surgery eor review question

A 45-year-old man with a history of chronic constipation presents with an acute onset of colicky right lower quadrant pain and abdominal distention. He also reports obstipation, decreased appetite, nausea, and vomiting. On exam, he is noted to have distended abdomen and diffuse abdominal pain with palpation. His barium enema shows a gradual tapering of the sigmoid colon. Which of the following best describes this finding?

"Bird beak" sign dx:Large bowel obstruction is an emergent condition that results when the normal passage of intraluminal contents is interrupted.

Which of the following patients should be started on total parenteral nutrition? A43-year-old woman admitted for pancreatitis on day 1 of her hospital stay B50-year-old woman post-operative day 2 after large resection of small intestine C76-year-old man admitted for an acute cerebrovascular accident D80-year-old man admitted from home for severe protein-calorie deficiency

50-year-old woman post-operative day 2 after large resection of small intestine A 43-year-old woman admitted for pancreatitis on day 1 of her hospital stay (A) is incorrect. Many patients with pancreatitis do not require nutritional support. If the patient is unlikely to resume oral intake within 5-7 days, then nutritional support may be initiated; enteral nutrition is the preferred method for patients with acute pancreatitis. A 76-year-old man admitted for an acute cerebrovascular accident (C) should remain NPO until a swallow study can be completed. If the patient needs nutritional support prior to the study being completed or fails the study, enteral nutrition is recommended over parenteral nutrition. An 80-year-old man admitted from home for severe protein-calorie deficiency (D) should be started on a nutrient dense diet that is taken orally. As long as the patient is able to maintain adequate intake orally, enteral or parenteral nutrition is not recommended.

A 60-year-old woman with a past medical history of chronic constipation and a 15 pack-year history of tobacco usepresents to the emergency department complaining of lower abdominal pain. She also notes about 3 days of intermittent nausea and fevers that she has been treating with over-the-counter ibuprofen 400 mg every 6 hours. On physical exam, the patient is tender to her left lower quadrant on light and deep palpation. A complete blood count is drawn and shows a white blood cell count of 13,500/µL. What is the best imaging option to confirm this patient's diagnosis?

Abdominal CT scan with contrast dx:diverticulitis,

A 48-year-old woman presents with right upper quadrant abdominal pain and nausea for the past 2 days. Vital signs are within normal limits. Physical exam reveals abdominal tenderness in the right upper quadrant and jaundice. Laboratory testing is within normal limits except for elevated transaminases, serum bilirubin, and gamma-glutamyl transpeptidase. Which of the following is the most likely diagnosis?

Choledocholithiasis

A 42-year-old man presents to his primary care provider with abdominal pain for the past 3 weeks. He reports several episodes of vomiting what looked like coffee grounds during his first week of symptoms. His pain is worse immediately after eating, which has resulted in a decreased appetite and a 5-pound weight loss in the last 3 weeks. He started taking ranitidine and omeprazole 2 weeks ago. Physical examination is significant for mild epigastric abdominal tenderness to palpation. No left supraclavicular, anterior axillary, or periumbilical lymphadenopathy is noted. A urea breath test is negative. An upper endoscopy specimen yields a positive Campylobacter-like organism test. Gastric biopsy histology is pending. What is the most appropriate treatment at this time

Clarithromycin, amoxicillin, and omeprazole for 2 weeks

A 45-year-old woman presents for follow-up. She states she had an episode of intense abdominal pain with associated nausea and vomiting last week that brought her into the emergency department. An ultrasound was completed that showed gallstones in the gallbladder, and she was discharged home after she was given medications to relieve her symptoms. Since that episode, she has avoided fatty foods and has been feeling well. Which of the following is the most appropriate management of this patient, considering the most likely diagnosis?

Elective cholecystectomy

A 44-year-old man presents to the clinic with a concerning mole on his right upper arm. He states that, over the past month, the mole has been growing and changing in size. In addition, he states the mole has started to itch. Physical exam reveals a 1.5 cm lesion, which is pictured above. What is the most appropriate next step in management for this condition?

Excisional biopsy with skin margins of at least 2 mm

A 64-year-old man presents to the emergency department with his wife, who is concerned by his unusual behavior today. He complained of a headache all day and also mentioned feeling nauseated. At times, she has noticed him staring off into space and giving incoherent responses. Over dinner, he was slurring his words and seemed to be excessively sleepy. The patient has a history of hypertension and takes a diuretic and an angiotensin-converting enzyme inhibitor. He has not had any recent fevers or other illnesses. On exam, he is somnolent but responsive, in no acute distress, but unable to have a clear, coherent conversation. Due to his neurologic deterioration, an emergent workup is initiated. Which of the following is the best next test to establish the diagnosis?

Head CT without contrast dx:Intracranial hemorrhages are the second most common form of stroke behind ischemic strokes. The most common causes of spontaneous hemorrhagic stroke is hypertension, increasing age, and the use of anticoagulants. Cerebral amyloid angiopathy also commonly leads to nontraumatic lobar intracerebral hemorrhages, and among children, vascular malformations are more common. Signs and symptoms usually progress over minutes to hours, with unusual behavior and hemimotor changes first manifesting then trailing off as decreased mental status takes over. Headaches and vomiting are also common presenting symptoms, and some individuals are discovered obtunded or comatose.

A 60-year-old man presents to the emergency department with left lower quadrant abdominal pain for 3 days. He also has mild constipation. On exam, he has left lower quadrant abdominal tenderness without any peritoneal signs. CT of the abdomen and pelvis shows colonic wall thickening around diverticula. He is otherwise healthy, tolerates oral intake, and has normal vital signs. Which of the following is the best treatment in addition to dietary modification?

Outpatient treatment with oral amoxicillin-clavulanate dx:Acute diverticulitis

A 42-year-old man with a history of uncontrolled diabetes mellitus presents with gradual-onset left lower quadrant pain and nausea for 2 days. His last bowel movement was 1 day ago. He smokes 1 pack of cigarettes per day. His vitals are a T of 38.2°C, HR of 104 bpm, BP of 145/68 mm Hg, RR of 18/min, and SpO2 of 98%. A CT abdomen and pelvis with IV contrast shows microperforation and fat stranding of the sigmoid colon with a localized 4.5 cm abscess. Which of the following is indicated for first-line management in addition to bowel rest and IV antibiotics?

Percutaneous drainage + in this the actual event had occurred two days ago dx: diverticulitis #sigmoid mc of diverticulosis

An 18-month-old child presents to the clinic with an 8-hour history of intractable crying. The mother reports the child had three bright-red, jelly-like stools over the last 2 days. On physical exam, you notice the child draws his legs up to his chest every few minutes and appears in distress. He will only allow an abdominal exam once the pain temporarily subsides. On palpation, you find a sausage-shaped abdominal mass in the right upper abdomen. An ultrasound of the child's abdomen is shown above. What is the most appropriate clinical intervention for this patient based on these findings?

Pneumatic reduction intussusception Ultrasound of the abdomen is the diagnostic test of choice for intussusception as the cause for hematochezia. A "target" sign is often seen on ultrasound and is characteristic of intussusception. This "bull's-eye" sonographic finding is created by the bowel wall telescoping into itself. In the longitudinal plane, this may also be called a "pseudokidney" sign.

A 54-year-old woman with chronic kidney disease who is receiving hemodialysis is admitted to the hospital with acute cholecystitis and is scheduled to undergo a cholecystectomy during the hospitalization. The patient has normal vital signs, and there are no signs of volume overload on physical exam. Which of the following findings would be an indication for urgent preoperative dialysis in this patient?

Potassium of 6.1 mEq/L with peaked T waves on electrocardiogram The most common indications for urgent preoperative dialysis are hyperkalemia and volume overload. Potassium of 6.1 mEq/L with electrocardiogram changes consistent with hyperkalemia, such as tall and peaked T waves, is an indication for urgent preoperative dialysis. The indications for dialysis prior to surgery in patients with end-stage kidney disease vary based on whether the surgery is elective or considered urgent or emergent. When should hemodialysis patients be dialyzed prior to elective surgery? Answer: The day before surgery.

A 28-year-old woman presents to the emergency department with severe diarrhea and RLQ abdominal pain. Vital signs reveal T 101.5°F, BP 100/70 mm Hg, and HR 102 bpm. Laboratory evaluation includes an elevated ESR, elevated WBC, and positive stool guaiac test. A colonoscopy is performed which reveals cobblestoning of the bowel wall. Which of the following is the most appropriate initial medical intervention for the suspected diagnosis?

Prednisone dx:crohns Sulfasalazine (D) is a 5-ASA agent and is first-line treatment for remission maintenance therapy in mild-moderate disease. It should not be used to treat disease flares.

A 65-year-old woman with a history of ovarian cancer presents with right lower extremity swelling and discomfort. Physical exam reveals right calf tenderness without any overlying skin changes. She reports no shortness of breath, chest pain, or hemoptysis. An ultrasound confirms the diagnosis. A decision is made to begin anticoagulation therapy after assessing risk factors. Which of the following statements most accurately describes the most appropriate treatment plan?

This patient will be started on low-molecular-weight heparin for 3 months before reassessing the duration of therapy Unfractionated heparin (B) is administered intravenously and is typically reserved for patients who have kidney insufficiency. If apixaban is used, it does not need to be preceded with heparin therapy. Unfractionated heparin followed by warfarin therapy for 6 months (C) has been shown to be inferior to low-molecular-weight heparin for 3 months or monotherapy with a direct oral anticoagulant. Warfarin (D) takes several days before there is effective anticoagulation. Therefore, patients are typically started on warfarin in conjunction with unfractionated or low-molecular-weight heparin while the warfarin takes effect. Warfarin has been shown to be inferior to low-molecular-weight heparin in patients with malignancy for preventing recurrent venous thromboembolism. However, warfarin is preferred in a patient with renal dysfunction if used long term.

A 62-year-old woman is 4 days status post an explorative laparotomy and splenule excision when she develops muscle weakness, flaccid paralysis, and ileus. Her current medications include heparin, lisinopril, and spironolactone. Vital signs are stable. Her laboratory values are significant for a potassium of 6.6 mmol/L (and a calcium of 10.6 mg/dL. Her blood urea nitrogen and serum creatinine have been stable at 20 mg/dL and 1.1 mg/dL, respectively, since admission. Her 12-lead ECG is shown above. Physical examination is unremarkable. Which of the following is the most appropriate clinical intervention to prevent cardiotoxicity at this time?

ans:Intravenous calcium chloride dx:Hyperkalemia Intravenous insulin and dextrose (C) should be administered in the acute management of hyperkalemia, as these medications quickly decrease serum potassium and prevent hypoglycemia. However, insulin and dextrose do not play a direct role in preventing cardiotoxicity. Calcium chloride or calcium gluconate is needed to stabilize the cardiac membrane.

A 50-year-old man with a history of alcohol use disorder presents to the clinic with intermittent epigastric pain that radiates to his back. The patient still drinks alcohol daily. Laboratory studies, including a lipase, are unremarkable. CT of the abdomen and pelvis shows calcifications of the pancreas. Which of the following is the best initial management of this patient's pain?

Alcohol cessation and reduce dietary fat intake Chronic pancreatitis refers to progressive inflammatory changes of the pancreas, which result in structural damage to the pancreas,

A 52-year-old man with a history of alcoholic cirrhosis presents with altered mental status and hematemesis. The patient was intubated in the ED, and ICU treatment included blood transfusions, ceftriaxone, octreotide, and, prior to endoscopy four hours after admission, a dose of erythromycin. During endoscopy, a 4 mm esophageal varix with spurting blood is identified and cannot be controlled with band ligation. Which of the following is the best next step?

Balloon tamponade should be initiated in all patients with esophageal variceal hemorrhage who fail initial endoscopic management. Esophageal varices are enlarged veins that functionally decompress the hepatic portal vein in the setting of elevated portal venous pressure. Comorbid conditions include cirrhosis of the liver and, less commonly, portal vein thrombosis (Budd-Chiari syndrome). What is the only life-saving medication in the acute management of esophageal variceal hemorrhage? Answer: Ceftriaxone is the only medication proven to increase survival.

A 68-year-old man presents one day status post endovascular repair of a thoracic aortic aneurysm. He had no complications from surgery or anesthesia. The patient reports adequate analgesia. His vitals are stable, and he has a normal physical exam. A provider is educating the patient on postoperative care, including venous thromboembolism prophylaxis. Which of the following is also indicated for postoperative prophylaxis?

Incentive spirometry What are other interventions for prevention of postoperative pulmonary complications? Answer: Intercostal nerve blockade, early mobilization, and oral hygiene.

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?

Calcifications of the pancreas dx Chronic pancreatitis is most often associated with alcohol use disorder USA epigastric abdominal pain described as intense and radiating to the back. The pain is often associated with nausea or vomiting. Food intake makes the pain worse, and leaning forward may relieve the pain minimally Diagnostic imaging includes transabdominal ultrasound, computed tomography(CT) of the abdomen, or magnetic resonance imaging (MRI). These modalities will demonstrate ductal dilation, calcifications and diffuse enlargement of the pancreas, and cystic formations (pseudocysts). A magnetic resonance cholangiopancreatography (MRCP)largely replaced endoscopic retrograde cholangiopancreatography (ERCP) as the study of choice for chronic pancreatitis.

A 40-year-old woman presents to the emergency department with acute abdominal pain and cramping that began about 2 hours ago and has gotten progressively worse. She had episodes like this in the past that resolved after a few minutes and none have ever lasted this long. She has not had a bowel movement in 48 hours or any recent surgeries. On physical exam, her abdomen is largely distended and tympanitic. Given the results of the plain abdominal radiograph shown above, which of the following is the most likely diagnosis?

Cecal volvulus

A 40-year-old woman presents with complaints of left flank pain for 2 months. The patient reports no nausea, vomiting, dysuria, or urinary frequency. Physical exam is unremarkable. CT scan with contrast reveals a 5 cm adrenocortical mass on the left side. The mass has irregular borders and calcifications. Evaluation of 24-hour urinary fractionated catecholamines and metanephrines is normal. What is the most appropriate intervention for this patient?

Complete surgical resection Adrenocortical carcinoma is rare, with a yearly incidence of 1 to 2 per million people. This carcinoma is a highly malignant tumor t The only potentially curative treatment is with complete surgical resection. This treatment should be performed at a specialized referral center with specific surgical expertise to avoid tumor spillage and incomplete resection. Adjuvant mitotane is a postoperative recommendation for patients with high-grade disease, intraoperative tumor spillage, and large tumors with vascular or capsular invasion. Mitotane treatment is continued for 5 years after surgical resection for high-risk patients and for at least 3 years in low-risk patients. Mitotane requires serum monitoring and levels should be 14 to 20 mcg/mL. Patients on mitotane must also be treated with glucocorticoid replacement therapywhile on mitotane, as it induces atrophy or inhibits steroid production, and many patients require testosterone supplementation as well.

A 54-year-old woman presents to the clinic with an ulcer over her right anterior tibia. Physical exam reveals nonpitting edema and the ulcer shown above. What is the most appropriate initial treatment for this patient?

Compression therapy

A 48-year-old woman with a history of obesity, diabetes mellitus, and hypertension presents complaining of worsening abdominal pain and nausea for the past 2 hours. She reports the pain began after eating a fast food meal. It initially began around the center of her abdomen, but it is now worse in the right upper quadrant of her abdomen and radiates to her right shoulder. She reports the pain has been constant despite taking two doses of omeprazole. On physical exam, she is ill appearing. Palpation of the abdomen reveals significant tenderness in the right upper quadrant. Bloodwork shows total bilirubin of 0.8 mg/dL, alkaline phosphatase of 50 IU/L, and white blood cell count of 14,000/mm3. Which diagnostic study is considered to be the gold standard for the suspected diagnosis?

Cholescintigraphy aka HIDA dxCholecystitis

A 79-year-old woman with past medical history of hypertension and hypercholesterolemia presents to the office with a month-long history of worsening, dull, aching abdominal pain. The pain is generalized but is often worse in her midabdomen and significantly worsens 30 minutes after eating. The discomfort lasts approximately half an hour and then spontaneously resolves. She has lost all interest in food and avoids eating large amounts in an attempt to avoid abdominal pain. She has no recent medication changes and is consistent with taking hydrochlorothiazide and simvastatin. She reports an 8-pound unintentional weight loss over the last 3 weeks. Which of the following is the most likely diagnosis?

Chronic mesenteric ischemia #LOOK AT IMAGE FOR GOOD COMPARISON 1)60 years of age and older. 2)postprandial abdominal pain (pain after eating), avoidance of food to prevent pain, and resulting weight loss. !!!pain is caused by increased abdominal blood flow after a large meal in the setting of inadequate perfusion. Due to the collateral network of the mesenteric arteries, symptoms do not develop until two out of the three vessels are affected.-->15-30 minutes after eating and lasts for half an hour.!! CT angiography is the gold standard for diagnosing mesenteric ischemia and the preferred initial diagnostic test. Labs will show lactic acidosis The most common sites of atherosclerosis resulting in chronic mesenteric ischemia include the celiac, superior mesenteric, and inferior mesenteric arteries. Unlike acute mesenteric ischemia, chronic mesenteric ischemia is rarely caused by an embolus. The risk factors for chronic mesenteric ischemia include conditions that may contribute to or worsen atherosclerosis or embolic events. These conditions include hypertension, hyperlipidemia, hypercholesterolemia, diabetes mellitus, obesity, sedentary lifestyle, and tobacco use. tx: antiplatelet therapy with aspirin for secondary prevention of atherosclerosis. Anticoagulation is reserved for patients with an acute thrombus. Surgical options are for patients who are symptomatic, such as those with recurrent abdominal pain and weight loss. Surgical options include endovascular repair (with angioplasty or stenting) or open repair (with transaortic endarterectomy, direct reimplantation on the aorta

A 47-year-old woman presents with a painless bulge in the right upper quadrant of her abdomen. She noticed this bulge 3 months ago after an open cholecystectomy. On physical exam, there is a soft mass in the area of the healed surgical scar. Which of the following risk factors is associated with the diagnosis?

Connective tissue disorder incisional hernia

A 43-year-old woman has a routine mammogram that shows an area with microcalcifications. After discussing the risks versus benefits, she decides to proceed with a biopsy. Which biopsy technique is preferred in this scenario?

Core-needle biopsy preferred technique used to biopsy most breast lesions that are suspicious for malignancy. It is the method used for both palpable and nonpalpable breast lesions a 14-gauge needle is used to retrieve cellular material from the suspicious area. Vacuum-assisted and automated devices are also available with larger-gauge needles. This increases the amount of cellular material that can be retrieved when compared to the syringe method alone y. Advantages to a core-needle biopsy are low risk of complications, minimal scarring, lower cost, and quicker recovery times Fine-needle aspiration biopsy (B) is sometimes used as a measure to biopsy a suspicious lesion of the breast. However, this does not provide as much tissue and has lower sensitivity rates than core-needle biopsy. This is done more often when examining lesions that appear to be benign. Open biopsy (C) is mostly used when the initial biopsy findings do not support the clinical or radiographic findings. Ultrasound localization biopsy (D) is used when a mass is present but is not helpful for localizing microcalcification. Stereotactic localization techniques are more helpful when no mass is presen

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? Crohn disease vs UC?

Crohn disease An anal fistula occurs when a structure or pathway forms between the intestine and another adjacent structure. It is most commonly a complication of perirectal abscess.

A 75-year-old man presents to the clinic to discuss concerns regarding cancer screening. His brother was recently diagnosed with esophageal cancer, and he believes that he is having similar symptoms to what his brother had a year ago. What are the most common symptoms of esophageal carcinoma to look for in this patient?

Dysphagia and weight loss

A 40-year-old woman presents to the emergency department with right upper quadrant pain. On exam, she is afebrile but has right upper quadrant tenderness. Laboratory testing reveals an alkaline phosphatase of 640 U/L, AST of 204 U/L, and ALT of 220 U/L. The common bile duct measures 9 mm on transabdominal ultrasound, and the gallbladder is present. Which of the following is both diagnostic and therapeutic for the most likely diagnosis?

Endoscopic retrograde cholangiopancreatography dx:Choledocholithiasis

A 54-year-old man with a history of chronic pancreatitis presents to his primary care provider with complaints of persistent abdominal pain and anorexia for the past 6 weeks. Physical examination is significant for a palpable mass in the epigastric region. His CT scan shows a 7 cm x 8 cm thick-walled pancreatic pseudocyst. Which of the following clinical interventions is indicated at this time?

Fine-needle aspiration

A 72-year-old man with a history of cirrhosis presents to the emergency department with acute confusion. His wife reports he ran out of his lactulose 3 days ago. On exam, the patient is lethargic but arousable and has asterixis. Laboratory findings reveal a normal basic chemistry panel, and CT of the head shows no acute abnormalities. What is the most likely diagnosis?

Grade II hepatic encephalopathy q59

A 56-year-old woman is scheduled for an open reduction internal fixation of her right radius and ulna after she fell in her shower. She has a history of persistent atrial fibrillation and is instructed to hold her rivaroxaban for 48 hours prior to surgery. On the morning of her surgery, the patient suddenly develops pain in her right leg. Her right leg feels cold compared to her left leg. An emergent Doppler ultrasound is performed and reveals 1 pulses over the dorsalis pedis and posterior tibial arteries of the right leg and 3 pulses over the dorsalis pedis and posterior tibial arteries of the left leg. Which of the following physical examination findings is a late sign of the patient's condition?

Loss of motor function acute arterial occlusion from an arterial embolism secondary to atrial fibrillation. Discontinuing anticoagulants prior to surgery increases the risk for thromboemboli. Early clinical signs of acute arterial embolism in a limb include a cold and pale extremity, pain out of proportion to exam, loss of sensation, and loss of distal pulse. Loss of motor function and poikilothermia are late findings. Risk factors include increased age, hypercoagulability, cardiac abnormalities, and atherosclerotic disease. Arterial emboli mostly affect the brain and lower extremities but may also affect the upper extremities, mesenteric arteries, or renal arteries. Limb ischemia is the most common cause of morbidity and mortality from arterial embolism. Ischemia greater than 6 hours is associated with an increased risk of limb loss

A 60-year-old man presents with a red bump on the end of his nose that has gotten larger over the past several months. The patient states the lesion is not painful or ulcerating. On physical exam, there is an 8 mm pink, dome-shaped papule with prominent telangiectatic surface vessels on the tip of the nose. The patient has not had a lesion like this in the past. Punch biopsy reveals a basal cell carcinoma. Which of the following is the most appropriate next step in management?

Mohs micrographic surgery First-line therapies for lesions on the head and neck include standard surgical excision and Mohs micrographic surgery. Standard surgical excision is used for nodular or superficial disease that is less than 10 mm on noncritical areas of the face, such as cheeks, forehead, scalp, and neck. Margins should be 4-5 mm and the defect is typically immediately repaired with adjacent tissue or skin grafts. Mohs micrographic surgery is recommended for lesions in the high-risk areas of the face known as the H zone (the areas around the eyes, lateral cheeks, ears, nose, and mouth), tumors greater than 2 cm, and more invasive subtypes. This surgical approach allows for histologic evaluation of the whole peripheral margin at the time of the procedure, which allows for tissue sparing and better cosmetic or functional outcomes. Mohs micrographic surgery is not recommended for small primary basal cell carcinomas on the extremities or trunk that lack aggressive clinical or pathological features

A 72-year-old man presents with concerns over vision loss that lasted for 2 minutes and occurred just prior to arrival. He has never had this happen in the past, and his vision has returned to baseline now. During the episode, he had no other complaints, numbness, weakness, or speech difficulty. He describes the vision loss as a "curtain" being pulled downover his vision. Physical exam is benign except for carotid bruits auscultated bilaterally. Which of the following historical findings is most consistent with the most likely cause of his symptoms?

Monocular symptoms A transient loss of vision in one or both eyes is termed amaurosis fugax, meaning "fleeting darkness Contrast angiography is the gold standard for diagnosing carotid stenosis, however, this test is typically not necessary, as other less invasive methods of imaging are available, such as carotid duplex ultrasound, magnetic resonance angiography (MRA), and computed tomographic angiography (CTA). Carotid stenting and carotid endarterectomy are the standard interventional procedures used to treat carotid disease and reduce the risk of cerebrovascular accident (CVA).

A 56-year-old man with a history of polymyalgia rheumatica presents for evaluation prior to elective total right knee replacement. His medications include prednisone 10 mg PO daily for the last three months. His vitals and physical exam are normal. Which of the following is the best next step?

Morning serum cortisol level

An 80-year-old woman presents with cramping abdominal pain and vomiting for 1 day. Physical examination reveals high-pitched, tinkling bowel sounds and abdominal distention. There is diffuse tenderness of the abdomen with palpation. There is a positive Howship-Romberg sign and a palpable proximal thigh mass. Which of the following is the most likely diagnosis?

Obturator hernia

A 65-year-old man with a past medical history significant for kidney transplant is diagnosed with a solitary peripheral lung mass that is 1.2 cm in diameter. The decision is made to biopsy the lesion. Which of the following methods would be the best for this patient?

Open lung biopsy or surgical excision biopsy, is the gold standard for determining whether a peripheral lung lesion is malignant or infectious.

A 72-year-old man presents with a 6-month history of unintentional weight loss, anorexia, and epigastric abdominal pain. For the past 2 days, his wife was concerned that he looked "yellow." Laboratory testing is obtained as part of the workup, and a CA19-9 is elevated. Which of the following is the most likely diagnosis?

Pancreatic cancer

A 40-year-old woman presents to the emergency department with an abrupt onset of abdominal pain, vomiting, and abdominal distention. Abdominal X-rays show dilated loops of bowel with air-fluid levels. Which of the following clinical findings is classic for the most likely diagnosis?

Paroxysmal periumbilical abdominal pain dx:Bowel obstruction

A 56-year-old woman presents to the emergency department with bladder pain and inability to urinate. She had an outpatient surgical procedure yesterday to treat urinary incontinence and has been having difficulty voiding since she arrived home. Upon physical exam, the suprapubic area is distended and painful to palpation. Which of the following is the best next step in the management of her condition?

Perform in-and-out catheterization Decompression of the bladder by catheterization is the treatment of choice to reduce future complications either with in-and-out catheterization or with an indwelling Foley catheter, although the latter carries a higher risk of urinary tract infection development.

A 72-year-old man with a history of pancreatic cancer presents with jaundice. He states that he is otherwise feeling well and reports no nausea, vomiting, or bowel changes. Physical exam reveals mild epigastric tenderness, scleral icterus, and jaundice. Laboratory studies are completed. Which of the following would be most consistent with the suspected diagnosis?

Predominant alkaline phosphatase elevation

A 22-year-old woman presents with a breast mass she noticed while showering 1 week ago. She is not sure how long it has been present. After physical examination, the patient is told she likely has the most common type of benign breast lesion found in young women. Which of the following physical exam findings is most consistent with the diagnosis?

Rubbery, mobile mass Fibroadenoma Patient will be a woman of childbearing age PE will show painless, firm, solitary, mobile, slowly growing breast mass Treatment is conservative management or surgical excision Most common breast tumor in adolescent women

A 50-year-old woman presents to the ED with nausea and vomiting. The patient reports that she started having colicky abdominal pain about 12 hours ago, and it has progressively worsened with uncontrolled nausea and vomiting over the past 2 hours. The patient states she has been constipated over the past week and has not had a bowel movement in two days. On physical exam, she appears ill and complains of nausea. Her abdomen is diffusely tender, and when asked, she states her abdomen is more distended than usual. A well-healed midline abdominal scar is also noted. Her CBC and CMP are normal. Her abdominal X-ray is shown above. Which of the following is the most likely diagnosis?

Small bowel obstruction Small Bowel Obstruction History of prior abdominal or pelvic surgery Bilious vomiting PE will show high-pitched bowel sounds X-ray will show dilated bowel, air fluid levels, stack of coins or string of pearls sign Diagnosis is made by imaging Treatment is NGT, surgery Gastric outlet obstruction (A) leads to epigastric abdominal pain and postprandial vomiting. These patients can present in an acute manner similar to a small bowel obstruction, but plain films of the abdomen reveal an enlarged gastric bubble, dilated proximal duodenum, and paucity of air in the small bowel. Large bowel obstruction (B) can present acutely with abdominal distention and pain or subacutely with a change in bowel habits over time due to progressive luminal narrowing. Nausea and vomiting can occur and are more likely with a proximal obstruction that can mimic a small bowel obstruction. Abdominal X-ray findings of large bowel obstruction include colonic distention proximal to the obstruction with collapse of the colon distally. Paralytic ileus (C) can present similarly to a small bowel obstruction with abdominal distention, nausea, and vomiting. It most commonly occurs postoperatively but can be caused by opioid medications, tricyclic antidepressants, and Crohn disease. Abdominal X-ray findings in patients with paralytic ileus show dilation of the large and small bowel, multiple air fluid levels, and elevation of the diaphragm.

A 62-year-old man with a history of chronic low back pain and alcohol use disorder presents to the emergency department with severe epigastric abdominal pain that started 1 hour prior to arrival. Vital signs reveal BP 94/45 mm Hg, HR 116 bpm, and T 95.5°F. Exam reveals a weak and thready pulse, cool extremities, and abdominal guarding. You obtain a hemoglobin level, which is 12.1 g/dL, and an upright chest radiograph, which is shown above. What is the next most appropriate step in management after initial hemodynamic stabilization?

Surgical consultation dx:Peptic ulcer disease (PUD) Peptic Ulcer Disease Patient presents with gnawing epigastric painDuodenal ulcer: pain is alleviated by ingesting food (mnemonic: DUDe, give me food)Gastric ulcer: pain is exacerbated by ingesting food Diagnosis is confirmed by endoscopy Diagnosis of H. pylori infection is made by H. pylori fecal antigen or urea breath test Most commonly caused by H. pylori infection or nonsteroidal anti-inflammatory use Most common cause of upper GI bleed Increases risk of perforation

A 23-year-old woman presents to her primary care provider with a complaint of an itchy rash. She states that the rash appeared on her trunk and arms this morning. Upon further inquiry, she reports that she had a minor outpatient surgical procedure last week and was given a short course of cephalexin, which she finished yesterday. She states that she is not taking any other medications, has no known drug allergies, and has not had any reactions like this in the past. Physical examination reveals a morbilliform rash on the trunk and upper extremities, as shown in the image above. The face, palms, and lower extremities are spared. Which of the following clinical interventions is most appropriate?

Topical triamcinolone and hydroxyzine 25 mg PO tid for 7 days dx:mild postoperative drug eruption drug-induced exanthems, typically occur 5-14 days after initial exposure to the offending agent. In previously sensitized patients, drug eruptions may occur within 1-2 days of exposure. Oral antihistamines (e.g., diphenhydramine, hydroxyzine, cetirizine) and topical corticosteroids may be used for symptomatic relief.

A 40-year-old woman presents with an intense, intermittent right upper quadrant pain that radiates to her back. Pain is exacerbated by eating and is worse at night. She denies any fever or chills. Laboratory studies are unremarkable. Which of the following diagnostic studies is the initial test of choice?

Transabdominal ultrasonography Cholelithiasis is a condition of having stones in the gallbladder. There are three types of stones: cholesterol stones (most common, yellow to green), pigment stones Hepatoiminodiacetic acid (HIDA) scan (C) is not used to diagnose cholelithiasis but can be used to exclude acute cholecystitis in patients who present with acute biliary colic.

A 56-year-old woman with a history of poorly controlled hypertension, tobacco dependence, and hyperlipidemia presents to the emergency department with severe abdominal pain that started 1 hour ago. She states the pain is epigastric, has a "tearing" quality, and is radiating distally. Vital signs are BP 80/63 mm Hg, HR 110 bpm, RR 26 breaths per minute, and T 98.1°F. The vascular exam demonstrates 2+ pulses over the carotid, brachial, and radial arteries bilaterally and 1+ pulses over the femoral and dorsalis pedis arteries bilaterally. Which of the following is the most appropriate initial diagnostic study for this patient?

Transesophageal echocardiogram Aortic dissection occurs when a tear in the intima of the aortic wall causes a second lumen to form within the wall of the aorta. The Stanford and DeBakey classification system . Stanford A refers to proximal aortic dissection (occurring proximal to the subclavian artery), while Stanford B lesions refer to distal aortic dissections (occurring distal to the subclavian artery). Importantly, the Stanford A classification also includes dissections that encompass the proximal and distal aorta. The DeBakey classification includes three categories: type I lesions (both distal and proximal involvement of the aorta), type II lesions (distal involvement of the aorta only), and type III lesions (proximal involvement of the aorta only). Beta-blockers, like esmolol or labetalol, are first-line to achieve the target blood pressure, however, sodium nitroprusside can also be used. For Stanford A aortic dissections, open vascular repair is needed. For Stanford B aortic dissections, medical therapy plus or minus surgical vascular repairs (endovascular or open repairs) are the indicated treatments. Aortic Dissection Patient will be older, usually a man History of HTN, Marfan syndrome Sudden "ripping" or "tearing" CP, radiating to back PE will show asymmetric pulses and BP CXR will show widened mediastinum Type A: involves ascending aorta Type B: involves only descending aorta Diagnosis is made by CT angiography or transesophageal echocardiogram (TEE) Treatment is reduce BP and HR, surgery (depending on dissection type)

A 65-year-old man with a history of Helicobacter pylori gastritis presents with abdominal pain and dark, tarry stools. He also notes loss of appetite and unintentional weight loss over the past several months. On exam, he is noted to have an enlarged left supraclavicular node. A barium upper GI series demonstrates gastric ulcers. Which of the following endoscopic features increases the likelihood the ulcers may be malignant?

Ulcers with thickened margins

A 27-year-old woman presents with a tender, painful left breast. She is breastfeeding her 1-month-old infant, and the pain began 1 week ago. She saw her primary care provider, who prescribed her an antibiotic that she has been taking, but since then, the pain and swelling have worsened. Exam reveals a tender, fluctuant mass near the areola. The skin is erythematous and intact without any necrosis. Which of the following is the best intervention at this time?

breast abcess = needle aspiration 57)What antibiotics are most commonly prescribed for mastitis and breast abscess? Answer: Dicloxacillin or cephalexin.

A 69-year-old woman presents to the emergency department with unilateral vision loss. Her past medical history includes hypertension, hyperlipidemia, and a 40 pack-year smoking history. She reports sudden, painless loss of vision in her left eye 15 minutes ago, and she also noticed some weakness in her right hand. Her vitals are within normal limits. A computed tomography scan of her head does not show evidence of intracranial hemorrhage or infarction. Her ECG revealed a normal sinus rhythm. A bedside carotid ultrasound shows 85% occlusion. What intervention is indicated at this time?

A) Carotid endarterectomy pts was experiencing a transient ischemic attack secondary to vascular disease of the carotid artery. Carotid artery stenting is a treatment option for patients who are not candidates for carotid endarterectomy, the stenosis is radiation induced, the patient experienced restenosis after a previous endarterectomy or have significant cardiopulmonary disease that would increase the risk of anesthesia during surgery.

A previously healthy 8-year-old boy presents to your office with his parents for his annual well-child exam. The parents are wondering about the need for cancer screening, given the patient's father having a recent diagnosis of colorectal cancer at age 35 years due to familial adenomatous polyposis. Which of the following is the most appropriate guidance?

AScreening starting at age 10 years Familial adenomatous polyposis is a genetic disorder resulting in the development of hundreds to thousands of adenomatous polyps in the colon at an early age. This disorder is caused by a genetic mutation involving the APCgene. Familial adenomatous polyposis affects men and women equally and has been seen in all ethnicities. The average age of onset is 16 years. Patients having one first-degree relative with colorectal cancer or an advanced adenoma prior to 60 years of age or two first-degree relatives with colorectal cancer diagnosed at any age should start screening colonoscopy at 40 years of age or 10 years before the youngest diagnosis in the family. This guidance is not the case for those with familial adenomatous polyposis, thus, screening starting at age 25 years (B) in this patient is not appropriate.

A 70-year-old man has a solid kidney mass identified on abdominal imaging performed for unrelated reasons. The radiologic features of the mass are concerning for malignancy. Which of the following is the classic triad for the most likely diagnosis?

Abdominal mass, flank pain, and hematuria dx:Renal cell carcinoma is the most common type of primary kidney neoplasm. Hematuria typically occurs from local invasion of the collecting system. Abdominal or flank masses are more commonly palpable in lower pole tumors and in thin patients. Scrotal varicoceles occur in a minority of cases. Inferior vena cava involvement also occurs in a minority of cases and may present with lower extremity edema, ascites, or pulmonary embolism. The most common sites of metastasis are the lymph nodes, liver, lungs, and brain. CT of the abdomen is the recommended initial radiologic study. The diagnosis is confirmed by tissue diagnosis via biopsy, which is most often achieved through partial or total nephrectomy of tumors suspicious for renal cell carcinoma. The treatment of resectable renal cell carcinoma is surgical removal. Radical nephrectomy is the most common approach.

A 17-year-old boy is admitted for acute appendicitis after presenting with fever, abdominal pain, and anorexia for the last 3 days. He undergoes a laparoscopic appendectomy, in which the surgeon notes and removes a ruptured appendix. After the surgery is completed without complications, he is admitted postoperatively for IV antibiotics, pain control, and supportive care. He does not have drains or a urinary catheter. On postoperative day 5, he is still unable to tolerate oral intake though he is passing gas. He is requiring pain medication and has a rising fever curve. On physical exam, his belly is mildly distended and tender to palpation. His surgical wounds are clean, dry, and intact. He reports no dysuria. The rest of his exam is unremarkable. Which of the following is the most important next test?

Abdominal ultrasound

A 4-year-old boy presents to the office complaining of abdominal pain that is on and off and has been getting more frequent over the past few months. His mother states that his symptoms are not associated with meals and are not relieved with defecation. He does not have any dysuria or gross hematuria. Upon physical exam, there is a painless palpable mass to the right side of the abdomen. Which of the following imaging studies should be ordered for initial evaluation of his condition?

Abdominal ultrasound Wilms tumor, also known as nephroblastoma, is the most common childhood malignancy of the abdomen

A 45-year-old man presents to his family doctor for evaluation of his chronic abdominal pain. The patient reports epigastric pain that radiates to his back for the past three months. The pain worsens with eating and is relieved by leaning forward. The patient also reports weight loss. Past medical history includes a few episodes of acute pancreatitis and hypertension. The patient currently takes lisinopril 10 mg daily. Which of the following risk factors is most commonly associated with the patient's diagnosis?

Alcohol use disorder #acute pancreatitis

A 67-year-old man presents with abdominal pain and fever for the past 2 hours. Physical exam reveals tenderness below the navel and heme-positive stool. Duplex ultrasound is ordered and demonstrates a complete lack of arterial blood flow to the superior mesenteric artery. Which of the following risk factors would you expect to find in this patient's history?

Atrial fibrillation dx: Mesenteric ischemia results from decreased oxygenation due to a lack of blood supply to the intestinal circulation, which can be acute or chronic. The superior mesenteric artery is the most commonly affected in cases of acute mesenteric ischemia Angiography is both diagnostic and therapeutic as a means to reestablish blood flow. It is the gold standard for diagnosis of acute and chronic mesenteric ischemia. Treatment involves fluid resuscitation, thrombolytic therapy, fibrinolytic intervention, orsurgical resection of necrotic bowel. Which drug to support blood pressure should be avoided when treating mesenteric ischemia? Answer: Vasopressin.

A 55-year-old man presents to a primary care provider with complaints of slowly worsening fatigue, weakness, and decreased appetite over the past 6 months. He reports no alcohol or tobacco use. His CBC results are WBC 8,500/mcL, RBC 3.7 million/mcL, MCV 115 fL, MCH 32 pg, MCHC 36 g/dL, and platelets 250,000/mcL. His CBC differential is within normal limits. His folate level is 8.6 nmol/L, and his vitamin B12 level is 90 ng/mL. Serum methylmalonic acid and homocysteine levels are elevated. A Schilling test reveals abnormal vitamin B12 absorption in stage 1 (radiolabeled vitamin B12 only) and normal vitamin B12 absorption in stage 2 (radiolabeled vitamin B12 with intrinsic factor). Which of the following best describes the underlying pathology of the patient's condition?

Autoimmune disorder

A 27-year-old woman presents with vomiting and 10/10 right lower extremity pain. The symptoms started suddenly one hour ago when she was lifting weights. The pain is constant and worsening. She has no medical or surgical history, but one month ago, she noticed a painless mass below her right inguinal crease. Her vitals are T 37.1°C, HR 107 bpm, BP 141/92 mm Hg, RR 23/minute, and SpO2 99%. Her body mass index is 22 kg/m2. On examination, she is diaphoretic and pale, and there is a right-sided erythemic mass protruding inferior and lateral to the pubic tubercle. The mass is hot, firm, pulseless, and exquisitely tender to palpation. What is the best way to diagnose this condition?

Clinical exam Clinical exam is the best way to diagnose a strangulated groin hernia in nonobese patients. An intestinal hernia is aperitoneal sac protruding through an abnormal opening in the abdominal musculoaponeurotic barrier. CT abdomen and pelvis with IV contrast (B) is useful when the diagnosis of strangulated hernia is uncertain or there are additional competing diagnoses. Hernia sac laparoscopy (C) is one way to assess bowel viability after spontaneous hernia reduction, but there is no consensus recommendation on its superiority in bowel viability assessment. Ultrasound abdomen and pelvis (D) is indicated for undifferentiated groin pain or when there is suspicion for occult hernia. When clinical examination is adequate, imaging is a delay to surgical intervention.

A 62-year-old man presents with abdominal pain at five days status post endovascular with conversion to open repair of infrarenal aortic aneurysm. The pain started gradually today and is constant. The patient has no other symptoms and has tolerated an oral diet for the last two days. His abdomen is soft and tender to palpation in the left upper quadrant. The abdominal midline incision wound is clean, dry, and intact. He has a normal Hb and a positive guaiac-based fecal occult blood test. Which of the following is the most likely diagnosis?

Colonic ischemia q56

Colonoscopy with biopsy is the diagnostic test of choice for colorectal cancer. An "apple-core" lesion may be seen on barium enema, although this is rarely performed in practice. Laboratory tests may reveal iron deficiency anemia and elevated carcinoembryonic antigen. Right-sided tumors are more likely to ulcerate, which leads to iron deficiency anemia, melena, and fatigue. Because the proximal colon is larger in diameter and contains fecal contents that are more of liquid nature, obstructive symptoms are less likely. Tumors in the transverse and descending colon lead to cramping and signs and symptoms of obstruction. Tumors in the rectosigmoid colon present with hematochezia, stool narrowing and tenesmus. Colorectal Cancer Second leading cause of death Third most common cancer in men and women Adenocarcinoma Risk factors: age, IBD, adenomatous polyps, FAP, HNPCC Rectosigmoid > ascending > descending Left-sided cancer: tends to obstruct Right-sided cancer: tends to bleed Iron deficiency anemia Colonoscopy CEA Which side of the colon is more likely to develop colorectal cancer? Answer: The left side.

Colorectal cancer

A 62-year-old man presents to the emergency department with the complaint of acute onset of abdominal pain two hours ago. He is evaluated by a vascular surgeon. The patient has a history of tobacco use, hypertension, and hyperthyroidism, for which he is on the appropriate medication. He reports the abdominal pain started suddenly after eating and is worst around his umbilicus. He had a large, forceful bowel movement one hour ago. Vitals are blood pressure 145/90 mm Hg, pulse 116 bpm irregularly, respirations 18 per minute, and temperature 39.2°C. Physical exam reveals severe periumbilical abdominal pain with no masses, guarding, or rebound tenderness noted. Laboratory testing reveals heme-positive stool, leukocytosis, and lactic acidosis. What is the gold standard diagnostic test to confirm the suspected condition?

Computed tomography angiography Acute mesenteric ischemia is the result of visceral arterial insufficiency. The arterial insufficiency may be due to an embolic occlusion, such as in a state of atrial fibrillation, or loss of blood flow, such as in a state of hypotension or heart failure. Most commonly, the superior mesenteric artery is the affected vessel. Patients may present classically with abdominal pain, fever, and heme-positive stool.

A 78-year-old man is brought by his daughter to his primary care provider with gradually worsening headaches, light-headedness, apathy, somnolence, and occasional seizures. He has never had these symptoms before. His medications include atorvastatin 10 mg and aspirin 81 mg daily. The daughter denies that the patient has had any falls or major head trauma other than he hit his head one time 3 weeks ago while grabbing an item from underneath the sink. Which one of the following findings would be expected on a noncontrast CT scan of the head given the most likely diagnosis?

Concave, crescent-shaped hypodensity chronic subdural hematoma gradual onset headaches, light-headedness, cognitive impairment, apathy, somnolence, and seizures. Elderly patients and alcoholics are at higher risk of subdural hematomas, particularly of chronic presentation, because brain atrophy results in increased vulnerability for rupture of the bridging veins.

A 28-year-old woman presents to clinic with a 2-month history of hematochezia, abdominal pain, and diarrhea. Physical exam reveals diffuse abdominal tenderness, occult rectal blood, and a skin ulceration, as shown above. Laboratory evaluation reveals an elevated ESR, a positive fecal calprotectin, a negative stool culture, and a negative stool ovum and parasite. Which of the following findings is most consistent with the suspected diagnosis?

Crypt abscesses dx:UC dermatologic manifestations (erythema nodosum in Crohn disease and pyoderma gangrenosum in ulcerative colitis) Bloody diarrhea, crampy abdominal pain, tenesmus Mild-moderate: mesalamine, topical or oral steroids, 5-ASA Severe: IV steroids +/- topical steroids initially, then anti-TNF or anti-integrin, colectomy for refractory cases (curative) Complications: toxic megacolon, ↑ colon cancer risk

A 62-year-old man presents to the emergency department with redness and blistering to his entire chest and bilateral thighs. He states he was walking to the kitchen sink to drain hot water from his boiling pasta when his dog ran in front of him, causing him to slip and drop the entire pot onto his chest. The affected area is only painful when pressure is applied. It appears as red blisters that make up approximately 36% of his total body surface area. When touching the blisters, they easily burst open. His vaccines are up to date, including a tetanus booster he received two years ago. Which of the following is the correct staging for this patient's burn?

Deep partial-thickness burn

A 55-year-old woman presents with a history of vague, nonspecific abdominal pain that began 6 months ago. Endoscopy reveals a one centimeter firm growth in the jejunum, which is biopsied and sent for pathology. A 24-hour urinary excretion reveals elevated levels of 5-hydroxyindoleacetic acid. Which of the following additional symptoms is likely present given the most likely diagnosis?

Diarrhea and flushing Carcinoid tumors are a type of slow-growing and difficult to detect neuroendocrine cancer that arises from enterochromaffin cells of the digestive tract. Carcinoid tumors most commonly present between the ages of 50 to 60 years old. These tumors most commonly arise from the small intestine, bronchus/lung and rectum. The majority of patients are asymptomatic or will report vague abdominal pain. Carcinoid syndrome presents with diarrhea, flushing, wheezing, hemodynamic instability and metabolic acidosis. Serotonin is responsible for causing diarrhea; histamine and tachykinin release causes flushing; both histamine and serotonin release induce wheezing and intra-abdominal fibrosis. elevated levels of 5-HIAA, which is a metabolite of serotonin. Chromogranin A is a serum marker of carcinoid tumors : What amino acid is serotonin synthesized from? Answer: Tryptophan. Treatment typically includes surgery, chemotherapy, and radiation with the addition of somatostatin analogs (i.e., octreotide) to lessen the effects of elevated serotonin levels.

A 62-year-old man presents with epigastric pain, nausea, early satiety, and unintentional weight loss over the past 2 months. An upper endoscopy shows an ulcerated, friable mass of the gastric mucosa. Which one of the following risk factors would place him at risk for the most likely diagnosis?

Diet high in processed meat Gastric cancers Dietary risk factors include a high-salt diet, a diet rich in nitroso compounds (found in tobacco smoke, processed meats, and fried foods), and a diet low in folate. Both obesity and smoking are modifiable risk factors associated with a greater risk of gastric cancer

A 65-year-old woman with obesity presents with an acute onset of left lower quadrant pain accompanied by nausea, vomiting, and fever. A rectal exam shows a painful mass near the rectum. Laboratory studies reveal leukocytosis with a left shift. An abdominal radiograph is unremarkable. Localized bowel wall thickening and increased soft tissue density in pericolonic fat are demonstrated on an abdominal CT scan. Which of the following is the most likely diagnosis?

Diverticulitis

A 70-year-old man with a history of longstanding gastroesophageal reflux disease presents with a gradual onset of difficulty with swallowing solid food for several months. He reports unintentional weight loss and no alcohol or tobaccouse. A barium swallow study reveals blockage of barium media at the squamocolumnar junction. Edema, basal cell hyperplasia, and increased type III collagen deposition are seen on esophagogastroduodenoscopy with biopsy. Which of the following is the most likely diagnosis? A 65-year-old man is referred to a gastrointestinal surgeon for an upper endoscopy with biopsy. The patient has a history of painless, solid food dysphagia that has been progressively worsening over 8 months. He has a significant past medical history of gastroesophageal reflux disease but reports he has not been having as many episodes of reflux lately. The physical exam is unremarkable, and vital signs are within normal limits. The endoscopy with biopsy reveals narrowed esophageal lumen, active esophagitis, and benign esophageal tissue histology. What clinical intervention is indicated at this time?

Esophageal stricture Balloon dilation at the site of narrowing Future esophageal strictures can be prevented by initiating long-term proton pump inhibitor therapy.

A 45-year-old man with a recent history of anterior neck surgery presents to the clinic with symptoms of generalized fatigue over the previous 2 months. Laboratory evaluation reveals a TSH of 15.1 mU/L and a free T4 of 0.6 ng/dL. Which of the following physical exam findings is likely present in this patient?

Hypothyroidism is the deficiency of circulating thyroxine, most commonly caused by autoimmune inflammation of the thyroid gland (Hashimoto thyroiditis). Other etiologies of hypothyroidism include iatrogenic causes (e.g., partial or complete thyroidectomy and radioablation of the thyroid) and secondary or tertiary hypothyroidism. Patients will commonly present with indolent symptoms, such as fatigue, dyspnea, lethargy, weakness, paresthesias, headaches, cold intolerance, constipation, and dry skin. Physical exam findings common in hypothyroidism include bradycardia, hair thinning, brittle nails, peripheral edema (myxedema), puffy eyes, goiter, delayed deep tendon reflexes, and diastolic hypertension.

A 75-year-old man was admitted to the hospital from a long-term care facility for fever and an elevated WBC count. A stage 3 sacral decubitus injury with superficial necrosis is discovered. He is on sequential compression devices for deep vein thrombosis prophylaxis and is not on any anticoagulants. Which of the following is an appropriate clinical intervention?

Management of pressure injuries includes reducing pressure, removing necrotic tissue, and maintaining a moist wound bed to promote healing. Necrotic tissue must be debrided to expose granulation tissue, reduce infection risk, and facilitate healing. Sterile scissors or a scalpel are used for sharp debridement, which is indicated if the pressure injury is infected or if a large amount of infected tissue or bone must be removed promptly. General anesthesia is reserved for patients needing extensive debridement. Anticoagulation is a relative contraindication to sharp debridement. Mechanical debridement includes hydrotherapy, wound irrigation, and whirlpool baths to loosen bacteria, increase local circulation, reduce pain, and speed wound healing. Autolytic debridement is useful in removing only nonviable tissue and provides a moist environment to allow the body's enzymes to digest necrotic tissue. Enzymatic debridement is most effective in moist wounds and uses enzymes, such as collagenase, to remove necrotic tissue. A moist wound environment can be maintained with transparent films, hydrocolloids, hydrogels, alginates, or foams. Broad-spectrum antibiotics are warranted for patients with sepsis, osteomyelitis, cellulitis, fever, or leukocytosis. Patients who need debridement and have a history of previous bacterial endocarditis, congenital cyanotic cardiac malformations, or prosthetic valves should receive prophylactic antibiotics. Autolytic debridement (A) is most appropriate for stage 1 or stage 2 injuries that are not infected. It is not recommended for deep ulcers with superficial necrosis. Repositioning the patient every 6 hours (B) is incorrect. Patients should be advised to shift their weight every 10 minutes if they are able. Patients who cannot move themselves should be repositioned every 2 hours. Wet-to-dry dressing changes (D) are no longer recommended in clinical practice because they can remove viable tissue and cause the patient pain.

A 54-year-old man presents with complaints of frequent heartburn and diarrhea for the past 2 months that seems to be worsening. He has completed a trial of medications but continues to complain of pain in the epigastric area that is the worst about 3 hours after eating a meal. Endoscopy is performed and shows prominent gastric folds and multiple duodenal ulcers. Which one of the following diagnostic results would be most consistent with the diagnosis?

Markedly elevated fasting serum gastrin Zollinger-Ellison syndrome. Tumor localization is accomplished viaendoscopy, computed tomography (CT), or magnetic resonance imaging (MRI). Endoscopy will demonstrate prominent gastric folds and solitary peptic ulcers typically located in the duodenum. Treatment is dependent upon staging of the gastrinoma.

A 35-year-old woman presents to her primary care provider for her annual physical. She has no significant past medical history, however, she has a significant family medical history of pheochromocytoma and hyperparathyroidism on her father's side. On physical exam, she has a palpable, nontender nodule in the left lobe of her thyroid. She denies dysphagia or hoarseness. Ultrasound confirms the presence of a suspicious thyroid nodule. She is referred to a general surgeon. What type of thyroid cancer is most likely?

Medullary multiple endocrine neoplasia type 2 (medullary thyroid cancer, hyperparathyroidism, and pheochromocytoma). Patients may report flushing, diarrhea, and fatigue as symptoms of medullary thyroid cancer. Anaplastic (A) is the most common type of thyroid cancer in men over the age of 65. Follicular (B) thyroid cancer is most common after 40 years of age and is associated with iodine deficiency. Papillary (D) thyroid cancer is the most common type of thyroid cancer overall but is associated with head or neck radiation exposure.

A 44-year-old man presents with pain in the anal area that began 2 days ago and has been gradually worsening. He denies any rectal bleeding or itching. He also denies any constipation or changes in bowel movements, although he states having a bowel movement today was extremely painful. Physical exam reveals a tender, fluctuant mass that is erythematous to the right of the anus and involves the anal verge. Which of the following is the best next step in managing this patient's care?

Perform incision and drainage dx:Perianal abscesses Applying liquid nitrogen (A) is an appropriate treatment for anal warts when there are few lesions and if other topical therapies are not appropriate. This treatment is not used for a perianal abscess. Instructing the patient to perform warm sitz baths frequently (B) may be appropriate as part of a postoperative course or if a patient is diagnosed with hemorrhoids, however, this is not an appropriate therapy for perianal abscess. The abscess will worsen if not promptly incised and drained. Prescribing amoxicillin-clavulanate (D) is an appropriate course after incision and drainage, however, only prescribing an antibiotic without draining the abscess will not resolve the condition.

A 65-year-old woman is three days post-liver resection. The nurse calls to tell you the patient has been coughing more frequently. Her temperature is 101°F, RR is 30 breaths per minute, oxygen saturation is 92% on room air, and HR is 102 bpm. On physical exam, the patient appears lethargic and coughs occasionally. Lung examination reveals dullness to percussion and decreased breath sounds over the right lower lobe. Which of the following is the most likely diagnosis?

Pneumonia

A 21-year-old man presents to the office complaining of swelling and achiness to the right testicle. He does not have any other complaints. Upon physical exam, there is a palpable, painless, scrotal mass to the right testis with well-defined margins. The mass does not transilluminate when a light is held behind the scrotum. He does not have any palpable lymph nodes to the inguinal or supraclavicular areas. A testicular ultrasound reveals a well-defined hypoechoic lesion within the right testicle. Which of the following is the most likely diagnosis?

Testicular cancer ages of 20-35 years. Most tumors are germ cell tumors that are further categorized into nonseminomas and seminomas. Nonseminomas are more aggressive than seminomas. A strong risk factor for the development of testicular cancer (particularly seminomas) is a history of cryptorchidism. The right testis is more commonly affected than the left, although some patients may have bilateral disease. Patients will typically present with a history of a unilateral painless and enlarged testis and may describe a feeling of heaviness or achiness to the scrotum. Seminomas appear as well-defined hypoechoic lesions without fluid, while nonseminomas are nonhomogeneous hyperechoic with indistinct margins, calcification, and cystic areas. What type of testicular tumors are found in bilateral primary testicular cancer? Answer: Seminomas.

A 72-year-old man presents to the emergency department with left-sided chest pain radiating down his left arm for the past 2 hours. He states the pain began at rest and is heavy and crushing in nature. He was given aspirin 325 mg shortly after his symptoms started. Vital signs are T 37.2°C (99.0°F), BP 132/96 mm Hg, HR 96 bpm, RR 20 breaths per minute, and oxygen saturation 95% on room air. A 12-lead ECG is obtained and shown above. His initial troponin level is 36.8 ng/mL. The patient's current medication list includes atorvastatin, metoprolol, and sildenafil. Which of the following interventions is indicated prior to percutaneous coronary intervention in this patient and is strongly associated with a reduced mortality for the patient's condition?

Ticagrelor cardiac enzyme marker troponin, confirm the diagnosis of an ST elevation myocardial infarction (STEMI) PCI is preferred if it can be performed within 120 minutes of first medical contact. Patients with symptom onset of < 2 hours in whom PCI cannot be performed in a timely manner should receive a fibrinolytic therapy (e.g., tenecteplase, reteplase, alteplase) with close monitoring and transfer to a facility where PCI can be performed. PCI can be performed. Aspirin and a P2Y12 receptor blockers such as ticagrelor or prasugrel are associated with improved mortality in STEMI patients and should be administered as soon as possible after diagnosis has been confirmed. D

A 70-year-old man presents to the office complaining of urinating pink urine for the past week. He does not have any pain with urination, urinary urgency, frequency, pelvic pain, flank pain, or fever. Physical exam is unremarkable and urine culture is negative for infection. A voided urine cytology is ordered. Which of the following is the most common risk factor in the United States for the suspected condition?

Tobacco use Bladder cancer is the most common urologic cancer that almost always originates in the urothelium, which is the mucosal layer within the bladder. The most common type of bladder cancer is transitional (urothelial) cell carcinoma a The second most common cancer is squamous cell carcinoma A majority of bladder cancer is associated with exposure to environmental factors. In the United States, tobacco use is the most common cause of bladder cancer due to the carcinogenic agents found in cigarettes. Exposure to other toxic agents, such as heavy metals, diesel exhaust, petroleum products, solvents, chemicals, and dyes, also increases the risk of disease development classically with painless gross hematuria. Less common symptoms include dysuria, urinary urgency, and frequency.

A 60-year-old man presents to his primary care physician with complaints of lower extremity pain. The patient reports he has pain in his lower legs while walking that is relieved by rest. On physical exam, skin on bilateral lower legs is shiny and hair loss is present. The patient has a history of type 2 diabetes and hypertension. Medications include metformin 500 mg bid and lisinopril 10 mg daily. Ankle-brachial index is 1.5. Which of the following is the most appropriate next step for diagnosis?

Toe-brachial index dx:Peripheral artery disease Peripheral Artery Disease Patient presents with pain in the affected extremity related to activity (intermittent claudication) PE will show cool extremity with absent or diminished pulses Diagnosis is made by ankle-brachial index (ABI)If limb is threatened: contrast arteriography (gold standard) Most commonly caused by atherosclerotic disease

A 61-year-old man with a history of hypercholesterolemia and hypertension presents to his primary care provider for his annual checkup and medication refills. Other than feeling out of shape, he has no other complaints. With further questioning, he explains he gets tired more quickly than he used to and feels out of breath quickly with exercise. His exam is concerning for a new 3/6 holosystolic murmur best heard at the apex and radiating to the axilla. Which of the following is the best test to establish the diagnosis?

Transthoracic echocardiogram dx:Mitral valve regurgitation

A 54-year-old man presents to the office with a nonhealing, painful lesion on his left thigh for 7 days. He reports no fever or chills. He enjoys karate and is concerned about a fungal infection. He is at the gym 5 days a week and uses the mats frequently. On exam, there is a 3 cm firm, erythematous, tender nodule with 4 cm of circumferential erythema on his left thigh. There is no purulence or drainage. There is no lymphadenopathy. A potassium hydroxide preparation is negative. What is the first-line treatment of choice, given this patient's suspected condition?

Trimethoprim-sulfamethoxazole MRSA Vancomycin (D) is the preferred therapy for hospital-acquired MRSA. In the above clinical vignette, the patient was diagnosed in an outpatient setting, which classifies the illness as community-acquired MRSA. Amoxicillin-clavulanic acid (A) is an available option for patients presenting with methicillin-sensitive Staphylococcus aureus. However, it is not indicated in the treatment of community-acquired MRSA. Ciprofloxacin (B) is not an appropriate option for the treatment of community-acquired MRSA.

If the aneurysm is 5.0 to 5.4 cm in diameter, then repeat imaging with either an ultrasound or computed tomography should be completed every six months. If the aneurysm is 4.0 to 4.9 centimeters in diameter, then it should be monitored with ultrasound imaging every 12 months.

What is the average diameter of a healthy abdominal aorta? Answer: < 3 cm.

A 24-year-old woman presents to the emergency department with acute right upper quadrant abdominal pain that radiates to her right scapula. She has had similar episodes previously, but they were less severe. Vital signs are T 100.6°F, HR 102 bpm, BP 128/78 mm Hg, RR 16/min, and oxygen saturation 99% on room air. On exam, she has tenderness to palpation of the right upper quadrant. Laboratory studies show a leukocytosis with normal bilirubin, alkaline phosphatase, and liver transaminases. Her abdominal ultrasound is shown above. Which of the following is the most likely diagnosis?

acute cholecystitis Acute calculous cholecystitis is a complication of gallstone disease defined by acute inflammation of the gallbladder due to gallstones, Cholecystitis Sx: colicky, steadily increasing RUQ or epigastric pain after eating fatty foods PE: Murphy sign, Boas sign (hyperaesthesia, increased or altered sensitivity, below the right scapula) DiagnosisInitial: U/SGold standard: HIDA Most commonly caused by obstruction by a gallstone Treatment is cholecystectomy

65-year-old woman presents to the emergency department via EMS from an apartment fire. Vitals are BP 85/45 mm Hg, respirations 20 breaths/minute, pulse 110 bpm, and oxygen saturation 96% via 2-liter nasal cannula. She is currently unconscious. There is an open fracture of her right, distal radius. Second-degree burns are noted on her anterior upper extremities bilaterally, chest, and portions of her upper abdomen. Her neck and bilateral lower extremities do not have any signs of burning or trauma. Two large bore intravenous lines are placed and orthopedic surgery is consulted for the open fracture. Which of the following is the preferred access site for a central line in this patient?

insert a central venous catheter in the internal jugular vein easily visualized, has a direct trajectory into the cavoatrial junction, and bleeding can be easily recognized and controlled. However, the insertion of central venous access at the internal jugular vein is uncomfortable for awake patients, is associated with a higher risk of infection and thrombosis than the subclavian vein, and also has the highest risk for arterial cannulation. The subclavian vein is also easily visualized and is associated with the lowest risk for infection and thrombosis. However, the subclavian vein has the highest risk for pneumothorax, and it is difficult to achieve hemostasis in the event of bleeding. Relative contraindications for placement of a subclavian venous catheter include altered local anatomy, history of pacemaker placement, or if this access site will be needed for hemodialysis. Femoral vein has good external landmarks for localizing the vein, is easily accessed during cardiopulmonary arrest, and bleeding is easily identified and controlled. However, the femoral vein is associated with the highest risk of infectionand the highest risk thrombosis. Placement here should be avoided if the patient is incontinent of stool or urine. Additionally, clinicians are unable to measure central venous pressure from this access site Potential complications of the internal jugular and subclavian vein central line placement include neck hematoma, pneumothorax, phrenic nerve injury, brachial plexus injury, and stroke. Potential complications of femoral vein central line placement include a retroperitoneal hematoma, psoas muscle hematoma, bladder perforation, bowel perforation, or femoral nerve injury.

A 20-year-old woman presents with atraumatic chest pain. Eight hours ago, she had sudden-onset coughing, retching, and left-sided chest pain after inhaling marijuana smoke from a water pipe. The patient has no medical history and takes no prescribed medications. Her only substance use is marijuana three times daily. Her HR is 122 bpm, and her other vital signs are within normal limits. On examination, the patient is holding an emesis bag with 25 mL of yellow emesis with streaks of bright red blood. At the left parasternal and anterior cervical region she has reproducible pain andsubcutaneous emphysema that progressively worsens each time she coughs. Her chest X-ray is shown above. Which of the following is the most likely diagnosis? ABoerhaave syndrome

vomiting followed by chest pain and subcutaneous emphysema (Mackler triad) Palpable mediastinal or cervical crepitus (subcutaneous emphysema)