SCORE Quarter 1

D. Plasmapheresis

A 19-year-old female presents to the emergency room with abdominal pain and malaise shortly after playing in the snow with her friends. Her boyfriend recently contracted mononucleosis. She complains of recently having malaise and a viral syndrome that she recovered from with supportive care. Her vitals are: HR 87 bpm, BP 130/73 mm Hg, RR 15/min, O2 sat 100% on room air. Her hemoglobin is 9.3 g/dL. Her direct agglutinin test is +C3b only. Given this patient's diagnosis, what is the most definitive step in treatment? A. Steroids and re-warming B. Splenectomy C. Blood transfusion D. Plasmapheresis E. Cyclophosphamide

A. for 24 hours.

A 19-year-old man has a laparotomy after a gunshot wound to the abdomen in which he sustained injuries to colon, liver, and small bowel. Perioperative antibiotics should be administered A. for 24 hours. B. for 3 days. C. for 5 days. D. for 7 days. E. until the patient is afebrile with a normal WBC count.

A. Complete cyst excision

A 21-year-old Asian female s/p MVC is found to have an incidental finding of a cystic-appearing lesion within the biliary tree. Upon further questioning, the patient states she has a history of recurring episodes of abdominal pain and scleral icterus. The mass is then further characterized by MRCP as a saccular diverticulum off the common bile duct without communication with the biliary tree. Which of the following is the appropriate management of this cyst? A. Complete cyst excision B. Complete cyst excision and cholecystectomy C. Complete cyst excision, cholecystectomy and Roux-en-Y- hepaticojejunostomy D. Complete cyst excision and Roux-en-Y hepaticojejunostomy E. Liver transplantation

E. Admit for immediate surgical exploration and debridement.

A 22-year-old male is POD7 s/p open appendectomy for perforated appendicitis. The patient was seen 2 days prior in the ED in which the incision was opened, and was discharged with local wound care. He returns complaining of severe pain at the incision; however, the intern only notes erythema extending 1 cm proximal to the incision, and slight induration around the wound. He has a temperature of 37.9°C, HR 110 bpm, BP 110/80 mm Hg and RR 16 breaths/min. Labs: Leukocytosis of 15,000, hemoglobin of 10.5 g/dl, sodium of 134 and creatinine of 1.7. What is the next best step? A. Obtain immediate CT scan. B. Reassure and discharge the patient as the wound has been opened and drained. C. Discharge the patient with oral Clindamycin for 10 days. D. Admit the patient for intravenous piperacillin-tazobactam. E. Admit for immediate surgical exploration and debridement.

D. Intraoperative massive blood transfusion

A 22-year-old male with PMH of ETOH and cocaine abuse is in the OR for an exploratory laparotomy s/p multiple gunshot wounds. The patient has required a small bowel resection, right hemicolectomy, splenectomy, and primary bladder repair. He is now stable but required 12 units of PRBC intraoperatively. Recent labs show a serum calcium of 6.5 mg/dl. What is the most likely cause of this patient's electrolyte abnormality? A. Decreased serum magnesium due alcohol abuse B. Metabolic alkalosis C. Cocaine-related divalent electrolyte deficit D. Intraoperative massive blood transfusion E. A small bowel fistula

B. Superior- Iliopubic tract; Inferior- Cooper ligament; Lateral- Femoral vein; Medial- Lacunar ligament

A 23-year-old female presents to the ED with acute onset of excruciating groin pain with a feeling of heaviness in her vaginal area. Physical exam is negative for hernia; however, CTAP scan notes a hernia sac located lateral to the pubic tubercle with associated venous compression. The borders of the type of hernia in question are? A. Superior- Iliopubic tract; Inferior- Lacunar ligament; Lateral- Femoral vein; Medial- Cooper ligament B. Superior- Iliopubic tract; Inferior- Cooper ligament; Lateral- Femoral vein; Medial- Lacunar ligament C. Superior- Inguinal ligament; Inferior-Cooper ligament; Lateral- Femoral vein; Medial- Lacunar ligament D. Superior- Inguinal ligament; Inferior- Lacunar ligament; Lateral- Femoral vein; Medial- Cooper ligament E. Superior- Iliopubic tract; Inferior- Cooper ligament; Lateral- Femoral vein; Medial- Inferior epigastric vessels

B. Administer IV immunoglobulin.

A 24-year-old pregnant woman in her 2nd trimester presents with epistaxis, gingival bleeding, and ecchymosis throughout her body. She reports bleeding from her oral mucosa. She denies abdominal pain, or taking any medications other than prenatal vitamins, as she is in her second trimester of pregnancy. She has had one other child without incident, or complications during her previous pregnancy. She is otherwise healthy and denies a history of myeloproliferative disorders. Her pregnancy is progressing normally per her OB/GYN. She does not have tenderness or splenomegaly on abdominal exam. Her platelet count is 22,000/mm3. What is the next step in management? A. Administer glucocorticoid. B. Administer IV immunoglobulin. C. Transfuse platelets. D. Splenectomy E. Administer rituximab.

D. CT-guided drain placement, IV antibiotics, and interval CT in 4-6 weeks

A 28-year-old female presents to the ED with sudden onset diaphoresis, nausea, vomiting, and loose stools. She had initially presented to an outside hospital three days ago with mid-abdominal pain and was treated with Zantac. Vitals are T 101.5°F, BP 110/60 mm Hg, HR 98 bpm. WBC is 17.2 with 2 bands. A CT of the abdomen and pelvis is obtained and shown below. What is the most appropriate management? A. Open appendectomy, incision left open to heal by secondary intention B. Laparoscopic appendectomy, washout, and drain placement C. CT-guided drain placement, IV antibiotics, interval appendectomy in 4-6 weeks D. CT-guided drain placement, IV antibiotics, and interval CT in 4-6 weeks E. Open ileocecectomy

C. Upsize both current drains and insert a third into the undrained collection.

A 28-year-old female with three known hepatic abscesses secondary to intravenous drug usage had two percutaneous drains placed one week ago, with some improvement. Today, however, she again had fevers to 38.5°C and a leukocytosis of 15.5. Her antimicrobial therapy is broadened, and her previously inserted percutaneous drains are evaluated. Drainage from each of these two drains has ceased over the past 3 days. An updated CT scan confirms that both drains are well positioned within moderate-sized abscesses, with a third undrained abscess. What is the next step in treatment of this patient? A. Replace both current drains with new drains. B. Insert a new drain into the undrained collection. C. Upsize both current drains and insert a third into the undrained collection. D. Pull out both drains and add an antifungal agent to the therapy. E. Nonanatomic liver resection of the areas containing an abscess

C. Oral vancomycin

A 29-year-old female with a postpartum breast mastitis was treated with amoxicillin/clavulanate, and subsequently developed C. difficile-associated diarrhea. She was initially treated with oral metronidazole, and returns to the office 3 days later with continued diarrhea. What is the most appropriate antibiotic therapy? A. Continue oral metronidazole. B. IV metronidazole C. Oral vancomycin D. IV vancomycin E. Vancomycin enemas

D. A peripherally located, non-rim-enhancing lesion with peripheral edema

A 30-year-old male presents to the ED with right shoulder pain, intermittent fever, and malaise for the past 6 months. He complains of nausea, weight loss, and anorexia for the past month. He recently moved from rural Central America, where he worked in a farm and lived with the other workers in a 1 room building on the property. His vitals are stable. Abdominal exam is remarkable for tenderness in the right upper quadrant. His laboratory findings are remarkable for a WBC of 13,200mm3 with eosinophilia, and mildly elevated total bilirubin, AST, and ALT. He undergoes a CT of the abdomen. Which of the following lesions is likely to be observed in his liver? A. A central, non-enhancing lesion without air B. A central, non-enhancing lesion containing air C. A peripherally located, round, rim-enhancing lesion D. A peripherally located, non-rim-enhancing lesion with peripheral edema E. A peripherally located, rim-enhancing lesion with peripheral edema

D. Observation with serial imaging

A 32-year-old female presents to your office with vague abdominal pain. She had a recent history of a motor vehicle accident, and was referred to your clinic for a 3-cm well-circumscribed, hyperintense lesion seen on the arterial phase of a CT scan that was performed as part of her evaluation after the accident. She denies smoking, history of deep venous thrombosis, or abdominal malignancy in her family. She confirms use of oral contraceptives for the past 10 years. MRI of the abdomen reveals central scarring. What is the next step in managing this patient? A. Liver ultrasound B. Cessation of oral contraceptives C. CT-guided biopsy D. Observation with serial imaging E. Laparoscopic biopsy with ultrasound guidance

B. 4.6 L

A 32-year-old male is admitted to the ICU after sustaining multiple long bone fractures, rib fractures and moderate traumatic brain injury (GCS = 10) with multiple craniofacial fractures. His vital signs are as follows: T 36.9°C, HR 102 beats/min, BP 134/74 mm Hg, RR 14 breaths/min, 96% on 2L nasal cannula, weight is 83 kg. His serum Na is 153 mEq/dL, up from 147 2 days ago. What is the calculated free water deficit in this patient? A. 5.1 L B. 4.6 L C. 3.9 L D. 2.7 L E. 2.3 L

C. Repair of the galea with absorbable sutures and suture or staple repair of the skin

A 32-year-old male is brought into the trauma bay after being involved in a motor vehicle collision. He was intubated at the scene and noted to have a large posterior scalp laceration with bleeding. On examination, an 8-cm scalp laceration that extends through the galea is noted without an obvious skull fracture. What is the most appropriate treatment after washout of the laceration? A. Primary repair of the skin with staples B. Packing with wet-to-dry dressings to allow for secondary closure C. Repair of the galea with absorbable sutures and suture or staple repair of the skin D. Negative pressure dressing to the laceration to allow for healing by secondary intention

D. Liver biopsy

A 33-year-old female with no PMH s/p MVC with femur fracture is noted to have a 3.5-cm liver mass spanning segments 2 and 3 found incidentally on CT scan. No other abdominal findings. LFTs and AFP WNL. The patient takes oral contraceptives for birth control, no other medications. Further questioning reveals a 15-lb unintentional weight loss and vague abdominal pain after eating. On triphasic helical CT, the lesion demonstrates strong enhancement in the arterial phase with the lesion becoming isointense in the portal and delayed phases. No central scar is seen. MRI was equivocal. What is the next step in management? A. No further testing is necessary B. Repeat imaging in 3 months C. Fine needle aspiration D. Liver biopsy E. Left hepatectomy

C. Order an ultrasound of the right upper quadrant.

A 34-year-old female presents via the Emergency Department with 2 days of pain in the right upper quadrant. She states the pain got worse and she developed fevers and chills 1 day ago, and came to the ED today when she started to have nausea and vomiting. She is hemodynamically stable, WBC 13, temperature 38.0°C. She is moderately tender on exam in the RUQ. The ED resident ordered a CT, which showed questionable cholecystitis. No gallstones were visualized. What is the next best step in this patient's management? A. Percutaneous cholecystostomy tube placement B. Proceed to OR for laparoscopic cholecystectomy. C. Order an ultrasound of the right upper quadrant. D. Admit the patient, start broad-spectrum antibiotics, serial abdominal exams. E. Discharge the patient home with oral pain medication.

C. Von Willebrand disease

A 34-year-old woman with symptomatic cholelithiasis is being evaluated for elective laparoscopic cholecystectomy. She has never had surgery and has never been pregnant. Her family history is significant for "bleeding after surgery," but she doesn't know specifics. Which of the following is the most likely etiology for bleeding risk in this patient? A. Hemophilia B. Factor V Leiden deficiency C. Von Willebrand disease D. Acquired thrombocytopenia E. Factor XII deficiency

C. Open and examine the incision; if wound infection appears confined to the skin and superficial subcutaneous tissue, leave open and prescribe broad spectrum antibiotics.

A 35-year-old female patient comes to the office on POD 5 s/p open appendectomy for gangrenous appendicitis. The intern notes erythema extending 3 cm proximal to the incision, irregular wound edges, warmth and induration. The patient is found to have a temperature 38.1°C; remaining vitals were within normal ranges. What is the next best step in management of this patient? A. Send the patient for immediate CT scan. B. Open and examine the incision; if wound infection appears confined to the skin and superficial subcutaneous tissue, leave open and provide local wound care. C. Open and examine the incision; if wound infection appears confined to the skin and superficial subcutaneous tissue, leave open and prescribe broad spectrum antibiotics. D. Admit the patient for intravenous antibiotics. E. Admit for immediate surgical exploration and debridement.

B. Retract the infundibulum laterally.

A 35-year-old female presented to the ED complaining of abdominal pain and is diagnosed with acute cholecystitis. The patient is taken to the operating room for a laparoscopic cholecystectomy. After the 4 trocars are placed and the abdomen accessed, the fundus is retracted towards the right shoulder. What is the most appropriate next step? A. Begin dissection at the infundibulum. B. Retract the infundibulum laterally. C. Dissect the bottom third of the gallbladder from the hepatic bed. D. Expose the hepatocystic triangle. E. Establish the critical view of safety.

B. Attempting to fully identify two tubular structures between the gallbladder and hepatoduodenal ligament prior to ligation

A 35-year-old female with a BMI of 42 kg/m2 presents to the ED complaining of abdominal pain and fever. Ultrasound demonstrates thickening of the gallbladder wall and pericholecystic fluid, and the diagnosis of acute cholecystitis is determined. During the laparoscopic cholecystectomy, the surgeon notes a tough dissection as she dissects the lower third of the gallbladder from the liver. Due to the tough dissection, she is only able to view one tubular structure between the gallbladder and hepatoduodenal ligament which she believes to be the cystic artery. She proceeds to clip and divide the artery; however shortly after the ligation, an unexpected leak of bile is seen. Which of the following could have prevented this? A. Attempting to identify the cystic artery lymph node prior to ligation B. Attempting to fully identify two tubular structures between the gallbladder and hepatoduodenal ligament prior to ligation C. Obtaining an intraoperative cholangiogram (IOC) prior to the dissection of the lower third of the gallbladder D. Performing an intraoperative ultrasound prior to dissection of the lower third of the gallbladder E. Having a bariatric surgeon perform the operation due to the patient's size

C. Radionuclide spleen scan

A 35-year-old female with idiopathic thrombocytopenic purpura refractory to glucocorticoids underwent uncomplicated laparoscopic splenectomy. She recovered well and had improvement in her platelet count. Ten months later she presents to her PCP with frequent epistaxis and bruising and is found to have a platelet count of 40,000. No Howell-Jolly Bodies are seen on peripheral blood smear. What is the next best step in diagnosis? A. CT angiogram B. MRI of the abdomen C. Radionuclide spleen scan D. Bone marrow biopsy E. Platelet fragility testing

E. Coagulopathy

A 35-year-old female, G1P0, 15 weeks pregnant by date of conception presented to the ED complaining of abdominal pain. The patient states for the past 7 weeks she has had multiple episodes of pain after meals; however, tonight the pain is unremitting. She admits to eating 4 hamburgers with potato salad at a barbeque late this afternoon. She has a history of von Willebrand disease and had bleeding following an open appendectomy 20 years ago. Laboratory findings demonstrate a leukocytosis of 12,500. Ultrasound demonstrates 5-mm thickening of the gallbladder wall, gallstones and pericholecystic fluid. The surgeon decides to proceed with cholecystectomy. Which of the following poses the strongest relative contraindication to a laparoscopic approach? A. Pregnancy B. Previous abdominal surgery C. Ultrasound findings D. Long duration of symptoms E. Coagulopathy

A. Emergent liver resection

A 35-year-old male patient presents to the emergency room obtunded, with the following vitals: HR 126 bpm, BP 82/43 mm Hg, RR 15 breaths/min, O2 sat 100% on non-rebreather. One month ago, he underwent a CT of the abdomen to rule out kidney stones, and was found to have a 12-cm mass in the right lobe of his liver occupying segments 5, 6 and 7, without a defined capsule. He did not have kidney stones, and was discharged from the ED. Otherwise, his previous medical history is unremarkable. He denies taking any medications but admits to using androgenic steroids. What is the most definitive step in management? A. Emergent liver resection B. Cessation of steroids C. CT abdomen/pelvis D. Intensive care admission, IV fluid resuscitation E. Percutaneous liver embolization

D. ERCP

A 35-year-old male with a PMH of ulcerative colitis presents to your clinic for evaluation of his inguinal hernia. Preoperative labs show an elevated bilirubin, alkaline phosphatase, AST and ALT. The patient admits to fatigue and recent bouts of pruritus, but otherwise is in his normal state of health. What test would most likely confirm the suspected diagnosis? A. KUB B. CT abdomen and pelvis C. MRI abdomen and pelvis D. ERCP E. Liver biopsy

B. Roux-en-Y hepaticojejunostomy with exchange of the biliary catheter for a silastic stent

A 36-year-old female presents with cholangitis and jaundice one year after laparoscopic cholecystectomy. CT imaging and ultrasound show intraductal biliary dilatation. Percutaneous transhepatic cholangiography confirms a 2-cm stricture in the common hepatic duct just distal to the bifurcation. A stent is left in place for drainage. After stabilization, the patient is taken for surgical repair. The surgical procedure required is: A. Roux-en-Y hepaticojejunostomy B. Roux-en-Y hepaticojejunostomy with exchange of the biliary catheter for a silastic stent C. Segmental hepatic duct resection with primary anastomosis with T-tube insertion D. Segmental hepatic duct resection with primary anastomosis with insertion of silastic stent E. Choledochoduodenostomy

C. Use a laparoscopic ultrasound in order to identify structures.

A 36-year-old pregnant woman in her second trimester of pregnancy presents with fevers, nausea, and right upper quadrant pain which has lasted for a day. The patient is tender to palpation in the right upper quadrant. Her vitals are Temp 101.1°F, BP 116/54 mm Hg, HR 103 bpm, O2 sat 98% on room air. Labs are significant for WBC 13.5, total bilirubin 0.6 and direct bilirubin 0.2. Ultrasound shows cholelithiasis with positive pericholecystic fluid. The patient is admitted, started on intravenous antibiotics, and opts to undergo a laparoscopic cholecystectomy. The patient has refused intraoperative cholangiography because of potential radiation exposure to the fetus. During surgery, the anatomy is unclear as there are three tubular structures. What is the next step in the management of this patient? A. Cut into the structures to attempt identifying the cystic artery and cystic duct. B. Clip all three structures. C. Use a laparoscopic ultrasound in order to identify structures. D. Perform intraoperative cholangiogram after placing a lead shield over the lower abdomen. E. Convert to open cholecystectomy.

C. Perform a longitudinal choledochotomy and pass a choledoscope into the CBD

A 36-year-old woman presented to the ED with a sudden onset of epigastric and right upper quadrant abdominal pain. She is obese (BMI > 35 kg/m2) but otherwise healthy. Vital signs are: Temp 98.9°F, BP 115/67 mm Hg, HR 69 bpm, and O2 sat 99% on RA. Laboratory findings are significant for mild leukocytosis 11.3. Total bilirubin and direct bilirubin are elevated to 3.2 and 1.5. Amylase and lipase are normal. Ultrasound shows cholelithiasis with gallbladder wall thickness measuring 5 mm and pericholecystic fluid. Common bile duct (CBD) is 1 cm in diameter, and no stones are visualized. The patient is taken to the operating room for laparoscopic cholecystectomy and intraoperative cholangiogram (see below) was performed through a very friable cystic duct. Following administration of glucagon, no change is seen. What is the next best step in management? A. Complete the laparoscopic cholecystectomy and observe the patient. B. Perform a transcystic duct laparoscopic common bile duct exploration. C. Perform a longitudinal choledochotomy and pass a choledoscope into the CBD D. Open and perform an open bile duct exploration.

C. CBD smaller than 6 mm

A 36-year-old woman presents to the ED with a one-day history of fevers, nausea, and right upper quadrant pain. She is tender to palpation in the right upper quadrant. Her vitals are Temp 101.1°F, BP 116/54 mm Hg, HR 103 bpm, O2 sat 98% on room air. Labs are significant for WBC 13.5, total bilirubin is 1.2 and direct bilirubin is 0.8. Ultrasound shows cholelithiasis with positive pericholecystic fluid and gallbladder wall of 5 mm. The CBD doesn't show any choledocholithiasis and measures 4 mm in diameter. The patient is admitted and started on antibiotics. You decide to perform an intraoperative cholangiogram (IOC) during her laparoscopic cholecystectomy. If a filling defect was found on IOC, which of the following findings would preclude her from a choledochotomy? A. Friable cystic duct B. Stones > 9 mm C. CBD smaller than 6 mm D. More than six stones E. Common hepatic duct stones

C. Percutaneous drainage of the biloma and Roux-en-Y hepaticojejunostomy once patient stabilizes but before 7 days

A 40-year-old female POD 2 s/p an elective laparoscopic cholecystectomy for symptomatic gallstones comes to the ED because of increasing right upper quadrant pain, nausea and abdominal distention. Vitals are temperature of 38°C, HR 110 bpm, BP 102/70 mm Hg and RR 18 breaths/min. Labs are unremarkable except for a total bilirubin of 1.9 mg/dL. Upon physical exam, the patient is exquisitely tender in the right upper quadrant. Ultrasound demonstrates a large subhepatic fluid collection near the bifurcation and in proximity to surgical clips. Dilated intrahepatic ducts are also noted. Intravenous fluids are begun. HIDA scan shows a bile leak and no visualization of the extrahepatic bile ducts or bowel. ERCP shows filling only of the distal bile duct, and PTC shows leakage of bile from a small remnant of the CHD. What is the best management for this patient? A. Observation and antibiotics B. Percutaneous drainage of the biloma and sphincterotomy C. Percutaneous drainage of the biloma and Roux-en-Y hepaticojejunostomy once patient stabilizes but before 7 days D. Percutaneous drainage of the biloma, sphincterotomy and Roux-en-Y hepaticojejunostomy in 6-8 weeks E. Urgent choledochoduodenostomy and drainage of the biloma in 12 hours

D. Complete transection

A 42-year-old female presents to the ED with right upper quadrant abdominal pain, fever, decreased appetite and vomiting. CBC reveals a mild leukocytosis, and an abdominal ultrasound reveals findings consistent with acute cholecystitis. The patient is eventually taken to the OR for cholecystectomy. What is the most common type of bile duct injury sustained during this operation? A. Occlusion of the proximal common bile duct with a surgical clip B. Thermal injury to the duct system C. Avulsion of the cystic duct D. Complete transection E. Incomplete laceration of the cystic duct

D. Obtain percutaneous drainage of both abscesses.

A 42-year-old male presents to the emergency department with malaise and fevers as well as right upper quadrant pain and tenderness on exam. His past medical history is significant for recurrent attacks (4) of diverticulitis over the preceding 4 years. His vital signs are stable. His cross-sectional imaging (CT) identifies two 5-cm hepatic abscesses. Empiric antibiotic therapy has been initiated. What is the next therapeutic step for this patient? A. Obtain blood cultures. B. Obtain urine cultures. C. Add an antifungal agent to his therapy. D. Obtain percutaneous drainage of both abscesses. E. Operative drainage

D. Bronchioalveolar lavage with culture

A 42-year-old male underwent splenectomy for splenic fracture and intracranial bleed following an MVC 3 days ago. He required multiple blood products intra- and postoperatively. He has remained intubated for depressed mental status and hypoxia, and has a fever of 39.2°C. Which study is necessary to establish the most likely infectious cause of fever? A. Chest x-ray B. Blood culture C. Urinalysis D. Bronchioalveolar lavage with culture E. CT abdomen/pelvis

D. Retrograde cystogram; urinary drainage

A 43-year-old male presented to the ER with a right-sided incarcerated hernia and was taken to the OR for reduction and open repair of the inguinal hernia. No Foley was used during the operation. He tolerated the procedure well with post-operative vitals as follows: BP 135/85 mm Hg, HR 85 bpm, Temp 100.3°F, RR 18 breaths/min. Five hours after surgery, the patient begins to complain of progressive suprapubic pain and hematuria. His vitals are now BP 150/95 mm Hg, HR 105 bpm, Temp 101. A. CT abdomen/pelvis with oral contrast; consult to interventional radiology for drain placement B. Pelvic US; take the patient to the OR for exploratory laparotomy C. X-ray KUB; take the patient to the OR for exploratory laparotomy D. Retrograde cystogram; urinary drainage E. CT abdomen/pelvis without contrast; take the patient to the OR for exploratory laparotomy

D. Schedule surgery now; continue metoprolol, pravastatin and aspirin at the time of surgery.

A 67-year-old man presents to the clinic for a surgical evaluation for right colectomy; he was diagnosed with a sessile polyp on colonoscopy that showed a focus of poorly differentiated adenocarcinoma with lymphovascular invasion. The patient had a myocardial infarction 4 months ago for which he had percutaneous coronary intervention and a bare metal stent placed. He is now on metoprolol, pravastatin, and low-dose aspirin. When should surgery be scheduled and how should the patient's medications be adjusted? A. Schedule surgery at 12 months after stent placement; continue metoprolol, pravastatin, and aspirin at the time of surgery. B. Schedule surgery at 12 months after stent placement; continue metoprolol and pravastatin, discontinue aspirin 7 days prior to surgery. C. Schedule surgery at 12 months after stent placement; discontinue metoprolol, pravastatin, and aspirin 7 days prior to surgery. D. Schedule surgery now; continue metoprolol, pravastatin and aspirin at the time of surgery. E. Schedule surgery now; continue metoprolol and pravastatin, discontinue aspirin 7 days prior to surgery.

A. Biopsy of the wound

A 67-year-old paraplegic male, who resides at a skilled nursing facility with PMH of DM, HTN and hyperlipidemia, is admitted to the MICU for urosepsis. The general surgery team is consulted for sacral decubitus ulcer management. The patient has a 2.6-cm x 4.1-cm wound on his right ischium that has been present for 14 months per nursing home records. While it had decreased in size at one point, it has not healed since first documented and has increased in size within the past 2 months. The wound has irregular edges which are curled-under and hyperkeratotic. The wound bed is 20% necrotic tissue and 80% granulation tissue. What is the most appropriate next best step in managing this patient's wound? A. Biopsy of the wound B. Bedside debridement C. Collagenase therapy D. Periodic rotation E. Tight glycemic index control

E. laparoscopic repair

A 68-year-old male presents with a non-tender bulge below the inguinal ligament on the left. He is a nonsmoker and had a normal colonoscopy one month ago. There is a soft non-tender mass that cannot be reduced below the inguinal ligament. He has no nausea or vomiting, and no abdominal distention on exam. The next appropriate step in his management is: A. watchful waiting B. CT scan of the pelvis C. Lichtenstein repair D. McVay repair E. laparoscopic repair

B. Subtotal colectomy with end-ileostomy

A 68-year-old woman was admitted through the emergency room with diarrhea and abdominal pain, and diagnosed with C. difficile colitis two days ago. She had been treated with intravenous flagyl. Today, she has a leukocytosis of 36,000 and diffuse abdominal tenderness. Her HR is 115, BP 85/50, RR 20. Which of the following is the best course of action for this patient? A. Vancomycin enemas B. Subtotal colectomy with end-ileostomy C. Fecal transplantation D. Transverse colostomy E. Colonoscopy

E. Give Prothrombin complex concentrate (PCC), bridge with heparin before and after the procedure, hold heparin for the procedure.

A 70-year-old male was admitted to the ICU for septic shock and was found to have acute cholecystitis on right upper quadrant ultrasound. He has a past medical history of atrial fibrillation, a mitral mechanical valve on Coumadin, and an ejection fraction of 20% wearing a LifeVest, personal defibrillator. His INR is 4.5 and WBC is 21000. You plan for a cholecystostomy tube. How would you manage the patient's anticoagulation prior to the procedure? A. Discontinue Coumadin and wait for INR to trend down; no bridge with heparin is necessary before or after the procedure. B. Give IV Vitamin K; no bridge with heparin is necessary before or after the procedure. C. Give IV Vitamin K, bridge with heparin before and after the procedure, hold heparin for the procedure. D. Give Prothrombin complex concentrate (PCC); no bridge with heparin is necessary before or after the procedure. E. Give Prothrombin complex concentrate (PCC), bridge with heparin before and after the procedure, hold heparin for the procedure.

C. Aortic stenosis

A 70-year-old male with multiple medical comorbidities comes to your office for preoperative evaluation of a symptomatic inguinal hernia. His past medical history includes hypertension (controlled with a single medication), aortic stenosis and diet-controlled type II non-insulin dependent diabetes. He is worried about the risk of surgery and asks you which comorbidity places him at the highest risk for postoperative events. What is your response? A. Age > 70 B. Hypertension C. Aortic stenosis D. Diabetes E. Male sex

D. EKG with Q waves

A 72-year-old man presents with symptomatic iliac artery stenosis. He has a past medical history of hypertension, well-controlled CHF, hyperlipidemia, and diabetes mellitus. The Revised Cardiac Risk Index is employed to evaluate this patient's preoperative risk of a major adverse cardiac event (MACE). Which of the following is used to evaluate the risk for this patient? A. Beta blocker therapy B. BUN level C. Duration of surgery D. EKG with Q waves E. Functional status

E. Increased bacteria within the bile duct with elevated intraductal pressure that allows translocation of bacteria or endotoxins into the vascular system.

A 73-year-old woman is brought to the ED from a nursing home due to an acute change in mental status. She is found to have a temperature of 38.3°C, BP 80/50 mm Hg with a HR 110 bpm and RR of 25 breaths/min. She appears jaundiced and winces with inspiration upon palpation of the right upper quadrant during physical exam. Laboratory findings demonstrate leukocytosis, elevated alkaline phosphatase, total bilirubin, AST and ALT. Ultrasonography demonstrates gallstones within the gallbladder and a common hepatic duct diameter of 7 mm. The underlying pathophysiology is most likely: A. Primary inflammation of hepatocytes secondary to an infectious agent B. Concentration of biliary solutes and stasis in the gallbladder C. Temporary elevation of pancreatic ductal pressures causing a secondary inflammation. D. Obstruction of the cystic duct and infection secondary to stasis and inflammation E. Increased bacteria within the bile duct with elevated intraductal pressure that allows translocation of bacteria or endotoxins into the vascular system.

B. Measure urine osmolarity and sodium.

A 74-year-old man with a past medical history of hepatitis C and hypertension presents with a perforated pyloric channel ulcer. He has a duodenal ulcer repair with a Graham patch. On postoperative day 4, he is found to have a sodium level of 123 mEq/L. He is asymptomatic. What is the next step in management? A. No further workup or treatment is necessary. B. Measure urine osmolarity and sodium. C. Administer furosemide. D. Fluid restriction E. Administer 3% saline

C. Stop heparin and start argatroban.

A 75-year-old male with diabetes, hypertension, dyslipidemia, and type III CKD is admitted with unstable angina. His echocardiogram shows EF of 20% and cardiac catheterization reveals left main stenosis with triple vessel disease. Preop IABP is inserted and he undergoes on pump CABG with four bypass grafts. Postoperatively he is supported with inotropes and balloon pump and maintaining a cardiac output of 2.3 L/min/m2. His labs are WBC 8,000/mm3, platelet count 48,000 from 260,000 preop, serum creatinine 1.8, INR 1.2, optical density (OD) reactivity of sequence of reactivity algorithms (SRA) is 0.4. Which of the following is the most appropriate next step in management? A. Discontinue IABP and reassess after 2 days. B. Withhold all forms of heparin except heparin flushes to maintain arterial line patency. C. Stop heparin and start argatroban. D. Stop heparin and start enoxaparin. E. Stop heparin and start bivalirudin.

A. Captopril

A 75-year-old male with hypertension, dyslipidemia, and heart failure is scheduled to undergo a right hemicolectomy for a 5-cm ascending colon mass detected on colonoscopy. Withholding which one of these from his medication list on the day of surgery may reduce the risk of perioperative death, stroke and myocardial injury? A. Captopril B. Digoxin C. Verapamil D. Furosemide E. Pravastatin

A. End-tidal carbon dioxide (EtCO2) determination

A 78-year-old female is in respiratory distress due to multiple rib fractures sustained due to a fall at a nursing home. You perform rapid sequence intubation. What is the most accurate means of confirming endotracheal tube placement? A. End-tidal carbon dioxide (EtCO2) determination B. Visualization of endotracheal tube going through vocal cords C. Auscultation of breath sounds D. Mist visualized within the endotracheal tube. E. Post-intubation chest plain film

A. Piperacillin/tazobactam and vancomycin

A 79-year-old female with an enterocutaneous fistula had a subclavian triple lumen catheter placed 10 days ago. She is noted to have developed fevers over the last 12 hours. Her current vitals are: T 38.6°C, HR 105 bpm, BP 105/55 mm Hg, RR 12 breaths/min. WBC count is 13,000. Which of the following is appropriate empiric therapy in this situation? A. Piperacillin/tazobactam and vancomycin B. Nafcillin and clindamycin C. Ampicillin and micafungin D. Linezolid and diflucan E. Ciprofloxacin and metronidazole

B. Metronidazole for 10 days

A healthy 35-year-old male presents with fever, diarrhea, chills, and right upper quadrant pain after returning from backpacking near the Amazon river. He has leukocytosis without evidence of eosinophilia. Alkaline phosphatase is elevated but AST and ALT are within normal limits. CT scan with contrast demonstrates an area in the right lobe of the liver with a cavity that has an enhancing wall and hypoattenuation in the center. What is the first line of treatment for this patient? A. Ampicillin, gentamicin, and metronidazole for 6 weeks B. Metronidazole for 10 days C. Open surgical drainage D. Percutaneous surgical drainage E. Ciprofloxacin and metronidazole for 6 weeks

C. injection of bupivacaine and hydrocortisone, repeating weekly

A patient has an open inguinal hernia repair with mesh. The ilioinguinal nerve is seen and retracted out of the field and then placed under the external oblique closure at the end of the case. He is seen two weeks postop with some pain which was felt to be normal postoperative pain. Eight weeks later, he returns with more pain that is persistent in his groin. He has no seroma, recurrent hernia, no erythema or other signs of infection. His pain has not been controlled with nonsteroidals, narcotics, ice, or rest. The next best step would be: A. exploration of the groin and mesh replacement B. continue the nonsteroidals and change to another narcotic C. injection of bupivacaine and hydrocortisone, repeating weekly D. exploration of the groin with neurectomy of the affected nerve E. exploration of the groin with triple neurectomy

B. Functional residual capacity

A patient with acute respiratory distress syndrome (ARDS) is on mechanical ventilation. During rounds, the team increases the positive end expiratory pressure (PEEP) from 8 cm H20 to 12 cm H20. Which of the following parameters is likely to increase? A. Cardiac output B. Functional residual capacity C. Preload D. PaCO2 on repeat ABG E. pH on repeat ABG

B. The risk of incarceration or strangulation is less than 1% within 2 years.

A vibrant 78-year-old male is referred for management of a right inguinal hernia diagnosed by his primary care physician during his annual evaluation one year ago. He denies symptoms attributable to the hernia, which is easily reducible. Which of the following is appropriate to consider when recommending watchful waiting rather than repair? A. Pain which limits his physical activity is more likely within the next year if the hernia is not repaired. B. The risk of incarceration or strangulation is less than 1% within 2 years. C. Less than 10% of patients will have a hernia repair within 2 years. D. Wearing a supportive truss will decrease the risk of complications. E. Men are at a higher risk of developing hernia complications, compared to women.

C. Small bowel resection with primary anastomosis, repair of inguinal hernia with biologic mesh.

A 43-year-old male presents to the ED with a painful bulge in his right groin. The patient states that the bulge has been present and freely reducible for years, but over the past 24 hours, it has become "stuck out" and increasingly painful. His vitals are BP 120/80 mm Hg, HR 75 bpm, RR 18 breaths/min, Temp 99.5°F. He denies changes in bowel habits or hematochezia. A CT reveals a large right-sided inguinal hernia that contains fat and small bowel. Multiple attempts to reduce the hernia by ER physicians and the surgical team are unsuccessful, so the patient is taken to the OR for a right open inguinal hernia repair. Upon entering the hernia sac, necrotic bowel is discovered. What is the appropriate operation to perform? A. Small bowel resection with primary anastomosis, repair of inguinal hernia with synthetic mesh. B. Small bowel resection with mid-line incision for creation of an end ileostomy, repair of inguinal hernia with biologic mesh. C. Small bowel resection with primary anastomosis, repair of inguinal hernia with biologic mesh. D. Small bowel resection with primary anastomosis, leave inguinal hernia to repair at a later time. E. Small bowel resection with mid-line incision for creation of loop ileostomy, repair inguinal hernia with biologic mesh.

E. Laparoscopic cholecystectomy and intraoperative cholangiogram

A 44-year-old woman is in the emergency department with a 24-hour history of epigastric abdominal pain with nausea. She is in mild distress and has diffuse epigastric tenderness without guarding. Her serum amylase is 3450 IU/L. Ultrasound examination shows cholelithiasis and normal ducts. A computed tomographic (CT) scan reveals minimal pancreatic edema. She is admitted to the hospital and 48 hours later, her abdominal pain has resolved and her amylase and bilirubin are normal. The next step in management should be A. Open cholecystectomy and common bile duct exploration B. ERCP, sphincterotomy, and pancreatic stent placement C. Discharge and readmission in 6 weeks for laparoscopic cholecystectomy D. Discharge with a low-fat diet E. Laparoscopic cholecystectomy and intraoperative cholangiogram

D. Laparoscopic cholecystectomy with intraoperative cholangiogram (IOC) and common bile duct exploration

A 45-year-old female with a history of Roux-en-Y gastric bypass presents with a one-day history of increasing abdominal pain that began after a meal. The patient admits to a history of biliary colic following fatty meals. On physical exam she has right upper quadrant pain, positive murphy sign, and mild scleral icterus. Vitals T: 101°F, BP: 130/60 mm Hg, HR 105 bpm, RR: 18 breaths/min, O2 98% RA. Laboratory evaluation demonstrates; Alkaline phosphatase: 180 U/L Total Bilirubin: 4 mg/dL AST/ALT: 80/100 U/L, WBC: 12,000/mm3. Abdominal US shows gallbladder wall thickening, pericholecystic fluid, echogenic shadowing and a common bile duct measuring 10mm. What is the next step in management? A. MRCP B. Preoperative transoral ERCP C. Cholecystostomy tube with interval laparoscopic cholecystectomy D. Laparoscopic cholecystectomy with intraoperative cholangiogram (IOC) and common bile duct exploration E. Laparoscopic cholecystectomy with intraoperative cholangiogram (IOC) with postoperative transoral ERCP

D. Doripenem

A 45-year-old female with ulcerative colitis was taken emergently to the OR for peritonitis and shock and a perforated megacolon. She is now POD1 s/p total abdominal colectomy with end ileostomy. Prior to the OR she was started on a single antimicrobial agent. Which of the following agents would have been appropriate? A. Cefuroxime B. Cefazolin C. Cefepime D. Doripenem E. Ertapenem

B. Salmonella; start IV imipenem

A 45-year-old male presented to the emergency room with a 2-day history of severe abdominal pain, nausea, vomiting, and diarrhea. The patient has a past medical history of hypertension and recently diagnosed HIV with CD4 cell count of 150 cells/microL. His abdomen is tender in all four quadrants; no generalized peritonitis appreciated. His vitals were the following: Temp 102°F, BP 100/72 mm Hg, HR 121 bpm, 97% sats on RA. A CT scan with IV contrast showed thickened small bowel loops consistent with enteritis with a small amount of pelvic fluid without any free air or ischemic changes. What is a likely diagnosis and appropriate treatment? A. Cryptosporidium; start ciprofloxacin B. Salmonella; start IV imipenem C. Mycobacterium avium complex; proceed to exploratory laparotomy D. CMV; proceed to exploratory laparotomy E. Coccidioidomycosis; start fluconazole

A. Transarterial embolization of the bleeding vessel

A 45-year-old man with hepatitis C undergoes an uneventful percutaneous liver biopsy for a lesion in segment IV. About 6 weeks later, he presents to the ER with RUQ pain and jaundice. BP 98/58 mm Hg, Pulse 120 bpm. His hemoglobin is 7.2 mg/dL, and fecal occult blood testing is positive. He has an episode of bloody emesis. The patient receives 2 units of PRBCs and hemoglobin after transfusion is 7 gm/dl. EGD is performed and blood is seen at the ampulla of Vater. What is the best treatment for this patient? A. Transarterial embolization of the bleeding vessel B. Cholecystectomy C. Segmental resection of the segment IV D. Laparotomy and liver packing E. ERCP and stenting of CBD

B. Surveillance

A 47-year-old female with a recent history of trauma underwent trauma workup, which was unremarkable, except for a 3-cm abnormality in the liver found incidentally. She denies nausea, vomiting, abdominal pain, or ever taking oral contraceptives. She has a history of chronic kidney disease stage III. CT scan demonstrates a 3.1-cm peripherally enhancing mass that is asymmetric and gradually enhances with delayed films. To further characterize the mass, you obtain an MRI without contrast. T1 shows a hypodense lesion. T2 shows hyperintense lesion. What is the next step in management? A. Liver biopsy B. Surveillance C. MRI with gadolinium D. Liver resection for diagnosis E. Colonoscopy

B. Partial splenectomy

A 47-year-old otherwise healthy male is evaluated for LUQ abdominal pain. CT imaging demonstrates a simple splenic cyst on the along the superior aspect of the spleen measuring 6 cm. What is the most appropriate treatment option? A. Total splenectomy B. Partial splenectomy C. Observation D. Percutaneous drainage E. Injection of sodium chloride solution

E. Hyperkalemia from administration of succinylcholine causing muscle depolarization

A 48-year-old male with a PMH of COPD sustained a 60% TBSA electrical burn 7 days ago from a high-voltage injury. He returns to the OR for his second burn wound excision under general anesthesia and is given succinylcholine during induction. During draping, the EKG shows an increase in T wave amplitude with narrow peaked symmetrical T waves and widening of the QRS complex. What is the most likely cause for the EKG changes? A. Hypokalemia from massive fluid loss and tissue breakdown from his burn injury B. Hypokalemia from release of extracellular potassium from the eschar C. Hypercalcemia from delayed rhabdomyolysis D. Hyperkalemia from an unrecognized hypoaldosterone state due to chronic steroid use for his COPD E. Hyperkalemia from administration of succinylcholine causing muscle depolarization

C. Hold metformin, take half the dose of insulin glargine, and hold insulin aspart.

A 52-year-old female is scheduled for an elective left hemicolectomy for diverticular disease. She has a past medical history of hypertension, hyperlipidemia and diabetes. She takes metformin, insulin glargine twice a day, and insulin aspart before every meal. How should the patient be instructed to adjust her diabetes medications the morning of surgery? A. Hold metformin, insulin glargine, and insulin aspart. B. Hold metformin, take half the dose of insulin glargine, and half the dose of insulin aspart. C. Hold metformin, take half the dose of insulin glargine, and hold insulin aspart. D. Take metformin, insulin glargine and insulin aspart at the regular doses. E. Take metformin and insulin glargine at the regular doses but hold insulin aspart.

D. Myofibroblasts

A 52-year-old obese female with PMH of multiple abdominal surgeries is POD 4 s/p exploratory laparotomy and lysis of adhesions for small bowel obstruction. The intern notes erythema, induration and serous drainage from the distal edge of the wound. A decision is made to open the wound and allow it to heal by secondary intention. What is responsible for the contraction of the wound? A. Platelet-derived growth factor B. Transforming growth factor-beta C. Fibroblasts D. Myofibroblasts E. Vascular endothelial growth factor

C. ICU admission, IV antibiotics, IV fluids, chest x-ray

A 53-year-old elementary school teacher s/p splenectomy 15 months ago for hypotension after blunt abdominal trauma presents to the ER with fever, chills, malaise, and purulent nasal discharge. He denies abdominal pain. He is otherwise healthy. He denies receiving vaccinations post-splenectomy, as he had to reschedule his appointment secondary to work commitments. His vitals are the following: T 40.1°C, HR 112 bpm, BP 90/51 mm Hg, RR 23/min, O2 sat 97% on room air. His abdominal exam is unremarkable. What is the next best step in management? A. IV fluid bolus and discharge on oral antibiotics B. Administration of trivalent vaccinations and oral antibiotics C. ICU admission, IV antibiotics, IV fluids, chest x-ray D. As his sinus infection will likely resolve on its own, follow up in 2 weeks in the office E. CT scan of the abdomen/pelvis

C. Anemia, neutropenia, thrombocytopenia

A 54-year-old female is diagnosed with non-Hodgkin lymphoma (NHL) and is referred to you for splenomegaly. She has no abdominal pain, early satiety or fullness. What findings on laboratory testing would be an indication for splenectomy? A. Polycythemia B. Leukocytosis, thrombocytosis C. Anemia, neutropenia, thrombocytopenia D. Thrombocytopenia, elevated transaminases E. Anemia, leukocytosis, thrombocytosis

B. Smoking status

A 55-year-old female is being evaluated for a laparoscopic cholecystectomy for symptomatic cholelithiasis. She has a past medical history of mild asthma requiring occasional albuterol inhaler use. Her BMI is 30 kg/m2. Creatinine was 0.8 mg/dL on previous laboratory work. She smokes half a pack of cigarettes a day. Which risk factor helps determine this patient's preoperative risk for major pulmonary morbidity? A. Age over 50 B. Smoking status C. Serum creatinine D. BMI of 30 E. Mild asthma

A. Continue 10 mg prednisone.

A 55-year-old female patient presents to your office for elective umbilical hernia repair. The patient has taken 10 mg of prednisone for a history of well-controlled ulcerative colitis for greater than 10 years. She states she has no other health issues. What should be the perioperative management of the patient's steroids? A. Continue 10 mg prednisone. B. Stop steroids for 5 days preoperative. C. Give 150 mg hydrocortisone in Preoperative holding area. D. Give 150 mg hydrocortisone in Preoperative holding area and continue for 2 days. E. Check a cosyntropin stimulation test

C. Remove the catheter within 24 hours.

A 55-year-old healthy male undergoes an elective laparoscopic sigmoidectomy for a newly diagnosed cancer. A urinary catheter is placed at the time of the operation. His immediate postoperative course is unremarkable. Which of the following is the most reliable method to reduce the risk of catheter-associated UTI (CAUTI) in this patient? A. Use a silver impregnated catheter. B. Apply triple antibiotic ointment to the catheter-meatus junction. C. Remove the catheter within 24 hours. D. Use a condom catheter. E. Continue perioperative antibiotics until the catheter is removed.

C. IV calcium gluconate

A 56-year-old construction worker had his leg trapped under a fallen piece of heavy machinery for 2 hours before he could be removed. He is transferred to the surgical ICU after intubation during which succinylcholine was given. An initial EKG is obtained shows a wide QRS and a flat P wave. What should be administered while obtaining laboratory studies? A. Furosemide B. Kayexalate C. IV calcium gluconate D. Sodium bicarbonate E. Insulin and dextrose

C. Spilled gallstone

A 56-year-old man presents to the ED with right flank pain and fever with sweats for the past 2 days. He is S/P right inguinal hernia repair as a child, appendectomy 25 years ago and laparoscopic cholecystectomy for acute gangrenous cholecystitis 16 months ago. Temperature is 38.6°C, BP- 120/70 mmHg, P- 90 bpm, R- 18/min. O2 sat is 98% on room air. Heart is regular. There are decreased breath sounds on the right. Abdomen is soft. No masses are palpable. There is tenderness in the lateral right upper quadrant with some CVA tenderness to percussion. WBC is 15,400 with a shift. LFTs and lipase are normal. CXR shows a small pleural effusion on the right side. CT of the abdomen shows a rim-enhancing fluid collection between the lower posterior edge of the liver and the chest wall, and a non-enhancing pleural effusion. What is the most likely cause for these findings? A. Chronic biloma B. Perforated duodenal ulcer C. Spilled gallstone D. Infected pancreatic pseudocyst E. Empyema

C. ERCP

A 56-year-old woman is presenting to the ED with right upper quadrant pain for the past 3 days. She has a known history of cholelithiasis. Her urine has been quite dark for the past day. Her vitals at the presentation are: Temp 100.3°F, BP 89/54 mm Hg, HR 114 bpm, O2 sat 96% on room air. Her abdomen is tender in the left upper quadrant. WBC 14.9, total bilirubin 3.4 mg/dL, and direct bilirubin 1.8 mg/dL, Antibiotics and fluid resuscitation is begun. What is the next best step in management? A. Laparoscopic cholecystectomy B. Percutaneous cholecystostomy C. ERCP D. MRCP E. Antibiotics x 14 days

D. Hypokalemia

A 57-year-old female is postoperative day four from a laparoscopic right hemicolectomy for colonic adenocarcinoma. She has a past medical history of hypertension, insulin-dependent diabetes, and congestive heart failure with an EF of 38%. Her home medications include metformin, carvedilol, losartan, and furosemide. She now complains of worsening abdominal distention, persistent nausea, emesis and is no longer passing flatus. A KUB demonstrates paralytic ileus. Which of these electrolyte abnormalities is most likely to contribute to her ileus? A. Hypermagnesemia B. Hypomagnesemia C. Hypocalcemia D. Hypokalemia E. Hyperkalemia

A. Discontinue omeprazole.

A 57-year-old female presents to her primary physician for a routine yearly visit. Her past medical history includes hypertension, GERD, and hypercholesterolemia. Her medications include metoprolol, omeprazole, and atorvastatin. A routine metabolic panel reveals potassium of 3.4 mEq/L, magnesium of 1.2 mEq/L, and m calcium of 7.0 mg/dL. What is the next step in management? A. Discontinue omeprazole. B. Obtain serum albumin. C. Check PTH levels. D. Perform a high-resolution ultrasound of the neck. E. Discontinue atorvastatin.

E. Splenectomy

A 57-year-old male presents to the emergency room with a temperature of 39°C, multiple episodes of chills, and non-specific abdominal pain. He states he has been having night sweats. He has a history of intravenous drug use, and recently underwent a tricuspid valve replacement for endocarditis. His vitals are the following: BP 145/78 mm Hg, HR 110 bpm, RR 22 breaths/min, O2 saturation 98% on room air, T 38.8°C. On abdominal exam, he has epigastric tenderness and no rebound. His laboratory findings are remarkable for the following: White Blood Cell Count is 23,100mm3. A CT of the abdomen is shown below. What is the most definitive step in management? A. Observation, serial abdominal exams B. CT-guided drain C. Discharge home with oral antibiotics, and follow up in 1 week D. Fluids, IV antibiotics E. Splenectomy

C. Obtain a serum phosphorous.

A 58-year-old male with Hepatitis C and hepatocellular carcinoma underwent successful right hepatectomy. He was extubated postoperatively. On hospital day 4, he develops progressive confusion and mental status changes. He denied alcohol abuse in the past. He is afebrile. BP - 110/80 mm Hg, P- 90 bpm and regular, Resp - 22 breaths/min. An ABG is obtained: pH 7.27, PCO2 78, PaO2 80. After intubation, which of the following steps should be taken? A. Early tracheostomy B. Obtain head CT. C. Obtain a serum phosphorous. D. Obtain intact PTH. E. Start CIWA protocol.

D. Splenectomy can be performed to treat the anemia.

A 6-year-old boy presented to his ED due to jaundice and fatigue and was found to have severe anemia. His family history is unknown as he was adopted. On exam, he has icterus and splenomegaly. Lab work demonstrates an increased reticulocyte count, increased osmotic fragility and a negative Coombs test. Which of the following is appropriate definitive management of his condition? A. Splenectomy should be delayed until 10 years of age. B. Splenectomy has no role in management. C. Steroids should be initiated as first-line treatment. D. Splenectomy can be performed to treat the anemia. E. Blood transfusion and observation

C. Segment 4

A 60-year-old male undergoing a right colectomy is noted to have a questionable area on his liver. This lesion was not seen on preoperative testing. Intraoperative ultrasound reveals an intraparenchymal nodule on the left side of the liver posterior to the ligamentum teres. The left hepatic vein lies medially. The left branch of the portal vein runs transversely along the base of the nodule. The liver is methodically scanned with no other lesions are found. In which Couinaud segment is this lesion located? A. Segment 2 B. Segment 3 C. Segment 4 D. Segment 5 E. Segment 8

D. excessive tightening of the internal ring; recommendation of physical exercises

A 62-year-old male is 4 days postoperative from a repeat open right inguinal hernia repair with mesh placement. He complains of right scrotal fullness and pain. He is normotensive with normal sinus rhythm and euthermic. Physical exam reveals a firm, tender, and engorged testicle. Ultrasonographic examination is pending. The most likely diagnosis and subsequent initial treatment for this condition includes: A. ligation of the external spermatic artery; a period of non-operative management B. disruption of the pampiniform plexus; use of non-steroidal anti-inflammatories C. transection of the testicular artery; operative exploration and revascularization D. excessive tightening of the internal ring; recommendation of physical exercises E. adherence of vasculature to mesh; operative exploration with mesh explantation

E. Low-molecular-weight heparin postoperatively for 4 weeks

A 62-year-old woman is scheduled to undergo a robotic LAR for rectal cancer. What should her venous thromboembolism prophylaxis after surgery consist of? A. Sequential compression devices and ambulation B. Low-molecular-weight heparin postoperatively for 24 hours C. Low-molecular-weight heparin postoperatively until discharge D. Low-molecular-weight heparin postoperatively for 1 week E. Low-molecular-weight heparin postoperatively for 4 weeks

A. Observation

A 64-year-old female with PMH of HTN and DM is referred to you for evaluation of a splenic cyst that was incidentally discovered on CT scan. The patient denies abdominal pain, early satiety or fullness. On CT there is a ~3-cm smooth unilocular, thick-walled cyst. On further history she states she was in a motor vehicle crash 2 months ago and was admitted for traumatic injuries. What should you recommend to this patient? A. Observation B. Percutaneous drainage C. Partial splenectomy D. Splenectomy E. Biopsy

A. FFP

A 64-year-old male with diabetes, hypertension, and gout is diagnosed with retroperitoneal sarcoma and undergoes resection. His intraoperative blood loss is 2.5 L for which he receives 6 units of PRBC, 4 units of FFP and 2 units of platelets. Postoperatively in the ICU, his drains are showing moderate amounts of sanguineous drainage. He is maintaining hemodynamics with fluid bolus. Labs: Hct 28, Platelet count 110,000/mm3, PTT 35 sec, INR 1.4, Creatinine 1.3. TEG reveals prolonged R and K with decreased MA angle. What is the next step in further managing this patient? A. FFP B. Cryoprecipitate C. DDAVP D. Tranexamic acid E. Aprotinin

B. Cholecystostomy tube placement

A 65-year-old male is experiencing right upper quadrant abdominal pain and fever 3 days post CABG. Vitals signs: T: 103°F, BP 140/60 mm Hg, HR: 100 bpm, RR: 16 breaths/min, O2 sat: 96% 2L. Ultrasound shows gallbladder wall thickening, pericholecystic fluid and no gallstones. A HIDA scan is ordered and a representative image is shown. What is the best definitive treatment of this patient? A. Antibiotics and fluid resuscitation B. Cholecystostomy tube placement C. Endoscopic retrograde cholangiopancreatography (ERCP) D. Laparoscopic cholecystectomy E. Percutaneous transhepatic cholangiography (PTC)

A. Incorporation of a medially located nonabsorbable suture placed between the pectineal ligament and the iliopubic tract

A 65-year-old male presents with a non-reducible inguinal bulge and 24 hours of obstipation. BP 136/92 mm Hg, HR 106 bpm, T 98.9°F. PSH is notable for sleeve gastrectomy and radical prostatectomy. During open operative exploration, you notice bowel exiting inferior to the inguinal ligament that ascends in a cephalad direction. Your repair should include which of the following elements? A. Incorporation of a medially located nonabsorbable suture placed between the pectineal ligament and the iliopubic tract B. Utilization of a polypropylene mesh inserted into the deep inguinal ring and deployed in an upside-down umbrella fashion C. Placement of tension-free mesh secured to pubic tubercle medially, iliopubic tract inferiorly, transverse abdominis superiorly D. Inspection of the identified bowel for ischemia followed by high ligation of the hernia sac and closure of the internal ring E. Conversion to a laparoscopic approach for placement of preperitoneal mesh covering the direct, indirect, and femoral spaces

B. Diltiazem

A 65-year-old man is undergoing an elective laparoscopic cholecystectomy. He has a history of hypertension, hyperlipidemia, and diabetes mellitus type 2 and took metoprolol, diltiazem, atorvastatin, furosemide (Lasix), and spironolactone prior to coming to the hospital. During the operation, he experiences hypotension and an EKG tracing shows a new conduction defect. Withholding which of the following medications before surgery might have prevented these findings? A. Metoprolol B. Diltiazem C. Furosemide D. Atorvastatin E. Spironolactone

E. Congestive heart failure

A 66-year-old male presents to the emergency room with pneumoperitoneum due to a perforated viscus. Both he and his family, who are bedside, desire surgery and all aggressive medical measures. As you review his history, you explain the increased likelihood of postoperative pulmonary complications such as respiratory failure and prolonged mechanical ventilation. Which comorbidity places him at highest risk for postoperative pulmonary complications? A. Recent weight loss B. Age C. Serum albumin < 3.5 g/dL D. COPD E. Congestive heart failure

D. Anatomical location

A 67-year-old diabetic man presents for evaluation of a hypertrophic scar along his sternum. He underwent a sternotomy for coronary artery bypass grafting several years ago. He states that the wound was closed using staples. His postoperative course was notable for pneumonia, which resolved with antibiotic treatment. In this patient, which of the following is the strongest risk factor for hypertrophic scarring? A. Diabetes B. Post-operative pneumonia C. Closure of skin with staples D. Anatomical location

C. Twitching of the facial muscles with percussion of the facial nerve

A 67-year-old female underwent total thyroidectomy yesterday for a large goiter compressing her airway. On morning rounds, she complains of perioral numbness and tingling. Her vital signs are T 37.5°C, HR 84 beats/min, BP 116/85 mm Hg, RR 14 breaths/min, O2 sat 97% on room air. Which of the following physical exam findings is most likely to be present? A. Hypoactive deep tendon reflexes B. Proximal muscle weakness C. Twitching of the facial muscles with percussion of the facial nerve D. Abdominal rigidity

E. Recombinant PDGF

A 67-year-old female with PMH of diabetes and right lower extremity lymphedema presents to the clinic with a chronic, non-healing 5-cm x 4-cm x 0.4-cm wound on her right heel of two years duration. Biopsy is negative for carcinoma and demonstrates chronic inflammation. The wound bed has minimal slough, 100% granulation tissue with no necrosis. Drainage is moderate. She had been treated with a negative pressure system that has since been discontinued several months ago due to non-resolution of the wound after 3 months. Which of the following adjunctive therapies can be utilized to improve healing of this wound? A. E-Stim B. Negative pressure therapy C. Hydrocolloid D. Collagenase E. Recombinant PDGF

C. Vitamin A

A 67-year-old male with a past medical history significant for Crohn disease presents with a small bowel obstruction (SBO) believed to be secondary to a stricture. He has been on steroid therapy for the past three months due to a recent flare. He has failed conservative management for his SBO and the surgery team is planning to take him to the OR for an exploratory laparotomy and possible small bowel resection. What vitamin can be administered postoperatively to help with wound healing? A. Vitamin B1 B. Vitamin B6 C. Vitamin A D. Zinc E. Copper

A. Wash the wound, elevate the arm with a loose splint, re-evaluate every 15 minutes, and administer tetanus vaccine or immunoglobulin (TIG).

An 11-year-old boy is bit by a rattlesnake in the right hand 1 hour prior while on a ranch in Arizona. Puncture marks are seen between the first and second digits, redness and swelling of the hand is noticed up to the wrist, motor and sensation are intact throughout, and pulse is 2/2. Vital signs are normal. Labs are pending. What is the best management of this patient? A. Wash the wound, elevate the arm with a loose splint, re-evaluate every 15 minutes, and administer tetanus vaccine or immunoglobulin (TIG). B. Perform fasciotomy of forearm and upper arm, administer six vials of Crofab and repeat dose 2 vials every 2 hours. C. Administer 1 mg epinephrine, broad-spectrum antibiotics, and perform fasciotomy of forearm. D. Wash the wound, administer six vials of Crofab, one gram of ceftriaxone, and discharge patient. E. Use a suction device to remove venom, apply a tight-fitting splint on the entire arm, and administer fresh frozen plasma (FFP).

C. Open posterior repair with mesh

An 80-year-old male with PMH of HTN, DM and BMI 25 kg/m2 and overall good health presents with a recurrence a left inguinal hernia s/p laparoscopic repair 5 years ago without mesh. The patient is asymptomatic; however, the patient states his hernia has been increasing in size since it reappeared a year ago. He also states he had a seroma postoperatively that was not aspirated. A small fascial defect is palpated on physical exam, with an easily reducible hernia. What is the appropriate operation for this patient? A. Laparoscopic repair with mesh B. Laparoscopic repair without mesh C. Open posterior repair with mesh D. Open posterior repair without mesh E. No repair at this time, due to hernia characteristics and patient age

A. An absorptive dressing

An 81-year old woman with a medical history notable for peripheral vascular disease and diabetes is being managed for chronic ulcers in her bilateral lower extremities. She complains of significant exudative drainage from the wounds, which frequently weep and saturate her socks. Which of the following types of dressings would be most appropriate for management of this patient's leg wounds? A. An absorptive dressing B. An occlusive dressing C. A non-adherent fabric D. An antibacterial cream E. An enzymatic dressing

A. Divide the inguinal ligament.

An 87-year-old female presents with an incarcerated femoral hernia. Upon exploration, the surgeon is unable to reduce the hernia. How should the surgeon proceed? A. Divide the inguinal ligament. B. Bowel resection C. Omentectomy with bowel resection D. Place a prosthetic mesh using the plug and patch technique.

C. Magnesium

Mr. T is a 46-year-old male with a past medical history of alcohol use disorder currently admitted with diverticulitis, which is being managed with antibiotics. For the past 3 mornings, his electrolyte panel has demonstrated hypokalemia, despite receiving appropriate potassium repletion. Which other electrolyte should be corrected prior to attempting potassium repletion again? A. Sodium B. Calcium C. Magnesium D. Phosphate E. Chloride

A. Physical examination

You are called to evaluate a 66-year-old man who had a laparoscopic right colectomy 8 hours ago and now has a fever. Vital signs are: BP 110/68 mm Hg; P 95 bpm, regular; RR 22 breaths/min; T 38.7oC. The patient has mild incisional pain that is controlled with analgesics. A preoperative Foley catheter is in place. Which of the following is most important in your evaluation? A. Physical examination B. Portable chest x-ray C. Urinalysis and culture D. CT scan of the abdomen and pelvis E. Sputum culture

B. Complete the cholecystectomy and perform a Roux-en-Y hepaticojejunostomy.

You are performing a laparoscopic cholecystectomy for chronic cholecystitis in a hemodynamically stable patient with moderate adhesions. During the case, while dissecting around the cystic triangle with a mixture of blunt dissection and electrocautery, you note the presence of bile leaking from a structure you worry may be the common bile duct. You convert to open and note an injury to the common hepatic duct, roughly 50% of the circumference with slight "charring" of the edges, located 0.5 cm proximal to the cystic duct take-off from the CBD. What is the next best step in this patient's management? A. Complete the cholecystectomy and leave a drain. B. Complete the cholecystectomy and perform a Roux-en-Y hepaticojejunostomy. C. Abort the procedure and leave a drain. D. Complete the cholecystectomy, repair primarily with 5-0 absorbable suture and place a T-tube. E. Resect the damaged segment, mobilize and perform primary anastomosis with placement of T-tube via separate choledochotomy.

C. Incentive spirometer and cough/deep breathing

You are the surgical resident on call overnight. You receive a call from a nurse regarding a patient who is recovering from a laparoscopic sigmoid colectomy earlier that day regarding a fever of 100.6°F. What is the most appropriate next step in management of this patient? A. Send blood cultures and start broad-spectrum antibiotics. B. Send a urinalysis and order a chest x-ray. C. Incentive spirometer and cough/deep breathing D. CT abdomen/pelvis E. Observation

B. Stop Coumadin 5 days before surgery and resume after 24 hours.

You plan to perform a laparoscopic cholecystectomy of a 59-year-old female for symptomatic cholecystectomy. She has a several year history of atrial fibrillation and is on therapeutic Coumadin. She denies any shortness of breath and can climb a flight of stairs. What additional steps must you take before proceeding with surgery? A. Proceed with surgery. B. Stop Coumadin 5 days before surgery and resume after 24 hours. C. Admit the patient for a heparin drip 3 days prior to surgery and stop 4 hours prior to surgery. D. Stop Coumadin and bridge to therapeutic low-molecular-weight heparin. E. Stop Coumadin and bridge to enoxaparin.

A. 6 weeks after closure

A 14-year-old male sustains a 5-cm linear laceration to the upper bicep when he fell through a glass window. Cleansing of the wound, tetanus shot, and wound closure were completed in the emergency room. When will the wound achieve the highest possible tensile strength? A. 6 weeks after closure B. 24 hours after closure C. 2 weeks after closure D. 4 days after suture removal E. 8 days after closure

D. Two weeks preoperatively

A 17-year-old female with hereditary spherocytosis is scheduled for an elective splenectomy for severe anemia. When should you administer her splenic vaccinations? A. One month postsplenectomy B. Two weeks postsplenectomy C. On the day of discharge postsplenectomy D. Two weeks preoperatively E. Vaccinations are not indicated.

A. Type I

A 19-year-old Asian female with no PMH and BMI of 17 kg/m2 presents to her PCP with complaints of pruritus, abdominal pain, nausea and vomiting. On physical exam, the physician notes slight scleral icterus and a palpable small right upper quadrant mass. CBC, CMP and liver panel are within normal limits. CT scan notes a cystic-appearing lesion within the biliary tree which is further characterized by MRCP as a fusiform dilation of the common bile duct What is the Todani classification of this biliary cyst? A. Type I B. Type II C. Type III D. Type IVa E. Type IVb

C. Temperature is > 38.5°C.

On POD #5 following a colon resection, a patient develops erythema and induration of the midline wound. Which of the following is an indication to begin antimicrobial therapy? A. Erythema extends > 2 cm from the incision B. White blood cell count is 10,000. C. Temperature is > 38.5°C. D. Serum glucose > 180 mg/dL