty foods and is relieved by the administration of anticholinergic medications. The pain is colicky, radiates to the right shoulder and around to the back, and is accompanied by nausea and occasional vomiting. The patient has no pain at this time, but is anxious to avoid further episodes. She is afebrile, and physical examination is unremarkable. Which of the following is the most appropriate next step in management?
Sonogram of the biliary tract and gallbladder
Upper gastrointestinal series with barium
Antibiotics, IV fluids, and nothing by mouth
Endoscopic retrograde cholangiopancreatogram (ERCP)
Exploratory surgery
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?
Esophagitis with stricture
Esophageal carcinoma
Lung carcinoma with invasion into the esophagus
Lymphoma
Achalasia
A 68-year-old man presents to the physician’s office complaining of progressive dysphagia over the last 3 months associated with mild chest discomfort. He reports a 15-lb weight loss, a 30 pack-year smoking history, and occasional alcohol intake. The physical examination, including vital signs, is unremarkable. A chest x-ray was normal, and a barium esophagogram shows an irregular filling defect in the distal third of the esophagus with distortion and narrowing of the lumen. Which of the following is the most appropriate next step in management?
CT scan
Esophagoscopy
MRI scan
Surgical resection
Bronchoscopy
In this patient, a benign gastric ulcer was found, and he was placed on a proton-pump inhibitor and triple antibiotics for Helicobacter pylori. He returns to the physician’s office 3 months later with similar complaints and, on re-evaluation, the gastric ulcer was found to persist. Which of the following is the most appropriate next step in management?
A second trial of proton-pump inhibitors with triple antibiotics and re-evaluation in 2 months
Trial of H2 blockers with triple antibiotics and re-evaluation in 2 months
A trial of sucralfate and re-evaluation in 2 months
Surgical management
Trial of prostaglandins and re-evaluation in 2 months
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. We decided to do surgical repair. Several weeks later, the child presents to the emergency department with a 4-hour history of irritability. He has had one episode of nonbilious vomiting and has refused to breast-feed. In the emergency department, the infant appears inconsolable. He is afebrile, and his abdomen is mildly distended but soft. On removal of his diaper, the same abnormality is documented (see Figure 6-19). Which of the following is the most appropriate management at this time?
Urgent surgical exploration
Systemic antibiotics
Elective surgical repair
Sedation with manual reduction and arrangements for elective surgical repair
Sedation with manual reduction, admission, rehydration, and surgical repair within 24–48 hours
A 29-year-old man presents with a 2-day history of severe left-sided scrotal pain and swelling. He is sexually active and has had "many" sexual partners. His temperature is 38.2 C (100.8 F), blood pressure is 120/70 mm Hg, and pulse is 80/min. Examination shows unilateral intrascrotal tenderness and swelling. Testicular support makes the pain less intense. Which of the following is the most likely diagnosis?
Epididymitis
Prostatitis
Testicular torsion
Urethritis
Varicocele
A 65-year-old woman presents to the physician’s office for her yearly physical examination. She has no complaints except for a recent 10-lb weight loss. Past history is pertinent for a 40 pack-year smoking history, hypertension, asthma, and hypothyroidism. Examination reveals a thin woman with normal vital signs and unremarkable heart and abdominal examinations. Lung examination reveals mild wheezing and a few bibasilar rales. A chest x-ray is obtained and is shown in Figure 6-13. A chest x-ray obtained 3 years ago was normal. Yearly laboratory tests including a CBC, electrolytes, and lipid panels are normal. Which of the following is the most likely diagnosis?
Small cell lung cancer
Tuberculosis
Nonsmall cell lung cancer
Hamartoma
Abscess
A 65-year-old woman presents to the physician’s office for her yearly physical examination. She has no complaints except for a recent 10-lb weight loss. Past history is pertinent for a 40 pack-year smoking history, hypertension, asthma, and hypothyroidism. Examination reveals a thin woman with normal vital signs and unremarkable heart and abdominal examinations. Lung examination reveals mild wheezing and a few bibasilar rales. A chest x-ray is obtained and is shown in Figure 6-13. A chest x-ray obtained 3 years ago was normal. Yearly laboratory tests including a CBC, electrolytes, and lipid panels are normal. Which of the following is the most appropriate next diagnostic test?
Percutaneous needle biopsy
CT scan
Pulmonary function tests
Mediastinoscopy
Bronchoscopy
A 75-year-old woman with history of angina is admitted to the hospital for syncope. Examination of the patient reveals a systolic murmur best heard at the base of the heart that radiates into the carotid arteries. Electrocardiogram (ECG) is notable for left ventricular hypertrophy with evidence of left atrial enlargement. ECG reveals an aortic valve area of 0.7 cm2. What is the most appropriate next step in her management?
Medical management with a nitrate and an angiotensin-converting enzyme inhibitor
Bilateral carotid endarterectomies
Percutaneous coronary artery angioplasty and stenting
Coronary artery bypass surgery
Aortic valve replacement
A 68-year-old man is diagnosed with lung cancer. In preparation for pulmonary resection he undergoes pulmonary function tests. Which of the following results indicate a favorable prognosis?
Elevated PCO2
Forced expiratory volume in 1 second (FEV1) more than 60% of predicted
Carbon monoxide diffusing capacity (DLCO) less than 40%
Low FEV1/FVC (forced vital capacity)
Normal FEV1/FVC
A 24-year-old man comes to the physician because of 1 week of abdominal pain. It is localized in the right lower quadrant and somewhat exacerbated by motion. Over the past 2 days, it has radiated to the back. He initially had two episodes of vomiting but now just has decreased appetite. He had one episode of diarrhea 1 day ago. He denies urinary frequency. His other medical problems include mild intermittent asthma and gastroesophageal reflux disease. He traveled to Mexico for 5 days 1 month ago and did not have any gastrointestinal symptoms during his stay there. His mother was diagnosed with colon cancer at the age of 49 years. His temperature is 38.2°C (100.8°F), blood pressure is 122/77 mm Hg, and pulse is 109/min and regular. Physical examination reveals prominent tenderness in the right lower quadrant, without rebound. Flexion of the right hip against resistance elicits significant abdominal pain. Laboratory results show: WBC count 16,000/mm' Hemoglobin 14.2 g/dl Platelet count 620,000/mm' Potassium 4.5 mEq/L Creatinine 1.0 mg/dl Which of the following is the most likely diagnosis?
Appendiceal perforation
Colonic malignancy
Complicated pyelonephritis
Inflammatory bowel disease
Parasitic colitis
A pediatrician's office gets a phone call from a frantic mother. Her 7-year-old daughter was playing under the sink and accidentally spilled Liquid Plumber (a strong, corrosive alkaline drain cleaner) all over her arms and legs. The nurse on the phone can hear the girl screaming in the background. Which of the following are the most appropriate instructions to give the mother?
Cover the burned areas with triple antibiotic ointment until the girl can be seen at the office
Get the girl into the shower right away and keep the water running over her for 30 minutes before bringing her to the emergency department
Get the girl to the emergency department as soon as possible
Wash the burned areas with diluted vinegar and bring the girl to the office
Wrap the burned areas in sterile dressings before bringing the girl to the emergency department 325. A 59-year-old man sustains blunt trauma in an automobile accident, resulting in multiple
A 59-year-old man sustains blunt trauma in an automobile accident, resulting in multiple intra-abdominal injuries. Surgery for the repair of these injuries takes several hours and requires multiple blood transfusions and infusions of Ringer's lactate. Before all the operative steps are completed, the patient develops a significant coagulopathy, a core body temperature less than 34 C (93.2 F), and refractory acidosis. The anesthesiologists are administering fresh frozen plasma and platelet packs. Which of the following is the most appropriate next step in management for the surgeon?
Provide hemostasis by liberal use of electrocoagulation
Wash the abdomen with warm saline and continue to operate
Complete the operation as soon as possible and do a formal abdominal closure
Pack the bleeding surfaces and close the abdomen temporarily with towel clips
Abort the operation and leave the abdomen open, covering the bowel with mesh
A previously healthy 19-year-old man presents to the emergency department with a penetrating wound to the right neck. There were reports of bleeding at the scene. The patient is talking, complaining of pain at the injury site and pain with swallowing. On examination, he has a normal respiratory rate, clear air entry on auscultation, blood pressure of 120/70 mmHg, and heart rate of 95 beats/min. There is a penetrating right neck wound in zone 2 (between the clavicle and the lower part of the mandible), with a surrounding hematoma. On probing, there is violation of the platysma. Which of the following is the best next step in the management of this patient?
Intubation and observation in the ICU
Admission to the ICU for close observation without intubation
Observation in the ICU only if carotid angiogram is normal
Observation in the ICU only if carotidangiogram, contrast esophagram, and bronchoscopy are normal
Neck exploration
A 45-year-old man is brought to the emergency department after being involved in an automobile crash. He is alert and oriented, with a normal neurologic examination. His respiratory rate is 20/min, with clear lungs, pulse rate of 120/min, and blood pressure of 80/40 mmHg. On examination, he is noted to have a distended abdomen, with decreased bowel sounds, and a fracture of the right ankle. IV access is established, and the patient receives a rapid infusion of 2 L of saline, without changes to pulse rate or blood pressure. Which of the following is the most appropriate next step in his management?
Abdominal CT scan
Insertion of a Swan-Ganz catheter
Exploratory laparotomy
Focused abdominal sonography for trauma (FAST)
Diagnostic peritoneal lavage
A 56-year-old woman presents to her primary care physician for a routine checkup. She states that she was recently hospitalized for surgery and was told she had some metal placed in a large blood vessel to prevent blood clots from moving to her lungs. An abdominal x-ray is shown here. Which of the following is the most appropriate indication for placement of this device?
Recurrent pulmonary embolus despite adequate anticoagulation therapy
Axillary vein thrombosis
Pulmonary embolus due to DVT of the lower extremity that occurs 2 weeks postoperatively
DVT in a patient with patient with metastatic carcinoma
Pulmonary embolus in a patient with metastatic carcinoma
A 55-year-old man presents to the emergency department at 5 a.m. Complaining of vomiting blood. After binge drinking last night, the patient began to vomit repeatedly. After a number of episodes, the patient noted blood in the vomitus, followed by a melanotic stool 5 hours later. His past history is pertinent for ethanol abuse and a 40 pack-year smoking history. Vital signs reveal a BP of 100/60 mmHg, pulse rate of 95/min, respiratory rate of 12/min, and temperature of 97°F. Examination reveals a thin man with normal chest, cardiac, and abdominal findings. Rectal examination reveals heme-positive stool. Laboratory data show normal electrolytes and a hematocrit of 30. A chest x-ray is unremarkable. Volume resuscitation, gastric lavage, and NG tube decompression are initiated. Which of the following is the most appropriate diagnostic test?
Barium esophagogram
Water-soluble contrast esophagogram
Esophagoscopy
CT scan
Angiogram
A 70-year-old man with a 50 pack-year history of smoking presents with a 6-week history of intermittent, painless, gross hematuria and urinary frequency. There are no masses palpable on abdominal examination, and rectal examination is normal. Urinalysis confirms the presence of hematuria, and urine culture is negative. Which of the following is the most appropriate initial diagnostic evaluation of this patient?
Plain abdominal radiographs and an intravenous pyelogram (IVP)
Voiding cystourethrogram
Cystourethroscopy
Abdominal ultrasound
Urine for cytology
A 70-year-old man with a 50 pack-year history of smoking presents with a 6-week history of intermittent, painless, gross hematuria and urinary frequency. There are no masses palpable on abdominal examination, and rectal examination is normal. Urinalysis confirms the presence of hematuria, and urine culture is negative. The initial diagnostic evaluation does not reveal any abnormalities. Which of the following is the best next step in the diagnostic workup?
An abdominal CT scan
Cystourethroscopy and urinary cytology
A transrectal ultrasound
Exploratory laparoscopy
Re-evaluation in 2–4 weeks, with repeat urinalysis and urine culture
A 7-week-old, breast-fed, term infant presents with increasing jaundice, abdominal distention, and abnormal stools (Figure 6-20). Liver function tests demonstrate a conjugated hyperbilirubinemia, mildly elevated transaminases, and an elevated gamma-glutamyl transpeptidase. TORCH (congenital infection complex, including toxoplasmosis, rubella, cytomegalovirus, and hepatitis) serology and screening for inborn errors of metabolism are negative. As part of the diagnostic evaluation, the most sensitive imaging study in this clinical setting would be which of the following?
Radioisotope scanning
Radioisotope scanning with pre-imaging phenobarbital administration
Abdominal ultrasound
CT scan of the abdomen
MRI scan of the abdomen
Two days after admission to the hospital for a myocardial infarction, a 65-year-old man complains of severe, unremitting midabdominal pain. His cardiac index is 1.6. Physical examination is remarkable for an absence of peritoneal irritation or distention despite the patient’s persistent complaint of severe pain. Serum lactate is 9 mmol/L (normal is < 3 mmol/L). Which of the following is the most appropriate next step in this patient’s management?
Perform computed tomography
Perform mesenteric angiography
C. Perform laparoscopy
Perform flexible sigmoidoscopy to assess the distal colon and rectum
Defer decision to explore the abdomen until the arterial lactate is greater than 10 mmol/L.
A 55-year-old man comes to the emergency department because of severe retrosternal chest pain that suddenly started a few hours ago. He has been having some chest pain and epigastric burning for the past few days but says that the current pain is different. His other medical problems include nonischemic cardiomyopathy for which he takes furosemide, carvedilol, spironolactone, lisinopril, and potassium chloride. He also has HIV infection but has chosen not to take any medication related to this diagnosis. His temperature is 38.9° C (102° F), blood pressure is 110/65 mm Hg, pulse is 110/min, and respirations are 22/min. Examination shows that he is in obvious distress secondary to pain. His lungs are clear to auscultation. The remainder of the examination shows no abnormalities. His ECG is within normal limits. Chest x-ray shows a widened mediastinum and some mediastinal air. Which of the following is the most appropriate next step in the management of this patient?
Aspirin, clopidogrel, and repeat ECG in 30 minutes
Contrast esophagography
Oral omeprazole and antacids
Transesophageal echocardiography
Upper gastrointestinal endoscopy
A 36-year-old woman presents with palpitations, anxiety, and hypertension. Workup reveals a pheochromocytoma. Which of the following is the best approach to optimizing the patient preoperatively?
Fluid restriction 24 hours preoperatively to prevent intraoperative congestive heart failure
Initiation of an α-blocker 24 hours prior to surgery
Initiation of an α-blocker at 1 to 3 weeks prior to surgery
Initiation of a β-blocker 1 to 3 weeks prior to surgery
Escalating antihypertensive drug therapy with β-blockade followed by α-blockade starting at least 1 week prior to surgery
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?
Nonanion gap metabolic acidosis
Anion gap metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Normal serum electrolytes
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. Which of the following is the most appropriate management of this acid-based derangement?
Administration of sodium bicarbonate to correct the base deficit
Restoration of blood volume with aggressive IV fluid resuscitation
IV hydrochloric acid
Intubation and hyperventilation
This patient has no acid-based abnormality
A 1-day-old infant with Down syndrome, feeding intolerance, bilious vomiting, and a double bubble on plain radiographs (Figure 6-18). Which one is the most likely diagnostic?
Congenital hypertrophic pyloric stenosis
Annular pancreas
Duodenal atresia
Midgut volvulus
Intussusception
A 33-year-old pregnant woman notices a persistent, painless lump in the left breast. On examination the left breast has a single mobile mass without evidence of skin changes or lymphadenopathy in the neck or axilla. An ultrasound demonstrates a solid, 1-cm mass in the upper outer quadrant of the breast. A core-needle biopsy shows invasive ductal carcinoma. The patient is in her first trimester of pregnancy. Which of the following is the most appropriate management of this patient?
Termination of the pregnancy followed by modified radical mastectomy
Immediate administration of chemotherapy followed by modified radical mastectomy after delivery of the baby
Administration of radiation in the third trimester followed by modified radical mastectomy after delivery of the baby
Total mastectomy with sentinel lymph node biopsy
Modified radical mastectomy
A 40-year-old woman presents with a rash involving the nipple-areola complex for the last month with associated itching. On physical examination there is crusting and ulceration of the nipple with surrounding erythema involving the areola and surrounding skin, no palpable breast masses, and no cervical or axillary lymphadenopathy. Which of the following is the most appropriate next step in the management of this patient?
Reexamine the patient in 1 month
Corticosteroid cream to the affected area
Administration of oral antibiotics
Mammogram and biopsy of the affected area
Modified radical mastectomy
A 54-year-old woman presents to her physician for an opinion regarding additional therapy following curative resection of recently diagnosed colon cancer. She underwent uncomplicated sigmoid resection for invasive colon cancer 4 weeks ago. The pathology revealed carcinoma invading into, but not through, the muscularis propria, with one of eight positive mesenteric nodes. There was no evidence of liver metastases at the time of operation. Preoperative chest x-ray and CT scan of the abdomen showed no evidence of distant disease. Preoperative carcinoembryonic antigen (CEA) level was normal. Past history is positive for diabetes and mild hypertension. Examination is unremarkable except for a healing abdominal incision. Which of the following is the correct stage of this patient’s colon cancer?
Stage 0
Stage I
Stage II
Stage III
Stage IV
A 54-year-old woman presents to her physician for an opinion regarding additional therapy following curative resection of recently diagnosed colon cancer. She underwent uncomplicated sigmoid resection for invasive colon cancer 4 weeks ago. The pathology revealed carcinoma invading into, but not through, the muscularis propria, with one of eight positive mesenteric nodes. There was no evidence of liver metastases at the time of operation. Preoperative chest x-ray and CT scan of the abdomen showed no evidence of distant disease. Preoperative carcinoembryonic antigen (CEA) level was normal. Past history is positive for diabetes and mild hypertension. Examination is unremarkable except for a healing abdominal incision. Which of the following is the most appropriate recommendation regarding adjuvant therapy?
A. No therapy indicated
5-fluorouracil chemotherapy
5-fluorouracil chemotherapy with leucovorin
Doxorubicin (Adriamycin) chemotherapy
Adriamycin chemotherapy with methotrexate and Cytoxan
A 43-year-old man develops excruciating abdominal pain at 8:23 PM (he looked at his watch when the pain "hit him"). When seen in the emergency department about 30 minutes later, he has a rigid abdomen, lies motionless on the examination table, has no bowel sounds, and is obviously in great pain, which he describes as constant and encompassing the entire abdomen. There is very severe pain when deep palpation of the abdomen is attempted in any of the four quadrants. However, the examining hand cannot make much of an indentation because of the impressive muscle guarding. When the attempt is aborted, he manifests severe rebound tenderness. X-ray films show free air under both diaphragms. Which of the following does this man most likely have?
Acute abdomen, the nature of which cannot yet be defined
Acute inflammatory process affecting an intra-abdominal viscera
Acute obstruction of an intra-abdominal viscera
Ischemic process affecting intra-abdominal organs
Perforation of the gastrointestinal tract
On the 5th postoperative day after abdominal surgery, a patient has been draining copious amounts of clear pink fluid from his midline laparotomy wound. A medical student removes the dressing, confirms that it is soaked, and sees a normal-appearing fresh wound with a row of skin staples in place. The student asks the patient to sit up so he can get out of bed and be helped to the treatment room for a more thorough examination. When the patient complies, the wound opens widely, and a handful of small bowel suddenly rushes out. Which of the following is the most appropriate management at this time?
Cover the bowel with dry sterile dressings and schedule urgent surgical closure
Cover the bowel with sterile dressings soaked in warm saline and rush the patient to the operating room
Irrigate the bowel with cold antiseptic solutions while awaiting urgent surgical closure
Take the patient to the treatment room and suture the skin edges together
Wearing sterile gloves, push the bowel back in and tape the wound securely
Several days following esophagectomy, a patient complains of dyspnea and chest tightness. A large pleural effusion is noted on chest radiograph, and thoracentesis yields milky fluid consistent with chyle. Which of the following is the most appropriate initial management of this patient?
Immediate operation to repair the thoracic duct
Immediate operation to ligate the thoracic duct
Tube thoracostomy and low-fat diet
Observation and low-fat diet
Observation and antibiotics
A 56-year-old woman presents for evaluation of a murmur suggestive of mitral stenosis and is noted on echocardiography to have a lesion attached to the fossa ovalis of the left atrial septum. The mass is causing obstruction of the mitral valve. Which of the following is the most likely diagnosis?
Endocarditis
Lymphoma
Cardiac sarcoma
Cardiac myxoma
Metastatic cancer to the heart
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?
Hepatitis A
Hemolysis
Pancreatitis
Liver metastases
Cirrhosis
A 56-year-old woman presents to the physician’s office with complaints of a new left breast mass. She denies any pain, nipple discharge, or skin dimpling. She has a prior history of breast cysts 5 years ago, treated by aspiration at that time. Her last mammogram was at age 53. Past history is pertinent for a 30 pack-year smoking history, prior total abdominal hysterectomy bilateral salpingo-oophorectomy (TAH-BSO) at age 54 for leiomyomas, and current use of hormone replacement therapy (HRT). Family history is negative for breast disease. Examination reveals a firm, welldefined, mobile, 1.5-cm nodule in the upper outer quadrant of the left breast without any regional lymphadenopathy. Which of the following is the most appropriate next step in management?
Fine-needle aspiration (FNA) biopsy
Discontinuation of HRT and reexamination in 4–6 weeks
Breast imaging
Open surgical biopsy
Core needle biopsy
A 54-year-old African American man, with a history of smoking and drinking, describes progressive dysphagia that began 3 months ago. He first noticed difficulty swallowing meat; it then progressed to other solid foods, then to soft foods, and now to liquids as well. He locates the place where the food "sticks" at the lower end of the sternum. He has lost 30 pounds. Which of the following is the most appropriate first step in diagnosis?
Barium swallow
Gastrografin swallow
Esophageal manometry
Esophageal pH monitoring
Esophagoscopy
A 65-year-old woman presents to the physician’s office with a 6-month history of epigastric discomfort, poor appetite, and 10-lb weight loss. Past history is pertinent for hypertension, diabetes, a 30 pack-year smoking history, and occasional alcohol intake. Examination is unremarkable except for mild epigastric tenderness to deep palpation. An abdominal ultrasound reveals cholelithiasis, and one view of a UGI x-ray series is shown in Figure 6-8. Which of the following is the most appropriate next step in management?
H2 blockers with re-evaluation by UGI in 6 month
Vagotomy and pyloroplasty
Total gastrectomy
Endoscopy
CT scan
A 55-year-old man presents to the physician’s office for his yearly physical examination. He is asymptomatic. Past history is pertinent for hypertension. Family history is positive for breast cancer in his mother at age 70 and colon cancer in his father at age 65. His examination is unremarkable except for guiac positive stool. Barium enema shows a sigmoid colon polyp. Colonoscopy confirms a 3-cm pedunculated polyp in the sigmoid colon, and snare polypectomy is performed. Pathologic examination reveals an adenomatous polyp with a focus of invasive carcinoma in the head, with a 4-mm resection margin and no tumor noted in the stalk. Which of the following is the most appropriate next step in management?
CT scan
Magnetic resonance imaging (MRI) scan
Surgical resection of sigmoid
Observation
Egular use of nonsteroidal antiinflammatory drugs (NSAIDs)
A 65-year-old male cigarette smoker reports onset of claudication of his right lower extremity approximately 3 weeks previously. He can walk 3 blocks before the onset of claudication. Physical examination reveals palpable pulses in the entire left lower extremity, but no pulses are palpable below the right groin level. Non-invasive flow studies are obtained and are pictured here. What is the level of the occlusive process in this patient?
Right anterior tibial artery
Right superficial femoral artery
Right profunda femoris artery
Right external iliac artery
Right internal iliac artery
An elderly woman with osteoporosis falls on her outstretched hand. She comes in with a deformed and painful wrist that looks like a dinner fork. X-ray films show a dorsally displaced, dorsally angulated fracture of the distal radius. There is also an associated fracture of the ulnar styloid. A neurologic examination is normal. Which of the following is the most appropriate management?
Closed reduction and short arm cast
Closed reduction and long arm cast
Skeletal traction
Intramedullary rod
Open reduction and internal fixation
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 fontanelle and decreased skin turgor. The abdomen is scaphoid, and with a test feed, there is a visible peristaltic wave in the epigastrium. Which of the following is the most likely diagnosis?
Viral gastroenteritis
Gastroesophageal reflux
Urinary tract sepsis
Pyloric stenosis
Milk protein allergy
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?
Abdominal ultrasound
Careful clinical examination with palpation of an epigastric mass
UGI contrast study
Surgical exploration
Endoscopy
An 80-year-old man is found to have an asymptomatic pulsatile abdominal mass. An arteriogram is obtained (shown below). Which of the following is the most frequent and lethal complication of this condition?
Rupture
Acute thromboembolism
Dissection
High-output congestive heart failure
Myocardial infarction
A 75-year-old man is found by his internist to have an asymptomatic carotid bruit. Which of the following is the most appropriate next test?
Transcranial Doppler studies
Doppler ultrasonography (duplex)
Spiral CT angiography
Arch aortogram with selective carotid artery injections
Magnetic resonance arteriogram (MRA)
An older, overweight man complains of disabling, sharp heel pain every time his foot strikes the ground. The pain is worse in the mornings, preventing him from putting any weight on the heel. X-ray films show a bony spur matching the location of his pain, and physical examination shows exquisite tenderness to direct palpation right over that heel spur. Furthermore, when the ankle is dorsiflexed, the entire inner border of the fascia is tender to palpation. Which of the following is the most likely diagnosis?
Epiphysitis of the calcaneus
Fracture of the posterolateral talar tubercle
Plantar fasciitis
Posterior Achilles tendon bursitis
Posterior tibial nerve neuralgia
A 65-year-old woman presents to the physician’s office with a 6-month history of epigastric discomfort, poor appetite, and 10-lb weight loss. Past history is pertinent for hypertension, diabetes, a 30 pack-year smoking history, and occasional alcohol intake. Examination is unremarkable except for mild epigastric tenderness to deep palpation. An abdominal ultrasound reveals cholelithiasis, and one view of a UGI x-ray series is shown in Figure 6-8. Which of the following is the most likely diagnosis?
Cholecystoenteric fistula
Duodenal ulcer
Gastric ulcer
Gastric diverticulum
Duodenal diverticulum
A 75-year-old woman is brought to the emergency department from a nursing home for abdominal pain, distention, and obstipation over the last 2 days. Past history is pertinent for stroke, diabetes, atrial fibrillation, and chronic constipation. Examination reveals a temperature of 98.6°F, pulse rate 90/min and irregularly irregular, and BP 160/90 mmHg. Heart examination reveals irregularly irregular rhythm with no murmurs; lung examination reveals few bibasilar rales; and abdominal examination reveals a distended, tympanic abdomen with mild tenderness and no rebound tenderness. Plain abdominal x-rays reveal dilated loops of bowel, and a barium enema is obtained and shown in Figure 6-9. Which of the following is the most likely diagnosis?
Ischemic colitis with stricture
Diverticulitis with obstruction
Cecal volvulus
Sigmoid volvulus
Colon cancer with obstruction
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?
Histoplasmosis (sclerosing mediastinitis)
Substernal thyroid
Thoracic aortic aneurysm
Constrictive pericarditis
Bronchogenic carcinoma
During endoscopic biopsy of a distal esophageal cancer, perforation of the esophagus is suspected when the patient complains of significant new substernal pain. An immediate chest film reveals air in the mediastinum. Which of the following is the most appropriate management of this patient?
Placement of a nasogastric tube to the level of perforation, antibiotics, and close observation
Spit fistula (cervical pharyngostomy) and gastrostomy
Left thoracotomy, pleural patch oversewing of the perforation, and drainage of the mediastinum
Left thoracotomy with esophagectomy
Thoracotomy with chest tube drainage and esophageal exclusion
In preparation for an inguinal hernia repair, a 22-year-old man has a spinal anesthetic placed. The level of sensory block turns out to be much higher than had been planned, and shortly thereafter his blood pressure drops to 75/20 mm Hg. He looks warm and flushed, and his central venous pressure is near zero. Which of the following should be included in his therapy?
Diuretics and fluid restriction
Whole blood and clotting factors
Inotropic agents and cardiac assist pump
Vasoconstrictors and IV fluids
Vasodilators and IV fluids
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?
Ulcerative colitis
Appendicitis
Crohn’s disease
Irritable bowel syndrome
Lactose intolerance
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 best diagnostic test to confirm the diagnosis?
Repeat CT scan with delayed imaging
Ultrasonography
Sigmoidoscopy
Colonoscopy
Small-bowel radiography
A 27-year-old woman seeks your advice regarding pain and numbness in the right arm and hand. She reports that it is exacerbated by raising her arm over her head. On examination, the right radial pulse disappears when the patient takes a deep breath and turns her head to the left. A provisional diagnosis is made. Which of the following is the most appropriate initial treatment for this patient?
Physical rehabilitation
Gabapentin to treat neuropathic pain
Right first rib resection
Thoracoscopic sympathectomy
Upper thoracic discectomy
A 35-year-old man with a history of melanoma status post wide local excision with negative margins and lymph node dissection presents with 2, peripherallylocated pulmonary lesions seen on chest CT scan. Percutaneous biopsy of the lesion is consistent with metastatic melanoma. He has no evidence of recurrence or extrathoracic disease and is in good general health. Which of the following is the most appropriate management of this patient?
Chemotherapy
Radiation therapy
Pulmonary metastasectomy
Pulmonary metastasectomy followed by radiation therapy
Neoadjuvant radiation therapy followed by pulmonary metastasectomy
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?
Atelectasis of the involved apical segment
Horner syndrome
Pain in the T4 and T5 dermatomes
Nonproductive cough
Hemoptysis
A 65-year-old man presents to the physician’s office for his yearly physical examination. His only complaint relates to early fatigue while playing golf. Past history is pertinent for mild hypertension. Examination is unremarkable except for trace hematest-positive stool. Blood tests are normal except for a hematocrit of 32. A UGI series is performed and is normal. A barium enema is performed, and one view is shown in Figure 6-10. Which of the following is the most appropriate therapy following colonoscopy?
Proximal colostomy with mucous fistula
Radiation therapy
Chemotherapy
Surgical resection and primary anastomosis
Surgical bypass (colocolostomy)
A 65-year-old man presents to the emergency department with sudden onset of pain and weakness of the left lower extremity of 2-hour duration. Past history reveals chronic atrial fibrillation following a myocardial infarction 12 months ago. On examination, he is found to have a cool, pale left lower extremity with decreased strength and absent popliteal and pedal pulses. The opposite leg has a normal appearance with palpable pulses. Which of the following is the treatment of choice for this patient?
R-TPA (tissue plasminogen activator) infusion following anticoagulation
Administration of vasodilators
Four-compartment fasciotomy
Thromboembolectomy
Anticoagulation and close observation
A 53-year-old woman presents with complaints of weakness, anorexia, malaise, constipation, and back pain. While being evaluated, she becomes somewhat lethargic. Laboratory studies include a normal chest x-ray, serum albumin 3.2 mg/dL, serum calcium 14 mg/dL, serum phosphorus 2.6 mg/dL, serum chloride 108 mg/dL, blood urea nitrogen (BUN) 32 mg/dL, and creatinine 2.0 mg/dL. Which of the following is the most appropriate initial management?
Intravenous normal saline infusion
Administration of thiazide diuretics
Administration of intravenous phosphorus
Use of mithramycin
Neck exploration and parathyroidectomy
Which of the following patients with primary hyperparathyroidism should undergo parathyroidectomy?
A 62-year-old asymptomatic woman
A 54-year-old woman with fatigue and depression
A 42-year-old woman with a history of kidney stones
A 59-year-old woman with mildly elevated 24-hour urinary calcium excretion
A 60-year-old woman with mildly decreased bone mineral density measured at the hip of less than 2 standard deviations below peak bone density
A 45-year-old woman presents with hypertension, development of facial hair, and a 7-cm suprarenal mass. Which of the following is the most likely diagnosis?
Myelolipoma
Cushing disease
Adrenocortical carcinoma
D. Pheochromocytoma
Carcinoid
A 44-year-old homeless woman presents to the emergency department because she is "bleeding from the breast." Physical examination shows a huge, fungating, ulcerated mass that occupies the entire right breast and is firmly attached to the chest wall. The right axilla is full of hard masses that are not movable either. Core biopsies of the breast are read as highly undifferentiated infiltrating ductal carcinoma, and assay for estrogen and progesterone receptors are negative. Which of the following is the most appropriate next step in management?
Local wound care, but no specific antineoplastic therapy
Tamoxifen therapy
Radiation and chemotherapy
Palliative mastectomy
Radical mastectomy with extended lymph node dissection
A 64-year-old woman complains of right calf pain and swelling. She recently underwent an uncomplicated left hemicolectomy for diverticular disease. A duplex ultrasound confirms the presence of deep vein thrombosis (DVT) of the calf. Which of the following is the most appropriate initial management of this patient?
Pneumatic compression stockings
Warfarin
Heparin
Thrombolysis
Inferior vena cava filter
For the first 6 hours following a long and difficult surgical repair of a 7-cm abdominal aortic aneurysm, a 70-year-old man has a total urinary output of 25 mL since the operation. Which of the following is the most appropriate diagnostic test to evaluate the cause of his oliguria?
Renal scan
Aortogram
Left heart preload pressures
Urinary sodium concentration
Creatinine clearance
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 appropriate next step in management?
Collection of discharge for repeat cytologic analysis
Observation, with repeat examination and imaging studies in 3–6 months
Modified radical mastectomy
Central lumpectomy (including removal of the nipple/areolar complex
Terminal duct excision (microdochectomy)
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 likely diagnosis?
Sliding hiatal hernia
Hernia of Bochdalek (posterorlateral congenital diaphragmatic hernia)
Hernia of Morgagni (parasternal congenital diaphragmatic hernia)
Paraesophageal hernia
Eventration of the diaphragm (central diaphragm)
A 66-year-old man presents with progressive jaundice, which he first noticed 6 weeks ago. He has a total bilirubin of 22 mg/dL, with a direct (conjugated) bilirubin of 16 mg/dL. His transaminases are minimally elevated, whereas his alkaline phosphatase is about six times the upper limit of normal. A sonogram shows dilated intrahepatic ducts, dilated extrahepatic ducts, and a very distended, thin-walled gallbladder without stones. Which of the following is the most appropriate next step in diagnosis?
CT scan of the upper abdomen
Endoscopic retrograde cholangiopancreatography (ERCP)
Exploratory laparotomy
Percutaneous transhepatic cholangiogram (PTC)
Serologies to define the type of hepatitis
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 appropriate next step in management?
Observation, with repeat mammogram in 6 months
Observation, with repeat mammogram on an annual basis
Biopsy
Lumpectomy, radiation therapy, and SLN biopsy
Total mastectomy
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 likely diagnosis?
Papilloma
Invasive carcinoma
Cystosarcoma phyllodes
DCIS
Fat necrosis
A 45-year-old woman presents with a 7-cm renal cell carcinoma with radiologic evidence of abdominal lymph node involvement with no distant metastases. Which of the following is the most appropriate management of this patient?
Radical nephrectomy
Radiation
Chemotherapy
Radiation followed by nephrectomy
Chemotherapy followed by nephrectomy
A 58-year-old man is found to have high serum prostate–specific antigen (PSA) concentration with a normal prostate examination. A biopsy of the prostate confirms low-grade carcinoma. The patient wishes to avoid therapy involving any risk for impotence. Which of the following is the most appropriate management of this patient?
Observation
Chemotherapy
Prostatectomy
Radiation therapy
Hormonal therapy
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?
Bell's palsy
Facial nerve tumor
Hemorrhagic stroke
Parotid gland cancer
Pleomorphic adenoma of the parotid gland
A 28-year-old man with a past history of bilateral orchiopexy for cryptorchidism presents with a painless, unilateral right scrotal enlargement. On examination, there is a palpable right testicular mass and enlarged inguinal nodes. Scrotal ultrasonography demonstrates heterogeneity of the testis, with an associated hydrocele. A CT scan of the abdomen and pelvis demonstrated right-sided retroperitoneal adenopathy. CT scan of the chest is normal. Which of the following would help confirm the diagnosis?
Transscrotal needle biopsy
Transscrotal aspiration of the hydrocele for cytology
Radical orchiectomy through an inguinal incision
Transscrotal exploration and orchiectomy
Laparotomy with pelvic and retroperitoneal node dissection
A 28-year-old man with a past history of bilateral orchiopexy for cryptorchidism presents with a painless, unilateral right scrotal enlargement. On examination, there is a palpable right testicular mass and enlarged inguinal nodes. Scrotal ultrasonography demonstrates heterogeneity of the testis, with an associated hydrocele. A CT scan of the abdomen and pelvis demonstrated right-sided retroperitoneal adenopathy. CT scan of the chest is normal. Staging workup and surgery reveal a seminoma of the testicle, with positive inguinal and retroperitoneal nodes. Therapeutic management for this patient is which of the following?
External beam radiotherapy
Multidrug combination chemotherapy
Combination radiotherapy and multidrug chemotherapy
Clinical surveillance
Laparotomy with pelvic and retroperitoneal node dissection
A 45-year-old woman complains to her primary care physician of nervousness, sweating, tremulousness, and weight loss. The thyroid scan shown here exhibits a pattern that is most consistent with which of the following disorders?
Hypersecreting adenoma
Graves disease
Lateral aberrant thyroid
Papillary carcinoma of thyroid
Medullary carcinoma of thyroid
A patient with mild skin pigmentation is admitted emergently to your service because of sudden abdominal pain, fever, and a rigid abdomen. Her blood work indicates a marked leukocytosis, a blood sugar of 55 mg/dL, a sodium value of 119 mEq/dL, and a potassium value of 6.2 mEq/dL. Her blood pressure is 88/58-mmHg. She undergoes an exploratory laparotomy. Which of the following is the definitive treatment for her primary condition?
10% dextrose infusion
Bicarbonate
Hypertonic saline
Corticosteroids
Vasopressors
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?
Blood loss at the fracture sites
Fat embolism
Neurogenic shock from pain
Unrecognized intracranial bleeding
Unrecognized pericardial tamponade
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 appropriate next step in the diagnostic evaluation and management of this patient?
Proctoscopy
Oral rehydration and stool cultures
IV fluid rehydration and a hydrostatic barium enema
Technetium scan
IV fluid rehydration, NG decompression, and a UGI contrast study
A 24-year-old patient with known neurofibromatosis type 2 undergoes an MRI for ringing in his ears. The MRI demonstrates lesions in bilateral auditory canals. Which of the following is the most likely diagnosis?
Gangioneuroma
Schwannoma
Ependymoma
Meningioma
Pituitary adenoma
A40-year-old man with a history of alcohol abuse presents after an episode of binge drinking. He is complaining of epigastric pain, radiating to the back, associated with nausea and vomiting. On examination, he has marked tenderness in the epigastrium, with guarding, decreased bowel sounds, and moderate abdominal distention. Laboratory findings include leukocytosis and increased serum amylase and lipase. Abdominal roentgenograms demonstrate several dilated bowel loops in the upper abdomen. Select the most likely diagnosis.
Gastroenteritis
Acute appendicitis
Sigmoid diverticulitis
Acute pancreatitis
Acute cholecystitis
A 65-year-old man presents with a 4-day history of worsening lower abdominal pain and constipation. On examination, he is febrile (38.5°C) and has lower abdominal tenderness that is most intense in the midline and left lower quadrant associated with a palpable fullness. Laboratory findings demonstrate a moderate leukocytosis and abdominal roentgenograms show an ileus pattern. Select the most likely diagnosis
Gastroenteritis
Regional enteritis
Acute appendicitis
Perforated peptic ulcer
Sigmoid diverticulitis
A 65-year-old man presents to the physician’s office with complaints of abdominal discomfort and jaundice for the past 3 weeks. Past history is pertinent for 30 pack-year smoking history, occasional alcohol intake, and a 5.5-mm ulcerating melanoma removed from his back 21/ 2 years ago. Examination reveals a mildly jaundiced patient with normal vital signs and a slightly distended abdomen with mild right upper quadrant tenderness and significant hepatomegaly. Which one is the most likely diagnosis?
Hepatitis A
Hemolysis
Choledocholithiasis
Liver metastases
Cirrhosis
A 45-year-old woman presents with left-sided weakness. A CT scan of the head demonstrates a well-circumscribed mass abutting the skull in the right hemisphere. Workup of the mass reveals a meningioma. Which of the following is the best next step in treatment?
Cerebral angiography with tumor embolization
Preoperative radiation therapy followed by surgical excision
Surgical excision
Chemotherapy with adriamycin
Chemoradiation
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?
Small-bowel obstruction
Dead bowel
Perforated colon carcinoma
Perforated duodenal ulcer
Perforated gastric ulcer
A 15-year-old otherwise healthy female high school student begins to notice galactorrhea. A pregnancy test is negative. Which of the following is a frequently associated physical finding?
Gonadal atrophy
Bitemporal hemianopsia
Exophthalmos and lid lag
Episodic hypertension
Buffalo hump
A 52-year-old woman sees her physician with complaints of fatigue, headache, flank pain, hematuria, and abdominal pain. She undergoes a sestamibi scan that demonstrates persistent uptake in the right superior parathyroid gland at 2 hours. Which of the following laboratory values is most suggestive of her diagnosis?
Serum acid phosphatase above 120 IU/L
Serum alkaline phosphatase above 120 IU/L
Serum calcium above 11 mg/dL
Urinary calcium below 100 mg/day
Parathyroid hormone levels below 5 μmol/L
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 step in management?
Immediate laparotomy
Nonoperative management with NG decompression and antibiotics
Fluid resuscitation
Administration of H2 blockers
Placement of a central venous line
A 55-year-old man presents to the physician’s office complaining of upper abdominal pain of 2 months’ duration. The pain is described as gnawing, localized to the upper midline, and associated with nausea. The pain is exacerbated by food, and there is an associated 20-lb weight loss over 2 months. His past history is pertinent for a 30 pack-year smoking history, occasional alcohol intake, and a prior history of a benign gastric ulcer 5 years ago. Physical examination reveals normal vital signs, mild epigastric pain with deep palpation, and mildly hemepositive stool. An evaluation for recurrence of a gastric ulcer is recommended. Which of the following tests is the most reliable method for diagnosing a gastric ulcer?
UGI barium x-rays
Fiberoptic upper endoscopy
CT scan
Endoscopic ultrasound
MRI
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?
Lumbar puncture
Noncontrast head CT
Contrast-enhanced head CT
Placement of ICP monitor
Placement of ventriculoperitoneal shunt
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?
Milk of calcium
LCIS with or without an invasive component
DCIS with or without an invasive component
Involuting fibroadenoma
Phyllodes tumor
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
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?
CT scan
UGI water-soluble contrast study
C. lower GI water-soluble contrast study
Abdominal ultrasound
None of the above
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
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
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
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
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%
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?
Positron emission tomography (PET) scan
Radionuclide liver scan
Ultrasound
CT scan
MRI scan
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
E. Repeat imaging studies in 3 months to determine the growth rate of the disease
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?
5–10%
15–20%
25–35%
40–50%
60–70%
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?
Antiplatelet therapy
Anticoagulation
Thrombolytic therapy
Surgery
Reassurance and re-examination if the patient develops symptoms
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?
Analgesics and bed rest for about 3 weeks
Appropriate antibiotics
Body cast for 3-6 months
Radiotherapy to the affected area
Surgical decompression
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
Chemotherapy
Expectant, with intervention only if the patient develops significant clinical bleeding.
Systemic steroids
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
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
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
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
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?
Age group of 20–40 years
Female gender
Low-dose irradiation during infancy
Chronicity of the nodule
Past history of Hashimoto’s disease
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?
Ultrasound of the neck
Thyroid scinti-scan
MRI of the neck
CT scan of the neck and chest
FNA of the nodule
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?
Cystosarcoma phyllodes
Intraductal carcinoma
Malignant lymphoma
Fibroadenoma
Juvenile hypertrophy
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
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
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
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
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?
Invasive carcinoma
Intraductal carcinoma
Intraductal papilloma
Fibrocystic disease
Duct ectasia
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?
Excessive valgus laxity of the knee
Excessive varus laxity of the knee
Locked knee
Positive Lachman test
Positive posterior drawer test
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
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
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.
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
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.
Gastroenteritis
Regional enteritis
Acute appendicitis
Perforated peptic ulcer
Sigmoid diverticulitis
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
Gastroenteritis
Regional enteritis
Acute appendicitis
Perforated peptic ulcer
Acute cholecystitis
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?
Thyroid carcinoma
Cystic hygroma
Acute suppurative lymphadenitis
Thyroglossal duct cyst
Lipoma
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?
Anteriorly
Superiorly
Posteriorly
Laterally
Medially
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?
Median nerve
Radial nerve
Posterior interosseous nerve
Ulnar nerve
Ascending circumflex brachial nerve
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
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
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?
6-mercaptopurine
Azathioprine
Opioid antidiarrheals
Colonoscopic decompression
High-dose IV steroids and broad-spectrum antibiotics
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?
Brain abscess
High-grade astrocytoma
Parenchymal hemorrhage
Metastatic lesion
Toxoplasmosis
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
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?
Cerebral atrophy
Pituitary adenoma
Optic glioma
Pontine hemorrhage
Multiple sclerosis plaque
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?
Carotid artery aneurysm
Mixed parotid tumor (pleomorphic adenoma
Laryngeal carcinoma
Parathyroid adenoma
Branchial cleft cyst
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?
Thyroid carcinoma
Cystic hygroma
Acute suppurative lymphadenitis
Thyroglossal duct cyst
Lipoma
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?
Thyroid carcinoma
Cystic hygroma
Acute suppurative lymphadenitis
Thyroglossal duct cyst
Laryngeal carcinoma
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?
Thyroid carcinoma
Cystic hygroma
Acute suppurative lymphadenitis
Thyroglossal duct cyst
Lipoma
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?
Thyroid carcinoma
Cystic hygroma
Acute suppurative lymphadenitis
Thyroglossal duct cyst
Laryngeal carcinoma
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
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
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?
Staphylococcal enterocolitis
Diverticulitis
Bleeding arteriovenous (AV) malformation
Bleeding arteriovenous (AV) malformation
Bleeding colonic carcinoma
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?
3
4
5
6
7
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?
Hepatitis A
Pancreatic carcinoma
Liver metastases
Cirrhosis
Pancreatitis
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?
Choledochal cyst
Pancreatic carcinoma
Liver metastases
Cirrhosis
Pancreatitis
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?
Hepatitis A
Hemolysis
Choledocholithiasis
Biliary stricture
Choledochal cyst
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?
A ruptured berry aneurysm
An acute subdural hematoma
An epidural hematoma
An intra-abdominal hemorrhage
A ruptured arteriovenous malformation
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
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?
Respiratory irregularities
Decreased blood pressure
Tachycardia
Papilledema
E. Compression of the fifth cranial nerve
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
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?
Umbilical hernia
Omphalitis
Omphalocele
Gastroschisis
Traumatic evisceration
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?
Observation
Repeat imaging of the humerus
Elevation of the extremity
Removal of the cast
Surgical decompression (fasciotomy)
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?
Closed reduction and application of a long leg cast
Intramedullary nailing
Surgical fixation with unreamed nailing
External fixation
Plate fixation
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?
Thyroid carcinoma
Cystic hygroma
Acute suppurative lymphadenitis
Thyroglossal duct cyst
Lipoma
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?
Thyroid carcinoma
Cystic hygroma
Acute suppurative lymphadenitis
Thyroglossal duct cyst
Lipoma
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?
Thyroid carcinoma
Acute suppurative lymphadenitis
Thyroglossal duct cyst
Lipoma
Branchial cleft cyst
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
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
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
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
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?
Surgical exploration
Aggressive resuscitation followed by surgical exploration
Colonoscopy
Acid suppression therapy
IV steroids
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
Ductal carcinoma in situ (DCIS) with or without an invasive component
Involuting fibroadenoma
Phyllodes tumor
Lobular carcinoma in situ (LCIS) with or without an invasive component
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?
Slipped capital femoral epiphysis (SCFE)
Legg-Calve-Perthes (LCP) disease
Dysplasia of the hip
Blount disease
Talipes equinovarus
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?
White blood cell count
X-ray of the knee
Magnetic resonance imaging (MRI) of the knee
Bone scan
Evaluation of synovial fluid aspirate
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
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
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
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
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
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?
Esophageal carcinoma
Bronchogenic carcinoma with invasion of the esophagus
Benign esophageal polyp
Leiomyoma
Lymphoma
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?
Repeat esophagoscopy with biopsy
Thoracotomy with extramucosal resection
Thoracotomy with esophageal resection
Radiation therapy
E. chemotherapy
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?
Arterial injury with air embolization
Major vein injury with air embolism
Sudden pneumothorax with lung collapse
Sympathetic discharge
Tracheal injury
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?
Fibroma
Chondroma
Osteochondroma
Hamartoma
Aspergilloma
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
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?
Partial splenectomy
Splenectomy
Increase in steroid dose and frequency
Bone marrow transplant
Lasmapheresis
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?
IV furosemide
A bolus of IV crystalloid
A dopamine infusion
A nitroprusside infusion
IV digoxin administration
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?
IV furosemide
A bolus of IV crystalloid
A dopamine infusion
A nitroprusside infusion
IV digoxin administration
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?
Orotracheal intubation
Nasotracheal intubation
Cricothyroidotomy
Tracheostomy
Placement of bilateral chest tubes
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?
Aspiration of scrotal contents
Retrograde cystogram
Retrograde urethrogram
Scrotal sonogram
Scrotal surgical exploration
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
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
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
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?
Urinary tract infection
Benign prostatic hyperplasia
Prostatitis
Pyelonephritis
Nephrolithiasis
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?
Metastatic carcinoma
B. Infectious parotitis
Pleomorphic adenoma of the parotid
Hodgkin’s disease
Reactive cervical lymphatic hyperplasia
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?
Antibiotics
Excisional biopsy
Observation with re-evaluation in 2–4 weeks
Superficial parotidectomy
Chest x-ray
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?
A. gastroenteritis
Intussusception
Midgut volvulus
D. Meckel’s diverticulum
Juvenile rectal polyp
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?
Exploratory neck surgery
MRI of the pituitary gland
Needle core biopsy of the thyroid mass
Radionuclide thyroid scan
Serum levels of T3
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
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
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
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
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
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