USS DES Test 11 (Start from 1862_ 1874 & 1913_1934 )

1) A 7-year-old boy was brought to the emergency department after falling onto his outstretched arm. He complains of pain in his left arm and refuses to move his arm at the elbow. On examination, the left arm is swollen, slightly pale, and edematous. His radial pulse is intact. The patient's radiograph is shown below. While the patient is waiting for the orthopedic resident on call to examine him, he continues to complain of increasing pain despite multiple doses of pain medication.

P1862 Q1

2) A 3-year-old girl is brought to the emergency department because she became partially unconscious, lethargic and febrile. Her mother claims that "she suddenly took a turn for the worse" 24 hours ago after an upper respiratory tract infection. She has no allergies, and was not taking oral antibiotics. Her blood pressure is 60/45mm Hg and pulse is 120/min. On examination, she appears emaciated and lethargic. Despite numerous attempts, it is impossible to start a peripheral intravenous line, and the child's condition continues to deteriorate. What is the best next step to obtain IV access in this patient?

3) An infant who appears to be of normal size is noted to be lethargic and somewhat limp after birth. The mother is 28 years old, and this is her fourth delivery. The pregnancy was uncomplicated, with normal fetal monitoring prior to delivery. Labor was rapid, with local anesthesia and intravenous meperidine (Demerol) administered for maternal pain control. Which of the following therapeutic maneuvers is likely to improve this infant’s condition most rapidly?

4) At 43 weeks’ gestation, a long, thin infant is delivered. The infant is apneic, limp, pale, and covered with “pea soup” amniotic fluid. Which of the following is the best first step in the resuscitation of this infant at delivery?

5) A 15-year-old is participating in high school football practice in August in Texas. He had complained of headache and nausea earlier in practice, but kept playing after a cup of water. He is now confused and combative. He is dizzy and sweating profusely. His temperature is 41°C (105.8°F). Therapy should consist of which of the following?

6) A fully immunized 2-year-old presents to the emergency room with several days of low-grade fever, barking cough, and noisy breathing. Over the past few hours he has developed a fever of 40°C (104°F) and looks toxic. He has inspiratory and expiratory stridor. The family has not noticed drooling, and he seems to be drinking without pain. Direct laryngoscopy reveals a normal epiglottis. The management of this disease process includes which of the following?

7) A 2-year-old boy presents to the emergency department (ED) with severe wheezing. His symptoms have not improved even after three treatments with nebulizers. This is his third trip to the ED in the past two weeks. In the ED, he is given a dose of intravenous steroids, but continues to wheeze. On auscultation, there is no air entry bilaterally. His chest x-ray result is normal. His oxygen saturation is 91% on 6 liters of oxygen. What is the next best step in the management of this patient?

8) A 7 -year-old Caucasian male with a history of peanut allergy develops sudden shortness of breath after lunch at school. On physical examination, his blood pressure is 70/50 mmHg and his heart rate is 130/min. Inspirations and expirations are labored and noisy. Which of the following is the best initial treatment?

9) You admitted to the hospital the previous evening a 1-year-old boy who presented with cough, fever, and mild hypoxia. At the time of his admission, he had evidence of a right upper lobe consolidation on his chest radiograph. A blood culture has become positive in less than 24 hours for Staphylococcus aureus. Approximately 20 hours into his hospitalization, the nurse calls you because the child has acutely worsened over the previous few minutes, with markedly increased work in breathing, increasing oxy- gen requirement, and hypotension. As you move swiftly to the child’s hospital room, you tell the nurse to order which of the following?

10) A previously heathy 3-year-old boy is brought to the emergency department (ED) due to stridor of sudden onset. Last night, he suddenly developed a high fever followed by breathing difficulty. His temperature is 40C (104F), pulse is 130/min, and respirations are 40/min. In the ED, the child is toxic-appearing, sitting up, leaning forward and drooling. His lungs are clear, and oxygen saturation is 85% in room air. What is the most appropriate next step in management? Admit the patient and start him on broad spectrum antibiotics

11) An 18-month-old infant is found with the contents of a bottle of drain cleaner in his mouth. Which of the following treatment options is most appropriate?

12) A 2 week post mature baby is born and immediately exhibits severe respiratory distress. Previously, green-tinged meconium was noted in the amniotic fluid. Which of the following is the most appropriate next step?

13) A 2-year-old arrives in the emergency center after having swallowed a button battery from one of her toys. She is breathing comfortably, without stridor. Radiographs show the battery to be lodged in the esophagus. Which of the following is the correct next step?

14) A 9-month-old infant is brought to the emergency department with lethargy and tachypnea. He was healthy before developing fever and diarrhea four days ago. He has been taking some formula, but has had two to three episodes of diarrhea with each bottle. He has lost three pounds (1 .4 kg) since his routine check-up two weeks ago. He has had one wet diaper in the past twenty four hours. On examination, his temperature is 102.5F (39.1c), pulse is 200/min, respiratory rate is 42/min, and blood pressure is 70/45 mm Hg. He is lethargic with decreased tone and decreased deep tendon reflexes. His mucous membranes are dry. Cardiopulmonary exam reveals tachycardia and tachypnea. His abdominal exam is unremarkable. Capillary refill is four seconds. Laboratory results are shown below. Chemistry panel: Serum sodium 165 mEq/L, Serum potassium 4.5 mEq/L, Chloride 108 mEq/L, Bicarbonate 14 mEq/L, Blood urea nitrogen (BUN) 20 mg/dl, Serum creatinine 0.8 mg/dl, Calcium 10.0 mg/dl, Blood glucose 98 mg/dl. Which of the following fluids should be used as a bolus in the resuscitation of this infant?

15) A 5-year-old boy is brought into the ER immediately after an unfortunate altercation with a neighbor’s immunized Chihuahua that occurred while the child was attempting to dress the dog as a superhero. The fully immunized child has a small, irregular, superficial laceration on his right forearm that has stopped bleeding. His neuromuscular examination is completely normal, and his perfusion is intact. Management should include which of the following?

16) Aunt Mary is helping her family move to a new apartment. During the confusion, 3-year-old Jimmy is noted to become lethargic. The contents of Aunt Mary’s purse are strewn about on the floor. In the ER, the lethargic Jimmy is found to have miosis, bradycardia, and hypotension. He develops apnea, respiratory depression, and has to be intubated. His condition would most likely benefit from which of the following therapies?

17) An infant is born at terrn to a 27-year-old Caucasian female. The prenatal course was uncomplicated. The amniotic fluid is clear. Immediately after the delivery, the infant starts crying and is moving all four extremities actively. Heart rate is 140/min. He is making a grimace on the attempt to put the suction catheter into his nostrils. His body is pink, but extremities are cyanotic. Which of the following is the next best step in the management of the infant?

18) A 15-year-old boy with Duchenne muscular dystrophy is brought to the emergency department with increasing respiratory distress and cyanosis. On examination, he is diaphoretic, with gasping respirations, poor air entry, and diminished responsiveness. He is tachycardic at 160 beats/min. His chest x-ray film shows a lingular pneumonia, and he is intubated. He improves over the next 10 days with antibiotics but is not extubated secondary to hypoventilation on weaning because of muscle weakness. Which of the following modalities will most likely help wean him off the ventilator?

19) A 6-year-old Hispanic boy is brought to your office by his mother because of severe pain in his right hip and refusal to walk for the last 2 days. His blood pressure is 100/70 mm Hg, pulse is 90/min, respirations are 18/min, and temperature is 38.7C (102.7F). His WBC count is 19,000/mm3 and ESR is 55 mm at one hour. On examination, he keeps his right hip externally rotated, and cries out in pain on any movement involving the right hip. Joint aspiration reveals a turbid fluid with total WBC: 90,000/mm3 and numerous bacteria. What is the most appropriate management in this patient?

20) A newborn infant becomes markedly jaundiced on the second day of life, and a faint petechial eruption, first noted at birth, is now a generalized purpuric rash. Hematologic studies for hemolytic diseases are negative. Acute management should include which of the following?

21) A 14-year-old girl, angry at her mother for taking away her MP3 player, takes an unknown quantity of a friend’s pills. Within the first hour she is sleepy, but in the emergency center she develops a widened QRS complex on her electrocardiogram (ECG), hypotension, and right bundle branch block. The therapy you would initiate for this ingestion is which of the following?

22) You are called to a delivery of a woman with no prenatal care; she is in active labor but has no history of amniotic rupture. The biophysical profile done in the emergency center revealed severe oligohydramnios. When you get this infant to the nursery, you should carefully evaluate him for which of the following?

23) Parents bring a 5-day-old infant to your office. The mother is O negative and was Coombs positive at delivery. The term child weighed 3055 g (6 lb, 1 oz) at birth and had measured baseline hemoglobin of 16 g/dL and a total serum bilirubin of 3 mg/dL. He passed a black tarlike stool within the first 24 hours of life. He was discharged at 30 hours of life with a stable axillary temperature of 36.5°C (97.7°F). Today the infant’s weight is 3000 g, his axillary temperature is 35°C (95°F), and he is jaundiced to the chest. Parents report frequent yellow, seedy stool. You redraw labs and find his hemoglobin is now 14 g/dL, and his total serum bilirubin is 13 mg/dL. The change in which of the following parameters is of most concern?

24) A 20-month-old child is brought to the ED because of fever and irritability and refusal to move his right lower extremity. Physical examination reveals a swollen and tender right knee that resists passive motion. Which of the following is the most likely to yield the diagnosis in this patient?

25) A 12-year-old boy presents to his pediatrician with frequent episodes of headache, nausea, blurry vision, and sweating. On physical examination, his temperature is 37.4 C (99.3 F), blood pressure is 148/94 mm Hg, pulse is 92/min, and respirations are 18/min. The rest of his examination is unremarkable. His 24-hour urinary vanillylmandelic acid (VMA) and metanephrines are increased. An abdominal CT reveals an extrarenal mass above the left kidney. Which of the following is the most appropriate pharmacotherapy?

26) A 12-year-old girl with mild asthma comes to the office for a health maintenance visit. Her mother states that she is using her albuterol inhaler 2-3 times a week and that she has a cough that wakes her up at night about 3 times a month. On physical examination, she has diffuse inspiratory and expiratory wheezes. She has no accessory muscle use. Pulse oximetry shows 95% oxygen saturation on room air. Which of the following is the most appropriate treatment for her at this time?

27) A 2-week postmature neonate exhibits severe respiratory distress immediately after birth. Previously, greentinged meconium was noted in the amniotic fluid. Which of the following is the most appropriate next step in management? Chest x-ray Suctioning of the mouth and nasopharynx

28) A 3-month-old, previously well male infant presents to the emergency department in January with a 2-day history of clear rhinorrhea, low-grade fever, and poor appetite, but no cough. On physical examination, there are mild subcostal retractions, coarse breath sounds heard throughout the lung fields, and scattered expiratory wheezes. The child receives an intravenous fluid bolus in the emergency department and is admitted for observation. Which of the following is the most severe, life-threatening complication of this child's illness?

29) A father brings his 18-month-old daughter to the office for the evaluation of fever for the past 10 days. The father, who works as a phlebotomist, says that the temperature seems higher in the morning and again at night, often reaching 40.5C (105F), and is sometimes associated with shaking chills. He remembers that the child developed severe respiratory distress and skin rash when treated with penicillin in the past. He has heard about the development of 'liver toxicities' in children treated with aspirin, and he is interested in knowing everything about his daughter's condition. On examination, the child is in no acute distress. Her temperature is 39.4C (103F), pulse rate is 90/min, and blood pressure is 100/60 mmHg. Her sclerae are anicteric. There is bulbar conjunctival injection, and the oropharynx shows diffuse mucosal injection with fissuring and crusting of the lips. There are numerous hyperemic macules over her entire body, and her palms appear edematous. Based on the above description, which of the following is the most accurate statement?

31) A 6-month-old boy presents to the Emergency Department with a three-day history of cough, congestion and low grade fever. The mother states that the baby has not been feeding well and has used only two diapers over the past 24 hours. Physical examination reveals a pale infant with a temperature of 37.8 C (100.1 F), pulse of 170/min, respirations of 60/min and oxygen saturation of 88% on room air. The patient exhibits nasal flaring, subcostal and intercostal retractions. Lung examination reveals diffuse wheezing. Cardiac examination reveals a regular but tachycardic rhythm with no murmur. Central capillary refill is four seconds. The remainder of the examination is normal. Which of the following is the most appropriate initial step in management?

32) A 6-year-old boy is often teased at school because he has stooled in his underwear almost daily for the last 3 months. He was toilet trained at 2 years of age without difficulty, but over the last 2 years he had developed ongoing constipation. His family is frustrated because they cannot believe him when he says “I didn’t know I had to go.” He is otherwise normal; school is going well, and his home life is stable. His only finding on examination is significant for stool in the rectal vault. The plain radiograph of his abdomen is shown. Initial management of this problem should include which of the following?

P1872 Q32

33) A 15-year-old Caucasian male is brought to the office by his mother for the evaluation of a six-month history of unstable gait and speech difficulty which are getting worse over time. His past medical history is insignificant. He is not taking any medications, and denies smoking or alcohol consumption. His blood pressure is 120/70 mmHg and pulse is 80/min. Musculoskeletal examination showed scoliosis and feet deformity with 'hammer toes.' The neurologic examination showed dysarthria, dysmetria, nystagmus, and absence of deep plantar reflexes on lower extremities. What is the most common cause of death in this patient population?

34) An 8-month-old male infant is brought to the emergency department (ED) by his mother due to vomiting and a decreased urine output. Three days ago, he had a fever, sore throat and ear pain. He was subsequently diagnosed with otitis media and treated with oral amoxicillin. Today, in the ED, his temperature is 40.0C(104F), pulse is 80/min, respirations are 40/min and irregular, blood pressure is 100/60 mm Hg, and weight is 8kgs ( 15 lbs). He is lethargic and arousable only to painful stimuli. His anterior fontanel is full and tense. His tympanic membranes are red and bulging. His pupils are reactive, but his eyes do not focus well on his parents. What is the most appropriate next step in the management of this patient?

35) A 17-year-old girl is found unconscious in a bathroom after ingesting a large amount of unknown sleeping pills. On arriving at the emergency department, she is somnolent; her temperature is 37.2 C (98.9 F), blood pressure is 120/74 mm Hg, pulse is 68/min, and respirations are 12/min. She responds to painful stimuli and to hearing her name loudly by opening her eyes briefly. However, she returns to the somnolent state immediately afterward. Which of the following is the most appropriate initial intervention?

37) A 6-year-old child, attempting to pet a neighbor's domestic dog while the dog is eating, is bitten in the hand. The dog has been vaccinated regularly. Which of the following steps are needed for rabies prophylaxis in this case?

1) A 48-year-old woman develops constipation postoperatively and self-medicates with milk of magnesia. She presents to clinic, at which time her serum electrolytes are checked, and she is noted to have an elevated serum magnesium level. Which of the following represents the earliest clinical indication of hypermagnesemia?

2) A football player is tackled, and he develops severe knee swelling and pain. On physical examination with the knee flexed at 90 degrees, the leg can be pulled anteriorly, like a drawer being opened. A similar finding can be elicited with the knee flexed at 20 degrees by grasping the thigh with one hand, and pulling the leg with the other. Which of the following is the most likely injured structure?

3) A 45-year-old woman with Crohn disease and a small intestinal fistula develops tetany during the second week of parenteral nutrition. The laboratory findings include: Na: 135 mEq/LK: 3.2 mEq/LCl: 103 mEq/LHCO3: 25 mEq/LCa: 8.2 mEq/LMg: 1.2 mEq/LPO4: 2.4 mEq/LAlbumin: 2.4An arterial blood gas sample reveals a pH of 7.42, PCO2 of 38 mm Hg, and PO2 of 84 mm Hg. Which of the following is the most likely cause of the patient’s tetany?

4) A 42-year-old, right-handed man has had a history of progressive speech difficulties and right hemiparesis for 5 months. He has had progressively severe headaches for the past 2 months, which are worse in the mornings. At the time of admission, he is confused and vomiting, and has blurred vision, papilledema, and diplopia. Shortly thereafter, his blood pressure increases to 190/110 mm Hg, and he develops bradycardia. Which of the following is most likely the significance of the hypertension and the bradycardia?

5) A 19-year-old man sustains multiple injuries in a high-speed automobile collision. There is a pneumothorax on the left, for which he has a chest tube placed. Over the next several days, a large amount of air drains continuously through the tube (a large "air leak"), and daily chest x-rays show that his collapsed left lung is not expanding. The patient is not on a respirator. Which of the following is the most likely cause of these findings?

6) A 23-year-old woman is brought to the emergency room from a halfway house, where she apparently swallowed a handful of pills. The patient complains of shortness of breath and tinnitus, but refuses to identify the pills she ingested. Pertinent laboratory values are as follows:Arterial blood gases: pH 7.45, PCO2 12 mm Hg, PO2 126 mm Hg.Serum electrolytes (mEq/L): Na+ 138, K+ 4.8, Cl− 102, HCO3− 8.An overdose of which of the following drugs would be most likely to cause the acid–base disturbance in this patient? Phenformin . Aspirin

7) A middle-aged man with symptomatic carotid stenosis underwent a carotid endarterectomy on the right side. The area of significant stenosis extended from die carotid bifurcation up into the internal carotid, requiring a very high dissection and clamping of the vessel. The endarterectomy was done with an in situ shunt and closed with a Dacron patch. In the postoperative period, the patient has persistent difficulty swallowing solids and even more difficulty swallowing liquids. Any attempt to do so results in violent coughing and aspiration. His lips look symmetric and move normally, he speaks in a normal tone of voice without tiring, and he has no trouble breathing. When he is asked to stick his tongue out, he does so without deviation to either side. His symptoms are due to intraoperative damage of which of the following nerves?

8) A 52-year-old man has been impotent ever since he had an abdominoperineal resection for cancer of the rectum. The tumor was staged as T3, NO, MO. He gets no nocturnal erections, and his impotence extends to all situations, regardless of sexual partner, and includes inability to masturbate. His erectile dysfunction is most likely due to which of the following?

9) A 60-year-old diabetic man undergoes incision and drainage of an infected boil on his back. The wound is left open and packed daily. Week by week, the wound grows smaller and eventually heals. Which of the following terms describes the method of wound closure by the patient?

10) A 55-year-old-woman of Asian descent goes to the emergency department because of vomiting and severe abdominal cramping of 3 days' duration. Her pain is centered on the umbilicus. She denies being exposed to a viral or bacterial illness. Her medical history includes a previous cholecystectomy and an appendectomy after which she developed an infection. Her abdomen is not tender, but hyperactive, high-pitched peristalsis with rushes coincides with palpable bowel cramping. Abdominal x-ray films taken in the supine and upright positions demonstrate a ladder-like series of distended small bowel loops. Which of the following is the most likely explanation for these findings?

11) A patient with a solid malignancy discusses chemotherapy with his oncologist. He is interested in the risks of the treatment. What is the primary toxicity of doxorubicin (Adriamycin)?

12) A 56-year-old woman is undergoing chemotherapy. She presents today with complaints of burning on urination and bloody urine. Which of the following agents causes hemorrhagic cystitis?

13) A 65-year-old man undergoes a technically difficult abdominal–perineal resection for a rectal cancer during which he receives 3 units of packed red blood cells. Four hours later, in the intensive care unit (ICU), he is bleeding heavily from his perineal wound. Emergency coagulation studies reveal normal prothrombin, partial thromboplastin, and bleeding times. The fibrin degradation products are not elevated, but the serum fibrinogen content is depressed and the platelet count is 70,000/μL. Which of the following is the most likely cause of his bleeding?

14) A 78-year-old man with a history of coronary artery disease and an asymptomatic reducible inguinal hernia requests an elective hernia repair. Which of the following would be a valid reason for delaying the proposed surgery?

15) A 53-year-old woman has been intubated for several days after sustaining a right pulmonary contusion after a motor vehicle collision as well as multiple rib fractures. Which of the following is a reasonable indication to attempt extubation?

16) A 74-year-old woman with a history of a previous total abdominal hysterectomy presents with abdominal pain and distention for 3 days. She is noted on plain films to have dilated small-bowel and air-fluid levels. She is taken to the operating room for a small-bowel obstruction. Which of the following inhalational anesthetics should be avoided because of accumulation in air-filled cavities during general anesthesia?

17) A 65-year-old man has an enterocutaneous fistula originating in the jejunum secondary to inflammatory bowel disease. Which of the following would be the most appropriate fluid for replacement of his enteric losses?

18) A 45-year-old woman is seen with wasting of the intrinsic muscles of the hand, weakness, and pain in the wrist. Which of the following nerves has most likely been injured?

19) A 68-year-old woman presents with a pigmented lesion on the trunk. Upon further examination the lesion has an irregular border, darkening coloration, and raised surface. An incisional biopsy is performed and confirms a melanoma with a thickness of 0.5 mm. The patient is scheduled for a wide local excision of the melanoma in the operating room. Which of the following is the smallest margi recommended for excision?

20) A 25-year-old woman presents with a benign nevus on the right upper arm. She desires removal and undergoes a clean incision and then closure of the incision without complication. With regard to the healing process, which of the following cell types are the first infiltrating cells to enter the wound site, peaking at 24 to 48 hours?

21) A 35-year-old woman undergoes an elective laparoscopic cholecystectomy for symptomatic cholelithiasis. Which of the following wound classes best describes her procedure?

22) A 65-year-old woman presents with a 1-cm lesion with a pearly border on her nose, and punch biopsy is consistent with a basal cell carcinoma. She is scheduled to undergo Mohs surgery. Which of the following is a benefit of Mohs surgery over wide local excision?

23) A 55-year-old man presents with worsening cirrhosis. After evaluation by a hepatologist, he presents for evaluation for hepatic transplantation. He is informed that prioritization for transplantation is based on the Model of End-stage Liver Disease (MELD) score, and that patients with higher MELD scores have a greater benefit from transplantation. Which of the following contributes to the MELD score?

24) A young woman who has received a transplant has posttransplant fever and malaise. Graft-versus-host disease (GVHD) is diagnosed. This has occurred most commonly with the transplantation of which of the following? Kidney . Lung . Heart . Bone marrow . Pancreas

25) A 55-year-old woman who has end-stage liver disease is referred to a hepatologist for evaluation. Which of the following would prevent her from being a transplantation candidate?

26) A 63-year-old man with a 40-pack per year smoking history undergoes a low anterior resection for rectal cancer and on postoperative day 5 develops a fever, new infiltrate on chest x-ray, and leukocytosis. He is transferred to the ICU for treatment of his pneumonia because of clinical deterioration. Which of the following is a sign of early sepsis? Respiratory acidosis . Decreased cardiac output

27) A 43-year-old trauma patient develops acute respiratory distress syndrome (ARDS) and has difficulty oxygenating despite increased concentrations of inspired O2. After the positive end-expiratory pressure (PEEP) is increased, the patient’s oxygenation improves. What is the mechanism by which this occurs?

28) An 80-year-old man comes to the physician because of a slowly growing ulcerated mass on the glans penis. A biopsy is positive for squamous cell carcinoma. Which of the following conditions is usually present in association with this tumor?

29) A 33-year-old woman seeks assistance because of a swelling of her right parotid gland. Biopsy is performed and reveals acinar carcinoma. You consent the patient for resection and inform her that at the very least, she will require superficial parotidectomy. Which of the following intraoperative findings would require sacrifice of the facial nerve?

30) A college student is tackled while playing football and develops severe knee pain. When examined shortly thereafter, the knee is swollen and the patient has pain on direct palpation over the lateral aspect of the knee. With the knee flexed 30 degrees, passive adduction elicits pain on the same area, and the leg can be adducted further than in the normal contralateral leg (varus stress test). The anterior drawer test, posterior drawer test, and Lachman test are negative. Which of the following is the most likely site of injury?

31) A 39-year-old woman presents with generalized malaise and lymphadenopathy. Biopsy of a supraclavicular lymph node reveals non-Hodgkin lymphoma. Fortyeight hours after initiation of chemotherapy, she develops a high-grade fever and her laboratory studies demonstrate hyperkalemia, hyperphosphatemia, and hypocalcemia. Which of the following cells mediate this syndrome?

33) A 57-year-old man has end-stage heart failure due to atherosclerosis. His cardiologist refers him for evaluation for heart transplantation. Which of the following is an absolute contraindication for heart transplantation?

34) A 55-year-old woman has been hospitalized because of recurrent pancreatitis, ARDS, prolonged ileus, and need for parenteral nutrition. She demonstrates weakness, lassitude, orthostatic hypotension, nausea, and fever. Which of the following abnormalities is most likely to explain these symptoms? Hypothermia . Hypokalemia . Hyperglycemia . Hyponatremia . Hypervolemia

35) A 25-year-old man presents to the same day surgical center for repair of an old injury to his lateral collateral ligament. The anesthesiologist wants to perform an axillary block for local pain control. If the posterior wall of the axillary artery is pierced during placement of the block, which of the following nerves will most likely be affected?

36) A 72-year-old woman who is planning to undergo ventral hernia repair is on warfarin for atrial fibrillation. She is advised to cease her warfarin several days before her surgery and is hospitalized preoperatively for heparinization. During her hospital stay, she complains of severe abdominal and flank pain. Her prothrombin time (PT) is normal, but her activated partial thromboplastin time (aPTT) is elevated. An abdominal CT scan demonstrates a large retroperitoneal hematoma. Which of the following should be administered to reverse the effects of the heparin?

37) A 24-year-old man whose father was just diagnosed with colon cancer presents to his family physician to discuss screening colonoscopy. His physician suspects that he has hereditary nonpolyposis colon cancer (HNPCC) or Lynch syndrome and recommends screening colonoscopy beginning at age 25. Which of the following is most supportive of a clinical diagnosis of HNPCC?

38) A patient requires both cardiac and renal transplantation. Preparation for the procedures has begun. How do cardiac allografts differ from renal allografts?

39) A patient with colon cancer has a mass in the upper lobe of his left lung 2.5 years following resection of his colon cancer and subsequent 12 months of chemotherapy. His CEA level is rising. Which of the following predicts a 5-year survival rate of greater than 20% following resection of pulmonary metastases?

40) A 60-year-old man presents with a 6-mm basal cell carcinoma on the tip of his nose. He is scheduled to undergo excision of the tumor in the operating room with repair of the defect using skin and subcutaneous tissue from his earlobe. Which of the following terms most appropriately describes this form of reconstructive surgery?

41) A 45-year-old woman with breast cancer undergoes a modified radical mastectomy with lymph node dissection. Six weeks later, she returns complaining of decreased mobility of her shoulder. On physical examination, the scapula protrudes from the body when pressing her outstretched arm on the wall. Which of the following nerves was most likely injured during the operation?

42) A 19-year-old college student presents with a testicular mass, and after treatment he returns for regular follow-up visits. Which of the following is the most useful serum marker for detecting recurrent disease after treatment of nonseminomatous testicular cancer?

43) A 72-year-old man undergoes resection of an abdominal aneurysm. He arrives in the ICU with a core temperature of 33°C (91.4°F) and shivering. Which of the following is a physiologic consequence of the shivering?

44) A 43-year-old man with a gangrenous gallbladder and gram-negative sepsis agrees to participate in a research study. An assay of tumor necrosis factor (TNF) is performed. Which of the following is the origin of this peptide?

45) A patient sustained third-degree burns on both his arms when his shirt caught on fire while he was lighting the backyard barbecue. The burned areas are dry, white, leathery, anesthetic, and circumferential all around the arms and forearms. Which of the following parameters should be very closely monitored?

46) A previously healthy 60-year-old man is referred for urologic evaluation of macroscopic hematuria. Urinary cytology is positive for malignant cells, and cystoscopic examination reveals an exophytic multifocal tumor. A biopsy of die tumor demonstrates papillary fronds lined by ccfls similar to transitional epithelium but showing nuclear atypia, mitoses, and necrosis. Which of the following is the most important risk factor in the U.S. For the development of this type of tumor?

47) A 54-year-old woman presents to her physician for an opinion regarding additional therapy following curative resection of recently diagnosed colon cancer. She underwent uncomplicated sigmoid resection for invasive colon cancer 4 weeks ago. The pathology revealed carcinoma invading into, but not through, the muscularis propria, with one of eight positive mesenteric nodes. There was no evidence of liver metastases at the time of operation. Preoperative chest x-ray and CT scan of the abdomen showed no evidence of distant disease. Preoperative carcinoembryonic antigen (CEA) level was normal. Past history is positive for diabetes and mild hypertension. Examination is unremarkable except for a healing abdominal incision. Which of the following is the correct stage of this patient’s colon cancer? stage 0 . stage I . stage II . stage III . stage IV

48) Which of the following patients with primary hyperparathyroidism should undergo parathyroidectomy?

49) 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 statements is true regarding Zenker’s diverticula?

50) A 36-year-old woman whose mother has just undergone treatment for breast cancer is asking about how this affects her and what can be done to lessen her chances of having the disease. Which of the following has the lowest risk factor for breast cancer? Dietary fat intake . Paternal relative with breast cancer 1 (BRCA1) mutation

51) A 39-year-old woman presents to the physician’s office for evaluation of a palpable nodule in the neck of 2 years’ duration. Her past history is pertinent for Hashimoto’s disease diagnosed 5 years ago, for which she takes thyroid hormone. She has a history of low-dose chest irradiation for an enlarged thymus gland during infancy. On examination, a 2.5-cm nodule is palpable in the left lobe of the thyroid and is firm and nontender. Which of the following portions of her history increases the risk for thyroid cancer?

52) While playing with his children, a 44-year-old man falls and lands on his right shoulder. There is immediate pain and deformity. In an uncomplicated dislocation of the glenohumeral joint, the humeral head usually dislocates primarily in which of the following directions?

54) In a failed suicide gesture, a depressed student severs her radial nerve at the wrist. Which of the following is her expected disability?

55) A 52-year-old woman presents with hypertension, obesity, and new skin striae. You are concerned about possible Cushing syndrome. Which of the following is the most common cause of Cushing syndrome?

56) A 62-year-old woman presents with invasive ductal carcinoma of the right breast. Which of the following findings would still allow her to receive breast conservation surgery (partial mastectomy)? Diffuse suspicious microcalcifications throughout the breast . Multifocal disease

57) 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?

58) 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? .

59) 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?

60) 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?

61) 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?

62) 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 eactive; he has papilledema. He responds to pain, has decorticated 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?

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

64) A 74-year-old woman is admitted with upper gastrointestinal (GI) bleeding. She is started on H 2 blockers, but experiences another bleeding episode. Endoscopy documents diffuse gastric ulcerations. Omeprazole is added to the H2 antagonists as a therapeutic approach to the management of acute gastric and duodenal ulcers. Which of the following is the mechanism of action of omeprazole?

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

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

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

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

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

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

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

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

73) Your hospital is conducting an ongoing research study involving the hormonal response to trauma. Blood is drawn regularly (with Institutional Review Board [IRB] approval) for various studies. Which of the following values are likely to be seen after a healthy 36-year-old man is hit by a bus and sustains a ruptured spleen and a lacerated small bowel?

74) A 45-year-old man was an unhelmeted motorcyclist involved in a high-speed collision. He was ejected from the motorcycle and was noted to be apneic at the scene. After being intubated, he was brought to the ER, where he is noted to have a left dilated pupil that responds only sluggishly. What is the pathophysiology of his dilated pupil?

75) A 25-year-old man comes to the physician because of a mass in his mouth. He has had the lump for many years. He denies weight loss. He was in a motor vehicle accident several years ago and sustained a concussion of the brain. He does not use tobacco, alcohol, or illicit drugs. Physical examination shows a nontender 2 x 2-cm mass located on the hard palate of the mouth that is immobile and has a bony hard consistency. Which of the following is the most likely cause of this patient's oral finding?