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Flashcards in Practice test 1 Deck (50):
1

3w after undergoing arteriography through the R groin for eval of progressive L calf claudication, a 64yo man is noted to have a palpable thrill and continuous machinery murmur at the arteriography site. exam shows decreased pedal pulses on the R. Pulses had been normal prior to the procedure. the arteriogram si shown. which of the following is most predictive of developent of heart failure in this pt?
a. degree of edema in the LE
b. groin compression causing bradycardia
c. presence of pallor with elevation and dependent rubor
d. presence of pseudoaneurysm
e. size of abnormality

E

b/c leaking lots of blood into space

2

12yo girl is brought to the ED 30min after falling off a second floor balcony. on arrival, her pulse is 105, RR 22, and BP 105/77. the chest is clear to auscultation. the abdomen is soft and nontender. an xray of the chest shows no abnormalities. which of the following is the most appropriate next step in diagnosis?
a. xray of the cervical spine
b. xray of the abdomen and pelvis
c. cystography
d. ultrasonography
e. CT scan of the abdomen
f. CT scan of the chest
G. peritoneal lavage
h. arteriography

A

fall from a a tall height. likely damage to spine

3

An unconscious 27yo man is brought to the ED immediately after being involved in a MVA. he was the unrestrained driver of a vehicle that struck a tree. at the scene, he was unconscious. he was not breathing spontaneously and was intubated and mechanically ventilated. on arrival, his Glasgow oma score is 9/15. he breathes spontaneously when mechanical ventilation is discontinued. his temp is 98.6F, pulse 124 RR 16 and palpable systolic BP is 100mmHg. exam shows copious bleeding from a laceration over the scalp. there is a pool of blood around his head. there is an obvious fracture of L humerus. breath sounds are heard b/l. the abdomen is soft. the pelvis is stable. in addition to IV administration of crystalloid solutiaon, which of the following is the most appropriate next step in management?
A. direct pressure to the bleeding laceration
b. CT scan of the abdomen.
C. IV administration of a vasopressor
d. transfusion of type-specific packed RBCs
e. closed reduction of the fracture

A

b/c BP is soft

4

19yo man is brought to the ED 15min after his motorcycle collided head-on with a truck. no loss of conscioussness at the scene is reported. on arrival, he is agitated but oriented to person, place and time. he resopnds to verbal commands. supplemental O2 and IV fluids are adminstered. his pulse is 115, RR 18, and BP 110/70. there are multiple abrasions over the forehead, chest, abdomen, and R LE. the pupils are equal and reactive to light. the trachea is midline, and breath sounds are equal b/l. heart sounds are normal. the abdomen is mildly distended, soft and diffusely tender. his Hgb conc is 11.8, and leukocyte count is 14,000. urinary catheterization yields clear urine. X rays of the cervical spine and pelvis show no abnormalities. an xray of the chest shows a moderate amt of free intra-abdominal air under the diaphragm. which of the following is the most appropriate next step in management?
a. lateral decubitus xray.
b. CT scan of the abdomen
C. upper GI endoscopy
D. diagnostic peritoneal lavage
e. laparotomy.

E

5

62 yo woman comes to the physician for a routine health maintenance exam. she feels well. Menarche was at the age of 13y, and menopause occurred 19y ago. she has no family hx of breast dz. examination shows a 2x2cm mass in the upper outer quadrant of the L breast. Mammography of the L breast shows calcifications in the upper outer quadrant. a biopsy of the breast mass shows invasive estrogen receptor-positive carcinoma with positive margins. which of the following is the most appropriate next step in management?
a. observation only
b. cytotoxin and doxorubicin therapy
c. tamoxifen therapy
d. radiation therapy
e. reexcision of the biopsy site

D

invasive with positive margins

6

a25 yo construction worker has had fever and a painful, swollen R hand for 2d. his temp is 102.2F. The dorsum of the hand is swollen, erythematous and tender. there is a small traumati laceration on the dorsum of hte hand with a beefy-red expanding margin and red streks extending up the arm. the axillary lymph nodes are palpable and tender. which of the following is the most likely pathogen?
a. bacteroides fragilis
b. clostridium difficile
c. clostridium perfringens
d. clostridium tetani
e. enterobacter cloacae
f. enterococcus faecalis
g. escherichia coli
h. staphylococcus epidermidis
i.. streptococcus pneumoniae
j. streotococcus pyogenes (group a)

J

Skin infection - Strep or Staph. pyogenes - for nec fasc

not C perfringens b/c no diarrhea

7

a previously healthy 37yo woman comes to the physician b/c of a 2mo history of intermittent, RUQ abdominal pain that usually occurs after meals. he has not had fever, chills, vomiting, nausea, weight loss, or change in bowel movements. she takes no medications. her temp is 98.6F, pulse is 68, RR are 16, and BP is 110/70. exam shows no jaundice or scleral icterus. abdominal exam shows no abnormalities. her leukocyte count is 5000. results of LFTs are within the reference ranges. abd ultrasonography shows a thickened gallbladder wall, cholelithiasis, and a 4.2cm hepatic mass int he R lobe. an abdominal CT scan shows the mass to be 4.2x3.5cm with a central scar. which of the following is the most appropriate next step in treatment?
a. measurement of serum alpha-fetoprotein concentration
b. hepatitis B virus etiology
c. radionuclide liver scan
d. MRI of liver
e. fine-needle aspiration biopsy of the mass
f. no further testing is indicated.

F

focal nodular hyperplasia ==> these do not have malignant potential

don't need to do anything about them

8

a12 yo boy has had weakness, pallor, and black, shiny stools for 5d. he has had no abdominal pain or other symptoms. laboratory studes show:
Hct 26%
MCV 70
MCHC 22%
An abdominal scintigram, using technitium 99m pertechnetate, shows uptake in the RLQ separate from the activity in the stomach, kidney and bladder. which of the following is the most likely diagnosis?
a. henoch-schonlein purpura
b. ileocecal intussusception
c. juvenile colonic polyp
d. meckel diverticulum
e. ulcerative colitis

D

TC99m is the diagnostic test for Meckel's

9

a 42yo construction worker is brought to the ED 20min after falling 30ft from a scaffold. en route to the hospital, he received 1L of lactated Ringer solution. on arrival, he is awake and alert & has severe abdominal and leg pain. he can move all extremities. his temp is 98.6F, pulse is 110, RR are 16, and BP is 120/70. examination shows ecchymoses over the L forehead and lower abdomen. there is obvious deformity of the L LE. there is no neck tenderness. cardiopulmonary exam shows no abnormalities. the lower abdomen is slightly distended and exquisitely eder. there is no blood at the urethral meatus. rectal examination shows no abnormalities. insertion of a urinary catheter yields 30ml of grossly bloody fluid. an additional 1.5L of lactated Ringer solution is administered, and the L LE is placed in traction. 30 min later, his pulase is 95/min, and BP is 140/80. no additional urine has drained from the cathter. which of the following is the most likely cause of this pt's anuria.
a. acute tubular necrosis
b. hypovolemia
c. rupture of the bladder
d. SIADH (vasopressin)
e. transection of the urethra

C

grossly bloody urine --> damage somewhere along the urinary tract --> from kidney - ureters - bladder - urethra

10

42yo woman, G3P3 comes to the physician b/c of a 3mo history of intermittent bloody discharge from her R nipple. her mother died of breast CA at the age of 60y. on exam, bloody discharge can be expressed with pressure on the R areola. no masses are palpable. palpation of the L breast and axilla shows no abnormalities. mammography shows normal findings. which of the following is the most likely diagnosis?
a. breast abscess
b. breast Ca
c. cystosarcoma phylodes
d. galactocele
e. hematoma
f. inflamatory carcinoma of the breast
g. intraductal papilloma
h. sebaceous cyst

G

U/L bloody discharge

intraductal papilloma is the most common cause (esp. 35-50yo).

11

an 87yo woman is brought to the ED from a skilled nusring care facility b/c of 6 episodes of loose brown stools daily during the past week. there is no visible blood or mucus in the stool, and she has not had fever or abd pain. 5y ago, she sustained a cerebral infarction and has residual left hemiparesis. she has atrial fibrillation and multiple compression fractures from osteoporosis. her medications include warfarin, digoxin,and famotidine. 1 mo ago, she began taking acetaminophen with codeine for her most recent compression fracture. her temp is 98.8, pulse 80 and irregular, RR 16 and BP 130/75. abd examination shows mild tenderness in the LLQ. bowel sounds are normal. rectal exam shows normal tone with hard stool in the vault. test of the stool for occult blood is negative. an abd xray shows copious stool throughout the bowel. there is no evidence of free air or obstruction. which of the following is the most appropriate next step in management?
a. elevation of the head of the bed during sleep
b. elimination of milk from the diet
c. elimination of spicy food from the diet
d. enemas
e. esophagogstroduodenoscopy
f. left hemicolectomy
g. low fat diet
h. mesenteric angiography
i. omeprazole therapy
j. recommendation to increase her milk consumption
k. stress management
l. total proctocolectomy
m. U/S of the abdomen
n. upper GI series

D

she has hard stool + diarrhea around it.

do the easiest, least morbid thing.

12

37yo woman comes to the physician b/c of a 3 mo history of neck swelling and tightness in her throat. seh has not had weakness, weight change, or heat / cold intolerance. exam shows a diffusely enlarged & firm thyroid gland. there is no modularity. serum TSH, T3, and T4 conc. are within normal limits. serum studies show circulating Antibodies against thyroid peroxidase and thyroglobulin. what is the most likely diagnosis?
a. anapalstic thyroid carcinoma
b. chronic lymphocytic thyroiditis (Hashimoto disease)
c. graves disease
d. papillary carcinoma of the thyroid gland
e. subacute thyroiditis

B

these are for Hashimoto's

13

65yo woman is brought to the ED 1h after she fell. she has R wrist pain. her last visit to a physician was 10y ago. exam shows swelling and tenderness of the R wrist. an xray of the wrist shows no fracture, but subperiosteal bone resorption is noted in the distal phalanges. her serum Ca conc. is 12.4, and serum creatinine conc. is 1.2 . which fo the following conc. is most likely to be decreased in this pt?
a. 1,25-dihydroxycholecalciferol
b. magnesium
c. parathyroid hormone
d. phosphorus
e. vit C

D

most common cause of hypercalcemia in an "outpt" --> hyperparathyroidism - though more likely in younger men. However, would lead to high PTH, Ca, with low phosphorus. would also cause osteoporosis b/c so much Ca in drawn into blood.

OR could be chronic renal disease, leading to high Cr, high Ca, with low phosphorus AND low PTH. (secondary hyperparathyroidism)

- either way - low phosphorus

14

a previously healthy 52yo woman comes to the ED b/c of a 2d hx of abdominal cramps & vomiting. she has not passed stool or flaatus during this period. she has no hx of similar sxs. she underwent an abd hysterectomy 10y ago. her temp is 99.8F. pulse is 110 and Bp 140/70. the lungs are clear to auscultation and percussion. abd examination shows distension and mild tenderness but no peritoneal signs. BS are active. lab studies show
Hct 42%
leuk 11,500
Na 140
Cl 101
K 3.6
HCOe 28
uera nitrogen 40
glucose 110
creatinine 1.7
which of the following is the most likely diagnosis?
a. acute cholecystitis
b. colon cancer
c. complete SBO
d. ileus secondary to renal failure
e .perforated viscus

C

constipation + obstipation

+ likely some degree of dehydration leading to AKI

15

4d after admission to the hospital for treatment of metastatic breast Ca with chemotherapy, a 42yo woman has increased pain of extremities and ribs. she has a history of HTN and renal insufficiency. she underwent b/l mastectomy 4y ago. she is currently takinga ceatminophen with codeine (2 tablets 4 x daily), and amitriptyline (50mg at bedtime) with no relief of pain. she sleeps well but awakens early b/c of pain. her appetite is good. her pulse is 100 and regular, RR 20, BP 100/80. the pupils are round and reactive. there is tenderness to palpation of the chest wall and vertebrae. she is alert and oriented but winces in painwhen she moves. she says that she does not feel depression but occasionally wishes that she would not wake up. she is hopeful tthat she will get better. her mood is reserved, but she smiles when she discusses her children. lab studies are pending. which of the following is the appropriate next step in management?
a. carbamazepine therapy
b. clonazepam therapy
c. oxycodone therapy
d. paroxetine therapy
e. valproic acid therapy
f. regional nerve blockade

C

no relief of pain. she has metastatic cancer. give her morphine

16

63 yo man has had dysphagia and chest pain during meals for 4 mo. he has a 6y hx of GE reflux. he has limited his intake to liquids for 3w b/c he regurgitates solid food. which of the following is the most likely cause of his sxs?
a. disordered neuromuscular transmission in the esophagus.
b. disordered neuromuscular transmission in the oropharynx
c. failure of oropharyngeal propulsion
d. paraesophageal hiatal hernia
e. stricture of the distal esophagus

E

anatomic stricture --> that allows fluids but not solids through

17

an obese 72yo man is brought to the ED 15 min after he collapsed at home. his wife reports that he has had upper abd pain, nausea, and vomiting for the past 24h. he has HTN and coronary artery disease. he is diaphoretic. his temp is 97.7, pulse is 115 and irregularly irregular, RR 22 and palpable systolic BP is 80. there is no jugular venous distension. the lungs are clear to auscultation. no murmurs or gallops are heard. the abdomen is tender and rigid. pulm artery catheterization shows:
cardiac index 1.2mmHg (n=2.5-4.2)
mean pulmonary arterial pressure 5mmHg (N=9-16)
pulmonary capillary wedge pressure 1mmHg (N=5-16)
systemic vascular resistance 1929 (N=770-1500)
a. anaphylactic
b. cardiogenic
c. hypovolemic
d. neurogenic
e. septic

C

abd perf? likely from SBO or ulcer.

abd pain and nausea for a whole day --> NOT MI or cardiac problem


increased SVR

18

57yo man comes to the physician b/c of persistent increasingly severe L sided chest pain for 1 mo. he works as an industrial engineer. exam shows absent breath sounds and dullness to percussion over the lower portion of the L hemithorax. an xray of the chest shows a L sided pleural effusion w/ an extensive peripheral soft tissue density. thoracentesis shows bloody, mitotic figures and areas of cuboidal epithelial cells. exposure to which of the following agents is the most likely cause of his condition?
a. asbestos
b. nickel
c. talc
d. tobacco
e. toluene diisocyanate

A

Cancer. Mesothelioma

further out at the edge
==> mitotic figures & cuboidal epithelial cells.

RF of lung cancer
- smoking
- asbestos
(? talc)

19

a 67yo man is brought to the physician bc of severe pain in the R foot for 6h. on exam, the R foot is pale and cool, and pedal pulses are nor palpable. he can wiggle his toes. exam of the L foot shows no abnormalities. there are b/l femoral pulses and pulsatile masses in the popliteal fossae. which of the following is the most appropriate next step in diagnosis?
a. cardiolipin antibody assay
b. measurement of transcutaneous O2 tension in the feet
c. measurement of serum antithrombin III concentration
d. impedance plesthysmography
e. arteriography with runoff
f. venography of the R LE.

E

emboli / claudication

20

87 yo woman brought to the ED from a skilled nursing care facility b/c of a change in mental status during the past 12h. she has severe dementia, Alzheimer type and is unable to give a history. she is currently taking donepezil, atenolol, digoxin, lisinopril, sertraline, docusate, psyllium, and aspirin. on arrival, she is agitated and does not respond to verbal stimuli. her temp is 100.4F, pulse is 92, RR24, and Bp 148/86. the lungs are clear to auscutation. the abdomen is distended. there is diffuse guarding with no rebound. test of the stool for occult blood is negative. her Hct is 34%, leuk count is 9500, and plt is 267,000. an xray of the abdomen is shown with dilation ofthe colon at the very inferior of the abdomen/pelvis which of the following is the most appropriate next step in management?
a. serial measurement of cardiac enzyme activities
b. CT scan of the abdomen
c. discontinuation fo sertraline
d. sigmoidoscopy-guided placement of the rectal tube
e. exploratory laparotomy

D

constipation

need to disimpact

21

2w ago, a 37yo woman noticed a small painless sore on her R thigh that now measures 2cm in diameter. she has a 9y hx of chornic ucerative colitis, for which she takes suulfasalazine. she currently has 3-4 semiformed stools daily. the ulcer has sharply defined edges and a flat base containing purulent debris. which of the following is the most likely explanation
a. allergic drug rxn
b. erythema nodosum
c. infarction
d. necrobiosis
e. pyoderma gangrenosum

E

chronic immunosuppressives

and grew pretty quickly. she was scratching at it?

22

a previously healthy 25yo woman is brought to the ED 2o min after being struck by an automobile. on arrival, she has pelvic and L LE pain. her temp is 98.3F, pulse is 135, RR 26, BP 90/48. exam shows an unstable pelvis and an obvious deformity of the L thigh. X rays show fractures of the L iliac wing and L midshaft femur. 10 U of packed RBCs are administered and her BP stabilizes. 9d after operative repair of her fractures, she develops jaundice. abd exam shows no abnormalities. serum studies show:
Bili - total 5
Direct 2.3
alkaline phosphatase 150
gamma-glutamyltransferase 35 (n=5-50)
which of the following is the most likely underlying cause of these findings?
a. decreased excretion of bilirubin into the bile
b. decreased hepatic conjugation of bilirubin
c. decreased hepatic uptake of bilirubin
d. obstruction of common bile duct
e. overproduction of bilirubin

E

lots of RBCs dying and putting out bilirubin

23

25yo woman remains in the ICU 5d after undergoing pancreaticoduodenoectomy for injuries sustained from a gunshot wound to the abdomen. a jejunostomy tube was placed distal to the anastomosis at the time of surgery. current medications injude morphine and cimetidine. she is 5ft tall and weighs 220lb, BMI is 43. exam shows a well-healing inscision. which of the following is the most appropriate next step in providing nutrition to this pt?
a. enteral tube feedings
b. IV administration of 10% dextrose in water
c. parenteral administration of lipid emulsion
d. total parenteral nutrition
e. no nutrients should be given at this time.

A

as long as she can eat, and there's no pancreas to leak lots of fluid after stimulation

and decrease fat in tube feeds

24

27yo man comes to the ED 6h after being bitten during a fistfight. he has a 3x2cm flap laceration on the dorsu of the R hand that extends into the subcu fat. the surrounding tissues are contused. no tendons are exposed. the avulsed skin is cyanotic and insensate on a 1cm margin. there is no bleeding. which of the following is hte most appropriate managmenet?
a. debridement and application of a sterile dressing to the open wound.
b. debridement and primary closure of the wound by mobilization of adjacent skin
c. debridement and flap rotation to achieve tension-free primary closure of the wound
d. debridement and split-thickness skin grafting to the soft tissue defect

A

want that to be open and heal - b/c concerns of infection from a dirty mouth = don't close completely

25

67 yo man comes to the physician b/c of an ulcer on the glans penis that has been increasing in size over the past 6mo. he is sexually active with multiple partners and rarely uses a condom. exam shows an uncircumcised penis with b/l, firm inguinal adenopathy and a painless ulcer on the glans. a serologic VDRL test is nonreactive. which of the following is the most likely diagnosis?
a. chancroid
b. epididymitis
c. gonococcal urethritis
d. herpes
e. inguinal hernia
f. nongonococcal urethritis
g. penile cancer
h. scrotal abscess
i. syphylis

G

not a lot of the STI's b/c VDRl is nonreactive

doesn't look like herpes

ulcer + b/l lymphadenopathy

26

27yo woman G2P2 comes to the physician b/c of a 1w history of painful BM. she has noticed bright red blood on the surface of her stool during this period. she reports she has had BM 2x weekly since delivery of her youngest child 2y ago. she has no hx of serious illness and takes no medications. exam of the perineum shoes an ulcer in the posterior midline of the anal canal with an adjacent edematous skin tag at the anal verge. rectal exam cannot be performed b/c of pain and increased anal sphincter toe in addition to treatment with stool softeners, which of the following is the most appropriate next step in management?
a. Sitz bath
b. hydrocortisone enemas
c. anal manometry
d. placement of elastic bands
e. surgical drainnage of abscess

A. similar to warm compress. let it heal on own.

there is no abscess

anomatry, enema and elastic bands is VERY painful and mean

27

an otherwise healthy 47yo woman comes to the physician b/c of a 2y hx of increasingly severe heartburn. current meds are cimetidine for the past 2y and an OTC antacid as needed. Neither med has relieved the sxs. she has smoked 1 PPD for 20 y and drinks 3-4 beers daily. she is 5'2" tall and weighs 130 lb . BMI is 24. vital signs are within normal limits. scattered wheezes are heard b/l. cardiac and abd exams show no abnormalities. finidng son ECG are normal. a chest xray shows an air fluid level posterior to the cardiac silhoueette. a barium swallow shows the proximal stomach herniating through the esophageal hiatus. which of the following is the most appropriate next step in diagnosis?
a. 24h pH monitoring
b. endoscopic ultrasonography
c. esophageal manometry
d. esphagogastroduodenoscopy
e. thoracoscopy

D

paraesophageal hernia

need to take a look at it --> and to consider surgical repair

28

62yo man is brought to the ED b/c of a 12h hx of fever, fatigue and severe pain in the toes of his L foot. he rates the pain as a 9/10. he has not had abd pain. 6w ago, he was discharged from the hospital following abx treatment for diverticulitis. at that time, he was prescribes a 14d course of IV piperacillin and tazobactam to be administered at home via percutaneous IV catheter. he has HTN treated with atenolol. his temp is 102F, pulse is 120 and regular, RR 22, and BP 100/60. there is an IV catheter in his medial R arm. a grade 2/6, descrescendo, diastolic murmur is heard best at the upper R sternal border. teh abdomen is flat and nontender. ther eis no pedal edema. the 2nd and 3rd toes of the L foot are pale blue and tender. his leuk is 17,000 (70% segmented neutrophils, 10% bands and 20% lymphocytes). a blood culture is positive for Staph. aureus. Echocardiography shows vegetations on the aoritc valve. which of the following is most likely to have prevented this complications?
a. implantation of a port instead of a catheter for administration of piperacicillin and tazobactam
b. initiation of ampicillin and gentamicin therapy instead of piperacillin and tazobactam
c. addition of fluconazole to the medication regimen for his diverticulitis
d. removal of the percutaneous intravenous catheter after completion of piperacillin and tazobactam therapy
e. administration of pneumococcal polysaccharide vaccine, 23 valent at discharge

D

throwing infectious emboli.

would NOT put a port for 2w. a catheter is appropriate

29

60yo manwith alcoholism has had diarrhea and generalized weakness for 5d. abd exam shows an enlarged liver and mild diffuse tenderness with shifting dullness. his serum Ca con si 6 and serum amylase activity is within normal limits. which of the following is the most likely cause of the hypocalcemia/
a. acute pancreatitis
b. acute renal failure
c. hypokalemia
d. hypomagnesemia
e. type 4 hyperlipoproteinemia

D

d/t malnutrition

30

3d after undergoing an appendectomy for a perforated appendix, a 42yo man develops dyspnea. arterial blood gas analysis on RA shows:
pH 7.34
pCO2 35
PO2 85
HCO3 22
ventilation perfusion lung scans shows a large perfusion defect in the LL with adequate ventilation. which of the following is the most apporpirate next step in management?
a. administration of heparin
b. administration of warfarin
c. pulmonary angiography
d. placement of a vena cava filter
e. pulmonary embolectomy

A

PE

Winter's formula

PCO2 = 1.5(22) = 33 +/- 8

31

57yo woman is admitted to the hopsital for an elective gastrectomy. during insertion of a subclavian venous catehter via a L infraclavicular approach, the pt suddenly begins squirming under the drapes and has SOB. her pulse is 100, RR 24, and BP 100/70. exam shows jugular venous distension. breath sounds are decreased on the L. which of the folliowing is the most likely diagnosis?
a. air embolism
b. cardiac tamponade
c. claustrophobia
d. massive hemothrax
e. tension pneumothorax

E

that can cause pneumothorax b/c approaching on the superior part of the lung

punctured the superior part of the lung

32

46yo man comes to the ED 2h after the sudden onset of high epigastric pain. he has recently developed rheumatic pains,, requiring frequent use of aspirin and ibuprofen. exam shows an acutely ill man who is perspiring freely. his temp is 98.6, pulse is 112, and BP 130/70. the lungs are clear to auscultation. the abdomen is diffusely tender with boardlike rigidity. the liver cannot be outlined by percussion. no peristalsis is audible. his leukocyte count is 14,200 with 88% segmented neutrophils. an xray of the chest shows free air under the diaphragm. which of the following is the most appropriate next step?
a. nasogastric suction, administration of abx, and admission for observation.
b. immediate xray of the upper GI tract
c. immediate administration of an H2 receptor blocking agent
d. immediate endoscopy of the upper GI tract
e. immediate surgical exploration of the upper abdomen

E

you know it's the stomach - perforation

emergent surgery

33

previously healthy 47yo man is admitted to the hospital b/c of a 3d history of constant increasingly severe abdominal pain. a diagnosis of diverticulitis is made and bowel rest & abx treatment are recommended. the pt insists that he undergo an operation to relieve the pain. a second opinion is otained from an independent physician who states that an operation is containdicated b/c it caries an unacceptable level of risk and will not improve the pt's condition. after a prolonged discussion with the pt and his wife, the pt continues to insist that he undergo an operation. which of the following is the most appropriate course of action?
a. ask the pt's wife to formally refuse the operation ot he pt's behalf
b. obtain a courst order to refuse the operation
c. obtain permission from the hospital ethics committee not ot perform the operation
d. proceed with the operation
e. refuse to proceed with the operation

E

you are a surgeon. you have to make the decision. don't pass it off

34

40yo woman is brought to the ED after a MVA. she is unresponsive and comatose with hyperextension f all extremities. which of the following is the most appropriate first step in management?
a. administration of a bolus of corticosteroids
b. IV administration of mannitol.
c. MRI of the brian
d. intubation with hyperventilation
e. b/l burr holes

D

decerebrate positioning ==> likely from incraesed ICP

tx
- hyperventilation
- IV mannitol
- hypertonic saline

35

52yo man comes to the physician for a f/up exam. he has a 4y hx of HTN and a 1y hx of hypokalemia. current meds include labetolol, enalapril and KCl. his BP is 154/90. the remainder of the exam shows no abnormalities. his fasting serum aldosterone:renin ratio is increased. a CT scan shows a 1cm L adrenal mass. adrenal vein sampling before and after administration of ACTH shows b/l hypersecretion of aldosterone. which of the following is the most appropriate next step in management?
a. candesartan therapy
b. furosemide therapy
c. spironolactone therapy
d. b/l adrenalectomy
e. u/l adrenalectomy

C

adrenal tumor - but it's small.

NOT D

treatment of adrenal tumor (hyperaldosteronism)
1) medical management = spironolactone (K-sparing
2) u/l adrenalectomy = b/c surgery only cures it 20% of the time.

36

72yo man is brought to the ED immediately after he fainted. he was eating breakfast 5min before he collapsed and had the sudden onset of back pain localized to the L1 vertebral body. he has no hx of back pain of any other sxs. his temp is 98.6F, pulse is 14, RR 30 and BP 85/40. breath sounds are normal. peripheral pulses are palpated. abd exam shows moderate distension and tenderness to deep palpation. which of the following is the most likely diagnosis?
a. acute hemorrhagic pancreatitis
b. compression fracture
c. ruptured abd aortic anueyrsm
d. thoracic aortic dissection
e. tuberculous spinal abscess

C

L1 = bifurcation of the common iliac artery

most common presentation of AAA = death.

37

62 yo man with HTn and T2Dm comes to the physician for a routine ophthalmologic exam. he reports no visual problems. a cholesterol embolus is seen in a branch of the L retinal artery. which of the following is the most likely cause?
a. carotid plaque
b. diabetic retinopathy
c. hypertensive retinal artery changes
d. idiopathic retinal artery thrombosis
e. mural thrombus in the L ventricle

A

leading to emboli into renal aretery

38

38yo man has vomited small amts of bright red blood on several occasions over the past 9mo. he has a duodenal ulcer and has had 4 episodes of abd pain and indigestion over the past 3y, with the most recent episode occurring 5months ago. over the past y, he has had severe, persistent diarrhea, with 4-6 stools daily. current exam shows a temp of 99.1F and marked tenderness. the most appropriate next step is measurement of which of the following serum concentrations?
a. amylase
b. alpha-antitypsin
c. carcinoembrynic antigen
d. cortisol
e. gastrin

E

gastrinoma --> leading to recurrent ulcer.

39

2d after undergoing laparoscopic cholecystectomy for symptomatic cholelithiasis, an 82yo woman vomits and has the onset of choking followed by difficulty breathing. her initial postop course was uncomplicated. she has parkinson dx treated with carbidopa-levodopa. she has had significant bradykinesia for 2y. she is currently receiving hydromorphone and acetaminophen therapy. she is now confused and appears slightly cyanotic. she has SOB. her temp is 101F, pulse is 108, respirations are 22, and BP is 100/60. pulse oximetry on RA shows an O2 sat of 90%. diffuse rhonchi are heard. which of the following is the most likely explanation for this pt's current condition?
a. adverse effect of carbidopa-levodopa
b. adverse effect of hydromorphone
c. impaired cough mechanism
d. impaired esophageal motility
e. increased salivation

C

combo of surgery (anaesthesia) and parkinson's - muscles aren't working the way they should

40

Select the pt with a limp, for the most likely diagnosis:
A. legg-calve-perthes disease
b. osgood schlatter disease
c. osteomyelitis
d. recurrent sprain
e. septic arthritis
f. slipped capital femoral epiphysis
g. stress fracture
h. tibial vara
i. toxic synovitis
A previously healthy 14yo boy is brought to the physician b/c of a 2w hx of severe pain in his R knee and hip and an associated limp. he has had intermittent, mild pain in the same knee and hip for 3 mo. he plays on his junior high school football team. he is at the 50th percentile for height and greater than the 95th percentile for weight. his temp is 98.6. abduction of the R hip is slightly decreased compared to the L. there is mild tenderness of the R hip. Exam of the L hip shows no abnormalities. he walks with a limp and is unable to bear his fulll weight on the R.

F

fat boy + hip pain (referred to knee) ==> SCFE

41

Select the pt with a limp, for the most likely diagnosis:
A. legg-calve-perthes disease
b. osgood schlatter disease
c. osteomyelitis
d. recurrent sprain
e. septic arthritis
f. slipped capital femoral epiphysis
g. stress fracture
h. tibial vara
i. toxic synovitis
3yo girl is brought to the physician b/c of a 2d history of a limp. 2w ago, she had fever and upper respiratory sxs that resolved spontaneously. she has no hx of serious illness and takes no eds. her temp is 98.6. examination of the L hip shows moderate pain to palpation. her leuk is 11,000 - 60% segmented neutrophils, 2% eosinophils, 30% lymphocytes and 8% monocytes, and ESR is 12.

I

Toxic synovitis occurs when there’s inflammation in the hip joint. The cause is unknown, but it often occurs after a viral infection. It usually only affects one hip, but it’s possible for swelling and inflammation to spread to other joints.

Hip pain
limping or walking on tiptoe due to discomfort
pain in the thigh or knee and no hip pain
low-grade fever under 101°F
refusing to walk if the pain is severe
crying and irritability in younger children

septic arthritis = bacterial or fungal infection that results in joint inflammation and can lead to permanent joint damage if it’s left untreated. Would have more of a swollen hip / knee.

42

37yo woman comes to the physician b/c of a 2d hx of increasing SOB and fatigue. at the age of 5y, she underwent successful repair of a ventricular septal defect. she has no other hx of serious illness and ttakes no edications. she does not smoke cigarettes. her pulse is 110 and irregularly irregular. RR 28, and Bp 110/60. exam shows perioral cyanosis. the lungs are clear to auscultation. on cardiac exam, a grade 4/5, soft holosystolic murmur is heard best at the L seternal border. there is 3+ pretibial edema . which of the following is the most likely explanation for this pt's sxs?
a. decreased pulmonary artery flow
b. decreased pulmonary vascular resistance
c. decreased systemic vascular resistance
d. increased pulmonary artery blood flow
e. increased pulmonary vascular resistance
f. increased systemic vascular resistance

E

L sternal border - pulmonary valve

V-fib (L-->R) --> leading to increased preload

pulmonary hypertension as a complication of VSD

43

a previously healthy 37yo woman is brought to the ED immediately after her husband found her lying in bed ina deep stupor. she has no hx of a seizure disorder and she does not take any meds. her temp is 99.5F, pulse is 54, and Bp is 180/100. exam shows a dense L hemiparesis and early decerebrate posturing. there is no evidence of trauma. which of the following is the most likely diagnosis?
a. arteriovenosu malformation
b. brain abscess
c. meningioma
d. ruptures intracerebral aneurysm
e. thrombosed middle cerebral artery

D

intracranial/parenchymal hemorrhage

no evidence of trauma, young woman.

44

a hospitalized 37yo man has moderate abd pain and diarrhea 3d after undergoing gastric bypass for morbid obesity. he has passed 10 watery stools during the past 24h. he received abx prophylaxis during the operation. his initial postoperative course was uncomplicatd. current meds include propanolol, morphine, and omeprazole. he is 5ft 10in tall and weighs 440 lb. BMi is 63. Temp is 100.8F, pulse is 92, RR 18, and BP 120/70. abd exam shows moderate distension and diffuse tenderness. the surgical wounds are clean, dry and intact. BS are normal. an upper GI series with a water-soluble contrast shows normal postoperative findings. colonoscopy shows multiple areas of patchy, white mucosa. which of the following is the most likely cause of this pt's diarrhea?
a. blind loop syndrome
b. clostridium difficile infection
c. dumping syndrome
d. sichemic colitis
e. loss of vagal innervation to the ileum
f. mesenteric vein thrombosis

B

all else besides diarrhea is normal.

patchy white mucosa - films. he also had had abx

45

32 yo man comes to the physician for evaluation of infertility. 2 mo ago, he was found to have a low sperm count during a infertility workup. there is no family hx of infertility. exam shows no abnormalities except for dilated veins in the L scrotum. which of the following is the most likely mechanism of this pt's infertility?
a. decreased serum testerosterone concentration
b. idiopathic
c. increased scrotal temperature
d. increased serum corticosteroid cocentration
e. isolated luteinizing hormone deficiency

C

leading to death of spermatocytes

46

1 42 yo man who is HIV positive comes to the ED bc of a 6wk hx of modreate pain and intermittent bleeding from his rectum. he also has an enlarging mass in his rectum that he first noticed 6mo ago. he has not sought treatment for the pain until today. he has a 10y hx of perianal warts that were last treated 2y ago with topical podophyllin. his meds are triple drug antiretroviral therapy. he also takes ibuprofen for pain. vital signs are within normal limits. there is no inguinal lymphadenopathy. exam shows a 10cm, cauliflower-like mass involving the entire perineum. lab studies show:
Hgb 14
Leuk 16,000
segmented neutrophils 72%
bands 8%
eosinophils 4%
basophils 4%
lymphocytes 10%
monocytes 2%
platelet 215,000
CD4+ T lymphocyte count 3000 (normal >500)
serum
Na+ 142
K 4.3
Cl 98
HCO3 28
urea nitrogen 26
creatinine 0.9
which of the following is the most appropriate next step in management?
a. topical podophyllin therapy
b. administration of HPV vacicne
c. biopsy of the mass
d. chemotherapy
e. radiation therapy
f. local excision of the mass

C

mass in rectum --> likely anal cancer from HPV

1) dx = biopsy
2) tx = excision

47

77yo man comes to the physician b/c of a 3d history of N&V and midabdominal cramps. during the past 2d, she has vomited within 1h of eating solid food. her last BM 2d ago was normal. she usually has a BM every 1-2d. she has not had fever. she has T2DM. 10y ago, she underwent an open cholecystectomy for cholecystitis. current meds include intermediate-acting insulin, lisinopril and aspirin. she does not smoke or drink alcohol. her pulse is 100 and BP is 110/70. abd exam shows mild distension and tenderness without rebound or guarding. BS are increased and high pitched. lab studies show:

Hct 45%
leuk 15,000
serum
Na+ 147
K 3.5
Cl 112
HCO3 24
urea nitrogen 25
creatinine 1.2
an xray of the abdomen shows dilated lops of small bowel and air-fluid levels w/out a clear transition zone or free air. which of the following is the most likely diagnosis?
a. adhesions
b. diabetic neuropathy
c. inguinal hernia
d. mesenteric ischemia
e. sigmoid volvulus

A

SBO due to adhesions

48

67 yo woman has required mechanical ventilation to maintain adequate tissue oxygenation since she sustained a severe head injury 2w ago. serial xrays of the chest during hospitalization show findings consistent with acute respiratory distress syndrome. cultures of bronchial washings have grown numerous organisms for which she is receiving broad-spectrum abx therapy. a current xray of the chest shows a cavitary lesion in the RUL of the lung. which of the most likely diagnosis
A. aspergillosis
b. atelectasis
c. lung abscess
d. pneumatocele
e. tuberculosis

C. likely simply because of bacterial infections.

b/c high up

tuberculosis --> would have more risk factors
aspergillosis --> invades the cavity left by TB

49

47yo man comes to the physician b/c of a 52 hx of generalized itching and yellow skin. he underwent a total colectomy for ulcerative colitis 10y ago. he has Gilbert syndrome, oseoarthritis, and OCD. current meds include fluoxetine and daily ibuprofen. he has smoked 2 packs of cigarettes daily for 20y and drinks 3 alcoholic beverages daily. his temp is 98.6F, pulse is 90, BP 120/70. exam shows scleral icterus and jaundice. there are excoriation over the back. abd exam shows no abnormalities. lab studies show:
Hgb 13
Hct 39%
leuk 8000
serum
bili, total 12.2
direct 10
alkaline phosphatase 490
endoscopic retrograde cholangiopancreatography shows narrowing of the biliary ducts. which of the following is the strongest predisposing factor for this pt's condition?
a. alcohol consumption
b. cigarette smoking
c. gilbert syndrome
d. ibuprofen therapy
e. ulcerative colitis

E

risk factors for biliary duct stricture
- injury to the bile ducts during surgery
-Cancer of the bile duct, liver or pancreas
-Damage and scarring due to a gallstone in the bile duct
-Damage or scarring after gallbladder removal
-Pancreatitis
- Primary sclerosing cholangitis
-choledocholithiasis
- diverticulum, Crohn disease, hepatic artery aneurysm, cystic fibrosis with liver involvement, eosinophilic cholecystitis, and cholangitis.

50

10yo girl has had fatigue and pallor for 3w. 6w ago, she underwent aortic valve replacement iwth a mechanical prosthesis. she is receiving digoxin therapy. her temp is 98.6F, pulse is 115, RR 24. and BP is 100/60. a grade 2/6, systolic ejection murmur is heard along the L sternal border and a grade 2/6 descrescendo diastolic murmur is heard along the L sternal border to the cardiac apex. the liver and spleen are palpable. her Hgb conc is 4.6. a blood smear shows schistocytes. which of the following is the most appropriate next step in management?
a. discontinuation of digoxin therapy
b. transfusion of pRBCs
b. transfusion of whole blood
d. furosemide therapy
e. IV methylprednisolone therapy

B