Chir

1) A 22-year-old man is stabbed in the right chest with a 5-cm-long knife blade. On arrival at the emergency department, he is wide awake and alert. He is speaking with a normal tone of voice but complaining of shortness of breath. The right hemithorax is hyperresonant to percussion and has no breath sounds; the rest of the initial survey is negative. His blood pressure is 110/75 mm Hg, pulse is 86/min, and venous pressure is 3cm H2O. Pulse oximetry shows a saturation of 85%. Which of the following is the most appropriate next step in patient care?

7) A 33-year-old woman is undergoing a diagnostic work-up because she appears to have Cushing syndrome. She has elevated levels of cortisol, which are not suppressed when she is given high-dose dexamethasone. ACTH levels are greater than 200 pg/ mL. A chest x-ray film shows a central, 3-cm round mass on the hilum of the right lung. Bronchoscopy and biopsies confirm a diagnosis of small cell carcinoma of the lung. Which of the following is the preferred treatment for this woman?

8) A multiple trauma patient receives 14 units of packed red cells and several liters of Ringer's lactate solution during a laparotomy for multiple intra-abdominal injuries. The surgeons note that blood is oozing from all dissected raw surfaces, as well as from his TV line sites. His core temperature is normal. Which of the following is the most appropriate next step in management?

18) A 57-year-old man is undergoing a femoral-popliteal bypass of his right lower extremity because of severe peripheral vascular disease. This patient has a longstanding history of claudication and shortness of breath. He had a myocardial infarction 3 years ago and has had progressive limitation of his exercise capacity because of his peripheral vascular disease. He has not had any risk stratification after his infarction. Two weeks ago, he underwent a lower extremity arterial study that showed severe diffuse disease of his right leg arterial system. The patient is brought to the operating room, and, during the procedure, his right lower extremity is made bloodless by application of a thigh tourniquet for 1.5 hours. The surgeons complete their bypass and are preparing to restore blood flow. Which of the following is an expected consequence of this maneuver?

21) A victim of blunt abdominal trauma has splenic and liver lacerations as well as an unstable pelvic fracture. He is hypotensive and tachycardic with a heart rate of 150 despite receiving 2 L of crystalloid en route to the hospital. He was intubated prior to arrival due to declining mental status. He is taken emergently to the operating room for exploratory laparotomy and external fixation of his pelvic fracture. Which of the following is the best resuscitative strategy?

22) A 62-year-old man who had a motorcycle accident has been in a coma for several weeks. He is on a respirator, has had pneumonia on and off, has been on pressors, and shows no signs of neurologic improvement. The family inquires about brain death and possible organ donation. An independent neurologic evaluation confirms that the patient is brain dead. What advice should be given to his family?

23) A 35-year-old man with new diagnosis of Crohn disease presents with rapidly enlarging painful ulcerations on the lower extremities. Cultures of the lesion are negative, and skin biopsy reveals no evidence of malignancy. Which of the following is the most appropriate treatment option?

26) A 60-kg, 53-year-old man with no significant medical problems undergoes lysis of adhesions for a small-bowel obstruction. Postoperatively, he has high nasogastric output and low urine output. What is the most appropriate management of his fluids?

27) Four days after surgical evacuation of an acute subdural hematoma, a 44-year-old man becomes mildly lethargic and develops asterixis. He has received 2400 mL of 5% dextrose in water intravenously each day since surgery, and he appears well hydrated. Pertinent laboratory values are as follows:Serum electrolytes (mEq/L): Na+ 118, K+ 3.4, Cl− 82, HCO3− 24Serum osmolality: 242 mOsm/LUrine sodium: 47 mEq/LUrine osmolality: 486 mOsm/LWhich of the following is the best treatment of his hyponatremia?

32) A 30-year-old woman in her last trimester of pregnancy suddenly develops massive swelling of the left lower extremity. Which of the following would be the most appropriate workup and treatment at this time?

33) A 20-year-old woman with a family history of von Willebrand disease is found to have an activated partial thromboplastin time (aPTT) of 78 (normal = 32) on routine testing prior to cholecystectomy. Further investigation reveals a prothrombin time (PT) of 13 (normal = 12), a platelet count of 350,000/mm3, and an abnormal bleeding time. Which of the following should be administered in the perioperative period?

37) A 35-year-old woman has dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, cough, and hemoptysis. The symptoms have been slowly progressive for about 5 years. She looks thin and cachectic, and has atrial fibrillation and a low-pitched, rumbling diastolic apical heart murmur. At age 15, she had rheumatic fever. Surgery has been recommended. Which of the following is the most appropriate management?

45) A 24-year-old Jehovah’s Witness who was in a high-speed motorcycle collision undergoes emergent splenectomy. His estimated blood loss was 1500 mL. Which of the following strategy should be employed for his resuscitation?

47) A 60-year-old woman with no previous medical problems undergoes a total colectomy with diverting ileostomy for a cecal perforation secondary to a sigmoid stricture. Postoperatively, she has 2 L of ileostomy output per day. Her heart rate is 110 beats per minute, her respiratory rate is 24 breaths per minute, and her oxygen saturation is 98% on 2-L nasal cannula (NC). Her hemoglobin levels have been stable postoperatively at 9.0 mg/dL. Her other laboratory values on postoperative day 6 are as follows:Na+: 128K+: 3.0Cl−: 102HCO3-: 20Which of the following statements is the best strategy for correcting her acid–base disorder?

48) A 39-year-old man is undergoing resuscitation with blood products for an upper GI bleed. He is suspected of having a hemolytic transfusion reaction. Which of the following is appropriate in the management of this patient?

49) A 70-kg woman is to undergo nail removal from her right ring finger in the ambulatory surgery clinic. Which of the following is the most appropriate option for local anesthesia?

51) A 72-year-old chronic smoker with severe chronic obstructive pulmonary disease (COPD) is found to have a central hilar mass on chest x-ray. Bronchoscopy and biopsies establish a diagnosis of squamous cell carcinoma of the lung. Pulmonary function studies show that he has a FEVj of 1100 mL, and a ventilation-perfusion scan indicates that 60% of his pulmonary function comes from the affected lung. Which of the following is the most appropriate next step in management?

53) A 37-year-old woman has developed a 6-cm mass on her anterior thigh over the past 10 months. The mass appears to be fixed to the underlying muscle, but the overlying skin is movable. Which of the following is the most appropriate next step in her management?

54) A 50-year-old man is incidentally discovered to have a low-grade mucosa-associated lymphoid tissue (MALT) lymphoma on biopsy of the stomach during esophagogastroduodenoscopy for dyspepsia. CT scans of the chest, abdomen, and pelvis demonstrate no evidence of enlarged regional lymph nodes or distant metastases. Which of the following is the initial treatment of choice?

61) A 62-year-old woman undergoes a pancreaticoduodenectomy for a pancreatic head cancer. A jejunostomy is placed to facilitate nutritional repletion as she is expected to have a prolonged recovery. What is the best method for delivering postoperative nutrition?

66) A young man is shot in the upper part of the neck with a .22 caliber revolver. Inspection of the entrance and exit wounds indicates that the trajectory of the bullet is all above die level of the angle of the mandible, but below the skull. He is fully conscious and neurologically intact. A steady trickle of blood flows from both wounds, and it does not seem to respond to local pressure. He is hemodynamically stable. Which of the following is the most appropriate next step in diagnosis?

67) A 21-year-old college student undergoes surgery to remove a small cyst in his palm at the base of his third digit. He receives an axillary regional block prior to die procedure but still has discomfort post- operatively. Injection of anesmetic in which of the following sites may be used to treat his pain?

68) A 62-year-old man is suffering from arrhythmias on the night of his triple coronary bypass. Potassium has been administered. His urine output is 20 to 30 mL/h. Serum potassium level is 6.2. Which of the following medications counteracts the effects of potassium without reducing the serum potassium level?

69) An in-hospital workup of a 78-year-old hypertensive, mildly asthmatic man who is receiving chemotherapy for colon cancer reveals symptomatic gallstones. Preoperative laboratory results are notable for a hematocrit of 24% and urinalysis with 18 to 25 WBCs and gram-negative bacteria. On call to the operating room, the patient receives intravenous penicillin. His abdomen is shaved in the operating room. An open cholecystectomy is performed and, despite a lack of indications, the common bile duct is explored. The wound is closed primarily with a Penrose drain exiting a separate stab wound. On postoperative day 3, the patient develops a wound infection. Which of the following changes in the care of this patient could have decreased the chance of a postoperative wound infection?

70) A 72-year-old man with diabetes, renal insufficiency, and coronary artery disease presents in septic shock from emphysematous cholecystitis. His oxygen saturation is 100% on 6-L nasal cannula and his hemoglobin is 7.2 mg/dL. His mixed venous oxygen saturation is 58%. Which of the following treatment options will improve his oxygen delivery the most?

76) Following a boating injury in an industrial-use river, a patient begins to display fever, tachycardia, and a rapidly expanding area of erythema, blistering, and drainage from a flank wound. An x-ray shows gas in the soft tissues. Which of the following measures is most appropriate?

78) A 53-year-old woman presents with bright red blood per rectum, increased abdominal distention, and weight loss. She is found to have a large fungating mass 8 cm from the anal verge. No other lesions are identified. Biopsy is consistent with invasive rectal adenocarcinoma. Endorectal ultrasound shows invasion of the tumor into the perirectal fat and multiple enlarged lymph nodes. CT scans of the chest, abdomen, and pelvis do not show any metastases. She would like to preserve her sphincter if possible. Which of the following is the best treatment option for this patient given her preferences?

79) A 35-year-old woman presents with a right breast mass. You perform a thorough history and physical examination as well as a core biopsy of the right breast mass. In which of the following circumstances would a sentinel lymph node biopsy be indicated?

81) A 40-year-old woman undergoes an incisional biopsy of a pigmented lesion on her right thigh. Pathologic examination reveals malignant melanoma with a thickness of 3 mm. Findings on examination of the groin is normal. Which of the following is the most appropriate next step in her management?

85) A 44-year-old woman has a 2-cm firm palpable mass in the upper outer quadrant of her right breast. The mass is freely movable, and her breast is of normal, rather generous size. There are no palpable axillary nodes. Mammogram shows no other lesions. A core biopsy establishes a diagnosis of infiltrating ductal carcinoma. She has no neurologic or skeletal symptoms, and a chest x-ray film and liver enzymes are normal. She understands that systemic therapy may eventually be needed once the full extent of her disease is known. Although she wants the best chance for cure, she is very concerned about cosmetic deformity and wants to know what can be done about the breast itself. Which of the following is the most appropriate management?

87) During a bar brawl, a 19-year-old man sustains a 4-in laceration on his left arm from glass and presents to the emergency room the following morning, 10 hours later. He is neurovascularly intact and the wound is deep, extending down to fascia. Which of the following is the most appropriate management of the wound?

89) While playing football, a college student injures his shoulder. He comes in with his arm held close to his body, complaining of pain over the clavicle, rather than the shoulder joint. Physical examination shows a normal shoulder, but there is point tenderness at the junction of the middle and distal thirds of the clavicle. Gentle pressure elicits a gritty feeling of bone crunching on bone. He has normal pulses on that arm. After appropriate x-ray studies are performed, which of the following is the most appropriate initial step in management?

90) A 50-year-old man complains of loss of libido and impotence after starting treatment with leuprolide for prostatic hyperplasia. An alpha-blocker and finasteride have also been tried, but with similar adverse effects. So far, the patient has not experienced any episodes of urinary tract infection or hematuria, but he is excessively bothered by his symptoms without any medication. Digital rectal examination shows mild prostatic enlargement. At this time, his prostate-specific antigen (PSA) is 4.5 ng/mL, and his creatinine is 0.7 mg/dL. Dipstick examination shows no hematuria. Which of the following is the most appropriate alternative to his current pharmacologic treatment?

91) A 65-year-old man sustains a 50% TBSA burn while burning trash in the backyard. The patient is resuscitated with lactated Ringer (LR) solution using the Parkland formula and a weight of 80 kg. What is the rate of LR given in the first 8 hours?

92) A 67-year-old man presents to his primary care physician with a 1-cm skin lesion on his left forearm. On examination, it has a waxy appearance with rolled pearly borders surrounding a central ulcer. Which of the following is the most appropriate management of this patient?

94) You are the physician on call for the extracorporeal membrane oxygenation (ECMO) service. There are 5 calls today, but only one machine and one technologist available. Which of the following patients is the most appropriate recipient of this service?

95) A 45-year-old man shows up in the emergency department with a pale, pulseless, paresthetic, painful, and paralytic right lower extremity. The process began suddenly 2 hours ago. On examination, no pulses are apparent in the right lower extremity. Pulse at the wrist is 95/min and grossly irregular. Treatment would likely be based on which of the following?

96) A neonate does not pass any meconium during the first day of life. On day 2 he is brought for evaluation because of repeated green vomiting and progressive abdominal distention. X-ray films of the abdomen show multiple dilated loops of small bowel and no gas in the colon. A contrast enema shows a normally positioned microcolon, and the contrast material refluxes freely into the small bowel, filling some of the more distal distended loops. Exploratory laparotomy is done. There is no malrotation, the small bowel does not have any atretic or obstructed segments, and there is no inspissated meconium in it. Which of the following is most appropriate next step in management?

100) A 25-year-old man is found on a pre-employment chest x-ray film to have a 3-cm peripheral coin lesion. The patient has never smoked, and a chest x-ray film that he had 2 years ago when he enrolled in graduate school had been normal. Prompted by this finding, he undergoes a more thorough physical examination, which discloses the presence of a firm, 2-cm testicular mass of which he was not previously aware. There are also palpable inguinal nodes on the same side. Which of the following is the most appropriate next step in management?

75) A 28-year-old medical student seeks your attention because of a testicular mass. Biopsy is consistent with pure seminoma. There is no evidence of enlarged retroperitoneal lymph nodes on CT scan. Which of the following is the best treatment strategy for this patient?