Appendix

General Surgery (Board Review Series) 1st Edition

Appendix: Comprehensive Examination

Directions: Each of the numbered items or incomplete statements in this section is followed by answers or by completions of the statement. Select the ONE lettered answer or completion that is BEST in each case.

A 65-year-old man is admitted to the surgical intensive care unit following pancreatic débridement for necrotizing pancreatitis. The patient is extubated, although his respiratory status remains guarded. Parenteral nutrition therapy is initiated with 35 kcal/kg/day; 65% is administered as carbohydrates, 30% as lipids, and 5% as protein. The patient also receives vitamin supplements. Over the next 24 hours the patient complains of worsening fatigue and numbness around his lips. He develops a tremor in both hands and becomes more lethargic as the day continues until he must be reintubated. This patient's abnormality would be most adequately treated if he were administered

(A) KPO₄^-

(B) MgCl₂

(D) Thiamine

(E) Insulin

A 27-year-old, 80-kg, male athlete sustained deep partial-thickness burns to approximately 60% total body surface area (TBSA). He has been receiving lactated Ringer's in direct accordance with the Parkland formula calculations for volume resuscitation, however, he remains tachycardic with a heart rate of approximately 110 beats/min. Which of the following is true with regard to fluid management in this patient?

(A) A Foley catheter is not necessary in this patient if he is awake

(B) A urine output of 30 mL/hour is not satisfactory in this patient

(D) One 18-gauge intravenous (IV) catheter is sufficient for treating this patient

(E) If significant peripheral edema is present, IV fluid rates should be decreased

A 70-year-old man with an asthma exacerbation suffers a first time episode of atrial fibrillation in the hospital. The ventricular response is 160, but the patient's blood pressure remains stable. The decision is made to cardiovert the rhythm, however, secondary to increasing dyspnea. Ketamine is administered intravenously, the man loses consciousness but continues to spontaneously ventilate, and is successfully converted to sinus rhythm after one 100 J synchronized cardioversion. Upon awakening he complains of intensely frightening illusions. Which of the following premedications could have lessened this unwanted side effect?

(A) Propofol

(B) Fentanyl

(D) Etomidate

(E) Midazolam

A 15-year-old boy is admitted with the chief complaint of right lower quadrant abdominal pain, nausea, vomiting, and anorexia for the past 5 hours. His vital signs are: respiration, 24/min; heart rate, 90 beats/min; blood pressure, 120/70 mm Hg; temperature, 38.3°C. Which of the following findings is most likely to be present in this patient?

(A) Pelvic crepitus

(B) Psoas sign

(D) Flank ecchymosis

(E) Periumbilical ecchymosis

P.518

A 63-year-old man is being treated with a 7-day course of oral antibiotics for an acute episode of diverticulitis. Now, 4 days into the course of antibiotics, the patient presents with persistent fever and worsening pain and advancing erythema in the perineal area. Upon evaluation, he is felt to have worsening necrotizing fasciitis of the perineum extending to and including the scrotum. Which of the following would be an appropriate treatment strategy for this patient?

(A) Aggressive débridement of the affected tissue with orchiectomy and intravenous (IV) antibiotics

(B) Aggressive débridement of the affected tissue with sparing of the testes and IV antibiotics

(D) Sitz baths 4 times a day and broad spectrum IV antibiotics

(E) Aggressive débridement of the affected tissue with orchiectomy and immediate resection of affected colon with primary reanastomosis

A 42-year-old man undergoes elective laparoscopic hernia repair for bilateral inguinal hernias. On postoperative day one, the patient develops worsening abdominal pain associated with nausea and vomiting. On physical examination, the patient is noted to have severe abdominal pain with rebound and guarding. Which of the following is the most likely cause of this patient's findings?

(A) Strangulation of bowel

(B) Recurrence of the hernia

(D) Wound infection

(E) Adhesion formation

A 45-year-old woman underwent an uneventful total colectomy for ulcerative colitis. On postoperative day 5, the patient was found to be minimally responsive. Physical examination reveals a temperature of 40.0°C; blood pressure of 70/36 mm Hg; pulse of 130/min; respiration of 32/min; and cold, clammy skin, diaphoresis, and cool extremities. There was 85 mL of urine output overnight. Laboratory studies showed a white blood cell count of 2.2, hematocrit = 44.1, platelets = 700,000, Na⁺= 145, K⁺ = 5.9, Cl^- = 111, HCO₃^- = 18, blood urea nitrogen = 64, and creatinine = 3.0. Urinalysis was significant for renal tubular cells. Which of the following statements is true regarding this patient's renal function?

(A) This patient is anuric and must immediately be started on hemodialysis

(B) Treating the initial condition has little effect in allowing renal function to recover

(D) Persistent disease will result in severe metabolic alkalosis, hypokalemia, and dehydration

(E) In most patients, this complication is irreversible

A 65-year-old woman presents with obstructive jaundice and a history of 20-lb weight loss. She denies any complaints of fever, pain, nausea, or vomiting. Her abdominal examination is unremarkable. An endoscopic retrograde cholangiopancreatography (ERCP) has been performed and reveals a focal common bile duct stenosis with dilation of the common hepatic and intrahepatic ducts. Significant laboratory values include a normal white blood cell count, total bilirubin = 12.0, conjugated bilirubin = 11.2, alkaline phosphatase = 2000, and normal transaminases. Which of the following is the most likely diagnosis?

(A) Primary sclerosing cholangitis

(B) Cholangitis

(D) Mirizzi's syndrome

(E) Cholangiocarcinoma

P.519

A 30-year-old healthy woman presents to the office 1 year after having an uncomplicated cesarean section. She complains of a persistently large, unsightly scar at the surgical site, which is found to be a hypertrophic scar. Intralesional triamcinolone improves the appearance of the scar. The effect of this drug is best described by which of the following mechanisms?

(A) Enhancement of collagenase activity

(B) Decrease in the number of active fibroblasts

(D) Inhibition of intracellular collagen synthesis

(E) Inhibition of extracellular intermolecular collagen cross-linking, increasing collagen solubility

A 50-year-old man receives a transfusion of packed red blood cells (PRBCs) for anemia secondary to chronic gastrointestinal bleeding. Fifteen minutes after the infusion begins, the patient develops back pain, chills, fever, and dark urine. His temperature is 38.8°C (102°F), his pulse rate is 124/min, his respiratory rate is 28/min, and his blood pressure is 116/44 mm Hg. Examination reveals moderate respiratory distress and crackles throughout his lung fields. Which of the following is the most likely source of this patient's problem?

(A) Infection secondary to bacterial contamination of donor blood

(B) Donor leukocytes reacting with the recipient's red blood cells (RBCs)

(D) Volume overload secondary to rapid administration of blood

(E) Hypocalcemia secondary to citrate in the donor blood

One month after an orthotopic liver transplant, a 43-year-old woman presents to the office with complaints of fatigue and weakness. On physical examination she is noticeably jaundiced. She denies fever or chills. Her aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are significantly elevated, as is her total bilirubin. Her chest radiograph is clear, and blood and urine cultures are negative. Doppler ultrasound of the right upper quadrant reveals no fluid collections and a patent hepatic artery and portal vein. Liver biopsy reveals portal lymphocytic infiltration and injury to the bile canaliculi. Which of the following is the most appropriate initial therapy for this patient?

(A) Glucocorticoids

(B) Cyclosporine

(D) Azathioprine

(E) Mycophenolate mofetil

A 73-year-old man with chronic obstructive pulmonary disease is hospitalized for recurrent pneumothoraces. He has been critically ill in the surgical intensive care unit with multiple bouts of pneumonia and sepsis for 5 weeks. On reviewing his laboratory data you notice a steady trend downward of his hematocrit from 48% to 21%. Which of the following would be the most appropriate initial step in the management of this patient?

(A) Emergent laparotomy

(B) Observation

(D) Nasogastric tube placement and stools for guaiac

(E) Immediate mesenteric angiography

An 18-year-old college student presents with 4 hours of severe chest and epigastric pain after a night of binge drinking. She states that she vomited several times upon returning home and that the pain began shortly thereafter. She is currently stable and her chest radiograph reveals pneumomediastinum and a pleural effusion on the left side. Which of the following is true regarding this scenario?

(A) As is the case in more than 75% of cases, this patient can be treated successfully with intravenous (IV) hydration and antibiotics alone

(B) Primary repair of the esophagus is unlikely to be successful in this patient

(D) Despite proper intervention, survival is generally less than 50% in this patient

(E) Radical procedures such as esophageal exclusion are usually not necessary in patients who present within 24 hours of the injury

P.520

A 35-year-old man with hypertension and end-stage renal disease secondary to systemic lupus erythematosus is receiving an axillary block as the anesthetic for an arterioventricular fistula placement. During injection of the local anesthetic (bupivacaine) into the axilla, the patient abruptly seizes. Which of the following agents given intravenously would be most appropriate in the treatment of this patient's seizure?

(A) Fentanyl

(B) Succinylcholine

(D) Etomidate

(E) Lidocaine

A 57-year-old man with severe liver disease from alcohol abuse is admitted to the hospital with worsening ascites and encephalopathy. He is placed on the recipient list for a donor liver and managed in the intensive care unit. Because of his encephalopathy, he is unable to eat; therefore, he is started on enteral nutritional support via a nasoduodenal feeding tube. He is receiving 1.3 mg protein/kg/day with a predominance of branched-chain amino acids. Which of the following is an appropriate statement regarding the administration of branched-chain amino acid to patients in this setting?

(A) Branched-chain amino acids include leucine, isoleucine, and alanine

(B) Muscle preferentially metabolizes these amino acids

(D) Branched-chain amino acids act as hepatotoxins in liver failure

(E) Branched-chain amino acids are nonessential amino acids

A 72-year-old man is evaluated in the emergency room with a primary complaint of nausea and vomiting for 2–3 days and a 2- to 3-week history of intermittent right upper quadrant pain. His past surgical history is significant for triple coronary artery bypass surgery. Physical examination reveals a distended abdomen with hyperactive bowel sounds. Rectal examination is heme-negative. His temperature is 37.7°C (100°F), his heart rate is 105 beats/min, and his blood pressure is 140/75 mm Hg. His abdominal radiograph shows multiple step-ladder air–fluid levels throughout the abdomen and notable air within the biliary tree. Which of the following is the most likely diagnosis?

(A) Superior mesenteric artery syndrome

(B) Cancer of the colon

(D) Sigmoid diverticulitis

(E) Gallstone ileus

A 64-year-old man presents to your office with right breast hyperplasia. He states that he has only noticed his right breast getting bigger over the last few months, but his wife stated that she thought he had always been a little bigger on the right. He states that he does drink, but no more than a few beers each night. On physical examination, you notice that his right breast is larger than his left, and there is a firm mass just under the nipple. There are no palpable masses in his axilla, but the mass does seem to be fixed to the chest wall. Which of the following is the most appropriate treatment for this patient?

(A) A lumpectomy, axillary node dissection with postoperative radiation therapy

(B) Fine needle aspiration (FNA) and, if malignant disease is discovered, a modified radical mastectomy

(D) Systemic chemotherapy alone

(E) Observation

A 62-year-old man with a history of a previous episode of diverticulitis presents to the emergency room with complaints of fever, nausea, and abdominal pain that is greatest in the left lower quadrant. Computed tomography (CT) scan reveals multiple sigmoid diverticula, a 4-cm abscess in the left lower quadrant, and free air in the peritoneum. Which of the following is the most appropriate course of management for this patient?

(A) Percutaneous drainage of the abscess and administration of intravenous (IV) antibiotics

(B) Emergent resection of the affected colon with end colostomy and abscess drainage

(D) Emergent total colectomy with abscess drainage

(E) Emergent operative drainage of the abscess, IV antibiotics, and elective resection of the colon at a later date

P.521

Which of the following is characteristic of malignant tumors of the liver?

(A) α-Fetoprotein may be elevated with hepatic metastases or hepatocellular carcinoma

(B) Alcoholic cirrhosis is the most common cause of hepatocellular carcinoma worldwide

(D) Fibrolamellar variant of hepatocellular carcinoma is associated with a worse prognosis compared with hepatocellular carcinoma

(E) Hepatoblastoma is generally insensitive to chemotherapy

A 34-year-old man with acquired immunodeficiency syndrome (AIDS) and a recent episode of Pneumocystis cariniiinfection has been suffering from progressive symptoms of early satiety, abdominal bloating, weight loss, and intermittent, dull left upper quadrant abdominal pains. Physical examination reveals a markedly enlarged spleen, the tip of which is palpable in the left lower quadrant. Abdominopelvic computed tomography (CT) scan confirms massive splenomegaly but no other masses are identified. Antiplatelet antibodies are not identified in his blood. Which of the following is the most appropriate therapy for this patient?

(A) Elective splenectomy

(B) Plasmapheresis

(D) Intravenous (IV) gamma globulin

(E) Splenic artery embolization

A 42-year-old woman with a history of Graves' disease currently being treated medically presents with a 3-cm mass in the left lobe of the thyroid. Fine needle aspiration (FNA) reveals follicular cell carcinoma. Before induction, during palpation of the thyroid gland, the patient develops sudden fever and tachycardia intraoperatively. Which of the following is the most appropriate treatment measure in this setting?

(A) Administration of calcium carbonate

(B) β-Blockade, propylthiouracil (PTU), and Lugol's solution

(D) Mechanical cooling and dantrolene

(E) Administration of 4 units of packed red blood cells (PRBCs)

A 65-year-old, obese woman underwent a left hemicolectomy with primary re-anastomosis for colon adenocarcinoma. On postoperative day 14, the patient complains of abdominal pain, anorexia, and fever (temperature of 39.1°C). Her physical examination is significant for mild diffuse abdominal tenderness, a mildly distended abdomen with few bowel sounds, and guarding in the left lower quadrant. Laboratory studies show a white blood cell count of 16.9 (91% polys), and are otherwise within normal limits. Computed tomography (CT) scan of the abdomen reveals a fluid collection in the left lower quadrant. An anastomotic leak is diagnosed. Which of the following is true regarding her intestinal anastomoses?

(A) Anastomotic leaks occur more frequently in the colon than in the small bowel because of the increased bowel wall thickness of the colon

(B) Avoidance of gross contamination while making anastomoses has little impact on the incidence of leakage because the abdomen may be easily irrigated before closure

(D) Ensuring the absence of distal obstruction is important in creating successful intestinal anastomoses

(E) Percutaneous drainage should not be attempted because it carries a high failure rate

P.522

A 38-year-old, African-American woman with a history of gastroesophageal reflux disease and sickle cell disease presents with a 36-hour history of nausea, vomiting, and right upper quadrant pain. The pain is described as spasmodic in nature and is exacerbated by eating. The patient denies fever, chills, and previous abdominal surgery. Her vital signs are: temperature, 36.9° C; pulse, 101/min; blood pressure, 140/86 mm Hg; and respiration, 13/min. Her abdomen is soft but tender to palpation in the right upper quadrant. Her laboratory results are: white blood cells = 6000; hematocrit = 34; platelets = 212; Na⁺= 132; K⁺ = 4.1; Cl^- = 104; CO₂ = 25; blood urea nitrogen = 14; creatinine = 0.8; glucose = 89; total bilirubin = 7.5; conjugated bilirubin = 6.6; alkaline phosphatase = 540; and amylase = 41. A right upper quadrant ultrasound reveals multiple gallstones and a distended common duct but no other abnormalities. Which of the following statements is appropriate regarding this patient's condition?

(A) The patient most likely has a common bile duct obstruction from a stone formed in the gallbladder

(B) The pathogenesis of this patient's condition is related to bile stasis and bacterial deconjugation of bilirubin

(D) Pain on palpation is an uncommon finding in this disease

(E) An endoscopic retrograde cholangiopancreatography (ERCP) may be diagnostic but plays no role in the treatment of this disease

A 45-year-old woman sustains multiple injuries in a motor vehicle accident, including a splenic laceration requiring emergent splenectomy, a transverse process fracture of the third lumbar vertebrae, and a fracture of the shaft of the left tibia. During placement of a Swan-Ganz catheter via the left subclavian vein, the patient suddenly develops hypotension with a blood pressure of 80/60 mm Hg initially. A chest tube is placed without improvement in her blood pressure. A large quantity of blood is noted to be coming out of the endotracheal tube. Which of the following is the most likely cause of this patient's hypotension?

(A) Tension pneumothorax

(B) Severe hemothorax

(D) Pulmonary artery perforation

(E) Acute pulmonary embolus

A 28-year-old woman presents to the surgical clinic with a known history of a thyroid nodule. History reveals that her mother and sister died secondary to thyroid cancer and a hypertensive crisis, respectively. Fine needle aspiration (FNA) of the thyroid mass reveals medullary thyroid carcinoma. Which of the following is correct regarding further treatment of this patient?

(A) Surgical treatment of her thyroid cancer involves lobectomy and isthmusectomy

(B) If a pheochromocytoma is found, a laparoscopic approach is contraindicated in this patient

(D) If hyperparathyroidism is found, the patient can generally be managed with parathyroidectomy of the adenoma

(E) Urine tests for catecholamines, metanephrines, vanillylmandelic acid, parathyroid hormone, and calcium should be obtained

A 62-year-old woman presents with a 3-cm, dark, elevated mass on her upper back. The report of an incisional biopsy of the lesion performed at another hospital states that the lesion is a melanoma, 0.7 mm thick. Which of the following is the most appropriate therapy for the treatment of the primary lesion?

(A) Wide local excision of the lesion with 1-cm margins

(B) Cryosurgical ablation of the lesion

(D) Mohs' microsurgical technique of surgical resection

(E) Wide local excision of the lesion with 2-cm margins

A 45-year-old woman presents with a 3-cm neck mass in the right lobe of the thyroid partially involving the isthmus. Fine needle aspiration (FNA) of the lesion reveals a poorly differentiated Hürthle cell variant of follicular carcinoma. Which of the following is the most appropriate treatment for this patient?

(A) Lobectomy and isthmusectomy followed by radioiodine (¹³¹I) ablation therapy

(B) Total thyroidectomy followed by ¹³¹I ablation therapy

(D) Total thyroidectomy with node dissection for positive nodes

(E) Lobectomy and isthmusectomy

P.523

After a motor vehicle accident, a 28-year-old woman was found to have a 3-cm, simple liver cyst on computed tomography (CT) scan during her evaluation in the emergency room. The patient was found to have isolated orthopedic injuries and was discharged 2 days later. Which of the following would be a contraindication to surgical management or percutaneous drainage of a simple liver cyst in this patient?

(A) Pain associated with cyst

(B) Fever, chills, and positive cultures from cyst contents

(D) Rupture of cyst

(E) Presence of von Meyenburg complexes (biliary ductal epithelium) within biopsy specimen of cyst wall

A 38-year-old man presents with a firm nodule in his neck and hypertension that has been refractory to medical therapy. Subsequent work-up also reveals a pheochromocytoma as the probable source of the patient's hypertension as well as a medullary thyroid cancer consistent with the diagnosis of the multiple endocrine neoplasia (MEN) II syndrome. Which of the following is true regarding the sequence of treatment of this patient?

(A) Immediate resection of the pheochromocytoma should be performed, followed by resection of the medullary cancer at a later date

(B) Control of hypertension and resection of the pheochromocytoma and the medullary cancer during the same procedure

(C) Control of hypertension and resection of the pheochromocytoma, followed by neck exploration and resection of the medullary cancer at a later date

(D) Resection of the cancerous lesion first, followed by resection of the pheochromocytoma

(E) Resection of the pheochromocytoma, followed by neck irradiation

A 30-year-old man sustained multiple injuries in a motor vehicle accident. On hospital day two, he remains intubated in the intensive care unit in critical condition and it is decided that enteral nutritional support should be initiated. During placement of a nasogastric feeding tube to 40 cm the patient's blood pressure is noted to drop precipitously to 50/30 mm Hg. During forceful insufflation of air through the feeding tube there are no sounds noted over the epigastric region. Which of the following would be the most appropriate definitive step in the management of this patient?

(A) Removal of the feeding tube and fluid resuscitation

(B) Removal of the feeding tube and chest tube placement

(D) Removal of the feeding tube and immediate laparotomy

(E) Removal of the feeding tube and immediate pulmonary angiogram

A 59-year-old woman is taken to the operating room and undergoes an exploratory laparotomy for a high-grade small bowel obstruction. During the operation she is found to have a large leiomyoma that is obstructing the distal ileum. A large segment of the terminal ileum is resected with the tumor. Which of the following long-term nutritional risks is associated with this procedure?

(A) Dumping syndrome

(B) Pernicious anemia

(D) Afferent loop syndrome

(E) Iron deficiency anemia

P.524

A 29-year-old, breast-feeding mother presents to the clinic with the primary complaint of right breast tenderness. She states that the tenderness began suddenly, and was first associated with pain when she began breast-feeding, but now is continuous. She denies fever, chills, or any other associated symptoms. On physical examination, she has a tender right breast with an area of erythema in the lower outer quadrant. There is no expressible discharge and no definitive masses to palpation. Which of the following is the most appropriate treatment for this patient?

(A) Place patient on nonsteroidal anti-inflammatory drugs (NSAIDs)

(B) Antibiotics to cover skin organisms, Staphylococcus aureus, and discontinue breast-feeding until pain resolves

(D) Consider placing patient on danazol

(E) Reassure the patient that with continued breast feeding her pain should resolve

A patient who has been diagnosed with diverticular disease presents with massive hemorrhage. After the site of bleeding is well localized, the patient continues to bleed and requires 5 units of blood over the next 24 hours. Which of the following therapies will provide the lowest morbidity and least chance of rebleeding?

(A) Surgical resection of the diseased segment

(B) Angiographic embolization of the bleeding vessel

(D) Subtotal colectomy

(E) Further observation and transfusion as needed

A 16-year-old boy presents to the emergency room 36 hours after being bitten in the hand during an altercation. He is febrile [39.0°C (102.2°F)] and he has purulent drainage from the 2-cm wound over the metacarpophalangeal joint of his ring finger. The finger cannot be actively extended. Which of the following is the most appropriate management strategy?

(A) Topical cleansing followed by oral antibiotics

(B) Débridement and irrigation followed by intravenous (IV) antibiotics

(D) Repair of the affected extensor tendon followed by open packing

(E) Application of a sterile dressing and close observation

A 59-year-old man presents to the emergency department with complaints of persistent fever and mild left lower quadrant abdominal pain for the previous 4 days. The patient is otherwise healthy and denies nausea or vomiting. Physical examination reveals localized pain to deep palpation in the left lower quadrant without rebound or guarding. Subsequent computed tomography (CT) scan reveals a localized 8-cm pelvic abscess with multiple diverticula noted throughout the sigmoid colon. Which of the following is the most appropriate next step in the management of this patient?

(A) Percutaneous drainage of the abscess with adjunctive antibiotics

(B) Immediate laparotomy with resection of adjacent bowel

(D) Antibiotic therapy directed against principally aerobic bacteria

(E) Antifungal therapy should be initiated because of a significant risk of fungal contamination

A 55-year-old man has been experiencing chronic epigastric burning pain for the past 10 years. He initially was able to control his symptoms with over-the-counter medications. However, his pain has persisted despite a 12-month course of ranitidine and most recently a 6-month course of omeprazole. Repeat endoscopy reveals a persistent duodenal ulceration without active bleeding. Multiple biopsies reveal no evidence of malignancy or Helicobacter pylori.Which of the following operations is associated with the lowest morbidity, but the highest recurrence in this patient?

(A) Truncal vagotomy

(B) Truncal vagotomy and pyloroplasty

(D) Parietal cell (highly selective) vagotomy

(E) Total gastric resection

P.525

A 21-year old woman is brought to the emergency room because she has been experiencing lower abdominal pain for the past 8 hours that has been getting progressively worse. The date of her last menstrual period was 8 weeks ago. The patient was found by paramedics to be pale and lethargic. Examination now reveals a distended abdomen with rigidity and guarding diffusely. Her vital signs are: heart rate, 120 beats/min; blood pressure, 70/30 mm Hg; respiration, 28/min; temperature, 36.0°C. Which of the following is the most likely diagnosis?

(A) Appendicitis

(B) Crohn's disease

(D) Perforated duodenal ulcer

(E) Torsed ovary

A 24-year-old man is involved in a motor vehicle accident resulting in a severe closed head injury. This injury is believed to be irreversible and evaluation for possible organ donation is undertaken. Which of the following would exclude him as a heart-beating organ donor?

(A) Absence of response to painful stimuli

(B) Intact deep tendon reflexes

(D) Core body temperature of 38.2°C

(E) The requirement of 10 µg/kg/min of dopamine for hemodynamic stability

A 55-year-old woman undergoes an excisional biopsy for a palpable breast mass. The biopsy results return indicating invasive ductal adenocarcinoma of less then 1 cm in diameter, and no cancer cells at the margin of the biopsy. Which of the following is the most appropriate next step in the treatment of this patient?

(A) Axillary node dissection or sampling for staging, and radiation therapy to the breast

(B) Axillary node dissection for staging alone

(D) Simple mastectomy

(E) Radical mastectomy

Work-up of a right-sided colon mass found in a 68-year-old, otherwise healthy woman reveals an incompletely resected adenocarcinoma upon colonoscopic polypectomy. The patient subsequently undergoes an elective segmental colonic resection of the lesion, which confirms adenocarcinoma upon pathologic evaluation. Which of the following adjuvant therapies would be appropriate in the further management of this patient?

(A) Chemotherapy for stage III adenocarcinoma

(B) Chemotherapy for stage I adenocarcinoma

(D) Radiation therapy for stage III adenocarcinoma

(E) Chemotherapy and radiation therapy for stage III adenocarcinoma

A 180-kg, 21-year-old man with spina bifida and lower extremity paralysis is in the medical intensive care unit with urosepsis. The patient also has a history of a seizure disorder. The patient was extubated after a prolonged period of intubation, however, his respiratory status continues to deteriorate and the decision is made to reintubate. His blood pressure is 78/40 mm Hg, respiration rate exceeds 30/min, and the SaO₂is 89% on 100% oxygen. The anesthesiologist judges the airway to be difficult because of limited neck motion and inability to visualize the uvula with mouth opening. Which of the following is the most appropriate strategy in the initial airway management of this patient?

(A) Rapid sequence intubation with etomidate and rocuronium

(B) Rapid sequence intubation with thiopental and rocuronium

(D) Topical anesthesia (lidocaine) to the airway

(E) Intubation after administration of ketamine and rocuronium

P.526

A 79-year-old woman underwent an uneventful abdominal-perineal resection for a rectal cancer. She was slow to recover and on postoperative day 10, she was noted to have an open, excoriated wound near her buttocks and blisters on both heels. Which of the following statements most accurately reflects this condition?

(A) This is a common complication in all populations of postoperative patients

(B) Frequent bathing and skin conditioners frequently cause this complication

(D) Early mobilization and frequent position changes have little impact in preventing this complication

(E) Maintaining proper nutritional status is helpful in the prevention and treatment of this condition

A 55-year-old, obese woman presents with a painful 4-cm mass just below the umbilicus in the midline. The patient states that she had noticed the mass for several years but presents today because of progressively worsening pain associated with the mass over the past day. On physical examination there is an exquisitely tender mass just under the umbilicus. Although difficult, the mass is eventually reduced with firm pressure and moderate sedation. After reduction of the mass, the patient continues to complain of abdominal pain and is noted to have significant guarding and rebound tenderness. Which of the following is the most appropriate treatment strategy for this patient?

(A) Immediate abdominal exploration

(B) Immediate local wound exploration and hernia repair

(D) Discharge and elective hernia repair if the hernia recurs

(E) Observation and exploration if the pain worsens

A 32-year-old man presents with a history of intermittent dysphagia, most often following a hurried swallow. These episodes generally occur with solids and he reports a history of mild gastroesophageal reflux symptoms. Upper endoscopy reveals the presence of a Schatzki's ring. Which of the following statements is true regarding this patient?

(A) This patient almost certainly has an associated type II esophageal hernia

(B) A Schatzki's ring is covered by columnar epithelium on both the upper and lower surfaces

(D) Symptomatic lesions generally respond to either rigid or pneumatic dilation of the ring

(E) The presence of gastroesophageal reflux symptoms and a Schatzki's ring is an indication for fundoplication without any further preoperative studies

A 44-year-old is started on parenteral nutritional therapy for acute necrotizing pancreatitis. He undergoes pancreatic débridement and shows some improvement in the immediate postoperative period. On postoperative day 3, the patient gradually becomes increasingly lethargic and confused. His heart rate is 140 beats/min, blood pressure is 80/40 mm Hg, and respiration is 24/min. His K⁺= 3.7, Na⁺ = 145, Cl^- = 120, blood urea nitrogen = 75, and creatinine = 1.7. His hematocrit is 45%. Arterial blood gas is pH 7.24, PO₂ = 85 on 2 L nasal cannula, PCO₂ = 30, and HCO₃^- = 19. He is currently receiving fluids via parenteral nutrition with 35 kcal/kg/day: 60% carbohydrates, 35% kcal as lipids, and the rest as protein. He is also receiving morphine sulfate via a patient-controlled analgesia pump. Which of the following would most likely account for this patient's current status?

(A) Deficiency in thiamine

(B) Hypoglycemia

(D) Dehydration

(E) Morphine overdose

P.527

A patient presents to the emergency room after sustaining a gunshot injury to the right chest. The entrance wound is approximately 2 inches below the nipple and along the anterior axillary line with an exit wound near the posterior axillary line on the right. Along with the placement of a chest tube, treatment should include which of the following?

(A) Performance of a subxiphoid window

(B) Immediate aortogram

(D) Exploratory laparotomy

(E) No further treatment

A 52-year-old man with a history of hypertension is referred for biopsy-proven gastric adenocarcinoma. The patient states that the cancer was found when he underwent a routine upper endoscopy for the evaluation of his epigastric pain. The pain has been recent in onset, about 1 month. Otherwise, the patient denies any melanotic stools or weight loss. Extensive evaluation does not demonstrate any metastatic disease. Which of the following would be the best advice to give to this patient?

(A) Undergo chemotherapy and radiation only

(B) Undergo surgical resection

(D) Undergo a gastric bypass for symptomatic relief

(E) Undergo radiation therapy alone

A 57-year-old woman underwent an abdominal hysterectomy for fibroids 8 years ago. She now presents to the emergency room with a 2-day history of worsening nausea and vomiting, as well as complaints of crampy central and lower abdominal pain. On physical examination her temperature is 37.7°C (100°F), her heart rate is 110 beats/min, her respiratory rate is 16/min, and her blood pressure is 140/80 mm Hg. Her abdomen is distended and mildly tender but without rebound or guarding. Initial management should include which of the following?

(A) Ultrasound examination of the abdomen

(B) Nasogastric tube placement

(D) Administration of analgesics and antiemetics

(E) Continued observation in the emergency room

A 65-year-old man recently diagnosed with renal cell carcinoma presents to the office with complaints of increased abdominal bloating. On physical examination, he is found to have a tense, but nontender abdomen with shifting dullness. The liver edge is also palpable 6 cm below the costal margin. Computed tomography (CT) scan reveals tumor extending through the inferior vena cava to the right atrium. In this patient, which of the following is the most likely cause of ascites and portal hypertension?

(A) Alcoholic cirrhosis

(B) Budd-Chiari syndrome

(D) Cirrhosis secondary to Hepatitis B

(E) Portal vein thrombosis

A 65-year-old man presents for an elective total knee replacement. His is otherwise in a good state of health but reports that he remembers being on a ventilator for a long time after a laparoscopic cholecystectomy 5 years prior. A review of his chart reveals that he received succinylcholine and the prolonged paralysis was thought to have been the result of a pseudocholinesterase deficiency. Which of the following agents could potentially result in prolonged muscle relaxation if used in this patient?

(A) Pancuronium

(B) Vecuronium

(D) Rocuronium

(E) Mivacurium

A patient who had sustained a severe crush injury to both the lower extremities 2 days prior is noted to have frequent long runs of ventricular tachycardia on the electrocardiogram (ECG) monitor, although his blood pressure is stable at 115/75 mm Hg. A formal ECG reveals deep S waves, peaked T waves, and widening of the QRS complex. Which of the following is the most appropriate initial therapy in the management of this patient?

(A) Administer 1 mg of epinephrine

(B) Administer insulin and 25% dextrose in water

(D) Administer potassium chloride

(E) Administer calcium gluconate

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A 33-year-old, intravenous drug abuser presents to the emergency department febrile (40°C) complaining of left upper quadrant abdominal pain. He is tachycardic with a blood pressure of 110/50 mm Hg. Examination reveals a systolic ejection murmur over the right sternal border, several tiny erythematous lesions on the palm of his right hand, and a tender left upper quadrant. Echocardiogram reveals several vegetations on the tricuspid valve. Abdominal ultrasound reveals a fluid-filled mass within the spleen measuring 4 × 5 cm². A peripheral blood smear is notable for gram-positive cocci. Which of the following is the best treatment option for this patient?

(A) Image-guided drainage of the splenic lesion alone

(B) Intravenous (IV) antibiotics alone

(D) IV antibiotics and splenectomy

(E) Splenectomy alone

An 80-year-old man presents to the office with a history of “abdominal fullness” sensation that has been worsening over the past several months. A computed tomography (CT) scan reveals a 9-cm lesion suggestive of a retroperitoneal sarcoma. Which of the following is the most important prognostic factor in this patient?

(A) Age of the patient

(B) Number of positive lymph nodes

(D) Aneuploidy

(E) Location of the lesion

A 68-year-old man presents to the office after noting a neck mass. On examination, he has a 1.5-cm mass in the left lobe of the thyroid gland. Which of the following characteristics is most suggestive that this thyroid nodule is benign?

(A) The presence of only 1 nodule

(B) The lesion is cystic

(D) Family history of multiple endocrine neoplasia (MEN) II

(E) Dysphagia or hoarseness

A 68-year-old woman presents after referral from a primary care physician who noted occult positive stools on routine physical examination. The patient denies any previous history of bleeding from her rectum but has noticed a significant decrease in the caliber of her stools over the past several months. Which of the following is the most appropriate diagnostic method in the evaluation of this patient?

(A) Computed tomography (CT) scan

(B) Colonoscopy

(D) Laparoscopy

(E) Exploratory laparotomy

A 25-year-old woman with recurrent episodes of headaches, sweating, and hypertension is noted to have elevated vanillylmandelic acid (VMA) and metanephrines. Computed tomography (CT) scan reveals no abnormalities in either adrenal gland. Which of the following is the most likely location of the pheochromocytoma?

(A) Bladder

(B) Bifurcation of the aorta

(D) Carotid body

(E) Thorax

A 68-year-old man presents to the office with a 7-cm mass in his posterior right thigh. A recent biopsy revealed a high-grade sarcoma. A complete work-up revealed no evidence of metastatic disease. Which of the following is the most appropriate definitive treatment for this patient?

(A) Surgical resection plus combination chemotherapy

(B) External beam radiation alone

(D) Surgical resection plus radiation therapy

(E) Surgical resection alone

A 43-year-old woman undergoes elective left thyroid lobectomy and isthmusectomy for follicular cell carcinoma. Mobilization of the lobe was initially difficult but the patient tolerated the procedure well and was transferred to the postoperative recovery room where she was extubated. Twelve hours later, the patient is noted to be developing worsening shortness of breath and stridor with associated anxiety. Which of the following is the most likely cause of her current condition?

(A) Left recurrent laryngeal nerve injury

(B) Hematoma formation

(D) Bilateral superior laryngeal nerve injury

(E) Thyroid storm syndrome

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A 45-year-old woman consults her gynecologist for menorrhagia and during the review of systems she also reports weakness and fatigue. Work-up includes a serum aldosterone level, which is elevated. Which of the following clinical findings would most likely be found in this patient?

(A) Hyperkalemia

(B) Edema

(D) Expanded blood volume

(E) Oliguria

A 35-year-old woman is found to have a 2-cm, solid mass in the right lobe of the liver on computed tomography (CT) scan evaluation during a trauma work-up following a motor vehicle accident. Based on the CT scan findings, the lesion is diagnosed as a benign hepatic adenoma. The patient otherwise was found to have no major injuries and was discharged the following day. In the office, the patient denies any symptoms potentially related to the adenoma. Which of the following is an appropriate statement regarding hepatic adenomas?

(A) Administration of oral contraceptive agents may produce regression of the lesion

(B) These lesions are benign and are not associated with malignant transformation

(D) Further diagnostic studies should be performed because these lesions rarely occur in women of child-bearing age

(E) The patient should be reassured that there is no indication for surgery on this lesion unless it becomes symptomatic

A 35-year-old woman presents to your office with the primary complaint of nodular, painful, lumpy breast tissue. She states that her symptoms include mastodynia and sometimes nipple discharge. She has noted that her pain increases just before her menses and seems to diminish after, but rarely is she asymptomatic. She has a history of irregular menses, but was able to have 3 children. She is of a normal body weight and has never been on birth control pills. On physical examination, you discover that she has very tender breasts with no dominant masses. You obtain a mammogram and discover an area of microcalcifications. A needle localized excisional biopsy reveals microscopic and macroscopic cysts with fibrosis, adenosis with lymphocytic infiltration, and regularity of nuclei with an absence of mitoses. Which of the following is the best treatment for this patient?

(A) Modified radical mastectomy

(B) Reassuring the patient that the process is benign with close follow-up

(D) Radiation therapy alone

(E) Reassurance in combination with pain control alone

A 34-year-old, diabetic man undergoes combined kidney-pancreas transplantation. The pancreatic exocrine drainage is performed using an enteric anastomosis. Close monitoring of which of the following is most effective in monitoring for pancreatic rejection?

(A) Glucose levels

(B) Urinary amylase levels

(D) Serum amylase levels

(E) Serum creatinine levels

A 25-year-old man presents to the emergency department with acute onset of severe abdominal pain. His vital signs are: heart rate, 135 beats/min; blood pressure, 70/20 mm Hg; respiration, 30/min; temperature, 36.0°C. Examination reveals a rigid abdomen. Which of the following is the most appropriate next step in the management of this patient?

(A) Obtain a detailed history

(B) Insert a urinary catheter

(D) Provide fluid resuscitation

(E) Perform a barium enema

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A 45-year-old man presents for evaluation with complaints of epigastric pain and gastroesophageal reflux. He has been treated with proton pump inhibitor therapy for 3 months without relief of his symptoms. Which of the following statements is true regarding further treatment of this patient?

(A) If 24-hour pH probe reveals gastroesophageal reflux, surgery is indicated without further work-up

(B) An additional 3 months of medical therapy is recommended before surgery

(D) Manometry is not indicated, because the patient has no difficulty swallowing

(E) Barrett's changes can be cured by Nissen fundoplication

A 38-year-old, asymptomatic, human immunodeficiency virus (HIV)-positive woman presents with complaints of a new breast mass in her right breast noted on routine self-examination. She states that she noticed the mass about 1 month before and that it has gradually increased in size. On physical examination, there is a 2-cm, firm mass in the upper outer quadrant of the right breast without any evidence of palpable axillary nodes. Core needle biopsy reveals ductal adenocarcinoma. Which of the following is appropriate regarding the management of this patient?

(A) Treatment should be palliative, given the likelihood of unrecognized metastatic disease

(B) Administration of prophylactic perioperative antibiotics two days before and after any surgery, given the increased risk of wound infections in HIV-positive patients

(C) A modified radical mastectomy is favored over lumpectomy with lymph node dissection and postoperative radiation therapy because of the risk of wound complications with radiation

(D) Breast reconstruction is contraindicated, given the risk of wound healing problems in the HIV-positive patient

(E) Either a modified radical mastectomy or lumpectomy with lymph node dissection and postoperative radiation therapy would be appropriate in an HIV-positive patient

A 62-year-old male smoker with a history of peripheral vascular disease presents to the office for a routine visit. On physical examination the patient is noted to have a 2-cm nonhealing ulcer on his right leg at the site of previous skin grafting for a burn injury 15 years previously. The patient states that the ulcer has not bothered him and that he has been taking good care of it with frequent cleansing and dressing changes at home. He states that the ulcer has remained stable in size since he first noticed it 5 months ago. Distal pulses are noted by Doppler. Which of the following is most appropriate in the initial management of this patient?

(A) Continued wound care with subsequent arteriography

(B) Aggressive wound débridement and continued wound care at home

(D) Regrafting of wound with split-thickness skin graft

(E) Recommended cessation of smoking and observation of wound as outpatient

A 65-year-old woman with a history of coronary artery disease is admitted to the hospital with a high-output pancreaticocutaneous fistula 6 weeks after a Whipple procedure performed for treatment of pancreatic cancer. She complains of nausea, vomiting, and weakness. Her physician has great difficulty maintaining adequate serum levels of potassium. Which of the following coexisting electrolyte imbalances may be contributing to this patient's condition?

(A) Hyponatremia

(B) Hypomagnesemia

(D) Hypercalcemia

(E) Hypermagnesemia

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A 45-year-old woman who is a known alcoholic presents to the emergency department in extremis. Foul-smelling, bloody vomit is grossly visible on her dress. Her skin is cold and ashen gray. Her blood pressure is 80/40 mm Hg and her heart rate is 130 beats/min. Her abdomen is cachectic and her stool is guaiac-positive. Initial nasogastric tube placement evacuates 1200 ml of bright red blood. After initial management steps are taken, including administration of 2 L of normal saline and 2 units of packed red blood cells (PRBCs), the patient's heart rate is 109 beats/min with a blood pressure of 98/65 mm Hg. However, nasogastric aspirate still demonstrates significant bright red blood. Which of the following is the most appropriate next step in the management of this patient?

(A) Immediate laparotomy

(B) Vasopressin infusion

(D) Placement of Sengstaken-Blakemore tube

(E) Administration of omeprazole, continued intravenous fluids, and observation

A 28-year-old man presents to the emergency room with the complaint of recurrent, colicky, midabdominal pain. Physical examination reveals a palpable abdominal mass and several areas of increased pigmentation on his lips, palms, and soles. He states that his mother had a polyp removed from her colon several years ago. Which of the following is the most likely diagnosis?

(A) Familial polyposis with malignant degeneration

(B) Gardner's syndrome with intussusception

(D) Symptomatic Crohn's disease

(E) Human immunodeficiency virus (HIV) enteropathy

A 38-year-old, previously healthy, white woman presents 1 week after a laparoscopic cholecystectomy at an outside institution. Approximately 3 days after her surgery she developed recurrent high fever associated with abdominal pain. She is placed on broad spectrum antibiotics with some improvement in her clinical course. Abdominal computed tomography (CT) scan reveals a moderately large fluid collection in the gallbladder fossa. Cholangiography demonstrates a leak in the common bile duct. Which of the following statements is appropriate regarding the management of this patient?

(A) There is no role for administration of antibiotics

(B) Proximal biliary decompression and external drainage can be used to control the leak

(D) Surgical intervention is required in most cases to allow for resolution of the leak

(E) A Roux-en-Y choledochojejunostomy is contraindicated

A 45-year-old woman presents to the office with a nontender right groin mass. The patient states she noticed the mass approximately 1 week ago after working in the garden all day. On examination, the mass is approximately 5 cm and is soft. Which of the following is the most likely cause of this mass?

(A) Femoral hernia

(B) Direct inguinal hernia

(D) Obturator hernia

(E) Femoral artery aneurysm

After an uneventful laparoscopic cholecystectomy, a 58-year-old woman had the urinary catheter removed and began to ambulate. During routine vital sign checks, she was noted to have had no urine output over the previous 8 hours. An intravenous bolus of normal saline (500 mL) was ordered but did not stimulate voiding. She underwent straight catheterization of her bladder, which revealed 1000 mL of urine. Urine analysis showed a specific gravity of 1.022, a pH of 5, moderate blood, and positive leukocyte esterase and nitrites. There were 23 red blood cells/high power field (hpf) and 212 white blood cells/hpf. What is the most likely explanation for her failure to void?

(A) Bilateral ureteral obstruction

(B) Acute renal failure (ARF)

(D) Hemorrhagic cystitis

(E) Normal urinary retention

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A 52-year-old man with a history of stage I colon cancer treated with surgical resection 1 year ago develops chronic renal failure due to diabetes. Which of the following is the best recommendation for this patient?

(A) Treatment with hemodialysis without future transplantation

(B) Treatment with continuous ambulatory peritoneal dialysis without future transplantation

(D) Hemodialysis for 1 year followed by kidney transplantation

(E) Hemodialysis for 3 months followed by kidney transplantation

A 50-year-old woman is receiving a lumbar epidural to provide anesthesia for a transabdominal hysterectomy. During administration of local anesthetic (lidocaine) through the epidural catheter, the woman complains of shortness of breath then rapidly becomes unresponsive and apneic. The local anesthetic had been injected in small divided doses and at no point did the catheter aspirate cerebrospinal fluid or blood. She is promptly intubated and given 100% oxygen with positive pressure ventilation. Which of the following is the most likely cause of this patient's symptoms?

(A) Unintentional subdural or subarachnoid injection

(B) Allergic reaction to lidocaine

(D) Pulmonary embolization

(E) Myocardial infarction

A 55-year-old, alcoholic man has been receiving parenteral nutrition for the past 4 weeks following a protracted course of critical illness associated with an episode of necrotizing pancreatitis. Over the past 2–3 days he has tolerated oral intake of water and other liquids and some pureed foods. The next morning his parenteral nutrition is stopped and he continues to tolerate oral water. Later that morning, the patient becomes lethargic and confused, and eventually becomes unresponsive. Which of the following is the most appropriate initial management strategy for this patient?

(A) Fluid resuscitation and immediate pulmonary arteriogram

(B) Fluid resuscitation and immediate head computed tomography (CT)

(D) Fluid resuscitation and chest tube placement

(E) Fluid resuscitation and serum glucose analysis

A 67-year-old man presents to the office for a routine check-up. His wife states that he has a dark skin lesion on his back that she would like examined. Which of the following factors would most likely suggest that this is a benign lesion?

(A) 6-mm, smooth lesion, with areas of black and purple pigmentation

(B) 6-mm, blue lesion, with irregular borders

(D) 6-mm, smooth, dark purple lesion

(E) 8-mm, smooth, blue lesion, with a central ulceration

Directions: Each set of matching questions in this section consists of a list of four to twenty-six lettered options followed by several numbered items. For each numbered item, select the appropriate lettered option(s). Each lettered option may be selected once, more than once, or not at all.

Questions 77–79

Amylase
Alkaline phosphatase
Lactic acid
Hematocrit
Leukocyte esterase
Lactate dehydrogenase
Thyroid hormone
Serum myoglobin

For each clinical scenario, select the laboratory value or values that are likely to be abnormal.

A 60-year-old woman with a history of gallstones presents to the emergency room with severe epigastric pain radiating to the back, nausea, vomiting, and anorexia. Her vital signs are: heart rate, 80 beats/min; blood pressure, 120/70 mm Hg. The patient has had good urine output. Ultrasound of the right upper quadrant shows small gallstones throughout the biliary tree. (SELECT 2 LAB VALUES)
A 30-year-old, pregnant woman with a gestational age of 30 weeks presents to the emergency room with suprapubic discomfort and dysuria. Her vital signs are: heart rate, 90 beats/min; blood pressure, 125/70 mm Hg; respiration, 24/min; temperature, 38.3°C. Abdominal films are unremarkable. (SELECT 1 LAB VALUE)

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A 70-year-old woman presents to the emergency room with pain localized to the upper abdomen. Abdominal ultrasound reveals pericholecystic fluid. The patient takes no medications and has no significant past medical history. Her vital signs are: blood pressure, 130/80 mm Hg; heart rate, 88 beats/min; respiration, 18/min; temperature, 38.3°C. (SELECT 1 LAB VALUE)

Questions 80–81

Radical pancreaticoduodenectomy
Radical cholecystectomy
Roux-en-Y hepaticojejunostomy
Roux-en-Y choledochojejunostomy
Cholecystojejunostomy
Percutaneous cholecystostomy
End-to-end primary anastomosis with T-tube placement

For each clinical scenario, select the most appropriate procedure.

A 47-year-old, white man with a previous laparoscopic cholecystectomy performed 1 year ago presents with a 6-month history of fluctuating jaundice, pruritus, and abdominal pain. Computed tomography (CT) scan has been performed and reveals no mass lesions but distension of the intrahepatic ducts. A cholangiogram reveals a 3-cm segmental narrowing of the common bile duct near the cystic duct remnant. (SELECT 2 PROCEDURE)
A 68-year-old, African-American man with a history of hypertension, coronary artery bypass surgery, and bilateral inguinal hernia repairs presents with a 2-week history of jaundice and pruritus. Laboratory examination is significant for elevated total and conjugated bilirubin. Computed tomography (CT) scan of the abdomen reveals distended intrahepatic and extrahepatic biliary ducts to the level of the common bile duct. No mass lesions or lymphadenopathy are identified. A cholangiogram reveals a stricture of the common bile duct approximately 2 cm from the ampulla of Vater. Cytology on brushings is suggestive of adenocarcinoma. (SELECT 1 PROCEDURE)

Questions 82–86

Gastrinoma
Pituitary adenoma
Vasoactive intestinal peptide tumors (VIPoma)
Insulinoma
Incidentaloma
Glucagonoma
Somatostatinoma

Match each of the following case scenarios with the associated endocrine neoplasm.

A 35-year-old man presents with a history of recurrent bleeding gastric ulcers refractory to 1 year of intensive medical therapy. (SELECT 1 NEOPLASM)
A thin, 37-year-old, otherwise healthy man was recently diagnosed with diabetes mellitus. In addition, he is noted to have a 3-cm mass in the head of the pancreas. (SELECT 2 NEOPLASMS)
A 33-year-old woman presents with recurrent episodes of diaphoresis and palpitations. Her symptoms are often exacerbated by minimal fasting. (SELECT 1 NEOPLASM)
A thin, 38-year-old man presents to the office with complaints of a recurring erythematous rash over his chest, abdomen, and thighs. He states that the rash presents as patches that come and go and appear in different areas each time. (SELECT 1 NEOPLASM)
A 43-year-old woman presents to the office with complaints of persistent watery diarrhea over the past several months. An abdominal computed tomography (CT) scan reveals a 2-cm mass in the head of the pancreas. (SELECT 2 NEOPLASMS)

Questions 87–89

History of pelvic inflammatory disease
Gallstones
Bedridden state
Chronic steroid use
Atherosclerosis
Atrial fibrillation
History of myocardial infarction
Chronic laxative use
Rheumatic fever

For each clinical scenario, select the most appropriate risk factor(s) for that disease.

A 22-year-old woman presents with abdominal pain, vaginal bleeding, and an ultrasound showing a gestational sac in the ampullary part of the fallopian tube. (SELECT 1 RISK FACTOR)
A 64-year-old man with progressively increasing abdominal and back pain presents with an 8-cm pulsatile abdominal mass. (SELECT 1 RISK FACTOR)

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A 70-year-old man with dementia is admitted from a local nursing home with severe left lower quadrant pain, abdominal distention, and constipation. An extremely dilated sigmoid colon is present on abdominal film and appears to taper both proximally and distally. (SELECT 2 RISK FACTORS)

Questions 90–94

Tension pneumothorax
Cardiac tamponade
Massive liver injury
Aortic disruption
Tension hemothorax
Flail chest
Femur fracture
Pelvic fracture
Spinal cord injury
Closed head injury

Match the following cause(s) of hypotension with the clinical scenario listed below.

A 19-year-old man is shot from behind, with a gunshot entrance wound below and just medial to the right scapula. The exit wound is visualized 3–4 finger breadths superior to the inferior costal margin along the anterior axillary line. The patient is hypotensive with decreased breath sounds on the right. (SELECT 4 CAUSES OF HYPOTENSION)
A 23-year-old man presents to the emergency room with hypotension. He was involved in a head-on, high-speed motor vehicle accident. He was not wearing his seatbelt and the emergency medical technician noted deformation of the steering wheel. The patient has normal breath and heart sounds although he is tachycardic. His chest film reveals normal lung fields bilaterally, however his mediastinum appears to be slightly widened with no visualization of the aortic knob. The patient's abdominal and pelvic computed tomography (CT) scan are normal. (SELECT 1 CAUSE OF HYPOTENSION)
The driver in a high-speed motor vehicle accident presents to the emergency room with hypotension and tachycardia. Examination reveals normal breath sounds bilaterally. Heart sounds are muffled with enlarged jugular veins. Chest and pelvis films appear normal. Abdominal examination is unremarkable, with a negative diagnostic peritoneal lavage. (SELECT 1 CAUSE OF HYPOTENSION)
A 35-year-old woman presents to the emergency room after being struck in the lower back and buttocks region with a steel beam. She is conscious but confused, hypotensive, and has a heart rate of 90 beats/min. Examination reveals normal reactive pupils, normal chest and abdominal examinations, and no movement of her lower extremities. Her legs and thighs appear normal with no evidence of trauma. Her chest film is normal. Pelvic radiograph reveals a fracture of the superior ramus on the right and a right acetabular fracture. Rectal examination reveals loss of normal tone of the sphincter muscle. (SELECT 2 CAUSES OF HYPOTENSION)
A 23-year-old man presents to the emergency room after being hit in his left chest with a baseball bat. He is hypotensive, tachypneic, and has no breath sounds noted on the left side. Heart sounds are normal and his upper airway is open, although the trachea is deviated to the right. (SELECT 2 CAUSES OF HYPOTENSION)

Questions 95–96

Dilutional coagulopathy
Disseminated intravascular coagulation
Heparin-induced coagulopathy
von Willebrand's disease
Hemophilia A
Hypothermia-induced coagulopathy
Primary fibrinolysis
Vitamin K deficiency

For the each of the following clinical scenarios, select the most likely diagnosis(es).

A 44-year-old man sustained a gunshot wound to his left chest and left upper quadrant that required emergent exploratory laparotomy, splenectomy, and left hemicolectomy. On postoperative day 3, he was noted to have necrotizing fasciitis at the blast wound. He subsequently developed acute oliguric renal failure that required intermittent hemodialysis. On postoperative day 20, after a hemodynamically stable hemodialysis session, the patient was noted to be bleeding from his central line and hemodialysis catheter sites. Coagulation profile had the following results: prothrombin time (PT) = 14.0 seconds, partial thromboplastin time (PTT) > 200 seconds, platelets = 230,000. (SELECT 1 DIAGNOSIS)
A 32-year-old woman was involved in a high-speed motor vehicle accident where she sustained blunt abdominal injury. She was hypotensive at the scene and throughout most of the operation to resect her damaged intestine. Upon presentation to the intensive care unit, however, she remained hypotensive despite administration of 12 L of crystalloid, 12 units of

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packed red blood cells (PRBCs), and 5 units of fresh frozen plasma. Current vital signs include a blood pressure of 70/40 mm Hg, heart rate of 140 beat/min, and temperature of 34.5°C. Laboratory studies showed prothrombin time (PT) = 16.2, partial thromboplastin time (PTT) = 48.3, and platelets = 18,000. In addition, she was noted to be bleeding from her wound, mucous membranes, and at all catheter sites. (SELECT 3 DIAGNOSES)

Questions 97–100

Packed red blood cells (PRBCs)
Fresh frozen plasma
Cryoprecipitate
Recombinant factor VIII
Single donor platelets
Desmopressin
5% Albumin
25% Albumin
Heparin sodium
Warfarin

For each patient description, select the most appropriate treatment.

A 38-year-old female diabetic with acute renal failure requires urgent removal of her gallbladder but has an elevated bleeding time after receiving hemodialysis. Prothrombin time (PT) and partial thromboplastin time (PTT) are normal. (SELECT 2 MODES OF TREATMENT)
A 29-year-old man presents with a tibial fracture that will require intraoperative fixation. The patient gives a history of “excessive bleeding” with a tonsillectomy as a child. His PT and PTT are normal, although his bleeding time is elevated. Intraoperatively, there is a significant amount of blood loss from oozing, without any obvious sources of arterial or venous bleeding. (SELECT 2 MODES OF TREATMENT)
A 78-year-old woman requires urgent replacement of an implanted defibrillator. She has been taking warfarin for an artificial heart valve. Before surgery, the surgeon wishes to reverse the effects of warfarin. (SELECT 1 MODE OF TREATMENT)
A 45-year-old woman with protein C deficiency presents with worsening aortic stenosis secondary to a bicuspid aortic valve. The patient undergoes replacement of this valve with an artificial mechanical valve. Postoperatively, the surgeon wishes to provide anticoagulation therapy to prevent thrombus formation on the valve. (SELECT 2 MODES OF TREATMENT)

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