Surgery 1 Quizzes
You are seeing a 64-year old female who is presenting with painless bright red rectal bleeding for the last two days. She notes bright red blood coating the stool and on the toilet paper when she wipes. He vitals are normal and her physical exam shows a soft non tender abdomen. Stool is brown with red streaks. What is the most likely cause of bleeding in this patient and the most common overall cause of lower GI bleeding in adults?
Diverticulosis
You are seeing a 15-year-old African-American female in your office because she and her mom are concerned about a non tender breast lump that she just noticed the other day. On exam you note a rubbery, well-defined, nontender breast mass approximately 2 cm in diameter. The patient denies any history of breast tenderness, nipple discharge, or skin changes. What is most likely diagnosis?
Fibroadenoma
You are seeing a 25-year old white female who is presenting to your clinic with bloody nipple discharge over the last 3 days. She denies any history of a breast lump, she is not breast feeding and denies family history of breast cancer. Her exam shows no palpable masses but there is scant bloody discharge coming from her left nipple. You order a mammogram that does not show any suspicious lesions. What is the most likely diagnosis?
Intraductal papilloma
You are seeing a 48-year old white female who has no past medical/family history in your office. She is complaining of right sided bloody nipple discharge over the last 2 days. She denies any trauma or palpation of any mass. On exam you note a reddish discharge from her right breast that is guaiac positive. What it the most likely cause of her findings?
Intraductal papilloma
You are seeing a 42-year-old female following in the trauma bay following a high-speed motor vehicle collision. She was was a restrained passenger and her car flipped over after she lost control. She had to be cut out of the car and is complaining of shortness of breath and upper abdominal pain. She is awake and alert and her GCS is 15. Her pulse is 120/min, respirations are 28/min, and blood pressure is 80/40 mm Hg. Breath sounds are decreased at the left lung base. An x-ray of the chest shows opacification of the left lower lung field. You decide to place an emergent chest tube that yields a small amount of air followed by greenish fluid. Which of the following is the most appropriate next step in management?
Laparotomy
In cases of blunt trauma to the diaphragm, the injury is on the ____ side __% of the time?
Left; 75%
You are evaluating a 56-year old female for a suspicious breast mass in her right breast. Her last mammogram 2 years ago was normal and you have sent her for another mammogram. She denies family history of cancer and has no current medical problems. Which of the following calcification patterns is more suspicious for a ductal carcinoma in situ?
Linear calcifications
What is the most common abdominal organ injured in the setting of blunt abdominal trauma?
Liver
Which of the following is considered a benign lesion that usually does not require cancer treatment?
Lobular carcinoma in situ
You are seeing a 24-year old male who presents with fever, right lower quadrant pain (RLQ), and vomiting over the last 12 hours. On exam he has severe RLQ tenderness without rebound. His current oral temp is 102.1 F, heart rate 110 beats/min, RR 16, blood pressure 134/90. His WBC comes back at 18,000mm3 with 10% bands. What is the most common underlying cause of the disease process in this patient?
Lymphoid hyperplasia
Where is the surgical amphitheaters known as "The Ether Dome" located?
Massachusetts General Hospital
Nonoperative Management of solid-organ injuries can be pursued in hemodynamically stable patients who do not have overt peritonitis or other indications for laparotomy. According to contemporary data, what percentage of patients with splenic injuries are candidates for nonoperative management?
60%
In the setting of trauma, what is the recommended transfusion target goal?
7 g/dl
The most common method of monitoring patients' nutritional status with nutritional supplementation is to measure the serum albumin and prealbumin (transthyretin) concentrations. What is the half life of prealbumin?
1-2 days
Oozing from a surgical wound in a patient who has an adequate platelet count and normal coagulation parameters may be a signal of platelet dysfunction. How many days does it take for sufficient numbers of new platelets to be formed such that the effect of aspirin and clopidogrel lapses, respectively?
10 days/ 5 days
In the absence of a major surgical insult or concomitant coagulopathy, what platelet count is required for normal coagulation?
20,000/μL
You are seeing a 78-year old female who is post op day 1 following a colon resection following a bout of recurrent diverticulitis with perforation. She has a past medical history of cirrhosis from hepatitis C. On exam you note chronic lower extremity swelling and 2+ pitting edema. Her albumin level was 2.7 g/dL. You are wanting to give her a liter of normal saline (NS) suspecting dehydration as she has not eaten anything in 48 hours and her heart rate has increased to around 105 beats/min. Out of the 1 Liter given of NS, what volume administered stays in the intravascular space?
250-330cc
Following abdominal surgery, how many days does a postoperative ileus usually last?
3 days
You are seeing a 63-year old obese black male who presented with left lower quadrant abdominal pain. His CT scan showed mild sigmoid diverticulitis and you decide to treat him with outpatient antibiotics. You also suggested increasing his fiber intake and recommend outpatient colonscopy as he denies prior in the past. What percentage of patients will go on to have another episode of acute diverticulitis after their first episode?
30%
Healthy young patients can usually maintain a normal blood pressure until their blood loss exceeds what % of their blood volume (or roughly __ L)?
40%/2L
You are seeing a 63-year old white female on morning rounds after she was admitted last night for acute cholecystitis. She has a planned cholecystectomy later today but her platelets this am are 20,000 k/mcL. You plan on giving her a transfusion prior to surgery and are in discussion with the general surgeon. A transfusion of a six pack of platelets can be expected to raise the platelet count by which of following?
40,000-60,000
Initial wound management after an operative procedure generally entails placement of a sterile dressing to cover the incision. The traditional recommendation has been to keep this dressing in place and dry for what period of time?
48 hours
There is a high risk of pathogen transfer during surgery. This is a risk from which both the patient and the surgical team must be protected. The risk can be reduced by using protective barriers, such as surgical gloves. A 2002 Cochrane Review concluded that wearing two pairs of latex gloves can further reduce the risk of contamination to what %?
5%
What % of benign appearing gastric ulcers are found to be harbor malignancy?
5-11%
Urinary catheters can serve a large variety of purposes. In the setting of bladder or genitourinary surgery, they are often employed to decompress the system so that it will heal more readily. After general surgical procedures—and many other surgical procedures as well—they are used to provide accurate measurements of volume output and thus, indirectly, to give some indication of the patient's overall volume and resuscitation status. Their utility and importance notwithstanding, urinary catheters are associated with the development of nosocomial urinary tract infections (UTIs). As many as 40% of all hospital infections are UTIs. What % of these UTI's are associated with urinary catheters?
80%
You are seeing a 49 -ear old obese male who presents with two days of worsening left sided abdominal pain. He denies fever or chills but does note painful bowel movements that have streaks of blood. On exam you note moderate left lower quadrant tenderness to palpation without rebound or guarding. His labs show a white blood cell count of 14,000mm3 and his CT scan of his abdomen/pelvis shows acute uncomplicated sigmoid diverticulitis. Nonoperative treatment with oral antibiotics will resolve acute uncomplicated diverticulitis in what percent of patients?
80%
What percentage of diveriticulosis affects the sigmoid colon?
95%
What is the risk for serious medical complications from surgery in healthy patients?
<0.1%
Roughly what percentage of patients with blunt liver injury initially managed non-operatively will go on to need surgical intervention?
<10%
You are seeing a 24-year old white male who presents with fever and lower abdominal pain since yesterday. He has no appetite and his last meal was yesterday morning for breakfast. On exam he has guarding and rebound in his right lower quadrant. You order a CT scan of his abdomen/pelvis in search of acute appendicitis. Of the options below, what appendix size is considered abnormal and diagnostic of acute appendicitis?
>6mm
A 72-year-old African-American male comes to your office for surgical clearance for an elective left hemicolectomy for recurrent diverticulitis. His past medical history includes an inferior-wall myocardial infarction approximately 12 months ago. Since then he had a stress test that was normal 6 months ago. Currently, the patient feels well, walks while playing nine holes of golf weekly, and is able to walk up a flight of stairs without chest pain or significant dyspnea. Findings are normal on a physical examination. Which one of the following would be most appropriate for this patient prior to surgery?
A 12-lead resting EKG
In the setting of trauma, which of the following patients does not have a contraindication to the placement of a foley catheter?
A 34 y/o female with no past medical history with a minimally displaced inferior ramus pelvic fracture
What is a primary goal in the management of patients with abdominal pain?
A, B, and C are all primary goals
You are seeing a 20-year-old male in hospital 12 hours after he was admitted for observation following an MVC. Initially he was complaining of left sided chest wall pain after his car was t-boned on the passenger side. His initial physical examination showed bruises on the anterior chest wall and upper abdominal wall. X-rays revealed fractures of his sixth and seventh ribs on the left (but no pneumothorax or pleural effusion). A FAST Exam did not show any free intraperitoneal fluid. Currently, he complains of worsening epigastric pain, left shoulder pain and mild nausea. His current vitals show his blood pressure is now 95/60 and pulse rate 115 beats/min, and O2 saturation is 96% on room air. Which of the following is the next best step in treatment?
Abdominal CT scan with intravenous contrast
A 45-year old female presents with acute onset of epigastric pain after eating at a family picnic. She notes the pain has fluctuated with intensity since it started. Since the pain started she has vomited twice. Her vitals show an oral temperature of 99.1F, heart rate 110 beats/min, respirations 18/min, blood pressure 141/91, O2 sat on room air is 99%. Physical exam shows voluntary guarding in her right upper quadrant and epigastrum. What is the next best step?
Abdominal Ultrasound to evaluate her gall bladder
Which of the following is not an example of referred pain?
Acute appendicitis causing periumbilical pain
A 46-year obese black female presents to you with 2 days of worsening of right upper abdominal pain and vomiting. She feels hot and cold chills and says that she sometimes feels this pain after eating but now its much worse. Vitals: Temp is 39.0 C, heart rate 125 beats/min, blood pressure 124/90. Physical exam reveals inspiratory arrest upon palpation of her RUQ to deep palpation. Her labs show a WBC of 17,000. Her ALT, AST, bilirubin, and lipase are within normal limits. What is the most likely diagnosis?
Acute cholecystitis
A 30-year old white female presents to your office with right breast pain. She is currently breast feeding her healthy 4-week old infant and has been having focal tenderness, swelling and redness to her right breast near the nipple over the last 2 days. She reports no past medical history and is a non smoker. Given the patient's history and physical, which of the following inflammatory disorders is the most likely diagnosis?
Acute mastitis
Same-day surgery is appropriate for patients who (1) have few or no comorbid medical conditions and (2) are undergoing a procedure that involves short-duration anesthesia or local anesthesia plus sedation and that carries a low likelihood of urgent complications. Operations commonly performed on a same-day basis include which of the following?
All of the above
Which of the following complications of cholelithiasis can present with fever, persistent tachycardia, hypotension, or jaundice?
All of the above
Which of the following pathologies can be seen on plain abdominal xray?
All of the above
You are seeing a 64-year old male in clinic for a follow up visit. He has a past medical history of GERD and has had 2-3 EGDs in the past with no evidence or signs of Barrett's esophagus. He takes (omeprazole 40 mg BID) but is always forgetful about taking his medication. Which of the following options is an indication to consider surgery for the treatment of GERD?
All of the above
You are seeing a 44-year-old female in your outpatient GI clinic for persistent acid reflux symptoms. She was on zantac for 4 weeks following her last EGD and then switched to protonix daily for 2 months which did not seem to help. Her records indicate a normal upper endoscopy 4 months ago as she was complaining of some mild dysphagia and biopsies were negative for h. pylori. She otherwise has no other past medical history and takes no other medications, denies alcohol ingestion and is not a smoker. Vital signs and physical examination are normal. Which of the following studies should be done next to confirm this patient's most likely diagnosis?
Ambulatory esophageal pH-impedance monitoring
Which of the following statements about H. pylori is not true?
Anti-H. pylori IgG antibodies is the test of choice for confirming successful eradication of the organism 4 to 6 weeks after the cessation of antibiotic treatment
What is the most common surgical cause of abdominal pain in adults?
Appendicitis
You are rounding on a 46-year old female who post-op day 1 following a cholecystectomy. She has no other past medical history, takes no medications and she is a one pack per day smoker for the last 20 years. Upon reviewing her 6 am vital signs, you notice that her O2 saturations were declining all night from 99% to currently 90% on room air. The rest of her vitals show an oral temperature of 98.1 F, respirations 16/min, BP 125/90, and heart rate is 85 beats/min. You order an ABG which shows a pH of 7.44, pO2 65 mmhg and CO2 of 35 mmhg. What is the most likely explanation of these findings?
Atelectasis
What is the most common complication of peptic ulcer disease?
Bleeding
What is the most common cancer among woman?
Breast
You are seeing a 32-year old male who presents after being kicked multiple times in his right flank. He is complaining of severe flank pain and gross hematuria. What is the gold standard for imaging of renal trauma?
CT abdomen/pelvis with contrast
You are seeing a 58-year-old female who is presenting with two days of a low-grade fever and increasing abdominal cramps that are exacerbated by bowel movements. She began a course of augmentin 2 days ago that her PCP gave her but has had no relief of her symptoms and is getting worse. She has not had nausea, vomiting, urinary symptoms, or bloody stools. She has a past medical history of hypertension. Her vitals show a temperature is 100.6°F, pulse is 75/min, and blood pressure is 150/80 mm Hg. Her lungs are clear to auscultation. Cardiac examination shows no abnormalities. Her abdomen is soft, and there is tenderness to palpation of the left lower quadrant with guarding but no rebound. Bowel sounds are normal. Her stool is brown, and test for occult blood is negative. Her hemoglobin concentration is 14.5 g/dL, leukocyte count is 15,800/mm3, and platelet count is 280,000/mm3; serum studies and urinalysis show no abnormalities. Which of the following is the most appropriate next step in diagnosis?
CT scan of the abdomen/pelvis with IV and oral contrast
You are seeing a 24-year old female who is 4-weeks post postpartum in your clinic. She is complaining of bilateral nipple pain over the last two days along with a nipple rash. She notes pain both with breastfeeding and even when she is not feeding. The pain is so bad that she didn't breastfeed her baby this morning because of the pain. Physical exam shows erythema to both breasts along with cracking around both areolas. There are no signs of an abscess and no induration present. What is the most likely cause of this patient's symptoms?
Candida infection
Which of the following statements regarding the pre-operative care of patients is false?
Cooling patients during colorectal surgery have been shown to reduce infection rates
You are seeing a 78-year-old black female who is presenting with painless bright red blood per rectum that began last night. She has a past medical history of type 2 diabetes and takes metformin 1000mg twice daily. On physical examination her vitals show an oral temperature of 99.1 F, heart rate 68 beats/min, respirations 14/min, blood pressure 128/71. Physical exam reveals an obese non tender abdomen. Rectal examination discloses no external hemorrhoids; bright red blood is noted in the rectal vault and brown stool. A CBC show a hemoglobin level of 10.4 g/dL and a platelet count of 210,000/µL. Which of the following is the most likely cause of this patient's bleeding?
Diverticulosis
In December 2015, The American Gastroenterological Association has just released its new guidelines on the management of acute diverticulitis. Which of the following is NOT recommended in these new guidelines?
Elective colonic resection is recommended in patients with an initial episode of acute uncomplicated diverticulitis
You are seeing a 28-year old white male who was brought in by EMS after he was assaulted while at a night club. On exam his GCS is 7, he is breathing spontaneously and localizes pain. He has a large scalp laceration to his right parietal region. He is rushed to the CT scanner and the image is shown below. What is the diagnosis?
Epidural hematoma
A 22-year old male presents with severe epigastric pain that radiates into his chest after vomiting over a dozen times following a night of heavy drinking. Vital signs show an oral temperature of 100.7 F, blood pressure 147/97, heart rate 127beats/min, respirations 24/min. Physical exam shows crepitus in the suprasternal notch, clear lung exam bilaterally, and severe epigastric tenderness on abdominal exam. What is most likely causing this patients symptoms?
Esophageal perforation
You are seeing a 26-year old college student in the ER following a roll over MVC. He was wearing a seat belt and was not ejected. Upon arrival his complaining of abdominal pain. His vital signs show a heart rate of 120/min, blood pressure is 134/98, RR 20/min, O2 98% on room air. Physical exam shows he has a seat belt sign across his abdomen and has tenderness greatest in his upper abdomen with no guarding. His CT scan of the abdomen/pelvis with IV contrast only shows a liver laceration. True or False: Most liver lacerations/injuries are managed operatively as they often fail non-operative management.
False
You are seeing a 31-year old male who presents with 24 hours of progressively worsening lower abdominal pain, vomiting and chills. He denies past medical history and denies prior surgery. On exam his heart rate is 95 bpm, BP is 129/80, oral temp 100.2 F and O2 sat is 100% on room air. Upon palpation he has right lower quadrant pain when you palpated his left lower quadrant. His labs show a WBC of 9,700mm3 with no bands. True or False: A normal white blood cell count effectively rules out appendicitis in this patient.
False
You are seeing a 46-year old female smoker in the ER who presents tonight with acute onset of epigastric pain, nausea and vomiting. She past medical history except for right hip arthritis and only takes Alleve daily. Her vitals show a blood pressure of 145/75, heart rate of 95/min, respiratory rate of 14/min, O2 saturation of room air of 99%, oral temperature 98.7 F Her physical exam shows mild upper abdominal tenderness that is greatest in the epigsatric area along with no voluntary guarding in her upper abdomen. Upright chest xray reveals free air under the right hemidiaphragm. True or False: Based on these findings, surgery is always indicated for definitive treatment.
False
The liver is the most commonly injured solid organ in blunt trauma, comprising 5% of all trauma admissions. With that being said, over 80% of patients with liver injuries may be managed nonoperatively. Which of the following is not a predictor of nonoperative management?
Female sex
You are seeing a 44-year old female who presents with worsening epigastric pain following meals and "heartburn" that has been getting more persistent over the last few days. She has a past medical history of hypertension. Her only medication is naprosyn 500 mg BID and HCTZ 25mg daily. On exam she has mild epigastric tenderness to palpation. Her rectal exam shows her stool is brown but guaiac positive for blood. Her portable upright chest xray shows no signs of free air or perforation. Based on her history of current NSAID use, where would you likely expect the location of her ulcer?
Gastric
Numerous complications may arise in the postoperative period especially fevers, pneumonia, urinary tract infections, and wound infections. Which of the following statements is FALSE regarding post operative fevers/infections?
Given the high mortality associated with post operative infections, a shotgun approach to the workup of postoperative fever is usually warranted
You are seeing a 64-year old white male who is presenting with left lower abdominal pain since last night. His WBC is 14,000mm3 and his CT scan of the abdomen and pelvis of the abdomen/pelvis shows acute uncomplicated sigmoid diverticulitis. What bacteria is usually the target in the treatment of acute diverticulitis?
Gram negative rods
Which of the following imaging studies is most sensitive for the diagnosis of acute cholecystitis?
HIDA scan
Which of the following is NOT associated with an increased risk of esophageal adenocarcinoma?
Helibactor pylori infection
You are seeing a 45-year old obese male with type II diabetes who presents with acute onset left lower quadrant abdominal pain, vomiting, pain with defecation, and fever. Physical exam is normal except for his abdominal exam that shows left lower quadrant tenderness without signs of peritonitis. His labs are remarkable for a WBC of 16,000 mm3. Which of the following choices is most likely to reduce repeat incidences of this patients condition?
High fiber diet
You are assessing a 64-year-old obese black male with rheumatoid arthritis for a preoperative assessment before a scheduled right hip replacement in 2 weeks. His only other medical problem is hypertension. His medications include prednisone, 5 mg/d; naproxen, 500 mg twice daily; hydrohlorothiazide, 25 mg/d; and lisinopril 20 mg. On physical examination, his pulse rate is 63/min and his blood pressure is 132/82 mm Hg. His physical exam is normal.What is the most appropriate regimen for perioperative management of his corticosteroid therapy?
Hydrocortisone, 50 mg intravenously every 8 hours for 3 doses; followed by hydrocortisone, 25 mg intravenously every 8 hours for 3 doses; then resume usual outpatient regimen
You are seeing a 31-year old native American female who is currently 24 weeks pregnant and has a history of chronic hypertension in your clinic with a complaint of upper abdominal pain over the last few days. The pain is intermittent, worse after she eats and generally lasts between 30 min to an hour. You are suspecting gall stones and discuss with the patient about ordering an ultrasound to confirm. Which of the following is NOT a risk factor for cholesterol gallstones?
Hypertension
You are seeing a 49-year old obese female who presents with recurrent worsening left lower quadrant abdominal pain since last night. Her PCP diagnosed her with diverticulitis 5 days prior and started her on oral cefazolin and flagyl. She denies past medical history and takes no other medications at home. Vital signs show an oral temperature of 100.8 F, heart rate 101 beats/min, respirations 16/min, blood pressure 154/87, O2 saturation on room air 97%. Physical exam is normal except for moderate left lower quadrant tenderness with no guarding. IV and oral contrasted CT scan shows acute sigmoid diverticulitis with a 4.5cm peri-sigmoid fluid collection consistent with abscess formation. What is the next best step in management?
IV antibiotics and Percutaneous Abscess Drainage
Treatment for all patients with acute nonperforated appendicitis must include:
Immediate antibiotics
Of the options below, what is the recommended first step of the abdominal exam?
Inspection
You seeing a 68-year-old white male in your office for a pre-operative evaluation before cataract replacement and intraocular lens implantation that is scheduled two weeks from now. He has been your patient for about 12 years now and has a past medical history of osteoarthritis. His medications include alleve as needed and a multivitamin. He denies new complaints. He notes being able to climb the stairs in his house and mow the grass without getting short of breath. Which of the following laboratory evaluations is indicated in preoperative evaluation of this patient?
No laboratory tests are needed
According to multiple sources, what is the most common diagnosis of abdominal pain in the adult?
Non Diagnostic Abdominal Pain
You are seeing a 59-year-old male for preoperative evaluation before an elective right hip replacement. in the morning. His medical history includes hypertension treated with norvasc, lisinopril, and hydrochlorothiazide, prior cholecystectomy and dental extractions. He usually drinks 1 to 2 glasses of wine with dinner, does not smoke, and does not use illicit drugs. Results of laboratory studies performed last month, including serum electrolyte levels, creatinine level, and lipid profile, were normal. On physical examination, pulse rate is 72/min, and blood pressure is 141/85 mm Hg. The remainder of the examination is normal. Which of the following blood pressure medications is recommended to be continued on the morning of the surgery?
Norvasc
You are seeing a 64-year old morbidly obese male in clinic for a pre operative evaluation prior to a scheduled colectomy next week for a suspicious colon lesion that was found on colonoscopy. His past medical history is significant for type II diabetes mellitus and hypertension. He has no formal diagnosis of obstructive sleep apnea per history. His exam shows a morbidly obese male in no acute distress. Blood pressure is 145/91, heart rate is 78 beats/min, respiratory rate 14/min and oral temperature is 98.5 F. Of the option below which of the following screening tests prior to surgery is recommended for this patient?
Obstructive sleep apnea
Which of the following is NOT true regarding post operative placement of foley catheters?
Only 10% of hospital acquired UTIs are associated with urinary catheters
You are seeing a 34-year old female in the trauma following an MVC. He is complaining intense diffuse abdominal pain after his car was hit from behind causing him to spin out and crash into a wall. Initially he had a GCS of 15. His vitals showed a BP of 125/76, HR 95, RR 18, O2 of 98% on room air. On physical exam his lungs are clear and his abdomen shows diffuse tenderness to light palpation and ecchymosis over his epigastrium. His initial fast exam is negative but technically limited and you order a CT scan with IV contrast of his abdomen and pelvis as you suspect a possible liver injury. What description from the options below accurately describes a grade IV liver laceration on CT imaging?
Parenchymal distruption involving 25 - 75% hepatic lobes
Which of the following statements regarding peri and post-operative MI is true?
Perioperative beta blockade for patients at risk for MI is now routine as this practice yields significant risk reductions in terms of both cardiac morbidity and mortality
You are consulted to a 38-year-old black male for evaluation of his preoperative cardiovascular risk. He has a 20-year history of type 1 diabetes mellitus and hypertension and is undergoing preoperative evaluation for renal transplantation secondary to uncontrolled hypertension and diabetic nephropathy. His current blood pressure is 142/85 mm Hg. He currently smokes one half of a pack of cigarettes daily. His electrocardiogram is consistent with left ventricular hypertrophy and left atrial enlargement. Which of the following is the most appropriate recommendation at this time?
Pharmacologic stress nuclear study
Which of the following blood products is associated with a higher rate of transfusion related infections?
Platelets
A 48-year old black male presents to you with sudden onset of vomiting and diffuse abdominal pain that hurts to breathe two hours prior to arrival. He denies past medical history and his only medications are ibuprofen for chronic right shoulder pain. He smokes 1 pack per day and occasionally drinks alcohol. His vitals show an oral temperature of 99.3 F, heart rate of 129 beats/min, respiratory rate 20/min, blood pressure 151/100, O2 saturation of 98% on room air. Physical exam shows him to be uncomfotable. Cardiac exam shows tachycardia, his lungs are clear to auscultation, and abdominal exam shows diffuse tenderness to light palpation greatest in the right upper quadrant along with guarding. Rectal exam shows heme positive brown stool. An upright chest x-ray which is shown below. What is the diagnosis?
Pneumoperitoneum
Which sign on physical examination is MOST predictive in diagnosing appendicitis?
RLQ tenderness and rigidity
You are seeing a 64-year old black female who is presenting with 2 days of worsening upper abdominal pain that has become persistent. She denies fever at home but has a n oral temp of 38.0 (100.4 F) in the ER. Her BP is 94/50, HR is 122 bpm and respiratory rate 16/min. On exam she appears slightly jaundiced in her sclera, she has a positive murphy's sign with some involuntary guarding. Her WBC comes back at 20k with 11% bands. Her BMP is unremarkable. What triad of symptoms is classically associated with cholangitis?
RUQ pain, fever, jaundice
You are consulted to see a 61-year-old male because of continuing symptoms due to refractory gastroesophageal reflux that have not improved despite lifestyle modifications and treatment with a twice daily proton pump inhibitor (omeprazole 40 mg daily). He notes that he continues to have occasional chest pain and epigastric burning with eating. He denies dysphagia, regurgitation, weight loss, or a change in bowel habits. He denies other past medical history and has no cardiac risk factors. Vital signs and physical examination are normal. His upper endoscopy shows no ulcers and is otherwise unremarkable. Which of the following is the most appropriate treatment at this time?
Schedule consultation for evaluation for antireflux surgery
You are seeing a 64-year old female in your clinic for a recurrent breast rash overlying her left nipple. She says it has been there for about 4 months and she was initially given a topical steroid by her primary care. On exam you note her nipple to have eczematous changes along erythematous ulcerated skin on her nipple. There are no palpable masses or lymph node swelling in the axilla. Which of the following is the next best step in treatment?
Skin biopsy of the lesion
Neoplastic lesions of the appendix are found in as many as 5% of specimens obtained with routine appendectomy for acute appendicitis. Most are benign. Preoperative detection of such conditions is rare, and intraoperative diagnosis is made in fewer than 50% of cases. Which of the following statement regarding neoplastic lesions of the appendix is true?
The incidence of malignancy in the appendix is 1.35%.
Which of the following statements about massive transfusion protocol is true?
The use of fresh whole blood transfusion in war zones were shown to improve outcomes prompting military surgeons to advocate a different transfusion ratio
The incidence of TRALI (Transfusion-related acute lung injury) has declined in recent years due to which of the following choices below?
The use of plasma from male donors only
A 48-year old white female presents with sudden onset of abdominal pain that radiates to her back. She appears in moderate distress and is vomiting up coffee ground material upon exam. She denies any past medical history and denies the use of alcohol or drugs. She takes over the counter ibuprofen for arthritis in her knees. On exam she is diffusely tender in both upper quadrants and is guarding. Her chest xray is shown below. Her labs show a normal lipase and slightly elevated amylase. Her NG lavage showed clear fluid on aspirate without blood or bile. What is this patient's definitive treatment?
To the OR for closure with a piece of omentum (Graham patch) for a perforated duodenal ulcer
You are rounding on 62-year-old male who status post an elective AAA repair. He was given 3 units of packed red blood cells during surgery and about an hour after he developed fever and chills. He received one dose of prophylactic antibiotics before the surgery. Currently his oral temperature is 101.3°F, blood pressure is 124/80, pulse rate 88 beats/min, and respirations are 14/minute. Physical examination shows a mildly tender wound without induration or redness and his lungs are clear. He has a Foley catheter that was placed at the time of surgery. What is the most likely cause of his fever?
Transfusion reaction
Biliary colic localizes to the mid epigastrum as often as to the right upper quadrant
True
With regards to positioning patients in the operating room, which of the following statements if FALSE?
Ulnar neuropathy and brachial plexopathy are the two most common complications in this position and constitute around 90% of claims.
You are seeing a 32-year-old white female who is currently 16 weeks' pregnant and is presenting with right lower quadrant pain that started abruptly last night along with nausea, vomiting, and a low grade fever. Which one of the following imaging studies would be most appropriate for initial evaluation of this patient?
Ultrasonography of the abdomen and Right lower quadrant
You are seeing a 7-year old boy in the ER accompanied by his mother. She notes that he has been complaining of a fever aand lower abdominal pain for the last 24 hours. She also notes that he has not eaten anything since yesterday morning as he vomits everything he attempts to eat. His vitals show a temp is 101.2 F, HR 120, BP 98/70, RR 18 and O2 sat of 99% on room air. On exam he has moderate periumbilical tenderness to light palpation as well as in his right lower quadrant. His lab work is pending and the surgeon on call tells you to get some radiology study for confirmation. What is the recommended initial imaging modality for this patient?
Ultrasound of the Right lower quadrant
You are seeing a 35-year old male who presents with upper abdominal pain over the last 4 hours along with bilious emesis and the pain comes on in waves. He notes the pain came on shortly after he ate Arby's for dinner. He denies similar pain in the past. What is the best initial imaging modality in the evaluation of this patients pain?
Ultrasound of the abdomen
You are seeing a 27-year old male in the trauma bay shortly after being stabbed in this back with a 6 cm buck knife by his disgruntled neighbor after an argument. He arrived via EMS sitting up, awake and alert with a GCS of 15. His BP is 140/90, HR 120 and O2 sat is 85% on a non re-breather. On physical exam there is a 3 cm non bleeding wound just left of his mid thoracic spine. Upon auscultation there is decreased breath sounds on his left side. There are no signs of tracheal deviation or JVD. What is the next best step in management?
Upright chest xray followed by a chest tube
You are seeing a 75-year old elderly male for a pre-operative consult for a hip replacement after he fell breaking his right hip. The last time you saw him he weighed about 150 lbs. He has no prior cardiac history but he does have terminal lung cancer and needs palliative surgery but his recent fragility and weight loss has changed his risk. He notes losing 30 lbs in the last 6 weeks and his last serum albumin was 2.4 g/dl. What is his overall operative risk?
Very high but can be improved with 7 days of intensive nutritional support via his gut
A 41-year-old obese white female presents to the emergency room with severe epigastric pain and right shoulder pain that has been on or off over the last month but now constant over the last 2 hours associated with vomiting. She notes it comes on after eating and normally goes away on its own after an hour but tonight it has persisted longer. Her past medical history is significant for frequent heartburn for which she takes zantac and tums. After examination and history the patient notes that her pain has resolved completely. Which of the following answers best explains the source of her pain?
Viscus distention
Multiple randomized clinical trials have now demonstrated that routine use of drains (such as Penrose, Hemovac, Jackson-Pratt, and Blake) after what elective operation has shown benefit in preventing anastomotic and other complications besides seromas?
none of the above operations have shown benefit
Multiple randomized clinical trials have now demonstrated that routine use of drains after elective operations—including appendectomies and colorectal, hepatic, thyroid, and parathyroid procedures-- reduces which of the following?
seroma formation
