Chir Test Q 101 to 141

101) A 34-year-old unrestrained male driver is brought to the ER after a motor vehicle accident. His cervical spine is immobilized. At the scene of the accident, his blood pressure is 80/40 mm Hg and heart rate is 130/min. He is able to communicate and follows simple commands. Lungs are clear to auscultation. Abdominal wall ecchymosis is present. Abdomen is mildly distended. Bowel sounds are decreased. Neck veins are collapsed. After two liters of intravenous fluids, his blood pressure is 90/60 mmHg. Which of the following is the most appropriate next step in management of this patient?

102) A 42-year-old man comes to the physician because of a 3-month history of substernal chest pain after every meal. He has chronic alcoholism and a long history of heartburn. Upper endoscopy shows mucosal irregularity and ulceration of the squamocolumnar junction above the lower esophageal sphincter (LES). Multiple biopsies were taken. 4 hours later he is complaining of worsening substernal pain radiating to the back, left chest pain, and shortness of breath. His temperature is 37.10C (98.90F), blood pressure is 110/70 mm Hg, pulse is 140/min, and respirations are 34/min. An x-ray film of the chest shows minimal left pleural effusion. Which of the following is the most appropriate next step in management?

103) A 65-year-old man comes to the physician four years after suffering a burn injury to his entire right leg. One area of the leg never healed and has now started increasing in size. He has constant pain and drainage from the site of the lesion. Several topical creams and antibiotics have not helped. Biopsy of the lesion is attempted. Which of the following is most likely be identified on biopsy?

104) A 47-year old woman comes to the clinic because of worsening left breast swelling and pain. She had mastitis when she nursed her first child 20 years ago. She has not seen a doctor since that time. She is afebrile. Breast examination shows the left breast is enlarged with a 7 x 6 cm area of edema and erythema. A poorly localized mass without fluctuation is palpated in that area. Scant non-bloody discharge is noted on the nipple, and several large axillary nodes are palpated. Which of the following is the most appropriate next step in management?

05) A 50-year-old man comes to the physician because of a 2-day history of constipation and not passing flatus. For the last 3 days he has been having intermittent, but worsening, right lower quadrant (RLQ) pain. He has vomited several times today and feels nauseated. Examination shows a distended abdomen with tenderness in the RLQ; there is no rebound; there are no masses or hernias; bowel sounds are absent. Rectal examination shows an enlarged prostate. An upright x-ray film of the abdomen shows gas distributed throughout the small and large bowel, and some fluid levels. After nasogastric tube placement and hydration, his temperature is 36.50C (97.60F), blood pressure is 140/80 mm Hg, pulse is 57/min, and respirations are 12/min. Laboratory studies show: RBC count 4.5 million, WBC 7,400, Na 140, K 3.5, Cl 100, BUN 15 mg/dl, Creatinine 1.0 mg/dl, Urine pH 5.5, Urine sediment: 2 W BC and 15 RBC/high power field, and needle-shaped crystals are present. Which of the following is the most appropriate next step in management?

106) A 25-year-old male is brought to the trauma center by the paramedics after being involved in a road traffic accident that occurred 90 minutes ago. He was a front seat passenger in a 3-car accident. His initial blood pressure at the scene of the accident was 90/60 mm Hg and pulse was 126/min. The paramedics administered 2 liters of normal saline in the ambulance. In the ED, his blood pressure is 110/70 mm Hg and pulse is 90/min. His abdomen is tender in the left upper quadrant. Ultrasound shows fluid in the spleno-renal angle. The most appropriate next step is?

107) A 62-year-old man complains of right knee pain. He says that the pain started two days ago and has been limiting his daily activities. He required 2 grams of acetaminophen in order to sleep through the previous night. He has a long history of rheumatoid arthritis treated with daily low-dose prednisone. Physical examination reveals swelling, limited flexion, and tenderness to palpation of the right knee. Synovial fluid aspiration is performed. Which of the following synovial fluid characteristics would warrant immediate surgical intervention?

108) A 38-year-old woman comes to the emergency department because of the sudden onset of severe abdominal pain. The pain started one hour ago in the epigastrium but now it is mostly localized to the lower abdomen. She has some nausea but denies any vomiting. Her last menstrual period (LMP) was 25 days ago. Her temperature is 36.8C (98.1F), blood pressure is 160/90 mm Hg, pulse is 110/min, and respirations are 25/min. The abdomen is tender on palpation with prominent guarding and positive rebound. There is no shifting dullness, and bowel sounds are absent. Laboratory studies show: Hb 13.1 g/dl, Hct 43%, WBC 10,900/mm3. Which of the following is the most appropriate next step in management?

109) A 36-year-old forest worker is brought to the emergency department after being hit by a falling tree, 3 hours ago. He has pain in the left subscapular region. His temperature is 36C (96.9F), blood pressure is 120/76 mm Hg, pulse is 90/min, and respirations are 18/min. Physical examination shows aggravation of the pain in the left subscapular region with taking a deep breath and with anteroposterior and lateral chest compression. He has ecchymoses on the anterior and posterior chest and on the upper abdominal wall. His abdomen is vaguely tender to palpation in the left upper quadrant (LUQ) and he has left costovertebral angle (CVA) tenderness. Examination otherwise shows no abnormalities. An x-ray film of the chest shows posterior factures of the 8th, 9th and 1Oth ribs on the left. An x-ray film of the abdomen shows blunting of the left psoas shadow. Abdominal ultrasound shows no abnormalities. Laboratory studies show: Hb 15.3 g/dL, Hematocrit 43%, WBC 6,200/mm3, Urinary sediment Many erythrocytes; WBC 4-5/hpf; oxalate crystals. Which of the following is the most appropriate next step in management?

110) A 35-year-old woman presents to the physician's office after she palpated a lump in her right breast. She has no other complaints. She has not seen a doctor for 10 years. She regularly performs breast self-exams after menses. She has no significant past medical history. Her mother died of breast cancer at the age of 40. Breast examination shows a 1 x 1 cm, rubbery, firm, freely mobile round mass in the upper, outer quadrant of the right breast; no axillary lymph nodes are palpable. Which of the following is the most appropriate next step in management?

111) A 45-year-old male comes to the hospital because of severe retrosternal chest pain that started suddenly a few hours ago. He says that he has been having mild chest pain for the past few days, but that this pain is completely different. His past medical history is significant for nonischemic cardiomyopathy for which he takes furosemide, carvedilol, spironolactone, lisinopril and potassium chloride. He also has HIV infection but is not taking any edications related to this diagnosis by his own choice. On physical examination, his temperature is 38.9C (102F), blood pressure is 110/65 mm Hg, pulse is 110/min, and respirations are 22/min. He is in obvious distress secondary to pain. His lungs are Test clearto auscultation and the remainder of his physical examination is unremarkable. His EKG is within normal limits. Chest X-ray shows a widened mediastinum and mediastinal air. W hich of the following is the most appropriate next step in the management of this patient?

112) A 78-year-old man with Alzheimer's disease was brought to the ER because of bright red bleeding per rectum. He has chronic constipation and is being treated with bisacodyl. On admission, his temperature was 36.6C (97.9F), blood pressure was 130/80 mm Hg with no orthostatic change, pulse was 90/min and respirations were 14/min. Nasogastric tube drainage showed normal stomach contents without blood. His bleeding stopped a few hours after dmission, and he remained hemodynamically stable during that time. Colonoscopy showed extensive diverticulosis but no active bleeding source. Later that night he started bleeding again, and he is now hypotensive with a BP of 100/70 mm Hg. Packed red cells and intravenous fluid are started. Which of the following is the most appropriate next step in management?

113) A 44-year-old unrestrained male driver is brought to the ER after a motor vehicle accident. Cervical spine is immobilized. His breathing is normal. At the scene of the accident, his blood pressure is 70/30 mm Hg. After receiving two liters of intravenous fluid, his blood pressure is 80/40 mmHg. Neck veins are collapsed. Lungs are clear to auscultation. Abdomen is mildly distended. There is no obvious source of external bleeding. No intraperitoneal blood or solid organ damage is seen on ultrasonogram or diagnostic peritoneal lavage. Imaging studies reveal a pelvic fracture and fracture of the right fourth rib. Which of the following is the most appropriate next step in management?

114) A full-term, female infant is born to a 26-year-old, primigravid mother via C-section secondary to breech position. The mother has lived in New York City for the past 5 years. She denies the use of any drugs, alcohol or cigarettes during her pregnancy. She denies having any sexually transmitted infections. Her lead levels were within the normal range throughout her pregnancy. Prenatal ultrasound done at 30 weeks gestation showed normal anatomy of the fetus. The Apgar scores at 1 and 5 minutes are 7 and 9, respectively. There are some bluish-brown spots located on the infant's lumbosacral area. Flexion and abduction of the lower extremities reveal a palpable clunk. The rest of the physical examination is normal. Which of the following is the best next step in the management of this patient?

115) A 36-year-old woman is brought to the emergency department after she jumped from the second floor of a burning building. On arrival examination shows an unconscious woman with blood coming from her nose and with an open tibial fracture of left leg. Her eyes are closed and her pupils are equal and responsive bilaterally. She makes muffled sounds and responds to pain by opening the eyes and moving all the limbs. After the initial resuscitation, which of the following is the most appropriate next step in management?

116) A 34-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He was the restrained front passenger. He has had epigastric pain since the accident. He is hemodynamically stable and has no obvious injury or other complaints. An x-ray of the abdomen shows retroperitoneal air. Which of the following is the most appropriate next step in management?

117) A 22-year-old football player comes to the physician because of difficulty in extending his right knee. This started one month ago after he twisted his knee while playing. There was mild swelling immediately; he took pain relievers which relieved both the pain and swelling. However, now the knee motion is limited and this is significantly restricting his physical activities. Physical examination shows no swelling of the knee. While passively flexed and extended, a popping sensation is noted under the examiner's finger (which is placed at the right knee). Which of the following is the most appropriate next step in management?

118) A 48-year-old man with a strong history of cigarette use and heavy alcohol intake presents with an intraoral mass. Biopsy shows squamous cell cancer. Chest xray shows hyperinflated lungs but is otherwise normal. Which of the following is indicated as part of his staging workup?

119) A 42-year-old man is brought to the emergency department after a motor vehicle accident. He was a restrained driver and hit a car from behind on a highway. He drank one glass of wine before driving. He occasionally uses cocaine. His medical problems include mild intermittent asthma and peptic ulcer disease. On initial evaluation, his blood pressure is 112/92 mm Hg and pulse is 96/min. His pulse oximetry shows 95% on room air. Examination shows bruises on the anterior chest wall and abdominal wall. X-rays reveal a fracture of the eighth left rib but no pneumothorax or pleural effusion. Cervical C-spine series are negative. An ultrasound does not show free intraperitoneal fluid. An ECG shows normal sinus rhythm with no ST-segment or T-wave changes. He is treated with intravenous fluids and analgesics. Eight hours later, he complains of epigastric discomfort, left shoulder pain, and mild nausea. His blood pressure is 97/62 mm Hg and pulse is 112/min. His pulse oximetry shows 96% on room air. Which of the following is most likely to diagnose this patient's current condition?

120) A 56-year-old previously healthy physician notices that his eyes are yellow and he has been losing weight. On physical examination the patient has jaundice and scleral icterus with a benign abdomen. Transcutaneous ultrasound of the abdomen demonstrates biliary ductal dilation without gallstones. Which of the following is the most appropriate next step in the workup of this patient?

121) A 42-year-old man with no history of use of NSAIDs presents with recurrent gastritis. The patient was diagnosed and treated for Helicobacter pylori 6 months ago. Which of the following tests provides the least invasive method to document eradication of the infection?

122) A 45-year-old executive experiences increasingly painful retrosternal heartburn, especially at night. He has been chewing antacid tablets. An esophagogram shows a hiatal hernia. In determining the proper treatment for a sliding hiatal hernia, which of the following is the most useful modality?

123) A 62-year-old man has been noticing progressive difficulty swallowing, first solid food and now liquids as well. A barium study shows a ragged narrowing just below the carinal level. Endoscopic biopsy confirms squamous cell carcinoma. Which of the following provides the most accurate information regarding the T stage of an esophageal carcinoma?

124) A 53-year-old woman with a history of a vagotomy and antrectomy with Billroth II reconstruction for peptic ulcer disease presents with recurrent abdominal pain. An esophagogastroduodenoscopy (EGD) demonstrates that ulcer and serum gastrin levels are greater than 1000 pg/mL on three separate determinations (normal is 40-150). Which of the following is the best test for confirming a diagnosis of gastrinoma?

126) A 28-year-old woman presents with hematochezia. She is admitted to the hospital and undergoes upper endoscopy that is negative for any lesions. Colonoscopy is performed and no bleeding sources are identified, although the gastroenterologist notes blood in the right colon and old blood coming from above the ileocecal valve. Which of the following is the test of choice in this patient?

127) A 36-year-old man is in your intensive care unit on mechanical ventilation following thoracotomy for a 24-hour-old esophageal perforation. His WBC is markedly elevated, and he is febrile, hypotensive, and coagulopathic. His NG tube fills with blood and continues to bleed. Which of the following findings on upper endoscopy would be most suspicious for stress gastritis?

128) A 2-month-old boy is examined because he has been straining while passing stool and has a distended abdomen. He is very low on the growth chart for age. The primary care physician suspects that the boy has Hirschsprung disease. Which of the following findings on workup is diagnostic?

129) A patient is brought to the ER after a motor vehicle accident. He is unconscious and has a deep scalp laceration and one dilated pupil. His heart rate is 120 beats per minute, blood pressure is 80/40 mm Hg, and respiratory rate is 35 breaths per minute. Despite rapid administration of 2 L normal saline, the patient’s vital signs do not change significantly. Which of the following is the most appropriate next step in the workup of his hypotension?

130) A 47-year-old man is extricated from an automobile after a motor vehicle accident. He is hypotensive with a systolic blood pressure of 80. The patient has a steering wheel bruise on the anterior chest. His electrocardiogram (ECG) shows some premature ventricular complexes, and his cardiac isoenzymes are elevated. Which of the following is the best next test for evaluation for a blunt cardiac injury?

131) A 36-year-old man sustains a gunshot wound to the left buttock. He is hemodynamically stable. There is no exit wound, and an x-ray of the abdomen shows the bullet to be located in the right lower quadrant. Which of the following is most appropriate in the management of his suspected rectal injury?

132) A 32-year-old man is in a high-speed motorcycle collision and presents with an obvious pelvic fracture. On examination, he has a scrotal hematoma and blood at his urethral meatus. Which of the following is the most appropriate next step in his management?

133) An intoxicated 22-year-old man is a restrained driver in a high-speed motor vehicle collision. Examination reveals normal vital signs, but the rest of the examination is unreliable secondary to the patient’s intoxicated state from alcohol. Which of the following sole findings on a CT scan of the abdomen and pelvis mandates an exploratory laparotomy?

134) A 23-year-old man arrives in the ER after a motor vehicle collision. Examination reveals an unstable pelvis and blood at the urethral meatus. Which of the following studies would most accurately identify a urethral injury?

135) A 2-year-old asymptomatic child is noted to have a systolic murmur, hypertension, and diminished femoral pulses. Which of the following should be performed as part of the preoperative workup and management of this child’s disorder?

136) A 16-year-old boy was brought to the emergency department because of left shoulder and left hand pain after falling on his outstretched hand while playing soccer. He heard a crunching sound and had intense pain in his left shoulder area following the injury. Examination shows bruising around the clavicle area. He is holding his left arm with his right hand. There is a palpable gap in the middle of the clavicle. Auscultation shows a loud bruit just beneath the clavicle. An x-ray film of the left shoulder and chest shows the middle of the clavicle is fractured and displaced. Which of the following is the most appropriate next step in management?

137) A 36-year-old woman presents to the physician's office after she palpated a lump in her right breast. She has no other complaints. She has not seen a doctor for 10 years. She regularly performs breast self-exams after menses. She has no significant past medical history. Her mother died of breast cancer at the age of 40. Breast examination shows a 1 x 1 cm rubbery, firm, freely mobile, round mass in the upper, outer quadrant of the right breast. No axillary lymph nodes are palpable. Which of the following is the most appropriate next step in management?

138) A 78-year-old man with Alzheimer's disease was brought to the ER because of bright red bleeding per rectum. He has chronic constipation and is being treated with bisacodyl. On admission, his temperature was 36.6°C (97.9°F), blood pressure was 130/80 mm Hg with no orthostatic change, pulse was 90/min, and respirations were 14/min. Nasogastric tube drainage showed normal stomach contents and bile but no blood. His bleeding stopped a few hours after admission, and he remained hemodynamically stable during that time. Colonoscopy showed extensive diverticulosis but no active bleeding source. Later that night he started bleeding again from the rectum. Packed red cells and intravenous fluid are started. Which of the following is the most appropriate next step in management?

139) A 45-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He is unable to void. Examination shows blood at the urethral meatus and a scrotal hematoma. His temperature is 37°C (98.6°F), blood pressure is 100/50, pulse is 100/min and respirations are 16/min. Examination shows a high-riding prostate with no other signs of trauma. Which of the following is the most appropriate next step in management?

140) A 23-year-old man comes to the emergency department because of a painful swollen left knee. The pain began after he twisted his leg while playing football. Examination shows a swollen left knee with marked tenderness of the medial side of the knee. When compared to the right knee, on valgus stressing the left knee shows exaggerated laxity at the joint line. Which of the following is the most appropriate next step to confirm the diagnosis?

141) A 36-year-old male comes to the emergency department because of worsening right lower quadrant (RLQ) abdominal pain. One week ago he was started on cephalexin for furunculosis. He has had type I diabetes mellitus for 1Oyears and is on insulin. His temperature is 38.83°C (101.9°F). Examination shows multiple furuncles on the inner side of both thighs; most of them are in regression. Abdominal examination shows tenderness on deep palpation in RLQ without rebound or guarding; no masses are palpated; psoas sign is positive; bowel sounds are present. Rectal examination shows no abnormalities. Laboratory studies show: Hemoglobin 13.0 g/L, Leukocyte count 17,500/mm3. Which of the following is the most appropriate next step in management?