Surgery (50q).1
- 1.Ten days after undergoing liver transplantation, a patient's levels of gamma-glutamyl transferase (GGT), alkaline phosphatase, and bilirubin begin to rise. Which of the following is the most appropriate next step in diagnosis?
- A.
Measurement of preformed antibody levels
- B.
Ultrasound of biliary tract and Doppler studies of the anastomosed vessels
- C.
Liver biopsy and determination of portal pressures
- D.
Liver biopsy and more detailed liver function tests
- E.
Liver biopsy and trial of steroid boluses
- 2.A previously healthy, intoxicated, 19-year-old man is driving a car without using a seat belt. He crashes the car into the back of a parked truck. In the process he slams his abdomen into the steering wheel and ruptures his spleen. Which of the following is the most important problem associated with this type of injury?
- A.
Bacteremia
- B.
Electrolyte abnormalities
- C.
External blood loss
- D.
Internal blood loss
- E.
Peritonitis
- 3.After suitable calculations have been made using the modified Parkland formula, a 70-kg man with extensive third-degree burns is receiving Ringer's lactate at the calculated rate, which happens to be 750 mL/hr. The infusion was started within 30 minutes of the time when the burn occurred. Over the next 3 hours, his urinary output is recorded as 15 mL, 22 mL, and 18 mL. It is verified that the Foley catheter is open and draining freely. The urine is dark yellow, without blood, and has a specific gravity of 1040 and a sodium concentration of 10 mEq/L. The patient's blood pressure is 100/70 mm Hg, his pulse is 98/min, and his central venous pressure is 2 cm H2O. On the basis of these findings, which of the following is the most appropriate next step in management?
- A.
Diuretics should be given
- B.
Fluid administration should continue at the present rate
- C.
The rate of fluid administration should be decreased
- D.
The rate of fluid administration should be increased
- E.
Treatment is needed for renal failure
- 4.A 27-year-old immigrant from El Salvador has a 14 × 12 × 9 cm mass in her left breast. It has been present for 7 years and has slowly grown to its present size. The mass is firm, nontender, rubbery, and completely movable, and it is not attached to the overlying skin or the chest wall. There are no palpable axillary nodes or skin ulceration. Which of the following is the most likely diagnosis?
- A.
Breast cancer
- B.
Chronic cystic mastitis
- C.
Cystosarcoma phyllodes
- D.
Intraductal papilloma
- E.
Mammary dysplasia
- 5.A 32-year-old woman in the 2nd month of pregnancy is found to have a 5-cm mass in the upper outer quadrant of her left breast. Mammogram shows no other lesions, and core biopsy reveals infiltrating ductal carcinoma. Which of the following would be the best course of action at this time?
- A.
Chemotherapy now, deferring surgery until after delivery
- B.
Radiation therapy now, deferring surgery until after delivery
- C.
Lumpectomy and axillary sampling, followed in 6 weeks by radiotherapy
- D.
Modified radical mastectomy now, deferring systemic therapy until later
- E.
Immediate therapeutic abortion and palliative breast surgery
- 6.In the course of a robbery, a young woman is stabbed repeatedly. On arrival at the emergency department, she is shivering and asks for a blanket and a drink of water; she is noted to be pale and perspiring. Her blood pressure is 72/50 mm Hg and her pulse is 130/min. Her neck and forehead veins are large and distended. A quick initial survey reveals entry wounds in her left chest and upper abdomen. She has bilateral breath sounds and a scaphoid, nontender abdomen. As IV infusions of Ringer's lactate are started, her systolic blood pressure drops further to 40 mm Hg, no distal pulses can be felt, and she loses consciousness. Her central venous pressure at that time is 28 cm H2O. Which of the following is the most appropriate next step in management?
- A.
Chest x-ray to direct further therapy
- B.
Bilateral chest tubes
- C.
Diagnostic peritoneal lavage
- D.
Evacuation of the pericardial sac
- E.
Crash laparotomy in the emergency department to clamp the aorta
- 7.A 62-year-old man reports an episode of gross, painless hematuria. There is no history of trauma, and further questioning determines that he had total hematuria, rather than initial or terminal hematuria. The man does not smoke and has had no other symptoms referable to the urinary tract. He has no known allergies. Physical examination, including rectal examination, is unremarkable. His serum creatinine is 0.8 mg/dL, and, except for the presence of many red cells, his urinalysis is normal and shows no red cell casts. His hematocrit is 46%. Which of the following is the most appropriate initial step in the workup?
- A.
Coagulation studies and urinary cultures
- B.
Intravenous pyelogram (IVP) and cystoscopy
- C.
PSA determination and prostatic biopsies
- D.
Sonogram and CT scan of both kidneys
- E.
Retrograde cystogram and pyelograms
- 8.A 63-year-old man, who weighs 65 kg, is in his 2nd postoperative day after an abdominoperineal resection for cancer of the rectum. An indwelling Foley catheter was left in place after surgery. The nurses are concerned because, even though his vital signs have been stable, his urinary output in the past 2 hours has been zero. In the preceding 3 hours, they had collected 56 mL, 73 mL, and 61 mL. Which of the following is the most likely diagnosis?
- A.
Acute renal failure
- B.
Damage to the bladder during the operation
- C.
Damage to the ureters during the operation
- D.
Dehydration
- E.
Plugged or kinked catheter
- 9.A 37-year-old woman undergoes a lumpectomy and axillary dissection for a 3-cm infiltrating ductal carcinoma, diagnosed by core biopsies, located on the upper outer quadrant of her left breast. The pathology report of the surgical specimen is received 3 days after the operation. It indicates that all margins around the tumor are clear, and that 4 of 17 axillary lymph nodes have metastatic tumor. The tumor is reported to be estrogen and progesterone receptor negative. Which of the following should further therapy most likely include?
- A.
Antiestrogen medication (tamoxifen)
- B.
Conversion to modified radical mastectomy
- C.
Radiation to the remaining left breast
- D.
Radiation to the remaining left breast and systemic chemotherapy
- E.
Radiation to both breasts and tamoxifen
- 10.A 45-year-old man with alcoholic cirrhosis is bleeding from a duodenal ulcer. He has required 6 units of blood over the past 8 hours, and all conservative measures to stop the bleeding, including irrigation with cold saline, IV vasopressin, and endoscopic use of the laser have failed. He is being considered for surgical intervention. Laboratory studies done at the time of admission, when he had received only one unit of blood, showed a bilirubin of 4.5 mg/dL, a prothrombin time of 22 seconds, and a serum albumin of 1.8 g/dL. He was mentally clear when he came in, but has since then developed encephalopathy and is now in a coma. Which of the following best describes his operative risk?
- A.
Acceptable as he now is
- B.
Amenable to improvement if he receives vitamin K
- C.
Amenable to improvement if he is given albumin
- D.
Prohibitive unless he is dialyzed to normalize his bilirubin
- E.
Prohibitive regardless of attempts to improve his condition
- 11.A 55-year-old woman falls in the shower and hurts her right shoulder. She shows up in the emergency department with her arm held close to her body, but the forearm rotated outward as if she were going to shake hands. She is in pain and will not move the arm from that position. Her shoulder looks "square" in comparison with the rounded unhurt opposite side, and there is numbness in a small area of her shoulder over the deltoid muscle. Which of the following is the most likely diagnosis?
- A.
Acromioclavicular separation
- B.
Anterior dislocation of the shoulder
- C.
Fracture of the upper end of the humeral shaft
- D.
Posterior dislocation of the shoulder
- E.
Scapular fracture
- 12.A 22-year-old convenience store clerk is shot once with a .38 caliber revolver. The entry wound is in the left midclavicular line, 2 inches below the nipple. There is no exit wound. He is hemodynamically stable. A chest x-ray film shows a small pneumothorax on the left, and demonstrates the bullet to be lodged in the left paraspinal muscles. In addition to the appropriate treatment for the pneumothorax, which of the following will this patient most likely need?
- A.
Barium swallow
- B.
Bronchoscopy
- C.
Extraction of the bullet via local back exploration
- D.
Extraction of the bullet via left thoracotomy
- E.
Exploratory laparotomy
- 13.A 68-year-old man is brought to the emergency department with excruciating back pain that began suddenly 45 minutes ago. The pain is constant and is not exacerbated by sneezing or coughing. He is diaphoretic and has a systolic blood pressure of 90 mm Hg. There is an 8-cm pulsatile mass deep in his epigastrium, above the umbilicus. A chest x-ray film is unremarkable. Two years ago, he was diagnosed with prostatic cancer and was treated with orchiectomy and radiation. At that time, his blood pressure was normal, and he had a 6-cm, asymptomatic abdominal aortic aneurysm for which he declined treatment. Which of the following is the most likely diagnosis?
- A.
Dissecting thoracic aortic aneurysm
- B.
Fracture of lumbar pedicles with cord compression
- C.
Herniated disc
- D.
Metastatic tumor to the lumbar spine
- E.
Rupturing abdominal aortic aneurysm
- 14.A middle-aged homeless man is brought to the emergency department because of very severe pain in his forearm. He had passed out after drinking a bottle of cheap wine, and then slept on a park bench for an indeterminate time, probably more than 12 hours. Shortly after he woke up and began to walk, the pain began. There are no signs of trauma, but the muscles in his forearm are very firm and tender to palpation, and passive motion of his fingers and wrist elicits excruciating pain. Pulses at the wrist are normal. Which of the following is the most appropriate next step in management
- A.
Analgesics and observation
- B.
Immobilization in a sling
- C.
Immobilization in a plaster cast
- D.
Emergency embolectomy
- E.
Emergency fasciotomy
- 15.A 54-year-old obese man gives a history of burning retrosternal pain and heartburn that is brought about by bending over, wearing a tight belt, or lying flat in bed at night. He gets symptomatic relief from over-the-counter antiacids or H2 blockers, but has never been formally studied or treated. The problem has been present for many years and seems to be progressing. Which of the following is the most appropriate next step in management?
- A.
Barium swallow
- B.
Cardiac enzymes and ECG
- C.
Proton pump inhibitors
- D.
Endoscopy and biopsies
- E.
Laparoscopic Nissen fundoplication
- 16.A pedestrian is hit by a car and knocked unconscious. Within a few minutes, he starts to move around and moan. When the ambulance arrives, he is moving all four extremities and mumbling that his neck hurts. Shortly thereafter, he lapses again into a deep coma. In the emergency department, it is noted that his left pupil is fixed and dilated, and he has clear fluid dripping from the left ear. The trauma team intubates him nasally over a fiberoptic bronchoscope and does a quick initial survey that reveals no other obvious injuries. He is hemodynamically stable. Which of the following is the most appropriate next step in management?
- A.
Antibiotics and high dose corticosteroids
- B.
Cervical spine and skull x-ray films
- C.
CT scan of the head, extended to include the cervical spine
- D.
Otoscopic examination and laboratory studies of the fluid
- E.
Emergency ear surgery to stop the leak of cerebrospinal fluid
- 17.While working at a bookbinding shop, a young man suffers a traumatic amputation of his index finger. The finger was cleanly severed at its base. The patient and the finger are brought to a first-aid station, from which both are to be transported to a highly specialized medical center for replantation to be done. Which of the following is the correct way to prepare and transport the severed finger?
- A.
Dry the finger of any traces of blood and place it in a cooler filled with crushed ice
- B.
Freeze it as quickly as possible, and transport it immersed in liquid nitrogen
- C.
Immerse it in cold alcohol for the entire trip
- D.
Paint it with antiseptic solution and place it on a bed of dry ice
- E.
Wrap it in a moist gauze, place it on a plastic bag, and place the bag on a bed of ice
- 18.An out-of-shape, recently divorced, 42-year-old man is trying to impress a young woman by challenging her to a game of tennis. In the middle of the game, a loud "pop" (like a gunshot) is heard, and the man falls to the ground clutching his ankle. He limps off the court with pain and swelling in the back of the lower leg. Although he can still weakly plantar-flex his foot, he seeks medical help the next day because of persistent pain, swelling, and limping. He can put weight on that foot with no exacerbation of the pain, but the motion of taking a step is painful. Which of the following would be the most likely finding on physical examination?
- A.
Tapping on the calcaneus is extremely painful
- B.
The ankle joint can be abducted farther out than the normal contralateral side
- C.
The ankle joint can be adducted farther in than the normal contralateral side
- D.
There is a gap in the Achilles tendon easily felt by palpation
- E.
There is crepitation and grating by direct palpation over either malleoli
- 19.A 66-year-old man with diabetes and generalized arteriosclerotic occlusive disease notices a gradual loss of erectile function over several years. Initially, he can get erections, but they do not last long enough. Later, he notices a decrease in the quality of his erections, and more recently he becomes, by his own criteria, completely impotent. He has occasional, brief nocturnal erections, but "he can never get an erection when he needs one." Which of the following is the most appropriate initial step in management?
- A.
Psychotherapy
- B.
Pharmacologic therapy
- C.
Erectile nerve reconstruction
- D.
Implantable penile prosthesis
- E.
Pudendal artery revascularization
- 20.A 54-year-old woman has a severe ureteral colic. An intravenous pyelogram shows a 7-mm ureteral stone at the ureteropelvic junction. She has a normal coagulation profile. Which of the following would most likely be the best therapy in this case?
- A.
Plenty of fluids and analgesics and await spontaneous passage
- B.
Extracorporeal shock wave lithotripsy (ESWL)
- C.
Endoscopic retrograde basket extraction
- D.
Endoscopic retrograde laser vaporization of the stone
- E.
Open surgical removal
- 21.A 68-year-old woman presents with an obviously incarcerated umbilical hernia. She has gross abdominal distention, is clinically dehydrated, and reports persistent fecaloid vomiting for the past 3 days. Although tired, weak, and thirsty, she is awake and alert and her sensorium is not particularly affected. Laboratory analysis reveals a serum sodium concentration of 118 mEq/L. Which of the following is the most likely physiologic explanation for the serum sodium?
- A.
She has acute water intoxication
- B.
She has been vomiting and trapping hypertonic fluids in the bowel lumen
- C.
She has vomited and sequestered sodium-containing fluids, and has retained endogenous and ingested water
- D.
There must be a laboratory error, because such a serum sodium level would have produced coma
- E.
Volume deprivation leads to renal wasting of sodium
- 22.A 31-year-old woman smashes her car against a bridge abutment. She sustains multiple injuries, including upper and lower extremity fractures. She is fully awake and alert, and she reports that she was not wearing a seat belt and distinctly remembers hitting her abdomen against the steering wheel. Her blood pressure is 135/75 mm Hg, and her pulse is 88/min. Physical examination shows that she has a rigid, tender abdomen, with guarding and rebound in all four quadrants. She has no bowel sounds. Which of the following would be the most appropriate step in evaluating potential intraabdominal injuries?
- A.
Continued clinical observation
- B.
CT scan of the abdomen
- C.
Sonogram of the abdomen
- D.
Diagnostic peritoneal lavage
- E.
Exploratory laparotomy
- 23.A 27-year-old man sustained penetrating injuries of the chest and abdomen when he was repeatedly stabbed with a long ice-pick. At the time of admission, he had a right pneumothorax, for which a chest tube was placed prior to undergoing a general anesthetic for exploratory laparotomy. The operation revealed no intraabdominal injuries and was terminated sooner than had been anticipated. The patient remained intubated, waiting for the anesthetic to wear off. Because he was not moving enough air, he was placed on a respirator. Then, he suddenly went into cardiac arrest and died. All through this time he had been hemodynamically stable, and never had any signs of hypotension or arrhythmias. Which of the following was the most likely cause of the cardiac arrest?
- A.
Air embolism
- B.
Fat embolism
- C.
Myocardial infarction
- D.
Pulmonary embolus
- E.
Tension pneumothorax
- 24.A 13-year-old, obese boy complains of persistent knee pain for several weeks. The family brings him in because he has been limping. He sits in the examining table with the sole of the foot on the affected side pointing to the other leg. Physical examination is normal for the knee, but shows limited hip motion. As the hip is flexed, the leg goes into external rotation and cannot be rotated internally. Which of the following is the most likely diagnosis?
- A.
Avascular necrosis of the femoral head
- B.
Developmental dysplasia of the hip
- C.
Osteogenic sarcoma of the lower femur
- D.
Slipped capital femoral epiphysis
- E.
Tibial torsion with foot inversion
- 25.A 72-year-old man has a 3-mm ureteral stone impacted at the ureterovesical junction. He has been having mild ureteral colicky pain for about 12 hours, and he has been given fluids and analgesics in the expectation that he will spontaneously pass the stone. He then has shaking chills, and spikes a temperature of 40 C (104 F). When seen shortly thereafter, he has flank pain and looks quite ill. Which of the following is the most appropriate next step in management?
- A.
Addition of IV antibiotics to the current therapeutic regimen
- B.
Crushing and extraction of the stone via cystoscopy
- C.
Extracorporeal shock wave lithotripsy and parenteral antibiotics
- D.
Immediate insertion of a suprapubic catheter into the bladder
- E.
IV antibiotics and immediate decompression of the urinary tract above the stone
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