Chir emergency
2) A 75-year-old man slips and falls at home, hitting his right chest wall against the kitchen counter. He has an area of exquisite pain to direct palpation over the seventh rib, at the level of the anterior axillary line. A chest x-ray film confirms the presence of a rib fracture, with no other abnormal findings. Which of the following is the most appropriate initial step in management?
Supplemental oxygen to compensate for hypoventilation
Systemic narcotic analgesics
Binding of the chest to limit motion
Intercostal nerve block to minimize pain
Open reduction and internal fixation to accelerate healing
3) A 71-year-old woman is brought to the physician by her distressed daughter. The daughter relates that, 3 days ago, her mother began to complain of right upper quadrant abdominal pain. She did not want to eat and "took to her bed sick." The daughter recalls that she complained of chills, nausea, and some vomiting. Physical examination reveals an obtunded, hypotensive, and obviously very sick elderly woman. She has impressive pain to deep palpation in the right upper quadrant, along with muscle guarding and rebound. Her temperature is 40C (104F), and laboratory analysis shows a white cell count of 22,000/mm3 with multiple immature forms, a bilirubin of 5 mg/dL and alkaline phosphatase of 840 U/L. The serum amylase is normal. An emergency sonogram shows multiple stones in the gallbladder, normal thickness of the gallbladder wall without pericholecystic fluid, dilated intrahepatic ducts, and common duct with a diameter of 2.1 cm. The sonographer cannot identify stones in the common duct. In addition to IV fluids and antibiotics, which of the following is the most appropriate next step in management?
. Elective cholecystectomy
. Emergency decompression of the common duct
. Emergency cholecystectomy
. Emergency surgical exploration of the common duct
Emergency transhepatic cholecystostomy
7) A 40-year-old woman complains of mild, intermittent pain and paresthesias in her right wrist. She reports the pain is worse at night and with driving. On physical examination hyperflexion of the right wrist reproduces the paresthesia. With regard to her diagnosis, which of the following is the most appropriate initial treatment?
. Ice pack to the affected wrist at nighttime
. Heat pad to the affected wrist at nighttime
. Wrist splint worn at nighttime
. Surgical treatment with division of the flexor retinaculum
. Surgical treatment with division of the extensor retinaculum
9) A 64-year-old man with history of severe emphysema is admitted for hematemesis. The bleeding ceases soon after admission, but the patient becomes confused and agitated. Arterial blood gases are as follows: pH 7.23; PO2 42 mm Hg; PCO2 75 mm Hg. Which of the following is the best initial therapy for this patient?
. Correct hypoxemia with high-flow nasal O2
. Correct acidosis with sodium bicarbonate
. Administer 10 mg intravenous dexamethasone
. Administer 2 mg intravenous Ativan
. Intubate the patient
10) A 16-year-old adolescent boy with a history of severe hemophilia A is undergoing an elective inguinal hernia repair. Which of the following is the best option for preventing or treating a bleeding complication in the setting of this disease?
. Fresh-frozen plasma
Combination of desmopressin and fresh-frozen plasma
. DDAVP
Combination of ε-aminocaproic acid and desmopressin
. Factor IX concentrate
12) A 24-year-old firefighter sustains 30% total body surface area (TBSA) burns to his torso, face, and extremities. His wounds are treated topically with silver nitrate. Which of the following complications is associated with use of this agent?
. Hypernatremia
. Metabolic acidosis
. Hyperchloremia
. Neutropenia
. Hyponatremia
15) A 59-year-old man with a history of myocardial infarction 2 years ago undergoes an uneventful aortobifemoral bypass graft for aortoiliac occlusive disease. Six hours later he develops ST segment depression, and a 12-lead electrocardiogram (ECG) shows anterolateral ischemia. His hemodynamic parameters are as follows: systemic BP 70/40 mm Hg, pulse 100 beats per minute, CVP 18 mm Hg, PCWP 25 mm Hg, cardiac output 1.5 L/min, and systemic vascular resistance 1000 (dynes)/cm5. Which of the following is the single best pharmacologic intervention for this patient?
. Sublingual nitroglycerin
. Intravenous nitroglycerin
A short-acting β-blocker
. Sodium nitroprusside
. Dobutamine
17) A cirrhotic patient with abnormal coagulation studies due to hepatic synthetic dysfunction requires an urgent cholecystectomy. A transfusion of FFP is planned to minimize the risk of bleeding due to surgery. What is the optimal timing of this transfusion?
. The day before surgery
. The night before surgery
. On call to surgery
. Intraoperatively
. In the recovery room
18) Ten days after an exploratory laparotomy and lysis of adhesions, a patient, who previously underwent a low anterior resection for rectal cancer followed by postoperative chemoradiation, is noted to have succus draining from the wound. She appears to have adequate source control—she is afebrile with a normal white blood count. The output from the fistula is approximately 150 cc per day. Which of the following factors is most likely to prevent closure of the enterocutaneous fistula?
. Previous radiation
. Previous chemotherapy
. Recent surgery
. History of malignancy
. More than 100-cc output per day
20) An 18-year-old woman develops urticaria and wheezing after an injection of intravenous contrast for an abdominal CT scan. Her blood pressure is 120/60 mm Hg, heart rate is 155 beats per minute and respiratory rate is 30 breaths per minute. Which of the following is the most appropriate immediate therapy?
. Intubation
. Epinephrine
. β-Blockers
. Iodine
. Fluid challenge
22) A 22-year-old woman is involved in a major motor vehicle accident and receives a tracheostomy during her hospitalization. Five days after placement of the tracheostomy she has some minor bleeding around the tracheostomy site. Which of the following is the most appropriate immediate therapy?
. Removal of tracheostomy at bedside.
. Exchange the tracheostomy at bedside.
. Exchange the tracheostomy in the operating room.
Bronchoscopic evaluation of the trachea at bedside.
. Bronchoscopic evaluation of the trachea in the operating room.
26) Shortly after the administration of an inhalational anesthetic and succinylcholine for intubation prior to an elective inguinal hernia repair in a 10-year-old boy, he becomes markedly febrile, displays a tachycardia of 160, and his urine changes color to a dark red. Which of the following is the most appropriate treatment at this time?
. Complete the procedure but pretreat with dantrolene prior to future elective surgery.
. Administer inhalational anesthetic agents.
. Administer succinylcholine.
. Hyperventilate with 100% O2.
. Acidify the urine to prevent myoglobin precipitation in the renal tubules.
27) A 37-year-old woman is brought to the surgical floor after undergoing a routine vaginal hysterectomy that morning. She had been fasting since midnight the night prior to her surgery. She has no past medical history except for uterine fibroids and takes only oral contraceptive pills regularly. During the procedure, she was reported to lose approximately 300 mL of blood. On the floor, she appears well but complains of some fatigue. Her blood pressure is 110/60 mm Hg, and her pulse is 100/min. She is not taking food or water yet because of persistent nausea and vomiting postoperatively. Which of the following is the most appropriate next step in management?
No further intervention
Administer IV crystalloid
Administer IV 25% albumin (colloid)
Transfuse packed red blood cells
Re-explore the patient under anesthesia for possible bleeding
29) A 32-year-old man undergoes a distal pancreatectomy, splenectomy, and partial colectomy for a gunshot wound to the left upper quadrant of the abdomen. One week later he develops a shaking chill in conjunction with a temperature spike of 39.4°C (103°F). His blood pressure is 70/40 mm Hg, pulse is 140 beats per minute and respiratory rate is 45 breaths per minute. He is transferred to the intensive care unit (ICU), where he is intubated and a Swan-Ganz catheter is placed. Which of the following is consistent with the expected initial Swan-Ganz catheter readings?
. An increase in cardiac output
. An increase in peripheral vascular resistance
. An increase in pulmonary artery pressure
. An increase in PCWP
. An increase in central venous pressure
31) 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. Once the diagnosis has been confirmed, Rupture cerebral aneurysm, which of the following is the next most important step in patient management?
. Admission to the ICU, close monitoring, and aggressive treatment of hypertension
. Urgent surgical intervention with aneurysm clipping
. Admission to the ICU, close monitoring, and IV antibiotics
. Serial lumbar punctures to drain cerebrospinal fluid (CSF)
. Anticoagulation and antiplatelet therapy.
34) Several days following esophagectomy, a patient complains of dyspnea and chest tightness. A large pleural effusion is noted on chest radiograph, and thoracentesis yields milky fluid consistent with chyle. Which of the following is the most appropriate initial management of this patient?
. Immediate operation to repair the thoracic duct
. Immediate operation to ligate the thoracic duct
. Tube thoracostomy and low-fat diet
. Observation and low-fat diet
. Observation and antibiotics
35) A 16-year-old girl with a history of ulcerative colitis managed with steroid therapy presents to the emergency department with a 36-hour history of nausea, crampy abdominal pain, and severe bloody diarrhea. On examination, the patient is febrile and pale, with a blood pressure of 90/60 mmHg and heart rate of 130 beats/min. Her abdomen is distended and diffusely tender. A complete blood count (CBC) demonstrates a leukocytosis with a left shift. The patient receives IV fluid resuscitation and nasogastric (NG) tube decompression. Further therapeutic interventions should include which one of the following?
. 6-mercaptopurine
. azathioprine
. Opioid antidiarrheals
. Colonoscopic decompression
. high-dose IV steroids and broad-spectrum antibiotics
36) A severely traumatized woman is seen in the emergency room (ER) with decreased mental status. Prior to intubation, she does not open her eyes, withdraws with all of her extremities, and makes incomprehensible sounds. What is her Glasgow coma scale score?
.3
.4
.5
.6
.7
37) A 25-year-old woman was involved in a motor vehicle crash and sustained a significant closed-head injury, a pulmonary contusion, and a pelvic fracture. She is unresponsive and is ventilated in the intensive care unit (ICU). Which of the following is the best initial approach to the management of this patient’s nutritional needs?
. Insertion of a subclavian venous catheter and initiation of central IV hyperalimentation
wait for extubation and improvement of neurologic status, allowing institution of an oral caloric intake
. Early institution of NG or nasojejunal tube feeding with an elemental formulation
. Wait for resolution of the associated gastrointestinal ileus, followed by delayed initiation of NG tube feeding with a complex hypercaloric formulation
. peripheral IV hyperalimentation
39) A 70-year-old man is admitted to the ICU after repair of an abdominal aortic aneurysm. He has a prior history of hypertension and mild congestive heart failure, which were adequately controlled with digoxin and diuretics. To facilitate perioperative management, a Swan-Ganz (multilumen pulmonary artery) catheter was inserted in the operating room. During the first few hours postoperatively, the patient is noted to have a blood pressure of 140/70 mmHg, heart rate of 110/min, flat neck veins, a pulmonary arterial wedge pressure of 9 mmHg, and poor urine output. Which of the following is the most appropriate next step in management of this patient?
. IV furosemide
. A bolus of IV crystalloid
. A dopamine infusion
. A nitroprusside infusion
. IV digoxin administration
40) The left ureter is partially transected (50% of circumference) during the course of a difficult operation on an unstable, critically ill patient. Which of the following would be the most appropriate management of this injury given the patient’s unstable condition?
. Placement of an external stent through the proximal ureteral stump with delayed reconstruction
. Ipsilateral nephrectomy
. Placement of a catheter from the distal ureter through an abdominal wall stab wound
. Placement of a closed-suction drain adjacent to the injury
. Bringing the proximal ureter up to the skin as a ureterostomy
44) 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. Which of the following is the most appropriate next step in management of this patient?
. Immediate consultation with cardiology to assess cardiac risk for surgery, followed by transfer to the operating room
. Resuscitation in the emergency department with IV fluids, transfer to radiology for a CT scan to assess for the location and degree of rupture, followed by transfer to the operating room
. Resuscitation in the emergency department with IV fluids to achieve a systolic BP greater than 100, followed by transfer to the operating room
. Immediate transfer to the operating room with concomitant resuscitation and laparotomy
. Resuscitation in the emergency department with IV fluids, transfer to radiology for immediate aortic angiogram for assessment of the location of the rupture, followed by transfer to the operating room
45) A 14-year-old boy dives into the shallow end of a swimming pool and hits his head against the bottom. When he is rescued, he shows a complete lack of neurologic function below the neck. He is still breathing on his own, but he cannot move or feel his arms and legs. The paramedics carefully immobilize his neck for transportation to the hospital, and they alert the emergency department to his impending arrival. Once there, which of the following would most likely have an immediate benefit for this patient?
. Hyperbaric oxygenation
. IV antibiotics
. IV high-dose corticosteroids
. Massive diuresis induced by loop diuretics.
. Surgical decompression of the cord
47) In a rollover car accident, a 42-year-old woman is thrown from the car. The car subsequently lands on her and crushes her. On physical examination in the emergency department, it is determined that she has a pelvic fracture, which is confirmed by portable x-rays done as she is being resuscitated. Her initial blood pressure is 50/30 mm Hg, and her pulse is 160/min and barely perceptible. Thirty minutes later, after 2 L Ringer's lactate and 2 U packed cells have been infused, her pressure is only 70/50 mm Hg, and her pulse is 130/min. A sonogram done in the emergency department shows no intra-abdominal bleeding, and a diagnostic peritoneal lavage confirms that there is no blood in the abdomen (the recovered fluid is pink, but not grossly bloody). Rectal and vaginal exams show no injuries to those organs. There is no blood in her urine. Which of the following is the most appropriate next step in management?
. Packing of the vagina and rectum
. Angiographic embolization of torn veins
. External fixation of the pelvis
. Open reduction and internal fixation of the pelvis
. Exploratory laparotomy with pelvic dissection and hemostasis
48) A 34-year-old man is brought to the emergency department after being rescued from a burning building. His temperature is 36.90C (98.60 F), blood pressure is 90/60 mm Hg, pulse is 100/min and respirations are 28/min. Examination shows second and third degree burns over 15% of his body. His oropharynx shows erythema and scattered blisters. His lungs are clear to auscultation and his abdomen is soft and nondistended. His blood carboxyhemoglobin concentration is 20%. Which of the following is the best management for this patient?
. High-dose corticosteroids
. Endotracheal intubation
. Broad-spectrum antibiotics
. Fluid restriction
. Acetylcysteine inhalation
52) A 23-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He has multiple organ injuries and is listed in critical condition. Physical examination shows an open wound in the right lower extremity and significant blood loss. He is in hypovolemic shock. Which of the following is the first parameter to change in hypovolemic shock?
. Systolic blood pressure
. Pulse rate
. Respiratory rate
. Level of consciousness
. Skin vasoconstriction
54) A 35-year-old previously healthy male comes to the emergency department because of a 4-hour history of severe abdominal pain. The pain had initially started in the periumbilical area but has now shifted to the right lower quadrant. He also felt nauseated and vomited twice. He has had no previous surgeries. His temperature is 38.9C (102F), blood pressure is 125/80 mm Hg, pulse is 100/min and respirations are 20/min. Examination shows tenderness in the right lower quadrant. Palpation of the left lower quadrant produces pain in the right lower quadrant. Urinalysis is negative. Which of the following is the most appropriate next step in management?
. Ultrasound of the abdomen
. CT scan of the abdomen
. Conservative management
. Immediate surgery
Colonoscopy
58) A 25-year-old woman arrives in the ER following an automobile accident. She is acutely dyspneic with a respiratory rate of 60 breaths per minute. Breath sounds are markedly diminished on the right side. Which of the following is the best first step in the management of this patient?
Take a chest x-ray.
. Draw arterial blood for blood-gas determination.
. Decompress the right pleural space.
. Perform pericardiocentesis.
. Administer intravenous fluids.
63) A 4-week-old male infant presents with projectile, nonbilious emesis. Ultrasound of the abdomen reveals a pyloric muscle thickness of 8 mm (normal 3-4 mm). Which of the following is the best initial management of this patient?
. Urgent pyloromyotomy
. Urgent pyloroplasty
. Urgent gastroduodenostomy
. Fluid hydration and correction of electrolyte abnormalities prior to operative management
. Administration of sodium bicarbonate to correct aciduria prior to operative management
66) A 10-year-old girl is the unrestrained backseat passenger in a high-speed motor vehicle collision. She is intubated in the field for unresponsiveness and on presentation to the ER, her heart rate is 160 beats per minute, and her blood pressure is 60/35 mm Hg. She weighs 30 kg. Which of the following is the most appropriate recommendation for her fluid resuscitation?
. Bolus 1 L of normal saline initially.
. Bolus 1 L of 5% albumin initially.
. Transfuse 300 cc of packed RBCs initially.
. Bolus 600 cc of normal saline initially. Transfuse if no response.
. Bolus 600 cc of normal saline initially followed by a repeat bolus. Transfuse if no response
67) A 21-year-old woman sustains a stab wound to the middle of the chest. Upon arrival to the ER she has equal breath sounds, blood pressure of 85/46 mm Hg, distended neck veins, and pulsus paradoxus. Which of the following is the most appropriate management of this patient?
. Emergent intubation and mechanical ventilation in the ER
. Emergent intubation and mechanical ventilation in the ER
. Emergent thoracotomy in the ER
. Emergent pericardiocentesis or subxiphoid pericardial drainage after anesthetic induction in the operating room
. Emergent pericardiocentesis or subxiphoid pericardial drainage under local anesthesia in the operating room
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