UWorld-Surgery
A 57-year-old man comes to the office with "red urine." He has had several episodes of gross hematuria over the last 3 months, followed by spontaneous clearing. The patient has no fever, dysuria, back pain, or weight loss. He has no family history of cancer, but he does have a 20-pack-year smoking history. Vital signs are normal. Examination shows a left-sided varicocele that fails to reduce when the patient is recumbent. The remainder of the examination shows no abnormalities. Laboratory results are as follows: Hemoglobin18 g/dLLeukocytes7,400/mm3Platelets580,000/mm3Urinalysis>10 red blood cells/high-power field Which of the following is the most appropriate diagnostic procedure for this patient?
Abdominal CT
A 19-year-old woman comes to the emergency department due to abdominal pain for the past several hours. The pain was initially mid-abdominal and crampy, and now the patient has constant pain in the right lower quadrant and an episode of vomiting. Temperature is 38 C (100.4 F), blood pressure is 118/70 mm Hg, and pulse is 96/min. The patient is supine on the bed with her hips flexed and reports worsening of the pain when her hips are extended. There is mild tenderness in the right lower quadrant, with guarding. Bowel sounds are decreased. Pelvic examination reveals tenderness in the right adnexal area. Leukocyte count is 14,000/mm3 and urinalysis shows 10-20 leukocytes/hpf, 1+ blood, and no bacteria. Urine pregnancy test is negative. Which of the following is the most likely cause of this patient's current condition? A. Acute appendicitis [90%] B. Acute pyelonephritis [3%] C. Ectopic pregnancy [3%] D. Nephrolithiasis [1%] E. Small bowel obstruction [0%]
Acute appendicitis
A 27-year-old woman on postoperative day 3 from a cesarean delivery, develops fever, chills, uterine tenderness, and hypotension. The patient is started on broad-spectrum antibiotics and intravenous fluids for postpartum endometritis. Over the next 24 hours, she develops increasing dyspnea. Temperature is 38.5 C (101.3 F), blood pressure is 110/66 mm Hg, pulse is 110/min, and respirations are 24/min. Pulse oximetry is 80% on a 100% nonrebreather mask, and the patient is intubated. There is no jugular venous distension. Cardiac examination has no rubs or murmurs. Lung auscultation has diffuse bilateral crackles. Chest x-rays 24 hours earlier (left) and at intubation (right) are shown above. After intubation, arterial blood gases show PaO2 of 60 mm Hg while receiving 100% oxygen, and PaCO2 of 34 mm Hg. Which of the following best explains this patient's respiratory symptoms?
Acute respiratory distress syndrome
A 65-year-old man comes to the emergency department due to severe right leg pain and is found to have an acute thrombotic occlusion of the right popliteal artery. The patient is admitted to the surgical floor, and intravenous unfractionated heparin is initiated. The following morning, he undergoes surgical revascularization of the right leg. The patient's hospital course progresses well, but on postoperative day 5, his platelet count decreases from 240,000/mm3 on admission to 65,000/mm3. Vital signs are stable. The surgical wound is healing well. There are no rashes or pitting edema. In addition to stopping the unfractionated heparin, which of the following is the best next step in management?
Argatroban
A 76-year-old man comes to the emergency department due to cough and low-grade fever. He was treated for pneumonia twice in the last year. For the past 6 months, he has had difficulty swallowing and has occasionally regurgitated undigested food. Temperature is 38.5 C (101.3 F), blood pressure is 150/95 mm Hg, pulse is 102/min, and respirations are 16/min. BMI is 22 kg/m2. Physical examination is notable for foul-smelling breath and a fluctuant mass in the left neck. Auscultation shows crackles in the right lung base. Chest x-ray shows an infiltrate without cavitation in the right lower lung field. The patient is admitted to the hospital, sputum and blood cultures are sent to the laboratory, and antibiotics are started. A few days later, the patient's condition is markedly improved. Which of the following is the best next step in management of this patient?
Barium Swallow study
A 65-year-old man comes to the office due to 4 weeks of persistent epigastric pain and nausea. The pain is constant and has not changed with diet. The patient lost 4.5 kg (9.9 lb) over this period. He was diagnosed with type 2 diabetes mellitus 6 months ago, which is controlled with a low-carbohydrate diet. He has a 45-pack-year history of smoking. Vital signs are normal. BMI is 21 kg/m2. The abdomen is soft with mild epigastric tenderness to deep palpation. No hepatosplenomegaly or shifting dullness is present. Complete blood count, serum chemistry, and liver function studies is all normal except a fasting blood sugar of 130 mg/dL. Which of the following is the best next step in management of this patient?
CT scan of the abdomen
A 56-year-old man comes to the office due to pain, redness, and swelling in his right arm. The patient was recently diagnosed with unresectable lung cancer. He received the first cycle of chemotherapy 2 weeks ago through a right-sided peripherally inserted central catheter (PICC). Temperature is 36.9 C (98.4 F), blood pressure is 130/80 mm Hg, pulse is 78/min, and respirations are 14/min. Oxygen saturation is normal. Examination shows right arm swelling and mild erythema. Capillary refill is normal. No discharge is seen around the PICC line. The remainder of the examination is normal. Which of the following is the best next step in management?
Duplex US
A 53-year-old man comes to the office due to right-sided lateral hip pain that makes it difficult for him to lie on that side while sleeping. He describes the pain as burning and localizes it to the outer surface of his thigh. The pain has recently occurred during the day and is worse with activity and prolonged standing. On examination, there is localized tenderness over the lateral aspect of the right hip with deep palpation. Neurologic examination is normal. Which of the following is the most likely cause of this patient's pain?
Greater Trochanteric pain syndrome
A 2-month-old, full-term infant is brought to the emergency department after a fall from her father's arms. The father was walking down the stairs at home when he tripped 3 steps from the bottom and the patient fell out of his arms. She cried immediately and had no loss of consciousness. Since the fall, the patient has been fussier than usual. Temperature is 36.7 C (98.1 F), blood pressure is 88/42 mm Hg, pulse is 144/min, and respirations are 42/min. Head and neck examination shows a 2-cm occipital hematoma with a palpable step-off. The rest of the examination is normal. Which of the following is the best next step in management of this patient?
Head CT scan
A 45-year-old woman has had numbness and tingling in the palms of both hands for 3 months and has been treated with night-time wrist splints for 6 weeks for carpal tunnel syndrome. At follow up, these symptoms have not improved. Which of the following is the best next step in management of this patient?
Nerve conduction study
A 34-year-old man comes to the emergency department with severe right arm pain after a motor vehicle collision. He was a restrained driver and used his arm to brace the impact. Vital signs are normal. Examination shows a deformed right upper arm that appears shorter than the left. The midportion of the right arm is swollen and tender. He has limited extension at the wrist joint and decreased sensation over the dorsoradial aspect of the right hand. Radial pulse is 1+ on the right and 2+ on the left. An x-ray of the arm shows an oblique fracture of the midshaft of the right humerus. Which of the following is the best next step in management of this patient? A. Application of a neutral wrist splint only [0%] B. Electromyogram of the right upper extremity [3%] C. Long arm hanging cast of the right upper extremity [17%] D. Open reduction and surgical exploration [70%] E. Placement of an external fixation device [7%]
Open reduction and surgical exploration
A 30-year-old man comes to the emergency department with a 4-day history of progressively worsening abdominal pain and bloody diarrhea. He was started on mesalamine therapy 6 months ago after being diagnosed with ulcerative colitis but has been noncompliant with treatment. Temperature is 38.8 C (102 F), blood pressure is 100/70 mm Hg, and pulse is 130/min. The patient is lethargic and has dry mucous membranes. There is marked abdominal distension and tenderness without rebound or guarding. Rectal examination shows guaiac-positive, maroon-colored, liquid stool. Which of the following is the best next step in this patient's workup?
Plain abdominal xray
A 52-year-old man is found to be tachypneic 2 days after an uncomplicated upper abdominal ventral hernia repair. Until now, his postoperative course had been unremarkable, and he has low-dose morphine for pain control. The patient feels short of breath but has no chest pain. He has an occasional cough with a small amount of early-morning sputum. The patient is an active smoker with a 15-pack-year history. Temperature is 36.7 C (98.1 F), blood pressure is 123/79 mm Hg, pulse is 90/min, and respirations are 28/min. BMI is 32 kg/m2. There are decreased breath sounds at the right lung base without wheezes or prolonged expiration. Heart sounds are normal. There is abdominal distension and diffuse tenderness without rebound. Chest x-ray reveals a dense opacity at the right lung base. Which of the following would have been most effective in preventing this patient's current condition?
Post Op deep breathing exercise
A 57-year-old man comes to the emergency department due to nausea, vomiting, and severe crampy pain in the right flank. Several days ago, the patient had similar, but less severe, pain that resolved spontaneously. He has type 2 diabetes mellitus, obesity, hyperlipidemia, hypertension, and gout. Temperature is 37 C (98.6 F) and blood pressure is 160/100 mm Hg. Physical examination shows right flank tenderness. Blood urea nitrogen and serum creatinine are normal. Abdominal ultrasound reveals right-sided hydronephrosis and proximal ureteral dilation. Urinalysis in this patient would most likely reveal which of the following?
RBC's
A 66-year-old man with a history of hypertension is brought to the emergency department with sudden-onset neurologic symptoms. MRI of the brain shows an acute left lacunar infarct. Which of the following is the most likely finding in this patient?
Right hemiparesis
An 80-year-old woman is brought to the hospital with progressively increasing abdominal pain, nausea, vomiting, and an inability to keep food down since yesterday. The patient has had no previous surgeries. She does not use tobacco or alcohol. Temperature is 37.1 C (98.8 F), blood pressure is 150/80 mm Hg, and pulse is 96/min. The abdomen is distended and tympanic, but there is no tenderness, rebound, or rigidity. Bowel sounds are increased and high-pitched. Rectal examination shows no stool in the rectal vault and no masses. Fullness and tenderness are noted in the right groin area. The extremities are without cyanosis, clubbing, or edema. Abdominal x-ray reveals distended bowel loops with air-fluid levels. Which of the following most likely predisposed this patient to her current condition?
Small bowel herniation
An 80-year-old Asian man comes to the office for evaluation of fatigue and a 4.5-kg (10-lb) weight loss. The patient does not use tobacco and drinks 2 shots of whiskey daily. He eats a vegetarian diet. Physical examination shows a nodular prostate and inguinal lymphadenopathy. Serum prostate-specific antigen level is 25 ng/mL (normal: <4.5). Biopsy of the prostate reveals adenocarcinoma. Which of the following risk factors is most strongly associated with development of cancer in this patient?
advanced age
An 82-year-old nursing home resident is brought to the emergency department due to 3 days of progressively worsening abdominal pain. He has had several episodes of vomiting during the past 24 hours and his last bowel movement was 4 days ago. The patient has Alzheimer disease, hypertension, and osteoarthritis. He has had no prior abdominal surgery. Temperature is 37.2 C (99 F), blood pressure is 140/88 mm Hg, and pulse is 96/min. Physical examination shows a distended and tympanic abdomen with tenderness to palpation. Peritoneal signs are absent. Bowel sounds are high pitched and increased. The patient has discomfort during rectal examination and no stool is present. Abdominal radiography reveals a markedly distended bowel loop, without any haustra, extending from the pelvis to the right upper quadrant in an inverted U shape. No air is present in the rectum. Which of the following is the most likely cause of this patient's abdominal pain?
Torsion of Sigmoid colon
A 72-year-old man comes to the office with a 3-month history of weak urinary stream, straining on urination, and nocturia. He has no burning or pain with urination. The patient is a nonsmoker and has a history of hypertension and osteoarthritis. He has no family history of cancer. Rectal examination shows smooth and firm enlargement of the prostate. Neurologic examination is normal. Which of the following is the best next step in evaluation of this patient?
UA
A 16-year-old girl is seen in the emergency department due to knee pain. Two days ago, the patient noticed swelling and a deep, aching pain in the left knee, which is now worse. She has no chronic medical conditions. Temperature is 36.7 C (98 F). On the palmar side of each hand, there are a few nontender pustules with a surrounding erythematous rim, each 3-4 mm in diameter. The left knee has an effusion but is without erythema; range of motion is decreased due to pain. Joint aspiration reveals a leukocyte count of 30,000/mm3; synovial fluid culture is negative. Which of the following historical factors is most commonly associated with this patient's presentation?
Unprotected Sex
A term newborn is undergoing routine evaluation in the nursery. The boy was born 12 hours ago via spontaneous vaginal delivery to a 24-year-old woman. Vital signs are normal. Physical examination shows a sleeping newborn with normal tone. A 1/6 systolic murmur is best heard at the left sternal border. Peripheral pulses are strong. Genitourinary examination shows a penis of normal length with no curvature. The urethral meatus is located at the coronal margin, and there is a dorsal hooded foreskin. Testes are present bilaterally within the scrotum. The patient urinates through the urethral meatus during examination. The father is present and requests that a circumcision be performed. Which of the following is the best next step in management of this patient?
Urology Eval
A 66-year-old man is found to have a 4-cm abdominal aortic aneurysm on screening ultrasonogram. His other medical conditions include hypertension, type 2 diabetes mellitus, hypercholesterolemia, and hypothyroidism. The patient is an active smoker with a 50-pack-year history and drinks 1-2 glasses of wine daily. Blood pressure is 155/90 mm Hg, and pulse is 80/min. Examination shows no abnormalities. Laboratory results are as follows: Serum creatinine1.8 mg/dLLow-density lipoprotein140 mg/dLHbA1c8.2% Which of the following is associated with the highest rate of aneurysm expansion and rupture in this patient?
active smoking
A 56-year-old postmenopausal woman comes to the office due to abdominal pain and nausea. The patient has had 2 days of dull, persistent pain in the left lower abdomen that has progressively worsened. She has had no appetite and vomited once today. She has not had a bowel movement during this period but is passing flatus. Medical history includes hypertension and type 2 diabetes mellitus. Temperature is 38 C (100.4 F), blood pressure is 134/82 mm Hg, and pulse is 94/min. BMI is 33 kg/m2. Physical examination shows left lower quadrant abdominal tenderness with no rebound tenderness or guarding. Bowel sounds are normoactive in all quadrants. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis in this patient?
acute diverticulitis
A 28-year-old woman comes to the office after noticing a lump in her left breast last week. The size of the mass has not changed. The patient has no associated nipple discharge or skin discoloration. She has no chronic medical conditions or previous surgery. Her last menstrual period was 5 days ago. Blood pressure is 110/70 mm Hg and pulse is 70/min. BMI is 25 kg/m2. Physical examination reveals a 1.5-cm, round, mobile, tender mass in the lateral superior quadrant of the left breast, 4 cm from the nipple. There is no fluctuance or erythema. No nipple discharge is expressed. Supraclavicular and axillary lymph nodes are not palpable. Which of the following is the best next step in management of this patient?
breast ultrasound
A 26-year-old man comes to the emergency department due to sudden onset of severe, colicky, left-sided flank pain that radiates to the scrotum. He also has nausea, vomiting, and dark urine. The patient has never before had these symptoms. Examination shows no abnormalities. Noncontrast helical CT scan reveals a 5-mm radiopaque stone in the left upper ureter. Laboratory results are as follows: Serum calcium9.8 mg/dLSerum creatinine0.9 mg/dLBlood urea nitrogen15 mg/dL Urinalysis shows hematuria but no casts. Which of the following is the most likely cause of this patient's symptoms?
calcium oxalate
A 23-year-old man is brought to the emergency department after a motor vehicle collision. The patient was found unresponsive at the scene and intubated by the paramedics, who also administered 2 L of normal saline. He was the unrestrained driver. Upon arrival, blood pressure is 72/54 mm Hg, and pulse is 120/min. The patient responds to strong vocal and tactile stimuli by opening his eyes. Pupils are equal and reactive to light. Neck veins are distended. There are multiple bruises involving the anterior chest and upper abdomen. Chest x-ray reveals slightly enlarged cardiac contours and no mediastinal widening. Which of the following is the most likely diagnosis?
cardiac tamponade
A 60-year-old man comes to the office due to right-sided neck and shoulder pain. The pain worsens with neck movement and is associated with forearm numbness. For the past 2 years, he has had several similar that improved with rest and ibuprofen. The patient has had no neck or shoulder trauma. Vital signs are normal. Physical examination shows limited neck rotation and lateral bending. There is decreased pinprick sensation on the posterior aspect of the right forearm but no muscle weakness. Triceps reflex is normal. Left upper extremity examination shows no abnormalities. An xray of the cervical spine is ordered. This patient's symptoms are most likely due to which of the following?
cervical spondylosis
A 26-year-old woman is evaluated for intermittent abdominal discomfort, diarrhea, and melena. The patient undergoes colonoscopy followed by total colectomy due to significant colonic abnormalities. Representative colon findings are shown in the image above. Her sister, who has the same biological parents and has no symptoms, also undergoes screening colonoscopy and has similar findings. If left untreated, which of the following is the most likely lifetime risk of colon cancer in the patient's sister? A. About 25% [5%] B. About 50% [15%] C. About 75% [14%] D. Close to 100% [63%] E. Same as general population [0%]
close to 100%
A 65-year-old man comes to the office due to 3 days of progressive right flank pain. The patient also notes 4 weeks of dysuria and urinary frequency. Temperature is 37.1 C (98.8 F). The abdomen is soft and nontender. No suprapubic tenderness is present, but there is mild right-sided costovertebral angle tenderness. The external genitalia are normal, and there is no penile discharge. Rectal examination shows mildly enlarged prostate without nodules or tenderness. Laboratory results are as follows: Creatinine1.5 mg/dLUrinalysis Bloodmoderate Bacterianone Red blood cells30-40/hpf Castsnone Dysmorphic cellsnone Urine gram stain is negative, and urine culture does not grow any organisms. Abdominal ultrasound reveals right-sided hydronephrosis and a normal left-sided kidney and ureter. Which of the following is the most appropriate next step?
cystoscopy
A 65-year-old man comes to the emergency department due to sudden-onset chest pain followed by syncope. The pain started an hour ago, during which he had an episode of syncope lasting 1-2 minutes. The patient has had no dyspnea or palpitations. He has hypertension and a 40-pack-year smoking history. Blood pressure is 190/110 mm Hg in both arms; pulse is 100/min and regular; and respirations are 24/min. Pulses are symmetric and equal in all extremities. There is an S4 gallop. ECG shows changes consistent with left ventricular hypertrophy. Serum troponin is normal. Chest x-ray shows an enlarged cardiac silhouette and CT scan of the chest is shown above. Which of the following is the best next step in management of this patient?
emergent surgical repair
A 21-year-old man fell and hit the left side of his head on a rock. He did not lose consciousness, but over the next 30 minutes he developed a headache and vomited twice. Blood pressure is 136/90 mm Hg and pulse is 68/min. On examination, the patient is drowsy but otherwise well oriented. Swelling and tenderness are noted over the left frontoparietal region. CT scan of the head will most likely reveal which of the following?
epidural hematoma
An 18-year-old man is brought to the emergency department after falling and striking his chest. He tripped, lost his balance, and hit his left chest against the coffee table. The patient now has moderate left-sided chest pain, worse with deep inspiration. He also feels lightheaded. On examination, the patient appears uncomfortable and is taking shallow breaths. Blood pressure is 88/50 mm Hg, pulse is 122/min, and respirations are 28/min. Jugular veins are flat. The trachea is midline. The left chest wall has intact, bruised skin and is exquisitely tender to palpation. Breath sounds are present on the right but diminished in the left lung base, which is dull to percussion. Heart sounds are normal without murmurs. Which of the following is the most likely diagnosis in this patient?
hemothorax
A 36-year-old man comes to the office after experiencing intermittent episodes of rectal bleeding over the past 2 months. Initially, he noted only small streaks of blood on the tissue when wiping, but yesterday he dripped bright red blood after defecating and the stool was coated with blood. The patient has had no anal or abdominal pain, anorexia, weight loss, or changes in bowel pattern. He has no other medical concerns and takes no medications. Vital signs are normal. Inspection of the perianal skin shows no abnormalities. No mass or tenderness is palpable on digital rectal examination. Anoscopy reveals purplish mucosal bulges. Which of the following is the best next step in management of this patient?
high fiber diet and follow up
A 46-year-old woman comes to the office for evaluation of an abdominal mass. The patient first noticed a small, non-painful abdominal mass 2 months ago. Over the past month, the mass has slowly grown and sometimes causes mild abdominal discomfort. The patient has had no weight loss or changes in bowel patterns. She underwent a total abdominal hysterectomy 6 years ago. BMI is 32 kg/m2. The patient has a large, vertical midline abdominal scar consistent with her prior surgery. There is a small, nontender mass at the midline below the umbilicus that is palpable while the patient is supine and increases in size with Valsalva. Which of the following is the most likely diagnosis in this patient?
incisional hernia
A 40-year-old man is brought to the hospital after being rescued from a bridge collapse. He was trapped and crushed under the wreckage and it took 4 hours to extricate him. The patient has pain over multiple areas. Blood pressure is 110/70 mm Hg, pulse is 90/min, and respirations are 16/min. Examination shows widespread bruises and abrasions. The extremities are slightly swollen, and peripheral pulses are palpable. Laboratory results are as follows: Sodium 136 mEq/L Potassium 5.2 mEq/L Creatinine 1.9 mg/dL Calcium 7.4 mg/dL Creatine kinase, serum 65,000 U/L Which of the following is the most appropriate initial therapy for this patient?
infusion of 0.9% saline
A 38-year-old woman with chronic constipation is evaluated for occasional blood in the stool over the last 6 months. She describes bright red blood coating the stool and on several occasions dripping into the toilet at the end of defecation. The patient has no abdominal or rectal pain, nausea, vomiting, or weight loss. She has never had a colonoscopy and has no family history of cancer. Further evaluation is most likely to show which of the following as the cause of her symptoms?
internal hemorrhoids
A 21-year-old man comes to the emergency department due to abdominal pain, nausea, and vomiting. The patient started having vague periumbilical pain in the morning. Over the next several hours, the pain became more severe, sharper, and localized to the right lower abdominal quadrant. Temperature is 38.3 C (100.9 F), blood pressure is 132/84 mm Hg, pulse is 102/min, and respirations are 12/min. Physical examination shows maximal tenderness in the right lower abdomen two-thirds of the distance from the umbilicus to the anterior superior iliac spine. Bowel sounds are decreased. Leukocyte count is 16,000/mm3. The change in this patient's pain characteristics is most likely explained by which of the following?
irritation of parietal peritoneum
A 62-year-old man comes to the emergency department due to painful swelling in the right groin. The patient also has had nausea and 2 episodes of bilious vomiting since the onset of pain several hours ago. Temperature is 38.2 C (100.8 F), blood pressure is 140/80 mm Hg, and pulse is 110/min. On examination, the abdomen is soft and mildly distended with hyperactive bowel sounds. There is a tender, 4-cm mass in the right inguinal region, with erythema of the overlying skin. The patient subsequently undergoes urgent exploratory surgery of the right groin. Which of the following is most likely to be found during surgery?
ischemic bowel segment
A physician assistant (PA) is on her way to morning signout after her overnight shift and gets into an elevator crowded with nurses and other hospital staff members. The PA student on the team gets on the elevator and asks the PA how her shift went. During the conversation, the student is careful not to mention the patient's name, asking, "Did the patient in Room 232 get her CT scan?" Which of the following is the most appropriate response to the student? A. "Discussing patient information in a public setting is against hospital policy." [38%] B. "I have the brain scan results and can discuss them during signout." [5%] C. "Let me pull up the results on my phone." [0%] D. "Let's discuss all of your patients at signout." [50%] E. "The scan was read, but ask the daytime resident about the results." [6%]
lets discuss all of your patients at signout
A 64-year-old woman is hospitalized after injuring her right hip when she slipped on ice while carrying groceries. X-ray reveals a right femoral neck fracture, and the patient undergoes a total hip arthroplasty. Two days after surgery, the patient develops acute hemodynamic decompensation. A contrast-enhanced CT scan of the chest is immediately obtained and shows a large pulmonary embolism, as shown in the image above. Administration of which of the following is most appropriate for reducing the risk of developing this complication?
low-molecular weight heparin
A 78-year-old man comes to the office due to 6 months of progressive bilateral buttock pain that radiates to the thighs and calves. The pain is worse with standing but improves with leaning on a cane or sitting. The patient has no pain at night and no problems with bowel or bladder function. He has coronary artery disease. Physical examination shows normal strength, reflexes, and sensation in the legs. A straight-leg raise test does not reproduce the pain. Ankle-brachial index is 1.1 on the right and 1.2 on the left (normal: 0.9-1.3). Which of the following is the most likely cause of this patient's current condition?
lumbar spinal stenosis
A 65-year-old man is brought to the emergency department after a motor vehicle collision. The patient was the restrained front passenger in a car that hit a tree at 25 miles/hr. His right leg was pinned under the dashboard, and extrication took 2 hours. The patient has continued right leg pain, which is minimally relieved with morphine. He had a myocardial infarction 6 months ago for which he takes aspirin and clopidogrel. Blood pressure is 102/72 mm Hg and pulse is 111/min. On physical examination, the right leg appears swollen, bruised, and shiny. Sensation is intact. Passive motion of the right ankle and toes causes pain. Bilateral pedal pulses are palpable. X-ray of the right lower extremity is negative for fracture. Which of the following is the best next step in management of this patient's leg pain? A. Apply a compression wrap [1%] B. Measure leg compartment pressures [84%] C. Obtain a lower extremity arteriogram [3%] D. Order a CT scan of the lower extremity [2%] E. Perform lower extremity Doppler ultrasound [7%]
measure leg compartments
A 65-year-old man is being evaluated for new-onset ptosis. Earlier today, the patient underwent right total knee arthroplasty without complications. Postoperatively, he had difficulty opening his left eye and developed slurred speech. The patient has never had these symptoms, and his preoperative neurologic examination was unremarkable. Medical history includes type 2 diabetes mellitus and a 20-pack-year smoking history. Vital signs are normal. Neurologic examination reveals bilateral ptosis, left greater than right. Pupils are equal in size and reactive to light. An ice pack is placed over the closed eyelids for 2 minutes, leading to improvement of the ptosis. Which of the following is the most likely cause of this patient's current symptoms? A. Bell palsy [6%] B. Diabetic mononeuropathy [5%] C. Horner syndrome [12%] D. Lambert-Eaton myasthenic syndrome [14%] E. Myasthenia gravis [61%]
myesthenia gravis
A 36-year-old woman presents with severe left calf pain that came on suddenly while she was running. She started retraining a week ago, after not running for 2 years. Vital signs are normal. Which of the following is the most accurate test to confirm complete Achilles tendon rupture in this patient?
no plantar flexion on calf flexion
A 26-year-old man comes to the office for evaluation of worsening left knee pain and swelling for 3 months. The patient has tried ice and ibuprofen without relief. He has no chronic medical conditions, and his only surgery is an enucleation for retinoblastoma when he was an infant. The left knee appears swollen, but there is no overlying rash or skin lesion. The left knee has full range of motion with no crepitus, but deep palpation over the distal thigh is associated with pain. X-ray of the knee shows a sclerotic lesion that has ill-defined margins on the femoral condyle and is surrounded by a sunburst periosteal reaction. Which of the following is the most likely diagnosis in this patient?
osteosarcoma
A 34-year-old man comes to the office due to erectile dysfunction. For the past 2 months, he has had pain and penile curvature during erections, which has made vaginal penetration difficult and has started to adversely affect his self-esteem. The patient has had no urethral discharge or other symptoms. The patient has had a total of 5 female sexual partners. Vital signs are normal. The abdomen is soft and nontender with no masses. There is no inguinal lymphadenopathy. A palpable plaque is present on the dorsal side of the penis approximately half way between the glans and the pubis. The testes are normal with no scrotal erythema or skin ulceration. Which of the following is the most likely diagnosis?
peyronie disease
A 54-year-old man comes to the office for evaluation of left foot pain. The patient has had progressively worsening pain for the last month since starting a walking program to help lose weight. He has been walking 2-3 miles each morning and has pain and a burning sensation on the sole of his left foot during walks. The pain usually improves with rest and typically does not recur during the day or overnight. BMI is 36 kg/m2. The left foot has a normal arch. When the toes are dorsiflexed, there is tenderness to palpation between the heel and forefoot. There is no pain with firm palpation along the back or sides of the heel. Sensation and range of motion are normal. Which of the following is the most likely diagnosis?
plantar fasciitis
A 54-year-old man comes to the office due to right upper eyelid swelling for 1 week. There is no associated pain or itching of the eye or eyelid. Vital signs are normal. Examination of the right eye shows a rubbery swelling, as shown in the image above. Bilateral visual acuity is 20/20, and extraocular movements are normal in all directions. Conservative measure with warm compress is initiated. Eight weeks later, the lesion has not resolved, and the patient returns to the office. The eye examination remains unchanged. Which of the following is the most appropriate next step in management of this patient?
refer to ophthalmologist
A 23-year-old man presents after injuring the right shoulder during basketball. He was trying to block a shot when his abducted and externally rotated arm was forced backward by an opposing player. The patient immediately felt excruciating pain. On examination, there is gross asymmetry of the right shoulder compared to the left, and the right arm is held in slight abduction and external rotation. Distal pulses are 2+. X-ray of the right shoulder is shown above. If left untreated, which of the following is the most likely complication of this injury?
shoulder abduction weakness
A 64-year-old man with a history of coronary artery disease and peripheral vascular disease undergoes coronary artery bypass surgery. His postoperative course is complicated by hypotension, which is treated successfully with intravenous fluids; however, a few hours later, he experiences abdominal pain followed by bloody diarrhea. Temperature is 37.8 C (100 F), blood pressure is 110/60 mm Hg, and pulse is 110/min. Abdominal examination shows normal bowel sounds, with no significant guarding or focal tenderness. A venous lactic acid level is elevated. An abdominal CT scan is ordered. Which of the following areas will most likely show abnormal findings?
splenic flexure
A 58-year-old woman presents with diffuse swelling and tenderness at the left distal forearm. She is uncooperative during examination. X-rays are shown above. Which of the following is the most likely mechanism of injury?
tripping and falling forward
A 32-year-old man comes to the clinic for an infertility evaluation. The patient's vital signs are normal. On physical examination, the penis is uncircumcised and without lesions. Bilateral testes are palpable within the scrotum and are normal in size. There is no excessive firmness or tenderness within either testis. The left testis is positioned lower than the right. Superior to the left testis, there is a nontender clustered mass. It does not transilluminate and decreases in size when the patient is supine. A semen analysis shows a normal seminal volume but slightly reduced sperm count and decreased motility. Which of the following is the most likely cause of this patient's infertility?
vericocele
