De Virgilio Surgery Questions and Explanations

Rationale for the Previous Question

-A diagnostic mammogram should be ordered in a woman over the age of 30 who presents with a new breast mass. Mammography helps to look for suspicious calcifications in other areas of the affected breast, characterize the mass, as well as evaluate the contralateral breast. It is important to note that the mammogram may be normal despite the presence of a palpable breast cancer. For this reason, a tissue biopsy is recommended for palpable breast masses regardless of the mammogram results. Tissue sampling is best performed via ultrasound-guided core needle biopsy. Ultrasound also provides more information about the mass (cystic vs. solid). Fine-needle aspiration (B) is rarely used as it relies on cytology rather than histology. MRI (C) is not routinely needed. Follow-up examination in 3 months (D) without a biopsy would be inappropriate. Genetic testing (E) would be indicated if this patient had a strong family history of breast or ovarian cancer, but would not be done until tissue diagnosis of breast cancer is confirmed.

Rationale for the Previous Question

-A sudden rise in blood pressure after anesthetic induction raises concern for an undiagnosed pheochromocytoma, malignant hyperthermia, and thyrotoxicosis (thyroid storm). For each of these situations, cessation of anesthesia is recommended. There are several clues that point to pheochromocytoma as the cause. The administration of beta-blockers without alpha-blockade first leads to worsening hypertension due to unopposed alpha-mediated vasoconstriction as in the case above. Pheochromocytoma is associated with neurofibromatosis-1, which may present with skin neurofibromas (rubberlike discolored skin lesions) and cataracts. Malignant hyperthermia (B) presents with muscle rigidity (most often the masseter), a rapid increase in core body temperature, a rise in end tidal CO2, arrhythmia, and a mixed metabolic and respiratory acidosis at anesthetic induction. Treatment is immediate cessation of surgery and dantrolene. Thyrotoxicosis (C) presents in a similar fashion to malignant hyperthermia (fever, hypertension, tachycardia); however, it is not associated with muscle rigidity or rising end tidal CO2. The associated hypertension and tachycardia respond to the administration of beta-blockade. It is due to a hypermetabolic state caused by excess thyroid hormone. Inadequate anesthetic agents (D) may lead to hypertension and tachycardia, but would not lead to high fevers. An undiagnosed pituitary tumor resulting in excess ACTH production can cause hypertension, but this will be accompanied with symptoms consistent with Cushing's disease (e.g., truncal obesity, abdominal striae, muscle wasting, hirsutism).

Rationale for the Previous Question

-Acute pericarditis is inflammation in the pericardial sac accompanied by pericardial effusion. It can occur following post-MI (termed Dressler's syndrome), chest radiation, or recent heart surgery. Patients present with pleuritic chest pain that lessens when leaning forward, friction rub heard on auscultation, global ST elevation, and PR depression. Patients with myocarditis (A) usually present with signs and symptoms of acute decompensating heart failure (e.g., tachycardia, gallop, mitral regurgitation, and edema). Chest pain accompanied with MI (C) would not be expected to lessen with leaning forward. Furthermore, global ST elevation would not be expected. Cardiac tamponade (C) can occur once the effusion reaches a critical mass in which cardiac output is compromised. Pulmonary embolism (E) can present with pleuritic chest pain, but it will not be influenced by positioning and is more likely to have ECG findings suggestive of right heart failure.

Rationale for the Previous Question

-All of the above are risk factors for aortic dissection (A- C, E). However, the most significant risk factor for aortic dissection is systemic hypertension.

A 36-year-old woman is evaluated for a lump in her right breast that she noticed 5 months ago. She denies any nipple discharge, nipple retraction, or skin changes. She has no family history of breast cancer. On physical exam, the breasts appear normal. Palpation reveals a 1 cm dominant lump in the left upper quadrant that does not appear to be fixed to the surrounding structures. The patient has no other dominant masses in either breast. There is no axillary lymphadenopathy. Mammogram is negative. What is the next step in the management? (A) Ultrasound-guided core needle biopsy (B) Fine-needle aspiration (C) MRI (D) Follow-up clinical breast exam in 3 months (E) Genetic testing

-Answer is A

A 45-year-old female undergoes screening mammography which demonstrates an area of suspicious microscopic calcification in her right upper outer breast. Stereotactic-guided biopsy confirms ductal carcinoma in situ (DCIS). Which of the following is true about this condition? (A) It should be excised to a negative margin (B) It is considered a marker for malignancy in either breast (C) The cribriform type has a worse prognosis than the comedo type (D) It does not occur in men (E) Radiation therapy is an acceptable alternative to surgical excision

-Answer is A

A 45-year-old man has had hazy vision for the past month, particularly when he is driving at night. He also endorses small rubberlike nodules on the skin of his trunk, back, arms, and legs that are not painful and do not itch. After seeing his ophthalmologist, he is diagnosed with bilateral cataracts and is scheduled to receive elective cataract surgery. During induction of anesthesia, following intubation, the patient's pressure increases from 110/ 70 to 200/ 90 mmHg. PaCO2 is normal as is his pH. His temperature is 101.5 ° F. An esmolol drip is immediately instituted, after which BP increases to 220/ 90 mmHg and an ECG shows T wave inversion. What is the most likely underlying etiology? (A) Intra-abdominal tumor (B) Malignant hyperthermia (C) Thyrotoxicosis (D) Inadequate anesthetic agent (E) Undiagnosed pituitary tumor

-Answer is A

A 55-year-old schizophrenic homeless man arrives to the ED with abdominal pain and vomiting. He reports that the abdominal pain started yesterday and has been worsening. He is afebrile, blood pressure is 122/ 86 mmHg, and heart rate is 116/ min. In the ED he vomits green emesis without blood. His last bowel movement was 48 h ago. Physical examination reveals a large scar in his right upper quadrant. On abdominal examination, the abdomen is distended, with hyperactive bowel sounds, and is tympanic to percussion, with mild diffuse tenderness, and no rebound or guarding. WBC is 9 × 103/ μL (normal 4.1- 10.9 × 103/ μL). Abdominal series shows dilated loops of bowel with multiple air fluids levels. After fluid resuscitation, what is the most appropriate next step in management? (A) Nasogastric tube suction (B) Laparoscopy (C) Exploratory midline laparotomy (D) Intravenous erythromycin (E) CT scan of the abdomen

-Answer is A

A 61-year-old female presents with swelling and redness of her entire left breast that has persisted for 4 weeks. On physical exam her temperature is 98.7 ° F, pulse is 82/ min, blood pressure is 136/ 78 mmHg, and respirations are 16/ min. Her left breast appears larger than her right one. The entire breast is warm, and the skin is edematous. No breast masses are palpable. There is no nipple discharge or rashes. There are several palpable enlarged lymph nodes in her left axilla. Ultrasound and mammography show thickening of the skin but otherwise no masses. Which of the following is the best option for further management? (A) Punch biopsy of skin (B) Oral antibiotics (C) Intravenous antibiotics (D) Nonsteroidal anti-inflammatory drugs (E) Incision and drainage

-Answer is A

A 65-year-old female has breast cancer and a remote history of congestive heart failure. Her physician is planning to administer a chemotherapeutic agent that has potential for cardiac toxicity. Which of the following is the most accurate test to measure ejection fraction? (A) Multi Gated Acquisition Scan (MUGA) scan (B) Echocardiography (C) Electrocardiogram (D) Coronary angiography (E) Exercise stress test

-Answer is A

A 65-year-old male is about to undergo an elective inguinal hernia repair. Which of the following findings on history or physical would portend the highest operative risk? (A) Systolic, crescendo-decrescendo murmur at the sternal border of the right second intercostal space radiating into neck (B) A history of myocardial infarction 10 years ago (C) Insulin-dependent diabetes mellitus with an elevated HgbA1C (D) Renal insufficiency not yet on dialysis (E) Smoking

-Answer is A

A 65-year-old male presents to the ED with nausea, vomiting, and severe abdominal pain. Past history is significant for prior sigmoid colectomy for diverticulitis 10 years ago. On physical exam, his temperature is 100.9 ° F, blood pressure is 110/ 80 mmHg, and heart rate is 110/ min. His abdomen has a well-healed midline scar and is distended. Bowel sounds are hyperactive with occasional rushes and tinkles. He has marked right upper quadrant tenderness to palpation with guarding. The rest of the abdominal exam is unremarkable. Abdominal series demonstrates one loop of markedly distended small bowel in the right upper quadrant with an air fluid level. No gas is seen in the colon or rectum. Laboratory values demonstrate a WBC count of 18 × 103/ μL (normal 4.1- 10.9 × 103/ μL) with 15 % bands and a serum lactate of 5 mmol/ L (normal 0.5- 1.6 mmol/ L), BUN 30 mg/ dL (7- 21 mg/ dL), and creatinine 1.2 mg/ dL (0.5- 1.4 mg/ dL). Amylase, lipase, and liver chemistries are normal. NG tube and IV fluids are given. What is the next step in the management? (A) Exploratory laparotomy (B) Admit for close observation (C) Upper GI with small bowel follow through with barium (D) Upper GI with small bowel follow through with Gastrografin (E) Right upper quadrant ultrasound

-Answer is A

A 65-year-old man is rushed to the ED by ambulance after he suddenly lost strength and sensation in his left leg and arm. He was hospitalized 2 months ago with a NSTEMI. He is compliant with all of his medications and had been recovering well until the present episode. ECG shows normal sinus rhythm without evidence of ischemia. Chest X-ray is unremarkable. Carotid ultrasounds show < 30 % stenosis bilaterally. What is the most likely etiology of the patient's present symptoms? (A) Ventricular thromboembolism (B) Septic embolism to the brain (C) Type A dissection involving the right carotid artery (D) Thromboembolism from the left atrial appendage (E) Paradoxical venous thromboembolism

-Answer is A

A 65-year-old woman returns to clinic for a 3-month follow-up. Three months ago she developed a pruritic, erythematous, ulcerated rash surrounding the areola of her right breast. She tried hydrocortisone 1 % on the lesion at the recommendation of her primary care physician, but the lesion persisted. She has no history of skin diseases in the family. She takes warfarin for atrial fibrillation. She started a new medication, hydrochlorothiazide, for hypertension about 3 months ago. Otherwise, she is healthy. What is the best next step in the management of this patient? (A) Punch biopsy of the skin lesion (B) Change hydrocortisone 1 % to triamcinolone to treat eczema (C) Treatment with antibiotics (D) Oral steroid course to treat psoriasis (E) Increase the dose of hydrocortisone

-Answer is A

A 66-year-old man is recovering in the ICU after receiving a CABG for coronary artery disease. On the fourth postoperative day, he complains of chest pain. He is sweating, anxious, short of breath, and nauseated. ECG shows evidence of right-sided MI. His blood pressure is 98/ 65 mmHg. What is the next best step in management? (A) Administer 1 L of normal saline (B) Nitroglycerin (C) Nitroprusside (D) Nifedipine (E) Lisinopril

-Answer is A

Following open inguinal hernia repair, a 50-year-old male complains of numbness and burning pain on the scrotum. This most likely represents injury to: (A) The genital branch of the genitofemoral nerve (B) The femoral branch of the genitofemoral nerve (C) The ilioinguinal nerve (D) The lateral femoral cutaneous nerve (E) The iliohypogastric nerve

-Answer is A

In addition to elevated plasma free metanephrine, a change in what other serum marker can help support the diagnosis of pheochromocytoma? (A) Plasma chromogranin A (B) Plasma superoxide dismutase (C) Malondialdehyde (D) CA 19- 9 (E) 5-Hydroxyindoleacetic acid (HIAA)

-Answer is A

One week after open repair of a large right scrotal hernia, a 45-year-old male returns complaining of severe pain in his right testicle. On physical exam, the testicle appears to be slightly swollen and very tender to palpation. Doppler study demonstrates no flow within the right testicle with normal flow in the left. Which of the following is true about this condition? (A) It is most commonly due to thrombosis of the pampiniform plexus (B) Urgent exploration of the right testicle is recommended (C) It is most likely due to transection of the testicular artery (D) It most likely represents testicular torsion (E) The testicle will likely remain permanently enlarged

-Answer is A

A 12-year-old boy presents to the doctor for a lump in his neck. He is healthy with no previous medical problems. On physical examination, he has a well-defined anterior neck mass, located in the midline and above the cricoid cartilage. The mother states that she has noted the lesion since he was about 2 years old. It does not bother him. On physical examination, the mass elevates with swallowing and is non-tender. He has no cervical adenopathy and no other complaints. The neck mass is described as a hypoechoic mass on ultrasonography. A subsequent thyroid scintogram is performed and confirms the thyroid gland is in its correct anatomic position. Which of the following would be recommended next for this mass? (A) FNA biopsy (B) Proceed to surgical excision (C) Reassurance and observation (D) TSH and free T4 (E) CT scan

-Answer is B

A 30-year-old female presents with bloody discharge from her left breast that she has noticed intermittently for the past month. She denies any palpable breast mass, weight loss, fevers, or night sweats. She has no medical history or family history of breast cancer. The skin around the breast and areola are normal with no rashes or lesions. No breast mass is palpable, and there is no axillary lymphadenopathy. Ultrasound did not reveal any masses. What is the most likely diagnosis? (A) Fibrocystic changes (B) Intraductal papilloma (C) Ductal carcinoma in situ (DCIS) (D) Paget's disease of the breast (E) Infiltrating ductal carcinoma

-Answer is B

A 31-year-old breastfeeding female comes to the doctor for localized swelling, redness, and pain of the left breast. She also reports muscle aches and fatigue. On physical exam her temperature is 101.1 ° F, pulse is 82/ min, blood pressure is 126/ 68 mmHg, and respirations are 16/ min. Physical exam reveals a localized area of erythema and warmth in the left breast with no palpable masses. There is no axillary lymphadenopathy. What is the most likely next course of action? (A) Biopsy (B) Antibiotic treatment and continue breast feeding (C) Antibiotic treatment and encourage bottle-feeding only (D) Diagnostic mammography (E) Incision and drainage

-Answer is B

A 55-year-old man presents with a mass in the left groin that is intermittently painful. The mass protrudes upon straining and reduces when he is in the supine position. With the patient standing, there is an obvious mass in his left scrotum that protrudes from the internal ring and becomes more prominent when the patient coughs. Elective surgery is recommended. At surgery, the posterior wall of the hernia sac feels very thickened and is consistent with a possible sliding hernia. Which of the following is true regarding this type of hernia? (A) Every attempt should be made to excise the entire sac (B) It poses a higher risk of colon injury during repair (C) It is more common on the right side (D) It is most often associated with direct inguinal hernias (E) The hernia sac should be divided at the internal ring

-Answer is B

A 55-year-old otherwise healthy patient undergoes a non-contrast CT abdomen to evaluate for possible kidney stones and is incidentally noted to have a 8 cm mass in the left adrenal gland. The mass has irregular borders and high attenuation, suggesting a lipid-poor lesion, and appears to be adherent to the kidney. How should this patient be managed? (A) Observation with repeat CT scan in 3 months (B) Open adrenalectomy (C) Laparoscopic adrenalectomy (D) Radiation therapy (E) Percutaneous biopsy

-Answer is B

A 67-year-old male is diagnosed with a type B aortic dissection. At the time of initial presentation on the previous day, his blood pressure was 178/ 110 mmHg. He was treated with intravenous beta-blocker, and his blood pressure was reduced to 112/ 60 mmHg and has remained in that range. However, one day later, he suddenly develops severe abdominal pain. His blood pressure is measured to be 110/ 56 mmHg. Which of the following is the most likely explanation? (A) C. difficile infection (B) Occlusion of the superior mesenteric artery (C) Pancreatitis (D) Aortoenteric fistula (E) Diverticulitis

-Answer is B

A 75-year-old male with severe aortic stenosis has a routine check-up at his primary care doctor. Which of the following symptoms portends the worst prognosis? (A) Exertional chest pain (B) Swollen legs (C) Fainting spells (D) Mid-systolic murmur heard loudest at the upper right sternal border (E) Small head nodding movements at each heartbeat

-Answer is B

A 27-year-old woman has 3 months of intermittent spells of severe headache, heart palpitations, and sweating. A pregnancy test at her primary care doctor's office is positive. Further workup reveals that her plasma metanephrine level is 220 pg/ ml (normal 12-60 pg/ ml). What is the next step in establishing the diagnosis? (A) CT abdomen (B) Repeat plasma metanephrine level after the patient has delivered (C) MRI abdomen (D) I131-MIBG scan (E) Reassure patient that symptoms are related to pregnancy

-Answer is C

A 40-year-old male presents with acute chest pain and nausea. Serum troponin levels are elevated, and the ECG demonstrates ST segment elevation. Which of the following would be the strongest contraindication to intravenous thrombolytic therapy? (A) Right knee arthroscopic surgery 1 month ago (B) Recently completed antibiotic course for H. pylori infection (C) Wide mediastinum on CXR (D) History of alcohol abuse (E) Endovascular aortic aneurysm repair 1 month ago

-Answer is C

A 42-year-old man with a family history of endocrine tumors is diagnosed with MEN-2A after presenting with uncontrolled hypertension and subsequent genetic workup. He was found to have a right adrenal pheochromocytoma and asymptomatic hyperparathyroidism. What is the recommended surgical management for this patient? (A) Parathyroid surgery first, followed by adrenalectomy (B) Adrenalectomy first, followed by parathyroid surgery (C) Medical conditioning for 2 weeks prior to adrenalectomy, followed by parathyroid surgery (D) Medical conditioning for 2 weeks prior to simultaneous parathyroid surgery and adrenalectomy (E) Medical conditioning for 2 weeks followed by adrenalectomy only

-Answer is C

A 57-year-old woman comes to clinic to discuss surgical treatment for a new diagnosis of breast cancer. Her annual screening mammogram revealed a 1.7 cm mass in the right breast. Biopsy of the mass was performed and revealed infiltrating ductal carcinoma. Estrogen receptor and progesterone receptor testing were negative, while HER-2 receptor testing was positive. In addition to lumpectomy and breast irradiation, the treating doctor decides to add hormonal therapy with trastuzumab to the treating regimen. What study must be done prior to starting trastuzumab? (A) TSH and free T4 (B) Liver function tests (C) Echocardiogram (D) Creatinine clearance (E) CXR

-Answer is C

A 60-year-old man is found to have a 3 cm right adrenal mass on CT scan which was obtained a month earlier following a MVC. He is asymptomatic, and does not report a history of hypertension or diabetes. What is the most appropriate next step in management? (A) Repeat CT scan in 6 months (B) Percutaneous needle biopsy (C) Biochemical workup for hormone excess (D) Laparoscopic adrenalectomy (E) No further follow-up is necessary

-Answer is C

A 65-year-old female is diagnosed with aortic dissection beginning 2 cm distal to the left subclavian artery and extending distally. Her blood pressure is 180/ 70 mmHg, and her heart rate is 88/ min. Peripheral pulses are all 2 +, and her abdomen is soft and non-tender. What is the next best step in treatment? (A) Surgical repair (B) Aggressive IV fluids (C) Labetalol drip (D) Endovascular repair (E) Nicardipine drip

-Answer is C

A 71-year-old woman is evaluated for a lump in her right breast that she noticed 3 weeks ago. She denies any nipple discharge, nipple retraction, or skin changes. She has a sister who was diagnosed with breast cancer at the age of 57. She had menarche at the age of 9 and menopause at the age of 56. She had two children, one at the age of 39 and the other at the age of 41. On physical exam, the breasts are normal on inspection. Palpation reveals a 1.5 cm dominant lump that does not appear to be fixed to the surrounding structures in the left upper, outer quadrant. The patient has no other dominant masses in either breast. There is no axillary lymphadenopathy. What is the biggest risk factor in this patient predisposing her to breast cancer? (A) Early menarche (B) Family history of breast cancer (C) Older age (D) Age at first pregnancy (E) Late menopause

-Answer is C

An obese 52-year-old man with a 50-pack-year smoking history and hypertension controlled with chlorthalidone presents to a remote hospital without interventional capabilities with 30 min of crushing chest pain radiating to his left arm and jaw. Troponin and CK-MB levels are elevated, and ECG shows ST segment elevations in leads V1 through V4. He is treated with thrombolytic therapy, and his symptoms resolve. The next morning, the patient is found dead in his bed. Which of the following is the most likely cause of death? (A) Ventricular free wall rupture (B) Embolic stroke (C) Ventricular arrhythmia (D) Post-MI pericarditis (E) Overwhelming infection

-Answer is C

Preoperative medical optimization for a patient with a pheochromocytoma routinely includes: (A) Octreotide drip for 24 h before surgery (B) Control of hypertension with beta-blockade as first-line agent (C) Control of hypertension with alpha-blockade as first-line agent (D) Metyrosine (E) Diuretics for blood pressure management

-Answer is C

Which of the following is most consistent with an aldosterone-secreting adrenal adenoma? (A) Hyperglycemia, hirsutism, and abdominal striae (B) Hypertension and hyperkalemia (C) Hypertension and hypokalemia (D) Elevated plasma metanephrine and hypertension (E) Increased vanillylmandelic acid excretion and hypertension

-Answer is C

A 17-year-old African American male presents for a pre-participation physical before track season. A harsh systolic murmur is heard at the second right intercostal space. He denies ever experiencing chest pain, dizziness, or difficulty breathing. Which of the following would be expected on further workup? (A) T wave inversion on ECG (B) Laterally displaced PMI on palpation (C) Weak femoral pulses compared to brachial pulses (D) Increased intensity of the murmur with Valsalva maneuver (E) Increased intensity of the murmur with squatting

-Answer is D

A 17-year-old female presents with breast pain that she noticed for several months. She states that she feels multiple breast masses in both breasts. She denies any weight loss, fevers, or night sweats. She has no medical history or family history of breast cancer. Physical examination reveals that her heart has a regular rate and rhythm. The skin around the breast and areola are normal with no rashes or lesions. No solitary breast masses are palpable, but both breasts are lumpy and painful to palpation, most notably in the upper outer quadrants. There is no axillary lymphadenopathy. What is the most appropriate next step in management? (A) Diagnostic mammography (B) Excisional biopsy (C) Ultrasound-guided core needle biopsy (D) Reassurance and re-examine in 1 month (E) Fine-needle aspiration (FNA)

-Answer is D

A 30-year-old woman is recovering from an open cholecystectomy in the hospital. On the second postoperative day, she begins to complain of cramping abdominal pain without vomiting. She has no past medical or surgical history, and her postoperative course has been unremarkable. She is receiving oral hydrocodone for pain and is on a clear liquid diet. She has a temperature of 99.5 ° F, blood pressure is 128/ 84 mmHg, and pulse is 82/ min. Her physical exam is significant for absent bowel sounds, a mildly distended abdomen with mild diffuse tenderness without rebound or guarding. Which of the following would most benefit her abdominal findings? (A) Encouraging ambulation (B) Placement of a nasogastric tube (C) Neostigmine (D) Conversion of hydrocodone to a nonsteroidal anti-inflammatory drug (E) Return to the operating room for exploration

-Answer is D

A 32-year-old female patient arrives for follow-up for new-onset hypertension. She was started on hydrochlorothiazide 6 months ago. During her visit, she was found to have a blood pressure of 152/ 98 mmHg. She also complains of recent episodes where she experiences sudden palpitations, chest pain, diaphoresis, headache, and anxiety. Her laboratory exam demonstrates a calcium of 13.2 mg/ dl (normal 8.5- 10.2 mg/ dl), PTH of 102 pg/ ml (10- 55 pg/ ml), and an elevated plasma metanephrine. Which of the following would be an important additional component in the workup? (A) Fasting blood glucose (B) Prolactin level (C) MRI of the sella turcica (D) Serum calcitonin (E) Serum gastrin level

-Answer is D

A 35-year-old patient presents for a follow-up visit for an elevated serum calcium level of 12.8 mg/ dL and an elevated PTH. He is a thin man without a significant past medical history. He reports that for the past 2 weeks he has been experiencing loose stools, polydipsia, and polyuria. On physical exam he was found to have large erythematous erosions with blisters over the lower abdomen. Which tumor would best explain the patient's symptoms and rash? (A) Insulinoma (B) Prolactinoma (C) VIPoma (D) Glucagonoma (E) Adrenal adenoma

-Answer is D

A 39-year-old man is recovering from bilateral adrenalectomy for a pheochromocytoma. On his second postoperative day, he begins to complain of nausea, vomiting, weakness, blurry vision, and mild abdominal pain. His temperature is 102.9 ° F, and blood pressure is 90/ 68 mmHg. His ECG shows sinus tachycardia. His laboratory examination from that morning showed: Sodium: 134 mEq/ L (137- 145 mEq/ L) Potassium: 5.8 mEq/ L (3.6- 5.0 mEq/ L) Calcium: 7.4 mg/ dL (8.9- 10.4 mg/ dL) BUN: 12 mg/ dL (7- 21 mg/ dL) Creatinine: 1.2 mg/ dL (0.5- 1.4 mg/ dL) Glucose: 70 mg/ dL (65- 110 mg/ dL) Albumin: 2.4 g/ dL (3.5- 4.8 g/ dL) WBC 10.5 × 103/ μL (4.1- 10.9 × 103/ μL) Which of the following can best explain this patient's current presentation? (A) Volume depletion (B) Sepsis (C) Hypocalcemia (D) Low cortisol (E) Loss of catecholamine production

-Answer is D

A 50-year-old female has been recently diagnosed with primary hyperparathyroidism. She comes in to her doctor complaining of increased bone pain in her legs. She is found to have elevated serum calcium, alkaline phosphate, and PTH. Her doctor decides to order plain films of her lower extremities. The radiographs show very thin bones with a stress fracture and bowing of both femur bones. She also has characteristic cysts with a moth-eaten appearance. What is the most likely diagnosis? (A) Osteoporosis (B) Osteopetrosis (C) Osteomalacia (D) Osteitis fibrosa cystica (E) Paget's disease of the bone

-Answer is D

A 63-year-old woman with diabetes is recovering in the ICU after receiving a CABG for coronary artery disease. On the sixth postoperative day, she starts complaining of chest pain. Her temperature is 101.4 ° F, blood pressure is 108/ 72 mmHg, and pulse is 125/ min. On physical exam, there is drainage from her sternal wound, and there is a crunching sound heard with a stethoscope over the precordium during systole. The sternum feels somewhat unstable to palpation. Her laboratory examination is significant for an elevated white blood count (16.7 × 103/ μL). What is the most likely diagnosis? (A) Acute pericarditis (B) Postoperative MI (C) Empyema (D) Acute mediastinitis (E) Pneumonia

-Answer is D

A 65-year-old woman arrives to the ED complaining of chest pain. Her past medical history includes hypertension, atherosclerosis, and coronary artery disease. She underwent a coronary artery bypass graft (CABG) 3 weeks ago for three-vessel disease. She reports that her chest pain worsens with inspiration and lessens when leaning forward. A friction rub is heard on auscultation. ECG shows global ST elevation. What is the most likely diagnosis? (A) Myocarditis (B) Myocardial infarction (C) Cardiac tamponade (D) Acute pericarditis (E) Pulmonary embolism

-Answer is D

A Richter's hernia: (A) Most often contains colon or bladder in the posterior aspect of the sac (B) Has a low risk of incarceration (C) Most commonly presents as a small bowel obstruction (D) Can mislead the clinician as strangulated bowel can easily be missed (E) Should be manually reduced in the emergency department provided there is no evidence of bowel obstruction

-Answer is D

A patient is diagnosed with type A aortic dissection, and there is concern for cardiac tamponade. Which of the following findings would be the MOST consistent with cardiac tamponade? (A) Pulsus bisferiens (B) Watson's water hammer pulse (C) Peaked T waves (D) Equalization of central pressures (E) Pulsus alternans

-Answer is D

Which of the following is the most important risk factor for aortic dissection? (A) History of coronary artery bypass grafting (CABG) (B) Giant cell arteritis (C) Pregnancy (D) Hypertension (E) Bicuspid aortic valve.

-Answer is D

A 50-year-old woman comes to clinic to discuss treatment for a new diagnosis of breast cancer. Her annual screening mammogram revealed a 1.3 cm mass in the right breast. The patient does not have any other breast masses, skin changes, nipple discharge, or axillary adenopathy. Mammography revealed no other suspicious calcifications within the breast. Biopsy of the mass was performed and revealed infiltrating ductal carcinoma. Estrogen receptor, progesterone receptor, and Her2/ neu receptor testing were negative. Which of the following is the best option for the management of this patient's breast cancer? (A) Lumpectomy and breast irradiation (B) Lumpectomy and hormone therapy (C) Lumpectomy and chemotherapy (D) Lumpectomy, sentinel node biopsy, and breast irradiation (E) Lumpectomy, sentinel node biopsy, breast irradiation, and chemotherapy

-Answer is E

A 65-year-old male presents with a painful nodule in his wrist that is determined to be a ganglion cyst. Despite attempts at aspiration, it recurs. He is unable to work as a computer programmer, is on disability, and is feeling depressed. He is scheduled for wrist surgery. He reports having been discharged 1 week ago for an episode of chest pain. Troponins were elevated at that time, but there was no elevation of his ST segment. Which of the following is the best recommendation? (A) Proceed with surgery with intraoperative transesophageal echocardiography (B) Proceed with surgery but perform under local anesthesia with sedation (C) Proceed with surgery only if echocardiogram shows normal ejection fraction (D) Proceed with surgery after aggressive beta blockade to get heart rate into low 60s (E) Postpone surgery for at least 4 weeks

-Answer is E

A 65-year-old male undergoes a videoscopic right upper lobectomy for squamous cell lung cancer. On postoperative day one, he suddenly develops chest pain and diaphoresis. Blood pressure is 120/ 60 mmHg, and heart rate is 80/ min. Serial highly sensitive troponin I assays demonstrate levels of 0.4, 0.3, and 0.01 ng/ dl. ECG demonstrates nonspecific T wave changes with no ST segment elevation. Following the administration of oxygen, morphine, aspirin, and a beta-blocker, his symptoms resolve. What is the next step in the management? (A) Intravenous thrombolytic therapy (B) Percutaneous coronary intervention without stenting (C) Percutaneous coronary intervention with stenting (D) Coronary artery bypass graft (CABG) (E) Continue medical management and reevaluate as outpatient in 4- 6 weeks

-Answer is E

A 66-year-old woman presents to her family doctor complaining of a pain in her left groin that has appeared intermittently over the past several months. On physical exam, a soft mass is palpated in her left groin, below the inguinal ligament, and near her femoral pulse. On palpation, the mass is soft and slightly tender and disappears with gentle compression. Which of the following is true regarding these types of hernias? (A) They are the most common hernia type in women (B) The risk of strangulation is relatively low (C) The hernia sac travels lateral to the femoral vein (D) If discovered incidentally and the patient is asymptomatic, repair is not indicated (E) It is associated with multigravida

-Answer is E

A 76-year-old man is driven to the ED by his wife and is complaining of severe chest pain that started 30 min ago. He denies abdominal or extremity pain. Pulses in arms and legs are 2 +. His kidney function is normal. CT scan shows an aortic dissection. Which of the following findings on CT scan would most strongly indicate the need for urgent surgery? (A) Dissection of entire descending thoracic aorta (B) Involvement of common iliac arteries (C) Involvement of renal arteries (D) Extension into mesenteric vessels (E) Involvement of origin of innominate artery

-Answer is E

A worried mother presents to you with concerns that her 6-month-old boy has a large protrusion at his belly button that is worse when he cries but reduces when he is sleeping. On exam you palpate a 1 cm fascial defect at his umbilicus. Which of the following is true about this condition? (A) Elective repair is recommended (B) The condition is associated with cardiac anomalies (C) The size of the defect predicts that it will not likely close on its own (D) The risk of incarceration is significant (E) Repair should be delayed until the child is 4 years old

-Answer is E

An elderly nursing home patient has been bedridden for several months due to a series of debilitating strokes. Past medical history is significant for hypertension, controlled with a diuretic, and Paget's disease. Recently, the patient has been complaining of vague abdominal pain, constipation, and depressed mood. On physical examination, the patient is alert and oriented. Abdominal examination is unremarkable. Which of the following electrolyte abnormalities would most likely explanation her symptoms? (A) Hyponatremia (B) Hypernatremia (C) Hyperphosphatemia (D) Hypocalcemia (E) Hypercalcemia

-Answer is E

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-Based on the description of the site of the dissection, this is a type B aortic dissection. These are usually managed medically (A) unless the patient has evidence of malperfusion. Since her peripheral pulses are all 2 + and her abdomen is soft and non-tender, there is no evidence of malperfusion. The goal is to maintain a relatively low blood pressure in order to minimize stress on the aorta. Aggressive IV fluids (B) will not reduce blood pressure and may actually raise it. Nicardipine (E) will lower blood pressure, but intravenous beta-blocker is the treatment of choice because it also reduces the rate of pressure increase with each beat of the heart, which lowers the stress on the aortic wall. Endovascular therapy (D) is not routinely needed for most type B dissections.

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-DCIS is characterized by malignant epithelial cells within the mammary ductal system, without invasion into the surrounding stroma. Comedo-type DCIS is typically high grade and associated with a worse prognosis (C). DCIS lesions have a high risk of subsequent invasive carcinoma at the site of the DCIS. As such if left unresected, it will often progress to invasive ductal cancer. Thus the mainstay of DCIS treatment is lumpectomy (excision of entire lesion with negative margins). Lobular carcinoma in situ is considered a marker for malignancy in either breast (B). Breast cancer in males is rare (1 % of all breast cancers) with most cases identified as invasive ductal carcinoma. DCIS can occur in men but is even more rare, as DCIS most often presents as abnormal calcifications on mammogram (D). Radiation therapy can be used in combination with surgical excision, but cannot replace it (E).

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-Elevated serum calcium combined with elevated PTH is consistent with primary hyperparathyroidism. Rarely, it can be associated with MEN-1 which includes parathyroid, pituitary, and pancreatic pathology (3Ps). Pancreatic tumors include gastrinoma, insulinoma, VIPoma, and glucagonoma. Glucagonoma should be suspected in a patient with new-onset diabetes mellitus (even if thin), diarrhea, and the classic rash: annular, erythematous erosions with blisters over the lower abdomen (necrolytic migratory erythema). The patient's symptoms of polyuria and polydipsia are highly suggestive of diabetes mellitus. Insulinoma (A) is characterized by hypoglycemia, headache, visual changes, confusion, weakness, and diaphoresis. Prolactinomas (B) are excess prolactin-producing anterior pituitary tumors that may result in amenorrhea, galactorrhea, decreased libido, and gynecomastia. A VIPoma (C) (also called WDHA syndrome: watery diarrhea hypokalemia achlorhydria) presents with profuse diarrhea, but will not have any skin manifestations of the disease. An adrenal adenoma (E) is oftentimes benign, nonfunctional, and incidentally found on imaging (incidentalomas).

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-Hypercalcemia can cause abdominal pain, constipation, mental status changes, and depressed mood (stones, bones, moans and groans). Prolonged immobilization is a known cause of hypercalcemia and is seen in adolescents and in other patients with increased bone turnover such as Paget's disease. Certain diuretics (thiazide) also cause hypercalcemia by increasing renal calcium resorption.

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-If a patient that has undergone bilateral adrenalectomy presents postoperatively with severe hypotension and hypoglycemia, suspect Addisonian crisis (acute adrenal insufficiency) and check a cortisol level. This is considered to be a life-threatening condition caused by insufficient levels of cortisol, which is responsible for maintaining blood pressure and glucose homeostasis. Patients will present with nausea, vomiting, weakness, blurry vision, and mild abdominal pain. Laboratory exam would be expected to show hypoglycemia, hyperkalemia, and mild hyponatremia. Plasma ACTH levels will be low, and a Cortrosyn (synthetic ACTH) stimulation test will demonstrate a low cortisol response. This patient should receive immediate fluid resuscitation (normal saline) and intravenous corticosteroids. Acute adrenal insufficiency does not respond to vasopressors. Additionally, it can mimic sepsis. However, he does not meet SIRS criteria. Similarly, sepsis (B) is unlikely to present with this patient's lab abnormalities. Patients that have had major surgery should always be monitored for signs of internal hemorrhaging. Although his serum calcium is shown to be low (C), this should be corrected for hypoalbuminemia. His corrected serum calcium is 8.7 mg/ dL, is within the normal range, and would not explain the hypotension (B). Although he may be volume depleted (A), this would not cause hypoglycemia or hyperkalemia. Loss of catecholamine production (E) may accompany Addisonian crisis and is also seen after removing a pheochromocytoma. It is associated with hypotension and hypoglycemia; however, it will not cause hyperkalemia and hyponatremia.

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-It is important to know the timing of causes of death after MI. In the first 48 h after MI, death is likely due to ventricular arrhythmia. If arrhythmia occurs after 48 h, an implantable defibrillator should be placed. Ruptures of the myocardium, either as a ventricular septal rupture or free wall rupture (A), usually do not occur until 4- 5 days after MI, at which point the dead myocardium has been weakened by the body's inflammatory response. Post-MI pericarditis, also known as Dressler's syndrome, (D) usually occurs weeks or months after MI or cardiac surgery. An embolic stroke (B) would present with sudden onset of numbness on one side of the body, cranial nerve deficits, and/ or aphasia. It is unlikely to cause death so quickly. There is no reason to believe the patient has sustained an overwhelming infection (E).

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-It is important to rapidly identify Stanford type A dissections, as they require urgent surgical intervention due to the fact that they can lead to cardiac tamponade, acute aortic valve insufficiency, acute MI, and stroke. A Stanford A dissection involves the ascending aorta and/ or the aortic arch. Thus an aortic dissection involving the innominate artery is a Stanford type A. Stanford type B aortic dissection is more common. A Stanford type B dissection begins in the descending aorta, distal to the takeoff of the left subclavian artery (A- D). Stanford Type B dissections are much less likely to cause acute complications since the ascending aorta/ aortic arch are not involved. A type B dissection may involve the mesenteric, renal, or iliac arteries, but not occlude them, as blood may continue to flow normally (either though the true or the false lumen). Most can be managed medically with blood pressure control (beta-blockers). Surgical intervention is needed if the involvement of these vessels leads to malperfusion (such as leg ischemia, bowel ischemia, or renal failure).

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-Major predictors of adverse postoperative cardiac events must be identified prior to elective noncardiac surgery. These include recent (within 1 month) MI, unstable or severe angina, decompensated CHF, and significant arrhythmias. Such cardiac conditions require postponing surgery and performing further cardiac workup. A systolic, crescendo-decrescendo murmur at the sternal border of the right second intercostal space radiating into the neck is highly suggestive of aortic stenosis and would require an echocardiogram to rule out severe aortic stenosis. Aortic stenosis impairs coronary perfusion, which can become further exacerbated during induction of anesthesia. From all the choices listed, it portends the highest operative risk. Lee's revised cardiac risk index identifies intermediate risk factors; these include known coronary artery disease (B) history of CHF, history of stroke or TIA, insulin-dependent diabetes (C), creatinine > 2.0 mg/ dl (possibly D), and high-risk surgery (i.e., aortic). Adding a point for each factor and a assigning a score (from 0 to 6) are highly effective in stratifying cardiac risk. Interestingly, smoking (E) has not been shown to be an independent risk factor for adverse perioperative cardiac events in most studies.

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-Multigravida causes stretching of the abdominal musculature and increases the risk of femoral hernia. Femoral hernias occur in the femoral canal, inferior to the inguinal ligament traversing the empty space medial (C) to the femoral vein (recall the mnemonic "NAVEL" {from lateral to medial: femoral nerve, artery, vein, empty space, lymphatic}). The most common type of hernia in women, and in men, is an indirect inguinal hernia (A). Although femoral hernias appear infrequently (10 % of all hernias), they occur more commonly in females and have the highest risk of strangulation (B). Because of the high risk of strangulation, surgical repair of a femoral hernia is indicated (D) once diagnosed, regardless of whether the patient is having symptoms.

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-Osteitis fibrosa cystica is a skeletal disorder that results from a surplus of parathyroid hormone. Patients experience increased bone pain, bone fractures, and skeletal deformities with bowing of the bones. Radiographs show thin bones, fractures, and cysts with a moth-eaten appearance. Osteoporosis (A) usually occurs in elderly patients and is characterized by decreased bone density with normal mineralization. It does not have any associated cyst-like features. Similarly, osteopetrosis (B) would not have any cysts seen on plain films. Paget's disease (E) results from overactive osteoclasts and osteoblasts leading to excessive bone turnover and is characterized by tibial bowing, kyphosis, increased cranial diameter, and deafness. Patients with Paget's disease and osteoporosis have normal serum calcium, while patients with osteomalacia (C) would be expected to have decreased serum calcium.

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-Patients with MEN-2A can develop pheochromocytoma, hyperparathyroidism, and medullary thyroid cancer. The definitive management for pheochromocytoma consists of medical conditioning with alpha-blockade and sometimes beta-blockade for at least 2 weeks, followed by an adrenalectomy (B). This should be performed first (A, D- E) because a pheochromocytoma can increase the risk of complications during the surgical management of other endocrine tumors. Although he is asymptomatic with respect to his hyperparathyroidism, parathyroid surgery is generally recommended for most patients with inherited forms, as it tends to be more aggressive and presents at a much younger age. Age less than 50 is an indication for parathyroid surgery for sporadic forms as well, as the patient is more likely to suffer one of the sequelae of hyperparathyroidism.

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-Patients with a recent history of myocardial infarction are at risk of thrombus formation on the scarred endocardium, which can then embolize to the brain and cause a stroke. Patients with a recent history of MI and evidence of thrombus on echocardiography should be treated with warfarin to maintain an INR of 2- 3 and followed up within 3 months. Thromboembolism from the left atrial appendage (D) is a concern in patients with atrial fibrillation. Paradoxical venous thromboembolism (E) is a concern in patients with an atrial septal defect or patent foramen ovale, wherein a deep venous thrombus can travel through the defect into the left heart and ultimately to the brain. Septic embolism (B) is a concern in IV drug abusers and can lead to cerebral abscess. Type A dissection (C) would usually present with severe chest pain radiating to the back.

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-Patients with hyperaldosteronism have hypertension and hypokalemia - not hyperkalemia (B). Aldosterone acts on the kidney to increase sodium reabsorption, and potassium is excreted to balance the positively charged sodium ions. Hyperglycemia, hirsutism, and abdominal striae (A) are more consistent with Cushing's syndrome. Elevated plasma metanephrine, hypertension, and increased vanillylmandelic acid excretion (D, E) are all consistent with pheochromocytoma.

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-Patients with pheochromocytoma are volume depleted due to intense alpha-mediated vasoconstriction. Hypertension is controlled with alpha-blockade (e.g., phenoxybenzamine) for 10- 14 days before surgery. This allows for volume expansion, and the patient is encouraged to liberally intake salt and fluids. The dose is titrated until hypertensive episodes are controlled, often resulting in mild orthostatic hypotension. Beta-blockers (B) can be used to decrease reflex tachycardia once appropriate alpha-blockade has been established. Initiating beta-blocker therapy prematurely can precipitate a hypertensive crisis due to unopposed alpha-adrenergic vasoconstriction. Octreotide (A) is a somatostatin analogue that may have minimal efficacy in the palliation of symptoms from malignant pheochromocytoma, but it has no role in preparing a patient for surgery. Metyrosine (D) inhibits catecholamine production and is a secondary agent for pheochromocytoma, though now rarely used. Diuresis (E) would be contraindicated as these patients are volume depleted.

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-Plasma free metanephrine is highly sensitive for pheochromocytoma but is more prone to false-positive results. Plasma chromogranin A is released from neuroendocrine cells and is elevated in the majority of patients with pheochromocytoma. It is nonspecific (i.e., it is elevated in other neuroendocrine tumors) but can help confirm the diagnosis. Superoxide dismutase and malondialdehyde (B, C) are both markers for oxidative stress, and neither has been shown to be associated with pheochromocytoma. CA 19- 9 (D) may be elevated in some patients with pancreatic cancer. Increased level of 5-hydroxyindoleacetic acid (HIAA) (E) would be expected in a patient with carcinoid syndrome.

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-Proceeding with elective surgery 1 week after an acute MI is inappropriate (A- D). Patients with a recent MI are at significantly increased cardiac risk during noncardiac surgery, particularly within the first month after MI. Since the proposed operation is elective, options A- D would place the patient under unnecessary risk. Although performing the operation under local anesthesia with sedation (B) seems appealing, there is still considerable stress and cardiac risk with such an approach. The best recommendation for this patient is to postpone surgery for at least 4 weeks. At that point, consideration should still be given to cardiac stress testing prior to surgery or even further surgical delay, as the cardiac risk persists for at least 6 months after an MI.

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-Severe hypertension in a young patient should raise suspicion for surgically correctable causes such as aldosteronoma, Cushing's disease, coarctation of the aorta, fibromuscular dysplasia of the renal arteries, and pheochromocytoma. Her symptoms, combined with an elevated plasma metanephrine level, make pheochromocytoma the most likely cause. The addition of labs consistent with primary hyperparathyroidism (elevated calcium and PTH) suggests she has MEN-2A which is characterized by primary hyperparathyroidism, pheochromocytoma, and medullary thyroid cancer. Calcitonin is a reliable tumor marker for medullary thyroid cancer and should always be ordered to rule out this very aggressive cancer in this patient population. Fasting blood glucose (A) (insulinoma), prolactin levels (prolactinoma) (B), MRI of the sella turcica (C) (pituitary adenoma), and serum gastrin level (E) (gastrinoma) are all associated with MEN-1.

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-Sliding inguinal hernias have a much higher risk of colonic injury during repair than other hernias. This is because the posterior wall of the hernia sac is formed by a retroperitoneal organ (colon or bladder). A clue to the presence of a sliding hernia is the finding of a thickened posterior wall of the hernia sac at surgery, in association with a large indirect hernia (D) that has descended into the scrotum (direct hernias rarely descend into the scrotum). Attempting to completely excise the hernia sac (A) (which is otherwise normally done), or to divide the sac completely at the internal ring (E) (which is again normally recommended), would result in dividing the bowel or bladder. Sliding hernias are more common on the left side (C) (the sigmoid colon is less fixed and more likely to slide down than the right colon). A sliding hernia is an indirect inguinal hernia (D).

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-The MUGA scan is the most accurate test in measuring ejection fraction. It is a noninvasive nuclear test that uses a radioactive isotope called technetium to evaluate the function of the ventricles. Though not as accurate, an echocardiogram (B) is used more commonly because it is cheaper and more readily available and can look for valve function as well as focal areas of wall motion abnormality. Electrocardiogram (C) and exercise stress test are unable to measure a patient's ejection fraction. Coronary angiography (D) is considered the gold standard in identifying coronary artery disease and can estimate ejection fraction, but is not as accurate.

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-The classic signs of severe aortic stenosis are angina (A), syncope (C), and congestive heart failure (which may manifest as swollen legs). Of the three, congestive heart failure portends the worst prognosis, with median survival as low as 2 years. A loud mid-systolic murmur (D) indicates hemodynamically significant obstruction but is a better prognostic sign than an absent murmur, which indicates low blood flow across the valve. Small head nodding movements with each heartbeat (E) are known as de Musset's sign and is found in aortic regurgitation.

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-The first step in the evaluation of an incidentally discovered adrenal mass is to perform a biochemical workup to determine if the tumor is functional or nonfunctional (E). In practice, it is common to order a single battery of tests: serum aldosterone, plasma renin activity, and a 24-h urine collection to simultaneously measure catecholamines, metanephrines, and cortisol. Given that this patient is normotensive, the suspicion for pheochromocytoma and hyperaldosteronism is low. In addition, adrenal masses < 6 cm are unlikely to be malignant. If the mass is found to be a hormonally active adrenal adenoma, then laparoscopic adrenalectomy (D) would be recommended. If biochemical testing reveals a nonfunctioning mass, this small lesion may be observed with interval CT scanning (A). Percutaneous needle biopsy (B) cannot readily distinguish between benign and malignant primary adrenal tumors. .

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-The genital branch of the genitofemoral nerve provides sensation to the scrotum and the cremaster reflex. The femoral branch of the genitofemoral nerve (B) provides sensation to the proximal medial thigh. The ilioinguinal nerve (C) provides sensation to the lower abdomen and medial thigh. The lateral femoral cutaneous nerve (D) provides sensation to the lateral thigh as low as the knee. The iliohypogastric nerve (E) supplies the gluteal region.

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-The history and physical exam is most consistent with a diagnosis of fibrocystic changes of the breast, which is considered a normal variant of the breast in adolescents and young adults. Patients will present with painful breast tissue before menses that improves during menstruation. On examination, fibrotic tissue may be palpated and is generally found in the upper outer quadrants of the breast. This patient should be counseled and instructed to look for these changes with a follow-up appointment in a month. Persistent cystic breast lesions can be evaluated and treated with fine-needle aspiration (E), although this is not be needed in children and adolescents. Cystic lesions that resolve with aspiration should be reevaluated with ultrasonography 3 months after aspiration (C). Excisional biopsy (B) may be warranted for cystic lesions that do not resolve with aspiration or for suspicious solid lesions. Diagnostic mammography (A) is not indicated for adolescents and should be reserved for females > 30 years old who present with a breast mass.

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-The most important risk factors for breast cancer are female gender, increasing age, and a family history of premenopausal breast cancer. A new breast mass in a woman over the age of 50 should be considered cancer until proven otherwise, as it carries the highest relative risk of being cancer. A family history of breast cancer (B) can also significantly increase the risk of breast cancer, particularly if diagnosed in a premenopausal woman. The majority of inherited breast cancers are associated with BRCA1 or BRCA2 gene mutations. Other important risk factors associated with a slightly higher risk of developing breast cancer include early menarche (A), nulliparity or older age at first full-term pregnancy (D), and/ or late menopause (E).

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-The patient likely has hypertrophic obstructive cardiomyopathy, an asymmetric thickening of the ventricular septum that creates a narrowing of the left ventricular outflow tract. Vigorous exercise places him at increased risk of sudden cardiac death. T wave inversion (A) would be found in ischemic heart disease, very unlikely in an otherwise healthy 17-year-old. Laterally displaced PMI (B) would be found in patients with congestive heart failure, also very unlikely in this patient. Weak femoral pulses compared to brachial pulses (C) is a finding in coarctation of the aorta, and would not create the characteristic murmur. Murmurs due to aortic regurgitation, mitral regurgitation, and ventricular septal defect (VSD) increase in intensity with squatting (E).

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-The patient most likely has inflammatory breast carcinoma, an especially aggressive type of breast cancer. Inflammatory breast cancer can be easily confused with mastitis, as there is usually no palpable breast mass and ultrasound and mammography similarly are often negative. As such, it is imperative to perform a biopsy of the skin, which may show cancer cells invading the subdermal lymphatics. Additional workup should include a breast MRI (which is more likely to show the breast cancer in this setting than ultrasound and mammogram), as well as consideration for needle biopsy of the lymph nodes. Antibiotics (B- C) or NSAIDs (D) would be inappropriate. Incision and drainage (E) would be appropriate if there was an indication on physical examination or evidence of a breast abscess on ultrasound. Inflammatory breast carcinoma typically presents as swelling of the breast and with edematous skin due to obstruction of subdermal lymphatics by tumor (termed peau d'orange, meaning orange peel in French). At presentation, positive lymph node involvement is frequent, and approximately one-third of patients have distant metastases. Inflammatory breast carcinoma can present during pregnancy and should be suspected if suspected mastitis does not respond to appropriate antibiotic treatment.

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-The patient most likely has lactation mastitis. Lactation mastitis is a localized, painful inflammation of the breast accompanied by fever and malaise occurring in breastfeeding women. The diagnosis of mastitis is made clinically based on an erythematous, tender, swollen area of one breast associated with fever in a nursing mother. Other symptoms may include muscle pain (myalgias) and malaise. Transmission occurs via introduction of bacteria in small breaks in the skin caused by the trauma of breastfeeding. Most cases of lactation mastitis are a result of an infection by Staphylococcus aureus. Treatment consists of antibiotics to cover skin flora, symptomatic relief with analgesics including anti-inflammatory agents such as ibuprofen, and cold compresses to reduce local pain and swelling. Patients should be encouraged to continue breastfeeding (C) as this helps relieve any ductal obstruction that might be contributing to the infection. Biopsy (A) would be appropriate if the patient has suspected inflammatory breast carcinoma. Although very rare, inflammatory breast carcinoma can occur during pregnancy. If mastitis fails to resolve after antibiotics, then consideration should be given to performing a biopsy of the skin. Diagnostic mammography (D) would not be indicated at this time. Incision and drainage (E) is appropriate if there was evidence of a localized abscess with fluctuance. Ultrasound can help differentiate mastitis from a breast abscess.

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-The presentation is concerning for Paget's disease of the breast. This presents as an eczematous, scaling, and ulcerating lesion around the areola. Paget's disease of the breast is a type of DCIS that extends into the ducts to involve the skin of the nipple. Patients are initially misdiagnosed with a skin condition, including eczema and psoriasis, and receive a variety of ointments that do not resolve the lesion. Paget's disease of the breast is almost always associated with an underlying carcinoma and must be diagnosed via biopsy of the lesion. Trying different regimens of steroids and antibiotics is inappropriate given the high likelihood that she has cancer (B- E).

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-This patient has a SBO with evidence of ischemic or gangrenous bowel most likely secondary to adhesions from past surgery (e.g., sigmoidectomy). Necrotic bowel generally does not occur in association with a SBO unless there is a closed-loop obstruction. A closed-loop obstruction is a particularly dangerous form of bowel obstruction in which a segment of intestine is obstructed both proximally and distally. Gas and fluid accumulate within this segment of bowel, and cannot escape. This progresses rapidly to strangulation with risk of ischemia, gangrene, and subsequent perforation. Clues to ischemic bowel include the presence of acidosis, fever, leukocytosis, and severe localized pain (unusual for SBO). As such the patient will need exploratory laparotomy, and any bowel that is obviously nonviable needs to be resected. Most patients with SBO (without necrotic bowel) due to adhesions improve with conservative management, and do not require surgery. Observation is not appropriate for this patient (B). Upper GI studies (C- D) would not be indicated since this patient has strong evidence of necrotic bowel and requires urgent surgical intervention. RUQ ultrasound (E) is appropriate in the workup for cholelithiasis.

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-This patient has a postoperative right-sided MI, resulting in compromised cardiac output secondary to decreased preload. One of the steps in management of right-sided MI is to administer fluids to help increase filling of the heart. Avoid nitrates (B, C) in these patients as it may further reduce preload. Acutely, patients with MI need oxygen, aspirin, analgesics, and beta-blockers. Dihydropyridine calcium channel blockers, such as nifedipine (D), are contraindicated in MI because of the associated peripheral vasodilation that may lead to reactive tachycardia and subsequently result in even more stress on the heart. ACE inhibitors (E) should be considered for long-term treatment after the acute episode has resolved.

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-This patient has a thyroglossal duct cyst, which is the most common midline congenital malformation of the neck. Though present at birth, these do not often appear until age 2 as baby fat recedes. During embryological development, the thyroid originates at the base of the tongue and travels down the thyroglossal duct to the anterior neck, where it normally involutes. However, if a persistent duct remains, it may undergo cystic dilation later in life and present as a well-defined anterior neck mass, located midline and above the cricoid cartilage. Unlike a brachial cleft cyst, this elevates with tongue protrusion or swallowing. Ectopic thyroid gland may be associated with thyroglossal duct cysts so it's necessary to confirm the thyroid gland is in its correct anatomic location prior to surgical intervention. The definitive management involves thyroglossal duct cyst excision or the Sistrunk procedure. Reassurance and observation (C) are inappropriate as thyroglossal duct cysts have a high rate of recurrent infections and a small risk of progressing to malignancy. FNA biopsy (A) is appropriate for a thyroid nodule, but not for suspected thyroglossal duct cyst. He does not have symptoms suggestive of hyper- or hypothyroidism so a thyroid panel would not be indicated (D). CT scan (E) is unnecessary for the diagnosis, and additionally should not be performed in such a young patient secondary to significant radiation exposure.

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-This patient is diagnosed with infiltrating ductal carcinoma. Treatment for stage I and II breast cancers includes the option of breast conserving therapy (BCT), which consists of excision of the primary tumor (lumpectomy), sentinel lymph node biopsy (SLNB), followed by radiation therapy to the remaining breast. Studies have shown that breast conserving therapy leads to survival rates that are equivalent to that of mastectomy (though a higher local recurrence rate), while providing a more aesthetically pleasing surgical result. Triple negative breast cancers (ER, PR and Her2/ neu receptor) are thought to have a worse prognosis as it is insensitive to some of the best therapies (tamoxifen and aromatase inhibitors for hormone positive, and trastuzumab for Her2/ neu positive). As such, chemotherapy is recommended postoperatively.

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-This patient likely has ischemic orchitis secondary to damage to or thrombosis of the pampiniform plexus. This is most likely to occur in patients with large or densely adhesed hernia sacs. The condition is usually self-limited (E), so urgent exploration (B) is not indicated. Ischemic orchitis is more commonly caused by injury to the pampiniform plexus than to the testicular artery (C). Testicular torsion (D) is less likely than a vascular injury in this case, although both would present with acute testicular pain and decreased or absent Doppler signal.

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-This patient presents with the rare but classic presentation of pheochromocytoma during pregnancy. The preferred imaging modality in pregnancy is an MRI, due to the risks of exposing the fetus to radiation with other types of imaging (A, D). In men and non-pregnant women, CT with contrast can also be considered a first line imaging study. Pheochromocytoma is usually hyperintense on T2-weighted images due to its high water content. Failing to work up and treat a potential pheochromocytoma in pregnancy exposes the fetus and mother to a very high risk of mortality during the pregnancy and delivery (B, E).

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-This patient was incidentally found to have an adrenal mass. Guidelines for surgical resection include tumors > 6 cm, features on CT suspicious for malignancy (high attenuation, irregular borders, inhomogeneous), and those that are hormonally active. Most adrenal carcinomas are hormonally active. Thus the patient described has several indications for adrenalectomy. Open adrenalectomy is preferred when malignancy is suspected, as this allows for a wider resection with en bloc resection if adjacent structures are involved and eliminates the possibility of seeding the port sites that may occur with laparoscopic adrenalectomy (C). Laparoscopic adrenalectomy is preferred for benign lesions. Radiation therapy (D) is not the mainstay of treatment for adrenal cortical carcinoma. Percutaneous biopsy (E) is not recommended as there are no histologic features that diagnose adrenal cortical carcinoma and a biopsy may risk seeding the biopsy tract.

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-Trastuzumab is a monoclonal antibody that blocks the HER-2 receptors. The medication is used in the treatment of HER-2-positive breast cancers to help reduce recurrence and improves survival. Since there is a high risk of cardiomyopathy in patients receiving trastuzumab, it is recommended that all patients receive an echocardiogram prior to initiating therapy with trastuzumab. An alternative is to obtain a MUGA scan (multigated acquisition scan), which is a nuclear study that evaluates ventricular function. Trastuzumab-related cardiotoxicity is most often manifested by an asymptomatic decrease in ejection fraction. The optimal surveillance for trastuzumab-related cardiotoxicity is not well defined. The remaining answer choices are not needed prior to starting trastuzumab (A- B, D- E).

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-Wide mediastinum on chest X-ray is concerning for aortic dissection. Patients with type A aortic dissection can present with coronary artery malperfusion and thus have a similar presentation as an acute MI. Suspected aortic dissection is considered an absolute contraindication to thrombolysis in patients with myocardial infarction. The remaining choices (A- B, D- E) are all relative contraindications for intravenous thrombolytics.

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Although bloody nipple discharge should raise concern for cancer, intraductal papilloma is the most common cause of bloody nipple discharge. This is a benign breast tumor arising from the proliferation of mammary duct epithelium that classically occurs in females 20- 40 years of age. Treatment includes excision, which is diagnostic as well as curative. Fibrocystic changes (A) are a common cause of breast pain in young females. Patients report painful breast tissue before menses with improvement during menstruation. Physical exam reveals fibrotic tissue and cystic, lumpy tissue. It may be associated with bilateral serous discharge. DCIS (C) and infiltrating ductal carcinoma (E) are more common in older women. DCIS most often presents as suspicious calcifications on mammography, and not with bloody nipple discharge. Although breast cancer can present with bloody nipple discharge, it is less common than intraductal papilloma, especially in a young woman. Paget's disease of the breast (D) causes an eczematous lesion on the breast that is associated with an underlying breast carcinoma. Given that this patient's skin exam is normal, this diagnosis is unlikely.

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Always consider a nonmechanical postoperative ileus in patients that have had a recent surgery. This occurs in up to 50 % of patients that have undergone abdominal surgery. Although the exact cause has not been elucidated, it most likely involves impaired peristalsis of intestinal contents. Inflammatory mediators (e.g., recent surgery) and opioid analgesics are thought to contribute to the development of postoperative ileus. Initial management should begin with changing pain medication to a non-opiate analgesic. Encouraging ambulation (A) should also be done for all postoperative patients, but is not as imperative as discontinuing opiates. If the patient's postoperative ileus continues with worsening symptoms (e.g., emesis), bowel decompression including a NGT (B) can be considered. Returning to the OR for exploration (E) is inappropriate for postoperative ileus. Neostigmine is used in patients with pseudo-obstruction

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In cardiac tamponade, fluid (blood or effusion) in the pericardial space externally compresses the heart, which limits diastolic filling and reduces stroke volume. Since pericardial fluid is free flowing, the pressure is distributed equally along the pericardium. As this continues the rising pressure in the pericardium is transmitted to all four cardiac chambers resulting in equalization of central pressures. Pulsus bisferiens (A), also known as a biphasic pulse, refers to two strong systolic pulses with a mid-systolic dip, in other words, two pulses during systole. It can be seen in aortic regurgitation with or without aortic stenosis and hypertrophic cardiomyopathy. Watson's water hammer pulse (B) is a pulse with a rapid upstroke and descent seen in patients with aortic regurgitation. Peaked T waves (C) is most often associated with hyperkalemia. It is unlikely to be seen in patients with cardiac tamponade since their ECG findings are characteristically low voltage. Pulsus alternans (E) is a physical exam finding wherein the amplitude of a peripheral pulse changes from beat to beat associated with changing systolic blood pressure. It is most commonly caused by left ventricular failure.

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Sudden onset of severe abdominal pain in association with an aortic dissection should always raise suspicion for malperfusion of the bowel which can lead to bowel gangrene and death. This most likely would occur if the dissection extends into, and suddenly occludes, the superior mesenteric artery, which supplies blood to the bowel from the ligament of Treitz to the mid-transverse colon. It is also important to recognize that bowel ischemia early on causes excruciating pain in the absence of peritonitis (" pain out of proportion to physical exam"). He has not been on broad-spectrum antibiotics, and has no reason to have C. difficile infection (A), which most often presents with vague abdominal pain and diarrhea. Pancreatitis (C) presents with epigastric pain radiating to the back, nausea, vomiting, anorexia, fever, and tachycardia and is most commonly associated with cholelithiasis and alcohol abuse. Aortoenteric fistula (D) is a possible long-term sequela in patients who have had an intra-aortic synthetic graft placed. Diverticulitis (E) is a common cause of left lower quadrant abdominal pain in elderly patients, and does not typically cause such sudden severe pain.

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The patient has suffered a postoperative NSTEMI. Most NSTEMI (as opposed to a STEMI) in the postoperative setting are managed without percutaneous coronary intervention (PCI) with a combination of oxygen, morphine for pain relief, aspirin, and a beta-blocker. Optimally, an additional antiplatelet agent (such as clopidogrel) and intravenous heparin are also given, but this depends on how recent the operation was and the potential for postoperative bleeding. Consideration should be given to stress testing at 4- 6 weeks after surgery, and depending on the results, PCI is then considered. Urgent PCI (B, C) is indicated in the setting of a STEMI, and in certain high-risk NSTEMIs (continued rise in troponins, ongoing chest pain), but will require clopidogrel (again may not be desirable so soon after surgery) if a stent is placed. The patient described has a down trend of troponins and relief of symptoms, further supporting medical management. Emergent CABG (D) would be considered if PCI fails or is not technically feasible with severe three-vessel disease. Emergent operations for acute MI continue to have a high mortality despite many technological advances in myocardial protection. Thrombolytic therapy (A) is an alternative when PCI is not available but would be contraindicated within 2- 3 weeks of major surgery.

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This patient has an umbilical hernia, which is a common finding in newborns. It is recommended that repair be delayed (A) until after the child is 4 years old, unless the defect is larger than 2 cm, the defect is growing, or there is evidence of strangulation. Umbilical hernias are not associated with the VACTERL (vertebral, anal, cardiac, tracheoesophageal fistula, renal, limb) complex of anomalies (B). Defects smaller than 2 cm will likely close spontaneously (C). It is very rare for umbilical hernias in children to incarcerate (D).

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This patient has evidence (on history, physical, and radiologic imaging) of a small bowel obstruction (SBO) that is most likely secondary to adhesions from prior surgery (scar in RUQ). SBO from adhesions can present many years after surgery. The initial management of SBO includes placing the patient NPO, aggressive intravenous fluid resuscitation (the patient is tachycardic and likely very dehydrated), and NG tube placement. Aside from the salutatory effect of NG decompression on the distended bowel, patients with SBO are at risk of aspiration. Once the patient has been adequately resuscitated, CT scan (E) with oral contrast is recommended as it is useful in confirming the diagnosis of SBO, determining if the SBO is partial or complete, and ruling out other diagnosis. Most patients with SBO due to adhesions improve with these maneuvers, and do not require surgery. Operative management (C) with laparotomy and lysis of adhesions should be considered in the following conditions: if the patient demonstrates evidence of clinical deterioration as manifest by increasing pain, tenderness, fever, leukocytosis, or acidosis. Operative management can be achieved either via open laparotomy or laparoscopy (B). Evidence of a complete SBO is a relative indication for surgery, but recent studies suggest that some of these patients resolve with nonoperative management as well. Intravenous erythromycin acts as a prokinetic agent and has some utility for gastroparesis, but not for a SBO (D).

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This patient's presentation is most concerning for acute mediastinitis. This is a life-threatening infection of the mediastinum with a very high mortality rate that is most commonly associated with cardiac surgery. The incidence rate is 1- 2 % following CABG. The source of infection may be a sternal wound infection, combined with instability of the sternum that permits bacteria to enter the mediastinum. Hamman's sign is a crunching sound heard with a stethoscope over the precordium during systole and is suggestive of acute mediastinitis. Patients will frequently present with chest pain, increased drainage from sternal wound, fevers, and leukocytosis. Chest radiograph findings include pneumomediastinum and/ or air-fluid levels within the mediastinum. A CT scan can also support the diagnosis by demonstrating dehiscence of the sternum and stranding, fluid and air pockets within the anterior mediastinum. Management includes surgical debridement, drainage, antibiotics, and rewiring the sternum. Acute pericarditis (A) will present with pleuritic chest pain that lessens when leaning forward, friction rub heard on auscultation, and characteristic ECG findings (global ST elevation). Pneumonia (E) would present with shortness of breath, productive cough, and abnormal lung sounds. Postoperative MI (B) would not be expected to present with evidence of systemic inflammation. Empyema (C) is defined as pus in the pleural space, and would not explain the physical exam findings of sternal instability and Hamman's sign. CT scan would demonstrate a loculated fluid collection within the right or left pleural cavity.

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With a Richter's hernia, only one wall of the bowel protrudes into the hernia sac (A). That segment of bowel is prone to incarceration and strangulation but does so without associated symptoms, signs, or radiologic evidence of SBO (C). Therefore, it may easily mislead clinicians into thinking that the hernia is not incarcerated (B). Manual reduction of hernias (including Richter's) should not be attempted if strangulation is suspected as dead bowel will be reduced into the peritoneum. Strangulation should be suspected in the presence of fever, leukocytosis, acidosis, severe pain, or marked erythema overlying the skin of the hernia. It is often difficult to palpate a Richter's hernia, and it should be reduced in the operating room (E).