ROSH/Smarty PANCE Surgery
A 24-year-old woman presents with intense right lower quadrant abdominal pain for several hours. She has no significant medical history and takes no daily medications. Vital signs include a temperature of 100.6°F, blood pressure of 104/58 mm Hg, heart rate of 107 bpm, and respiratory rate of 18/minute. Physical examination reveals diffuse abdominal tenderness to light palpation that is worse in the right lower quadrant, with guarding and rebound tenderness observed. CT of the abdomen reveals enhancement of the appendiceal wall with presence of free intraperitoneal gas. Which of the following clinical interventions would be most appropriate for this patient? A: A single dose of cefotetan 2 g IV and prepare for surgery B: Single dose metronidazole 500 mg IV and prepare for surgery C: Erythromycin 1 g IV daily for 5 days D: Levofloxacin 750 mg daily and metronidazole 500 mg every 8 hours for 7 days
A: A single dose of cefotetan 2 g IV and prepare for surgery f there is evidence of perforation, abscess, appendicolith, diffuse peritonitis, pregnancy or immunocompromised state, or hemodynamic instability, the patient should undergo surgical intervention with an appendectomy with administration of prophylactic antibiotics to prevent intra-abdominal and wound infections. A single dose of cefotetan 2 g, cefoxitin, or cefazolin IV is recommended for preoperative administration. The targeted florae represent those that are found within the colon, including gram-negative aerobes and anaerobes. In patients with a penicillin or cephalosporin allergy, the recommended antibiotic regimen is clindamycin plus ciprofloxacin, levofloxacin, gentamicin, or aztreonam.
A 3-week-old otherwise healthy boy presents for evaluation of projectile vomiting immediately after breastfeeding. The patient's parent notes that he typically wants to be re-fed soon after vomiting. Physical examination reveals a firm olive-shaped mass in the right upper quadrant. What is the diagnostic study of choice for your suspected diagnosis? A: Abdominal US B: Abdominal X-ray C: Barium Swallow D: Upper Endoscopy
A: Abdominal US
A 59 year-old otherwise healthy female develops acute dyspnea and chest pain one week post total abdominal hysterectomy. Echocardiogram demonstrates normal heart size with normal right and left ventricular function. Lung scan demonstrates two segmental perfusion defects. Which of the following is the next step in the management of this patient? A: Anticoagulation B: Embolectomy C: Thrombolysis D: IVC Filter
A: Anticoagulation Anticoagulation is the treatment of choice in patients with pulmonary embolism with normal ventricular function and no absolute contraindications.
A 64-year-old man presents for evaluation of a lesion on the face. It has been present for the past six months. He has tried treating it with various over-the-counter ointments without any success. Physical examination reveals a flesh-colored papule that has a pearly quality. Telangiectatic vessels are noted within the papule. Which of the following is the most likely diagnosis? A: BCC B: Melanoma C: Molluscum Contagiosum D: SCC
A: BCC
52-year-old male with a history of hypertension and hyperlipidemia presents with an acute myocardial infarction. Urgent cardiac catheterization is performed and shows a 90% occlusion of the left anterior descending artery. The other arteries have minimal disease. Ejection fraction is 45%. Which of the following is the treatment of choice in this patient? A: Coronary artery bypass grafting (CABG) B: Streptokinase C: Percutaneous coronary intervention (PCI) D: Warfarin (Coumadin)
A: Coronary artery bypass grafting (CABG) Class I indications for CABG from the American College of Cardiology (ACC) and the American Heart Association (AHA) are as follows: - Over 50% left main coronary artery stenosis - Over 70% stenosis of the proximal left anterior descending (LAD) and proximal circumflex arteries - Three-vessel disease in asymptomatic patients or those with mild or stable angina - Three-vessel disease with proximal LAD stenosis in patients with poor left ventricular (LV) function - One- or two-Vessel disease and a large area of viable myocardium in high-risk area in patients with stable angina - Over 70% proximal LAD stenosis with either an ejection fraction (EF) below 50% or demonstrable ischemia on noninvasive testing
What is the term for blue discoloration about the umbilicus? A: Cullen's Sign B: Murphy's Sign C: Rovsing's Sign D: Turner Sign
A: Cullen's Sign occurs from hemorrhagic pancreatitis (hemoperitoneum)
A 28-year-old man with hemophilia A presents to the clinic for presurgical consultation for an epidermal inclusion cyst removal. His hematology records reveal a mild severity of his hemophilia for which he is not taking any daily prophylactic therapy. Which of the following therapies should be employed prior to his surgery? A: Desmopressin (DDAVP) B: Fresh Frozen Plasma (FFP) C: Protamine Sulfate D: Vitamin K
A: Desmopressin (DDAVP) Hemophilia A is a deficiency of factor VIII, a clotting factor in the intrinsic pathway. An X-linked genetic mutation causes the deficiency, and therefore mainly males are affected. Since von Willebrand factor (VWF) is a carrier protein for factor VIII, a VWF deficiency can lead to low levels of factor VIII as well. Patients with hemophilia A usually have a history of soft tissue, joint, or urinary tract bleeding beginning in childhood. Desmopressin (DDAVP) is an analog of vasopressin (antidiuretic hormone) which promotes factor VIII and VWF release from storage pools. In the setting of mild bleeding or mild hemophilia, a presurgical DDAVP test dose can determine whether DDAVP is effective at raising the factor VIII level in an individual. This should be done at least one week prior to surgery because tachyphylaxis can occur.
Which of the following is a risk factor for developing small bowel carcinoma? A: Diet high in salt-cured foods B: History of IBS C: Obesity D: Tobacco use
A: Diet high in salt-cured foods
A 33-year-old woman who is obese presents with sudden onset of fever and abdominal pain. On physical exam she is found to be jaundiced and her blood pressure is 88/58 mm Hg. She has epigastic pain with palpation. She is found to have elevated liver enzymes and leukocytosis. In addition to administering broad-spectrum parenteral antibiotics, which of the following interventions is the best choice for the suspected diagnosis? A: ERCP B: EGD C: Lap Chole D: Lap Herniorrhaphy
A: ERCP Ascending Cholangitis ERCP followed by a cholecystecomy
A 76-year-old man with a history of diabetes mellitus and hyperlipidemia presents to the emergency room with a sudden onset of epigastric pain 48 hours ago. Now he is experiencing intractable nausea, vomiting, and fever beginning 12 hours prior to arrival. Physical examination reveals marked tenderness and guarding in the epigastrium, poor turgor, hypotension, tachycardia, and a temperature of 101.3°F. Laboratory results show amylase of 301 U/L and lipase of 1186 U/L. CT scan of the abdomen is pending. Based on the patient's expected diagnosis, which of the following findings would be consistent with his most likely diagnosis? A: Ecchymosis of the flanks B: Improvement in pain when lying supine C: Melena D: Pain radiating to the left scapula
A: Ecchymosis of the flanks Ecchymosis of the flanks, also referred to as Grey-Turner sign, is a physical examination finding consistent with retroperitoneal bleeding (a complication of necrotic pancreatitis). Acute pancreatitis is an inflammation of the pancreas most commonly precipitated by gallbladder disease, alcohol use, high triglycerides, infection, smoking, medications, vascular disease, and pregnancy. The inflammation results in elevated pancreatic enzymes. Patients commonly complain of epigastric pain that radiates to the back and worsens when lying supine. Pain is often associated with nausea and vomiting. In severe cases, patients may have fever, hypotension, jaundice, and ecchymosis of the flanks (Grey-Turner sign) or periumbilicus (Cullen's sign), concerning for retroperitoneal bleeding. Pancreatic enzymes (lipase and amylase) are elevated three times or greater than normal in patients with acute pancreatitis. Ultrasound can be used to look for gallstones and CT scan is used to evaluate for pancreatic enlargement, necrosis, and possible mass. Oral intake should be delayed in patients while managing symptoms with intravenous fluids, antiemetics, and analgesics. When infection or sepsis is suspected, antibiotics should be initiated. If an underlying condition, such as gallstones, is identified as the cause, surgical intervention such as laparoscopic cholecystectomy or Endoscopic Retrograde Cholangiopancreatography (ERCP). Complications of acute pancreatitis include pseudocyst, necrosis of the pancreas, sepsis, and death.
A 26 year-old gravida 0 sexually active female presents to the emergency room complaining of colicky pain in her lower abdomen for the past 12 hours. She passed out earlier in the day while trying to have a bowel movement. Her last menstrual period was 6 weeks ago. She has noted vaginal spotting over the last 24 hours. Vital signs show Temp 37 degrees C, BP 96/60mmHg, P 110, R 16, Oxygen Sat. 98%. Abdominal exam is positive for distension and tenderness. Bowel sounds are decreased. Pelvic exam shows cervical motion and adnexal tenderness. Which of the following is the most likely diagnosis? A: Ectopic Pregnancy B: Appendicitis C: Crohn's Disease D: Pelvic Inflammatory Disease
A: Ectopic Pregnancy
An adult presents with a three month history of progressive severe muscle cramps, extremity paresthesias and lethargy which began shortly after a thyroidectomy for a malignant thyroid lesion. Which of the following is the most likely diagnosis? A: Hypoparathyroidism B: Hypothyroidism C: Hyperparathyroidism D: Hyperthyroidism
A: Hypoparathyroidism
25 year-old male presents to the ED with left calf pain and cramping, as well as nausea and vomiting. He admits to "partying with cocaine all night". He describes his urine as a dark brown color. Serum creatinine kinase (CK) is 1325 IU/L (Normal Range 32-267 IU/L). Which of the following is the initial mainstay of therapy for this condition? A: IV rehydration B: Fasciotomy C: Toradol (Ketorolac) D: Hydrotherapy
A: IV rehydration IV rehydration with crystalloids for 24 to 72 hours is the mainstay of therapy for rhabdomyolysis.
Which of the following pathophysiological processes is believed to initiate acute appendicitis? A: Obstruction B: Perforation C: Hemorrhage D: Vascular Compromise
A: Obstruction Obstruction of the appendiceal lumen by lymphoid hyperplasia, a fecalith or foreign body initiates most cases of appendicitis
Lab results for a post-operative oliguric patient reveals an increased BUN to creatinine ratio. The patient has a low fractional excretion of sodium (less than 1%). Which of the following is the most likely diagnosis? A: Prerenal Azotemia B: Acute tubular necrosis C: Acute glomerulonephritis D: Obstructive uropathy
A: Prerenal Azotemia Patients who have prerenal azotemia with otherwise normal kidneys will have severe sodium retention in order to help to save fluid. The amount of sodium in the urine is therefore very low. Lack of blood flow to the kidneys (hypoveolemia, hypotension, etc.)
28 year-old male presents with burns sustained from hot grease splashed on his left hand earlier this afternoon. The burn extends from his palm to the volar aspect of his wrist and has an erythematous base, covered by an intact blister. There are a few small scattered blisters over the dorsum of the left hand. Which of the following is the initial intervention of choice? A: Tetanus prophylaxis B: Admission to a burn unit C: IV fluid administration D: Debridement of blisters
A: Tetanus prophylaxis Tetanus prophylaxis should be initially considered in all burn patients.
Ulcerative colitis usually presents with which of the following? A: bloody diarrhea B: toxic megacolon C: fever and left quadrant pain D: alternating constipation and diarrhea
A: bloody diarrhea Ulcerative colitis typically presents with episodic bloody diarrhea, lower abdominal cramps, and urgency to defecate.
A 65-year-old man with a history of benign prostatic hyperplasia presents to the urologist for removal of a Foley catheter. The catheter was placed to decompress the bladder due to acute urinary retention. What type of medication could be prescribed prior to catheter removal that would relax the smooth muscle of the bladder neck and prostatic capsule and thereby relieve the obstruction and prevent early recurrence of retention? A: 5-alpha-reductase inhibitors B: Alpha-1-adrenergic antagonists C: Phosphodiesterase-5 inhibitors D: Prostaglandin E1
B: Alpha-1-adrenergic antagonists Alpha-1-adrenergic antagonists should be administered immediately at the time of catheterization to prevent the recurrence of early acute urinary retention due to benign prostatic hyperplasia (BPH). These medications, such as alfuzosin and tamsulosin, relieve the obstruction in the case of BPH by relaxing smooth muscle in the bladder neck, prostatic capsule, and prostatic urethra. Following removal of the catheter, voiding trials must be performed, as half of men with BPH will have a recurrence of acute urinary retention within one week. Alpha-1 adrenergic antagonists have been proven to decrease the incidence of early recurrence. They have also been shown to postpone the need for surgery in many patients. Surgery should be considered if a patient with BPH fails two voiding trials.
A 65 year-old patient with adenocarcinoma of the colon in remission presents for follow-up. Which of the following tumor markers should be monitored? A: AFP B: CEA C: CA 19-9 D: CA-125
B: CEA CA 19-9 is used to monitor recurrence of pancreatic carcinoma. CA-125 is used to monitor recurrence of ovarian carcinoma
A 63-year-old man has a routine postoperative basic metabolic panel drawn which demonstrates a potassium level of 6.8 mEq/L. An ECG reveals peaked T waves. Which of the following should be administered first? A: Albuterol B: Calcium gluconate C: Insulin with glucose D: Sodium Polystyrene
B: Calcium gluconate have to stabilize the heart first and then you can try insulin or albuterol to push potassium intracellularly
65 year-old female presents to the office with a six-month history of back pain. The patient states that she is shrinking and thinks she is about an inch shorter than she was a year ago. Serum parathyroid hormone, calcium, phosphorus, and alkaline phosphatase are all normal. Which of the following would you most likely see on the x-ray of her spine? A: Radiolucent lesions B: Demineralization C: Chondrocalcinosis D: Subperiosteal resorption
B: Demineralization Osteoporosis presents with varying degrees of back pain and loss of height is common. The serum calcium, parathyroid hormone, phosphorus, and alkaline phosphatase are normal. Xray findings demonstrate demineralization in the spine and pelvis.
A 34-year-old nulliparous woman presents to the clinic out of concern for possible pregnancy. She reports she is sexually active with her husband and has not had her menstrual period in seven months. The woman states that she has taken multiple home pregnancy tests over the past few months that all indicate that she is not pregnant. The patient states that her breasts have been more sensitive lately and have been secreting a large amount of milky fluid. She has been putting pads in her bra to soak up the discharge. On further questioning, the patient reports frequent headaches and changes to her vision. The patient's thyroid function tests come back within normal range and a prolactin value returns at 163 ng/mL. MRI reveals an eight millimeter sellar mass. What visual finding would you expect on physical examination? A: Aniscoria B: Diminished temporal vision C: Torsional diplopia D: Unilateral spatial neglect
B: Diminished temporal vision Prolactinoma of the pituitary gland
An 18 month-old female presents to the Emergency Department having possibly swallowed a hearing aid battery within the past hour. She is drooling and appears anxious but parents have noticed no stridor or dyspnea. She has no history of previous esophageal injury. Physical examination is unremarkable. Chest radiograph reveals a radiopaque round object at the distal esophagus. Which of the following is the most appropriate treatment option? A: Observation for 24 hours B: Esophagoscopy for removal C: Barium Swallow D: Bronchoscopy
B: Esophagoscopy for removal Esophagoscopy is the procedure of choice for acutely ingested foreign bodies.
A 35-year-old woman presents to the office with multiple complaints that have been worsening over the last several weeks. She is complaining of anxiety, intermittent palpitations, unintentional weight loss, and heat intolerance. Physical exam reveals a tremor. Which of the following best describes the tremor associated with the most likely diagnosis? A: Dampens with activity B: High frequency and low amplitude C: Occurs exclusively with standing position D: Present at rest
B: High frequency and low amplitude This patient's presentation suggests a diagnosis of hyperthyroidism. The tremor that occurs with hyperthyroidism is typically a high frequency, low amplitude tremor that is present with action. Tremor is present in approximately 76 percent of patients with thyrotoxicosis. The cause of the tremor is thought to be a heightened beta-adrenergic state which is why this type of tremor typically responds favorably to propranolol. Other theories suggest an increased metabolism of dopamine as the cause of tremor in thyrotoxicosis. Symptoms of hyperthyroidism include weight loss, diarrhea, sweats, heat intolerance, palpitations, and anxiety. Testing includes thyroid-stimulating hormone, T3 and T4 levels, and antithyroid antibody tests. Treatment for hyperthyroidism includes antithyroid drugs, radioiodine ablation, or surgery.
Perforation is a complication that occurs in 10% of patients with acute cholecystitis and is characterized by which of the following? A: Coarse Cough B: Hypoactive bowel sounds C: Jaundice D: Nausea and vomiting
B: Hypoactive bowel sounds
Which of the following is the most common indication for operative intervention in patients with chronic pancreatitis? A: Weight loss B: Intractable pain C: Exocrine deficiency D: To decrease risk of cancer
B: Intractable pain
A 40-year-old woman who previously underwent a Roux-en-Y gastric bypass presents to the clinic with a chief complaint of increasing fatigue, headaches, irritability, and dry skin. Examination reveals mild pallor, atrophic glossitis, cheilosis, and koilonychia. She is otherwise healthy. Laboratory evaluation reveals a microcytic anemia with a low serum iron level, increased serum transferrin, and a low ferritin level. Which of the following is the most effective management? A: Intramuscular Iron B: Intravenous Iron C: Oral Iron D: RBC transfusion
B: Intravenous Iron Can't be oral iron because the absorption pathway has been disturbed by the bypass.
A 70-year-old man complains of abdominal pain of four hours duration. He states that he has vomited twice since the onset of pain. He also complains of three days of constipation. He is afebrile and the physical examination is noteworthy for a distended, diffusely tender abdomen with normoactive bowel sounds. His rectal exam reveals hemoccult positive brown stool. Medications include omeprazole (Prilosec) for GERD, digoxin and warfarin (Coumadin) for atrial fibrillation, OTC multivitamins and stool softeners. The abdominal and chest x-rays show no abnormalities. Which of the following is the most likely diagnosis? A: Acute cholecystitis B: Mesenteric Infarction C: Perforated duodenal ulcer D: Small bowel obstruction
B: Mesenteric Infarction Acute onset of severe diffuse abdominal pain in a person with atrial fibrillation warrants the suspicion of mesenteric infarction. Vomiting and constipation may be seen, along with occult blood in the stool. Bowel sounds may be normal.
A 76-year-old female presents to the ED with the worst abdominal pain in her life. The pain began following a large meal and is located periumbilically. Although she is writhing in pain, she does not have an exacerbation of the pain on palpation of the abdomen. She has a history of coronary artery disease, asthma, and atrial fibrillation. Which of the following is the most likely diagnosis? A: Toxic megacolon B: Mesenteric Thrombosis C: Fulminant hepatitis D: Acute diverticulitis with perforation
B: Mesenteric Thrombosis This patient is at risk for mesenteric ischemia due to advanced age, atherosclerosis and atrial fibrillation. This is the classic presentation for this condition with pain out of proportion to physical examination findings.
A 78-year-old man undergoes laparoscopic surgery for a small bowel obstruction. Which metabolic disturbance is he most at risk for postoperatively? A: Metabolic acidosis B: Metabolic alkalosis C: Respiratory acidosis D: Respiratory alkalosis
B: Metabolic alkalosis Metabolic alkalosis would be the most likely acid-base disturbance to develop postoperatively in this patient presentation. Volume contraction combined with gastric fluid loss is the most common cause. During this type of surgery, aggressive third-spacing of fluid into the peritoneal cavity, as well as the intestinal lumen, is the cause of volume contraction. Postoperatively, nasogastric decompression of the stomach causes acid loss. As the stomach works to replenish hydrochloric acid, bicarbonate (HCO3-) is released into the serum. The patient also loses potassium from the gastric fluid during nasogastric suctioning. The combination of the volume contraction and the postoperative measures causes a hypochloremic, hypokalemic metabolic alkalosis. Metabolic acidosis (A) postoperatively is most common in situations of large blood loss or resuscitation causing lactic acidosis and reduced end-organ oxygenation. Respiratory acidosis (C) in the postoperative patient is typically secondary to hypoventilation from respiratory depression. This can often be attributed to narcotic medications or excessive sedation. Respiratory alkalosis (D) occurs in patients who have undergone upper abdominal or thoracic surgery and are taking shallow breaths to avoid incisional pain. This causes hypocarbia and hypokalemia.
A 56 year-old female four days post myocardial infarction presents with a new murmur. On examination the murmur is a grade 3/6 pansystolic murmur radiating to the axilla. She is dyspenic at rest and has rales throughout all her lung fields. Blood pressure is 108/68 mmHg, pulse 70 bpm. Which of the following would be the definitive clinical intervention? A: Intra-aortic balloon counterpulsation B: Mitral valve replacement C: Coronary artery bypass surgery D: Immediate fluid bolus
B: Mitral valve replacement MVR is the definitive intervention to correct MR caused by papillary muscle rupture.
A person presenting with bleeding esophageal varicies should be treated with which of the following while awaiting arrival of endoscopy? A: Carafate (Sucralfate) B: Octreotide (Sandostatin) C: Omeprazole (Prilosec) D: Enoxaparin (Lovenox)
B: Octreotide (Sandostatin) Octreotide is a vasoacctive drug used in the treatment of GI bleeding as well as somatostatin, vasopressin, and terlipressin. Somatostatin and octreotide are preferred due to safety and less incidence of serious side effects.
A patient is scheduled for a unilateral adrenal tumor resection for suspected adrenocortical carcinoma. Which of the following surgical approaches would be best for this adrenalectomy? A: Laparoscopic transabdominal B: Open transabdominal C: Posterior retroperitoneoscopic D: Retroperitoneal open
B: Open transabdominal An open transabdominal approach is typically used for resection of any adrenal tumor when malignancy is suspected. The open approach allows for greater visualization of the surrounding structures and resection of the surrounding lymph nodes. The open approach also allows for resection of adjacent structures should this be necessary if abnormalities are discovered during the surgery. Minimally invasive techniques, such as laparoscopic techniques, have been associated with reduced blood loss and length of stay, fewer intraoperative complications, and quicker recovery than open approaches, however, when malignancy is known or suspected, the increased visualization and access to adjacent structures makes the open approach optimal. Minimally invasive techniques are the preferred method for benign adrenal tumors. Laparoscopic transabdominal (A) and posterior retroperitoneoscopic (C) approaches are both minimally invasive techniques and do not allow the visualization of or access to adjacent structures. The retroperitoneal approach (D) is not preferred because of the increased risk of subcostal neuropathy and lumbar hernias, as well as the increased amount of incisional pain from cutting through the latissimus dorsi muscle.
Which of the following is the most appropriate intervention for a stage I testicular seminoma in a patient willing and able to comply with follow-up? A: Chemotherapy initially B: Orchiectomy and active surveillance C: Orchiectomy and radiation D: Orchiectomy and chemotherapy
B: Orchiectomy and active surveillance
A 62 year-old male presents with complaints of vague epigastric abdominal pain associated with jaundice and generalized pruritus. Physical examination reveals jaundice and a palpable non-tender gallbladder, but is otherwise unremarkable. Which of the following is the most likely diagnosis? A: Viral hepatitis B: Pancreatic cancer C: Acute cholecystitis D: Gilbert Syndrome
B: Pancreatic cancer Pancreatic cancer is suggested by the vague epigastric pain with the jaundice resulting from biliary obstruction due to cancer involving the pancreatic head. The presence of a palpable non-tender gallbladder (Courvoisier's sign) also indicates obstruction due to the cancer.
50 year-old male with history of alcohol abuse presents with acute, severe epigastric pain radiating to the back. The patient admits to an episode of coffee ground emesis. On examination he is ill-appearing with a rigid, quiet abdomen and rebound tenderness. Which of the following is the most likely diagnosis? A: Abdominal aortic aneurysm B: Perforated duodenal ulcer C: Acute myocardial infarction D: Cholecystitis
B: Perforated duodenal ulcer Perforation of a duodenal ulcer causes sudden, severe pain, with rebound tenderness and rigid abdomen on physical examination. It is often associated with coffee ground emesis.
Which of the following is the therapy of choice for long-term management of esophageal varices in a patient who cannot tolerate beta blocker therapy? A: Octreotide B: Sclerotherapy C: TIPS procedure D: Sengstaken-Blakemore tube
B: Sclerotherapy
Postmenopausal patient is diagnosed with grade I breast cancer. The tumor is 0.7 cm in size, estrogen-receptor positive, and axillary nodes are negative. After undergoing a lumpectomy, which of the following adjuvant therapy is indicated for this patient? A: Chemotherapy B: Tamoxifen C: Ovarian Ablation D: Bisphosphonate therapy
B: Tamoxifen Tamoxifen is the adjuvant therapy of choice in post-menopausal estrogen receptor positive axillary node negative breast cancer.
A 19 year-old female presents with complaint of palpitations. On examination you note the patient to have particularly long arms and fingers and a pectus excavatum. She has a history of joint dislocation and a recent ophthalmologic examination revealed ectopic lentis. Which of the following echocardiogram findings would be most consistent with this patient's physical features? A: right atrial enlargement B: aortic root dilation C: pulmonic stenosis D: ventricular septal defect
B: aortic root dilation This patient has the signs and symptoms consistent with Marfan's syndrome. Ectopia lentis, aortic root dilation and aortic dissection are major criteria for the diagnosis of the disease.
A 60 year-old patient returned from the recovery room to the floor following a subtotal gastrectomy. At 3 AM the next morning, the patient's temperature is 102° F (39° C) and pulse is 112/min. Which of the following is the most likely cause? A: wound infection B: atelectasis C: phlebitis D: shock
B: atelectasis Atelectasis is the most common pulmonary complication, affecting 25% of patients with abdominal surgery. It is more common in elderly and overweight patients and occurs within the first 12 to 24 hours postoperatively.
A 54 year-old female who has diabetes presents with rubor, absence of hair, and brittle nails of her left foot. She complains of leg pain that awakens her at night. Examination reveals a femoral bruit with diminished popliteal and pedal pulses on the left side. The most appropriate therapy would be: A: vasodilator therapy B: bypass surgery C: exercise program D: embolectomy
B: bypass surgery Bypass surgery is indicated in the presence of rest pain and provides relief of symptoms in 80 to 90% of patients. While an exercise program is appropriate with claudication, rest pain is a surgical indication.
Primary hyperparathyroidism is characterized by which of the following? A: decreased serum magnesium B: decreased serum phosphate C: increased hematocrit D: increased bone density
B: decreased serum phosphate Parathyroid hormone stimulates the osteoclasts to increase bone resorption, leading to elevated calcium levels. It works in the kidney to increase calcium reabsorption and increase renal excretion of phosphorous. Hematocrit is not affected by parathyroid hormone.
A 20-year-old male presents with a mass in the groin. On inspection with the patient standing a symmetric, round swelling is noted at the external ring. When the patient lies down the mass disappears. The patient denies any trauma. The most likely diagnosis is: A: indirect inguinal hernia B: direct inguinal hernia C: obturator hernia D: femoral hernia
B: direct inguinal hernia A direct inguinal hernia is symmetrical, round and disappears easily with the patient lying down. An indirect inguinal hernia is typically elliptic that does not reduce easily. An obturator hernia is more commonly seen in elderly women and are rarely palpable in the groin. Femoral hernias are rare in males and do not typically reduce with lying down.
Post-infarction syndrome (Dressler's syndrome) occurs after acute myocardial infarction presenting as: A: ventricular aneurysm B: pericarditis and pleuritis C: cardiac tamponade D: pleural effusion and rash
B: pericarditis and pleuritis
A 16-year-old male is found on physical examination to have a history of cryptorchidism of the right testes. This was surgically corrected at age 18 months. This patient should be monitored for the development of: A: prostate cancer B: testicular cancer C: bladder cancer D: penile cancer
B: testicular cancer Cryptorchidism increases the risk of testicular cancer. In fact, the major predisposing risk factor is cryptorchidism unrepaired until after age two and Caucasian men at highest risk.
Which of the following hyperthyroid patients would be the best candidate for radioiodine therapy? A: A 30-year old patient with toxic adenoma B: A 50-year old man with subacute thyroiditis C: A patient over 65 with Grave's disease D: A pregnant woman with Hasimoto's thyroiditis
C: A patient over 65 with Grave's disease Radioactive iodine is the recommended treatment for overactive thyroid tissue in patients without risk for subsequent thyroid cancer, leukemia, or other malignancies. Subacute thyroiditis is usually self-limited. Thyroid iodine uptake is low in this condition, thus rendering radioactive iodine ineffective.
A 25 year-old female presents with right lower quadrant pain, right flank pain, nausea, and vomiting. Her temperature is 39.6 degrees C. There is right CVA tenderness and RLQ tenderness. Pelvic exam is unremarkable. Urinalysis reveals pH 7.0, trace protein, negative glucose, negative ketones, positive blood, and positive nitrates. Specific gravity is 1.022. Microscopic shows 102 RBCs/HPF, 50-75 WBCs/HPF, rare epithelial cells, and WBC casts. The most likely diagnosis is: A: Acute Salpingitis B: Nephrolithiasis C: Acute Pyelonephritis D: Appendicitis
C: Acute Pyelonephritis Acute pyelonephritis presents with flank pain, fever, and generalized muscle tenderness. Urinalysis shows pyuria with leukocyte casts.
A patient diagnosed with Barrett's esophagus is at an increased risk for the development of what type of cancer? A: Squamous cell B: Transitional cell C: Adenocarcinoma D: Atypical carcinoid
C: Adenocarcinoma
A 29 year-old female G4P2Ab1 at 20 weeks gestation complains of nausea and vomiting with tenderness in the RUQ. Vital signs reveal the patient to be febrile. On physical examination, the abdominal examination reveals positive bowel sounds in all quadrants with a positive Murphy's sign. Fundus can be palpated at the level of the umbilicus. The skin is warm and dry with slight tenting. Oral mucosa is dry as well. What is the most likely diagnosis? A: Peptic Ulcer Disease B: Hyperemesis gravidarum C: Cholecystitis D: Viral gastroenteritis
C: Cholecystitis Gallbladder disease represents one of the most common medical and surgical conditions seen during pregnancy. This is thought to be due to a decrease in gallbladder contractility and lithogenicity of the bile. There is an increased risk in multiparous women. Pain medications and intravenous fluids may be given in the hospital to help with symptoms. If biliary colic does not resolve with these measures, cholecystectomy should be considered. The minimally invasive surgery typically is done in the second or early third trimester.
A patient with a history of severe peptic ulcer disease is 5 weeks status post Billroth I surgery. One week ago he restarted his normal diet and has had the onset of severe nausea, abdominal cramping, and light-headedness that occur approximately thirty minutes after eating. The abdominal exam reveals a healing surgical scar without areas of unusual tenderness or any palpable masses. Which of the following is the most likely diagnosis? A: Anxiety disorder B: Celiac sprue C: Dumping Syndrome D: Irritable bowel syndrome
C: Dumping Syndrome Dumping syndrome typically occurs after Billroth type I surgeries as well as gastric bypass surgeries when the patient attempts to eat a large amount of simple sugars.
Which of the following is the most consistent physical examination finding in a patient with duodenal ulcer? A: Flank tenderness B: Right Upper Quadrant tenderness C: Epigastric tenderness D: Rebound tenderness
C: Epigastric tenderness
A 63-year-old man with a 40-pack-year smoking history presents for evaluation of a 25-pound weight loss over the past six months. He complains of intermittent epigastric pain as well as progressive difficulty swallowing. Physical exam reveals a nodule around the umbilicus and left supraclavicular lymphadenopathy. Which of the following is the most likely diagnosis? A: Duodenal ulcer B: Esophageal cancer C: Gastric cancer D: Gastric ulcer
C: Gastric cancer Gastric cancer is the third leading cause of global cancer mortality and the leading cause of infection-associated cancer death. Histologically, it is most often adenocarcinoma. Risk factors include smoking, chronic Helicobacter pylori infection, a diet high in salt, and obesity. Most patients with gastric cancer already have advanced incurable disease at the time of presentation. Weight loss and persistent epigastric abdominal pain are the most common symptoms at initial diagnosis. Dysphagia may be present in patients with cancers arising in the proximal stomach. Physical exam may reveal a palpable abdominal mass. Tumor extension or spread may cause left supraclavicular adenopathy, called a Virchow's node, a periumbilical nodule, called Sister Mary Joseph's node, or a left axillary node, called an Irish node. Upper gastrointestinal endoscopy with biopsy is the diagnostic study of choice. Treatment depends on staging.
A 32-year-old man presents with complaints of bleeding with defecation and anal pruritus. Exam reveals a hemorrhoid prolapsed out of the anal canal requiring manual reduction. How would you classify this patient's hemorrhoids? A: Grade I B: Grade II C: Grade III D: Grade IV
C: Grade III
A 62-year-old man is having routine lab work drawn as part of a complete yearly physical. His complete blood count demonstrates a decreased hemoglobin and hematocrit with an elevated mean corpuscular volume. Which of the following in his patient's history could explain these findings? A: Beta-thalassemia trait B: CKD C: Hx of partial gastrectomy D: Ulcerative Colitis
C: Hx of partial gastrectomy
A 55-year-old with an abdominal mass is diagnosed with a cortisol-secreting adrenocortical carcinoma. He is immediately referred for surgical resection. Which of the following medications is the best choice to be administered immediately after surgery to prevent hypotension? A: Dobutamine B: Fludrocortisone C: Hydrocortisone D: Vasopressin
C: Hydrocortisone Intravenous hydrocortisone (50 to 100 mg) is administered to prevent hypotension secondary to adrenal insufficiency in a patient undergoing unilateral or bilateral adrenalectomy. Adrenal glands regulate cortisol and aldosterone which effects sodium and potassium balance and water retention. Adrenal insufficiency manifests as muscle weakness, fatigue, vomiting, abdominal pain, and hypotension. An adrenal crisis typically is caused by a stressor such as an injury, illness, or surgery. Patients in adrenal crisis are at risk of developing shock and, ultimately, at risk for death. If a patient has a cortisol-secreting tumor and then undergoes surgical resection of the tumor and the adrenal gland, the possibility of adrenal crisis is increased from the sudden drop in serum cortisol levels. Fludrocortisone (B) is an oral mineralocorticoid medication. It is typically used in conjunction with a glucocorticoid to treat chronic adrenal insufficiency and helps prevent sodium loss, volume depletion, and hyperkalemia. It is not used in the acute phase of treatment as it takes days to become effective. This is also not the best choice since the patient will be unable to take any oral medications during or immediately after surgery.
Patient with chronic rheumatoid arthritis on maintenance prednisone and methotrexate undergoes surgery. She develops hyponatremia, hypoglycemia, and hypotension. In addition to IV fluid therapy, which of the following is the best initial therapy? A: Epinephrine B: Fludrocortisone (Florinef) C: Hydrocortisone D: Glucagon
C: Hydrocortisone The acute phase of adrenal crisis is treated with IV saline and hydrocortisone.
A 72 year-old female is being evaluated for recurrent kidney stones. PE reveals no abnormal findings. Laboratory findings show elevated calcium and decreased phosphate levels. Which of the following is the most likely diagnosis? A: Pheochromocytoma B: Adrenal Insufficiency C: Hyperparathyroidism D: Breast Cancer
C: Hyperparathyroidism The majority of patients with hyperparathyroidism are asymptomatic. Recurrent nephrolithiasis may be one of the presentations of primary hyperparathyroidism. Measurement of parathyroid levels would be the initial laboratory test for the evaluation of hypercalcemia.
A septic patient is noted to have respiratory alkalosis. What electrolyte disturbance is commonly associated with this patient presentation? A: Hypercalcemia B: Hypermagnesemia C: Hypokalemia D: Hyponatremia
C: Hypokalemia Alkalosis can result in hypokalemia and an intracellular acidosis from the shift of potassium from the serum into the intracellular space. In acidotic states, potassium is exchanged from the intracellular space for hydrogen ions causing an increase in serum potassium. In alkalotic states, the opposite occurs as potassium leaves the extracellular space in exchange for hydrogen ions. The same occurs with ionized calcium, causing decreased levels in the serum in alkalotic states. Hypokalemia and hypocalcemia can cause paresthesias, carpopedal spasm, and tetany.
A 50-year-old man presents to the emergency department with diffuse abdominal pain and obstipation. Imaging reveals high-grade small bowel obstruction. The patient is admitted to the hospital, however, fails to improve with medical management. He is taken to the operating room for exploratory laparotomy with lysis of adhesions with minimal blood loss. Postoperatively, the patient is tachycardic and hypotensive with low urine output. Hemoglobin is 17 g/dL. Lactic acid is 4 mmol/L. Which of the following is the most likely diagnosis? A: Cardiogenic shock B: Distributive shock C: Hypovolemic shock D: Obstructive shock
C: Hypovolemic shock
Which of the following is appropriate initial treatment for uncomplicated symptomatic Crohn's disease? A: Antibiotic therapy B: Chemotherapy C: Immunosuppressant therapy D: Watchful waiting
C: Immunosuppressant therapy steroids for acute flares
Patient with adrenal insufficiency is taking hydrocortisone 25 mg daily. What should the patient do with the hydrocortisone dose when they develop a minor illness such as a cold? A: Stop hydrocortisone until illness resolves B: Continue current dose C: Increase dose to 50 mg daily until illness resolves D: Increase dose to 250 mg daily until illness resolves
C: Increase dose to 50 mg daily until illness resolves To better mimic the normal physiologic response the baseline dose should be doubled for the duration of the illness. Doses should be increased 5-10 fold with major events such as surgery.
Chronically untreated dyspepsia can lead to which of the following pathologic changes in the esophagus? A: Atrophic squamous epithelium B: Increased intraepithelial lymphocytes C: Metaplastic columnar epithelium D: Stratified squamous epithelium
C: Metaplastic columnar epithelium Barrett's esophagus
Which of the following beta-adrenergic blocking agents has cardioselectivity for primarily blocking beta-1 receptors? A: Propranolol (Inderal) B: Timolol (Blocadren) C: Metoprolol (Lopressor) D: Pindolol (Visken)
C: Metoprolol (Lopressor) along with atenolol, bisoprolol, esmolol, and nebivolol
A 42 year-old patient who is being treated for colon cancer with chemotherapy develops nausea and vomiting. Which of the following drugs would be the most effective in controlling the nausea and vomiting? A: Scopolamine B: Meclizine C: Ondansetron (Zofran) D: Loperamide (Imodium)
C: Ondansetron (Zofran) Ondansetron selectively blocks 5-HT3 receptors in the periphery (visceral afferent fibers) and in the brain (chemoreceptor trigger zone). It is indicated for use in chemotherapy induced nausea and vomiting.
A 22 year-old male presents several hours after sustaining a hand injury when he punched a wall. X-rays of the hand demonstrate fracture of the fifth metacarpal neck with 65 degrees dorsal angulation and a claw hand. What is the most appropriate intervention? A: ABX and ulnar gutter splint immobilization B: Closed reduction and ulnar gutter splint immobilization C: Open reduction and ulnar gutter splint immobilization D: ulnar gutter splint immobilization only
C: Open reduction and ulnar gutter splint immobilization Open reduction is indicated with angulation of greater than 40 degrees.
A 32-year-old man presents to the outpatient clinic for follow-up regarding his hypertension. Despite the use of three antihypertensive agents, he remains hypertensive. He also has episodes of nonexertional palpitations, diaphoresis, and headache. He recently completed a 24-hour urinary fractionated metanephrines test, which was positive. A computed tomography of the abdomen and pelvis is done and reveals a 5 cm tumor of the right adrenal gland. Which of the following is the most appropriate next step in management? A: Adrenalectomy B: High Sodium Diet C: Phenoxybenzamine D: Propranolol
C: Phenoxybenzamine Pheochromocytoma followed by propranolol and then the adrenalectomy Pheochromocytomas are catecholamine-secreting tumors that arise from chromaffin cells of the adrenal medulla. Although they can occur at any age, they most commonly present between the ages of 30 to 49 and occur equally between men and women. While the majority of pheochromocytomas are benign, approximately 10% are malignant. The symptoms of pheochromocytomas are caused by tumoral hypersecretion of one or more of the following catecholamines: norepinephrine, epinephrine, and dopamine. The classic triad of symptoms consists of episodic headache, sweating, and tachycardia. Paroxysmal hypertension is found in one-half of patients, with the remaining having primary hypertension. Other symptoms include forceful palpitations, tremor, pallor, dyspnea, generalized weakness, and panic attack-type symptoms. Diagnosis is typically made by measurements of urinary and plasma fractionated metanephrines and catecholamines. A 24-hour urinary fractionated metanephrines and catecholamines test is indicated if there is a low index of suspicion, while a plasma fractionated metanephrines test is the preferred testing if there is a high index of suspicion. In patients with positive biochemical testing, radiological evaluation to locate the tumor is done with either computed tomography or magnetic resonance imaging of the abdomen and pelvis. Treatment with an alpha-adrenergic blocker, such as phenoxybenzamine, is started first to control blood pressure and expand the contracted blood volume. This is continued for 10-14 days preoperatively. Side effects of phenoxybenzamine include orthostasis, nasal stuffiness, marked fatigue, and in men it can cause retrograde ejaculation. After adequate alpha-adrenergic blockade is achieved, beta-adrenergic blockade is initiated, usually with propranolol. Laparoscopic adrenalectomy is the procedure of choice, although surgical removal of even a benign tumor does not always lead to long-term cure of the pheochromocytoma or hypertension. For this reason, long-term monitoring is indicated in all patients, with annual biochemical screening recommended for most patients.
A 39-year-old woman is admitted to the hospital following a scheduled open hysterectomy. Intraoperative blood loss is one liter. Postoperatively, labs return with a hemoglobin of 6.5 g/dL. Which of the following is the most appropriate treatment? A: FFP Transfusion B: Platelet transfusion C: RBC transfusion D: Sodium chloride 0.9% infusion
C: RBC transfusion Fresh frozen plasma (A), known as FFP, is a blood product that is collected by separating the plasma from the blood cells. It contains all soluble plasma proteins and clotting factors. FFP is indicated for the reversal of an elevated international normalized ratio for patients taking a vitamin K antagonist, patients with vitamin K deficiency, for replacement of coagulation factors in patients with deficiencies, and as a part of massive transfusion protocols. Platelet transfusion (B) is indicated in the treatment of active bleeding or prophylaxis for bleeding in patients with low platelet counts, platelet function defects, and in patients who are receiving a large number of red blood cell transfusions. Sodium chloride 0.9% infusion (D) is an isotonic crystalloid solution which may be used for volume resuscitation in hypovolemic patients. The patient above is anemic secondary to intraoperative blood loss and requires transfusion of red blood cells.
A 30-year-old man who weighs 75 kg presents to the emergency department for burns to his left arm and left leg after a large container of boiling water spilled on him just prior to arrival. There is white, peeling skin on the entirety of both his left arm and left leg. He has severe pain along the borders of the burn, but no sensation to the burned areas. Distal pulses are intact. After ensuring there is no airway or breathing compromise and removal of overlying materials and clothes, what is the next step in treatment? A: Escharotomy B: Prophylactic ABX infusion C: Ringer's lactate solution 4 L infusion over 8 hours D: Transfer to a burn center
C: Ringer's lactate solution 4 L infusion over 8 hours Fluid resuscitation with Ringer's lactate solution is the most important initial intervention for severely burned patients after removal of the source of the burn and ensuring adequate airway and breathing. The progression of assessment and treatment follows the ABCDE model (airway, breathing, circulation, disability, environment/exposure). The most widely used fluid resuscitation protocol is the Parkland formula, which recommends 4 mL of Ringer's lactate solution for every percent of body surface burned (second and third-degree burns) multiplied by the patient's weight in kilograms. Half of the result of the formula is to be given in the first eight hours, with the rest being administered over the remaining 16 hours.
A 60-year-old man has been bedridden following a stroke several months ago. Urinalysis shows high levels of protein in the urine and nephrotic syndrome is suspected. On physical exam, where would the provider likely detect edema? A: Hands B: Lower leg C: Sacrum D: Upper leg
C: Sacrum Peripheral and periorbital edema are commonly seen in patients with nephrotic syndrome. Factors causing these symptoms are sodium retention and hypoalbuminemia which leads to fluid retention. Laboratory results show proteinuria > 3.5 g/day. Peripheral edema is generally seen in the lower extremities as those areas are where excess interstitial water will collect in an ambulatory patient. In a non-ambulatory patient, the fluid will collect around the sacrum. Because fluid is influenced by posture, weight loss or weight gain is another way to monitor edema or the efficacy of diuretic therapy in these patients.
A 40 year-old-man presents to the emergency department reporting continuous, severe pain in the left groin for four hours. He has vomited three times since the onset of pain. On exam, he has a tender left inguinal hernia with slight erythema of the overlying skin, as well as abdominal tenderness and guarding. His temperature is 101.1°F. What is the best treatment? A: Analgesia and ABX B: Manual Reduction C: Surgical Repair D: Truss Application
C: Surgical Repair Surgical repair is required to treat a strangulated hernia. Hernias are described by location, etiology (congenital or acquired), and as reducible, incarcerated (unable to be reduced) or strangulated (loss of blood supply). Additionally, groin hernias (the most common type) are also described as femoral, direct (protrudes medial to the epigastric artery), or indirect (protrudes lateral to the epigastric artery through the inguinal canal). An incarcerated hernia greatly increases the risk of strangulation, loss of viable bowel tissue, and potentially perforation with spillage of bowel contents into the peritoneal cavity. Symptoms of strangulation include tenderness, pain, abdominal distension, nausea, vomiting, erythema over the hernia site, fever, and peritonitis. Strangulation is a surgical emergency and there should be no delays to definitive surgical treatment. Uncomplicated hernias may be managed without surgery, however, all femoral hernias should be surgically treated, as they have a high risk of incarceration and strangulation. The most common imaging test for groin hernias is ultrasound, however, computed tomography is sometimes obtained and can evaluate for complications. DO NOT try to reduce a strangulated hernia -- increases chance of perforation
A 22 year-old male received a stab wound in the chest an hour ago. The diagnosis of pericardial tamponade is strongly supported by the presence of: A: pulmonary edema B: wide pulse pressure C: distended neck veins D: early diastolic murmur
C: distended neck veins
A patient presents to the office with worsening fatigue, weight loss, and weakness. She notes that she is having recurrent bouts of abdominal pain and has been losing her pubic hair. Patient is found to have orthostatic hypotension. Which of the following conditions is most likely? A: Cushing's Syndrome B: Pheochromocytoma C: Primary hyperparathyroidism D: Addison's disease
D: Addison's disease Patients with Addison's disease have primary adrenal failure from an autoimmune problem in the adrenal gland or due to hemorrhage into the adrenal gland. These patients are not able to make glucocorticoids, mineralocorticoids, or sex hormones which result in hypotension, hyperpigmentation (from an increase in the ACTH and MSH hormones) and are hyponatremic.
Which of the following is the most common presentation for an elderly female patient with primary hyperparathyroidism? A: Abdominal pain B: Renal lithiasis C: Acute pancreatitis D: Asymptomatic
D: Asymptomatic
A 62 year-old male presents with a right hilar mass. Needle-biopsy of the mass reveals the presence of small-cell carcinoma and a bone scan reveals the presence of scattered hot spots throughout the skeleton. Which of the following is the most appropriate treatment? A: Lobectomy B: Pneumonectomy C: Thoracic Radiation therapy D: Combination chemotherapy
D: Combination chemotherapy Combination chemotherapy is the treatment of choice for a patient with small-cell carcinoma of the lung.
A 38 year-old male sustained a fracture of the left distal tibia following a 25-foot fall and is taken to the operating room for an open reduction internal fixation of the distal tibia. Sixteen hours post-op, the patient develops sustained pain, which is not relieved with narcotics. On passive range of motion of the toes the patient "yells" in agony. The patient also states that the top of his foot has decreased sensation. On physical examination the physician assistant notes that the leg is swollen and the foot is cool to touch. Based upon this information what diagnostic testing should be done? A: X-ray of the lower leg and ankle B: Doppler studies C: Bone scan D: Compartment pressures
D: Compartment pressures
Which of the following treatments will most benefit the diabetic patient with two vessel coronary disease? A: Stent placement B: Percutaneous balloon angioplasty C: Medical management D: Coronary artery bypass graft
D: Coronary artery bypass graft CABG is the treatment of choice in a diabetic with two or three vessel disease.
A 48-year-old man presents with epigastric pain which radiates to his back. He has a history of alcohol misuse disorder. Which of the following serum blood analysis abnormalities most specifically indicates the suspected diagnosis? A: Elevated ALT B: Elevated Amylase C: Elevated AST D: Elevated Lipase
D: Elevated Lipase Acute pancreatitis is most commonly caused by gallstones and by chronic excessive alcohol consumption. Affected patients generally present with severe acute-onset epigastric abdominal pain which often radiates to the back, as well as nausea and vomiting. A typical physical examination finding is epigastric tenderness on palpation. The most specific blood analysis abnormality is serum lipase elevated three times greater than the upper limit of normal. Serum amylase is usually also elevated but is less specific. The diagnosis of acute pancreatitis requires at least two of the following three criteria: (1) acute severe epigastric abdominal pain; (2) a serum lipase or amylase elevated greater than three times the upper limit of normal; (3) characteristic findings of acute pancreatitis on imaging (contrast-enhanced computed tomography, magnetic resonance imaging, or transabdominal ultrasonography). Once the diagnosis is made, the etiology should be identified and treated. The Ranson criteria Elevated ALT (A) and AST (C) are signs of hepatic impairment, which can occur due to conditions such as gallstone obstruction, acetaminophen toxicity, viral hepatitis, and mushroom toxicity. Elevated amylase (B) greater than three times the upper limit of normal is a common finding in acute pancreatitis but is less specific than lipase, and has a shorter half-life than lipase.
A 23-year-old patient presents to the emergency department after a motor vehicle accident. The patient was an unrestrained driver involved in a head-on collision. The patient is heavily intoxicated on what he claims is only alcohol. An initial trauma assessment is performed and is notable for significant bruising of the right forearm. The patient is in the trauma bay and complains of severe pain in his right forearm. A physical exam is performed and is notable for pallor, decreased sensation, and cool temperature of the skin of the right forearm. Pain is elicited upon passive movement of the right forearm and digits. A thready radial pulse is palpable. A FAST exam is performed and is negative for signs of internal bleeding. The patient's temperature is 99.5°F (37.5°C), pulse is 100/min, blood pressure is 110/70 mmHg, respirations are 12/min, and oxygen saturation is 98% on room air. Radiography of the right forearm is ordered. The patient is still heavily intoxicated. Which of the following is the best next step in management? A: Detoxification B: IV Fluids C: Analgesics D: Fasciotomy E: Pressure Measurement
D: Fasciotomy Compartment syndrome presents with the 6 P's: Pain, Paresthesias, Poikilothermia, Pallor, Pulselessness, and increased Pressure, and the best initial step in management is a fasciotomy.
A 20 year-old presents 30 minutes after being struck by a hockey puck in the mouth. On physical examination a central incisor is missing from its socket. The patient has the tooth wrapped in tissue paper and the root appears intact. Which of the following is the most appropriate next step in the treatment of this patient? A: Administration of IM penicillin B: No treatment is warranted C: Place tooth in saline and refer to plastic surgery for reimplantation D: Immediately reimplant tooth and refer to oral surgeon
D: Immediately reimplant tooth and refer to oral surgeon Avulsed permanent teeth should be cleansed, transported in Hanks solution or saline and reimplanted by an oral surgeon within one hour.
A 46-year-old woman presents to the clinic with a two week history of abdominal pain, rectal bleeding, and decreased stool caliber. She reports that her sister had colon cancer and her mother had colon and endometrial cancer. Physical examination reveals abdominal tenderness to palpation in the right lower quadrant without rebound tenderness or peritoneal signs. Colonoscopy and biopsy findings result in a diagnosis of colon cancer. Which of the following genetic syndromes should this patient be evaluated for? A: Birt-Hogg-Dube syndrome B: Ehlers-Danlos syndrome C: Li-Fraumeni syndrome D: Lynch syndrome
D: Lynch syndrome Lynch syndrome is an autosomal dominant disorder and the most common inherited colorectal cancer susceptibility syndrome. Individuals with Lynch syndrome are also at increased risk for endometrial cancer, as well as several other malignancies including cancers of the ovary, renal pelvis, ureter, stomach, small bowel, bile duct, skin (sebaceous neoplasms), and brain (gliomas). Colorectal cancers in Lynch syndrome differ from sporadic colorectal cancers in that they are predominantly right-sided in location. The transition from adenoma to carcinoma progresses much more rapidly in Lynch syndrome as compared with sporadic colorectal cancers. Lynch syndrome should be suspected in patients with synchronous or metachronous colorectal cancer, colorectal cancer prior to the age of 50 years, multiple Lynch syndrome associated cancers, and in cases of familial clustering of Lynch syndrome associated cancers. Surgical management consists of total colectomy with ileorectal anastomosis and annual endoscopic surveillance of the remaining rectum. Women undergoing surgery for colorectal cancer should be offered concurrent prophylactic hysterectomy and bilateral salpingo-oophorectomy. Aspirin significantly reduces the incidence of cancer in Lynch syndrome. However, further studies are needed to identify the optimal dose.
A 40-year-old male is hit in the face with a baseball. There is nasal deformity with bleeding. The most appropriate initial management is to: A: Treat the hematoma with I&D and antibiotics B: Consult with an ENT for immediate reconstructive nasal surgery C: Reduce septal defect using open technique D: Maintain nasal patency and nasal cosmesis
D: Maintain nasal patency and nasal cosmesis A. Septal hematoma is less likely due to the finding of epistaxis, and is not of highest priority. B. Reconstructive nasal surgery is a delayed procedure. C. Open reduction is not indicated for nasal trauma. D. Maintain nasal patency until closed reduction can be attempted in 1 week
A patient with prostate cancer has a nonpalpable, focal lesion, and the patient is reluctant to have surgery at this time. Which of the following would best monitor disease progression? A: Periodic rectal exams B: Transrectal US C: Measurements of serum acid phosphatase D: Measurements of PSA
D: Measurements of PSA PSA measurement correlates well with volume and stage of disease and is the recommended examination formonitoring disease progression. Ultrasonography is used largely for staging disease, not monitoring disease progression.
A 58-year-old man presents to the clinic with vague epigastric pain that developed gradually over the past two months. The pain radiates to his back. He denies acid reflux, nausea, vomiting, and diarrhea. He has smoked cigarettes for decades but has never consumed alcohol. He has no history of chronic hepatic disease. Physical exam reveals a 12 lb weight loss since his last visit three months ago and he denies trying to lose weight. There is also mild scleral icterus. Exam is otherwise unremarkable. Which of the following is the most likely diagnosis? A: Cholelithiasis B: Chronic Pancreatitis C: Cirrhosis D: Pancreatic Cancer
D: Pancreatic Cancer
When evaluating a 65-year-old man with scleral icterus, you note a positive Courvoisier sign on abdominal examination. What is the most likely diagnosis? A: Acute Cholangitis B: Alcoholic hepatitis C: Cholecystitis D: Pancreatic malignancy
D: Pancreatic malignancy A positive Courvoisier sign is the presence of a painless, palpable gallbladder in the right-upper quadrant of the abdomen. Painless distension of the gallbladder is generally secondary to obstruction of the biliary tree. The most common causes of this are gallbladder and pancreatic malignancies causing mechanical obstruction of the distal biliary tree. Infectious or inflammatory gallbladder changes will typically elicit tenderness with palpati
A 37-year-old woman presents to the clinic after being sent by her primary care provider for further evaluation of a thyroid nodule, discovered on her most recent annual physical exam. Thyroid-stimulating hormone was found to be 3.4 mU/L. Ultrasound of the thyroid revealed a solid hypoechoic mass with irregular margins. Fine needle aspiration revealed calcified psammoma bodies. Based on the patient's ultrasound and histology results, which of the following would be the most likely diagnosis? A: Anaplastic thyroid cancer B: Benign thyroid nodule C: Follicular thyroid cancer D: Papillary thyroid cancer
D: Papillary thyroid cancer
A 45-year-old man presents to the office complaining of a "racing heart", palpitations, increased sweating, and headaches for the past three months. He denies any new life stressors and history of anxiety or panic attacks. He is not currently on any medications. The patient reports his father experienced similar symptoms when he was around the same age and was ultimately diagnosed with a tumor on his adrenal gland. Patient's blood pressure in the office is 164/98 mm Hg and his pulse rate is 88 beats per minute with a regular rhythm. Physical examination reveals a diaphoretic, well developed man without focal neurological deficits. TSH and T3/T4 levels were all reported within normal limits. Which of the following diagnostic tests would be the most appropriate next step for this patient? A: 24-hour urine fractionated metanephrines and catecholamines B: CT scan C: Genetic testing D: Plasma fractionated metanephrines
D: Plasma fractionated metanephrines Plasma fractionated metanephrines would be the initial biochemical test performed for a patient who is considered high risk for a pheochromocytoma (family history, familial tumor syndrome, history of previously resected pheochromocytoma, or presence of adrenal mass found incidentally). Pheochromocytoma is a neuroendocrine catecholamine-secreting tumor typically found on the adrenal gland. These types of tumors are often associated with familial tumor disorders, such as multiple endocrine neoplasia type 2 (MEN2) and von Hippel-Lindau (VHL) syndrome. The triad associated with pheochromocytoma include palpitations or tachycardia, episodic headaches, and diaphoresis. Patients have a history of hypertension. The majority of tumors are located on the adrenal gland. Patients in whom a pheochromocytoma is suspected, who have a positive family history, or who have an adrenal mass found incidentally, should be tested for the disease. Prior to diagnostic studies, any possible offending drug should be discontinued. In patients who are low risk for a pheochromocytoma, 24-hour urine fractionated metanephrines and catecholamines should be the first biochemical test. After a positive biochemical test, patients should be evaluated via imaging (either CT scan or MRI) to locate the catecholamine-secreting tumor. Genetic testing may also be indicated if a familial disorder is suspected. Treatment includes surgical resection of the pheochromocytoma preceded by a preoperative α-adrenergic blockade using phenoxybenzamine and β-adrenergic blockade using a β-blocker such as propranolol to maintain cardiovascular and hemodynamic stability during surgery.
A 34-year-old woman presents to the general surgery clinic for preoperative consult for an elective procedure. She is a lifelong nonsmoker and she has no chronic illnesses. Her only prescription medication is a hormonal oral contraceptive she has taken for years. Postoperative pain management will likely include an opioid. She is worried because after previous procedures she developed nausea and vomiting. Which of the following interventions is the best next step to prevent postoperative nausea and vomiting? A: Discontinue her hormonal contraceptive B: Dissuade her from undergoing surgery C: Plan to use oxycodone instead of hydrocodone after surgery D: Prescribe scopolamine transdermal patch
D: Prescribe scopolamine transdermal patch
A 24-year-old woman presents to the clinic for preoperative evaluation for a scheduled right anterior cruciate ligament repair. Preoperative clearance was requested by the surgeon secondary to the patient complaining of chest pain. Review of systems is positive for a chronic nonproductive cough, chest pain, fatigue, and weight loss. She denies any history of tobacco use. A chest radiograph reveals bilateral hilar adenopathy with symmetric enlargement of the hila. Serum angiotensin-converting enzyme levels are ordered and found to be elevated. Which of the following is the most likely diagnosis? A: Asthma B: Lung Cancer C: OSA D: Sarcoidosis
D: Sarcoidosis Sarcoidosis is a granulomatous disorder which affects multiple organ systems. The etiology is unknown and is pathologically characterized by the presence of noncaseating granulomas in the involved organs. It most commonly affects young adults, typically presenting between the ages of 20 and 60 years. Initial presentation is most often one or more of the following: bilateral hilar adenopathy, pulmonary reticular opacities, skin, joint, or eye lesions. Sarcoidosis most commonly involves the lungs, with many patients presenting with cough, dyspnea, and chest pain. Systemic symptoms such as fatigue, malaise, fever, and weight loss are often present. Skin lesions are also common and may be present around tattoos or scars. Approximately one-half of cases will be detected in asymptomatic patients, due to incidental chest radiographic abnormalities. A comprehensive evaluation should be done on patients with suspected sarcoidosis and should include chest radiography, pulmonary function tests, electrocardiogram, ophthalmologic exam, and tuberculin skin test. Serum markers include an elevated angiotensin-converting enzyme level. Pulmonary imaging is important, starting with a chest radiograph and often followed up by high-resolution computed tomography. The classic radiographic finding in a patient with sarcoidosis is bilateral hilar adenopathy, which may occur in combination with parenchymal opacities. Diagnosis requires a combination of clinical and radiographic manifestations, exclusion of other diseases with similar presentations, and histopathologic detection of noncaseating granulomas. Biopsy is indicated in most cases of suspected sarcoidosis, with accessible peripheral lesions being preferred. Treatment is not required for asymptomatic patients. For patients with
Episodes of hemoptysis. Chest x-ray reveals a hilar nodule with hilar adenopathy and mediastinal widening. What is the most likely diagnosis? A: Large cell lung cancer B: Adenocarcinoma C: Bronchiectasis D: Squamous cell lung cancer
D: Squamous cell lung cancer Squamous cell cancer is common in patients with a smoking history and presents with a central mass, hilar adenopathy and mediastinal widening
A 57 year-old male presents with acute bilateral lower extremity weakness and urinary incontinence that began after he fell earlier today. His examination is significant for bilateral lower extremity sensory deficits and weakness along with decreased rectal sphincter tone. Which of the following is the most appropriate intervention? A: Epidural steroids B: Oral NSAIDs C: Physical therapy D: Surgery
D: Surgery Cauda equina syndrome is a rare but serious surgical emergency because the duration of nerve compression is inversely correlated with the likelihood of full neurologic recovery
A 20-year-old office worker presents with nine months of gradually worsening pain and swelling at his intergluteal cleft. Physical exam demonstrates a slightly tender mass near his natal cleft accompanied by purulent drainage with a hair protruding near the sinus opening. He is afebrile and there is no evidence of abscess. Which of the following interventions is likely to have the best long-term outcome for him? A: Daily gentle washing with an antibacterial cleanser B: Incision and drainage C: Initiate broad spectrum ABX D: Surgical excision of all sinus tracts
D: Surgical excision of all sinus tracts This patient is presenting with symptoms of chronic pilonidal disease, for which the definitive treatment requires surgical excision or marsupialization of the sinus tracts. Pilonidal disease occurs when the skin and subcutaneous tissue at or near the upper region of the natal cleft of the buttocks becomes infected, often in the setting of ongoing inflammation and damage of local hair follicles. This problem is most common in young adults and often occurs in patients with sedentary occupations, obesity, or a positive family history. Patient presentations can range from asymptomatic to chronic pain and drainage. Acute abscess formation can also occur. Pilonidal disease is a clinical diagnosis that does not require any imaging or laboratory procedures. The role of antibiotics (A) is typically limited to causes of pilonidal disease that are complicated by superimposed cellulitis, a condition not suggested by this patient's presentation. Daily gentle washing with an antibacterial cleanser (B) is a helpful suggestion for patients with hidradenitis suppurativa, which is sometimes confused with pilonidal disease. However, it would not be helpful in a case of pilonidal disease. Incision and drainage (C) is necessary in the setting of an acute pilonidal abscess, but is not the definitive step in management due to high recurrence rates after incision and drainage treatment alone.
A 28 year-old female with diabetes mellitus type 2 sustains a partial thickness burn to her left upper arm and her chest when hot grease spilled on her at home. The burn to her arm is circumferential and the estimated total body surface burned is 18%. She has no allergies. The most appropriate treatment of this patient would include: A: Outpatient treatment with silver sulfadiazine B: Debridement of all intact blisters C: IV Cefazolin D: Transfer to a burn center
D: Transfer to a burn center Reasons for transfer to a burn center include a partial thickness burn covering greater than 10% of total body surface area. In addition, burns in patients with pre-existing medical conditions, such as diabetes, that could complicate their management, prolong recovery, or affect their outcome, is also a reason for transfer to a burn center.
A 66-year-old man with type II diabetes mellitus presents to the clinic one week after undergoing a lower leg mole biopsy to discuss pathology results. He complains of redness, tenderness, and pus at the biopsy site. Physical exam reveals erythema and edema surrounding the biopsy site and purulent drainage, but no fluctuance is appreciated. Which of the following therapies would be best for the most likely diagnosis? A: Cephalexin B: Ciprofloxacin C: Piperacillin/tazobactam D: Trimethoprim/sulfamethoxazole
D: Trimethoprim/sulfamethoxazole Cephalexin can be used for non-purulent cellulitis
A 54-year-old man presents to the clinic complaining of difficulty swallowing food for the past two years, which has been gradually worsening. He has no problem swallowing liquids. He has had uncontrolled gastroesophageal reflux for several years. He has no history of tobacco use and has not had any head or neck radiation therapy. Which of the following is the best initial test for this patient? A: Barium esophagram B: Esophageal manometry C: Soft tissue neck US D: Upper endoscopy
D: Upper endoscopy
Surgical treatment of peptic ulcer disease is reserved for those patients with complications associated with ulcer lesions, those refractory to medical intervention, or patients with giant (greater than 3 cm) gastric ulcers. Which of the following is considered the most common postsurgical complication experienced by patients undergoing surgical treatment for peptic ulcer disease? A: Blind loop syndrome B: Gastroparesis C: Steatorrhea D: Weight Loss
D: Weight Loss Weight loss is experienced by up to 30% of patients postsurgically. Patients may limit food intake due to early satiety. Distention or discomfort may occur shortly after even a moderate-sized meal as the residual gastric pouch is smaller. Patients should be counseled to eat smaller and more frequent meals. Additionally, weight loss can be a result of other postsurgical complications such as maldigestion or dumping syndrome. partial gastrectomy is the surgery for PUD
Renal cell carcinoma most commonly presents with which of the following symptoms or signs? A: hypocalcemia B: inguinal pain C: anemia D: hematuria
D: hematuria The most common presenting symptom/sign of renal cell carcinoma is hematuria (approximately 60%). Flank pain or abdominal mass is present in about 30% of new cases. Renal cell cancer may present with hypercalcemia.
While examining a patient you notice decreased breath sounds at the right lower lobe with decreased tactile fremitus and dullness to percussion. Which of the following is the most likely cause? A: asthma B: consolidation C: pneumothorax D: pleural effusion
D: pleural effusion A decreased tactile fremitus and dullness to percussion would be found in a pleural effusion. Consolidation from pneumonia is characterized by dullness to percussion, but would have an increased, not decreased, tactile fremitus.
Which of the following forms of lung cancer is associated with the poorest prognosis? A: squamous cell B: adenocarcinoma C: large cell D: small cell
D: small cell Small cell lung cancer is the most common type of lung cancer that is metastatic at the time of discovery, and therefore has the poorest prognosis
A 35-year-old woman is having a preoperative evaluation in clinic. Preoperative blood analysis reveals a hemoglobin 6.2 g/dL, hematocrit 18%, platelets 210 x 109/L. The patient mentions that she has been anemic on and off for several years which was always attributed to her heavy menstrual periods. She has no previous surgical history. She does not take any medications. A few of her male and female family members have required blood transfusions after routine surgery. Which of the following tests is most likely to reveal the correct diagnosis? A: Factor IX level B: Factor III level C: Prothrombin time D: von Willebrand Factor antigen
D: von Willebrand Factor antigen Von Willebrand disease (VWD) is the most common heritable bleeding disorder. An autosomal dominant mutation causes the deficiency in von Willebrand factor (VWF), which assists in hemostasis by bridging platelets with subendothelial factors at sites of injury as well as transporting factor VIII. Patients typically present with easy bruising, skin bleeding, and prolonged bleeding from mucosal surfaces. They may have a history of epistaxis longer than 10 minutes, heavy menstrual bleeding, and prolonged bleeding after dental surgeries or other procedures, including childbirth. Patients with a presentation suggesting VWD should have an initial laboratory analysis that consists of a complete blood count, prothrombin time (PT), activated partial thromboplastin time (aPTT), plasma VWF antigen, plasma VWF activity, and factor VIII activity. Patients with VWD usually have a low VWF antigen, low VWF activity or both and may have low factor VIII due to inability to bind to VWF, but the rest of the analysis is often normal. Patients who are actively bleeding may present with a normocytic anemia. Further testing to determine the specific type of VWD is indicated to direct therapy. Desmopressin (DDAVP) or replacement with VWF concentrate can be effective therapies for the most common types of VWD in the postsurgical setting. A hematologist should be consulted on recommended therapy prior to surgery in patients with known VWD.
What are the five W's of post-op fever?
Wind -- Lungs (atelectasis and pneumonia -- 12-24 hrs post-op) Water -- UTI Wound -- infection (up to a week post-op) Walking -- Thromboembolism Wonder Drugs -- any meds given during hospitalization or blood products