Surgery Practice
Which of the following asymptomatic patients would be considered a good candidate for abdominal aortic aneurysm screening?
65 year old man with a 20 pack year smoking history
A 72-year-old woman presents to the emergency department with left lower quadrant abdominal pain and mild diarrhea. On abdominal exam, there is left lower quadrant tenderness. Which of the following is the best study to confirm the most likely diagnosis?
CT of the abdomen with oral and IV contrast
A 57-year-old man presents to the clinic reporting small amounts of bright red blood in his stool. His last screening colonoscopy was seven years ago when two benign adenomas were found and removed. He has a past medical history of hypertension, dyslipidemia, and gastroesophageal reflux disease. Vital signs include HR 89 bpm, RR 17/min, BP 129/87 mm Hg, T 98.8°F, and SpO2 99% on room air. Which of the following diagnostic studies is most appropriate?
Colonoscopy
A 42-year-old woman presents to the office with fatigue and generalized malaise over the past month. She feels like her neck "looks thick," and she is concerned about her thyroid. On exam, you palpate a nodular lesion in the left isthmus. A thyroid-stimulating hormone test is done and shows decreased levels. She is sent for a thyroid ultrasound that confirms a nodule that is solid, regular in shape, and 0.9 cm in diameter. Which of the following would you expect on thyroid scintigraphy?
Hyperfunctioning nodule
A 32-year-old man is admitted following a laparoscopic appendectomy. He has no complaints following recovery in the postanesthesia care unit, and his urine output is 19 mL over the past hour. Vitals indicate HR 87 bpm, RR 17 breaths/min, BP 102/63 mm Hg, T 97.9°F, and SpO2 99% on room air with a postoperative weight of 72 kg. Laboratory findings include serum potassium 5.8 mEq/L, serum sodium 138 mEq/L, and serum phosphate 1.2 mEq/L. Findings from ECG monitoring are shown above. Which of the following interventions is indicated?
IV administration of calcium gluconate
A 50-year-old man presents to the ED with new-onset abdominal pain since yesterday with radiation to his back. His history is notable for long-standing alcohol use disorder. Review of systems is positive for nausea On vital signs, he has a T of 98.9°F, HR of 110 bpm, BP of 116/70 mm Hg, RR of 20 breaths per minute, and oxygen saturation of 98%. Mild hepatomegaly and diffuse epigastric tenderness to palpation are present on physical exam. Complete blood count is notable for a hematocrit of 50%. Comprehensive metabolic panel reveals a blood urea nitrogen level of 30 mg/dL. Serum amylase level is 400 U/L, and serum lipase level is 285 U/L. Abdominal ultrasound shows a diffusely enlarged, hypoechoic pancreas, and no gallstones are present in the bile duct or gallbladder. Intravenous fentanyl is administered for pain control, and he is admitted to the hospital. Which of the following is recommended at this time?
IV normal saline
A 66 year-old man reports to the clinic to discuss his screening colonoscopy results, which indicate stage I colorectal cancer. The biopsied lesion was found in the transverse colon. Which artery requires ligation during resection of this tumor?
Middle colic artery
A 36-year-old woman with a history of severe obesity and who had bariatric surgery performed 2 years ago presents to the emergency department with abdominal pain, bloating, massive diarrhea, and palpitations. She had been at a county fair and ate a funnel cake shortly before the symptoms developed. Vital signs show a HR of 126 bpm, BP of 96/60 mm Hg, and T of 37.3°C. The bedside fingerstick is 52 mg/dL. What type of bariatric surgery did this patient have 2 years ago that most likely contributes to this presentation?
Roux-en-Y gastric bypass
A 4-week-old male presents with nonbilious projectile vomiting immediately after each feeding. On physical exam, an olive-like mass is palpated at the lateral edge of the rectus abdominis muscle in the right upper quadrant of the abdomen. Which of the following is the most appropriate diagnostic test?
US
A 21-year-old woman presents to the clinic with fatigue, headaches, weakness, abdominal pain, and nausea. Review of her past visits indicates an unintentional weight loss. Vitals are HR 87, RR 16, BP 104/67, T 98.6°F, and SpO2 100% on room air. Physical examination reveals hyperpigmentation of the gingival mucosa. Which of the following tissues is responsible for producing the deficient hormone that is causing her symptoms?
Zona fasciculata
A 35-year-old woman presents to the emergency department with an acute onset of right upper quadrant abdominal pain, nausea, and vomiting. She is afebrile and has had similar episodes previously. Which of the following is the best initial diagnostic imaging modality?
abdominal US
You are asked to evaluate a 64-year-old woman hospital inpatient who underwent a mastectomy for malignancy 36 hours ago. Her temperature was 39oC during a routine vital signs check. Her past medical history is unremarkable other than recently diagnosed breast cancer. On physical examination, she appears comfortable. Her oxygen saturation is 99% on room air. She has a suction drain in her wound, which is draining serosanguinous fluid. Her incision has mild surrounding ecchymosis and a small amount of serous drainage on the dressing. She has mildly decreased breath sounds at both lung bases. Her abdomen is soft and nontender. She has no swelling or tenderness of her lower extremities. Urinalysis is unremarkable. Which of the following is the most appropriate intervention?
acetaminophen and observation
Which of the following diagnostic studies confirms the diagnosis of miliary tuberculosis?
acid fast smear and culture of sputum
A 16-year-old girl is being evaluated for an appendectomy by general surgery. The patient reports having very heavy menstrual periods with frequent bleeding through pads and tampons onto her clothing. She uses 12-16 pads or tampons per day but states this is normal for all the women in her family. She reports no spontaneous joint pain or other bleeding problems. Which of the following diagnostic studies may be increased in this patient?
activated partial prothrombin time
A 65-year-old woman presents with abdominal pain for two days. Physical examination reveals scleral icterus, generalized jaundice, and a negative Murphy sign. Vital signs are temperature 102.6°F, respiratory rate 16 breaths/minute, blood pressure 90/45 mm Hg, heart rate 110 bpm, and oxygen saturation 98% on room air. The following results are observed on laboratory studies: white blood cell count of 16,000 cells/mm3, lipase of 190 U/L, direct bilirubin of 3.8 mg/dL, and AST and ALT of 120 U/L and 200 U/L, respectively. A bedside abdominal ultrasound demonstrates a common bile duct measuring 2 cm. Which of the following is the most likely diagnosis?
acute cholangitis
The Rapid Response Team is called on the surgical floor for your patient who is reporting palpitations and lightheadedness. The patient is stable, and your examination is normal except for tachycardia with a regular rhythm noted on auscultation. An ECG shows supraventricular tachycardia. Which one of the following medications would be most appropriate to administer to the patient in this acute setting?
adenosine
A 30-year-old man with a medical history of ulcerative colitis presents to the emergency department with complaints of severe, bloody diarrhea, abdominal pain, and malaise. Vital signs show HR 132 bpm, RR 19/min, BP 86/57 mm Hg, T 103.4°F, and SpO2 98% on room air. Physical examination reveals a toxic-appearing patient with lower abdominal distention and tenderness. Laboratory results indicate neutrophilic leukocytosis of 11,528/microL. Abdominal radiography results are shown above. Which of the following is an important component of the initial management?
administration of methylprednisolone
A 30-year-old woman with a history of biliary colic presents to the emergency department with right upper quadrant pain, vomiting, and fever that has lasted for eight hours. Labs show leukocytosis with normal liver enzymes and a normal lipase. Abdominal ultrasound shows gallstones and gallbladder wall thickening. Which of the following is the most appropriate management of this patient?
admission and cholecystectomy
A 40-year-old woman presents to your office to discuss whether she should begin yearly screening mammography. She tells you she has five children and had her first at age 17. Her age of menarche was 15. She acknowledges that she drinks approximately 8-10 drinks per week. Which part of her history is consistent with a positive risk factor for breast cancer?
alcohol consumption
A patient is diagnosed with mild to moderate ulcerative colitis. Which of the following is the most appropriate first-line maintenance therapy for this disease?
aminosalicylates
A 40-year-old man presents with mild bloody stools for three days. He also reports a severe, tearing pain during defecation followed by throbbing discomfort. Medical history is significant for constipation. A longitudinal tear in the posterior midline of the anoderm is noted on physical exam. Which of the following is the most likely diagnosis?
anal fissure
A 67-year-old man presents to the emergency department with burning lower extremity pain. He rates the pain as 7/10 at the onset but states it is now 10/10 after walking to the emergency department. He has had this pain before but notes it has been gradually worsening. The patient has a history of hypertension but does not take any medications. He currently smokes cigarettes. His BMI is 35 kg/m², T is 97.6°F (36.4°C), BP is 174/99 mm Hg, HR is 92 bpm, RR is 14/min, and SpO2 is 98% on room air. Physical exam reveals the finding above. The patient has bilateral, weak dorsalis pedis and posterior tibial pulses. While resting in the emergency department, he notes his pain is starting to improve. Which of the following is the most appropriate next step in diagnosis and overall management?
ankle-brachial index
A 27-year-old man is brought to the emergency room via ambulance after a motor vehicle collision. Vital signs are HR of 103 bpm, RR 21/min, BP 148/92 mm Hg, T 98.9°F, and SpO2 99% on room air. Physical examination reveals a seat belt sign across the chest and abdomen. A computed tomography scan reveals the findings shown above. Which of the following is the best diagnosis?
aortic dissection
A 70-year-old woman presents to the emergency department with acute-onset left leg pain. She has no history of trauma to the extremity. The left femoral pulse is present, but popliteal and pedal pulses are absent on the left. There is pallor of the lower left leg, decreased sensation below the knee, and decreased muscle strength in the left foot. Which of the following is the most likely diagnosis?
arterial thrombosis
Shifting dullness on abdominal percussion is a typical sign of what condition?
ascites
A 30-year-old man is transported to the postanesthesia care unit following transcatheter aortic valve replacement. After 20 minutes, he begins to report dyspnea and chest pain. Vitals indicate HR 42, RR 28, BP 96/57, T 98.1°F, and SpO2 98% on room air. Findings on ECG are shown above. Which of the following is the best initial treatment?
atropine
A 49-year-old man received a burn injury 10 years ago involving his anterior torso and lower extremities. He presents with the complaint that an area on his left leg that had fully healed after the initial injury has opened up again and has been seeping serous fluid for the last month. He has had no trauma to the area and has not had any fevers. What is the best next step?
biopsy of the wound
A 47-year-old right-handed woman presents to the office reporting numbness and a "pins and needles" sensation in both hands for the past 6 months. At times, the sensation extends proximally along her arm to her shoulder. Sometimes the symptoms wake her up at night. On physical examination, she has intact sensation to light touch over her fingers. Range of motion and strength testing are normal. Tapping over the volar aspect of the wrist produces tingling, radiating to the palms bilaterally. Manual compression of the wrists produces tingling in the thumb, index, and middle fingers bilaterally at 30 seconds. Holding the wrists in flexion produces tingling in the thumb, index, and middle fingers bilaterally at 60 seconds. Which of the following is the most likely diagnosis?
carpal tunnel syndrome
A 42-year-old woman presents to the clinic with difficulty breathing. She underwent a salpingectomy for permanent sterilization two days ago without complications. On physical exam, she is mobile, healthy-appearing, and talkative, although you notice she appears to be working harder than usual to draw in a breath. You order a D-dimer test, which is negative. Which of the following is the best next diagnostic test?
chest radiography
A 72-year-old woman with a medical history of coronary artery disease, hypertension, and diabetes mellitus presents to the clinic with episodic abdominal pain that has been ongoing for three months. She describes the pain as dull and crampy and identifies the epigastric area as the site of her pain. The pain begins 30 minutes after each meal and has caused her to avoid eating, with subsequent significant weight loss. Physical examination reveals a soft abdomen without tenderness or guarding despite current episode of pain reported by patient. An epigastric bruit is noted with abdominal auscultation. Which of the following is the most likely diagnosis?
chronic mesenteric ischemia
A 55-year-old man presents to the clinic with a history of intermittent epigastric pain, anorexia, and weight loss. He has several episodes of abdominal pain that typically occur 30 minutes after a meal, often radiate to the back, and are associated with nausea and vomiting. He describes his stools as bulky, foul, and fatty, and he often has to flush the toilet several times. Laboratory studies reveal normal levels of serum amylase and lipase, and elevated levels of alkaline phosphatase and total bilirubin. Which of the following is the most likely diagnosis?
chronic pancreatitis
Which of the following descriptions best characterizes the cutaneous physical exam findings in drug-induced urticaria?
circumscribed, raised, and erythematous lesions with central pallor
A 55-year-old man reports to the clinic with fatigue, lightheadedness, and blood in his stool. Laboratory findings reveal hemoglobin 10.5 g/dL, mean corpuscular volume 71 fL, mean corpuscular hemoglobin concentration 29 g/dL, and total iron-binding capacity 376 mcg/dL. In-office fecal occult blood testing is positive. Which of the following tests should be ordered to definitively diagnose the suspected disease?
colonoscopy
What sign is characterized by ecchymosis in the periumbilical region associated with acute necrotizing pancreatitis?
cullen sign
A 65-year-old man presented to the ED with confusion and shortness of breath 3 days ago. He was diagnosed with COPD exacerbation, admitted to the ICU, and was treated with intermittent positive pressure ventilation, intravenous steroids, and nebulizers. He responded well to therapy and is now ready for discharge. He is an Army veteran with a 40 pack-year smoking history. Vital signs are a temperature of 98°F, blood pressure of 132/80 mm Hg, heart rate of 83 bpm, and respiratory rate of 13/minute. Physical exam is unremarkable except for mild expiratory wheezing. His height and weight are 70 inches and 140 lb, decreased by 14 lb since his last admission 2 months ago for a urinary tract infection. He has no symptoms other than occasionally seeing red urine. He reports no dysuria.Which of the following should be performed next and will most likely lead to a diagnosis of this patient's underlying disorder?
cystoscopy
Which of the following postoperative interventions is effective at reducing aspiration pneumonia?
deep breathing and incentive spirometry
A 38-year-old man presents to the clinic reporting gnawing epigastric pain that cyclically worsens throughout the day and awakens him at night. He reports relief of his pain with eating and after drinking milk. He has no hematochezia, melena, weight loss, dysphagia, or odynophagia. Which of the following is the most likely diagnosis?
duodenal ulcer
A 23-year-old man reports to the emergency department reporting diffuse abdominal pain. He states the pain began around his umbilicus when he awoke in the morning and migrated to the right lower quadrant by midafternoon. The pain is exacerbated with riding in a car and walking, and he has been unable to eat due to nausea. Physical examination reveals diffuse abdominal rebound tenderness to gentle palpation with abdominal rigidity and guarding. Which of the following is indicated at this time?
emergent appendectomy
a 67 year old man presents with gradually worsening dysphagia and unexplained weight loss. He describes the dysphagia as a "sticking" of food in his esophagus and states that he has to carefully chew his food to prevent this from happening. Which of the following would be the best test to order at this time?
endoscopy
A 78-year-old woman is referred to the surgical clinic after a 7.0 cm abdominal aortic aneurysm was incidentally noted on ultrasound. The patient is asymptomatic and received the ultrasound to rule out kidney disease. Her blood pressure is 160/100 mm Hg on three different oral antihypertensives. Her hemoglobin A1C is 12.9% on insulin and oral therapies. Which of the following represents the best clinical intervention for this patient's abdominal aortic aneurysm?
endovascular aneurysm repair
A 63-year-old woman with a history of alcoholic cirrhosis presents to the emergency department with hematemesis. She reports vomiting a large amount of bright red blood just prior to arrival, and when you begin to examine her, she begins vomiting again. Her blood pressure is 98/52 mm Hg, and her heart rate is 112 beats per minute. Which of the following is the best initial step in managing this patient's care?
establish two large-bore IV catheters and begin fluid resuscitation
A patient with a history of a sigmoid colectomy due to complicated diverticulitis presents with progressive diffuse abdominal pain over two days. This has acutely worsened in the past six hours and is accompanied by vomiting and obstipation. A CT scan of the abdomen and pelvis reveals a C-shaped segment of dilated small bowel with two transition points at either end. The involved loop demonstrates bowel wall thickening, inter-loop edema, and stranding. Which of the following is the most appropriate next step in the management of this patient?
exploratory laparotomy
A 28-year-old woman presents to the clinic with concerns for a "lump" in her neck that she noticed about one week ago. She has no tenderness in the area. She is concerned because she has a strong family history of thyroid cancer. An ultrasound shows a 1.2 cm mass in the left isthmus that is solid and irregular. Which of the following would be the most appropriate clinical intervention at this time?
fine needle aspiration
A 30-year-old man is following up to receive results from his recent endoscopy for suspected peptic ulcer disease. Biopsy urease testing is positive, and he is started on the appropriate therapy. When should repeat testing be performed?
four weeks after completing therapy
Which of the following terms describes a thermal injury that involves the epidermis, dermis, and subcutaneous tissues?
full-thickness burn
Which of the following pathogens is most likely to cause infection in a patient postsplenectomy?
haemophilus influenzae
A 78-year-old man with a history of hypertension presents to the emergency department with worsening neurologic deficits. His spouse reports he became confused shortly after completing yard work this morning. His vital signs show a blood pressure of 224/116 mm Hg, pulse of 110 beats per minute, and temperature of 98.3°F. He is alert and oriented but is having trouble finding appropriate words. He reports a severe headache and feels nauseous. Physical exam reveals right hemisensory loss and left gaze preference. Throughout the exam, the patient becomes aphasic. Suddenly, he has a myoclonic seizure lasting 3 minutes. He is taken for computed tomography, which reveals the image above. Which of the following is the most likely diagnosis?
hemorrhagic stroke
Wound healing is a complex process that is initiated by tissue injury. Which one of the following phases occurs directly after injury?
hemostasis
A 52-year-old man with alcoholic cirrhosis is admitted following a transjugular intrahepatic portosystemic shunt placement. After 12 hours, he exhibits signs of confusion with day-night reversal and disorientation. Physical examination reveals asterixis, increased deep tendon reflexes, and a bilateral positive Babinski sign. Cranial nerves III through X are intact with normal function. Which of the following is the most likely diagnosis?
hepatic encephalopathy
A 25-year-old woman presents with fatigue, anorexia, and nausea. She returned from a business trip in Mexico two weeks ago. Physical examination reveals vague abdominal discomfort. ALT and AST are elevated. Anti-HBs as well as Anti-HAV IgM is detected in serum. Which of the following is the most likely diagnosis?
hepatitis A
A 53-year-old man with a medical history including hypertension, chronic hepatitis B, and diabetes mellitus presents to the clinic reporting unintentional weight loss, fatigue, and right upper quadrant pain. Physical examination reveals the dermatologic findings shown above in addition to splenomegaly, abdominal wall collateral vessels, and jaundice. Laboratory testing reveals an elevated serum alpha-fetoprotein level. Diagnostic imaging identifies a 3 cm lesion within the right hepatic lobe. Which of the following is the most likely diagnosis?
hepatocellular carcinoma
A 56-year-old woman presents with painless cervical and supraclavicular lymphadenopathy. She reports unintentional weight loss and occasional night sweats for three months. Pruritus, Waldeyer ring, and hepatosplenomegaly are noted on physical exam. Laboratory studies show anemia, lymphopenia, and hypercalcemia. Histology of lymph node biopsy reveals cells with at least two nucleoli in two separate nuclear lobes with a characteristic "owl's eyes" appearance. Which of the following is the most likely diagnosis?
hodgkin lymphoma
A 45-year-old woman who is an inpatient at a hospital after surgery for a thyroidectomy done earlier today reports numbness around her mouth, tingling in her hands and feet, and muscle cramps. On physical examination, she has hyperactive deep tendon reflexes, a positive Chvostek sign, and a positive Trousseau sign. Laboratory testing reveals a serum calcium of 7.4 mg per dL and an albumin level of 4.0 g per dL. Which of the following is the most likely underlying cause of her diagnosis?
hypoparathyroidism
A 49-year-old man presents to the emergency department with sudden-onset, severe, colicky right lower quadrant abdominal pain. His pain was initially intermittent but has become constant in the past 30 minutes. He reports nausea and vomiting, and physical examination reveals diffuse abdominal distention and tympany to percussion without rebound tenderness or guarding. Abdominal X-ray results are shown above. Which of the following is the most appropriate definitive intervention?
ileocecectomy
A 36-year-old woman with a medical history of hypertension and type 2 diabetes presents to the ED for an abscess on her right buttock. Her physical exam reveals a 4 cm area of warmth and fluctuance on her right superior buttock with surrounding erythema. Which of the following is the most effective management?
incision and drainage and antibiotics
A 27-year-old woman presents with complaints of rectal pain for four days. Her vital signs show a blood pressure of 140/92 mm Hg, pulse of 110 BPM, temperature of 100.4°F, and respirations of 19. Lab results reveal a white blood cell count of 13,000/mcL. On physical exam, you find a 1.3 cm mobile, fluctuant, and tender perianal abscess with surrounding heat and erythema. She reports a history of recurrent perianal abscesses in the same location. Which of the following is the best initial therapeutic approach?
incision and drainage followed by wound culture and antibiotics
A 58-year-old woman presents to the clinic with a pruritic rash on her right breast. She states this rash has spread over the past 4 weeks, and her breast has become tender. Physical examination reveals a tender, warm right breast with thickened, purplish skin overlying half of the breast and an erythematous, flattened nipple. Axillary lymph nodes are enlarged, mobile, and nontender. Which of the following is the most likely diagnosis?
inflammatory breast cancer
What is the mechanism of the thionamide class of medications, which includes propylthiouracil, methimazole, and carbimazole?
inhibition of the thyroid peroxidase enzyme
A 38-year-old woman is having surgery for elective laparoscopic cholecystectomy. She does not smoke and is generally in good health. Her only medication is levothyroxine. She has had two uneventful pregnancies and no previous surgery. Which of the following is appropriate prophylaxis for deep vein thrombosis in this patient?
intermittent pneumatic compression devices, intra and postoperatively until ambulating
A patient presents for evaluation of hemorrhoids. Upon anoscopy, you find that the hemorrhoids are located above the dentate line, prolapse with strain, and spontaneously reduce. Which of the following is the most appropriate categorization of these hemorrhoids?
internal, second degree
An 89-year-old man with a history of atherosclerosis and peripheral artery disease presents with a sudden onset of severe abdominal pain for the last two hours. He has associated nausea and vomiting. Abdominal exam reveals mild diffuse tenderness without any focal areas of tenderness, distention, or organomegaly. Hemoccult is negative. Considering the most likely diagnosis, which of the following laboratory tests would you expect to be elevated?
lactate
A 68-year-old previously healthy woman underwent surgery for a left hemicolectomy for suspected malignancy. Approximately 36 hours after surgery she noted the onset of chest pain and difficulty breathing. On physical examination, she appears anxious and has a temperature of 37oC, blood pressure of 130/80 mm Hg, heart rate of 100 beats per minute, and respiratory rate of 30 breaths per minute. Her oxygen saturation is 88% on room air. Breath sounds are normal and cardiac exam reveals tachycardia with a normal rhythm. Examination of her extremities reveals moderate swelling and tenderness of the left lower leg. Chest X-ray is normal, and an electrocardiogram shows sinus tachycardia and nonspecific ST changes. Ultrasound examination of the left leg shows a large thrombus in the femoral vein. In addition to administering supplemental oxygen and intravenous fluids, which of the following is the most appropriate next step?
low molecular weight heparin subq
A 32-year-old woman presents to your office with pain and swelling in her left leg, which has been getting worse over the past three days. She underwent surgery for left anterior cruciate ligament reconstruction one week ago, and the surgery was uneventful. She has been ambulating with crutches and elevating the leg at home. She is otherwise healthy and her only medication is an oral contraceptive. On physical examination, she has a mild effusion in her left knee and the incisions appear clean without drainage or erythema. She has diffuse edema of her lower leg and foot. Her calf is tender and firm to palpation, and her calf circumference measures 3 cm greater than that of the right leg. An ultrasound of the left lower extremity reveals thrombi in the femoral and popliteal veins. Which of the following is the most appropriate intervention?
low-molecular-weight heparin given subq plus warfarin orally
A 42-year-old woman presents to the clinic reporting early satiety, increased belching, abdominal bloating, and postprandial nausea. She has a medical history of hypertension, diabetes mellitus, and major depressive disorder. Her current medications include amlodipine, metformin, repaglinide, and amitriptyline. A scintigraphic gastric emptying study reveals reduced gastric motility, and she is started on conservative therapy. Which of the following medications should be added with refractory symptoms?
metoclopramide
A 31-year-old man is admitted following a laparoscopic cholecystectomy. After two days, he reports obstipation, nausea, and vomiting with mild, diffuse abdominal pain. Physical examination reveals abdominal distention with tympany and mild abdominal tenderness to palpation without rebound tenderness or guarding. Which of the following makes ileus a more likely diagnosis than small bowel obstruction?
mild, diffuse abdominal pain
A 24-year-old man presents to the emergency department reporting a severe "thunderclap" headache and associated vomiting with sudden onset after intercourse 30 minutes prior. Which of the following diagnostic studies should be performed first?
noncontrast CT
A 70-year-old man is referred to vascular surgery in preparation for hemodialysis initiation in the near future. He has progressive late stage 4 chronic kidney disease and was referred by his nephrologist for permanent long-term vascular access planning. In addition to chronic kidney disease, he has a history of type 2 diabetes. His anticipated life expectancy is > 3 years. He has no known vascular abnormalities. Which of the following is the recommended approach for chronic long-term hemodialysis access for this patient?
nondominant upper extremity arteriovenous fistula
A 49-year-old man with history of mitral valve prolapse with moderate mitral regurgitation presents for preoperative clearance prior to right knee meniscal repair surgery. He reports no other medical conditions, and review of systems is negative. His last echocardiogram 10 months ago and ECG 2 years ago were not notable for new abnormalities. Physical exam is unrevealing. Which of the following is the most appropriate next step for this patient?
obtain an EKG
A 48-year-old woman with no significant medical history returns to the clinic for a follow-up appointment. She reports having a sour taste in her mouth and burning pain in her throat after meals. She has been following a weight loss program and avoiding alcohol and caffeine, but her symptoms have not improved, and she is still experiencing them two to four times each week. What is the best next step in managing this patient's condition?
omeprazole once daily
A 22-year-old man presents to the clinic with well-circumscribed, painful, inflammatory nodules on his buttocks. He has tried topical mupirocin without improvement. A culture is collected and shows methicillin-resistant Staphylococcus aureus. Which of the following is the recommended treatment?
oral clindamycin
A 56-year-old man presents to your office for his annual physical. He has a 10-year history of well-controlled hypertension and hyperlipidemia and reports a 16-year history of smoking two packs per day. He reports no daily alcohol use. His medications include daily lisinopril, atorvastatin, and a low-dose aspirin. He has no pertinent family history, and his physical examination is unremarkable. He reports he had a routine screening colonoscopy 2 months ago. You review his records and note he had a prostate-specific antigen (PSA) level of 1.8 ng/mL 1 year ago. What would be the most appropriate next step in the management of age-appropriate screening for this patient?
order a low dose CT scan of the chest for lung cancer screening
A 50-year-old man presents to the emergency department with abdominal pain. The pain started 3 days ago in the left lower quadrant and has been persistent since onset. The patient also reports nausea, vomiting, and constipation but is able to tolerate oral intake. Past medical history is notable for obesity and hyperlipidemia. Vital signs are notable for a T of 100.2°F, HR of 85 bpm, RR of 16/min, BP of 132/74 mm Hg, and oxygen saturation of 98% on room air. On examination, the patient has localized tenderness to palpation in the left lower quadrant. Complete blood count is normal. A CT scan of the abdomen and pelvis reveals acute diverticulitis of the sigmoid colon. Which of the following is the most appropriate management for this patient?
outpatient management with oral antibiotics
A 33-year-old man presents to the clinic with nonbloody diarrhea and right lower quadrant pain. Review of past visits reveals a significant weight loss over the past 3 months, which the patient states is unintentional. He has a medical history of vitamin B12 deficiency and recurrent nephrolithiasis and reports a 35 pack-year smoking history. Which of the following is most likely found on colonoscopy?
patchy transmural inflammation
A 68-year-old man with a past medical history of hypertension, dyslipidemia, and prior acute myocardial infarction with coronary artery bypass grafting presents to the emergency department. His current medication regimen includes clopidogrel, enalapril, propranolol, aspirin, and atorvastatin. He describes intense, diffuse abdominal pain of sudden onset two hours ago that has since decreased in severity. Vital signs are HR 113 bpm, RR 19/min, BP 114/86 mm Hg, T 95.7°F, and SpO2 99% on room air. Physical exam reveals marked abdominal rigidity and right lower quadrant tenderness. XR is shown above. Which of the following is the most likely diagnosis?
perforated peptic ulcer
A 72-year-old woman presents to the clinic reporting pain on ambulation. She is no longer able to walk more than 10 feet without pain in both lower legs that is relieved by rest. She does not take any medications and currently smokes cigarettes, with a 20 pack-year smoking history. Physical exam reveals diminished pedal pulses bilaterally, with absent leg hair below the knees. Vital signs are within normal limits except for a blood pressure of 140/90 mm Hg. Which of the following represents the most likely diagnosis?
peripheral arterial disease
A 65-year-old man presents to the clinic with concerns about his umbilical hernia, which has been stable for 5 years. Over the last week, he reports overlying skin erythema and an aching sensation radiating into the area of the hernia. Yesterday, he developed nausea, vomiting, and abdominal pain. He has an obese BMI. On physical exam, you palpate a 3 cm firm abdominal mass protruding from the umbilicus. It is exquisitely tender when palpated. Which of the following signs would be most concerning?
peritonitis
A 45-year-old man presents with impaired balance for two days. He is of Northern European descent. Physical exam reveals glossitis and absent reflexes. Complete blood count shows white blood cell count 5.8/L, hemoglobin 9 mg/dL, hematocrit 29%, and platelet count 265,000. Mean corpuscular volume is 110 fL, while 2% of neutrophils have 6 lobes, as seen on peripheral smear. Homocysteine and methylmalonic acid are elevated. Anti-intrinsic factor antibodies are detected on immunoassay. Which of the following is the most likely diagnosis?
pernicious anemia
A woman presents to the emergency department following the sudden onset of numbness in her right arm and the right side of her face, slurred speech, and visual field defect. Computed tomography does not display findings of intracranial hemorrhage. Which of the following is a contraindication to first-line therapy for this patient?
persistent blood pressure readings of 191/105
An 80-year-old woman with an ejection fraction of 25% three months after coronary artery bypass grafting presents to the clinic with continued shortness of breath and palpitations despite rigid medication compliance. She has no dyspnea at rest. Which of the following represents an appropriate clinical intervention for her?
placement of an implanted cardioverter-defibrillator
A 70-year-old man with a history of congestive heart failure and heavy smoking presents to the emergency department with a gradual onset of cough productive of frothy pink sputum, paroxysmal nocturnal dyspnea, and worsening dyspnea on exertion over the past several weeks. He has gained several pounds and has 3+ pitting edema of his lower extremities up to his knees. Which one of the following most indicates a transudative pleural effusion according to Light criteria?
pleural fluid LDH to serum LDH ratio <0.6
A postoperative patient in the surgical ICU gets an infection. Which of the following is the most common cause of infection in this patient?
pneumonia
A left subclavian central line was placed in a 76-year-old man. The patient tolerated the procedure well, and initial chest radiography showed correct placement of the line. Two hours after initial placement, the nurse called general surgery to report that the patient is experiencing left-sided chest pain and shortness of breath. The left chest is hyperresonant on percussion and has decreased breath sounds on the left upon auscultation. No tracheal deviation is observed. Vital signs are within normal limits. What is the most likely diagnosis?
pneumothorax
You are a member of the rapid response team and are called to the bedside of an 81-year-old patient admitted for surgical repair of a fractured hip for which he has been NPO. This morning, he has acute onset of altered mental status, confusion, and lethargy. Which of the following is the most appropriate initial action in the management of this patient?
point of care glucose measurement
A 68-year-old woman initially presented to her primary care doctor with exertional angina, and physical exam revealed a crescendo-decrescendo holosystolic murmur. Echocardiography confirmed the diagnosis of aortic stenosis, and she was therefore referred to your clinic for operative evaluation for mechanical heart valve replacement. Which of the following findings would delay the operation if discovered in the immediate preoperative period?
poor dentition
A 72-year-old man has been recently diagnosed with an esophageal stricture. Which of the following findings in the patient's past medical history would be most consistent with this diagnosis?
radiation therapy to the neck
A 65-year old woman presents with abdominal pain and diarrhea. The symptoms began two weeks ago and have become progressively more severe. Her past medical history is notable for type 2 diabetes, hypertension, and osteoarthritis. Her medications include metformin, amlodipine, and nonsteroidal anti-inflammatory medications. On examination, temperature is 97.8°F, blood pressure 138/73, pulse 83, respiratory rate 18. She is mild distress. A gastrin level is 900 pg/ml (normal 25-100 pg/ml). An upper endoscopy reveals multiple peptic ulcers. A computed tomography of the abdomen and pelvis reveals a 3.4 cm mass in the pancreas. A positron-emission tomography-computed tomography scan does not reveal any abnormalities besides the 3.4 cm pancreatic tumor. Which of the following is the most appropriate management strategy for her presentation?
resection of tumor
A 48-year-old woman presents to the clinic with a painful varicosity in her right lower extremity, despite one year of conservative therapy. On exam, there is a tortuous vein in the midcalf with several surrounding telangiectasias and reticular veins. Duplex ultrasound reveals saphenous vein reflux. Which of the following treatment options represents the best clinical intervention for this patient?
saphenous radio-frequency ablation
A 25-year-old man with a history of excessive alcohol use presents to the emergency department after a sudden onset of severe epigastric pain that radiates to the back five hours prior to arrival. Associated symptoms include nausea and vomiting. Which of the following tests is most likely to confirm the suspected diagnosis?
serum lipase
A 79-year-old man presents with cramping, periumbilical abdominal pain that began yesterday and gradually has worsened. He has associated anorexia, nausea, and vomiting. A CT scan of the abdomen is ordered and shows dilated proximal loops of bowel and collapsed distal segments of bowel with nonspecific bowel wall thickening noted. Which of the following is the most likely diagnosis based on the CT findings?
small bowel obstruction
Which of the following upper endoscopy findings is consistent with a benign peptic ulcer?
smooth ulcer base filled with exudate
A 68-year-old man with a history of diabetes and hypertension is scheduled for an elective inguinal hernia repair. Which of the following classes of diabetic medication is recommended by most experts to be avoided in patients starting from 3-4 days before surgery because of an increased risk of hypovolemia?
sodium-glucose cotransporter 2 inhibitors
A 57-year-old woman presents to your clinic to discuss the results of a carotid artery ultrasound she had performed after enrolling in a research study at the local university. The ultrasound results note a 60% stenosis of the right proximal internal carotid artery. She has a past medical history of well-controlled hypertension and hyperlipidemia treated with losartan 50 mg and pravastatin 80 mg. She does not smoke and reports no history of stroke or coronary artery disease. Her vitals signs reveal a blood pressure of 110/75 mm Hg and a heart rate 75 beats/minute; the remainder of her examination is unremarkable. What would be the most appropriate next step in the management of this patient?
start of a low-dose daily aspirin
A 63-year-old woman undergoes resection of non-small cell lung cancer tumors and is placed on mechanical ventilation during her recovery in the intensive care unit. Following extubation, she reports epigastric pain with nausea and later produces coffee-ground emesis. Upper endoscopy reveals multiple petechial hemorrhages with small red and black erosions. Which of the following is the most likely diagnosis?
stress gastritis
An 18-year-old man presents to the clinic with a bulge in his groin. Which of the following anatomic locations would be consistent with an indirect inguinal hernia?
superior to the inguinal ligament
A 57-year-old man presents with nocturia, urgency, and urinary incontinence. He also reports previously having a slow stream, hesitancy, and straining to void. Symptoms are bothersome and have affected his ability to complete activities of daily living. His International Prostate Symptom Score is consistent with moderate symptoms. The symptoms began two months ago and have progressed. He drinks one cup of coffee daily. He has a history of coronary artery disease and osteoarthritis for which he takes aspirin, metoprolol, and ibuprofen. Which of the following is a first-line therapy that will provide immediate relief of symptoms?
tamsulosin
A 31-year-old woman presents with a new skin rash for one month. She reports intensely pruritic papules and vesicles that occur in grouped arrangements on the anterior aspects of her lower shins. She also reports an unintentional 18-pound weight loss and a four-month history of diarrhea with bulky, foul-smelling, floating stools. On physical exam, she is thin, afebrile, and appears comfortable. In addition to a skin biopsy, what diagnostic test should be ordered to confirm the suspected diagnosis?
tissue transglutaminase IgA antibody
A 68 year old woman with diabetes mellitus, hypertension, and dyslipidemia presents to the postoperative floor after repair of an abdominal aortic aneurysm. Her vitals are blood pressure 110/70 mmHg, pulse 98 beats/minute, respiration rate 18 breaths/minute, temp 99.7F, oxygen saturation 98%, and blood glucose 180 mg/dL. Her serum pH is 7.25, and serum lactate is 4.7 mmol/L. Which of the following is the most likely diagnosis?
type A lactic acidosis
A 25-year-old man presents to the clinic with a bulge in his groin on the right side. The bulge is palpated above the inguinal ligament on exam and protrudes with Valsalva maneuver. It is easily reducible, minimally tender to palpation, and does not have overlying erythema or edema. What is the most likely diagnosis?
uncomplicated inguinal hernia
A 17-year-old nulliparous woman presents to your office with a palpable left breast mass. She first noticed this three months ago and describes it as stable in size since that time but occasionally tender. She has no trauma to the area and has not noticed any drainage. She has no medical problems and has never had any breast biopsies. Her family history is significant for diabetes only. On exam of the left breast, you palpate a 4 cm by 3 cm well-circumscribed, mobile, rubbery mass at 11 o'clock, 2 centimeters from the nipple. Her bilateral axilla and right breast exam are negative. Which of the following is the most likely next step in diagnosis?
unilateral focused US of the left breast
A 75-year-old man presents to the clinic reporting difficulty swallowing, regurgitation of undigested food, and a mass on the left side of his neck that enlarges after meals. Which of the following is the most likely diagnosis?
zenker diverticulum
