clinical mastery Surgery Form 3 & 4 Please help!
18. A 16-year-old girl is brought to the emergency department after being stabbed in the anterior neck 30 minutes ago. A large hematoma is evident and is pulsatile at the level of the thyroid cartilage. As the physician watches, the hematoma expands. Which of the following is the most appropriate initial step in management?
A) Barium esophagography to rule out esophageal injury
B) Endotracheal intubation
C) Esophagoscopy to rule out esophageal injury
D) Indirect laryngoscopy to determine vocal cord injury
• WRONG E) Tracheostomy
For each patient with a bleeding disorder, select the most likely diagnosis.
A) Anticardiolipin antibodies
B) Antithrombin 111 deficiency
• WRONG C) Fibrinogen abnormality
H) von Willebrand disease
25. A 64-year-old man is undergoing an elective surgical repair of an abdominal aortic aneurysm. During the operation, a retroaortic renal vein is lacerated, and the patient subsequently loses a large amount of blood. In addition to 4 L of blood retained by the cell-saver autotransfusion device, 22 units of packed red blood cells are replaced. The patient is hemodynamically stable, but blood is oozing from every surface in the operative field and from the intravenous and arterial catheter sites.
26. A 22-year-old man comes to the emergency department because of a swollen, painful, and slightly plethoric right lower extremity. He has had two episodes of superficial thrombophlebitis of the right lower extremity; the first episode occurred 30 months ago and the second episode occurred 18 months ago. Venous duplex scan confirms deep venous thrombosis involving the infrapopliteal veins.
39. A 32-year-old woman comes to the emergency department because of a 10-hour history of increasingly severe, constant pain in her abdomen. She has nausea but has not vomited. She has systemic lupus erythematosus well controlled with prednisone. She takes no other medications. Her temperature is 38°C (100.4 °F), pulse is 11 O/min, respirations are 16/min, and blood pressure is 115/65 mm Hg. Examination shows no scleral icterus. The abdomen is soft and tender to palpation over the right upper quadrant; there is mild guarding without rebound. Laboratory studies show:
Hemoglobin 14 g/dL
Leukocyte count 12,000/mm3
Results of liver function tests are within the reference ranges. Abdominal ultrasonography shows a distended gallbladder with a thickened wall and a gallstone lodged in the neck of the gallbladder. Following administration of cefazolin and an intravenous infusion of lactated Ringer solution, the patient is taken to the operating room for laparoscopic cholecystectomy. On induction with propofol, her blood pressure abruptly decreases to 60/40 mm Hg and remains constant despite administration of an additional 500-mL bolus of lactated Ringer solution. Which of the following is the most appropriate next step in pharmacotherapy?
A) Administer diphenhydramine
B) Administer dopamine
C) Administer gentamicin
D) Administer hydrocortisone
• WRONG E) Decrease the dose of propofol
40. A 28-year-old woman comes to the physician because of fatigue, increasing breast size and tenderness, and increased urinary frequency over the past 8 weeks. She has also had slight intermittent cramping in the midline. She is uncertain when her last menstrual period occurred. She is 152 cm (5 ft) tall and weighs 85 kg (187 lb); BMI is 37 kg/m2. Ultrasonography shows a viable pregnancy high in the uterus consistent with an 8-week gestation. Two weeks later, she has severe right-sided abdominal pain associated with right shoulder pain. Ultrasonography of the pelvis shows a viable pregnancy in the right cornual area of the uterus. Immediately after the ultrasonography, the patient's vital signs become unstable with a pulse of 140/min, respirations of 20/min, and blood pressure of 90/40 mm Hg. Which of the following is the most likely diagnosis?
B) Corpus luteum cyst
C) Ectopic pregnancy
F) Follicular cyst
G) Leiomyomata uteri
H) Pelvic inflammatory disease
• WRONG I) Ruptured ovarian cyst
J) Spontaneous abortion
1. A previously healthy 37-year-old woman is brought to the emergency department immediately after her husband found her lying in bed in a deep stupor. She has no history of a seizure disorder, and she does not take any medications. Her temperature is 37.5°C (99.5°F), pulse is 54/min, and blood pressure is 180/100 mm Hg. Examination shows a dense left hemiparesis and early decerebrate posturing. There is no evidence of trauma. Which of the following is the most likely diagnosis?
• WRONG A) Arteriovenous malformation
B) Brain abscess
D) Ruptured intracerebral aneurysm
E) Thrombosed middle cerebral artery
8. A previously healthy 37-year-old woman comes to the physician because of a 2-month history of intermittent, right upper abdominal pain that usually occurs after meals. She has not had fever, chills, vomiting, nausea, weight loss, or change in bowel movements. She takes no medications. Her temperature is 37°C (98.6°F), pulse is 68/min, respirations are 16/min, and blood pressure is 110/70 mm Hg. Examination shows no jaundice or scleral icterus. Abdominal examination shows no abnormalities. Her leukocyte count is 5000/mm3. Results of liver function tests are within the reference ranges. Abdominal ultrasonography shows a thickened gallbladder wall, cholelithiasis, and a 4.2-cm hepatic mass in the right lobe. An abdominal CT scan shows the mass to be 4.2 x 3.5 cm with a central scar. Which of the following is the most appropriate next step in diagnosis?
A) Measurement of serum a-fetoprotein concentration
B) Hepatitis B virus serology
C) Radionuclide liver scan
D) MRI of the liver
• WRONG E) Fine-needle aspiration biopsy of the mass
F) No further testing is indicated
31. A 67-year-old man comes to the physician because of an ulcer on the glans penis that has been increasing in size over the past 6 months. He is sexually active with multiple partners and rarely uses a condom. Examination shows an uncircumcised penis with bilateral, firm inguinal adenopathy and a painless ulcer on the glans. A serologic VDRL test is nonreactive. Which of the following is the most likely diagnosis?
C) Gonococcal urethritis
E) Inguinal hernia
F) Nongonococcal urethritis
G) Penile cancer
H) Scrotal abscess
• WRONG I) Syphilis
For each patient with a limp, select the most likely diagnosis.
A) Legg-Calve-Perthes disease
B) Osgood-Schlatter disease
D) Recurrent sprain
• WRONG E) Septic arthritis
F) Slipped capital femoral epiphysis
G) Stress fracture
H) Tibia vara
I) Toxic synovitis
38. A 3-year-old girl is brought to the physician because of a 2-day history of a limp. Two weeks ago, she had fever and upper respiratory symptoms that resolved spontaneously. She has no history of serious illness and takes no medications. Her temperature is 37°C (98.6°F). Examination of the left hip shows moderate pain to palpation. Her leukocyte count is 11 ,000/mm3 (60% segmented neutrophils, 2% eosinophils, 30% lymphocytes, and 8% monocytes), and erythrocyte sedimentation rate is 12 mm/h.
39. A previously healthy 25-year-old woman is brought to the emergency department 20 minutes after being struck by an automobile. On arrival, she has pelvic and left lower extremity pain. Her temperature is 36.8°C (98.3°F), pulse is 135/min, respirations are 26/min, and blood pressure is 90/48 mm Hg. Examination shows an unstable pelvis and an obvious deformity of the left thigh. X-rays show fractures of the left iliac wing and left midshaft femur. Ten units of packed red blood cells are administered, and her blood pressure stabilizes. Nine days after operative repair of her fractures, she develops jaundice. Abdominal examination shows no abnormalities. Serum studies show:
Bilirubin, total 5 mg/dl
Direct 2.3 mg/dl
Alkaline phosphatase150 U/L
y-GIutamyltra nsferase35 U/L (N=5-50)
Which of the following is the most likely underlying cause of these findings?
A) Decreased excretion of bilirubin into the bile
B) Decreased hepatic conjugation of bilirubin
C) Decreased hepatic uptake of bilirubin
• WRONG D) Obstruction of common bile duct
E) Overproduction of bilirubin
for #39 what is the reasoning behind administration of hydrocortisone if the pt's SLE is already well controlled? Did you get it marked right on the nbme? Thank you
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