Surgery USMLE (827-926)

A 30-year-old man comes to the physician because of a 2-week history of swelling and pain in the right knee. He first experienced pain when he twisted his leg while playing football 15 days ago. He felt something 'popping' in the knee at that time but ignored it. The pain and swelling has been increasing since, and he feels sudden pain with extension of his leg. Examination shov1s the right knee is swollen and tender along the medial side. Full extension of the right knee is not possible due to sudden pain during terminal extension. Snapping can be felt in the right knee on tibial torsion with the knee flexed at 90 degrees. An x-ray film of the knee joint shows no abnormalities. Which of the following is the most likely diagnosis?

A 25-year-old male is brought to the emergency department following a motor vehicle accident in which he was the unrestrained driver. The emergency response team's reports indicate that his breath smelled of alcohol at the scene. En route to the hospital, the patient receives 2 liters of intravenous normal saline, and in the ED his blood pressure is 100/60 mmHg, heart rate is 120/min, and respiratory rate is 34/min. His neck veins are flat. You note multiple bruises overlying his anterior chest wall and upper abdomen. On inspiration, there is inward motion of the right side of his chest wall. His abdomen is soft and non-distended. He is put on positive pressure mechanical ventilation and his chest movements become symmetric. Which of the following is the most likely diagnosis?

A 55-year-old man comes to the emergency department because of severe right-sided chest pain. His temperature is 37.8° C (1000 F), blood pressure is 138/88 mm Hg, pulse is 88/min and respirations are 19/min and shallow. Examination shows decreased respiratory movements on the right side of the chest and tenderness on palpation over the right mid-chest. An x-ray film of the chest shows a fracture of the right 6th rib. Which of the following is the most important goal in management of the rib fracture in this patient?

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?

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?

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?

A 56-year-old woman is referred to you about 3 months after a colostomy subsequent to a sigmoid resection for cancer. She complains that her stoma is not functioning properly. Which of the following is the most common serious complication of an end colostomy?

A 56-year-old previously healthy physician notices that his eyes are yellow and he has been losing weight. On physical examination the patient has jaundice and scleral icterus with a benign abdomen. Transcutaneous ultrasound of the abdomen demonstrates biliary ductal dilation without gallstones. Which of the following is the most appropriate next step in the workup of this patient?

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?

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?

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?

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 a 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?

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 6weeks trial of medical therapy, the ulcer is unchanged. Which of the following is the best next step in his management?

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?

A 42-year-old man with no history of use of NSAIDs presents with recurrent gastritis. The patient was diagnosed and treated for Helicobacter pylori 6 months ago. Which of the following tests provides the least invasive method to document eradication of the infection?

A 22-year-old college student notices a bulge in his right groin. It is accentuated with coughing, but is easily reducible. Which of the following hernias follows the path of the spermatic cord within the cremaster muscle?

An 80-year-old man with history of symptomatic cholelithiasis presents with signs and symptoms of a small-bowel obstruction. Which of the following findings would provide the most help in ascertaining the diagnosis?

A 42-year-old man has bouts of intermittent crampy abdominal pain and rectal bleeding. Colonoscopy is performed and demonstrates multiple hamartomatous polyps. The patient is successfully treated by removing as many polyps as possible with the aid of intraoperative endoscopy and polypectomy. Which of the following is the most likely diagnosis?

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?

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, and 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?

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?

An 18-year-old woman at 9 weeks' gestation is brought to the emergency department because of an open fracture of the tibia and fibula. She is hemodynamically stabilized and referred to the orthopedic department. She is scheduled for internal fixation of the tibia for the following day. However, before the surgery she develops severe dyspnea and confusion. Her temperature is 37.7° C (99.9° F), blood pressure is 110/70 mmHg, pulse is 110/min, and respirations are 22/min. Examination shows numerous non-palpable petechiae in the upper part of the body. Which of the following is the most likely diagnosis?

A 38-year-old woman who underwent total thyroidectomy for multinodular goiter 6 months ago presents with persistent hoarseness. Which of the following nerves was most likely injured during her operation?

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?

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?

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?

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?

A 48-year-old woman develops pain in the right lower quadrant while playing tennis. The pain progresses and the patient presents to the emergency room later that day with a low-grade fever, a WBC count of 13,000/mm3 and complaints of anorexia and nausea as well as persistent, sharp pain of the right lower quadrant. On examination, she is tender in the right lower quadrant with muscular spasm, and there is a suggestion of a mass effect. An ultrasound is ordered and shows an apparent mass in the abdominal wall. Which of the following is the most likely diagnosis?

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?

A 45-year-old executive experiences increasingly painful retrosternal heartburn, especially at night. He has been chewing antacid tablets. An esophagogram shows a hiatal hernia. In determining the proper treatment for a sliding hiatal hernia, which of the following is the most useful modality?

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?

A 22-year-old woman presents with a painful fluctuant mass in the midline between the gluteal folds. She denies pain on rectal examination. Which of the following is the most likely diagnosis?

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?

A 62-year-old man has been diagnosed by endoscopic biopsy as having a sigmoid colon cancer. He is otherwise healthy and presents to your office for preoperative consultation. He asks a number of questions regarding removal of a portion of his colon. Which of the following is most likely to occur after a colon resection?

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?

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?

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?

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?

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?

A 62-year-old man has been noticing progressive difficulty swallowing, first solid food and now liquids as well. A barium study shows a ragged narrowing just below the carinal level. Endoscopic biopsy confirms squamous cell carcinoma. Which of the following provides the most accurate information regarding the T stage of an esophageal carcinoma?

A 53-year-old woman with a history of a vagotomy and antrectomy with Billroth II reconstruction for peptic ulcer disease presents with recurrent abdominal pain. An esophagogastroduodenoscopy (EGD) demonstrates that ulcer and serum gastrin levels are greater than 1000 pg/mL on three separate determinations (normal is 40-150). Which of the following is the best test for confirming a diagnosis of gastrinoma?

A 52-year-old man with a family history of multiple endocrine neoplasia type 1 (MEN1) has an elevated gastrin level and is suspected to have a gastrinoma. Which of the following is the most likely location for his tumor?

A 73-year-old woman presents to the emergency room complaining of severe epigastric pain radiating to her back, nausea, and vomiting. CT scan of the abdomen demonstrates inflammation and edema of the pancreas. A right upper quadrant ultrasound demonstrates the presence of gallstones in the gallbladder. Which of the following is an important prognostic sign in acute pancreatitis according to Ranson’s criteria?

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?

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?

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?

A 40-year-old female is brought to the emergency department following a motor vehicle accident in which she was the front seat passenger. She reports hitting her head against the windshield and hurting her right leg. She appears completely alert and oriented. Glasgow Coma Scale =15/15. Her pupils are equal and reactive to light. There is a bruise over the right forehead, but no tenderness is present on palpation of the cranial bones. Examination of the right leg reveals a hematoma over the thigh. Knee extension on the right is markedly reduced when compared to the left. Sensory examination reveals decreased sensory perception to both sharp and dull stimuli over the medial side of the right lower thigh and leg. All other dermatomes are intact. What nerve injury is most likely present in this patient?

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 5 Umin 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?

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?

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?

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?

A 28-year-old woman who is 15 weeks pregnant has new onset of nausea, vomiting, and right sided abdominal pain. She has been free of nausea since early in her first trimester. The pain has become worse over the past 6 hours. Which of the following is the most common non- obstetric surgical disease of the abdomen during pregnancy?

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?

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?

A 30-year-old female patient who presents with diarrhea and abdominal discomfort is found at colonoscopy to have colitis confined to the transverse and descending colon. A biopsy is performed. Which of the following is a finding consistent with this patient’s diagnosis?

A 24-year-old man presents to the emergency room with abdominal pain and fever. CT scan of the abdomen reveals inflammation of the colon. He is referred to a gastroenterologist to be evaluated for inflammatory bowel disease (Crohn disease versus ulcerative colitis). Which of the following indications for surgery is more prevalent in patients with Crohn disease?

A 62-year-old man presents with a 3-month history of an enlarged lymph node in the left neck. He is a long-time smoker of cigarettes and denies fevers, night sweats, fatigue, or cough. On physical examination there is a 1.5 cm hard, fixed mass below the angle of the mandible in the left neck. Which of the following is the most likely cause of an enlarged lymph node in the neck?

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?

A 28-year-old woman presents with hematochezia. She is admitted to the hospital and undergoes upper endoscopy that is negative for any lesions. Colonoscopy is performed and no bleeding sources are identified, although the gastroenterologist notes blood in the right colon and old blood coming from above the ileocecal valve. Which of the following is the test of choice in this patient?

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?

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?

A 43-year-old mildly overweight female complains of periodic right knee swelling and pain with physical activity for the past three months. She says that this problem started while on a hiking trip three months ago, at which point she experienced a 'popping' sensation in her right knee. She recalls that her knee was swollen the next day, and responded to over-the-counter pain killers. Recently, she has been having to limit her physical activities due to knee pain. On physical examination, there is tenderness of the anterior and medial right knee joint. Which of the following is the most likely diagnosis?

A 53-year-old male is brought to the emergency room after a high-speed motor vehicle accident. He was an unrestrained driver and admits to consuming a moderate amount of alcohol before driving. In the ER, he complains of bilateral chest pain and left leg pain. His past medical history is significant for emphysema, diabetes mellitus and remote drug abuse. A traumatic fracture of the left femur is evident on physical examination. His initial arterial blood gas analysis shows a pH of 7.45, p02 of 81 mmHg and pC02 of 32 mmHg. His pulmonary capillary wedge pressure is 1OmmHg. After a 2000 ml IV fluid challenge, his p02 is 76 mmHg and his pulmonary capillary wedge pressure is 12 mmHg. Chest x-ray shows alveolar opacities over the right and left lower lobes. Hours after the accident, he complains of continued chest pain and shortness of breath. Which of the following diagnoses is most likely responsible for his shortness of breath?

A 36-year-old man is in your intensive care unit on mechanical ventilation following thoracotomy for a 24-hour-old esophageal perforation. His WBC is markedly elevated, and he is febrile, hypotensive, and coagulopathic. His NG tube fills with blood and continues to bleed. Which of the following findings on upper endoscopy would be most suspicious for stress gastritis?

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?

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?

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?

A 31-year-old male is brought to the emergency department after being involved in a motor vehicle collision as an unrestrained passenger. He was given 3L of normal saline in the ambulance on his way to the hospital and has been receiving 5L/min of oxygen by nasal cannula. He is agitated and moves all four extremities spontaneously. His blood pressure is 85/55 mmHg and his heart rate is 120/min. His respiratory rate is 30/min. His pupils are symmetric and reactive to light. His neck veins are flat and his trachea is shifted slightly to the right. Over the left hemithorax, breath sounds are absent and there is dullness to percussion. Which of the following diagnoses is most likely?

A 23-year-old woman comes to the physician because of right-sided foot pain. The pain started 5 weeks ago and is sharp and localized to the forefoot. She recalls no trauma or other inciting event but is an avid runner training for a long-distance race. The pain has been worsening over the past 1 week and prevents her from doing her daily running activities. She takes no medications. She is a vegetarian and does not drink soda. She does not use tobacco, alcohol, or illicit drugs. She is not sexually active, and her last menstrual period was 8 weeks ago. Her temperature is 37° C (98.6° F), blood pressure is 100/60 mm Hg, pulse is 68/min, and respirations are 12/min. Her body mass index is 15 kg/m2• Examination reveals tenderness to palpation along the first four metatarsal bones on the dorsal surface of the right foot, normal range of motion, and no erythema or bruising. Which of the following is the most likely diagnosis?

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?

A 2-month-old boy is examined because he has been straining while passing stool and has a distended abdomen. He is very low on the growth chart for age. The primary care physician suspects that the boy has Hirschsprung disease. Which of the following findings on workup is diagnostic?

A newborn has a midline defect in the anterior abdominal wall. The parents ask what, if anything, should be done. Spontaneous closure of which of the following congenital abnormalities of the abdominal wall generally occurs by the age of 4?

A neonate is found to have an imperforate anus. As the pediatric surgeon you recommend studies to search for other anomalies. Which of the following is an associated abnormality?

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?

A 45-year-old man is examined for a yearly executive physical. A mass is palpated in the rectum, and a biopsy suggests carcinoid. Which of the following findings is most likely to be associated with the carcinoid syndrome?

An ultrasound is performed on a patient with right upper quadrant pain. It demonstrates a large gallstone in the cystic duct but also a polypoid mass in the fundus. Which of the following is an indication for cholecystectomy for a polypoid gallbladder lesion?

An alcoholic man has been suffering excruciating pain from chronic pancreatitis recalcitrant to analgesics and splanchnic block. A surgeon recommends total pancreatectomy. A patient who has a total pancreatectomy might be expected to develop which of the following complications?

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?

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

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?

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?

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?

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?

A 36-year-old man who was hit by a car presents to the ER with hypotension. On examination, he has tenderness and bruising over his left lateral chest below the nipple. An ultrasound examination is performed and reveals free fluid in the abdomen. What is the most likely organ to have been injured in this patient?

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?

A 27-year-old man sustains a single gunshot wound to the left thigh. In the ER, he is noted to have a large hematoma of his medial thigh. He complains of paresthesias in his left foot. On examination, there are weak pulses palpable distal to the injury and the patient is unable to move his foot. Which of the following is the most appropriate initial management of this patient?

A 25-year-old woman arrives in the ER following an automobile accident. She is acutely dyspneic with a respiratory rate of 60 breaths per minute. Breath sounds are markedly diminished on the right side. Which of the following is the best first step in the management of this patient?

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?

A 31-year-old biker is involved in a motor vehicle accident after attending a party where he drank a lot of soda drinks. He describes a direct blow to his lower abdomen and pelvis during the accident. He complains of diffuse abdominal pain that refers to his left shoulder. Which of the following injuries most likely accounts for this patient's current symptoms?