Final w/ chapter 19
A 59yo woman is in the ICU following emergnecy surgery for perforated diverticultitis. In the ER her admission BP was 90/60, pulse 120, temp 38.8, O2 sat 95% on 4L of nasal oxygen. she received three liters of lactate ringers solution, ciprofloxacin and metronidazole and was taken for emergency surgery. during the procedure her systolic was rarely above 100mmHg despite administration of neoesynephrine. she received 6 more liters of lactate ringers as well as 500cc of hetastarch during the 2 hour procedure and made 60cc urine. Venous IV showed MAP 600mm on neosynephrine, CVP is 8mmHg, CV 55%, Arterial blood gas: pH is 7.30, pO2 75, FIO2 60%, PEEP 7.5, PCO2 36, Arterial lactic acid 4.2. The principal value of lactic acid measurement for this patient is as a marker of
response to circulatory resuscitation
83yo asian man with recurrent common bile duct stones presents with fever, jaundice, RUQpain. treatment is
resuscitation, IV antibiotics, and urgent ERCP to relieve the bile duct obstruction
A 63yo woman had a celiotomy for a recurrent bowel obstrucion. One week postop she develops a high output entercutaneous fistula. Subsequent evaluation indicated the fistula involves her distal small bowel. the most appropriate fluid for replacing the loss from the fistula is
ringer's lactate
48yo man in ER with 48hr abdominal pain, obstipation, nausea, and vomitting. Initially it was crampy, but for past 4 hours it has been steady. Previously healthy, no history of previous surgery. No smoke/drink. BMI 24. Vitals, pulse 120, BP 100/70, R26, T37. Heart lung, clear. abdomen is distended and diffusely tender to light palpation. Bowel sounds absent. Abdominal film show dilated air-filled loops of small intesting and minimal colonic gas. IV fluids started, NG tube removes 1200mL of thick greenish-brown fluid. Next best step is?
schedule an emergent laparotomy
25 yo man is brought to the ER after being involved in a high-speed MVC during which his vehicle burst into flames. he is unresponsive, on a back boar, with cervical collar on. his bp is 85/45, pulse 133, and he has obvious third degree burns to a majority of his body. what is the correct sequence of treatment for this patient?
secure his airway, obtain two large bore IVs, bolus 2l LR, examine the patient, CT scan the head and abdomen, calculate the TBSA, start the consensus formula, treat the burns of silvadene.
A 40yo man comes to the ER with a 4 day history of nausea and vomitting. he has had burning abdominal epigastric pain for at least 1 week. he takes a beta-blocker for hypertension. his temperature is 37.5C, blood pressure on admission is 110/90 mmHg, his pulse is 104, and his RR is 14. He weighs 80kg. Which of teh following laboratory tests would provide the msot assistance in the diagnosis and treatment of this patient?
serum electrolytes
55yo woman with hep c cirrhosis and severe emphysema, requires O2, is admitted for abdominal pain and distention. Has ascites and treated for spontaneous bateria peritonitis. Symptoms improve. 3x2x3 cm lesion in liver found consistent with hepatocellular carcinoma. Patietn is referred for evaluation for hepatic transplantation and was found to be not a candidate due to
severe pulmonary disease
64yo man is scheduled for an elective sigmoid colon resection for biopsy-proven adenocarcinom. his medical history includes a 3 vessel coronary artery bypass graft adn insulin-dependent diabetes mellitus. what is the most appropriate antibiotic management for this patient.
should be administered within an hour prior to the incision
42yo man is admitted to the burn unit 8hrs after sustaining 60% TBSA full and deep partial thickness burns involving his face, upper extremities including his hands, his torso and left thigh in a house fire. he is intubated and receiving intravenous fluid according to the consensus formula. which one of the following best describes the most appropriate rehabilitation for this patient?
should be directed to restoring patients to functional status by preventing scar contractures and immobility
65yo woman has had no flatus or stools for 3 days. vitals normal. abdomen is firmly distended and tympanitic, but nontender. Xray shows large air-filled loop of colon interpreted as sigmoid volvulus. Best management at this time?
sigmoidoscopic attempt at reduction
56yo man is in the ICU being treated for 80% TBSA burns involving his trunk, face, and all four extremities. allograft skin will be used in order to optimize healing and cover his wounds. which one of the following statements best describes an allograft?
skin graft taken from a human cadaver
A 70yo woman is being transfused following a low anterior resection for rectal cancer earlier today. thirty minutes after starting the transfusion, you receive a phone call from the nurse who states that hte patient's temperature is 39 degrees. the most appropriate action is to:
stop the transfusion and go to the ward to assess the patient
75yo man for painless jaundice for 6 days and 20lb weight loss for 2months. HTN treated w/lininopril and HTZ. No PSH, 40ppy history but quit 10 years go. Thin and profoundly jaundiced. Palpable globular mass in RUQ with minimal tender to deep. CT shows dilated intra and extrahepatic bile duct, a distended gallbladder, and 2cm hypodense mass in pancreatic head. Tumor mass does not appear to involve any vascular structures, and there is no evidence of metastates. Which of the following is the next best step in management?
surgical excision
36yo for recurrent painless bleeding and a tissue protrusion from the anus for the past 18 months. Moderately large external hemorrhoids. The internal hemorrhoids prolapse and require manual reduction. the best management at this time is:
surgical hemorrhoidectomy
A 39yo woman presents because of a nodule at an incision site. she underwent a cesarean section approximately 5 months ago. on examination she has a healed pfannestiel incision with a 1.5cm firm nodule in the center of the incision. the nodule is excised and microscopically reveals a granuloma with giant cell formation with polarized refractive material. the most likely diagnosis is:
sutured granuloma
64yo woman is in the ER with signs and symptoms of a bowel obstruction. she has no history of prior abdominal operations. the symptoms/signs most consistent with the diagnosis of an obturator hernia would be
symptoms of intermittent bowel obstruction
25yo man evaluated for maroon stool per rectum. otherwise healthy. colonoscopy is normal. capsule endoscopy suggests the bleeding is coming from the distal small intestine. the presence of meckel's diverticulum as a potential etiology for the bleeding may be able to be identified by which of the following tests?
technetium pertechnetate scan
65yo man in hospital for hematochezia. 3 bm with dark red blood. on admission Hgb 14.6, p80, bp142/72, rr16, appears comfortable. over next 12 hrs w/ no bloody stool, but hgb 12.2. then passes another bloody stool. Vitals stabe. best choice to identify the bleeding site is?
technetium-labeled red blood cell scan
A 72yo man is in clinic to discuss coronary artery bypass grafting. he has questions about the risks associated with the operation. the term "informed consent" refers to:
the process wherein the patient and surgeon decide on a plan.
A 45yo man comes to the ER with complaint of upper admonial and back pain of 12 hour duration. he was admitted to the hospital 3 weeks ago for alcoholic withdrawal. today he vomited green looking material several times. he denies hematemesis, diarrhea, bloody bowel movements, and liver disease. he is not diabetic. His temp 38.6, BP 90/60, pulse 120, resp 26, O2 sat 92% on 4L oxygen. Physical exam show agitated middle-aged male who is pale with cyanotic fingers. he is disoriented to place and date. His chest is clear, his neck veins are flat and his heart is without murmur or gallop. his abdomen shows epigastric distention and no scars or bulges. He has no bowel sounds. He has percussion tenderness and involuntary guarding in the epigastrium. His hands and feet are cyanotic and cold. Bladder cath returns 100cc of dark urine. Compared to 3 weeks ago, Hgb is up from 13.3 to 16.7. WBC are 16000, platelets 96, BUN is up 45 from 22, Creatinine is up 1.9 from 0.8, bili is 1.8, alk phos is 130, AST is 120, amylase 1200, Arterial pH is 7.28, pCO2 is 28, PO2 is 66, lactic acid up to 6, ionized calcium down to .96, and blood alcohol is 1845. Plain Xray of chest abd is unrevealing. Ab CT scan shows a markedly enlarged, edematous pancreas, with several peripancreatic fluid collections. The therapy that would be most specific for the circulatory disorder in this patient is administration of
three liters of isotonic crystalloid
You are evaluating a 75yo man in our office with a moderate left-sided inguinal hernia. his past medical history is significant for laparoscopic cholecystectomy, open radical prostatectomy, and thyroidectomy. which of the following repair is a relative contraindication?
total extraperiotoneal laparoscopic repair
a 40yo man is known to have von willebrand disease. he undergoes an appendectomy and has ongoing bleeding at the site, which persists despite prolonged application of pressure. the best treatment option for the bleeding at this time is
transfusion of cryoprecipitate
62yo man is found to have early stage 1 esophageal adenocarcinoma. his past medical history is significant for severe bilateral pulmonary emphysematous disease and is s/p bilateral thoracotomy for lung reduction therapy. he is on chronic home oxygen. the best treatment plan for this patient is:
transhiatal esophagectomy with gastric pull-up
72yo man with advanced cirrhosis in ER for vomitting blood. known portal hypertension and had endoscopic banding of esophagela varices in the past. admitted to ICU and meds initiated. endoscopy shows bleeding from gastic varices, not treatable with banding. What is next step?
transjugular intrahepatic portacaval shunt
64yo man is on the surgical ward recovering from a gastric resection for a large duodenal ulcer complicated by a duodenal stump leak, pneumonia, and cather related sepsis. a nasal swab was positive for MRSA. he was in the ICU for 5 weeks and received a variety of IV antibiotics including clindamycin, a thirdgen cephalosporin, metronidazole, and clindamycin. Neomycin irrigant was used to irrigate his periotoneal cavity at the initial surgery. he is now noted to have decreased hearing acuity. the most likely antimicrobial agent for this toxicity is:
vancomycin
A 43yo man was admitted to ICU 36 hrs earlier for a diagnosis of severe alcoho-induced pancreatitis. He weighed 70kg on admission. his MAP throughout is less than 65, his urine out has been less than 30, and his poor resp status has resulted in mechanical ventilation. His fluid balance is fifteen liters positive and his abdomen is noted to be tense with an abdominal pressure of 30mmHg. the principal cause of his ongoing hypotension is decresed
venous return
a 20yo male driver is brought to the ER following a motor vehicle crash. he was the driver and was not wearing a seat bealt. he is on a backboard with a hard cervical collar in place. he is recieving nasal oxygen at 4 liters. he is speaking and complaining of chest pain and shortness of breath. his blood pressure is 90/60, puls 130. he has ecchymossis and abrasions over his right chest. There are no breath sounds in the right chest. his oxygen saturation is 85%. he has cool cyanotic extremities. Removal of his neck collar with in-line traction of his head reveals distended neck veins. the principal cause of his hypotension is decreased
venous return
27yo man comes to clinic with a recurrent umbilical hernia three months after initial repair. his BMI is 26. his dieat is high in dairy, breads, and meats, and he rarely eats fruits and vegetables. a complete blood count in normal. before attempting repair of the recurrent hernia, supplementation with which of the following should be started and maintained after surgery?
vitamen c
JR is a 24yo male who has been in the trauma ICU for 42 days due to a closed head injury and multiple fracutres sustained in a motorcylce accident. the patient has been NPO due to his obtunded state and is on IV fluids (saline and glucose). he has been on multiple IV antibiotics as therapy for multi-site infections. Surgery is again scheduled to stabilize his pelvic fracture. preoperative laboratory studies show the prothrombin time and partial thromboplastin time both to be mildly elevated. these same tests were normal when the patient was admittted to the hospital. the most likely explanation for this change in his laboratory results is
vitamin K deficiency
76yo woman is in the hospital recovering ten days following an emergency laparotomy for a perforated dicerticulum. she has a hisotry of pernicious anemia and cirrhosis secondary to chronic hepatitis C. on the fifth postoperative day she developed a wound infection and the skin staples were removed and the wound was packed open. the fascia was intact. she is now afebrile with normal vital signs and tolerating a soft diet. her abdomen is non-tender and the wound is clean with some granulation tissue. which of the following places her at greatest risk for incisional hernia formation?
wound infection
A 45yo man has a history of gastric outlet obstruction secondary to chronic ulcer disease and is referrred to you for treatment. He is 5'9" and weighs 135 lbs. He has lost 25% of his body mass over the last 3 months and needs nutritional repletion. what are his calculated ideal body weight ad caloric needs?
160lbs/1545Kcal
44yo woman for red skin on rt breast for 10 days. her last menstrual period was 3wks ago, menarche at 12. first child was at 25, no previous breast problems. no FMH, no medical illnesses. physical skin over rt upper outer breast is red and edematous with minimal tenderness. no masses, no discharge, or lymphadenopathy. biopsy of skin shows breast cancer cells. which of the following stage classification for this breast cancer?
3
75yo man is schedule to undergo left inguinal hernia repair with local anesthesia sedation. he has a history of hypertension treated with hydrocholorthiazide and lisinopril. he weighs 60kg. there is a reducible left inguinal hernia. what is the safest maximum volume of 1% lidocaine that can be used for local anesthesia in this man?
40mL
23yo woman is brought to the ER with third degree burns involving her entire posterior trunk, half her antierior trunk, her circumferential right thigh, an dher circumfernetial left upper extremeity. what is the size of her burn as %TBSA( percent total body surface area)?
45%
A 42 yo woman is being transistion from parental nutrion (PN) to (EN) and she is requiring approximately 1900 caloris per day. the Nurse caring for her wishes to know know when to stop the PN. her PN can be safely stopped with her EN caloric intake reaches what percentage of her current PN?
66%
52yo woman is assaulted and sustains a brief loss of consciousness according to bystanders. upon arrival to the ER, she opens her eyes to painful stimuli only, has decorticate posturing, and moans incomprehenisbly. her Glasgow coma scale (GCS) score is:
7
You are in the preoperative evaluation clinic seeing patients who are scheduled for surgery. which of the following patients should have a preoperative electrocardiogram?
A 55yo hypertensive man being evaluated for carotid endarterectomy.
A 68yo woman underwent a subtotal gastric resection for a distal gastric cancer. her sotmach was reconstructed with a gastrojejunostomy. On postoperative day 3, a larger amount of bilious drainage is noted coming from a drain placed in her right upper quadrant (800 mL in teh last 24hr). this most likely represents which of teh following.
A biliary leak from the duodenal stump
62 yo woman is seen in the office to discuss further management of GER that is not well controlled with medication. she wants to undergo surgical relief of her reflux symptoms. Workup confirms reflux disease on pH study with a shortened esophagus on upper GI study. the best surgical approach for treating this patient is:
A collis gastroplasty with a nissen fundoplication
53yo woman comes to clinic becasue of dysphagia to liquids and solids for the past three weeks. she has been on PPI for treatment of heartburn. a barium swallow shows prominent proximal esophageal dilation with a stricture of the distal esophagus (bird's beak appearance). endoscopy shows no distal esophageal lesion, manometry shows elevated lower esoshageal sphincter tone with swallowing. what is the most appropriate surgical treatment for her?
A combined heller myotomy and Nissend fundoplication
80 yo man has a recurrent inguinal hernia. he has an incision close to his groin that he states was from a hernia that was fixed as a young adult. he brings you a copy of the operative report and it s unreadable except for the diagnosis of a richter's hernia. what was the most likely finding at the time of the first hernia repair?
A non-circumferential incarceration of bowel wall.
36 yo woman is intubated for respiratory failure in hte ICU 8 hrs. She sustained a liver lac and multiple pelvic fractures in a high-speed MVC. She did not LOC. She was resuscitated with 8 units of packed RBC and 4 liters of lactated ringer's solution. her BP is now 110/70 and her pulse is 100. Breath sounds are equal bilaterally, and her abdomen is tensely distended. arterial blood gas analyis reveals a respiratory acidosis, and serum hemoglobin is 13.2 what is the most likely diagnosis?
Abdominal compartment syndrome
A 45yo man with a history of inflammatory bowel disease requiring steroirds has been admitted to the ICU following a high-speed motorcycle accident. on his fifth post-op day following a splenectomy adn internal fization of bilateral femur fractures, he develops hypotension (85/40) which is refractory to 3000 mL intravenous saline bolus and dopamine infusion. he is afebrile. O2sat on RA is 96%. Hct 38%, WBC 8, Na 129, K 5.3. CT normal. Next appropriate therapeutic action would be?
Administer hydrocotisone
An 82 yo man undergoes screening colonoscopy. he is found to have a biopsy proven adenocarcinoma of the sigmoid colon. his medical history is notable for hypertension and dilated cardiomyopathy. which of the following finding is most likely to increase his risk of perioperative cardiac complications?
An audible S3 gallop
21yo man in ER for RLQ pain and nausea for 18hrs. Vomited once. Not eaten in 20hr, but not hungry. Exquisitely tender with rebound in RLQ. WBC 14,200. Best management?
Appendectomy
58yo man for frequent UTI in the last year. occasionally passes gas from his urethra. otherwise well. Barium enema 5yrs ago showed sigmoid diverticulosis. next step in diagnosis is?
CT
20yo man is brought to ER following a blunt assault while intoxicated. he is hemodynamically stable and complains of abdominal pain. mild epigastric tenderness is noted to direct palpation. FAST is negative. what is the appropriate next diagnostic test to assess for significant abdominal injury?
CT of abdomen and pelvis
A 46yo woman underwent total thyroidectomy for multinodular goiter. on the second postoperative morning she complains of circumoral tingling and numbness of her fingertips. the most likely additional finding in this patient will be
Carpopedal spasm
58yo man presents to clinic for evaluation for weight loss surgery. BMI is 36. Workup shows uncontrollled diabetes and sever sleep apne. Stable angina, recently discovered colon cancer, past history of alcohol abuse with cirrhosis, but no portal hypertension. Which comorbidity is a potential contraindication for surgical intervention to assist in weight loss.
Colon cancer
32yo man was admitted to the burn unit 12 hrs ago with a 45% TBSA third degree burn. his entire right lef is circumferential burned. after 12hr of consensus formula resuscitation the nurse calls you with a report of no pulse in the right foot. what is the most appropriate next step in management?
Confirm the presence of vascular compromise, and then perform lateral and medial escharotomies of the right lower extremity from teh hip to the ankle
A 42yo man is referred to your clinic for an enlarging reducible inguinal hernia. he has a history of cirrhosis following hepatitis C. you are trying to assess the level of risk associated with his liver disease. Components of the MELD score for this patient include bilirubin, INR, and
Creatinine.
40yo man is undergoing an open inguinal hernia repair. after incising the skin and the external layer of subcutaneous fat, you see scarpa's fascia. if you were to follow scarpa's fascia medially to the scrotum, it would turn into which structure?
Dartos fascia
75yo man who resides in a nursing home because of progressive dementia and hemiplegia becomes febrile and is found to have a sacral decubitus ulcer. the base of the wound is gray and covered with an exudate. the wound edges are erythematous. what is the most effective next step to reduce the bacterial load in this wound?
Depride necrotic tissue from the wuond
68yo man f/o for nonhealing prepyloric gastric ulcer that biopsy has histological evidence of signet ring cells. Work-up for this patient's condition should include which of the following
Diagnostic laparoscopy
29yo woman presents to ER with abdominal pain, nausea, and vomitting. Has gallstones since her last pregnancy 2 years ago. lab results normal except elevated amylase, alk phos, and bili. Afebrile. After IV fluids and meds for pain/nausea, what is the most reasonable next step.
ERCP with sphincterotomy and gallstone removal if laboratory values do not improve
83yo man in clinic for cancer managaement. history of rectal carcinoma, treated with chemo and surgery 3 years ago. feeling well and very active. But recent increase in CEA to 21. Met workup showed 4 hepatic lesions, consistent with colorectal mets. What is the next step in this patients management?
Evaluation for surgical resection
A 52 yo man in the surgical ward has a temperature of 102.4 four days after a laparotomy and lysis of adhesions for intestinal obstruction. Prior to surgery he was treated with an NG tube and IV fluids for 5 days but his obstruction failed to resolve. his prior surgical history included an appendectomy (age 10) and traumatic splenectomy (age 24). he has had an uneventfull postoperative course, has regained bowel function, and his only oral medication is for incisional pain. his physical exam is unremarkable except for a swollen right forearm with a small amount of purulent drainage noted from an old IV site. what is the next best step in management?
Excision and drainage of IV site.
A 28yo G1P0 woman who is 20 weeks into her pregnancy presents with 2cm hard, nontender mass in teh upper outer quadrant on her left breast. she first noticed the mass about a month before she learned she was pregnant. it has been enlarging over the last two months. which of the following is the most appropriate recommendation for her?
Excisional biopsy of the mass
A 40yo man is involved in a motor vehicle crash and sustains a fractured pelvis and ruptured spleen. he has required transfusion of 5 units of packed red blood cells. he is at greatest risk for which of teh following infections?
Hepatitis B
A 2wk boy is brought to the ER becasue of two days of nonbilious vomiting, lethardy and low urine output. the boy is somnolent. his abdomen is nontender. US show hypertrophic pylorus. the most likely metabolic derangement is
Hypochloremic hypokalmeic metabolic alkalosis
30yo woman is brought to the ER because of partial thickness burns to her chest, arms and abdomen when a pressure cooker explodes while she is canning tomatoes. her wounds are bright red, moist and blanch on direct pressure and involve 22% of her TBSA. she has severe pain. which of the following is the best pain management for thie patient?
IV narcotic initially, with transition to oral narcotics and non-steroidals
A 68yo man is seen in clinic with a reducible right inguinal hernia that is uncomfortable at times. he has a history of hypertension adn suffered an uncomplicated anterior wall mmyocardial infaction that was treated with lytic therapy. he remains on a beta-blocker, a statin and an antiplatelet agent. regarding hernia repiar in this patient, what is the most appropriate way to decrease his risk of cardiac complications?
If possible, surgery should be postponed for six months following infarction.
22yo man is in the hospital three weeks after an abdominal gunshot wound that penetrated the spleen, stomach, adn proximal small bowel. the internal injuries had been repaired primarily and the spleen removed. he has been eating a soft diet. he now has intermittent fevers associated with chills and sweats and uniloculated right subhepatic abscess is noted on CT. Vital signs are stable. in addition to broad-spectrum antibiotics, what is the next best step in management?
Image-guided percutaneous drainage.
A 73yo woman is in the recovery room following a hemicolectomy for a cecal adenocarcinoma. she received preoperative subcutaneous heparin for DVT prophylaxis. it is noted that her abdomen has become progressively distended, her HR has risen to 110/min, and her BP has dropped from 120/80 to 95/60mmHg. the attending surgeon decides to take the patient back to the operating room and finds 1500mL of blood in teh abdomen. the most likely cause of this bleeding is:
Inadequate surgical hemostasis during first operation
a 56yo man develops acute respiratory failure after a bowel resection for ischemic bowel. with an FiO2 of 50% and positive end expiratory pressure (PEEP) 5cm H2O, his PaO2 is 52 torr. which of the following would be most likely to improve oxygenation?
Increase PEEP
34yo woman for episodic painless rectal bleeding with BM for several years. Otherwise healthy, no FMH of colon cancer. One internal hemorrhoid, with slight prolapse, but reduces spontaneously. Best management?
Increase dietary fiber and fluids and reevaluate in 2-3 months
65yo man with pancreatic cancer. wants pancreatic resection. Ct angiogram shows 2.5cm tumor in uncinate process that is not impinging on any major vascular structures, and the tumor is deemed resectable. the pancreaticoduodenectomy is planned. In addition to the gastroduodenal artery, which of the following arteries must be ligated and divided to complete the procedure?
Inferior anterior pancreaticoduodenal
A 22yo man crashed his motorcylcle into a tree and is brought to the ER. He was unconsious and intubated at the scene. two large bore IVs were placed and infusion of 2 liters of normal saline was administered in route to the ED. On arrival at the ED his BP is 80/40 mm HG and his pulse is 130/minute. he has a flail chest on the right side. a chest tube was placed and yielded 500mL of blood.Abdomen is tender, FAST shows fluid in abdomen. Pelvis unstable, Deformities in femurs and compound fracture in right leg. What is the best blood product.?
Initial transfusion of red cells, FFP and platelets in a 1:1:1 ratio may improve his outcome.
24yo man in SICU for MVC 2 days ago. at admissino he was stable and GCS of 15. Main complaing was RUQ pain. CT showed grade 3 liver lac, rib fracture, and RLL contusion. No free air or fluid in abdomen. Now secodn hospital day, has 3 episodes of hematemesis. on exam his abdomen is benign without evidence of peritonitis. Next step?
Interventional radiology with selective hepatic artery embolization if a bleeding site is identified.
38yo woman is undergoing preoperative counseling prior to undergoing Roux-en-Y gastric bypass surgery for morbid obesity. History of DM and sleep apnea. BMI is 46. Without proper supplementation, what is the most likely nutrional deficiency to occur following her Roux-en Y gastric bypass surgery.
Iron
a 47yo patient underwent a major bowel resection approximately 7 months ago. the patient has been well, overall, until recently whe he has been feeling tired. a CBC is done this patient and reveals a microcytic anemia. which region of the GI tract was mostlikely resected?
Jejunum
a 41yo woman comes to the office complaining of large unsightly scars 6 months after she underwent a laparoscopic cholecystectomy for biliary colic and cholelithiasis. her postoperative course was uneventful. she has no pain. on physical exam two of her trocar incision sites are raised, red and thick and appear to extend beyond the confines of her original incisions. they are nontender and show no stigmata of infection or neoplasm. what is the most likely diagnosis?
Keloids
18yo man sustains a single stab wound to the left parasternal area. initial blood pressure upon arrival in the ER is 82/46 and HR is 121. left sided chest tube is placed and 100ml of blood is evacuated. FAST reveals a large amount of pericardial fluid. during FAST exam, the patients blood pressure becomes undetectable. what is the next more apprpriate step in management?
Left thoracotomy and cardiac repair
35yo woman for diarrhea after meals and progressive weight loss for past 6 months. she has crohns disease and has undergone multiple abdominal operations for crohn's disease and episodes of adhesive smal bowel obstruction. Six months ago she underwent a small bowel resection at a site of a previous small bowel anastomosis. No evidence of recurrent disease. Which of the following postsurgical scenarios might be most consistent with short syndrome as an etiology for the patient's symptoms?
Less than 60cm small intestine preserved.
A 62 yo man is in the intesive care unit following surgery for a shotgun wound to teh abdomen 2 weeks ago. he remains intubated and is beign treated with TPN. he has developed an elevated respiratory quotient and you believe this is a result of excessive caloric intake, you need to be able to evaluate the relative impact of each caloric source on total caloric intake. Which of the following sequences represents the nutritional value in kilocalories from lowest to highest?
Lipids, proteins, carbohydrates
42yo woman is in clinic to discuss medical management for her obesity. BMI is 44. sibutramine is FDA approved anti-obesity drugs. which of the following combination of MOA and SE is characteristic of this medication?
MOA: Serotonin and norepinephrine uptake inhibitor SE: Hypertension
75yo man with jaundice. imaging shows large stone in neck of gallbladder, with inflammation that involves the adjacent common hepatic duct. the biliary tree is dilated proximal to this area. Distal isn't dilated. Which on of the following is the most likely diagnosis?
Mirizzi's syndrome
a 38yo woman recovering froma laparoscopic cholecystectomy returns to teh office 5 days after surgery complaining of right upper qudrant pain. she is midly jaundiced. subsequent workup suggests a bile leak, and a percutaneous drain is placed after ERCP is unsuccessful. over the next 24 hours, almost 600 mL of bile-colored fluid is collected from the drain. the electroly composition of the fluid in the drain is closest to:
Na 130 mEq/L, CL 100 mEq/L, K 4.0 mEq/L, Bicarbonate 25mEq/L
A 65yo man is in the SICU after undergoing appendectomy and abdominal lavage because of a ruptured appendicitis with diffuse peritonitis. He is noted to have hyperthyroidism. Postoperatively, he develops fever and tachycardia. the Diagnosis of thyroid storm in the SICU includes the following features
Nearly nondetectable TSH levels, elevated T3, T4, and glucose levels
72yo woman in ER for 3days of abdominal pain and constipation. Temp 38.2, BP 130/80, P90, RR18. moderately tender to palpation in LLQ without rebound. No mass. WBC 14,000. which of the following is the best choice for managing this patient now?
Order CT scan of abdomen and pelvis
24yo man f/o total proctolectomy and ileoanal pouch anastomosis for familiarl polyposis. several family members ask if other sites are prone to malignancy besides the colon in family members affected with the disease. The most common site for an affected relative to develop an extracolonic malignancy is which of the following?
Periampullary duodenum
A 33yo man is being treated for a 35% TBSA burn over the course of the last three weeks. he has now completed all of his skin grafting and no longer appears to have any evidence of sepsis or a need for further direct therapy for his burns. At this point you are interested in identifying whether he's beginning to lay down structural proteins and has turned the tide from catabolism to anabolism. Which of the following laboratory measurement most likely reflect the return to normal protein anabolism?
Pre-albumin
A 37 yo man is admitted with a several week history of abdominal pain, dehydration and hypotension. he is found to have a perforated gastric ulcer and undergoes a partial gastrectomy. he is begun on TPN on post-op day two and over the next 3 days develops anemia and respiratory distress. the most likely cause of his symptoms is
Re-feeding syndrome
A 30yo woman underwent a total parathyroidectomy for hyperparathyroidism and 2 hyperplastic adenomas are removed. one half of hte right inferior gland was implanted on the sternocheidomastoid muscle. on posoperative day 1 she complains of generalized muscle cramps and she is slightly confused. what is teh msot likely diagnosis?
Sever hypocalemia
A 62yo woman with morbid obesity, diabetese, hypertension and chronic kidney disease (GFR of 55ml/min) undergoes elective right hip replacement under general anesthesia. which of the following is the primary goal of postoperative fluid management in this patient?
She should be maintained at euvolemia
38yo man in ER complaining of abdominal pain, nausea, non-bilious vomiting, diarrhea, and palpitaions. Recent antrectomy with Biliroth 1 reconstruction for nonhealing type 1 gastric ulcer. Symptoms began 20 minute drinking his first milkshake since operation. which of the following drugs would be most helpful for this patient?
Somatostatin
a 72yo man is scheduled to undergo robot-assisted prostatectomy for adenocarcinoma of the prostate. his past medical history is unremarkable and he takes no medications. which one of the following is the best management to reduce his risk of thromboembolic complications?
Subcutaneous low molecular weight heparin
A 32yo woman presents to the ER sunday evening with an incarcerated ventral hernia. she has end-stage renal disease and undergoes hemodialysis on mondays, wednesday and fridays. she underwent surgery for a perforated duodenal ulcer 2 years ago. On physical examinatio, there is tender, non-reducible mass in the central portion of the epigastric midline incision.Emergency surgery is planned. which of the following is most likely to produce life-threatening hyperkalemia in this patient?
Succinylcholine
38yo woman is being treated in hospital for burns sustained to her left arms when her sleeve caught on fire when she was burning brush. she has third-degree burns of the circumferential forearm extending just above the elbow. which of the following treatments will provide the best functional and cosmetic outcome for this patient?
Tangential excision and full-thickness grafting
65yo man for 80% subtotal pancreatectomy because of mucinous cystic tumor involving the body of the pancreas. the surgeon explains to him that the body and tail of pancrease will be removed with only the head and uncinate remaining. Patient is concerned about diabetes after surgery. Which of the following is the most accurate information to share with this patient?
The islet of langerhans are more abundant in the tail of the pancreas than in the head and uncinate
35yo man is declared brain-dead following an isolated gunshot wound. his family agrees to solid organ donation but his in-depth medical and social history obtained by the organ donor staff details multiple heterosexual encounters and IV drug abuse. the drug activity occured with the previous week. which of the following best assess his acceptability for organ donation?
The latent HTLV virus status in this patient is documented by enzyme-linked, immunosorbent seropositive assay (ELISA) and confirmed by nucleic acid testing (NAT).
61yo male is in the recovery room following elective colon resection for colon cancer. this surgery lasted two hours and there is minimal blood loss and intraoperative contamination. cefoxitin was administered 30 minutes prior to the incision. what is the most appropriate postoperative antibiotic regimen for this patient?
There is no need for antibiotics
28yo man episodic bloody diarrhea and rectal urgency for 3 years. Often has painful cramps just before bowel movement, and has lost 25 pounds. Eats a regular diet. No history of travel, no meds. Afebrile, Vitals stable. He is thin, abdomen soft and mildly tender diffusely, bowel sounds hyperactive. Rectal normal. Stool O/P neg, enteric path neg. Colonoscopy shows inflamed mucosa with ulcerations and mucous from dentate line to transverse colon. Right colon grossly normal. Diagnosis?
Ulcerative colitis
79 yo woman has been in the ICU on a ventilator for exacerbation of COPD for six days. her past medical history includes an endovascular graft for an abdominal aortic aneurysm. she has a central venous line for fluid and medication administration beacause of lack of peripheral IV access. Blood cultures obtained in response to a 102.7c temperature are positive for E.coli. the most likely source for bacteria is
Urinary tract infection
23yo f/o of known ileocolic crohn's disease. he is concerned with the potential metabolic side effects of his disease. which on of the following metabolic SE is he at most risk for developing?
Vitamin B12 deficiency
A 28yo man is admitted following a motorcycle crash in which he sustained a fractured left tibia, multiple left rib fractures, adn a head injury. one week after the injury he is suspected of having SIADH because of dependent edeman and a persistsent low urin output in spite of noral vital signs. he has a serum sodium of 130 mEq/L and his hemoglobin and hematocrit have slowly decreased to 9.2 gm/gL and 28% respectively. the most appropriate treatment of the suspected SIADH at this time should be:
Water restriction to less than 1000mL/day
80yo man comes to clinic because of difficulty swallowing solids and frequent regurgitation of undigested food for the past 3 months. a barium swalllow demonstrated a Zenker's diverticulum. the best treatment for this man is:
a diverticulectomy with cricopharyngeal and lower esophageal myotomy
A variety of patients were evaluated for surgery. for which one of the following are periprocedural prophylactic antibiotics considered a standard of care issue?
a patient who requires an open repair of an abdominal aortic aneurysm
50yo woman is at local restaurant for dinner. her first plate of the evening is brought out to her. As she sees, smell, and thinks about tasting the food in front of her, acid begins to be secreted in her stomach. this initial phase of secretion is mediated by which of the following compound?
acetylcholine
56 yo man seen in clinic peroperatively before a right hemicolectomy for a large sessile polyp located in the cecum. he has hypertension controlled with hydrochlorothiazide and lisinopril and type2 diabetes mellitus controlled with insulin. in order to be effective for this patient, itravenous prophylactic antibiotic therapy should be:
administrated within one hour prior to the operation
24 yo man who works as a carpenter is seen in the ER because of a deep rusty nail puncture wound to the dorsal surface of the foot. he had a tetanus booster shot six years ago. what is the recommended treatment protocol to prevent tetanus in this man?
administration of .5mL absorbed tetanus toxin
54yo man comes to ER because of diffuse abdominal pain for three days. he has cirrhosis secondary to hepatitis C and a history of GERD. his temperature is 38C, BP 110/90, Puls 100, R 18, there is mild scleral icterus. his chest is clear bilaterally and heart is regular. his abdomen is distended and there is diffuse tenderness. an abdominal CT scna shows diffuse ascites and no free peritoneal air. a gallstone is also noted as well as sigmoid diverticulosis. A peritoneal tap shows 500 leukocytes/mL and gram stain shows gram-positive cocci. What is the management for this patient?
admit to the hospital for intravenous antibiotic therapy
A 75yo woman is 3 days post right total knee replacement. she develops left leg sweeleing and duplex ultrasound confirms a left deep venous thrombosis. she is started on low molecular weight heparin. she beings to develop nosebleeds, bleeding from her IV site, and some bleeding from her wound. which is the best laboratory test to assess bleeding in this patient?
anti-Xa activity
45yo woman for severe pain and swelling behind her right nipple-areolar. history of previous episode, treated with warm compress until it resolved with yellow thick discharge from nipple. no family history. 25 ppy. physical showed painful, distorted, partially retracted nipple with yellow discharge. definitve therapy requires
antibiotic followed by excision of the subareolar ducts and fistula tract
60yo man with anorexia and weight loss associated with gnawing epigastric pain when eating for 2 months. Upper endoscopy reveals 2.5cm Type3 gastric ulcer. Rapid urease testing of a gastric tissue biopsy is negatic. four quadrant biopsy neg for malignancy. Undergoes on 6wk therapy, including ulcerogenic agents. Repeat endoscopy reveals the persistence of Type3 ulcer with size of 2.3cm. Repeat biopsy neg for malignancy.
antrectomy with truncal vagotomy
A 45yo man presents with acute onset of dyspnea and chest pain. pulmonary embolism is confirmed by CT angiogram. he has a history of heparin-induced thrombocytopenia. the most appropriate initial management includes administration of
argatroban
78yo man with loss of appetite and abominal discomfort for 3days. temp is 36.8. HR95, bp 100/60. epigastrium is mildly tender. does labs then goes home. WBC 11.5, hgb 16, creatine increase from .7 to 1.3. Na 132, Hco2 18, amylase 250. for followup the most appropriate plan is
ask the office staff to call the patient to the ER
25yo woman for 2wk history of tender lump in rt breast. last menstrual period was 3 weeks ago. physcial reveals discrete 2.5cm mass in upper outer quadrant of rt breast. US shows smooth, oval, 2.5cm hypoechoic mass with no internal echoes. next best step
aspirate the lesion
a 70yo woman is brought to the ICU with resp failure after undergoing a sigmoid resection for perforated diverticulitis. which ventilator mode would assume the most work of breathing?
assist control ventilation
35yo woman for cholecystectomy following abdominal US originally due to recurrent UTI. a recommendation for observation w/o surgery would be made for the following condition:
asymptomatic gallstones
A 67yo man has been under your care for a chronic leg ulcer. His wound has been progressing nicely, but over the last few weeks you notice a significant thickening and overturning of the wound edge. the most appropriate intervention at this point should be
biopsy the wound edges
29yo woman for 5week history of rt breast mass from self exam. no significant risk factors. physical shows increased density versus a mass in the upper outer quadrant of right breast. rest of exam unremarkable. next step?
breast ultrasound
43yo woman to discuss surgical plans for removing a small intestine tumor. she had several bouts of otherwise unexplained abdominal pain and bloating for 6 months. there is evidence of a small bowel tumor on capsule endoscopy. You discuss the embryologic origins of intestinal tumors with her. you strongly suspect that her tumor has arisen from cells that are part of APUD (amine precursor uptake dexarboxylase) system. which of the following lesions is your most likely diagnosis?
carcinoid tumor
A 55yo man is in the hospital 3 days following an open cholecystectomy for acute cholecystitis. he has been ill at home for 2 days before seeking medical attention and was operated on the day following admission. during induction of anesthesi his systolic pressure fell from his usual 150-160 to 110 and remained at that level for the first 30 minutes of the case. during the procedure the gallbladder was torn adn bile spilled into the abdomen. a culture of teh bile recovered E.coli and klebsiella species. his fascia was closed and skin left open. his ionized calcium during the procedure was 1.00umoles/L. he was continued on ampicillin-sulbactam that was started before the procedure. During the last two days he sequestered 4 and then 2.5 liters of fluid. his systolic BP has been mostly 140-170, pulse 80-90s. he was started on beta-blocker the day before surgery and this is continued post-op. on morning rounds he is noted to be dyspneic with a O2sat of 98% on 40% face, and a resp rate of 26-30. his BP is 180, pulse 120. On exam he is sitting upright. his neck veins are distended, chrackles are heard throughout both lungs and his heart has a gallop. his abdomen is mildly distended with bowel sounds. his wound is unremarkable. his extremities are cool, his hands and feet are cyanotic. the principle cause of his hemodynamic state is decreased
cardiac conctractility
a 72 yo in ICU develops sudden onset agitation and hypertenstion (180) 6 hours after an open abdominal aortic aneurysm repair. he receives a dose of narcotic analgesic and 10 later he has a blood pressure of 90 systolic. pulmonary artery cath information: Cardiac index: 1.8, CVP: 28, PAOP:32, SVR 1500. An EKG shows ischemia. He is still intubated and on a ventilator. His hemodynamic state is best characterized as
cardiogenic hypoperfusion
48yo man is brought to the ER after striking his head against the bottom of a swimming pool after diving into shallow water. no loss of consciousness is reported. he has tenderness of the cervical spine, and marked motor weakness of both arms. he is able to move his lower extremities, though he states subjectively that his legs feel weak. vital signs are normal. what is the most likely diagnosis?
central cord syndrome
a 24 yo woman develops acute liver failure secondary to acetaminophen overdose. the most common cause of death in this situation is
cerebral edema
54yo man known diagnosis of gallstone presents to ER with abdominal pain and fever for the past 8hrs. Oriented, no jaundice, tenderness with guarding in RUQ. US shows stones in gallbladder and normal caliber bile ducts. the most likely diagnosis is
cholecystitis becuase patients with cholangitis are often jaundiced
62 yo man eye jaundice. otherwise well. no weight loss. PMH of HTN and mild obesity. Labs show alk phos 412, total bili 7.2, AST 110, ALT 105. most likely diagnosis is
choledocholithiasis
43yo woman for RUQ pain following fatty meal. she is native american. married w/4 kids. no history of hematologic disorders, denies alc. US shows gallstones. Which of the following molecules is primarily responsible for the formatino of her gallstone?
cholesterol
68yo woman history of epigastric pain and nausea w/o vomitting. the pain is burning, constant, and sometimes worse after meals. she underwent antrectomy with truncal vagotomy and billroth 1 reconstruction for treatment of a nonhealing pre-pyloric ulcer 6months ago. She has mild epigastric tenderness, but physical otherwise normal. Endoscopy shows erythematous friable stomach mucosa, small ulcer near the gastroduodenal anastomosis, and pool of bile in the dependent portion of the stomach. mucosal biopsies reveal a corkscrew appearance of submucosal vessels. Rapid urease testing is negative. Which of the following drug would be most helpful for this patient?
cholestyramine
29yo man is in the ER 90 mins following a fall from a ladder where he sustained fractures of ribs 9 and 10 on the left and a grade 3 splenic laceration documented by CT scan. no other injuries were found. he has recieved 2 liters of lactated ringer's solution since arrival. his pulse is now 125 and bp is 95/52. urinary output over the last hour is 10mL, and he appears pale and anxious. his physiologic state is best characterized as:
class III hemorhagic shock
78yo woman in ER for abdominal pain and distension for the past 12hrs. She has dementia and a hisotry of chronic constipation. Barium enema done 2 years ago showed a very redundant colon, but no abnormalities. Vitals stable. Abdomen distended with diffuse tenderness to deep palpation. Rectal shows trace stool, heme neg. Images show dilated colon loops, no free air. WBC 13000, urinalysis normal. Diagnosis?
colonic volvulus
41yo woman with recurrent nausea and bloating not related to eating. no travel or pets. vitals stable. mild tenderness in RUQ. physical normal. RUQ US reveals 12x8x10cm right liver cystic lesion. has thick wall and multiple septation in it. what most likely diagnosis ad next step?
cystadenoma, resection
37yo woman is being treated for a nonhealing elbow wound following excision of a benign nevus. she has been on home TPN for the past 18 months following resection f most of her small bowel due to mesenteric venous thrombosis. laboratory evaluation reveals a zinc deficiency. the most likely mechanism for her non-healing wound is:
decreased fibroblast proliferation, decreased collagen synthesis, and impaired overall strength
45yo undergoing endoscopy for severe abdominal pain that is not relieved by over-the-counter proton pump inhibitor and antacids. She recently has been having frequent diarrhea. Otherwise healthy, no FMH contributory. Endoscopy shows hypertrophic gastric rugal folds and large antral ulcer and multiple duodenal ulcers. Serum gastin level is 1200. Where is the most likely place of her gastrinoma?
descending duodenum
65yo man is admitted to the hospital because of severe abdominal pain. has recurrent bouts of pancreatitis related to alc abuse. CT revealse atrophic pancrease with some calcifications consistent with chronic pancreatitis. in addition to chronic pain, he is at risk for developing what complication?
diabetes
52 yo man is referred to you by his PCP for possible hernia. the patient states that when he strains while donig situps on the floor he notices a bulge in the epigastric area. a ct scan ordered by his family physcian shows the entire transversalis fascia has thinned out but is intact. on examination he does a situp and indeed has a bulde in the epigastrium from the xiphoid to just below the umbilicus between the rectus muscles. based on your exam and CT scan finding, what is the most likely diagnosis?
diastasis recti
71 yo patient with history of alcohol abuse develops the acute onset of confusion and agitation two days after undergoing femoral-to-popliteal bypass. his heart rate is 120 bpm and blood pressure is 150/80 mmHg. his lab tests and CT are normal. the most appropriate next step in his management is administration of:
diazepam
A 73yo woman is in the ICU for hypotension and Respiratory failure. on admission yesterday, her blood pressure was 7/40, pulse 130, resp 26, temp 40. Over teh last 24 hr she received 12 liters of isotonic crystalloid infusion, as well as infusion of norepinephrine and vasopressin in an effort to maintain her mean arterial pressure > 65mm. Her chest radiograph shows consolidation in the left upper lobe. a sputum sample and four out of four blood cultures at 24hr show Gr+ coccin in chains. She is receivign broad-spectrum PCN. Her hemoglobin that was 13.6 on admission has risen to 15.5. Her WBC that was 3.600 on admission has increased to 12,000. the principal reason for the increase in hemoglobin is plasma volume depletion from
diffuse interstitial fluid accumulation
A 58yo man comes to your status post stomahc resection for a perforated ulcer in teh past. he thinks part of this stomach was resected and reconnected to his jejunum. he takes warfarin because of chronic atrial fibrillation. he is currently having difficulty maintainng his INR with warfarin and the dosages have been consistenetly increased. you bliever that this may be due to this surgery ad think that he may not be adequately absorbing his warfarin. you surmise this because most oral medication are absorbed in the
duodenum
22yo man is in the ER 20 mins after he is stabbed in the left anterior neck, approximately 2cm below the angle of teh mandible. BP is 88/56, hr is 134, and pulsatile bleeding is noted from the neck wound. the patient is intubated and bigital pressure is applied to control the hemorrhage. after intubation, breath sounds are equal bilaterally.what is the next appropriate step in management?
emergent operative neck exploration.
58 yo man was seen in clinic because of dysphagia for 3 weeks. Barium swallow shows a distal esophageal stricture. he undergoes upper endoscopy, with biopsy showing adenocarcinoma. the most useful diagnostic procedure to Tstage this patient's tumor is
endoscopic ultrasound
20 yo man is brought to the ER after attempting suicide by ingesting a bottle of drain cleaner. the patient is delirious and tachypneic and tachycardic, with hypoxia and fever. the inital priority for this patient is:
endotracheal intubation
19yo woman is seen for counseling of ileocolic chrohn's disease. she asks about the possibility of developing fistulous disease in the future, and whether this would require surgical intervention if it occurred. which of the following fistulous complications of crohn's diseases most commonly requires surgical therapy?
enterovesical
30yo woman comes to clinic because of dysphagia to solids for the past month. a barium swallow shows a mass lesion in the mid-esophagus. Upper endoscopy demonstrates a smooth, submucosal lesion. endoscopic US confirms a smooth delineated mass in the muscularis layer. the best approach to relieve this patient from her symptoms of dysphagia is:
enucleation of the leasion with reapproximation of the muscle layer
78 yo man was brought to the ER after he was struck on teh head with a baseball bat during a robery attempt. he had a brief LOC but was awake and alert when he arrived in the ER. Thirty minutes later he became agitated with a Glasgow coma scale (GCS) of 12, and is intubated for airway control. CT of brain reveals a convex collection of blood just beneath the right parietal bone. what is the most likely diagnosis?
epidural hematoma
A 65 yo man being admitted to the SICU following an elective aortofemoral bypass for bilateral aortoiliac occlusive disease. the intraoperative course was notable for one eiposde of hypotension (80) when the aortic clamp was released that lasted for about 10 min. he has a history of CAD with stable angina and a negative stress test prior to the surgery. When he arrives to teh ICU his BP is 130/80 pulse 95. Cardiac Index 2.8, CVP 16, PAOP 18, SVR 950. his hemodynamic state is best designated as
euvolemic, normal perfusion
37yo man is admitted to the burn unit 6hr after sustaining 40% TBSA full adn deep paritial thickness burns involving his torso, arm, and thighs. his clothes caught on fire when he was starting a charcoal grill with gasoline. he is intubated ad receiving IV fluid according to the consensus formula. he is receiving sedation and pain medication. his wounds were cleansed and dressed. which one of the following is the best choice for preventing burn wound sepsis in this patient?
excision and grafting within 5-7 days of the injury
A 64yo comes to the office for a routine 3month followup after elective open colon resection for a primary adenocarcinoma of the cecum. T2N0M0. He has noted a slight amount of drainage frmothis incision site for some time, otherwise he has had an unremarkable postoperative course. on physical exam there is a small, ulcerated nodule on his midline incision, which is draining serous fluid. A recent FDG-PET scan revealed abnormal uptake on the anterior abdominal wall at the site of the draining wound. what is the most appropriate next step in management?
excision of the lesion and tract with pathological analysis.
48yo man comes in to the ER because of a painful left index finger for 3 days. he works as a short-order cook at a local diner where he works the breakfast shift. he hasa history of type2 diabetes treated with oral medication. he smokes a pack of cigarettes daily. on exam, there is erythema and swelling involving the soft tissue and adjacent to the nail on the ulnar aspect of his left index finger. the sweelling and erythema surround the base of the nail but does not extend beyond the DIP joint. it is very tender but there is no increased pain with active flexion or extension of the distal phalanx. there is no tenderness of the pulp of the distal phalanx. what is the best management for this patient?
excision of the overlying nail plate
16yo boy is brought to the ER after being shot in an altercation. he is hemodynamically stable, and physical examination reveals a small caliber gunshot wound just to the left of the umbilicus. a second wound in noted in the left lumbar paraspinal area. his abdomen is diffusely tender and a small amount of blood is noted on rectal examination. the next step in his management should be:
exploratory lapartomy
67yo man presents to the emergency department complaining of excuciating right groin pain. on examination he is found to have an incarcerated inguinal hernia. he undergoes an open hernia repair. the incision is taken down from the skin, camper and scarpa's fascia. what is the next layer?
external oblique aponeuroses
a 2yo man comes to the ER with a swollen left leg. last evening he took a 3-hour plane ride to return home from a friends wedding. duplex ultrasonography shows a clot in the left femoral vein. Testing confirms that he has activated protein C resistance (APCR) which of the following best explains these findings?
factor V neutralization is impaired.
28yo woman for breast pain. pain started 3 months ago is cyclical and bilateral. menarche at 11. nulliparous. started on OCP for heavy bleeding. paternal gm died of endometrial cancer, and her mother and maternal gm had breast cancer in 40s, but living. no other complaints. physcial isn't suspicious. which of the following elements of her hisotry place her at greatest risk for breast cancer?
family history of breast cancer
38yr woman is concerned about her risk for needing cholecystectomy after her 72yo mother underwent cholecystectomy for cholecystitis. she takes medication for DM and HTN. she recently was treated for E.coli urinary tract infection. she has never been pregnant. her biggest risk factor for the development of gallstones is:
female gender
25yo man comes to the office because of a bulge in his groin. he is otherwise healthy. on physical examination there is a reducible bulge inferior to the inguinal ligament medially at the top of the thigh. no bulge can be palpated at the external ring. which of the following is the most likely diagnosis?
femoral hernia
60yo f/o of excision of intraductal carcinom in situ of her left breast. she wants to know possible problems of radiation therapy. what are adverse effects of whole breast radiation?
fibrosis
a 70yo woman is scheduled for a hysterectomy. she states she is on no prescription medications but does take a number of over the counter supplements. which one of her medications listed below is associated with potential for increased bleeding?
garlic
46yo man was admitted to the SICU 3wks ago with severe pancreatitis. he required intensive IV fluid resuscitation and was intubated upon admission. he remains on parenteral pain meds and insulin. Afebrile. BP 130/80, P100, R18. Is making urine. Transfuse 2 units for anemia. NPO. Can't pass feeding tube beyond pylorus. Getting TPN. Abdomen distended and tedner in epgastrium. CT shows large pancreatic phlegmon with narrowing duodenum. 3 small acute fluid collections. Glucose 140, amylase 200, Hct 29. What is the best indication for surgical intervention in this patient?
gastic outlet obstruction
A 52yo woman with insulin-dependent diabetes is scheduled to undergo mastectomy with sentinel lymph node biopsy at 7:30am. Perioperative glucose management of this patient is best achieved with:
half the usual dose of long-acting insuling the morning of surgery.
23yo woman is brought to the ER after being rescued from a house fire. she ran into a burning room and reached into flames to rescue her cat. there are some superficial burns with redness and blisters on her face. there are deep partial thickness burns on her legs and arms and full thickness burns on her hands and forearms. her thighs are red and blanch with compression. she is in sever pain. which area of burn injury is most likely to be the least painful to this patient.
hands
24yo woman f/o for small bowel motility dysfunction. She has read a lot of info on the internet, with a number of questions about normal physiology of the small intestine. As part of this discussion, you explain the migrating motor complex (MMC). which of the following best characterizes MMC?
helps to prevent stasis and bacterial overgrowth
33yo woman in ER for sever diffuse abdominal pain, started 2 hrs ago. otherwise healthy. only meds are OCP. intial vitals 90/60, p110, r20, abdomen is diffusely tender with rebound. Vitals have improved to 110/70, p90, after saline. CT shows 2cm hypodense lesion on surface of left liver with evidence of hemorrhage into abdomen. contrast extravsation is thought to be seen. Select diagnosis and next step.
hepatic adenoma, arterial embolization
A 52yo man presents to your office with diffuse diarrhea and a fever. he is currently undergoing nutritional replacement via tube feeding because of a gastric outlet obstruction. the possible cuases for his diarrhea include either an infectious cause of a complication of tube feeding. which of the following indicates that this diarrhea may be a result of tube feedings?
high osmolarity feedings
54yo man comes to your office because of abdominal pain and distention. he has a long history of excessive alcohol consuption. on physical examination he has severe sleral icterus. his abdomen is quite protuberant and mildly tender. he has a large umbilical hernia surrounded by engorded veins. how do you best explain these large abdominal wall veins?
high pressure portal vein blood is divered to the lower pressure veins of the abdomen wall via the paraumbilical veins.
60yo woman f/o partial mastectomy and sentinel node for stage 1 infiltrating ductal carcinoma of rt breast. menarch at 14, menopause at 53. no previous breast problems. no FMH. has HTN with betablocker. arimadex therapy planned. which of the following is the best way to follow this patient during the next 3 years?
history and physical every 6months and annual mammograms
A 35yo woman is in the ICU 48hr after admission for severe gallstone induced pancreatitis. When she ws in the ER her blood pressure was 95/60, pulse 120, respirations 22. Her oxygen saturation was 90 on room air, hemoglobin was 15mg/dL and WBC was 18000. Her blood sugar was 250mg/dL and she is not a known diabetic. Over the past 48 hours, efforst to maintain a urine output of 30-40cc/hr are accompanied by a 10-kg gain in weight, seguestration of 12 liters of fluid, as well as intubation and mechanical ventilation (FIO2 50%, 7.5 PEEP) to maintain arterial oxygen saturation >90%. Now her blood pressure is 95/60 and pulse is 110. He abdomen is distended with no bowel sounds. the extremities are warm with brisk cap refill. Hemoglobin - 10.5, WBC - 20,000, BUN and creatinine increased from 30 and 1.5 to 35 and 1.8, respectivel. total calcium is 6 mg/dl and ionized calcium is .98. a pulmonary artery catheter is placed and the following data measured or calculated: cardiac index - 4.8, CVP 18, pulmonary artery pressure 35/22, PAOP 15, systemic vascular resistance 600. Her hemodynamic state is best characterized as
hyperdynamic perfusion
a 52 yo woman in the SICU following a MVC develops acute kidney injury with ruptured spleen and hemorrhagic shock. which of the following findings is an urgent indication for renal replacement therapy.
hyperkalemia
A 17yo girl with anorexia nervosa was admitted to the hospital for total parental nutriotional support. two days after the start of her treatment she experiences proximal muslce weakness and visual defects. this patient most likely has:
hypophosphatemia
A 65yo woman is in the ICU following emergency surgery for perforated diverticultitis. In the ER her admission BP was 90/60, pulse 120, temp 38.8, O2 sat 95% on 4L of nasal oxygen. she received three liters of lactate ringers solution, ciprofloxacin and metronidazole and was taken for emergency surgery. during the procedure her systolic was rarely above 100mmHg despite administration of neoesynephrine. she received 6 more liters of lactate ringers as well as 500cc of hetastarch during the 2 hour procedure and made 60cc urine. Venous IV showed MAP 600mm on neosynephrine, CVP is 8mmHg, CV 55%, Arterial blood gas: pH is 7.30, pO2 75, FIO2 60%, PEEP 7.5, PCO2 36, Arterial lactic acid 4.2. Her hemodynamic state is best characterized as
hypovolemic hypoperfusion
A 69 yo woman with diabetes and PVD presents to the ER with sepsis from a necrotizing soft tissue infection. her blood sugard is 350mg/dL. hyperglycemia has been shown to do which of the following:
increase infectious complications
37yo man for palpitation and tremulousness over past 2 months. symptoms relieved with food. History of peptic ulcer disease, was treated for H.pylori 2yrs ago. Had IBS since he was a teen. No medication. physical normal. fasting blood sugar 40, cpeptide elevated. CT scan showed 1.5cm mass in head of pancreas that enhances on arteriogram phase. Mass visible on somatostatin scan. no other lesion identified. Likely diagnosis?
insulinoma
43yo woman in clinic 2 weeks after partial mastectomy and sentinal node for 1.8cm invasive ductal adenocarcinoma of left breast. complaining of numbness and tingling on posterior asbect of upper left arm. no swelling or edema. incision healing well. injury to what is most likely reason for symptoms?
intercostal brachial nerve
44yo woman is brought to the ER because of burns sustained in a house fire. she fell asleep while smoking, setting an upholstered chair on fire. she was rescued by firement adn paramedics. upon arrival, she is somnolent, has burns to her face with carbonaceous debris in her nose a dmouth and repiratory stridor. there are full-thickness circumferential burns on both arms and forearms and her torso and thighs. her O2 saturation is 98% on 2 liters of nasal oxygen. what is the next best step in management?
intubate the patient and administer 100% oxygen
48yo man for weight loss and diarrhea. history of alcoholism and chronic pancreatitis. he has been abstinent from alc for 2 years. only medication is pancreatic enzyme replacement. he has a number of questions about his symptoms and the absorptive functions of the small intestine. which of the following best characterizes small intestinal absorptive function?
is closely linked to Na-coupled nutrient reabsorption
A 72yo woman has Acute resp failure as the result of a head injury. which intervention will help prevent ventilator-associated pneumonia
keep the head of the bed elevated
60yo woman with chronic hep c for confusion. physical shows jaundice, spider angiomata, and splenomegaly. neuro shows lethargic, asterixis present. What pharm agent is most appropriate for treatment?
lactulose
63yo woman with repeated episodes of cholecystitis is being considered for cholecystectomy. PSH for open appendectomy 40years ago, hysterectomy 15years ago. when counseling patient about open vs laparoscopic cholecystectomy the patient should know that:
laparoscopic cholecystectomy can be safely performed in patient who have already had open abdominal surgery.
56yo man with hep c to discuss 7cm mass on US of liver. MRI with gadolinium shows 3 segments with arterial enhancement and ring-type enhancement on delayed images. liver is not cirrhosis in appearance and a recent biopsy of nontumor portion of the liver showed only mild fibrosis. best treatment?
liver resection
A 40yo man has been sent to you by a primary care physician with a presumptive diagnosis of short bowel syndrome because of decreasing weight and apparent cachexia. he has multiple active symptoms nd findings. which of these symptoms/findings is teh majjor cause of cachexia ina patient with short bowel syndrome?
malabsorption
a thin 18yo man is undergoing an appendectomy. an incision is made 2-4 cm above the anterior superior iliac spine and runs parallel to the external oblique muscles of the abdomen. the senior resident asks you to name the incision
mcburney
a 34yo man is admitted from the ER for surgery for a perforated appendicitis. he has diabetes that he controls with oral medications. during the preoperative workup he is noted to have severealy elevated serum glucose and his serum sodium level is 124mEq/L. the hyponatremia should not be treated initally because with hyperglycemia:
measured serum sodium concentration decreases as a result of dilution in response to the osmolar gradient created by the increase in serum glucose
8yo in ER because acute abdominal pain and vomiting. feeling well until the pain developed suddenly several hours before presentation. The parent mention a CT scan done a year ago following a fall off a bicycle showed malrotation of the intestine. What is the most likely cause of the patient's symptoms?
midgut volvulus
45yo smoker presents to the ER with 4days of projectile vomiting. On physical exam he is hypotensive and tachycardic. he has abdominal fullness, decreased skin turgor, and dry mucus membranes. Peristalitc waves are visible in his epigastrium. Treatment for this disorder includes placement of a nasogastric tube and fluid resuscitation using
normal saline
you are currently treating a 85kg, 20yo female who is 5'4" tall for a perforated duodenal ulcer and sepsis. this patient is classified as which of the following:
obese - high risk of nutritional deficiency
40yo man is referred to the office because of a large type 2 paraesophageal hernia that was found on a routine screening chest radiograph. He denies any symptoms of chest pain, dyspnea, abdominal pain, or other GI symptoms. he is otherwise healthy and very active. the most appropriate approach at this time is:
observant management
22yo woman for rt breast mass. nulliparous. menarche at 13. no FMH. healthy with no meds. has 1.5cm firm, non-tender mobile mass in upper outer qudrant of rt breast. rest of exam is normal. US shows ovoid, solid mass measuring 1.5cm with smooth borders. needle biopsy shows cell consistent with fibroadenoma. next step is?
observation
32yo woman in ER following MVC. driver and wearing seatbelt. hit a tree. no LOC. mild abdominal pain, is stable. contrast CT shows 12 cm mass in right lobe of liver with progressive peripheral-to-central prominent enhancement and central hypodense region. No extravasation of contrast. best recommendation is?
observation only
21yo man for MVC 60 minutes ago. is stable wtih GCS 15. main complain severe RUQ abdominal pain. CT shows grade 3 lac, rib fractures, and RLL contusion. no free air or fluid is noted. for liver injury was is best next step?
observation with close monitoring
46yo man was involved in a workplace accident in which his left calf was crushed in a mechanical printing press. the extrication process was prolonged and whe was brought to the ER several hours after the initial injury. upon arrival, he is normotensive with slight tachycardia. his calf is tensely swollen and he complains of numbness to his toes. Dorsalis pedis and posterior tibial pulses are present. plain radiographs reveal no evidence of fracture or dislocation. IV fluid is started. what is the next appropriate step to his management?
operative fasciotomy
48 yo retired army vet of the Iraq War has profuse diarrhea 10 days after a sigmoid colon resection and reanastomosis for perforated diverticulitis. he is on a regular diet and is afebrile and has mild diffuse abdominal tenderness but no indication of peritonitis. his stool specimen is bloody and C. difficile toxin is detected. initial management should be
oral vancomycin therapy
55yo woman no PMH in ER for 24hr abdominal pain, N/V. history of HTN, non-insulin dependent DM, peptic ulcer disease which was treated 2 years ago. Had cholecystectomy for pancreatitis 4 years ago. no gallstones. Meds are glyburide and simvastatin. On exam she is tachy, tenderness in mid abdomen and back. laboratory values on admission reveal an elevated WBC and amylase >250 consistent with acute pancreatitis. CT scan shows evidence of edematous pancreatitis and pancreas divisum. What is the likely cause of her recurrent pancreatitis?
pancreas divisum
62yo woman for abdominal pain and fullness for past 6 weeks. Was discharged 10 wks ago for sever bout of pancreatitis. CT shows 12cm cystic structure in central pancreas, which is new. ERCP shows that the cyst communicates with pain pancreatic duct. What is the next best step in management?
pancreatic cyst gastrostomy
67yo man otherwise healthy for operation on biopsy-proven adenocarcinoma of the pancreas. A bile duct stent was placed peroperatively because of severe jaundice and pruritus. Pre-operative CT show 2.6cm mass in head and incinate, with vascular involvement. during exploration, mass palpated, and pancreas not fixed. a 5mm lesion on the surface of right lobe of liver was excised and froze section confirmed bile duct hamartoma. no other findings. What is the best procedure to do at this time?
pancreaticoduodenectomy (whipple procedure)
28yo man presents to teh ER with hematemesis. He reports a history of chronic diarrhea and upper abdominal pain. He is not taking any medications. Endoscopy reveals anterior and posterior duodenal bulb ulcer. a gastrin level is elevated at 1200. Electrolytes normal except calcium at 11.3. Diagnostic imaging modalities are all negative for disease. After confirmatory testing, appropriate management for this patient would include
parathyroidectomy
75yo man comes to the ER complaining of a fish bone stuck in his throat. with difficulty the bone is removed endoscopicallly, and the patient is sent home. he returns 2 days later with fever chills, and chest pain. the most likely cause of his symptoms is an infection involving the:
posterior mediastinum
37 yo man comes to clinic two weeks following an elective inguinal hernia repair. he has minimal pain controlled with ibuprofen. the incision, which was closed with an absorbable suture, appears to be healing normally. there in minimal swelling and no erytherma or eccymosis. a biopsy of the wound at this time would likely reveal:
predominantly collagen with scarce inflammatory cells.
32yo woman for mass in left breast. 6 months pregnant and has very large breasts. mother had breast cancer at 62. 3.5cm hard, irregular mass in left breast. 2.5cm mobile node is palpable in left axilla. both breast and axillary mass show malignant cells on fine needle. which of these factors is a contraindication to lumpectomy?
pregnancy
44yo man with tender lump near anus for 1 wk. exam shows 3cm fluctuant erythematous swelling in rt anterior perianal skin, very close to anal orifice.Can't tolerate rectal exam. best choice of management is:
proceed to operating room for exam under anesthesia and abscess drainage
A 55yo male with severe symptomatic anemia after GI bleeding is rapidely transfuse with 3 units of packed RBC. he beings to experience severe muscle cramps. the msot likely finding on an ECG would be:
prolonged QT interval secondary to ST segment elongation
50yo man is being evaluated because of chronic GER symptoms. on endoscopy he is found to have Barrett's esophagus with low-grade dysplasia on biopsy. management of this patient should be to:
repeat endoscopy in 6 months with repeat 4-quadrant biopsy of the barrett's.
