Surgery 8 - Q's PDF

1. O ne day after undergoing uncomplicated splenectomy for management of injuries sustained in a motor vehicle collision, a 43-ye ar-old man has the sudden onset of shortness of bre ath while receiving a transfusion of packed red blood cells. H e also has moderate pain at the intravenous site and...

1. O ne day after undergoing uncomplicated splenectomy for management of injuries sustained in a motor vehicle collision, a 43-ye ar-old man has the sudden onset of shortness of bre ath while receiving a transfusion of packed red blood cells. H e also has moderate pain at the intravenous site and moderate back pain. H e has no other history of serious illness. His medications are hydromorphone and subcutaneous heparin. H e is diaphoretic. His temperature is 37.2°C (99°F), pulse is 90/min, respirations are 24/min, and blood pressure is 120/60 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 97%. E xamination of the skin shows no abnormalities. Bre ath sounds are cle ar bilaterally; no whe e z es or rhonchi are he ard. Abdominal examination shows a well-he aling surgical incision. Which of the following is the most likely mechanism of this patient's condition? < CO Q Q ) E ndotoxin rele ase from infused bacteria oooo ) Immune response to transfused plasma proteins ) Intra-abdominal hemorrhage ) Preformed antibodies to transfused red blood cells 2. A 62-ye ar-old woman has shortness of bre ath immediately after beginning transfusion of fresh froz en plasma and 2 units of packed red blood cells to manage acute lower gastrointestinal ble eding. She has be en hospitaliz ed for 24 hours. Five ye ars ago, she underwent mechanical valve replacement for tre atment of aortic stenosis. She has no other history of serious illness. H er only outpatient medications are warfarin and lisinopril, which have be en discontinued since admission. H er temperature is 37.8°C (100°F), pulse is 110/min and regular, respirations are 28/min, and blood pressure is 100/60 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 82%. Crackles are he ard from the lung bases to the midlung fields. There is cyanosis of the upper and lower extremities. A urinary catheter is draining cle ar urine. A chest x-ray is pending. Which of the following is the most likely diagnosis? ) Acute hemolytic transfusion re action ) Pneumonia ooooo m o o co > ) Pulmonary embolism ) S epsis ) Transfusion-related acute lung injury 3. An 18-ye ar-old man is brought to the emergency department 30 minutes after sustaining injuries to the he ad, chest, and abdomen when he was thrown from his motorcycle. E n route to the hospital, he received 2 L of crystalloid. O n arrival, his temperature is 35.9°C (96.6°F), pulse is 110/min, and blood pressure is 115/90 mm Hg. Glasgow C oma score is 11. E xamination shows multiple ecchymoses and abrasions. His hematocrit is 29%. Two units of packed red blood cells are administered. A C T scan of the he ad shows diffuse axonal injuries, and an x-ray of the chest shows a pulmonary contusion without pneumothorax. A C T scan of the abdomen is shown. Which of the following is the most appropriate next step in management of his abdominal injuries? A) S erial examinations in the intensive care unit B) Angiography C) Ultrasonography D) R epe at C T scan in 24 hours E) Diagnostic peritone al lavage F) Laparotomy 4. A 20-ye ar-old man is brought to the emergency department 50 minutes after being involved in a motor vehicle collision. H e was an unrestrained passenger. O n arrival, he is alert. H e says he has neck pain and numbness in both legs; he cannot move his legs. His temperature is 37.2°C (99°F), pulse is 70/min, respirations are 20/min and unlabored, and blood pressure is 80/50 mm Hg. E xamination shows a patent airway. There is no jugular venous distention. There are multiple contusions over the trunk and a bony deformity of the right calf. The cervical spine is tender. S ensation to touch is absent below the midchest. Abdominal ultrasonography for trauma (F A S T) shows no fre e fluid in the pelvis. X-rays of the cervical spine show subluxation of C 7 on T1. X-rays of the chest and pelvis show no abnormalities. An x-ray of the right lower extremity shows comminuted fractures of the tibia and fibula. C T scans of the abdomen and pelvis show a small contained hematoma. After infusion of 2 L of crystalloid solution, the patient's blood pressure does not improve. Which of the following is the most likely cause of this patient's persistent hypotension? < CO O O L ) Aortic disruption ooooo ) Ble eding from the fractures ) Closed he ad injury ) H epatic injury ) Spinal cord injury  5. An 18-ye ar-old woman comes to the emergency department because of a 3-we ek history of he adache. The he adache has worsened today and is now accompanied by mildly blurred vision. H er mother has a history of migraines. The patient is 163 cm (5 ft 4 in) tall and weighs 91 kg (200 lb); BMI is 34 kg/m 2. H er temperature is 37°C (98.6°F), pulse is 76/min, respirations are 16/min, and blood pressure is 140/80 mm Hg. F unduscopic examination shows bilateral papilledema. The remainder of the examination shows no abnormalities. A C T scan of the he ad without contrast shows no abnormalities. Which of the following is the most appropriate next step in management? < C O O Q LU ) O ptical coherence tomography ooooo ) Intravenous administration of methylprednisolone ) Intravenous administration of nifedipine ) Visual evoked potentials ) Lumbar puncture 6. A 76-ye ar-old man comes to the physician because of a lesion on his nose that has be en gradually incre asing in siz e during the past 5 ye ars. H e has hypercholesterolemia tre ated with atorvastatin. E xamination shows no lymphadenopathy. There is a 1-cm lesion on the nose. A photograph is shown. Which of the following is the most likely diagnosis? A) Actinic keratosis B) B asal cell carcinoma C) H emangioma D) Melanoma E) Squamous cell carcinoma  7. A 65-ye ar-old man comes to the office because of a 6-month history of an enlarging lesion on his left fore arm. The lesion is not painful or itchy; it does not ble ed and has not changed shape. H e has no history of serious illness and takes no medications. Vital signs are within normal limits. A photograph of the lesion is shown. Which of the following is the most appropriate next step in this patient’s management? ) E xcision with 1-cm margins ) E xcision with 2-cm margins oooooo > ) E xcision with 5-cm margins cd ) S entinel node biopsy and excision with 1-cm margins Ti m o o ) S entinel node biopsy and excision with 2-cm margins ) S entinel node biopsy and excision with 5-cm margins  8. A 47-ye ar-old man is brought to the emergency department by paramedics after rescue workers found him on a snow-covered mountain. At the scene, he was alert and oriented but shivering and unable to walk without assistance. H e said he had become lost while cross-country skiing. O n arrival, he is shivering and reports that his toes are numb. His temperature is 36°C (96.8°F), pulse is 60/min, respirations are 16/min, and blood pressure is 120/65 mm Hg. E xamination shows pale toes bilaterally. Blisters are noted on the 4th and 5th toes bilaterally. S ensation to touch is absent over the toes bilaterally. P edal pulses are faintly palpable in both fe et. Ankle brachial indices are 0.85 bilaterally (N>1). T etanus toxoid is administered, and the fe et are immersed in a 104°F water bath for 20 minutes. During immersion, his fe et become painful. In addition to administration of acetaminophen, which of the following is the most appropriate next step in management? < C O O Q LU ) Hospital admission for observation ooooo ) Application of nitroglycerin ointment to the fe et ) Intravenous infusion of unfractionated heparin ) Immediate arteriography of the lower extremities ) Amputation of all toes with blisters at 24 hours post injury  9. An 87-ye ar-old man is transferred to the hospital from a skilled nursing care facility 6 hours after staff noticed black skin on his right leg. H e has had thre e strokes during the past 2 ye ars. H e has hypertension and type 2 diabetes mellitus. C urrent medications include metoprolol, glipizide, and clopidogrel. H e does not smoke. H e is not communicative and responds only to painful stimuli. There are severe contractures of the lower extremities. E xamination of the lower extremities shows black skin over the right ankle and foot. Pulses are absent in the lower extremities distally. E xtension of the hips is limited to 110 degre es; extension of the kne es is limited to 70 degre es. Which of the following is the most appropriate next step in management? < C O O Q LU ) Cilosta zol therapy ooooo ) Arteriography with contrast ) P ercutaneous balloon angioplasty ) Surgical revasculariz ation ) Amputation  10. A 47-ye ar-old woman comes to the physician because of a 2-ye ar history of a lump on her right ankle that se ems to have incre ased in siz e during the past 2 months. The lump is slightly painful only when she is active. She has had no other symptoms. She has no history of serious illness and takes no medications. E xamination of the right ankle shows a 2.8-cm raised lesion that is firm and adherent to the bone. There are no skin changes or lymphadenopathy. R ange of motion of the ankle is full. X-rays of the right lower extremity are shown. Which of the following is the most appropriate next step in management? ) Nonweight-be aring exercises ) S econd x-ray in 2 months ooooo m o o ro > ) Bone scan ) D E X A scan ) Biopsy of the lesion  11. Thre e days after undergoing emergency partial gastrectomy for upper gastrointestinal hemorrhage, a 72-ye ar-old man has incre asing abdominal pain. His postoperative course had be en uncomplicated. H e has hypertension tre ated with lisinopril and type 2 diabetes mellitus tre ated with glipizide. H e underwent coronary angioplasty with stent placement 2 ye ars ago. His current medications are patient-controlled morphine and subcutaneous unfractionated heparin. H e is anxious and diaphoretic. His temperature is 37.2°C (99°F), pulse is 110/min, respirations are 20/min, and blood pressure is 145/90 mm Hg. E xamination of the abdomen shows an upper midline incision without signs of infection. The remainder of the examination shows no other abnormalities. His hematocrit is 32%, and leukocyte count is 8000/mm 3. In addition to administering morphine, which of the following is the most appropriate next step in management? ) S erum D-dimer assay ) 12-Le ad E C G ooooo m o o co > ) C T scan of the abdomen ) Upper endoscopy ) Local wound exploration at bedside 12. A 62-ye ar-old woman comes to the physician for a routine he alth maintenance examination. She does not smoke and only drinks socially. A systolic ejection murmur is best he ard over the second right intercostal space with transmission to the carotid arteries. An E C G shows normal sinus rhythm and a pattern of left ventricular hypertrophy with strain. Which of the following manifestations would indicate the ne ed for aortic valve replacement? A) Angina and syncope B) G eneraliz ed we akness and fatigue C) P eripheral edema and ascites O 0) Pulmonary embolus E) V entricular arrhythmia  13. A 77-ye ar-old man comes to the emergency department 5 hours after he was awakened by severe pain in his left leg. H e reports that his left foot fe els numb and he cannot move his foot and toes. H e has a 4-ye ar history of stable claudication of both calves, a 40-ye ar history of hypercholesterolemia, and a 15-ye ar history of type 2 diabetes mellitus. H e was recently diagnosed with atrial fibrillation. Medications include aspirin and digoxin daily. H e is in mild distress. His pulse is 84/min and irregularly irregular, and blood pressure is 145/85 mm Hg. The left lower extremity is pale and cool below the kne e. F emoral pulses are 1+ on the right and absent on the left. Which of the following is the most likely diagnosis? < C O O Q LU ) C ompartment syndrome ooooo ) D e ep venous thrombosis ) Left femoral artery embolism ) R est pain secondary to progressive atherosclerotic peripheral vascular dise ase ) Thrombosis of the left superficial femoral artery  14. A 67-ye ar-old woman develops swelling of her left leg 3 days after Roux-en-Y choledochojejunostomy for an obstructing cancer of the he ad of the pancre as. V enous Doppler ultrasonography is positive. Which of the following is the most appropriate next step in management? ) Elevation of the left lower extremity ) Use of compression stockings ooooo m o o co > ) Physical therapy ) Intravenous streptokinase therapy ) Anticoagulant therapy with heparin  15. Two hours after admission to the hospital for injuries sustained in a motor vehicle collision, a 77-ye ar-old woman has the onset of tachycardia. She was the restrained driver of a vehicle that struck a tre e he ad on. She sustained bilateral anterior fractures of the 5th and 6th ribs. O n admission, E C G showed occasional premature atrial contractions, and 1 L of lactated Ringer solution was administered. Vital signs on admission and now are: Two Hours Ago on Now Admission T emperature 37.0°C (98.6°F) 37.4°C (99.3°F) Pulse 86/min 100/min and irregular R espirations 20/min 24/min Blood pressure 110/60 mm Hg 110/60 mm Hg E xamination shows no jugular venous distention or pulsus paradoxus. Posterior crackles are he ard over the lower quarter of the lung fields bilaterally. H ematocrit is 43%. Which of the following is the most likely cause of the cardiovascular findings? < CD O Q L ) Blunt cardiac injury ooooo ) C ardiomyopathy ) C or pulmonale ) Hypovolemic shock ) P ericardial tamponade  16. A 37-ye ar-old man comes to the physician with his wife because of a 10-we ek history of severe shortness of bre ath after walking one block and swelling of his legs. His wife says that he has snored for many ye ars and during the past 6 months has had many episodes every night in which he stops bre athing for 15 seconds and then suddenly wakes up. H e has had constant daytime fatigue for the past 3 months. H e has type 2 diabetes mellitus and hypertension. C urrent medications include insulin and an A C E inhibitor. H e appe ars cyanotic and is in mild respiratory distress. H e is 173 cm (5 ft 8 in) tall and weighs 145 kg (320 lb); BMI is 49 kg/m 2. His pulse is 90/min, respirations are 24/min, and blood pressure is 144/88 mm Hg. E xamination shows decre ased air movement at the lung bases. Scattered rhonchi are he ard. H e art sounds are distant. E xamination of the lower extremities shows brawny induration and 3-cm granulating ulcers above the medial malleoli. There is 3+ pitting edema to the midtibia bilaterally. Arterial blood gas analysis on room air shows a Pco 2 of 50 mm Hg and a Po 2 of 52 mm Hg. If this patient is not tre ated for the current findings, he will be at incre ased risk for which of the following? < CO O Q L ) Aortic dissection ooooo ) C or pulmonale ) Intracerebral hemorrhage ) Iron deficiency anemia ) Thrombotic stroke  17. A 62-ye ar-old man is brought to the emergency department 3 hours after the onset of shortness of bre ath at rest. O ne we ek ago, he was discharged from the hospital after undergoing a partial colectomy for a diverticular abscess. His postoperative course had be en uncomplicated. O n arrival, he is in mild respiratory distress. His temperature is 37°C (98.6°F), pulse is 110/min, respirations are 22/min, and blood pressure is 140/98 mm Hg. The lungs are cle ar to auscultation. Abdominal examination shows a well-he aling incision with no erythema or tenderness. Pulse oximetry on room air shows an oxygen saturation of 89%. O xygen is administered via nasal cannula, and his symptoms improve. Laboratory studies are pending. An x-ray of the chest shows no abnormalities. An E C G shows sinus tachycardia. Which of the following is the most appropriate next step in management? ) R e assurance ) Aspirin therapy ooooo m o o co > ) H eparin therapy ) Metronida zole therapy ) Transfusion of 2 units of packed red blood cells 18. O ne hour after undergoing a colon resection for a sigmoid carcinoma, a 57-ye ar-old woman is tachypneic and agitated in the recovery room. She was extubated in the operating room and is bre athing 30% oxygen by nasal cannula. She is 178 cm (5 ft 10 in) tall and weighs 140 kg (308 lb); BMI is 44 kg/m 2. H er pulse is 120/min, respirations are 40/min, and blood pressure is 135/90 mm Hg. Bre ath sounds are shallow and symmetrical. H e art sounds are normal. Arterial blood gas analysis shows: pH 7.25 Pco 2 60 mm Hg Po 2 70 mm Hg Which of the following is the most appropriate next step in management? A) Administration of a fluid bolus B) Administration of naloxone C) Diuretic therapy D) Fiberoptic bronchoscopy E) H eparin therapy F) Intubation G) Laryngoscopy 19. A 42-ye ar-old man comes to the office for examination prior to undergoing gastric bypass. H e reports a 2-month history of shortness of bre ath after walking less than one-half block. H e has hypertension tre ated with hydrochlorothia zide. H e is 180 cm (5 ft 11 in) tall and weighs 171 kg (376 lb); BMI is 52 kg/m 2. His pulse is 84/min, respirations are 14/min, and blood pressure is 132/82 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. D ecre ased bre ath sounds are he ard bilaterally. D ecre ased he art sounds are he ard. Arterial blood gas analysis on room air shows: pH 7.31 Pco 2 56 mm Hg Po 2 72 mm Hg Which of the following mechanisms is the most likely cause of these findings? A) D ecre ased diffusion capacity O B) D ecre ased ventilation O C) Incre ased diffusion capacity O D) Incre ased ventilation O E) Left-to-right shunting O F) Right-to-left shunting O 6) V entilation-perfusion mismatch 20. A 32-ye ar-old woman is brought to the emergency department 30 minutes after being involved in a he ad-on motor vehicle collision. She was the unrestrained front se at passenger. She is alert. H er temperature is 36.8°C (98.2°F), pulse is 110/min, respirations are 16/min, and blood pressure is 140/85 mm Hg. E xamination shows ecchymoses over the forehe ad, left side of the chest, and upper abdomen. Pupils are equal and re active to light. There is no jugular venous distention. Bre ath sounds are decre ased over the left lung base. H e art sounds are normal. Abdominal examination shows epigastric tenderness. X-rays of the chest are shown. Which of the following is the most likely diagnosis? A) Aortic rupture B) Diaphragmatic rupture C) Flail chest 20. A 32-ye ar-old woman is brought to the emergency department 30 minutes after being involved in a he ad-on motor vehicle collision. She was the unrestrained front se at passenger. She is alert. H er temperature is 36.8°C (98.2°F), pulse is 110/min, respirations are 16/min, and blood pressure is 140/85 mm Hg. E xamination shows ecchymoses over the forehe ad, left side of the chest, and upper abdomen. Pupils are equal and re active to light. There is no jugular venous distention. Bre ath sounds are decre ased over the left lung base. H e art sounds are normal. Abdominal examination shows epigastric tenderness. X-rays of the chest are shown. Which of the following is the most likely diagnosis? A) Aortic rupture B) Diaphragmatic rupture C) Flail chest D) H emothorax E) Pneumothorax F) Pulmonary contusion G) Trache al laceration  21. S even days after undergoing a splenectomy for refractory ble eding after being kicked by a horse, a 25-ye ar-old woman has a temperature of 39°C (102.2°F) and malaise. She received 8 units of packed red blood cells during the first 24 hours after the operation. H er postoperative course had be en uncomplicated until today. H er pulse is 110/min, and blood pressure is 120/70 mm Hg. E xamination shows a well-he aling surgical incision without erythema or tenderness. Bre ath sounds are decre ased on the left. The abdomen is soft with mild fullness in the left upper quadrant. H er hematocrit is 30%, leukocyte count is 25,000/mm 3 with a left shift, and platelet count is 800,000/mm 3. An x-ray of the chest shows a left pleural effusion. Which of the following is the most appropriate next step in diagnosis? < C O O Q LU ) Ultrasonography of the gallbladder ooooo ) Upper gastrointestinal series ) C T scan of the abdomen ) Liver-sple en scan ) Bronchoscopy 22. A previously he althy 25-ye ar-old woman comes to the office because of a 4-month history of intermittent abdominal cramps. During this period, she has noticed occasional mucus mixed with her stools but has never noted any bright red blood. She is 168 cm (5 ft 6 in) tall and weighs 45 kg (100 lb); BMI is 16 kg/m 2. H er vital signs are within normal limits. Abdominal examination shows mild tenderness to palpation of the right lower quadrant; there is no distention, guarding, or rebound. R ectal examination shows normal sphincter tone, a noninflamed anal fistula, brown stool, and no masses. T est of the stool for occult blood is positive. Which of the following is the most likely diagnosis? O A) Crohn dise ase O B ) Diverticulitis C) E ndometriosis O D) G astritis O E) Irritable bowel syndrome O F) Ischemic colitis O G ) Ulcerative colitis  23. A 16-ye ar-old boy is brought to the emergency department because of a 6-month history of intermittent bright red rectal ble eding. H e has no history of serious illness and takes no medications. Vital signs are within normal limits. C ardiopulmonary examination shows no abnormalities. Digital rectal examination shows blood in the rectal vault. E ndoscopy shows scattered 1-cm to 2-cm polyps throughout the colon. E ndoscopic polypectomy of the larger polyps is performed. R esults of biopsy of the polyps show dilated, cystic, < C D O Q LU LL mucus-filled glands with abundant lamina propria and inflammatory infiltrates. Which of the following is the most likely diagnosis? ) C owden dise ase oooooo ) Cronkite-C anada syndrome ) F amilial adenomatous polyposis ) H ereditary nonpolyposis colorectal cancer ) Juvenile polyposis ) P eutz-Jeghers syndrome  24. A 33-ye ar-old man comes to the office as a new patient after he recently moved to the state. His last visit to a physician was 2 ye ars ago. H e has a 13-ye ar history of ulcerative colitis well controlled with mesalamine. His mother has type 2 diabetes mellitus. His father was diagnosed with colon cancer at the age of 55 ye ars. The patient does not smoke cigarettes. H e drinks two 12-oz be ers monthly. Vital signs are within normal limits. E xamination shows no abnormalities. Which of the following is the most appropriate colon < C D O Q LU LL cancer scre ening for this patient? ) C olonoscopy now oooooo ) C olonoscopy at the age of 45 ye ars ) C olonoscopy at the age of 50 ye ars ) Virtual colonoscopy now ) Virtual colonoscopy at the age of 45 ye ars ) Virtual colonoscopy at the age of 50 ye ars  25. A 67-ye ar-old man with a 2-ye ar history of gastroesophage al reflux dise ase comes to the physician for a follow-up examination. Tre atment with the maximum dosage of proton pump inhibitors has not relieved his symptoms. H e also has hypertension and hypercholesterolemia. His only other medication is hydrochlorothia zide. His blood pressure is 135/85 mm Hg. E xamination shows no other abnormalities. E sophagogastroduodenoscopy (E G D) shows grade III esophagitis and B arrett esophagus. A biopsy specimen of the esophagus shows mild dysplasia. H e undergoes Nissen fundoplication, and his symptoms resolve. Which of the following is the most appropriate next step in management? < C O O Q LU ) C ontinue proton pump inhibitor therapy ooooo ) R epe at the E G D if the patient's symptoms recur ) R epe at the E G D and biopsy in 6 months ) P erform laser ablation of B arrett esophagus ) No further tre atment is indicated  26. A 67-ye ar-old woman is admitted to the hospital through the emergency department for evaluation of rectal ble eding that began 6 hours ago. R esults of colonoscopy 2 ye ars ago showed several scattered diverticula. O n admission, vital signs are within normal limits. The abdomen is nontender, and she has not had any abdominal pain. Digital rectal examination discloses gross blood. R esults of laboratory studies show: H emoglobin 6.8 g/dL Leukocyte count 8000/mm 3 Platelet count 215,000/mm 3 C olonoscopy is done and shows maroon blood and stool throughout the colon. R adiolabeled erythrocyte scan shows activity in the right lower quadrant. Visceral angiography does not demonstrate active contrast extravasation. During the procedure, the patient receives a transfusion of 3 units of packed red blood cells; repe at hemoglobin concentration obtained after transfusion is 6.6 g/dL. Which of the following is the most appropriate next step in management? < C O O Q LU ) C apsule endoscopy ooooo ) Left hemicolectomy ) R epe at angiography ) R epe at radiolabeled erythrocyte scan ) Total abdominal colectomy 27. A 62-ye ar-old woman has had halitosis and progressive dysphagia with spontaneous regurgitation of undigested food over the past 2 ye ars; she has lost 2.3 kg (5 lb) during this period. There are no lesions in the mouth. Abdominal examination shows no tenderness or masses. T est of the stool for occult blood is negative. Which of the following is the most appropriate next step in diagnosis? ) 24-Hour esophage al pH monitoring ) E sophage al manometry ooooo m o o co > ) B arium swallow ) Ultrasonography of the abdomen ) E sophagogastroduodenoscopy 28. A 57-ye ar-old man comes to the physician because of a 4-we ek history of mild epigastric pain and nause a 1 hour after me als. H e has not had vomiting, he artburn, a bitter taste in his mouth, weight loss, or change in the color of his stools. H e has no history of serious illness and takes no medications. H e drinks coffe e with dinner. H e does not smoke. E xamination shows no abnormalities. T est of the stool for occult blood is positive. Which of the following is the most appropriate next step in management? O A) R ecommend avoidance of caffeine O B ) S erum H elicobacter pylori antibody assay C) Upper gastrointestinal series O D) C T scan of the abdomen E) E sophagogastroduodenoscopy  29. A 53-ye ar-old woman comes to the emergency department because of incre asingly severe abdominal cramping and malaise. She has a 3-ye ar history of ulcerative pancolitis, tre ated with sulfasala zine. F our days ago she had hematoche zia and an incre ase in the frequency and volume of bowel movements; tre atment with prednisone resulted in no significant improvement. H er temperature is 37.6°C (99.6°F), pulse is 110/min, respirations are 24/min, and blood pressure is 110/70 mm Hg. Abdominal examination shows moderate distention, diminished bowel sounds, and diffuse tenderness without rigidity on palpation. Supine and erect x-rays of the abdomen show gas distending the colon. Which of the following is the most likely diagnosis? < C O O Q LU ) C arcinoma of the colon with obstruction ooooo ) Dysplasia of the colon with hemorrhage ) E nterocolonic fistula ) G astroenteritis ) Toxic megacolon  30. A 72-ye ar-old man who is in the hospital has had abdominal cramps and bright red rectal ble eding for the past 6 hours. During this period, he has passed thre e bloody, moderately siz ed stools. Two days ago, he underwent surgical resection of an infrarenal abdominal aortic aneurysm. H e had a hemorrhage during dissection of the aneurysm and had hypotension for the first 20 minutes of the operation. H e received 6 units of packed red blood cells. His initial postoperative course was uncomplicated, and he was extubated within 24 hours. C urrent medications are intravenous cefa zolin and subcutaneous heparin. His current temperature is 38.2°C (100.8°F), pulse is 100/min, and blood pressure is 124/80 mm Hg. Abdominal examination shows mild distention and moderate left lower quadrant tenderness. Which of the following is the most likely diagnosis? < C O O Q LU ) Aortoenteric fistula ooooo ) C ecal angiodysplasia ) Diverticulosis ) Ischemic colitis ) Pseudomembranous colitis 31. A 77-ye ar-old woman is brought to the emergency department because of abdominal distention and obstipation for 2 days. She has no history of an abdominal operation. She takes 2 mg of dia z epam thre e times daily. T est of the stool for occult blood is negative. An x-ray of the abdomen is shown. Which of the following is the most likely diagnosis? A) C arcinoma of the colon B) Diverticulitis of the colon C) Ileocolic intussusception D) Ischemic colitis E) Volvulus of the sigmoid colon  32. A 37-ye ar-old woman comes to the physician because of a 6-month history of moderate rectal pain, rectal itching, and ble eding with bowel movements. She is otherwise he althy and takes no medications. O n digital rectal examination, the rectal tissue is tender and inflamed. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in diagnosis? < C D O Q LU ) B arium enema ooooo ) E ndorectal ultrasonography ) C T scan of the abdomen ) Anoscopy ) C olonoscopy  33. A 42-ye ar-old woman comes to the emergency department because of incre asingly severe abdominal pain for the past 4 hours and a temperature of 39°C (102.2°F) and shaking chills for the past 2 hours. The pain began 1 hour after e ating dinner. During the past 2 we eks, she has had 30-minute episodes of epigastric and right upper quadrant abdominal pain after e ating. Tre atment with antacids sometimes relieves the pain. She now is lying still on the examination table. H er temperature is 39.5°C (103.1 °F), pulse is 110/min, respirations are 22/min, and blood pressure is 90/60 mm Hg. E xamination shows scleral icterus and jaundice. Abdominal examination shows right upper quadrant tenderness to percussion and involuntary guarding; bowel sounds are normal. Urinalysis is positive for bile. Which of the following is the most likely diagnosis? < C O O Q LU ) C holangitis ooooo ) C holecystitis ) G astritis ) H epatitis ) P ancre atitis  34. A 57-ye ar-old woman comes to the emergency department because of a 1-hour history of incre asingly severe left-sided chest pain that is worse when she inhales. Six hours ago, she underwent upper gastrointestinal endoscopy because of a 1-month history of progressive dysphagia. R esults showed a benign-appe aring stricture of the distal esophagus that was balloon-dilated. H er only medication is esomepra zole for gastroesophage al reflux dise ase. She does not smoke cigarettes or drink alcohol. She appe ars anxious. H er temperature is 37.9°C (100.3°F), pulse is 110/min, respirations are 20/min, and blood pressure is 110/65 mm Hg. E xamination shows splinting of the left chest during inspiration. C ardiac examination shows a regular tachycardia. Abdominal examination shows no abnormalities. C hest x-ray shows a small left pleural effusion. Which of the following is the most appropriate next step in diagnosis? < C O O Q LU ) W ater-soluble contrast esophagography ooooo ) C T scan of the chest ) R epe at upper gastrointestinal endoscopy ) Thoracentesis ) Thoracostomy  35. A 25-ye ar-old man has postoperative pain 6 hours after a mesh repair of an inguinal hernia under local (lidocaine) anesthesia. Which of the following is the most appropriate analgesic pharmacotherapy for the incisional pain? ) Oral aspirin ) Oral dia z epam oooooo ) Oral morphine sulfate n m o o oo > ) Oral oxycodone-acetaminophen compound ) Transcutaneous fentanyl ) Infiltration of the wound with bupivacaine  36. A 5-we ek-old boy is brought to the physician because of a 4-we ek history of progressive jaundice. H e was born at term following an uncomplicated pregnancy and delivery. His mother says that his stools are white. H e is at the 50th percentiles for height and weight. His temperature is 37.4°C (99.3°F). E xamination shows moderate jaundice. The liver edge is palpated 4 cm below the right costal margin and is firm and slightly nodular. S erum studies show: Bilirubin, total 12.4 mg/dL Direct 8.3 mg/dL Alkaline phosphatase 551 U/L AST 51 U/L ALT 48 U/L a r Antitrypsin normal A T O R C H assay is negative. An ultrasonography of the abdomen does not show a gallbladder. A technetium 99m scan shows prompt uptake throughout the liver and no gallbladder; no tracer appe ars in the bowel. Which of the following is the most likely mechanism of this patient's jaundice? < C D O Q LU ) D ecre ased bilirubin conjugation by hepatocytes ooooo ) D ecre ased bilirubin excretion by hepatocytes ) D ecre ased bilirubin uptake by hepatocytes ) Impaired bile flow through ducts ) Incre ased bilirubin production  37. Twenty-four hours after undergoing splenectomy for trauma sustained in a motor vehicle collision, a previously he althy 25-ye ar-old woman has oliguria. A urinary catheter is in place, and her urine output has be en 20 mL/h during the past 3 hours. Intraoperative complications included a 30-minute period of hypotension and a total blood loss of 2.5 L requiring 4 units of packed red blood cells. C urrently, her temperature is 38.0°C (100.4°F), pulse is 100/min, respirations are 14/min, and blood pressure is 120/80 mm Hg. The lungs are cle ar to auscultation, and bre ath sounds are he ard bilaterally. Abdominal examination shows no distention. Bowel sounds are absent. Laboratory studies show a hematocrit of 28%, serum ure a nitrogen concentration of 30 mg/dL, and serum cre atinine concentration of 2.5 mg/dL; her serum electrolyte concentrations are within the reference ranges. C entral venous pressure is 8 cm H 2 O (N=5-8). Which of the following is the most appropriate next step to confirm the cause of the oliguria? < C O O Q LU ) Administration of spironolactone ooooo ) Me asurement of plasma fre e hemoglobin concentration ) Me asurement of urine sodium and cre atinine concentrations ) R enal ultrasonography ) R eplacement of the urinary catheter  38. A 32-ye ar-old man is brought to the emergency department 1 hour after sustaining extensive injuries in a motor vehicle collision. His pulse is 100/min, respirations are 15/min, and blood pressure is 120/70 mm Hg. C ardiopulmonary examination shows no abnormalities. The lower abdomen is tender. There is blood at the urethral me atus. O n rectal examination, the prostate is not palpable, and there is no blood. Which of the following is the most appropriate next step in evaluation of the urinary tract? ) C ystography ) Intravenous pyelography oooooo n m o o ot > ) R etrograde urethrography ) Ultrasonography of the pelvis ) C T scan of the pelvis ) Insertion of a urinary catheter  39. A 32-ye ar-old woman comes to the physician because of bloody discharge from the right nipple for 2 we eks. There are no bre ast masses or axillary or supraclavicular adenopathy. Mammography shows normal findings. The nipple and areola appe ar normal. Which of the following is the most likely diagnosis? ) Ductal carcinoma in situ ) Fibroadenoma ooooo m o o co > ) Intraductal papilloma ) P aget dise ase of the bre ast ) Prolactin-producing pituitary adenoma  40. An otherwise he althy 40-ye ar-old woman, gravida 2, para 2, comes to the office 2 we eks after she noticed a tender mass on her left bre ast while showering. Menarche was at the age of 12 ye ars. The patient had her first child at the age of 28 ye ars and underwent tubal ligation after the birth of her second child 8 ye ars ago. The patient's maternal aunt was diagnosed with bre ast cancer at the age of 75 ye ars. E xamination of the patient shows no lymphadenopathy. The bre asts appe ar normal and symmetric. P alpation of the bre asts shows normal bre ast tissue bilaterally; there is a 2-cm firm mass on the upper outer quadrant of the left bre ast with no skin or chest wall attachment. Mammography confirms a solitary, well-defined mass in the same location. Ultrasonography of the bre asts shows that the mass is fluid-filled and compressible with posterior shadowing. Which of the following is the most appropriate next step in management? < C O O Q LU ) E xcisional biopsy ooooo ) Incisional biopsy ) Mammography-localiz ed core ne edle biopsy ) MRI ) N e edle aspiration 41. A previously he althy 42-ye ar-old woman comes to the office because of a painful mass in the right bre ast for 3 we eks. Menarche was at the age of 12 ye ars. She had her first child at the age of 22 ye ars. E xamination shows a 1 -cm, firm, tender mass in the upper outer quadrant of the right bre ast; there is no lymphadenopathy. E xamination of a biopsy specimen shows fibroadenoma and lobular carcinoma in situ. O ver the next 10 ye ars, this patient is at gre atest risk for which of the following? < C D O LU ) Bone metastasis ooooo ) Fibrocystic bre ast condition ) Intraductal papilloma ) Invasive ductal carcinoma ) O varian metastasis 42. A previously he althy 21-ye ar-old man is brought to the emergency department 45 minutes after falling 12 fe et from a barn loft. H e landed straddling a wooden be am. His pulse is 120/min; other vital signs are within normal limits. E xamination of the scrotum and penis shows edema and ecchymoses. Urinalysis shows numerous R B C s. Doppler ultrasonography of the testes shows a scrotal hematoma; there is no blood flow to the testes. An analgesic is administered. Which of the following is the most appropriate next step in diagnosis? < C O O Q LU ) R enal ultrasonography ooooo ) MRI of the pelvis ) Intravenous pyelography ) C ystoscopy ) Surgical exploration 43. A 32-ye ar-old man has a 6-month history of irritability, frequent bowel movements, and a 5.4-kg (12-lb) weight loss. E xamination shows a single thyroid nodule. S erum thyroxine (T 4) concentration is 16.1 pg/dL, and serum thyroid-stimulating hormone concentration is less than 0.1 pU/mL. Which of the following is the most likely diagnosis? A) D efect in thyroxine (T 4) biosynthesis B) Graves dise ase C) Multinodular goiter D) Riedel thyroiditis E) Thyroid carcinoma F) Thyroid cyst G) Thyroiditis H) Toxic adenoma I ) Triiodothyronine (T3) thyrotoxicosis 44. Twenty-four hours after undergoing total thyroidectomy and lymph node dissection for metastatic papillary thyroid carcinoma, a 57-ye ar-old woman has circumoral paresthesia and tingling of the fingertips. E xamination shows hyperreflexia when the facial nerve is tapped. Which of the following is the most appropriate pharmacotherapy? ) C ontact the hospital ethics committe e to give consent ) Discontinue sedation and determine if the patient can communicate her wishes ) Proce ed with tracheostomy as a medical necessity