ROSH General surgery
Triad for Wolff-parkinson white syndrome (EKG characteristics)
1. Slurred upstroke of QRS (delta wave) 2. shortened PR interval 3. Wide QRS
What is the goal INR in a patient anticoagulated with warfarin due to a mechanical heart valve?
2.5-3.5.
A 27-year-old man presents with generalized weakness. He appears pale on physical examination. Laboratory testing is obtained demonstrating a hemoglobin of 8.5 g/dL. On further questioning, he has been taking ibuprofen three times a day for the last 10 days for a knee injury. Which of the following do you expect to find on physical examination? A. Melena B. Petechiae C. Stool mixed with bright red blood D. Tenderness on rectal examination
A
A 24-year-old woman presents with intense right lower quadrant abdominal pain. Diagnostic imaging confirms acute appendicitis without evidence of intra-abdominal abscess or perforation. Which of the following pharmacologic treatments would be most appropriate for this patient? A. A single dose of intravenous cefotetan 2 grams given preoperatively B. A single dose of intravenous metronidazole 500 mg given preoperatively C. Ertapenem 1 g intravenously daily for five days D. Levofloxacin 750 mg daily and metronidazole 500 mg every 8 hours for five days
A
A 28-year-old man with hemophilia A presents to the clinic for presurgical consultation for an epidermal inclusion cyst removal. His hematology records reveal a mild severity of his hemophilia for which he is not taking any daily prophylactic therapy. Which of the following therapies should be employed prior to his surgery? A. Desmopressin B. Fresh frozen plasma C. Protamine sulfate D. Vitamin K
A
A 28-year-old woman is brought into the emergency room by ambulance from home, after sustaining a head injury when riding her bike in traffic without a helmet earlier this morning. The patient's boyfriend reports that she initially had told him that she "came to" on the sidewalk after the accident and that a pedestrian had offered to call for an ambulance, but she declined. The boyfriend reports when at home, she had initially complained of a headache, but was acting normally up until three hours ago when she was difficult to arouse from a nap and became disoriented while slurring her speech. On physical examination, the patient is found to have a GCS of 6, a left dilated pupil, a heart rate of 48 beats per minute, and a blood pressure of 168/92 mm Hg. After intubating the patient, she is brought to CT scan which reveals a lenticular shaped collection. Which of the following is the most likely diagnosis? A. Epidural hematoma B. Hydrocephalus C. Subarachnoid hemorrhage D. Subdural hematoma
A
A 31-year-old man presents to the emergency department after an episode of syncope following sexual intercourse. Upon regaining consciousness at home, patient began complaining of a severe headache and started to vomit. Physical examination reveals an uncomfortable man with positive meningeal signs. Blood pressure is 162/94 mm Hg. CT scan of the head without contrast reveals no acute pathology. Based on the most likely diagnosis, what would you expect on the patient's lumbar puncture? A. Decreased opening pressure B. Decreased protein C. Elevated glucose D. Hemoglobin degradation products
A
A 33-year-old woman who is obese presents with sudden onset of fever and abdominal pain. On physical exam she is found to be jaundiced and her blood pressure is 88/58 mm Hg. She has epigastic pain with palpation. She is found to have elevated liver enzymes and leukocytosis. In addition to administering broad-spectrum parenteral antibiotics, which of the following interventions is the best choice for the suspected diagnosis? a. Endoscopic retrograde cholangiopancreatography b. Esophagogastroduodenoscopy c. Laparoscopic cholecystectomy d. Laparoscopic herniorrhaphy
A
A 37-year-old man presents with burning in his rectum. Earlier today, he had severe, sudden pain while having a bowel movement and noted a small amount of bright red blood on the toilet paper while wiping. What is the most likely etiology of his symptoms? a. Anal fissure b. Anorectal fistula c. Procidentia d. Thrombosed external hemorrhoid
A
A 42-year-old man presents to the clinic complaining of 6 months of intermittent chest pain. He feels the pain tightening his chest, and it is most noticeable with moderate activity like mowing the lawn or going for long walks. He has not had a heart attack before but is worried he may have one in the future. He has no remarkable past medical history, but on initial appearance, he seems overweight. His vital signs in the clinic show a heart rate of 79 beats per minute and blood pressure of 147/91 mm Hg. Physical examination is normal. You order an ECG, which shows normal sinus rhythm. Which of the following is the most appropriate test to determine this patient's cardiac risk? A. Exercise stress ECG B. Pharmacologic stress ECG C. Repeat resting ECG D. Stress echocardiogram
A
A 46-year-old man presents to the emergency department complaining of waxing and waning left flank pain associated with intermittent nausea and vomiting. A urinalysis shows a moderate amount of white blood cells and red blood cells. A plain abdominal radiograph is positive for a 4 mm stone in the left ureter. Which of the following is the stone most likely composed of? A. Calcium phosphate B. Cystine C. Struvite D. Uric acid
A
A 54-year-old man presents to clinic complaining of abdominal pain and watery diarrhea. He has had these symptoms intermittently for the last two years. He has a history of endoscopy-confirmed peptic ulcer disease with multiple peptic ulcers that have been refractory to treatment with a proton pump inhibitor. He denies any nausea, vomiting, hematemesis, melena, or hematochezia. Physical exam shows moist mucous membranes, normal heart sounds, clear lung sounds, and epigastric tenderness. His blood glucose level is 132 mg/dL. Which of the following tests should be performed next? a. Fasting serum gastrin level b. Fasting serum vasoactive intestinal peptide level c. Serum glucagon level d. Urine catecholamine levels
A
A 55-year-old man with a history of alcohol use disorder presents with epigastric abdominal pain, nausea, and several episodes of emesis for the past 2 days. The pain is much worse after eating. A review of systems is positive for unintentional weight loss and steatorrhea over the last few months. He also reports episodes of pain and emesis like this multiple times in the past. Serum amylase and lipase are within normal limits. A CT scan of the abdomen is ordered. Which of the following is the most likely finding on diagnostic imaging? A. Calcifications of the pancreas B. Obstructive gallstone C. Pancreatic duct stricture D. Pericholecystic fluid
A
A 57-year-old woman with a history of recurrent nephrolithiasis presents to the clinic for evaluation of ongoing nausea, constipation, loss of appetite, generalized bone pain, and depressed mood. Laboratory results include elevated serum calcium, elevated parathyroid hormone levels, and decreased phosphate levels. A sestamibi scan performed was suspicious for a right inferior parathyroid gland adenoma. During the surgical excision of the parathyroid adenoma, which of the following should be measured intraoperatively to confirm the cause of the primary hyperparathyroidism has been removed? A. Parathyroid hormone level B. Serum calcium level C. Serum phosphate level D. Urine calcium excretion level
A
A 58-year-old man presents to the ED complaining of a moderate amount of hemoptysis that began earlier that day. He has no history of cigarette smoking or chronic lung disease. He has felt ill for the past week and has had an ongoing dry cough. After further clarification, he estimates he has expectorated < 30 mL of blood. Which of the following is the best next step in evaluating this patient? a. Chest radiograph b. High-resolution computed tomography c. Lung biopsy d. Magnetic resonance imaging
A
A 64-year-old man presents for evaluation of a lesion on the face. It has been present for the past six months. He has tried treating it with various over-the-counter ointments without any success. Physical examination reveals a flesh-colored papule that has a pearly quality. Telangiectatic vessels are noted within the papule. Which of the following is the most likely diagnosis? a. Basal cell carcinoma b. Melanoma c. Molluscum contagiosum d. Squamous cell carcinoma
A
A 65-year-old man with a history of diabetes, atrial fibrillation, peripheral vascular disease, chronic obstructive pulmonary disease, and hyperlipidemia presents to the emergency department for evaluation of gradually worsening left leg pain that began eight hours ago. The pain is constant and exacerbated by minimal walking. Both dorsalis pedis pulses are thready, however, the left femoral pulse is weaker than the right. There is equal movement and intact sensation in both lower extremities. Which of the following is the best test to confirm the diagnosis and facilitate timely treatment? a. CTA of the pelvis with runoff b. D-dimer c. Doppler ultrasound d. Magnetic resonance angiography of the pelvis with runoff
A
A 76-year-old man with a history of diabetes mellitus and hyperlipidemia presents to the emergency room with a sudden onset of epigastric pain 48 hours ago. Now he is experiencing intractable nausea, vomiting, and fever beginning 12 hours prior to arrival. Physical examination reveals marked tenderness and guarding in the epigastrium, poor turgor, hypotension, tachycardia, and a temperature of 101.3°F. Laboratory results show amylase of 301 U/L and lipase of 1186 U/L. CT scan of the abdomen is pending. Based on the patient's expected diagnosis, which of the following findings would be consistent with his most likely diagnosis? A. Ecchymosis of the flanks B. Improvement in pain when lying supine C. Melena D. Pain radiating to the left scapula
A
An 82-year-old man is admitted to the intensive care unit with severe Clostridioides difficile diarrhea. Which of the following arterial blood gases (ABG) is the most consistent with the patient's diagnosis? a .pH 7.22, PaO2 81 mm Hg, PaCO2 45 mm Hg, HCO3 12 mmol/L b. pH 7.29, PaO2 74 mm Hg, PaCO2 51 mm Hg, HCO3 23 mmol/L c. pH 7.48, PaO2 99 mm Hg, PaCO2 16 mm Hg, HCO3 22 mmol/L d. pH 7.50, PaO2 92 mm Hg, PaCO2 38 mm Hg, HCO3 30 mmol/L
A
An 82-year-old woman presents with postprandial cramping abdominal pain, diarrhea, and a weight loss of 10 pounds over the last five months. Her medical history includes coronary artery disease with myocardial infarction two years ago, and cerebrovascular accident with residual right arm weakness. She currently smokes a pack of cigarettes a day. On exam, she shows signs of recent weight loss and has an epigastric bruit. What is the initial diagnostic study you would order? a. CT angiogram of the abdomen and pelvis b, CT angiogram of the chest c. Mesenteric arteriography d. RUQ ultrasound exam
A
Following an appendectomy, a 20-year-old woman develops widespread urticaria and pruritus without any respiratory, gastrointestinal, or cardiovascular symptoms. The lesions are transient and appear to move to different locations on her skin. She denies any known drug allergies. She had received preoperative antibiotic prophylaxis with cefotetan approximately one hour earlier. Which of the following is the most likely explanation for the urticaria and pruritus? A. Allergic reaction to cefotetan B. Contact dermatitis C. Drug eruption D. Urticarial vasculitis
A
In addition to the inflammatory stimulus of surgery, which of the following is the most common noninfectious cause of postoperative fever? a. Atelectasis b. Deep vein thrombosis c. Malignant hyperthermia d. Medications
A
Which of the following is a risk factor for developing small bowel carcinoma? A. Diet high in salt-cured foods B. History of irritable bowel syndrome C. Obesity D. Tobacco use
A
Which of the following is considered the gold standard method for diagnostic evaluation of peptic ulcer disease? A. Histologic tissue evaluation B. Proton pump inhibitor trial C. Serum gastrin level analysis D. Urea breath test
A
Which of the following therapeutic options would be beneficial for a patient attempting to quit cigarette smoking before surgery? a. Bupropion b. Buspirone c. Sertraline d. Venlafaxine
A
What is median arcuate ligament syndrome?
A rare form of chronic mesenteric ischemia due to celiac artery stenosis or compression from the median arcuate ligament.
An 84-year-old man presents to the clinic with an ulcer on his left medial malleolus. The 1.5 cm ulcer has an irregular shape and well-defined borders, and no purulence is noted. The skin surrounding the ulcer is firm, dry, and pruritic. He has bilateral peripheral edema and hyperpigmentation at his ankles and feet. The hyperpigmentation does not change with leg elevation. Aside from venous duplex ultrasonography, which of the following tests is also recommended before initiating the treatment for this patient's most likely condition? A. Ankle-brachial index B. Microcirculation assessment C. Venous plethysmographyYour Answer D. Wound biopsy
A. wound care for venous ulcers involves a zinc impregnated gauze wrapped around the lower extremity and then wrapped with coband to provide compression. this compression can be detrimental to those with arterial disease, so ABI is recommended before tx
Epigastric pain ddx
Acute MI acute pancreatitis peptic ulcer disease gastroparesis GERD
A 35-year-old woman presents to the office with multiple complaints that have been worsening over the last several weeks. She is complaining of anxiety, intermittent palpitations, unintentional weight loss, and heat intolerance. Physical exam reveals a tremor. Which of the following best describes the tremor associated with the most likely diagnosis? A. Dampens with activity B. High frequency and low amplitude C. Occurs exclusively with standing position D. Present at rest
B
A 40-year-old woman is admitted to the hospital five days after an uncomplicated hysterectomy. She has had nausea and vomiting for the past 24 hours that is unrelieved by IV antiemetics. On abdominal X-ray, you see dilated loops of bowel with air in the rectum. What is the best next step in management? a. CT of the abdomen and pelvis b. Nasoduodenal tube placement c. Nasogastric tube placement d. Surgical intervention
C
A 27-year-old woman is diagnosed with peptic ulcer disease from H. pylori infection. In addition to omeprazole and amoxicillin, which of the following medication is part of the triple therapy for eradication of H. pylori? a. Bismuth salicylate b. Clarithromycin c. Ranitidine d. Trimethoprim-sulfamethoxazole
B
A 35-year-old man presents to the clinic with a complaint of epigastric pain for about a month. He reports that he has been taking naproxen for the past month due to knee pain. How long after a meal would pain be expected to occur if the symptoms are due to a duodenal ulcer? A. 1 hour B. 3 hours C. 30 minutes D. 9 hours
B
A 38-year-old female with a past medical history of chronic constipation presents with anal pain which only occurs with defecation. She has noticed occasional blood streaking on her toilet paper when wiping. On physical exam there are no bulges or masses appreciated. There is a superficial tear with no drainage. Which of the following is the first-line therapy for the suspected diagnosis? a. Botulinum toxin injection b. Fiber c. Lateral internal sphincterotomy d. Oral nifedipine
B
A 40-year-old woman presents to clinic reporting a nodule in her neck that has been present for one year but is not enlarging. She denies any family history of thyroid problems or exposure to radiation and states she is otherwise healthy with no complaints. On examination, there is a single, non-tender, smooth, non-adherent, five-millimeter thyroid nodule noted. There is no lymphadenopathy. Thyroid sonography confirms the presence and size of the nodule with a benign pattern noted by the radiologist. Thyroid function tests show slightly elevated thyroid-stimulating hormone level. Radionuclide testing shows a hyperfunctioning lesion corresponding to the nodule. Which of the following is the most appropriate treatment? A. Fine-needle aspiration B. Observation with routine assessment C. Radioactive iodine Your Answer D. Thyroidectomy
B
A 42-year-old man presents to the clinic with abdominal pain. He reports it has been going on for 2 weeks, and it is worse with eating. The pain starts in the middle of his stomach but moves to the right side. He has had some fevers and chills, and he had a cough and sore throat recently. At the clinic, his temperature is 101.6°F, with a blood pressure of 111/67 mm Hg and heart rate of 94 bpm. On exam, there is no abdominal distention, but the patient abruptly holds his breath with deep palpation of the right upper quadrant. Laboratory examination shows a white blood cell count of 12,000/µL. Which of the following is the recommended treatment for this patient's condition? a. Endoscopic retrograde cholangiopancreatography b. Laparoscopic cholecystectomy c. Observation d. Oral ursodeoxycholic acid
B
A 50-year-old woman presents to the emergency room for management of painful swelling of her right lower extremity. She is diagnosed on ultrasound with a deep venous thrombosis of her right femoral vein. Past medical history is notable for newly diagnosed colon cancer. Vital signs are normal. Physical exam is notable for swelling and warmth of her right lower extremity. Review of systems is negative for bleeding. Complete blood count, comprehensive metabolic panel, and prothrombin time, partial thromboplastin time, and international normalized ratio are within normal limits. Which of the following is the recommended next step for this patient? A. Edoxaban therapy B. Low-molecular-weight heparin therapy C. Unfractionated heparin bridge to warfarin therapy D. Vena cava filter placement
B
A 6-year-old boy presents to the ED complaining of pain near his belly button that started yesterday and today moved to the right lower quadrant. He mentions that going over bumps in the car on the way to the ED made his stomach hurt even worse. His parents have been giving him acetaminophen for his fever, but it hasn't helped his pain. His appetite has been poor and he vomited once earlier today. Vital signs include a temperature of 100.2°F, blood pressure 108/68 mm Hg, and pulse 96 beats per minute. Exam reveals right lower quadrant tenderness and involuntary guarding. Which of the following is the best next step for this patient? A. Admit the patient for intravenous antibiotic therapy B. Call a pediatric surgeon C. Order abdominal and pelvic computed tomography D. Send the patient home and advise supportive care
B
A 63-year-old man has a routine postoperative basic metabolic panel drawn which demonstrates a potassium level of 6.8 mEq/L. An ECG reveals peaked T waves. Which of the following should be administered first? A. Albuterol B. Calcium gluconate C. Insulin with glucose D. Sodium polystyrene
B
A 65-year-old man with a history of benign prostatic hyperplasia presents to the urologist for removal of a Foley catheter. The catheter was placed to decompress the bladder due to acute urinary retention. What type of medication could be prescribed prior to catheter removal that would relax the smooth muscle of the bladder neck and prostatic capsule and thereby relieve the obstruction and prevent early recurrence of retention? a. 5-α-reductase inhibitors b. Alpha-1-adrenergic antagonists c. Phosphodiesterase-5 inhibitors d. Prostaglandin E1
B
A 65-year-old man with a past medical history of tobacco abuse and hypertension presents to the clinic with leg pain during exercise that is relieved by rest. Physical exam is significant for lower extremity hair loss and weak pulses over the dorsalis pedis and posterior tibial arteries. An ankle-brachial index test is performed and calculated as 0.8. Which of the following is the most appropriate treatment option? A. Anticoagulation B. Aspirin C. Hormone replacement therapy D. Revascularization
B
A 65-year-old man with hypertension presents to the clinic complaining of worsening shortness of breath with physical exertion for the past two weeks. He has no history of chronic lung disease. He denies chest discomfort and palpitations. Vital signs include heart rate 78 beats per minute, blood pressure 134/84 mm Hg, temperature 98.8°F, pulse oxygenation 93%, and 20 respirations per minute. Exam reveals an obese man, bibasilar lung crackles, normal heart sounds, and 1+ pitting edema in both ankles. Which of the following is the best next step? a. Duplex ultrasonography of the lower extremities b. Echocardiogram c. Helical chest computed tomography d. Thoracentesis
B
A 65-year-old woman presents for her annual physical to her primary care physician. She has a history of recurrent urinary tract infections and has a 30 pack-year smoking history. She has worked in a textile factory for 40 years. With her increased risk, what is the most common symptom of bladder cancer that would necessitate further investigation? a. Fever b. Hematuria c. Suprapubic pain d. Weight loss
B
A 66-year-old woman with a past medical history of uncontrolled diabetes mellitus, obesity, and rheumatoid arthritis who is on methotrexate presents to the emergency department complaining of redness, drainage, and pain at her incision site. She had an umbilical hernia repair approximately six days prior. On exam, you note the patient has a fever of 100.6°F and the incision site is erythematous and warm with a small amount of purulent drainage noted. There are no signs of wound dehiscence and no areas of fluctuance noted. Which of the following is the most likely diagnosis? a. Abscess b Cellulitis c. Hematoma d. Seroma
B
A 67-year-old man with a history of excessive alcohol use presents to the emergency department with hematemesis beginning two hours ago. He reports epigastric abdominal pain over the last two days and started vomiting today. He reports only one episode of vomiting blood. Vital signs show HR 128/min, BP 118/62 mm Hg, RR 20/min, and oxygen saturation 97% on room air. He is chronically ill appearing with scleral icterus. His abdomen is distended with ascites, and he has 2+ pitting edema in both legs. He currently reports nausea. What medication should be started to help achieve hemostasis in this patient who is likely still bleeding? A. Metoclopramide B. Octreotide C. Tranexamic acid D. Vasopressin
B
A 34-year-old woman presents with a urinary tract infection. She has had recurrent UTIs in the past 2 months. Each time, a urine culture has demonstrated E. coli growth. She complains of foul-smelling urine and has noted anal irritation and bloody drainage from the anus at times. Which one of the following in her past medical history would be most consistent with the suspected diagnosis? a. Chronic constipation b. Crohn disease c. Pilonidal disease d. Ulcerative colitis
B risk of anal fistula greater with Chron's than UC
A 70-year-old man with hypertension presents to the ED with sudden onset of sharp stabbing pain in the middle of his chest radiating to his back for the past two hours. Vital signs are pulse 100 beats per minute, blood pressure 150/60 mm Hg, oxygen saturation 98%, temperature 98.8°F, and 20 respirations per minute. Exam reveals a decrescendo diastolic murmur at the right sternal border. Electrocardiogram does not show any ischemic changes and chest X-ray reveals a widened mediastinum. Which of the following is the most likely diagnosis? A. Acute pericarditis B. Aortic dissection C. Myocardial infarction D. Pulmonary embolism
B
For which of the following individuals does the United States Preventive Services Task Force recommend one-time screening for abdominal aortic aneurysm with abdominal ultrasonography? a. A 58-year-old man with a 35 pack-year smoking history b. A 66-year-old man with a 30 pack-year smoking history c. A 72-year-old woman who has never smoked d. A 78-year-old man who has never smoked
B
Which of the following recommendations is the most appropriate counseling to provide a patient receiving methadone for a known opioid use disorder during his or her preoperative evaluation for an elective procedure? a. Avoid any use of methadone one week prior to surgery b. Continue the use methadone, including on the day of surgery c. Start benzodiazepines to avoid the risk of withdrawal d. Transition from methadone maintenance to buprenorphine
B
Which one of the following is the most common cause of small bowel obstruction in patients with no prior surgical history? a. Crohn disease b. Hernia c. Malignancy c. Tuberculosis
B
Why must the preoperative preparation for surgical resection of a patient with a diagnosed pheochromocytoma involve propranolol initiation after a 10-14 day course of phenoxybenzamine? A. To allow for an initial decrease in the contracted blood volume B. To avoid unopposed alpha-adrenergic receptor stimulation C. To avoid unopposed beta-adrenergic receptor stimulation D. To normalize the blood pressure elevation exacerbated by phenoxybenzamine
B
A 67-year-old man presents with bloody diarrhea, abdominal pain, fever, tachycardia, and hypotension. Imaging shows a 10 cm dilation in the transverse colon. White blood cells are 17,000/µL. Which of the following medical history, if present, places the patient at highest risk for the suspected condition? A. Atherosclerosis B. Crohn disease C. Kidney injury D. Small bowel obstruction
B complication of concern: toxic megacolon
56-year-old woman with stage IV breast cancer presents to the emergency department complaining of dyspnea and cough that started one hour ago. She was first diagnosed with breast cancer five years ago and had a lumpectomy with adjuvant radiation. She was diagnosed with metastatic disease six months ago. She also has a history of hypertension, hypothyroidism, and gastroesophageal reflux disease. Her pulse is 102, blood pressure is 115/76 mm Hg, respiratory rate is 16, and temperature is 98.3°F. Which of the following is the most likely diagnosis? a. Community-acquired pneumonia b. Congestive heart failure c. Pulmonary embolism d. Radiation pneumonitis
C
A 30-year-old man who weighs 75 kg presents to the emergency department for burns to his left arm and left leg after a large container of boiling water spilled on him just prior to arrival. There is white, peeling skin on the entirety of both his left arm and left leg. He has severe pain along the borders of the burn, but no sensation to the burned areas. Distal pulses are intact. After ensuring there is no airway or breathing compromise and removal of overlying materials and clothes, what is the next step in treatment? A. Escharotomy B. Prophylactic antibiotic infusion C. Ringer's lactate solution 4 L infusion over eight hours D. Transfer to a burn center
C
A 32-year-old man is admitted to the hospital with multiple injuries after a motor vehicle collision three weeks ago. A week ago he was diagnosed with a deep venous thrombosis of his left common femoral vein and is currently on therapeutic anticoagulation with subcutaneous enoxaparin. Today he had large volume hematemesis and became hypotensive. Hb was measured at 6 g/dL. An esophagogastroduodenoscopy shows a large ulcer in the gastric body with an adherent clot and diffuse gastritis. After stopping enoxaparin, what is the most appropriate management for his deep venous thrombosis? A. Catheter-directed thrombolysis B. Clopidogrel 75mg daily C. IVC filter placement D. Place continue sequential compression devices
C
A 32-year-old man presents with complaints of bleeding with defecation and anal pruritus. Exam reveals a hemorrhoid prolapsed out of the anal canal requiring manual reduction. How would you classify this patient's hemorrhoids? a. Grade I b. Grade II c. Grade III d. Grade IV
C
A 32-year-old woman presents for evaluation of acute-onset left-sided flank pain. She is unable to sit still due to the pain. She also has noted blood in her urine. Physical examination reveals the patient to be restless. She is afebrile and has mild costovertebral angle tenderness. Urinalysis reveals gross hematuria. Which of the following is the most likely diagnosis? a. Diverticulitis b. Dysmenorrhea c. Nephrolithiasis d. Pyelonephritis
C
A 32-year-old woman presents to the office with a concerning skin lesion on her arm. The lesion is biopsied and she is diagnosed with melanoma that is less than 1 mm in thickness. Which of the following is the next best step in caring for this patient? A. Application of imiquimod for 90 days B. Mohs microsurgical approach C. Wide excision with a 1 cm margin of normal tissue D. Wide excision with a 2 cm margin of normal tissue
C
A 39-year-old woman is admitted to the hospital following a scheduled open hysterectomy. Intraoperative blood loss is one liter. Postoperatively, labs return with a hemoglobin of 6.5 g/dL. Which of the following is the most appropriate treatment? A. Fresh frozen plasma transfusion B. Platelet transfusion C. Red blood cell transfusion D. Sodium chloride 0.9% infusion
C
A 40 year-old-man presents to the emergency department reporting continuous, severe pain in the left groin for four hours. He has vomited three times since the onset of pain. On exam, he has a tender left inguinal hernia with slight erythema of the overlying skin, as well as abdominal tenderness and guarding. His temperature is 101.1°F. What is the best treatment? a. Analgesia and antibiotics b. Manual reduction c. Surgical repair d. Truss application
C
A 45-year-old man presents for evaluation of acute-onset severe abdominal pain located in his epigastric region radiating to his back. He also complains of nausea and vomiting. Upon questioning, he states that he drinks a 12-pack of beer daily. Physical exam reveals diffuse abdominal tenderness on palpation as well as ecchymosis around his umbilicus. Laboratory evaluation is notable for a serum lipase of 472 U/L. Which of the following is the most likely diagnosis? A. Acute cholecystitis B. Acute hepatitis C. Acute pancreatitis D. Mesenteric ischemia
C
A 50-year-old man presents to the emergency department with diffuse abdominal pain and obstipation. Imaging reveals high-grade small bowel obstruction. The patient is admitted to the hospital, however, fails to improve with medical management. He is taken to the operating room for exploratory laparotomy with lysis of adhesions with minimal blood loss. Postoperatively, the patient is tachycardic and hypotensive with low urine output. Hemoglobin is 17 g/dL. Lactic acid is 4 mmol/L. Which of the following is the most likely diagnosis? a. Cardiogenic shock b. Distributive shock c. Hypovolemic shock d. Obstructive shock
C
A 52-year-old man with COPD who is a current cigarette smoker presents for preoperative consultation. He reports worsening shortness of breath and productive cough over the past month. He reports no chest pain or dependent edema. Vital signs include a resting room air pulse oximetry of 97%. Physical exam reveals expiratory wheezing bilaterally. Which of the following diagnostic studies is indicated? A. Arterial blood gases B. Chest computed tomography C. Chest radiograph D. Pulmonary function tests
C
A 55-year-old with an abdominal mass is diagnosed with a cortisol-secreting adrenocortical carcinoma. He is immediately referred for surgical resection. Which of the following medications is the best choice to be administered immediately after surgery to prevent hypotension? A. Dobutamine B. Fludrocortisone C. Hydrocortisone D. Vasopressin
C
A 55-year-old woman presents status post exploratory laparotomy with lysis of adhesions. On postoperative day 3, the patient begins to experience nausea and vomiting and a nasogastric tube is placed. At postoperative day 5, she continues to experience high output from the nasogastric tube and complains of abdominal pain and nausea. Her vital signs are within normal limits. The physical exam reveals diffuse abdominal discomfort, abdominal distention, and absent bowel sounds. Her basic metabolic panel this morning reveals calcium 8.8 mg/dL, glucose 85 mg/dL, and potassium 2.7 mEq/L. Abdominal X-ray reveals air-fluid levels and distended gas-filled loops of both the small and large intestine. What clinical intervention is indicated at this time? a. Discontinue nasogastric tube and start liquid diet b. Initiate antibiotics c. Initiate intravenous potassium replacement d. Obtain CT scan of the abdomen
C
A 58-year-old man who works as a truck driver presents to the clinic with symptoms of rectal itching and painless bleeding, mainly on the toilet paper when he wipes. Colonoscopy shows internal grade I-II hemorrhoids. After several weeks of increased fiber and water intake, sitz baths, and stool softeners, he continues to have symptoms. Which of the following is the preferred next step in the treatment of his hemorrhoids? a. Excisional hemorrhoidectomy b. Infrared photocoagulation c. Office-based rubber band ligation d. Stapled hemorrhoidopexy
C
A 62-year-old man is having routine lab work drawn as part of a complete yearly physical. His complete blood count demonstrates a decreased hemoglobin and hematocrit with an elevated mean corpuscular volume. Which of the following in his patient's history could explain these findings? a. Beta-thalassemia trait b. Chronic kidney disease c. History of partial gastrectomy d. Ulcerative colitis
C
A 64-year-old man presents to the clinic complaining of worsening fatigue over the past six months despite no change in his sleep habits. He has no chronic health conditions and does not take any medications or supplements. He denies hot and cold intolerance, unintentional weight gain or loss, abdominal pain, and rectal bleeding. He denies diet changes and states he has been well-hydrated from all of the ice that he eats. Physical exam reveals skin pallor and koilonychia. Which of the following is the most likely diagnosis? a. Beta thalassemia major b. Iron deficiency anemia c. Pernicious anemia d. Polycythemia vera
C
A hernia is found to protrude lateral to the inferior epigastric vessels and anteromedial to the spermatic cord. This is most consistent with which of the following diagnoses? A. Direct inguinal hernia B. Femoral hernia C. Indirect inguinal hernia D. Spigelian hernia
C
A 72-year-old man is brought to the emergency department by his son due to "passing out" at home. The patient was in his usual state of health and was conversing normally with his family. However, while the patient was standing, he became unresponsive and his son gently placed him on the ground. He was unresponsive for approximately 30 seconds, after which he completely regained consciousness. He does not recall the event but remembers feeling lightheaded prior. His son did not notice any tongue bite or bowel or bladder incontinence. The patient has a medical history of hypertension, hyperlipidemia, and Parkinson disease. His blood pressure is 135/80 mm Hg, pulse is 80/min, and respiration is 16/min. On neurological examination, the patient is alert to self, place, and time and is able to follow simple and complex commands. He has a normal cranial nerve, sensory, and motor examination. Cardiac auscultation is unremarkable. Which of the following is the most appropriate next step in management? a. CT head without contrast b. Echocardiography c. Electrocardiogram d. Electroencephalogram
C
A previously healthy 42-year-old man presents to your office with questions about colon cancer screening. He has no family history of colorectal cancer, but a friend of his who is the same age recently had a colonoscopy and he's wondering if he needs one now as well. Which of the following colorectal cancer screening guidelines is most appropriate to share with the patient? A. Colonoscopy is the preferred screening test B. Fecal occult blood testing is the preferred screening test C. Screening for average-risk individuals begins at age 45 years D. Screening for high-risk individuals begins at age 50 years
C
A septic patient is noted to have respiratory alkalosis. What electrolyte disturbance is commonly associated with this patient presentation? a. Hypercalcemia b. Hypermagnesemia c. Hypokalemia d. Hyponatremia
C
An elderly man with a history of atrial fibrillation presents with sudden onset of severe periumbilical pain that is out of proportion to physical examination. A CT scan will most likely show lack of flow in which visceral vessel? A. Celiac trunk B. Inferior mesenteric artery C. Superior mesenteric artery D. Superior mesenteric vein
C
In which segment of the colon do the majority of diverticula form? a. Ascending colon b. Descending colon c. Sigmoid colon d. Transverse colon
C
Which of the following is a physical exam finding characterized by pain and inspiratory arrest during palpation of the right upper quadrant? a. Courvoisier's sign b McMurray's sign c Murphy's sign d Rovsing sign
C
Which of the following is appropriate initial treatment for uncomplicated symptomatic Crohn's disease? A. Antibiotic treatment B. Chemotherapy C. Immunosuppressant therapy D. Watchful waiting
C
You are assessing a patient's perioperative cardiac risk for a noncardiac surgery. Which of the following surgical procedures is considered to have high intrinsic cardiac risk? A. Laparoscopic appendectomy B. Open appendectomy C. Open cholecystectomy D. Total hip arthroplasty
C
Which of the following medications can be used in the treatment of hemodynamically stable atrial fibrillation with concomitant Wolff-Parkinson-White syndrome? AAdenosine B Diltiazem C Ibutilide DMetoprolol
C all of the other options are all AV nodal blocking agents and should be avoided in patients with preexcited atrial fibrillation. Blocking the AV node can promote and enhance conduction down the accessory pathway, which can deteriorate into an unstable rhythm such as ventricular tachycardia or ventricular fibrillation.
A 45-year-old man with a past medical history significant for obesity, status post partial gastrectomy, returns to the clinic following a recent barium swallow study for complaints of abdominal pressure and fullness. Results from the study show displacement of the gastroesophageal junction and herniation of a portion of the gastric fundus into the thoracic cavity. Which of the following is the most likely diagnosis? A. Esophageal motility disorder B. Esophagitis C. Paraesophageal hiatus hernia D. Sliding hiatus hernia
C Paraesophageal hiatal hernias can be asymptomatic, but may also be associated with epigastric or postprandial fullness, nausea, and vomiting. Less commonly, they can be associated with gastroesophageal reflux disease (GERD) symptoms Tx: Fundoplication (Necessary if volvulus of stomach occurs)
A 63-year-old man with a 40-pack-year smoking history presents for evaluation of a 25-pound weight loss over the past six months. He complains of intermittent epigastric pain as well as progressive difficulty swallowing. Physical exam reveals a nodule around the umbilicus and left supraclavicular lymphadenopathy. Which of the following is the most likely diagnosis? a. Duodenal ulcer b. Esophageal cancer c. Gastric cancer d. Gastric ulcer
C Umbilical node: Sister Mary Joseph's node Supraclavicular: Virchow's node
An 86-year-old man with a history of hypertension and atrial fibrillation presents with concern for acute arterial occlusion of his right lower leg. Which of the following would be a late finding with this condition? A. Pain out of proportion to exam findings B. Pallor C. Paralysis D. Paresthesias
C paralysis can occur, but it is a late finding
A 53-year-old man presents to the emergency department with rectal pain for two days. He describes the pain as constant and unrelated to bowel movements. He does not have fever or any other associated symptoms. He has a history of diabetes, which he reports has been poorly controlled. Physical exam reveals a well-appearing, afebrile man with an area of perianal erythema and fluctuance that does not extend into the anus. Which of the following is the best next step in management? a. Initiate oral antibiotics b. Perform incision and drainage in ED c. Perform incision and drainage in ED and initiate antibiotics d. Surgical drainage performed in the OR
C perirectal abscess The antibiotics are indicated for patients with associated cellulitis, signs of systemic infection,diabetes, valvular heart disease, or immunosuppression.
What is the most useful serum marker for pancreatic cancer?
Carbohydrate antigen 19-9 (CA 19-9).
What are some causes of nephrogenic Diabetes insipidus?
Chronic kidney insufficiency, drug toxicity (e.g., lithium), pregnancy, and hypokalemia
A 1-month-old infant boy presents with progressive, nonbilious projectile vomiting occurring within minutes of feeding after previously feeding without difficulty. On physical examination, a firm, olive-sized nodule is palpable in the epigastrium. Which of the following metabolic derangements is expected to be found on initial laboratory evaluation in this infant? A. Hyperkalemic, hypochloremic metabolic acidosis B. Hyperkalemic, hypochloremic metabolic alkalosis C. Hypokalemic, hypochloremic metabolic acidosis D. Hypokalemic, hypochloremic metabolic alkalosis
D
What is the gold standard for diagnosing and staging of bladder cancer?
Cystoscopy with biopsy.
A 14-year-old girl presents for evaluation of suspected appendicitis. She experiences pain in the right lower quadrant with palpation of the left lower quadrant. What is this called? a. McBurney's point tenderness b. Obturator sign c. Psoas sign d. Rovsing's sign
D
A 24-year-old woman presents to the clinic for preoperative evaluation for a scheduled right anterior cruciate ligament repair. Preoperative clearance was requested by the surgeon secondary to the patient complaining of chest pain. Review of systems is positive for a chronic nonproductive cough, chest pain, fatigue, and weight loss. She denies any history of tobacco use. A chest radiograph reveals bilateral hilar adenopathy with symmetric enlargement of the hila. Serum angiotensin-converting enzyme levels are ordered and found to be elevated. Which of the following is the most likely diagnosis? a. Asthma b. Lung cancer c. Obstructive sleep apnea d. Sarcoidosis
D
A 34-year-old obese woman presents to the emergency room with sudden onset of right upper quadrant abdominal pain for several hours, associated with nausea and a few episodes of vomiting. The pain started after her last meal earlier this evening, which consisted of a fast-food cheeseburger and french fries. The patient reports similar pain over the past several months, though not as intense and resolved spontaneously. Physical exam is notable for fever of 101°C, and tenderness to palpation in the right upper quadrant. Leukocytosis is present on CBC. Which of the following tests is *most sensitive* to establish a diagnosis? A. CT of the abdomen and pelvis B. Endoscopic retrograde cholangiopancreatography (ERCP) C. Gallbladder ultrasound D. Hepatobiliary Iminodiacetic Acid (HIDA) scan
D
A 34-year-old woman presents with bloody diarrhea. She began to experience episodes of bloody diarrhea five months ago, however, the episodes have become more severe and more frequent. She has unintentionally lost 15 pounds in the past three months. Her medical history is unremarkable and she does not take medications. She smokes two packs of cigarettes daily and has a 15-pack-year smoking history. She does not drink alcohol. She denies drug use. On examination, temperature is 101.1°F, blood pressure 128/72, pulse 76, and respiratory rate 18. She is in mild distress. Lungs are clear to auscultation. A 2/6 systolic murmur is best heard at the right and left upper sternal borders. The abdomen is most tender at the left lower quadrant. No lower extremity edema is appreciated. On colonoscopy, uniform inflammation beginning from the distal rectum to the mid-transverse colon is appreciated. Which of the following is the most likely diagnosis? A. Celiac disease B. Crohn's disease C. Mesenteric ischemia D. Ulcerative colitis
D
A 35-year-old woman is having a preoperative evaluation in clinic. Preoperative blood analysis reveals a hemoglobin 6.2 g/dL, hematocrit 18%, platelets 210 x 109/L. The patient mentions that she has been anemic on and off for several years which was always attributed to her heavy menstrual periods. She has no previous surgical history. She does not take any medications. A few of her male and female family members have required blood transfusions after routine surgery. Which of the following tests is most likely to reveal the correct diagnosis? A. Factor IX level B. Factor VIII level C. Prothrombin time D. Von Willebrand factor antigen
D
A 46-year-old woman presents to the clinic with a two week history of abdominal pain, rectal bleeding, and decreased stool caliber. She reports that her sister had colon cancer and her mother had colon and endometrial cancer. Physical examination reveals abdominal tenderness to palpation in the right lower quadrant without rebound tenderness or peritoneal signs. Colonoscopy and biopsy findings result in a diagnosis of colon cancer. Which of the following genetic syndromes should this patient be evaluated for? A. Birt-Hogg-Dube syndrome B. Ehlers-Danlos syndrome C. Li-Fraumeni syndrome D. Lynch syndrome
D
A 39-year-old man presents for his annual physical. On exam, a painless mass is palpated on his left testicle. Which of the following is the most likely next step in diagnosis? a. CT scan of abdomen and pelvis b. Needle biopsy c. Serum tumor markers d. Trans-scrotal ultrasound
D
A 43-year-old woman presents to the clinic with three days of severe right upper quadrant pain with radiation toward the right inferior scapula that usually occurs for an hour or two after consuming a meal. She has experienced nausea and vomiting with the pain but no fever, diarrhea, or constipation. She is not in pain at the time of visit. On physical examination, the woman has no significant tenderness over the right upper quadrant. Based on the history and physical examination, which of the following is the most likely diagnosis? a. Acute mesenteric ischemia b. Acute pancreatitis c. Small bowel obstruction d. Symptomatic cholelithiasis
D
A 44-year-old man with a history of GERD presents complaining of worsening dysphagia with solid foods. The patient is diagnosed with esophageal stricture and is status post dilation. Which of the following therapies is most important to prevent recurrence of peptic esophageal strictures? A. Amoxicillin and clarithromycin B. Histamine-2 receptor antagonist C. Nonsteroidal anti-inflammatory drug D. Proton pump inhibitor
D
A 45-year-old woman presents to clinic with concern about a discoloration of her eyes. On assessment, there is a subtle yellow discoloration to the sclera. What is the most appropriate test to confirm the clinical finding and guide further assessment and treatment? a. Abdominal CT b. Abdominal ultrasound c. Complete blood count d. Fractionated bilirubin
D
A 48-year-old man presents with epigastric pain which radiates to his back. He has a history of alcohol misuse disorder. Which of the following serum blood analysis abnormalities most specifically indicates the suspected diagnosis? A. Elevated alanine aminotransferase (ALT) B. Elevated amylase C. Elevated aspartate aminotransferase (AST) D. Elevated lipase
D
A 55-year-old woman presents to clinic for a routine appointment six months after having a Roux-en-Y gastric bypass as part of management of obesity. What additional long-term treatment is routinely indicated? A .Cholestyramine B. H2 antagonist C. Liquid diet D. Micronutrient supplementation
D
A 63-year-old man presents with a three-day history of abdominal pain, urinary urgency, chills, and decrease appetite. Vital signs include T 101.3°F, HR 102, BP 115/70 mm Hg. Examination reveals rebound tenderness in the left lower quadrant of the abdomen, but no guarding. Rectal examination is normal. The white blood cell (WBC) count is 15 x 109/L with 85% neutrophils. A urinalysis reveals 5-10 white blood cells/hpf and 5-10 red blood cells/hpf. A CT scan of the abdomen reveals the presence of a thickened colon wall and associated fat stranding around a collection of contrast in the region. No perforation or abscess formation is seen. Which one of the following is the next best step in the management of this patient? a. Colonoscopy b. CT-guided percutaneous drainage c. Emergency colectomy d. Intravenous antibiotics
D
A 66-year-old man with type II diabetes mellitus presents to the clinic one week after undergoing a lower leg mole biopsy to discuss pathology results. He complains of redness, tenderness, and pus at the biopsy site. Physical exam reveals erythema and edema surrounding the biopsy site and purulent drainage, but no fluctuance is appreciated. Which of the following therapies would be best for the most likely diagnosis? a. Cephalexin b. Ciprofloxacin c. Piperacillin/tazobactam d. Trimethoprim/sulfamethoxazole
D
An obese 68-year-old woman with hypertension is admitted to the hospital due to acute hypoxia. She is a lifelong nonsmoker with no history of lung disease. A chest radiograph reveals a moderate pleural effusion. Which of the following is the best next step in the management of this patient? A .Echocardiogram B. Magnetic resonance imaging of the chest C. Pericardiocentesis D. Thoracentesis
D
When evaluating a 65-year-old man with scleral icterus, you note a positive Courvoisier sign on abdominal examination. What is the most likely diagnosis? A. Acute cholangitis B. Alcoholic hepatitis C. Cholecystitis D. Pancreatic malignancy
D
Which of the following descriptions of chest discomfort is more typical of angina than a nonischemic etiology? a. Constant pain for days b. Pain localized with one finger c. Pleuritic pain d. Relief with rest
D
Which of the following is the most appropriate next intervention for a patient with varicose veins who has failed to improve with conservative treatment? a. Anticoagulation b. Compression therapy c. Diuretics d. Vein ablation
D
While assessing a patient's functional capacity as part of the preoperative cardiac risk, the patient states that she can walk independently, but slowly, and can complete light chores around her home, but she cannot do her own yard work or go up and down stairs without assistance. Which of the following options is the correct way to document her functional capacity? a. 4-7 METs b. 7-10 METs c. Greater than 10 METs d. Less than 4 METs
D
You are evaluating a 48-year-old woman with right lower extremity swelling, pain, and redness. She is eight days status-post open cholecystectomy. She was on Lovenox for two days postoperatively but is not currently taking any medications except oxycodone for pain. What is the test of choice to confirm your suspected diagnosis? A. Ankle-brachial index B. D-dimer C. Lower extremity MRI D. Venous Doppler ultrasound
D
A 20-year-old office worker presents with nine months of gradually worsening pain and swelling at his intergluteal cleft. Physical exam demonstrates a slightly tender mass near his natal cleft accompanied by purulent drainage with a hair protruding near the sinus opening. He is afebrile and there is no evidence of abscess. Which of the following interventions is likely to have the best long-term outcome for him? a. Daily gentle washing with an antibacterial cleanser b. Incision and drainage c. Initiate broad spectrum antibiotics d. Surgical excision of all sinus tracts
D (Pilonidal cyst)
What is the gold standard for the treatment of choledocholithiasis?
ERCP with stone extraction.
What basic metabolic panel abnormality is associated with upper GI bleeding?
Elevated BUN/Creatinine ratio.
Where are small bowel carcinoid tumors most commonly found?
In the ileum
Aside from infection, what is a serious complication of chronic venous ulcers?
Malignancy such as squamous cell carcinoma.
What bone is typically affected in patients with basal cell nevus syndrome who have bone cysts?
Mandible
What topical therapies are available for the treatment of anal fissures?
Nitroglycerin, nifedipine, lidocaine.
What is the most common dermatological manifestation of chronic venous insufficiency?
Stasis dermatitis.
Which genetic variations have been associated with chronic pancreatitis?
The CFTR gene linked to cystic fibrosis, SPINK1, and the PRSS1 gene associated with hereditary pancreatitis.
Which nerve arises from the L1 nerve root and runs superior to the spermatic cord through the superficial inguinal ring in men?
The ilioinguinal nerve arises from L1 and provides sensory innervation to the scrotum in men and the labium majus canal in women.
In cases of acute, nonperforated appendicitis, how soon should appendectomy be performed?
Within 12 hours.
A 60-year-old woman presents to the clinic reporting left lower quadrant abdominal pain, constipation, and bloating. She denies nausea, vomiting, fever, or consumption of undercooked foods. On physical exam, there is moderate tenderness to palpation of the left lower quadrant but no rigidity or guarding. Bowel sounds are hypoactive throughout. All vital signs are within normal parameters for age. Which of the following is most likely to confirm the diagnosis? a. Abdominal CT with contrast b. Abdominal X-ray c. Colonoscopy d. Pelvic ultrasound
a
A 72-year-old woman presents to the emergency department for pain in the gluteal region. Medical history includes diabetes mellitus, orthostatic hypotension, and a right-sided hemiplegia from a stroke four years ago after which she has been bed-bound. Her daughter, who is the primary caretaker, noticed some erythema in the sacral region two weeks ago. She has applied several topical products, including an antibiotic ointment that did not improve the erythema, and a lesion developed in the area, which became progressively ulcerated. Medications include insulin, midodrine, aspirin, and cyclobenzaprine. On physical examination, she is afebrile, her blood pressure is 110/80 mm Hg, and heart rate is 64 bpm. Her BMI is 19. An 8 cm diameter ulcer is visible in the mid-sacral area with a black eschar covering the base. Which of the following is the best next step in management? A. Debridement B. Gauze dressing C. Hydrocolloid dressing D. Negative pressure wound therapy
a
A 75-year-old previously healthy woman presents to the clinic with a sudden onset of left-sided weakness that started 1 hour prior to arrival. She has a pulse rate of 105 bpm with an irregularly irregular rhythm. Her ECG shows no signs of cardiac ischemia. She denies headache, chest pain, shortness of breath, or any other complaints. Which of the following is the best next step in evaluating the diagnosis? A. CT of the head B. Echocardiogram C. Holter monitor D. Lumbar puncture
a
A 34-year-old nulliparous woman presents with concerns of bloody discharge from her left nipple. She states she first noticed it on her bra a few days ago. She has never had this problem in the past. A breast exam reveals a small, palpable mass near the nipple. Which of the following is the most likely diagnosis? a. Fibrocystic breast disease b. Intraductal papilloma c. Pituitary tumor d. Subareolar abscess
b
A 40-year-old woman who previously underwent a Roux-en-Y gastric bypass presents to the clinic with a chief complaint of increasing fatigue, headaches, irritability, and dry skin. Examination reveals mild pallor, atrophic glossitis, cheilosis, and koilonychia. She is otherwise healthy. Laboratory evaluation reveals a microcytic anemia with a low serum iron level, increased serum transferrin, and a low ferritin level. Which of the following is the most effective management? a. Intramuscular iron b. Intravenous iron c. Oral iron d. Red blood cell transfusion
b
A 60-year-old man presents to his primary care provider with the complaint of feeling lightheaded and dizzy when he stands. The patient is currently prescribed hydrocortisone and fludrocortisone for treatment of adrenal insufficiency, doxazosin for treatment of urinary symptoms from enlarged prostate, and erythropoietin for anemia due to renal failure. What is the most appropriate treatment to decrease his orthostatic hypotension symptoms? a. Decrease salt intake b. Discontinue doxazosin c. Discontinue erythropoietin d. Discontinue fludrocortisone
b
A 79-year-old woman with a past medical history significant for recent myocardial infarction and atrial fibrillation on apixaban presents with abdominal pain that has worsened over the last 12 hours. She is found to have a blood pressure of 90/55 mm Hg and heart rate of 110 bpm. She has mild left lower quadrant tenderness. As you examine her, she passes a bloody bowel movement. Which of the following is the most likely cause of her hematochezia? a. Diverticulitis b. Ischemic colitis c. Platelet inhibition d. Sigmoid volvulus
b
A 32-year-old man presents to the outpatient clinic for follow-up regarding his hypertension. Despite the use of three antihypertensive agents, he remains hypertensive. He also has episodes of nonexertional palpitations, diaphoresis, and headache. He recently completed a 24-hour urinary fractionated metanephrines test, which was positive. A computed tomography of the abdomen and pelvis is done and reveals a 5 cm tumor of the right adrenal gland. Which of the following is the most appropriate next step in management? A. Adrenalectomy B. High sodium diet C. Phenoxybenzamine D. Propranolol
c
A 21-year-old woman presents for evaluation of bloody emesis. She reports drinking several alcoholic beverages to celebrate her birthday. Just prior to vomiting, she noted severe retching. Which of the following is the most likely diagnosis? a. Duodenal ulcer b. Esophageal varices c. Esophagitis d. Mallory-Weiss syndrome
d
A 37-year-old woman presents to the clinic after being sent by her primary care provider for further evaluation of a thyroid nodule, discovered on her most recent annual physical exam. Thyroid-stimulating hormone was found to be 3.4 mU/L. Ultrasound of the thyroid revealed a solid hypoechoic mass with irregular margins. Fine needle aspiration revealed calcified psammoma bodies. Based on the patient's ultrasound and histology results, which of the following would be the most likely diagnosis? a. Anaplastic thyroid cancer b. Benign thyroid nodule c. Follicular thyroid cancer d. Papillary thyroid cancer
d
A 54-year-old man presents to the clinic complaining of difficulty swallowing food for the past two years, which has been gradually worsening. He has no problem swallowing liquids. He has had uncontrolled gastroesophageal reflux for several years. He has no history of tobacco use and has not had any head or neck radiation therapy. Which of the following is the best initial test for this patient? a. Barium esophagram b. Esophageal manometry c. Soft tissue neck ultrasound d. Upper endoscopy
d
A 72-year-old woman presents to the ED with a complaint of massive hematemesis that began abruptly 30 minutes ago. She has never experienced these symptoms before and has not seen a doctor in years. Her medical and surgical histories are unknown. On physical examination, she is tachycardic and afebrile. She appears pale, and her abdomen is mildly tender to palpation. There are small angiomas across her chest and engorged veins radiating from her umbilicus. What is the most likely mechanism underlying this patient's hematemesis? a. Acute pancreatic inflammation b. Azygous vein thrombosis c. Perforation of a duodenal ulcer d. Rupture of esophageal varices
d
Which of the following is the gold standard for diagnosing renal artery stenosis? A. Captopril renal scintigraphy (renography) B. Duplex Doppler ultrasonography C. Plasma renin activity D. Renal arteriography
d
In addition to fever, jaundice, and abdominal pain, what symptoms may be present in suppurative Cholangitis?
hypotension & AMS
