USMLE surgery treatment 1 (2)
156) 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
157) 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
158) 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
159) 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
160) 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
161) 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
162) The imaging studies demonstrate three lesions in the right hepatic lobe suspicious for metastatic disease, each measuring 3–4 cm in diameter. There was no evidence of extrahepatic disease. Which of the following is the most appropriate next step in management?
Systemic chemotherapy
Intra-arterial chemotherapy through the hepatic artery
Surgical resection
Radiation therapy to the liver
Repeat imaging studies in 3 months to determine the growth rate of the disease
163) 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%
164) 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
165) 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
166) 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 lightning" 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 rising gives her excruciating pain. She has good sphincter 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
167) During diagnostic evaluation, a 14-year-old girl with menorrhagia, frequent nosebleeds, and iron deficiency anaemia is found to have a low platelet count with a normal coagulation profile. Bone marrow biopsy reveals abundant megakaryocytes. On abdominal examination, no organomegaly is noted. Which of the following is the most appropriate initial therapy for this patient?
Splenectomy
Platelet transfusion when peripheral platelet count drops below 50,000/mL
Systemic steroids
Chemotherapy
Expectant, with intervention only if the patient develops significant clinical bleeding.
168) 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
169) 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
170) 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
171) 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
172) 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
173) 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
174) 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
175) 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
176) 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 intraoperative, with modified radical neck dissection reserved for patients with extra-capsular invasion.
The patient should undergo right thyroid lobectomy followed by iodine 131 (131I) therapies.
The patient should undergo right thyroid lobectomy.
177) 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
178) 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
Tetanus prophylaxis, intravenous (IV) antibiotics, and operative wound irrigation and debridement, with application of an external fixation device
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, IV antibiotics, long leg splint for immobilization, and operative intervention during elective surgical schedule
Tetanus prophylaxis, IV antibiotics, operative wound irrigation with closure of the soft-tissue defect, closed reduction, and immobilization in a long-leg cast
179) 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
180) 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
181) 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.
182) 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
183) 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)
184) 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
185) 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.
186) 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.
187) 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
188) 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
189) 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
190) 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
191) 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
192) 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 contra-indicated in this patient?
Right thyroid lobectomy
Subtotal thyroidectomy
Total thyroidectomy
Total thyroidectomy with lymph node dissection
131I radioactive ablation of the thyroid gland
193) 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
Chemotherapy
194) 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
195) 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
Plasmapheresis
196) 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
197) 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
198) 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
199) 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
200) 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
201) 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
202) 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
203) 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
204) 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
205) 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
206) 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
207) A 35-year-old woman with a history of previous right thyroidectomy for a benign thyroid nodule now undergoes completion thyroidectomy for a suspicious thyroid mass. Several hours postoperatively, she develops progressive swelling under the incision, stridor, and difficulty breathing. Orotracheal intubation is successful. Which of the following is the most appropriate next step?
Fiberoptic laryngoscopy to rule out bilateral vocal cord paralysis
Administration of intravenous calcium
Administration of broad-spectrum antibiotics and debridement of the wound
Wound exploration
Administration of high-dose steroids and antihistamines
208) In a 6-month-old previously healthy male infant, an abnormality is revealed during a routine diaper change, as illustrated in Figure 6-19. The parents have noted this finding on and off on several occasions over the last month. On each occasion, the child has been feeding well, and is content and playful. Which of the following is the most appropriate management at this time?
Antibiotics
Reassurance to the parents that the abnormality will resolve without intervention
Referral to the emergency department for immediate surgical consultation
Referral for elective surgical repair
Scrotal support
209) A 60-year-old man seeks medical attention because of recurrent urinary tract infections. The patient also reports a history of increasing difficulty in urination (decreased flow, straining, and hesitancy) over the last several months. A prostate-specific antigen (PSA) level is mildly elevated and a prostate biopsy proves benign. Which of the following is the most appropriate initial management of this patient with benign prostatic hyperplasia (BPH)?
α-Adrenergic blocker
5-alpha reductase inhibitor
α-Adrenergic blocker and 5-alpha reductase inhibitor
Transurethral resection of the prostate (TURP)
Open prostatectomy
210) An 83-year-old woman presents to a mammographic facility for a screening mammogram. The technician notices a mass in the lateral right breast. The patient denies any breast pain, nipple discharge, skin changes, or breast trauma. A right breast CC view is shown in Figure 6-7. Which of the following is the most appropriate next step in management?
Incisional biopsy
Needle biopsy
Lumpectomy, axillary dissection, and irradiation
Total mastectomy
Modified radical mastectomy
211) A 25-year-old unhelmeted man involved in a motorcycle collision has multiple cerebral contusions on head computed tomographic (CT) scan. He is agitated but hemodynamically stable, with a heart rate of 80 beats per minute and a mean arterial pressure (MAP) of 90 mm Hg. An intracranial pressure monitor is placed, and the initial ICP reading is 30 mm Hg. Which of the following is the most appropriate in the management of his traumatic brain injury (TBI) over the next few days?
Hyperventilation to maintain a cerebral PCO2 of 25 to 30 mm Hg
Administration of neosynephrine to increase his MAP and, consequently, his cerebral perfusion pressure (CPP)
Administration of mannitol (1 g/kg) to reduce his ICP
Placement of the patient in Trendelenburg position to increase cerebral perfusion
Avoidance of all sedating drugs in the first 24 to 48 hours in order to accurately assess his neurologic status
212) A 50-year-old woman complains of headaches and lateralizing weakness. A CT scan of the brain reveals an irregular mass in the right cerebral hemisphere. A biopsy documents that this is a glioblastoma. Which of the following is the best treatment strategy for potential cure?
Chemotherapy with temozolomide alone
Combination chemotherapy with carmustin, cisplatin, and temozolomide
External beam radiation alone
Surgical resection alone
Combined surgical resection, external beam radiation, and chemotherapy with temozolomide
213) An 85-year-old man presents to the emergency room with an acute onset of midepigastric pain, nausea, vomiting, and hiccups starting 2 days ago. He is unable to keep any food down. Past history is pertinent for a long-standing hiatal hernia, hypertension, and diet-controlled diabetes. Examination reveals vital signs of pulse rate 82/min, BP 100/52 mmHg, respiratory rate 16/min, and temperature 97.2°F. The patient is in no acute distress, but has epigastric tenderness without guarding. Laboratory analysis revealed a hematocrit of 46 and a normal white blood cell (WBC) count. A chest x-ray is shown in Figure 6-5a. A fluoroscopically guided NG tube was placed using contrast, and his stomach was decompressed. After adequate fluid and electrolyte resuscitation, an upper gastrointestinal (UGI) contrast study was obtained and is shown in 6-5b. Which of the following is the most appropriate next step in management?
Laparotomy or laparoscopy and operative repair
Continued NG tube decompression and initiation of total parenteral nutrition (TPN)
Thoracotomy or thoracoscopy and operative repair
Endotracheal intubation and initiation of ventilatory support
Upper endoscopy
214) A 49-year-old woman presents to her physician with dysphagia, regurgitation of undigested food eaten hours earlier, and coughing over the last 6 months. She was hospitalized 1 month ago for aspiration pneumonia and successfully treated with antibiotics. Examination reveals a thin-appearing woman with normal vital signs and unremarkable chest, heart, and abdominal examination. A UGI contrast study is performed and reveals a pharyngoesophageal (Zenker’s) diverticulum. Which of the following is the most important aspect of treatment?
Resection of the diverticulum
Cricopharyngeal muscle myotomy
H2 blockers
Elevation of the head of the bed
Diverticulopexy
215) A 40-year-old alcoholic is brought to the emergency department with frostbite to both lower extremities. His core body temperature is 36°C. Which of the following is the most appropriate initial treatment for the patient’s thermal injury?
Sympathectomy without any delay
Debridement of devitalized tissues
Slow rewarming at room temperature
Slow rewarming with dry heat
Rapid rewarming in warm water
216) A 35-year-old woman presents with a serum calcium level of 15.2 mg/dL and an elevated parathyroid hormone level. Following correction of the patient’s hypercalcemia with hydration and furosemide, which of the following is the best therapeutic approach?
Administration of steroids
Radiation treatment to the neck
Neck exploration and resection of all 4 parathyroid glands
Neck exploration and resection of a parathyroid adenoma
Avoidance of sunlight, vitamin D, and calcium-containing dairy products
217) 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. Following successful treatment for an embolus to the left femoral artery with no evidence of a reperfusion injury (anticoagulation with heparin and thromboembolecctomy), which of the following long-term treatments would most likely decrease the chance of recurrent embolus?
Anticoagulation
Exercise program
Coronary artery bypass grafting
Aortofemoral bypass grafting
Placement of a vena cava filter
218) A 63-year-old man has a chylothorax that after 2 weeks of conservative therapy appears to be persistent. The chest tube output is approximately 600 mL/day. Appropriate management at this time includes which of the following procedures?
Neck exploration and ligation of the thoracic duct
Subdiaphragmatic ligation of the thoracic duct
Thoracotomy and repair of the thoracic duct
Thoracotomy and ligation of the thoracic duct
Thoracotomy and abrasion of the pleural space
219) A 32-year-old woman has a CXR screening, and a 1.5-cm mass is noted in the right lower lobe. She is a nonsmoker. Bronchoscopy shows a mass in the right lower lobe orifice, covered with mucosa. Biopsy indicates this is compatible with a carcinoid tumor. Imaging suggests ipsilateral mediastinal lymph node involvement but no extrathoracic disease. Which of the following is the most appropriate treatment plan?
Right lower lobectomy and mediastinal lymph node dissection
Right lower lobectomy and mediastinal lymph node dissection followed by adjuvant chemotherapy
Neoadjuvant chemotherapy followed by right lower lobectomy and mediastinal lymph node dissection
Neoadjuvant chemoradiation followed by right lower lobectomy and mediastinal lymph node dissection
Chemoradiation
220) 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.Initial management should include which of the following?
Antibiotics and IV fluids
Lactose-free diet
Antispasmodics
Nutritional supplementation and systemic steroids
Laparotomy
221) A 33-year-old woman is found to have a palpable thyroid nodule during a routine medical checkup. A sonogram confirms the presence of a solid, 1.5-cm nodule in the right lobe of the thyroid gland. Fine needle aspirate cytology (FNA) is reported as "follicular tumor, otherwise unspecified." At surgery, a frozen section is read as follicular carcinoma. With the neck open, the surgeon can feel for enlarged jugular and peritracheal lymph nodes, and finds none. Which of the following is the most appropriate treatment?
Enucleation of the tumor
Right thyroid lobectomy
Total thyroidectomy
Total thyroidectomy plus postoperative radioactive iodine
Total thyroidectomy, radical neck dissection, and postoperative radioactive iodine
222) A 63-year-old woman with chronic obstructive pulmonary disease (COPD) presents with a several-week history of fever, night sweats, weight loss, and cough. Her CXR is noted to have a density in the left upper lobe with a relatively thin-walled cavity. Bronchoscopy and computed tomographic (CT) scan are suggestive of a lung abscess rather than a malignant process. Which of the following is the most appropriate initial management of this patient?
Percutaneous drainage of the lung abscess
Systemic antibiotics directed against the causative agent
Tube thoracostomy
Left upper lobectomy
Surgical drainage of the abscess
223) A 4-year-old previously healthy girl presents to the emergency department with a 24-hour history of rectal bleeding and dizziness. She has no other gastrointestinal symptoms. On examination, she appears pale. Her heart rate is 140 beats/min, and she has a 20 mmHg postural drop in systolic blood pressure. The child’s abdomen is nondistended and nontender, and fresh blood and clots are in the rectal vault on rectal examination. Definitive management of this child should include which of the following?
Immediate exploratory laparotomy
IV fluid resuscitation, transfusion with blood products as indicated, followed by a laparotomy with Meckel’s diverticulectomy and ileal resection
IV fluid resuscitation, followed by a colonoscopic polypectomy
Hemorrhoidectomy
Stool softeners and topical steroids
224) A 29-year-old nonhelmeted motorcycle driver is involved in a single vehicular crash, resulting in a significant closed-head injury. He is intubated in the field and transported to a level 1 trauma center. On arrival, he is oxygenating well with assisted ventilation and has a normal blood pressure and moderate tachycardia. His Glasgow Coma Score is 7, and his pupils are equal and sluggishly reactive. After stabilization in the emergency department, the patient undergoes a CT scan of the head that demonstrates a small amount of subarachnoid blood and a right frontal lobe contusion with edema with no midline shift. CT scan of the abdomen is normal. The patient is transferred to the ICU. The optimal initial management of this patient’s intracranial pressure (ICP) would be which of the following?
Craniotomy
Fluid restriction, hyperventilation, and osmotic diuresis
Fluid restriction, hyperventilation, and ventriculostomy
Hyperventilation and IV steroids
Normovolemia, normocarbia, sedation, and ventriculostomy
225) A 49-year-old obese man has become irritable, his face has changed to a round configuration, he has developed purplish lines on his flanks, and he is hypertensive. A 24-hour urine collection demonstrates elevated cortisol levels. This is confirmed with bedtime cortisol measurements of 700ng/mL. Which of the following findings is most consistent with the diagnosis of Cushing disease?
Decreased ACTH levels
Glucocorticoid use for the treatment of inflammatory disorders
A 3-cm adrenal mass on computed tomography (CT) scan
Suppression with high-dose dexamethasone suppression testing
A 1-cm bronchogenic mass on magnetic resonance imaging (MRI)
226) A 70-year-old man presents with back pain and increasing difficulty with initiating a urinary stream. On rectal examination, he is found to have a hard, irregularly enlarged prostate. He has an elevated prostate-specific antigen (PSA), and osteoblastic lesions in the vertebral column and bones of the pelvis. A needle biopsy of the prostate shows well-differentiated adenocarcinoma. Which of the following is the treatment of choice?
Radical prostatectomy
Transurethral prostatectomy
Cytotoxic chemotherapy
Hormonal manipulation
Radiotherapy
227) A 69-year-old man with mild hypertension and chronic obstructive pulmonary disease (COPD) presents with transient ischemic attacks and the angiogram shown here. Which of the following is the most appropriate treatment recommendation?
Medical therapy with aspirin 325 mg/day and medical risk factor management
Medical therapy with warfarin
Angioplasty of the carotid lesion followed by carotid endarterectomy if the angioplasty is unsuccessful
Carotid endarterectomy
Medical risk factor management and carotid endarterectomy if neurologic symptoms develop
228) 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 appropriate next step in management of this infant?
Immediate surgical exploration
Send the child home with an oral electrolyte rehydration solution
Change the infant’s formula and feeding regimen
IV fluid resuscitation, followed by surgical intervention
Initiate therapy with a prokinetic agent
229) A 49-year-old woman has a firm, 2-cm mass in the right breast that has been present for 3 months. Mammogram has been read as "cannot rule out cancer," but it cannot diagnose cancer either. A fine-needle aspiration of the mass (FNA) and cytology do not identify any malignant cells. Which of the following is the most appropriate next step in management?
Reassurance and reappointment in a year
Repeat mammogram and FNA in 1 month
Core or incisional biopsies
Lumpectomy and axillary dissection
Modified radical mastectomy
230) A 60-year-old man sees a urologist for what he describes as bloody urine. A urine sample is positive for cytologic evidence of malignancy. Cystoscopy confirms the presence of superficial transitional cell carcinoma. Which of the following is the recommended treatment for stage A (superficial and submucosal) transitional cell carcinoma of the bladder?
Topical (intravesicular) chemotherapy
Radical cystectomy
Radiation therapy
Local excision and topical (intravesicular) chemotherapy
Systemic chemotherapy
231) A 36-year-old man presents to the emergency room with renal colic. His vital signs are normal and a urinalysis shows microscopic hematuria. A radiograph reveals a 1.5-cm stone. Which of the following is the most appropriate management of this patient?
Hydration and analgesics
α-Adrenergic blocker
Extracorporeal lithotripsy
Percutaneous nephrostomy tube
Open surgery to remove the stone
232) An 8-month-old boy is seen by a pediatrician for the first time. The physician notes that there are no testes in the scrotum. Which of the following is the optimal management of bilateral undescended testicles in an infant?
Immediate surgical placement into the scrotum
Chorionic gonadotropin therapy for 1 month; operative placement into the scrotum before age 2 if descent has not occurred
Observation until age 2; operative placement into the scrotum if descent has not occurred
Observation until age 5; if no descent by then, plastic surgical scrotal prostheses before the child enters school
No therapy; reassurance of the parent that full masculinization and normal spermatogenesis are likely even if the testicle does not fully descend
233) A 55-year-old man presents to the emergency department with left lower quadrant abdominal pain. The pain has been present for 1 week, but has increased in intensity over the last 2 days associated with nausea, constipation, and dysuria. Past history is unremarkable. Examination reveals a temperature of 101°F, pulse rate of 95/min, BP of 130/70 mmHg, and normal heart and lung examinations. Abdominal examination reveals fullness and marked tenderness in the left lower quadrant, with voluntary guarding and decreased bowel sounds. Laboratory tests reveal a WBC count of 18,000 with a left shift and 20–50 WBCs in the urinalysis. A CT scan of the abdomen reveals a thickened sigmoid colon with pericolonic inflammation. He is admitted to the hospital for treatment. We find this patient has diverticulitis. Which of the following is the most appropriate management of this patient?
NPO, IV fluids, and IV antibiotics for gram-negative and anaerobic coverage
NPO, IV fluid hydration, followed by immediate sigmoid colon resection
NPO, IV fluids, and anticoagulation
NPO, IV fluids, evaluation of stool for Clostridium difficile toxin, and either metronidazole or vancomycin antibiotic therapy
NPO, IV fluids, initiation of bowel preparation for elective sigmoid colon resection during the current hospitalization
234) A 39-year-old woman completed her last course of postoperative adjuvant chemotherapy for breast cancer 6 months ago. She now comes to the clinic complaining of constant back pain for about 3 weeks. She is tender to palpation over two well-circumscribed areas in the thoracic and lumbar spine. Which of the following is the most appropriate next step in management?
CT scan of the trunk
Needle biopsy of the tender spots
Radionuclide bone scan
Sonogram of the affected areas
X-ray films of the affected areas
235) A 42-year-old woman returns to the clinic following an uneventful biopsy for a well-defined, mobile mass. The pathology report describes the mass as a fibro adenoma, but LCIS is identified in the breast parenchyma adjacent to the fibro adenoma and extending to the margin of resection. She has no current illnesses, is on no medications, and her family history is negative for breast cancer. Breast imaging studies show fatty breasts with no abnormal findings except for the fibro adenoma. Which of the following is the most appropriate management option?
Re-excision of the biopsy cavity to gain negative margins of resection
Ipsilateral mastectomy
Contralateral breast biopsy
Observation including examinations and mammography
Bilateral total mastectomies
236) A 59-year-old man is found to have a 6-cm thoracoabdominal aortic aneurysm which extends to above the renal arteries for which he desires repair, but he is concerned about the risk of paralysis postoperatively. Which of the following maneuvers should be employed to decrease the risk of paraplegia after repair?
Infusion of a bolus of steroids immediately postoperatively with a continuous infusion for 24 hours
Maintenance of intraoperative normothermia
Clamping of the aorta proximal to the left subclavian artery
Cerebrospinal fluid (CSF) drainage
Extracorporeal membrane oxygenation
237) A man who weighs 65 kg sustains second and third degree burns over both of his lower extremities when his pants catch on fire. When examined shortly thereafter, it is ascertained that virtually all of the skin from both groins to the tip of the toes, front and back, has been burned. According to the modified Parkland formula, which of the following is the approximate total amount of IV fluid that he can be expected to require during the first 24 hours post-burn?
3,460 mL
4,960 mL
6,760 mL
8,160 mL
11,360 mL
238) 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 most appropriate first step in management of this patient?
Echocardiography
Anticoagulation with heparin
Anticoagulation with warfarin
Arteriography
Alkalinization of the urine with IV sodium bicarbonate
239) A 29-year-old woman with a history of difficulty becoming pregnant presents to her primary care physician and is diagnosed with Grave disease on iodine uptake scan; her thyrotropin (TSH) level is markedly suppressed and her free thyroxine (T4) level is elevated. She desires to conceive as soon as possible and elects to undergo thyroidectomy. After she is rendered euthyroid with medications preoperatively, which of the following management strategies should also be employed to reduce the risk of developing thyroid storm in the operating room?
Drops of Lugol iodine solution daily beginning 10 days preoperatively.
Preoperative treatment with phenoxybenzamine for 3 weeks.
Preoperative treatment with propranolol for 1 week.
Twenty-four hours of corticosteroids preoperatively.
No other preoperative medication is required.
240) A 72-year-old woman with severe COPD who requires home oxygen is unable to ambulate inside her home without experiencing severe left hip pain. She was hospitalized 1 year ago for a viral pneumonia and was ventilator-dependent at that time for 6 weeks. On examination, her blood pressure is 165/80 mm Hg. She has weakly palpable bilateral femoral pulses. An angiogram demonstrates severe aortoiliac disease involving bilateral iliac vessels. Which of the following is the most appropriate vascular procedure for this patient?
Femorofemoral bypass
Axillofemoral bypass
Femoropopliteal bypass
Aortobifemoral bypass
Common femoral and profunda femoral endarterectomise
241) A 52-year-old woman has terminal cervical cancer with extensive pelvic invasion, and requires strong opiate analgesia to control severe pain. Intermittent nausea and vomiting have precluded the use of oral agents. She was on fentanyl patches but she developed allergic skin reactions to the adhesive and now requests to be switched to parenteral medication. Because of prior chemotherapy treatments she has no available venous access, but she is willing to have her family administer intramuscular injections. Assuming equianalgesic dosages, which of the following would be the most appropriate pharmacotherapy?
Codeine
Hydromorphone (Dilaudid)
Meperidine (Demerol)
Methadone
Morphine sulfate
242) A 71-year-old woman with a 40-year smoking history is noted to have a peripheral nodule in her left upper lobe on chest x-ray. Workup is consistent with small cell lung cancer with ipsilateral mediastinal lymph node involvement but no extrathoracic disease. What is the best treatment option for this patient?
Thoracotomy with left upper lobectomy and mediastinal lymph node dissection
Thoracotomy with left upper lobectomy and mediastinal lymph node dissection followed by adjuvant chemotherapy
Neoadjuvant chemotherapy followed by thoracotomy with left upper lobectomy and mediastinal lymphnode dissection
Neoadjuvant chemoradiation followed by thoracotomy with left upper lobectomy and mediastinal lymph-node dissection
Chemoradiation
243) A 42-year-old homeless man presents with a 3-week history of shortness of breath, fevers, and pleuritic chest pain. Chest x-ray (CXR) reveals a large left pleural effusion. Thoracentesis reveals thick, purulent-appearing fluid, which is found to have glucose less than 40 mg/dL and a pH of 6.5. A chest tube is placed, but the pleural effusion persists. Which of the following is the most appropriate management of this patient?
Placement of a second chest tube at the bedside and antibiotic therapy
Infusion of antibiotics via the chest tube
Intravenous antibiotics for 6 weeks
Thoracotomy with instillation of antibiotics into the pleural space
Thoracotomy with decortication and antibiotic therapy
244) During a campaign appearance, a political candidate is shot point blank in the right chest with a .22 caliber revolver. The entrance wound is well above the nipple line, just under the third rib, at the level of the anterior axillary line. His motorcade brings him to the emergency department, but he makes it a point to walk in, holding his right chest with a bloody hand and waving for the news media. A chest x-ray shows a hemothorax on the right, and the bullet is seen to be embedded in the right paraspinous muscles. A chest tube is placed in the right pleural cavity, and 650 mL blood is recovered. Over the ensuing 4 hours, he continues to drain between 250 and 350 mL blood per hour. Which of the following is the most appropriate next step in management?
Continued observation and appropriate blood replacement
A second chest tube in a better position to drain the blood
Thoracotomy and ligation of bleeding vessels
Thoracotomy, ligation of bleeding vessels, and removal of the bullet
Thoracotomy and pneumonectomy
245) A 65-year-old woman presents to the physician’s office for a second opinion on the management options for recently diagnosed breast cancer. She presents with a 2.5-cm mass in the upper outer quadrant of the left breast associated with a palpable axillary node suspicious for metastatic disease. The remainder of her examination is normal. Mammography demonstrates the cancer and shows no other suspicious lesions in either breast. Chest x-ray, bone scan, and blood test panel, including liver function tests, are normal. Family history is positive for breast cancer diagnosed in her sister at age 65. Past history is unremarkable. The first physician recommended modified radical mastectomy. Which of the following is the most appropriate management option for locoregional control yielding results equally effective as mastectomy?
Radical mastectomy
Lumpectomy, irradiation, and axillary node dissection
Lumpectomy and axillary node dissection
Irradiation of the breast and axilla
Quadrantectomy, irradiation, and axillary node dissection
246) During a hunting trip, a young man is bitten by a coyote. The animal is captured and brought to the authorities alive. Which of the following is the most important criterion to determine the patient's need for rabies prophylaxis?
The patient's history of previous immunizations
The patient's clinical course over the next few weeks
Observing the animal's behavior over the next few days
Killing the animal and examining the brain
The events that took place have already established the need to proceed with rabies immunization
247) A 64-year-old man with a history of a triple coronary artery bypasses 2 years ago presents with peripheral arterial occlusive disease. His only medication is a thiazide diuretic. Which of the following medications would be most appropriate in the medical management of his atherosclerosis?
Aspirin
Warfarin
Low-dose heparin
High-dose heparin
Low-molecular-weight heparin
248) 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 appropriate next step in management?
Wide excision with 2 cm margin
Wide excision with 2 cm margin and SLN mapping
Shave biopsy
Excisional biopsy with 1–2 mm margins
Mohs’ surgical excision
249) A 62-year-old man has had gastroesophageal reflux disease diagnosed by pH monitoring, and present for several years. He has been less than totally compliant with medical management, which he follows when the pain is bad, but discontinues when he feels better. Endoscopy and biopsies show severe peptic esophagitis, with Barrett's esophagus and early dysplastic changes, but no overt carcinoma. Additional tests show good esophageal motility, with low pressure in the lower esophageal sphincter and normal gastric emptying. Which of the following is the most appropriate treatment at this time?
Heller myotomy of the lower esophageal sphincter
Laparoscopic Nissen fundoplication
Transhiatal total esophagectomy
Transthoracic resection of the lower esophagus
Vagotomy, pyloroplasty, and fundic gastric wrap
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