UWorld Review- Surgery

B. Epidural hematoma Epidural hematoma are caused by tearing of the middle meningeal artery & typically occur with skull fracture. Although some patients have characteristic loss of consciousness followed by a lucid interval, many initially remain alert. However, hematoma expansionists results in neurologic decompensation with signs of elevated intracranial pressure (headache, N/V, AMS) within minutes to hours.

21-year-old man fell & hit the left side of his head on a rock. He did not lose consciousness but over the next 30 mins he developed a headache & vomited twice. BP: 136/90 & HR: 68/min. On exam, the patient is drowsy but otherwise oriented. Swelling & tenderness are noted over the left frontoparietal region. Head CT will most likely reveal what? A. diffuse axonal injury B. epidural hematoma C. intracerebral hemorrhage D. subarachnoid hemorrhage E. subdural hematoma

C. Prompt reduction of foreskin Paraphrimosis refers to the retraction & entrapment of the prepuce in an uncircumcised male patient. Management is urgent manual or surgical reduction of the prepuce

3-year-old boy is brought to the ED by his parents due to penile pain & swelling. Several hours ago, while bathing the child, his mother retracted the foreskin & was unable to return it to its normal position. The patient soon was in pain & has appeared progressively more uncomfortable. He was able to void at home with mild pain. PE shows edema & tenderness of the retracted foreskin & glans penis, which is pink & soft. Which of the following is the best next step in management of this patient? A. Emollients & sitz bath B. Penile phenylephrine injection C. Prompt reduction of the foreskin D. Topical glucocorticoid E. UA & culture

E. Weight management & exercise Initial management of osteoarthritis of the knee includes weight loss, regular moderate activity & simple analgesics. Exercises to strengthen the quadriceps muscles can reduce abnormal loading on the joint & protect the articular cartilage from further stress.

A 61-year-old man presents to the office due to chronic left knee pain. The pain is associated with mild stiffness. He has a similar pain in his hips that is gradually getting worse. The patient has no chronic medical conditions & no history of trauma. BMI is 35kg/m2. On exam, the left knee has a small effusion & mild pain over the joint lines. There is no clicking or locking of the knee, but crepitus is present with ROM. The patient is able to bear weight without pain & the joint is stable to Varus & Valgus stress. XR of the knee shows narrowing of the joint space most notable in the medial compartment & periarticular osteophyte formation. Which of the following is the most appropriate initial treatment for this patient's knee pain? A. Aspiration of the knee joint B. Corticosteroid injection of the knee C. Knee replacement surgery D. Placement of a pillow between the knees at night E. Weight management & exercise

A. Incisional hernia Incisional hernias develop due to fascial closure breakdown & may have delayed presentation (months to years). Patients typically have a slowly enlarging abdominal mass (protruding abdominal contents) that is palpable while supine & enlarges with the Valsalva maneuver.

46-year-old woman presents to the ED for an eval of an abdominal mass. The patient first noticed a small, non-painful abdominal mass 2 months ago. Over the past month, the mass has slowly grown & sometimes causes mild abdominal discomfort. The patient has had no weight loss or changes in bowel patterns. She underwent a total hysterectomy 6 years ago. BMI is 32kg/m2. The patient is a large, vertical midline abdominal scar consistent with her prior surgery. There is a small, non-tender mass at the midline below the umbilicus that is palpable while the patient is supine & increases in size with Valsalva. Which of the following is the most likely diagnosis in this patient? A. Incisional hernia B. Rectus abdominis diastasis C. Rectus health hematoma D. SQ lipoma E. Umbilical hernia

B. hemianopsia Large pituitary adenomas can cause bitemporal hemianopsia due to compression of the optic chiasm.

53-year-old woman is evaluated for progressively worsening headaches. The patient has a history of HTN & hyperlipidemia. She drinks a glass of wine daily & does not use tobacco or illicit drugs. Her LMP was 13 months ago. An MRI of her brain is performed; a sagittal image shows a large macroadenoma of the pituitary gland. Which of the following PE findings is most likely to be found in this patient? A. Facial palsy B. Hemianopsia C. Hemiparesis D. Unilateral ataxia E. Upward gaze palsy

B. lumbosacral spinal imaging Imaging is not recommended for uncomplicated acute low back pain. However, patients at risk of infection, malignancy or fractures or those with significant neurological deficits (caudal equina syndrome) warrant imaging with XR &/or MRI.

61-year-old woman presents with low back pain for 2 weeks. It is a constant aching pain that is worse at night & has awoken her from sleep. She has had no trauma or precious back problems. There is no associated fever, chills, bowel or bladder incontinence or lower extremity weakness or numbness. Medical Hx is notable for breast cancer. VS are normal. Spinal exam shows no deformities or focal tenderness. Lower extremity motor strength & reflexes are normal & symmetric. The remainder of the exam is normal. Which of the following is the most appropriate next step in management of this patient? A. epidural CCS B. lumbosacral imaging C. opioid analgesic at bedtime D. supervised exercise program E. trial of NSAIDs and follow-up

E. Urinalysis Patients with suspected benign prostatic hyperplasia should be evaluated with digital rectal & neurologic exam. Initial tests should include UA & prostate-specific antigen.

72-year-old man presents with a 3-month history of weak urinary stream, straining on urination & nocturne. He has no burning or pain with urination. The patient is a nonsmoker & has a history of HTN & osteoarthritis. He has no family history of cancer. Rectal exam shows smooth & firm enlargement of the prostate. Neurologic exam is normal. Which of the following is the best next step in eval of this patient? A. Cystoscopy B. Prostate biopsy C. Renal US D. Transrectal US of the prostate E. Urinanalysis

C . This curve is at low risk of progressing; no additional follow up is required Mild adolescent idiopathic scoliosis in a skeletally mature patient has a low risk for progression & does not require treatment or follow up.

16-year-old girl comes to the office b/c she "leans to the side" when trying to stand up straight. Her LMP was 2 weeks ago. Height & weight are at the 50th percentile. The neck is supple. The lungs have good air entry in all fields. Breast & pubic hair at Tanner stage 5. Forward bend test reveals a right rib prominence that is not relieved by placing a block under her contralateral foot. Achilles DTRs are 2+. Posteroanterior & lateral spine XRs reveal a Cobb angle of 12 degrees, indicating mild scoliosis. Which of the following is true about management of this patient? A. Annual imaging of the spine is indicated due to the patient's age B. Bracing the back will decrease this patient's risk for needing surgery in the future C. This curve is at low risk of progressing; no additional follow up is required D. This patient needs an orthopedic referral for surgery due to the degree of the curve

D. Esophageal perforation Effort rupture of the esophagus (Boerhaave syndrome) can occur with vomiting. leakage of esophageal air through the full-thickness perforation may cause pneumomediatstinum, evidence by suprasternal crepitus on exam. Confirmation with esophagography of CT scan should prompt emergent surgical consult.

19-year-old college student is brought to the ED by his friends due to severe retrosternal & upper abdominal pain. The patient was out with his friends drinking alcohol. An hour before arrival, he had several episodes of emesis, which is when he began experiencing the pain. Temp is 38.3C (101F), BP is 95/56, HR is 120/min and RR are 30/min. Pulse Ox is 97% on room air. On PE, the patient appears intoxicated & diaphoretic. Oral mucous membranes are dry & there is no pharyngeal erythema. There is palpable crepitus in the suprasternal notch. Cardiopulmonary exam is normal. Thee is mild epigastric tenderness without guarding or rebound. Which of the following is the most likely diagnosis? A. Alcohol-induced pancreatitis B. Aortic dissection C. Aspiration pneumonitis D. Esophageal perforation E. Mallory-Weiss syndrome

B. Flail chest Fracture of > 3 contiguous ribs in > 2 locations can result in flail chest, with paradoxical movement of the fractured flail segment during respiration. Flail chest can cause hypoxia due to ineffective ventilation, pulmonary contusion & atelectasis.

25-year-old man is brought to the ED after a high-speed motor vehicle collision. The patient was restrained, but there was prolonged extrication due to extensive vehicular damage. On arrival, the patient is alert & can speak but appears to have increased work of breathing. BP is 110/66, HR is 120/min and RR are 34/min. Pulse Ox is 88% on 10L of O2 via nonrebreather mask. The trachea is midline & the neck veins are flat. There are several chest wall bruises. A portion of the anterior left chest moves inward during inspiration. Breath sounds are diminished in the anterior left lung but normal elsewhere. The left thigh is deformed but compartments are soft & distal pulses are intact. There are no focal neurologic deficits. Which of the following is the most likely cause of this patient's hypoxia? A. Fat embolism B. Flail chest C. Hemothorax D. Myocardial contusion E. Tension pneumothorax

D. close to 100% Familial Adenomatous Polyposis (FAP) is an autosomal dominant disorder caused by gremlin mutation to the tumor suppressor gene adenomatous polyposis coli. Patients with FAP develop hundreds or thousands of colonic polyps; lifetime risk of colon cancer is close to 100%.

26-year-old woman is evaluated for intermittent abdominal discomfort, diarrhea & Selena. The patient undergoes colonoscopy followed by total colectomy due to significant colonic abnormalities. Representative colon findings show hundreds of thousands of colonic polyps. Her sister, who has the same biological parents & has no symptoms, also undergoes screening colonoscopy & has similar findings. If left untreated, which of the following is the most likely lifetime risk of colon cancer in this patient's sister? A. about 25% B. about 50% C. about 75% D. close to 100% E. same as general population

A. acute respiratory distress syndrome This patient has developed sepsis from postpartum endometritis which rapidly progresses into the most common consequence, ARDS. Sepsis results in systemic inflammation, which can cause damage of the pulmonary capillaries, recruitment of inflammatory cytokines & diffuse alveolar damage with leakage of proteinaceous fluid into the alveoli & alveolar collapse. The end result is impaired gas exchange. Findings of ARDS include respiratory distress, diffuse crackles on lung exam, severe hypoxemia & bilateral alveolar infiltrates on chest imaging, all of which are not completely explained by volume overload. ARDS risk factors include infections, trauma & other causes (massive transfusion).

27-year-old woman on postoperative day 3 from cesarean delivery, develops fever, chills, uterine tenderness & hypotension. The patient is started on broad-spectrum ABX & IV fluids for postpartum endometritis. Over the next 24 hours, she develops increasing dyspnea. Temp is 38.5C (101.3F), BP: 110/66, HR: 110/min, RR: 24/min. Pulse ox: 80% on a 100% nonrebreather mask and the patient is intubated. There is no jugular venous distension. Cardiac exam has no rubs or murmurs. Lung auscultation has diffuse bilateral crackles. CXR 24-hours earlier appears to be normal with minimal infiltrates throughout bilaterally. CXR at intubation shows bilateral infiltrates throughout with non identifiable landmarks. After intubation, arterial blood gases show PaO2 of 60mmHg while receiving 100% O2 and PaCO2 of 34mmHg. Which of the following best explains this patient's respiratory symptoms? A. Acute respiratory distress syndrome B. Hospital-acquired pneumonia C. Iatrogenic volume overload D. Postpartum cardiomyopathy E. Pulmonary thromboembolism

D. Plain abdominal XR Toxic megacolon is a well-recognized complication of ulcerative colitis. Patients typically present with abdominal pain/distension, blood diarrhea, fever & signs of shock. Plain abdominal XR is the preferred diagnostic imaging study. Barium contrast studies & colonoscopy are contraindicated due to the risk of perforation.

30-year-old man presents to the ED with a 4-day history of progressively worsening abdominal pain & bloody diarrhea. He was started on Mesalamine therapy 6 months ago after being diagnosed with ulcerative colitis but has been noncompliant with treatment. Temp is 38.8C (102), BP is 100/70 and HR is 130/min. The patient is lethargic & has dry mucous membranes. There is marked abdominal dissension & tenderness without rebound or guarding. Rectal exam shows guaiac-positive, maroon-colored, liquid stool. Which of the following is the best next step in this patient's workup? A. Abdominal US B. Barium enema C. Colonoscopy D. Plain abdominal XR E. Small-bowel contrast study

C. Regular dressing changes only Superficial wound dehiscence, separation of the epidermis &/or SQ tissue with an intact fascia, is typically managed conservatively with regular dressing changes. In contest, deep (fascial) dehiscence involves the fascia & is a surgical emergency.

32-year-old woman is evaluated due to fluid leakage from her incision. 2 days ago, the patient underwent a cesarean delivery. She had her incision bandage removed this morning. The patient then walked to the nursery, where she noticed that serosanguineous fluid had stained her hospital gown. Fluid has continued to drain from her abdominal incision. Temp is 37.2C (99F). BMI is 35kg/m2. The incision has a 4-cm defect at the right corner that is draining scant fluid. There is no surrounding erythema or induration. The SQ tissue has no areas of necrosis or crepitus & the rectus fascia is intact. Which of the following is the best next step in management of this patient? A. CT scan of the abdomen & pelvis B. Emergency surgical exploration C. Regular dressing changes only D. Systemic ABX & wound debridement E. Topical ABX & abdominal binder placement

E. Urology eval for stone removal < 10mm: hydration, pain control, alpha blockers & strain urine Urology consult is indicated in patients with stones(s) > 10mm, those with complicated nephrolithiasis (acute kidney injury, sepsis, complete ureteral obstruction, uncontrolled pain), and those whose stones do no pass within 4-6 weeks require urology eval for stone removal.

32-year-old woman presents to the ED due to right flank pain for the last 12 hours. The patient has severe, intermittent pain lasting 20-30 mins. She has also had nausea & several episodes of vomiting but no fever, chills or dysuria. PE shows mild right flank tenderness without guarding or rebound tenderness. Serum creatinine is 1.4mg/dL (normal: 0.6-1.2mg/dL) and blood urea nitrogen (BUN) is 33mg/dL (normal: 7-19mg/dL). UA shows moderate blood & a pH of 6.5. Pregnancy test is negative. Noncontrast abdominal CT scan reveals a high-density, 15-mm calculus in the proximal right ureter without hydronephrosis. IV analgesics, antiemetics & fluids are administered. Which of the following is the best next step in management of this patient? A. Oral Tamsulosin to facilitate stone passage B. Percutaneous nephrostomy tube insertion C. Supportive care with urine straining D. Urine alkalization therapy E. Urology eval for stone removal

D. Reassurance & observation Hiatal hernia is a common disorder that occurs when the contents of the abdominal cavity herniate through the diaphragm into the thoracic cavity at the esophageal hiatus. Plain XR typically reveals a retrocardiac opacity (often with an air/fluid level), within the thoracic cavity. Asymptomatic sliding hiatal hernias do not require further workup of intervention whereas patients with gastroesophageal reflux disease should be medically managed.

35-year-old man presents to the office for follow-up of an abnormal CXR. The patient went to the ED 2 weeks ago after a chest injury; during a softball game, he was struck in the chest by a ball thrown from a distance of 4 feet. Initial eval showed no significant trauma or rib fracture but the CXR revealed an air/fluid level posterior to the cardiac silhouette consistent with a sliding hiatal hernia. The patient feels well & has had no heartburn, regurgitation, difficult swallowing, or abdominal discomfort. He has no other medical conditions & takes no meds. VS are normal. PE shows no abnormalities. Which of the following is the best next step in management of this patient? A. 24-hour esophageal pH monitoring B. Esophageal manometry C. Laparoscopic Nissen fundoplication D. Reassurance & observation E. Upper GI endoscopy

E. Serum TSH Thyroid nodules should be evaluated by serum TSH & US. A radionuclide scan is indicated ONLY for patients with LOW TSH.

36-year-old woman is found to have a thyroid nodule during a routine physical exam. She has had no heat or cold intolerance, skin changes or fatigue. Her appetite & stooling habits have not changed, and her weight is stable. Menstrual cycles are regular with no excessive bleeding. The patient has no other medical conditions & takes no meds. Family Hx is negative for thyroid disorders. PE shows a 1-cm, discrete, nontender & firm nodule in the left thyroid lobe. Which of the following is the best next step in management of this patient? A. Anti-thyroid peroxidase antibody B. CT scan of the neck C. Radionucleotide thyroid scan D. Reassurance & close follow up E. Serum TSH

A. cholecystectomy within 72 hours Acute cholecystitis presents with RUQ pain, fever & leukocytosis. Patients with acute cholecystitis should be treated with laparoscopic cholecystectomy within 72 hours.

38-year-old woman presents to the ED due to 12 hours of RUQ pain associated with nausea & vomiting. The patient has had similar pain, usually after the ingestion of fatty foods, but past episodes have always resolved in 1-2 hours. Medical Hx includes hypertriglyceridemia, for which she takes Fenofibrate. Temp is 38.3C (100.9F), BP is 130/70, HR is 98/min and BMI is 34kg/m2. Exam shows RUQ tenderness. Leukocyte count is 15,000/mm3. LFTs are normal. Abdominal US reveals gallstones, a thickened gallbladder wall with edema, and a normal common bile duct. In addition to supportive care, which of the following is the best next step in management of this patient? A. Cholecystectomy within 72 hours B. Delayed cholecystectomy after 7 days C. D/c of Fenofibrate & reevaluation in 3 months D. Endoscopic retrograde cholangiopancreatography E. HIDA scan

B. Alcohol withdrawal Delirium tremens is a late manifestation of alcohol withdrawal that is characterized by delirium, hyperthermia, hypertension & tachycardia 48-96 hours after the last drink. Delirium tremens is associated with a mortality rate of 5% & requires aggressive ICU-level support management in addition to benzodiazepine therapy.

39-year-old woman undergoes an appendectomy for appendicitis. The patient has an uncomplicated postoperative course until hospital day 3, when she suddenly becomes acutely agitated. She shouts, "Get your hands off me! God is watching" when the nurses try to redirect her back into bed. The patient has a history of schizophrenia & multiple substance use disorders. She has had multiple admissions related to her substance use. Temp is 39C (102.2F), BP is 171/95 and HR is 102/min. The patient is oriented only to person. She is diaphoretic but the remainder of the exam is limited due to agitation. Which of the following is the most likely cause of this patient's condition? A. Acute schizophrenia exacerbation B. Alcohol withdrawal C. Cocaine intoxication D. Malignant hyperthermia E. Opioid withdrawal

D. Ruptured berry aneurysm Nontraumatic subarachnoid hemorrhage is most commonly due to ruptured saccular (berry) aneurysm and typically presents with thunderclap headache and symptoms of meningeal irritation (nuchal rigidity, photophobia, nausea). Noncontrast CT scan usually reveals acute bleeding around the brainstem and basal cisterns.

40-year-old man presents to the ED due to severe headache associated with photophobia & nausea for the past several hours. He has a 2-year history of HTN and has smoked a pack of cigarettes daily for 15 years. His father died of stroke at the age of 75. Temp is 37.7C (100F), BP is 170/100, HR is 92/min and regular. He appears to be uncomfortable & had an episode of non bilious vomiting in the ED. Neurologic exam shows 4/5 motor strength & 2+ deep tendon reflexes bilaterally in the upper & lower extremities. Sensation to light touch & pinprick is normal. CT scan of the head without contrast shows acute bleeding around the brainstem. Which of the following is the most likely cause of this patient's headache? A. Cerebral arteriovenous malformation B. Cerebral venous thrombosis C. Hypertensive encephalopathy D. Ruptured berry aneurysm E. Vertebral artery dissection

A. bowel rest and serial exam Prolonged postoperative ileus, the delayed return of bowel function > 72 hours after surgery, is typically self-resolving; therefore, management is conservative with bowel rest & serial exams. Abdominal XR is suggestive of postoperative ileus showing uniformly dilated bowel loops due to generalized bowel paralysis throughout small & large bowel. In contrast, patients with SBO has a discrete transition point (the obstruction) that results in dilated small bowel proximal to the obstruction & decompressed large bowel (absent rectal gas) distally.

45-year-old woman is evaluated for nausea & vomiting on postoperative day 3 after a total abdominal hysterectomy complicated by ureteral stent placement. She was placed on a clear liquid diet on postoperative day 2, when she began to have some nausea. Since then, the patient has had multiple episodes of vomiting but no hematemesis. She has not passed flatus or had a bowel movement since the surgery. Temp is 37.2C (99F), BP: 130/80, HR: 80/min. The abdomen is mildly distended & has decreased bowel sounds. The incisions has no surrounding erythema or d/c. CBC and serum chemistry panel are normal. Abdominal XR shows uniformly dilated bowel loops throughout both small & large bowel. In addition to IV fluid administration, which of the following is the best next step in the management of this patient? A. bowel rest & serial exam B. broad spectrum ABX C. rectal enema D. small bowel follow through E. urgent surgical exploration

A. Acalculous cholecystitis This condition is most often seen in severely ill patients in the ICU with multi organ failure, severe trauma, surgery, burns, sepsis or prolonged parenteral nutrition. Acalculous cholecystitis is likely due to cholestasis & gallbladder ischemia leading to secondary infection & resultant gallbladder edema & necrosis. Radiologic signs include gallbladder wall thickening & distension with pericholecystic fluid. Emergent treatment in critically ill patients includes ABX followed by percutaneous cholecystectomy. The clinical presentation may be similar to calculous cholecystitis showing fever, leukocytosis, elevated LFTs, RUQ pain, jaundice +/- RUQ mass

46-year-old man is brought to the ED after being involved in a MVA. He is unresponsive & has multiple fractures, contusions & hemopneumothorax on the right. After multiple blood product transfusions & placement of a chest tube, his condition stabilizes. On the 5th day of his hospital stay, he is minimally responsive. Exam shows diminished bowel sounds & pain with palpation of the RUQ. An abdominal CT scan reveals gaseous distension of the small & large bowels without air-fluid levels. The gallbladder is distended with no gallstones; there is a small amount of pericholecystic fluid. Which of the following is the most likely cause of this patient's condition? A. Acalculous cholecystitis B. Duodenal perforation C. Mesenteric ischemia D. Pancreatitis E. Small-bowel obstruction

A. Abdominal US Hepatocellular carcinoma (HCC) is a common complication of cirrhosis; therefore, screening with abdominal US every 6 months is recommended. HCC often presents with liver decompensation (new-onset ascites, vatical bleeding), which should prompt abdominal US to evaluate for HCC.

50-year-old man presents to the office due to 2 months of progressive generalized weakness, anorexia & abdominal distension. The patient has a history of EtOH use disorder & liver cirrhosis, which was diagnosed 5 years ago. RUQ US performed 18 months ago was consistent with cirrhosis. VS are normal. The patient is alert & oriented. Cardiopulmonary exam is normal & there is no jugular venous distension. The abdomen is distended & has shifting dullness to percussion. There is bilateral lower extremity pitting edema. Multiple spider angiomas are noted. LFTs show: Albumin: 3.1 g/dL Total bilirubin: 2.1 mg/dL Alkaline phosphatase: 330 U/L Aspartate aminotransferase: 89 U/L Alanine aminotransferase: 95 U/L Serology is negative for viral hepatitis. Which of the following is the best next step in management of this patient? A. Abdominal US B. Anti-mitochondrial antibodies C. Diuretic therapy & follow-up in 2 weeks D. Echocardiography E. Lactulose with follow-up in 2 weeks

D. XR of the chest Superior pulmonary sulcus tumors are usually malignant lung neoplasms & most commonly present with referred shoulder pain. Other common findings include Horner Syndrome & radicular pain, paresthesias, or weakness of the ipsilateral arm due to invasion of the brachial plexus.

50-year-old woman presents to the office due to right shoulder pain that radiates to her hand. The patient was diagnosed with rheumatoid arthritis 10 years ago & usually has pain in her joints. However, she believes that the current pain is not due to her arthritis. The patient has had a cough for several months & feels more tired than usual. Her meds include Methotrexate & Naproxen. She has a 25-pack-year smoking history. Vital signs are normal. Physical exam shows bilateral hand joint deformities with mild swelling & tenderness. The right pupil is constricted & there is drooping of the eyelid. ROM over the right shoulder is normal. Which of the following is the best next step in management of this patient? A. CT scan of the head B. Edrophonium (Tensilon) test C. Nerve conduction study D. XR of the chest E. XR of the right shoulder

B. Postoperative deep-breathing exercises This postoperative patient with dyspnea most likely has atelectasis, developed likely from a combo of retained airway secretions & postoperative abdominal pain (likely causing patient to take short/shallow breaths). Postoperative atelectasis is common after thoracic or abdominal procedures & typically manifests 2-5 days following surgery. Deep-breathing exercises & incentive spirometry can help prevent this from occurring.

52-year-old man is found to be tachypneic 2 days after an uncomplicated upper abdominal ventral hernia repair. Until now, his postoperative course had been unremarkable, and he has low-dose morphine for pain control. The patient feels SOB but has no chest pain. He has an occasional cough with a small amount of early-morning sputum. The patient is an active smoker with a 15-pack-year history. Temp is 36.7C (98.1F), BP is 123/79, HR is 90/min and RR are 28/min. BMI is 32kg/m2. There are decreased breath sounds at the right lung base without wheezes or prolonged expiration. Heart sounds are normal. There is abdominal distension & diffuse tenderness without rebound. CXR reveals a dense opacity at the right lung base. Which of the following would have been most effective in preventing this patient's current condition? A. Perioperative broad-spectrum ABX B. Postoperative deep-breathing exercises C. Postoperative low-molecular-weight Heparin D. Preoperative systemic glucocorticoids & albuterol E. Smoking cessation 1 week before surgery

B. Greater trochanteric pain syndrome Greater trochanteric pain syndrome is an overuse syndrome involving the tendons of the gluteus medius minimus at the grater trochanteric. It presents with chronic lateral hip pain that is worsened with repetitive hip flexion or lying on the affected side. Physical exam shows local tenderness over the greater trochanter.

53-year-old man comes to the office due to right-sided lateral hip pain that makes it difficult for him to lie on that side while sleeping. He describes the pain as burning & localized it to the outer surface of the thigh. The pain has recently occurred during the day & is worse with activity & prolonged standing. On exam, there is localized tenderness over the lateral aspect of the right hip with deep palpation. Neuro exam is normal. Which of the following is the most likely cause of this patient's pain? A. Femoral neck stress fracture B. Greater trochanteric pain syndrome C. Hip osteoarthritis D. Iliotibial band syndrome E. Lumbar radiculopathy

E. Venous thrombosis Tamoxifen, a selective estrogen receptor modulator is used for adjuvant therapy in some patient with estrogen receptor-positive breast cancer. Tamoxifen is associated with an increased risk for venous thromboembolism and uterine cancers (endometrial and uterine sarcoma).

53-year-old postmenopausal woman presents to the office for a follow-up visit. The patient recently had surgery for early-stage, estrogen receptor-positive breast cancer initially found on screening mammography. She was given an aromatase inhibitor postoperatively but d/c the therapy due to intolerable side effects. Today she is starting tamoxifen as an adjuvant endocrine treatment. The patient has no other chronic medical conditions. Her mother has type 2 DM & had a minor stroke. Her father died from metastatic colon cancer. VS are normal. BMI is 29kg/m2. This patient is at highest risk for which of the following complications from tamoxifen therapy? A. Diabetes mellitus B. Myocardial infarction C. Osteoporosis D. Ovarian cancer E. Venous thrombosis

B. Duplex US Peripherally inserted central catheters (PICC) increase the risk of upper extremity deep venous thrombosis. Patients at the greatest risk are hospitalized patients, particularly those with malignancy or other hyper-coagulable state. Manifestations include arm swelling, erythema & pain. The diagnosis with duplex US. Treatment with 3 months of anticoagulation is required.

56-year-old man presents with pain, redness & swelling in his right arm. The patient was recently diagnosed with unresectable lung cancer. He received the 1st cycle of chemotherapy 2 weeks ago through a right-sided peripherally inserted catheter (PICC). Temp is 36.9C (98.4F), BP is 130/80, HR is 78/min and RR are 14/min. O2 saturation is normal. Exam shows right arm swelling & mild erythema. Capillary refill is normal. No d/c seen around the PICC line. The remainder of the exam is normal. Which of the following is the best next step in management? A. Chest MRI B. Duplex US C. Echocardiography D. Empiric ABX E. Warm compresses & NSAIDs

B. RBC casts This patient has acute, recurrent flank pain associated with ureteral dilation; this presentation is consistent with acute ureterolithiasis (kidney stones). Although US is relatively sensitive for ureteral & calyceal dilation due to an obstructing stone (hydronephrosis), small stones themselves may not be visible. Urine sediment in acute ureterolithiasis typically shows free RBCs (hematuria) & crystals consistent with the type of stone.

57-year-old man comes to the ED due to nausea, vomiting & severe cramps pain in the right flank. Several days ago, the patient had similar, but less severe, pain that resolved spontaneously. He has DM2, obesity, hyperlipidemia, HTN and gout. Temp is 37C (98.6F) and BP is 160/100. Physical exam shows right flank tenderness. BUN and serum creatinine are normal. Abdominal US reveals right-sided hydronephrosis & proximal ureteral dilation. UA in this patient would most likely reveal which of the following? A. Malignant cells B. RBCs C. RBC casts D. Specific gravity of 1.002 E. WBC casts

C. Emphysematous cholecystitis Emphysematous cholecystitis is a life-threatening form of acute cholecystitis that occurs more commonly in patients with immunosuppression (diabetes) or vascular disease. It arises due to infection of the gallbladder wall with gas-forming bacteria & requires emergency cholecystectomy

59-year-old woman arrives at the ED due to RUQ pain, nausea, vomiting & fever since yesterday. She has no hematemesis, constipation, diarrhea or SOB. Temp is 38.9C (102F), BP is 112/76 & HR is 101/min. BMI is 34kg/m2. There is marked tenderness & voluntary guarding to palpation in the RUQ of the abdomen. Lab results- Leukocytes: 18,300/mm3 (high) Total bilirubin: 1.9 mg/dL (high) Alkaline phosphatase: 93 U/L(high) Aspartate aminotransferase: 42 U.L (normal) Alanine aminotransferase: 40 U/L (high) Abdominal imaging demonstrates a distended gallbladder with gas in the gallbladder wall & lumen. There is no gas in the biliary tree. Which of the following is the most likely diagnosis in this patient? A. Acute cholangitis B. Biliary-enteric fistula C. Emphysematous cholecystitis D. Gallstone ileus E. Peptic ulcer perforation

B. Alkaline phosphatase level Paget disease of bone is characterized by excessive & disordered bone formation. It commonly affects the skull, long bones & vertebral column. The increased formation of new bone is associated with an elevated serum alkaline phosphatase level. Radiographs shows lytic or mixed lytic-sclerotic lesions, thickening of cortical & trabecular bone & bony deformities.

60-year-old man presents to the office due to a 4-month history of increasing mid thoracic back pain, which is aggravated by coughing. The patient has also had right thigh pain but no numbness or weakness in the legs & no bowel or bladder incontinence. He has no other medical conditions. Vital signs are normal. On exam, there is tenderness over the 8th and 9th thoracic vertebrae. Neurologic exam is normal. The prostate is normal in size & has no palpable nodules. Serum calcium level is normal. Imaging studies reveal enlarged vertebral bodies with cortical thickening. Serum testing for which of the following would most likely help establish a diagnosis in this patient? A. 25-hydroxyvitamin D level B. Alkaline phosphatase level C. ESR D. Parathyroid hormone level E. Prostate-specific antigen level

D. Weakness of the transversals fascia Direct inguinal hernias occur most commonly in older men due to weakness of the transversalis fascia. They protrude medial to the inferior epigastric vessels into the Hesselbach triangle & pass only through the superficial inguinal ring with no direct route to the scrotum.

62-year-old man presents due to intermittent groin pain. The pain is most severe when the patient lifts heavy loads and after a long day at his job as a construction worker. PE shows a right-sided groin bulge directly directly above the inguinal ligament. The bulge increases in size when he bears down. An US reveals that the mass originates medial to the inferior epigastric vessels. This patient's condition is most likely caused by which of the following? A. Failure of the internal inguinal ring to close B. Patient processus vaginalis C. Separation of the abdominal muscles D. Weakness of the transversalis fascia E. Widening of the femoral ring

E. Renal cell carcinoma Renal cell carcinoma is common in older patients who smoke. It often presents with weight loss, hematuria, firm/non-tender flank mass &/or intermittent fever.

62-year-woman comes to the office due to 6 weeks of malaise & intermittent fever. She has also had decreased appetite & unintentional weight loss but no bowel or bladder symptoms. The patient has DM2 & HTN. She has smoked a pack of cigarettes daily for 30 years. Temp is 37.9C (100.2F), BP is 140/90, HR is 90/min and RR are 16/min. On exam, she appears thin & pale. A hard mass is palpated over the right flank area. There is no abdominal tenderness, and bowel sounds are normal. The liver & spleen are not enlarged. No lymphadenopathy is present. Lab results: Hemoglobin: 10.5g/dl (normal: 12.0-16.0) Leukocytes: 9,800/mm3 Creatinine: 1.2mg/dL (normal) Calcium 9.8mg/dL (normal) Which of the following is the most likely diagnosis in this patient? A. Appendiceal abscess B. Hydronephrosis C. Non-Hodgkin lymphoma D. Polycystic kidney disease E. Renal cell carcinoma

A. Finasteride 5-alpha reductase inhibitors (Finasteride, Dutasteride) inhibit the conversion of testosterone to dihydrotestosterone in the prostate. These drugs reduce prostate volume in patients with BPH and relieve the fixed component of bladder outlet obstruction. BPH is due to the effects of dihydrotestosterone on prostatic epithelial cells & is characterized by progressive prostate enlargement with age, leading to bladder outlet obstruction & incomplete bladder emptying. Bladder outlet obstruction is composed of a dynamic component (increased smooth muscle tone in the bladder neck, prostate capsule & prosthetic urethra) and a fixed component (structural effects of the enlarged prostate).

64-year-old man presents to the office due to urinary frequency, hesitancy & dribbling. His symptoms began insidiously 5 years ago & have progressively worsened. He has to get up 2 or 3 times each night to urinate. Vital signs are normal. Exam shows a smooth, symmetrically enlarged prostate without nodules or tenderness. There is no suprapubic tenderness. Prostate-specific antigen level is 3.5ng/mL (WNL), creatinine is 1.2mg/dL (WNL), and UA is normal. The patient is prescribed a new medication. After 6 months of therapy, his urinary symptoms improve & prostate volumes decreases by 20%. Which of the following meds is most likely responsible for the decreased prostate volume in this patient? A. Finasteride B. Phenazopyridine C. Tadalafil D. Tamsulosin E. Tolterodine

E. Splenic flexure This patient with acute abdominal pain followed by lower GI bleeding after an episode of hypotension most likely has ischemic colitis. Ischemic colitis is characterized by acute abdominal pain & lower GI bleed. It typically follows an episode of hypotension & most commonly affects arterial watershed areas at the splenic flexure & rectosigmoid junction. CT scan may show a thickened bowel wall. Colonoscopy can confirm the diagnosis.

64-year-old man with a history of coronary artery disease & peripheral vascular disease undergoes coronary artery bypass surgery. His postoperative course is complicated by hypotension, which is treated successfully with IV fluids; however, a few hours later, he experiences abdominal pain followed by bloody diarrhea. Temp is 37.8C (100F), BP is 110/60, and HR is 110/min. Abdominal exam shows normal bowel sounds with no significant guarding or focal tenderness. A venous lactic acid level is elevated. An abdominal CT scan is ordered. Which of the following areas will most likely show abnormal findings? A. Ascending colon B. Hepatic flexure C. Jejunum D. Mid transverse colon E. Splenic flexure

E. Myasthenia gravis Myasthenia gravid presents with fatiguable weakness of the extra ocular & bulbar muscles. Diagnosis is supported by the bedside ice pack test, in which an ice pack is applied over the eyelids for several minutes, leading to improvement of ptosis. Patients with positive test results undergo confirmatory testing for acetylcholine receptor antibodies.

65-year-old man is being evaluated for new-onset ptosis. Earlier today, the patient underwent right total knee arthroplasty without complications. Postoperatively, he had difficulty opening his left eye & developed slurred speech. The patient has never had these symptoms, & his preoperative neurologic exam was unremarkable. Medical history includes DM2 & a 20-pack-year smoking history. VS are normal. Neurologic exam reveals bilateral ptosis, left greater than right. Pupils are equal in size & reactive to light. An ice pack is placed over the closed eyelids for 2 mins, leading to improvement of the ptosis. Which of the following is the most likely cause of this patient's current symptoms? A. Bell palsy B. Diabetic mononeuropathy C. Horner syndrome D. Lambert-Earton myasthenia syndrome E. Myasthenia gravis

A. Argatroban Suspected heparin-induced thrombocytopenia requires immediate cessation of all forms of heparin & initiation of anticoagulation with a non heparin age (Argatroban or Fondaparinux)

65-year-old man presents to the ED due to severe right leg pain & is found to have an acute thrombotic occlusion of the right popliteal artery. The patient is admitted to the surgical floor & IV unfractionated Heparin is initiated. The following morning, he undergoes surgical revascularization of the right leg. The patient's hospital course progresses well, but on post day 5, his platelet count decreases from 240,000/mm3 on admission to 65,000/mm3. VS are stable. The surgical wound is healing well. There are no rashes or pitting edema. In addition to stopping the unfractionated Heparin, which of the following is the best next step in management? A. Argatroban B. Low-molecular-weight-Heparin C. Observation only D. Platelet transfusion E. Warfarin

A. cystoscopy Bladder cancer is common in older adults & often presents with hematuria, voiding symptoms (dysuria, frequency), &/or hydronephrosis with flank pain. Cystoscopy is required to visualize the bladder wall & to biopsy suspicious masses.

65-year-old man presents to the office due to 3 days of progressive right flank pain. The patient also notes 4 weeks of dysuria & urinary frequency. Temp is 37.1C (98.8F). The abdomen is soft & nontender. No suprapubic tenderness is present, but there is mild right-sided costovertebral angle tenderness. The external genitalia are normal, and there is no penile d/c. Rectal exam shows mildly enlarged prostate without nodules or tenderness. Lab results: Creatinine 1.5mg/dL UA- Blood: moderate Bacteria: none RBCs: 30-40/hpf Casts: none Dysmorphic cells: none Urine gram stain is negative, urine culture does not grow any organism. Abdominal US reveals right-sided hydronephrosis & a normal left-sided kidney and ureter. Which of the following is the most appropriate next step? A. Cystoscopy B. Foley catheter placement C. Prostate biopsy D. Prostate specific antigen level E. Repeat UA in 3 months

D. prior abdominal surgery Small bowel obstruction commonly presents with moderate to severe colicky abdominal pain, vomiting, obstipation, dissension & diffuse tenderness. Prior abdominal or pelvic surgery is an important risk factor, but conditions including hernias, intestinal inflammation, malignancy & prior radiation also increase the risk

65-year-old woman presents to the ED with 24 hours of colicky abdominal pain, nausea & 2 episodes of vomiting. The patient has never had similar symptoms. She has a.fib, nonischemic cardiomyopathy, HTN & DM2 for which she takes multiple meds. The patient underwent an abdominal hysterectomy for endometrial hyperplasia 15 years ago. Temp is 37.2C (99F), BP: 139/88, HR: 98/min & RR: 16/min. Lungs are CTA. The abdomen is distended, tympanic & moderately tender. There is no rigidity or rebound, and bowel sounds are hyperactive. Abdominal XR is shown to have multiple dilated loops of the small bowel with multiple air fluid levels. This patient's condition is most strongly associated with which of the following? A. Diabetic autonomic neuropathy B. Digoxin toxicity C. Hypokalemia D. Prior abdominal surgery E. Recent ABX use

B. IV hypertonic saline This patient has severe hyponatremia, most likely due to SIADH. The resulting hyponatremia can be worsened by postoperative administration of IV fluids (5% Dextrose with 0.45% saline), which in the setting of SIADH can lead to further water retention. Patients with the syndrome of inappropriate antidiuretic hormone secretion who are asymptomatic or have mild symptoms usually respond to fluid restriction. Patients with severe symptoms are at high risk of rapid neurologic deterioration & death & require treatment with hypertonic (3%) saline.

66-year-old hospitalized man is evaluated after an episode of generalized tonic-clonic seizure. He underwent right hemicolectomy for cecal adenocarcinoma the previous day. Postoperatively, he has been receiving IV infusion of 5% dextrose with 0.45% saline. He is also receiving morphine via a patient-controlled device. On physical exam he is postictal. Vital signs are normal. Lab results: Sodium: 114 mEq/L (low) Potassium: 4.2 mEq/L (normal) Chloride: 90 mEq/L (low) Bicarbonate: 22 mEq/L (normal) Glucose: 120 mg/dL (high) Which of the following is the best next step in management of this patient? A. Fluid restriction B. IV hypertonic saline C. IV lactated Ringer solution D. IV Naloxone E. IV normal saline

D. Right hemiparesis This patient is presenting with a Lacunar stroke Ex: small penetrating artery occlusion due to HTN arteriolar sclerosis (Risk Factors: HTN, DM, advanced age, increased LDL & smoking) Affected areas: basal ganglia, subcortical white matter & pons Common lacunar presentations: pure motor hemiparesis (most frequent), pure sensory stroke, ataxic hemiparesis & dysarthria-clumsy hand syndrome. Cortical findings (aphasia, agnosia, neglect, apraxia, hemianopia), seizures & mental status changes (stupor, coma) are typically absent.

66-year-old man with a history of HTN is brought to the ED with sudden-onset neurologic symptoms. MRI of the brain shows an acute left lacunar infarct. Which of the following is the most likely finding in this patient? A. Expressive aphasia B. Left gaze deviation C. Right hemineglect D. Right hemiparesis E. Right homonymous hemianopia with macular sparing

D. Direct current cardioversion Immediate synchronized cardioversion is the initial treatment of choice in patients with persistent tachyarrhythmia (narrow or wide complex) associated with clinical or hemodynamic instability (hypotension, cariogenic shock, signs of ischemia, acute heart failure) ECG strip description is consistent with atrial fibrillation with rapid ventricular response (pulse > 100)

69-year-old man undergoes coronary artery bypass grafting & aortic valve replacement surgery. He has a history of aortic stenosis, coronary artery disease & HTN. The surgery is uncomplicated & the patient is extubated & transferred to the step-down unit on postoperative day 2. That night, he experiences sudden onset of weakness, chest tightness, & SOB. On exam, he appears in moderate distress. BP is 70/30, HR is 148/min & respirations are 26/min. Lung auscultation indicates bibasilar crackles. An ECG rhythm strip shows an irregularly irregular, narrow complex tachycardia along with fine fibrillary waves. Which of the following is the best next step in management of this patient? A. Amiodarone B. Defibrillation C. Diltiazem D. Direct current cardioversion E. Lidocaine

A. obtain medical interpreter services Family members should be used as medical interpreters only in urgent situations. Otherwise, trained medical interpreters should be used for all aspects of the health care provider-patient interaction (interview, explanation of diagnosis, consent, treatment planning, etc...)

74-year-old women comes to the office for a new patient visit, accompanied by her son. The patient's first language is Spanish, but she indicates that she is also comfortable speaking English. She points to a nonhealing ulcer on her right forearm that has been present for approx a year. PE shows a lesion concerning for squamous cell carcinoma. As the health care provider explains the diagnostic possibilities & need for a biopsy, it becomes apparent the patient is having difficulty understanding the info presented in English. The son suggests that he could serve as her interpreter. The patient's nurse offers to interpret, stating that he knows some Spanish. Which of the following is the most appropriate next step? A. obtain medical interpreter services B. provide written educational materials in Spanish C. repeat the explanation in English using simpler terminology D. use the patient's nurse as interpreter E. use the patient's son as interpreter

E. Vertebral compression fracture A vertebral compression fracture is a common complication of advanced osteoporosis. Such patients can develop a compression fracture with acute back pain following a minimal trauma (bending, coughing, lifting). Exam may show localized/point tenderness and neurologic exam is typically normal.

75-year-old woman comes to the ED due to sudden severe back pain that started after lifting a turkey from the freezer. The pain worsens with standing, walking & lying on her back. The patient has had no recent falls, lower extremity weakness, or sensory loss in the legs. She has been taking daily prednisone for several months for temporal arteritis. Vital sings are normal. Physical exam reveals midline tenderness to palpation of the lumbar spine, Knee reflexes are 2+. Muscle strength is 5/5 in both legs. Bilateral strains-leg raise test does not lead to shooting pain down the legs. Which of the following is the most likely diagnosis in this patient? A. Ankylosing spondylitis B. Herniated disc C. Lumbosacral strain D. Spinal stenosis E. Vertebral compression fracture

D. CT angiography Acute type A aortic dissection can extend into the pericardial space, causing hemoperricardium & rapidly progressing to cardiac tamponade & cardiogenic shock. CT angiography is the initial diagnostic study of choice in hemodynamically stable patients & reveals an intimal flap separating the true & false lumens in the ascending or descending aorta.

78-year-old man is brought is brought to the ED due to an episode of syncope while working in his garden. He is now alert & oriented. He has chest & neck pain that developed just prior to the syncopal episode. Over the past week, he has had a cough & chest tightness. Medical history is significant for HTN, hyperlipidemia & DM2. The patient is a lifetime nonsmoker. Temp is 37.3C (99.2F), BP is 144/92 on the right arm and 142/90 on the left arm and pulse is 109/min. ECG shows sinus tachycardia, left ventricular hypertrophy & no ST-segment or T-wave changes. CXR is shown as Which of the following is the best next step in management of this patient? A. ABX & fluid resuscitation B. Beta blockers & anticoagulation C. Cardiac cath D. CT angiography E. Immediate emergency pericardiocentesis

B. Rupture of cortical bridging veins Subdural hematoma occurs due to the rupture of cortical bridging veins. A crescent-shaped lesion is seen on CT head. In elderly patients it may occur after a minor trauma and gradually present with gait abnormalities, seizures, somnolence, confusion & memory loss.

78-year-old woman is brought to the ED due to AMS of recent onset. She has a history of Parkinsonism & has had difficulty walking lately. The patient lives along & has had a few falls recently. BP: 180/100; HR: 68/min. CT scan shows a crescent-shaped lesion. Which of the following is the most likely cause of her symptoms? A. Rupture of middle meningeal artery B. Rupture of cortical bridging veins C. Rupture of lateral striate arteries D. Rupture of berry aneurysm E. Rupture of posterior communicating artery

A. Advanced age The greatest risk factor for prostate cancer is advanced age; 30-80% of mean age > 70 have histologic evidence of prostate cancer. Less-prominent risk factors include black ethnicity & a diet high in meat & low in fruits and vegetables.

80-year-old Asian man presents for an eval of fatigue & a 4.5kg (10-lb) weight loss. The patient does not use tobacco and drinks 2 shots of whiskey daily. He eats a vegetarian diet. PE shows a nodular prostate & inguinal lymphadenopathy. Serum prostate-specific antigen level is 25ng/mL (normal: < 4.5). Biopsy of the prostate reveals adenocarcinoma. Which of the following risk factors is most strongly associated with development of cancer in this patient? A. Advanced age B. Alcohol use C. Benigh prostatic hyperplasia D. Ethnicity E. Vegetarian

B. Small bowel herniation This elderly woman has a physical exam suggestive of small bowel obstruction (SBO). The presence of fullness & tenderness within the right groin suggests SBO is due to an incarcerated hernia. Femoral hernias are more common in elderly women & are more likely than inguinal hernias to develop complications (incarceration, strangulation). Small bowel obstruction can occur & typically presents with progressive abdominal pain, nausea/vomiting, high-pitched bowel sounds on exam, & distended loops of bowel with air-fluid levels on XR.

80-year-old woman is brought to the hospital with progressively increasing abdominal pain, nausea & an inability to keep food down since yesterday. The patient has had no previous surgeries. She doesn't use tobacco or EtOH. Temp is 37.1C (98.8F), BP is 150/80 and HR is 96/min. the abdomen is distended & tympanic, but there is no tenderness, rebound or rigidity. Bowel sounds are increased and high-pitched. Rectal exam shows no stool in the rectal vault & no masses. Fullness & tenderness are noted in the right groin area. The extremities are without cyanosis, clubbing or edema. Abdominal XR reveals distended bowel loops with air-fluid levels. Which of the following is most likely predisposed this patient to her current condition? A. Small bowel adhesions B. Small bowel herniation C. Small bowel intussusception D. Small bowel stricture E. Watershed bowel hypoperfusion

D. Elder abuse Providers should screen for elder abuse in those patients with known risk factors (>80 y/o, female, psychological/physical impairment) and with specific warning signs (atypical injuries, malnutrition, pressure ulcers). Patients should be interviewed alone & the appropriate agencies notified if elder abuse is suspected.

81-year-old woman is brought to the ED by her nephew. The patient says that she fell on an outstretched arm while trying to get to the bathroom. The patient's medical history includes SLE, chronic kidney disease & remitted breast cancer. The patient's meds include Hydroxychloroquine and Prednisone. She lives with her nephew, who is her primary caregiver. Physical exam reveals a thin & disheveled woman with bruising over her left biceps. Lung fields are clears & she has a normal S1 and S2. The abdomen is soft and nontender. XR reveals a mid-shaft spiral fracture of her left humerus. Which of the following is the most likely cause of the patient's condition? A. Bone metastasis B. Chronic glucocorticoid use C. Chronic kidney disease D. Elder abuse E. Nutritional deficiency

D. "Let's discuss all of your patients at signout."

A physician assistant (PA) is on her way to morning signet after her overnight shift & gets into an elevator crowded with nurses & other hospital staff members. The PA student on the team gets on the elevator & asks the PA how her shift went. During the conversation, the student is careful no to mention the patient's name, asking, "Didi the patient in Room 232 get her CT scan?" Which of the following is the most appropriate response to the student? A. "Discussing patient information in a public setting is against hospital policy." B. "I have the brain scan results & can discuss them during signout." C. "Let me pull up the results on my phone." D. "Let's discuss all of your patients at signout." E. "The scan was read, but ask the daytime resident about the results."

D. Urology eval Hypospadias is characterized by a ventrally displaced urethral opening & dorsal hooded foreskin. Urologic eval is required prior to circumcision b/c the foreskin may be required for hypospadias repair & conventional circumcision techniques may be unsafe.

A term newborn is undergoing routine eval in the nursery. The boy was born 12 hours ago via spontaneous vaginal delivery to a 24-year-old woman. VS are normal. PE shows a sleeping newborn with normal tone. A 1/6 systolic murmur is best heard at the left sternal border. Peripheral pulses are strong. Genitourinary exam shows a penis of normal length with no curvature. The urethral meatus is located at the coronal margin, and there is a dorsal hooded foreskin. Testes are present bilaterally within the scrotum. The patient urinates through the urethral meatus during exam. The father is present & requests that a circumcision be performed. Which of the following is the best next step in the management of this patient? A. Echocardiogram B. Renal US C. Serum 17-hydroxyprogesterone D. Urology eval E. Perform circumcision immediately

E. Varicocele Varicoceles are dilations of the spermatic vein pampiniform plexus that enlarge with standing & regress with lying down. Patients may be asymptomatic or experience testicular atrophy, reduced fertility or aching pain relieved with recumbency.

26-year-old man presents due to a scrotal mass. He 1st noticed the painless mass 4 weeks ago while in the shoer & thinks it may be getting larger. Patient has no history of abdominal or genital trauma. On exam, he has a left-sided scrotal mass that is palpable when he stands but disappears when he lies down. Light does not shine through the mass when a penlight is held behind it. Which of the following is the most likely diagnosis? A. Hydrocele B. Spermatocele C. Testicular cancer D. Testicular torsion E. Varicocele

A. Fine-needs aspiration biopsy Thyroid nodules that have suspicious sonographic features should undergo fine-needle aspiration biopsy.

27-year-old women is found to have a thyroid nodule. The patient has no heat or cold intolerance & no skin changes. VS are normal. PE shows a 1.5cm nodule in her right thyroid gland. Serum TSH is normal. Thyroid US reveals a 1.5cm hypoechoic nodule in her right thyroid lobe with irregular margins, internal microcalcifications, & internal vascularity. Which of the following is the best next step in a management of this patient? A. Fine-needle aspiration biopsy B. Radionuclide scan C. Reassurance only D. Serum thyroglobulin E. Total thyroidectomy

B. Acute diverticulitis Acute diverticulitis is common in older individuals & typically presents with dull, LLQ pain; nausea & vomiting; and alteration in bowel habits

56-year-old postmenopausal woman comes to the office due to abdominal pain & nausea. The patient has had 2 days of dull persistent pain the LLQ that has progressively worsened. She has had no appetite & vomited once today. She has not had a bowel movement during this period but is passing flatus. Medical history included HTN & DM2. Temp is 38C (100.4F), BP is 134/82 & HR is 94/min. BMI is 33kg/m2. Physical exam shows LLQ tenderness with no rebound tenderness or guarding. Bowel sounds are normative in all quadrants. The remainder of the exam shows no abnormalities. Which of the following is the most likely diagnosis in this patient? A. Acute bacterial cystitis B. Acute diverticulitis C. Ovarian torsion D. Ruptured ovarian cyst E. Small bowel obstruction

D. prostate cancer Imaging of bone metastases assists in cancer diagnosis. Bone metastasis are characterized as osteolytic or osteoblastic. Bony pain in an older man with osteoblastic lesions on imaging is suspicious for prostate cancer

68-year-old man presents with persistent back pain for the past several months. He has not seen a health care provider for many years. The patient is a life-long nonsmoker. On exam, there is focal tenderness over the 10th rib & L1-2 vertebral region. Neurologic exam is normal. Radiographs show osteoblastic lesions which are suspicious for metastatic cancer. Which of the following is the most likely cause of this patient's symptoms and radiographic findings? A. Melanoma B. Multiple Myeloma C. Non-small cell lung cancer D. Prostate cancer E. Renal cell carcinoma

E. unprotected sex Neisseria gonorrhoeae contracted via unprotected sex can cause disseminated gonococcal infection, presenting with monarticular arthritis with or without a pustular rash. Concurrent features of gonococcal mucosal infection (cervicitis) are usually absent, and synovial fluid culture may be negative.

16-year-old girl is seen in the ED due to knee pain. 2 days ago, the patient noticed swelling & a deep, aching pain in the left knee, which is now worse. She has no chronic medical conditions. Temp is 36.7C (98F). On the palmar side of each hand, there are few nontender pustules with a surrounding erythematous rim, each 3-4mm in diameter. The left knee has an effusion but is without erythema; ROM is decreased due to pain. Joint aspiration reveals a leukocyte count of 30,000/mm3, synovial fluid culture is negative. Which of the following historical factors is most commonly associated with this patient's presentation? A. lack of vaccinations B. recent viral URI C. skin abrasion D. tick bite E. unprotected sex

A. Acute appendicitis typically presents with nausea, vomiting, anorexia & initially, diffuse abdominal pain that later localizes to the RLQ. When the appendix is located retrocecally, tenderness in the RLQ may be milder than expected & a positive psoas sign (highly specific for appendicitis) may be present.

19-year-old woman comes to the ED due to abdominal pain for the past several hours. The pain was initially mid-abdominal & cramps & now the patient has constant pain in the RLQ & an episode of vomiting. Temp is 38C (100.4F), BP is 118/70 and HR is 96/min. The patient is supine on the bed with her hips flexed & reports worsening of the pain when her hips are extended. There is mild tenderness in the RLQ, with guarding. Bowel sounds are decreased. Pelvic exam reveals tenderness in the right adnexal area. Leukocyte count is 14,000/mm3 and UA shows 10-20 leukocytes/hpf, 1+ blood & no bacterial. Urine pregnancy test is negative. Which of the following is the most likely cause of this patient's current condition? A. Acue appendicitis B. Acue pyelonephritis C. Ectopic pregnancy D. Nephrolithiasis E. Small bowel obstruction

D. limb-length discrepancy A Salter-Harris type III fracture is characterized by fracture of the distal tibial epiphysis and lateral physis and typically occurs in adolescents when the physis is partially fused. Injury to the growth plate can cause growth arrest and lead to persistent limb-length discrepancy.

12-year-old boy is brought to the ED to evaluate Ain & swelling in his right ankle. The boy was riding his skateboard when he attempted a jump and landed awkwardly on his foot. He has not been able to put weight on his leg since the injury. On exam, there is diffuse swelling of the right ankle. Exam is limited as any attempted motion of the ankle causes severe pain. Bilateral distal pulses are normal. Sensation is intact. Radiographs of the ankle partially visualize a fracture of the distal tibia. A CT scan of the fracture shows widening of lateral physis with distal tibial epiphysis fracture. This patient's fracture places him at increased risk for which of the following complications? A. Acute limb ischemia B. Avascular necrosis C. Compartment syndrome D. Limb-length discrepancy E. Persistent foot drop

E. tripping and falling forward Distal radius (Colles') fracture is common following a fall onto an outstretched hand (FOOSH) & is often accompanied by ulnar styloid fracture, scaphoid fracture, and acute carpal tunnel syndrome. Most can be treated with a sugar tong splint. Urgent ortho referral is needed for significantly angulated or displaced fractures.

58-year-old woman presents with diffuse swelling & tenderness at the left distal forearm. She is uncooperative during exam. XR shows a distal radius fracture with shortening and dorsal displacement. Which of the following is the most likely mechanism of injury? A. direct blow to the wrist B. hyperextending the fingers C. punching with a clenched fist D. sudden twisting of the hand E. tripping & failing forward

C. Middle cerebral artery A lesion in Wernicke's area can cause receptive aphasia, which is characterized by well-articulated, nonsensical speech paired with a lack of language comprehension. Wernicke's area is located in the left temporal lobe and is supplied by the middle cerebral artery. Option A. Patients with anterior cerebral artery injuries typically present with contralateral lower limb weakness & upper motor neuron signs (ex: left lower leg weakness in a right anterior cerebral artery injury) Option B & E: Patients with anterior inferior cerebellar or posterior inferior cerebellar artery occlusion characteristically have vestibulocerebellar symptoms (ex: ataxia, dizziness, nystagmus) rather than aphasia Option D: Posterior cerebral artery injuries classically cause patients to have visual field deficits rather than speech deficits

A highly agitated 54-year-old man is brought to the ED by his family b/c he is unable to effectively. communicate. He speaks clearly & with conviction but his sentences are incomprehensible. he does not appear to understand questions, does not follow oral or written instructions and cannot repeat simple phrases. Branch occlusions of which of the following arteries is most likely responsible for this patient's conditions? A. Anterior cerebral artery B. Anterior inferior cerebellar artery C. Middle cerebral artery D. Posterior cerebral artery E. Posterior inferior cerebellar artery