Surgery Quiz 3

54 year old man with a known diagnosis of gallstones presents to the ER with abdominal pain and fever for the past 8 hours. He is oriented to time, place and person. There is no jaundice. There is tenderness with guarding in the RUQ of the abdomen. Ultrasonography shows stones in the gallbladder and normal caliber bile ducts. The most likely diagnosis is:

. Cholecystitis because patients with cholangitis are often jaundiced.

A 50 yo woman comes to the clinic because of severe heartburn and regurgitation after meals and on lying down. She has been on long term PPIs with good relief of symptoms but now wants to have antireflux surgery. Her BMI is 32.4. The preop study most useful in predicting symptomatic relief from antireflux surgery is a(n)

24h ph monitoring study

A 62-year old woman is seen in the office to discuss further management of gatroesophageal reflux that is not well controlled with medications. She wants to undergo surgical relief of her reflux symptoms. Workup conirms reflux disease on pH study with a shortened esophagus on upper GI study. The best surgical approach for treating this patient is:

A Collis gastroplasty with a nissen fundoplication

A 53-year old woman comes to clinic because of dysphagia to liquids and solids for the past three weeks. She has been on proton pump inhibitors for treatment of heartburn. A barium swallow shows prominent proximal esophageal dilatation with a stricture of the distal esophagus (Bird's beak appearance). Endoscopy shows no distal esophageal lesion. Manometry shows elevated lower esophageal sphincter tone with swallowing. What is the most appropriate surgical treatment for her?

A combined Heller myotomy and Nissen fundoplication

An 80 year old man has a recurrent inguinal hernia. He has an incision close to his groin that he states was from a hernia that was fixed as a young adult. He brings you a copy of the operative report and it is unreadable except for the diagnosis of Richter's hernia. What was the most likely finding at the time of the first hernia repair?

A non-circumferential incarceration of bowel wall

A 62 year old man is found to have early stage I esophageal adenocarcinoma. His past medical history is significant for severe bilateral pulmonary emphy sematous disease and is s/p bilateral thoracotomy for lung reduction therapy. He is on chronic home oxygen. The best treatment plan for this patient is:

A transhiatal esophagectomy with gastric pull-up

A 54-year-old man presents to the clinic with abdominal pain over the past 8 hours. The pain is mid-abdominal and getting worse. Your evaluation has found an elevated white blood cell count, an amylase of 792 U/L, and normal liver function tests. An ultrasound reveals gallstones. Which of the following is the most appropriate management at this time?

C. Admit the patient to the hospital, hold any intake by mouth, and schedule the patient for a cholecystectomy before discharge.

A 57-year-old man comes to clinic with complaints of foul- smelling urine and two urinary tract infections treated with antibiotics by his primary care physician over the past 6 weeks. He has no pain at this time. Two months ago, he was seen in the emergency department with 2 days of left lower quadrant pain and constipation and was treated with oral antibiotics for diverticulitis. His past history is otherwise negative. His only medication is ciprofl oxacin. He is afebrile and vital signs are normal. A urine sample is cloudy with sediment. What is the next best step in diagnosis?

CT scan of abdomen and pelvis

58 year old man is seen in the clinic because of frequent UTIs in the last year. He occasionally passes gas from his urethra. He is otherwise well. A barium enema study done 5 years ago showed sigmoid diverticulosis. What is the next best step in diagnosis for this patient?

Computed Tomography

29 year old woman presents to the ER with abdominal pain, N/V. She is known to have gallstones since her last pregnancy 2 years ago. Her laboratory results reveal normal hemoglobin, platelets, and WBC. The amylase, alk phos, and bilirubin are all elevated. She remains afebrile. After administering IV fluids and medication for pain and nausea, what is the most reasonable next step?

ERCP with sphincterotomy and gallstone removal if laboratory values do not improve

A 67-year-old man presents to the emergency department complaining of excruciating right groin pain. On examination he is found to have an incarcerated inguinal hernia. He undergoes an open hernia repair. The incision is taken down through the skin, Camper, and Scarpa's fascia. What is the next layer?

External oblique aponeuroses

A 63-year old woman comes to the clinic with symptoms of nonspecific abdominal pain. HEr past medical history is unremarkable. She takes vitamins and calcium supplements. A recent CT scan shows a small bowel mass lesion. LAboratory evaluations show an elevated serum level of c-kit protein, with normal chromogranin A. Which of the following intestinal tumors is this consistent with?

GIST

A 46 year old man was admitted to the surgical ICU 3 weeks ago with severe pancreatitis. He required intensive IV fluid resuscitation and was intubated upon admission. He remains on parenteral pain meds and insulin. He is afebrile. Vital signs are BP 130/80mmHg, P 100bpm, R 18/min. He is making urine. He was transfused yesterday with 2 units of pRBCs because of a severe anemia. He remains NPO and cannot tolerate anything by mouth. Attempts at passing NGT beyond the pylorus failed and he is receiving TPN. his abdomen is distended and tender in the epigastrum. CT scan yesterday showed a large pancreatic phlegmon with associated narrowing of the duodenum and three small acute fluid collections. Most recent blood work shows: glucose-140mg/dL; amylase-200U; Hct-29. What is the best indication for surgical intervention int his patient?

Gastric outlet obstruction

A 54-year-old man comes to your office because abdominal pain and distension. He has a long history of excessive alcohol consumption. On physical examination he has severe scleral icterus. His abdomen is quite protuberant and mildly tender. He has a large umbilical hernia surrounde by engorged veins how do you best explain these large abdominal veins?

High-pressure portal vein blood is diverted to the lower pressure veins of the abdominal wall via the paraumbilical veins.

A 24 year old man is in the surgical ICU for treatment of injuries sustained in a motor vehicle collission two days ago. At the tim eof admission he was stable with normal vital signs and a GCS of 15. His main complaint was severe RUQ abdominal pain. A CT scan is obtained and reveals a grade 3 liver laceration, rib fractures, and a right lower lung contusion. No free air or fluid is seen in the abdomen. Nonoperative management was elected. Now, the second hospital day, he has three episodes of hematemesis. On exam his abdomen is benign with any evidence of peritonitis. Next step?

IR with selective hepatic artery embolization if a bleeding site is identified

What is the most appropriate immediate therapy?

IV abx

34 year old woman is seen in clinic because of episodic painless rectal bleeding with bowel movements for several years. She has otherwise been healthy. There is no family history of colon cancer. Examination shows one internal hemorrhoid, which prolapses slightly through the anal orifice, but reduces spontaneously. The best management at this time is:

Increase dietary fiber and fluids and reevaluate in 2-3 months

A 37 year old man comes to the office because of palpitations and tremulousness for the past 2 months. His symptoms are relieved by eating. He has a history of peptic ulcer disease and was treated for H pylori 2 years ago. He has had IBS since he was a teenager manifested by alternating constipation and diarrhea. He takes no medications. His physical examination is normal. Fasting blood sugar is 40mg/dL and C peptide level is elevated. A CT scan showed a 1.5-cm mass in the head of the pancreas that enhances brightly on the arteriogram phase. The mass is easily visible on somatostatin scan and there are no other lesions identified. What is the diagnosis?

Insulinoma

A 48-year-old man is seen in clinic because of weight loss and diarrhea. He has had a history of alcoholism and chronic pancreatitis. He has been abstinent from alcohol for the past two years. His only medication is pancreatic enzyme replacement. He has number of questions about his symptoms and the absorptive functions of the small intestine. Which of the following best characterizes small intestine absorptive function?

Is closely linked to Na+ coupled nutrient reabsorption

63 year old woman with repeated episodes of cholecystitis is being considered for cholecystectomy. Past surgical history includes an open appendectomy 40 years ago and a hysterectomy 15 years ago. When counseling a patient about the risks and benefits between an open and laparoscopic cholecystectomy, the patient should know that:

Laparoscopic cholecystectomy can be safely performed in patients who have already had open abdominal surgery.

A 35-year-old woman comes to clinic because of diarrhea after meals and progressive weight loss for the past 6 months. SHe has Crohn's disease and has undergone multiple abdominal operations for Crohn's disease and episodes of adhesive small bowel obstruction. Six months ago she underwent a small bowel resection for recurrent Crohn's disease at a site of a previous small bowel anastomosis. Updated endoscopic and contradt evaluations show no evidence of active recurrent Crohn's disease. Which of the following postsurgical scenarios might be most consistent with short bowel syndrome as an etiology for the patient's symptoms?

Less than 60cm small intestine preserved

A 42-year-old woman is in clinic to discuss medical management for her obesity. Her BMI is 44kg/m2. Sibutramine is one of the FDA approved anti-obesity drugs. Which of the following combination of mechanism of action (MOA) and side effects (SE) is characteristic of this medication?

MOA: Serotonin and Norepinephrine uptake inhibitor; SE: Hypertension

75 year old man presents with jaundice. On imaging, a large stone is identified in the neck of the gallbladder where there is surrounding inflammation that involves the adjacent common hepatic duct. The biliary tree is dilated proximal to this area. The common bile duct distal to this is not dilated. Which of the following is the most likely diagnosis?

Mirizzi's syndrome

A 55 year old woman with no past medical history is brought to the ED by her husband because of a 24 hour history of abdominal pain, N/V. she has a history of hypertension, non-insulin dependent diabetes mellitus and peptic ulcer disease and underwent treatment for H. pylori two years ago. She underwent a cholecystectomy empirically following a bout of pancreatitis 4 years ago. There were no gallstones. Her medications are glyburide and simvastatin. On exam she was tachycardic and has tenderness in the mid abdomen and back. Laboratory values on admission reveal and elevated white cell count and amylase of >250 consistent with acute pancreatitis. A CT scan shows evidence of edematous pancreatitis and pancreas divisum. Which of the following is the most likely cause for her recurrent pancreatitis?

Pancreas divisum

44 year old man is seen in clinic complaining of a tender lump near the anus for one a week. Exam shows a 3-cm fluctuant, erythematous swelling in the right anterior perianal skin, very close to the anal orifice. He cannot tolerate a digital exam. The best choice for management is to:

Proceed to the operating room for exam under anesthesia and abscess drainage.

A 50-year-old man is being evaluated because of chronic gastroesophageal reflux symptoms. On endoscopy he is found to have Barrett's esophagus with low-grade dysplasia on biopsy. Management of this patient should be to:

Repeat endoscopy in 6 months with repeat 4-quadrant biopsy of the Barrett's

83 year old Asian man with a known history of recurrent common bile duct stones presents with fever, jaundice, and RUQ pain. Treatment of the patient includes:

Resuscitation, IV antibiotics, and urgent ERCP to relieve the bile duct obstruction

65 year old woman has had no flatus or stools for three days. She is awake and alert, afebrile, with normal vital signs. Her abdomen is firmly distended and tympanic, but nontender. Plain films for a large air-filled loop of colon interpreted as sigmoid volvulus. Which of the following is the best management at this time?

Sigmoidoscopic attempt at reduction

65 year old man is admitted to the hospital because of hematochezia. He had three bowel movements consisting of dark red blood. On admission to the hospital, hemoglobin is 14.6 g/dL, pulse is 80 bpm, BP 142/76 mmHg, RR 16/min, and he appears comfortable. Over the next 12 hours he has no bloody stools; repeat hemoglobin is 12.2 g/dL. He then passes another bloody stool. Vital signs remain stable. The best choice for identification of the bleeding site at this time is:

Technetium-labeled red bleed cell scan

A 65 year old man is scheduled to undergo an 80% subtotal pancreatectomy because of a cystic tumor involving the body of the pancreas. The surgeon explains to him that the body of the pancreas will be removed with only the head and incinate remaining. The patient is concerned about his risk for developing diabetes after the surgery. Which of the following is the most accurate information to share with the patient?

The islets of Langerhans are more abdundant in the tail of the pancreas than in the head and uncinate

A frail 85yo man underwent upper endoscopy with dilation and biopsy of a distal esophageal stricture. Concerned about a perforation, the endoscopist obtained a water soluble contrast upper GI study that confirmed perforation. Nonsurgical management is acceptable if

The upper GI study shows leak of contrast which drains back into the esophagus

You are evaluating a 75-year-old man in your office with a moderate left-sided inguinal hernia. His past medical history is significant for laparoscopic cholecystectomy, open radical prostatectomy, and thyroidectomy. Which of the following repairs is a relative contraindication?

Total extraperitoneal laparoscopic repair

28 year old man comes to clinic complaining of episodic bloody diarrhea and rectal urgency, which he has had for 3 years. He often has painful cramps just before a bowel movement, and he has lost 25 pounds. He eats a regular diet. There is no history of travel. He takes no medications. He is afebrile. Vital signs are stable. He is thin. His abdomen is soft and mildly tender diffusely. Bowel sounds are hyperactive. Rectal exam shows a normal anus and digital exam shows no masses and a small amount of bloody mucous. Stool for ova and parasites and enteric pathogens are negative. Colonoscopy shows inflamed mucosa with ulcerations and mucous from the dentate line to the transverse colon. The right colon appears grossly normal as does the terminal ileum. What is the most likely diagnosis?

Ulcerative colitis

A 42 year old man comes to the ED with severe abdominal pain. He takes no medications. He drinks a quart of vodka daily and smokes one to two packs of cigarettes daily. Temperature is 38C, BP is 110/90, pulse is 20bpm, and respirations are 24/min. He has severe epigastric tenderness. Which of the following varibles is induced in Ranson's critera on admission to predict the severity of this patients illness?

WBC

A 80 year old man comes to clinic because of difficulty swallowing solids and frequent regurgitation of undigested food for the past 3 months. A barium swallow demonstrated a Zenker's diverticulum. The best treatment for this man is:

a. A diverticulectomy with cricopharyngeal and lower esophageal myotomy

A 30 year old woman comes to clinic because of dysphagia to solids for the past month. A barium swallow shows a mass lesion in the mid-esophagus Upper endoscopy demonstrates a smooth, sub-mucosal lesion. Endoscopic ultrasound confirms a smooth delineated mass in the muscularis layer. A best approach to relieve this patient from her symptoms of dysphagia is:

a. Enucleation of the lesion with reapproximation of the muscle layer

A 50 year-old woman is at a local restaurant for dinner. Her first plate of the evening is brought out to her. As she sees, smells, and thinks about tasting the food in front of her, acid begins to be secreted in her stomach. This initial phase of secretion is mediated by which of teh following compounds?

acetylcholine

A 66 year old man presented to the clinic with painless jaundice. Further evaluation with CT and EUS showed a small resectable tumor in the head of the pancreas and no evidence of metastatic disease. EUS guided biopsy confirmed the diagnosis of pancreatic adenocarcinoma. Pancreaticoduodenectomy is planned. Which of the following statements regarding the role of adjuvant or neoadjuvant therapy is true?

adjuvant and neoadjuvant strategies can include radiation and/or chemotherapy

A 50 year old woman has severe gallstone pancreatitis. She is receiving IV fluid and is receiving nothing by mouth in an effort to slow pancreatic secretion to decrease the amount of active pancreatic enzyme leaking into the disrupted glandular tissue. Which of the following enzymes is produced by the pancreas and secreted in its active form?

amylase

A 60-year-old man comes to clinic with anorexia and weight loss associated with gnawing epigastric pain when eating for the past 2 months. Upper endoscopy reveals the presence of a 2.5cm Type III gastric ulcer. Rapid urease testing of a gastric tissue biopsy is negative. Four quadrant biopsies from the ulcer are negative for malignancy. He undergoes a 6-week course of therapy including cessation of ulcerogenic agents . Repeat endoscopy reveals the persistence of the Type III ulcer with reduction in size to 2.3cm. Repeat four-quadrant biopsies are negative for malignancy. Which of the following therapies is most appropriate for this patient?

antrectomy with truncal vagotomy

21 year old man comes to the ED because of RLQ pain and nausea of 18 hours duration. He has vomited once. he has not eaten in 20 hours and denies being hungry. On physical examination, he is exquisitely tender in the RLQ with rebound tenderness. WBC is 14,200/mm^3; other laboratory tests are normal. Which of the following is the best management for this patient?

appendectomy

78 year old man is seen in the office for loss of appetite and abdominal discomfort for the last 3 days. His temperature is 36.8 C, his heart rate is 95 bpm, and his BNP is 100/60. His epigastrium is mildly tender and he is sent for laboratory testing, after which he goes home. The laboratory tests reveal: WBC - 11,500/mm^3, hemoglobin 16 g/dL, a new increase in creatinine from 0.7 to 1.3 mg/dL, a serum sodium of 132 mEq/L, bicarb of 18 mEq/L and an amylase of 250 U/L. For the patient's follow-up the most appropriate plan is to:

ask the office staff to call the patient to the ER

35 year old woman is referred for consideration of cholecystectomy following abdominal ultrasonography that was done to evaluate recurrent UTIs. A recommendation for observation without surgery would be made for the following condition:

asymptomatic gallstones

A 62yo man is in the operating room undergoing an open left inguinal hernia repair. A large indirect sliding hernia is found, and during the dissection, the sigmoid colon is inadvertently injured. The colostomy is easily repaired with sutures. Which of the following hernia repairs should be used in this situation?

bassini repair

A 43-year-old woman is seen in the office to discuss surgical plans for removing a small intestinal tumor. She has had several bouts of otherwise unexplained abdominal pain and bloating for the past 6 months. There is evidence of a small bowel tumor on capsule endoscopy. You are discussing the embryologic origins of intestinal tumors with her. You strongly suspect that her tumor has arisen from cells that are part of the APUD (amine precursor uptake decarboxylase) system. Which of the following lesions is your most likely diagnosis?

carcinoid tumor

A 51-year-old woman comes to the emergency department because of fever and abdominal pain. Her temperature is 38.4ºC. She is tender with guarding in the right upper quadrant of her abdomen. Her WBC is 17,000/mm3. LFTs and lipase levels are within the normal range. Ultrasound of the right upper quadrant identifi es gallstones, a gallbladder wall of 5 mm, and fl uid surrounding the gallbladder. The most appropriate antibiotic to treat this condition is

cefoxitin

62 year old man comes to your clinic because his wife noticed that his eyes were yellow. Otherwise he is feeling well, able to work, and has a stable weight. His past medical history is notable for hypertension and mild obesity. The laboratory tests reveal an alk phos of 412 U/L, total bili of 7.2 mg/dl, AST of 110 U/L and ALT of 105 U/L. The most likely diagnosis is:

choledocholithiasis

43 year old woman presents to your clinic complaining of RUQ pain following a fatty meal. She is of Native American descent. She is married and has 4 children. there is no history of any hematological disorders. She does not drink alcohol. Ultrasonography demonstrates gallstones. Which of the following molecules is primarily responsible for the formation of her gallstones:

cholesterol

A 68-year-old woman presents to the general surgery clinic with a history of epigastric pain and nausea without vomiting. The pain is burning, constant and sometimes worse after meals . She underwent antrectomy with truncal vagotomy and Billroth I reconstruction for treatment of a nonhealing prepyloric ulcer 6 months ago. She has mild epigastric tenderness otherwise her physical exam is normal. Work-up includes an upper endoscopy, which reveals erythematous, friable stomach mucosa, a small ulcer near the gastroduodenal anastomosis, and a pool of bile in the dependent portion of the stomach. Mucosal biopsies reveal a corkscrew appearance of submucosal vessels. Rapid urease testing is negative. Which of the following drugs would be most helpful for this patient?

cholestyramine

A 28yo man comes to clinic because of an inguinal hernia. He works as a stonemason and first noticed the hernia when he developed a painful bulge while lifting a bag of cement. He has otherwise been healthy and takes no meds. An open inguinal hernia repair w/ mesh has been recommended. During a discussion of the anticipated risks, which of the following represents the most common complication?

chronic pain

A 34-year-old woman is being evaluated for epigastric pain and is found to have an ulcer in the anterior duodenal bulb on upper endoscopy. Rapid urease testing of a mucosal biopsy of the antrum of the stomach is positive. In addition to omeprazole, appropriate therapy at this time would include a 2-week course of omeprazole, metronidazole and

clarithromycin and amoxicillin

A 58 year-old man presents to clinic for evaluation for weight loss surgery. His BMI is 36 kg/m2. On work-up he is found to have poorly controlled diabetes and severe sleep apnea. In addition, he has stable angina, a recently discovered colon cancer, and a past history of alcohol abuse with cirrhosis but no portal hypertension. Which of his comorbidities would be considered a potential contraindication for surgical intervention to assist with weight loss?

colon cancer

78 year old woman is sent to the ED from a local nursing home because of abdominal pain and distension for the past 12 hours. She has dementia and a history of chronic constipation. A barium enema done 2 years ago showed a very redundant colon but no other abnormalities. She is now afebrile and her vital signs are stable. Her abdomen is very distended with tenderness diffusely to deep palpation. Rectal exam shows a trace amount of stool that is heme negative. An acute abdominal series now shows dilated colon loops and no free air. Laboratory studies show a WBC of 13,000/mm^3 and urinalysis is unremarkable. What is the most likely diagnosis?

colonic volvulus

A 41-year-old man is seen in clinic with bright red rectal bleeding, seen on the toilet tissue intermittently over the last several months. He is an insurance agent, exercises regularly, and eats a well-balanced diet. He denies changes in bowel habits. Family history is unremarkable. His vital signs are normal. His abdomen exam is normal. Digital rectal exam is normal, and blood is identifi ed on the examining fi nger. Anoscopy shows no other pathology. What is the next best step in diagnosis?

colonoscopy

A 41 year old woman complains of recurrent nausea and bloating that does not seem to be related to eating. She has not traveled and has no pets. Her vital signs are stable and she is afebrile. There is mild tenderness in the RUQ. the rest of her physical exam is normal. A RUQ US is done and reveals a 12x9x10 cm right liver cystic lesion. The cystic lesion is found to have a thick wall with multiple septations within it. Select the correct combination of the most likely diagnosis and the most appropriate next step in management?

cystadenoma, resection

A 40-year-old man is undergoing an open inguinal hernia repair. After incising the skin and the external laeyer of subcutaneous fat, you see Scarpa's fascia. If you were to follow Scarpa's fascia medally to the scrotum, it would turn into which structure?

dartos fascia

A 43 yo woman is being considered for antireflux surgery. She has a long hx of reflux symptoms that are now only partially controlled with lifestyle changes and a PPI. Upper endoscopy showed a small hiatal hernia and a short segment of intestinal metaplasia, but no evidence of dysplasia. She wants to know the possible advantage of Toupet (partial) fundoplication as compared to the Nissen (full) fundoplication. The theoretical advantage for the Toupet fundoplication procedure is

decreased postop symptoms of dysphagia and gas bloat

A 45 year old woman is undergoing an upper endoscopy because of severe abdominal pain that is not relieved by an OTC PPI and antacids. She recently has been having frequent diarrhea. She has otherwise been healthy and there is no family history of chronic or inherited diseases. Endoscopy shows hypertrophic gastric rugal folds and a large antral ulcer and multiple duodenal ulcers. Serum gastrin level is 1200pg/mL. Where is the most likely place to find her gastrinoma?

descending duodenum

A 65 year old man is admitted to the hospital because of severe abdominal pain. He has a history of recurrent bouts of pancreatitis related to alcohol abuse and has been admitted to the hospital multiple times for pain control. A CT scan of the abdomen reveals an atrophic pancreas with some calcifications consistent with chronic pancreatitis. In addition to chronic pain, he is at risk for developing which of the following?

diabetes

A 68-year-old man is being seen in clinic in follow-up of a nonhealing prepyloric gastric ulcer that on four-quadrant biopsy has histological evidence of signet ring cells. Work-up for this patient's condition should include which of the following:

diagnostic laparoscopy

A 52-year old man is referred to you by his primary care physician for a possible hernia. The patient states that when he strains while doing sit-ups on the floor he notices a bulge in the epigastric area. A CT scan ordered by his family physician shows the entire transversalis fascia has thinned out but is intact. Pn examination he does a sit-up and indeed has a bulge in the epigastrium from the xiphoid to just below the umbilicus between the rectus muscles. Based on your exam and CT scan findings what is the most likely diagnosis?

diastasis recti

A 46 year old man presents to the ED with hematemesis. There have been no prior episodes. He admits to drinking a pint of hard liquor daily for more than 10 years. Upper GI endoscopy is performed and shows bleeding esophageal varices. Which of the following is the best management?

endoscopic rubber band ligation

A 58-year-old man was seen in clinic because of dysphagia for 3 weeks. Barium swallow shows a distal esophageal stricture. He undergoes upper endoscopy, with biopsy showing adenocarcinoma. The most useful diagnostic procedure to T stage this patient's tumor is:

endoscopic ultrasound

A 74 yo man has a recent diagnosis of adenocarcinoma of the distal esophagus. He has a long hx of reflux and barrett's esophagus, and a recent upper endoscopy and biopsies confirmed the diagnosis. A staging workup is planned. What is the best study for assessing T (tumor invasion depth)?

endoscopic us

A 20-year-old man is brought to the emergency room after attempting suicide by ingesting a bottle of drain cleaner. The patient is delirious and tachypneic and tachycardic, with hypoxia and fever. The initial priority for this patient is:

endotracheal intubation

A 19 year-old woman is seen in clinic for counseling after being diagnosed with ileocolic Crohn's disease. She asks about the possibility of developing fistulous disease in the future, and whether this would require surgical intervention if it occurred. Which of the following fistulous complications of Crohn's disease most commonly requires surgical therapy?

enterovesical

An 83 year old man is seen in clinic to discuss further cancer management. He has a history of rectal carcinoma, treated with neoadjuvant chemo/XRT and surgery 3 years ago. He has been feeling well and is very active, but there has been a recent increase in his CEA to 21. This initiated a workup for recurrent/metastatic carcinoma and 4 hepatic lesions were found. On imaging, MRI, and PET scan, these lesions are consistent with hepatic colorectal metastasis and no other lesions are found. What is the next step?

evaluation for surgical resection

38 year old woman is concerned about her risk needing cholecystectomy after her 72 year old mother underwent cholecystectomy for cholecystitis. She takes medications for diabetes and hypertension. She recently was treated for an E. coli UTI. She has never been preggerz. Her biggest risk factor for the development of gallstones is:

female gender

A 25-year-old man comes to the office because of a bulge in the groin. He is otherwise healthy. On physical examination there is a reducible bulge inferior to the inguinal ligament medially at the top of the thigh. No bulge can be palpated at the external ring. Which of the following is the most likely diagnosis?

femoral hernia

An 83-year-old woman presents to the emergency department with a 2-day history of nausea and vomiting. She has a prior history of a hysterectomy, and on exam, her abdomen is slightly distended and nontender on palpation. Her laboratory evaluation reveals a normal white blood cell count and a metabolic alkalosis. Abdominal x-rays show a small bowel obstruction and air in the biliary tree. Which of the following is the most likely diagnosis?

gallstone ileus

A 53-year-old woman comes to the clinic for evaluation for weight loss. She has recently diagnosed diabetes, asthma, sleep apnea and hypertension. Her BMI is 38 kg/m2. Which of the following weight loss options is most appropriate for this patient?

gastric bypass

A 60-year old man comes to the emergency room because of hematemesis and bright red blood per rectum. He reports a history of gnawing epigastric pain radiating to the back and improved with eating. His past medical history is significant only for frequent headaches and back pain, for which he takes nonsteroidal anti-inflammatory drugs (NSAIDs) and over-the-counter medications. On physical exam, he is pale, hypotensive and tachycardic. After resuscitation, initial upper endoscopy reveals evidence of an upper GI hemorrhage and an ulcer in the posterior duodenal bulb. Which blood vessel is the most likely source of bleeding?

gastroduodenal artery

A 24-year old woman is in clinic in follow-up because of small bowel motility dysfunction. She has reda a lot of information on the Internet and has a number of questions regarding the normal physiology of the small intestine. As part of this discussion, you explain the migrating motor complex (MMC). Which of the following best chracterizes the MMC?

helps to prevent stasis and bacterial growth

A 33 year old woman is brought to the ED by her husband because of severe diffuse abdominal pain that began suddenly two hours ago. She has otherwise been healthy. Her only medication is OCP. her initial vital signs were BP 90/60mmHg, pulse 110bpm, R 20/min and her abdomen was diffusely tender with rebound. Her vital signs improved to 110/70mmHg and pulse 90bpm after receiving a rapid infusion of normal saline. A CT scan shows a 2cm solid hypodense lesion ont he surface of the left liver with evidence of hemorrhage into the abdomen. Contrast extravastion is thought to be seen. Select the correct combination of the most likely diagnosis and the most appropriate next step?

hepatic adenoma

A 40yo man comes to clinic because of a large incisional hernia. One year ago, he underwent splenectomy for a ruptured spleen following a motor vehicle crash. There is a large hernia in the epigastrium in the central portion of a long midline incision. A laparoscopic incisional hernia repair is recommended to the pt. Which of the following should be included in the discussion with the patient while obtaining informed consent?

hernia recurrence rate

1. A 46 yo man comes to your office 6mo after an open inguinal hernia repair complaining of pain, which has never resolved after his surgery. On further questioning, he complains of radicular pain into the testicle, which worsens when sitting for longer than 10 mins. On exam, he is hyperesthetic overlying his scar and has numbness over the ipsilateral scrotum and medial thigh. All else is normal. Injury to which nerve is most likely the cause for his pain?

ilioinguinal nerve

A 38 year-old woman is undergoing pre-operative counseling prior to undergoing Roux-en-Y gastric bypass surgery for morbid obesity. She has a history of type 2 DM and sleep apnea. Her BMI is 46 kg/m2. Without proper supplementation, what is the most likely nutritional deficiency to occur following her Roux-en Y gastric bypass surgery?

iron

A 70 year old woman is brought to the clinic by her family because of jaundice. She has also had a 20 pound weight loss over the past few months and has recently noticed very dark urine and light-colored stools. She does not have any pain. She is thin. There is a non-tender globular mass in the RUQ. An ultrasound shows dilated intrahepatic and extrahepatic bile ducts with a dilated pancreatic duct and a mass in the head of the pancreas. Mutations in which of the following is most likely associated with this patients diagnosis.

k-ras

A 60 year old woman with chronic Hep C is brought to an acute care clinic by her family because of increasing confusion. Physical examination identifies jaundice, spider angiomata, and splenomegaly. Neurologic examination shows the patient to be lethargic; asterixis is present. Which of the following pharmacologic agents is most appropriate for treatment of this condition?

lactulose

A 60 year old woman with chronic Hep C is brought to an acute care clinic by her family because of increasing confusion. Physical examination identifies jaundice, spider angiomata, and splenomegaly. Neurological examination shows the patient to be lethargic; asterixis is present. Which of the following pharmacological agents is most appropriate for treatment?

lactulose

A 50yo man has the onset of chest pain shortly after he undergoes pneumatic dilatation of the lower esophageal sphincter to treat achalasia. An upper GI water soluble contrast study shows free extravasation of the contrast material at the level of the distal esophagus. The decision is made to take the pt to the OR for immediate repair. The best surgical incision to use is a(n)

left thoracotomy

A 56 year old man with a history of Hep C infection is seen in the clinic to discuss treatment for a 7cm mass seen on UF of the liver. An MRI of the liver, performed with gadolinium, shows a mass in segent 3 with arterial enhancement and ring-type enhancement on delayed images. The liver is not cirrhotic in appearance and a recent biopsy of the nontumor portion of the liver showed only mild fibrosis. The best treatment for this patient is:

liver resection

A thin 18-year old man is undergoing an appendectomy. An incision is made 2 to 4 cm above the anterior superior iliac spine and runs parallel to the external oblique muscle of the abdomen. The senior resident asks you to name the incision.

mcburney incision

A 62-year-old woman is seen in the emergency department with dark red rectal bleeding and hypotension. Initial hemoglobin is 7.2. She is given intravenous fl uids and two units of packed red blood cells but continues to have large amounts of bloody stools. Nasogastric tube effl uent is clear bilious fl uid. The best choice for identifi cation of the bleeding site at this time is

mesenteric angiography

A 65-year-old woman comes to clinic with a vague history of diffuse abdominal discomfort over the past 3 weeks. She denies any history of trauma or prior abdominal surgery and has no known stigmata of peripheral vascular disease. She takes Vitamin D and calcium supplements. On exam, she has diffuse mild to moderate subjective tenderness without guarding or peritoneal signs. She is in sinus rhythm EKG. Which of the following is the most likely diagnosis?

mesenteric venous thrombosis

An 8-year-old boy is brought to the Emergency Department by his parents because of acute abdominal pain and vomiting. He had been feeling well until the pain developed suddenly several hours before presentation. The parents mention that a CT scan done a yera ago following a fall off a bicycle showed malrotation of the intestine. What is the most likely cause of the patient's symptoms?

midgut volvulus

A 43 year-old woman comes to the emergency department with a 3-day history of abdominal distention, nausea and vomiting. She also reports decreased urine output over the last 24 hours. She has a history of total abdominal hysterectomy 5 years ago for benign disease. She does not take any medications. Her pulse is 110 beats/minute. Her abdomen is distended and there is mild diffuse tenderness. Bowel sounds are hyperactive. The rest of her exam is normal. Serum electrolytes are sodium-140, chloride-90, bicarbonate-32, and potassium-4.0. Which of the following is the most appropriate initial intravenous fluid to administer to this patient?

normal saline

A 45-year-old smoker presents to the emergency room with a 4-day history of projectile vomiting. On physical exam he is hypotensive and tachycardic. He has abdominal fullness, decreased skin turgor and dry mucus membranes. Peristaltic waves are visible in his epigastrium. Treatment for this disorder includes placement of a nasogastric tube and fluid resuscitation using

normal saline

A 40-year-old man is referred to the office because of a large type II paraesophageal hernia that was found on a routine screening chest radiogrpah. He denies any symptoms of chest pain, dyspnea, abdominal pain, or other GI symptoms. He is otherwise healthy and very active. The most appropriate approach at this time is:

observant management

A 32 year old woman is being evaluated in the ED following a motor vehicle accident. She was the driver and was wearing a seatbelt. She skidded off the road and hit a tree. She did not lose consciousness. She has mild abdominal pain but is hemodynamically stable. A contrast enhanced CT scan of the abdomen shows a 12cm mass in the right lobe of the liver with progressive peripheral to central prominent enhancement and a central hypodense region. There is no extravasation of contrast. The most appropriate recommendation for her would be

observation only

A 21 year old man is being evaluated in your trauma bay following a motor vehicle collission 60 minutes ago. He is stable with normal vital signs and a GCS of 15. His main complaint is of severe RUQ abdominal pain. A CT scan is ordered and reveals a grade 3 liver laceration, rib fractures, and a right lower lung contusion. No free air or fluid is noted in the abdomen. With respect to his liver injury, what is the most appropriate next step in management

observation with close monitoring

A 72-year-old woman comes to the ED with 3 days of abdominal pain and constipation. Temp is 38.2 C, BP 130/80 mmHg, P 90 bpm, RR 18/min. ON examination she is moderately tender to palpation in the LLQ without rebound tenderness. No mass is appreciated. WBC is 14,000/mm^3. Which of the following is the best choice for managing this patient at this time?

order CT scan of the abdomen and pelvis

A 72-year-old man comes to clinic because his wife noticed that his eyes are yellow. Recently he has found that his urine is dark and the stool light in color. He has recently had a diminished appetite, but otherwise feeling well without other complaints. His past medical history is unremarkable. He smoked cigarettes for 30 years but quit 15 years ago. He is afebrile. Vital signs are normal. He is deeply jaundiced. There is a nontender smooth globular mass consistent with an enlarged gallbladder in the right upper quadrant of his abdomen. The rest of his examination is normal. Which of the following is the most likely diagnosis in this patient?

pancreatic cancer

A 62 year old woman comes to the office with abdominal pain and fullness for the past 6 weeks. She is discharged from the hospital 10 weeks ago when she was treated for a severe bout of pancreatitis. A CT scan now shows a 12 cm cystic structure of the central pancreas, which was not present on prior scans. ERCP shows that the cyst communicates with the main pancreatic duct. What is the next step in management?

pancreatic cyst gastrostomy

67 year old man who has been otherwise healthy is undergoing an operation for biopsy-proven adenocarcinoma of the pancreas involving the head and uncinate process. A bile duct stent was placed preoperatively because of severe jaundice and pruritus. Pre-operative CT imaing and endoscopic US showed a 2.6cm mass in the head and uncinate process and vascular involvement. During exploration the pancreatic mass is easily palpable and the pancreas is not fixed to the surrounding tissues. A 5mm lesion on the surface of the right lobe of the liver was excised and frozen section confirmed a bile duct hamartoma. There are no other findings. What is the best procedure to do at this time?

pancreaticoduodenectomy (whipple)

A 28 year-old man presents to the emergency department with hematemesis. He reports a history of chronic diarrhea and upper abdominal pain. He is not taking any medications. Endoscopy reveals the presence of both an anterior and posterior duodenal bulb ulcer. A gastrin level is elevated at 1200pg/mL. Electrolytes are within normal limits except for an elevated calcium level of 11.3mg/dL. Diagnostic imaging modalities are all negative for disease. After confirmatory testing, appropriate management for this patient would include

parathyroidectomy

A 24-year-old man is seen in clinic following total proctocolectomy and ileoanal pouch anastomosis for familial polyposis. Several of his family members are with him and ask if other sites are prone to malignancy besides the colon in family members affected with the disease. The most common site for an affected relative to develop an extracolonic malignancy is which of the following?

periampullary duodenum

A 75 year old man comes to the Emergency Room complaining of a fish bone stuck in his throat. With difficulty the bone is removed endoscopically, and the patient is sent home. He returns 2 days later with fever, chills, and chest pain.The most likely cause of his symptoms is an infection involving the:

posterior mediastinum

A 38-year-old man has undergone for operations for Crohn's disease in the last 10 years and recently underwent the last of these for treatment of recurrent disease proximal to a prior ileocolic anastomosis.Which of the following agents is most useful for managing acute exacerbations rather than helping to maintain him in remission from active disease?

prednisone

A 32yo man comes to the emergency department with an acutely incarcerated inguinal hernia. With sedation, the hernia is reduced and he feels better. Eighteen hours later, he complains of increasing abdominal pain and diffuse tenderness on examination. He most likely had which of the following?

richter's hernia

An 85-year-old male nursing home resident is brought to the emergency department with 3 days of painless abdominal distention and obstipation. He appears to be in no pain, but his abdomen is massively distended and tympanitic. Plain abdominal films show a kidney-bean-shaped air-filled structure suspicious for cecal volvulus. The best management at this point is

right colon resection

A 24-year-old female graduate student comes to the emergency department because of abdominal pain for the past 12 hours. Initially she had vague mid-abdominal pain that has localized to the RLQ about 3 hours ago. She is otherwise healthy and takes no medications. Her temperature is 37 ℃. There is guarding and rebound tenderness in the right lower quadrant and a positive Rosving's sign. A CT scan shows fat stranding around a dilated appendix. At surgery, there is a 2.5cm firm, smooth yellowish mass at the base of an inflamed appendix. There is no evidence of perforation and no other abnormalities are found. Frozen section biopsy is consistent with a neuroendocrine tumor. Which of the following is the most appropriate management at this time?

right hemicolectomy

A 52 year old man with sigmoid colon adenocarcinoma is being evaluated for surgery. Preoperative workup reveals two liver mets. One met encases the right hepatic vein, and the other is in segment 4. There is no evidence of intrinsic liver disease and he is fit for surgery. From an anatomical prospective, which of the following surgical recommendations is most appropriate regarding his liver findings?

right trisectionectomy

A 48-year-old man is brought to the Emergency Department by his wife with a 48-hour history of abdominal, pain, obstipation, nausea, and vomiting. Initially he had crampy pain, but for the past 4 hours it has been steady. He was previously healthy and there is no history of previous surgery. He does not smoke or drink alcohol. His BMI is 24. Vital signs are: pulse, 120 beats/min; BP 100/70 mmHg; respirations 26/min. His temperature is 37℃. His heart is regular with no murmurs and his lungs are clear. His abdomen is distended and diffusely tender to light palpation. Bowel sounds are absent. Abdominal films show dilated air-filled loops of small intestine and minimal colonic gas. Intravenous fluids are started and a nasogastric tube is inserted with immediate removal of 1200 mL of thick greenish-brown fluid. What is the next best step in management?

schedule an emergency laporotomy

A 20 year man comes to the ED with severe epigastric pain. He has a history of pancreatitis 8 months ago, but no cause identified. He has otherwise been healthy. He does not smoke or drink alcohol. He takes no medications. His vital signs are temperature-- 38C, BP 130/80mmHg, P 110bpm, and RR 18/min. He hassevere epigastric tenderness with guarding. There is no scleral icterus. An US does not show gallstones. The bile ducts are not dilated. Labs show-- lipase 20,000; bilirubin 0.9; Ca 9.0. Which of the following additional findings is most likely to support the diagnosis of pancreas divisum?

separate dorsal and ventral ducts

A 55 year old woman with known HEp C cirrhosis and severe emphysema, requiring continuous oxygen is admitted with abdominal pain and distension. Workup reveals ascites and patient is treated empirically for spontaneous bacteria peritonitis and her symptoms do improve. incidentally , on imaging, a 3x2x3cm lesion in the liver is found and is consistent with hepatocellular carcinoma. The patient is referred for evaluation for hepatic transplantation and was found to be not a candidate due to:

severe pulmonary disease

A 24-year-old woman is seen in clinic with anal pain. Examination shows a fissure in the anterior midline of the anal canal. Digital rectal exam cannot be performed due to pain. The next step in management should be

sitz baths, bulking agents, and reassurance

A 38 year old man presents to the emergency room complaining of abdominal pain, nausea, non-bilious vomiting, diarrhea, and palpitations. He recently underwent an antrectomy with Billroth I reconstruction for a nonhealing Type I gastric ulcer. He reports that the symptoms began approximately 20 minutes after drinking his first milkshake since the operation. Which of the following drugs would be most helpful for this patient?

somatostatin

A 55 year old man with known cirrhosis presents to the ED with severe abdominal pain. He appears ill. Blood pressure is 90/50, pulse is 110, respirations are 24, temperature is 38.6. The abdomen is distended and tender; a fluid wave is present. Blood test results show an elevated WBC. a CT scan shows a small shrunken liver, an enlarged spleen, and a large volum eof ascites. The ascites sampled by paracentesis and results show WBC with cultures positive for GN aerobic organisms. Which of the following is the mostly likely diagnosis?

spontaneous bacterial peritonitis

A 63-year-old man came to the office because of epigastric pain of 2 months' duration not relieved with antacids. He has a history of an adenomatous gastric polyp removed 3 years ago. At upper endoscopy, he was found to have another gastric polyp in his antrum that, on endoscopic ultrasound, appeared to be superficial and not associated with any enlarged lymph nodes. Pathological analysis of the polyp reveals evidence of adenocarcinoma invading into the submucosa. On clinical staging, there is no evidence of distant metastasis. The next step in therapy for this patient is:

subtotal gastrectomy

A 75 year old man comes to the office because of painless jaundice for 6 days and a 20 pound weight loss over the past two months. He has hypertension treated with lisinoprile and HCTZ. He has never had surgery. He quit smoking 10 years ago, but had a 40 pack year history prior to that time. He is quite thin and is profoundly jaundice. There is a palpable globular mass in the RUQ that is minimally tender to deep palpation. A CT scan shows dilated intra and extra-hepatic ducts, a distended gallbladder, and a 2cm hypodense mass in the pancreatic head consistent with the diagnosis of pancreatic cancer. The tumor mass does not appear to involve any vascular structures, and there is no evidence of metastatic disease. Which of the following is the next best step?

surgical excision

36 year old woman comes to clinic because of recurrent painless bleeding and a tissue protrusion from the anus for the past 18 months. On examination, there are moderately large external hemorrhoids. The internal hemorrhoids prolapse and require manual reduction. The best management at this time is:

surgical hemorrhoidectomy

A 64-year-old woman is in the emergency room with signs and symptoms of a bowel obstruction. She has no history of prior abdominal operations. The symptoms/sign most consistent with the diagnosis of an obturator hernia would be

symptoms of intermittent bowel obstruction

A 25-year-old man is being evaluated because of maroon stool per rectum. He has otherwise been healthy. Colonoscopy is normal and capsule endoscopy suggests the bleeding is coming from the distal small intestine. The presence of a Meckel's diverticulum as a potential etiology for the bleeding may be able to be identified by which of the following tests?

technetium pertechnetate scan

A 72 year old man with known advanced cirrhosis is brought to the ED by ambulance after vomiting large quantity of blood. The patient has known portal hypertension and has undergone endoscopic banding of esophageal varices in the past. He is admitted to the ICU and medical therapy is initiated. Endoscopy is performed and shows bleeding from gastric varices which are not able to be treated with banding. Which of the following would be the most appropriate next step in the management of this patient?

transjugular intrahepatic portacaval shunt

A 41-year-old woman presents to the emergency department with 18 hours of nausea, right upper quadrant abdominal pain, and fever. She ate a heavy meal the night before and has never experienced similar symptoms. Laboratory evaluation reveals an elevated white blood cell count, normal bilirubin, and slightly elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT). The most appropriate imaging study to determine the etiology of her symptoms is a(n)

ultrasonography

A 42 year old woman comes to the emergency room with epigastric pain radiating to right upper quadrant. She underwent a laparoscopic adjustable gastric band 6 months ago. She has lost approximately 80lbs over the 6 months. She is afebrile with stable vital signs. A right upper quadrant U/S is shown below. Which of the following medications would have been most effective in preventing this complication?

ursedeoxycholic acid

A 23 year-old man is seen in clinic in follow-up of known ileocolic Crohn's disease. He is concerned with the potential metabolic side effects of his disease. Which one of the following metabolic side effects is he at most risk for developing?

vitamin b12 deficiency

A 76 y/o woman is in the hospital recovering ten days following an emergency laparotomy for a perforated diverticulum. She has a history of pernicious anemia and cirrhosis secondary to chronic Hepatitis C. On the 5th postoperative day she developed a wound infection and the skin staples were removed and the wound was packed open. The fascia was intact. She is no afebrile with normal vital signs and tolerating a soft diet. Her abdomen is non-tender and the wound is clean with some granulation tissue. Which of the following places her at greatest risk for incisional hernia formation?

wound infection