Part IV picture
368) The child shown below presents with a 3-day history of malaise, fever to 41.1C (106F), cough, coryza, and conjunctivitis. He then develops the erythematous, maculopapular rash pictured. He is noted to have white pinpoint lesions on a bright red buccal mucosa in the area opposite his lower molars. Which of the following is the most likely diagnosis?
. Parvovirus
. Rubella
. Herpes
. Rubeola
. Varicella
369) A 3-week-old infant with hypoplastic left heart syndrome comes to the physician for a follow-up visit. The infant was born at term via normal spontaneous vaginal delivery. The patient had the first of 3 palliative heart surgeries shortly after birth. He did well after surgery and was discharged home one week ago. Over the last 24 hours, the infant has difficulty feeding and one episodes of vomiting. On examination, the infant is afebrile, pulse is 160/min, respiratory rate is 55/min, blood pressure is 90/50mmHg, and pulse oximetry is 80% on room air. He is mildly cyanotic, small, but well developed. His cardiovascular exam reveals tachycardia and distant heart sounds with a systolic ejection murmur heard throughout the precordium. His chest radiographs from discharge and today are shown below. What is the most likely diagnosis?
. Congestive heart failure
. Endocarditis
. Pleural effusion
. Pericardial effusion
. Myocarditis
374) A 2-year-old boy is brought to the emergency department by his mother for the evaluation of a productive cough and low-grade fever. He has had ten such infections over the past year, all of which required antibiotics. He was delivered vaginally without any complications. He is an only child. His mother's siblings have a history of similar infections. He is alert and has normal vital signs, except for a mild fever. Auscultation reveals rales and rhonchi in both lungs. The chest x-ray is shown below. What is the most likely diagnosis?
. Cystic fibrosis
. Foreign body
. Kartagener's syndrome
. Immunoglobulin deficiency
. Congenital bronchiectasis
376) The developmentally delayed 6-month-old child in the picture below had intrauterine growth retardation (including microcephaly), hepatosplenomegaly, prolonged neonatal jaundice, and purpura at birth. The calcific densities in the skull x-ray shown are likely the result of which of the following?
. Congenital cytomegalovirus (CMV) infection
. Congenital toxoplasmosis infection
. Congenital syphilis infection
. Tuberculous meningitis
. Craniopharyngioma
377) The infant pictured below develops infantile spasms. Which of the following disorders is most likely to be affecting this infant?
. Neurofibromatosis
. Tuberous sclerosis
. Incontinentia pigmenti
. Pityriasis rosea
. Psoriasis
381) A 10-year-old patient (pictured below) calls his parents from summer camp to state that he has had fever, muscular pain (especially in the neck), headache, and malaise. He describes the area from the back of his mandible toward the mastoid space as being full and tender and that his earlobe on the affected side appears to be sticking upward and outward. Drinking sour liquids causes much pain in the affected area. When his father calls your office, you remind him that he had refused immunizations for his child on religious grounds. Which of the following preventable diseases has this child acquired?
. Mumps
. Varicella
. Rubella
. Measles
. Diphtheria
23) A chubby 6-month-old baby boy is brought to the clinic by his father. His father is concerned that his penis is too small (see photograph). The child is at the 95% for weight and the 50% for length; he has been developing normally and has had no medical problems. Which of the following is the most appropriate first step in management of this child?
Surgical consultation
Evaluation of penile length after retracting the skin and fat lateral to the penile shaft
Ultrasound for uterus and ovaries
Weight loss
Serum testosterone levels
25) You are performing a well-child examination on the 1-year-old child shown in the picture. For this particular problem, which of the following is the most appropriate next step in management?
Patch the eye with the greater refractive error
Patch the eye that deviates
Defer patching or ophthalmologic examination until the child is older and better able to cooperate
Reassure the mother that he will outgrow it
Refer immediately to ophthalmology
45) After her first urinary tract infection, a 1-year-old has a voiding cystourethrogram with findings shown below. Which of the following is the most appropriate treatment option?
. Low-dose daily antibiotics
. Immediate surgical reimplantation of the ureters
. Weekly urinalyses and culture
. Diet low in protein
. Early toilet training
50) A previously healthy 3-year-old male is brought to the emergency department with abdominal pain. The abdominal pain began several hours ago. Since then, he has had several episodes in which he clutches his stomach and screams. These episodes are associated with nonbloody, nonbilious vomiting and loose, watery stools. Between the episodes, the patient denies abdominal pain and is playful. On examination, his temperature is 99F (37.2C), pulse is 100/min, respiratory rate is 20/min, and blood pressure is 85/50 mmHg. The child is alert and in no acute distress. Abdominal examination reveals a soft, nontender, nondistended abdomen with bowel sounds present in all four quadrants. A tubular mass is felt in the right upper quadrant, and a rectal exam is hemoccult positive. An ultrasound image of the patient's abdomen is shown below. What is the best next step in the management of this patient?
Emergent laparotomy
Computed topography of the abdomen
Laparoscopic cholecystectomy
Meckel's scan
Air contrast enema
51) A 4-year-old boy presents with a history of constipation since the age of 6 months. His stools, produced every 3 to 4 days, are described as large and hard. Physical examination is normal; rectal examination reveals a large ampulla, poor sphincter tone but present anal wink, and stool in the rectal vault. The plain film of his abdomen is shown. Which of the following is the most appropriate next step in the management of this child?
. Lower gastrointestinal (GI) barium study
. Parental reassurance and dietary counselling
. Serum electrolyte measurement
. Upper GI barium study
. Initiation of thyroid-replacement hormone
52) A previously healthy 2-year-old black child has developed a chronic cough during the previous 6 weeks. He has been seen in different emergency rooms on two occasions during this period and has been placed on antibiotics for pneumonia. Upon auscultation, you hear normal breath sounds on the left. On the right side, you hear decreased air movement during inspiration but none upon expiration. Inspiratory (Image A) and expiratory (Image B) radiographs of the chest are shown below. Which of the following is the most appropriate next step in making the diagnosis in this patient?
Measure the patient’s sweat chloride
Consult pediatric surgery for bronchoscopy
Prescribe broad-spectrum oral antibiotics
Initiate a trial of inhaled β-agonists
Prescribe appropriate doses of oral prednisone
53) A 13-year-old boy has a 3-day history of low-grade fever, symptoms of upper respiratory infection, and a sore throat. A few hours before his presentation to the emergency room, he has an abrupt onset of high fever, difficulty swallowing, and poor handling of his secretions. He indicates that he has a marked worsening in the severity of his sore throat. His pharynx has a fluctuant bulge in the posterior wall. A soft tissue radiograph of his neck is shown. Which of the following is the most appropriate initial therapy for this patient?
Narcotic analgesics
Trial of oral penicillin V
Surgical consultation for incision and drainage under general anesthesia
Rapid streptococcal screen
Monospot test
68) A 2-year-old child (Image A) presents with a 4-day history of a rash limited to the feet and ankles. The papular rash is both pruritic and erythematous. The 3-month-old sibling of this patient (Image B) has similar lesions also involving the head and neck. The most appropriate treatment for this condition includes which of the following?
Coal-tar soap
Permethrin
Hydrocortisone cream
Emollients
Topical antifungal cream
82) You are seeing a 4-year-old girl with the physical examination finding shown below. She has no significant past history. The most appropriate management is which of the following?
. Surgical consultation for correction
. Topical estrogen cream daily for a week
. Topical steroid cream for a week
. Referral to social services for possible sexual abuse
. Karyotypestudies
84) A 3-year-old girl is admitted with the x-ray shown below. The child lives with her parents and a 6-week-old brother. Her grandfather stayed with the family for 2 months before his return to the West Indies 1 month ago. The grandfather had a 3-month history of weight loss, fever, and hemoptysis. Appropriate management of this problem includes which of the following?
Bronchoscopy and culture of washings for all family members
Placement of a Mantoux test on the 6-week-old sibling
Isolating the 3-year-old patient for 1 month
Treating the 3-year-old patient with isoniazid (INH) and rifampin
HIV testing for all family members
86) A mother arrives to the clinic with her three children (ages 2 months, 18 months, and 36 months). The 18-month-old has an intensely pruritic scalp, especially in the occipital region, with 0.5-mm lesions noted at the base of hair shafts, as shown in the picture. Which of the following therapies should be avoided in this situation?
Treatment of all household contacts with 1% lindane (Kwell)
Use of 1:1 vinegar-water rinse for hair for nit removal
Washing of all clothing and bedding in very hot water
Replacement of all commonly used brushes
Advice to the mother that treatment will again be necessary in 7 to 10 days
98) A 5-year-old boy presents with the severe rash shown in the photographs. The rash is pruritic, and it is especially intense in the flexural areas. The mother reports that the symptoms began in infancy (when it also involved the face) and that her 6-month-old child has similar symptoms. Which of the following is the most appropriate treatment of this condition?
Coal-tar soaps and shampoo
Topical antifungal cream
Ultraviolet light therapy
Moisturizers and topical steroids
Topical antibiotics
106) A 2-year-old child is seen in the emergency center with a 10-day complaint of fever and a limp. The child has an elevated erythrocyte sedimentation rate (ESR) and the radiograph shown below. Which of the following statements about this child’s condition is correct?
. It is most commonly caused by Streptococcus pyogenes
It can arise following development of deep cellulitis
. It usually results in tenderness in the region of infection that is diffuse, notlocalized
. It causes diagnostic radiographic changes on plain films within 48 hours of the beginning of symptoms
. It requires antibiotic therapy usually for 10 to 14 days
115) A 4-week-old boy presents with a 10-day history of vomiting that has increased in frequency and forcefulness. The vomitus is not bile stained. The child feeds avidly and looks well, but he has been losing weight. An ultrasound of the abdomen is shown. Which of the following is the most likely diagnosis?
. Surgical consultation for pyloromyotomy
. Upper GI with small-bowel follow through
. Intravenous (IV) fluids alone to maintain hydration
. Air contrast enema
. Computed tomography (CT) of the brain
133) A 6-month-old Hispanic boy is brought to the office for a well-baby check-up and follow-up immunizations. His mother denies any new complaints. Physical examination reveals lesions that do not fade into the surrounding skin, shown in picture below. What is the most appropriate next step in the management of this patient?
Perform fundoscopy to rule out retinal hemorrhages
Coagulation tests to rule out a coagulopathy
Immediately report to the authorities for child abuse
Do nothing. Since it is likely that these lesions will disappear in the next few years
Schedule for excisional therapy with laser
142) A 13-year-old boy’s scrotum is shown below. He complains of several months of swelling but no pain just above his left testicle. He is sexually active but states that he uses condoms. On physical examination, the area in question feels like a “bag of worms.” Which of the following is the most appropriate management for this condition?
. Doppler flow study of testes
. Radionuclide scan of testes
. Urinalysis and culture
. Ceftriaxone intramuscularly and doxycycline orally
. Reassurance and education only at this time
143) A 3-day-old infant’s scrotum is shown below. Palpation reveals a tense, fluid-filled area surrounding the right testicle. The scrotum transil luminates well, and the amount of fluid does not vary with mild pressure. Which of the following is the most appropriate approach to this condition?
. Request a surgical consultation
. Incision and drainage
. Administer prophylactic antibiotics
. Observe only
. Perform a chromosome determination
144) An 8-year-old girl is brought to the emergency department with fever for the past 6 days. Her parents report that she has been very "cranky" and has developed a new rash. Six weeks ago, she completed a 10-day course of amoxicillin for streptococcal pharyngitis. She has no other medical problems and takes no medications. Her temperature is 39.4° C (103° F), blood pressure is 110/60 mm Hg, pulse is 120/min, and respirations are 24/min. Physical examination shows injected lips and pharynx. Bilateral conjunctivae are also injected, with no exudates. A 1.7-cm mobile lymph node is palpated on the left neck. A blanching erythematous rash is present across her face, trunk, and extremities, including the palms and soles. Her mouth is shown below. What is the most appropriate next step in management of this patient?
. Amoxicillin
. Aspirin and intravenous immunoglobulin
. Doxycycline
. Lymph node biopsy
. Reassurance and close follow-up
145) A 1-week-old black infant presents to you for the first time with a large, fairly well-defined, purple lesion over the buttocks bilaterally, as shown in the photograph. The lesion is not palpable, and it is not warm nor tender. The mother denies trauma and reports that the lesion has been present since birth. This otherwise well-appearing infant is growing and developing normally and appears normal upon physical examination. Which of the following is the most appropriate course of action in this infant?
Report the family to child protective services
Reassurance of the normalcy of the condition
Soft tissues films of the buttocks to identify calcifications
Administration of vitamin K
Measurement of bleeding time as well as factor VII and XI levels
162) A well-appearing, 3200-g (7-lb, 1-oz) black infant is noted to have fifth finger (postaxial) polydactyly. The extra digit has no skeletal duplications and is attached to the rest of the hand by a threadlike soft tissue pedicle (see photograph). Appropriate treatment for this condition includes which of the following?
Chromosomal analysis
Excision of extra digit
Skeletal survey for other skeletal abnormalities
Echocardiogram
Renal ultrasound
184) A 55-day-old infant born prematurely at 27 weeks of gestation is shown below. The swelling is not tender, firm, hot, or red, and it does not transil luminate. It seems to resolve with pressure, but returns when the infant cries or strains. Which of the following is the most appropriate course of action at this point?
. Obtain a surgical consultation
. Perform a needle aspiration
. Order a barium enema
. Order a KUB (plain radiographs of kidney, ureter, and bladder)
. Observe the patient and reassure the patient and family
198) A previously well 1-year-old infant has had a runny nose and has been sneezing and coughing for 2 days. Two other members of the family had similar symptoms. Four hours ago, his cough became much worse. On physical examination, he is in moderate respiratory distress with nasal flaring, hyper- expansion of the chest, and easily audible wheezing without rales. His chest radiographs are shown. Which of the following is the appropriate next course of action?
Monitoring oxygenation and fluid status alone
Inhaled epinephrine and a single dose of steroids
Acute-acting bronchodilators and a short course of oral steroids
Emergent intubation and antibiotics
Chest tube placement
199) A 6-year-old girl presents with a 2-day history of cough and fever. At your office she has a temperature of 39.4°C (103°F), a respiratory rate of 45 breaths per minute, and decreased breath sounds on the left side. Her chest x-ray is shown below. Which of the following is the most appropriate initial treatment?
N-acetylcysteine chest physiotherapy
Vancomycin
Partial lobectomy
Postural drainage
Placement of tuberculosis skin test
205) The nurse from the level 2 neonatal intensive care nursery calls you to evaluate a baby. The infant, born at 32 weeks’ gestation, is now 1 week old and had been doing well on increasing nasogastric feedings. This afternoon, however, the nurse noted that the infant has vomited the last two feedings and seems less active. Your examination reveals a tense and distended abdomen with decreased bowel sounds. As you are evaluating the child, he has a grossly bloody stool. The plain film of his abdomen is shown. The next step in your management of this infant should include which of the following?
. Surgical consultation for an emergent exploratory laparotomy
. Continued feeding of the infant, as gastroenteritis is usually self-limited
. Stool culture to identify the etiology of the bloody diarrhea and an infectious diseases consultation
. Stopping feeds, beginning intravenous fluids, ordering serial abdominal films, and initiating systemic antibiotics
. Removal of nasogastric tube, placement of a transpyloric tube and, after confirmation via radiograph of tube positioning, switching feeds from nasogastric to nasoduodenal
223) A 15-year-old presents with the complaint of a rash, as pictured below. Which of the following statements is correct concerning the management of this common condition?
. Fried foods must be avoided
. Frequent scrubbing of the affected areas is key
. Topical antibiotics are of no value
. Topical benzoyl peroxide is the mainstay of treatment
. This rash is solely a disease of the adolescent
224) An infant weighing 1400 g (3 lb) is born at 32 weeks’ gestation. Initial evaluation was benign, and the infant was transferred to the level 2 nursery for prematurity. The nurse there calls at 1 hour of life and reports the infant is tachypneic. Vital signs include a heart rate of 140 beats per minute, a respiratory rate of 80 breaths per minute, a temperature of 35°C (95°F), and a peripheral oxygen saturation of 98%. The lungs are clear with bilateral breath sounds and there is no murmur; the infant is in no dis- tress. The child’s chest radiograph is shown. Which of the following is the most appropriate next step in evaluating the infant?
. Obtain a complete blood count and differential
. Perform a lumbar puncture
. Administer intravenously 5cc of D50W
. Place the infant under a warmer
. Administer supplemental oxygen
1) A 7-year-old boy was brought to the emergency department after falling onto his outstretched arm. He complains of pain in his left arm and refuses to move his arm at the elbow. On examination, the left arm is swollen, slightly pale, and edematous. His radial pulse is intact. The patient's radiograph is shown below. While the patient is waiting for the orthopedic resident on call to examine him, he continues to complain of increasing pain despite multiple doses of pain medication. Which of the following should you be most concerned about in this patient?
. Displacement of the fracture
. Transient neuropraxia
. Brachial artery injury
. Compartment syndrome
. Narcotic abuse
30) A 6-year-old, fully immunized boy is brought to the emergency room with a 3-hour history of fever to 39.5°C (103.1°F) and sore throat. The child appears alert, but anxious and toxic. He has mild inspiratory stridor and is drooling. He is sitting on the examination table leaning forward with his neck extended. A lateral radiograph of his neck is shown below. Which of the following is the most appropriate immediate management of this patient?
Examine the throat and obtain a culture
Obtain an arterial blood gas and start an IV line
Administer a dose of nebulized epinephrine
Prepare to establish an airway in the operating room
Admit the child and place him in a mist tent
32) A 6-year-old boy is often teased at school because he has stooled in his underwear almost daily for the last 3 months. He was toilet trained at 2 years of age without difficulty, but over the last 2 years he had developed ongoing constipation. His family is frustrated because they cannot believe him when he says “I didn’t know I had to go.” He is otherwise normal; school is going well, and his home life is stable. His only finding on examination is significant for stool in the rectal vault. The plain radiograph of his abdomen is shown. Initial management of this problem should include which of the following?
Barium enema and rectal biopsy
Family counseling
Time-out when he stools in his underwear
Clear fecal impaction and short-term stool softener use
Daily enemas for 4 weeks
36) A 3-month-old infant is brought to your office for pallor and listless- ness. Your physical examination reveals tachycardia that is constant and does not vary with crying. He has no hepatomegaly and the lungs are clear. His ECG is shown. Which of the following is the most appropriate initial management of this patient?
Rapid verapamil infusion
Transthoracic pacing of the heart
Carotid massage
DC cardioversion
Precordial thump
9) A very upset mother brings her 8-month-old child to the emergency room because he will not move his leg. She reports that when she was carrying him to the car about half an hour ago, she slipped on some ice and fell on top of him. The mother, an 18-year-old African American woman, has been exclusively breast-feeding her child. She has only recently started him on cereals, and has not supplemented his diet with vitamins. A radiograph of the child’s leg is shown below. Which of the following laboratory findings would be expected?
. Hypocalcemia
. Hypophosphaturia
. Reduced serum alkaline phosphatase
. Hypocalciuria
. Hyperphosphatemia
108) A 2-month-old infant is brought to the physician for evaluation of fever. The infant was born at 37 weeks gestation via normal spontaneous vaginal delivery. His mother had an uncomplicated pregnancy and delivery. He has been doing well until this morning when he developed a temperature of 101.5 F (38.6 C). His mother reports that he is still taking his formula well. He has some clear rhinorrhea and intermittent sneezing. His 3-year-old brother had an upper respiratory tract infection one week ago. The patient's chest radiograph is shown below. Which of the following best describes the findings on this patient's chest radiograph?
. Right upper lobe infiltrate
. Right middle lobe infiltrate
. Hilar lymphadenopathy
. Cardiomegaly
. Normal cardiothymic silhouette
111) A 4-year-old girl is brought to the pediatrician’s office. Her father reports that she suddenly became pale and stopped running while he had been playfully chasing her and her pet Chihuahua. After 30 minutes, she was no longer pale and wanted to resume the game. She has never had a previous episode and has never been cyanotic. Her physical examination was normal, as were her chest x-ray and echocardiogram. An ECG showed the pattern seen on the next page, which indicates which of the following?
Paroxysmal ventricular tachycardia
Paroxysmal supraventricular tachycardia
Wolff-Parkinson-White syndrome
Stokes-Adams pattern
Excessive stress during play
112) Physical examination of a baby boy shortly after birth reveals a large bladder and palpable kidneys. The nurses note that he produces a weak urinary stream. A voiding cystourethrogram is shown below. He appears to be otherwise normal. Which of the following is the most likely diagnosis?
. Ureteropelvic junction obstruction
. Posterior urethral valve
. Prune belly syndrome
. Duplication of the collecting system
. Horse shoe kidney
119) The photomicrograph below is of a urine specimen from a 15-year-old girl. She has had intermittent fever, malaise, and weight loss over the previous several months. Recently she has developed swollen hands, wrists, and ankles, the pain of which seems out of proportion to the clinical findings. She also complains of cold extremities and has some ulceration of her distal digits. Which of the following laboratory tests is most likely to assist in the diagnosis of this condition?
. Antibodies to nDNA and Sm nuclear antigens
. Throat culture for group A β-hemolytic streptococcus
. Simultaneously acquired urine and serum bicarbonate levels
. A urine culture
. Erythrocyte sedimentation rate
53) A 29-year-old construction worker fell 15 ft from a roof and broke his right humerus, as depicted in the accompanying radiograph. Given his injury, which of the following nerves is most at risk?
. Median nerve
. Radial nerve
. Posterior interosseous nerve
. Ulnar nerve
. Ascending circumflex brachial nerve
17) A 60-year-old woman presents with the skin lesion shown here. She reports a history of a burn injury to the hand while cooking a few years ago. She reports the wound has never healed completely. You are concerned about the skin lesion and perform a punch biopsy. Which of the following is the most accurate diagnosis given the patient’s history?
. Basal cell carcinoma
. Malignant melanoma
. Erythroplasia of Queyrat
. Bowen disease
. Marjolin ulcer
41) 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?
. Cardiac anomalies
. Hemihypertrophy
. Hypoglycemia
. Macroglossia
. Aniridia
63) A 45-year-old man presents to the physician’s office for evaluation of a skin lesion on his abdomen. He states that the lesion has been present for 1 year, but has recently enlarged over the last 2 months. The mass is nontender, and he is otherwise asymptomatic. Past history is unremarkable. Examination reveals a 3-cm, pigmented, irregular skin lesion located in the left lower quadrant of the abdomen, as shown in Figure 6-12. Heart, lung, and abdominal examination are normal. There are no palpable cervical, axillary, or inguinal lymph nodes. Chest x-ray and liver function tests are normal. Which of the following is the most likely diagnosis?
. Squamous cell carcinoma
. Basal cell carcinoma
. Merkel cell carcinoma
. melanoma
. keratoacanthoma
69) A 65-year-old woman presents to the physician’s office for her yearly physical examination. She has no complaints except for a recent 10-lb weight loss. Past history is pertinent for a 40 pack-year smoking history, hypertension, asthma, and hypothyroidism. Examination reveals a thin woman with normal vital signs and unremarkable heart and abdominal examinations. Lung examination reveals mild wheezing and a few bibasilar rales. A chest x-ray is obtained and is shown in Figure 6-13. A chest x-ray obtained 3 years ago was normal. Yearly laboratory tests including a CBC, electrolytes, and lipid panels are normal. Which of the following is the most likely diagnosis?
. Small cell lung cancer
. tuberculosis
. Nonsmall cell lung cancer
. hamartoma
. abscess
72) A 1-day-old infant with Down syndrome, feeding intolerance, bilious vomiting, and a double bubble on plain radiographs (Figure 6-18). Which one is the most likely diagnostic?
. Congenital hypertrophic pyloric stenosis
. Annular pancreas
. Duodenal atresia
. Midgut volvulus
. intussusception
76) A 65-year-old male cigarette smoker reports onset of claudication of his right lower extremity approximately 3 weeks previously. He can walk 3 blocks before the onset of claudication. Physical examination reveals palpable pulses in the entire left lower extremity, but no pulses are palpable below the right groin level. Non-invasive flow studies are obtained and are pictured here. What is the level of the occlusive process in this patient?
. Right anterior tibial artery
. Right superficial femoral artery
. Right profunda femoris artery
. Right external iliac artery
. Right internal iliac artery
79) An 80-year-old man is found to have an asymptomatic pulsatile abdominal mass. An arteriogram is obtained (shown below). Which of the following is the most frequent and lethal complication of this condition?
. Rupture
. Acute thromboembolism
. Dissection
. High-output congestive heart failure
. Myocardial infarction
81) A 65-year-old woman presents to the physician’s office with a 6-month history of epigastric discomfort, poor appetite, and 10-lb weight loss. Past history is pertinent for hypertension, diabetes, a 30 pack-year smoking history, and occasional alcohol intake. Examination is unremarkable except for mild epigastric tenderness to deep palpation. An abdominal ultrasound reveals cholelithiasis, and one view of a UGI x-ray series is shown in Figure 6-8. Which of the following is the most likely diagnosis?
. Cholecystoenteric fistula
. Duodenal ulcer
. Gastric ulcer
. Gastric diverticulum
. Duodenal diverticulum
82) A 75-year-old woman is brought to the emergency department from a nursing home for abdominal pain, distention, and obstipation over the last 2 days. Past history is pertinent for stroke, diabetes, atrial fibrillation, and chronic constipation. Examination reveals a temperature of 98.6°F, pulse rate 90/min and irregularly irregular, and BP 160/90 mmHg. Heart examination reveals irregularly irregular rhythm with no murmurs; lung examination reveals few bibasilar rales; and abdominal examination reveals a distended, tympanic abdomen with mild tenderness and no rebound tenderness. Plain abdominal x-rays reveal dilated loops of bowel, and a barium enema is obtained and shown in Figure 6-9. Which of the following is the most likely diagnosis?
. Ischemic colitis with stricture
. Diverticulitis with obstruction
. Cecal volvulus
. Sigmoid volvulus
. Colon cancer with obstruction
87) An 85-year-old man presents to the emergency room with an acute onset of midepigastric pain, nausea, vomiting, and hiccups starting 2 days ago. He is unable to keep any food down. Past history is pertinent for a long-standing hiatal hernia, hypertension, and diet-controlled diabetes. Examination reveals vital signs of pulse rate 82/min, BP 100/52 mmHg, respiratory rate 16/min, and temperature 97.2°F. The patient is in no acute distress, but has epigastric tenderness without guarding. Laboratory analysis revealed a hematocrit of 46 and a normal white blood cell (WBC) count. A chest x-ray is shown in Figure 6-5a. A fluoroscopically guided NG tube was placed using contrast, and his stomach was decompressed. After adequate fluid and electrolyte resuscitation, an upper gastrointestinal (UGI) contrast study was obtained and is shown in 6-5b. Which of the following is the most likely diagnosis?
. Sliding hiatal hernia
. Hernia of Bochdalek (posterorlateral congenital diaphragmatic hernia)
. Hernia of Morgagni (parasternal congenital diaphragmatic hernia)
. Paraesophageal hernia
. Eventration of the diaphragm (central diaphragm)
88) An 83-year-old woman presents to a mammographic facility for a screening mammogram. The technician notices a mass in the lateral right breast. The patient denies any breast pain, nipple discharge, skin changes, or breast trauma. A right breast CC view is shown in Figure 6-7. Which of the following is the most likely diagnosis?
Papilloma
Invasive carcinoma
Cystosarcoma phyllodes
DCIS
Fat necrosis
91) A 45-year-old woman complains to her primary care physician of nervousness, sweating, tremulousness, and weight loss. The thyroid scan shown here exhibits a pattern that is most consistent with which of the following disorders?
. Hyper secreting adenoma
. Graves’ disease
. Lateral aberrant thyroid
. Papillary carcinoma of thyroid
. Medullary carcinoma of thyroid
99) A 65-year-old woman presents to the physician’s office for evaluation of an abnormal screening mammogram. She denies any breast masses, nipple discharge, pain, or skin changes. Past history is pertinent for hypertension. Family history is positive for postmenopausal breast cancer in a sister. She has a normal breast examination and no axillary adenopathy. The remainder of her examination is unremarkable. An MLO view of the right breast is shown in Figure 6-6a along with a magnification view of the craniocaudal (CC) film (Figure 6-6b). Which of the following is the most likely diagnosis?
. Milk of calcium
. LCIS with or without an invasive component
. DCIS with or without an invasive component
. Involuting fibroadenoma
. Phyllodes tumor
102) A 14-year-old black girl has her right breast removed because of a large mass. The tumor weighs 1400 g and has a bulging, very firm, lobulated surface with a whorl-like pattern, as illustrated here. Which of the following is the most likely diagnosis?
. Cystosarcoma phyllodes
. Intraductal carcinoma
. Malignant lymphoma
. Fibroadenoma
. Juvenile hypertrophy
103) A 51-year-old woman presents to the physician’s office with a 2-month history of a right breast blood tinged nipple discharge. Past history is unremarkable. Family history is positive for postmenopausal breast cancer in a maternal grandmother. Examination reveals no palpable masses or regional adenopathy, but a serous discharge is easily elicited from a single duct in the right breast. Bilateral mammograms show no abnormalities. Cytology from the discharge was not diagnostic. A ductogram was ordered, and the results are shown: Which of the following is the most likely diagnosis?
. Invasive carcinoma
. Intraductal carcinoma
. Intraductal papilloma
. Fibrocystic disease
. Duct ectasia
109) A 39-year-old man presents to his physician with the complaint of loss of peripheral vision. Which of the following findings are demonstrated by the subsequent magnetic resonance imaging (MRI) scan, shown here?
. Cerebral atrophy
. Pituitary adenoma
. Optic glioma
. Pontine hemorrhage
. Multiple sclerosis plaque
113) A 76-year-old woman presents with acute onset of persistent back pain and hypotension. A CT scan is obtained (shown below), and the patient is taken emergently to the operating room. Three days after surgery she complains of abdominal pain and bloody mucus per rectum. Which of the following is the most likely diagnosis?
. Staphylococcal enterocolitis
. Diverticulitis
. Bleeding arteriovenous (AV) malformation
. Ischemia of the left colon
. Bleeding colonic carcinoma
119) A term infant is born at a small community hospital by caesarean section for failure to progress. The infant is noted to have the following abnormality at birth. Which of the following is the most likely diagnosis?
. Umbilical hernia
. omphalitis
. omphalocele
. gastroschisis
. Traumatic evisceration
123) A 55-year-old-woman presents to the physician’s office for evaluation of mammographic findings on a screening mammogram. She denies any breast masses, nipple discharge, pain, or skin changes. Past history is pertinent for insulin-dependent diabetes. Family history is positive for postmenopausal breast cancer in her mother. She has a normal breast examination and no axillary adenopathy. A mediolateral oblique (MLO) view of the right breast is shown: Which of the following is the most likely diagnosis?
. Milk of calcium
. Lobular carcinoma in situ (LCIS) with or without an invasive component
. Ductal carcinoma in situ (DCIS) with or without an invasive component
. Involuting fibroadenoma
. Phyllodes tumor
130) A 10-month-old infant presents to the emergency department with a 24-hour history of low-grade fever and anorexia. The parents report several episodes in which the child has been suddenly inconsolable and crying, followed by periods of lethargy. He has had nonbilious vomiting and several loose stools. On examination, the infant is pale and mildly dehydrated. His abdomen is soft and nondistended, with fullness to palpation in the right upper quadrant. The child passed another stool in the emergency department (see Figure 6-14). Which of the following is the most likely diagnosis?
. gastroenteritis
. intussusception
. Midgut volvulus
. Meckel’s diverticulum
. Juvenile rectal polyp
131) In a 6-month-old previously healthy male infant, an abnormality is revealed during a routine diaper change, as illustrated in Figure 6-19. The parents have noted this finding on and off on several occasions over the last month. On each occasion, the child has been feeding well, and is content and playful. Which of the following is the most likely diagnosis?
. Noncommunicating hydrocele
. Inguinal adenitis
. Reducible inguinal hernia
. Incarcerated inguinal hernia
. Undescended testes
133) A 10-day-old infant presenting with bilious vomiting, paucity of gas on plain radiographs, and duodenal obstruction on UGI contrast study (Figures 6-15 and 6-16). Which one is the most likely diagnostic?
. Congenital hypertrophic pyloric stenosis
. Annular pancreas
. Duodenal atresia
. Midgut volvulus
. intussusception
134) A neonate with bile-stained vomiting, abdominal distention, dilated loops of bowel on plain radiographs, and a small-caliber colon on contrast enema (Figure 6-17). Which one is the most likely diagnosis?
. Congenital hypertrophic pyloric stenosis
. Annular pancreas
. Duodenal atresia
. Midgut volvulus
. Jejunal atresia
143) A 65-year-old man presents to the physician’s office for his yearly physical examination. His only complaint relates to early fatigue while playing golf. Past history is pertinent for mild hypertension. Examination is unremarkable except for trace hematest-positive stool. Blood tests are normal except for a hematocrit of 32. A UGI series is performed and is normal. A barium enema is performed, and one view is shown in Figure 6-10. Which of the following is the most likely diagnosis?
. Diverticular disease
. Colon cancer
. lymphoma
. Ischemia with stricture
. Crohn’s colitis with stricture
4) A 62-year-old woman presents to the physician’s office with complaints of constipation. She has had constipation for the last 6 months, which has worsened over the last month, associated with mild bloating. She noted that her stool has become “pencil thin” in the last month, with occasional blood, but she continues to have bowel movements daily. Past history is unremarkable. Examination reveals normal vital signs and heart and lung examination. Abdominal examination reveals mild fullness, especially in the lower quadrants. Rectal examination shows no rectal masses, but the stool is hematest positive. A barium xray is obtained, and one view is shown in Figure 6-11. Which of the following is the most likely diagnosis?
. Crohn’s disease
. Ischemia with stricture
. Rectal carcinoma
. Sigmoid volvulus
. Diverticulitis with colovesical fistula
82) A 46-year-old male is brought to the emergency department after falling on his head and back during a downhill bike race and losing consciousness for 1 minute. He has severe back and abdominal pain. AP and lateral skull films show no abnormalities. Lumbar films show anterior compression wedge fractures of the bodies of L1 and L2. A brace is placed. CT scan of the abdomen shows a mild retroperitoneal bleed and splenic laceration. During the hospitalization he was treated conservatively with analgesics and supportive measures. On hospital day 3, he started to have abdominal distention, pain and nausea. His last bowel movement was 4 days ago and he is not passing gas. His abdomen is distended, tympanic and mildly tender without rebound or guarding. Bowel sounds are absent. An x-ray film of the abdomen is shown below: Which of the following is the most likely diagnosis?
. Functional constipation
. Paralytic ileus
. Large bowel obstruction
. Peritonitis
. Worsening hematoma
85) A 7-year-old boy has been complaining of left hip pain for the past 8 months. Over recent weeks, he has developed a limp. When you examine his gait, you note that he takes short steps with his left leg. On physical examination, his left hip has significantly limited range of motion, and there is atrophy of the left proximal thigh muscle. X-ray of the patient's pelvis is shown below: W hich of the following is most likely responsible for this patient's condition?
. Slipped epiphysis
. Bone infection
. Osteonecrosis
. Muscle dystrophy
. Synovitis
89) A 53-year-old male comes to the emergency department complaining of sudden onset intense, stabbing epigastric pain. He also vomited once and a dull, aching pain then spread through his entire abdomen. He has had nonspecific epigastric pain for several months and saw a physician one month ago. He also has a history of constipation, type II diabetes mellitus and hyperlipidemia. He has smoked one and a half packs of cigarettes daily for 26 years. He drinks 4 oz of alcohol daily. His temperature is 38.3C (100.4F), blood pressure is 160/95 mm Hg, pulse is 100/min and respirations are 26/min. The entire abdomen is tender to palpation with rebound, but there is no guarding. No masses are palpable, and Murphy's sign elicits mild pain. Rectal examination shows no abnormalities. Abdominal ultrasound performed 2 weeks ago showed stones in the gall bladder. Upright chest x-ray is shown below: Which of the following is the most likely diagnosis in this patient?
. Acute cholecystitis
. Acute alcoholic pancreatitis
. Acute gallstone pancreatitis
. Perforated peptic ulcer
. Perforated diverticulitis
94) A 55-year-old man comes to the physician because of chronic leg problems. He has had multiple medical problems and is unable to get good medical care due to lack of insurance. A photograph of his legs is shown below. Which of the following is the most likely cause of his condition?
. Arterial thrombosis
. Arterial spasm
. Venous hypertension
. Peripheral neuropathy
. Posterior spinal cord lesion
102) A 35-year-old man is brought to the emergency department after a motorcycle accident. He is unconscious when the emergency medical team arrived. He regains consciousness on the way to the emergency department. Upon arrival, he is mildly confused and complains of headache and nausea. His temperature is 36.9° C (98.5° F), blood pressure is 102/60 mm Hg, pulse is 116/min, and respirations are 22/min. Pupils are equal and reactive to light. He moves all extremities on command, and deep tendon reflexes are symmetric. Head CT scan shows: Which of the following is the most likely diagnosis?
. Acute epidural hematoma
. Acute subdural hematoma
. Concussion
. Diffuse axonal injury
. Intracerebral bleeding
104) A 46-year-old man is brought to the emergency department after a fall during a downhill bike race. He lost consciousness for approximately 1 minute after the fall. He complains of severe back and abdominal pain. He has no other medical problems. Head computed tomography (CT) scan shows no intracranial bleeding. Lumbar films suggest a compression wedge fracture of the body of L2 vertebra, and a brace is placed. Abdominal CT scan shows a small retroperitoneal bleed and splenic laceration. He is conservatively treated with analgesics and supportive measures. On hospital day three, he complains of abdominal pain and nausea. His abdomen is distended, tympanic, and mildly tender, without rebound or guarding. Bowel sounds are absent. X-ray of the abdomen reveals. Which is the most likely diagnosis?
. Erosive gastritis
. Expanding retroperitoneal hematoma
. Colonic pseudoobstruction
. Mesenteric ischemia
. Paralytic ileus
105) A 22-year-old man who was involved in a motor vehicle accident undergoes intravenous fluid resuscitation with 2 L normal saline over 20 minutes. He is in respiratory distress, with a respiratory rate of 40/min. He receives bilateral chest tubes. Endotracheal intubation is performed and mechanical ventilation is initiated due to progressive respiratory failure. His blood pressure is 92/50 mm Hg and pulse is 121/min. The patient is responsive to painful stimuli only. Pulmonary examination shows coarse breath sounds bilaterally. The chest x-ray is shown below. Which of the following most likely contributed to this patient's progressive respiratory failure?
. Diaphragmatic tear
. Esophageal rupture
. Flail chest
. Pulmonary edema
. Tension pneumothorax
123) An 18-year-old woman presents with abdominal pain, fever, and leukocytosis. With the presumptive diagnosis of appendicitis, a right lower quadrant (McBurney) incision is made and a lesion 60 cm proximal to the ileocecal valve is identified (see photo). Which of the following is the most likely diagnosis?
. Intestinal duplication
. Mesenteric cyst
. Meckel diverticulum
. Ileoileal intussusception
. “Christmas tree” type of ileal atresia
51) A 62-year-old man presents to the emergency department (ED) with one hour of severe epigastric pain. He has been having some epigastric pain exacerbated by eating for the last several days. He feels nauseous, and has vomited once since the pain began. His past medical history is significant for hypertension, diabetes, hyperlipidemia, and coronary artery disease. He underwent coronary bypass surgery one year back. His current medications are simvastatin, aspirin, clopidogrel, metoprolol, enalapril and metformin. His blood pressure is 140/ 100 mmHg, and heart rate is 65/min. His ECG is normal. Chest x-ray findings are shown on the slide below. Which of the following is the best step in the management of this patient?
. Transthoracic echocardiography
. Nothing by mouth (NPO) and gastric suction
. Mesenteric angiography
. Abdominal CT scan
. Immediate surgical evaluation
56) A 4-year-old boy is brought into the emergency room by his parents for difficulty in breathing and swallowing. On physical examination the child is febrile, tachycardic, and tachypneic. He is anxious, drooling, and becomes increasingly exhausted while struggling to breathe. A lateral cervical spine radiograph is shown here. Which of the following is the most appropriate management of this patient?
. Examine the larynx at bedside
. IV antibiotics and admission to the floor
. Immediate endotracheal intubation in the emergency room
. Immediate endotracheal intubation in the operating room
. Immediate tracheostomy in the operating room
65) A full-term male newborn experiences respiratory distress immediately after birth. A prenatal sonogram was read as normal. An emergency radiograph is shown here. The patient is intubated and placed on 100% O2. Arterial blood gases reveal pH 7.24, PO2 60 kPa, and PCO2 52 kPa. The baby has sternal retractions and a scaphoid abdomen. Which of the following should be performed in the management of this patient?
. Administration of intravenous steroids
. Placement of bilateral tube thoracostomies
. Immediate thoracotomy with lung resection
. Immediate laparotomy with repair of the diaphragm
. Mechanical ventilation with low tidal volumes
70)A 62-year-old man presents to the emergency department (ED) with one hour of severe epigastricpain. He has been having some epigastric pain exacerbated by eating for the last several days. He feels nauseated, and has vomited once since the pain began. His past medical history is significant for hypertension, diabetes, hyperlipidemia, and coronary artery disease. He underwent coronary bypass surgery one year back. His current medications are simvastatin, aspirin, clopidogrel, metoprolol, enalapril and metformin. His blood pressure is 140/100 mmHg, and heart rate is 65/min. His ECG is normal. Chest x-ray findings are shown on the slide below. Which of the following is the best step in the management of this patient?
. Transthoracic echocardiography
. Nothing by mouth (NPO) and gastric suction
. Mesenteric angiography
. Abdominal CT scan
. Immediate surgical evaluation
36) 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)?
. Transfusion of banked blood to correct acute anemia
. Correction of acute anemia with erythropoietic stimulating agent
. Administration of bicarbonate to promote metabolic alkalosis
. Hypoventilation to increase the PaCO2
. Administration of an antipyretic to lower the patient’s temperature
46) A 43-year-old woman develops acute renal failure following an emergency resection of a leaking abdominal aortic aneurysm. One week after surgery, the following laboratory values are obtained:Serum electrolytes (mEq/L): Na+ 127, K+ 5.9, Cl− 92, HCO3− 15Blood urea nitrogen: 82 mg/dLSerum creatinine: 6.7 mg/dLThe patient has gained 4 kg since surgery and is mildly dyspneic at rest. Eight hours after these values are reported, the following electrocardiogram is obtained. Which of the following is the most appropriate initial treatment in the management of this patient?
. 10 mL of 10% calcium gluconate
. 0.25 mg digoxin every 3 hours for 3 doses
. Oral Kayexalate
. 100 mg lidocaine
. Emergent hemodialysis
117) A 62-year-old woman presents to the physician’s office with complaints of constipation. She has had constipation for the last 6 months, which has worsened over the last month, associated with mild bloating. She noted that her stool has become “pencil thin” in the last month, with occasional blood, but she continues to have bowel movements daily. Past history is unremarkable. Examination reveals normal vital signs and heart and lung examination. Abdominal examination reveals mild fullness, especially in the lower quadrants. Rectal examination shows no rectal masses, but the stool is hematest positive. A barium xray is obtained, and one view is shown in Figure 6-11. Which of the following is the most appropriate next step in management?
. Proctoscopy and passage of a rectal tube
. Proctoscopy and biopsy
. colonoscopy
. Endoscopic dilation of the stricture
. NPO, IV fluids, and antibiotics
119) A 62-year-old man comes to the emergency department because of severe abdominal pain. He states that he suddenly felt weak, diaphoretic, and had no energy. He is a smoker and has hypertension. His blood pressure on initial examination was 110/70 mm Hg. Physical examination shows a diffusely tender abdomen. During CT scan he becomes pale and drowsy. CT scan is shown below. Repeat examination shows a man with anxiety and a blood pressure of 80/50 mm Hg and pulse of 110/min. Which of the following is the most appropriate next step in management?
. Exploratory abdominal surgery
. Obtain ultrasound
. Check amylase and lipase
. Laparoscopy
. Drain fluid from the abdomen
125) In a 6-month-old previously healthy male infant, an abnormality is revealed during a routine diaper change, as illustrated in Figure 6-19. The parents have noted this finding on and off on several occasions over the last month. On each occasion, the child has been feeding well, and is content and playful. We decided to do surgical repair. Several weeks later, the child presents to the emergency department with a 4-hour history of irritability. He has had one episode of nonbilious vomiting and has refused to breast-feed. In the emergency department, the infant appears inconsolable. He is afebrile, and his abdomen is mildly distended but soft. On removal of his diaper, the same abnormality is documented (see Figure 6-19). Which of the following is the most appropriate management at this time?
. Urgent surgical exploration
. Systemic antibiotics
. Elective surgical repair
. Sedation with manual reduction and arrangements for elective surgical repair
. Sedation with manual reduction, admission, rehydration, and surgical repair within 24–48 hours
131) A 56-year-old woman presents to her primary care physician for a routine checkup. She states that she was recently hospitalized for surgery and was told she had some metal placed in a large blood vessel to prevent blood clots from moving to her lungs. An abdominal x-ray is shown here. Which of the following is the most appropriate indication for placement of this device?
. Recurrent pulmonary embolus despite adequate anticoagulation therapy
. Axillary vein thrombosis
. Pulmonary embolus due to DVT of the lower extremity that occurs 2 weeks postoperatively
. DVT in a patient with patient with metastatic carcinoma
. Pulmonary embolus in a patient with metastatic carcinoma
145) A 65-year-old man presents to the physician’s office for his yearly physical examination. His only complaint relates to early fatigue while playing golf. Past history is pertinent for mild hypertension. Examination is unremarkable except for trace hematest-positive stool. Blood tests are normal except for a hematocrit of 32. A UGI series is performed and is normal. A barium enema is performed, and one view is shown in Figure 6-10. Which of the following is the most appropriate therapy following colonoscopy?
. Proximal colostomy with mucous fistula
. Radiation therapy
. chemotherapy
. Surgical resection and primary anastomosis
. Surgical bypass (colocolostomy)
150) A 51-year-old woman presents to the physician’s office with a 2-month history of a right breast blood tinged nipple discharge. Past history is unremarkable. Family history is positive for postmenopausal breast cancer in a maternal grandmother. Examination reveals no palpable masses or regional adenopathy, but a serous discharge is easily elicited from a single duct in the right breast. Bilateral mammograms show no abnormalities. Cytology from the discharge was not diagnostic. A ductogram was ordered, and the results are shown in picture. Which of the following is the most appropriate next step in management?
. Collection of discharge for repeat cytologic analysis
. observation, with repeat examination and imaging studies in 3–6 months
. Modified radical mastectomy
. Central lumpectomy (including removal of the nipple/areolar complex
. Terminal duct excision (microdochectomy)
151) A 65-year-old woman presents to the physician’s office for evaluation of an abnormal screening mammogram. She denies any breast masses, nipple discharge, pain, or skin changes. Past history is pertinent for hypertension. Family history is positive for postmenopausal breast cancer in a sister. She has a normal breast examination and no axillary adenopathy. The remainder of her examination is unremarkable. An MLO view of the right breast is shown in Figure 6-6a along with a magnification view of the craniocaudal (CC) film (Figure 6-6b). Which of the following is the most appropriate next step in management?
. observation, with repeat mammogram in 6 months
. observation, with repeat mammogram on an annual basis
. biopsy
. lumpectomy, radiation therapy, and SLN biopsy
. Total mastectomy
156) A 10-month-old infant presents to the emergency department with a 24-hour history of low-grade fever and anorexia. The parents report several episodes in which the child has been suddenly inconsolable and crying, followed by periods of lethargy. He has had nonbilious vomiting and several loose stools. On examination, the infant is pale and mildly dehydrated. His abdomen is soft and nondistended, with fullness to palpation in the right upper quadrant. The child passed another stool in the emergency department (see Figure 6-14). Which of the following is the most appropriate next step in the diagnostic evaluation and management of this patient?
. proctoscopy
. Oral rehydration and stool cultures
. IV fluid rehydration and a hydrostatic barium enema
. Technetium scan
. IV fluid rehydration, NG decompression, and a UGI contrast study
165) A 60-year-old man is found on a routine physical examination to have a 3-cm pulsatile mass in the right popliteal fossa. X-ray of the right of the right lower extremity is shown below. Which of the following is the most appropriate management of this patient?
. Antiplatelet therapy
. Anticoagulation
. Thrombolytic therapy
. Surgery
. Reassurance and re-examination if the patient develops symptoms
173) A 55-year-old-woman presents to the physician’s office for evaluation of mammographic findings on a screening mammogram. She denies any breast masses, nipple discharge, pain, or skin changes. Past history is pertinent for insulin-dependent diabetes. Family history is positive for postmenopausal breast cancer in her mother. She has a normal breast examination and no axillary adenopathy. A mediolateral oblique (MLO) view of the right breast is shown. Which of the following is the most appropriate next step in management?
. observation, with repeat mammogram in 6–12 months
. ultrasound
. biopsy
. lumpectomy, radiation therapy, and sentinel lymph node (SLN) biopsy
. Total mastectomy
188) A term infant is born at a small community hospital by cesarean section for failure to progress. The infant is noted to have the following abnormality at birth. Which of the following is the most likely diagnosis? Which of the following is the most appropriate initial management?
. IV antibiotics alone
. Emergency surgery for reduction
. Monitor for spontaneous closure, with surgical intervention for persistent fascial defect
. IV fluids, IV antibiotics, warm occlusive dressing, and transfer to a center with a pediatric surgeon
. Elective umbilical exploration
189) A 2-year-old child presents with a 2-day history of painless rectal bleeding. On examination, the child is pale with tachycardia. The abdomen is nondistended and nontender. There is dark blood on rectal examination. The child has the following imaging study (see Figure 6-2). Which of the following is the most appropriate management?
. Surgical exploration
. Aggressive resuscitation followed by surgical exploration
. colonoscopy
. Acid suppression therapy
. IV steroids
208) In a 6-month-old previously healthy male infant, an abnormality is revealed during a routine diaper change, as illustrated in Figure 6-19. The parents have noted this finding on and off on several occasions over the last month. On each occasion, the child has been feeding well, and is content and playful. Which of the following is the most appropriate management at this time?
. antibiotics
. Reassurance to the parents that the abnormality will resolve without intervention
. Referral to the emergency department for immediate surgical consultation
. Referral for elective surgical repair
. Scrotal support
210) An 83-year-old woman presents to a mammographic facility for a screening mammogram. The technician notices a mass in the lateral right breast. The patient denies any breast pain, nipple discharge, skin changes, or breast trauma. A right breast CC view is shown in Figure 6-7. Which of the following is the most appropriate next step in management?
. Incisional biopsy
. Needle biopsy
. lumpectomy, axillary dissection, and irradiation
. Total mastectomy
. Modified radical mastectomy
213) An 85-year-old man presents to the emergency room with an acute onset of midepigastric pain, nausea, vomiting, and hiccups starting 2 days ago. He is unable to keep any food down. Past history is pertinent for a long-standing hiatal hernia, hypertension, and diet-controlled diabetes. Examination reveals vital signs of pulse rate 82/min, BP 100/52 mmHg, respiratory rate 16/min, and temperature 97.2°F. The patient is in no acute distress, but has epigastric tenderness without guarding. Laboratory analysis revealed a hematocrit of 46 and a normal white blood cell (WBC) count. A chest x-ray is shown in Figure 6-5a. A fluoroscopically guided NG tube was placed using contrast, and his stomach was decompressed. After adequate fluid and electrolyte resuscitation, an upper gastrointestinal (UGI) contrast study was obtained and is shown in 6-5b. Which of the following is the most appropriate next step in management?
. Laparotomy or laparoscopy and operative repair
. continued NG tube decompression and initiation of total parenteral nutrition (TPN)
. Thoracotomy or thoracoscopy and operative repair
. Endotracheal intubation and initiation of ventilatory support
. Upper endoscopy
227) A 69-year-old man with mild hypertension and chronic obstructive pulmonary disease (COPD) presents with transient ischemic attacks and the angiogram shown here. Which of the following is the most appropriate treatment recommendation?
. Medical therapy with aspirin 325 mg/day and medical risk factor management
. Medical therapy with warfarin
. Angioplasty of the carotid lesion followed by carotid endarterectomy if the angioplasty is unsuccessful
. Carotid endarterectomy
. Medical risk factor management and carotid endarterectomy if neurologic symptoms develop
248) A 45-year-old man presents to the physician’s office for evaluation of a skin lesion on his abdomen. He states that the lesion has been present for 1 year, but has recently enlarged over the last 2 months. The mass is nontender, and he is otherwise asymptomatic. Past history is unremarkable. Examination reveals a 3-cm, pigmented, irregular skin lesion located in the left lower quadrant of the abdomen, as shown in Figure 6-12. Heart, lung, and abdominal examination are normal. There are no palpable cervical, axillary, or inguinal lymph nodes. Chest x-ray and liver function tests are normal. Which of the following is the most appropriate next step in management?
. Wide excision with 2 cm margin
. Wide excision with 2 cm margin and SLN mapping
. Shave biopsy
. Excisional biopsy with 1–2 mm margins
. Mohs’ surgical excision
49) A 62-year-old man comes to the emergency department because of severe abdominal pain. He states that he suddenly felt weak, diaphoretic, and had no energy. He is a smoker and has hypertension. His blood pressure on initial examination was 110/70 mm Hg. Physical examination shows a diffusely tender abdomen. During CT scan he becomes pale and drowsy. CT scan is shown below: Repeat examination shows a man with anxiety and a blood pressure of 80/50 mm Hg and pulse of 110/min Which of the following is the most appropriate next step in management?
. Exploratory abdominal surgery
. Obtain ultrasound
. Check amylase and lipase
. Laparoscopy
. Drain fluid from the abdomen
76) A 12-year-old boy is brought to the emergency department after being involved in a motor vehicle collision. He was in the rear seat and was thrown out of the car during the accident. He was immediately resuscitated, and the trauma work-up showed no abnormalities. His discharge was uneventful. Two months later he was seen in the emergency department because of vague chest pain and discomfort. Auscultation showed decreased air entry into the left lower base. An x-ray film of the chest is shown below. Which of the following is the most appropriate next step in management?
. Place chest tube
. Bronchoscopy
. Start antibiotics
. Barium swallow
. Angiogram
94) A previously healthy 79-year-old woman presents with early satiety and abdominal fullness. CT scan of the abdomen, pictured here, reveals a cystic lesion in the body and tail of the pancreas. CT-guided aspiration demonstrates an elevated carcinoembryonic antigen (CEA) level. Which of the following is the most appropriate treatment option for this patient?
. Distal pancreatectomy
. Serial CT scans with resection if the lesion increases significantly in size
. Internal drainage with Roux-en-Y cyst-jejunostomy
. Percutaneous drainage of the fluid-filled lesion
. Endoscopic retrograde cholangiopancreatography (ERCP) with pancreatic stent placement
119) A 32-year-old woman undergoes a cholecystectomy for acute cholecystitis and is discharged home on the sixth postoperative day. She returns to the clinic 8 months after the operation for a routine visit and is noted by the surgeon to be jaundiced. Laboratory values on readmission show total bilirubin 5.6 mg/dL, direct bilirubin 4.8 mg/dL, alkaline phosphatase 250 IU (normal 21-91 IU), serum glutamic oxaloacetic transaminase (SGOT) 52 kU (normal 10-40 kU), and serum glutamic pyruvic transaminase (SGPT) 51 kU (normal 10-40 kU). An ultrasonogram shows dilated intrahepatic ducts. The patient undergoes the transhepatic cholangiogram seen here. Which of the following is the most appropriate next management step?
. Choledochoplasty with insertion of a T tube
. Choledochoplasty with insertion of a T tube
. Roux-en-Y hepatico-jejunostomy
. Percutaneous transhepatic dilatation
. Choledochoduodenostomy
129) A 65-year-old man who is hospitalized with pancreatic carcinoma develops abdominal distention and obstipation. The following abdominal radiograph is obtained. Which of the following is the most appropriate initial management of this patient?
. Urgent colostomy or cecostomy
. Discontinuation of anticholinergic medications and narcotics and correction of metabolic disorders
. Digital disimpaction of fecal mass in the rectum
. Diagnostic and therapeutic colonoscopy
. Detorsion of volvulus and colopexy or resection
131) An upper GI series is performed on a 71-year-old woman who presented with several months of chest pain that occurs when she is eating. The film shown here is obtained. Investigation reveals a microcytic anemia and erosive gastritis on upper endoscopy. Which of the following is the most appropriate initial management of this patient?
. Cessation of smoking, decreased caffeine intake, and avoidance of large meals before lying down
. Antacids
. Histamine-2 blocker
. Proton-pump inhibitor
. Surgical treatment
135) A 35-year-old woman presents with abdominal pain and jaundice. Subsequent ERCP reveals the congenital cystic anomaly of her biliary system illustrated in the film shown here. Which of the following is the most appropriate treatment?
. Cholecystectomy with resection of the extrahepatic biliary tract and Roux-en-Y hepaticojejunostomy
. Internal drainage via choledochoduodenostomy
. Internal drainage via choledochocystojejunostomy
. Percutaneous transhepatic biliary drainage
. Liver transplantation
138) After a weekend drinking binge, a 45-year-old man presents to the hospital with abdominal pain, nausea, and vomiting. On physical examination, the patient is noted to have tenderness to palpation in the epigastrium. Laboratory tests reveal an amylase of 25,000 U/dL (normal < 180U/dL). The patient is medically managed and sent home after 1 week. A CT scan done 4 weeks later is pictured here. Currently the patient is asymptomatic. Which of the following is the most appropriate initial management of this patient?
. Distal pancreatectomy
. Percutaneous catheter drainage
. Endoscopic drainage
. Surgical drainage
. No intervention is warranted at this time
141) A 36-hour-old infant presents with bilious vomiting and an increasingly distended abdomen. At exploration, the segment pictured here is found as the point of obstruction. What is the best next step in management?
. Gentle, persistent traction on the specimen
. Enteroenterostomy
. Small bowel resection with exteriorization of the ends
. Small bowel resection with anastomosis
. Lysis of Ladd band
165) A 34-year-old prostitute with a history of long-term intravenous drug use is admitted with a 48-hour history of pain in her left arm. She is tachycardic to 130 and her systolic blood pressure is 80 mm Hg. Physical examination is remarkable for crepitus surrounding needle track marks in the antecubital space with a serous exudate. The plain x-ray of the arm is shown here. Which of the following is the most appropriate next step in her management?
. Treatment with penicillin G and close observation
. MRI of the arm
. CT scan of the arm
. Surgical exploration and debridement
. Hyperbaric oxygen therapy
189) A 12-year-old boy comes to the emergency department complaining of vague left-sided chest discomfort. Two months ago, he was involved in a high-speed motor vehicle accident but sustained only minor injuries. He was observed in the emergency department overnight and discharged home. His past medical history is otherwise unremarkable. Vital signs are normal. Auscultation of the lungs shows decreased air entry into the left lower base. An x-ray of the chest is shown below. Which of the following is the most appropriate next step in management of this patient?
. Chest tube placement
. Computed tomography scan of the chest and abdomen
. Flexible bronchoscopy
. Intravenous antibiotics
. Reassurance and outpatient follow-up
49) A 65-year-old woman presents to the physician’s office for her yearly physical examination. She has no complaints except for a recent 10-lb weight loss. Past history is pertinent for a 40 pack-year smoking history, hypertension, asthma, and hypothyroidism. Examination reveals a thin woman with normal vital signs and unremarkable heart and abdominal examinations. Lung examination reveals mild wheezing and a few bibasilar rales. A chest x-ray is obtained and is shown in Figure 6-13. A chest x-ray obtained 3 years ago was normal. Yearly laboratory tests including a CBC, electrolytes, and lipid panels are normal. Which of the following is the most appropriate next diagnostic test?
. Percutaneous needle biopsy
. CT scan
. Pulmonary function tests
. mediastinoscopy
. bronchoscopy
54) A 7-week-old, breast-fed, term infant presents with increasing jaundice, abdominal distention, and abnormal stools (Figure 6-20). Liver function tests demonstrate a conjugated hyperbilirubinemia, mildly elevated transaminases, and an elevated gamma-glutamyl transpeptidase. TORCH (congenital infection complex, including toxoplasmosis, rubella, cytomegalovirus, and hepatitis) serology and screening for inborn errors of metabolism are negative. As part of the diagnostic evaluation, the most sensitive imaging study in this clinical setting would be which of the following?
. Radioisotope scanning
. Radioisotope scanning with pre-imaging phenobarbital administration
. Abdominal ultrasound
. CT scan of the abdomen
. MRI scan of the abdomen
57) A 65-year-old woman presents to the physician’s office with a 6-month history of epigastric discomfort, poor appetite, and 10-lb weight loss. Past history is pertinent for hypertension, diabetes, a 30 pack-year smoking history, and occasional alcohol intake. Examination is unremarkable except for mild epigastric tenderness to deep palpation. An abdominal ultrasound reveals cholelithiasis, and one view of a UGI x-ray series is shown in Figure 6-8. Which of the following is the most appropriate next step in management?
. H2 blockers with re-evaluation by UGI in 6 month
. Vagotomy and pyloroplasty
. Total gastrectomy
. endoscopy
. CT scan
74) A 75-year-old woman is brought to the emergency department from a nursing home for abdominal pain, distention, and obstipation over the last 2 days. Past history is pertinent for stroke, diabetes, atrial fibrillation, and chronic constipation. Examination reveals a temperature of 98.6°F, pulse rate 90/min and irregularly irregular, and BP 160/90 mmHg. Heart examination reveals irregularly irregular rhythm with no murmurs; lung examination reveals few bibasilar rales; and abdominal examination reveals a distended, tympanic abdomen with mild tenderness and no rebound tenderness. Plain abdominal x-rays reveal dilated loops of bowel, and a barium enema is obtained and shown in Figure 6-9. Which of the following is the most appropriate next step in management following NG tube decompression and resuscitation?
. Urgent sigmoid resection
. Nonoperative reduction by proctoscopy and rectal tube
. Proximal colostomy
. Urgent operative detorsion
. Nonoperative reduction by passage of well-lubricated rectal tube
125) A 50-year-old man presents to the emergency room with a 6-hour history of excruciating abdominal pain and distention. The abdominal film shown here is obtained. Which of the following is the most appropriate next diagnostic maneuver?
. Emergency celiotomy
. Upper GI series with small-bowel follow-through
. CT scan of the abdomen
. Barium enema
. Sigmoidoscopy
{"name":"Part IV picture", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"368) The child shown below presents with a 3-day history of malaise, fever to 41.1C (106F), cough, coryza, and conjunctivitis. He then develops the erythematous, maculopapular rash pictured. He is noted to have white pinpoint lesions on a bright red buccal mucosa in the area opposite his lower molars. Which of the following is the most likely diagnosis?, 369) A 3-week-old infant with hypoplastic left heart syndrome comes to the physician for a follow-up visit. The infant was born at term via normal spontaneous vaginal delivery. The patient had the first of 3 palliative heart surgeries shortly after birth. He did well after surgery and was discharged home one week ago. Over the last 24 hours, the infant has difficulty feeding and one episodes of vomiting. On examination, the infant is afebrile, pulse is 160\/min, respiratory rate is 55\/min, blood pressure is 90\/50mmHg, and pulse oximetry is 80% on room air. He is mildly cyanotic, small, but well developed. His cardiovascular exam reveals tachycardia and distant heart sounds with a systolic ejection murmur heard throughout the precordium. His chest radiographs from discharge and today are shown below. What is the most likely diagnosis?, 374) A 2-year-old boy is brought to the emergency department by his mother for the evaluation of a productive cough and low-grade fever. He has had ten such infections over the past year, all of which required antibiotics. He was delivered vaginally without any complications. He is an only child. His mother's siblings have a history of similar infections. He is alert and has normal vital signs, except for a mild fever. Auscultation reveals rales and rhonchi in both lungs. The chest x-ray is shown below. What is the most likely diagnosis?","img":"https://cdn.poll-maker.com/13-558362/1.png?sz=1200"}
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