Surgery/USLME/DES/Exam

1. 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?

2. 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?

3. 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?

4. 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?

5. A 68-year-old man is brought to the emergency department following a high-speed automobile accident. He is alert and complains of chest pain and mild back pain. His blood pressure is 80/60 mm Hg. Chest x-ray shows a widened mediastinum, tracheal deviation, bronchial displacement, and loss of the aortic knob. Which of the following is the most likely diagnosis?

6. A one-year-old boy is brought to the emergency department with scalds on both the buttocks and thighs. His mother states that the child was burned because she accidentally drew a bath for the child with water that was too hot. She states the injury occurred 2 days ago. On examination, the child is irritable. Second-degree burns are noted on the buttocks, genitalia, waist, proximal thighs and feet. There is an abrupt demarcation between the burned and unaffected skin. A faint yellow patch of discoloration is noted on the left thorax with a slight violaceous hue. The child has not yet had his 1-year vaccinations. Which of the following is the most appropriate next step in management?

7. 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?

8. A 35-year-old man comes to the physician because of persistent dull perineal pain and dysuria for 6 months. The patient denies urinary tract infections or urethral discharge. His temperature is 37 C (98.6 F). On digital rectal examination, the prostate is slightly tender and boggy but not enlarged or indurated. Urinalysis is normal. Expressed prostatic secretions show the following: Leukocytes 30 cells/high power field Bacteria None Cultures of prostatic secretion and urine are negative for bacteria. Which of the following is the most likely diagnosis?

9. An otherwise healthy 28-year-old man comes to his physician because of painless enlargement of the right testis. He began to feel a sensation of heaviness in the right hemiscrotum approximately 6 months ago. Physical examination reveals diffuse enlargement of the right testis, but it is difficult to determine whether this is due to an intratesticular or extratesticular lesion. Which of the following is the most appropriate next step in diagnosis?

10. A man involved in a high-speed, head-on automobile collision arrives at the emergency department in a deep coma. His pupils react poorly to light but are of equal size. An airway is placed, and the patient is sent for CT scan of the head with extension to the neck. The study shows no cervical spine fractures, but does reveal a small, crescent-shaped hematoma on the right side, with no deviation of the midline structures. Which of the following is the most appropriate next step in management?

11. A 19-year-oldgangmemberisshotintheabdomenwith a .38 caliber revolver. The entry wound is in the epigastrium, to the left of the midline. The bullet is lodged in the psoas muscle on the right. He is hemodynamically stable, and the abdomen is moderately tender. Which of the following is the most appropriate next step in diagnosis?

12. Five days after an uneventful cholecystectomy, an asymptomatic middle-aged woman is found to have a serum sodium level of 125 mEq/L. Which of the following is the most appropriate management strategy for this patient?

13. A 50-year-old patient presents with symptomatic nephrolithiasis. He reports that he underwent a jejunoileal bypass for morbid obesity when he was 39. Which of the following is a complication of jejunoileal bypass?

14. Following surgery a patient develops oliguria. You believe the oliguria is due to hypovolemia, but you seek corroborative data before increasing intravenous fluids. Which of the following values supports the diagnosis of hypovolemia?

15. 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?

16. 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?

17. A 53-year-old woman comes to the physician because of a "lump" in her neck. She says that her masseuse noticed it 1 month ago. There is no associated pain, pressure, or hoarseness. She feels fine and has no other complaints. She has no history of radiation exposure. Examination reveals a palpable thyroid nodule that is approximately 3 cm. Which of the following is the most appropriate next step in diagnosis?

18. A 56-year-old man has been having bloody bowel movements on and off for the past several weeks. He reports that the blood is bright red, it coats the outside of the stools, and he can see it in the toilet bowl even before he wipes himself. When he does so, there is also blood on the toilet paper. After further questioning, it is ascertained that he has been constipated for the past 2 months and that the caliber of the stools has changed. They are now pencil thin, rather the usual diameter of an inch or so that was customary for him. He has no pain. Which of the following is the most likely diagnosis?

19. 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?

20. A 75-year-old man slips and falls at home, hitting his right chest wall against the kitchen counter. He has an area of exquisite pain to direct palpation over the seventh rib, at the level of the anterior axillary line. A chest x-ray film confirms the presence of a rib fracture, with no other abnormal findings. Which of the following is the most appropriate initial step in management?

21. 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/L K: 3.2 mEq/L Cl: 103 mEq/L HCO3: 25 mEq/L Ca: 8.2 mEq/L Mg: 1.2 mEq/L PO4: 2.4 mEq/L Albumin: 2.4 An 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?

22. A patient with a nonobstructing carcinoma of the sigmoid colon is being prepared for elective resection. Which of the following reduces the risk of postoperative infectious complications?

23. A 75-year-old man with a history of myocardial infarction 2 years ago, peripheral vascular disease with symptoms of claudication after walking half a block, hypertension, and diabetes presents with a large ventral hernia. He wishes to have the hernia repaired. Which of the following is the most appropriate next step in his preoperative workup?

24. A young man is shot with a .45 caliber revolver, point blank in the lower abdomen, just above the pubis. The entrance wound is at the midline, and there is no exit wound. X-ray films show the bullet embedded in the sacral promontory, to the right of the midline. Digital rectal examination and proctoscopic examination are negative, but he has gross hematuria. He is hemodynamically stable. Which of the following is the most appropriate next step in management?

25. A front-seat passenger in a car involved in a head-on collision relates that he hit the dashboard with his knees, however, he is specifically complaining of severe pain in his right hip, rather than knee pain. He lies in the stretcher in the emergency department with the right lower extremity shortened, adducted, and internally rotated. Which of the following is the most likely injury?

26. A 71-year-old woman is brought to the physician by her distressed daughter. The daughter relates that, 3 days ago, her mother began to complain of right upper quadrant abdominal pain. She did not want to eat and "took to her bed sick." The daughter recalls that she complained of chills, nausea, and some vomiting. Physical examination reveals an obtunded, hypotensive, and obviously very sick elderly woman. She has impressive pain to deep palpation in the right upper quadrant, along with muscle guarding and rebound. Her temperature is 40 C (104 F), and laboratory analysis shows a white cell count of 22,000/mm3 with multiple immature forms, a bilirubin of 5 mg/dL and alkaline phosphatase of 840 U/L. The serum amylase is normal. An emergency sonogram shows multiple stones in the gallbladder, normal thickness of the gallbladder wall without pericholecystic fluid, dilated intrahepatic ducts, and common duct with a diameter of 2.1 cm. The sonographer cannot identify stones in the common duct. In addition to IV fluids and antibiotics, which of the following is the most appropriate next step in management?

27. A 25-year-old man is shot with a .22 caliber revolver. The entrance wound is in the anteromedial aspect of his upper thigh, and the exit wound is about 3 inches lower, in the posterolateral aspect of the thigh. He has a large, expanding hematoma in the upper inner thigh. There are no palpable pulses in the foot. The bone is intact by physical examination and x-ray films. Which of the following is the most appropriate next step in management?

28. A 7-year-old boy passes a large, bloody bowel movement. He is hemodynamically stable, and he has a hemoglobin of 14 g/dL. Nasogastric aspiration yields clear, greenish fluid. Physical examination, including anoscopy, is unremarkable. Which of the following is the most appropriate next diagnostic test?

29. An 81-year-old man with Alzheimer disease who lives in a nursing home undergoes surgery for a fractured femoral neck. On the 5th postoperative day, it is noted that his abdomen is grossly distended and tense, but not tender. He has occasional bowel sounds. The rectal vault is empty on digital examination, and there is no evidence of occult blood. X-ray films show a few distended loops of small bowel and a very distended colon. The cecum measures 9 cm in diameter, and the gas pattern of distention extends throughout the entire large bowel, including the sigmoid and rectum. No stool is seen in the films. Other than the abdominal distention, and the ravages of his mental disease, he does not appear to be ill. Vital signs are normal for his age. Which of the following is the most likely diagnosis?

30. A 46-year-old woman was applying her make-up while also drinking her morning cup of coffee. She noticed in the mirror that a round, 2-cm mass would move up and down in the lower part of her neck whenever she swallowed. Her physician confirms that she has a single, firm, thyroid nodule in the right lobe. There are no other abnormalities in the history or physical examination. Her pulse is 82/min and regular. Thyroid stimulating hormone (TSH) is within normal limits. Which of the following is the most appropriate next step in management?

31. A 44-year-old woman is recovering from a mild episode of acute ascending cholangitis secondary to choledocholithiasis. When seen initially, she had a spiking fever, leukocytosis, and a very high alkaline phosphatase; however, all these findings subsided rapidly after she was placed on IV antibiotics. A sonogram of the right upper quadrant on the day of admission showed the presence of gallstones in the gallbladder, but the diameter of the biliary ducts was normal. It was assumed that she had passed a common duct stone, and plans to do an endoscopic retrograde cholangiopancreatogram (ERCP) were canceled. While awaiting elective cholecystectomy, she again developed a fever and leukocytosis, and her liver function tests showed minimal elevation of her bilirubin (to 2.5 mg/dL) and alkaline phosphatase (to 115 U/L). A repeat sonogram shows no changes in her biliary ducts, but now there is a 6-cm abscess in the right lobe of the liver. Which of the following is the most appropriate treatment for this new development?

32. A 55-year-old, HIV-positive man has a fungating mass growing out of the anus. He can feel it when he wipes himself after having a bowel movement, but it is not painful. For the past 6 months, he has noticed blood on the toilet paper, and from time to time there has also been blood coating the outside of the stools. He has lost weight, and he looks emaciated and ill. On physical examination, the mass is easily visible. It measures 3.5 cm in diameter, is fixed to surrounding tissues, and appears to grow out of the anal canal. He also has rock-hard, enlarged lymph nodes on both groins, some of them as large as 2 cm in diameter. Which of the following is the most likely diagnosis?

33. A 79-year-old man with atrial fibrillation develops an acute abdomen. When seen 2 days after the onset of the abdominal pain, he has a silent abdomen, with diffuse tenderness and mild rebound. There is a trace of blood on the rectal examination. He also has acidosis and looks quite sick. X- ray films show distended small bowel and distended right colon, up to the middle of the transverse colon. Which of the following is the most likely diagnosis?

34. 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?

35. After a grand mal seizure, a 32-year-old epileptic woman notices pain in her right shoulder, and she cannot move it. She goes to a minor emergency clinic, where she has a limited physical examination and anteroposterior (AP) x-ray films of her shoulder. The films are read as negative, and she is diagnosed as having a sprain and given pain medication. The next day, she still has the same pain and is unable to move her arm. She comes to the emergency department holding her arm close to her body, with her hand resting on her anterior chest wall. Which of the following is the most likely diagnosis?

36. A 69-year-old man who smokes and drinks and has rotten teeth, has a hard, fixed, 4-cm mass in his left neck. The mass is just medial to and in front of the sternomastoid muscle, at the level of the upper notch of the thyroid cartilage. It has been there for at least 6 months, and it is growing. Which of the following is the most appropriate next step in diagnosis?

37. On the 5th postoperative day, it is noticed that large amounts of clear, pink, salmon-colored fluid are soaking the wound dressings of a patient who had a negative exploratory laparotomy for a stab wound of the abdomen. The laparotomy was done through a midline supraumbilical and infraumbilical incision. When seen by the surgical staff, the patient is lying in bed in the supine position, with the dressings removed. In the dim light of his hospital room, the incision appears intact and not particularly red or inflamed, but there are indeed traces of the clear pink fluid on his skin. He has no specific complaints. He is still NPO and on IV fluids, but has already been passing gas per rectum, and plans had been made to feed him today. The abdomen is not distended, and he has normal bowel sounds. He is afebrile. Which of the following is the most appropriate next step in management?

38. A 2-year-old child has been shot in the arm in a drive-by shooting. His brachial artery was partially transected, and there was copious bleeding. The EMTs control the site of bleeding by local pressure, and the child is no longer losing blood; however, he is hypotensive and tachycardic. IV fluid resuscitation is urgently needed, but several attempts at starting peripheral IV lines have been unsuccessful. Which of the following would be the best alternative route in this situation?

39. A 24-year-old woman sustains multiple injuries in a car accident, including a pelvic fracture. She is hemodynamically stable. Initial assessment shows no vaginal or rectal injuries; however, when a Foley catheter is inserted, bloody urine is recovered. Which of the following would be the best way to evaluate her urologic injury?

40. A 62-year-old woman has a 4-cm, hard mass under the nipple and areola of her rather small left breast. The mass occupies most of the breast, but the breast is freely movable from the chest wall. There is no dimpling or ulceration of the skin over the mass, and careful palpation of the axilla is completely negative. A core biopsy of the breast mass has established a diagnosis of infiltrating ductal carcinoma, and the mammogram showed no other lesions in that breast or the other one. A chest x-ray film and liver function tests are normal. She has no symptoms suggestive of brain or bone metastasis. Which of the following should be offered to this woman

41. A 54-year-old man, who 5 years ago underwent a laparotomy for a gunshot wound to the abdomen, is admitted to the hospital because of protracted vomiting and progressive abdominal distention. The symptoms began 5 days earlier, and since then he has not had a bowel movement or passed any gas. At the time of hospitalization, he has hyperactive bowel sounds and some abdominal discomfort, but does not have an acute abdomen. His abdominal x-ray films show dilated loops of small bowel, multiple air-fluid levels, and no free air under the diaphragms. He is placed on nasogastric suction and IV fluids. After 6 hours, he develops fever, leukocytosis, abdominal tenderness, and rebound tenderness, and his abdomen is silent. Which of the following is the most appropriate next step in management?

42. While running to catch a bus, and old man twists his ankle and falls on his inverted foot. Anteroposterior (AP), lateral, and mortise x-ray films show displaced fractures of both malleoli. Which of the following would be the preferred form of treatment?

43. 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?

44. A 54-year-old woman is brought to the emergency department after a head-on automobile accident. On arrival, she is breathing well. She has multiple bruises over the chest and multiple sites of point tenderness over the ribs. X-ray films show multiple rib fractures on both sides, but the lung parenchyma is clear, and both lungs are expanded. Two days later she is in respiratory distress, and her lungs "white out" on repeat chest x-ray films. Which of the following is the most likely diagnosis?

45. Renal ultrasound and intravenous pyelography (IVP) in a 65-year-old man evaluated for urinary incontinence reveal bilateral hydronephrosis. Which of the following is the most likely condition leading to this complication?

46. 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?

47. A previously healthy 55-year-old man undergoes elective right hemicolectomy for a stage I (T2N0M0) cancer of the cecum. His postoperative ileus is somewhat prolonged, and on the fifth postoperative day his nasogastric tube is still in place. Physical examination reveals diminished skin turgor, dry mucous membranes, and orthostatic hypotension. Pertinent laboratory values are as follows: Arterial blood gases: pH 7.56, PCO2 50 mm Hg, PO2 85 mm Hg. Serum electrolytes (mEq/L): Na+ 132, K+ 3.1, Cl- 80; HCO-3 42. Urine electrolytes (mEq/L): Na+ 2, K+ 5, Cl- 6. What is the patient’s acid–base abnormality?

48. A 52-year-old man with gastric outlet obstruction secondary to a duodenal ulcer presents with hypochloremic, hypokalemic metabolic alkalosis. Which of the following is the most appropriate therapy for this patient?

49. 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?

50. A 31 -year-old man is brought to the emergency department after a motor vehicle accident. He sustained a severe head injury and, on arrival to the emergency department, has a Glasgow coma score of 8. His blood pressure is stable, and an urgent CT scan of the head reveals a large subdural bleed with evidence of a midline shift and cerebellar tonsillar compression. The patient is breathing spontaneously without any respiratory assistance and is not intubated. Which of the following is the most appropriate next step in management?

51. A 40-year-old retired professional football player complains of the sudden onset of palpitations and shortness of breath 5 days after having knee replacement surgery. His pulse is 100/min and regular. Oxygen saturation is 90% room air. An ECG reveals sinus tachycardia. A chest x-ray film is unremarkable. Which of the following is the most appropriate next step in management?

52. A 19-year-old man is involved in a motorcycle accident in which he sustains a closed fracture of his right femur and a pelvic fracture. In addition to the obvious deformity in his leg, physical examination is remarkable for the presence of a scrotal hematoma and blood at the meatus. There is no blood in the rectal exam, but the prostate cannot be felt. The patient states that he feels the need to void, but cannot do it. Which of the following is the most appropriate next step in diagnosis?

53. A 65-year-old man undergoes a low anterior resection for rectal cancer. On the fifth day in hospital, his physical examination shows a temperature of 39°C (102°F), blood pressure of 150/90 mm Hg, pulse of 110 beats per minute and regular, and respiratory rate of 28 breaths per minute. A computed tomography (CT) scan of the abdomen reveals an abscess in the pelvis. Which of the following most accurately describes his present condition?

54. 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?

55. In the first postoperative day after an open abdominal procedure, a patient develops a temperature of 38.9 C (102 F). He is encouraged to ambulate, cough, and breathe deeply, but he is noncompliant. On the second day, he is still febrile. Incentive spirometry and postural drainage are instituted, but his participation is less than enthusiastic. He lies in bed all day and hardly moves. By the third day, he is still spiking fevers in the same range, although efforts to improve his ventilation continue, resolution of his problem will most likely require which of the following?

56. 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?

57. 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?

58. 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?

59. A 3-year-old boy is brought to the emergency room after spilling bleach onto his lower extremities. He is diagnosed with a chemical burn and all involved clothing are removed. In addition to resuscitation, which of the following is the most appropriate initial management of this patient?

60. 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?

61. Following a weekend of snowmobiling, a 42-year-old man comes to the emergency department with pain, numbness, and discoloration of his right forefoot. You diagnose frostbite. Which of the following is the proper initial treatment?

62. A 23-year-old man is admitted to the hospital after being struck by a motor vehicle. The patient sustained a compound fracture of his left femur in the accident and has had moderate blood loss. He was admitted to the hospital, has been stabilized over the past few days, and is now preparing for physical therapy. His hematocrit is 24%. The man feels weak and fatigued and easily gets short of breath with mild exertion. Which of the following is the most appropriate next step in management?

63. A 24-year-old man comes to the physician 24 hours after sustaining an injury to the right knee while playing soccer. He can walk, but he limps on the right side. He reports that he was hit by another player on the lateral side of his right knee, but did not feel a snap or pop at the time of the accident. On examination, the right knee appears normal, but palpation elicits tenderness along the medial aspect of the joint line. Increased laxity is observed when a valgus stress is applied to the knee flexed at 30 degrees, but not when the knee is in full extension. Lachman's test and posterior drawer tests are negative. Which of the following is the most likely diagnosis?

64. A 54-year-old man sees you because of a growth on his lower lip. He smokes tobacco, has a fair complexion, and works outdoors. The biopsy report confirms a carcinoma. Which of the following is the most common diagnosis for tumors involving the lips?

65. A 40-year-old woman complains of mild, intermittent pain and paresthesias in her right wrist. She reports the pain is worse at night and with driving. On physical examination hyperflexion of the right wrist reproduces the paresthesia. With regard to her diagnosis, which of the following is the most appropriate initial treatment?

66. 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?

67. A 24-year-old woman is brought to the emergency department after being stabbed by her boyfriend. The examining physician notes a 1.5-cm puncture wound lateral to her sternum. She has a blood pressure of 70/palpable, distended neck veins, and muffled heart sounds. Which of the following is the most appropriate next step in management?

68. 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?

69. 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?

70. 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− 24 Serum osmolality: 242 mOsm/L Urine sodium: 47 mEq/L Urine osmolality: 486 mOsm/L Which of the following is the best treatment of his hyponatremia?

71. A 35-year-old man had a splenectomy 8 days ago, following a motor vehicle accident. He is now complaining of left shoulder pain. His temperature is 39.0 C (102.2 F), blood pressure is 110/80 mm Hg, pulse is 110/min, and respirations are 30 min and shallow, Physical examination shows clear lungs with equal breath sounds bilaterally and mild tenderness to palpation in the left upper quadrant with a well-healing midline laparotomy incision. Laboratory studies show: Hemoglobin 15 g/dL Hematocrit 45% Leukocyte counts 15,000/mm3 A chest x-ray film shows no infiltrates or effusions. Which of the following is the most likely diagnosis?

72. A 42-year-old man is diagnosed with an osteosarcoma. His family history is significant for a 37- year-old sister with breast cancer and an uncle with adrenocortical carcinoma. His family physician suspects that he may have Li-Fraumeni syndrome and suggests genetic testing. Which of the following genes is most likely to be mutated if he has the syndrome?

73. 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)?

74. A 22-year-old woman has a known family history of breast cancer in her first-degree relatives. She undergoes genetic testing and is found to be a BRCA1 mutation carrier. She does not currently desire bilateral prophylactic mastectomy. Which of the following is the next best option to manage her risk for breast cancer?

75. 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?

76. A 30-year-old woman comes to the physician 6 hours after falling on her outstretched right hand. She has pain and limitation of movement in her wrist, but denies sensations of tingling or numbness. The right wrist is mildly swollen, and its range of passive motion is limited compared with the left side. Palpation elicits maximal tenderness in the area of the anatomic snuffbox, between the tendons of the extensor pollicis longus and abductor pollicis muscles. Ulnar and radial pulses are normal, and Tinel's and Phalen's tests are negative. Further examination rules out signs of nerve or vascular damage. Plain x-ray films performed in the anteriorposterior, lateral, and oblique views fail to show any evidence of fractures. At this time, which of die following is the most appropriate next step in management?

77. A 72-year-old woman undergoes a partial colectomy for adenocarcinoma of the sigmoid colon. She receives appropriate antibiotic coverage and low-dose heparin prophylaxis. On the 5th hospital day, the patient begins complaining of right chest pain, difficulty in breathing, and dry cough. Her temperature is 37.9 C (100.2 F), blood pressure is 134/78 mm Hg, pulse is 115/min and regular, and respirations are 20/rnin. Examination shows crackles in the right chest, but no tenderness or edema in the legs. A chest x-ray film reveals areas of opacification in the right lung. ECG reveals sinus tachycardia with nonspecific ST changes. Laboratory studies show: Arterial blood gas analysis - PaQ2 74 mm Hg - Pa C 0 2 37 mm Hg - pH 7.35 - Blood/serumHematocrit 40% - Leukocytes 8300/mm3 - Lactate dehydrogenase 350 U/L - Fibrin D-dimer 600 ng/mL (normal upper limit 500 ng/mL) Which of the following is the most appropriate step in diagnosis?

78. A 65-year-old man complains of blood in his urine for the past 2 months. He has had no similar episodes in the past. He is otherwise healthy and denies abdominal pain, any trauma, fever, chills, anorexia, or dysuria. He reports having a good urinary stream and no nocturia or dribbling. He is not sexually active. He has no other medical problems and is not taking any medications. His vital signs are stable. Lung, heart, abdominal, and groin examination are unremarkable. Rectal exam reveals a nontender prostate with no masses or enlargement- Urinalysis reveals packed red cells, a few white cells, and no casts. Which of the following is the most appropriate management?

79. 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?79. 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?

80. 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?

81. A 68-year-old man is admitted to the coronary care unit with an acute myocardial infarction. His postinfarction course is marked by congestive heart failure and intermittent hypotension. On the fourth day in hospital, he develops severe midabdominal pain. On physical examination, blood pressure is 90/60 mm Hg and pulse is 110 beats per minute and regular; the abdomen is soft with mild generalized tenderness and distention. Bowel sounds are hypoactive; stool Hematest is positive. Which of the following is the most appropriate next step in this patient’s management?

82. 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?

83. 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?

84. A pedestrian is hit by a car. Physical examination shows the leg to be angulated midpoint between the knee and the ankle. X-ray films confirm fractures of the shaft of the tibia and fibula. Satisfactory alignment is achieved by external manipulation, and a long leg cast applied. In the ensuing 8 hours, the patient complains of increasing pain. When the cast is removed, the pain persists, the muscle compartments feel tight, and there is excruciating pain with passive extension of the toes. Which of the following is the most appropriate next step in management?

85. A 27-year-old man is shot point blank with a .22-caliber revolver. The entrance wound is in the anterior chest wall, just to the left of the sternal border, at the level of the 4th intercostal space. There is no exit wound. He is diaphoretic, cold, shivering, and anxious, and is asking for a blanket and a drink of water. His blood pressure is 65/40 mm Hg, and his pulse is 145/min and barely perceptible. He has large, distended veins in his neck and forehead. He is breathing adequately and has bilateral breath sounds. He is neurologically intact. Which of the following is the most likely diagnosis?

86. A 75-year-old thin cachectic woman undergoes a tracheostomy for failure to wean from the ventilator. One week later, she develops significant bleeding from the tracheostomy. Which of the following would be an appropriate initial step in the management of this problem?

87. 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?

88. A 19-year-old man receives un-cross-matched blood during resuscitation after a gunshot wound to the abdomen. He develops fever, tachycardia, and oliguria during the transfusion and is diagnosed as having a hemolytic reaction. Which of the following is the most appropriate next step in the management of this patient?

89. 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?

90. A 61-year-old alcoholic man presents with severe epigastric pain radiating to his back. His amylase and lipase are elevated, and he is diagnosed with acute pancreatitis. Over the first 48 hours, he is determined to have 6 Ranson’s criteria, including a PaO 2 less than 60 mm Hg. His chest x-ray reveals bilateral pulmonary infiltrates, and his wedge pressure is low. Which of the following criteria must be met to make a diagnosis of adult respiratory distress syndrome (ARDS)?

91. A 50-year-old man has respiratory failure due to pneumonia and sepsis after undergoing splenectomy for a traumatic injury. Which of the following management strategies will improve tissue oxygen uptake (ie, shifting the oxygen dissociation curve, depicted here, to the right)?

92. A 64-year-old man with history of severe emphysema is admitted for hematemesis. The bleeding ceases soon after admission, but the patient becomes confused and agitated. Arterial blood gases are as follows: pH 7.23; PO2 42 mm Hg; PCO2 75 mm Hg. Which of the following is the best initial therapy for this patient?

93. A 62-year-old woman has an eczematoid lesion in the areola of her right breast that has been present for 3 months. She has self-medicated with skin lotions and over-the-counter steroid ointments, but the area has not improved. On physical examination, the nipple is inverted, the skin of the areola is reddish and desquamated, and the entire area feels firm, with no discrete mass demarcated from the rest of the breast. Which of the following is the most appropriate next step in management?

94. 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?

95. A 74-year-old man presents with sudden onset of extremely severe, tearing precordial chest pain that radiates to the back and migrates downward shortly after its onset. As far as the man can tell, there was no precipitating event. He is seen within an hour and is in obvious distress. He is afebrile, but his blood pressure is 220/110 mm Hg and his pulses in the upper extremities are unequal at 102/min. Chest x-ray shows a wide mediastinum. Which of the following could best establish the diagnosis?

96. A 16-year-old adolescent boy with a history of severe hemophilia A is undergoing an elective inguinal hernia repair. Which of the following is the best option for preventing or treating a bleeding complication in the setting of this disease?

7. A 59-year-old man is planning to undergo a coronary artery bypass. He has osteoarthritis and consumes nonsteroidal anti-inflammatory drugs (NSAIDs) for the pain. Which of the following is the most appropriate treatment prior to surgery to minimize his risk of bleeding from his NSAID use?

98. A 63-year-old man undergoes a partial gastrectomy with Billroth II reconstruction for intractable peptic ulcer disease. He presents several months postoperatively with a megaloblastic anemia. Which of the following is the best treatment for this surgical complication?

99. A 52-year-old woman undergoes a sigmoid resection with primary anastomosis for recurrent diverticulitis. She returns to the emergency room 10 days later with left flank pain and decreased urine output; laboratory examination is significant for a white blood cell (WBC) count of 20,000/mm3. She undergoes a CT scan that demonstrates new left hydronephrosis, but no evidence of an intra-abdominal abscess. Which of the following is the most appropriate next step in management?

100. A 23-year-old woman undergoes total thyroidectomy for carcinoma of the thyroid gland. On the second postoperative day, she begins to complain of a tingling sensation in her hands. She appears quite anxious and later complains of muscle cramps. Which of the following is the most appropriate initial management strategy?

101. 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?

102. 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?

103. 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 margin recommended for excision?

104. 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?

105. A 63-year-old man with history of poorly controlled diabetes presents with right leg swelling and pain. The patient denies trauma to the leg and reports it was normal yesterday. Examination of the right lower extremity is significant for extreme tenderness to palpation, erythema, and edema extending up to the knee. X ray of the right leg shows tissue swelling without gas or osteomyelitis. The patient’s vital signs are normal and he is started on broad- spectrum IV antibiotics and insulin. An hour later the patient’s heart rate increases to 125 beats per minute and the erythema has progressed to the thigh with new blister formation on the leg. Which of the following is the most appropriate next step in management?

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

107. 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?

109. A 25-year-old man is brought to the emergency room after sustaining burns during a fire in his apartment. He has blistering and erythema of his face, left upper extremity, and chest. He also has circumferential frank charring of his right upper extremity with decreased capillary refill. He is agitated, hypotensive, and tachycardic. Which of the following is the most appropriate initial management of his wounds?

110. A 24-year-old firefighter sustains 30% total body surface area (TBSA) burns to his torso, face, and extremities. His wounds are treated topically with silver nitrate. Which of the following complications is associated with use of this agent?

111. A 25-year-old man is shot with a .22 caliber revolver. The entrance wound is in the anteromedial aspect of his upper thigh, 5 cm below the groin crease. The exit wound is in the posterolateral aspect of the thigh, half way between the greater trochanter and the knee. He has palpable pulses in the dorsum of his foot and in the posterior tibial artery behind the malleolus. The popliteal pulse is reported normal by one examiner, but cannot be felt by another. There is no hematoma under the entrance wound, and blood is oozing from both wounds but not at an alarming rate. He is hemodynamically stable. Neurologic examination of the leg is normal. X-ray films show the femur to be intact. In addition to local wound care and the appropriate tetanus prophylaxis, which of the following is the most appropriate next step in management?

112. A 62-year-old man with alcoholic cirrhosis of the Uver and ascites presents with generalized abdominal pain that started 12 hours ago. He now has moderate tenderness over the entire abdomen, with minimal guarding and equivocal rebound. Bowel sounds are diminished but present. He has a temperature of 38.4 C (101.2 F) and a leukocyte count of 11,000/mm3. Although he used to be a heavy drinker, he has not touched a drop of alcohol for the past 7 years. Except for the presence of ascites, upright and flat x-ray films of the abdomen are unremarkable. Which of the following is the most appropriate next step in diagnosis?

113. A 56-year-old man presents with progressive jaundice that he first noted 6 weeks ago. The patient has lost about 20 pounds over the past 2 months and he has persistent, nagging pain deep into his epigastrium and upper back. Except for the obvious jaundice and the signs of weight loss, physical examination is remarkable only for the presence of a vaguely palpable, nontender mass under the liver edge. His hemoglobin is 14 g/dL, and there is no occult blood in the stool. Total bilirubin is 22 mg/dL, with 16 mg/dL direct (conjugated) fraction. The transaminases are minimally elevated, whereas the alkaline phosphatase is about 8 times the upper limit of normal. A sonogram shows dilated intrahepatic ducts, dilated extrahepatic ducts, and a very distended, thinwalled gallbladder without stones. Which of the following is the most appropriate next step in diagnosis?

114. A 31-year-old accounting student presents with a persistent headache that began approximately 4 months ago. The headache has been gradually increasing in intensity, and is worse in the mornings. Thinking that she might need new glasses, she sought help from her optometrist, who discovered that she has bilateral papilledema and sent her in for medical evaluation. On direct questioning, she admits to repeat vomiting for the past 3 weeks, with no heaving, straining, or preceding nausea. "I would just open my mouth, and the stuff would hit the wall," she explains. She denies any other neurological symptoms. Which of the following is the most likely diagnosis?

115. 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?

116. 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?

117. A brain-dead potential donor has become available. You must plan for the dispersal of the thoracic organs. Which of the following will necessitate a heart-lung transplant?

118. A 35-year-old man who has had type 1 diabetes for many years undergoes a pancreas transplant with enteric drainage (connection of the donor duodenum to the recipient jejunum). Postoperatively, he has increased pain near his pancreas transplant. Which of the following should be performed to confirm a diagnosis of rejection?

119. 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?

120. A 12-year-old boy with a femur fracture after a motor vehicle collision undergoes operative repair. After induction of anesthesia, he develops a fever of 40°C (104°F), shaking rigors, and blood-tinged urine. Which of the following is the best treatment option?

21. 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?

123. 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?

124. 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+: 128 K+: 3.0 Cl−: 102 HCO3-: 20 Which of the following statements is the best strategy for correcting her acid–base disorder?

125. 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?

126. 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?

127. A 27-year-old man was assaulted and stabbed on the left side of the chest between the areola and the sternum. He is hemodynamically unstable with jugular venous distention, distant heart sounds, and hypotension. Which of the following findings would be consistent with a diagnosis of hemodynamically significant cardiac tamponade?

128. A 55-year-old woman requires an abdominoperineal operation for rectal cancer. She has a history of stable angina. Which of the following clinical markers is most likely to predict a cardiac event during her noncardiac surgery and should prompt further cardiac workup prior to her operation?

129. 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?

130. A 22-year-old man sustains severe blunt trauma to the back. He notes that he cannot move his lower extremities. He is hypotensive and bradycardic. Which of the following is the best initial management of the patient?

131. A 58-year-old woman with multiple comorbidities and previous cardiac surgery is in a high-speed motor vehicle collision. She is intubated for airway protection. Because of hemodynamic instability, a central venous catheter is placed in the right subclavian vein. While the surgeon is securing the catheter, the cap becomes displaced and air enters the catheter. Suddenly, the patient becomes tachycardic and hypotensive. What is the best next maneuver?

132. An 18-year-old man was traveling at a high speed when his car slammed into a wall. He is brought into the emergency department by ambulance. His blood pressure is 60/40 mmHg, pulse is 115/min and weak, respirations are 18/min, and central venous pressure is 2 cmH2O. He is responsive only to painful stimuli. Breath sounds are equal bilaterally, and cardiac auscultation reveals only tachycardia. The abdomen is soft, nondistended, and nontender with active bowel sounds. A chest x-ray film shows a widened mediastinum. Which of the following is the most likely diagnosis?

133. A 22-year-old woman is taken to the emergency department after she injures her foot. She had been standing on a chair changing a light bulb, when she accidentally stepped off the chair backward. She heard a cracking sound when she fell and developed pain and swelling behind the ankle. Her symptoms worsened when she tried to descend the stairs in her house. Physical examination demonstrates marked swelling behind her ankle, and her pain is exacerbated by plantar flexion and dorsiflexion of the hallus. Which of the following is the most likely diagnoses?

134. 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 an 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?

135. A 14-year-old boy presents in the emergency department with very severe pain of sudden onset in his right testicle. There is no history of either trauma or recent mumps. He is afebrile, and a urinalysis shows no pyuria. The testis is swollen, exquisitely painful, high in the scrotum, and riding in a horizontal position. The cord above the testis is not tender. Which of the following is the most appropriate next step in management?

136. 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?

137. An 11-year-old girl presents to your office because of a family history of medullary carcinoma of the thyroid. Physical examination is normal. Which of the following tests should you perform?

138. 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?

139. 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?

140. 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?

141. A 29141. A 29-year-old woman on oral contraceptives presents with abdominal pain. A computed tomography (CT) scan of the abdomen demonstrates a large hematoma of the right liver with the suggestion of an underlying liver lesion. Her hemoglobin is 6, and she is transfused 2 units of packed red blood cells and 2 units of fresh frozen plasma. Two hours after starting the transfusion, she develops respiratory distress and requires intubation. She is not volume overloaded clinically, but her chest x-ray shows bilateral pulmonary infiltrates. Which of the following is the management strategy of choice?-year-old woman on oral contraceptives presents with abdominal pain. A computed tomography (CT) scan of the abdomen demonstrates a large hematoma of the right liver with the suggestion of an underlying liver lesion. Her hemoglobin is 6, and she is transfused 2 units of packed red blood cells and 2 units of fresh frozen plasma. Two hours after starting the transfusion, she develops respiratory distress and requires intubation. She is not volume overloaded clinically, but her chest x-ray shows bilateral pulmonary infiltrates. Which of the following is the management strategy of choice?141. A 29-year-old woman on oral contraceptives presents with abdominal pain. A computed tomography (CT) scan of the abdomen demonstrates a large hematoma of the right liver with the suggestion of an underlying liver lesion. Her hemoglobin is 6, and she is transfused 2 units of packed red blood cells and 2 units of fresh frozen plasma. Two hours after starting the transfusion, she develops respiratory distress and requires intubation. She is not volume overloaded clinically, but her chest x-ray shows bilateral pulmonary infiltrates. Which of the following is the management strategy of choice?

142. A 68-year-old hypertensive man undergoes successful repair of a ruptured abdominal aortic aneurysm. He receives 9 L Ringer lactate solution and 4 units of whole blood during the operation. Two hours after transfer to the surgical intensive care unit, the following hemodynamic parameters are obtained: systemic blood pressure (BP) 90/60 mm Hg, pulse 110 beats per minute, central venous pressure (CVP) 7 mm Hg, pulmonary artery pressure 28/10 mm Hg, pulmonary capillary wedge pressure (PCWP) 8 mm Hg, cardiac output 1.9 L/min, systemic vascular resistance 1400 (dyne·s)/cm5 (normal is 900-1300), PaO2 140 mm Hg (FiO2: 0.45), urine output 15 mL/h (specific gravity: 1.029), and hematocrit 35%. Given this data, which of the following is the most appropriate next step in management?

143. A 59-year-old man with a history of myocardial infarction 2 years ago undergoes an uneventful aortobifemoral bypass graft for aortoiliac occlusive disease. Six hours later he develops ST segment depression, and a 12-lead electrocardiogram (ECG) shows anterolateral ischemia. His hemodynamic parameters are as follows: systemic BP 70/40 mm Hg, pulse 100 beats per minute, CVP 18 mm Hg, PCWP 25 mm Hg, cardiac output 1.5 L/min, and systemic vascular resistance 1000 (dyne·s)/cm5. Which of the following is the single best pharmacologic intervention for this patient?

144. A 56-year-old man undergoes a left upper lobectomy. An epidural catheter is inserted for postoperative pain relief. Ninety minutes after the first dose of epidural morphine, the patient complains of itching and becomes increasingly somnolent. Blood-gas measurement reveals the following: pH 7.24, PaCO2 58, PaO2 100, and HCO3− 28. Which of the following is the most appropriate initial therapy for this patient?

145. A 71-year-old man returns from the operating room (OR) after undergoing a triple coronary bypass. His initial cardiac index is 2.8 L/ (min·m 2). Heart rate is then noted to be 55 beats per minute, BP is 110/80 mm Hg, wedge pressure is 15, and his cardiac index has dropped to 1.6 L/(min·m2). He has a normal left ventricle. Which of the following maneuvers will increase his cardiac output?

146. Eight days after a difficult hemigastrectomy and gastroduodenostomy for gastric ulcer, a patient begins to leak 2-3 L of greenish fluid per day through the right corner of his bilateral subcostal surgical incision. He is afebrile and has no clinical signs of an acute abdomen. At surgery, a feeding catheter jejunostomy was placed, through which the patient has been receiving 3 L/day of elemental diet with a caloric content of 1 cal per mL, and 1 g nitrogen per 100 cal. The nursing staff has rigged a very effective collection device for the fluid that is leaking through the wound, and the skin around the site is well protected. Which of the following is the most appropriate next step in management?

147. 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?

148. Six hours after undergoing laparoscopic bilateral inguinal hernia repairs, a 62-year-old man complains of suprapubic discomfort and fullness. He feels the need to void but has not been able to do so since the operation. There is a palpable suprapubic mass that is dull to percussion. Palpation of that mass exacerbates the symptoms. Which of the following is the most appropriate next step in management?

149. A 49-year-old man crashes his car against a bridge abutment at high speed. On arrival at the emergency department, he is breathing well, but he has multiple bruises over the chest, and there is a specific spot at about the middle of the sternum that is exquisitely painful to touch. Gentle palpation of that area elicits a gritty feeling of bone grating on bone. He distinctly recalls hitting the steering wheel with his chest and is certain that he hurt that particular spot in that manner. Anteroposterior and lateral chest x-ray films confirm that he has a sternal fracture. The films do not show any mediastinal widening or mediastinal air, and both lung fields are clear. His vital signs are normal, and he does not have subcutaneous emphysema. Which of the following studies is most likely to show evidence of additional injuries?

150. A 60-year-old man complains of anal itching and discomfort, particularly toward the end of the day. He works as a salesman in a department store, where he has to be on his feet all day. When he goes home in the evening, he finds himself sitting sideways to avoid the discomfort. He has no fever, rectal bleeding, or soiling of his underwear, and he has never had surgery in that area. Which of the following is the most likely diagnosis?

151. An 18-year-old previously healthy man is placed on intravenous heparin after having a pulmonary embolism (PE) after exploratory laparotomy for a small-bowel injury following a motor vehicle collision. Five days later, his platelet count is 90,000/μL and continues to fall over the next several days. The patient’s serum is positive for antibodies to the heparin-platelet factor complexes. Which of the following is the most appropriate next management step?

152. 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?

153. A 65-year-old woman has a life-threatening pulmonary embolus 5 days following removal of a uterine malignancy. She is immediately heparinized and maintained in good therapeutic range for the next 3 days, then passes gross blood from her vagina and develops tachycardia, hypotension, and oliguria. Following resuscitation, an abdominal CT scan reveals a major retroperitoneal hematoma. Which of the following is the best next step in management?

154. A 71-year-old man develops dysphagia for both solids and liquids and weight loss of 60 lb over the past 6 months. He undergoes endoscopy, demonstrating a distal esophageal lesion, and biopsies are consistent with squamous cell carcinoma. He is scheduled for neoadjuvant chemoradiation followed by an esophagectomy. Preoperatively he is started on total parenteral nutrition, given his severe malnutrition reflected by an albumin of less than 1. Which of the following is most likely to be a concern initially in starting total parenteral nutrition in this patient?

155. 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?

156. A 33-year-old diabetic man receives a renal allograft. The physicians choose cyclosporine as one of the antirejection medications. Which of the following functions does cyclosporine A primarily inhibit?

157. A 24-year-old woman presents with lethargy, anorexia, tachypnea, and weakness. Laboratory studies reveal a BUN of 150 mg/dL, serum creatinine of 16 mg/dL, and potassium of 6.2 mEq/L. Chest x-ray shows increased pulmonary vascularity and a dilated heart. Which of the following is the most appropriate management of this patient?

158. A hypertensive 47-year-old man is proposed for kidney transplantation. He is anemic but is otherwise functional. Which of the following would preclude renal transplantation?

159. A 56-year-old woman is undergoing a cadaveric renal transplant. After revascularization of the transplanted kidney, the transplanted renal parenchyma becomes swollen and blue. The surgeon suspects hyperacute rejection. What is the treatment of choice for this patient?

160. 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?

161. A 38-year-old woman who underwent a cadaveric renal transplant 8 years ago presents with fevers, fatigue, and weight loss. Evaluation included CT scans of the head, neck, chest, abdomen, and pelvis; she is noted to have diffuse lymphadenopathy and pulmonary nodules. A biopsy and histologic examination of a lymph node is performed. Which of the following viruses is most likely to be present in the lymph node?

162. A 41-year-old man underwent a successful living-related kidney transplantation 1 year ago with good results. Preoperatively, he was noted to have an elevated calcium level; post-transplantation, he continues to have elevated calcium levels and associated symptoms. Which of the following is the most appropriate next step in management?

163. A 53-year-old man presents with constipation and a 20-lb weight loss over the course of 6 months. Colonoscopy reveals a fungating mass in the sigmoid colon; biopsy is consistent with adenocarcinoma. His metastatic workup is negative. A CEA level is obtained and is 4-fold greater than normal. Which of the following is the appropriate use of this test?

164. An elderly diabetic woman with chronic steroid-dependent bronchospasm has an ileocolectomy for a perforated cecum. She is taken to the ICU intubated and is maintained on broad-spectrum antibiotics, renal dose dopamine, and a rapid steroid taper. On postoperative day 2, she develops a fever of 39.2°C (102.5°F), hypotension, lethargy, and laboratory values remarkable for hypoglycemia and hyperkalemia. Which of the following is the most likely explanation for her deterioration?

165. A cirrhotic patient with abnormal coagulation studies due to hepatic synthetic dysfunction requires an urgent cholecystectomy. A transfusion of FFP is planned to minimize the risk of bleeding due to surgery. What is the optimal timing of this transfusion?

166. On postoperative day 5, an otherwise healthy 55-year-old man recovering from a partial hepatectomy is noted to have a fever of 38.6°C (101.5°F). Which of the following is the most common nosocomial infection postoperatively?

167. Ten days after an exploratory laparotomy and lysis of adhesions, a patient, who previously underwent a low anterior resection for rectal cancer followed by postoperative chemoradiation, is noted to have succus draining from the wound. She appears to have adequate source control—she is afebrile with a normal white blood count. The output from the fistula is approximately 150 cc per day. Which of the following factors is most likely to prevent closure of the enterocutaneous fistula?

168. A 62-year-old, right-handed man has transient episodes of paralysis of the right arm and inability to express himself. There is no associated headache. The episodes have sudden onset, last about 5-10 minutes, and leave no neurologic sequela. The patient is overweight and sedentary. He smokes one pack of cigarettes per day and has high cholesterol, but he is not hypertensive. The only abnormality in the physical examination is a bruit over the left carotid bifurcation. Which of the following is the most appropriate initial step in diagnosis?

169. Eight hours after undergoing a transnasal, transsphenoidal resection of a prolactinoma, a young lady becomes lethargic, confused, and eventually comatose. Review of the record shows that her urinary output since surgery has averaged 600 mL/hr, while her intake of IV fluids (5% dextrose in 0.45% saline) has been 100 mL/hr. Her blood pressure is 110/75 mm Hg, and her pulse is 88/min. Which of the following would most likely yield the correct diagnosis?

170. A 42-year-old man has had a rocky course for the 3 days following a bowel resection for intestinal perforation due to inflammatory bowel disease. His CVP had been 12 to 14 but is now 6, in the face of diminished blood pressure and oliguria. Which of the following is the most likely etiology of his hypotension?

171. Acute renal failure occurs following aortic angiography in a 72-year-old man. His weight has been rising, his lungs show rales at both bases, and he is dyspneic. His fractional excretion of sodium is greater than 1. He has eosinophilia on his peripheral smear, an elevated erythrocyte sedimentation rate, and proteinuria with microscopic hematuria. Which of the following is the most likely cause of his renal failure?

172. 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?

173. 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?

174. 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?

175. A 26-year-old man is resuscitated with packed red blood cells following a motor vehicle collision complicated by a fractured pelvis and resultant hemorrhage. A few hours later the patient becomes hypotensive with a normal central venous pressure (CVP), oliguric, and febrile. Upon examination, the patient is noted to have profuse oozing of blood from his intravenous (IV) sites. Which of the following is the most likely diagnosis?

176. 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?

177. 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?

178. A 72-year-old man undergoes a subtotal colectomy for a cecal perforation due to a sigmoid colon obstruction. He has had a prolonged recovery and has been on total parenteral nutrition (TPN) for 2 weeks postoperatively. After regaining bowel function, he experienced significant diarrhea. Examination of his abdominal wound demonstrates minimal granulation tissue. He complains that he has lost his taste for food. He also has increased hair loss and a new perioral pustular rash. Which of the following deficiencies does he most likely have?

179. A 45-year-old woman undergoes an uneventful laparoscopic cholecystectomy for which she receives 1 dose of cephalosporin. One week later, she returns to the emergency room with fever, nausea, and copious diarrhea and is suspected of having pseudomembranous colitis. She is afebrile and has no peritoneal signs on abdominal examination. She has a mild leukocytosis with a left shift. Which of the following is the appropriate initial management strategy?

180. An 18-year-old woman develops urticaria and wheezing after an injection of intravenous contrast for an abdominal CT scan. Her blood pressure is 120/60 mm Hg, heart rate is 155 beats per minute, and respiratory rate is 30 breaths per minute. Which of the following is the most appropriate immediate therapy?

181. A patient develops a fever and tachycardia during a blood transfusion after a redo coronary artery bypass procedure. The nurse subsequently discovers that there was a mix-up in the cross-match because of a labeling error. Which of the following is diagnostic in a patient with an immediate hemolytic reaction secondary to a blood transfusion?

182. 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?

183. An obese 50-year-old woman undergoes a laparoscopic cholecystectomy. In the recovery room, she is found to be hypotensive and tachycardic. Her arterial blood gases reveal a pH of 7.29, PaO2 of 60 mm Hg, and PaCO2 of 54 mm Hg. Which of the following is the most likely cause of this patient’s problem?

184. A 65-year-old man who had a 25-lb weight loss over the previous 6 months is diagnosed with adenocarcinoma of the distal esophagus. He undergoes a transhiatal esophagectomy complicated by a cervical leak. He is receiving enteral feeds through a jejunostomy tube. After a week, his physicians wish to assess his nutritional resuscitation. Which of the following is the most accurate measure of adequacy of his nutritional support?

185. A 47-year-old man with hypertensive nephropathy develops fever, graft tenderness, and oliguria 4 weeks following cadaveric renal transplantation. Serum creatinine is 3.1 mg/dL. A renal ultrasound reveals mild edema of the renal papillae but normal flow in both the renal artery and the renal vein. Nuclear scan demonstrates sluggish uptake and excretion. Which of the following is the most appropriate next step?

186. Approximately 6 weeks following a kidney transplant, a 59-year-old woman develops fever, malaise, and myalgias and is found to have a cytomegalovirus (CMV) infection. Which of the following is a potential sequela of CMV infection?

187. A kidney transplant recipient presents with severe acute rejection that does not respond to steroid treatment. Administration of which of the following agents is the best step in her management?

188. A 24-year-old woman develops moderate, generalized abdominal pain of sudden onset and shortly thereafter faints. At the time of evaluation in the emergency department, she has regained consciousness, is pale, and has a blood pressure of 95/70 mm Hg and a faint pulse rate of 90/min. The abdomen is mildly distended and tender, with normal bowel sounds. Her hemoglobin is 7 g/dL. There is no history of trauma, but it is suspected that she might be bleeding into her abdomen, and a diagnostic peritoneal lavage is performed. The study shows that there is free blood in the peritoneal cavity. She denies the possibility of pregnancy because she has been on birth control pills since the age of 14 and has never missed taking them. Pelvic examination is normal, and a pregnancy test is negative. At laparotomy, the surgeons are likely to find which of the following?

189. A 56-year-old man presents to his urologist for continued evaluation of hypertension and hematuria. The patient has a 10-year history of hypertension and recent onset of painless hematuria for which he sought the attention of an urologist 3 months ago. On detailed questioning, the man states that he has been having severe headaches that are refractory to narcotic analgesics. Three days ago, a renal ultrasound was obtained that demonstrated bilaterally enlarged kidneys with multiple cysts. Which of the following is the most appropriate next step in diagnosis?

190. A patient involved in a high-speed automobile collision arrives in the emergency department unconscious, with multiple facial fractures; brisk bleeding into his nose, mouth, and throat; and gurgly, irregular, noisy breathing. Which of the following would be the best method to secure an airway in this patient?

191. A 30-year-old man is scheduled for a laparoscopic cholecystectomy for biliary colic. He reports a family history of prolonged paralysis during general anesthesia. Which of the following medications should be avoided during his procedure?

192. A 63-year-old man with multiple rib fractures and a pulmonary contusion requires prolonged intubation. He is unable to be weaned from the ventilator and is on a volume control mode. He has a tracheostomy and a percutaneous gastrotomy in place through which he is being fed. The surgeon orders a respiratory quotient (RQ), which is the ratio of the rate of carbon dioxide production over the rate of oxygen uptake. The RQ is 1. Based on this information, which of the following is the next step in his management?

193. A 22-year-old woman is involved in a major motor vehicle accident and receives a tracheostomy during her hospitalization. Five days after placement of the tracheostomy she has some minor bleeding around the tracheostomy site. Which of the following is the most appropriate immediate therapy?

194. A 42-year-old man is undergoing chemotherapy after resection of a cecal adenocarcinoma with positive lymph nodes. You are asked to see him regarding a potential surgical complication. Which of the following potentially operable complications is a common occurrence among patients receiving systemic chemotherapy?

195. 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?

196. A 25-year-old woman with end-stage renal disease is exploring the benefits of renal transplantation. Which of the following is an advantage of dialysis over renal transplantation?

197. A 30-year-old previously healthy man presents with refractory hypertension on four medications. Urinalysis is positive for metanephrines. He was adopted as an infant and therefore does not know his family history. Which of the following inherited syndromes is not associated with this disease?

198. A 48-year-old man with alcoholic cirrhosis has several episodes of massive hematemesis. Upper gastrointestinal endoscopy confirms that he is bleeding from esophageal varices. Sclerosing injections fail to control the bleeding. After the patient has been transfused 7 units of packed red cells, he is subjected to an emergency side-to-side portacaval shunt. At the time of surgery he has a serum albumin level of 3.1 g/dL, a total bilirubin of 1,7 mg/dL, and a prothrombin time (PT) 2 seconds above the control After surgery, the bleeding stops, and the patient wakes up briefly from the anesthetic but then lapses into a coma. The reason for his neurologic deterioration would most likely be revealed by a laboratory determination of which of the following?

199. A 57-year-old man is returned to the post-surgical recovery unit after an open cholecystectomy. The patient had an uneventful, but prolonged, operative course in a very cold operating room. His past medical history is unremarkable. The only attempt at patient warming was raising the ambient temperature of the room. His urine output since arrival in the post-anesthesia care unit (PACU) has been 5 mL/hr. Which of the following is most likely to confirm the diagnosis?

200. 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?

201. A 55-year-old man is diagnosed with benign prostatic hyperplasia. The patient declines pharmacologic treatment and elects to undergo transurethral resection of the prostate (TURP). Which of the following is the most common complication of this procedure?

202. A 33-year-old woman is brought to the emergency room from the scene of a severe motor vehicle accident. She is combative, confused, uncooperative, and appear dusky and dyspneic. Which of the following is the most appropriate management of her airway?

203. 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?

204. Following pelvic gynecologic surgery, a 34-year-old woman becomes dyspneic, her peripheral arterial O2 saturation falls from 94% to 81%, and her measured PaO2 is 52 on a 100% non-rebreather mask. She is hemodynamically stable. A CT angiogram is consistent with a right lower lobe pulmonary embolus. Which of the following is the next step in her management?

205. 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?

206. A 42-year-old man who was in a house fire is transferred to your burn unit. He has singed nose hairs and facial burns. Direct laryngoscopy in the emergency room demonstrates pharyngeal edema and mucosal sloughing. He has 60% total body surface area burns. Which of the following is the next step in the management of this patient?

207. A 24-year-old man presents in septic shock from an empyema. He is febrile to 103°F, tachycardic in the 120s, and hypotensive to the 90s. His oxygen saturation is 98% on 2-L oxygen. His white blood cell count is 25,000/mL and creatinine is 0.8 mg/dL. His blood pressure does not respond to fluid administration despite a CVP of 15. Which of the following therapies is indicated in managing this patient?

208. 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?

209. 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?

210. 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?

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

212. 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?

213. A 70-year-old man is concerned when his dentist finds a white patch on his oral mucosa during a routine examination. Proper management should include which of the following?

214. 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?

214. 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?

214. 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?

215. 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 are normal. Which of the following is the most appropriate next step in her management?

215. 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 are normal. Which of the following is the most appropriate next step in her management?

215. 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 are normal. Which of the following is the most appropriate next step in her management?

216. A 22-year-old healthy African-American woman presents with a recurrent growth on her right thigh. She has a childhood history of a third-degree scald burn to the same area that did not require skin grafting. The growth was completely removed 2 years ago. On physical examination there is a 5 cm × 2 cm, raised, irregularly shaped purple lesion with a smooth top. Which of the following is the most likely diagnosis?

216. A 22-year-old healthy African-American woman presents with a recurrent growth on her right thigh. She has a childhood history of a third-degree scald burn to the same area that did not require skin grafting. The growth was completely removed 2 years ago. On physical examination there is a 5 cm × 2 cm, raised, irregularly shaped purple lesion with a smooth top. Which of the following is the most likely diagnosis?

216. A 22-year-old healthy African-American woman presents with a recurrent growth on her right thigh. She has a childhood history of a third-degree scald burn to the same area that did not require skin grafting. The growth was completely removed 2 years ago. On physical examination there is a 5 cm × 2 cm, raised, irregularly shaped purple lesion with a smooth top. Which of the following is the most likely diagnosis?

217. A 49-year-old woman undergoes surgical resection of a malignancy. The family asks about the prognosis. The histopathology is available for review. For which of the following malignancies does histologic grade best correlate with prognosis?

217. A 49-year-old woman undergoes surgical resection of a malignancy. The family asks about the prognosis. The histopathology is available for review. For which of the following malignancies does histologic grade best correlate with prognosis?

217. A 49-year-old woman undergoes surgical resection of a malignancy. The family asks about the prognosis. The histopathology is available for review. For which of the following malignancies does histologic grade best correlate with prognosis?

218. A mother notices an abdominal mass in her 3-year-old son while giving him a bath. There is no history of any symptoms, but the boy’s blood pressure is elevated at 105/85 mm Hg. Metastatic workup is negative and the patient is explored. The mass shown here is found within the left kidney. Genetic testing reveals deletion of 2 genes on chromosome band 11p13. Which of the following anomalies in addition to the identified tumor is associated with these chromosomal deletions?

218. A mother notices an abdominal mass in her 3-year-old son while giving him a bath. There is no history of any symptoms, but the boy’s blood pressure is elevated at 105/85 mm Hg. Metastatic workup is negative and the patient is explored. The mass shown here is found within the left kidney. Genetic testing reveals deletion of 2 genes on chromosome band 11p13. Which of the following anomalies in addition to the identified tumor is associated with these chromosomal deletions?

218. A mother notices an abdominal mass in her 3-year-old son while giving him a bath. There is no history of any symptoms, but the boy’s blood pressure is elevated at 105/85 mm Hg. Metastatic workup is negative and the patient is explored. The mass shown here is found within the left kidney. Genetic testing reveals deletion of 2 genes on chromosome band 11p13. Which of the following anomalies in addition to the identified tumor is associated with these chromosomal deletions?

219. A 61-year-old man undergoes upper endoscopy for evaluation of weight loss and is identified to have a submucosal mass in the stomach. Biopsy is consistent with a gastrointestinal stromal tumor (GIST). Workup reveals the presence of liver metastases. Which of the following is the best initial treatment for this patient?

219. A 61-year-old man undergoes upper endoscopy for evaluation of weight loss and is identified to have a submucosal mass in the stomach. Biopsy is consistent with a gastrointestinal stromal tumor (GIST). Workup reveals the presence of liver metastases. Which of the following is the best initial treatment for this patient?

219. A 61-year-old man undergoes upper endoscopy for evaluation of weight loss and is identified to have a submucosal mass in the stomach. Biopsy is consistent with a gastrointestinal stromal tumor (GIST). Workup reveals the presence of liver metastases. Which of the following is the best initial treatment for this patient?

220. A 57-year-old woman develops bony metastases 1 year after right modified radical mastectomy for breast cancer. The tumor was estrogen receptor-negative, progesterone receptor-negative, and Her-2/neu positive. Which of the following agents is indicated for treatment of her metastatic disease?

220. A 57-year-old woman develops bony metastases 1 year after right modified radical mastectomy for breast cancer. The tumor was estrogen receptor-negative, progesterone receptor-negative, and Her-2/neu positive. Which of the following agents is indicated for treatment of her metastatic disease?

220. A 57-year-old woman develops bony metastases 1 year after right modified radical mastectomy for breast cancer. The tumor was estrogen receptor-negative, progesterone receptor-negative, and Her-2/neu positive. Which of the following agents is indicated for treatment of her metastatic disease?

221. A 61-year-old man with severe three-vessel coronary disease and diabetes mellitus is scheduled for abdominal surgery. The patient has a long history of coronary disease and had a q-wave myocardial infarction 2 years ago. He has had type 1 diabetes mellitus for 12 years. His medications include atenolol, insulin, and captopril. His last hemoglobin Alc, 3 months ago, was 9.2%. Which of the following is the most predictive of a perioperative complication in this patient?

221. A 61-year-old man with severe three-vessel coronary disease and diabetes mellitus is scheduled for abdominal surgery. The patient has a long history of coronary disease and had a q-wave myocardial infarction 2 years ago. He has had type 1 diabetes mellitus for 12 years. His medications include atenolol, insulin, and captopril. His last hemoglobin Alc, 3 months ago, was 9.2%. Which of the following is the most predictive of a perioperative complication in this patient?

221. A 61-year-old man with severe three-vessel coronary disease and diabetes mellitus is scheduled for abdominal surgery. The patient has a long history of coronary disease and had a q-wave myocardial infarction 2 years ago. He has had type 1 diabetes mellitus for 12 years. His medications include atenolol, insulin, and captopril. His last hemoglobin Alc, 3 months ago, was 9.2%. Which of the following is the most predictive of a perioperative complication in this patient?

222. 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?

222. 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?

222. 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?

223. A 26-year-old, drug-addicted man develops congestive heart failure over a period of a few days. He is febrile, has a loud, diastolic murmur at the right second intercostal space, and has a blood pressure of 120/20 mmHg. A physical examination performed a few weeks ago, when he attempted to enroll in a detoxification program, was completely normal. His blood pressure at that time was 120/80 mm Hg, and no murmurs were noted. In addition to long-term antibiotic therapy, which of the following is the most appropriate next step in management?

223. A 26-year-old, drug-addicted man develops congestive heart failure over a period of a few days. He is febrile, has a loud, diastolic murmur at the right second intercostal space, and has a blood pressure of 120/20 mmHg. A physical examination performed a few weeks ago, when he attempted to enroll in a detoxification program, was completely normal. His blood pressure at that time was 120/80 mm Hg, and no murmurs were noted. In addition to long-term antibiotic therapy, which of the following is the most appropriate next step in management?

223. A 26-year-old, drug-addicted man develops congestive heart failure over a period of a few days. He is febrile, has a loud, diastolic murmur at the right second intercostal space, and has a blood pressure of 120/20 mmHg. A physical examination performed a few weeks ago, when he attempted to enroll in a detoxification program, was completely normal. His blood pressure at that time was 120/80 mm Hg, and no murmurs were noted. In addition to long-term antibiotic therapy, which of the following is the most appropriate next step in management?

224. 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?

224. 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?

224. 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?

225. A 12-year-old boy is in a motor vehicle collision in which the car caught fire. He sustains significant inhalation injury and a circumferential burn without fractures or other soft tissue trauma to his left lower extremity during extrication from the burning vehicle. He is intubated and aggressively resuscitated in the intensive care unit. Which of the following is the most appropriate method of assessing for compartment syndrome of the left lower extremity?

225. A 12-year-old boy is in a motor vehicle collision in which the car caught fire. He sustains significant inhalation injury and a circumferential burn without fractures or other soft tissue trauma to his left lower extremity during extrication from the burning vehicle. He is intubated and aggressively resuscitated in the intensive care unit. Which of the following is the most appropriate method of assessing for compartment syndrome of the left lower extremity?

225. A 12-year-old boy is in a motor vehicle collision in which the car caught fire. He sustains significant inhalation injury and a circumferential burn without fractures or other soft tissue trauma to his left lower extremity during extrication from the burning vehicle. He is intubated and aggressively resuscitated in the intensive care unit. Which of the following is the most appropriate method of assessing for compartment syndrome of the left lower extremity?

226. 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?

226. 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?

226. 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?

227. A 59-year-old woman undergoes an exploratory laparotomy for peritonitis and is found to have perforated diverticulitis. She undergoes a sigmoid resection with an end colostomy. She is administered a third-generation cephalosporin within 1 hour prior to the incision and the antibiotic is continued postoperatively. One week later, she develops an intra-abdominal abscess, which is percutaneously drained. Bacteroides fragilis is isolated from the cultures. Which of the following statements regarding her perioperative antibiotic regimen is most accurate?

227. A 59-year-old woman undergoes an exploratory laparotomy for peritonitis and is found to have perforated diverticulitis. She undergoes a sigmoid resection with an end colostomy. She is administered a third-generation cephalosporin within 1 hour prior to the incision and the antibiotic is continued postoperatively. One week later, she develops an intra-abdominal abscess, which is percutaneously drained. Bacteroides fragilis is isolated from the cultures. Which of the following statements regarding her perioperative antibiotic regimen is most accurate?

227. A 59-year-old woman undergoes an exploratory laparotomy for peritonitis and is found to have perforated diverticulitis. She undergoes a sigmoid resection with an end colostomy. She is administered a third-generation cephalosporin within 1 hour prior to the incision and the antibiotic is continued postoperatively. One week later, she develops an intra-abdominal abscess, which is percutaneously drained. Bacteroides fragilis is isolated from the cultures. Which of the following statements regarding her perioperative antibiotic regimen is most accurate?

228. A 30-year-old man with a history of Crohn disease develops an enterocutaneous fistula and is placed on total parenteral nutrition through a right subclavian central venous catheter. After 5 days, the patient develops a fever and leukocytosis; CT scan of the abdomen reveals no intra- abdominal abscess. The subclavian catheter insertion site is inspected and noted to be erythematous and painful. Blood cultures are positive. Which of the following organisms is the most likely cause of his fever?

228. A 30-year-old man with a history of Crohn disease develops an enterocutaneous fistula and is placed on total parenteral nutrition through a right subclavian central venous catheter. After 5 days, the patient develops a fever and leukocytosis; CT scan of the abdomen reveals no intra- abdominal abscess. The subclavian catheter insertion site is inspected and noted to be erythematous and painful. Blood cultures are positive. Which of the following organisms is the most likely cause of his fever?

228. A 30-year-old man with a history of Crohn disease develops an enterocutaneous fistula and is placed on total parenteral nutrition through a right subclavian central venous catheter. After 5 days, the patient develops a fever and leukocytosis; CT scan of the abdomen reveals no intra- abdominal abscess. The subclavian catheter insertion site is inspected and noted to be erythematous and painful. Blood cultures are positive. Which of the following organisms is the most likely cause of his fever?

229. A 32-year-old woman has an episode of upper gastrointestinal bleeding after a night of heavy alcoholic intake followed by ingestion of multiple aspirin tablets for the hangover. There was no prior vomiting until the time when she felt nauseated, went to the bathroom, and "filled the wash basin with vomiting of bright red bloody fluid." When she arrives in the emergency department, an upper gastrointestinal endoscopy is promptly performed, which confirms a diagnosis of acute erosive gastritis. She has no duodenal ulcer and no esophageal varices. Gastric lavage with ice-cold saline is performed and the bleeding stops. Laser photocoagulation or electrocautery are not used, neither is pitressin infused. She remains hemodynamically stable throughout the procedure, and she has a normal hemoglobin. She is sent home 2 hours later. Four hours after discharge, she returns complaining of severe, constant chest pain. She is in acute distress, has a temperature of 39.0 C (102.2 F), is having chills, and looks quite ill. Physical examination is remarkable for the presence of crepitation to palpation in the upper chest and lower neck, and chest x-rays confirm the presence of air in the mediastinum and the subcutaneous tissues. Which of the following is the most likely diagnosis?

229. A 32-year-old woman has an episode of upper gastrointestinal bleeding after a night of heavy alcoholic intake followed by ingestion of multiple aspirin tablets for the hangover. There was no prior vomiting until the time when she felt nauseated, went to the bathroom, and "filled the wash basin with vomiting of bright red bloody fluid." When she arrives in the emergency department, an upper gastrointestinal endoscopy is promptly performed, which confirms a diagnosis of acute erosive gastritis. She has no duodenal ulcer and no esophageal varices. Gastric lavage with ice-cold saline is performed and the bleeding stops. Laser photocoagulation or electrocautery are not used, neither is pitressin infused. She remains hemodynamically stable throughout the procedure, and she has a normal hemoglobin. She is sent home 2 hours later. Four hours after discharge, she returns complaining of severe, constant chest pain. She is in acute distress, has a temperature of 39.0 C (102.2 F), is having chills, and looks quite ill. Physical examination is remarkable for the presence of crepitation to palpation in the upper chest and lower neck, and chest x-rays confirm the presence of air in the mediastinum and the subcutaneous tissues. Which of the following is the most likely diagnosis?

229. A 32-year-old woman has an episode of upper gastrointestinal bleeding after a night of heavy alcoholic intake followed by ingestion of multiple aspirin tablets for the hangover. There was no prior vomiting until the time when she felt nauseated, went to the bathroom, and "filled the wash basin with vomiting of bright red bloody fluid." When she arrives in the emergency department, an upper gastrointestinal endoscopy is promptly performed, which confirms a diagnosis of acute erosive gastritis. She has no duodenal ulcer and no esophageal varices. Gastric lavage with ice-cold saline is performed and the bleeding stops. Laser photocoagulation or electrocautery are not used, neither is pitressin infused. She remains hemodynamically stable throughout the procedure, and she has a normal hemoglobin. She is sent home 2 hours later. Four hours after discharge, she returns complaining of severe, constant chest pain. She is in acute distress, has a temperature of 39.0 C (102.2 F), is having chills, and looks quite ill. Physical examination is remarkable for the presence of crepitation to palpation in the upper chest and lower neck, and chest x-rays confirm the presence of air in the mediastinum and the subcutaneous tissues. Which of the following is the most likely diagnosis?

230. A 45-year-old man comes to the emergency department because of severe right flank pain that began abrupdy 3 hours ago. The pain comes in waves and radiates down to the ipsilateral testis. The patient is nauseated and extremely restless. His temperature is 37.0 C (98.6 F). Dipstick examination of urine is positive for hematuria. Urinary pH is 5.8. Which of die following is the most appropriate next step in diagnosis?

230. A 45-year-old man comes to the emergency department because of severe right flank pain that began abrupdy 3 hours ago. The pain comes in waves and radiates down to the ipsilateral testis. The patient is nauseated and extremely restless. His temperature is 37.0 C (98.6 F). Dipstick examination of urine is positive for hematuria. Urinary pH is 5.8. Which of die following is the most appropriate next step in diagnosis?

230. A 45-year-old man comes to the emergency department because of severe right flank pain that began abrupdy 3 hours ago. The pain comes in waves and radiates down to the ipsilateral testis. The patient is nauseated and extremely restless. His temperature is 37.0 C (98.6 F). Dipstick examination of urine is positive for hematuria. Urinary pH is 5.8. Which of die following is the most appropriate next step in diagnosis?

231. A 71-year-old man is involved in a minor automobile accident on the road between Guadalajara and Lake Chapala in Mexico. The man is an American citizen who at the age of 65 years retired to a lakeside home in that area. Although he is asymptomatic, he decides to return to the United States to be "thoroughly checked." He is admitted to a veteran's hospital in south Texas, where he undergoes a CT scan of his abdomen. There are no signs of traumatic injuries, but the scan reveals the presence of four simple, thin walled cystic structures, approximately 1 cm in diameter, scattered throughout both lobes of his liver. They have no septations. There are no cysts in the kidneys or pancreas. The man is completely asymptomatic and afebrile. Liver function tests are normal, as is his white blood count and differential. Which of the following is the most likely diagnosis?

231. A 71-year-old man is involved in a minor automobile accident on the road between Guadalajara and Lake Chapala in Mexico. The man is an American citizen who at the age of 65 years retired to a lakeside home in that area. Although he is asymptomatic, he decides to return to the United States to be "thoroughly checked." He is admitted to a veteran's hospital in south Texas, where he undergoes a CT scan of his abdomen. There are no signs of traumatic injuries, but the scan reveals the presence of four simple, thin walled cystic structures, approximately 1 cm in diameter, scattered throughout both lobes of his liver. They have no septations. There are no cysts in the kidneys or pancreas. The man is completely asymptomatic and afebrile. Liver function tests are normal, as is his white blood count and differential. Which of the following is the most likely diagnosis?

231. A 71-year-old man is involved in a minor automobile accident on the road between Guadalajara and Lake Chapala in Mexico. The man is an American citizen who at the age of 65 years retired to a lakeside home in that area. Although he is asymptomatic, he decides to return to the United States to be "thoroughly checked." He is admitted to a veteran's hospital in south Texas, where he undergoes a CT scan of his abdomen. There are no signs of traumatic injuries, but the scan reveals the presence of four simple, thin walled cystic structures, approximately 1 cm in diameter, scattered throughout both lobes of his liver. They have no septations. There are no cysts in the kidneys or pancreas. The man is completely asymptomatic and afebrile. Liver function tests are normal, as is his white blood count and differential. Which of the following is the most likely diagnosis?

232. 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?

232. 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?

232. 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?

233. An edentulous 72-year-old man with a 50-year history of cigarette smoking presents with a nontender, hard mass in the lateral neck. Which of the following is the best diagnostic test for establishing a diagnosis of malignancy?

233. An edentulous 72-year-old man with a 50-year history of cigarette smoking presents with a nontender, hard mass in the lateral neck. Which of the following is the best diagnostic test for establishing a diagnosis of malignancy?