DES 2016-2017 : 2040-2299 (Fabien) 6

175) A 35-year-old woman is brought to the emergency department after being rescued from a burning building by firefighters. She had a brief tonic-clonic seizure en route to the hospital. Her past medical history is unknown. She is confused and mildly agitated. Her temperature is 37°C (98.6°F), blood pressure is 100/60 mm Hg, pulse is 115/min, and respirations are 24/min. Her oxygen saturation is 96% on room air. Physical examination shows no burns and her skin color is normal. There are symmetric breath sounds bilaterally with scattered end-expiratory wheezes. Neurological examination shows no abnormalities except some confusion. The abdomen is soft and non-tender. Which of the following is the best initial treatment for the patient?

176) A 24-year-old woman comes to the physician's office because of breast pain. She has a 2-month-old baby who she breastfeeds. Her temperature is 38.8°C (101.9°F). Examination shows a hard, red, tender and swollen area on her right breast. There is no fluctuance noted. Which of the following is the most appropriate next step in management?

177) A 60-year-old man comes to the clinic because of right calf pain. He has a history of chronic diverticular disease and has had multiple attacks of diverticulitis in the past. His most recent attack occurred 3 weeks ago, and he was treated with antibiotics and underwent left hemicolectomy. He had a stable postoperative course and was discharged from the hospital 1 week ago. He developed right calf pain 3 days ago, with swelling and difficulty bearing weight on his right leg. He currently takes no medication. He does not use tobacco, alcohol, or illicit drugs. His temperature is 36.8°C (98.2°F), blood pressure is 120/70 mm Hg, pulse is 92/min, and respirations are 14/min. Physical examination reveals the right calf slightly larger than the left calf, moderate right ankle edema, and right calf pain with dorsiflexion of the right foot. Duplex ultrasonography shows a clot in the right distal portion of the femoral vein. Which of the following is the most appropriate initial treatment?

178) A 23-year-old man is brought to the emergency department in an obtunded state following a gun-shot wound to the right upper quadrant of the abdomen. His systolic blood pressure is 60 mm Hg and unable to obtain diastolic blood pressure. His pulse is 136/min. Chest auscultation shows clear heart and breath sounds. The abdomen appears distended, and there is an obvious gun-shot wound on the right upper quadrant. The bowel sounds are decreased. Which of the following is the most appropriate next step in management?

179) A 35-year-old woman is being evaluated for a breast mass. She had a bilateral reduction mammoplasty for mammary hyperplasia 12 years ago. She has no family history of cancer. Breast examination shows a slightly retracted right nipple. A fixed mass is palpated in the upper outer quadrant of the right breast. Mammogram shows a 3 x 3 cm spiculated mass with coarse calcifications in the upper outer quadrant of the right breast. Ultrasonogram of the breast shows a hypoechoic mass. Multiple core biopsy samples show foamy macrophages and fat globules. Which of the following is the most appropriate course of action?

180) A 67-year-old male comes to the clinic for medical clearance prior to an elective abdominal aortic aneurysm repair. He denies any cough, shortness of breath or chest pain. He has coronary artery disease, diabetes and hypertension. He does not use tobacco, alcohol or drugs. His blood pressure is 120/76 mm Hg, pulse is 60/min, and respirations are 14/min. Examination shows no abnormalities, except prominent epigastric pulsations. Which of the following interventions would be most helpful in preventing postoperative pneumonia in this patient?

181) A 24-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He complains of severe back pain and abdominal discomfort. He was placed on a board in the field for spinal immobilization. His blood pressure is 111/78 mm Hg, pulse is 55/min and regular, and respirations are 16/min. Pulse oximetry shows 96% on room air. He is alert and fully oriented. There are several lacerations on the face and anterior chest. Air entry is bilaterally symmetric. There is weakness and decreased pain sensation in both legs. Proprioceptive sensation is preserved. Chest x-ray and CT scans of the abdomen and spine are performed. Which of the following is the most appropriate next step in managing this patient?

182) A 72-year-old man undergoes coronary artery bypass graft (CABG) for severe coronary artery disease. He is extubated on the second postoperative day. His temperature is 36.6°C (97.9°F), blood pressure is 120/70 mm Hg, pulse is 80/min, and respirations are 12/min. On the third postoperative day, he complains of dyspnea and worsening retrosternal pain despite continuous analgesia with morphine. His temperature is 38.6°C (101.5°F), blood pressure is 112/52 mm Hg, pulse is 125/min and irregularly irregular and respirations are 28/min. Examination shows normal heart sounds. A small amount of cloudy fluid is present in the sternal wound drain. His ECG shows atrial fibrillation with rapid ventricular response. An x-ray film of the chest shows widening of the mediastinum. Echocardiography reveals a small amount of pericardial fluid. Laboratory studies show: Hemoglobin 8.9 mg/dl, WBC count 16,300/mm3, Platelet count 512,000/mm3, Creatinine 1.7 mg/dl, CPK 430 U/L.Which of the following will this patient most likely require?

183) A 16-year-old boy is brought to the emergency department after falling off a bicycle and hitting his head on the ground. He briefly lost consciousness but had no seizures. He had two episodes of vomiting and complains of mild headache. His mother accompanies him and demands immediate evaluation. He has no other medical problems. His blood pressure is 121/67 mm Hg and pulse is 78/min. Examination shows a small bruise on his forehead but no bony abnormalities. The rest of the physical examination, including neurologic examination, shows no other abnormalities. Which of the following is the most appropriate next step in management?

184) A 12-year-old boy is brought to the physician because of right groin pain, knee pain, and limping. He has had these symptoms for the past 2 weeks. He is at the 90th percentile for weight and 60th percentile for height. He is afebrile, and his other vital signs are within normal limits. Examination shows that the range of motion of the right knee joint is within normal limits but hip movements are restricted and the right foot points outward. There is external rotation of the right thigh on flexion of the hip. After confirming the diagnosis, which of the following is the most appropriate management?

185) While working on-site at a factory doing physical examinations for workers, a physician is suddenly called to help a worker who amputated his finger. Which of the following is the most appropriate next step in management in this situation?

186) A 29-year-old woman is brought to the emergency department after burning her right upper extremity in a cooking accident Examination shows a circumferential burn of the right upper extremity. She is given fluids, an analgesic and a wound dressing. On day three she develops severe deep tissue pain in the right limb with edema of the hand. Examination shows a circumferential eschar over the right arm. Her right radial and ulnar pulses are faint compared to the left and she has paresthesias in her right hand. Which of the following is the most appropriate next step in management?

187) A 42-year-old man comes to the physician because of a 3-month history of burning substernal chest pain after every meal. His other medical problems include chronic alcoholism. Upper endoscopy shows mucosal irregularity and ulceration of the squamocolumnar junction above the lower esophageal sphincter. Multiple biopsies are taken. He complains of worsening substernal pain radiating to the back, left chest pain, and mild shortness of breath 4 hours later. His temperature is 37.1°C (98.9°F), blood pressure is 110/70 mm Hg, pulse is 120/min, and respirations are 34/min. A chest x-ray shows a small left pleural effusion that was not present on a chest radiograph taken 2 weeks ago. Which of the following is the most appropriate next step in management?

188) A 3-year-old girl 1s brought to the emergency department because she is not moving her right arm. Her mother states that the child was perfectly normal in the morning. She remembers that she lifted the child with the child's right forearm and since then she has not been moving her right arm. Examination shows the right arm is held in pronation against the chest. The child avoids any movement of her right arm. Which of the following is the most appropriate next step in management?

190) A 46-year-old man comes to the emergency department because of abrupt onset of epigastric pain radiating to the back and associated vomiting. He has had these symptoms for the past 1 day. The symptoms are progressively getting worse. He has no other medical problems or previous surgeries. He does not use tobacco, alcohol, or illicit drugs. His temperature is 36.5°C (97.6°F), blood pressure is 100/70 mm Hg, pulse is 100/min, and respirations are 20/min. Abdomen is mildly distended and very tender to palpation in the epigastric region; bowel sounds have decreased. There is no rebound tenderness or organomegaly. Rectal examination shows no abnormalities. Laboratory findings reveal: CBC: Hb 15.0 g/dL, Platelet count 223,000/mm3, Leukocyte count 14,500/mm3, Serum Chemistry: Serum Na 134 mEq/L, Serum K 3.6 mEq/L, Chloride 93 mEq/L, Bicarbonates 29 mEq/L, BUN 30 mg/dL, Serum creatinine 0.8 mg/dL, Calcium 10.3 mg/dL, Blood glucose 168 mg/dL, LFT 1.4 mg/dL. Total bilirubin: Alkaline phosphatase 220 U/L, Aspartate aminotransferase 88 U/L, Alanine aminotransferase 155 U/L, Lipase 523 U/L. Abdominal x-ray shows gaseous distention of the small bowel in the upper abdomen. Computed tomography (CT) scan with contrast shows diffuse hypodense enlargement of the pancreas and peripancreatic and perirenal fluid collections. Nasogastric suction, intravenous normal saline, analgesics, and antibiotics are started. Which of the following is the most appropriate next step in management?

1) 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?

2) 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?

3) 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?

4) 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?

5) A 7-year-old boy passes a large, bloody bowel movement. He is hemodynamically stable, and he has 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?

6) 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?

7) 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?

8) 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?

9) 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?

10) 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?

11) 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?

12) 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?

13) 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?

14) 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?

15) 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?

16) 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?

17) 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?

18) 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?

19) 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 much distended, thinwalled gallbladder without stones. Which of the following is the most appropriate next step in diagnosis?

20) 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?

21) 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?

22) 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?

23) 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?

24) 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?

25) 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?

26) 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?

27) 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?

28) 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?

29) 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?

30) 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?

31) 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?

32) 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?

33) 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 37.0C (98.6F). 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?

34) 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?

35) A 38-year-old immigrant from Latin America sustained a third-degree burn in the lateral aspect of her lower leg when she was 14. The burn was untreated. Ever since the incident, she has had shallow ulcerations at the scar site that heal and break down all the time. In the past few months she has developed an indolent, dirty-looking, deeper ulcer at the site, with "heaped up" tissue growth around the edges. The ulcer is steadily growing and showing no signs of healing. Which of the following is the most appropriate next step in diagnosis?

36) A 69-year-old man, who smokes and drinks heavily, complains of an earache on his left side. The earache has been present for 6 weeks and is not getting any better despite systemic antibiotics and ear drops. On physical examination, he is found to have very poor oral hygiene, only a few remaining stumps of rotten teeth, and big tonsils that are hard to see because he gags easily. Otoscopic examination shows a perfectly normal right tympanic membrane, although the left is distorted by what appears to be a serous otitis media. Tuning fork testing shows conductive hearing loss on the left but equal bone conduction on both sides. He is afebrile. Which of the following will most likely confirm the diagnosis?

37) A 31-year-old man is brought by helicopter to the trauma center after a motor vehicle accident in which he sustained massive lower extremity crush injury. The patient is alert and awake but in tremendous pain. His blood pressure is 140/80 mm Hg, and his pulse is 110/min. There is copious ongoing blood loss from the sites of injury. Urgent laboratory data will most likely show which of the following electrolyte abnormalities?

38) A window cleaner falls from a third-story scaffold and lands on his feet. Physical examination and x-rays show comminuted fractures of both calcaneus. He is tender to palpation over multiple bruises and abrasions in other parts of his trunk and extremities, but he has normal vital signs and a normal neurologic exam. Given the mechanism of injury, which of the following is the most appropriate next step in diagnosis?

39) On the second postoperative day after an abdomino-perineal resection for cancer of the rectum, a 72-yearold man complains of severe retrosternal pain. The pain is crushing in nature and radiates to the left arm. He also becomes short of breath and tachycardic. Except for his fresh surgical wounds and postoperative discomfort, physical examination is unremarkable. He does not have distended neck veins. Which of the following is the most appropriate next step in diagnosis?

40) A young man is brought to the emergency department following a head-on collision at 30 miles per hour. He is awake and alert. Other than a forehead laceration, physical examination is normal and laboratory values are within normal limits. Chest x-ray films are unremarkable. Which of the following is the most appropriate next step in diagnosis?

41) A 52-year-old woman in renal failure is listed as a transplant candidate. In order to assess the propriety of the transplant, which of the following combinations represents how a cross-match is performed?

42) A 65-year-old man comes to the physician for a health maintenance examination. Which of the following screening methods would allow the highest detection rate of prostatic carcinoma in early stages?

43) A patient with severe neurological devastation after head trauma has a prolonged course in the intensive care unit. He has been mechanically ventilated for his entire hospital stay. Which of the following clinical findings is diagnostic of a ventilator-associated pneumonia?

44) A 40-year-old obese woman, mother of five children, presents with progressive jaundice that she first noticed 4 weeks ago. She has a total bilirubin of 22 mg/dL, with 16 mg/dL direct (conjugated) and 6 mg/dL indirect (unconjugated). Her transaminases (AST and ALT) are minimally elevated, but her alkaline phosphatase is about 6 times the upper limit of normal. She has no anemia or occult blood in the stools. She has a history of multiple episodes of colicky right upper quadrant abdominal pain, brought about by the ingestion of fatty food; the last episode occurred a few days before her jaundice was first noted. She currently has no pain and is afebrile. A sonogram of her upper abdomen shows a contracted gallbladder full of stones, as well as dilated intrahepatic and extrahepatic biliary ducts; however, no stone can be identified in die common duct. Which of the following is the most appropriate next step in diagnosis?

45) A 34-year-old woman is admitted to the hospital because of septic shock secondary to a urinary tract infection. In the intensive care unit, she receives intravenous fluids and antibiotics. Her initial ECG shows sinus tachycardia but is otherwise unremarkable. Chest x-ray shows no abnormalities. An internal jugular vein catheter is placed on the right side using ultrasound guidance to locate the vein. The patient is properly draped, and the skin is cleaned with chlorhexidine solution. Blood is freely aspirated from all ports after insertion. Vital signs are stable, and oxygenation is maintained. Which of the following is the most appropriate next step in managing this patient?

46) A 23-year-old man known to have neurofibromatosis, type 1 (von Recklinghausen's disease), presents with a left lower quadrant abdominal mass and signs of neurologic deficits in his left leg. In the ensuing workup, it is determined that he has higher than normal values of catabolites of epinephrine and norepinephrine in a 24-hour urinary collection. He is currently normotensive. Before invasive steps are taken to biopsy and eventually remove his left lower quadrant abdominal mass, which of the following is the most appropriate next step in management?

47) A car is involved in a head-on collision. The driver, who is sober and wearing his seat belt, explains that he clearly saw his drunk, unrestrained front seat passenger hit the windshield with his face and the dashboard with his knees. Examination of the passenger indeed shows multiple facial lacerations, but because of his intoxication he cannot explain where else he might be hurting. He is neurologically intact, and his cervical spine x-ray films are normal. Additional injury, representing a potential orthopedic emergency, is not obvious but is suspected. Therefore, an x-ray film of which of the following areas should most likely be obtained?

48) A 68-year-old man presents to the physician’s office complaining of progressive dysphagia over the last 3 months associated with mild chest discomfort. He reports a 15-lb weight loss, a 30 pack-year smoking history, and occasional alcohol intake. The physical examination, including vital signs, is unremarkable. A chest x-ray was normal, and a barium esophagogram shows an irregular filling defect in the distal third of the esophagus with distortion and narrowing of the lumen. Which of the following is the most appropriate next step in management?

50) A 68-year-old man is diagnosed with lung cancer. In preparation for pulmonary resection he undergoes pulmonary function tests. Which of the following results indicate a favorable prognosis?

51) A 55-year-old man presents to the emergency department at 5 a.m. Complaining of vomiting blood. After binge drinking last night, the patient began to vomit repeatedly. After a number of episodes, the patient noted blood in the vomitus, followed by a melanotic stool 5 hours later. His past history is pertinent for ethanol abuse and a 40 pack-year smoking history. Vital signs reveal a BP of 100/60 mmHg, pulse rate of 95/min, respiratory rate of 12/min, and temperature of 97°F. Examination reveals a thin man with normal chest, cardiac, and abdominal findings. Rectal examination reveals heme-positive stool. Laboratory data show normal electrolytes and a hematocrit of 30. A chest x-ray is unremarkable. Volume resuscitation, gastric lavage, and NG tube decompression are initiated. Which of the following is the most appropriate diagnostic test?

52) A 70-year-old man with a 50 pack-year history of smoking presents with a 6-week history of intermittent, painless, gross hematuria and urinary frequency. There are no masses palpable on abdominal examination, and rectal examination is normal. Urinalysis confirms the presence of hematuria, and urine culture is negative. Which of the following is the most appropriate initial diagnostic evaluation of this patient?

53) A 70-year-old man with a 50 pack-year history of smoking presents with a 6-week history of intermittent, painless, gross hematuria and urinary frequency. There are no masses palpable on abdominal examination, and rectal examination is normal. Urinalysis confirms the presence of hematuria, and urine culture is negative. The initial diagnostic evaluation does not reveal any abnormalities. Which of the following is the best next step in the diagnostic workup?

55) A 56-year-old woman presents to the physician’s office with complaints of a new left breast mass. She denies any pain, nipple discharge, or skin dimpling. She has a prior history of breast cysts 5 years ago, treated by aspiration at that time. Her last mammogram was at age 53. Past history is pertinent for a 30 pack-year smoking history, prior total abdominal hysterectomy bilateral salpingo-oophorectomy (TAH-BSO) at age 54 for leiomyomas, and current use of hormone replacement therapy (HRT). Family history is negative for breast disease. Examination reveals a firm, welldefined, mobile, 1.5-cm nodule in the upper outer quadrant of the left breast without any regional lymphadenopathy. Which of the following is the most appropriate next step in management?

56) A 54-year-old African American man, with a history of smoking and drinking, describes progressive dysphagia that began 3 months ago. He first noticed difficulty swallowing meat; it then progressed to other solid foods, then to soft foods, and now to liquids as well. He locates the place where the food "sticks" at the lower end of the sternum. He has lost 30 pounds. Which of the following is the most appropriate first step in diagnosis?

58) A 75-year-old man is found by his internist to have an asymptomatic carotid bruit. Which of the following is the most appropriate next test?

59) A 55-year-old woman presents with a 6-month history of weight loss, abdominal cramps, and intermittent non-bloody diarrhea. On examination, her abdomen is mildly distended and there is a palpable mass in the right lower quadrant. Stool cultures yield normal fecal flora. CT scan with oral contrast demonstrates an inflammatory mass in the right lower quadrant, with thickening of the terminal ileum and ileocecal valve. Which of the following is the best diagnostic test to confirm the diagnosis?

60) For the first 6 hours following a long and difficult surgical repair of a 7-cm abdominal aortic aneurysm, a 70-year-old man has a total urinary output of 25 mL since the operation. Which of the following is the most appropriate diagnostic test to evaluate the cause of his oliguria?

61) A 66-year-old man presents with progressive jaundice, which he first noticed 6 weeks ago. He has a total bilirubin of 22 mg/dL, with a direct (conjugated) bilirubin of 16 mg/dL. His transaminases are minimally elevated, whereas his alkaline phosphatase is about six times the upper limit of normal. A sonogram shows dilated intrahepatic ducts, dilated extrahepatic ducts, and a much distended, thin-walled gallbladder without stones. Which of the following is the most appropriate next step in diagnosis?

62) A 52-year-old woman sees her physician with complaints of fatigue, headache, flank pain, hematuria, and abdominal pain. She undergoes a sestamibi scan that demonstrates persistent uptake in the right superior parathyroid gland at 2 hours. Which of the following laboratory values is most suggestive of her diagnosis?

63) A 55-year-old man presents to the physician’s office complaining of upper abdominal pain of 2 months’ duration. The pain is described as gnawing, localized to the upper midline, and associated with nausea. The pain is exacerbated by food, and there is an associated 20-lb weight loss over 2 months. His past history is pertinent for a 30 pack-year smoking history, occasional alcohol intake, and a prior history of a benign gastric ulcer 5 years ago. Physical examination reveals normal vital signs, mild epigastric pain with deep palpation, and mildly hemepositive stool. An evaluation for recurrence of a gastric ulcer is recommended. Which of the following tests is the most reliable method for diagnosing a gastric ulcer?

64) A middle-aged homeless man is brought to the ER by EMS for altered mental status, seizures, and vomiting. On physical examination he has no fever, neck stiffness, or evidence of head trauma. He does, however, have multiple dental caries and a focal neurologic deficit. Which of the following is the best next step in the patient’s workup?

65) A 30-year-old man presents to the emergency department with sudden onset of severe epigastric pain and vomiting 3 hours ago. He reports a 6-month history of chronic epigastric pain occurring nearly every day and relieved by antacids. On examination, he appears sweaty and avoids movement. Vital signs reveal a temperature of 100°F, BP of 100/60 mmHg, pulse rate of 110/min, and respiratory rate of 12/min. The remainder of his examination reveals diminished bowel sounds and a markedly tender and rigid abdomen. A chest x-ray and abdominal films reveal pneumoperitoneum. Which of the following is the most appropriate next diagnostic test?

66) A 65-year-old man presents to the physician’s office for his yearly examination. His past history is pertinent for a 40 pack-year smoking history and colon cancer 3 years ago for which he underwent a sigmoid colectomy. The most recent colonoscopic follow-up 3 months ago was negative. His physical examination is normal. Laboratory results show a normal CBC and electrolytes, markedly elevated cholesterol, and a CEA of 12 compared to values of less than 5 obtained every 6 months since colectomy. A repeat CEA 4 week later was 15, and liver function tests revealed a minimally elevated alkaline phosphatase, with normal transaminases and bilirubin. Which of the following is the most appropriate next diagnostic test in this patient?

67) A 34-year-old woman has recurrent fainting spells induced by fasting. She also reports palpitations, trembling, diaphoresis, and confusion prior to the syncopal episodes. She has relief of symptoms with the administration of glucose. Which of the following findings is most consistent with the diagnosis of an insulinoma?

68) A 34-year-old woman presents with hypertension, generalized weakness, and polyuria. Her electrolyte panel is significant for hypokalemia. Which of the following is the best initial test given her presentation and laboratory findings?

69) A 65-year-old man presents with acute onset of pain, swelling, and erythema of the left knee. He denies previous episodes or trauma to the knee. The differential diagnosis includes septic arthritis and gout. Which of the following is the best study to differentiate between gout and septic arthritis?

70) A 14-year-old boy slides down a banister and crashes into a large ornamental knob at its base, thereby injuring his scrotal contents. He presents in the emergency department with acute testicular pain and a scrotal hematoma the size of a grapefruit. He is able to void normally, and his urine does not contain blood. A rectal examination is unremarkable. Findings from which of the following tests will most likely determine further therapy?

71) A 44-year-old woman has a palpable nodule in the right lobe of her thyroid gland. The nodule measures 2 cm and is firm. The rest of the thyroid gland cannot be felt and is not tender. She also describes losing weight in spite of a ravenous appetite, palpitations, and heat intolerance. She is thin, fidgety, and constantly moving, with moist skin and a pulse of 105/min. She has no exophthalmos or pretibial edema. Her TSH is reported as much lower than normal, and she has elevated levels of free T4. Which of the following is the most appropriate next step in diagnosis?

72) A 72-year-old man undergoes an aortobifemoral graft for symptomatic aortoiliac occlusive disease. The inferior mesenteric artery (IMA) is ligated at its aortic attachment. Twenty-four hours after surgery the patient has abdominal distention, fever, and bloody diarrhea. Which of the following is the most appropriate diagnostic study for this patient?

73) A 50-year-old salesman is on a yacht with a client when he has a severe vomiting and retching spell punctuated by a sharp substernal pain. He arrives in your emergency room 4 hours later and has a chest film in which the left descending aorta is outlined by air density. Which of the following is the most appropriate next step in his workup?

75) A 4-year-old previously healthy girl presents to the emergency department with a 24-hour history of rectal bleeding and dizziness. She has no other gastrointestinal symptoms. On examination, she appears pale. Her heart rate is 140 beats/min, and she has a 20 mmHg postural drop in systolic blood pressure. The child’s abdomen is nondistended and nontender, and fresh blood and clots are in the rectal vault on rectal examination. Which of the following is the most appropriate diagnostic study to order for this patient?

76) A 66-year-old woman presents with severe right lower extremity claudication. Surgery is considered, but her hypertension, smoking, and diabetes puts her at risk for associated coronary heart disease. What test is most predictive of postoperative ischemic cardiac events following surgery?

77) A 5-week-old infant presents with a 1-week history of progressive nonbilious emesis, associated with a 24-hour history of decreased urine output. The infant continues to be active and eager to feed. On examination, the infant has a sunken fontanels and decreased skin turgor. The abdomen is scaphoid, and with a test feed, there is a visible peristaltic wave in the epigastrium. Electrolytes and a urinalysis are evaluated. Which of the following laboratory findings are most likely to be seen in this patient?

78) A 77-year-old man becomes "senile" over a period of 3 or 4 weeks. He used to be active and managed all of his financial affairs. Now, he stares at the wall, barely talks, and sleeps most of the day. His daughter recalls that he fell from a horse about a week before the mental changes began. Which of the following would a CT scan of his head most likely show?

79) A 50-year-old man presents with intractable peptic ulcer disease, severe esophagitis, and abdominal pain. Which of the following is most consistent with the diagnosis of Zollinger-Ellison syndrome?

80) A postoperative patient with swelling and pain in his right calf is suspected of having a deep venous thrombosis. Prior to initiating treatment with anticoagulants, he requires a confirmatory examination. Which of the following is a limitation of the duplex ultrasound in evaluating a DVT?

81) A 75-year-old man is brought to the emergency department for severe pain in the left flank and back of 1 hour duration. He has a prior history of a myocardial infarction and coronary artery bypass grafting 8 years ago. On examination, he is found to have a BP of 80/50 mmHg, pulse rate of 110/min, respiratory rate of 15/min, and a pulsatile, tenderabdominal mass. He has had two large-bore IV lines placed by the paramedics. He is alert and oriented, and gives consent for surgery. On postoperative day 3, the patient develops dark-colored diarrhea but remains normotensive, on full mechanical ventilation, and is awake. Laboratory analysis reveals normal electrolytes, blood urea nitrogen (BUN), and creatinine; hematocrit of 30; and WBC of 15,000. Which is the most appropriate next step in management?

82) A pedestrian is hit by a car. The paramedics report that he was unconscious at the site, and he arrives at the emergency department in coma, strapped to a head board with sandbags on either side of his head. Initial survey shows stable vital signs, and his pupils are of equal size and reactive to light. He is rapidly intubated by the nasotracheal route over a flexible bronchoscope and then sent for CT scans of the head. As he is being positioned on the table, it is noted that there is a sizable hematoma behind his right ear and that clear fluid is dripping from the ear canal. Which of the following is most advisable, considering this new finding?

83) A 76-year-old man is admitted to the coronary care unit after an episode of substernal chest pain. His other medical problems include hypertension, hyperlipidemia, and type 2 diabetes mellitus. He has a history of a diverticular bleed 2 years ago. After initial workup, cardiac catheterization is performed and shows 50% left main coronary artery stenosis, 90% proximal left anterior descending artery stenosis, and 65% right coronary artery stenosis. Antiplatelet agents are stopped, and the patient is continued on a heparin drip in preparation for coronary artery bypass surgery the next day. Five hours after the catheterization, his blood pressure is 75/60 mm Hg and pulse is 120/min and regular. He complains of some generalized weakness and back pain but denies chest pain, shortness of breath, nausea, and abdominal discomfort. He appears to be diaphoretic and clammy. Neck veins are flat. Heart sounds are normal, and the chest is clear to auscultation. The groin site for arterial puncture is mildly tender, without subcutaneous hematoma. He receives 1000 ml of normal saline, with symptomatic improvement. His blood pressure is 96/60 mm Hg and pulse is 85/min. His ECG seems to be unchanged. Which of the following is the most appropriate next step in managing this patient?

84) A 65-year-old woman presents to the physician’s office for a second opinion on the management options for recently diagnosed breast cancer. She presents with a 2.5-cm mass in the upper outer quadrant of the left breast associated with a palpable axillary node suspicious for metastatic disease. The remainder of her examination is normal. Mammography demonstrates the cancer and shows no other suspicious lesions in either breast. Chest x-ray, bone scan, and blood test panel, including liver function tests, are normal. Family history is positive for breast cancer diagnosed in her sister at age 65. Past history is unremarkable. The first physician recommended modified radical mastectomy. The patient has read about SLN biopsy. She avidly wants to avoid the risk of lymphedema that her sister must endure. She asks the question “Am I a candidate for a SLN biopsy instead of a complete axillary dissection?” Which of the following is the most appropriate answer to her question?