Part8(1922-1956).......(1785-2039)5brettpit

A group of medical professionals discussing over a large wall chart filled with diagrams and anatomical models in a bright, modern clinic.

Medical Knowledge Challenge

Test your medical knowledge with our extensive quiz featuring 108 carefully crafted questions spanning various topics in healthcare. Perfect for students, professionals, or anyone interested in the medical field.

Engage with questions that cover:

  • Transplant Surgery
  • Oncology
  • Cardiology
  • Endocrinology
  • Surgical Techniques
108 Questions27 MinutesCreated by StudyingSurgeon472
A 33-year-old diabetic man receives a renal allograft. The physicians choose cyclosporine as one of the antirejection medications. Which of the following functions does cyclosporine A primarily inhibit?
. Interleukin 2 production
Interleukin 1 production
. Macrophage function
Cytotoxic T-cell effectiveness
. Antibody production
33) A 57-year-old man has end-stage heart failure due to atherosclerosis. His cardiologist refers him for evaluation for heart transplantation. Which of the following is an absolute contraindication for heart transplantation?
Cirrhosis
. Reversible high pulmonary vascular resistance
. Age over 65
. History of colon cancer resected 5 years ago with no evidence of recurrence
. Diabetes without end-organ damage
A 55-year-old woman has been hospitalized because of recurrent pancreatitis, ARDS, prolonged ileus, and need for parenteral nutrition. She demonstrates weakness, lassitude, orthostatic hypotension, nausea, and fever. Which of the following abnormalities is most likely to explain these symptoms?
Hyponatremia
Hyperglycemia
Hypothermia
. Hypervolemia
. Hypokalemia
A 25-year-old man presents to the same day surgical center for repair of an old injury to his lateral collateral ligament. The anesthesiologist wants to perform an axillary block for local pain control. If the posterior wall of the axillary artery is pierced during placement of the block, which of the following nerves will most likely be affected?
Ulnar
Musculocutaneus
Axillary
Radial
Median
A 72-year-old woman who is planning to undergo ventral hernia repair is on warfarin for atrial fibrillation. She is advised to cease her warfarin several days before her surgery and is hospitalized preoperatively for heparinization. During her hospital stay, she complains of severe abdominal and flank pain. Her prothrombin time (PT) is normal, but her activated partial thromboplastin time (aPTT) is elevated. An abdominal CT scan demonstrates a large retroperitoneal hematoma. Which of the following should be administered to reverse the effects of the heparin?
. Protamine sulphate
Aprotinin
Thrombin
. Platelet transfusion
. Vitamin K
37) A 24-year-old man whose father was just diagnosed with colon cancer presents to his family physician to discuss screening colonoscopy. His physician suspects that he has hereditary nonpolyposis colon cancer (HNPCC) or Lynch syndrome and recommends screening colonoscopy beginning at age 25. Which of the following is most supportive of a clinical diagnosis of HNPCC?
. A father, uncle, and grandfather (same side of the family) with colon cancer at 50 years of age
. A father and grandfather (same side of the family) with colon cancer
. A father with colon cancer at 52 years of age
. A father and 2 uncles (same side of the family) with colon cancer
. A father and an uncle (same side of the family) with colon cancer
A patient requires both cardiac and renal transplantation. Preparation for the procedures has begun. How do cardiac allografts differ from renal allografts?
. Cardiac allografts are matched only by size and ABO blood type.
. One-year graft survival for cardiac allografts is substantially lower than that for renal allografts.
. Cardiac allografts are matched by HLA tissue typing and renal allografts are not.
Cyclosporine is a critical component of the immunosuppressive regimen for cardiac allografts but not renal allografts.
. Cardiac allografts can tolerate a longer period of cold ischemia than renal allografts.
A patient with colon cancer has a mass in the upper lobe of his left lung 2.5 years following resection of his colon cancer and subsequent 12 months of chemotherapy. His CEA level is rising. Which of the following predicts a 5-year survival rate of greater than 20% following resection of pulmonary metastases?
Lung lesions are solitary.
. The tumor doubling time is less than 20 days.
. Other organ metastases are present.
. The patient has received prior chemotherapy.
. Local tumor recurrence is found.
A 60-year-old man presents with a 6-mm basal cell carcinoma on the tip of his nose. He is scheduled to undergo excision of the tumor in the operating room with repair of the defect using skin and subcutaneous tissue from his earlobe. Which of the following terms most appropriately describes this form of reconstructive surgery?
. Composite graft
. Pedicle flap
. Split-thickness graft
. Free flap
. Full-thickness graft
A 45-year-old woman with breast cancer undergoes a modified radical mastectomy with lymph node dissection. Six weeks later, she returns complaining of decreased mobility of her shoulder. On physical examination, the scapula protrudes from the body when pressing her outstretched arm on the wall. Which of the following nerves was most likely injured during the operation?
Long thoracic
Medial pectoral
Intercostal
Thoracodorsal
Lateral pectoral
A 19-year-old college student presents with a testicular mass, and after treatment he returns for regular follow-up visits. Which of the following is the most useful serum marker for detecting recurrent disease after treatment of nonseminomatous testicular cancer?
. Human chorionic gonadotropin (hCG)
CA125
. Carcinoembryonic antigen (CEA)
. p53 oncogene
. Prostate-specific antigen (PSA)
43) A 72-year-old man undergoes resection of an abdominal aneurysm. He arrives in the ICU with a core temperature of 33°C (91.4°F) and shivering. Which of the following is a physiologic consequence of the shivering?
. Increased production of CO2
. Rising base excess
. Rising mixed venous O2 saturation
. Decreased minute ventilation
. Decreased consumption of O2
A 43-year-old man with a gangrenous gallbladder and gram-negative sepsis agrees to participate in a research study. An assay of tumor necrosis factor (TNF) is performed. Which of the following is the origin of this peptide?
. Monocytes/macrophages
. Activated T lymphocytes
Fibroblasts
. Activated killer lymphocytes
. Damaged vascular endothelial cells
A patient sustained third-degree burns on both his arms when his shirt caught on fire while he was lighting the backyard barbecue. The burned areas are dry, white, leathery, anesthetic, and circumferential all around the arms and forearms. Which of the following parameters should be very closely monitored?
Peripheral pulses and capillary filling
Carboxyhemoglobin levels
Blood gases
Myoglobinemia and myoglobinuria
Body weight
A previously healthy 60-year-old man is referred for urologic evaluation of macroscopic hematuria. Urinary cytology is positive for malignant cells, and cystoscopic examination reveals an exophytic multifocal tumor. A biopsy of die tumor demonstrates papillary fronds lined by ccfls similar to transitional epithelium but showing nuclear atypia, mitoses, and necrosis. Which of the following is the most important risk factor in the U.S. For the development of this type of tumor?
Smoking
Radiation
Aniline dyes
Recurrent cystitis
Phenacetin
A 54-year-old woman presents to her physician for an opinion regarding additional therapy following curative resection of recently diagnosed colon cancer. She underwent uncomplicated sigmoid resection for invasive colon cancer 4 weeks ago. The pathology revealed carcinoma invading into, but not through, the muscularis propria, with one of eight positive mesenteric nodes. There was no evidence of liver metastases at the time of operation. Preoperative chest x-ray and CT scan of the abdomen showed no evidence of distant disease. Preoperative carcinoembryonic antigen (CEA) level was normal. Past history is positive for diabetes and mild hypertension. Examination is unremarkable except for a healing abdominal incision. Which of the following is the correct stage of this patient’s colon cancer?
. stage III
. stage II
. stage 0
. stage IV
. stage I
Which of the following patients with primary hyperparathyroidism should undergo parathyroidectomy?
. A 42-year-old woman with a history of kidney stones
. A 59-year-old woman with mildly elevated 24-hour urinary calcium excretion
. A 62-year-old asymptomatic woman
A 60-year-old woman with mildly decreased bone mineral density measured at the hip of less than 2 standard deviations below peak bone density
. A 54-year-old woman with fatigue and depression
A 49-year-old woman presents to her physician with dysphagia, regurgitation of undigested food eaten hours earlier, and coughing over the last 6 months. She was hospitalized 1 month ago for aspiration pneumonia and successfully treated with antibiotics. Examination reveals a thin-appearing woman with normal vital signs and unremarkable chest, heart, and abdominal examination. A UGI contrast study is performed and reveals a pharyngoesophageal (Zenker’s) diverticulum. Which of the following statements is true regarding Zenker’s diverticula?
. Pharyngoesophageal diverticula are of the pulsion type.
. Pharyngoesophageal diverticula are true diverticula.
. Cervical dysphagia is related to the size of the diverticulum.
. Pharyngoesophageal diverticula are congenital in origin.
. Upper esophageal sphincter function is usually normal.
A 36-year-old woman whose mother has just undergone treatment for breast cancer is asking about how this affects her and what can be done to lessen her chances of having the disease. Which of the following has the lowest risk factor for breast cancer?
. Dietary fat intake
. Previous biopsy with atypical hyperplasia
. Paternal relative with breast cancer 1 (BRCA1) mutation
. Exposure to ionizing radiation
. Excessive estrogen exposure—early menarche, late menopause, nulliparity
A 39-year-old woman presents to the physician’s office for evaluation of a palpable nodule in the neck of 2 years’ duration. Her past history is pertinent for Hashimoto’s disease diagnosed 5 years ago, for which she takes thyroid hormone. She has a history of low-dose chest irradiation for an enlarged thymus gland during infancy. On examination, a 2.5-cm nodule is palpable in the left lobe of the thyroid and is firm and nontender. Which of the following portions of her history increases the risk for thyroid cancer?
. low-dose irradiation during infancy
. Chronicity of the nodule
. Age group of 20–40 years
. Past history of Hashimoto’s disease
. Female gender
While playing with his children, a 44-year-old man falls and lands on his right shoulder. There is immediate pain and deformity. In an uncomplicated dislocation of the glenohumeral joint, the humeral head usually dislocates primarily in which of the following directions?
Anteriorly
. Laterally
Superiorly
. Medially
Posteriorly
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?
. Radial nerve
. Ulnar nerve
. Median nerve
. Ascending circumflex brachial nerve
. Posterior interosseous nerve
54) In a failed suicide gesture, a depressed student severs her radial nerve at the wrist. Which of the following is her expected disability?
. Sensory loss over the thenar pad and the thumb web
. Wasting of the intrinsic muscles of the hand
. Loss of ability to extend the wrist
. Palmar insensitivity
. Loss of ability to flex the wrist
A 52-year-old woman presents with hypertension, obesity, and new skin striae. You are concerned about possible Cushing syndrome. Which of the following is the most common cause of Cushing syndrome?
. Pharmacologic glucocorticoid use
. Primary adrenal neoplasms
. Adrenocortical hyperplasia
. Ectopic adrenocorticotropic hormone (ACTH)–secreting carcinoid tumor
. Adrenocorticotropic hormone (ACTH)–producing pituitary tumor
A 62-year-old woman presents with invasive ductal carcinoma of the right breast. Which of the following findings would still allow her to receive breast conservation surgery (partial mastectomy)?
. Multifocal disease
. Large tumor relative to breast size
. Diffuse suspicious microcalcifications throughout the breast
. Persistently positive margins after multiple reexcisions of the breast cancer
. Previous treatment of a breast cancer with lumpectomy and radiation
A 56-year-old woman presents to the clinic for routine health screening. Her concern is the development of breast cancer. She has no current breast-related complaints. Past history is pertinent for fibrocystic changes with atypical ductal hyperplasia and a single fibroadenoma, both diagnosed by open biopsy 5 years ago. She smokes one pack per day and drinks one can of beer daily. Family history is positive for breast cancer in her mother, diagnosed at the age of 85. Current medications include a cholesterol-lowering agent, an antihypertensive, and HRT, which she has taken for 5 years. Physical examination is unremarkable. Mammograms show dense breasts, decreasing the accuracy of the study, but no suspicious findings were noted. Which of the following is the most common risk factor in evaluating women for breast cancer?
Age
. Positive family history
. Fibrocystic changes with atypical ductal hyperplasia
HRT
. Alcohol consumption
A patient who has had angina as well as claudication reports feeling light-headed on exertion, especially when lifting and working with his arms. The subclavian steal syndrome is associated with which of the following hemodynamic abnormalities?
. Occlusion of the subclavian artery
. Occlusion of the carotid artery
. Antegrade flow through a vertebral artery
. Occlusion of the vertebral artery
. Venous congestion of the upper extremities
While working at a bookbinding shop, a young man suffers a traumatic amputation of his index finger. The finger was cleanly severed at its base. The patient and the finger are brought to a first-aid station, from which both are to be transported to a highly specialized medical center for replantation to be done. Which of the following is the correct way to prepare and transport the severed finger?
. Wrap it in a moist gauze, place it on a plastic bag, and place the bag on a bed of ice
. Immerse it in cold alcohol for the entire trip
. Dry the finger of any traces of blood and place it in a cooler filled with crushed ice
. Paint it with antiseptic solution and place it on a bed of dry ice
. Freeze it as quickly as possible, and transport it immersed in liquid nitrogen
A 27-year-old basketball player jumps to block a shot with his right hand. As his hand contacts the ball, he feels severe pain in his right shoulder. He presents to the emergency department with continuing shoulder pain. You note that he holds his right arm in slight external rotation, supporting its weight with his left hand. On physical examination, he resists internal rotation of his right arm. Which of the following nerves is most likely to be injured in this patient?
Axillary
Musculocutaneous
Radial
. Long thoracic
Ulnar
A 23-year-old male is found at the scene of a motor vehicle accident with bilateral lower extremity fractures. You also note extensive abdominal bruising and scalp lacerations. At the scene, the patient's blood pressure is 80/60 mmHg and his heart rate is 120/min. He is given 2 liters of IV fluids wide open. On the way to the hospital he becomes progressively drowsy, and he develops progressive weakness on the right side of his body. This patient is also likely to show deficits in the functioning of which of the following nerves?
Oculomotor
Glossopharyngeal
Abducens
Trigeminal
Accessory
A 34-year-old man is brought to the emergency department after being involved in a motorbike accident. Examination shows a hematoma on the forehead and bleeding from his leg. His pupils are bilateral round and eactive; he has papilledema. He responds to pain, has decorticated posture and speaks incoherently. After the initial resuscitation you start the treatment with intravenous fluids, hyperventilation, head elevation and intravenous mannitol. Which of the following is the mechanism of action of hyperventilation in this patient?
. Hyperventilation causes vasoconstriction and thus decreases the cerebral blood flow
. Hyperventilation helps to wash out the carbon dioxide
. Hyperventilation acts as stimuli to brain and helps to arouse the patient
. Hyperventilation causes vasoconstriction and helps to reduce his bleeding
. Hyperventilation corrects hypoxia
A 40-year-old female is brought to the emergency department following a motor vehicle accident in which she was the front seat passenger. She reports hitting her head against the windshield and hurting her right leg. She appears completely alert and oriented. Glasgow Coma Scale = 15/ 15. Her pupils are equal and reactive to light. There is a bruise over the right forehead, but no tenderness is present on palpation of the cranial bones. Examination of the right leg reveals a hematoma over the thigh. Knee extension on the right is markedly reduced when compared to the left. Sensory examination reveals decreased sensory perception to both sharp and dull stimuli over the right lower medial leg. All other dermatomes are intact. What nerve injury is most likely present in this patient?
. Femoral nerve
. Common peroneal nerve
. Tibial nerve
. Fibular nerve
. Obturator nerve
A 74-year-old woman is admitted with upper gastrointestinal (GI) bleeding. She is started on H 2 blockers, but experiences another bleeding episode. Endoscopy documents diffuse gastric ulcerations. Omeprazole is added to the H2 antagonists as a therapeutic approach to the management of acute gastric and duodenal ulcers. Which of the following is the mechanism of action of omeprazole?
. Inhibition of parietal cell hydrogen potassium ATPase (adenosine triphosphatase)
. Buffering of gastric acids
Blockage of the breakdown of mucosa-damaging metabolites of nonsteroidal anti-inflammatory drugs (NSAIDs)
. Inhibition of gastrin release and parietal cell acid production
. Provision of a direct cytoprotective effect
A 38-year-old woman who underwent total thyroidectomy for multinodular goiter 6 months ago presents with persistent hoarseness. Which of the following nerves was most likely injured during her operation?
. Unilateral recurrent laryngeal nerve
. Hypoglossal nerve
. Superior laryngeal nerve
. Marginal mandibular branch of the facial nerve
. Bilateral recurrent laryngeal nerves
A 52-year-old man with a family history of multiple endocrine neoplasia type 1 (MEN1) has an elevated gastrin level and is suspected to have a gastrinoma. Which of the following is the most likely location for his tumor?
Within the triangle formed by the junction of the second and third portions of the duodenum, the junction of the neck and body of the pancreas, and the junction of the cystic and common bile duct Q
. Tail of the pancreas
. Fundus of the stomach
Within the triangle formed by the inferior edge of the liver, the cystic duct, and the common hepatic duct
. Antrum of the stomach
A 73-year-old woman presents to the emergency room complaining of severe epigastric pain radiating to her back, nausea, and vomiting. CT scan of the abdomen demonstrates inflammation and edema of the pancreas. A right upper quadrant ultrasound demonstrates the presence of gallstones in the gallbladder. Which of the following is an important prognostic sign in acute pancreatitis according to Ranson’s criteria?
. Age
. Albumin level
. Amylase level
. Lipase level
. Total bilirubin level
A 24-year-old man presents to the emergency room with abdominal pain and fever. CT scan of the abdomen reveals inflammation of the colon. He is referred to a gastroenterologist to be evaluated for inflammatory bowel disease (Crohn disease versus ulcerative colitis). Which of the following indications for surgery is more prevalent in patients with Crohn disease?
. Fistulas between the colon and segments of intestine, bladder, vagina, urethra, and skin
. Massive bleeding
. Toxic megacolon
. Intractable disease
. Dysplasia or carcinoma
A newborn has a midline defect in the anterior abdominal wall. The parents ask what, if anything, should be done. Spontaneous closure of which of the following congenital abnormalities of the abdominal wall generally occurs by the age of 4?
. Umbilical hernia
. Omphalocele
. Patent urachus
Gastroschisis
. Patent omphalomesenteric duct
A neonate is found to have an imperforate anus. As the pediatric surgeon you recommend studies to search for other anomalies. Which of the following is an associated abnormality?
. Congenital heart disease
. Hydrocephalus
. Congenital pulmonary airway malformation
. Corneal opacities
. Duodenal atresia
A 45-year-old man is examined for a yearly executive physical. A mass is palpated in the rectum, and a biopsy suggests carcinoid. Which of the following findings is most likely to be associated with the carcinoid syndrome?
. Tumor > 2 cm
. Involvement of regional lymph nodes
. Tumor < 2 cm
. Hepatic metastases
. Tumor < 2 cm with ulceration
A 31-year-old biker is involved in a motor vehicle accident after attending a party where he drank a lot of soda drinks. He describes a direct blow to his lower abdomen and pelvis during the accident. He complains of diffuse abdominal pain that refers to his left shoulder. Which of the following injuries most likely accounts for this patient's current symptoms?
. Bladder dome
. Anterior bladder wall
. Bladder neck
. Pseudomembranous urethra
. Anterior urethra
Your hospital is conducting an ongoing research study involving the hormonal response to trauma. Blood is drawn regularly (with Institutional Review Board [IRB] approval) for various studies. Which of the following values are likely to be seen after a healthy 36-year-old man is hit by a bus and sustains a ruptured spleen and a lacerated small bowel?
. Increased secretion of insulin
. Decreased secretion of glucagon
. Increased secretion of thyroxine
. Decreased secretion of aldosterone
. Decreased secretion of vasopressin (antidiuretic hormone [ADH])
A 45-year-old man was an unhelmeted motorcyclist involved in a high-speed collision. He was ejected from the motorcycle and was noted to be apneic at the scene. After being intubated, he was brought to the ER, where he is noted to have a left dilated pupil that responds only sluggishly. What is the pathophysiology of his dilated pupil?
. Herniation of the uncal process of the temporal lobe
. Occult damage to the superior cervical ganglion
. Infection within the cavernous sinus
. Cerebellar hypoxia
. Laceration of the corpus callosum by the falx cerebri
A 25-year-old man comes to the physician because of a mass in his mouth. He has had the lump for many years. He denies weight loss. He was in a motor vehicle accident several years ago and sustained a concussion of the brain. He does not use tobacco, alcohol, or illicit drugs. Physical examination shows a nontender 2 x 2-cm mass located on the hard palate of the mouth that is immobile and has a bony hard consistency. Which of the following is the most likely cause of this patient's oral finding?
. Congenital
Traumatic
Infectious
Vascular
Neoplastic
A 32-year-old female presents with intermittent blood staining of her bra from her left breast. She has not felt any lumps on either breast. Physical examination shows no breast mass or axillary lymphadenopathy. Ultrasonogram of the breast is within normal limits. Which of the following is the most likely diagnosis?
. Intraductal papilloma
. Ductal carcinoma in situ
. Fibrocystic changes
. Hyperprolactinemia
Fibroadenoma
A 68-year-old man is brought to the emergency department following a high-speed automobile accident. He is alert and complains of chest pain and mild back pain. His blood pressure is 80/60 mm Hg. Chest x-ray shows a widened mediastinum, tracheal deviation, bronchial displacement, and loss of the aortic knob. Which of the following is the most likely diagnosis?
. Traumatic aortic rupture
. Pulmonary contusion
. Cardiac tamponade
. Tension pneumothorax
. Myocardial contusion
A 35-year-old man comes to the physician because of persistent dull perineal pain and dysuria for 6 months. The patient denies urinary tract infections or urethral discharge. His temperature is 37 C (98.6 F). On digital rectal examination, the prostate is slightly tender and boggy but not enlarged or indurated. Urinalysis is normal. Expressed prostatic secretions show the following: Leukocytes 30 cells/high power field Bacteria None Cultures of prostatic secretion and urine are negative for bacteria. Which of the following is the most likely diagnosis?
Chronic nonbacterial prostatitis
Chronic bacterial prostatitis
Acute cystitis
Prostatodynia
Acute prostatitis
A 56-year-old man has been having bloody bowel movements on and off for the past several weeks. He reports that the blood is bright red, it coats the outside of the stools, and he can see it in the toilet bowl even before he wipes himself. When he does so, there is also blood on the toilet paper. After further questioning, it is ascertained that he has been constipated for the past 2 months and that the caliber of the stools has changed. They are now pencil thin, rather the usual diameter of an inch or so that was customary for him. He has no pain. Which of the following is the most likely diagnosis?
. Cancer of the rectum
. External hemorrhoids
. Anal fissure
. Internal haemorrhoids
. Cancer of the cecum
A front-seat passenger in a car involved in a head-on collision relates that he hit the dashboard with his knees, however, he is specifically complaining of severe pain in his right hip, rather than knee pain. He lies in the stretcher in the emergency department with the right lower extremity shortened, adducted, and internally rotated. Which of the following is the most likely injury?
. Posterior dislocation of the hip
. Intertrochanteric fracture
. Femoral neck fracture
. Posterior dislocation of the knee
. Fracture of the shaft of the femur
An 81-year-old man with Alzheimer disease who lives in a nursing home undergoes surgery for a fractured femoral neck. On the 5th postoperative day, it is noted that his abdomen is grossly distended and tense, but not tender. He has occasional bowel sounds. The rectal vault is empty on digital examination, and there is no evidence of occult blood. X-ray films show a few distended loops of small bowel and a much distended colon. The cecum measures 9 cm in diameter, and the gas pattern of distention extends throughout the entire large bowel, including the sigmoid and rectum. No stool is seen in the films. Other than the abdominal distention, and the ravages of his mental disease, he does not appear to be ill. Vital signs are normal for his age. Which of the following is the most likely diagnosis?
. Ogilvie syndrome
. Paralytic ileus
. Fecal impaction
. Volvulus of the sigmoid colon
. Mechanical intestinal obstruction
A 55-year-old, HIV-positive man has a fungating mass growing out of the anus. He can feel it when he wipes himself after having a bowel movement, but it is not painful. For the past 6 months, he has noticed blood on the toilet paper, and from time to time there has also been blood coating the outside of the stools. He has lost weight, and he looks emaciated and ill. On physical examination, the mass is easily visible. It measures 3.5 cm in diameter, is fixed to surrounding tissues, and appears to grow out of the anal canal. He also has rock-hard, enlarged lymph nodes on both groins, some of them as large as 2 cm in diameter. Which of the following is the most likely diagnosis?
. Squamous cell carcinoma of the anus
. External hemorrhoids
. Adenocarcinoma of the rectum
. Rectal prolapse
. Condyloma acuminata of the anus
A 79-year-old man with atrial fibrillation develops an acute abdomen. When seen 2 days after the onset of the abdominal pain, he has a silent abdomen, with diffuse tenderness and mild rebound. There is a trace of blood on the rectal examination. He also has acidosis and looks quite sick. X-ray films show distended small bowel and distended right colon, up to the middle of the transverse colon. Which of the following is the most likely diagnosis?
. Mesenteric ischemia
. Perforated viscus
. Acute pancreatitis
. Primary peritonitis
. Midgut volvulus
After a grand mal seizure, a 32-year-old epileptic woman notices pain in her right shoulder, and she cannot move it. She goes to a minor emergency clinic, where she has a limited physical examination and anteroposterior (AP) x-ray films of her shoulder. The films are read as negative, and she is diagnosed as having a sprain and given pain medication. The next day, she still has the same pain and is unable to move her arm. She comes to the emergency department holding her arm close to her body, with her hand resting on her anterior chest wall. Which of the following is the most likely diagnosis?
. Posterior dislocation of the shoulder
. Articular cartilage crushing
. Acromioclavicular separation
. Torn teres major and minor muscles
. Anterior dislocation of the shoulder
A 54-year-old woman is brought to the emergency department after a head-on automobile accident. On arrival, she is breathing well. She has multiple bruises over the chest and multiple sites of point tenderness over the ribs. X-ray films show multiple rib fractures on both sides, but the lung parenchyma is clear, and both lungs are expanded. Two days later she is in respiratory distress, and her lungs "white out" on repeat chest x-ray films. Which of the following is the most likely diagnosis?
Pulmonary contusion
Tension pneumothorax
Flail chest
Traumatic rupture of the aorta
Myocardial contusion
A previously healthy 55-year-old man undergoes elective right hemicolectomy for a stage I (T2N0M0) cancer of the cecum. His postoperative ileus is somewhat prolonged, and on the fifth postoperative day his nasogastric tube is still in place. Physical examination reveals diminished skin turgor, dry mucous membranes, and orthostatic hypotension. Pertinent laboratory values are as follows:Arterial blood gases: pH 7.56, PCO2 50 mm Hg, PO2 85 mm Hg.Serum electrolytes (mEq/L): Na+ 132, K+ 3.1, Cl- 80; HCO3- 42.Urine electrolytes (mEq/L): Na+ 2, K+ 5, Cl- 6What is the patient’s acid–base abnormality?
. Metabolic alkalosis with respiratory compensation
. Uncompensated metabolic alkalosis
. Respiratory acidosis with metabolic compensation
. Combined metabolic and respiratory alkalosis
. Mixed respiratory acidosis and respiratory alkalosis
A 65-year-old man undergoes a low anterior resection for rectal cancer. On the fifth day in hospital, his physical examination shows a temperature of 39°C (102°F), blood pressure of 150/90 mm Hg, pulse of 110 beats per minute and regular, and respiratory rate of 28 breaths per minute. A computed tomography (CT) scan of the abdomen reveals an abscess in the pelvis. Which of the following most accurately describes his present condition?
Sepsis
. Septic shock
. Systemic inflammatory response syndrome (SIRS)
. Severe septic shock
. Severe sepsis
A 24-year-old man comes to the physician 24 hours after sustaining an injury to the right knee while playing soccer. He can walk, but he limps on the right side. He reports that he was hit by another player on the lateral side of his right knee, but did not feel a snap or pop at the time of the accident. On examination, the right knee appears normal, but palpation elicits tenderness along the medial aspect of the joint line. Increased laxity is observed when a valgus stress is applied to the knee flexed at 30 degrees, but not when the knee is in full extension. Lachman's test and posterior drawer tests are negative. Which of the following is the most likely diagnosis?
Sprain of the medial collateral ligament
Tear of the anterior cruciate ligament
Meniscus injury
Tear of the posterior cruciate ligament
Sprain of the lateral collateral ligament
A 35-year-old man had a splenectomy 8 days ago, following a motor vehicle accident. He is now complaining of left shoulder pain. His temperature is 39.0C (102.2F), blood pressure is 110/80 mm Hg, pulse is 110/min, and respirations are 30 min and shallow, Physical examination shows clear lungs with equal breath sounds bilaterally and mild tenderness to palpation in the left upper quadrant with a well-healing midline laparotomy incision. Laboratory studies show: Hemoglobin 15 g/dL, Hematocrit 45%, Leukocyte counts 15,000/mm3.A chest x-ray film shows no infiltrates or effusions. Which of the following is the most likely diagnosis?
Subphrenic abscess
Post-splenectomy sepsis
Left clavicle fracture
Subphrenic hematoma
Left lower lobe pneumonia
A 27-year-old man is shot point blank with a .22-caliber revolver. The entrance wound is in the anterior chest wall, just to the left of the sternal border, at the level of the 4th intercostal space. There is no exit wound. He is diaphoretic, cold, shivering, and anxious, and is asking for a blanket and a drink of water. His blood pressure is 65/40 mm Hg, and his pulse is 145/min and barely perceptible. He has large, distended veins in his neck and forehead. He is breathing adequately and has bilateral breath sounds. He is neurologically intact. Which of the following is the most likely diagnosis?
Extrinsic cardiogenic shock due to pericardial tamponade
Intrinsic cardiogenic shock due to myocardial damage
Extrinsic cardiogenic shock due to tension pneumothorax
Vasomotor shock
Hemorrhagic shock
A 61-year-old alcoholic man presents with severe epigastric pain radiating to his back. His amylase and lipase are elevated, and he is diagnosed with acute pancreatitis. Over the first 48 hours, he is determined to have 6 Ranson’s criteria, including a PaO2 less than 60 mm Hg. His chest x-ray reveals bilateral pulmonary infiltrates, and his wedge pressure is low. Which of the following criteria must be met to make a diagnosis of adult respiratory distress syndrome (ARDS)?
. Hypoxemia defined as a PaO2/FiO2 ratio of less than 200
. A pulmonary capillary wedge pressure greater than 18 mm Hg
. Hypoxemia defined as a PaO2 of less than 60 mm Hg
. Presence of a focal infiltrate on chest x-ray
. Lack of improvement in oxygenation with administration of a test dose of furosemide
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?
. Marjolin ulcer
. Erythroplasia of Queyrat
. Basal cell carcinoma
. Bowen disease
. Malignant melanoma
A 31-year-old accounting student presents with a persistent headache that began approximately 4 months ago. The headache has been gradually increasing in intensity, and is worse in the mornings. Thinking that she might need new glasses, she sought help from her optometrist, who discovered that she has bilateral papilledema and sent her in for medical evaluation. On direct questioning, she admits to repeat vomiting for the past 3 weeks, with no heaving, straining, or preceding nausea. "I would just open my mouth, and the stuff would hit the wall," she explains. She denies any other neurological symptoms. Which of the following is the most likely diagnosis?
Brain tumor
Multiple sclerosis
Brain abscess
Subarachnoid bleeding
Chronic subdural hematoma
A brain-dead potential donor has become available. You must plan for the dispersal of the thoracic organs. Which of the following will necessitate a heart-lung transplant?
. Idiopathic dilated cardiomyopathy with long-standing secondary pulmonary hypertension
. End-stage emphysema
. Primary pulmonary hypertension
. End-stage pulmonary fibrosis secondary to sarcoidosis
. Cystic fibrosis
A 55-year-old woman who has end-stage liver disease is referred to a hepatologist for evaluation. Which of the following would prevent her from being a transplantation candidate?
. Use of alcohol 3 months ago
. Development of hepatorenal syndrome requiring hemodialysis
. Two 2-cm hepatocellular carcinomas (HCCs) in the right lobe of the liver
. History of breast cancer 5 years ago with no evidence of disease currently
. A 4-cm hepatocellular carcinoma in the right lobe of the liver
A 55-year-old woman requires an abdominoperineal operation for rectal cancer. She has a history of stable angina. Which of the following clinical markers is most likely to predict a cardiac event during her noncardiac surgery and should prompt further cardiac workup prior to her operation?
. Unstable angina
. Uncontrolled hypertension
. Abnormal electrocardiogram
. Her age
. Prior stroke
An 18-year-old man was traveling at a high speed when his car slammed into a wall. He is brought into the emergency department by ambulance. His blood pressure is 60/40 mmHg, pulse is 115/min and weak, respirations are 18/min, and central venous pressure is 2 cmH2O. He is responsive only to painful stimuli. Breath sounds are equal bilaterally, and cardiac auscultation reveals only tachycardia. The abdomen is soft, nondistended, and nontender with active bowel sounds. A chest x-ray film shows a widened mediastinum. Which of the following is the most likely diagnosis?
Flail chest
Ruptured thoracic aorta
Cardiac contusion
Tension pneumothorax
Cardiac tamponade
A 22-year-old woman is taken to the emergency department after she injures her foot. She had been standing on a chair changing a light bulb, when she accidentally stepped off the chair backward. She heard a cracking sound when she fell and developed pain and swelling behind the ankle. Her symptoms worsened when she tried to descend the stairs in her house. Physical examination demonstrates marked swelling behind her ankle, and her pain is exacerbated by plantar flexion and dorsiflexion of the hallus. Which of the following is the most likely diagnosis?
Fracture of the posterolateral talar tubercle
Epiphysitis of the calcaneus
Anterior Achilles tendon bursitis
Posterior tibial nerve neuralgia
Calcaneal spur syndrome
A 60-year-old man complains of anal itching and discomfort, particularly toward the end of the day. He works as a salesman in a department store, where he has to be on his feet all day. When he goes home in the evening, he finds himself sitting sideways to avoid the discomfort. He has no fever, rectal bleeding, or soiling of his underwear, and he has never had surgery in that area. Which of the following is the most likely diagnosis?
External hemorrhoids
Internal hemorrhoids
Anal fissure
Perirectal abscess
Fistula in ano
A 71-year-old man develops dysphagia for both solids and liquids and weight loss of 60 lb over the past 6 months. He undergoes endoscopy, demonstrating a distal esophageal lesion, and biopsies are consistent with squamous cell carcinoma. He is scheduled for neoadjuvant chemoradiation followed by an esophagectomy. Preoperatively he is started on total parenteral nutrition, given his severe malnutrition reflected by an albumin of less than 1. Which of the following is most likely to be a concern initially in starting total parenteral nutrition in this patient?
Hypophosphatemia
Hypoglycemia
. Hyperkalemia
Hypochloremia
Hypermagnesemia
A 38-year-old woman who underwent a cadaveric renal transplant 8 years ago presents with fevers, fatigue, and weight loss. Evaluation included CT scans of the head, neck, chest, abdomen, and pelvis; she is noted to have diffuse lymphadenopathy and pulmonary nodules. A biopsy and histologic examination of a lymph node is performed. Which of the following viruses is most likely to be present in the lymph node?
. Epstein-Barr virus
. Human papillomavirus
Cytomegalovirus
. Human herpesvirus 8
. Coxsackie virus
An elderly diabetic woman with chronic steroid-dependent bronchospasm has an ileocolectomy for a perforated cecum. She is taken to the ICU intubated and is maintained on broad-spectrum antibiotics, renal dose dopamine, and a rapid steroid taper. On postoperative day 2, she develops a fever of 39.2°C (102.5°F), hypotension, lethargy, and laboratory values remarkable for hypoglycemia and hyperkalemia. Which of the following is the most likely explanation for her deterioration?
. Adrenal insufficiency
. Acute tubular necrosis
Sepsis
. Diabetic ketoacidosis
Hypovolemia
On postoperative day 5, an otherwise healthy 55-year-old man recovering from a partial hepatectomy is noted to have a fever of 38.6°C (101.5°F). Which of the following is the most common nosocomial infection postoperatively?
. Urinary tract infection
Pneumonia
. Wound infection
. Intra-abdominal abscess
. Intravenous catheter-related infection
A 42-year-old man has had a rocky course for the 3 days following a bowel resection for intestinal perforation due to inflammatory bowel disease. His CVP had been 12 to 14 but is now 6, in the face of diminished blood pressure and oliguria. Which of the following is the most likely etiology of his hypotension?
. Gram-negative sepsis
. Positive-pressure ventilation
. Pulmonary embolism
. Pneumothorax
. Hypervolemia
Acute renal failure occurs following aortic angiography in a 72-year-old man. His weight has been rising, his lungs show rales at both bases, and he is dyspneic. His fractional excretion of sodium is greater than 1. He has eosinophilia on his peripheral smear, an elevated erythrocyte sedimentation rate, and proteinuria with microscopic hematuria. Which of the following is the most likely cause of his renal failure?
. Renal artery cholesterol embolism
. Cardiogenic shock
. Hypovolemia
. Aortic dissection
. Acute tubular necrosis
A 26-year-old man is resuscitated with packed red blood cells following a motor vehicle collision complicated by a fractured pelvis and resultant hemorrhage. A few hours later the patient becomes hypotensive with a normal central venous pressure (CVP), oliguric, and febrile. Upon examination, the patient is noted to have profuse oozing of blood from his intravenous (IV) sites. Which of the following is the most likely diagnosis?
. Transfusion reaction
. Gram-negative bacteremia
. Hypovolemic shock
. Ureteral obstruction
. Acute adrenal insufficiency
A 72-year-old man undergoes a subtotal colectomy for a cecal perforation due to a sigmoid colon obstruction. He has had a prolonged recovery and has been on total parenteral nutrition (TPN) for 2 weeks postoperatively. After regaining bowel function, he experienced significant diarrhea. Examination of his abdominal wound demonstrates minimal granulation tissue. He complains that he has lost his taste for food. He also has increased hair loss and a new perioral pustular rash. Which of the following deficiencies does he most likely have?
. Zinc
. Chromium
Selenium
Thiamine
. Molybdenum
A patient develops a fever and tachycardia during a blood transfusion after a redo coronary artery bypass procedure. The nurse subsequently discovers that there was a mix-up in the cross-match because of a labeling error. Which of the following is diagnostic in a patient with an immediate hemolytic reaction secondary to a blood transfusion?
Myoglobinuria
. Direct bilirubin greater than 5 mg/dL
. Serum haptoglobin above 50 mg/dL
. Positive Coombs test
. Indirect bilirubin greater than 5 mg/dL
An obese 50-year-old woman undergoes a laparoscopic cholecystectomy. In the recovery room, she is found to be hypotensive and tachycardic. Her arterial blood gases reveal a pH of 7.29, PaO2 of 60 mm Hg, and PaCO2 of 54 mm Hg. Which of the following is the most likely cause of this patient’s problem?
. Alveolar hypoventilation
. Pulmonary edema
. Acute pulmonary embolism
. Atelectasis from a high diaphragm
. Carbon dioxide (CO2) absorption from induced pneumoperitoneum
Approximately 6 weeks following a kidney transplant, a 59-year-old woman develops fever, malaise, and myalgias and is found to have a cytomegalovirus (CMV) infection. Which of the following is a potential sequela of CMV infection?
. Gastrointestinal (GI) ulceration and haemorrhage
. Intra-abdominal abscess
. Pyelonephritis
. Parotitis
. Cholecystitis
A 24-year-old woman develops moderate, generalized abdominal pain of sudden onset and shortly thereafter faints. At the time of evaluation in the emergency department, she has regained consciousness, is pale, and has a blood pressure of 95/70 mm Hg and a faint pulse rate of 90/min. The abdomen is mildly distended and tender, with normal bowel sounds. Her hemoglobin is 7 g/dL. There is no history of trauma, but it is suspected that she might be bleeding into her abdomen, and a diagnostic peritoneal lavage is performed. The study shows that there is free blood in the peritoneal cavity. She denies the possibility of pregnancy because she has been on birth control pills since the age of 14 and has never missed taking them. Pelvic examination is normal, and a pregnancy test is negative. At laparotomy, the surgeons are likely to find which of the following?
Ruptured hepatic adenoma
Ruptured abdominal aortic aneurysm
Bleeding ovarian follicle
Ruptured hepatic artery aneurysm
Ruptured ectopic pregnancy
A 42-year-old man is undergoing chemotherapy after resection of a cecal adenocarcinoma with positive lymph nodes. You are asked to see him regarding a potential surgical complication. Which of the following potentially operable complications is a common occurrence among patients receiving systemic chemotherapy?
. Perirectal abscess
. Incarcerated femoral hernia
. Acute cholecystitis
Diverticulitis
Appendicitis
A 30-year-old previously healthy man presents with refractory hypertension on four medications. Urinalysis is positive for metanephrines. He was adopted as an infant and therefore does not know his family history. Which of the following inherited syndromes is not associated with this disease?
. Neurofibromatosis II
. von Hippel-Lindau disease
MEN2A
. Neurofibromatosis I
MEN2B
A 55-year-old man is diagnosed with benign prostatic hyperplasia. The patient declines pharmacologic treatment and elects to undergo transurethral resection of the prostate (TURP). Which of the following is the most common complication of this procedure?
Retrograde ejaculation
Incontinence
Bladder neck contracture
Recurrence of symptoms
Impotence
40) A 22-year-old healthy African-American woman presents with a recurrent growth on her right thigh. She has a childhood history of a third-degree scald burn to the same area that did not require skin grafting. The growth was completely removed 2 years ago. On physical examination there is a 5 cm × 2 cm, raised, irregularly shaped purple lesion with a smooth top. Which of the following is the most likely diagnosis?
Keloid
. Squamous cell carcinoma
Angiosarcoma
. Kaposi sarcoma
. Malignant melanoma
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?
Aniridia
Hemihypertrophy
. Cardiac anomalies
Hypoglycemia
. Macroglossia
A 61-year-old man with severe three-vessel coronary disease and diabetes mellitus is scheduled for abdominal surgery. The patient has a long history of coronary disease and had a q-wave myocardial infarction 2 years ago. He has had type 1 diabetes mellitus for 12 years. His medications include atenolol, insulin, and captopril. His last hemoglobin Alc, 3 months ago, was 9.2%. Which of the following is the most predictive of a perioperative complication in this patient?
Recent myocardial infarction (MI)
Premature ventricular contractions (PVCs) on ECG
Poor exercise tolerance
Recent shortness of breath
Use of a beta blocker in the preoperative period
A 30-year-old man with a history of Crohn disease develops an enterocutaneous fistula and is placed on total parenteral nutrition through a right subclavian central venous catheter. After 5 days, the patient develops a fever and leukocytosis; CT scan of the abdomen reveals no intra-abdominal abscess. The subclavian catheter insertion site is inspected and noted to be erythematous and painful. Blood cultures are positive. Which of the following organisms is the most likely cause of his fever?
. Coagulase-negative staphylococci
. Group A Streptococcus
. Coagulase-positive staphylococci
Enterococcus
. Escherichia coli
A 32-year-old woman has an episode of upper gastrointestinal bleeding after a night of heavy alcoholic intake followed by ingestion of multiple aspirin tablets for the hangover. There was no prior vomiting until the time when she felt nauseated, went to the bathroom, and "filled the wash basin with vomiting of bright red bloody fluid." When she arrives in the emergency department, an upper gastrointestinal endoscopy is promptly performed, which confirms a diagnosis of acute erosive gastritis. She has no duodenal ulcer and no esophageal varices. Gastric lavage with ice-cold saline is performed and the bleeding stops. Laser photocoagulation or electrocautery are not used, neither is pitressin infused. She remains hemodynamically stable throughout the procedure, and she has normal hemoglobin. She is sent home 2 hours later. Four hours after discharge, she returns complaining of severe, constant chest pain. She is in acute distress, has a temperature of 39.0C (102.2F), is having chills, and looks quite ill. Physical examination is remarkable for the presence of crepitation to palpation in the upper chest and lower neck, and chest x-rays confirm the presence of air in the mediastinum and the subcutaneous tissues. Which of the following is the most likely diagnosis?
Iatrogenic esophageal perforation
Gastric perforation
Boerhaave syndrome
Myocardial infarction
Dissecting thoracic aortic aneurysm
A 71-year-old man is involved in a minor automobile accident on the road between Guadalajara and Lake Chapala in Mexico. The man is an American citizen who at the age of 65 years retired to a lakeside home in that area. Although he is asymptomatic, he decides to return to the United States to be "thoroughly checked." He is admitted to a veteran's hospital in south Texas, where he undergoes a CT scan of his abdomen. There are no signs of traumatic injuries, but the scan reveals the presence of four simple, thin walled cystic structures, approximately 1 cm in diameter, scattered throughout both lobes of his liver. They have no septations. There are no cysts in the kidneys or pancreas. The man is completely asymptomatic and afebrile. Liver function tests are normal, as is his white blood count and differential. Which of the following is the most likely diagnosis?
Simple liver cysts
Hydatid cysts
Amebic abscesses
Polycystic liver disease
Cystadenocarcinoma of the liver
A 78-year-old man comes to the physician because of a bloody urethral discharge for 3 days. He has had increasing frequency of urination and hesitancy for the past 2 years, but these symptoms have never been severe enough to require medical attention. Digital rectal examination reveals a slightly enlarged and firm prostate. Expressed prostatic secretions are negative for bacteria and leukocytes. Collection of clean-catch urine in separate aliquots reveals initial hematuria, with blood present in the first 5 mL. Which of the following is the most likely diagnosis?
Urethral carcinoma
Nonbacterial prostatitis
Gonococcal infection
Prostatic carcinoma
Testicular cancer
A 19-year-old man sustains severe lower-extremity trauma, including a femur fracture and a crush injury to his foot. He requires vascular reconstruction of the popliteal artery. On the day after surgery, he becomes dyspneic and hypoxemic and requires intubation and mechanical ventilation. Which of the following is the most likely etiology of his decompensation?
. Fat embolism syndrome
. Fluid overload
Aspiration
Pneumonia
. Atelectasis
An 18-year-old gang member is stabbed in the back, just to the right of the midline. Physical examination shows paralysis and loss of proprioception distal to the injury on the right side, and loss of pain perception distal to the injury on the left side. Which of the following is the most likely diagnosis?
Hemisection of the spinal cord
Central cord syndrome
Anterior cord syndrome
Complete transection of the spinal cord
Posterior cord syndrome
A 14-year-old girl has a firm, movable, rubbery mass in her left breast. The mass was first noticed 6 months ago and has since grown to about 6 cm in diameter. Which of the following is the most likely diagnosis?
Giant juvenile fibroadenoma
Fibrocystic disease (mammary dysplasia)
Cancer of the breast
Intraductal papilloma
Cystosarcoma phyllodes
A 3-week-old infant is brought in because of 2 days of protracted bilious vomiting. He looks acutely ill, and plain x-rays show two large air fluid levels in the upper abdomen, the larger one on the left side and a smaller one on the right side. The radiologist describes the finding as a "double bubble sign." He also reports that there is intraluminal gas distal to those two air fluid levels, but that it is sparse and does not outline distended loops. Which of the following is the most likely tentative clinical diagnosis?
Malrotation
Intestinal atresia
Hypertrophic pyloric stenosis
Meconium ileus
Necrotizing enterocolitis
A 16-year-old boy is persuaded by his older brother to accompany him and his friends on a beer-drinking binge. This is the first such experience for the boy, and it leads to the development of severe colicky left flank pain. When rescued by his parents, he is diaphoretic and doubled up in pain. He relates that he began to urinate frequently and profusely after the third or fourth beer and that the pain seized him shortly thereafter. He is tender to fist percussion over the left costovertebral angle but is afebrile. Which of the following is the most likely diagnosis?
Ureteropelvic junction obstruction
Ureteral stone
Bladder calculi
Vesicoureteral reflux
Low implantation of one ureter
52) A 53-year-old man is brought to the emergency department by his wife because of headache and visual changes. Approximately 3 hours ago, he had the acute onset of an extremely severe posterior headache that was non-radiating but was associated with nausea and vomiting. This headache subsided, but over the past hour he has developed mild neck stiffness and pain on flexion of his neck. The patient is not cooperative, so no additional history is known; however, his wife states that he was feeling well until recently and has no allergies. The patient appears moderately uncomfortable and is complaining of the worst headache he has ever experienced. Which of the following is the most likely cause for his symptoms?
Ruptured berry aneurysm
Putamenal bleed
Arteriovenous malformation
Thalamic bleed
Cerebellar bleed
A 72-year-old man has a 4-cm hard mass in the left supraclavicular area. The mass is movable and nontender and has been present and steadily growing for the past 3 months. On direct questioning the only additional findings include a 20-pound weight loss and a vague feeling of epigastric discomfort over the past 2 months. Physical examination shows evidence of the weight loss but no other significant findings in the abdominal examination. The supraclavicular mass are obvious, but no other masses can be felt anywhere else in the neck, axillas, or groins. There is occult blood in the stool, and his hemoglobin is 10.5 g/dL. Which of the following would a biopsy of the supraclavicular mass most likely reveal?
Metastatic gastric cancer
Metastatic squamous cell carcinoma
Chronic inflammation
Metastatic thyroid cancer
Lymphoma
A 6-year-old boy has insidious development of limping with decreased motion in one hip. He complains occasionally of knee pain on that side. He walks into the office with an antalgic gait. Examination of the knee is normal, but passive motion of the hip is guarded. The child is afebrile, and the parents indicate that his gait and level of activity were completely normal all his life until this recent problem. He has not had a recent febrile illness. Which of the following is the most likely diagnosis?
Avascular necrosis of the capital femoral epiphysis
Septic hip
Developmental dysplasia of the hip
Slipped capital femoral epiphysis
Hematogenous osteomyelitis of the femoral head
A patient involved in a car accident sustains burst fractures of several thoracic vertebral bodies. At the time of admission, he has no neurologic function at all below the level of the injury and he has flaccid sphincters. After a few days, there is partial recovery of function; the remaining deficits are loss of motor function and loss of pain and temperature sensation on both sides distal to the injury, with preservation of vibratory and positional senses. Which of the following is the most likely diagnosis?
Anterior cord syndrome
Cord hemisection
Central cord syndrome
Spinal shock
Complete cord transection
A 51-year-old man is undergoing abdominal surgery and becomes hypotensive while under general anesthesia. The patient had been doing well during most of the procedure but now has a blood pressure of 80/40 mm Hg. His past medical history is significant for coronary artery disease and diabetes mellitus. A pulmonary artery catheter placed prior to the procedure gives the following data: Central venous pressure 10 mmHg, Pulmonary artery pressure 60/30 mmHg, Pulmonary capillary occlusion 24 mm Hgpressure Cardiac output 2.3 L/min. Which of the following is the most likely diagnosis?
Acute left heart failure
Acute right heart failure
Acute mitral regurgitation
Hypoxic pulmonary vasoconstriction
Sepsis syndrome
A 62-year-old man complains of perineal discomfort and reports that there are streaks of fecal soiling in his underwear. Four months ago, he had a perirectal abscess drained surgically. Physical examination shows a perineal opening in the skin lateral to the anus, and a cord-like tract can be palpated going from the opening toward the inside of the anal canal. Brownish purulent discharge can be expressed from the tract. Which of the following is the most likely diagnosis?
. Fistula-in-ano
. Pilonidal cyst
. Anal fissure
. Thrombosed hemorrhoids
. Anorectal carcinoma
58) A 50-year-old woman with a history of essential hypertension presents to the emergency department with sudden onset of a severe headache, nausea and vomiting, and photophobia. On examination, her BP is 160/100 mmHg. She is mildly confused and has nuchal rigidity, without focal neurologic signs. Which of the following is the most likely diagnosis?
. Ruptured cerebral aneurysm
. Ischemic cerebrovascular accident
Meningitis
. Transient ischemic attack
. Hemorrhagic stroke
A 72-year-old man of Norwegian ancestry has a contracted hand that can no longer be extended and placed flat on a table. The problem developed gradually, over many years. He complains of no pain or neurologic abnormalities and, to the extent that the deformity allows, can move his fingers at will. Physical examination demonstrates the deformity described and in addition shows the presence of palpable fascial nodules. Which of the following is the most likely diagnosis?
. Dupuytren contracture
. Palmar tenosynovitis
. Carpal tunnel syndrome
. Rheumatoid arthritis
. De Quervain tenosynovitis
A previously healthy 28-year-old woman develops significant postpartum hemorrhage, with a rapid drop in hematocrit to 18%. Despite aggressive IV fluid resuscitation, the patient has a persistent tachycardia, labile systolic blood pressure, and poor urine output. Ongoing resuscitation includes emergency transfusion with 2 units of O-negative packed red blood cells. During transfusion of the second unit, the patient develops chills, fever, vomiting, and hypertension. These symptoms are most likely the result of which of the following?
. A febrile nonhemolytic transfusion reaction
. Delayed hemolytic transfusion reaction
. An anaphylactic transfusion reaction
. Acute bacterial infection transmitted in the blood product
. ABO incompatibility with acute hemolytic transfusion reaction
A 45-year-old woman underwent elective surgery for an inguinal hernia. In the postoperative recovery room, she developed nausea, vomiting, and acute abdominal pain. She has a history of systemic lupus erythematosus, pernicious anemia, type 1 diabetes, chronic low back pain, and uterine fibroids. Her preoperative medications include monthly vitamin B-12 injections, insulin, prednisone, hydroxychloroquine, and acetaminophen. Her blood pressure is 70/40 mm Hg and heart rate is 110/min. Initial laboratory studies show blood glucose of 50 mg/dl. Which of the following is the most likely cause of her condition?
. Adrenal insufficiency
. Diabetic ketoacidosis
. Postoperative bleeding
. Intra-abdominal abscess
. Intestinal obstruction
A 45-year-old woman, who wears high-heeled, pointed shoes, complains of pain in the forefoot after prolonged standing or walking. Occasionally, she also experiences numbness, a burning sensation, and tingling in the area. Physical examination shows no obvious deformities and a very tender spot in the third interspace, between the third and fourth toes. There is no redness, limitation of motion, or signs of inflammation. Which of the following is the most likely diagnosis?
. Morton's neuroma
. Metatarsophalangeal articulation pain
Gout
. Plantar fasciitis
. Hallux rigidus
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?
Melanoma
. Merkel cell carcinoma
. Squamous cell carcinoma
. keratoacanthoma
. Basal cell carcinoma
A 58-year-old man presents with pain in the left leg after walking more than one block that is relieved with rest. On physical examination, distal pulses are not palpable in the left foot and there is dry gangrene on the tip of his left fifth toe. An ankle-brachial index on the same side is 0.5. Which of the patient’s symptoms or signs of arterial insufficiency qualifies him for reconstructive arterial surgery of the left lower extremity?
. Toe gangrene
. Ankle-brachial index less than 0.7
. Rest pain
. Absent palpable pulses
Claudication
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