USMLE surgery treatment 2 (2)

96) A 5-year-old child presents with a small mass near the anterior border of the sternocleidomastoid muscle. The mass is associated with localized erythema and induration, and the child is febrile. Which of the following is the definitive treatment of this problem?

97) A 21-year-old woman asks you to evaluate a small painless lump in the midline of her neck that moves with swallowing. You make the clinical diagnosis of thyroglossal duct cyst. Which of the following is the most appropriate management of this patient?

98) A 60-year-old smoker is seen because of a 3-cm midline ulcerating mass that is visualized when he sticks out his tongue. Biopsy establishes that this is squamous cell carcinoma. Which of the following is the most appropriate treatment of his cancer?

99) A 45-year-old woman with history of heavy nonsteroidal anti-inflammatory drug ingestion presents with acute abdominal pain. She undergoes exploratory laparotomy 30 hours after onset of symptoms and is found to have a perforated duodenal ulcer. Which of the following is the procedure of choice to treat her perforation?

100) A 45-year-old man with a history of chronic peptic ulcer disease undergoes a truncal vagotomy and antrectomy with a Billroth II reconstruction for gastric outlet obstruction. Six weeks after surgery, he returns, complaining of postprandial weakness, sweating, light-headedness, crampy abdominal pain, and diarrhea. Which of the following would be the best initial management strategy?

101) A 60-year-old male patient with hepatitis C with a previous history of variceal bleeding is admitted to the hospital with hematemesis. His blood pressure is 80/60 mmHg, physical examination reveals splenomegaly and ascites, and initial hematocrit is 25%. Prior to endoscopy, which of the following is the best initial management of the patient?

102) A 32-year-old alcoholic with end-stage liver disease has been admitted to the hospital 3 times for bleeding esophageal varices. He has undergone banding and sclerotherapy previously. He admits to currently drinking 6 packs of beer per day. On his abdominal examination, he has a fluid wave. Which of the following is the best option for long-term management of this patient’s esophageal varices?

103) A 55-year-old man complains of chronic intermittent epigastric pain. A gastroscopy demonstrates a 2-cm prepyloric ulcer. Biopsy of the ulcer yields no malignant tissue. After a 6 week trial of medical therapy, the ulcer is unchanged. Which of the following is the best next step in his management?

104) A 45-year-old man was discovered to have a hepatic flexure colon cancer during a colonoscopy for anemia requiring transfusions. Upon exploration of his abdomen in the operating room, an unexpected discontinuous 3-cm metastasis is discovered in the edge of the right lobe of the liver. Preoperatively, the patient was counseled of this possibility and the surgical options. Which of the following is the most appropriate management of this patient?

105) A 70-year-old woman has nausea, vomiting, abdominal distention, and episodic crampy midabdominal pain. She has no history of previous surgery but has a long history of cholelithiasis for which she has refused surgery. Her abdominal radiograph reveals a spherical density in the right lower quadrant. Which of the following is the definitive treatment for this patient’s bowel obstruction?

106) A 65-year-old male presented to the ER with increasing shortness of breath, fever and productive cough of 2 days duration. He has smoked for several years and has been on home oxygen. Chest x-ray showed right lower lobe consolidation. His vital signs on admission were temperature 38.7°C (101.7°F), blood pressure 120/76 mm Hg, pulse 110/min and respirations 26/min. His condition worsened over the next several hours and required orotracheal intubation and mechanical ventilation. He was transferred to the intensive care unit. Placement of a central venous catheter in the right subclavian vein for IV access was attempted. After the line is successfully placed, the patient begins to deteriorate. Repeat vital signs are blood pressure 80/50 mm Hg and pulse 130/min. Examination shows absent breath sounds on the right side and distended neck veins. Which of the following is the most appropriate next step in management?

107) A 54-year-old woman comes to the clinic because of a forceful hyperextension injury to her hand after falling down. She complains of pain and swelling of the right wrist and pain associated with movement. She has no other complaints. She has no other medical conditions and takes no medication. Her blood pressure is 110/60 mm Hg, pulse is 84/min, and respirations are 12/min. Examination shows maximal tenderness in the anatomic snuffbox and pain with radial deviation of the wrist. The rest of the examination shows no other injuries. X-ray imaging of the wrist in multiple views does not reveal a fracture. Which of the following is the most appropriate next step in management?

108) A 58-year-old man is found to have a small mass in the right neck on a yearly physical examination. The patient reports that the mass has been slowly growing for the last few months and is not associated with pain or drainage. He has an otherwise negative review of systems. On examination there is a hard, mobile 2 cm mass along the mid-portion of the right sternocleidomastoid muscle. Which of the following is the most appropriate initial step in the workup of the neck mass?

109) A 53-year-old man presents to the emergency room with left lower quadrant pain, fever, and vomiting. CT scan of the abdomen and pelvis reveals a thickened sigmoid colon with inflamed diverticula and a 7-cm by 8-cm rim-enhancing fluid collection in the pelvis. After percutaneous drainage and treatment with antibiotics, the pain and fluid collection resolve. He returns as an outpatient to clinic 1 month later. He undergoes a colonoscopy, which demonstrates only diverticula in the sigmoid colon. Which of the following is the most appropriate next step in this patient’s management?

110) A 29-year-old woman complains of postprandial right upper quadrant pain and fatty food intolerance. Ultrasound examination reveals no evidence of gallstones or sludge. Upper endoscopy is normal, and all of her liver function tests are within normal limits. Which of the following represents the best management option?

111) A 47-year-old asymptomatic woman is incidentally found to have a 5-mm polyp and no stones in her gallbladder on ultrasound examination. Which of the following is the best management option?

112) A 32-year-old alcoholic man, recently emigrated from Mexico, presents with right upper quadrant pain and fevers for 2 weeks. CT scan of the abdomen demonstrates a non–rim-enhancing fluid collection in the periphery of the right lobe of the liver. The patient’s serology is positive for antibodies to Entamoeba histolytica. Which of the following is the best initial management option for this patient?

113) A 22-year-old woman is seen in a surgery clinic for a bulge in the right groin. She denies pain and is able to make the bulge disappear by lying down and putting steady pressure on the bulge. She has never experienced nausea or vomiting. On examination she has a reducible hernia below the inguinal ligament. Which of the following is the most appropriate management of this patient?

114) A 72-year-old man status post–coronary artery bypass graft (CABG) 5 years ago presents with hematochezia, abdominal pain, and fevers. Colonoscopy reveals patches of dusky-appearing mucosa at the splenic flexure without active bleeding. Which of the following is the most appropriate management of this patient?

115) A 39-year-old woman with no significant past medical history and whose only medication is oral contraceptive pills (OCP) presents to the emergency room with right upper quadrant pain. CT scan demonstrates a 6-cm hepatic adenoma in the right lobe of the liver. Which of the following describes the definitive treatment of this lesion?

116) A 43-year-old man without symptoms is incidentally noted on CT scan to have a 4 cm lesion in the periphery of the left lobe of the liver. The lesion enhances on the arterial phase of the CT scan and has a central scar suggestive of focal nodular hyperplasia (FNH). Which of the following is the recommended treatment of this lesion?

117) A 57-year-old previously alcoholic man with a history of chronic pancreatitis presents with hematemesis. Endoscopy reveals isolated gastric varices in the absence of esophageal varices. His liver function tests are normal and he has no stigmata of end-stage liver disease. Ultrasound examination demonstrates normal portal flow but a thrombosed splenic vein. He undergoes banding, which is initially successful, but he subsequently rebleeds during the same hospitalization. Attempts tocontrol the bleeding endoscopically are unsuccessful. Which of the following is the most appropriate next step in management?

118) A previously healthy 15-year-old boy is brought to the emergency room with complaints of about 12 hours of progressive anorexia, nausea, and pain of the right lower quadrant. On physical examination, he is found to have a rectal temperature of 38.18°C (100.72°F) and direct and rebound abdominal tenderness localizing to McBurney point as well as involuntary guarding in the right lower quadrant. At operation through a McBurney-type incision, the appendix and cecum are found to be normal, but the surgeon is impressed by the marked edema of the terminal ileum, which also has an overlying fibrinopurulent exudate. Which of the following is the most appropriate next step?

120) After complete removal of a sessile polyp of 2.0 cm by 1.5 cm found 1 finger length above the anal mucocutaneous margin, the pathologist reports it to have been a villous adenoma that contained​carcinoma in situ. Which of the following is the most appropriate next step in management?

121) A 55-year-old man who is extremely obese reports weakness, sweating, tachycardia, confusion, and headache whenever he fasts for more than a few hours. He has prompt relief of symptoms when he eats. Labarotory examination reveals an inappropriately high level of serum insulin during the episodes of fasting. Which of the following is the most appropriate treatment for this condition?

122) A 57-year-old woman sees blood on the toilet paper. Her doctor notes the presence of an excoriated bleeding 2.8-cm mass at the anus. Biopsy confirms the clinical suspicion of anal cancer. In planning the management of a 2.8-cm epidermoid carcinoma of the anus, which of the following is the best initial management strategy?

123) An 80-year-old man is admitted to the hospital complaining of nausea, abdominal pain, distention, and diarrhea. A cautiously performed transanal contrast study reveals an apple-core configuration in the rectosigmoid area. Which of the following is the most appropriate next step in his management?

124) A 28-year-old man is brought to the emergency department after being an unrestrained passenger in a motor vehicle collision. In the ambulance on the way to the hospital, he receives 2 L normal saline intravenously and 5l/min of oxygen by nasal cannula. His blood pressure is 80/42 mm Hg, pulse is 135/min, and respirations are 40/min. He is agitated and moves all 4 extremities spontaneously. His pupils are symmetric and reactive to light. Neck veins are distended, and his trachea is deviated to the right. Which of the following is the best initial management for this patient?

125) A 46-year-old woman who was recently diagnosed with Crohn disease asks about the need for surgery. Which of the following findings would be an indication for an immediate exploratory laparotomy?

126) A septuagenarian woman undergoes an uncomplicated resection of an abdominal aneurysm. Four days after surgery the patient presents with sudden onset of abdominal pain and distention. An abdominal radiograph demonstrates an air-filled, kidney-bean–shaped structure in the left upper quadrant. Which of the following is the most appropriate management at this time?

127) A 45-year-old man presents with right upper quadrant abdominal pain and fever. CT scan shows a large, calcified cystic mass in the right lobe of the liver. Echinococcus is suggested by the CT findings. Which of the following is the most appropriate management of echinococcal liver cysts?

128) A 56-year-old woman has nonspecific complaints that include an abnormal sensation when swallowing. An esophagram is obtained. Which of the following is most likely to require surgical correction?

130) A 48-year-old man presents with jaundice, melena, and right upper quadrant abdominal pain after undergoing a percutaneous liver biopsy. Endoscopy shows blood coming from the ampulla of Vater. Which of the following is the most appropriate first line of therapy for major hemobilia?

132) A 54-year-old man complains that his eyes are yellow. His bilirubin is elevated. His physical examination is unremarkable. A CT of the abdomen shows a small mass in the head of the pancreas encasing the superior mesenteric artery. Cytology from the ERCP is positive for cancer. Which of the following is the most appropriate treatment for this patient?

133) A 32-year-old woman undergoes an uncomplicated appendectomy for acute appendicitis. The pathology report notes the presence of a 1-cm carcinoid tumor in the tip of the appendix. Which of the following is the most appropriate management of this patient?

134) A 44-year-old man is brought to the emergency department after a motor vehicle accident. His cervical spine is immobilized and 2 large-bore intravenous lines are placed. His breath smells of alcohol. The patient is lethargic but responds to commands appropriately. A 3-cm laceration is present on his forehead. Ecchymoses are seen on his back and over the abdominal wall in the distribution of the seat belt. The lungs are clear to auscultation. The trachea is midline and the neck veins are collapsed. Passive movement of the right hip is limited due to pain. At the scene of the accident, blood pressure was 90/60 mm Hg and pulse was 130/min. After receiving a 1 L bolus of intravenous fluids, the patient's blood pressure remains 90/60 mm Hg and his pulse is now 122/min. Portable chest x-ray shows no pneumothorax or pleural effusions. A bedside abdominal ultrasound is inconclusive for hemoperitoneum or intra-abdominal injury due to poor image quality. What is the most appropriate next step in management of this patient?

136) A 35-year-old man presents with right upper quadrant pain, fever, jaundice, and shaking chills. Ultrasound of the abdomen demonstrates gallstones, normal gallbladder wall thickness, and common bile duct of 1.0 cm. The patient is admitted to the hospital and given IV fluids and antibiotics. He continues to be febrile with increasing WBCs. Which of the following is the most appropriate next step in this patient’s management?

137) An 88-year-old man with a history of end-stage renal failure, severe coronary artery disease, and brain metastases from lung cancer presents with acute cholecystitis. His family wants “everything done.” Which of the following is the best management option in this patient?

139) A 54-year-old man presents with sudden onset of massive, painless, recurrent hematemesis. Upper endoscopy is performed and reveals bleeding from a lesion in the proximal stomach that is characterized as an abnormally large artery surrounded by normal-appearing gastric mucosa. Endoscopic modalities fail to stop the bleeding. Which of the following is the most appropriate surgical management of this patient?

140) A neonate is examined in the nursery and found to have no anal orifice; only a small perineal fistulous opening is visualized. A complete workup is negative for any cardiac, esophageal, genitourinary, or musculoskeletal anomalies. Which of the following is the best next step in the management of this patient?

142) During an appendectomy for acute appendicitis, a 4-cm mass is found in the midportion of the appendix. Frozen section reveals this lesion to be a carcinoid tumor. Which of the following is the most appropriate management of this patient?

143) A 45-year-old woman has an incidental finding of a liver mass on a CT scan. Magnetic resonance imaging (MRI) is suggestive of a hemangioma. Which of the following is the most appropriate management strategy for this patient?

144) A 57-year-old woman presents with adenocarcinoma of the right colon. Laboratory evaluation demonstrates an elevation of carcinoembryonic antigen (CEA) to 123ng/mL. Which of the following is the most appropriate use of CEA testing in patients with colorectal cancer?

145) A 61-year-old woman with a history of unstable angina complains of hematemesis after retching and vomiting following a night of binge drinking. Endoscopy reveals a longitudinal mucosal tear at the gastroesophageal junction, which is not actively bleeding. Which of the following is the next recommended step in the management of this patient?

146) A teenage boy falls from his bicycle and is run over by a truck. On arrival in the emergency room (ER), he is awake and alert and appears frightened but in no distress. The chest radiograph suggests an air-fluid level in the left lower lung field and the nasogastric tube seems to coil upward into the left chest. Which of the following is the next best step in his management?

147) A 10-year-old boy was the backseat belted passenger in a high-speed motor vehicle collision. On presentation to the ER, he is awake, alert, and hemodynamically stable. He is complaining of abdominal pain and has an ecchymosis on his anterior abdominal wall where the seatbelt was located. Which of the following is the best next step in his management?

148) A 65-year-old man who smokes cigarettes and has chronic obstructive pulmonary disease falls and fractures the third, fourth, and fifth ribs in the left anterolateral chest. Chest x-ray is otherwise normal. Which of the following would be the most appropriate next step in his management?

149) A 52-year-old man is pinned against a loading dock. The patient has a fractured femur, a pelvic fracture, a tender abdomen, and no pulses in the right foot with minimal tissue damage to the right leg. Angiography discloses a popliteal artery injury with obstruction. At surgery, the popliteal vein is also transected. His blood pressure is 85/60 mm Hg. Which of the following is the best management strategy for his vascular injuries?

150) A 17-year-old adolescent boy is stabbed in the left seventh intercostal space, midaxillary line. He presents to the ER with a heart rate of 86 beats per minute, blood pressure of 125/74 mm Hg, and oxygen saturation of 98%. Breath sounds are equal bilaterally. Which of the following is the most appropriate next step in his workup?

151) A 29-year-old man sustained a gunshot wound to the right upper quadrant. He is taken to the operating room and, after management of a liver injury, is found to have a complete transection of the common bile duct with significant tissue loss. Which of the following is the optimal surgical management of this patient’s injury?

152) You evaluate an 18-year-old man who sustained a right-sided cervical laceration during a gang fight. Your intern suggests nonoperative management and observation. Which of the following is a relative, rather than an absolute, indication for neck exploration?

153) Following blunt abdominal trauma, a 12-year-old girl develops upper abdominal pain, nausea, and vomiting. An upper gastrointestinal series reveals a total obstruction of the duodenum with a coiled spring appearance in the second and third portions. In the absence of other suspected injuries, which of the following is the most appropriate management of this patient?

154) A 45-year-old man presents after a high-speed motor vehicle collision. He has a seatbelt sign across his neck and chest with an ecchymosis over his left neck. He is hemodynamically stable and neurologically intact. A CT angiogram shows a left carotid dissection. In the absence of other significant injuries, what is the next step in his management?

155) An 18-year-old man was assaulted and sustained significant head and facial trauma. Which of the following is the most common initial manifestation of increased intracranial pressure?

156) A 28-year-old man is brought to the ER for a severe head injury after a fall. He was intubated in the field for his decreased level of consciousness. He is tachycardic and hypotensive. On examination, he is noted to have an obvious skull fracture and his right pupil is dilated. Which of the following is the most appropriate method for initially reducing his intracranial pressure?

157) A 31-year-old man is brought to the ER following an automobile accident in which his chest struck the steering wheel. Examination reveals stable vital signs and no evidence of respiratory distress, but the patient exhibits multiple palpable rib fractures and paradoxical movement of the right side of the chest. Chest x-ray shows no evidence of pneumothorax or hemothorax. Which of the following is the most appropriate initial management of this patient?

158) Following a 2-hour firefighting episode, a 36-year-old fireman begins complaining of a throbbing headache, nausea, dizziness, and visual disturbances. He is taken to the ER, where his carboxyhemoglobin (COHb) level is found to be 31%. Which of the following is the most appropriate next step in his treatment?

159) An 18-year-old man climbs up a utility pole to retrieve his younger brother’s kite. An electrical spark jumps from the wire to his metal belt buckle and burns hisabdominal wall, knocking him to the ground. Which of the following should guide your treatment of this patient?

160) A 22-year-old man is examined following a motor vehicle accident. He has a right knee dislocation which is reduced in the emergency room. He has palpable pedal pulses and is neurologically intact. Which of the following is an appropriate next step in his workup and management?

161) A 23-year-old, previously healthy man presents to the ER after sustaining a single gunshot wound to the left chest. The entrance wound is 3 cm inferior to the nipple and the exit wound is just below the scapula. A chest tube is placed that drains 400 mL of blood and continues to drain 50 to 75 mL/h during the initial resuscitation. Initial blood pressure of 70/0 mm Hg has responded to 2L crystalloid and is now 100/70 mm Hg. Abdominal examination is unremarkable. Chest x-ray reveals a reexpanded lung and no free air under the diaphragm. Which of the following is the best next step in his management?

162) A 25-year-old man is involved in a gang shoot-out and sustains an abdominal gunshot wound from a .22 pistol. At laparotomy, it is discovered that the left transverse colon has incurred a through-and-through injury with minimal fecal soilage of the peritoneum. Which of the following is the most appropriate management of this patient?

163) A 1-year-old child has repeated episodes of vomiting and abdominal distention. An x-ray shows obstruction at the second portion of the duodenum. Laparotomy is performed and an annular pancreas is discovered. For a symptomatic partial duodenal obstruction secondary to an annular pancreas, which of the following is the operative treatment of choice?

164) Approximately 2 weeks after a viral respiratory illness, an 18-month-old child complains of abdominal pain and passes some bloody mucus per rectum. A long, thin mass is palpable in the right upper quadrant of the abdomen. No peritoneal signs are present. Intussusception is suspected. Which of the following is the most appropriate next step?

166) A 48-year-old man sustains a gunshot wound to the right upper thigh just distal to the inguinal crease. He is immediately brought to the ER. Peripheral pulses are palpable in the foot, but the foot is pale, cool, and hypesthetic. The motor examination is normal. Which of the following statements is the most appropriate next step in the patient’s management?

167) An 18-year-old high school football player is kicked in the left flank. Three hours later he develops hematuria. His vital signs are stable. A CT scan demonstrates a grade II renal injury based on the Urologic Injury Scale of the American Association for the Surgery of Trauma. Which of the following is the most appropriate treatment for this patient?

168) A 17-year-old adolescent boy sustains a small-caliber gunshot wound to the mid-epigastrium with no obvious exit wound. His abdomen is very tender; he is taken to the operating room and the bullet appears to have tracked through the stomach, distal pancreas, and spleen. The duct appears to have been injured. Which of the following is the best strategy for the management of this patient’s pancreatic injury?

169) A 22-year-old woman who is 4 months pregnant presents after a motor vehicle collision complaining of abdominal pain and right leg pain. She has an obvious deformity of her right femur. She is hemodynamically stable. Which of the following is the best next step in her management?

170) An infant is born with a defect in the anterior abdominal cavity. Upon examination there are abdominal contents (small bowel and liver) protruding directly through the umbilical ring. Which of the following should be considered in the management of this condition?

171) A 29-week-old previously healthy male infant presents with fevers, abdominal distention, feeding intolerance, and bloody stools at 3 weeks of age. The patient undergoes x-ray and ultrasound examination for possible necrotizing enterocolitis. Which of the following findings on imaging is an indication for surgical management?

172) A newborn presents with signs and symptoms of distal intestinal obstruction. Abdominal x-rays reveal dilated loops of small bowel, absence of air-fluid levels, and a mass of meconium within the right side of the abdomen mixed with gas to give a ground-glass appearance. Which of the following should be performed as the initial management of the patient?

173) A 22-year-old man undergoes an exploratory laparotomy after a gunshot wound to the abdomen. The patient has multiple injuries, including a significant liver laceration, multiple small-bowel and colon injuries, and an injury to the infrahepatic vena cava. The patient receives 35 units of packed RBCs, 15 L of crystalloid, 12 units of fresh-frozen plasma (FFP), and 12 packs of platelets. The patient’s abdomen is packed closed and he is taken to the intensive care unit for further resuscitation. Which of the following warrants a decompressive laparotomy?

174) A 42-year-old moderately obese female complains of abdominal discomfort two days after undergoing an elective cholecystectomy. Her past medical history is significant for hypertension, diabetes mellitus and hyperlipidemia. Her blood pressure is 132/90 mmHg and her heart rate is 76/min. Physical examination reveals a distended abdomen with decreased bowel sounds. Which of the following is most likely contributing to her current condition?

175) A 35-year-old woman is brought to the emergency department after being rescued from a burning building by firefighters. She had a brief tonic-clonic seizure en route to the hospital. Her past medical history is unknown. She is confused and mildly agitated. Her temperature is 37°C (98.6°F), blood pressure is 100/60 mm Hg, pulse is 115/min, and respirations are 24/min. Her oxygen saturation is 96% on room air. Physical examination shows no burns and her skin color is normal. There are symmetric breath sounds bilaterally with scattered end-expiratory wheezes. Neurological examination shows no abnormalities except some confusion. The abdomen is soft and non-tender. Which of the following is the best initial treatment for the patient?

176) A 24-year-old woman comes to the physician's office because of breast pain. She has a 2-month-old baby who she breastfeeds. Her temperature is 38.8°C (101.9°F). Examination shows a hard, red, tender and swollen area on her right breast. There is no fluctuance noted. Which of the following is the most appropriate next step in management?

177) A 60-year-old man comes to the clinic because of right calf pain. He has a history of chronic diverticular disease and has had multiple attacks of diverticulitis in the past. His most recent attack occurred 3 weeks ago, and he was treated with antibiotics and underwent left hemicolectomy. He had a stable postoperative course and was discharged from the hospital 1 week ago. He developed right calf pain 3 days ago, with swelling and difficulty bearing weight on his right leg. He currently takes no medication. He does not use tobacco, alcohol, or illicit drugs. His temperature is 36.8°C (98.2°F), blood pressure is 120/70 mm Hg, pulse is 92/min, and respirations are 14/min. Physical examination reveals the right calf slightly larger than the left calf, moderate right ankle edema, and right calf pain with dorsiflexion of the right foot. Duplex ultrasonography shows a clot in the right distal portion of the femoral vein. Which of the following is the most appropriate initial treatment?

178) A 23-year-old man is brought to the emergency department in an obtunded state following a gun-shot wound to the right upper quadrant of the abdomen. His systolic blood pressure is 60 mm Hg and unable to obtain diastolic blood pressure. His pulse is 136/min. Chest auscultation shows clear heart and breath sounds. The abdomen appears distended, and there is an obvious gun-shot wound on the right upper quadrant. The bowel sounds are decreased. Which of the following is the most appropriate next step in management?

179) A 35-year-old woman is being evaluated for a breast mass. She had a bilateral reduction mammoplasty for mammary hyperplasia 12 years ago. She has no family history of cancer. Breast examination shows a slightly retracted right nipple. A fixed mass is palpated in the upper outer quadrant of the right breast. Mammogram shows a 3 x 3 cm spiculated mass with coarse calcifications in the upper outer quadrant of the right breast. Ultrasonogram of the breast shows a hypoechoic mass. Multiple core biopsy samples show foamy macrophages and fat globules. Which of the following is the most appropriate course of action?

180) A 67-year-old male comes to the clinic for medical clearance prior to an elective abdominal aortic aneurysm repair. He denies any cough, shortness of breath or chest pain. He has coronary artery disease, diabetes and hypertension. He does not use tobacco, alcohol or drugs. His blood pressure is 120/76 mm Hg, pulse is 60/min, and respirations are 14/min. Examination shows no abnormalities, except prominent epigastric pulsations. Which of the following interventions would be most helpful in preventing postoperative pneumonia in this patient?

181) A 24-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He complains of severe back pain and abdominal discomfort. He was placed on a board in the field for spinal immobilization. His blood pressure is 111/78 mm Hg, pulse is 55/min and regular, and respirations are 16/min. Pulse oximetry shows 96% on room air. He is alert and fully oriented. There are several lacerations on the face and anterior chest. Air entry is bilaterally symmetric. There is weakness and decreased pain sensation in both legs. Proprioceptive sensation is preserved. Chest x-ray and CT scans of the abdomen and spine are performed. Which of the following is the most appropriate next step in managing this patient?

182) A 72-year-old man undergoes coronary artery bypass graft (CABG) for severe coronary artery disease. He is extubated on the second postoperative day. His temperature is 36.6°C (97.9°F), blood pressure is 120/70 mm Hg, pulse is 80/min, and respirations are 12/min. On the third postoperative day, he complains of dyspnea and worsening retrosternal pain despite continuous analgesia with morphine. His temperature is 38.6°C (101.5°F), blood pressure is 112/52 mm Hg, pulse is 125/min and irregularly irregular and respirations are 28/min. Examination shows normal heart sounds. A small amount of cloudy fluid is present in the sternal wound drain. His ECG shows atrial fibrillation with rapid ventricular response. An x-ray film of the chest shows widening of the mediastinum. Echocardiography reveals a small amount of pericardial fluid. Laboratory studies show: Hemoglobin 8.9 mg/dl, WBC count 16,300/mm3, Platelet count 512,000/mm3, Creatinine 1.7 mg/dl, CPK 430 U/L.Which of the following will this patient most likely require?

183) A 16-year-old boy is brought to the emergency department after falling off a bicycle and hitting his head on the ground. He briefly lost consciousness but had no seizures. He had two episodes of vomiting and complains of mild headache. His mother accompanies him and demands immediate evaluation. He has no other medical problems. His blood pressure is 121/67 mm Hg and pulse is 78/min. Examination shows a small bruise on his forehead but no bony abnormalities. The rest of the physical examination, including neurologic examination, shows no other abnormalities. Which of the following is the most appropriate next step in management?

184) A 12-year-old boy is brought to the physician because of right groin pain, knee pain, and limping. He has had these symptoms for the past 2 weeks. He is at the 90th percentile for weight and 60th percentile for height. He is afebrile, and his other vital signs are within normal limits. Examination shows that the range of motion of the right knee joint is within normal limits but hip movements are restricted and the right foot points outward. There is external rotation of the right thigh on flexion of the hip. After confirming the diagnosis, which of the following is the most appropriate management?

185) While working on-site at a factory doing physical examinations for workers, a physician is suddenly called to help a worker who amputated his finger. Which of the following is the most appropriate next step in management in this situation?

186) A 29-year-old woman is brought to the emergency department after burning her right upper extremity in a cooking accident Examination shows a circumferential burn of the right upper extremity. She is given fluids, an analgesic and a wound dressing. On day three she develops severe deep tissue pain in the right limb with edema of the hand. Examination shows a circumferential eschar over the right arm. Her right radial and ulnar pulses are faint compared to the left and she has paresthesias in her right hand. Which of the following is the most appropriate next step in management?

187) A 42-year-old man comes to the physician because of a 3-month history of burning substernal chest pain after every meal. His other medical problems include chronic alcoholism. Upper endoscopy shows mucosal irregularity and ulceration of the squamocolumnar junction above the lower esophageal sphincter. Multiple biopsies are taken. He complains of worsening substernal pain radiating to the back, left chest pain, and mild shortness of breath 4 hours later. His temperature is 37.1°C (98.9°F), blood pressure is 110/70 mm Hg, pulse is 120/min, and respirations are 34/min. A chest x-ray shows a small left pleural effusion that was not present on a chest radiograph taken 2 weeks ago. Which of the following is the most appropriate next step in management?

188) A 3-year-old girl 1s brought to the emergency department because she is not moving her right arm. Her mother states that the child was perfectly normal in the morning. She remembers that she lifted the child with the child's right forearm and since then she has not been moving her right arm. Examination shows the right arm is held in pronation against the chest. The child avoids any movement of her right arm. Which of the following is the most appropriate next step in management?

190) A 46-year-old man comes to the emergency department because of abrupt onset of epigastric pain radiating to the back and associated vomiting. He has had these symptoms for the past 1 day. The symptoms are progressively getting worse. He has no other medical problems or previous surgeries. He does not use tobacco, alcohol, or illicit drugs. His temperature is 36.5°C (97.6°F), blood pressure is 100/70 mm Hg, pulse is 100/min, and respirations are 20/min. Abdomen is mildly distended and very tender to palpation in the epigastric region; bowel sounds have decreased. There is no rebound tenderness or organomegaly. Rectal examination shows no abnormalities. Laboratory findings reveal: CBC: Hb 15.0 g/dL, Platelet count 223,000/mm3, Leukocyte count 14,500/mm3, Serum Chemistry: Serum Na 134 mEq/L, Serum K 3.6 mEq/L, Chloride 93 mEq/L, Bicarbonates 29 mEq/L, BUN 30 mg/dL, Serum creatinine 0.8 mg/dL, Calcium 10.3 mg/dL, Blood glucose 168 mg/dL, LFT 1.4 mg/dL. Total bilirubin: Alkaline phosphatase 220 U/L, Aspartate aminotransferase 88 U/L, Alanine aminotransferase 155 U/L, Lipase 523 U/L. Abdominal x-ray shows gaseous distention of the small bowel in the upper abdomen. Computed tomography (CT) scan with contrast shows diffuse hypodense enlargement of the pancreas and peripancreatic and perirenal fluid collections. Nasogastric suction, intravenous normal saline, analgesics, and antibiotics are started. Which of the following is the most appropriate next step in management?