Surgery NBME

Question 1

47 YOW comes in with a BMI of 67 , chafed skin on inner thighs, under breasts, twice requiring admission for abtx for panniculitis. Also has thick curdy vaginal discharge.Best long term management for this pt?

Answer 1

gastric bypass

Question 2

37 YOw bruising on arms and abdomen x3w. ibuprofen for HA. afebrile. PE:eccymoses over upper extremities and trunk. Lungs CTAB, Labs: norm Hb, 6.8k WBC, 45k plt, Bleeding time is high,PT normal. Bone marrow shows megakayocytes. Explanation for findings?

Answer 2

forumulation of antiplatelet antibodies (idiopathic thrombocytopenic purpura)

Question 3

87 YOM has sudden onset of SOB after emergent colon resection for obstructing Ca. T 100, HR 104, RR 32, BP 88/50. PE: JVD, crackles over midlungfields. NMRG.Liver span is 13. ECG shoews ST elevation. Mostlikely Dx?

Answer 3

Cardiogenic schock (MI)

Question 4

A 13 YOB has increasingly severe left thigh pain and knee pain and limp for 2 days. No Hx of trauma, BMI =20, Passive motion of hip elicits pain, Most likely Dx?

Answer 4

slipped capital femoral epiphysis

Question 5

12 hours after rod stabilization of a femoral fracture, 27 YO homeless ,an has sudden onset of combativeness and disorientation. HR 120, RR 24, BP 140/85. Exam shows petichiae over axila. Most likely cause?

Answer 5

fat embolism

Question 6

A previosuly healthy 47 YOM comes in with 2 weeks of progressive abd swelling. PE shows distention and shifting dullness, bowel sounds are normal. There is no tenderness, masses or organomegaly. Paracentesis: 50ml milky chylous fluid. Most likely cause?

Answer 6

Lymphoma

Question 7

52 YOW has back pain with hx of treatment for breast cancer 5 years ago. Decreases sensitivity below nipples. Hyperreflexive and decr strength with + babinski in legs, arms are normal. Where is the lesion?

Answer 7

Thoracic spinal cord: T10 is nipples

Question 8

Previously healthy *YOB has intermittent pain in the right anterior thigh for the past 3 w.activity level is high.mother notes he limps. 25th percentile ht and wt. Vitals normal. Atalgic gait. Abduction and internal rotation of the feur is limited. Dx?

Answer 8

avascular necrosis of the femoral head

Question 9

ASX 72 YOW comes in with decreased renal fx. Elevation in Cr over last 3 days. got 2nd renal transplant from 65 YO donor 1 m ago. Most likely explanation for decr renal fxx?

Answer 9

failure to surpress class II antigen recognition in the host ( rjection)

Question 10

For 4 hours, a 55 YOM has acute intermittent pain that begins in right flank and radiates to right testicle. Most likely finding on UA?

Answer 10

microscopic hematuria (30 /hpf in sediment)

Question 11

36 hours after admission for evaluation of diffuse abd pain, a 42 YOw is still obstipated. She has a 9yr history of scleroderma. Current temp is 100, P 110, RR22, BP 110/60. Abd is distended with colon dilation and WBC 14k. Next step?

Answer 11

laparotomy (toxic megacolon)

Question 12

The driver of an automobile is brought into ED after head on MVC at 50 mph. He has mid chest tenderness. All diagnostic tests are norma, except an XR of the chest which shows a widened mediatinum. NExt step?

Answer 12

aortic arch arteriogram ( I guess they are assuming CT is neg)

Question 13

A 68 YOM is broguht to the ED because of recurrent vomiting of bright red blood, and near syncope x 3 hours. He is afebrile, pulse 110, respirations are 16, BP 90/60 mm Hg and he has mild epigastric tenderness. Next step?

Answer 13

rapid infusion of 0.9% saline. Fluids, then you can figure out the bleeding source

Question 14

a 62 YOW comes to the physisics with 3 w of progressive SOB, mild pain in right chest, and nonproductive cough. 12 lb wt loss in last 3 m. She had br ca 6 years ago s/p mastectomy. She appears cyanotic and cachectic. friction rub is heard on the right.Dx?

Answer 14

malignant pleural effusion (lung mets)

Question 15

A 67 YOW, 8m bilateral calf pain with walking. initially only after long walk, now only after 300 ft. pain is relieved with rest. She has hypertension and hypercholesterol. She is on atherscler drugs and smokes. pulses decr bil.elevated BUN. Next step?

Answer 15

ABI is first before duplex. arteriogram is a preop test

Question 16

Following diganosis of ectopic pregnancy in a 25 YOW, an abdominal operation is performed. Exam of the abdomen shows a normal uterine pregnancy but an inflamed appendix. An appy is performed despite the fact the consented only ectopic removal. Is that ok?

Answer 16

inappropriate because the patient had not been previously infomred of the risks of an appendectomy

Question 17

A 67 YOW with ESRD, aterosclerodic CAD, T2DM undergoes formation of an AVF in left forearm under ax block. 24 hours later. SHe has SOB, , tacycardia, RR 38 with JVD. S3 and S4 are present. Most likely Dx?

Answer 17

high output congestive heart failure ( atelectasis just doesnt cover enoguh)

Question 18

4 days after CABG, a hospitalized 47 YOM has the sudden onset of severe pain in his left great toe. He was admitted to the hospital 10 days ago for chest pain with exertion, and has been getting aspirin and heparin. CBC: 12.2/27%/8. PT and PTT normal. Dx?

Answer 18

heparin induced thrombocytopenia

Question 19

a 27 YOw, HIV +, 6 m of nonbloody diarrhea now with bloody diarrhea. She has a high fever, and a rigid abdomen. She ends up with an ileostomy for a perforated cecum and the path report shows nuclear inclusion bodeis in colon. Most likely organism?

Answer 19

CMV

Question 20

12 hours after pancreatic abscess drainage, a 52 YOM with alcoholism becomes bradycardic and hypoxic and requires intubation. His FiO2 is 100, with a tidal volume of 1000 and PEEP of 2.5. He still has acidosis with O2 = 48 and CO2 of 40. Next step?

Answer 20

Increase PEEP

Question 21

a 60 YOW has a sigmoid resection and colostomy for diverticulitis with rupture. That night she becomes confused, oliguric and febrile. the area around the colostomy is indurated and crepitant. Most likely causal organism?

Answer 21

Clostridium perfringens ( gas gangrene)

Question 22

A 45 YOm has daily temps to 100.9 and 15 lb wt loss over 3 m. he has pallor, normal vitals and normal CV and P exams except a low pitched disatolic rumble at the apex that dissappears when he lies on his R side. Hb is 10. Most liekly dx?

Answer 22

Atrial myxoma ( cancer picture with diastolic rumble)

Question 23

52 YOW, 2m R foot swelling w/o fever or pain. No trauma history, 25 y histroy of T1 DM. Pe swelling on dorsal foot and med and lat ankles. The is small effusion over ankle. Decr sensation below ankles. XR shows osteopenia and disorganized foot. Cause?

Answer 23

lack of normal joint sensation (Charcot foot)

Question 24

62 YOM w hemoptysis for 1w.5 y hx of daily productive cough, 20 y of hypertension, 88 yr pack history. Ca concentration is 11 (high) with coin lesion in lung. Most likely dx?

Answer 24

PTH secreting tumor is squamous cell Ca

Question 25

Previously healthy 37 YOW has left groin and thigh pain for 3 d. Exam shows a non reducible mass in the groin. Operative exploration shows a hernia sac medial to the femoral vein. Dx?

Answer 25

femoral hernia

Question 26

A 62 YOW has difficulty swallowing liquidsand solid over the past month. 10 yr hx of dyspepsia, substernal burning and occasional n/v. EG shows GE junction stricture and baretts esophagus. Dx?

Answer 26

sliding hiatal hernia (much more common than paraesophageal)

Question 27

24 hr after romoval of parathyroid adenoma for primary hyperparathyroidism, a 42 YOW has perioral numbness and tingling. He serum Ca is 6.8 (low). Normal albumin levels. Next step?

Answer 27

oral vitamin D (make sure she can absorb Ca)

Question 28

A 30 YOM has painless, progressive enlargement of the left testicle for 8m. There is no nodule and the scrotum cant be transluminated, Most likely dx?

Answer 28

testicular tumor

Question 29

A 37 YOW comes w 3m of headaches. The headaches now occur daily and are relieved by aspirin. Her pulse is 76, RR 12, BP 158/95. Surum Na: 140. Cl 100. K 2.6 (low) Ibcarb 34, BUN 9. Dx?

Answer 29

aldosteronoma

Question 30

A 22 YOM is brought to the ED after a GSW to the right calf. Swelling and much pain with passive range of motion. Next step?

Answer 30

surgical decompression ( compartment syndrome)

Question 31

5 d after emergent sigmoid colectomy for perforated diverticulum , a 57 YOM has a temp of 104. Lots of oxygen therpay and now has decr breath sounds at a lung base. Sputum shows many leukocytes with G - rods. Most likely organism?

Answer 31

Psudomonas ( hospital acquied pneumonia)

Question 32

Before elective cholecystectomy, a 68 YOM with chronic renal failure has multiple electrolyte disturbances on Chemistry studies. Next step?

Answer 32

initiate dialysis before surgery

Question 33

A 77 YOM has a sever nosebleed not stopped by anterior packing and he spits clots out side his mouth. Most likely source of the bleed?

Answer 33

sphenopalatine artery (MCC posterior nosebleeds

Question 34

67 YO postal worker with a 5 min episode of weakness and numbness in his hand. Ni sequelae and has smoked 1ppd x 45 years. Carotid bruits are heard bilaterally. ECG shows normal sinus rhythym with mulitple premature atrial contraction.s Next step?

Answer 34

carotid duplex ultrasound

Question 35

A 42 YO is admitted to the hospital with a piece of meat lodged in the lower esophagus. With difficulty is it removed with an endoscope. That evening the pt has a temp of 101. Most apporopriate dx study?

Answer 35

water soluble contrast upper GI study( concern for esophageal rupture after endoscopy)

Question 36

A 25 YOW has 2m of a pigmented lesion under her ring finger. A photo of the lesion is shown (ugly, raised, black, irrrgular). Most likely Dx?

Answer 36

melanoma

Question 37

An 18 YOW comes to the physican for advice about screenin with a fam hx of colon ca. She has the APC gene.2 polyps are seen on colonoscopy. Best long term treatment?

Answer 37

prctocolectomy with ileoanal reservoir. Almost certainly will get Ca at some point

Question 38

Routine mammorgraphy on a 52 YOw shows six stippled microcalcification in a cluster in the upper outer quadrant of the left creast, not presen t 1 y ago. No lump. Next step?

Answer 38

needle localized open biopsy (not FNa)

Question 39

A 1 yr old boy has persistent cough, loose stools and facial rash for 2 m. 4lb wt loss. 50th percentile for ht and 20th for wt. Temp is 37, pulse is 100 resp is 18. Ct shows tumor in panceas. Most likely Dx?

Answer 39

VIPoma. especially with flushing. arises from non beta islet cells of pancreas

Question 40

A hospitalized 72 YOM has not voided since catheter removal 8h ago. He had a sigmoid colectomy for recurrent diverticulitis 2 d ago. He is currently receiving 5% dextrose and 0.45% saline. His temp is 100.8. Most likely cause of inability to void?

Answer 40

bladder outflow obstruction

Question 41

A 6YOB comes to ED 30 mins after MVC. On arrival he is awake and alert. There is an obvious scalp laceration over the left frontoparietal area. There are no neurologic deficits. A CT scan of the head shows a liner temporal skull fracture. Most likely CT?

Answer 41

epidural hematoma

Question 42

52 YOW with well controlled T2DM has 34 hr of abdominal pain. Vomited 3 times in ED. BMI is 38, Temp is 103.1, Pulse is 120, RR 28. Exam shows scleral icterus. She has high slk phos and mild LFTs. Dx?

Answer 42

ascending cholangitis

Question 43

52 YO nulligravid woman comes to physician due to 2 m of progressive abdominal swelling and decr appetitie. She has astma treated with steroidsand T2DM. Exam shows a fluid wave. An Ct shows mulple levic masses and omental thickening. Most likely dx?

Answer 43

ovarian adenocarcinoma

Question 44

18 YOM has pain in the R hip and flank after an autoaccident. He is stable. Exam shows eccymosis over the iliac crest, and right flank abraisions. urinalysis shows gross blood. Ct cervical spine is normal. next step?

Answer 44

Ct abdomen (but is might be slective renal angiography)

Question 45

A 42 YOW comes in with sever ranghe hypertension and a bruit with hyperplasia of the right renal artery. What is the mech of the patient HTN?

Answer 45

increased serum aldosterone ( not renin as that acts locally)

Question 46

A 46 YOM with chronic alcoholism comes to the ED w/ 12 hr of n/v and mid abdominal pain radiating toback.pulse is 120 , respirations are 20 and BP is 110/60. Abdominal exam shows tenderness to palpation upper quadrants. Most important thing to give?

Answer 46

Lactated ringers ( not any of the med choices, needs fluids)

Question 47

A 24 YOM is brought to ED with burns on 50% of body, He weighs 75 kg. clearly needs fluids. How much in next 24 hours?

Answer 47

15 L of lactated ringers ( 4ml/kg/% burn)

Question 48

A 47 YOM comes with 2 d of fever and severe rectal pain. Has type 2 DM treated w metformin. Temp is 102.4 Exam shows mass at anal verge on left. Hb is 9.6. WBC is 18 k. Next step?

Answer 48

I and D this is a perirectal abscess

Question 49

A 47 yOM comes to physician for eval prior to an abdominal perineal resection fro rectal Ca. In last 6 y he has had left ankle swelling. Duplex shows chrinic occlusion of left iliac and femoal veins. Most apporpiatemanagemnt for venus disease?

Answer 49

low does heparin rpophylaxis ( these are stable DVTs), just need to prevent new ones

Question 50

A 23 YOW has left shoulder pain for 12 h after falling down stair. She has diffuse abd tenderss, an Hb f 10, and WBC of 11k. Most likely Dx?

Answer 50

ruptured spleen

Question 51

37 YOM is brought to ED 30 min after MVC. Abd pain on arrival. Pulse 84, , RR 18, BP 110/82. Abd exam shows diffuse tenderness.Bowel sounds decreased. supine CXR shows bowel loops in the thorax and no left costophrenic angle. Dx?

Answer 51

ruptured diaphragm

Question 52

68 YOM has recurrent stridor x 2 hours. 2 y/a he underwent radiation for laryngeal cancer. Exam shows a bulky tumor involving the upper and middle neck bilaterally. ABGs on 100% O2 shows: low pH, CO2 52, O2 55, HCO3 17. Neck step?

Answer 52

tracheostomy ( retention of CO2 is impendings respiratory collapse)

Question 53

87 YOM has 3 episodes of pneumonia over last 6m, 1 requiring admission. Increasingly bad breath over this time period. CBC, electrolytes, LFTs all normal. CXR shows scarring of right lung base. dx?

Answer 53

Pharyngoesophageal diverticulum (Zenker's)

Question 54

57 YOM comes with 2 m of difficulty swallowing. Food stukc when swallows and he has drank more water to deal with this. Moderate dysphagia. Extensive smoking and drinking hx. CXR normal. next step?

Answer 54

EGD ( suspect SCCa)

Question 55

8 YOG has sensation that something is in her left eye for 1d with photophobia and decreased vision for 6h. Parents notice child frequently rubs eye. Exam shows tearing with erythema. Small vesicle with erythematous base on conjunctiva. Dx?

Answer 55

herpes simplex conjunctivitis

Question 56

66 YOW has acute vision loss in R eye x 1 h. No pain or previous hx. T2DM, HTN. Pupil does not react to direct light but is consensual with conlat light. Movement is intact. PE: pallor of disc, macular edema, thin arterioles, thickening of retinal v. Dx?

Answer 56

central retinal artery occlusion

Question 57

While recieving radiation for optic glioma in right paratemporal area , 62 YOM has sudden onset of severe abd pain. Steroids for edema, tenderness in all 4 quadrants. XR shows free air under diaphragm. Next step?

Answer 57

laparotomy for ruptured viscus

Question 58

37 YOM comes with inability to conceive for 3 y. Wife had kids no problems in previous marrige. Pt is healthy and well developed. irregular, ropy mass in upper left hemiscrotum. Results of semen analysis are normal. Most likely cause of infertility?

Answer 58

varicocele

Question 59

An 80 YOW with atherosclerosis and chronic Afib has severe abd pain x 4h. Exam shows mild abd pain with absent bowel sounds. Occult blood test is +.WBC: 28 k. ABG: ph 7.18, CO2 35, Po2 62. AXR shows non specific gas pattern. Next step?

Answer 59

exploratory celiotomy (likely mesenteric ischemia)

Question 60

healthy 19 YOF brought to ED with 4 h severe abd pain . Sx began 3w ago as intermittent colicky pain. Exam 1 w ago showed 5 cm cyst. Abd exam shows tenderness with rebound and guarding in RLQ, Palpable 10 cm that is complex, cystic on u/s. Next step?

Answer 60

exploratory laparoscopy or lapartomy ( point is this is ovarian torsion and IT IS NOT CT DRAINGAGE)

Question 61

35 YOW with chronic renal failure sustain compression fracture of T12. Ca 7, Ph 11, Cr 6, Alk Phos 600. Most likely cause of fracture?

Answer 61

secondary hyperparathyroidism ( renal failure)

Question 62

57 YOW in ED w 1 day of fever, chills weakness. Had spleen out for ITP 10 y ago. Got blood and appropriate Immunizations at that time. Temp 102.8. P 100, RR 20, BP 80/50. crackles at right lung base. CXr shows signs of pneumonia. Best abtx?

Answer 62

vancomycin and ceftriaxone

Question 63

52 YOW comes to physician because of 3 episodes of bright red blood per rectum in pat 2 w. 10 y hypercholesterolemai,. Stable vitals. CV is normal. Abdomen is soft and nontender, no masses are palpated. rectal exam shows internal hemmorids. Next step?

Answer 63

colonoscopy ( must r/o cancer)

Question 64

Previously healthy 42 YOM comes to physician because of 2 days of right knee pain. The symptoms began when he was getting up from a low chair. His temp is. Exam of knee shows tenderness to palpation along medial joint line and joint effusion. Dx?

Answer 64

torn meniscus

Question 65

76 YOM sustained a midshaft femur fracture during MVC. In ED circumference of right thigh is 2x left thigh. Pulse is 120, RR 16, BP 80/60.Large boe IV catherter is inserted. What finding best indicates adequate resuscitation in this pt?

Answer 65

urine output 30-40mL

Question 66

72 YOW brought in 48h after Son found her down . On arrival she has severe pain of hip and thigh. Pulse 126, RR 30, BP 80/40. There is marked external roation and shortening of the RLE. CV exam normal. Most likely cause for hemodynaic instability?

Answer 66

hypovolemia

Question 67

72 YOM is extubated and taken to recovery after a 4 hr operation for a bleeding duodenal . ABGs show: pH 7.24, PCO2 85, PO2 60. Next step in management?

Answer 67

reintubation and mechanical ventilation

Question 68

A 75 YOM is scheduled to undergo elective repair of AAA. Hx of HTN. PE: 6cm palpable AAA. A ECG is normal. What study is most accurate to predict his risk for a perioperative MI?

Answer 68

radionucleotide scan with thalium and dipyramidole

Question 69

82 YOW comes to physician with 4m of right sided HA, joint pain, malaise. Exam shows tenderness over right temporal a. Both temporal aa are palpable. ESR 87 (H). Next step?

Answer 69

predisone and temporal artery biopsy immediately (Giant cell arteritis, shoot first, ask questions later)

Question 70

42 YOW comes with 10 y of intermittent palpitation. Sx last a few mins and have no CP, SOB, or dizziness. Worse with stress and caffeine. No problems with exercise. CV largely normal. There is a midsystolic click heard best at the apex. Most likely dx?

Answer 70

hyperthyroidism

Question 71

42 YOW comes with 2 d of rust colored discharge in her bra. She has no hx of serious illness and takes no meds. No fhx of br ca. Stable vitals. Exam of breast shows no abnormalities, no fluid can be expressed from nipples. Most likely dx?

Answer 71

intraductal papilloma

Question 72

27 YOM comes to ED 40min after MVC. wearing a helmet. On arrival he is a and o x3. Stable vitals. Abd exam shows mild distention. Pelvis is unstable. Blood at urethral meatus. On DRE the prostate is not palpable. Next step to eval the urethral bleed?

Answer 72

retrograde urethrography

Question 73

An othersie healthy 30 YOM has an acneform infection of left axila for 2w. Previous infection of same region and groin area. Exam shows acute inflammatory changes woth purulent drainage from small sinus openings.Infection involves what skin structures?

Answer 73

apocrine glands (axilla and groin, this is hidradenitis suprativa), eccrine are the sweat glands that are everywhere

Question 74

After MVC, 23 YOM is brought to ED. He was unrestrained driver. BP is 150/90.He has retrosternal and interscap CP, dyspnea, hoarseness. XR shows fracture of sternum and left first rib, widening of superior mediatiunum, caudal displacement of bronch. Dx?

Answer 74

rupture of thoracic aorta

Question 75

Over past 6w, 30 YOW has increasing nervousness, sweating, insomnia. 10 lb wt loss .lump on right side of thyroid. Pulse 110, BP 130/50, 4x4 cm mass on the R side of the thyroid gland, no other thyroid tissue. Thyroid uptake only in area of nodule. Dx?

Answer 75

toxic thyroid adenoma

Question 76

42 YOW comes with 1w yellow eyes, nausea, R sided abdominal cramps. Had a lap choley 2m ago. Intraop cholangiogram not performed. no meds. Vitals normal. CVP exam normal. Abd exam shows RUQ tenderness w/ no distention or peroneal signs. Cause of jaundice?

Answer 76

choledocholithiasis (cystic duct stone not detected w/o cholangiogram)

Question 77

2 d S/P carotid endarterectomy, 62 YOM with slurred speech, weakness in R arm,leg for 1 h. He had no neuro findings at d/c. BP 170/95. Incision is clean dry and intact. No abnormalities on carotid duplex. CT head shows intraparenchymal hemorrhage. Cause?

Answer 77

hypertension

Question 78

56 YOW 3m of excessive sweating nervousness, tremors, tachycardia, hunger. Sx worsenby fasting. Selective angiography shows 1 cm tumor in tail of pancreas. Dx?

Answer 78

insulinoma

Question 79

presentaation of glucagonoma?

Answer 79

necrotizing migratory erythema, esp on abdomen, buttocks, perineum

Question 80

presentation of vipoma?

Answer 80

watery diarrhea, hypokalemia, dehydration, weakness

Question 81

presentation of somatostainoma?

Answer 81

mild DM, steatorrhea, galstones

Question 82

presentation of insulinoma?

Answer 82

neuroglycopenic sx: headache, lethargy, diplopia, and blurred vision, particularly with exercise or fasting. Severe hypoglycemia

Question 83

sx of carcinoid?

Answer 83

Flushing Diarrhea Wheezing Abdominal cramping Peripheral edema

Question 84

During exlap, a 4x7 cm cystic lesion in the tail of the pancreas is found in a 46 YOW. Biopsy of the wall cyst shows a cystadenoma. Managemnt?

Answer 84

distal pancreatectomy

Question 85

27 YOW brought to ED 30 mins after deep laceration on her back. What anaesthetic would provide the longest anaesthesia?

Answer 85

bupivacaine

Question 86

42 YOF 2 days of right upper abd pain and itching. 3 episodes of in last few months. No fever or vomiting. Exam shows scleral icterus. Mass is palpated in RUW. U/s shows no gallstones. CT shows 5cm cystic structure medial to gallbladder. Next step?

Answer 86

RUQ palpable mass, jaundic = choledochal cyst. tx is ruen en Y cystojejunostomy

Question 87

18 YOM c omes to ED 10 mins after stab wound to right chest. He is SOB. P 120, BP 70/40, Breath sounds absenmt on right. Trachea is midline, neck veins are flat. most likely dx?

Answer 87

massive hemothorax

Question 88

42 YOM had 4x4 cm painless ulcer over right medial malleolus x 6m. He has a histroy of DVT that occured during a femur fracture 30 years ago. Pedal pulses are plapable. 2+ edema of RLE. LLE is normal. Most liekly cause of ulcer?

Answer 88

venous valvular insudffioceicny

Question 89

67 YOM admitted for 6w of n/v.decreased appetitie resulting in 16 kg wt loss. has distal gastrectomv for peptic ulcer 35y/a. He is cachectic with severe temporal wasting. Biopsy of a stomach mass is adenoca. What is the cause of metabolic abnormalities?

Answer 89

increased serum tumor necrosis factor concentration ( causes cachexia)

Question 90

15 YOG has progressive SOB for 2 hours. she had an appendectomy yesterday, not out of bed since. @ L saline over last 24 hours. T 99.8, P 90, RR 22. BP 105/63. No jvd, decr br sounds. dullness in left lund field. 3/6 holosystolic murmur. Mech of SOB?

Answer 90

collapse of right middle lobe of lung from decreased inspiratory effort. POD1= atelectasis

Question 91

Previously healthy 27 YOM comes t with 3m of intermittent abd pain and diarrhea.. 10lb wt loss. T 100.4, P72, BP 114/82. Abd exam shows RLQ tenderness. Hct 31, WBC 12k, Barium enema shows massive colonic dilation. Dx?

Answer 91

crohns disease

Question 92

Immediate after birth of a 30 w infant, a harsh to and fro murmur consistent with PDA is heard. Indomethacin is given, and murmur stops. Explanation of effect?

Answer 92

cyclooxygenase inhibition with increased norepinephrine release

Question 93

28 YOW recently gained 80 lbs, which she atributes to stress. BMI is 40. BP 130/85. He obesity puts her at greatest risk for developing?

Answer 93

cholycystitis

Question 94

9 days after a pylorus sparing pancreatoduodenectomy for adenocarcinoma of the pancreas, a 62 YOM has tons of drainage from NG tube.high amalse in fluid. Serum electrolyes show low bicarb, and ABG shows met acidosis. What is the mech of these findings?

Answer 94

``` GI loss (lose bicarb -> metabolic acidosis) nasogastric suction ( metabolic alkalosis) ```

Question 95

62 YOM comes 5m after noticing a mass in right side of neck. Hx of enlarged thymus treated with radiation duroing infancy. Exam shows 4 cm mass that moves with swallowing. TSH is normal. FNA shows follicular neoplasm. Next step?

Answer 95

thyridectomy ( high suspicion for cancer in this gentleman)

Question 96

47 YOM has pearly surface papule on upper lip for 18m. Exam shows some telangiectasias. Pic shown on upper lip. Dx?

Answer 96

basal cell carcinoma

Question 97

42 YOM in ED after MVC where he briefly lost consciousness nd has brusing over abdomen in seatbelt pattern. 3 days later he vomits billious fluid positive for blood. He is afebrile, Abdomen is tympanic CBC lfts are normal. gastric bubble on XR. Dx?

Answer 97

duodenal hematoma

Question 98

67 YOW of dyspnea, myalgias anf flank pain during transfusionof RBCs immediately after colon resection for colon ca. Intraopperative blood loss 1200. Blood in surgical drain, urine is dark. Post op hct is 21. Next step to make dx?

Answer 98

repeat type and cross match of blood

Question 99

Previously healthy 15 YOB sudden onset of anterior right sided CP. temp is 36.9, pulse is 90, respirations are 18, BP 110/70, XR shows no problems. XR shows samll right pneumothorax. Next step?

Answer 99

observation

Question 100

24 YOW laparoscopy for eval of chronic pelvic pain shceduled. before operation she gets narcotics, freaks out and doesnt want operation. what do you do?

Answer 100

cancel operation

Question 101

67 YOM 1w of increasingly severe abd pain, fever, vomiting decr appetite.2 y/a he was admitted for similar porblme. Intermitten LLQ abd pain for 5 y. T 103, pulse 105, respirations 22, BP 150/90. WBC 21k. XRA non specific. Next step?

Answer 101

CT abdomen pelvis

Question 102

37 YOW woman with carpal tunnel. What study best helps confirm dx?

Answer 102

nerve conduction studies

Question 103

77 resident of SNF with 2d fever and vomting for 2 d. Alert but unable to give a history. Aks for drink of water. T101.5, BP 110/60, Exam shows distened abdomen with high pitched bowel sounds. Supine XRA shows multipl dilated lops of small bowel. Dx?

Answer 103

emphesematous cholycystitis i think

Question 104

Person comes in from trauma with GCS 5, next step?

Answer 104

intubate and ventilate

Question 105

52YOW w/ GBM does not want surgery. She understand an op is the only effective treatment of her tumor, and that without an operation she will die. She is afraid of the adverse effect. she lapses into a coma, husband wants surgery. important consideration?

Answer 105

her previous expressed wishes trump his new ones

Question 106

. Ten years ago, a 60YOW s/p aortic valve replacement with a pig valve. now has dysnea on exertion. Examination and x-ray of the chest show evidence of congestive heart failure. Which of the following is the most likely explanation for these findings?

Answer 106

degeneration of valve

Question 107

42 YOW in ED with 2 d of intermittent lower abd pain, n/v. No stoll or flatus in this time. High pitched bowel sounds. Had hysterectomy 2 y ago for leiomyota uteri. Most likely mech of sx?

Answer 107

adhesions= proliferation of fibroblasts forming scar tissue in area of operation

Question 108

4YOBis 4-month history of frequent falls. his calves increasing in size. PE: enlarged muscles of the calves and lumbar lordosis. Sensation is intact. He has difficulty arising from a supine position. Dx?

Answer 108

Duchenne muscular dstrophy

Question 109

18 YOM comes with stab wound unresponsive. Pulse is 130, RR 8, and shallow, BP 60/40/ Intubated and given fluids, pulse is now 130, BP 70/40. Exam shows 2cm wound at left 6th ICS in midclavicular line. + JVD. trachea midline. Inaudible heart sounds. Dx?

Answer 109

pericardual tamponade

Question 110

70 YOM in hospital for elective CABG. On day of operation carotid bruit is heard. Next step in Dx?

Answer 110

Duplex of neck

Question 111

Ten days after admission to the hospital because of acute pancreatitis, a 56-year-old man with alcoholism develops chills and temperatures to 39.4°C (103°F). Examination shows a tender abdomen with hypoactive bowel sounds. most likely Dx?

Answer 111

pancreatic abscess

Question 112

24 YOW nulligravid, has syncopal episode. sever cramps in lower abdomen over 6h. vaginal bleeding for 2d. She is diaphoretic. Her temp is 37 , P 130, RR 26, BP 80/60. PE: blood in vagina, diffuse abd tenderness, pain with cervical motion. next step?

Answer 112

Give Fluids

Question 113

A 52 YOM, 5m pain in left knee exacerbated by long distance walking. Has HTN controlled. Exam of knee shows mild crepitus with flexion and extension, no effusion or warmth. XR of knee shows narrowing L joint space. BMI is 29. What step might imrpove Sx?

Answer 113

weight loss program

Question 114

A previously healthy 32 YOM with 3d of pain and swelling of right knee. 2 w ago he injured his right knee during touch FB. HIV test negative. homosexual. T 101.5, p 100, BP 120/60. Exam shows warmth erythema, joint effusion. XR confirms. Next step?

Answer 114

arthrocentesis

Question 115

A 57 YOW with inoperable SmCCa of lung has lethargy, loss of appetite and nausea. Radiation 2.5 y ago. Stable angina pectoris. P is 68, RR 16, BP 118/72. No JVD, skin turgor normal. Labs show low Na, low urine Osm. Most likely explanation?

Answer 115

SIADH from tumor

Question 116

A 8lb 6 oz female newborn has a plapable clunk of her hip when it is abducted, flexed, and lifted forward. Posterior pressure on flexed hip elicits a similar clunk. Most likely Dx?

Answer 116

congenital hip displasia

Question 117

A previously helath 72 YOM comes to physician with decreased urinary output for 2d. No output in 8h. Exam shows suprapubic fullness and enlarged prostate. Serum urea concentration is 88, serum CR is 3.5. Next step?

Answer 117

bladder catherization

Question 118

3 YOB 2w of persistent cough and wheezing. Sx occur when he laughs . 3 w ago he had an episode of chocking. T 99.7, p 90, RR 20, BP 70/45. Expiratory wheezes are heard on right with normal airflow. Sx dont improves with albuterol. Dx?

Answer 118

foreign body aspiration

Question 119

2 h after undergoing a right hepatic lobectomy, a 59 YOW has a distended abdomen. Her pulse is 120, BP 100/60. Most likely cause of these findings?

Answer 119

poor mechanical hemostasis

Question 120

3 d after a lap choly, 42 YOW has hematomas at all surgical siters. She was treated for DVTs 3 y/a but not taking any meds. Prior to op labs were normal. she got heparin and ACDs for operation. Now has isolated low platelets. Dx?

Answer 120

heparin induced thrombocytopenia

Question 121

2 days after surgical repiar of AAA, 67 YOM requires increasing vent/intubated and is being mech vented at FiO2 0.6 and PEEP 7.5 . He is diaphoretic. BP 90/60, +JVD. No breath sounds on left, trachea shifted to right. Pulse ox 82. Next step?

Answer 121

needle aspiration of left side of chest

Question 122

A previously healthy 62 YOM comes with 2m of cough. He has smoked 2 ;acks of cigarettes for 40 y. Exam WNL. CXR shows 2.5 cm non calcified pulm nodule. CT scan confirms. XR 1 y/a has nothing. Next step?

Answer 122

bronchoscopy iwth transbronchial biopsy

Question 123

What is the mech of diabetes type 2?

Answer 123

abnormal insulin secretion with insulin resistance

Question 124

3 YOG with left leg pain after a fall. Hx of fractures after minor trauma. Has blue sclerae. Obvious deformity in left thigh. XR shows new fracture of left femur and evidence of previous fracture. Most likely cause of findings?

Answer 124

defective type 1 collagen