USMLE Surgery 1022 (511-760 / Part 3) GD

511. A neonate with bile-stained vomiting, abdominal distention, dilated loops of bowel on plain radiographs, and a small-caliber colon on contrast enema (Figure 6-17). Which one is the most likely diagnostic?
A. Congenital hypertrophic pyloric stenosis
B. Annular pancreas
C. Duodenal atresia
D. Midgut volvulus
E. Jejunal atresia
512. 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?
A. Chemotherapy with temozolomide alone
B. Combination chemotherapy with carmustin, cisplatin, and temozolomid
C. External beam radiation alone
D. Surgical resection alone
E. Combined surgical resection, external beam radiation, and chemotherapy with temozolomide
513. A 65-year-old man presents to the emergency department with an abrupt onset of excruciating chest pain 1 hour ago. The pain is localized to the anterior chest, but radiates to the back and neck. On examination, the patient is afebrile, with a BP of 210/110 mmHg, pulse rate of 95/min, and a respiratory rate of 12/min. He appears pale and sweaty. Unequal carotid, radial, and femoral pulses are noted. An electrocardiogram (ECG) shows nonspecific ST-T segment changes. Chest x-ray shows a slightly widened mediastinum and normal lung field. Which of the following is the first step in management of this patient?
A. Treatment with thrombolytic agents
B. Systemic anticoagulation
C. Control of hypertension
D. Placement of an intra-aortic balloon pump
E. Immediate operation
514. A 67-year-old man has had an indolent, unhealing ulcer at the heel of the right foot for several weeks. The patient began wearing a new pair of shoes shortly before the ulcer started and noticed a blister as the first anomaly at the site where the ulcer eventually developed. He indicates that neither the blister nor the ulcer ever gave him any pain. The ulcer is 3.5 cm in diameter, the ulcer base looks dirty, and there is hardly any granulation tissue. The skin around the ulcer looks normal. The patient has no sensation to pin prick anywhere in that foot. Peripheral pulses are weak but palpable. He is obese and has varicose veins, high cholesterol, and poorly controlled type 2 diabetes mellitus. Which of the following most accurately characterizes the ulcer?
A. Diabetic ulcer due to trauma, neuropathy, and microvascular disease
B. Ischemic ulcer due to arteriosclerosis
C. Ischemic ulcer due to embolization
D. Neoplastic in nature, probably squamous cell carcinoma
E. Stasis ulcer due to venous insufficiency
515. 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?
A. Laparotomy or laparoscopy and operative repair
B. continued NG tube decompression and initiation of total parenteral nutrition (TPN)
C. Thoracotomy or thoracoscopy and operative repair
D. Endotracheal intubation and initiation of ventilatory support
E. Upper endoscopy
516. 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 likely diagnosis?
A. Torsion of the right testicle
B. pyelonephritis
C. appendicitis
D. Right ureteral calculus
E. Acute urinary retention
517. A 72-year-old man undergoes an aortobifemoral graft for symptomatic aortoiliac occlusive disease. The inferior mesenteric artery (IMA) is ligated at its aortic attachment. Twenty-four hours after surgery the patient has abdominal distention, fever, and bloody diarrhea. Which of the following is the most appropriate diagnostic study for this patient?
A. Aortogram
B. Magnetic resonance imaging (MRI)
C. Computed tomographic (CT) scan
D. Sigmoidoscopy
E. Barium enema
518. A 26-year-old previously healthy man was pinned under a crane at a construction site. After a prolonged extrication, he was brought to the emergency department, immobilized on a back board and receiving 100% oxygen by mask. He is alert and complaining of chest pain with respiratory effort. On examination, he is found to have an oxygen saturation of 90% by pulse oximetry, shallow respirations at a respiratory rate of 35/min, heart rate of 120 beats/min, and a blood pressure of 85/60 mmHg. The trachea is deviated to the right. There is tenderness and crepitation over the left chest wall, asymmetric chest wall movement, and decreased air entry over the left lung field. Which of the following is the most appropriate next step in the initial evaluation and management of this patient?
A. Fluid resuscitation with 2 L of isotonic crystalloid
B. Needle decompression of the left chest, followed by insertion of a chest tube
C. Portable chest x-ray
D. Immediate intubation and assisted ventilation
E. Emergency department thoracotomy
519. 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. Which of the following is the most likely diagnosis?
A. A bleeding Meckel’s diverticulum
B. Juvenile rectal polyp
C.hemorrhoids
D. An anal fissure
E. intussusception
520. A 21-year-old previously healthy woman presents with abdominal pain of 48-hour duration. The pain was initially periumbilical and on progression became localized in the right lower quadrant. The woman had nausea and an appetite. She denied dysuria. Her last menstrual period was 2 weeks earlier. On examination, she was febrile (temperature 38.2°C), and was found to have localized tenderness in the right lower quadrant with guarding. Rectal examination was normal. Laboratory examination demonstrated mild leukocytosis. Select the most likely diagnosis?
A. gastroenteritis
B. Regional enteritis
C. Acute appendicitis
D. Perforated peptic ulcer
E. Sigmoid diverticulitis
521. 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?
A. Resection of the diverticulum
B. Cricopharyngeal muscle myotomy@
C. H2 blockers
D. Elevation of the head of the bed
E. diverticulopexy
522. 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?
A. Sympathectomy without any delay
B. Debridement of devitalized tissues
C. Slow rewarming at room temperature
D. Slow rewarming with dry heat
E. Rapid rewarming in warm water
523. A 25-year-old woman presents to the emergency room complaining of redness and pain in her right foot up to the level of the midcalf. She reports that her right lower extremity has been swollen for at least 15 years, but her left leg has been normal. On physical examination, she has a temperature of 39°C (102.2°F) and the right lower extremity is nontender with nonpitting edema from the groin down to the foot. There is cellulitis of the right foot without ulcers or skin discoloration. The left leg is normal. Which of the following is the most likely underlying problem?
A. Congenital lymphedema
B. Lymphedema praecox
C. Venous insufficiency
D. Deep venous thrombosis
E. Acute arterial insufficiency
524. A blond, blue-eyed, 69-year-old sailor has a non-healing, indolent, 1.5-cm ulcer on the lower lip, arising from the vermilion border. The ulcer has been present and growing for the past 8 months. He is a pipe smoker, but has no history of alcohol or drug abuse. Physical examination shows "weather-beaten" facial skin, but no other ulcers. There are no enlarged lymph nodes in his neck. Which of the following is the most likely diagnosis?
A. Adenocarcinoma
B. Basal cell carcinoma
C. Benign ulceration due to chronic trauma
D. Invasive malignant melanoma
E. Squamous cell carcinoma
525. A 30-year-old woman presents with hypertension, weakness, bone pain, and a serum calcium level of 15.2 mg/dL. Hand films below show osteitis fibrosa cystica. Which of the following is the most likely cause of these findings?
A. Sarcoidosis
B. Vitamin D intoxication
C. Paget disease
D. Metastatic carcinoma
E. Primary hyperparathyroidism
526. 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?
A. Administration of steroids
B. Radiation treatment to the neck
C. Neck exploration and resection of all 4 parathyroid glands
D. Neck exploration and resection of a parathyroid adenoma
Avoidance of sunlight, vitamin D, and calcium-containing dairy products
527. 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?
A. anticoagulation
B. Exercise program
C. Coronary artery bypass grafting
D. Aortofemoral bypass grafting
E. Placement of a vena cava filter
528. A 65-year-old man presents to the emergency department with an abrupt onset of excruciating chest pain 1 hour ago. The pain is localized to the anterior chest, but radiates to the back and neck. On examination, the patient is afebrile, with a BP of 210/110 mmHg, pulse rate of 95/min, and a respiratory rate of 12/min. He appears pale and sweaty. Unequal carotid, radial, and femoral pulses are noted. An electrocardiogram (ECG) shows nonspecific ST-T segment changes. Chest x-ray shows a slightly widened mediastinum and normal lung fields. Which of the following is the preferred modality in establishing the diagnosis?
A. Transcutaneous echocardiography
B. Transesophageal echocardiography
C. CT scan
D. Coronary angiography
E. aortography
529. 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?
A. Neck exploration and ligation of the thoracic duct
B. Subdiaphragmatic ligation of the thoracic duct
C. Thoracotomy and repair of the thoracic duct
D. Thoracotomy and ligation of the thoracic duct
E. Thoracotomy and abrasion of the pleural space
530. 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?
A. Right lower lobectomy and mediastinal lymph node dissection
B. Right lower lobectomy and mediastinal lymph node dissection followed by adjuvant chemotherapy.
C. Neoadjuvant chemotherapy followed by right lower lobectomy and mediastinal lymph node dissection
D. Neoadjuvant chemoradiation followed by right lower lobectomy and mediastinal lymph node dissection
E. Chemoradiation
531. 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?
A. Antibiotics and IV fluids
B. lactose-free diet
C. antispasmodics
D. Nutritional supplementation and systemic steroids
E. laparotomy
532. A 13-year-old boy is brought to the emergency department at midnight with a 4-hour history of right scrotal pain that was sudden in onset and associated with nausea and one episode of vomiting. On examination, he is in obvious distress. He has mild right lower abdominal tenderness, and high-riding, tender right testes. CBC and urinalysis are normal. Which of the following is the most appropriate next step in management?
A. Admit the patient to the hospital and place him on bed rest
B. Analgesics and a scrotal support
C. Antibiotic therapy
D. Schedule a testicular isotope scan
E. Urgent surgical exploration
533. 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?
A. Enucleation of the tumor
B. Right thyroid lobectomy
C. Total thyroidectomy
D. Total thyroidectomy plus postoperative radioactive iodine
E. Total thyroidectomy, radical neck dissection, and postoperative radioactive iodine
534. 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?
A. Percutaneous drainage of the lung abscess
B. Systemic antibiotics directed against the causative agent
C. Tube thoracostomy
D. Left upper lobectomy
E. Surgical drainage of the abscess
535. A 50-year-old salesman is on a yacht with a client when he has a severe vomiting and retching spell punctuated by a sharp substernal pain. He arrives in your emergency room 4 hours later and has a chest film in which the left descending aorta is outlined by air density. Which of the following is the most appropriate next step in his workup?
A. Contrast esophagram
B. Echocardiogram
C. Flexible bronchoscopy
D. Flexible esophagogastroscopy
E. Aortography
536. A 75-year-old woman is brought to the emergency department from a nursing home for abdominal pain, distention, and obstipation over the last 2 days. Past history is pertinent for stroke, diabetes, atrial fibrillation, and chronic constipation. Examination reveals a temperature of 98.6°F, pulse rate 90/min and irregularly irregular, and BP 160/90 mmHg. Heart examination reveals irregularly irregular rhythm with no murmurs; lung examination reveals few bibasilar rales; and abdominal examination reveals a distended, tympanic abdomen with mild tenderness and no rebound tenderness. Plain abdominal x-rays reveal dilated loops of bowel, and a barium enema is obtained and shown in Figure 6-9. Which of the following is the most appropriate next step in management following NG tube decompression and resuscitation?
A. Urgent sigmoid resection
B. Nonoperative reduction by proctoscopy and rectal tube
C. Proximal colostomy
D. Urgent operative detorsion
E. Nonoperative reduction by passage of well-lubricated rectal tube
537. A 65-year-old man presents to the physician’s office for his yearly physical examination. His only complaint relates to early fatigue while playing golf. Past history is pertinent for mild hypertension. Examination is unremarkable except for trace hematest-positive stool. Blood tests are normal except for a hematocrit of 32. A UGI series is performed and is normal. A barium enema is performed, and one view is shown in Figure 6-10. Which of the following is the most likely diagnosis?
A. Diverticular disease
B. Colon cancer
C. lymphoma
D. Ischemia with stricture
E. Crohn’s colitis with stricture
538. An elderly man is involved in a rear end automobile collision in which he hyperextends his neck. He develops paralysis and burning pain of both upper extremities, while maintaining good motor function in his legs. Which of the following is the most likely diagnosis?
A. Anterior cord syndrome
B. Central cord syndrome
C. Posterior cord syndrome
D. Reflex sympathetic dystrophy
E. Spinal cord hemisection
539. 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. Which of the following is the most appropriate diagnostic study to order for this patient?
A. colonoscopy
B. Barium enema
C. Technetium scan
D. UGI contrast study with small-bowel follow-through
E. laparoscopy
540. 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?
A. Immediate exploratory laparotomy
B. IV fluid resuscitation, transfusion with blood products as indicated, followed by a laparotomy with Meckel’s diverticulectomy and ileal resection
C. IV fluid resuscitation, followed by a colonoscopic polypectomy
D. hemorrhoidectomy
E. Stool softeners and topical steroids
541. 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?
A. craniotomy
B. Fluid restriction, hyperventilation, and osmotic diuresis
C. Fluid restriction, hyperventilation, and ventriculostomy
D. Hyperventilation and IV steroids
E. normovolemia, normocarbia, sedation, and ventriculostomy
542. A 53-year-old woman presents with weight loss and a persistent rash to her lower abdomen and perineum. She is diagnosed with necrolytic migrating erythema and additional workup demonstrates diabetes mellitus, anemia and a large mass in the tail of the pancreas. Which of the following is the most likely diagnosis?
A. Verner-Morrison syndrome (VIPoma)
B. Glucagonoma
C. Somatostatinoma
D. Insulinoma
E. Gastrinoma
543. 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 700 ng/mL. Which of the following findings is most consistent with the diagnosis of Cushing disease?
A. Decreased ACTH levels
B. Glucocorticoid use for the treatment of inflammatory disorders
C. A 3-cm adrenal mass on computed tomography (CT) scan
D. Suppression with high-dose dexamethasone suppression testing
E. A 1-cm bronchogenic mass on magnetic resonance imaging (MRI)
544. 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?
A. Radical prostatectomy
B. Transurethral prostatectomy
C. Cytotoxic chemotherapy
D. Hormonal manipulation
E. radiotherapy
545. A 25-year-old previously healthy man is scheduled for elective inguinal hernia repair under general anesthesia. After induction of anesthesia and initial inguinal incision, the patient develops tachycardia, muscle rigidity, fever of 38.5°C, and elevated end-tidal carbon dioxide. Which of the following is the most likely diagnosis?
A. pneumonia
B. atelectasis
C. Urinary tract infection
D. Myocardial infarction
E. Malignant hyperthermia
546. 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?
A. Medical therapy with aspirin 325 mg/day and medical risk factor management
B. Medical therapy with warfarin
C. Angioplasty of the carotid lesion followed by carotid endarterectomy if the angioplasty is unsuccessful
D. Carotid endarterectomy
E. Medical risk factor management and carotid endarterectomy if neurologic symptoms develop
547. A 66-year-old woman presents with severe right lower extremity claudication. Surgery is considered, but her hypertension, smoking, and diabetes puts her at risk for associated coronary heart disease. What test is most predictive of postoperative ischemic cardiac events following surgery?
A. Exercise stress testing
B. Electrocardiography (ECG)
C. Coronary angiography
D. Dipyridamole-thallium imaging
E. Transesophageal echocardiography
548. A 5-week-old infant presents with a 1-week history of progressive nonbilious emesis, associated with a 24-hour history of decreased urine output. The infant continues to be active and eager to feed. On examination, the infant has a sunken fontanels and decreased skin turgor. The abdomen is scaphoid, and with a test feed, there is a visible peristaltic wave in the epigastrium. Electrolytes and a urinalysis are evaluated. Which of the following laboratory findings are most likely to be seen in this patient?
A. Na 145, K 3.0, Cl 110, CO2 17, urine pH 8.0
B. Na 130, K 3.0, Cl 80, CO2 36, urine pH 4.0
C. Na 135, K 4.0, Cl 104, CO2 23, urine pH 7.0
D. Na 140, K 5.2, Cl 100, CO2 16, urine pH 4.0
E. Na 132, K 3.2, Cl 96, CO2 25, urine pH 7.0
549. 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?
A. Immediate surgical exploration
B. Send the child home with an oral electrolyte rehydration solution
C. Change the infant’s formula and feeding regimen
D. IV fluid resuscitation, followed by surgical intervention
E. Initiate therapy with a prokinetic agent
550. 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?
A. Reassurance and reappointment in a year
B. Repeat mammogram and FNA in 1 month
C. Core or incisional biopsies
D. Lumpectomy and axillary dissection
E. Modified radical mastectomy
551. 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?
A. Topical (intravesicular) chemotherapy
B. Radical cystectomy
C. Radiation therapy
D. Local excision and topical (intravesicular) chemotherapy
E. Systemic chemotherapy
552. 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?
A. Hydration and analgesics
B. α-Adrenergic blocker
C. Extracorporeal lithotripsy
D. Percutaneous nephrostomy tube
E. Open surgery to remove the stone
553. 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?
A. Immediate surgical placement into the scrotum
B. Chorionic gonadotropin therapy for 1 month; operative placement into the scrotum before age 2 if descent has not occurred
C. Observation until age 2; operative placement into the scrotum if descent has not occurred
D. Observation until age 5; if no descent by then, plastic surgical scrotal prostheses before the child enters school
E. No therapy; reassurance of the parent that full masculinization and normal spermatogenesis are likely even if the testicle does not fully descend
554. 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. Which of the following is the most likely diagnosis?
A. Colon cancer with contained perforation
B. Ischemic colitis
C. Pseudomembranous colitis
D. diverticulitis
E. pyelonephritis
555. 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. Which of the following is the most appropriate management of this patient?
A. NPO, IV fluids, and IV antibiotics for gram-negative and anaerobic coverage
B. NPO, IV fluid hydration, followed by immediate sigmoid colon resection
C. NPO, IV fluids, and anticoagulation
D. NPO, IV fluids, evaluation of stool for Clostridium difficile toxin, and either metronidazole or vancomycin antibiotic therapy
E. NPO, IV fluids, initiation of bowel preparation for elective sigmoid colon resection during the current hospitalization
556. 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?
A. CT scan of the trunk
B. Needle biopsy of the tender spots
C. Radionuclide bone scan
D. Sonogram of the affected areas
E. X-ray films of the affected areas
557. A 56-year-old woman presents to the clinic for routine health screening. Her concern is the development of breast cancer. She has no current breast-related complaints. Past history is pertinent for fibrocystic changes with atypical ductal hyperplasia and a single fibroadenoma, both diagnosed by open biopsy 5 years ago. She smokes one pack per day and drinks one can of beer daily. Family history is positive for breast cancer in her mother, diagnosed at the age of 85. Current medications include a cholesterol-lowering agent, an antihypertensive, and HRT, which she has taken for 5 years. Physical examination is unremarkable. Mammograms show dense breasts, decreasing the accuracy of the study, but no suspicious findings were noted. Which of the following is the most common risk factor in evaluating women for breast cancer?
A. Fibrocystic changes with atypical ductal hyperplasia
B. Alcohol consumption
C. Positive family history
D. HRT
E. age
558. 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?
A. re-excision of the biopsy cavity to gain negative margins of resection
B. Ipsilateral mastectomy
C. Contralateral breast biopsy
D. Observation including examinations and mammography
E. Bilateral total mastectomies
559. A 56-year-old woman has been treated for 3 years for wheezing on exertion, which was diagnosed as asthma. Chest radiograph, shown here, reveals a midline mass compressing the trachea. Which of the following is the most likely diagnosis?
A. Lymphoma
B. Neurogenic tumor
C. Lung carcinoma
D. Goiter
E. Pericardial cyst
560. 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?
A. Infusion of a bolus of steroids immediately postoperatively with a continuous infusion for 24 hours
B. Maintenance of intraoperative normothermia
C. Clamping of the aorta proximal to the left subclavian artery
D. Cerebrospinal fluid (CSF) drainage
E. Extracorporeal membrane oxygenation
561. A 77-year-old man becomes "senile" over a period of 3 or 4 weeks. He used to be active and managed all of his financial affairs. Now, he stares at the wall, barely talks, and sleeps most of the day. His daughter recalls that he fell from a horse about a week before the mental changes began. Which of the following would a CT scan of his head most likely show?
A. Chronic epidural hematoma
B. Chronic subdural hematoma
C. Diffuse intracerebral bleeding
D. Frontal lobe infarction
E. Generalized, severe brain atrophy
562. 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 24hours post-burn?
A. 3460 mL
B. 4960 mL
C. 6760 mL
D. 8160 mL
E. 11,360 mL
563. A 62-year-old woman presents to the physician’s office with complaints of constipation. She has had constipation for the last 6 months, which has worsened over the last month, associated with mild bloating. She noted that her stool has become “pencil thin” in the last month, with occasional blood, but she continues to have bowel movements daily. Past history is unremarkable. Examination reveals normal vital signs and heart and lung examination. Abdominal examination reveals mild fullness, especially in the lower quadrants. Rectal examination shows no rectal masses, but the stool is hematest positive. A barium xray is obtained, and one view is shown in Figure 6-11. Which of the following is the most likely diagnosis?
A. Crohn’s disease
B. Ischemia with stricture
C. Rectal carcinoma
D. Sigmoid volvulus
E. Diverticulitis with colovesical fistula
564. 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?
A. echocardiography
B. Anticoagulation with heparin
C. Anticoagulation with warfarin
D. arteriography
E. Alkalinization of the urine with IV sodium bicarbonate
565. A 50-year-old man presents with intractable peptic ulcer disease, severe esophagitis, and abdominal pain. Which of the following is most consistent with the diagnosis of Zollinger-Ellison syndrome?
A. Hypercalcemia
B. Fasting gastrin level of 10 pg/mL
C. Fasting gastrin level of 100 pg/mL
D. Increase in gastrin level (> 200 pg/mL) after administration of secretin
E. Decrease in gastrin level (> 200 pg/mL) after administration of secretin
566. 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?
A. Drops of Lugol iodine solution daily beginning 10 days preoperatively.
B. Preoperative treatment with phenoxybenzamine for 3 weeks.
C. Preoperative treatment with propranolol for 1 week.
D. Twenty-four hours of corticosteroids preoperatively.
E. No other preoperative medication is required.
567. A postoperative patient with swelling and pain in his right calf is suspected of having a deep venous thrombosis. Prior to initiating treatment with anticoagulants, he requires a confirmatory examination. Which of the following is a limitation of the duplex ultrasound in evaluating a DVT?
A. It is not very sensitive for detecting calf thrombi in symptomatic patients.
B. It is invasive.
C. It cannot differentiate between acute and chronic venous thrombi.
D. It is expensive.
E. It cannot image the proximal veins (iliac veins, IVC)
568. 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?
A. Femorofemoral bypass
B. Axillofemoral bypass
C. Femoropopliteal bypass
D. Aortobifemoral bypass
E. Common femoral and profunda femoral endarterectomise
569. A 25-year-old man was admitted to the ICU with severe head injury with a basal skull fracture. Eighteen hours after the injury, he developed polyuria. Urine osmolality was 150 mOsm/Land serum osmolality was 350 mOsm/L. IV fluids were stopped, and 1 hour later urine output and urine osmolality remained unchanged. Five units of vasopressin were administered intravenously, and urine osmolality increased to 300 mOsm/L. Select the most likely diagnosis of the patients with polyuria.
A. Central diabetes insipidus (DI)
B. nephrogenic DI
C. Water intoxication
D. Solute overload
E. Diabetes mellitus
570. A 70-year-old man was admitted to the ICU with severe pancreatitis. During his ICU course, he underwent several CT scans with IV contrast and was also treated with an aminoglycoside for a urinary tract infection. The patient required a prolonged course of TPN, and developed Candida sepsis treated with amphotericin. He subsequently developed polyuria with urine osmolality of 250 mOsm/L and serum osmolality of 350 mOsm/L. After receiving 5 units of vasopressin intravenously, there is no change in urine osmolality or urine output. Select the most likely diagnosis of the patients with polyuria.
A. Central diabetes insipidus (DI)
B. nephrogenic DI
C. Water intoxication
D. Solute overload
E. Diabetes mellitus
571. A 42-year-old man describes intermittent episodes of severe, crushing chest pain that extends to the back and the jaw and last anywhere from a few seconds to several minutes. Many times the pain is accompanied by dysphagia and triggered by the ingestion of very cold or very hot liquids. However, sometimes the pain occurs for no apparent reason. There is no history of regurgitation, and, although the problem has been present for many years, there has been no progression of the symptoms. Repeated ECGs and cardiac enzymes have always been negative. Barium swallow shows an area of "corkscrew" appearance. Manometry shows that about one half of wet swallows produce repetitive simultaneous esophageal contractions of the esophageal body, and that the lower esophageal sphincter has normal pressures and exhibits normal relaxation. Which of the following is the most likely diagnosis?
A. Achalasia of the esophagus
B. Cancer of the lower esophagus
C. Diffuse esophageal spasm
D. Nutcracker esophagus
E. Zenker's diverticulum
572. 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?
A. Codeine
B. Hydromorphone (Dilaudid)
C. Meperidine (Demerol)
D. Methadone
E. Morphine sulfate
573. A 29-year-old man presents to the ER with persistent vomiting and abdominal pain for the last 24 hours. The pain is crampy, diffuse, and has been getting worse. He had a normal bowel movement two days ago and denies diarrhea. The emesis appears green without blood or coffee grounds. He has not eaten since the onset of the pain due to nausea. On exam, his temperature is 36.8° C (98.2° F}, pulse is 91/min, and blood pressure is 116/75 mmHg while sitting and 94/65 mmHg while standing. His abdomen is distended with hyperactive bowel sounds. Percussion reveals tympany and he is diffusely tender to palpation. There is no rebound tenderness or guarding. Laboratory studies reveal: WBC count 9,600/mm3 Hematocrit 45% Sodium 147 mEq/L Potassium 3.1 mEq/L Creatinine 1.0 mg/dL AST 20 U/L ALT 12 U/L Bilirubin 0.8 mg/dL Which of the following historical findings would you most expect in this patient?
A. High alcohol consumption
B. Occasional black or tarry stool
C. Appendectomy six months ago
D. Fatty food intolerance
E. Recent weight loss
574. 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?
A. Thoracotomy with left upper lobectomy and mediastinal lymph node dissection
B. Thoracotomy with left upper lobectomy and mediastinal lymph node dissection followed by adjuvant chemotherapy
C. Neoadjuvant chemotherapy followed by thoracotomy with left upper lobectomy and mediastinal lymphnode dissection
D. Neoadjuvant chemoradiation followed by thoracotomy with left upper lobectomy and mediastinal lymph-node dissection
E. Chemoradiation
575. 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?
A. Placement of a second chest tube at the bedside and antibiotic therapy
B. Infusion of antibiotics via the chest tube
C. Intravenous antibiotics for 6 weeks
D. Thoracotomy with instillation of antibiotics into the pleural space
E. Thoracotomy with decortication and antibiotic therapy
576. A 75-year-old man is brought to the emergency department for severe pain in the left flank and back of 1hour duration. He has a prior history of a myocardial infarction and coronary artery bypass grafting 8 years ago. On examination, he is found to have a BP of 80/50 mmHg, pulse rate of 110/min, respiratory rate of 15/min, and a pulsatile, tenderabdominal mass. He has had two large-bore IV lines placed by the paramedics. He is alert and oriented, and gives consent for surgery. Which of the following is the most appropriate next step in management of this patient?
A. Immediate consultation with cardiology to assess cardiac risk for surgery, followed by transfer to the operating room
B. Resuscitation in the emergency department with IV fluids, transfer to radiology for a CT scan to assess for the location and degree of rupture, followed by transfer to the operating room
C. Resuscitation in the emergency department with IV fluids to achieve a systolic BP greater than 100, followed by transfer to the operating room
D. Immediate transfer to the operating room with concomitant resuscitation and laparotomy
E. Resuscitation in the emergency department with IV fluids, transfer to radiology for immediate aortic angiogram for assessment of the location of the rupture, followed by transfer to the operating room
577. A 75-year-old man is brought to the emergency department for severe pain in the left flank and back of 1hour duration. He has a prior history of a myocardial infarction and coronary artery bypass grafting 8 years ago. On examination, he is found to have a BP of 80/50 mmHg, pulse rate of 110/min, respiratory rate of 15/min, and a pulsatile, tenderabdominal mass. He has had two large-bore IV lines placed by the paramedics. He is alert and oriented, and gives consent for surgery. On postoperative day 3, the patient develops dark-colored diarrhea but remains normotensive, on full mechanical ventilation, and is awake. Laboratory analysis reveals normal electrolytes, blood urea nitrogen (BUN), and creatinine; hematocrit of 30; and WBC of 15,000. Which is the most appropriate next step in management?
A. Stool for C. Difficile toxin test and institution of metronidazole
B. sigmoidoscopy
C. Air contrast barium enema
D. CT scan
E. Abdominal x-rays
578. A pedestrian is hit by a car. The paramedics report that he was unconscious at the site, and he arrives at the emergency department in coma, strapped to a head board with sandbags on either side of his head. Initial survey shows stable vital signs, and his pupils are of equal size and reactive to light. He is rapidly intubated by the nasotracheal route over a flexible bronchoscope and then sent for CT scans of the head. As he is being positioned on the table, it is noted that there is a sizable hematoma behind his right ear and that clear fluid is dripping from the ear canal. Which of the following is most advisable, considering this new finding?
A. Extend the CT scan to include his neck
B. Do an MRI instead of a CT scan
C. Start antibiotics
D. Inject high-dose corticosteroids
E. Plan an emergency craniotomy
579. 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?
A. Continued observation and appropriate blood replacement
B. A second chest tube in a better position to drain the blood
C. Thoracotomy and ligation of bleeding vessels
D. Thoracotomy, ligation of bleeding vessels, and removal of the bullet
E. Thoracotomy and pneumonectomy
580. A 76-year-old man is admitted to the coronary care unit after an episode of substernal chest pain. His other medical problems include hypertension, hyperlipidemia, and type 2 diabetes mellitus. He has a history of a diverticular bleed 2 years ago. After initial workup, cardiac catheterization is performed and shows 50% left main coronary artery stenosis, 90% proximal left anterior descending artery stenosis, and 65% right coronary artery stenosis. Antiplatelet agents are stopped, and the patient is continued on a heparin drip in preparation for coronary artery bypass surgery the next day. Five hours after the catheterization, his blood pressure is 75/60 mm Hg and pulse is 120/min and regular. He complains of some generalized weakness and back pain but denies chest pain, shortness of breath, nausea, and abdominal discomfort. He appears to be diaphoretic and clammy. Neck veins are flat. Heart sounds are normal, and the chest is clear to auscultation. The groin site for arterial puncture is mildly tender, without subcutaneous hematoma. He receives 1000 ml of normal saline, with symptomatic improvement. His blood pressure is 96/60 mm Hg and pulse is 85/min. His ECG seems to be unchanged. Which of the following is the most appropriate next step in managing this patient?
A. Obtain a CT scan of the abdomen and pelvis without contrast
B. Obtain a CT scan of the chest with contrast
C. Place a nasogastric tube
D. Proceed to immediate coronary artery bypass surgery
E. Resume antiplatelet agents
581. A 63-year-old obese female undergoes an elective cholecystectomy after two episodes of acute calculous cholecystitis. Three days after surgery, her blood pressure is 150/100 mmHg, her heart rate is 90/min, and her arterial oxygen saturation is 91 % on room air. She is afebrile. Which of the following would most likely increase her functional residual lung capacity?
A. Inhaled albuterol
B. Sequential compression devices to her lower extremities
C. Elevation of the head of the bed
D. Decreasing the dose of her postoperative opioids
E. Postoperative benzodiazepines
582. 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?
A. Radical mastectomy
B. lumpectomy, irradiation, and axillary node dissection
C. Lumpectomy and axillary node dissection
D. Irradiation of the breast and axilla
E. quadrantectomy, irradiation, and axillary node dissection
583. 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. The patient has read about SLN biopsy. She avidly wants to avoid the risk of lymphedema that her sister must endure. She asks the question “Am I a candidate for a SLN biopsy instead of a complete axillary dissection?” Which of the following is the most appropriate answer to her question?
A. Yes, and if the SLN if positive, then a complete axillary dissection should be performed.
B. Yes, and if the SLN is negative, then an axillary dissection can be avoided.
C. No, because the success of SLN biopsy in patients over age 60 is decreased.
D. No, because SLN biopsy is contraindicated when a palpable axillary node is suspicious for metastatic disease.
E. No, because SLN biopsy is contraindicated for tumors greater than 2 cm.
584. 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?
A. The patient's history of previous immunizations
B. The patient's clinical course over the next few weeks
C. Observing the animal's behavior over the next few days
D. Killing the animal and examining the brain
E. The events that took place have already established the need to proceed with rabies immunization
585. A 62-year-old woman had an abdominal hysterectomy and salpingo-oophorectomy 3 days ago. She had an indwelling bladder catheter during the procedure, which was removed in the recovery room. She has been voiding at will since then. She also had compression pneumatic stockings on both lower extremities during the operation. She began ambulation on the 1st postoperative day, and has been as active as possible under the circumstances, including faithful adherence to a prescribed program of incentive spirometry. On the evening of the 3rd postoperative day, she spikes a fever, with a temperature to 39.4 C (103 F). Which of the following is the most likely source of the fever?
A. Atelectasis
B. Deep thrombophlebitis
C. Intra-abdominal abscess
D. Urinary tract infection
E. Wound infection
586. A 44-year-old male is found unresponsive and hypotensive at the scene of a high-speed motor vehicle accident. He is intubated and immediately rushed to the emergency department. The passenger in his car is pronounced dead at the scene. Physical examination in the ED shows large bruises over the entire chest wall and collapsed neck veins bilaterally. Lung exam reveals decreased breath sounds on the left side. Chest x-ray shows a large left hemothorax and a widened, rightward deviating mediastinum. The most likely diagnosis is:
A. Esophageal rupture
B. Aortic injury
C. Myocardial rupture
D. Myocardial contusion
E. Diaphragm rupture
587. An 85-year-old male is placed on mechanical ventilation after a complicated elective hernia repair. After five days of endotracheal intubation with mechanical ventilation, the ratio of the rate of carbon dioxide produced to the rate of oxygen uptake is 1.05. What is the best explanation for these findings?
A. Sepsis
B. High-protein tube feeding
C. Carbohydrate excess in the diet
D. High inspired oxygen fraction
E. Pulmonary atelectasis
588. A 64-year-old man with a history of a triple coronary artery bypass 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?
A. Aspirin
B. Warfarin
C. Low-dose heparin
D. High-dose heparin
E. Low-molecular-weight heparin
589. A patient who has had angina as well as claudication reports feeling light-headed on exertion, especially when lifting and working with his arms. The subclavian steal syndrome is associated with which of the following hemodynamic abnormalities?
A. Antegrade flow through a vertebral artery
B. Venous congestion of the upper extremities
C. Occlusion of the carotid artery
D. Occlusion of the vertebral artery
E. Occlusion of the subclavian artery
590. 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?
A. Wide excision with 2 cm margin
B. Wide excision with 2 cm margin and SLN mapping
C. Shave biopsy
D. Excisional biopsy with 1–2 mm margins
E. Mohs’ surgical excision
591. A 75-year-old woman is admitted to the hospital from a nursing home for abdominal pain and pneumonia. She was noted to be short of breath with increasing cough for 2 days before admission. Treatment, consisting of supplemental oxygen, IV antibiotics, and pulmonary toilet, is instituted, with improvement within 2 days. On the third hospital day, her abdominal pain worsens. Examination reveals a mildly distended abdomen with bowel sounds but no signs of peritonitis. Remainder of examination reveals a tender bulge in the medial left thigh below the inguinal ligament. Gentle pressure causes more pain but does not change the size or shape of the bulge. Abdominal films show a nonspecific bowel gas pattern. Laboratory analysis shows a WBC of 13,000, decreased from 18,000 at the time of admission. Which of the following is the most likely diagnosis?
A. Incarcerated direct inguinal hernia
B. Lymph node with abscess
C. Femoral artery aneurysm
D. Incarcerated indirect inguinal hernia
E. Incarcerated femoral hernia
592. A 66-year-old woman picks up a bag of groceries out of the supermarket cart to place it in the trunk of her car. As she does so, she feels sharp, sudden pain in the middle of her arm, and her humerus suddenly breaks. She arrives at the emergency department cradling her arm; the deformity leaves no doubt that the bone is broken. Which of the following is the most likely reason for the fracture?
A. Bony metastasis to the humerus from breast cancer
B. Osteitis fibrosa cystica from parathyroid disease
C. Osteomalacia from nutritional deficiency
D. Osteoporosis
E. Primary malignant bone tumor
593. 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?
A. Heller myotomy of the lower esophageal sphincter
B. Laparoscopic Nissen fundoplication
C. Transhiatal total esophagectomy
D. Transthoracic resection of the lower esophagus
E. Vagotomy, pyloroplasty, and fundic gastric wrap
594. An 18-year-old male comes to the physician's office because of dull aching and fullness of the scrotum. Examination shows soft left-sided scrotal swelling; transillumination testing is negative. The scrotal swelling increases when the patient performs the Valsalva maneuver. The physical examination is otherwise unremarkable. Which of the following is the most likely cause of his condition?
A. Hypoalbuminemia
B. Dilatation of pampiniform plexus
C. Fluid in the tunica vaginalis
D. Testicular neoplasia
E. Cystic dilations of the efferent ductules
595. A 72-year-old man underwent surgical repair of an aneurysm of the infrarenal aorta. He received perioperative prophylaxis with a second-generation cephalosporin antibiotic. On the first postoperative day he complains of progressive abdominal pain and bloody diarrhea. His temperature is 38.5° C (101° F), blood pressure is 110/65 mm Hg, pulse is 11 O/min and respirations are 22/min. His abdomen is mildly distended and tender to palpation. The tenderness is mostly in the left lower quadrant without rebound. Femoral pulses are full and symmetric. His white blood cell count is 12,000/mm3. Which of the following is the most likely diagnosis?
A. Pseudomembranous colitis
B. Invasive infectious diarrhea
C. Aortoenteric fistula
D. Ischemia of the bowel
E. Perforation of the colon
596. A 32-year-old male comes to the emergency department because of a 3 day history of increasing lower abdominal pain, mild diarrhea and rectal pain on defecation. Ten days ago he had right lower quadrant (RLQ) pain for about 24 hours that resolved spontaneously. Since then, he has had malaise and low-grade fever. His temperature is 38.7° C (101.6° F), blood pressure is 150/90 mm Hg, pulse is 11 0/min and respirations are 15/min. Examination shows lower abdominal tenderness without rebound. No masses are palpable, and bowel sounds are decreased. Rectal examination shows a very tender, boggy and fluctuant bulging mass on palpation with the tip of the finger anteriorly. Laboratory studies show: Complete blood count Hemoglobin 14.0 g/L Platelets 270,000/mm Leukocyte count 15,500/mm His current condition is most likely a complication of?
A. Anorectal abscess
B. Invasive diarrhea
C. Acute appendicitis
D. Acute diverticulitis
E. Colon cancer
597. A 4-year-old boy is seen 1 hour after ingestion of a lye drain cleaner. No oropharyngeal burns are noted. The CXR is normal, but the patient continues to complain of significant chest pain. Which of the following is the most appropriate next step in his management?
A. Parenteral steroids and antibiotics
B. Esophagogram with water-soluble contrast
C. Administration of an oral neutralizing agent
D. Induction of vomiting
E. Rapid administration of a quart of water to clear remaining lye from the esophagus and dilute material in the stomach
598. A previously healthy 20-year-old man is admitted to the hospital with acute onset of left-sided chest pain. Electrocardiographic findings are normal, but CXR shows a 40% left pneumothorax. Appropriate treatment consists of which of the following procedures?
A. Observation
B. Barium swallow
C. Thoracotomy
D. Tube thoracostomy
E. Thoracostomy and intubation
599. A 22-year-old professional basketball player falls on his outstretched hand during a scrimmage game. He has mild swelling at the wrist and tenderness to palpation in the anatomic snuffbox. No fracture is visible on multiple radiographs of the wrist and hand. Which of the following is the most appropriate management of this patient?
A. anti-inflammatory medication and application of ice
B. Elastic wrist support, analgesics, and restricted activity for 1–2 weeks
C. Presumptive diagnosis of a scaphoid fracture, with application of a wrist splint, and repeat x-rays in 10–14 days
D. Presumptive diagnosis of a scaphoid fracture, with application of a short-arm cast including the thumb
E. Presumptive diagnosis of a scaphoid fracture, application of a short-arm cast including the thumb, and removal of the cast, with repeat x-rays in 10–14 days
600. A 44-year-old man complains of vague right upper abdominal discomfort that he has had for about 1 month. He describes no other symptoms, and, except for enucleation of one eye at age 21 "for a tumor," he has been in excellent health all his life. He exercises regularly and neither smokes nor drinks. The only findings on physical examination include the artificial eye and a tender, enlarged, and nodular liver. CT scan of the upper abdomen demonstrates multiple masses within the liver. Which of the following will most likely be found on biopsy of these masses?
A. Metastatic malignant melanoma
B. Metastatic prostatic cancer
C. Metastatic retinoblastoma
D. Metastatic sarcoma
E. Primary hepatocellular carcinoma
601. A 71-year-old West Texas farmer of Irish ancestry has a nonhealing, indolent, punched out, clean-looking 2-cm ulcer over the left temple. The ulcer has been slowly growing over the past 3 years. There are no enlarged lymph nodes in the head and neck. Which of the following would best dictate proper management?
A. Full thickness biopsy of the center of the lesion
B. Full thickness biopsy of the edge of the lesion
C. Pathologic studies after the entire lesion is resected with a margin of 1 cm of normal skin all around
D. Response to a trial of radiation therapy
E. Scrapings and culture of the ulcer base
602. Ten days after undergoing liver transplantation, a patient's levels of gamma-glutamyl transferase (GGT), alkaline phosphatase, and bilirubin begin to rise. Which of the following is the most appropriate next step in diagnosis?
A. Measurement of preformed antibody levels
B. Ultrasound of biliary tract and Doppler studies of the anastomosed vessels
C. Liver biopsy and determination of portal pressures
D. Liver biopsy and more detailed liver function tests
E. Liver biopsy and trial of steroid boluses
603. A previously healthy, intoxicated, 19-year-old man is driving a car without using a seat belt. He crashes the car into the back of a parked truck. In the process he slams his abdomen into the steering wheel and ruptures his spleen. Which of the following is the most important problem associated with this type of injury?
A. Bacteremia
B. Electrolyte abnormalities
C. External blood loss
D. Internal blood loss
E. Peritonitis
604. After suitable calculations have been made using the modified Parkland formula, a 70-kg man with extensive third-degree burns is receiving Ringer's lactate at the calculated rate, which happens to be 750 mL/hr. The infusion was started within 30 minutes of the time when the burn occurred. Over the next 3 hours, his urinary output is recorded as 15 mL, 22 mL, and 18 mL. It is verified that the Foley catheter is open and draining freely. The urine is dark yellow, without blood, and has a specific gravity of 1040 and a sodium concentration of 10 mEq/L. The patient's blood pressure is 100/70 mm Hg, his pulse is 98/min, and his central venous pressure is 2 cm H2O. On the basis of these findings, which of the following is the most appropriate next step in management?
A. Diuretics should be given
B. Fluid administration should continue at the present rate
C. The rate of fluid administration should be decreased
D. The rate of fluid administration should be increased
E. Treatment is needed for renal failure
605. A 27-year-old immigrant from El Salvador has a 14 × 12 × 9 cm mass in her left breast. It has been present for 7 years and has slowly grown to its present size. The mass is firm, nontender, rubbery, and completely movable, and it is not attached to the overlying skin or the chest wall. There are no palpable axillary nodes or skin ulceration. Which of the following is the most likely diagnosis?
A. Breast cancer
B. Chronic cystic mastitis
C. Cystosarcoma phyllodes
D. Intraductal papilloma
E. Mammary dysplasia
606. A 32-year-old woman in the 2nd month of pregnancy is found to have a 5-cm mass in the upper outer quadrant of her left breast. Mammogram shows no other lesions, and core biopsy reveals infiltrating ductal carcinoma. Which of the following would be the best course of action at this time?
A. Chemotherapy now, deferring surgery until after delivery
B. Radiation therapy now, deferring surgery until after delivery
C. Lumpectomy and axillary sampling, followed in 6 weeks by radiotherapy
D. Modified radical mastectomy now, deferring systemic therapy until later
E. Immediate therapeutic abortion and palliative breast surgery
607. In the course of a robbery, a young woman is stabbed repeatedly. On arrival at the emergency department, she is shivering and asks for a blanket and a drink of water; she is noted to be pale and perspiring. Her blood pressure is 72/50 mm Hg and her pulse is 130/min. Her neck and forehead veins are large and distended. A quick initial survey reveals entry wounds in her left chest and upper abdomen. She has bilateral breath sounds and a scaphoid, nontender abdomen. As IV infusions of Ringer's lactate are started, her systolic blood pressure drops further to 40 mm Hg, no distal pulses can be felt, and she loses consciousness. Her central venous pressure at that time is 28 cm H2O. Which of the following is the most appropriate next step in management?
A. Chest x-ray to direct further therapy
B. Bilateral chest tubes
C. Diagnostic peritoneal lavage
D. Evacuation of the pericardial sac
E. Crash laparotomy in the emergency department to clamp the aorta
608. A 62-year-old man reports an episode of gross, painless hematuria. There is no history of trauma, and further questioning determines that he had total hematuria, rather than initial or terminal hematuria. The man does not smoke and has had no other symptoms referable to the urinary tract. He has no known allergies. Physical examination, including rectal examination, is unremarkable. His serum creatinine is 0.8 mg/dL, and, except for the presence of many red cells, his urinalysis is normal and shows no red cell casts. His hematocrit is 46%. Which of the following is the most appropriate initial step in the workup?
A. Coagulation studies and urinary cultures
B. Intravenous pyelogram (IVP) and cystoscopy
C. PSA determination and prostatic biopsies
D. Sonogram and CT scan of both kidneys
E. Retrograde cystogram and pyelograms
609. A 63-year-old man, who weighs 65 kg, is in his 2nd postoperative day after an abdominoperineal resection for cancer of the rectum. An indwelling Foley catheter was left in place after surgery. The nurses are concerned because, even though his vital signs have been stable, his urinary output in the past 2 hours has been zero. In the preceding 3 hours, they had collected 56 mL, 73 mL, and 61 mL. Which of the following is the most likely diagnosis?
A. Acute renal failure
B. Damage to the bladder during the operation
C. Damage to the ureters during the operation
D. Dehydration
E. Plugged or kinked catheter
610. A 37-year-old woman undergoes a lumpectomy and axillary dissection for a 3-cm infiltrating ductal carcinoma, diagnosed by core biopsies, located on the upper outer quadrant of her left breast. The pathology report of the surgical specimen is received 3 days after the operation. It indicates that all margins around the tumor are clear, and that 4 of 17 axillary lymph nodes have metastatic tumor. The tumor is reported to be estrogen and progesterone receptor negative. Which of the following should further therapy most likely include?
A. Antiestrogen medication (tamoxifen)
B. Conversion to modified radical mastectomy
C. Radiation to the remaining left breast
D. Radiation to the remaining left breast and systemic chemotherapy
E. Radiation to both breasts and tamoxifen
611. A 45-year-old man with alcoholic cirrhosis is bleeding from a duodenal ulcer. He has required 6 units of blood over the past 8 hours, and all conservative measures to stop the bleeding, including irrigation with cold saline, IV vasopressin, and endoscopic use of the laser have failed. He is being considered for surgical intervention. Laboratory studies done at the time of admission, when he had received only one unit of blood, showed a bilirubin of 4.5 mg/dL, a prothrombin time of 22 seconds, and a serum albumin of 1.8 g/dL. He was mentally clear when he came in, but has since then developed encephalopathy and is now in a coma. Which of the following best describes his operative risk?
A. Acceptable as he now is
B. Amenable to improvement if he receives vitamin K
C. Amenable to improvement if he is given albumin
D. Prohibitive unless he is dialyzed to normalize his bilirubin
E. Prohibitive regardless of attempts to improve his condition
612. A 55-year-old woman falls in the shower and hurts her right shoulder. She shows up in the emergency department with her arm held close to her body, but the forearm rotated outward as if she were going to shake hands. She is in pain and will not move the arm from that position. Her shoulder looks "square" in comparison with the rounded unhurt opposite side, and there is numbness in a small area of her shoulder over the deltoid muscle. Which of the following is the most likely diagnosis?
A. Acromioclavicular separation
B. Anterior dislocation of the shoulder
C. Fracture of the upper end of the humeral shaft
D. Posterior dislocation of the shoulder
E. Scapular fracture
613. A 22-year-old convenience store clerk is shot once with a .38 caliber revolver. The entry wound is in the left midclavicular line, 2 inches below the nipple. There is no exit wound. He is hemodynamically stable. A chest x-ray film shows a small pneumothorax on the left, and demonstrates the bullet to be lodged in the left paraspinal muscles. In addition to the appropriate treatment for the pneumothorax, which of the following will this patient most likely need?
A. Barium swallow
B. Bronchoscopy
C. Extraction of the bullet via local back exploration
D. Extraction of the bullet via left thoracotomy
E. Exploratory laparotomy
614. A 68-year-old man is brought to the emergency department with excruciating back pain that began suddenly 45 minutes ago. The pain is constant and is not exacerbated by sneezing or coughing. He is diaphoretic and has a systolic blood pressure of 90 mm Hg. There is an 8-cm pulsatile mass deep in his epigastrium, above the umbilicus. A chest x-ray film is unremarkable. Two years ago, he was diagnosed with prostatic cancer and was treated with orchiectomy and radiation. At that time, his blood pressure was normal, and he had a 6-cm, asymptomatic abdominal aortic aneurysm for which he declined treatment. Which of the following is the most likely diagnosis?
A. Dissecting thoracic aortic aneurysm
B. Fracture of lumbar pedicles with cord compression
C. Herniated disc
D. Metastatic tumor to the lumbar spine
E. Rupturing abdominal aortic aneurysm
615. A middle-aged homeless man is brought to the emergency department because of very severe pain in his forearm. He had passed out after drinking a bottle of cheap wine, and then slept on a park bench for an indeterminate time, probably more than 12 hours. Shortly after he woke up and began to walk, the pain began. There are no signs of trauma, but the muscles in his forearm are very firm and tender to palpation, and passive motion of his fingers and wrist elicits excruciating pain. Pulses at the wrist are normal. Which of the following is the most appropriate next step in management?
A. Analgesics and observation
B. Immobilization in a sling
C. Immobilization in a plaster cast
D. Emergency embolectomy
E. Emergency fasciotomy
616. A 54-year-old obese man gives a history of burning retrosternal pain and heartburn that is brought about by bending over, wearing a tight belt, or lying flat in bed at night. He gets symptomatic relief from over-the-counter antiacids or H2 blockers, but has never been formally studied or treated. The problem has been present for many years and seems to be progressing. Which of the following is the most appropriate next step in management?
A. Barium swallow
B. Cardiac enzymes and ECG
C. Proton pump inhibitors
D. Endoscopy and biopsies
E. Laparoscopic Nissen fundoplication
617. A pedestrian is hit by a car and knocked unconscious. Within a few minutes, he starts to move around and moan. When the ambulance arrives, he is moving all four extremities and mumbling that his neck hurts. Shortly thereafter, he lapses again into a deep coma. In the emergency department, it is noted that his left pupil is fixed and dilated, and he has clear fluid dripping from the left ear. The trauma team intubates him nasally over a fiberoptic bronchoscope and does a quick initial survey that reveals no other obvious injuries. He is hemodynamically stable. Which of the following is the most appropriate next step in management?
A. Antibiotics and high dose corticosteroids
B. Cervical spine and skull x-ray films
C. CT scan of the head, extended to include the cervical spine
D. Otoscopic examination and laboratory studies of the fluid
E. Emergency ear surgery to stop the leak of cerebrospinal fluid
618. While working at a bookbinding shop, a young man suffers a traumatic amputation of his index finger. The finger was cleanly severed at its base. The patient and the finger are brought to a first-aid station, from which both are to be transported to a highly specialized medical center for replantation to be done. Which of the following is the correct way to prepare and transport the severed finger?
A. Dry the finger of any traces of blood and place it in a cooler filled with crushed ice
B. Freeze it as quickly as possible, and transport it immersed in liquid nitrogen
C. Immerse it in cold alcohol for the entire trip
D. Paint it with antiseptic solution and place it on a bed of dry ice
E. Wrap it in a moist gauze, place it on a plastic bag, and place the bag on a bed of ice
619. An out-of-shape, recently divorced, 42-year-old man is trying to impress a young woman by challenging her to a game of tennis. In the middle of the game, a loud "pop" (like a gunshot) is heard, and the man falls to the ground clutching his ankle. He limps off the court with pain and swelling in the back of the lower leg. Although he can still weakly plantar-flex his foot, he seeks medical help the next day because of persistent pain, swelling, and limping. He can put weight on that foot with no exacerbation of the pain, but the motion of taking a step is painful. Which of the following would be the most likely finding on physical examination?
A. Tapping on the calcaneus is extremely painful
B. The ankle joint can be abducted farther out than the normal contralateral side
C. The ankle joint can be adducted farther in than the normal contralateral side
D. There is a gap in the Achilles tendon easily felt by palpation
E. There is crepitation and grating by direct palpation over either malleoli
620. A 66-year-old man with diabetes and generalized arteriosclerotic occlusive disease notices a gradual loss of erectile function over several years. Initially, he can get erections, but they do not last long enough. Later, he notices a decrease in the quality of his erections, and more recently he becomes, by his own criteria, completely impotent. He has occasional, brief nocturnal erections, but "he can never get an erection when he needs one." Which of the following is the most appropriate initial step in management?
A. Psychotherapy
B. Pharmacologic therapy
C. Erectile nerve reconstruction
D. Implantable penile prosthesis
E. Pudendal artery revascularization
621. A 54-year-old woman has a severe ureteral colic. An intravenous pyelogram shows a 7-mm ureteral stone at the ureteropelvic junction. She has a normal coagulation profile. Which of the following would most likely be the best therapy in this case?
A. Plenty of fluids and analgesics and await spontaneous passage
B. Extracorporeal shock wave lithotripsy (ESWL)
C. Endoscopic retrograde basket extraction
D. Endoscopic retrograde laser vaporization of the stone
E. Open surgical removal
622. A 68-year-old woman presents with an obviously incarcerated umbilical hernia. She has gross abdominal distention, is clinically dehydrated, and reports persistent fecaloid vomiting for the past 3 days. Although tired, weak, and thirsty, she is awake and alert and her sensorium is not particularly affected. Laboratory analysis reveals a serum sodium concentration of 118 mEq/L. Which of the following is the most likely physiologic explanation for the serum sodium?
A. She has acute water intoxication
B. She has been vomiting and trapping hypertonic fluids in the bowel lumen
C. She has vomited and sequestered sodium-containing fluids, and has retained endogenous and ingested water
D. There must be a laboratory error, because such a serum sodium level would have produced coma
E. Volume deprivation leads to renal wasting of sodium
623. A 31-year-old woman smashes her car against a bridge abutment. She sustains multiple injuries, including upper and lower extremity fractures. She is fully awake and alert, and she reports that she was not wearing a seat belt and distinctly remembers hitting her abdomen against the steering wheel. Her blood pressure is 135/75 mm Hg, and her pulse is 88/min. Physical examination shows that she has a rigid, tender abdomen, with guarding and rebound in all four quadrants. She has no bowel sounds. Which of the following would be the most appropriate step in evaluating potential intraabdominal injuries?
A. Continued clinical observation
B. CT scan of the abdomen
C. Sonogram of the abdomen
D. Diagnostic peritoneal lavage
E. Exploratory laparotomy
624. A 27-year-old man sustained penetrating injuries of the chest and abdomen when he was repeatedly stabbed with a long ice-pick. At the time of admission, he had a right pneumothorax, for which a chest tube was placed prior to undergoing a general anesthetic for exploratory laparotomy. The operation revealed no intraabdominal injuries and was terminated sooner than had been anticipated. The patient remained intubated, waiting for the anesthetic to wear off. Because he was not moving enough air, he was placed on a respirator. Then, he suddenly went into cardiac arrest and died. All through this time he had been hemodynamically stable, and never had any signs of hypotension or arrhythmias. Which of the following was the most likely cause of the cardiac arrest?
A. Air embolism
B. Fat embolism
C. Myocardial infarction
D. Pulmonary embolus
E. Tension pneumothorax
625. A 13-year-old, obese boy complains of persistent knee pain for several weeks. The family brings him in because he has been limping. He sits in the examining table with the sole of the foot on the affected side pointing to the other leg. Physical examination is normal for the knee, but shows limited hip motion. As the hip is flexed, the leg goes into external rotation and cannot be rotated internally. Which of the following is the most likely diagnosis?
A. Avascular necrosis of the femoral head
B. Developmental dysplasia of the hip
C. Osteogenic sarcoma of the lower femur
D. Slipped capital femoral epiphysis
E. Tibial torsion with foot inversion
626. A 72-year-old man has a 3-mm ureteral stone impacted at the ureterovesical junction. He has been having mild ureteral colicky pain for about 12 hours, and he has been given fluids and analgesics in the expectation that he will spontaneously pass the stone. He then has shaking chills, and spikes a temperature of 40 C (104 F). When seen shortly thereafter, he has flank pain and looks quite ill. Which of the following is the most appropriate next step in management?
A. Addition of IV antibiotics to the current therapeutic regimen
B. Crushing and extraction of the stone via cystoscopy
C. Extracorporeal shock wave lithotripsy and parenteral antibiotics
D. Immediate insertion of a suprapubic catheter into the bladder
E. IV antibiotics and immediate decompression of the urinary tract above the stone
627. A 14-year-old boy dives into the shallow end of a swimming pool and hits his head against the bottom. When he is rescued, he shows a complete lack of neurologic function below the neck. He is still breathing on his own, but he cannot move or feel his arms and legs. The paramedics carefully immobilize his neck for transportation to the hospital, and they alert the emergency department to his impending arrival. Once there, which of the following would most likely have an immediate benefit for this patient?
A. Hyperbaric oxygenation
B. IV antibiotics
C. IV high-dose corticosteroids
D. Massive diuresis induced by loop diuretics.
E. Surgical decompression of the cord
628. A 72-year-old man is scheduled to have elective sigmoid resection for diverticular disease. He has a history of heart disease, and had a documented myocardial infarction 2 years ago. He currently does not have angina, but he lives a sedentary life because "he gets out of breath" if he exerts himself. During the physical examination, it is noted that he has jugular venous distention. He has a hemoglobin of 12 g/dL. If surgery is indeed needed, which of the following should most likely be done prior to the operation?
A. Evaluate the patient as a candidate for coronary revascularization
B. Place the patient on intensive respiratory therapy
C. Order a transfusion to increase the patient's hemoglobin to 14 g/dL
D. Treat the patient for congestive heart failure
E. If at all possible, wait 6 months before performing surgery
629. A group of illegal immigrants is smuggled across the border in a closed metal truck in the middle of summer. When apprised by radio that the border patrol is on their trail, the smugglers abandon their charges in the middle of the desert, in the locked truck, with little water to drink. The victims are found and rescued 5 days later. One of them is brought to the emergency department, awake and alert, with obvious clinical signs of severe dehydration and a serum sodium concentration of 155 mEq/L. Which of the following would be the best choice and rate of IV fluid administration?
A. 5 L of 5% dextrose in water (D5W) over 2-3 days
B. 5 L of D5W over 5-10 hours
C. 5 L of 5% dextrose in half normal saline (D5 1/2 NS) over 5-10 hours
D. 10 L of D5 1/2 NS over 5-10 hours
E. 10 L of normal saline over 2-3 days
630. A 72-year-old man comes in complaining of persistent and nagging low back pain that he has had for several weeks. The pain seems to be increasing in intensity, is worse at night, is unrelieved by rest or positional changes, and is not exacerbated by coughing, sneezing, or straining to have a bowel movement. He is a chronic smoker, and for the past 3 months has had persistent cough with occasional bloody streaked sputum, as well as a 20-pound weight loss. On physical examination, he is distinctly tender to palpation at a particular spot over his lower thoracic spine. Which of the following is the most likely diagnosis?
A. Ankylosing spondylitis
B. Herniated disk
C. Metastatic tumor to the thoracic spine
D. Multiple myeloma
E. Primary malignant bone tumor
631. The unrestrained front-seat passenger in a car that crashes at high speed is brought to the emergency department by paramedics. At the site of injury, the patient was unconscious and had gurgly respiratory sounds, and the EMTs successfully accomplished blind nasotracheal intubation. The initial survey in the emergency department shows normal vital signs, multiple facial lacerations, and an unresponsive, comatose patient with fixed dilated pupils. Preparations are made to do a CT scan of the head. It is imperative that which of the following should be obtained as well?
A. Base of the skull x-ray films
B. Extension of the CT to include the entire cervical spine
C. Radiographs of all the teeth
D. Separate CT scan of the abdomen
E. Special views of the maxillary sinuses
632. A 55-year-old woman has been known for years to have mitral valve prolapse. She has now developed exertional dyspnea, orthopnea, and atrial fibrillation. She has an apical, high-pitched, holosystolic heart murmur that radiates to the axilla and back. Because of her deterioration, surgery has been recommended. Which of the following is the most appropriate procedure?
A. Aortic valve replacement
B. Mitral commissurotomy
C. Mitral valve annuloplasty
D. Mitral valve replacement
E. Both aortic and mitral valve replacement
633. A 23-year-old woman seeks help for exquisite pain with defecation and blood streaks on the outside of her stools, which she has been having for several weeks. Because of the pain, she has avoided having bowel movements, and when she finally did the stools were hard and even more painful. When seen, she has no fever or leukocytosis. Physical examination has to be done under spinal anesthesia, because the patient was so afraid of the pain that she initially refused even inspection of the area. The examination confirms the suspected diagnosis, and she is placed on stool softeners and appropriate topical agents, but without success. She is willing to undergo more aggressive treatment. Which of the following is the most appropriate next step?
A. Excision of the lesion
B. Fistulotomy
C. Incision and drainage
D. Lateral internal sphincterotomy
E. Rubber band ligation
634. An exploratory laparotomy for multiple intra-abdominal injuries has lasted 3 and a half hours. Multiple blood transfusions have been given, and several liters of Ringer's lactate have been infused. When the surgeons are ready to close the abdomen, they find that the abdominal wall edges cannot be pulled together without undue tension. Both the belly wall and the abdominal contents seem to be swollen. Which of the following is the most appropriate management in this situation?
A. Approximate the skin only, using towel clips
B. Close the abdomen with heavy retention sutures
C. Give diuretics and close the abdomen in the usual way
D. Leave the abdomen and its contents open to the air
E. Provide temporary bowel coverage with an absorbable mesh
635. A 61-year-old man comes in because of colicky abdominal pain and vomiting of 3 days' duration. On physical examination, he is moderately distended and has high pitched hyperactive bowel sounds and a 5-cm tender groin mass. On direct questioning, he explains that he has had that bulge for many years, but has always been able to "push it back in" when he lies down. For the past 3 days, however, he has been unable to do so. He has a temperature of 38.9 C (102 F) and a white blood cell count of 12,500/mm3. Which of the following is the most appropriate management at this time?
A. A sonogram of the mass
B. A trial of nasogastric suction and IV fluids for a few days
C. Insertion of a long rectal tube via sigmoidoscopy
D. Manual reduction of the hernia, followed by a period of observation
E. Urgent surgical intervention
636. In a rollover car accident, a 42-year-old woman is thrown from the car. The car subsequently lands on her and crushes her. On physical examination in the emergency department, it is determined that she has a pelvic fracture, which is confirmed by portable x-rays done as she is being resuscitated. Her initial blood pressure is 50/30 mm Hg, and her pulse is 160/min and barely perceptible. Thirty minutes later, after 2 L Ringer's lactate and 2 U packed cells have been infused, her pressure is only 70/50 mm Hg, and her pulse is 130/min. A sonogram done in the emergency department shows no intra-abdominal bleeding, and a diagnostic peritoneal lavage confirms that there is no blood in the abdomen (the recovered fluid is pink, but not grossly bloody). Rectal and vaginal exams show no injuries to those organs. There is no blood in her urine. Which of the following is the most appropriate next step in management?
A. Packing of the vagina and rectum
B. Angiographic embolization of torn veins
C. External fixation of the pelvis
D. Open reduction and internal fixation of the pelvis
E. Exploratory laparotomy with pelvic dissection and hemostasis
637. A 52-year-old nurse seeks medical retirement because of a "heart condition." She complains of disabling attacks of tachycardia and palpitations. The physical examination and ECG studies confirm that indeed her pulse is between 100 and 105/min at all times, and she is in and out of atrial fibrillation. It is also noted that she is fidgety and constantly moving, and various examiners remark that she arrives for tests lightly dressed when it is rather cold outside. Thyroid function studies show elevated free thyroxine (T4) and undetectable levels of thyroid stimulating hormone (TSH). Her thyroid gland is not clinically enlarged or tender. Which of the following is the most appropriate next step in diagnosis?
A. Fine needle aspiration cytology of the thyroid gland
B. MRI of the pituitary area
C. Radioactive iodine uptake
D. Serum levels of C peptide
E. Serum levels of triiodothyronine (T3)
638. A 59-year-old man is referred for evaluation because he has been fainting at his job, where he operates heavy machinery. He is pale and gaunt, but otherwise his physical examination is remarkable only for 4+ occult blood in the stool. Laboratory studies show a hemoglobin of 5 gm/dL with microcytosis, as well as decreased levels of serum iron and increased iron binding capacity. Which of the following will most likely establish the diagnosis?
A. Upper gastrointestinal series (swallowed barium studies)
B. Colonoscopy
C. Flexible sigmoidoscopy to 45 cm
D. Upper gastrointestinal endoscopy
E. Visceral angiogram
639. A 24-year-old woman is admitted to the hospital for a broken femur. The patient was in a motor vehicle accident 20 hours ago and was brought to the hospital by EMS. On the scene, she was found belted in her car in the drivers seat, and her only documented injury was the leg fracture. She had no loss of consciousness or altered mental status. On arrival to the hospital, radiographs confirmed a fracture of her femur. She was stabilized overnight and scheduled for surgery the next day. Which of the following is the major surgical risk for this patient?
A. Air embolism
B. Cerebrovascular accident
C. Fat embolism
D. Osteomyelitis
E. Permanent disability
640. A 42-year-old woman hit her breast with a broom handle while doing housework. She noticed a lump in that area at the time, and 1 week later the lump was still present. She then sought medical advice. On physical examination, she has a 3-cm, hard mass deep inside the affected breast, and some superficial ecchymosis over the area. Which of the following is the most appropriate next step, or steps, in management?
A. Reassess in about 2 months, with no specific therapy
B. Hot packs, analgesics, and surgical evacuation of the hematoma
C. Mammogram, and no further therapy if the report does not identify cancer
D. Mammogram and biopsy of the mass
E. Mastectomy
641. The unrestrained front-seat passenger in a car that crashed at high speed arrives at the emergency department with signs of moderate respiratory distress. Physical examination shows no breath sounds at all on the left hemithorax. Percussion is unremarkable, and his vital signs are normal. A chest x-ray film shows a collapsed left lung and multiple air-fluid levels filling the left pleural cavity. A nasogastric tube that had been placed prior to taking the film shows the tube reaching the upper abdomen and then curling up into the left chest. Which of the following is the most likely diagnosis?
A. Blow out of pulmonary blebs
B. Esophageal rupture or perforation
C. Left diaphragmatic rupture
D. Left hemopneumothorax
E. Major injury to the tracheobronchial tree
642. On the 7th postoperative day after the pinning of a broken hip, a 76-year-old man suddenly develops severe pleuritic chest pain and shortness of breath. When examined, he is found to be anxious, diaphoretic, and tachycardic, with a blood pressure of 140/85 mm Hg. He has prominent distended veins in his neck and forehead. Blood gases show hypoxemia and hypocapnia. His chest x-ray film is unremarkable. The nurses have placed him on supplemental oxygen by face mask. Which of the following is the most appropriate next step in management?
A. Aortogram and emergency surgical repair
B. ECG and cardiac enzymes
C. Intubation and respirator, with hyperventilation and PEEP
D. Retinal examination looking for fat droplets
E. Ventilation-perfusion lung scan, or spiral CT scan of the chest
643. A young man sustains a gunshot wound to the base of his neck. He was shot point blank with a .38 caliber revolver. The entrance wound is above the left clavicle, below the level of the cricoid cartilage, and just lateral to the sternomastoid muscle. The exit wound is just above the spinous process of the right scapula. He has normal breath sounds on both sides, is awake and alert, is talking with a normal tone of voice, is neurologically intact, and is hemodynamically stable. Portable x-ray films of the neck and chest taken in the emergency department show some air in the tissues of the lower neck, but are otherwise non-diagnostic. Which of the following is the most appropriate next step in management?
A. Observation for several hours
B. CT scan of the lower neck and upper chest
C. Angiogram, esophagogram, esophagoscopy, and bronchoscopy prior to surgical exploration
D. Immediate surgical exploration of the lower neck through a collar incision
E. Immediate surgical exploration of the upper chest through a median sternotomy
644. A 67-year-old man shows up in the emergency department because he has not been able to void for the past 12 hours. He feels the need to, but he cannot do it. He gives a history that, for several years now, he has been getting up four or five times a night to urinate. It would take him a considerable time to get the urinary stream going, and the stream lacked force and often ended in a dribble. Because of a cold, 2 days ago he began taking an antihistamine, taking a decongestant, and drinking plenty of fluids. Physical examination shows a palpable, smooth, round mass arising from the pubis and reaching about half way toward the umbilicus. The mass is dull to percussion, and pushing on it accentuates the feeling of needing to void. Rectal examination reveals a large, boggy, non-tender prostate gland without nodules. This a classic presentation for which of the following acute conditions?
A. Bacterial prostatitis
B. Cystitis in a patient with bladder cancer
C. Renal failure
D. Urinary retention in a patient with benign prostatic hypertrophy
E. Urinary retention in a patient with prostatic cancer
645. Several months after sustaining a crushing injury to his arm, a patient complains bitterly about constant, burning, agonizing pain in that arm, that does not respond to the usual analgesic medications. The pain in his arm is aggravated by the slightest stimulation of the area, such as rubbing from the shirt sleeves. The arm is cold, cyanotic, and moist, but it is not swollen. Pulses at the wrist are normal, and neurologic function of the three major nerves is intact. Which of the following is most appropriate to provide diagnostic confirmation of the nature of the problem and eventual therapy?
A. Angiogram and subclavian vein bypass
B. Cervical spine x-rays and cervical rib resection
C. Doppler studies and arterial reconstruction
D. Doppler studies and fasciotomy
E. Sympathetic block and surgical sympathectomy
646. A 57-year-old alcoholic man is being treated for acute hemorrhagic pancreatitis. He was in the intensive care unit for 1 week, where he required chest tubes for pleural effusions and was on a respirator for several days. Eventually, he improved sufficiently to be transferred to the floor. Three days after leaving the unit, and about 2 weeks after the onset of the disease, he spikes a fever and develops leukocytosis. Which of the following developments do these recent findings most likely suggest?
A. Chronic pancreatitis
B. Pancreatic abscess
C. Pancreatic pseudocyst
D. Pelvic abscess
E. Subphrenic abscess
647. A 31-year-old male immigrant from India is found on a routine physical examination to have a single, 2-cm nodule in the right lobe of his thyroid gland. The mass is firm, moves up and down with swallowing, and is not tender. The skin of his face and neck is pitted with multiple scars, which suggest smallpox; however, he explains that the scars are due to very severe acne that he had as a youngster, for which he eventually received external beam radiation therapy at the age of 14. His thyroid function tests are normal, and a fine needle aspiration (FNA) cytology of the mass is read by the pathologist as "indeterminate." Which of the following is the most appropriate next step in management?
A. No further care is needed
B. Thyroid function tests should be repeated yearly
C. Thyroid scan and sonogram are needed
D. FNA should be repeated until it can be read as benign or malignant
E. Thyroid lobectomy
648. A 33-year-old woman is involved in a high-speed automobile collision. She arrives at the emergency department gasping for breath. Her lips are cyanotic and she has flaring nostrils. There are bruises over both sides of the chest, and tenderness suggestive of multiple rib fractures. Her blood pressure is 60/45 mm Hg, pulse is 160/min and feeble, and central venous pressure is 25 cm H2O. Her neck and forehead veins are distended. She is diaphoretic and has a hint of subcutaneous emphysema in the lower neck and upper chest. Her left hemithorax has no breath sounds and is hyperresonant to percussion. The trachea is deviated to the right, as are the heart sounds. Which of the following is the most likely diagnosis?
A. Air embolism from tracheobronchial injuries
B. Flail chest due to multiple rib fractures
C. Massive intrapleural bleeding from torn intercostal vessels
D. Massive mediastinal bleeding from ruptured aorta
E. Tension pneumothorax caused by lung punctured by broken ribs
649. A 44-year-old woman complains bitterly of severe headache that has been present for several weeks and has not responded to the usual over-the-counter headache remedies. She locates the headache to the center of her head. It is pretty much constant but is worse in the mornings. She has no other neurologic signs or symptoms. She has had "tension headaches" in the past, but she says that those were located in the back of her head and felt different from the present pain. She is currently under considerable stress because she has been unemployed since undergoing modified radical mastectomy for T3, N1, M0 breast cancer 2 years ago. She had several courses of post-operative chemotherapy, which she eventually discontinued because of the side effects. Which of the following is the most appropriate next step in diagnosis?
A. CT scan of the head
B. Psychiatric evaluation
C. Skull x-rays
D. Aortic arch arteriogram
E. Lumbar puncture
650. A 59-year-old black man has a rock-hard, discrete, 1.5-cm nodule that is felt in his prostate during a routine physical examination. He is completely asymptomatic, and his prostatic specific antigen (PSA) done 3 months ago was normal for his age. His last rectal examination was performed a year earlier and was unremarkable. Which of the following will best establish the diagnosis?
A. Clinical follow-up during the ensuing year
B. Repeat determination of PSA
C. Transrectal needle biopsy of the mass
D. Transrectal sonogram of the prostate
E. Transurethral resection of the prostate
651. A 9-month-old infant is brought in by her parents because she has an umbilical hernia. Physical examination shows an umbilical defect about 1 cm in diameter, with a small bulge when the girl cries. The hernial contents can be easily reduced. The hernia is not painful, and the girl is otherwise asymptomatic. Which of the following is the most appropriate next step in management?
A. No therapy unless the hernia persists beyond the age of 2 years
B. Repeated injections of sclerosing agents
C. Elective laparoscopic surgical repair
D. Elective open surgical repair
E. Urgent surgical repair
652. A 53-year-old male is brought to the emergency department after being involved in a motor vehicle accident (MVA) as an unrestrained driver. He was found unresponsive at the scene and was intubated by paramedics. He has received 1L of normal saline over the last 20 minutes. His blood pressure in the emergency department is 70/30 mmHg, and his heart rate is 100/min. On physical examination, he responds to strong vocal and tactile stimuli by opening his eyes. His pupils are equal and reactive to light. On exam, there are multiple bruises over the anterior chest and upper abdomen. The trachea is midline. A Swan-Ganz catheter reveals a pulmonary capillary wedge pressure of 12 mmHg. Rapid infusion of 1L of normal saline increases the pulmonary capillary wedge pressure to 17 mmHg, with a blood pressure of 75/30 mmHg and heart rate of 103/min. Which of the following is the best treatment for this patient?
A. Anticoagulation
B. High-rate IV fluids
C. Inotropic agents
D. Pericardiocentesis
E. Chest tube
653. A 67-year-old male comes to the clinic for medical clearance prior to an elective abdominal aortic aneurysm repair. He denies any cough, shortness of breath or chest pain. He has coronary artery disease, diabetes and hypertension. He does not use tobacco, alcohol or drugs. His blood pressure is 120/76 mm Hg, pulse is 60/min, and respirations are 14/min. Examination shows no abnormalities, except prominent epigastric pulsations. Which of the following interventions would be most helpful in preventing postoperative pneumonia in this patient?
A. Albuterol inhalers
B. Prophylactic antibiotics
C. Incentive spirometry
D. Continuous positive airway pressure
E. Intercostal nerve blocks for pain control
654. A 32-year-old male is rushed to the emergency room after a motor vehicle accident. He was driving 55 mph when he suddenly lost control of his vehicle and hit a tree. He was wearing a seat belt. On physical examination, the patient appears scared and complains of moderate chest and abdominal discomfort. His voice is soft. His blood pressure is 190/ 100 mmHg and his heart rate is 100/min. The pupils are symmetric and reactive to light and the trachea is midline. You note bruising over the chest and upper abdomen. No penetrating injuries are evident. Which of the following injuries is most likely in this patient?
A. Esophageal rupture
B. Tracheobronchial disruption
C. Vagus nerve disruption
D. Aortic rupture
E. Pulmonary contusion
655. A 23-year-old male is brought to the emergency department following a motor vehicle accident (MVA) where he was the unrestrained driver. The patient was found unresponsive at the scene and was intubated by paramedics. He receives 2.5L of normal saline over the 20 minutes before he reaches the ED. His blood pressure there is 70/30 mmHg and his heart rate is 120/min. On physical examination, he responds to strong vocal and tactile stimuli by opening his eyes. His pupils are equal and reactive to light. There are multiple bruises over the anterior chest and upper abdomen. His neck veins are flat, trachea is midline and extremities are cold. Cardiac monitoring shows sinus tachycardia. Which of the following is the most likely cause of this patient's current condition?
A. Impaired myocardial contractility
B. Ventricular filling restriction
C. Loss of intravascular volume
D. Air embolism
E. Loss of vascular tone
656. A 33-year-old male falls while riding his bicycle in the park, and presents to the emergency department. Physical examination reveals upper abdominal bruises. His abdomen is non-distended, soft, and mildly tender in the epigastrium. Abdominal CT scan does not reveal any abnormalities. The patient is sent home with analgesic medications. He returns one week later with fever, shaking chills, poor appetite and deep abdominal pain Which of the following is most likely related to this patient's symptoms?
A. Spleen rupture
B. Stomach perforation
C. Pancreatic laceration
D. Small bowel necrosis
E. Meckel diverticulitis
657. A 34-year-old immigrant from Mexico presents following an episode of massive hemoptysis. He describes bringing up large amounts of bright red, foamy sputum. He denies any recent trauma. On physical examination, the patient is agitated and has difficulty speaking. His blood pressure is 100/60 mmHg and his heart rate is 110/min. On physical examination, breath sounds are audible bilaterally. You immediately initiate intravenous infusion of crystalloid. Portable chest x-ray shows an opacity in the right upper lobe. Which of the following is the best next step in the management of this patient?
A. Chest CT scan
B. Upper gastrointestinal endoscopy
C. Bronchoscopy
D. Pulmonary arteriography with embolization
E. Immediate thoracotomy
658. A 34-year-old man is brought to the emergency department after being rescued from a burning building. His temperature is 36.90C (98.60 F), blood pressure is 90/60 mm Hg, pulse is 100/min and respirations are 28/min. Examination shows second and third degree burns over 15% of his body. His oropharynx shows erythema and scattered blisters. His lungs are clear to auscultation and his abdomen is soft and nondistended. His blood carboxyhemoglobin concentration is 20%. Which of the following is the best management for this patient?
A. High-dose corticosteroids
B. Endotracheal intubation
C. Broad-spectrum antibiotics
D. Fluid restriction
E. Acetylcysteine inhalation
659. A 36-year-old woman presents to the emergency department with severe epigastric pain and right shoulder pain of about two hours duration. She also reports having one episode of emesis. When asked about her diet, she explains that she unintentionally fasted yesterday and had a large meal two hours ago. Her past medical history is significant for frequent heartburn for which she takes ranitidine. Several hours after presenting, the patient's pain resolves completely. Which of the following best explains this episode?
A. Viscus distention
B. Acid hypersecretion
C. Peritoneal irritation
D. Mucosal inflammation
E. Vascular obstruction
660. A 74-year-old male is undergoing elective abdominal aortic aneurysm repair. He is given two units of packed red blood cells during the surgery. He develops fever and chills one hour after finishing the surgery and transfusion. He received one dose of prophylactic antibiotics before surgery. He had coronary bypass grafting two months ago. His temperature is 38.50 C (101.30 F), blood pressure is 130/76 mm Hg, pulse is 90/min and respirations are 16/min. Physical examination shows a mildly tender wound; there is no redness. The lungs are clearto auscultation. He has a Foley catheter and right subclavian central venous access, each placed at the time of surgery. Which of the following is the most likely cause of his fever?
A. Nosocomial pneumonia
B. Drug fever
C. Transfusion reaction
D. Urinary tract infection
E. Catheter associated infection
661. A 63-year-old male presents to the urgent care center with a four hour history of abdominal pain which he describes as severe, diffuse and constant. He has had one episode of non-bloody vomiting since the pain started. His past medical history is significant for coronary artery disease, diabetes, hypertension, chronic atrial fibrillation and chronic kidney disease. His current medications are lisinopril, digoxin, warfarin, metoprolol, simvastatin and insulin glargine. On physical examination, his blood pressure is 130/70 mmHg and his heart rate is 100/min and irregular. Physical examination reveals an overweight male in moderate distress. His abdomen is diffusely tender to palpation with positive rebound tenderness. His laboratory findings are as follows: Hemoglobin 9.5 mg/dl W BC count 7,500/mm3 Platelets 90,000/mm3 Sodium 137 mEq/L Potassium 4.5 mEq/L Chloride 101 mEq/L Bicarbonate 22 mEq/L Glucose 210 mg/dl Creatinine 1.8 mg/dl INR 2.1 Blood digoxin level therapeutic An upright abdominal x-ray shows free air under the diaphragm. Which of the following is the best initial treatment for this patient?
A Packed red blood cell transfusion
B. Platelet transfusion
C. Vitamin K
D. Desmopressin
E. Fresh frozen plasma
662. A 55-year-old male comes to the physician's office because of chronic pain in his buttock, hip and thigh muscles. The aching pain is present in both legs and usually is associated with walking. He has multiple medical problems and takes several medications. He has a 30 pack year smoking history. His temperature is 36.70 C (980 F), blood pressure is 150/88 mm Hg, pulse is 80/min and respirations are 16/min. Examination shows decreased femoral, popliteal and dorsalis pedis pulses in both legs. Which of the following additional complaints is most likely in this patient?
A. Snoring
B. Headache
C. Anorexia
D. Ankle swelling
E. Impotence
663. A 62-year-old female is hospitalized with epigastric pain and vomiting. Her past medical history includes mild COPD, congestive heart failure, diabetes mellitus and a stroke that occurred 2 years ago. Her current medications are insulin glargine and aspirin. Her blood pressure is 110/70 and her heart rate is 76/min. Comprehensive work-up is suggestive of acute calculous cholecystitis, and a cholecystectomy is planned. Which of the following would reduce postoperative mortality in this patient?
A. Vancomycin
B. Enalapril
C. Metoprolol
D. Verapamil
E. Metformin
664. A 50-year-old postman presents with a six-month history of left calf pain that is brought on by walking and is relieved by rest. The patient reports no other symptoms. He has smoked cigarettes for the past 25 years, but does not drink alcohol or use illicit drugs. On physical examination, he has a blood pressure of 158/92 mm Hg and a pulse of 88 beats per minute. The heart and lung examinations are normal. A bruit is heard over the left femoral artery. Popliteal, dorsalis pedis and posterior tibial pulses are palpable bilaterally. The electrocardiogram shows normal sinus rhythm and Q-waves in II, Ill, and aVF. Which of the following is the best next step in management?
A. Reassurance
B. Ankle-brachial pressure index measurement
C. Duplex scan of arteries of lower limbs
D. Contrast arteriography
E. Endovascular stent placement
665. An 85-year-old male is placed on mechanical ventilation after a complicated elective hernia repair. After five days of endotracheal intubation with mechanical ventilation, the ratio of the rate of carbon dioxide produced to the rate of oxygen uptake is 1.05. What is the best explanation for these findings?
A Sepsis
B. High-protein tube feeding
C. Carbohydrate excess in the diet
D. High inspired oxygen fraction
E. Pulmonary atelectasis
666. A 23-year-old male is brought to the emergency department after a motor vehicle accident. He was an unrestrained driver. He was found unresponsive at the scene of the accident, and was intubated by the paramedics. He has received 2L of normal saline over the last 20 minutes. His blood pressure is 80/40 mmHg, and heart rate is 120/min. He responds to strong vocal and tactile stimuli by opening his eyes. His pupils are equal and reactive to light. His neck veins are distended. There are multiple bruises involving the anterior chest and upper abdomen. His chest x-ray shows a small, left-sided pleural effusion and normal cardiac contours. Which of the following is the most likely diagnosis?
A. Lung contusion
B. Aortic rupture
C. Esophageal rupture
D. Pericardial tamponade
E. Bronchial rupture
667. A 65-year-old male comes to the ER because of sudden onset severe pain in his right leg. He says he has never previously had pain in his leg and denies any recent trauma, fever or chills. He recently suffered an acute anterior wall myocardial infarction that resulted in cardiogenic shock and is currently undergoing cardiac rehabilitation. His other medical problems include hypertension, diabetes and hyperlipidemia. His temperature is 36.70 C (980 F), blood pressure is 11 0/70 mm Hg, pulse is 90/min (regular) and respirations are 16/min. His lungs are clear to auscultation. His heart rate is regular with no murmurs. Below the knee the right leg is cool to touch and appears pale. The dorsalis pedis pulse is not palpable while the popliteal pulses are full. Pulses are normal in the contralateral extremity. Neurologic examination shows numbness over the dorsum of the leg and foot. Which of the following is the most likely cause of his symptoms?
A. Nerve compression
B. Arterial thrombosis
C. Arterial embolism
D. Venous thrombosis
E. Arterial vasculitis
668. A 27-year-old basketball player jumps to block a shot with his right hand. As his hand contacts the ball, he feels severe pain in his right shoulder. He presents to the emergency department with continuing shoulder pain. You note that he holds his right arm in slight external rotation, supporting its weight with his left hand. On physical examination, he resists internal rotation of his right arm. Which of the following nerves is most likely to be injured in this patient?
A Radial
B. Ulnar
C. Musculocutaneous
D. Axillary
E. Long thoracic
669. An 88-year-old male complains of severe right calf pain several hours after undergoing a right femoral artery embolectomy. He also complains of a burning sensation in his posterior right leg. He has a long history of atrial fibrillation and hypertension. His past medical history also includes stroke, bleeding duodenal ulcer, diabetes mellitus and diabetic nephropathy. On physical examination, his blood pressure is 160/70 mm Hg and his heart rate is 100 per minute and irregular. His right calf is swollen, tense and exquisitely tender; the pain is worsened by passive extension of the right knee. Dorsalis pedis and posterior tibial pulses are palpable in the bilateral lower extremities. Which of the following is the most likely cause of this patient's symptoms?
A. Recurrent embolism
B. Venous thrombosis
C. Soft tissue swelling
D. Bone infarction
E. Anaerobic infection
670. A 28-year-old man is brought to the emergency department 4 hours after being involved in a motor vehicle collision. His blood pressure is 90/50 mm Hg, pulse is 120/min and respirations are 30/min. Examination shows a stuporous man with bruises over his extremities and upper abdomen. His trachea is midline and his neck veins are flat. His abdomen is moderately distended but non-tender. Immediately after being intubated and placed on mechanical ventilation he goes into cardiac arrest. Which of the following could have prevented cardiac arrest in this patient?
A High initial tidal volume
B. Positive end-expiratory pressure
C. Chest tube placement
D. Volume resuscitation
E. Pain management
671. A 42-year-old man develops right calf pain one week after having a left hemi-colectomy. On physical examination, there is moderate right ankle edema and right calf pain with dorsiflexion of the right foot. Duplex ultrasonography shows a clot in the right superficial femoral vein. Which of the following is the most appropriate initial treatment?
A Aspirin
B. Heparin
C. Streptokinase
D. Warfarin
E. Tissue plasminogen activator
672. A 62-year-old man is brought to the emergency department after being involved in a motor vehicle collision where he suffered serious burns. On physical examination there are second degree burns covering both upper extremities and third degree burns over the anterior aspects of both lower extremities. On day three of his hospitalization, the patient develops tachycardia and decreased urine output. His blood pressure is 90/60 mmHg, pulse is 120/min, temperature is 95°F (35°C), and respirations are 26/min. Laboratory analysis reveals: Blood glucose 230 mg/dL WBC 16,000/mm3 Platelets 80,000/mm3 Which of the following is the best explanation for this patient's current condition?
A. Myocardial injury
B. Extensive protein breakdown
C. Immune reaction to heterologous proteins
D. Bacterial infection
E. Renal glomerular injury
673. A 28-year-old male is brought to the emergency department after being an unrestrained passenger in a motor vehicle collision. In the ambulance on his way to the hospital, he receives 2 liters of normal saline intravenously and 5 Umin of oxygen by nasal cannula. On physical examination, his blood pressure is 100/70 mmHg, heart rate is 120/min, and respiratory rate is 40/min. He is agitated and moves all four extremities spontaneously. His pupils are symmetric and reactive to light. His 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. Immediate chest x-ray to confirm pneumothorax
B. Immediate ultrasound exam to confirm pleural fluid accumulation
C. Immediate endotracheal intubation to establish an adequate airway
D. X-ray series to exclude cervical spine injury
E. Needle insertion into the second intercostal space in the left midclavicular line
674. A 53-year-old male presents to the emergency room complaining of chest pain localized to the left chest wall and following a linear pattern along the fifth intercostal space. His past medical history is significant for polycystic kidney disease and hypertension. His current medications are metoprolol and amlodipine. He has a ten pack-year smoking history but quit 14 years ago. He consumes alcohol occasionally. His blood pressure is 160/90 mmHg and his heart rate is 90/min. Physical examination is noncontributory. His laboratory findings are as follows: Sodium 142 mEq/L Potassium 4.2 mEq/L Hemoglobin 9.5 mg/dl W BC 10,000/mm3 Creatinine 1 .9 mg/dl BUN 28 mg/dl Chest x-ray reveals a solitary round lesion in the left upper lung field that measures 2 cm in diameter. It does not about the pleura. Which of the following is the best next step in managing this patient?
A. Pulmonary function testing
B. CT scan of the chest
C. Percutaneous biopsy of the lesion
D. Bronchoscopy
E. Repeated chest x-ray in 2 months
675. A 36-year-old male presents with firm, non-tender swelling of his right cheek. He tells you that he had similar swelling at that site two years ago and was diagnosed with a tumor, which was subsequently removed without complication. Examination reveals fullness of the parapharyngeal space on the right side. Repeat surgery in this patient is most likely to result in which of the following complications?
A. Hoarseness
B. Tic douloureux
C. Facial droop
D. Tongue palsy
E. Jaw asymmetry
676. A 34-year-old man complains of severe abdominal pain. He describes the pain as "sharp" and "unbearable." It is located in the lower left abdomen and radiates to the perineum. He has vomited twice since the pain began. He denies dysuria. On exam, he is afebrile. He cannot lie still on the examination table due to his discomfort. Mucus membranes appear slightly dry. Lungs are clear to auscultation. Heart sounds are normal and there are no murmurs or gallops. His abdomen is soft and non-tender to palpation. Inspection and palpation of his genitalia is unrevealing. Extremities have no cyanosis, clubbing, or edema. Which of the following is the best test to diagnose this patient's condition?
A. Abdominal and pelvic X-ray
B. Abdominal CT scan
C. Urinalysis and urine culture
D. Colonoscopy
E. Radioisotope (HIDA) scanning
677. A 73-year-old male who is a nursing home resident underwent a laparotomy for intestinal obstruction. He has advanced dementia. On the 8th postoperative day, he complains of pain and swelling on the left angle of his jaw. His temperature is 38.90 C (102.00 F), blood pressure is 150/80 mm Hg, pulse is 90/min, and respirations are 16/min. Examination shows swelling, erythema, and tenderness in the region of the left parotid gland. Laboratory studies show a white blood cell count of 15,600/mm. Which of the following measures would most likely have prevented this complication?
A. Incentive spirometry
B. Adequate fluid intake and oral hygiene
C. Avoiding antibiotics
D. Tetanus toxoid
E. Polysaccharide vaccine
678. A 43-year-old male complains of right shoulder pain and weakness after falling on his outstretched hands two days ago. He denies any swelling or shoulder deformity. You passively abduct both his arms above his head and then ask him to bring his arms down slowly in an adducting motion. The right arm drops rapidly at the midpoint of its descent. What is the most likely diagnosis?
A. Biceps tendon tear
B. Long thoracic nerve injury
C. Lower brachial trunk injury
D. Rotator cuff tear
E. Humoral neck fracture
679. A 23-year-old male is brought to the emergency department from the scene of a motor vehicle accident. He appears distressed and complains of severe abdominal pain and distention. Urgent laparotomy reveals splenic laceration, and splenectomy is performed. There are no post-operative complications. The patient has no significant past medical history. He drinks alcohol occasionally but denies smoking cigarettes or using illicit drugs. He works as a computer programmer in a small office. Which of the following vaccines is recommended in this patient?
A Hepatitis A
B. Hepatitis B
C. Meningococcal
D. Pertussis
E. Salmonella
680. A 32-year-old female presents with intermittent blood staining of her bra from her left breast. She has not felt any lumps on either breast. Physical examination shows no breast mass or axillary lymphadenopathy. Ultrasonogram of the breast is within normal limits. Which of the following is the most likely diagnosis?
A. Fibrocystic changes
B. Fibroadenoma
C. Intraductal papilloma
D. Ductal carcinoma in situ
E. Hyperprolactinemia
681. A 31-year-old male presents to your office with pain and swelling over his coccyx. He has never had symptoms like this before. His past medical history is significant for an appendectomy two years ago and acute pyelonephritis one year ago. Which of the following is the most likely diagnosis?
A. Perianal abscess
B. Pilonidal disease
C. Crohn's disease
D. Suppurative hidradenitis
E. Bowen's disease
682. An 18-year-old male comes to the physician's office because of dull aching and fullness of the scrotum. Examination shows soft testicular swelling; transillumination testing is negative. The scrotal swelling increases when the patient performs the Valsalva maneuver. The physical examination is otherwise unremarkable. Which of the following is the most likely cause of his condition?
A. Hypoalbuminemia
B. Dilatation of pampiniform plexus
C. Fluid in the tunica vaginalis
D. Testicular neoplasia
E. Cystic dilations of the efferent ductules
683. A 12-year-old boy is brought to the emergency department after being involved in a motor vehicle collision. He is in no distress and is admitted for observation. Two hours after admission, he develops tachypnea and tachycardia. His temperature is 36.70 C (980 F), blood pressure is 110/66 mm Hg, pulse is 110/min, and respirations are 22/min. Examination shows bruises on the right side of the chest, but palpation of the ribs does not elicit pain or suspicion for rib fractures. Breath sounds are decreased on the right side. ABG on 6 liters of oxygen shows PO2 of 60 mm Hg, PCO2 of 32 mm Hg, and pH of 7.42. An x-ray film of the chest shows a patchy irregular alveolar infiltrate in the right middle and lower lobes. Which of the following is the most likely diagnosis?
A. Adult respiratory distress syndrome
B. Aspiration pneumonia
C. Fat embolism
D. Hemothorax
E. Pulmonary contusion
684. 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 5 L/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. Tension pneumothorax
B. Lung contusion
C. Lung atelectasis
D. Hemothorax
E. Diaphragmatic rupture
685. A 45-year-old policeman presents to your office complaining of tiredness and sleepiness. He says that his job seems tiring to him recently. It is difficult for him to get up in the morning and go to work. He goes to bed early because he feels tired and sleepy. Two months ago, he was investigating a case of massive murder. He slipped on the blood on the floor, fell and hit his head. He also describes recent abdominal pain that is constant and gnawing, interfering with his sleep. His appetite is poor, and he lost 15 pounds over the last month. Physical examination is significant only for tenderness and fullness in the epigastrium. Which of the following is the most likely diagnosis?
A. Duodenal ulcer
B. Major depressive episode
C. Pancreatic cancer
D. Post-traumatic stress disorder
E. Chronic subdural hematoma
686. A 68-year-old male undergoes colon resection surgery for diverticulosis. In the 24 hours following the surgery, he passes a total of 300 ml of urine. His past medical history is significant for coronary artery disease, right knee osteoarthritis and moderate chronic obstructive pulmonary disease. On physical examination, his blood pressure is 110/70 mm Hg and his heart rate is 90/min. His lungs are clearto auscultation and his abdomen is soft and non-distended. His current labs are given below: Hemoglobin 9.5 mg/dl W BC count 13,000/mm3 Platelet count 160,000/mm3 Sodium 138 mg/dl Potassium 5.1 mg/dl Glucose 108 mg/dl Creatinine 2.3 mg/dl BUN 82 mg/dl His indwelling bladder catheter is changed but no residual urine is drained. Which of the following is the best next step in managing this patient?
A. Furosemide
B. Bolus of IV fluids
C. Mannitol
D. Low-dose dopamine infusion
E. Intravenous pyelography
687. A 65-year-old diabetic male comes to the physician because of pain in his calf muscles. His pain increases with walking. He also has end stage renal disease, hyperlipidemia and hypertension. His temperature is 36.70 C (980 F), blood pressure is 150/96 mm Hg, pulse is 80/min and respirations are 16/min. Examination shows skin atrophy, shiny skin and loss of hair on both legs below the knee. Which of the following would be most appropriate next step in management?
A. Prescribe amitriptyline for his pain
B. Obtain Doppler ultrasound examination
C. Obtain resting and post-exercise systolic blood pressures in the ankle and arm
D. Segmental volume plethysmography
E. Obtain MRI of the spine
688. A 63-year-old obese female undergoes an elective cholecystectomy after two episodes of acute calculous cholecystitis. Three days after surgery, her blood pressure is 150/100 mmHg, her heart rate is 90/min, and her arterial oxygen saturation is 91% on room air. She is afebrile. Which of the following would most likely increase her functional residual lung capacity?
A Inhaled albuterol
B. Sequential compression devices to her lower extremities
C. Elevation of the head of the bed
D. Decreasing the dose of her postoperative opioids
E. Postoperative benzodiazepines
689. A 42-year-old moderately obese female complains of abdominal discomfort two days after undergoing an elective cholecystectomy. Her past medical history is significant for hypertension, diabetes mellitus and hyperlipidemia. Her blood pressure is 132/90 mmHg and her heart rate is 76/min. Physical examination reveals a distended abdomen with decreased bowel sounds. Which of the following is most likely contributing to her current condition?
A. Insulin for glucose control
B. Morphine for pain relief
C. Perioperative antibiotics
D. Metoclopramide for nausea
E. Absence of bile storage reservoir
690. A 54-year-old female with a 30 pack-year smoking history undergoes cholecystectomy after an episode of biliary pancreatitis. On the third postoperative day, she complains of discomfort in the upper abdomen. Though she is breathing comfortably, her oxygen saturation is 90%, compared with 98% yesterday. Her blood pressure is 130/80 mmHg, heart rate is 90/min, respiratory rate is 20/min, and temperature is 980 F (360 C). Arterial blood gas analysis reveals the following pH = 7.44 p02 =64 mmHg pC02 =34 mmHg Which of the following most likely explains the observed findings?
A. Aspiration of gastric secretions
B. Impaired cough and deep breathing
C. Bronchial wall edema and bronchospasm
D. Diaphragmatic paralysis
E. Ventilator-associated pneumonia
691. A 23-year-old male is found at the scene of a motor vehicle accident with bilateral lower extremity fractures. You also note extensive abdominal bruising and scalp lacerations. At the scene, the patient's blood pressure is 80/60 mmHg and his heart rate is 120/min. He is given 2 liters of IV fluids wide open. On the way to the hospital he becomes progressively drowsy, and he develops progressive weakness on the right side of his body. This patient is also likely to show deficits in the functioning of which of the following nerves?
A. Abducens
B. Oculomotor
C. Glossopharyngeal
D. Trigeminal
E. Accessory
692. A 35-year-old male presents with complaints of muscle weakness and sensory loss in his upper extremities. His medical history is significant for involvement in a motor vehicle accident seven years ago in which he sustained a whiplash cervical spine injury. Physical examination today reveals moderate wasting of the small hand muscles and impaired pain and temperature sensation in the bilateral upper extremities. Light touch, vibration, and position senses are all intact. Which of the following is the most likely diagnosis?
A. Amyotrophic lateral sclerosis
B. Syringomyelia
C. Cervical spondylosis
D. Intervertebral disk prolapse
E. Multiple sclerosis
693. A 45-year-old male presents to his physician with persistent nausea and vomiting of partially digested food for the past month. He has also lost 5 lbs of weight during this period of time. His appetite is good but he feels full after a few bites. His past medical history is significant for a one-year history of type 2 diabetes and a suicide attempt 6 months ago in which he ingested acid. He drinks alcohol and smokes one pack of cigarettes daily. His temperature is 36.80 C (98.20 F), blood pressure is 110/65 mm Hg, pulse is 11 0/min, and respirations are 16/min. Mucous membranes are dry. Examination shows succussion splash on the epigastrium. Which of the following is the most likely diagnosis?
A. Diabetic gastroparesis
B. Esophageal stricture
C. Duodenal carcinoma
D. Duodenal hematoma
E. Pyloric stricture
694. A 28-year-old woman with sickle cell anemia presents to the urgent care clinic complaining of 12 hours of right upper quadrant pain. She has had similar pain previously, usually after eating fatty foods. However, past episodes have always resolved within one to two hours. On examination, her temperature is 38.30 c and she has right upper quadrant pain with a positive Murphy's sign. Abdominal ultrasound reveals gallstones, a thickened gallbladder wall, and a normal common bile duct. Her alkaline phosphatase level is normal. What is the most appropriate next step in the management of this patient?
A. Conservative management and elective cholecystectomy
B. Endoscopic retrograde cholangiography
C. Emergent cholecystectomy
D. HIDA scan
E. Percutaneous transhepatic drainage
695. A 35-year-old man is brought to the emergency department after suffering a deep laceration from a rusted piece of barbed wire that was hidden in the grass. Examination shows a 6 cm laceration on the lateral leg that is contaminated with dirt and soil. The laceration is bleeding. The patient reports having received a complete set of childhood vaccinations. His last tetanus immunization was at age 23. Which of the following is the most appropriate next step in the management of this patient?
A. Clean the wound, no need for vaccination
B. Administer tetanus toxoid
C. Administer tetanus immunoglobulin
D. Administer tetanus toxoid and immunoglobulin
696. A 34-year-old unrestrained male driver is brought to the ER after a motor vehicle accident. His cervical spine is immobilized. At the scene of the accident, his blood pressure is 80/40 mm Hg and heart rate is 130/min. He is able to communicate and follows simple commands. Lungs are clear to auscultation. Abdominal wall ecchymosis is present. Abdomen is mildly distended. Bowel sounds are decreased. Neck veins are collapsed. After two liters of intravenous fluids, his blood pressure is 90/60 mmHg. Which of the following is the most appropriate next step in management of this patient?
A. Laparoscopy
B. Focused assessment with sonography
C. Angiogram
D. X-ray films of the abdomen and pelvis
E. CT scan of the chest
697. A 42-year-old man comes to the physician because of a 3-month history of substernal chest pain after every meal. He has chronic alcoholism and a long history of heartburn. Upper endoscopy shows mucosal irregularity and ulceration of the squamocolumnar junction above the lower esophageal sphincter (LES). Multiple biopsies were taken. 4 hours later he is complaining of worsening substernal pain radiating to the back, left chest pain, and shortness of breath. His temperature is 37.10C (98.90F), blood pressure is 110/70 mm Hg, pulse is 140/min, and respirations are 34/min. An x-ray film of the chest shows minimal left pleural effusion. Which of the following is the most appropriate next step in management?
A. Repeat the endoscopy
B. Contrast study of the esophagus
C. Check serum amylase and lipase level
D. Wait until the pathologic diagnosis is ready
E. Thoracocentesis
698. A 59-year-old man comes to the physician because of postprandial abdominal cramps, weakness, light-headedness, and diaphoresis. The symptoms begin 25-30 minutes after eating. He had a partial gastrectomy for intractable peptic ulcer disease two weeks ago. He takes no medications. His temperature is 36.70 C (980 F), blood pressure is 130/65 mmHg, pulse is 80/min, and respirations are 18/min. Which of the following is the most appropriate next step in management?
A Dietary modification
B. Endoscopy
C. Barium swallow
D. Octreotide
E. Reconstructive operation
699. A 34-year-old male undergoes successful laparotomy for a gun-shot wound. He received 5 units of packed red blood cells during the surgery. He has been receiving incentive spirometry and ampicillin/sulbactam. However, he developed a fever of 38.70 C (101.70 F) on the sixth postoperative day. His blood pressure is 120/76 mm Hg, pulse is 97/min and respirations are 14/min. Examination shows an alert, pleasant male in no acute distress. The oropharynx is clear. The lungs and heart are clear to auscultation. The abdomen is soft and non-tender, and the wound has no discharge. He has a right femoral triple lumen catheter and Foley catheter in place. Extremities have no swelling or redness. Two days later, four bottles of blood cultures grew coagulase negative Staphylococcus. Which of the following is the most likely cause of his fever?
A. Urinary tract infection
B. Catheter associated infection
C. Clostridium difficile infection
D. Cerebral hemorrhage
E. Neoplastic fever
700. An overweight 12-year-old boy presents with left knee pain that has been going on intermittently for the past three months. Physical activity, especially stair climbing, exacerbates the pain. The boy's mother also points out that he has been limping recently. On physical examination, his anterior left hip is moderately tender to palpation, and when he is asked to stand on his left leg, the right half of his pelvis tilts downward. Which of the following best explains this finding?
A. Tensor fascia lata weakness
B. Psoas muscle weakness
C. Quadratus lumborum weakness
D. Quadriceps muscle weakness
E. Gluteus muscle weakness
701. A 23-year-old woman comes to the physician because of a 4-week history of a whistling noise during respiration. She underwent a difficult rhinoplasty a few months ago. The noise is getting louder and is annoying. Which of the following is the most likely diagnosis?
A. Nasal septal perforation
B. Nasal polyp
C. Nasal foreign body
D. Allergic rhinitis
E. Nasal furunculosis
702. A 46-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He is unresponsive. His injuries include a basilar skull fracture, brain contusion, fractures of ribs 7-10, hemopneumothorax on the right and a pelvic fracture. After placement of a chest tube and pelvis fixation, his condition stabilized. On the fifth day of his hospital stay, he is still unresponsive with a Glasgow Coma Scale of 8. He is breathing spontaneously. Examination shows an abnormal facial reaction to abdominal palpation. Pain appears to be elicited by palpation in right upper quadrant. Bowel sounds are diminished. Rectal examination shows no abnormalities. Nasogastric tube aspiration shows retention of gastric contents. An abdominal CT scan shows gaseous distention of the small and large bowels without airfluid levels. The gall bladder is distended and pericholecystic fluid is present. Stones are not seen. Which of the following is the most likely diagnosis?
A. Bowel obstruction
B. Cholecystitis
C. Pancreatitis
D. Mesenteric contusion
E. Lung contusion
703. A 62-year-old man presents to the emergency department (ED) with one hour of severe epigastric pain. He has been having some epigastric pain exacerbated by eating for the last several days. He feels nauseous, and has vomited once since the pain began. His past medical history is significant for hypertension, diabetes, hyperlipidemia, and coronary artery disease. He underwent coronary bypass surgery one year back. His current medications are simvastatin, aspirin, clopidogrel, metoprolol, enalapril and metformin. His blood pressure is 140/ 100 mmHg, and heart rate is 65/min. His ECG is normal. Chest x-ray findings are shown on the slide above. Which of the following is the best step in the management of this patient?.
A. Transthoracic echocardiography
B. Nothing by mouth (NPO) and gastric suction
C. Mesenteric angiography
D. Abdominal CT scan
E. Immediate surgical evaluation
704. A 65-year-old man comes to the physician four years after suffering a burn injury to his entire right leg. One area of the leg never healed and has now started increasing in size. He has constant pain and drainage from the site of the lesion. Several topical creams and antibiotics have not helped. Biopsy of the lesion is attempted. Which of the following is most likely be identified on biopsy?
A. Malignant melanoma
B. Squamous cell carcinoma
C. Basal cell carcinoma
D. Dysplastic nevus
E. Actinic keratosis
705. A 77-year-old woman is brought to the emergency department because of sudden-onset intense diffuse abdominal pain followed by vomiting. Her past medical history is significant for chronic uncontrolled hypertension, cerebrovascular accident, diabetes and hyperlipidemia. She takes multiple medications. She does not use tobacco, alcohol or drugs. Her temperature is 38.30 C (1010 F), blood pressure is 180/100 mm Hg, pulse is 11 0/min and irregular and her respirations are 22/min. She is in severe distress. Lungs are clear to auscultation. Abdominal examination shows severe pain to palpation and nearly absent bowel sounds. There is rigidity and rebound. Rectal examination shows heme-positive stools. EKG shows absent P waves, irregular rhythm and inverted T waves. There are no previous EKGs for comparison. An x-ray film of the chest shows cardiomegaly. Laboratory studies show: Hematocrit 49% Leukocyte count 17,500/mm3 Troponin I normal What is the most likely diagnosis?
A. Myocardial infarction
B. Acute pancreatitis
C. Ruptured abdominal aortic aneurysm
D. Bowel infarction
E. Acute cholecystitis
706. A 37-year-old male is brought to the emergency department immediately after being smashed in a hydraulic press at a local factory. He is alert and oriented. Despite 10mg of IV morphine given by the paramedics, he is crying with pain. His blood pressure is 110/70 mm Hg, pulse is 11 0/min, and respirations are 18/min. Apparently, his left humeral shaft is fractured and the left arm is severely deformed being bent medially 90 degrees. Left radial artery pulse sensation and muscle strength in the left forearm are decreased compared to the right side. His right leg is shortened and externally rotated. Deformity of the right thigh is noted. Pedal pulses are symmetric. He has pain in the left anterior chest on antero-posterior sternal compression, but breath sounds are normal. Physical examination otherwise shows no abnormalities. The paramedics have placed 2 peripheral intravenous lines and immobilized the fractured limbs. Which of the following is the most appropriate next step in management?
A. X-ray of the left arm, right leg and chest
B. Repeat 10 mg morphine
C. Induction of general anesthesia for operative reduction of the fractures
D. Gentle traction of the left forearm to attempt alignment of the fragments of the humerus
E. Gentle traction of the right leg to attempt alignment of the fragments of the femur
707. A 47-year old woman comes to the clinic because of worsening left breast swelling and pain. She had mastitis when she nursed her first child 20 years ago. She has not seen a doctor since that time. She is afebrile. Breast examination shows the left breast is enlarged with a 7 x 6 cm area of edema and erythema. A poorly localized mass without fluctuation is palpated in that area. Scant non-bloody discharge is noted on the nipple, and several large axillary nodes are palpated. Which of the following is the most appropriate next step in management?
A. Antibiotic active against Streptococci and Staphylococci
B. Culture of the discharge and treatment depending on the findings of the culture
C. Drainage, culture of the drained exudate and treatment depending on the findings of the culture
D. Biopsy for culture and treatment depending on the findings of the culture
E. Biopsy for histology and treatment depending on the findings of the histology
708. A 50-year-old man comes to the physician because of a 2-day history of constipation and not passing flatus. For the last 3 days he has been having intermittent, but worsening, right lower quadrant (RLQ) pain. He has vomited several times today and feels nauseated. Examination shows a distended abdomen with tenderness in the RLQ; there is no rebound; there are no masses or hernias; bowel sounds are absent. Rectal examination shows an enlarged prostate. An upright x-ray film of the abdomen shows gas distributed throughout the small and large bowel, and some fluid levels. After nasogastric tube placement and hydration, his temperature is 36.50C (97.60F), blood pressure is 140/80 mm Hg, pulse is 57/min, and respirations are 12/min. Laboratory studies show: RBC count 4.5 million W BC 7,400 Na 140 K 3.5 Cl 100 BUN 15 mg/dl Creatinine 1.0 mg/dl Urine pH 5.5 Urine sediment: 2 W BC and 15 RBC/high power field, and needle-shaped crystals are present. Which of the following is the most appropriate next step in management?
A. Barium enema
B. Sigmoidoscopy
C. Colonoscopy
D. CT of abdomen
E. Enteroclysis
709. A 25-year-old male is brought to the trauma center by the paramedics after being involved in a road traffic accident that occurred 90 minutes ago. He was a front seat passenger in a 3-car accident. His initial blood pressure at the scene of the accident was 90/60 mm Hg and pulse was 126/min. The paramedics administered 2 liters of normal saline in the ambulance. In the ED, his blood pressure is 110/70 mm Hg and pulse is 90/min. His abdomen is tender in the left upper quadrant. Ultrasound shows fluid in the spleno-renal angle The most appropriate next step is to-
A. Perform exploratory laparotomy
B. Perform a CT scan
C. Admit to the surgical ICU
D. Admit to the ward
E. Laparoscopy
710. 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 38.70 C (101.70 F), blood pressure 120/76 mm Hg, pulse 11 0/min and respirations 26/min. His condition worsened over the next several hours and required oro-tracheal 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. Stat chest x-ray
B. Arterial blood gas analysis
C. Pericardiocentesis
D. Needle thoracostomy
E. Intravenous fluids and dopamine
711. A 36-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He is in obvious distress. His blood pressure is 80/30 mm Hg, pulse is 140/min and respirations are 23/min. Examination reveals collapsed neck veins. Breath sounds are present bilaterally, heart sounds are normal and the trachea is midline. He is semiconscious and his pupils are bilaterally reactive. There is no obvious head injury. Abdominal examination shows distention with tenderness in all four quadrants with guarding and rigidity. After initial resuscitation including control of his airway, breathing and circulation, which of the following is the most appropriate next step in management?
A. Diagnostic laparoscopy
B. Chest x-ray
C. CT of the abdomen
D. Exploratory laparotomy
E. Diagnostic peritoneal lavage
712. A 35-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He is unconscious. His blood pressure is 100/50 mm Hg, pulse is 100/min, and respirations are 19/min. Examination shows bilaterally reactive and non-dilated pupils. He does not follow commands and makes inappropriate sounds. A CT scan of the head shows numerous minute punctuate hemorrhages with blurring of the gray-white matter interface. Which of the following is the most likely diagnosis?
A. Epidural hematoma
B. Subdural hematoma
C. Diffuse axonal injury
D. Subarachnoid hemorrhage
E. Multiple sclerosis
713. A 42-year-old man is found unconscious at the scene of a motor vehicle collision. He is rushed to the emergency department, where his blood pressure is found to be 70/40 mm Hg and his respirations are 28/min. On physical examination, his trachea is deviated to the left and his breath sounds are decreased on the right side. His neck veins are distended bilaterally. You also note significant swelling over the right femur. Which of the following is the most appropriate next step in the management of this patient?
A. Intubation and mechanical ventilation
B. 100% oxygen via face mask
C.lmmediate thoracotomy
D. Chest tube placement
E. Intravenous fluid resuscitation
714. A 65-year-old man with cervical spondylosis secondary to degenerative changes in the cervical spine was admitted after being involved in a motor vehicle accident. He regained consciousness after 5 minutes. After regaining consciousness, he had complete weakness in both upper extremities but was able to move his lower extremities. Vital signs are stable. Plain x-ray films of the cervical spine show no abnormalities except those consistent with mild degenerative changes. Which of the following is the most likely diagnosis?
A. Brown-Sequard syndrome
B. Central cord syndrome
C. Cerebral contusion
D. Posterior spinal cord syndrome
E. Anterior spinal cord syndrome
715. A 54-year-old alcoholic man comes to the emergency department because of dysphagia, drooling and a fever. He has been sick for two days and has not been able to eat. His mouth is swollen and feels hot. Examination shows a pale, febrile man who is drooling. There is redness around the entire mouth extending into the floor of the mouth. A tender, symmetric and indurated swelling with palpable crepitus is present in the submandibular area. Laboratory study shows an elevated W BC count. Which of the following is the most likely source of the oral cavity infection?
A Blood
B. Lungs
C. Parotid gland
E. Tonsils
D. Teeth
716. A 46-year-old man comes to the physician because of a two day history of worsening abdominal discomfort and persistent vomiting. He has not had a bowel movement or passed flatus for 3 days. He had an appendectomy for appendicitis 20 years ago. Examination shows a distended abdomen that is tympanic on percussion. High-pitched bowel sounds and splashing are heard on auscultation. The abdomen is diffusely tender on palpation without rebound or guarding. An x-ray film of the abdomen shows distended small bowel loops with air-fluid levels; no gas is seen in the colon. IV rehydration is started. Which of the following is the most appropriate next step in management?
A. Emergency laparotomy
B. Barium enema under fluoroscopic control
C. Nasogastric suction and intravenous fluids
D. Administer bethanechol
E. Start total parenteral nutrition
717. A 25-year-old man comes to the physician because of a mass in his mouth. He has just noticed this mass and has had no trauma to his oral cavity. He does not use tobacco, alcohol or drugs. He has had no weight loss. Physical examination shows a large mass located on the hard palate of the mouth. On palpation, the mass is immobile, fleshy with bony surroundings and measures 3x 3 cm. Which of the following is the most appropriate next step in management?
A. Reassurance
B. Biopsy
C. Surgery
D. Radiation
E. Antifungal treatment
718. A 69-year-old man is evaluated after undergoing an elective repair of a rapidly expanding abdominal aortic aneurysm. The surgical procedure was complicated by a significant amount of blood loss and required multiple transfusions. In the postoperative recovery room, he had weakness in both lower extremities and developed urinary retention. Neurologic examination shows spastic paraplegia and loss of pain sensation over the lower extremities; vibratory sensation is intact. Upper extremity examination shows no abnormalities. Which of the following is the most likely pathophysiologic mechanism of the neurologic dysfunction?
A. Spinal cord ischemia
B. Hematoma compressing the spinal cord
C. Mechanical damage of the spinal cord
D. Mechanical damage to the peripheral nerves
E. Conversion disorder
719. A 24-year-old woman comes to the physician because of a one-week history of increasing pain in the right leg. She is an active dancer and practices 4-5 hours a day. One week ago, she felt a dull aching pain in the right middle leg; the pain has been increasing since and is particularly bad when she dances. The pain is interfering with her dancing sessions. She is afebrile and her other vital signs are within normal limits. Examination shows point tenderness over the midpoint of the right leg; there are no abnormalities of the skin overlying the tender point. Knee and ankle examinations show no abnormalities. An x-ray of the lower leg shows no abnormalities. ESR is within normal limits. Which of the following is the most likely cause of her pain?
A. Ligamentous tear
B. Stress fracture
C. Bone infection
D. Nerve entrapment
E. Bone neoplasm
720. A 32-year-old male comes to the emergency department because of a 3 day history of increasing lower abdominal pain, mild diarrhea and rectal pain on defecation. Ten days ago he had right lower quadrant (RLQ) pain for about 24 hours that resolved spontaneously. Since then, he has had malaise and low-grade fever. His temperature is 38.70C (101.60F), blood pressure is 150/90 mm Hg, pulse is 110/min and respirations are 15/min. Examination shows lower abdominal tenderness without rebound. No masses are palpable, and bowel sounds are decreased. Rectal examination shows a very tender, boggy and fluctuant bulging on palpation with the tip of the finger anteriorly. Laboratory studies show: Complete blood count Hemoglobin 14.0 g/L Platelets 270,000/mmJ Leukocyte count 15,500/mm3 His current condition is most likely a complication of?
A. Anorectal abscess
B. Invasive diarrhea
C. Acute appendicitis
D. Acute diverticulitis
E. Colon cancer
721. A 70-year-old male rushed to the emergency department because of bright red bleeding per rectum. He says his commode is full of blood and has never experienced any bleeding before. He has a history of constipation. He takes daily aspirin for prevention of stroke and hydrochlorothiazide for high blood pressure. His temperature is 36.50 C (97.80 F), blood pressure is 100/60 mm Hg, pulse is 120/min and respirations are 20/min. He is not hypoxic. Abdomen is soft, non-distended and non-tender; no masses or organomegaly are palpated; bowel sounds are normal. Rectal examination shows bright red blood and an enlarged prostate. Nasogastric tube aspirate shows non-bilious stomach contents without blood. An x-ray of the abdomen shows no abnormalities. Which of the following is the most likely cause of his bleeding?
A. Colon cancer
B. Ischemic colitis
C. Mesenteric thrombosis
D. Diverticulosis
E. Peptic ulcer disease
722. A 22-year-old man is brought to the emergency department after falling from a motorbike. He has right wrist pain. His temperature is 37.10C (98.60F), blood pressure is 110/70 mm Hg, pulse is 80/min, and respirations are 17/min. He is well oriented and cooperative. His pupils are bilaterally reactive. Physical examination shows no signs of trauma except for marked tenderness in the right anatomical snuff box. An x-ray film of the wrist joint shows a radiolucent line across the waist of the right scaphoid bone. Which of the following is the most next
A. Open reduction and internal fixation of scaphoid bone
B. Percutaneous fixation of scaphoid bone
C. Send the patient home with analgesics and repeat X ray after 15 days
D. Cast immobilization for 6-12 weeks
E. Advise rest, ice, compression and elevation for wrist joint
723. A 62-year-old man complains of right knee pain. He says that the pain started two days ago and has been limiting his daily activities. He required 2 grams of acetaminophen in order to sleep through the previous night. He has a long history of rheumatoid arthritis treated with daily low-dose prednisone. Physical examination reveals swelling, limited flexion, and tenderness to palpation of the right knee. Synovial fluid aspiration is performed. Which of the following synovial fluid characteristics would warrant immediate surgical intervention?
A High viscosity
B. 15,000 neutrophils per mcl
C. Negatively birefringent crystals
D. 1500 W BC per mcl
E. Positive rheumatoid factor
724. A 38-year-old woman comes to the emergency department because of the sudden onset of severe abdominal pain. The pain started one hour ago in the epigastrium but now it is mostly localized to the lower abdomen. She has some nausea but denies any vomiting. Her last menstrual period (LMP) was 25 days ago. Her temperature is 36.8C (98.1F), blood pressure is 160/90 mm Hg, pulse is 11 0/min, and respirations are 25/min. The abdomen is tender on palpation with prominent guarding and positive rebound. There is no shifting dullness, and bowel sounds are absent. Laboratory studies show: Hb 13.1 g/dl Hct 43% W BC 10,900/mm3 Which of the following is the most appropriate next step in management?
A. Abdominal CT scan
B. Diagnostic peritoneal lavage
C. Pelvic ultrasound
D. Pregnancy test
E. Upright abdominal X- ray
725. An 11-year-old boy is brought to the emergency department for evaluation of an injury from jumping off a 10 ft wall, 2 days ago. He had some pain in his feet immediately following the jump, but was able to walk. The past 2 days, he has had increasing pain in his right foot with walking. He has no pain at rest. He has some "crunching" in the right foot. Physical examination shows the foot appears normal with the exception of suffusion on the plantar surface. Passive motion of the second toe and passive dorsiflexion of the foot produces pain in the middle of the foot. Which of the following is the most likely diagnosis?
A. Fracture of second metatarsal
B. Stress fracture of second metatarsal
C. Tenosynoviitis of toe flexors
D. Metatarsophalangeal joint dislocation
E. Hematoma in middle plantar space
726. A 23-year-old man is brought to the emergency department after being hit in the neck with a dull instrument. He has neck pain and stiffness. Vital signs are stable. Neurological examination shows no abnormalities. An astute medicine resident decides to order an angiogram of the neck vessels to rule out carotid artery injury. Diagnostic angiography shows an intimal flap in the left internal carotid artery just above the carotid bifurcation. Which of the following is the most appropriate next step in management?
A. Neck exploration and repair
B. Observation
C. Heparin
D. Aspirin
E. Ligation of carotid artery
727. A 36-year-old forest worker is brought to the emergency department after being hit by a falling tree, 3 hours ago. He has pain in the left subscapular region. His temperature is 360C (96.90F), blood pressure is 120/76 mm Hg, pulse is 90/min, and respirations are 18/min. Physical examination shows aggravation of the pain in the left subscapular region with taking a deep breath and with anteroposterior and lateral chest compression. He has ecchymoses on the anterior and posterior chest and on the upper abdominal wall. His abdomen is vaguely tender to palpation in the left upper quadrant (LUQ) and he has left costovertebral angle (CVA) tenderness. Examination otherwise shows no abnormalities. An x-ray film of the chest shows posterior factures of the 8th, 9th and 1Oth ribs on the left. An x-ray film of the abdomen shows blunting of the left psoas shadow. Abdominal ultrasound shows no abnormalities. Laboratory studies show: Hb 15.3 g/dL Hematocrit 43% W BC 6,200/cmm Urinary sediment Many erythrocytes; W BC 4-5/hpf; oxalate crystals. Which of the following is the most appropriate next step in management?
A. Intravenous pyelography
B. Diagnostic peritoneal lavage
C. CT with contrast
D. Lumbar spine X-ray
E. Renal angiography
728. A 35-year-old woman is being evaluated after having a screening mammography. A 3 x 3 cm speculated mass with coarse calcifications is seen in the upper outer quadrant of her right breast. She has no complaints. She has a history of bilateral reduction mammoplasty for mammary hyperplasia 12 years ago. She has no family history of medical problems. Breast examination shows her right nipple is slightly retracted. A fixed mass is palpated in the upper outer quadrant of the right breast. Ultrasonography of the breast shows a hypo-echoic mass. Multiple core biopsy samples show foamy macrophages and fat globules. Which of the following is the most appropriate course of action?
A. Instruction for regular clinical breast examination and follow-up mammography
B. Radiation therapy of the right breast
C. MRI of the breast
D. Simple mastectomy
E. Segmental excision and axillary node dissection followed by radiation therapy
729. 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 37.70 C (99.90 F), blood pressure is 110/70 mm Hg, 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. Air embolism
B. Amniotic fluid embolism
C. Thromboembolism
D. Fat embolism
E. Acute respiratory distress syndrome
730. A 76-year-old woman comes to the emergency department because of left lower quadrant (LLQ) abdominal pain and fever. She takes acetaminophen for arthritis and docusate for constipation. A CT scan of the abdomen showed perisigmoid stranding suggestive of inflammation and sigmoid diverticulosis. She was started on intravenous ciprofloxacin and metronidazole; however, she had only mild improvement and is persistently febrile. Examination shows persistent LLQ tenderness to deep palpation. A repeat CT scan now shows a 5 x 6 cm mass in the left iliac fossa. Laboratory studies show: Hemoglobin 13.0 g/L Platelets 360,000/mm3 Leukocyte count 16,500/mm3 Which of the following is the most appropriate next step in management?
A. Add a cephalosporin to the current antibiotic regimen
B. CT guided percutaneous drainage
C. Laparoscopic drainage
D. Laparotomy for drainage and debridement
E. Continue current antibiotics for another 4 weeks
731. A 35-year-old woman presents to the physician's office after she palpated a lump in her right breast. She has no other complaints. She has not seen a doctor for 1 0 years. She regularly performs breast self-exams after menses. She has no significant past medical history. Her mother died of breast cancer at the age of 40. Breast examination shows a 1 x 1 cm, rubbery, firm, freely mobile round mass in the upper, outer quadrant of the right breast; no axillary lymph nodes are palpable. Which of the following is the most appropriate next step in management?
A. Observation
B. Ultrasonography
C. Excisional biopsy
D. Fine needle aspiration
E. Mammography
732. A 55-year-old man comes to the physician because of a 4-month history of an ulcer on the sole of his right foot. He has had no trauma and does not remember how he got the ulcer. He states the ulcer has been difficult to heal and readily gets infected. He does not use tobacco, alcohol or drugs. Examination shows the ulcer is located on the sole of his foot just below the head of the first metatarsal bone. His foot is warm and dry and appears slightly deformed. Dorsalis pedis pulses are present. Which of the following is the most likely cause of his condition?
A. Venous hypertension
B. Arterial spasm
C. Peripheral neuropathy
D. Central spinal cord lesion
E. Posterior spinal cord lesion
733. A 7-year-old child is brought to the emergency department after being involved in a highway motor vehicle collision. He had blunt trauma to his abdomen. Vital signs are stable, except for a respiratory rate of 30 per minute. Physical examination shows bruising of the upper abdomen, abdominal distention, and tenderness. He is in moderate respiratory distress; breath sounds are decreased on the left side. Chest tube placement shows no blood or air in the pleural cavity. An x-ray film of the chest shows an elevated left hemidiaphragm. Laboratory studies show hemoglobin and hematocrit within normal limits. Which of the following is the most likely diagnosis?
A. Tension pneumothorax
B. Hemothorax
C. Pulmonary contusion
D. Laceration of the liver
E. Diaphragmatic hernia
734. A 44-year-old obese male is brought to the ER after a motor vehicle accident. His cervical spine is immobilized. He is alert and able to speak in complete sentences. He complains of abdominal pain. At the scene of the accident, his blood pressure is 90/60 mm Hg and pulse is 120/min. Lungs are clearto auscultation. Ecchymosis is present over the abdominal wall in distribution of the seat belt. Bowel sounds are decreased. Neck veins are collapsed. After receiving one liter of intravenous fluids, his blood pressure remains at 90/60 mmHg. A focused assessment with sonography for trauma is inconclusive due to the poor image quality. Which of the following is the most appropriate next step in management of this patient?
A. CT scan of the abdomen
B. Plain X-ray films of the abdomen
C. Diagnostic peritoneal lavage
D. Immediate laparotomy
E. X-ray of the chest
735. A 62-year-old man comes to the emergency department because of severe abdominal pain. He states that he suddenly felt weak, diaphoretic, and had no energy. He is a smoker and has hypertension. His blood pressure on initial examination was 11 0/70 mm Hg. Physical examination shows a diffusely tender abdomen. During CT scan he becomes pale and drowsy. CT scan is shown above. Repeat examination shows a man with anxiety and a blood pressure of 80/50 mm Hg and pulse of 110/min Which of the following is the most appropriate next step in management?
A. Exploratory abdominal surgery
B. Obtain ultrasound
C. Check amylase and lipase
D. Laparoscopy
E. Drain fluid from the abdomen
736. A 60-year-old man undergoes a laparotomy for intestinal obstruction secondary to postoperative adhesions. He has a history of diabetes mellitus, type 2, and hypertension. He underwent a cholecystectomy two years ago. His takes insulin, hydrochlorothiazide, enalapril, and pravastatin. On postoperative day number five, he has intense pain around the wound. His temperature is 38.30 C (1010 F), blood pressure is 120/76 mm Hg, pulse is 100/min, and respirations are 16/min. Examination of the wound shows a cloudy-gray discharge and crepitus; sensation at the edges of the wound is decreased. Which of the following is the most appropriate next step in management?
A. Surgical exploration
B. Anti-staphylococcal antibiotics
C. Culture the discharge
D. Improve glycemic control
E. Observation
737. A 25-year-old motorcyclist is brought to the emergency department after being involved in a collision with an automobile. On arrival he is in obvious pain. He expresses an urge to void, but is unable to do so. Genital examination shows blood at the urethral meatus and a scrotal hematoma. Rectal examination reveals a high riding prostate. Abdominal examination is suggestive of a distended bladder. Which of the following is the most likely diagnosis?
A Urethral injury
B. Intraperitoneal bladder rupture
C. Extraperitoneal bladder injury
D. Fracture of penis
E. Renal injury
738. 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. Anterior cruciate ligament tear
B. Meniscal tear
C. Osteoarthritis
D. Patellar tendonitis
E. Anserine bursitis
739. A 35-year-old black man is brought to the emergency department after a motorcycle accident. He hit the street with the side of his head. He was found unconscious when the emergency medical team arrived. However, on the way to the emergency department he regains consciousness. Upon arrival he is confused and complains of a headache. His temperature is 36.9C (98.5F), blood pressure is 100/60 mm Hg, pulse is 11 0/min, and respirations are 22/min. Examination shows a dilated pupil on the right side, with some weakness of the left arm and leg. CT scan of the head shows a biconvex hematoma on the right side of the head. Which of the following is the most likely diagnosis?
A. Acute subdural hematoma
B. Acute epidural hematoma
C. Basilar fracture of skull
D. Intracerebral bleeding
E. Subarachnoid haemorrhage
740. A 16-year-old boy was brought to the emergency department because of left shoulder and left hand pain after falling on his outstretched hand while playing soccer. He heard a crunching sound and had intense pain in his left shoulder area following the injury. Examination shows bruising around the clavicle area. He is holding his left arm with his right hand. There is a palpable gap in the middle of the clavicle. Auscultation shows a loud bruit just beneath the clavicle. An x-ray film of the left shoulder and chest shows the middle of the clavicle is fractured and displaced. Which of the following is the most appropriate next step in management?
A. CT chest for pneumothorax
B. Nerve conduction studies
C. Angiogram
D. Open reduction of the clavicle
E. Closed reduction with figure of eight brace
741. A 16-year-old male is brought to the emergency department after falling off a bicycle and hitting the ground with his head. He briefly lost consciousness, but had no seizures. He has a mild headache but has no nausea or vomiting. Vital signs are stable. Examination shows no neurological deficit or any signs of fracture. Which of the following is the most appropriate next step in management?
A. Discharge the patient home if a skull radiograph is normal and ask him to return if he develops any unusual symptoms.
B. Discharge the patient home and ask him to return if he develops any unusual symptoms.
C. Admit the patient; do the imaging study; serial neurological exams every 2 hours.
D. Admit the patient and observe for neurological signs every 4 hours.
E. Discharge the patient home if CT scan of head is normal and ask him to return if he develops any unusual symptoms.
742. A 54-year-old man is brought to the emergency department 1 0 minutes after being involved in a motor vehicle collision. On arrival, he is breathing spontaneously, is non-cyanotic and has no signs of external injury. His temperature is 37C (98.6F), blood pressure is 104/50 mm Hg, pulse is 122/min and respirations are 16/min. Examination shows bilateral round and reactive pupils of 4 mm. He is making some incomprehensible sounds. He responds to his name by opening his eyes and on applying supraorbital pressure he extends his left extremity and grasps your hand with his right hand. What is the Glasgow coma scale (GCS) in this patient?
A. 6
B. 8
C. 10
D. 12
E. 14
743. A 46-year-old male is brought to the ER because of coffee ground emesis. He has a history of chronic hepatitis C and alcohol abuse. His temperature is 36.6C (97.9F), blood pressure is 120/70 mm Hg, pulse is 90/min and respirations are 14/min. He is oriented to time, place and person but somewhat sleepy. A flapping tremor is noted. His abdomen is soft, non-tender, and mildly-distended; liver and spleen are palpated below the costal margins; shifting dullness is present. Nasogastric tube aspiration shows bright red blood that was easily cleared with saline lavage. Endoscopy shows a fresh ulcer with a small adherent clot located high on the lesser curvature near the gastroesophageal junction. Non bleeding esophageal and gastric varices are also seen. Laboratory studies show: Hemoglobin 10.2 g/L MCV 105 fl Platelets 105,000/mm3 Leukocyte count 4,500/mm3 Prothrombin time 17 sec Aspartate aminotransferase (SGOT) 78 U/L Alanine aminotransferase (SGPT) 50 U/L Which of the following is the most appropriate next step in management?
A. Sclerotherapy of the varices
B. Porto-systemic shunt
C. Esophageal and proximal gastric devascularization and splenectomy
D. Gastric resection, selective vagotomy and pyloroplasty
E. Conservative medical management
744. A four-year-old boy is brought to the physician because of discomfort in the left hip and left knee that is causing him to limp. Examination shows normal knee joints bilaterally, but there is marked limitation of internal rotation and abduction of the left hip. His temperature is 37.1 C (98.6F), blood pressure is 90/60 mm Hg, pulse is 80/min and respirations are 16/min. Laboratory studies including complete blood count and basic metabolic profile show no abnormalities. Which of the following is the most likely diagnosis?
A Slipped capital femoral epiphysis
B. Septic arthritis of the hip joint
C. Hematogenous osteomyelitis
D. Legg-Calve-Perthes disease
E. Developmental dysplasia of the hip
745. A 65-year-old male is being evaluated for hip pain. The pain has been present for several months and is constant. He denies any weight loss or loss of appetite. His past medical history is significant only for high blood pressure. His temperature is 37.2 C (98.9 F), blood pressure is 150/88 mm Hg, pulse is 80/min and respirations are 12/min. Physical examination is unremarkable. Laboratory studies show: Alkaline phosphatase Elevated Gamma glutamyl transferase Normal Serum calcium Normal 25 (OH)2 vitamin D Normal Bone scan shows increased uptake in several spots. This patient is at high risk of developing?
A. Subarachnoid hemorrhage
B. Carpal tunnel syndrome
C. Renal cell carcinoma
D. Pulmonary hemorrhage
E. Hearing loss
746. A 45-year-old male comes to the hospital because of severe retrosternal chest pain that started suddenly a few hours ago. He says that he has been having mild chest pain for the past few days, but that this pain is completely different. His past medical history is significant for nonischemic cardiomyopathy for which he takes furosemide, carvedilol, spironolactone, lisinopril and potassium chloride. He also has HIV infection but is not taking any medications related to this diagnosis by his own choice. On physical examination, his temperature is 38.90C (1020 F), blood pressure is 110/65 mm Hg, pulse is 110/min, and respirations are 22/min. He is in obvious distress secondary to pain. His lungs are clearto auscultation and the remainder of his physical examination is unremarkable. His EKG is within normal limits. Chest X-ray shows a widened mediastinum and mediastinal air. W hich of the following is the most appropriate next step in the management of this patient?
A. Gastrografin contrast esophagogram
B. Barium swallow study
C. Upper gastrointestinal endoscopy
D. Transesophageal echocardiogram
E. Bronchoscopy
747. A 78-year-old man with Alzheimer's disease was brought to the ER because of bright red bleeding per rectum. He has chronic constipation and is being treated with bisacodyl. On admission, his temperature was 36.60 C (97.90 F), blood pressure was 130/80 mm Hg with no orthostatic change, pulse was 90/min and respirations were 14/min. Nasogastric tube drainage showed normal stomach contents without blood. His bleeding stopped a few hours after admission, and he remained hemodynamically stable during that time. Colonoscopy showed extensive diverticulosis but no active bleeding source. Later that night he started bleeding again, and he is now hypotensive with a BP of 100/70 mm Hg. Packed red cells and intravenous fluid are started. Which of the following is the most appropriate next step in management?
A. Upper gastrointestinal endoscopy
B. Capsule endoscopy
C. Barium enema
D. Labeled .erythrocyte scintigraphy
E. Laparotomy
748. A 44-year-old unrestrained male driver is brought to the ER after a motor vehicle accident. Cervical spine is immobilized. His breathing is normal. At the scene of the accident, his blood pressure is 70/30 mm Hg. After receiving two liters of intravenous fluid, his blood pressure is 80/40 mmHg. Neck veins are collapsed. Lungs are clear to auscultation. Abdomen is mildly distended. There is no obvious source of external bleeding. No intraperitoneal blood or solid organ damage is seen on ultrasonogram or diagnostic peritoneal lavage. Imaging studies reveal a pelvic fracture and fracture of the right fourth rib. Which of the following is the most appropriate next step in management?
A. Angiogram
B. CT scan of the abdomen
C. CT scan of the chest
D. Laparotomy
E. Chest tube placement
749. A 3-year-old girl is brought to the emergency department because she is not moving her right arm. Her mother states that the child was perfectly normal in the morning. She remembers that she lifted the child with the child's right forearm and since then she has not been moving her right arm. Examination shows the right arm is held in pronation against the chest. The child avoids any movement of her right arm. Which of the following is the most appropriate next step in management?
A. Refer the child to an orthopedic surgeon for possible supracondylar fracture of humerus
B. Report the case to child protection agency
C. Gentle passive elbow flexion and forearm supination
D. Closed reduction and casting of forearm and arm
E. Do a skeletal survey of the child
750. A 23-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He has multiple organ injuries and is listed in critical condition. Physical examination shows an open wound in the right lower extremity and significant blood loss. He is in hypovolemic shock. Which of the following is the first parameter to change in hypovolemic shock?
A. Systolic blood pressure
B. Pulse rate
C. Respiratory rate
D. Level of consciousness
E. Skin vasoconstriction
751. A 78-year-old diabetic man has undergone surgical repair of a large abdominal aortic aneurysm. Postoperatively, he develops left lower quadrant abdominal pain followed by bloody diarrhea. He has a history of prostate cancer and received radiation therapy several years ago. He eats a low fiber diet. He quit smoking recently. Vital signs show a low grade fever. Examination shows tenderness in the left lower quadrant and rectal examination reveals blood in the stool. CT scan of the abdomen demonstrates thickening of the colon at the rectosigmoid junction. On colonoscopy, ulcerations are seen in the same area while the colon above and below the lesions is completely normal. Which of the following is the most likely cause of his symptoms?
A. Acute diverticulitis
B. Radiation proctitis
C. Clostridium difficile colitis
D. Ischemic colitis
E. Lnflammatory bowel disease
752. A 45-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He is unable to void. Examination shows blood at the urethral meatus and a scrotal hematoma. His temperature is 370C (98.60F), blood pressure is 100/50, pulse is 100/min and respirations are 16/min. Examination shows a high-riding prostate with no other signs of trauma. Which of the following is the most appropriate next step in management?
A. Immediate surgical repair of urethra
B. Foley catheterization
C. Retrograde urethrogram
D. Diuretic to increase the urine output
E. Retrograde cystogram with post-void films
753. A 34-year-old man is brought to the emergency department after being involved in a motorbike accident. Examination shows a hematoma on the forehead and bleeding from his leg. His pupils are bilateral round and reactive; he has papilledema. He responds to pain, has decorticate posture and speaks incoherently. After the initial resuscitation you start the treatment with intravenous fluids, hyperventilation, head elevation and intravenous mannitol. Which of the following is the mechanism of action of hyperventilation in this patient?
A. Hyperventilation acts as stimuli to brain and helps to arouse the patient
B. Hyperventilation corrects hypoxia
C. Hyperventilation helps to wash out the carbon dioxide
D. Hyperventilation causes vasoconstriction and helps to reduce his bleeding
E. Hyperventilation causes vasoconstriction and thus decreases the cerebral blood flow
754. A full-term, female infant is born to a 26-year-old, primigravid mother via C-section secondary to breech position. The mother has lived in New York City for the past 5 years. She denies the use of any drugs, alcohol or cigarettes during her pregnancy. She denies having any sexually transmitted infections. Her lead levels were within the normal range throughout her pregnancy. Prenatal ultrasound done at 30 weeks gestation showed normal anatomy of the fetus. The Apgar scores at 1 and 5 minutes are 7 and 9, respectively. There are some bluish-brown spots located on the infant's lumbosacral area. Flexion and abduction of the lower extremities reveal a palpable clunk. The rest of the physical examination is normal. Which of the following is the best next step in the management of this patient?
A. Ultrasound of the hips
B. Reassurance
C. Ultrasound of the spinal cord
D. X-ray of the hips
E. X-ray of the lumbosacral region
755. A 42-year-old woman is brought to the emergency department after being involved in a motor vehicle collision. On arrival she is unconscious with bilaterally round and reactive pupils. Her temperature is 370 C (98.60 F), blood pressure is 70/20 mm Hg, pulse is 11 0/min and respirations are 22/min. There is a low jugular venous pulse. She does not respond to vocal commands but responds to pain with all 4 limbs. She is not vocalizing. Lung auscultation is unremarkable. Abdominal examination shows a distended abdomen with absent bowel sounds and some bruising. She is intubated and is rapidly infused with 2L of lactated Ringer's solution. Her blood pressure is now 80/30 mm Hg and her pulse is 118/min. Which of the following is the most appropriate next step in management?
A. X-ray of abdomen
B. CT scan of head
C. Exploratory laparotomy
D. Lateral x-ray of spine
E. Chest x-ray
756. A 34-year-old man comes to the physician after being involved in a street fight. He has a painful and swollen left arm. Neurovascular examination shows no abnormalities. An x-ray film of the arm shows a fracture of the midshaft of the humerus. Closed reduction of the facture is done and the arm is kept in a hanging cast. One hour later he has numbness of the left wrist and marked limitation of extension at the wrist. Which of the following is the most likely diagnosis?
A Radial nerve injury
B. Brachial artery injury
C. Compartment syndrome
D. Ulnar nerve injury
E. Median nerve injury
757. A 35-year-old man is brought to the emergency department after he jumped from the fourth floor of a burning building. His temperature is 36.90 C (98.50 F), blood pressure is 90/40, pulse is 90/min, and respirations are 20/min. Examination shows a fracture of the right tibia. He is conscious and his pupils are bilaterally equal and reactive to light and accommodation. His neurological examination shows paraplegia, with loss of pain and temperature in both legs but normal proprioception. Upper extremities do not show any neurological deficits. Passive straight leg raising test is negative. A CT scan of the spine shows a burst fracture at the level of the fourth thoracic vertebra. Which of the following is the most likely diagnosis?
A Central cord syndrome
B. Anterior cord syndrome
C. Brown Sequard syndrome
D. Acute disk prolapse
E. Cauda equine syndrome
758. A 36-year-old woman is brought to the emergency department after she jumped from the second floor of a burning building. On arrival examination shows an unconscious woman with blood coming from her nose and with an open tibial fracture of left leg. Her eyes are closed and her pupils are equal and responsive bilaterally. She makes muffled sounds and responds to pain by opening the eyes and moving all the limbs. After the initial resuscitation, which of the following is the most appropriate next step in management?
A. CT scan of head
B. X-ray of left leg
C. X-ray of spine
E. X-ray of head
D. Lumbar puncture
759. A 29-year-old woman is brought to the emergency department after burning her right upper extremity in a cooking accident. Examination shows a circumferential burn of the right upper extremity. She is given fluids, an analgesic and a wound dressing. On day three she develops severe deep tissue pain in the right limb with edema of the hand. Examination shows a circumferential eschar over the right arm. Her right radial and ulnar pulses are faint compared to the left and she has paresthesias in her right hand. Which of the following is the most appropriate next step in management?
A. Increase the dose of her analgesics and discharge her
B. Do an angiography to assess arterial blood flow
C. Do an escharotomy
D. Look for a missed fracture of the right upper limb
E. Elevation of the limb
760. A 34-year-old woman is brought to the emergency department after being hit by a motorbike. Examination shows a 3 cm x 2 cm laceration on the left calf. The wound is dirty and the underlying fascia can be seen. She has had four doses of tetanus toxoid in her life; the last dose was 7-years ago. In addition to wound debridement and surgical management, which of the following is the most appropriate course of action to protect her from developing tetanus?
A. Nothing more is required as the patient is already vaccinated
B. Give her tetanus immunoglobulin
C. Give her tetanus toxoid
D. Give her both tetanus immunoglobulin and tetanus toxoid
E. Observe the patient and give her tetanus immunoglobulin and tetanus toxoid if she develops any signs of tetanus
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