ROSH REVIEW general surgery

Which of the following therapeutic options would be beneficial for a patient attempting to quit cigarette smoking before surgery?

Bupropion

Which of the following describes the most common presentation of an acute bowel obstruction?

Colicky abdominal pain, distention, and emesis

Which of the following recommendations is the most appropriate counseling to provide a patient receiving methadone for a known opioid use disorder during his or her preoperative evaluation for an elective procedure?

Continue the use methadone, including on the day of surgery

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?

Desmopressin

Which of the following is a risk factor for developing small bowel carcinoma?

Diet high in salt-cured foods

Which of the following is an indicator of unresectability of gastric cancer?

Disease encasement of the hepatic artery

A 45-year-old woman presents to clinic with concern about a discoloration of her eyes. On assessment, there is a subtle yellow discoloration to the sclera. What is the most appropriate test to confirm the clinical finding and guide further assessment and treatment?

Fractionated bilirubin

You obtain an arterial blood gas on a patient in the intensive care unit. The results show a pH 7.32, PaCO2 50 mm Hg, and bicarbonate 24 mmol/L. Which of the following is the most likely cause of this acid-base disorder?

Hypoventilation (primary respiratory acidosis)

Which of the following is appropriate initial treatment for uncomplicated symptomatic Crohn's disease?

Immunosuppressant therapy

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?

Intravenous iron

While assessing a patient's functional capacity as part of the preoperative cardiac risk, the patient states that she can walk independently, but slowly, and can complete light chores around her home, but she cannot do her own yard work or go up and down stairs without assistance. Which of the following options is the correct way to document her functional capacity?

Less than 4 METs

Which of the following characterizes acute bowel obstruction in a patient experiencing postoperative complications?

Most postoperative bowel obstructions are partial and resolve spontaneously

A 21-year-old woman presents for evaluation of bloody emesis. She reports drinking several alcoholic beverages to celebrate her birthday. Just prior to vomiting, she noted severe retching. Which of the following is the most likely diagnosis?

Mallory-Weiss syndrome

Which of the following factors indicates a need for esophagogastroduodenoscopy in a patient with dyspepsia?

Melena

A 78-year-old man undergoes laparoscopic surgery for a small bowel obstruction. Which metabolic disturbance is he most at risk for postoperatively?

Metabolic alkalosis

Which of the following descriptions of chest discomfort is more typical of angina than a nonischemic etiology?

Relief with rest

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?

Ringer's lactate solution 4 liter infusion over eight hours

A 14-year-old girl presents for evaluation of suspected appendicitis. She experiences pain in the right lower quadrant with palpation of the left lower quadrant. What is this called?

Rovsing's sign

In which segment of the colon do the majority of diverticula form?

Sigmoid colon

A 35-year-old woman presents to the clinic with palpitations, tremors, and diffuse sweating. Which of the following is used in the diagnosis of hyperthyroidism?

Thyroid-stimulating hormone

A 64-year-old man with hyperlipidemia is sent to the clinic for evaluation of carotid artery disease after he was discovered to have a bruit over his left carotid artery in the emergency room following a recent transient ischemic attack. A Doppler ultrasound and cerebral angiography were performed showing 75% blockage of the left common carotid artery. The carotid plaque is surgically accessible and his perioperative morbidity and mortality risk is less than six percent. He has been started on daily aspirin and atorvastatin. Which of the following is the next best step in this patient's management?

Carotid endarterectomy

Which of the following serum blood analysis abnormalities most specifically indicates acute pancreatitis?

Elevated lipase

Which of the following options is the best therapy for an ascending aortic dissection?

Emergent surgical repair

Which of the following is the first-line therapy for a typical anal fissure?

Fiber

Which of the following is considered the gold standard method for diagnostic evaluation of peptic ulcer disease?

Histologic tissue evaluation

Perforation is a complication that occurs in 10% of patients with acute cholecystitis and is characterized by which of the following?

Hypoactive bowel sounds

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?

Calcium gluconate

A three-week-old, otherwise healthy, boy presents for evaluation of projectile vomiting immediately after breastfeeding. The patient's mother 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?

Abdominal ultrasound (pyloric stenosis)

Which of the following blood analysis tests is indicated to diagnose anemia?

Complete blood count

A 64-year-old woman presents to the emergency department complaining of a yellow tint to her eyes and skin. She states that this began approximately one month prior and has become progressively worse. She also has constant gnawing upper abdominal pain, which is worse at night. Additionally, she reports a 15-pound weight loss over the past few months, generalized weakness, dark urine, and pruritus. Physical exam confirms the presence of diffuse jaundice, scleral icterus, and pain on palpation of the epigastrium and right upper quadrant. Laboratory tests reveal elevated serum bilirubin and alkaline phosphatase levels. Bedside transabdominal ultrasound is performed and reveals a pancreatic mass. Which of the following is the most appropriate next step to assess disease extent and resectability?

Contrast-enhanced abdominal computed tomography (pancreatic cancer)

An obese 55-year-old woman with venous insufficiency presents to the clinic complaining of a painful rash and worsening swelling on her lower left leg. She notes that there was some fluid drainage from an area when she squeezed it. On exam, there is a fluctuant erythematous nodule with spontaneous, purulent drainage on her left lower leg. Which of the following options is the next best step in the evaluation?

Culture and sensitivity of drainage (skin abscess)

A 65-year-old man with obesity presents to the clinic with intermittent, painless hematochezia for the past week. He has no history of inflammatory bowel disease or hemorrhoids. He smokes cigarettes and reports an overall poor diet with frequent consumption of red meat. Blood pressure is 124/80 mm Hg, pulse is 80 beats per minute, and temperature is 98.8°F. No hemorrhoids are noted on exam and there is no evidence of active bleeding. Initial blood analysis reveals a hemoglobin of 13.6 g/dL and a white blood cell count of 9,600/mcL. What is the best next step in management of this patient?

Refer for colonoscopy

A 45-year-old man presents for evaluation of acute-onset severe abdominal pain located in his epigastric region radiating to his back. He also complains of nausea and vomiting. Upon questioning, he states that he drinks a 12-pack of beer daily. Physical exam reveals diffuse abdominal tenderness on palpation as well as ecchymosis around his umbilicus. Laboratory evaluation is notable for a serum lipase of 472 U/L. Which of the following is the most likely diagnosis?

Acute pancreatitis

A 22-year-old woman on her first postoperative night in the hospital complains of constant chest tightness and shortness of breath for the past hour. She has well-controlled asthma and is a lifelong nonsmoker. Vitals include a temperature of 98.8°F, heart rate 64 beats per minute, blood pressure 116/78 mm Hg, and oxygen saturation 99%. Physical exam reveals bilateral expiratory wheezing. Bedside chest radiograph and chest computed tomography are unremarkable. Which of the following is the best therapy for the most likely diagnosis?

Albuterol (bronchospasm)

A 63-year-old right-handed man presents to the emergency department with a sudden onset of numbness on the right side of his face, arm, and leg, as well as right arm and leg weakness. His symptoms started fifteen minutes prior to presentation. On exam, the patient has mild aphasia, mild dysarthria, a pronator drift of his right arm, diminished strength of his right arm and leg, and diminished sensation on the right side. Computed tomography of the brain and computed tomography angiography of his brain and neck were performed and by the time the scans were finished the patient had complete resolution of his symptoms. The computed tomography angiography of the neck revealed a 90% stenotic atherosclerotic lesion of the left internal carotid artery. Carotid endarterectomy was scheduled. The most appropriate next step is administration of which of the following?

Aspirin (transient ischemic attack)

A 65-year-old man with a history of diabetes, atrial fibrillation, peripheral vascular disease, chronic obstructive pulmonary disease, and hyperlipidemia presents to the emergency department for evaluation of gradually worsening left leg pain that began eight hours ago. The pain is constant and exacerbated by minimal walking. Both dorsalis pedis pulses are thready, however, the left femoral pulse is weaker than the right. There is equal movement and intact sensation in both lower extremities. Which of the following is the best test to confirm the diagnosis and facilitate timely treatment?

CTA of the pelvis with runoff (recommended imaging modality in the assessment of acute arterial embolism that is not immediately limb-threatening)

A 6-year-old boy presents to the ED complaining of pain near his belly button that started yesterday and today moved to the right lower quadrant. He mentions that going over bumps in the car on the way to the ED made his stomach hurt even worse. His parents have been giving him acetaminophen for his fever, but it hasn't helped his pain. His appetite has been poor and he vomited once earlier today. Vital signs include a temperature of 100.2°F, blood pressure 108/68 mm Hg, and pulse 96 beats per minute. Exam reveals right lower quadrant tenderness and involuntary guarding. Which of the following is the best next step for this patient?

Call a pediatric surgeon (appendicitis)

A 66-year-old woman with a past medical history of uncontrolled diabetes mellitus, obesity, and rheumatoid arthritis who is on methotrexate presents to the emergency department complaining of redness, drainage, and pain at her incision site. She had an umbilical hernia repair approximately six days prior. On exam, you note the patient has a fever of 100.6°F and the incision site is erythematous and warm with a small amount of purulent drainage noted. There are no signs of wound dehiscence and no areas of fluctuance noted. Which of the following is the most likely diagnosis?

Cellulitis

A 58-year-old man presents to the ED complaining of a moderate amount of hemoptysis that began earlier that day. He has no history of cigarette smoking or chronic lung disease. He has felt ill for the past week and has had an ongoing dry cough. After further clarification, he estimates he has expectorated < 30 mL of blood. Which of the following is the best next step in evaluating this patient?

Chest radiograph

A 32-year-old woman presents to the emergency department reporting nausea, vomiting, and intermittent, cramping abdominal pain. There is abdominal tenderness to palpation of the right upper quadrant and epigastric areas but no other abnormalities on physical exam. A pulse of 112 beats per minute, blood pressure 158/94 mm Hg, and temperature 98.6°F are noted. Mildly elevated serum amylase, lipase, alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, and conjugated bilirubin are noted on lab analysis. Ultrasound reveals a dilated common bile duct of 0.6 cm but normal gallbladder wall thickness and no gallstones in the lumen. What is the most likely diagnosis?

Choledocholithiasis (presence of a gallstone in the common bile duct)

Which of the following is a confirmatory test for cholecystitis?

Cholescintigraphy scan (aka HIDA scan)

A 65-year-old woman presents to the clinic with bilateral lower leg pain which worsens with physical exertion and goes away after about 10 minutes of rest. The pain recurs when she starts walking again. Which of the following terms best characterizes the patient's description of pain?

Claudication

A 60-year-old man presents to his primary care provider with the complaint of feeling lightheaded and dizzy when he stands. The patient is currently prescribed hydrocortisone and fludrocortisone for treatment of adrenal insufficiency, doxazosin for treatment of urinary symptoms from enlarged prostate, and erythropoietin for anemia due to renal failure. What is the most appropriate treatment to decrease his orthostatic hypotension symptoms?

Discontinue doxazosin (alpha-adrenergic antagonist)

A 28-year-old woman is brought into the emergency room by ambulance from home, after sustaining a head injury when riding her bike in traffic without a helmet earlier this morning. The patient's boyfriend reports that she initially had told him that she "came to" on the sidewalk after the accident and that a pedestrian had offered to call for an ambulance, but she declined. The boyfriend reports when at home, she had initially complained of a headache, but was acting normally up until three hours ago when she was difficult to arouse from a nap and became disoriented while slurring her speech. On physical examination, the patient is found to have a GCS of 6, a left dilated pupil, a heart rate of 48 beats per minute, and a blood pressure of 168/92 mm Hg. After intubating the patient, she is brought to CT scan which reveals a lenticular shaped collection. Which of the following is the most likely diagnosis?

Epidural hematoma (does not cross suture lines, biconvex opacity, most common artery ruptured is middle meningeal artery)

A 53-year-old overweight man presents to the outpatient clinic with recurrent burning abdominal pain that occurs two to three hours after a meal. Which of the following would be the most frequent physical examination finding in this patient?

Epigastric tenderness (peptic ulcer disease)

A 31-year-old man presents to the emergency department after an episode of syncope following sexual intercourse. Upon regaining consciousness at home, patient began complaining of a severe headache and started to vomit. Physical examination reveals an uncomfortable man with positive meningeal signs. Blood pressure is 162/94 mm Hg. CT scan of the head without contrast reveals no acute pathology. Based on the most likely diagnosis, what would you expect on the patient's lumbar puncture?

Hemoglobin degradation products (xanthochromia from subarachnoid hemorrhage; tx includes supportive and nimodipine)

A septic patient is noted to have respiratory alkalosis. What electrolyte disturbance is commonly associated with this patient presentation?

Hypokalemia (alkalosis)

A 30-year-old woman presents to the outpatient clinic for follow-up on her total thyroidectomy performed six weeks ago. Her incision is well-healed, and there are no signs of infection. The patient does complain of feeling cold, despite others around her being warm, fatigue, and weight gain. She has remained on levothyroxine 100 mcg by mouth once daily. Serum thyroid-stimulating hormone was performed prior to the appointment and was found to be elevated. Which of the following is the most likely diagnosis?

Hypothyroidism

A 32-year-old woman presents for evaluation of acute-onset left-sided flank pain. She is unable to sit still due to the pain. She also has noted blood in her urine. Physical examination reveals the patient to be restless. She is afebrile and has mild costovertebral angle tenderness. Urinalysis reveals gross hematuria. Which of the following is the most likely diagnosis?

Nephrolithiasis

A 40-year-old woman presents to clinic reporting a nodule in her neck that has been present for one year but is not enlarging. She denies any family history of thyroid problems or exposure to radiation and states she is otherwise healthy with no complaints. On examination, there is a single, non-tender, smooth, non-adherent, five-millimeter thyroid nodule noted. There is no lymphadenopathy. Thyroid sonography confirms the presence and size of the nodule with a benign pattern noted by the radiologist. Thyroid function tests show slightly elevated thyroid-stimulating hormone level. Radionuclide testing shows a hyperfunctioning lesion corresponding to the nodule. Which of the following is the most appropriate treatment?

Observation with routine assessment

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?

Open transabdominal (typically used of any adrenal tumor when malignancy is suspected)

A 70-year-old woman presents to the ED after collapsing at home earlier that day. She stood up out of bed that morning, felt lightheaded, and collapsed onto the floor. Her husband estimates she was unconscious for about 30 seconds. She has hypertension for which she takes metoprolol succinate and she denies ever fainting before. She also denies nausea, diaphoresis, palpitations, chest discomfort, and shortness of breath. Her electrocardiogram is shown above. Which of the following options is the most likely diagnosis?

Orthostatic hypotension

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?

Pancreatic cancer (ductal adenocarcinoma most common)

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?

Papillary thyroid cancer

A 45-year-old man with a past medical history significant for obesity, status post partial gastrectomy, returns to the clinic following a recent barium swallow study for complaints of abdominal pressure and fullness. Results from the study show displacement of the gastroesophageal junction and herniation of a portion of the gastric fundus into the thoracic cavity. Which of the following is the most likely diagnosis?

Paraesophageal hiatus hernia

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?

Plasma fractionated metanephrines

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?

Sacrum (peripheral and periorbital edema are commonly seen in patients with nephrotic syndrome caused by sodium retention and hypoalbuminemia; lab shows proteinuria > 3.5g/day)

A previously healthy 45-year-old man presents to your office with questions about colon cancer screening. He has no family history of colorectal cancer, but a friend of his who is the same age recently had a colonoscopy and he's wondering if he needs one now as well. Which of the following colorectal cancer screening guidelines is most appropriate to share with the patient?

Screening for average-risk individuals begins at age 50 years

A 43-year-old woman presents to the clinic with three days of severe right upper quadrant pain with radiation toward the right inferior scapula that usually occurs for an hour or two after consuming a meal. She has experienced nausea and vomiting with the pain but no fever, diarrhea, or constipation. She is not in pain at the time of visit. On physical examination, the woman has no significant tenderness over the right upper quadrant. Based on the history and physical examination, which of the following is the most likely diagnosis?

Symptomatic cholelithiasis

You are evaluating a 48-year-old woman with right lower extremity swelling, pain, and redness. She is eight days status-post open cholecystectomy. She was on lovenox for two days postoperatively but is not currently taking any medications except oxycodone for pain. What is the test of choice to confirm your suspected diagnosis?

Venous doppler ultrasound

A 30-year-old woman presents to the clinic to obtain preoperative clearance for her elective cholecystectomy. She has a history of a bleeding disorder, diagnosed when she was a teenager. Her symptoms include easy bruising, prolonged bleeding after prior dental extractions, and heavy menstrual bleeding. Other family members have the same bleeding disorder. Laboratory evaluation reveals a normal platelet count, decreased platelet function, normal prothrombin time, a normal activated partial thromboplastin time, and a prolonged bleeding time. Which of the following is the most likely diagnosis?

Von Willebrand disease

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?

Von Willebrand factor antigen (complaints of mucosal hemorrhage or bleeding that is difficult to control, decreased factor VIII, prolonged bleeding time, tx with DDVAP)

In addition to administering broad-spectrum parenteral antibiotics, which of the following interventions is the best choice for a patient with acute cholangitis?

Endoscopic retrograde cholangiopancreatography

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?

Grade III

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?

Surgical repair (strangulated hernia)

An obese 78-year-old woman with a history of venous insufficiency presents to the clinic complaining of a persistent open wound surrounded by a rash on her ankle for the past four months. She denies any trauma. It's only slightly painful. Physical exam reveals a red granulated wound with surrounding hyperpigmentation over the medial malleolus of her left ankle. Both shins have a light brown discoloration. Which of the following diagnoses is correct?

Venous stasis ulcer

A 46-year-old man presents to the emergency department reporting abdominal pain, bloating, nausea, anorexia, and vomiting. His symptoms have been worsening since onset three days ago. His last bowel movement was four days ago, but he continues to pass flatus. Which of the following tests has the highest sensitivity for confirming the most likely diagnosis?

Abdominal CT w/ contrast

A 60-year-old woman presents to the clinic reporting left lower quadrant abdominal pain, constipation, and bloating. She denies nausea, vomiting, fever, or consumption of undercooked foods. On physical exam, there is moderate tenderness to palpation of the left lower quadrant but no rigidity or guarding. Bowel sounds are hypoactive throughout. All vital signs are within normal parameters for age. Which of the following is most likely to confirm the diagnosis?

Abdominal CT w/ contrast (diverticulitis)

A 74-year-old woman presents for evaluation of fever after undergoing a bilateral mastectomy one week ago for a new diagnosis of breast cancer. Her daughter accompanies her and notes that she has not moved from bed much since surgery. Physical examination reveals a warm, edematous left calf. What is the initial diagnostic study of choice for your suspected diagnosis?

Doppler ultrasound of the lower extremity

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?

Ecchymosis of the flanks (Grey Turner sign)

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?

Pancreatic malignancy

An obese 68-year-old woman with hypertension is admitted to the hospital due to acute hypoxia. She is a lifelong nonsmoker with no history of lung disease. A chest radiograph reveals a moderate pleural effusion. Which of the following is the best next step in the management of this patient?

Thoracentesis (pleural effusion, decreased breath sounds, dullness to percussion, decreased tactile fremitus)

Which of the following is the most appropriate next intervention for a patient with varicose veins who has failed to improve with conservative treatment?

Vein ablation

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?

Alpha-1-adrenergic antagonists

A 24-year-old woman presents with intense right lower quadrant abdominal pain. Diagnostic imaging confirms acute appendicitis without evidence of intra-abdominal abscess or perforation. Which of the following pharmacologic treatments would be most appropriate for this patient?

A single dose of intravenous cefotetan 2 grams given preoperatively

Following an appendectomy, a 20-year-old woman develops widespread urticaria and pruritus without any respiratory, gastrointestinal, or cardiovascular symptoms. The lesions are transient and appear to move to different locations on her skin. She denies any known drug allergies. She had received preoperative antibiotic prophylaxis with cefotetan approximately one hour earlier. Which of the following is the most likely explanation for the urticaria and pruritus?

Allergic reaction to cefotetan

A 66-year-old man with hypertension and type II diabetes mellitus presents to the ED complaining of chest tightness, dyspnea, and dizziness while mowing his lawn earlier that day. He had similar symptoms two weeks ago. His symptoms resolved within a couple of minutes of sitting to rest. He is currently pain-free. Vital signs are pulse 88 beats per minute, blood pressure 134/88 mm Hg, temperature 98.8°F, oxygen saturation 97%, and 20 respirations per minute. Exam reveals an obese man in no acute distress and is otherwise unremarkable. Electrocardiogram is obtained and shown above. Which of the following is the most likely diagnosis?

Angina pectoris

A 70-year-old man with hypertension presents to the ED with sudden onset of sharp stabbing pain in the middle of his chest radiating to his back for the past two hours. Vital signs are pulse 100 beats per minute, blood pressure 150/60 mm Hg, oxygen saturation 98%, temperature 98.8°F, and 20 respirations per minute. Exam reveals a decrescendo diastolic murmur at the right sternal border. Electrocardiogram does not show any ischemic changes and chest X-ray reveals a widened mediastinum. Which of the following is the most likely diagnosis?

Aortic dissection

A 65-year-old man with a past medical history of tobacco abuse and hypertension presents to the clinic with leg pain during exercise that is relieved by rest. Physical exam is significant for lower extremity hair loss and weak pulses over the dorsalis pedis and posterior tibial arteries. An ankle-brachial index test is performed and calculated as 0.8. Which of the following is the most appropriate treatment option?

Aspirin (peripheral artery disease)

During a preoperative clearance appointment, a 60-year-old man reports sporadic palpitations that make him lightheaded over the past three weeks. His rhythm strip is shown above. Which of the following is the correct diagnosis?

Atrial fibrillation

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?

Basal cell carcinoma

A 20-year-old man presents to the clinic with a chief complaint of dyspnea and chest pain that began spontaneously six hours ago while playing basketball. He has never smoked, takes no medications, and has no family history of cardiovascular or pulmonary diseases. His vital signs are as follows: heart rate 112 beats per minute, respiratory rate 24 breaths per minute, blood pressure 114/68 mm Hg. He is six feet tall and weighs 165 pounds. On physical exam, the left upper lung field has diminished breath sounds and is hyperresonant to percussion. There are no other abnormalities noted. What is the best initial test to confirm the diagnosis?

Chest XR (pneumothorax, will show absence of lung markings along perophery)

A 52-year-old man with COPD who is a current cigarette smoker presents for preoperative consultation. He reports worsening shortness of breath and productive cough over the past month. He reports no chest pain or dependent edema. Vital signs include a resting room air pulse oximetry of 97%. Physical exam reveals expiratory wheezing bilaterally. Which of the following diagnostic studies is indicated?

Chest radiograph

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?

Diminished temporal vision (bitemporal hemianopsia from pituitary adenoma)

A 65-year-old man with hypertension presents to the clinic complaining of worsening shortness of breath with physical exertion for the past two weeks. He has no history of chronic lung disease. He denies chest discomfort and palpitations. Vital signs include heart rate 78 beats per minute, blood pressure 134/84 mm Hg, temperature 98.8°F, pulse oxygenation 93%, and 20 respirations per minute. Exam reveals an obese man, bibasilar lung crackles, normal heart sounds, and 1+ pitting edema in both ankles. Which of the following interventions is the best next step?

Echocardiogram

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?

Hypovolemic shock

Which of the following physical exam findings is more indicative of skin abscess than cellulitis?

Fluctuance

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?

Gastric cancer

A 64-year-old man presents to the clinic complaining of worsening fatigue over the past six months despite no change in his sleep habits. He has no chronic health conditions and does not take any medications or supplements. He denies hot and cold intolerance, unintentional weight gain or loss, abdominal pain, and rectal bleeding. He denies diet changes and states he has been well-hydrated from all of the ice that he eats. Physical exam reveals skin pallor and koilonychia. Which of the following is the most likely diagnosis?

Iron deficiency anemia

A 56-year-old man arrives in the PACU from an elective laparoscopic cholecystectomy. He smoked cigarettes for the past several decades but has no chronic health conditions. He did not take any prescription medications prior to surgery. He starts complaining of nausea and then vomits about two hours after awakening from surgery. Which of the following factors most likely contributed to his current condition?

General anesthesia (postoperative N/V common complication within first 24hrs after surgery)

A 65-year-old woman presents for her annual physical to her primary care physician. She has a history of recurrent urinary tract infections and has a 30 pack-year smoking history. She has worked in a textile factory for 40 years. With her increased risk, what is the most common symptom of bladder cancer that would necessitate further investigation?

Hematuria

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?

High frequency and low amplitude (hyperthyroidism)

Which of the following is the best initial diagnostic tool to assist in diagnosing the patient presenting with altered bowel habits?

History and physical exam

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?

Hydrocortisone (administered to prevent hypotension secondary to adrenal insufficiency in a patient undergoing unilateral/bilateral adrenalectomy)

A 64-year-old man presents with a five-day history of constant abdominal pain and fever. Laboratory evaluation reveals leukocytosis. You suspect diverticulitis. Where is the pain associated with diverticulitis most commonly located?

Left lower quadrant

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?

Lynch syndrome (autosomal dominant)

Chronically untreated dyspepsia can lead to which of the following pathologic changes in the esophagus?

Metaplastic columnar epithelium

A 55-year-old woman presents to clinic for a routine appointment six months after having a Roux-en-Y gastric bypass as part of management of obesity. What additional long-term treatment is routinely indicated?

Micronutrient supplementation

Which of the following is a physical exam finding characterized by pain and inspiratory arrest during palpation of the right upper quadrant?

Murphy's sign

A 75-year-old man presents to the emergency department with sudden onset of slurred speech. His vital signs are temperature 37°C, heart rate 80 beats per minute, respiratory rate 12 breaths per minute, and blood pressure 170/90. Neurological exam is significant for a right-sided facial droop and slurred speech. Which of the following is the most appropriate initial diagnostic study?

Non-contrast brain CT

A 38-year-old man with a history of alcohol abuse presents with hematemesis. After obtaining a history and performing a physical exam, a Mallory-Weiss tear is suspected. The patient's vital signs are stable with a normal heart rate and blood pressure. Which of the following is the next best step in caring for this patient?

Obtain intravenous access

Parents bring their previously healthy four-week-old boy to the ED due to repeated "projectile vomiting" immediately after he nurses for the past 24 hours. The parents report the emesis looks just like breast milk. He has had a normal pattern of wet diapers. The parents deny any rectal bleeding. He has not had any difficulty nursing before, and attempts at burping him have not brought any relief. Vital signs include a temperature of 98.8°F. Physical exam reveals an alert, crying infant with a small, firm right upper quadrant mass. Blood analysis is within normal limits. Which of the following choices is the best next step for this patient?

Order transabdominal ultrasound

A 57-year-old woman with a history of recurrent nephrolithiasis presents to the clinic for evaluation of ongoing nausea, constipation, loss of appetite, generalized bone pain, and depressed mood. Laboratory results include elevated serum calcium, elevated parathyroid hormone levels, and decreased phosphate levels. A sestamibi scan performed was suspicious for a right inferior parathyroid gland adenoma. During the surgical excision of the parathyroid adenoma, which of the following should be measured intraoperatively to confirm the cause of the primary hyperparathyroidism has been removed?

Parathyroid hormone level

A 55-year-old woman with a history of chronic back pain for which she takes ibuprofen daily presents to the emergency department following two episodes of coffee ground emesis. She reports mild upper abdominal pain and black stools overnight but reports no bright red blood per rectum, a history of gastrointestinal bleed, and liver disease or alcohol use. Physical exam reveals temperature 37°C, heart rate 90 beats per minute, respiratory rate 14 breaths per minute, blood pressure 120/70 mm Hg, and pulse oximetry 97% on room air. Abdomen is tender to palpation in epigastric region with no rebound. Digital rectal exam reveals melanotic stool. Which of the following is the most likely etiology of her bleed?

Peptic ulcer disease

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?

Phenoxybenzamine

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?

Prescribe scopolamine transdermal patch

An 80-year-old man presents to the clinic complaining of a tender area at the base of his lower back that has been progressively worsening over the past few weeks. He denies any injury to the area. He lives alone, uses a wheelchair, and has been unable to examine the area himself. He denies fever or chills. Vital signs include a temperature of 98.4°F, heart rate 80 beats per minute, and blood pressure 130/84 mm Hg. Physical exam reveals tender intact skin with non-blanching erythema overlying his sacrum without underlying fluctuance. Which of the following choices is the most likely diagnosis?

Pressure injury

Which of the following therapies is most important to prevent recurrence of peptic esophageal strictures?

Proton pump inhibitor

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?

Red blood cell transfusion

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?

Sarcoidosis

An 86-year-old man on warfarin presents to the emergency room with his daughter after he fell at the nursing home two nights ago when attempting to use the commode. The daughter reports there was no loss of consciousness and that her father was behaving normally after the fall up until the past day. The patient appears to be disoriented and is found to have anisocoria on physical examination. Based on the above radiograph, which of the following is the most likely diagnosis?

Subdural hematoma

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?

Surgical excision of all sinus tracts (chronic pilonidal disease)

Why must the preoperative preparation for surgical resection of a patient with a diagnosed pheochromocytoma involve propranolol initiation after a 10-14 day course of phenoxybenzamine?

To avoid unopposed alpha-adrenergic receptor stimulation

A 39-year-old man presents for his annual physical. On exam, a painless mass is palpated on his left testicle. Which of the following is the most likely next step in diagnosis?

Trans-scrotal ultrasound

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?

Trimethoprim/sulfamethoxazole (cellulitis)

Obtaining a history for a patient who complains of diarrhea, constipation, or any change in bowel habits must include assessment for alarm symptoms for underlying malignancy. Which of the following is considered an alarm symptom?

Unintentional weight loss

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?

Upper endoscopy (esophageal strictures)

A 50-year-old woman presents to the emergency department with sudden onset of a pruritic rash located on her back and arms. She denies associated symptoms or recent illnesses. Physical exam reveals several dry, raised erythematous lesions with central pallor. Lesions vary in size and shape. Which of the following is the most likely diagnosis?

Urticaria

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?

Weight loss

A 32-year-old woman presents to the office with a concerning skin lesion on her arm. The lesion is biopsied and she is diagnosed with melanoma that is less than 1 mm in thickness. Which of the following is the next best step in caring for this patient?

Wide excision with a 1 cm margin of normal tissue