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J2EE eBooks

admin — Mon, 23 Mar 2009 08:01:49 +0000

J2EE vs. Microsoft.NET
J2EE Architectures
Quick J2EE Architecture Overview
Simplified Guide to the Java 2 Platform, Enterprise Edition
Rapid application development for J2EE using Adobe ColdFusion 8
Choosing a J2EE application server .for your commercial software …
Leveraging Oracle Database Security with J2EE CMP
Classloading in Oracle9 i AS Containers for J2EE
The J2EE 1.4 Tutorial
WebObjects J2EE Programming Guide
J2EE Overview
J2EE and Enterprise Java Beans Patterns
Model Driven Development for J2EE Utilizing a Model Driven …
RIA, Flex and J2EE
The JBoss 4 Application Server J2EE Reference
J2EE on JBoss
J2EE and .Net security
J2EE Application Assembler’s Guide
Best Practices for Rapid Resolution of J2EE Application Problems …
Implementing Probes for J2EE Cluster Monitoring
All 4 versions

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All 4 versions
[PDF]

Magic Quadrant for J2EE Application Server Management, 2005
Java/J2EE Job Interview Companion
Core J2EE Patterns, Frameworks and Micro Architectures
Object-Oriented Hypermedia Design and J2EE Technology for Web …
Java Technology Overview JC, J2ME, J2SE, J2EE
How to Improve J2EE Performance and Reliability
J2EE and Hibernate replaces COBOL
Checking OCL Constraints in Distributed Systems using J2EE/EJB
Infrastructure for Automatic Dynamic Deployment of J2EE …
J2EE and .NET Application Server and Web Services Benchmark
Crosscutting Concerns in J2EE Applications
CMS J2EE Application Development Guidelines v_1.0_110504.doc
J2EE and JDBC: Foundations of Enterprise Computing
Log4j and J2EE
J2EE T O
Microsoft PowerPoint – serveur-J2EE.ppt
An Architects Guide Enterprise Application Integration J2EE and
Technical Paper: Java – J2EE Conventions and Guidelines
Introduction to Embedded Systems
PostgreSQL 8.1 for J2EE/JDBC applications
Artix and J2EE
Extending J2EE for Dynamic Integration
WebSphere Dynamic Cache: Improving J2EE application performance
W N Agents in a J2EE World
Improving Data Access of J2EE Applications by Exploiting …
ORACLE Forms/Reports to Java (J2EE) Migration
GemFire Enterprise Data Fabric for J2EE Applications
JSP 2.0 (in J2EE 1.4)
Microsoft PowerPoint – AspectJ2EE = AOP + J2EE.ppt

Pdf software eBooks

admin — Mon, 23 Mar 2009 07:52:21 +0000

Software eBooks

admin — Mon, 23 Mar 2009 07:41:10 +0000

Introduction to Oracle9i: SQL

admin — Wed, 18 Mar 2009 00:02:33 +0000

Biology Questions

admin — Tue, 17 Mar 2009 23:51:39 +0000

Total number of bones in the human body
206
Hardest substance in the human body
Tooth enamel
Which blood group is called as universal donor?
A group
What causes Pneumonia?
Bacteria
Which disease affects in Pancreas?
Diabetes
Which disease is caused by the bite of a mad dog?
Hydrophobia
Which Vitamin is essential for the formation of red blood cell?
Folic Acid
The scientists who discovered the structure of DNA
A. D. Watson and F,H..C. Crick
.
The name of the tissue is present in the eye that is highly
sensitive to colors
Cone Cells
The instrument used for RBC counting
Haemocyato Meter
The cell organ that helps in the synthesis of proteins
Ribosome .
Which gland is called ‘The chemical factory of the body’?
Liver
The membrane that covers the lungs
Pleura
The red coloured pigment of blood, which accepts oxygen
Hemoglobin
Tiger belongs to the family of
Cat
A substance that radiates light when heated is called
Incandescent
Fishes breath through
Gills
In onion food is stored in the form of ?
Cellulose
Which is known as the “prince of species” ?
Vanilla
Which is the first hormone prepared by’ genetic engineering? .
Insulin
Tachometer is a device used to measure
Revolutions per minute
Which chemicals used to remove acidity in stomach?
Magnesium hydroxide.
Pure water is obtained from seawater by the process called
Distillation
The unit used to measure the energy in food
Calorie
who prepared soda water for the first time?
Joseph Priestly
Which is ,the important Carbohydrate present in plants?
Starch
Which was the first metal made by man?
Copper
Tibia bone is present in which part of our body
Leg
Contact lenses are made from?
Polymethyl Methacrylate
Name the lens used to correct Astigmatism
Cylindrical lens
Which is known as animal starch
Glycogen’
Which is the edible portion of a mango?
Mesocarp
Which is the heaviest of the solar system? .
The Sun
Development of an egg without fertilization is called
Parthenogenesis
The acid present in Vinegar
Acetic acid
Which is the. metal used in Aircrafts ?
Titanium
The best conductor of electricity
Silver
The Process of coating of Iron with Zi’:1c
Galvanization
Leptospira the Pathogen, causing ?
Wails disease
A substance poisonous to an organism is called
Toxin
Which is the most common mineral ?
Silica
Name of the ester present in Orange
Octyl acetate
What is the botanical name of beetroot?
Beta Vulgaris
.
Name the pigment responsible for the red colour of Tomato :
Anthocyanin
An animal that conserves water for a very long time
Kangaroo Rat
Give the Chemical name of Styrene?
Vinyl Benzene.
Hydrophobia is caused by ?
Rabies Virus
Name the gas used in filling common tube lights
Mercury Vapor
Who is known as the ‘father of electricity’ ?
Faraday
Who invented artificial silk ?
J. W. Swan’
Which Vitamin is produced by Ultra Violet rays of the sun on
skin?
Vitamin D
Which Vitamin is stored in the Liver?
Vitamin -A
The Study of minute living organisms is known as
Microbiology
Which element is common in all acids?
Hydrogen
The brightest star in the solar system
Sirius
Who is regarded as the father of botany?
Theophrastus
The process of formation of red blood cells is called
Haemopoiesis
The Positively charged Particle of an atom?
Proton
A human heart has how many chambers?
Four
Number of Chromosomes in human body
46
Absence of Iodine in human b9dy causes
Goitre
What is the scientific name of soda water?
Carbonic acid
Pharmacology is the study of
Drugs
Who discovered Fluorescence ?
Sir George Stokes
Who was the inventor of stainless steel?
Brearley
The venom of the cobra acts on
Central Nervous system
Who first proposed the concept of Atomic number?
Henry Moseley
Which fruit is the ‘ king of fruits’?
Mango
Hearing frequency of human .ear
20 Hz to.20000 Hz
Cane Juice contains which type of sugar
Sucrose
The protecting membrane that cover the .heart
Pericardium
The Vitamin required for clotting of blood
Vitamin K
Which blood group is considered as a universal recipient ?
Group AB
What is called suicidal bags?
Lysosome
The balancing organ of our body
Ear
The largest sense organ of our body
Skin
The smallest bone in the human body
Stapes
Which hormone is called the emergency hormone?
Adrenaline
The Vitamins those are soluble. In ‘Water
Vitamin B and C
The Vitamins that is soluble in fat
Vitamin A, 0, E, K
The disease caused by the deficiency of protein
Kwashiorkor
The Vitamin that is produced by the influence of sunlight?
Vitamin 0
The elements that harden the tooth
Fluorine
The alkaloid present in coffee -.
Caffeine
A Local anesthetic from natural source?
Cocaine
The sugar present in milk
Lactose
The enzyme that present in saliva
Ptyalin
The colouring pigment of bile
Bilirubine
Which is the physical basis of life
Protoplasm
The enzyme that digest the fat
Lipase
The enzyme that digest the protein
Pepsin
The enzyme that digest the starch
Amylase
What is the preferred diet of the silver fish?
Starch and sugar
How many legs has a spider?
8
What is the upper age limit of stars?
15 billion years
How do ferns propagate?
Through spores on the leaves
Which world conqueror’s horse was named Bucephalus ?
Alexander
Ho many toes does a horse have on each hoof?
one
How do mother animals know their own babies?
By the Smell
For how long can an armadillo hold its breatH?
Six minutes
How many humps does a Dromedary have?
One
How many chambers does a cows stomach have?
Four
On which continent is the tiger predominantly found?
Asia
In which region where skunks are found?
North America
In Which country is th bearded pig found?
Indonesia
Which type of sheep is rare species?
Marco polo’s Sheep
What are man – eating tigers most commonly found?
Sunderbans
Which animal shams i:Jead when in grave danger?
Hyena
Which animal is present on ‘India’s national crest?
The lion .
Which animal is related to the suricate ?
The yellow mongoose
Which animal of the cat family cannot draw in its claws like
the other cat ?
The Cheetah
which animal lives the greatest height?
Wild yak
How many claws does a crab have?
Five pairs
What are sea wasps, ?
Jelly fish
How many arms does the Giant squid have?
10
How many chambers are seen in fish’s heart ?
Two chambers
In which region the ‘Platypus’ primarily live?
Australia
What is the average life span of Dolphin?
30 years
Which part of the body controls the ‘reflex action’ ?
spinal cord
Which snake can raise a hood behind its head?
Cobra.
Of which species of fish is the goldfish an ornamental variety?
The common carp
Which type of cloth are mosquitoes least atracted by ? .
Luminescent satin
Which fish uses a fishing rod to catch its prey?
The angler fish
Which naturalist was murdered because of her efforts to save
Gorfllas?
Dian Fossey
Which animals have the highest number of litters in a’ year?
Rabbits
Which animal did tt}e ancient Romans call “tig,er horse” ?
Zebra
Which animal in snowy mountains fe_eds on small plants
called lichens that grow under the snow ?
Reindeer
Which animal can roduce ‘double milk’ ?
Red kangaroo
Where did the Dodo live?
Mauritius
Where does the male gaint water buy carry its eggs?
On its back
Which animal is related to the zorilla ?
The Skunk
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material is only for free distribution among PSC aspirants notfor sale.Visit
www.pscoldquestions.blogspot.com to download more tools for PSC exam preparation.

Surgery Q&A Paper – 3

admin — Fri, 13 Mar 2009 05:14:24 +0000

Block 22 Explanations

1) A 68-year-old man is brought to the emergency department following a high-speed automobile accident. He is alert and complains of chest pain and mild back pain. His blood pressure is 80/60 mm Hg. Chest x-ray shows a widened mediastinum, tracheal deviation, bronchial displacement, and loss of the aortic knob. Which of the following is the most likely diagnosis?
A. Cardiac tamponade
B. Myocardial contusion
C. Pulmonary contusion
D. Tension pneumothorax
E. Traumatic aortic rupture
Explanation:
The correct answer is
E. This patient has a traumatic aortic rupture, which is the most common cause of immediate death following a motor vehicle accident. Deceleration causes twisting of the aorta and may lead to rupture. Up to 90% of the individuals die at the scene, however a high index of suspicion and early intervention may save the remaining few. The symptoms include chest pain, back pain, and hypotension. Angiography is the gold standard and immediate surgery is mandatory. X-ray findings include widening of the mediastinum, alteration of the aortic knob, pleural cap, tracheal deviation, bronchial displacement, and esophageal deviation. Cardiac tamponade (choice A) often results from penetrating trauma near the heart and is caused by a fluid collection within the pericardium. The clinical features include hypotension, distended neck veins, pulsus paradoxus, and distant heart sounds. Pericardiocentesis is the treatment. Myocardial contusion (choice B) is most commonly seen when there is a direct blow to the chest wall. Findings include right ventricular dysfunction, arrhythmias, and an elevation of creatine kinase. An echocardiogram may document ventricular wall motion abnormalities. Pulmonary contusion (choice C) is a hemorrhage into the pulmonary parenchyma. It is characterized by dyspnea and hypoxia. Tension pneumothorax (choice D) occurs when air is trapped within the pleural space and leads to an increase in the intrathoracic pressure. Findings include jugular venous distention, hypotension, tracheal deviation, and a mediastinal shift. Tension pneumothorax often occurs following blunt trauma. Treatment is with needle thoracocentesis.

2) A football player is tackled, and he develops severe knee swelling and pain. On physical examination with the knee flexed at 90 degrees, the leg can be pulled anteriorly, like a drawer being opened. A similar finding can be elicited with the knee flexed at 20 degrees by grasping the thigh with one hand, and pulling the leg with the other. Which of the following is the most likely injured structure?
A. Anterior cruciate ligament
B. Lateral collateral ligament
C. Medial collateral ligament
D. Medial meniscus
E. Posterior cruciate ligament
Explanation:
The correct answer is
A. Swelling of the knee after trauma usually denotes the presence of a significant injury. The tests described (anterior drawer and Lachman test) are classic for an injury to the anterior cruciate ligament. The lateral collateral ligament (choice B), if disrupted, would allow the leg to be bent inward to a greater extent than normally possible (varus test). The medial collateral ligament (choice C), when injured, would produce the opposite findings: the leg could be bent outward more than the normal leg (valgus test). The medial meniscus (choice D), when injured, produces loose intraarticular bodies and locking of the knee. The posterior cruciate ligament (choice E) is much less commonly injured than the anterior cruciate. When it is injured, it produces the very opposite findings to those described in the vignette: the leg could be pushed backward, as if a drawer was being closed rather than opened.

3) A 33-year-old woman is undergoing a diagnostic work-up because she appears to have Cushing syndrome. She has elevated levels of cortisol, which are not suppressed when she is given high-dose dexamethasone. ACTH levels are greater than 200 pg/ mL. A chest x-ray film shows a central, 3-cm round mass on the hilum of the right lung. Bronchoscopy and biopsies confirm a diagnosis of small cell carcinoma of the lung. Which of the following is the preferred treatment for this woman?
A. Bilateral adrenalectomy
B. General support only
C. Pneumonectomy
D. Radiation and chemotherapy directed at the lung cancer
E. Trans-sphenoidal hypophysectomy and pulmonary lobectomy
Explanation:
The correct answer is
D. The endocrine workup is indicative of ectopic ACTH production, and the obvious site is small cell carcinoma of the lung. The lung cancer is what is going to kill this woman, not the endocrine manifestations of the tumor. Although small cell carcinoma of the lung is rarely cured, longer survival can be obtained with radiation and chemotherapy. Adrenalectomy (choice A) would address the endocrine problem by depriving the ectopic ACTH of its target gland. But, as pointed out above, the lethal disease here is the lung cancer. General support only (choice B) would lead to death in about 2 months. Radiation and chemotherapy can prolong survival by approximately 2 years. Pneumonectomy (choice C) is not the treatment for small cell carcinoma of the lung. It is the appropriate treatment for resectable and potentially curable non?small cell cancers of the lung. The combination of hypophysectomy and lobectomy (choice E) is wrong for several reasons. Pituitary microadenomas suppress with high-dose dexamethasone, and their production of ACTH is typically much lower than that seen in ectopic disease (i.e., <200 pg/mL). Thus, this woman does not need pituitary surgery. As far as the lung is concerned, surgery is not the treatment for small cell carcinoma, and lobectomy would not be applicable for a central, hilar tumor.

4) A 53-year-old woman comes to the physician because of a “lump” in her neck. She says that her masseuse noticed it 1 month ago. There is no associated pain, pressure, or hoarseness. She feels fine and has no other complaints. She has no history of radiation exposure. Examination reveals a palpable thyroid nodule that is approximately 3 cm. Which of the following is the most appropriate next step in diagnosis?
A. Cutting needle biopsy
B. Fine needle aspiration (FNA)
C. Neck ultrasound
D. Surgical resection
E. Thyroid hormone replacement
Explanation:
The correct answer is
C. An ultrasound is the first step in the evaluation of a palpable thyroid nodule. An ultrasound is a noninvasive technique that can determine if the nodule is cystic or solid, the exact size of the lesion, and whether there are any additional masses. If the nodule is cystic, a fine needle aspiration (FNA; choice B) is performed. If the cyst disappears and the cytology is benign, no additional treatment is necessary. If the cyst remains, further evaluation is necessary. If the nodule is solid and < 3 cm, an FNA is performed. If the cytology is benign, thyroid hormone replacement (choice E) is given to suppress growth. If the nodule is solid and > 3 cm., a needle biopsy (choice A) is performed. If the pathology is indeterminate or malignant, surgical resection (choice D) is the treatment. If the nodule is benign, thyroid hormone is given.

5) A 56-year-old man has been having bloody bowel movements on and off for the past several weeks. He reports that the blood is bright red, it coats the outside of the stools, and he can see it in the toilet bowl even before he wipes himself. When he does so, there is also blood on the toilet paper. After further questioning, it is ascertained that he has been constipated for the past 2 months and that the caliber of the stools has changed. They are now pencil thin, rather the usual diameter of an inch or so that was customary for him. He has no pain. Which of the following is the most likely diagnosis?
A. Anal fissure
B. Cancer of the cecum
C. Cancer of the rectum
D. External hemorrhoids
E. Internal hemorrhoids
Explanation:
The correct answer is
C. The combination of red blood coating the stools and a change in bowel habit and stool caliber spells out cancer of the rectum in someone in this age group. Anal fissure (choice A) is typically seen in young women who have very painful bowel movements with streaks of blood. Pain is the dominant symptom in this condition. Cancer of the cecum (choice B) leads to anemia and occult blood in the stools, but the blood is rarely seen. If it is, the entire stool is bloody. Furthermore, there is no change in bowel habit or stool caliber when the tumor is so proximal in the colon. External hemorrhoids (choice D) hurt and itch, but they rarely bleed. Internal hemorrhoids (choice E) do indeed bleed, but they do so without changing the pattern of bowel movements or the caliber of the stools.

6) A young man is shot with a .45 caliber revolver, point blank in the lower abdomen, just above the pubis. The entrance wound is at the midline, and there is no exit wound. X-ray films show the bullet embedded in the sacral promontory, to the right of the midline. Digital rectal examination and proctoscopic examination are negative, but he has gross hematuria. He is hemodynamically stable. Which of the following is the most appropriate next step in management?
A. CT scan of the abdomen
B. Intravenous pyelogram
C. Retrograde cystogram
D. Diagnostic peritoneal lavage
E. Exploratory laparotomy
Explanation:
The correct answer is
E. He has an obvious indication for exploratory laparotomy: a gunshot wound to the abdomen. He also has evidence of injury to the urinary bladder, but that will be dealt with at the same time that other intraabdominal injuries are found and repaired. CT scan (choice A) would not change the surgical approach and the surgical indication. CT scan is called for in cases of blunt trauma to diagnose intraabdominal bleeding and to identify intraabdominal injuries. Intravenous pyelogram (choice B) would indeed show the bladder injury, as would a retrograde cystogram (choice C). However, we already know clinically that there is a bladder injury: we know the trajectory of the bullet and we have blood in the urine. Diagnostic peritoneal lavage (choice D) is used to diagnose intraabdominal bleeding in blunt trauma, when the patient is not stable enough to be taken to the CT scanner. In many centers the diagnostic peritoneal lavage has been replaced by sonogram done in the emergency department by the trauma team.

7) A front-seat passenger in a car involved in a head-on collision relates that he hit the dashboard with his knees, however, he is specifically complaining of severe pain in his right hip, rather than knee pain. He lies in the stretcher in the emergency department with the right lower extremity shortened, adducted, and internally rotated. Which of the following is the most likely injury?
A. Femoral neck fracture
B. Fracture of the shaft of the femur
C. Intertrochanteric fracture
D. Posterior dislocation of the hip
E. Posterior dislocation of the knee
Explanation:
The correct answer is
D. The mechanism of injury is classic. As the knee hits the dashboard in the sitting position, the femoral head is driven backward and out of the socket. The position of the injured extremity is also typical, with the internal rotation produced by the posteriorly dislocated femoral head. This injury is an orthopedic emergency because of the tenuous blood supply of the femoral head. Femoral neck (choice A) and intertrochanteric (choice C) fractures are seen in elderly patients who fall and “hurt their hip.” They present with a shortened extremity that is externally rotated. A fractured shaft of the femur (choice B) would produce pain right there (not in the hip) and would have an obvious deformity where the thigh has an angulation that is clearly abnormal. Posterior dislocation of the knee (choice E) is also an orthopedic emergency because of the potential disruption of the popliteal artery, but the pain and the deformity would be at the knee.

A 71-year-old woman is brought to the physician by her distressed daughter. The daughter relates that, 3 days ago, her mother began to complain of right upper quadrant abdominal pain. She did not want to eat and “took to her bed sick.” The daughter recalls that she complained of chills, nausea, and some vomiting. Physical examination reveals an obtunded, hypotensive, and obviously very sick elderly woman. She has impressive pain to deep palpation in the right upper quadrant, along with muscle guarding and rebound. Her temperature is 40 C (104 F), and laboratory analysis shows a white cell count of 22,000/mm3 with multiple immature forms, a bilirubin of 5 mg/dL and alkaline phosphatase of 840 U/L. The serum amylase is normal. An emergency sonogram shows multiple stones in the gallbladder, normal thickness of the gallbladder wall without pericholecystic fluid, dilated intrahepatic ducts, and common duct with a diameter of 2.1 cm. The sonographer cannot identify stones in the common duct. In addition to IV fluids and antibiotics, which of the following is the most appropriate next step in management?
A. Elective cholecystectomy
B. Emergency decompression of the common duct
C. Emergency cholecystectomy
D. Emergency surgical exploration of the common duct
E. Emergency transhepatic cholecystostomy
Explanation:
The correct answer is
B. The diagnosis is acute ascending cholangitis. This deadly disease is seen in patients with long-standing gallstones who get one or more stones in the common duct, where they produce partial obstruction that allows ascending infection. The fact that the sonographer cannot see the offending stones is irrelevant, as stones in the common duct are often not seen in sonograms. The study shows the indirect evidence of obstruction: dilated ducts. The chills, very high fever, and extremely elevated alkaline phosphatase are diagnostic. An advanced clinical form is present here, with obtundation, right upper quadrant tenderness, and hypotension. The key component of therapy is immediate decompression of the common duct, which is full of pus. How it is achieved is less important. Emergency endoscopic retrograde cholangiopancreatography (ERCP) is usually the first choice, but it can be done by percutaneous transhepatic cholangiography (PTC) or by open surgery. Elective cholecystectomy (choice A) will indeed be needed once the acute problem is resolved. But, if our planning included only such elective surgery, the patient would never get it: she would be dead. Emergency cholecystectomy (choice C) would not address the issue of pus in the common duct. She does not have acute cholecystitis, as evidenced by the normal thickness of the gallbladder wall and the absence of pericholecystic fluid. Furthermore, acute cholecystitis would not have produced the impressive levels of alkaline phosphatase. Surgical exploration of the common duct (choice D) is more than she can tolerate at this time. She does not need all the stones removed with a long operative procedure. She needs the pus out. The rest will come later. Cholecystostomy (choice E) is another choice for very sick people with acute cholecystitis, which is not the diagnosis.

9) A 25-year-old man is shot with a .22 caliber revolver. The entrance wound is in the anteromedial aspect of his upper thigh, and the exit wound is about 3 inches lower, in the posterolateral aspect of the thigh. He has a large, expanding hematoma in the upper inner thigh. There are no palpable pulses in the foot. The bone is intact by physical examination and x-ray films. Which of the following is the most appropriate next step in management?
A. Doppler studies
B. Venogram
C. Arteriogram
D. Embolectomy
E. Surgical exploration
Explanation:
The correct answer is
E. This one should be obvious. There is no question that the femoral vessels are injured, and the expanding hematoma plus absent pulses indicate that the femoral artery is involved (the vein may or may not be injured). Surgical exploration starts with proximal and distal control. Once the hematoma is safely entered, the extent of the injuries can be ascertained and the proper repair done. Doppler studies (choice A) are wonderful when we are trying to ascertain whether blood is flowing through a vessel. The clinical findings here are obvious. No fancy technology is needed. Venograms (choice B) are not needed prior to surgery. We can look at the vein during the operation. Arteriograms (choice C) are very often used in vascular trauma, but are not needed here. We would use an arteriogram if the anatomic location of the injury suggested vascular involvement, but the clinical signs did not confirm such suspicion. Arteriograms are also used when the specific surgical approach is dictated by precise knowledge of the site of extravasation, a situation that does not apply here. An embolectomy (choice D) will probably be done at the end of the surgical procedure, as a routine part of removing debris from the lumen of a vessel that has been repaired or re-anastomosed. However, embolectomy alone is the wrong answer for this vignette. The absent pulses are due to disruption of the artery, not to embolization from a distant source.

10) A 7-year-old boy passes a large, bloody bowel movement. He is hemodynamically stable, and he has a hemoglobin of 14 g/dL. Nasogastric aspiration yields clear, greenish fluid. Physical examination, including anoscopy, is unremarkable. Which of the following is the most appropriate next diagnostic test?
A. Celiac arteriogram
B. Colonoscopy
C. Radioactively labeled technetium scan
D. Radioactively tagged red cell study
E. Upper gastrointestinal endoscopy
Explanation:
The correct answer is
C. In this age group, with no obvious anal pathology and negative gastric aspirate, the leading cause of gastrointestinal bleeding is Meckel’s diverticulum. The specific source is ulceration of the normal ileal mucosa by acid produced by gastric mucosa in the diverticulum. The technetium scan identifies that ectopic gastric mucosa. Arteriogram (choice A) as a diagnostic step is a very invasive study that is appropriate only for very large hemorrhage (>2 mL/min) with clear gastric aspirate. An arteriogram may also be indicated for therapy (embolization) in severe gastrointestinal bleeding. Colonoscopy (choice B) would not identify the Meckel’s diverticulum. Colonoscopy is often needed in the older patient with lower gastrointestinal bleeding, in whom the source of the hemorrhage is likely to be polyps, cancer, diverticula, or angiodysplasia. A tagged red cell study (choice D) is often used as a prelude to an arteriogram in patients with substantial lower gastrointestinal bleeding. Upper gastrointestinal endoscopy (choice E) would have been appropriate if the gastric aspirate had produced blood.

11) An 81-year-old man with Alzheimer disease who lives in a nursing home undergoes surgery for a fractured femoral neck. On the 5th postoperative day, it is noted that his abdomen is grossly distended and tense, but not tender. He has occasional bowel sounds. The rectal vault is empty on digital examination, and there is no evidence of occult blood. X-ray films show a few distended loops of small bowel and a very distended colon. The cecum measures 9 cm in diameter, and the gas pattern of distention extends throughout the entire large bowel, including the sigmoid and rectum. No stool is seen in the films. Other than the abdominal distention, and the ravages of his mental disease, he does not appear to be ill. Vital signs are normal for his age. Which of the following is the most likely diagnosis?
A. Fecal impaction
B. Mechanical intestinal obstruction
C. Ogilvie syndrome
D. Paralytic ileus
E. Volvulus of the sigmoid colon
Explanation:
The correct answer is
C. Ogilvie syndrome is a type of colonic dysfunction often seen in elderly patients who are not too active to begin with and are then further immobilized by extra-abdominal surgery. Colonoscopy rules out obstructing cancer (always a consideration in this age group) and allows the gas to be sucked out as the instrument advances. A long tube is then left in place. Fecal impaction (choice A) is always a good thing to look for in old immobilized people with abdominal distention. However, the rectal vault would have been full of feces, and the x-ray films might have shown the fecal column extending up into the sigmoid and descending colon. Neither mechanical intestinal obstruction (choice B) nor paralytic ileus (choice D) would develop from hip surgery. When these complications occur after abdominal surgery, they affect primarily the small bowel, not the colon. Volvulus of the sigmoid (choice E) is another good thought in the distended old patient, but the radiologic picture would have been different, with a huge distended sigmoid way up into the right upper quadrant and tapering toward the left lower quadrant with the classic image of a “parrot’s beak.”

12) A 46-year-old woman was applying her make-up while also drinking her morning cup of coffee. She noticed in the mirror that a round, 2-cm mass would move up and down in the lower part of her neck whenever she swallowed. Her physician confirms that she has a single, firm, thyroid nodule in the right lobe. There are no other abnormalities in the history or physical examination. Her pulse is 82/min and regular. Thyroid stimulating hormone (TSH) is within normal limits. Which of the following is the most appropriate next step in management?
A. Clinical observation, repeating the TSH at least once a year
B. Determination of T3 and T4 levels
C. Radionuclide thyroid scan
D. Fine needle aspiration (FNA) cytology of the mass
E. Right thyroid lobectomy
Explanation:
The correct answer is
D. Most thyroid nodules are benign, and surgery must be reserved for selected candidates with the highest likelihood of malignancy. Fine needle aspiration (FNA) is the best way to make the selection. If read by an experienced pathologist as negative for cancer, patients can be safely followed. If read as either indeterminate or positive for cancer, surgery would be required. Choosing surgical candidates this way, cancer is found at surgery in 20% to 40% of patients operated, a vast improvement over earlier selection methods, where the yield was around 10% to 15%. Clinical observation alone (choice A) would not be appropriate. Thyroid cancers grow slowly, but they still need to be diagnosed and treated. Incidentally, they typically do not affect thyroid function, so that following the TSH would not alert you to the presence of malignancy. Thyroid nodules can be benign but hyperfunctioning (toxic adenoma), and therefore thyroid function must be determined. But, that has already been done here with the normal TSH. Further pursuit of T3 and T4 (choice B) is unnecessary in someone with no clinical evidence of hyperfunction (normal pulse). Thyroid scan (choice C) would have been the answer 10 or 20 years ago, before FNA displaced it as the best way to select surgical candidates. In the old days, a cold nodule raised suspicions of malignancy but gave low yields at surgery. Without a diagnosis of cancer, or an indeterminate FNA, one cannot justify the extremely aggressive approach of surgery as the next step in management. Thus, choice E is clearly wrong.

13) A 44-year-old woman is recovering from a mild episode of acute ascending cholangitis secondary to choledocholithiasis. When seen initially, she had a spiking fever, leukocytosis, and a very high alkaline phosphatase; however, all these findings subsided rapidly after she was placed on IV antibiotics. A sonogram of the right upper quadrant on the day of admission showed the presence of gallstones in the gallbladder, but the diameter of the biliary ducts was normal. It was assumed that she had passed a common duct stone, and plans to do an endoscopic retrograde cholangiopancreatogram (ERCP) were canceled. While awaiting elective cholecystectomy, she again developed a fever and leukocytosis, and her liver function tests showed minimal elevation of her bilirubin (to 2.5 mg/dL) and alkaline phosphatase (to 115 U/L). A repeat sonogram shows no changes in her biliary ducts, but now there is a 6-cm abscess in the right lobe of the liver. Which of the following is the most appropriate treatment for this new development?
A. Metronidazole
B. Long-term IV antibiotics
C. ERCP and biliary drainage
D. Percutaneous drainage of the liver abscess
E. Open surgical resection of the right lobe of the liver
Explanation:
The correct answer is
D. Liver abscess complicating biliary tract disease is described as “pyogenic” abscess (to contrast it with amebic abscess), and it requires drainage like any abscess anywhere else in the body. The percutaneous route is favored. Metronidazole (choice A) is the therapy of choice for amebic abscesses of the liver, and that condition represents the only exception to the rule that all abscesses have to be drained. However, this is not an amebic abscess. Amebic abscesses are seen in men (4 to 1 ratio compared with women) who come from Mexico, where the disease is very common. Long-term antibiotics (choice B) will not reach and sterilize an abscess. Abscesses have to be drained. Endoscopic retrograde cholangiopancreatogram (ERCP) (choice C) is often urgently needed to treat acute ascending cholangitis, but it will not do anything for a liver abscess. Resection (choice E) is not needed for a liver abscess. Drainage is enough.

14) A 55-year-old, HIV-positive man has a fungating mass growing out of the anus. He can feel it when he wipes himself after having a bowel movement, but it is not painful. For the past 6 months, he has noticed blood on the toilet paper, and from time to time there has also been blood coating the outside of the stools. He has lost weight, and he looks emaciated and ill. On physical examination, the mass is easily visible. It measures 3.5 cm in diameter, is fixed to surrounding tissues, and appears to grow out of the anal canal. He also has rock-hard, enlarged lymph nodes on both groins, some of them as large as 2 cm in diameter. Which of the following is the most likely diagnosis?
A. Adenocarcinoma of the rectum
B. Condyloma acuminata of the anus
C. External hemorrhoids
D. Rectal prolapse
E. Squamous cell carcinoma of the anus
Explanation:
The correct answer is
E. The entire description is classic for anal cancer, but the clincher is the presence of metastasis in the inguinal nodes. Adenocarcinoma of the rectum (choice A) could look like this if it arose very low in the rectum, but it would not metastasize to inguinal nodes. Condyloma acuminata (choice B) could give fungating masses, but it would not lead to cachexia and would not produce the rock-hard inguinal nodes. Viral infections may precede the development of this kind of tumor (and could coexist with it), but it would be wrong to assume that all the patient has is the benign viral process. External hemorrhoids (choice C) are not fungating masses, they do not bleed, and they do not lead to inguinal adenopathy or cachexia. Rectal prolapse (choice D) would produce a protruding mass with concentric mucosal folds, would come in and out with straining, and would be a nuisance–but it would not produce adenopathy and cachexia.

15) A 79-year-old man with atrial fibrillation develops an acute abdomen. When seen 2 days after the onset of the abdominal pain, he has a silent abdomen, with diffuse tenderness and mild rebound. There is a trace of blood on the rectal examination. He also has acidosis and looks quite sick. X-ray films show distended small bowel and distended right colon, up to the middle of the transverse colon. Which of the following is the most likely diagnosis?
A. Acute pancreatitis
B. Mesenteric ischemia
C. Midgut volvulus
D. Perforated viscus
E. Primary peritonitis
Explanation:
The correct answer is
B. The setting of an old patient with atrial fibrillation (or a recent myocardial infarction) who develops an acute abdomen, strongly suggests embolus to the mesenteric vessels. The combination of abdominal pain and a trace of blood in the lumen is also typical, as is the x-ray film outlining the territory supplied by the superior mesenteric. He probably has a dead bowel by now, as evidenced by his acidosis and severe illness. Any one of the other options could exist, but none are the most likely. Acute pancreatitis (choice A) would be expected in an alcoholic or a patient with biliary tract disease. There would have been no blood in the lumen. Midgut volvulus (choice C) would be far more likely to happen to an infant with malrotation. A perforated viscus (choice D) is indeed possible, but the x-ray films would have shown free air rather than distended bowel. Primary peritonitis (choice E) would have been a consideration in a patient with preexisting ascites.

16) A 42-year-old, right-handed man has had a history of progressive speech difficulties and right hemiparesis for 5 months. He has had progressively severe headaches for the past 2 months, which are worse in the mornings. At the time of admission, he is confused and vomiting, and has blurred vision, papilledema, and diplopia. Shortly thereafter, his blood pressure increases to 190/110 mm Hg, and he develops bradycardia. Which of the following is most likely the significance of the hypertension and the bradycardia?
A. The brain tumor has produced tentorial herniation
B. The brain tumor is pressing on the hypothalamus
C. The chronic subdural hematoma has ruptured
D. The genesis of his symptoms is aortic dissection
E. There is a near-terminal increase in intracranial pressure
Explanation:
The correct answer is
E. The clinical picture is that of a brain tumor with increased intracranial pressure. However, the development of hypertension and bradycardia (Cushing’s reflex) signifies that the brain has run out of compensatory mechanisms to minimize the intracranial pressure elevation generated by increased intracranial volume. When that point is reached, brain perfusion suffers and death is imminent. Choices A and B correctly identify the disease as a brain tumor, but assign an incorrect meaning to the hemodynamic changes. Tentorial herniation would lead to respiratory arrest. Pressure on the hypothalamus is not the reason for the Cushing’s reflex. Choice C makes a wrong diagnosis. Chronic subdural hematomas are seen in very old or alcoholic patients, where they press on the cortex-but do not “rupture” and create a sudden catastrophe in that fashion. Aortic dissection (choice D) happens to hypertensive patients, but what they get is chest and back pain, not a long-standing neurologic picture as depicted here.

17) After a grand mal seizure, a 32-year-old epileptic woman notices pain in her right shoulder, and she cannot move it. She goes to a minor emergency clinic, where she has a limited physical examination and anteroposterior (AP) x-ray films of her shoulder. The films are read as negative, and she is diagnosed as having a sprain and given pain medication. The next day, she still has the same pain and is unable to move her arm. She comes to the emergency department holding her arm close to her body, with her hand resting on her anterior chest wall. Which of the following is the most likely diagnosis?
A. Acromioclavicular separation
B. Anterior dislocation of the shoulder
C. Articular cartilage crushing
D. Posterior dislocation of the shoulder
E. Torn teres major and minor muscles
Explanation:
The correct answer is
D. The mechanism of injury (massive contraction of all muscles in the area) and the missed diagnosis on a single view AP x-ray film are classic for posterior dislocation of the shoulder. Axillary view x-ray films are needed to make the diagnosis. Acromioclavicular separation (choice A) would have been obvious on physical examination and on the x-ray film taken Anterior dislocation (choice B) is far more common than posterior dislocation. However, it happens with regular trauma, has a very typical posture where the arm is held close to the body but the forearm and hand are rotated out as if ready to shake hands, and is easily seen on x-ray films. Crushing of the articular cartilage (choice C) and tearing of shoulder girdle muscles (choice E) are not common injuries following seizures.

18) A 69-year-old man who smokes and drinks and has rotten teeth, has a hard, fixed, 4-cm mass in his left neck. The mass is just medial to and in front of the sternomastoid muscle, at the level of the upper notch of the thyroid cartilage. It has been there for at least 6 months, and it is growing. Which of the following is the most appropriate next step in diagnosis?
A. Radionuclide scan of the thyroid gland
B. Sputum cytology and CT scan of the lungs
C. Panendoscopy (triple endoscopy) and mucosal biopsies
D. Open incisional biopsy of the mass
E. Open excisional biopsy of the mass
Explanation:
The correct answer is
C. In this setting (old man who smokes and drinks and has rotten teeth), the clinical diagnosis is metastatic squamous cell carcinoma to a cervical lymph node, from a primary (or multiple primaries) somewhere in the mucosa of the aerodigestive tract. Endoscopy and biopsies should establish the diagnosis. Thyroid cancer could indeed metastasize to neck nodes, sometimes before the primary tumor is palpable. In this particular setting, however, a radionuclide scan (choice A) would be a very distant second choice. Sputum cytology and CT scan of the lungs (choice B) is another tempting thought for a smoker. But, when lung cancer metastasizes to the cervical nodes, it affects the supraclavicular nodes, not the nodes higher up in the neck. Open biopsy of the neck mass is an absolute no-no, whether it is excisional (choice E) or incisional (choice D). Doing so will in fact confirm the diagnosis, but at the cost of contaminating the tissues and interfering with the placement of incisions for the definitive surgery. Furthermore, the location of the primary (or primaries) would not be established.

19) On the 5th postoperative day, it is noticed that large amounts of clear, pink, salmon-colored fluid are soaking the wound dressings of a patient who had a negative exploratory laparotomy for a stab wound of the abdomen. The laparotomy was done through a midline supraumbilical and infraumbilical incision. When seen by the surgical staff, the patient is lying in bed in the supine position, with the dressings removed. In the dim light of his hospital room, the incision appears intact and not particularly red or inflamed, but there are indeed traces of the clear pink fluid on his skin. He has no specific complaints. He is still NPO and on IV fluids, but has already been passing gas per rectum, and plans had been made to feed him today. The abdomen is not distended, and he has normal bowel sounds. He is afebrile. Which of the following is the most appropriate next step in management?
A. Culture the pink fluid and start empiric antibiotic therapy
B. Gently probe the wound at several points until pus is found and drained
C. Help the patient out of bed and have him walk to the examining room for proper inspection of the wound
D. Stop plans for oral feedings and start total parenteral nutrition
E. Tape the wound securely, bind the abdomen, and avoid events that would suddenly increase his intra-abdominal pressure
Explanation:
The correct answer is
E. The situation described is that of a wound dehiscence that has not yet progressed to a wound evisceration. The former can be dealt with at leisure, if the latter is avoided. He will eventually require re-closure, but it can be done whenever it is most convenient. Cultures and antibiotics (choice A) assume the pink fluid to be a sign of infection. It is not. It is normal peritoneal fluid (with a trace of blood still in it from the recent surgery) that is seeping out through the unhealed wound. Probing (choice B) will not produce pus, but it might hasten the dreaded evisceration. He is afebrile, and the wound is not red. Clear pink salmon-colored fluid means dehiscence, not infection. Getting the patient out of bed (choice C) is the last thing you want to do. If this advice were followed, the person helping the patient would soon be looking at a handful of small bowel as it comes rushing out of the belly. The fluid described is not bowel contents; this is not a fistula. There is no need to go to parenteral nutrition (choice D).

20) A 2-year-old child has been shot in the arm in a drive-by shooting. His brachial artery was partially transected, and there was copious bleeding. The EMTs control the site of bleeding by local pressure, and the child is no longer losing blood; however, he is hypotensive and tachycardic. IV fluid resuscitation is urgently needed, but several attempts at starting peripheral IV lines have been unsuccessful. Which of the following would be the best alternative route in this situation?
A. Central line via subclavian puncture
B. Hypodermoclysis
C. Intraosseous cannulation in the proximal tibia
D. Percutaneous femoral vein cannulation
E. Saphenous vein cut-down
Explanation:
The correct answer is
C. In very small children, the preferred alternate route, if peripheral veins cannot be cannulated, is the placement of a trocar in the bone marrow of a long bone. The upper tibia is usually chosen. Subclavian puncture (choice A) was at one time routinely used in the resuscitation of patients in shock, but it is now recognized that it is invasive and has many possible complications. Furthermore, frequently in the trauma setting, the head and neck and upper thorax are not accessible, as many other life-saving and diagnostic examinations are being done. The extremities, on the other hand, are free to be used. The subcutaneous tissue (choice B) cannot take fluid fast enough to meet the needs here, The femoral vein by percutaneous puncture (choice D) or a saphenous vein cut-down (choice E) are the preferred alternate routes in an adult when peripheral veins cannot be rapidly cannulated.

21) A 24-year-old woman sustains multiple injuries in a car accident, including a pelvic fracture. She is hemodynamically stable. Initial assessment shows no vaginal or rectal injuries; however, when a Foley catheter is inserted, bloody urine is recovered. Which of the following would be the best way to evaluate her urologic injury?
A. Sonogram of the bladder
B. Intravenous pyelogram
C. Cystoscopy
D. Retrograde cystogram including post-void films
E. Retrograde cystogram including views of the ureters
Explanation:
The correct answer is
D. Bloody urine plus pelvic fracture equals bladder injury in either gender, or bladder or urethral injury in the male. In this case, with the very short and well-protected female urethra not being suspected, only the bladder is the obvious candidate. Injecting dye and taking x-ray films will show the extravasation, but it is important to include post-void films because extravasation at the bladder neck can be obscured by the dye that is filling the bladder. Sonogram (choice A) is a good, noninvasive way to look at things, but here we can get far better detail with a study (the retrograde cystogram) that is not particularly invasive. Intravenous pyelogram (choice B) would show dye extravasation, but with far less detail than that provided by direct injection. Cystoscopy (choice C) would be invasive and not easy to do. When a cystoscopy is done, fluid is injected into the bladder to expand it and see the walls. In this case, the injected fluid would go out into the peritoneal cavity or the preperitoneal space. Looking at the ureters (choice E) is not necessary when bladder injury is suspected. The ureters are rarely injured in blunt trauma.

22) A 62-year-old woman has a 4-cm, hard mass under the nipple and areola of her rather small left breast. The mass occupies most of the breast, but the breast is freely movable from the chest wall. There is no dimpling or ulceration of the skin over the mass, and careful palpation of the axilla is completely negative. A core biopsy of the breast mass has established a diagnosis of infiltrating ductal carcinoma, and the mammogram showed no other lesions in that breast or the other one. A chest x-ray film and liver function tests are normal. She has no symptoms suggestive of brain or bone metastasis. Which of the following should be offered to this woman
A. Lumpectomy only
B. Lumpectomy with axillary sampling and post-op radiation
C. Total mastectomy only
D. Modified radical mastectomy (including axillary sampling)
E. Radical mastectomy (including complete axillary dissection)
Explanation:
The correct answer is
D. The mass is too large, in a breast that is too small, to allow an adequate lumpectomy. Local control of the tumor requires mastectomy. However, mastectomy alone is not sufficient. We need to know what is happening in the axilla to make a decision regarding postoperative systemic therapy. The physical examination was negative, but the reliability of that finding is not much better than flipping a coin. Lumpectomy alone (choice A) cannot be done here, and it would not be the appropriate management even if the cancer had been smaller. Lumpectomy, axillary sampling, and post-op radiation (choice B) would have been the correct answer for a smaller tumor in a larger breast. Total mastectomy alone (choice C) would have been a wise palliative choice if she had had evidence of distant metastasis. She does not. We have to go for cure. We need the standard potentially curative operation: modified radical mastectomy, which includes axillary sampling. Radical mastectomy (choice E) is no longer used for the treatment of breast cancer. It offers no survival advantage over the less mutilating modified radical.

23) A 54-year-old man, who 5 years ago underwent a laparotomy for a gunshot wound to the abdomen, is admitted to the hospital because of protracted vomiting and progressive abdominal distention. The symptoms began 5 days earlier, and since then he has not had a bowel movement or passed any gas. At the time of hospitalization, he has hyperactive bowel sounds and some abdominal discomfort, but does not have an acute abdomen. His abdominal x-ray films show dilated loops of small bowel, multiple air-fluid levels, and no free air under the diaphragms. He is placed on nasogastric suction and IV fluids. After 6 hours, he develops fever, leukocytosis, abdominal tenderness, and rebound tenderness, and his abdomen is silent. Which of the following is the most appropriate next step in management?
A. Add antibiotics
B. Barium tag and serial abdominal x-ray films
C. CT scan of the abdomen
D. Upper gastrointestinal endoscopy and introduction of a long intestinal tube
E. Emergency exploratory laparotomy
Explanation:
The correct answer is
E. He came in with mechanical intestinal obstruction due to adhesions, and has now developed signs of bowel strangulation. If the strangulated loop is still viable, it has to be freed immediately. If it is necrotic, it has to be resected with equal urgency to prevent continued peritoneal soiling. Antibiotics (choice A) will not provide viability to a compromised loop of bowel, nor prevent peritonitis if the loop is dead. Barium tag (choice B) is what we do in the postoperative period after abdominal surgery when we cannot decide whether a sluggish bowel has paralytic ileus or early mechanical obstruction. This is not the situation here. CT scan (choice C) is our universal answer when we do not know what is happening inside the belly. Here we do. Had he shown up with obstruction, and no reasonable etiology for it (no prior surgery, no hernias), we might have done a CT. Endoscopy and a long tube (choice D) will not take care of dead or dying bowel.

24) While running to catch a bus, and old man twists his ankle and falls on his inverted foot. Anteroposterior (AP), lateral, and mortise x-ray films show displaced fractures of both malleoli. Which of the following would be the preferred form of treatment?
A. Closed reduction and casting
B. Skeletal traction
C. Open reduction and internal fixation
D. Replacement with a metal prosthesis
E. Fusion of the ankle joint
Explanation:
The correct answer is
C. Precise alignment of the displaced fragments is needed to ensure that the tight mortise of the ankle joint is restored. Closed reduction and casting (choice A) is unlikely to provide the necessary realignment. Skeletal traction (choice B), in general, is indicated only in areas of the body where strong muscle groups pull broken bones into unacceptable positions. Artificial joints are usually used for advanced articular disease. In the trauma setting, replacement with a prosthesis (choice D) is as a rule reserved for fractures where avascular necrosis is predictable. Fusion of a joint (choice E) is the ultimate step when everything else has failed. It would not be the first choice for a relatively common fracture.

25) A 19-year-old man sustains multiple injuries in a high-speed automobile collision. There is a pneumothorax on the left, for which he has a chest tube placed. Over the next several days, a large amount of air drains continuously through the tube (a large “air leak”), and daily chest x-rays show that his collapsed left lung is not expanding. The patient is not on a respirator. Which of the following is the most likely cause of these findings?
A. Air embolism
B. Injury to the lung parenchyma
C. Injury to a major bronchus
D. Insufficient suction being applied to the chest tube
E. Tension pneumothorax
Explanation:
The correct answer is
C. This patient most likely has an injury to a major bronchus. In addition to the wrenching effect of a sudden deceleration, these can happen when a major blow to the chest occurs at a time when the glottis is closed. If not recognized right away by the presence of subcutaneous emphysema, they become evident once the air leak persists and the lung does not re-expand. Air embolism (choice A) is manifested by sudden death shortly after a patient with unrecognized injuries to the tracheobronchial tree in proximity to major intrathoracic vessels is placed on a respirator. Injured lung parenchyma (choice B) can indeed leak air and produce a pneumothorax, but it typically heals rapidly. It is the delayed resolution of the pneumothorax that suggests that a major bronchus, rather than lung parenchyma, has been damaged. Suction applied to a chest tube (choice D) is used to accelerate the rate of resolution of a pneumothorax, but the large amount of air draining in this case indicates that the pleural space fills in as quickly as it is being drained out. No amount of suction can keep up with what literally is a situation in which the chest tube is sucking out the air in the room, by way of the bronchial tear. Tension pneumothorax (choice E) occurs when air cannot leave the pleural space and pressure builds up within. The manifestations are respiratory distress and extrinsic cardiogenic shock.

Surgery Q&A Paper – 2

admin — Fri, 13 Mar 2009 05:13:53 +0000

Block 21 Explanations

1) A 62-year-old man complains of perineal discomfort and reports that there are streaks of fecal soiling in his underwear. Four months ago, he had a perirectal abscess drained surgically. Physical examination shows a perineal opening in the skin lateral to the anus, and a cord-like tract can be palpated going from the opening toward the inside of the anal canal. Brownish purulent discharge can be expressed from the tract. Which of the following is the most likely diagnosis?
A. Anal fissure
B. Anorectal carcinoma
C. Fistula-in-ano
D. Pilonidal cyst
E. Thrombosed hemorrhoids
Explanation:
The correct answer is
C. The recent history of a drained perirectal abscess, along with the physical description of the current lesion, clearly identify this as a fistula-in-ano. Anal fissure (choice A) typically occurs in young women, who have exquisite pain with defecation and blood streaks in the stool. The lesion is in the anal mucosa, not in the nearby perineal skin. Anorectal carcinoma (choice B) always has to be ruled out in any patient with anorectal complaints, particularly those describing blood in the stool. In advanced cases, it can show up as an ulcerated, draining mass. But, it would not be a discrete opening with no obvious tumor mass, such as described here. Pilonidal cyst (choice D) is a good distracter, because they get infected, hurt, drain pus, soil the underwear, and have a skin opening. However, the opening is always cephalad to the anus, near the midline; the drainage is pus, not feces; and there is no connection with recent perirectal abscess. Thrombosed hemorrhoids (choice E) would produce excruciating pain, and appear as a small. red, angry, mass protruding out of the anus. If they drain spontaneously, blood and clot, not feces, come out.

2) A 72-year-old man of Norwegian ancestry has a contracted hand that can no longer be extended and placed flat on a table. The problem developed gradually, over many years. He complains of no pain or neurologic abnormalities and, to the extent that the deformity allows, can move his fingers at will. Physical examination demonstrates the deformity described and in addition shows the presence of palpable fascial nodules. Which of the following is the most likely diagnosis?
A. Carpal tunnel syndrome
B. De Quervain tenosynovitis
C. Dupuytren contracture
D. Palmar tenosynovitis
E. Rheumatoid arthritis
Explanation:
The correct answer is
C. Older men of Scandinavian descent are the victims of this otherwise mysterious contracture. The palpable nodules are classic, as is the deformity itself. Carpal tunnel syndrome (choice A) affects mostly young women, and the symptoms are tingling and numbness, without a deformity. De Quervain tenosynovitis (choice B) is seen in young women who complain of pain on the radial side of the wrist. There is no deformity. Tenosynovitis of any kind (choice D) would produce pain and limitation to the movement of the fingers Rheumatoid arthritis (choice E) is also a painful condition, and the deformity is classic along the joints, rather than in the palm of the hand.

3) A 44-year-old man complains of vague right upper abdominal discomfort that he has had for about 1 month. He describes no other symptoms, and, except for enucleation of one eye at age 21 “for a tumor,” he has been in excellent health all his life. He exercises regularly and neither smokes nor drinks. The only findings on physical examination include the artificial eye and a tender, enlarged, and nodular liver. CT scan of the upper abdomen demonstrates multiple masses within the liver. Which of the following will most likely be found on biopsy of these masses?
A. Metastatic malignant melanoma
B. Metastatic prostatic cancer
C. Metastatic retinoblastoma
D. Metastatic sarcoma
E. Primary hepatocellular carcinoma
Explanation:
The correct answer is
A. There are two malignant tumors of the eye for which enucleation would be done: retinoblastoma and melanoma. Only melanoma would have this weird timetable, in which 20-some years may elapse between primary tumor and metastatic manifestations. In fact, the patient with a glass eye and a liver full of tumor is one of the two classic examples that are given (the other one has a missing toe) to illustrate the unpredictable behavior of melanoma. Prostatic cancer (choice B) can show up with metastases before we know the primary is there, but the metastatic site would usually be in bone. Retinoblastoma (choice C) can indeed lead to eye enucleation, but if it goes on to kill the patient (which it often does), it does not wait 20-odd years to do it. Sarcomas (choice D) metastasize via the blood stream but are rare in organs that drain via the portal system. Thus, they favor the lungs as the metastatic site. Furthermore, the primaries are seldom hidden. Primary hepatocellular carcinoma (choice E) is rare in the U.S., where it is outnumbered 20 to 1 by metastatic tumors. When it happens it is usually in a cirrhotic patient, not in an otherwise healthy person.

4) A 71-year-old West Texas farmer of Irish ancestry has a nonhealing, indolent, punched out, clean-looking 2-cm ulcer over the left temple. The ulcer has been slowly growing over the past 3 years. There are no enlarged lymph nodes in the head and neck. Which of the following would best dictate proper management?
A. Full thickness biopsy of the center of the lesion
B. Full thickness biopsy of the edge of the lesion
C. Pathologic studies after the entire lesion is resected with a margin of 1 cm of normal skin all around
D. Response to a trial of radiation therapy
E. Scrapings and culture of the ulcer base
Explanation:
The correct answer is
B. The history (a fair skinned person who is out in the sun all day) suggests a skin cancer, and the location (the upper part of the face) favors a basal cell cancer but does not exclude a squamous cell carcinoma, or even a melanoma. Thus, diagnosis is needed before proper therapy is instituted. The edge of the lesion offers the best information for the pathologist. A biopsy of the center of the lesion (choice A) deprives the pathologist of all the clues that are found at the interface between the tumor and the normal skin, and in large lesions it runs the risk of sampling necrotic tumor that has outgrown its blood supply. A wide excision before pathologic diagnosis (choice C) risks doing too much (a basal cell cancer needs only 1 or 2 mm of margins) or too little (a melanoma should have at least 2 cm). Radiation therapy (choice D) is a viable therapeutic choice for squamous cell carcinoma, but not before a diagnosis has been established. Here, we are expecting a basal cell carcinoma, thus this course of action would be even less appropriate. Scrapings and cultures (choice E) assume an infectious process, ignoring the strong clinical suspicion of a tumor in this case.

5) A pediatrician’s office gets a phone call from a frantic mother. Her 7-year-old daughter was playing under the sink and accidentally spilled Liquid Plumber (a strong, corrosive alkaline drain cleaner) all over her arms and legs. The nurse on the phone can hear the girl screaming in the background. Which of the following are the most appropriate instructions to give the mother?
A. Cover the burned areas with triple antibiotic ointment until the girl can be seen at the office
B. Get the girl into the shower right away and keep the water running over her for 30 minutes before bringing her to the emergency department
C. Get the girl to the emergency department as soon as possible
D. Wash the burned areas with diluted vinegar and bring the girl to the office
E. Wrap the burned areas in sterile dressings before bringing the girl to the emergency department
Explanation:
The correct answer is
B. By far the most important thing that can be done for caustic chemical burns is to wash away the caustic agent as soon as possible, and the best way to do that is with massive irrigation. Any answer that allows the chemical agent to stay in touch with the skin, whether mixed with antibiotic ointment (choice A), wrapped in bandages (choice E), or with no specific additional instructions (choice C) will result in continued burning for the time that it will take to get to the emergency department or physicians’ office. Washing with an acid (choice D) is particularly inadvisable. Except for chemical burns of the esophagus, for which massive irrigation cannot be done, one should never “play chemist” when dealing with alkaline or acid burns. The chemical reaction will generate heat and compound the problem.

6) A 59-year-old man sustains blunt trauma in an automobile accident, resulting in multiple intra-abdominal injuries. Surgery for the repair of these injuries takes several hours and requires multiple blood transfusions and infusions of Ringer’s lactate. Before all the operative steps are completed, the patient develops a significant coagulopathy, a core body temperature less than 34 C (93.2 F), and refractory acidosis. The anesthesiologists are administering fresh frozen plasma and platelet packs. Which of the following is the most appropriate next step in management for the surgeon?
A. Provide hemostasis by liberal use of electrocoagulation
B. Wash the abdomen with warm saline and continue to operate
C. Complete the operation as soon as possible and do a formal abdominal closure
D. Pack the bleeding surfaces and close the abdomen temporarily with towel clips
E. Abort the operation and leave the abdomen open, covering the bowel with mesh
Explanation:
The correct answer is
D. Indeed, the appropriate course of action when coagulopathy develops in these circumstances is to empirically provide fresh frozen plasma and platelet packs. However, when hypothermia complicates the picture, the abdomen also has to be closed immediately albeit temporarily in the most expeditious manner. The bleeding surfaces have to be packed, waiting for a more propitious time in which to attempt hemostasis, once coagulation function and body temperature have improved. Electrocoagulation (choice A) is not magic, it requires clotting on the part of the patient. If the abdomen is kept open to do it, the hypothermia gets worse. Warming the abdomen with saline (choice B) is not sufficient if the abdomen is kept open while surgery continues. Although moving along quickly (choice C) would be better than leisurely continuation of surgery, it is not fast enough under the circumstances. Besides, with no clotting one can never truly complete the operation. Aborting the operation (choice E) is the right thing to do, but leaving the belly open is not. Closure with mesh is indicated when the abdominal compartment syndrome prevents normal closure.

7) A 42-year-old man describes intermittent episodes of severe, crushing chest pain that extends to the back and the jaw and last anywhere from a few seconds to several minutes. Many times the pain is accompanied by dysphagia and triggered by the ingestion of very cold or very hot liquids. However, sometimes the pain occurs for no apparent reason. There is no history of regurgitation, and, although the problem has been present for many years, there has been no progression of the symptoms. Repeated ECGs and cardiac enzymes have always been negative. Barium swallow shows an area of “corkscrew” appearance. Manometry shows that about one half of wet swallows produce repetitive simultaneous esophageal contractions of the esophageal body, and that the lower esophageal sphincter has normal pressures and exhibits normal relaxation. Which of the following is the most likely diagnosis?
A. Achalasia of the esophagus
B. Cancer of the lower esophagus
C. Diffuse esophageal spasm
D. Nutcracker esophagus
E. Zenker’s diverticulum
Explanation:
The correct answer is
C. The clinical, radiologic, and manometric criteria of diffuse esophageal spasm are all described in the vignette. Achalasia (choice A) typically has clinical progression, as well as regurgitation of undigested food. In the manometric studies, there are no effective peristaltic contractions and there is increased resting pressure in the lower sphincter, which fails to relax during swallowing. The dysphagia of esophageal cancer (choice B) is typically progressive, from solids to liquids. The barium swallow would be diagnostic. Nutcracker esophagus (choice D) is very similar to diffuse esophageal spasm. However, on manometry there is a mean distal esophageal peristaltic amplitude of more than 180 mm Hg, including an elevated baseline pressure in the lower sphincter. Zenker’s diverticulum (choice E) produces regurgitation of undigested food and symptoms referable to the upper esophagus. The barium swallow would be diagnostic.

A 52-year-old woman has terminal cervical cancer with extensive pelvic invasion, and requires strong opiate analgesia to control severe pain. Intermittent nausea and vomiting have precluded the use of oral agents. She was on fentanyl patches but she developed allergic skin reactions to the adhesive and now requests to be switched to parenteral medication. Because of prior chemotherapy treatments she has no available venous access, but she is willing to have her family administer intramuscular injections. Assuming equianalgesic dosages, which of the following would be the most appropriate pharmacotherapy?
A. Codeine
B. Hydromorphone (Dilaudid)
C. Meperidine (Demerol)
D. Methadone
E. Morphine sulfate
Explanation:
The correct answer is
D. Given the circumstances, the longest acting agent would be the best choice. Methadone lasts about 12 hours, compared with around 4 hours for all the others opiates listed (choices A, B, C, E).

9) A 43-year-old woman comes in because of a breast mass. Two days ago, she noticed a lump on self-examination. She has a 2-cm, firm, nontender mass in the left breast, which is movable from the chest wall, but not movable within the breast. She has no prior history of breast disease, but she is well read and well informed, and she specifically requests that a biopsy be done with a mammotome. Before proceeding, which of the following is the most appropriate initial step?
A. Discuss the surgical options in case cancer is found
B. Do a mammogram to ascertain whether biopsy is needed
C. Do a mammogram to find any other lesions that might also need to be addressed
D. First wait for two menstrual cycles to see whether there is spontaneous resolution.
E. Obtain a fine-needle aspirate and go no further if no malignant cells are found
Explanation:
The correct answer is
C. A breast lump in a 43-year-old needs to be biopsied, but before we undertake that aggressive step we must ascertain the full extent of her potential disease. Fingers can feel big lumps; x-ray films are needed to identify smaller ones. Discussing cancer therapy (choice A) is premature if we have not yet diagnosed cancer. We no longer live in the era of biopsy in the operating room, frozen section diagnosis, and surgery under the same anesthetic. The diagnosis should be established first, and then the options discussed. We need the mammogram to know what else may need to be biopsied, but not to tell us whether a biopsy is needed (choice B). We already have the indications for biopsy of the existing lesion, regardless of its appearance in a mammogram. Waiting for resolution (choice D) is okay for a woman with fibrocystic disease who gets lumps every month, but not for this woman who has never had breast disease before. Fine-needle aspiration (FNA) before a more invasive biopsy (choice E) is an acceptable choice, provided we understand that we will respond to a positive diagnosis established by cytology, but will not be dissuaded from getting a more complete sample if the FNA is negative. This option is unacceptable as worded.

10) A 35-year-old man falls on an outstretched hand and comes in complaining of wrist pain. He relates that he was not able to break the fall, and that the heel of his hand took the brunt of his full weight as it hit the pavement. On physical examination, he is distinctly tender to palpation over the anatomic snuff box. Anteroposterior and lateral x-rays are negative. Which of the following are the most likely diagnosis and most appropriate next step in management?
A. Carpal navicular fracture; thumb spica cast
B. De Quervain tenosynovitis; steroid injections
C. Displaced scaphoid fracture; open reduction and internal fixation
D. Ligamentous injury; Ace bandage and analgesics
E. No fracture; reassurance
Explanation:
The correct answer is
A. Nondisplaced fractures of the carpal navicular are notorious for not showing up on x-ray films at the time of injury. The mechanism of injury plus the physical findings described in this vignette are sufficient to make a presumptive diagnosis and to indicate the use of a cast. Tenosynovitis (choice B) is not the result of a direct blow, but it is seen in young mothers who carry the head of their babies with a hyperextended thumb and a flexed wrist. Displaced scaphoid fracture (choice C) would show up on x-ray films. The treatment for those fractures is indeed open reduction and internal fixation (they are notorious for non-healing), but the diagnosis is not correct in this option. Ligamentous injury (choice D) is often the assumption of those who are not aware of the peculiar nature of this injury. A similar mistake is made by those who assume that if an x-ray film appeared negative, there cannot be a fracture (choice E).

11) A 72-year-old woman has a red, swollen breast. She states that the condition has been present for at least several weeks, perhaps a month or two. She has no pain or fever. The skin over the area looks like orange peel. The area is not warm to the touch, but on physical examination there is a fullness to the entire breast, with no discrete mass. Which of the following is the most likely diagnosis?
A. Chronic cystic mastitis
B. Inflammatory cancer of the breast
C. Normal menopausal involutionary changes
D. Pyogenic breast abscess
E. Tuberculous or fungal breast abscess
Explanation:
The correct answer is
B. Age is your first tip-off: the older the patient is with any kind of breast problem, the more likely it is to be cancer. The description is that of inflammatory cancer, where the permeation of skin lymphatics has given the edema, redness, fullness, and orange peel appearance. The thick, tumor-laden skin actually masks the underlying mass, which is felt as “fullness” rather than a discreet lump. Chronic cystic mastitis (choice A) happens to younger women (aged 20-40) with recurrent pain linked to the menstrual cycle. Menopause (choice C) shrinks the breast and makes it more fat than stroma, but it does not make it red and swollen. Pyogenic abscess (choice D) happens almost exclusively to lactating women. At age 72, we know that is not happening. Tuberculosis or fungus (choice E) is our usual guess when an abscess is not hot and tender. However, apart from their rarity in the U.S., such thoughts here would detract from the compelling dictum that a red, swollen breast in an old woman is cancer until proven otherwise.

12) A 46-year-old woman, who had always been in good health, comes in because of the sudden onset of very severe back and leg pain that she experienced 2 hours ago when attempting to lift a heavy object. She says that she felt “a bolt of lightening” running down the back of her leg, and she still has very severe pain that prevents her from walking or moving. The pain is exacerbated by coughing, sneezing, or straining. She keeps the affected leg flexed; straight leg raising gives her excruciating pain. She has good sphincteric tone and intact sensation in the perineum. Once the diagnosis is confirmed with the appropriate studies, which of the following will be the most appropriate treatment?
A. Analgesics and bed rest for about 3 weeks
B. Appropriate antibiotics
C. Body cast for 3-6 months
D. Radiotherapy to the affected area
E. Surgical decompression
Explanation:
The correct answer is
A. The clinical features are those of a herniated lumbar disc. The diagnosis should be confirmed with an MRI, and then the patient should be treated conservatively with bed rest. Most patients get better with this simple approach. Giving antibiotics (choice B) assumes an infectious process. Infections can occur in the lumbar spine or the discs, but their symptoms do not start suddenly, like this vignette describes. A body cast (choice C) might be needed for fractures, scoliosis, or other spinal pathology, but casting is not needed for an extruded disc. Radiotherapy (choice D) assumes a neoplastic process. Although a weakened bone may indeed rupture suddenly, such patients are usually known to have had the kind of tumor that is likely to metastasize to bone (in women, breast cancer would lead the list), and would have been complaining of localized bony pain before the process gets to the point of fracture. Surgical decompression (choice E) would have been required if she had sphincteric deficits or perineal anesthesia.

13) A 56-year-old man develops slow, progressive paralysis of the facial nerve on one side. It took several weeks for the full-blown paralysis to become obvious, and it has been present now for 3 months. It affects both the forehead and the lower face. He has no pain anywhere, and no palpable masses by physical examination. Which of the following is the most likely diagnosis?
A. Bell’s palsy
B. Facial nerve tumor
C. Hemorrhagic stroke
D. Parotid gland cancer
E. Pleomorphic adenoma of the parotid gland
Explanation:
The correct answer is
B. Slowly developing paralysis on one side is suggestive of a tumor. Since there are no physical findings to place the tumor in the parotid gland, it must be impinging on the nerve itself at a more proximal location. Bell’s palsy (choice A) has sudden onset, rather than gradual development. Hemorrhagic stroke (choice C) would have occurred suddenly, with an excruciating headache. A parotid cancer (choice D) would have been palpable by physical examination and would have produced pain. Pleomorphic adenoma (choice E) would also have been palpable, and such tumors almost never produce facial nerve paralysis.

14) A young mother complains of pain along the radial side of the wrist and the first dorsal compartment. She relates that the pain is often caused by the position of wrist flexion and simultaneous thumb extension that she assumes to carry the head of her baby. On physical examination, the pain is reproduced by asking her to hold her thumb inside her closed fist, and then forcing the wrist into ulnar deviation. Which of the following is the most likely diagnosis?
A. Acute and chronic bursitis
B. Carpal tunnel syndrome
C. Hairline unrecognized fracture of the carpal navicular (scaphoid) bone
D. Palmar fascial contracture (Dupuytren’s contracture)
E. Tenosynovitis of the abductor or extensor tendons of the thumb (De Quervain’s tenosynovitis)
Explanation:
The correct answer is
E. The clinical presentation is classic for De Quervain’s tenosynovitis, including the positive Finkelstein sign (the pain reproduced by ulnar deviation to stretch the affected tendons). Bursitis (choice A) occurs where there are bursa; thus, the classic locations are places in which tendons or muscles pass over bony prominences. Carpal tunnel syndrome (choice B) affects young women, such as this patient, but the presentation is one of numbness along the innervation pattern of the entrapped median nerve. Fractures of the carpal navicular bone (choice C) often go unrecognized, but they occur when someone falls on an outstretched hand. The classic physical finding is pain with palpation over the anatomic snuff box. Dupuytren’s contracture (choice D) produces inability to fully open and extend the hand, and it typically happens to older men of Scandinavian descent.

15) A 44-year-old homeless woman presents to the emergency department because she is “bleeding from the breast.” Physical examination shows a huge, fungating, ulcerated mass that occupies the entire right breast and is firmly attached to the chest wall. The right axilla is full of hard masses that are not movable either. Core biopsies of the breast are read as highly undifferentiated infiltrating ductal carcinoma, and assay for estrogen and progesterone receptors are negative. Which of the following is the most appropriate next step in management?
A. Local wound care, but no specific antineoplastic therapy
B. Tamoxifen therapy
C. Radiation and chemotherapy
D. Palliative mastectomy
E. Radical mastectomy with extended lymph node dissection
Explanation:
The correct answer is
C. Although this is an impressive, very advanced cancer with a poor prognosis, it can be expected to shrink significantly with local radiation plus systemic chemotherapy. It may do so to the point at which a palliative mastectomy becomes technically feasible, something that cannot be done at this time. Taking care of the wound, and accepting defeat from the cancer (choice A), was the only available choice before chemotherapeutic agents and radiation therapy were developed. It would be entirely inappropriate at the present time. Tamoxifen (choice B) would be the weakest systemic weapon in this case. She is premenopausal and receptor negative. Tamoxifen alone would not shrink this tumor to any appreciable extent. Mastectomy, either simple (choice D) or radical (choice E), is not possible at this time. The description clearly depicts an inoperable tumor. We first need to make it operable.

16) A blond, blue-eyed, 69-year-old sailor has a non-healing, indolent, 1.5-cm ulcer on the lower lip, arising from the vermilion border. The ulcer has been present and growing for the past 8 months. He is a pipe smoker, but has no history of alcohol or drug abuse. Physical examination shows “weather-beaten” facial skin, but no other ulcers. There are no enlarged lymph nodes in his neck. Which of the following is the most likely diagnosis?
A. Adenocarcinoma
B. Basal cell carcinoma
C. Benign ulceration due to chronic trauma
D. Invasive malignant melanoma
E. Squamous cell carcinoma
Explanation:
The correct answer is
E. The location and history are classic for squamous cell carcinoma of the lower lip. The absence of metastatic nodes does not invalidate the diagnosis, as most cancers in this location do not metastasize until quite late. Adenocarcinoma (choice A) would be very rare in the lower lip. Basal cell carcinoma (choice B) favors the upper part of the face, above a horizontal line drawn across the mouth. Benign ulceration (choice C) is always a possibility, but it would be a terrible mistake to make such assumption. As pointed out before, this vignette is a “textbook case” for squamous cell carcinoma. Melanoma (choice D) is again very rare in this location. A history of a pigmented lesion that underwent changes in color, appearance, or diameter would have been suggestive.

17) A 54-year-old African American man, with a history of smoking and drinking, describes progressive dysphagia that began 3 months ago. He first noticed difficulty swallowing meat; it then progressed to other solid foods, then to soft foods, and now to liquids as well. He locates the place where the food “sticks” at the lower end of the sternum. He has lost 30 pounds. Which of the following is the most appropriate first step in diagnosis?
A. Barium swallow
B. Gastrografin swallow
C. Esophageal manometry
D. Esophageal pH monitoring
E. Esophagoscopy
Explanation:
The correct answer is
A. The clinical picture is that of a cancer of the esophagus, and given his race and history of smoking and drinking, it is probably a squamous cell carcinoma. The description of where the dysphagia is felt suggests a low location, but such subjective feelings lack precision. The tumor will eventually be seen and biopsied by endoscopy, but the endoscopist will first want to know the exact location of the tumor and the degree to which the lumen is occluded. Otherwise, there is a high risk of instrumental perforation of the esophagus. The best way to obtain that information is to do a barium swallow. Gastrografin (choice B) gives less detailed pictures and would be called for only if perforation was suspected. Manometry (choice C) would be called for if the history suggested a motility problem. Esophageal pH monitoring (choice D) would be the perfect test to document gastroesophageal reflux. Esophagoscopy (choice E) will indeed be done, but not until after the barium swallow.

18) A 39-year-old woman completed her last course of postoperative adjuvant chemotherapy for breast cancer 6 months ago. She now comes to the clinic complaining of constant back pain for about 3 weeks. She is tender to palpation over two well-circumscribed areas in the thoracic and lumbar spine. Which of the following is the most appropriate next step in management?
A. CT scan of the trunk
B. Needle biopsy of the tender spots
C. Radionuclide bone scan
D. Sonogram of the affected areas
E. X-ray films of the affected areas
Explanation:
The correct answer is
C. The most sensitive test to detect early bone metastasis is the radionuclide scan. In a woman who recently had cancer of the breast, we have to suspect bony metastasis when bone pain develops. CT scan (choice A) would be more expensive and less sensitive. Needle biopsy (choice B) is invasive and not the first thing to do. Sonogram (choice D) is superb for many other things, but not to detect early bone metastasis. X-ray films (choice E) will be done after the scan if the radionuclide “lights up.” The radionuclide scan is very sensitive, but not terribly specific. Once it lights up, we have to rule out other radiologically obvious bony problems that might have triggered the positive scan.

19) In preparation for an inguinal hernia repair, a 22-year-old man has a spinal anesthetic placed. The level of sensory block turns out to be much higher than had been planned, and shortly thereafter his blood pressure drops to 75/20 mm Hg. He looks warm and flushed, and his central venous pressure is near zero. Which of the following should be included in his therapy?
A. Diuretics and fluid restriction
B. Whole blood and clotting factors
C. Inotropic agents and cardiac assist pump
D. Vasoconstrictors and IV fluids
E. Vasodilators and IV fluids
Explanation:
The correct answer is
D. A high spinal anesthetic can produce vasomotor shock by inducing widespread vasodilation. Vasoconstrictors are the appropriate therapy, but since the capacity of the vascular tree is also increased under these circumstances, filling it up with additional volume is also helpful. Diuretics and fluid restriction (choice A) would compound the problem. The patient needs more fluid, not less. Whole blood and clotting factors (choice B) are not needed. The volume can be increased with cheaper and safer IV fluids until proper vascular tone is restored. Coagulation factors have not been lost. Inotropic agents and mechanical assistance to the circulation (choice C) are indicated in cardiogenic shock, which would be rare in a 22-year-old and would be identified, among other things, by a high central venous pressure. Vasodilators and fluids (choice E) are sometimes a good combination when hypovolemia plus high peripheral resistance deprive tissues of proper perfusion. In this case, however, vasodilation already exists (and is the genesis of the problem).

20) A 33-year-old woman is found to have a palpable thyroid nodule during a routine medical checkup. A sonogram confirms the presence of a solid, 1.5-cm nodule in the right lobe of the thyroid gland. Fine needle aspirate cytology (FNA) is reported as “follicular tumor, otherwise unspecified.” At surgery, a frozen section is read as follicular carcinoma. With the neck open, the surgeon can feel for enlarged jugular and peritracheal lymph nodes, and finds none. Which of the following is the most appropriate treatment?
A. Enucleation of the tumor
B. Right thyroid lobectomy
C. Total thyroidectomy
D. Total thyroidectomy plus postoperative radioactive iodine
E. Total thyroidectomy, radical neck dissection, and postoperative radioactive iodine
Explanation:
The correct answer is
D. Follicular cancers can metastasize by way of the blood stream to the liver, lung, brain, or bones. Because the tumor has rudimentary functional capability, it can be traced with and ablated by radioactive iodine; however, the tumor cannot compete successfully with normal thyroid tissue for the capture of iodine. After removal of the entire gland, the tumor becomes the most effective iodine trapper in the body. Enucleation (choice A) is never a good answer when dealing with cancer. Local recurrence would virtually be guaranteed. Lobectomy alone (choice B) would leave normal thyroid in place and thus prevent future use of radioactive iodine. Total thyroidectomy (choice C) is a correct, but incomplete, answer. Radical neck dissection (choice E) is not needed if there are no palpable nodes. Should they develop later, the procedure could be done then, or the nodes could be dealt with by means of radioactive iodine.

21) A 45-year-old woman, who wears high-heeled, pointed shoes, complains of pain in the forefoot after prolonged standing or walking. Occasionally, she also experiences numbness, a burning sensation, and tingling in the area. Physical examination shows no obvious deformities and a very tender spot in the third interspace, between the third and fourth toes. There is no redness, limitation of motion, or signs of inflammation. Which of the following is the most likely diagnosis?
A. Gout
B. Hallux rigidus
C. Metatarsophalangeal articulation pain
D. Morton’s neuroma
E. Plantar fasciitis
Explanation:
The correct answer is
D. The location and circumstances are classic for Morton’s neuroma, a benign neuroma of the third plantar interdigital nerve. Gout (choice A) happens to obese, elderly males, and redness and signs of inflammation in the affected joint are evident. Hallux rigidus (choice B) is osteoarthritis of the first metatarsophalangeal joint. There is deformity and limitation of motion. The joint is tender on physical examination. Metatarsophalangeal articulation pain (choice C) is likewise associated with misalignment of joint surfaces. There is pain when examining the joint, and there is no history of numbness, burning, or tingling. Plantar fasciitis (choice E) produces sharp pain on physical examination when pressing the plantar surface of the heel.

22) A 22-year-old gang member arrives in the emergency department with multiple gunshot wounds to the chest and abdomen. He has labored breathing and is cyanotic, diaphoretic, cold, and shivering. He is wide awake, and in a normal tone of voice he tells everyone that he is going to die. An initial survey reveals a blood pressure of 60/40 mm Hg. His pulse is 150/min and barely perceptible. He is in obvious respiratory distress and has big distended veins in his neck and forehead. His trachea is deviated to the left, and the right side of his chest is hyperresonant to percussion, with no breath sounds. Which of the following is the most appropriate initial step in management?
A. Emergency blood gases
B. Immediate chest x-ray films
C. Awake endotracheal intubation
D. A 16-gauge needle inserted in the second right intercostal space
E. Pericardiocentesis
Explanation:
The correct answer is
D. This patient obviously has a tension pneumothorax on the right. The pressure needs to be relieved immediately, which insertion of a needle will do. Then, a formal chest tube should be inserted. Blood gases (choice A) or chest x-ray films (choice B) are not needed to recognize the presence of a tension pneumothorax. These two studies will soon be done in this patient, but not before action is taken to save his life by prompt decompression of the tension pneumothorax. A patient who is awake and alert and speaking with a normal tone of voice has a patent airway. At this moment, he does not need endotracheal intubation (choice C), although given his multiple injuries, he will probably end up having surgery and being intubated for that anesthetic. Pericardiocentesis (choice E) assumes our first clinical diagnosis is pericardial tamponade. If he were still in shock and still had big distended veins after his pleural space had been decompressed, we might think that he also has a pericardial tamponade in addition to the tension pneumothorax. In fact, as the most pressing problems are resolved, we might uncover other reasons for his state of shock, such as internal bleeding. Right now, however, what is crying out for help is his right pleural space.

23) A 66-year-old woman picks up a bag of groceries out of the supermarket cart to place it in the trunk of her car. As she does so, she feels sharp, sudden pain in the middle of her arm, and her humerus suddenly breaks. She arrives at the emergency department cradling her arm; the deformity leaves no doubt that the bone is broken. Which of the following is the most likely reason for the fracture?
A. Bony metastasis to the humerus from breast cancer
B. Osteitis fibrosa cystica from parathyroid disease
C. Osteomalacia from nutritional deficiency
D. Osteoporosis
E. Primary malignant bone tumor
Explanation:
The correct answer is
A. A fracture from such trivial strain signifies a very weakened bone. In this age and gender, the most likely cause would be a lytic lesion from metastatic breast cancer. In a man, we would have suspected metastatic lung cancer (not prostate, because prostatic metastases are blastic rather than lytic). The bony reabsorption of parathyroid disease (choice B) is mostly seen as cystic lesions in the bones of the hand. In very advanced cases, bones may be deformable, but parathyroid hormone does not weaken major bones to the point at which they break. Osteomalacia (choice C), and its counterpart in children, rickets, deforms bones, but they would not break as described here. Osteoporosis (choice D) is indeed likely to be present in this woman. However, even with advanced osteoporosis, the only spontaneous fractures seen are compression fractures of vertebral bodies. Osteoporotic bones break easily, but there has to be more trauma than lifting a bag of groceries. Primary malignant bone tumors (choice E) occur in young people. They do not occur at this age.

24) A 62-year-old man has had gastroesophageal reflux disease diagnosed by pH monitoring, and present for several years. He has been less than totally compliant with medical management, which he follows when the pain is bad, but discontinues when he feels better. Endoscopy and biopsies show severe peptic esophagitis, with Barrett’s esophagus and early dysplastic changes, but no overt carcinoma. Additional tests show good esophageal motility, with low pressure in the lower esophageal sphincter and normal gastric emptying. Which of the following is the most appropriate treatment at this time?
A. Heller myotomy of the lower esophageal sphincter
B. Laparoscopic Nissen fundoplication
C. Transhiatal total esophagectomy
D. Transthoracic resection of the lower esophagus
E. Vagotomy, pyloroplasty, and fundic gastric wrap
Explanation:
The correct answer is
B. This man has indications for surgical intervention, but all he needs is an antireflux operation. By far the most commonly used procedure is a laparoscopic Nissen fundoplication. Heller myotomy (choice A) is used for achalasia. Here it would do the exact opposite of what is needed. Transhiatal total esophagectomy (choice C) is the most commonly used operation for esophageal cancer. It is only palliative, since it cannot provide a true “cancer operation” with wide dissection, but esophageal cancer is rarely amenable to true curative resection when it becomes symptomatic. Although this man could develop cancer if he is not treated, he does not have advanced cancer at this time. Transthoracic resection of the lower esophagus (choice D) would be the procedure if a very early cancer were to develop at the esophagogastric junction. If this man did not choose to have the antireflux surgery now, but he remained under close surveillance, he might get to the point where he became a candidate for this option. Acid reduction (choice E) is not part of the standard surgical treatment for gastroesophageal reflux. We can control acid medically. If we have to operate, we do it to provide a good one-way valve when the native sphincter no longer works.

25) A 14-year-old boy slides down a banister and crashes into a large ornamental knob at its base, thereby injuring his scrotal contents. He presents in the emergency department with acute testicular pain and a scrotal hematoma the size of a grapefruit. He is able to void normally, and his urine does not contain blood. A rectal examination is unremarkable. Findings from which of the following tests will most likely determine further therapy?
A. Aspiration of scrotal contents
B. Retrograde cystogram
C. Retrograde urethrogram
D. Scrotal sonogram
E. Scrotal surgical exploration
Explanation:
The correct answer is
D. The clinical findings do not suggest urethral injury, but testicular fracture is a potential injury that would require surgical intervention. Sonogram would be diagnostic. Aspiration (choice A) is not a good idea. We already know that blood is present, and putting needles into it would invite bacterial contamination. If the testicle is intact, the hematoma will resolve spontaneously. Neither the bladder (choice B) nor the urethra (choice C) need to be checked when the urine has no blood, the patient can void normally, and the rectal examination is unremarkable. Surgical exploration (choice E) is not indicated unless a diagnosis of testicular rupture has been made.

26) A 40-year-old, obese, white woman, mother of five children, gives a history of repeated episodes of right upper quadrant abdominal pain. The pain is brought about by the ingestion of fatty foods and is relieved by the administration of anticholinergic medications. The pain is colicky, radiates to the right shoulder and around to the back, and is accompanied by nausea and occasional vomiting. The patient has no pain at this time, but is anxious to avoid further episodes. She is afebrile, and physical examination is unremarkable. Which of the following is the most appropriate next step in management?
A. Sonogram of the biliary tract and gallbladder
B. Upper gastrointestinal series with barium
C. Antibiotics, IV fluids, and nothing by mouth
D. Endoscopic retrograde cholangiopancreatogram (ERCP)
E. Exploratory surgery
Explanation:
The correct answer is
A. The clinical description is classic for biliary colic, due to gallstones that are intermittently impacted at the cystic duct. The diagnostic study of choice to confirm the presence of gallstones is a sonogram. An upper gastrointestinal series (choice B) will miss the diagnosis. This woman does not have a problem in her stomach or duodenum. She has to be suspected of having gallstones, and the study has to target that area. Antibiotics and IV fluids (choice C) are required to “cool down” an episode of acute cholecystitis. However, this woman does not have fever, leukocytosis, and a tender right upper quadrant. She does not have acute cholecystitis. Endoscopic retrograde cholangiopancreatogram (ERCP) (choice D) would be an expensive, invasive, and totally unjustifiable way to take a look at the gallbladder. Exploratory surgery (choice E) would be even worse. This woman will need surgery, but it should be directed at the gallbladder and done laparoscopically as an elective procedure (i.e., at a convenient time) after a diagnosis has been confirmed.

27) A 29-year-old man presents with a 2-day history of severe left-sided scrotal pain and swelling. He is sexually active and has had “many” sexual partners. His temperature is 38.2 C (100.8 F), blood pressure is 120/70 mm Hg, and pulse is 80/min. Examination shows unilateral intrascrotal tenderness and swelling. Testicular support makes the pain less intense. Which of the following is the most likely diagnosis?
A. Epididymitis
B. Prostatitis
C. Testicular torsion
D. Urethritis
E. Varicocele
Explanation:
The correct answer is
A. This patient has epididymitis, most likely due to Chlamydia trachomatis. Epididymitis refers to inflammation of the epididymitis, which leads to unilateral intrascrotal pain, swelling, and fever. Testicular support usually relieves the pain to some extent. Asymptomatic urethritis can be associated with epididymitis due to
C. trachomatis or Neisseria gonorrhoeae. Urinalysis may reveal pyuria. Urethral culture, urine polymerase chain reaction (PCR) or ligase chain reaction (LCR) can confirm the diagnosis. Treatment is with azithromycin, doxycycline or tetracycline. The sexual partner should be treated to avoid reinfection. Prostatitis (choice B) is the inflammation of the prostate, which often presents with perianal and low back pain, urinary frequency, urgency, and pain during urination. Treatment is with antibiotics. Testicular torsion (choice C) is a surgical emergency, which is caused by twisting of the spermatic cord and vascular compromise. It typically occurs in young adult males, who present with acute unilateral testicular pain and normal urinalysis results. Testicular support does not relieve the pain. Urethritis (choice D) is an infection most often caused by Chlamydia or N. gonorrhoeae, and presents with a urethral discharge. The discharge is mucoid in chlamydial infection and purulent in gonorrhea. The treatment is ceftriaxone and doxycycline. Sexual partners should be treated. Varicoceles (choice E) are a collection of veins that feel like a “bag of worms”. Surgery is indicated if there is infertility or pain. They are more common on the left side.

28) A pedestrian is hit by a car. The paramedics report that he was unconscious at the site, and he arrives at the emergency department in coma, strapped to a head board with sandbags on either side of his head. Initial survey shows stable vital signs, and his pupils are of equal size and reactive to light. He is rapidly intubated by the nasotracheal route over a flexible bronchoscope and then sent for CT scans of the head. As he is being positioned on the table, it is noted that there is a sizable hematoma behind his right ear and that clear fluid is dripping from the ear canal. Which of the following is most advisable, considering this new finding?
A. Extend the CT scan to include his neck
B. Do an MRI instead of a CT scan
C. Start antibiotics
D. Inject high-dose corticosteroids
E. Plan an emergency craniotomy
Explanation:
The correct answer is
A. The clinical findings are indicative of a fracture of the base of the skull, and thus he has sustained very significant trauma to the head. The integrity of the cervical spine has to be ascertained, and the CT that he is already going to have can be extended to include that area. MRI (choice B) has no role in the acute trauma situation. If we were looking for a brain tumor, at leisure, an MRI would indeed be better than a CT-but not in this setting. Antibiotics (choice C) have proven to be of no value in base of the skull fractures. Corticosteroids (choice D) are being used in patients with spinal cord injury, but we have not yet diagnosed the presence of such an injury. Emergency craniotomy (choice E) is not needed to deal with a basilar skull fracture. He would need one if his CT scan showed an intracranial hematoma displacing the midline structures. He might need one later if the leak of CSF persists, but he does not need one now.

29) During a campaign appearance, a political candidate is shot point blank in the right chest with a .22 caliber revolver. The entrance wound is well above the nipple line, just under the third rib, at the level of the anterior axillary line. His motorcade brings him to the emergency department, but he makes it a point to walk in, holding his right chest with a bloody hand and waving for the news media. A chest x-ray shows a hemothorax on the right, and the bullet is seen to be embedded in the right paraspinous muscles. A chest tube is placed in the right pleural cavity, and 650 mL blood is recovered. Over the ensuing 4 hours, he continues to drain between 250 and 350 mL blood per hour. Which of the following is the most appropriate next step in management?
A. Continued observation and appropriate blood replacement
B. A second chest tube in a better position to drain the blood
C. Thoracotomy and ligation of bleeding vessels
D. Thoracotomy, ligation of bleeding vessels, and removal of the bullet
E. Thoracotomy and pneumonectomy
Explanation:
The correct answer is
C. Although most penetrating wounds of the chest that produce hemothorax require no surgery, there are cases in which systemic vessels (almost invariably intercostals), rather than the injured lung (which has low pressure circulation) are the source of bleeding. In those cases, surgical hemostasis is required. They are identified by the magnitude of the blood loss. Typical criteria suggest the need for thoracotomy if the initial blood recovery exceeds 1000 mL, or if subsequent drainage adds up to 600 mL or more, over the ensuing 6 hours. Continued observation (choice A) would be inappropriate given the rate of 250-350 mL of blood loss per hour. The problem is not lack of drainage; thus, another tube (choice B) would not resolve the problem. Although choice D is almost identical to choice C, it adds a medically unnecessary step: the bullet does not have to be removed. Additional operative time and operative dissection are not justified if the bullet is not pressing on some vital structure. If it happens to be lying there, just waiting to be plucked, we would of course take it. Pneumonectomy (choice E) targets the wrong organ. Bleeding from the lung is usually self-limiting. Bleeding that requires surgery is usually from systemic vessels, most commonly the intercostals.

30) During the performance of a supraclavicular node biopsy under local anesthesia, a hissing sound is suddenly heard, and the patient suddenly dies. At the time of the catastrophic event, the target node was under traction, and the final cut was being made blindly behind it to free it up completely. The patient, an otherwise healthy 24-year-old man, was inhaling at that moment. Which of the following most likely caused this patient’s death?
A. Arterial injury with air embolization
B. Major vein injury with air embolism
C. Sudden pneumothorax with lung collapse
D. Sympathetic discharge
E. Tracheal injury
Explanation:
The correct answer is
B. Major veins at the base of the neck have negative pressure during inspiration and, if injured at that moment, will suck air rather than bleed. The air embolism then leads to sudden death. Arterial injury (choice A) would have led to massive bleeding but not to sudden death. Pneumothorax (choice C) can indeed happen when surgery is being done in the supraclavicular area, and a sucking sound might even be heard. However, sudden lung collapse in a young, healthy person leads to dyspnea, not to sudden death. Sympathetic discharge (choice D) would be hard to produce while pulling and dissecting a node. If it were done, however, there would be vasoconstriction, tachycardia, perspiration, and hypertension, rather than sudden death. Had the trachea been injured (choice E), essentially nothing would have happened at the time.

31) An elderly woman with osteoporosis falls on her outstretched hand. She comes in with a deformed and painful wrist that looks like a dinner fork. X-ray films show a dorsally displaced, dorsally angulated fracture of the distal radius. There is also an associated fracture of the ulnar styloid. A neurologic examination is normal. Which of the following is the most appropriate management?
A. Closed reduction and short arm cast
B. Closed reduction and long arm cast
C. Skeletal traction
D. Intramedullary rod
E. Open reduction and internal fixation
Explanation:
The correct answer is
B. This is the famous Colles fracture, which typically can be reduced well with closed manipulation. Casting should immobilize both the wrist and the elbow, thus a long arm cast is needed. A short arm cast (choice A) would not immobilize the elbow. Skeletal traction (choice C) could correct the deformity, but at the cost of limiting future function of the hand. An intramedullary rod (choice D) is usually reserved for fractures of the shaft of long bones, like the femur. Open reduction and internal fixation (choice E) could indeed provide a very nice result, but it would be an unnecessarily expensive and intrusive way to do it.

32) A 43-year-old man develops excruciating abdominal pain at 8:23 PM (he looked at his watch when the pain “hit him”). When seen in the emergency department about 30 minutes later, he has a rigid abdomen, lies motionless on the examination table, has no bowel sounds, and is obviously in great pain, which he describes as constant and encompassing the entire abdomen. There is very severe pain when deep palpation of the abdomen is attempted in any of the four quadrants. However, the examining hand cannot make much of an indentation because of the impressive muscle guarding. When the attempt is aborted, he manifests severe rebound tenderness. X-ray films show free air under both diaphragms. Which of the following does this man most likely have?
A. Acute abdomen, the nature of which cannot yet be defined
B. Acute inflammatory process affecting an intra-abdominal viscera
C. Acute obstruction of an intra-abdominal viscera
D. Ischemic process affecting intra-abdominal organs
E. Perforation of the gastrointestinal tract
Explanation:
The correct answer is
E. There is no doubt that this patient has an acute abdomen, but we can tell more than that. The sudden onset, generalized extent, and silent abdomen in a man who does not want to move suggests a perforation. In addition, the presence of free air in the peritoneal cavity pinpoints the gastrointestinal tract as the source. We cannot tell whether he perforated a peptic ulcer, blew out a sigmoid diverticulum, or had his bowel perforated by a chicken bone, but there is a hole in his gastrointestinal tract. Choice A underestimates our diagnostic ability. An inflammatory process (choice B) would have gradual onset and would be localized to the area of the inflamed viscera. Obstruction (choice C) has sudden onset, but it leads to colicky pain. The patient would be thrashing about looking for a position of comfort, and would still have bowel sounds and not have free air. Ischemia (choice D) is a better bet in an older person. If it were to lead to necrosis and perforation, the latter would not be evident 30 minutes after the trouble began.

33) On the 5th postoperative day after abdominal surgery, a patient has been draining copious amounts of clear pink fluid from his midline laparotomy wound. A medical student removes the dressing, confirms that it is soaked, and sees a normal-appearing fresh wound with a row of skin staples in place. The student asks the patient to sit up so he can get out of bed and be helped to the treatment room for a more thorough examination. When the patient complies, the wound opens widely, and a handful of small bowel suddenly rushes out. Which of the following is the most appropriate management at this time?
A. Cover the bowel with dry sterile dressings and schedule urgent surgical closure
B. Cover the bowel with sterile dressings soaked in warm saline and rush the patient to the operating room
C. Irrigate the bowel with cold antiseptic solutions while awaiting urgent surgical closure
D. Take the patient to the treatment room and suture the skin edges together
E. Wearing sterile gloves, push the bowel back in and tape the wound securely
Explanation:
The correct answer is
B. Until the patient attempted to get out of bed, he had a wound dehiscence that could have been handled by taping the wound securely. Once the bowel came out, the problem became an evisceration. Immediate surgical repair is mandatory. While setting it up, the bowel must be protected from drying out, and the patient must be protected from significant heat loss. Thus, the key is warm and moist dressings. Dry dressings (choice A) would prevent further contamination but would fail in the key elements of “warm and moist.” Cold antiseptic solutions (choice C) would irritate the bowel and contribute to hypothermia. Once an evisceration has occurred, the entire abdominal wall has to be surgically closed. Suturing the skin edges in an inadequate facility (choice D) or resorting to tape (choice E) would not suffice.

34) A 77-year-old man becomes “senile” over a period of 3 or 4 weeks. He used to be active and managed all of his financial affairs. Now, he stares at the wall, barely talks, and sleeps most of the day. His daughter recalls that he fell from a horse about a week before the mental changes began. Which of the following would a CT scan of his head most likely show?
A. Chronic epidural hematoma
B. Chronic subdural hematoma
C. Diffuse intracerebral bleeding
D. Frontal lobe infarction
E. Generalized, severe brain atrophy
Explanation:
The correct answer is
B. People who are very old or alcoholic have smaller brains in a skull that has not changed in size; thus, very minimal trauma can make the brain “rattle around” and tear a venous sinus, from which a subdural hematoma very slowly forms. Senility does not occur in a 3-week period. Such marked changes in someone with recent trauma should trigger a search for chronic subdural hematoma. Epidural hematomas (choice A) are typically acute, from a tear of the middle meningeal artery following trauma that fractures the skull. Diffuse intracerebral bleeding (choice C) would occur with very severe trauma and would give more acute symptoms. The frontal lobe (choice D) is responsible for judgment and social graces, but not for financial acumen and level of activity-the functions that this man used to have and lost over a short period of time. Brain atrophy (choice E) is indeed present in the very old or the alcoholic. That is what makes them prone to develop chronic subdural hematomas. But, brain atrophy alone would not explain the mental changes that this man developed over a few weeks.

35) A man who weighs 65 kg sustains second and third degree burns over both of his lower extremities when his pants catch on fire. When examined shortly thereafter, it is ascertained that virtually all of the skin from both groins to the tip of the toes, front and back, has been burned. According to the modified Parkland formula, which of the following is the approximate total amount of IV fluid that he can be expected to require during the first 24 hours post-burn?
A. 3460 mL
B. 4960 mL
C. 6760 mL
D. 8160 mL
E. 11,360 mL
Explanation:
The correct answer is
E. The modified Parkland formula calls for 4 mL of Ringer’s lactate per kilogram of body weight, times the percentage of the body surface that has been burned; plus an additional 2000 mL of dextrose 5% in water to cover maintenance fluid needs. In the “rule of nines,” each lower extremity represents 18% of the body surface. Thus, this patient has sustained a 36% body burn: 4 × 65 × 36 = 9360, plus 2000 = 11,360 None of the other options provide enough fluid, although in the real world the formula calculations are used only to help determine a “ballpark figure” and a rate of initial infusion. Once fluid is going in, the fine tuning is done on the basis of hourly urinary output and central venous pressure.

36) A 49-year-old woman has a firm, 2-cm mass in the right breast that has been present for 3 months. Mammogram has been read as “cannot rule out cancer,” but it cannot diagnose cancer either. A fine-needle aspiration of the mass (FNA) and cytology do not identify any malignant cells. Which of the following is the most appropriate next step in management?
A. Reassurance and reappointment in a year
B. Repeat mammogram and FNA in 1 month
C. Core or incisional biopsies
D. Lumpectomy and axillary dissection
E. Modified radical mastectomy
Explanation:
The correct answer is
C. Negative findings do not have the same diagnostic value that positive findings have. If this had been a 19-year-old woman suspected of having a fibroadenoma, one would have been satisfied with negative imaging studies (in that age, a sonogram) or the negative FN
A. But, at age 49, the risk of cancer is much higher. Given negative findings in the least invasive studies, one would feel compelled to move to more aggressive ways to obtain better tissue sampling. Obviously, reassurance (choice A) is not justified yet, and waiting a whole year with what may be a cancer would be malpractice. Repeating the same studies in a month (choice B) leaves you with the quandary of what to do if they are negative again. No, you need more tissue for the pathologist right now. Lumpectomy and axillary dissection (choice D) is too much to do before the diagnosis has been established. Lumpectomy alone might have been okay. An excisional biopsy could indeed be justified under the circumstances, and a lumpectomy is not much more than a big excisional biopsy. But, messing with the axilla should not happen before we know it is cancer. Mastectomy (choice E) is even less acceptable. Patients are grateful when a cancer is ruled out by procedures that they do not perceive as mutilating. But, when surgery leaves them deformed, the “good news” that there was no cancer may lead them to call their lawyer.

37) A young mother is at the pediatrician’s office for a routine well-baby visit for her 18-month-old son. It is immediately noticed that one of the baby’s pupils is white, while the other one is black. When asked about it, the mother relates that she saw that curious situation for the first time 1 week ago, but since the baby was otherwise asymptomatic, she did not think it merited special attention. Which of the following is the most appropriate course of action?
A. Do nothing, this is a normal anatomic variant
B. Inquire if the father is an albino, and do appropriate genetic counseling
C. Seek an ophthalmologic consultation for suspected congenital cataract
D. Seek an emergency ophthalmologic consultation for possible retinoblastoma
E. Treat the child with antibacterial eye drops and re-check in 2 weeks
Explanation:
The correct answer is
D. A newly developed white pupil in a child raises the possibility of retinoblastoma. This tumor is so deadly that immediate diagnosis and treatment are imperative. Ignoring the finding (choice A) could prove to be lethal, and the same can be said for any delays caused by pursuing bizarre considerations, such as looking for albinos in the family (choice B) or treating for an eye infection that is not there (choice E). It could be argued that if an ophthalmologic consultation is obtained, even if it is for a wrong diagnosis (choice C), the true nature of the problem will eventually be recognized. But an appointment to check for cataracts (which would have been present since birth) will not be made with the same urgency that the situation requires.

38) A 23-year-old man known to have neurofibromatosis, type 1 (von Recklinghausen’s disease), presents with a left lower quadrant abdominal mass and signs of neurologic deficits in his left leg. In the ensuing workup, it is determined that he has higher than normal values of catabolites of epinephrine and norepinephrine in a 24-hour urinary collection. He is currently normotensive. Before invasive steps are taken to biopsy and eventually remove his left lower quadrant abdominal mass, which of the following is the most appropriate next step in management?
A. CT scan of the head looking for meningiomas
B. MRI of his adrenal glands
C. MRI of the acoustic nerves
D. Radionuclide scans from the neck to the pelvis looking for extra-adrenal pheochromocytomas
E. Radiation therapy to the left lower quadrant abdominal mass
Explanation:
The correct answer is
B. The concern is that even though he is now normotensive, invasive steps might trigger a hypertensive crisis from the previously undiagnosed pheochromocytoma that he probably has. The presence of catabolites from epinephrine indicates that the tumor is in the adrenal glands, and not at an extra-adrenal site. Thus, the diagnosis of the pheochromocytoma can best be confirmed by MRI of the adrenals. Meningiomas (choice A) and acoustic nerve tumors (choice C) occur in type 2 neurofibromatosis, not in type 1. Looking for pheochromocytomas outside of the adrenal glands (choice D) would have been a good idea if only elevated catabolites of norepinephrine had been detected. The presence of high levels of epinephrine catabolites implicates the adrenal glands. Radiation therapy (choice E) is a bad idea. Benign neurofibromas can be stimulated by radiation to undergo malignant transformation.

39) A car is involved in a head-on collision. The driver, who is sober and wearing his seat belt, explains that he clearly saw his drunk, unrestrained front seat passenger hit the windshield with his face and the dashboard with his knees. Examination of the passenger indeed shows multiple facial lacerations, but because of his intoxication he cannot explain where else he might be hurting. He is neurologically intact, and his cervical spine x-ray films are normal. Additional injury, representing a potential orthopedic emergency, is not obvious but is suspected. Therefore, an x-ray film of which of the following areas should most likely be obtained?
A. Both patellas
B. Both hips
C. The jaw
D. The lumbar spine
E. The skull
Explanation:
The correct answer is
B. When hitting the knees against the dashboard, the femurs can be driven backward and out of the acetabulum, resulting in posterior dislocation of the hips. Because of the tenuous blood supply of the femoral heads, such injury must be promptly recognized and treated. Both patellas (choice A) and the jaw (choice C) could indeed be fractured, but such fractures would be easily recognized clinically. If they were not identified until the next day, no damage would be incurred. The lumbar spine (choice D) should always be thought of when someone falls from a height and lands on his feet, but it is not a likely hidden injury in this setting. Skull x-ray films (choice E) have gone out of favor as a way to assess head injury. The main issue in head injuries is intracranial bleeding, and the study to show it is the CT scan.

40) During a hunting trip, a young man is bitten by a coyote. The animal is captured and brought to the authorities alive. Which of the following is the most important criterion to determine the patient’s need for rabies prophylaxis?
A. The patient’s history of previous immunizations
B. The patient’s clinical course over the next few weeks
C. Observing the animal’s behavior over the next few days
D. Killing the animal and examining the brain
E. The events that took place have already established the need to proceed with rabies immunization
Explanation:
The correct answer is
D. Examination of the animal’s brain for signs of rabies will determine whether the painful and risky process of rabies passive and active immunization is required. History of previous immunizations (choice A) is used to determine what to do for tetanus prophylaxis, but it has no application for rabies, because virtually no one has ever received such immunization in the past. Waiting for signs of rabies to appear in the patient (choice B) would be a death sentence. We can prevent rabies, but once established we cannot cure it. Observation of the animal’s behavior (choice C) is applicable when dealing with provoked bites by domestic pets. The behavior of a wild animal gives no clues to the presence or absence of rabies. If the animal had escaped, choice E would have been correct.

41) A 62-year-old woman had an abdominal hysterectomy and salpingo-oophorectomy 3 days ago. She had an indwelling bladder catheter during the procedure, which was removed in the recovery room. She has been voiding at will since then. She also had compression pneumatic stockings on both lower extremities during the operation. She began ambulation on the 1st postoperative day, and has been as active as possible under the circumstances, including faithful adherence to a prescribed program of incentive spirometry. On the evening of the 3rd postoperative day, she spikes a fever, with a temperature to 39.4 C (103 F). Which of the following is the most likely source of the fever?
A. Atelectasis
B. Deep thrombophlebitis
C. Intra-abdominal abscess
D. Urinary tract infection
E. Wound infection
Explanation:
The correct answer is
D. The timing is our major clue. Fever on postoperative day 3 is usually from the urinary tract. The circumstances are also there: she had instrumentation of her urinary tract during the procedure. Atelectasis (choice A) is usually seen on day 1, and she is doing everything possible to avoid this complication. Deep thrombophlebitis (choice B) could show up this early, but is more likely to do so 5-7 days after surgery. Furthermore, the patient had adequate protection during surgery and has been moving around since early on. Intra-abdominal abscess (choice C) would need at least 7-10 days to develop. This is too early for that. Wound infection (choice E) is likewise a later complication, typically seen about a week after the operation.

42) A 76-year-old man is undergoing an abdominoperineal resection for rectal cancer. During the surgery, unexpected severe bleeding is encountered, and the patient is hypotensive on and off for almost an hour. The anesthesiologist notes ST depression and T-wave flattening on the ECG monitor. Which of the following is the most likely diagnosis and the expected mortality?
A. Intraoperative air embolus, 100%
B. Myocardial infarction, 5% to 10%
C. Myocardial infarction, 50% to 90%
D. Pulmonary embolus, 5% to 10%
E. Pulmonary embolus, 50% to 90%
Explanation:
The correct answer is
C. Intraoperative myocardial infarction is mostly seen in elderly men, and the most common triggering event is prolonged hypotension. Furthermore, the mortality greatly surpasses that of a myocardial infarction de novo (ie, unrelated to surgery), reaching the levels quoted. Air embolism (choice A) can happen when big veins are open, allowing air to be sucked in; however, the location of the open veins is typically the upper chest or lower neck. The patient dies while undergoing a procedure under local anesthesia, breathing spontaneously rather than having air blown into his lungs. Choice B correctly identifies the problem, but assigns it a low mortality more typical of infarcts that do not happen during surgery. Pulmonary emboli (choices D and E) are not usually seen during surgery; they typically occur 5-7 days later.

43) A 44-year-old woman has a palpable nodule in the right lobe of her thyroid gland. The nodule measures 2 cm and is firm. The rest of the thyroid gland cannot be felt and is not tender. She also describes losing weight in spite of a ravenous appetite, palpitations, and heat intolerance. She is thin, fidgety, and constantly moving, with moist skin and a pulse of 105/min. She has no exophthalmos or pretibial edema. Her TSH is reported as much lower than normal, and she has elevated levels of free T4. Which of the following is the most appropriate next step in diagnosis?
A. Exploratory neck surgery
B. MRI of the pituitary gland
C. Needle core biopsy of the thyroid mass
D. Radionuclide thyroid scan
E. Serum levels of T3
Explanation:
The correct answer is
D. There is no question, both clinically and by laboratory, that the patient is hyperthyroid. She has no clinical signs of acute thyroiditis, and none of the other findings seen in Graves disease; however, she has a thyroid nodule, which raises the possibility of a hyperfunctioning adenoma (a “hot” adenoma). If indeed she does, the scan will show that the nodule traps all the iodine, with suppression of the rest of the gland. Exploratory neck surgery (choice A) would be premature without first defining the source of the hyperfunction. The pituitary (choice B) is not at fault if the TSH is low. Hyperthyroidism and thyroid cancer rarely coexist. Should one wish to exclude the latter, fine-needle aspiration would be the first test. Percutaneous core biopsy of thyroid nodules (choice C) is not favored in this country. Levels of T3 (choice E) are needed only when clinical hyperthyroidism and low TSH are found to exist in the presence of normal levels of free T4.

44) A 66-year-old man presents with progressive jaundice, which he first noticed 6 weeks ago. He has a total bilirubin of 22 mg/dL, with a direct (conjugated) bilirubin of 16 mg/dL. His transaminases are minimally elevated, whereas his alkaline phosphatase is about six times the upper limit of normal. A sonogram shows dilated intrahepatic ducts, dilated extrahepatic ducts, and a very distended, thin-walled gallbladder without stones. Which of the following is the most appropriate next step in diagnosis?
A. CT scan of the upper abdomen
B. Endoscopic retrograde cholangiopancreatography (ERCP)
C. Exploratory laparotomy
D. Percutaneous transhepatic cholangiogram (PTC)
E. Serologies to define the type of hepatitis
Explanation:
The correct answer is
A. Obstructive jaundice is evident by the high alkaline phosphatase and the dilated biliary ducts. Malignancy is suggested by the dilated, thin-walled gallbladder without stones. If there is a cancer of the head of the pancreas, CT has a good chance of showing it in a noninvasive manner. Endoscopic retrograde cholangiopancreatography (ERCP) (choice B) or percutaneous transhepatic cholangiogram (PTC) (choice D) would be the next step if the CT scan were negative. A smaller tumor at the ampulla, the common duct itself, or even the head of the pancreas, could escape detection by the CT and necessitate a more invasive test to show up. Either of these could be used, although ERCP is favored by most. Exploratory laparotomy (choice C) would be premature at this point. Serologies (choice E) would have been called for if he had very high transaminases, normal or near normal alkaline phosphatase, and an unremarkable sonogram.

45) An older, overweight man complains of disabling, sharp heel pain every time his foot strikes the ground. The pain is worse in the mornings, preventing him from putting any weight on the heel. X-ray films show a bony spur matching the location of his pain, and physical examination shows exquisite tenderness to direct palpation right over that heel spur. Furthermore, when the ankle is dorsiflexed, the entire inner border of the fascia is tender to palpation. Which of the following is the most likely diagnosis?
A. Epiphysitis of the calcaneus
B. Fracture of the posterolateral talar tubercle
C. Plantar fasciitis
D. Posterior Achilles tendon bursitis
E. Posterior tibial nerve neuralgia
Explanation:
The correct answer is
C. All the details are in the vignette, including the association with a heel spur that in the past led many of these patients to undergo unnecessary surgery to remove the spur. The spur is caused by the pull of the fascia and is not the cause of the plantar fasciitis. Epiphysitis of the calcaneus (choice A) affects children, and the pain occurs along the sides of the heel where the heel growth centers are located. Fracture of the posterolateral talar tubercle (choice B) occurs from a sudden jump on the ball of the foot, and the pain and swelling are behind the ankle. Posterior Achilles tendon bursitis (choice D) occurs mostly in young women, and an erythematous, indurated, tender area is present at the posterosuperior aspect of the heel. Posterior tibial nerve neuralgia (choice E) is the foot’s equivalent of the carpal tunnel syndrome, with the pain often extending to the toes, and tingling being produced by tapping the nerve.

46) An elderly man is involved in a rear end automobile collision in which he hyperextends his neck. He develops paralysis and burning pain of both upper extremities, while maintaining good motor function in his legs. Which of the following is the most likely diagnosis?
A. Anterior cord syndrome
B. Central cord syndrome
C. Posterior cord syndrome
D. Reflex sympathetic dystrophy
E. Spinal cord hemisection
Explanation:
The correct answer is
B. The mechanism of injury (hyperextension) and the relative sparing of the lower extremities in the presence of upper extremity deficits are classic for central cord syndrome. In anterior cord syndrome (choice A), all functions are lost, except for positional and vibratory sense. Those injuries occur with blowout of the vertebral bodies. Posterior cord syndrome (choice C) is quite rare, and it would show loss of positional and vibratory sense. Reflex sympathetic dystrophy (choice D) produces agonizing burning pain (thus, it is a good distracter for this vignette), but it typically follows crushing injuries of the affected extremity and does not affect motion. Hemisection of the spinal cord (choice E) produces loss of one set of functions on one side, and a different set of functions on the other side. In addition, it follows a clear-cut penetrating injury, rather than hyperextension of the neck.

47) A 67-year-old man has had an indolent, unhealing ulcer at the heel of the right foot for several weeks. The patient began wearing a new pair of shoes shortly before the ulcer started and noticed a blister as the first anomaly at the site where the ulcer eventually developed. He indicates that neither the blister nor the ulcer ever gave him any pain. The ulcer is 3.5 cm in diameter, the ulcer base looks dirty, and there is hardly any granulation tissue. The skin around the ulcer looks normal. The patient has no sensation to pin prick anywhere in that foot. Peripheral pulses are weak but palpable. He is obese and has varicose veins, high cholesterol, and poorly controlled type 2 diabetes mellitus. Which of the following most accurately characterizes the ulcer?
A. Diabetic ulcer due to trauma, neuropathy, and microvascular disease
B. Ischemic ulcer due to arteriosclerosis
C. Ischemic ulcer due to embolization
D. Neoplastic in nature, probably squamous cell carcinoma
E. Stasis ulcer due to venous insufficiency
Explanation:
The correct answer is
A. Diabetic ulcers typically develop at pressure points, and the heel is a favorite location. The patient has evidence of neuropathy, and the correlation with the trauma inflicted by the new shoes is classic. Ischemic ulcers, whether due to arteriosclerosis (choice B) or embolization (choice C) are typically seen at the tip of the toes, as far away from the heart as one can get. Neoplasms (choice D) can indeed develop in long-standing ulcers, but the history would have been one of 10 or 20 years of healing and breaking down, before heaped up edges of cancer begin to develop. Stasis ulcers (choice E) are seen above the malleolus, surrounded by edematous, hyperpigmented skin.

48) A 25-year-old man is stabbed once in the right chest. The entrance wound is on the midaxillary line, at the level of the fifth intercostal space. He arrives at the emergency department moderately short of breath, but he is fully awake and alert, is talking with a normal tone of voice, and has no distended veins visible in his neck or forehead. His blood pressure is 130/75 mm Hg, and his pulse is 82/min. Physical examination of the chest shows the wound, which is not visibly “sucking air,” and demonstrates no breath sounds at all on the right side, which is tympanitic to percussion. There is no evidence of mediastinal displacement. Which of the following would be the most appropriate next step in management?
A. Cover the wound with a regular dressing and get a chest x-ray
B. Cover the wound with Vaseline gauze, taped on three sides
C. Endotracheal intubation
D. Insert a chest tube at the right pleural base
E. Insert an 18-gauge needle into the right pleural space at the second intercostal space
Explanation:
The correct answer is
A. The clinical picture is that of a pneumothorax, but there is no life-threatening situation that would prevent obtaining a radiologic diagnosis of the exact nature and extent of the problem. Then the appropriate therapy can be instituted. Covering the wound with Vaseline gauze (choice B) is the standard advice for sucking chest wounds to prevent further inflow of air into the pleural space. This is not happening here. Endotracheal intubation (choice C) is not needed if he has a good airway. A person who is fully awake and has a normal tone of voice has a normal airway. A chest tube (choice D) should not be inserted blindly, not knowing yet what is going on. He may very well need a tube at the base if the x-ray shows a hemothorax, but we might prefer to put it at the top if all he has is air. Insertion of a needle (choice E) is the correct answer when there is a life-threatening tension pneumothorax. In that case, he would have been in shock, with distended veins and mediastinal displacement.

49) The unrestrained front-seat passenger in a car that crashes sustains closed comminuted fractures of both femoral shafts. Shortly after admission, he develops a blood pressure of 80/50 mm Hg, a pulse rate of 110/min, and a venous pressure of zero. He becomes pale, cold, and clammy, but the rest of his physical examination and x-ray films of the chest and pelvis are unremarkable. A sonogram of the abdomen done in the emergency department is likewise negative. Which of the following is the most likely reason for the low blood pressure?
A. Blood loss at the fracture sites
B. Fat embolism
C. Neurogenic shock from pain
D. Unrecognized intracranial bleeding
E. Unrecognized pericardial tamponade
Explanation:
The correct answer is
A. Comminuted fractures of the femurs are known to be one of the few places in the body where enough occult blood loss may occur to lead to hypovolemic shock. Fat embolism (choice B) is also associated with long bone fractures, but the manifestations are those of respiratory failure, rather than hypovolemic shock. Neurogenic shock (choice C) would rarely occur from pain alone, being more common as a sequela of high spinal cord transection. When it happens, the patient is hypotensive but looks warm and flushed rather than cold and pale. Intracranial bleeding (choice D) can lead to neurologic symptoms, but not to hypovolemic shock. There is not enough room within the head to accumulate the sizable blood loss required to go into shock. Pericardial tamponade (choice E) would produce high central venous pressure.

50) A 25-year-old man is stabbed in the right chest. He comes in fully awake and alert, and, in a normal tone of voice, he states that he feels short of breath. His vital signs are normal and stable. On physical examination, he has no breath sounds at the right base, and only faint breath sounds at the apex. He is dull to percussion over the right base. A chest x-ray film confirms that he has a hemothorax on that side. Which of the following is the most appropriate next step in management?
A. Oxygen by mask, analgesics, and no specific intervention
B. Intubation and use of a respirator
C. Insertion of a chest tube in the right second intercostal space
D. Insertion of a chest tube at the right base
E. Exploratory thoracotomy
Explanation:
The correct answer is
D. Although he is hemodynamically stable, and thus presumably not “bleeding to death,” contaminated blood should not be left in the pleural space, where it could lead to the development of an empyema. A chest tube placed at the base should evacuate it. In doing so, we will also learn whether the amount of blood recovered justifies a more aggressive step to stop the bleeding. No specific intervention (choice A) is incorrect because that contaminated blood needs to come out. Intubation and respirator (choice B) are not needed. A patient who is awake and alert and speaking in a normal tone of voice has a good airway. He does not need intubation. Neither does he need a machine to breathe for him, when he is doing it spontaneously. A chest tube high in the pleural space (choice C) is the correct prescription for a pneumothorax, but not for a hemothorax. Air goes to the top, and blood goes to the bottom. To retrieve the blood, the tube has to be at the bottom. Thoracotomy (choice E) is seldom needed for a hemothorax. Bleeding is usually from the lung, and it stops by itself. When a systemic vessel is injured (typically an intercostal), we find a lot of blood when the tube is placed (more than 1000 or 1500 mL), or a substantial amount drains out in the ensuing few hours (more than 600 mL in 6 hours). Only in those cases is a thoracotomy indicated.

Surgery Q&A Paper – 1

admin — Fri, 13 Mar 2009 05:13:18 +0000

Block 20 Explanations

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
Explanation:
The correct answer is
B. In all other solid organ transplants, deterioration of function 10 days out would suggest an acute rejection episode, and appropriate biopsies would be done to confirm the diagnosis. In the case of the liver, however, antigenic reactions are less common, whereas technical problems with the biliary and vascular anastomosis are the most common cause of early functional deterioration. They are, therefore, the first anomalies to be sought. Preformed antibodies (choice A) are responsible for hyperacute rejection, which would be evident within minutes of establishing blood flow to the graft. Choices C, D, and E are centered on liver biopsy, which would be done only after technical problems have been ruled out.

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
Explanation:
The correct answer is
D. The spleen is a highly vascularized organ, and is vulnerable to traumatic rupture. This can occur “spontaneously” (i.e. with minimal trauma such as falling against a table or even overly vigorous palpation during a physical examination) in patients with an enlarged spleen due to disease (e.g., leukemias, autoimmune diseases with red cell sequestration in the spleen, or as a complication of portal hypertension). Alternatively, splenic rupture can occur in previously normal individuals who have severe trauma to the abdomen. In either case, the heavily vascularized spleen is usually unable to stop (often massively) bleeding internally. Emergency splenectomy is indicated to control the bleeding. Bacteremia (choice A) and peritonitis (choice E) are much less of a risk in splenic rupture than in rupture of a hollow viscus such as the colon, since the spleen is usually sterile. Electrolyte abnormalities (choice B) can develop secondarily to the ischemia produced by severe blood loss; these are much less critical than the blood loss itself and will often correct spontaneously with adequate replacement of blood. External blood loss (choice C) is often insignificant in injuries such as this.

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
Explanation:
The correct answer is
D. The calculations made by standard formulas are only an educated guess. Once fluid administration begins, we judge its adequacy by the information provided by urinary output and central venous pressure, aiming for an output of 1-2 mL/kg/hr, while not exceeding a venous pressure of 10 or 15. In this case, our calculations fell short of the mark, and the patient needs more fluids at a faster rate. Diuretics (choice A) are not the answer when all indicators show fluid need: his venous pressure is low, his blood pressure and pulse rate are marginal, and he has very concentrated urine. He needs fluids! The present rate (choice B) may follow the “formula,” but it is clearly inadequate. Decreasing the rate (choice C) is the very opposite of what is needed. And as for renal failure (choice E), it is indeed part of the differential diagnosis whenever urinary output is not as high as it should be. However, the vignette told you that his urine is highly concentrated and has well less than 20 mEq/L of sodium: evidence of superb kidneys trying to conserve fluid to the best of their ability. Don’t blame them.

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
Explanation:
The correct answer is
C. Cystosarcoma phyllodes occurs in young women, grows to huge size over many years, and yet spares the skin, the nodes, and the underlying chest wall. There is no particular connection with Central America, but often these are seen in immigrants of limited financial circumstances, who have had no access to medical care in their own countries. Breast cancer (choice A) this big and for these many years, would have ulcerated the skin, would be fixed to the chest wall, and would have produced massive axillary metastasis. Chronic cystic mastitis (choice B), also known as mammary dysplasia (choice E), is seen in women of reproductive age, who complain of tender and lumpy breasts related to the menstrual cycle. Large cysts can develop in this disease, but not to the huge size described in the vignette. Intraductal papilloma (choice D) is the most common source of bleeding from the nipple. These tumors are tiny, just a few millimeters in diameter.

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
Explanation:
The correct answer is
D. The treatment of breast cancer in a pregnant woman should be the same as that in a nonpregnant woman, except for two restrictions: no chemotherapy during the first trimester, and no radiation therapy during the pregnancy. It is not necessary to terminate the pregnancy. The preferred treatment for a 5-cm tumor would be mastectomy (too big for lumpectomy). Should axillary nodes be positive, systemic therapy should be done later. Although the appropriate surgery can be done during the pregnancy, neither chemotherapy (choice A) nor radiation therapy (choice B) would be acceptable at this time. Lumpectomy (choice C) is not a good idea for a 5-cm tumor. Furthermore, the radiation therapy that must follow lumpectomy could not be given in 6 weeks, while she is still pregnant. Finally, let’s not terminate a pregnancy that is doing no harm. Therapeutic abortion (choice E) does not help with the treatment of breast cancer. Neither is the pregnant woman who gets cancer of the breast automatically incurable, and thus only fit for a palliative procedure.

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
Explanation:
The correct answer is
D. The diagnosis of pericardial tamponade should be obvious. The patient has the type of chest wound that can produce it, and the very high central venous pressure to prove it. Evacuation of the blood that is preventing normal ventricular filling will produce instant improvement. Later, she will need repair of the heart wound that is probably the source of the pericardial blood and may also need exploratory laparotomy. A chest x-ray (choice A) would never be ordered in a dying patient. This patient is in trouble, and she needs instant action based on a clinical diagnosis. She would die while waiting for an x-ray. Chest tubes (choice B) have nothing to offer when there are bilateral breath sounds. In this case, the patient probably does not have a tension pneumothorax to account for the shock and the high venous pressure. Diagnostic peritoneal lavage (choice C) assumes that the reason for the deterioration is intra-abdominal bleeding. With a very high central venous pressure, it is not a reasonable conclusion. Clamping the aorta (choice E) assumes that she is bleeding to death. She may be bleeding, but if that were the cause of her present predicament, her central venous pressure would be zero, or near zero.

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
Explanation:
The correct answer is
B. Although most patients with hematuria have benign disease, silent hematuria can be due to renal, ureteral, or bladder cancer, and these malignant processes must be effectively ruled out. Intravenous pyelogram (IVP) will visualize kidney and ureteral tumors, but is not reliable enough to rule out bladder cancer. Direct visualization of the bladder mucosa by cystoscopy is the only way to rule out bladder cancer. Thus, both procedures are needed. Assuming hematuria to be a manifestation of clotting problems or infection (choice A) is unwarranted as the first diagnostic consideration in the absence of a history suggestive of such problems. Prostatic cancer can produce hematuria when it is advanced, but typically it does not show up that way in a previously asymptomatic patient. At age 62, this man needs a PSA, but this test, along with prostatic biopsies (choice C), would do nothing to find the source of the hematuria. In patients with allergy to the IVP dye, or with a creatinine above 2 mg/dL (neither of which are present here), the IVP cannot be done. In those cases, sonogram or CT scan (choice D) would provide an alternative way to look at the kidneys. The bladder would still remain as a potential site of undiagnosed cancer. Retrograde studies (choice E) are invasive and unwarranted here. A bladder full of dye will not necessarily reveal the presence of a shallow bladder cancer. The collecting system outlined by radiopaque material would not show the renal parenchyma.

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
Explanation:
The correct answer is
E. In the presence of normal perfusion pressure, biological problems do not suddenly drive the urinary output from normal to zero. Such a change is invariably due to a mechanical problem. Acute renal failure (choice A) does not result in a urinary output of zero. Some urine is still produced, although it is a small volume, on the order of 5 or 10 mL per hour. Intraoperative damage to the bladder (choice B) or the ureters (choice C) would have become obvious immediately after the operation. Dehydration (choice D) would have produced a gradual decline in the urinary volume. The 3 hours preceding the onset of the problem had shown normal values (about 1 mL per kg of body weight per hour), with no downward trend.

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
Explanation:
The correct answer is
D. Lumpectomy alone has an unacceptably high incidence of local recurrence, which can be significantly reduced by radiation therapy. In addition, the presence of metastatic disease in the axillary nodes requires systemic therapy. As a rule, chemotherapy is preferred for premenopausal women, which this woman is, but it is also indicated here because she is not receptor positive. Antiestrogens alone (choice A) would not reduce the likelihood of local recurrence, and it would not help much with systemic disease because she is premenopausal and receptor negative. Conversion to mastectomy (choice B) is not needed because her surgical margins are clear of tumor. Radiation alone (choice C) would not suffice because her positive axillary nodes require the addition of systemic therapy. Radiation to the opposite breast (choice E) is not required in any event, and tamoxifen is the wrong drug for a premenopausal woman who had a receptor negative tumor.

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
Explanation:
The correct answer is
E. The studies show extremely marginal liver function, which would be tipped into overt liver failure by an anesthetic and an operation. He is not a surgical candidate. Choice A obviously misses the gravity of his situation. Vitamin K (choice B) works only when there is a functioning liver that can use it. In the absence of adequate liver function, it will not correct the prothrombin time. Albumin (choice C) can be given, but it will have a short life span and will not correct the liver dysfunction. The low albumin is not the main problem per se, it is a symptom of how bad his liver is. The same is true of bilirubin (choice D). It is a symptom, not the problem. We can operate on patients with much higher bilirubin if it is not due to intrinsic liver disease.

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
Explanation:
The correct answer is
B. Anterior dislocation of the shoulder is the most common dislocation of that joint. The position is classic, as is the lack of the rounded contour of the humeral head. The area of numbness represents injury to the axillary nerve, a common complication of anterior dislocation of the shoulder. Acromioclavicular separation (choice A) would be characterized by very localized pain at that particular spot and none of the other features described here. Fracture of the humeral shaft (choice C) would likewise lack the specific deformity, inasmuch as the humeral head would still be in place to provide the normal rounded contour. Posterior dislocation (choice D) typically occurs following massive uncoordinated muscle contractions (electrical injuries, epileptic seizures), and the arm and forearm are held in a more “normal” protective position, close to the body. Scapular fracture (choice E) happens only with extremely severe chest trauma; it would not happen by falling in the shower. Along with two other injuries (fracture of the sternum or fracture of the first rib), scapular fracture, when present, indicates that very severe trauma has occurred, and it is a useful clinical clue to look for hidden internal injuries.

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
Explanation:
The correct answer is
E. Although this vignette describes a gunshot wound of the chest, we must remember that the chest and the abdomen are not stacked up like pancakes. There is a dome – the diaphram – that separates them, and thus an area where chest and abdomen overlap. Any gunshot wound below the nipples involves the abdomen, and such is the case here. The management of all gunshot wounds of the abdomen requires exploratory laparotomy. Barium swallow and bronchoscopy (choices A and B) are indicated if there are signs suggestive of injury to those organs (coughing up blood, spitting up blood), or if the anatomic trajectory of the bullet puts the track in their vicinity. Here, we have an entry wound on the left and a bullet lodged on the left: the midline has not been crossed. Taking out the bullet (choices C and D) is unnecessary if the missile is not pressing on some vital structure. A bullet embedded in a muscle can be left there.

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
Explanation:
The correct answer is
E. Abdominal aortic aneurysms have a high incidence of rupture once they reach or exceed a size of 6 cm. Often, the first manifestation is excruciating back pain, as the blood leaks into the retroperitoneal space before the aneurysm blows out into the peritoneal cavity. The combination of a big aneurysm and sudden severe back pain should always lead to this presumptive diagnosis. Looking for orthopedic or neurologic explanations can be a deadly mistake. Dissecting thoracic aortic aneurysm (choice A) could also cause excruciating back pain, but the pain usually starts as retrosternal and later migrates down. The absence of hypertension mitigates against this diagnosis, and one would expect to see a wide mediastinum on the chest x-ray film. Fracture of the spine with cord compression (choice B) could indeed happen to someone who recently had prostatic cancer, but the symptoms would be primarily neurologic deficits from cord compression. The pain from a herniated disc (choice C) runs down the leg and is exacerbated by sneezing and coughing. Metastatic tumor (choice D) is a good bet in someone with prostatic cancer. However, the pain of bony metastasis is present for weeks or months, and is constant, dull, low grade, and worse at night-not the sudden excruciating pain of this vignette.

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
Explanation:
The correct answer is
E. The presentation is classic for compartment syndrome, triggered by prolonged ischemia followed by reperfusion (the arm pressed against the park bench until he woke up and changed position), and located in one of the two most common sites (forearm and lower leg). He has the most reliable physical finding (pain on passive extension), and the diagnosis is not ruled out by normal pulses. Only a fasciotomy will solve his problem. Analgesics and observation (choice A) will result in permanent damage to the compartment muscles. Immobilization, by sling (choice B) or cast (choice C), will allow the high pressure within the compartment to continue to destroy the muscles. Embolectomy (choice D) assumes an arterial occlusion, which his normal pulses rule out.

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
Explanation:
The correct answer is
D. The clinical picture is fairly convincing for long-standing gastroesophageal reflux. The main concern is the degree of peptic esophagitis that he may have developed, and the possibility of Barrett’s esophagus and premalignant changes. Endoscopy and biopsies will provide the answer. Barium swallow (choice A) would provide anatomic evidence of hiatal hernia and evidence of reflux, but would not tell us whether Barrett’s esophagus has developed. Cardiac enzymes and ECG (choice B) would be part of the work-up (along with pH monitoring) if we were uncertain as to the genesis of ill-defined low retrosternal and upper epigastric pain. This man gives a classic presentation for reflux. Proton pump inhibitors (choice C) might likewise be indicated for this man, but not until we know the severity and potential premalignant stage of his disease. Nissen fundoplication (choice E) may some day be needed here, but one would not jump to a surgical solution based only on a clinical presentation.

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
Explanation:
The correct answer is
C. Clinically, this man has a life-threatening head injury, with a high probability that he may have an intracranial hematoma that has to be drained. CT scan is the only study that will show such a hematoma. Furthermore, we know that the head trauma was severe enough to produce a fracture of the base of the skull (cerebrospinal fluid dripping from the ear); thus, it may well have produced injury of the cervical spine as well. This is likely since he was complaining of neck pain, and it is imperative that it be diagnosed to protect his cord, which is probably still intact (when he was last awake he still was moving all four extremities). The most expedient way to do it is to extend the CT scan to include the neck. Antibiotics and steroids (choice A) are not indicated. The former used to be given for cerebrospinal fluid leaks, but is no longer considered appropriate. Steroids are used if the cord is injured, but we have reason to believe that it is still intact. Cervical spine x-ray films (choice B) are a good idea, but skull x-ray films are not. If his only problem were the cervical spine, we would indeed go for the x-rays. But we also have to check his head, for which we need the CT. Let the CT take care of both issues. The same is true of choice
D. We do not need to look into the ear or to study the fluid. The CT will show the fracture to the base of the skull, at the same time that it will tell us if an intracranial hematoma has to be drained. Cerebrospinal fluid leaks caused by fractures to the base of the skull typically stop spontaneously. Surgery is rarely needed for them. When it is needed, it is not an emergency and would not be done through the ear. Thus, choice E is wrong on all counts.

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
Explanation:
The correct answer is
E. The digit must be kept from drying out, must not be injured with any chemical agents, and must not be placed in direct contact with ice or allowed to freeze. Direct contact with ice (choice A) is one of the damaging events to be avoided. Freezing (choice B) is absolutely contraindicated. Alcohol (choice C) would damage the tissues. Antiseptic solutions and direct contact with dry ice (choice D) would damage the finger both chemically and physically.

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
Explanation:
The correct answer is
D. The clinical description is that of a rupture of the Achilles tendon. The injured structure is so close to the skin that direct palpation of the gap in the tendon is usually possible. A fracture of the calcaneus (implied in choice A) would happen with a fall from a height, landing on one’s feet. The ability to bend a joint beyond the normal boundaries (choices B and C) implies damage to the ligaments that keep that joint tight. However, such damage would not produce the loud popping noise so characteristic of rupture of the Achilles tendon. Grating and crepitation (choice E) are findings that indicate bony fracture; if these were present, the patient would not be able to put weight on the injured side.

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
Explanation:
The correct answer is
B. This patient has organic impotence, but it is not related to trauma for which surgical reconstruction would be indicated. His remaining function can be augmented with sildenafil (Viagra®). Psychotherapy (choice A) is the thing to do for psychogenic impotence, which has a sudden onset rather than the gradual development described in this case. Nerve damage (as suggested in choice C) is the culprit in impotence following pelvic surgery (not the case here). As of now, there is no effective way to reanastomose those invisible little nerve fibers. Penile prosthesis (choice D) is always the last option, never the first one. Once a prosthesis is inserted, the normal erectile mechanism is destroyed forever. Had the history been that of a young man becoming impotent after a motorcycle accident, a vascular lesion would have been the likely problem, and a reconstruction (choice E) would be the thing to do.

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
Explanation:
The correct answer is
B. Extracorporeal shock wave lithotripsy (ESWL) is the most commonly used method to fragment urinary stones and allow their passage. Pregnancy and coagulation problems are contraindications. The first one is ruled out by her age, the second one we have been told she does not have. Waiting for spontaneous passage (choice A) would have been perfect for a much smaller stone (3 mm) that had already negotiated most of the ureter. A 7-mm stone way up at the ureteropelvic junction has a very small chance of spontaneous passage. Retrograde endoscopic approaches (choices C and D) are more invasive than ESWL. They would not be the first choice for this scenario. Open surgical removal (choice E) would have been good for a much bigger stone. A huge target (a stone 3 cm or larger) could indeed be fragmented by ESWL, but then we would be contending with dozens of still very large stones. In those cases, a direct approach to extract the huge intact stone would work better.

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
Explanation:
The correct answer is
C. Gastrointestinal tract fluids have a sodium concentration very close to that of plasma; as they are lost (internally or externally), they should be replaced with isotonic, sodium-containing fluids. But that is not what patients typically do at home. Thirsty and unable to eat solid (sodium-containing) foods, they drink water, Coke, and tea, fluids without significant amounts of sodium, which the body avidly retains because of the severe volume depletion. Endogenous water from catabolic activity is also retained. Dilutional hyponatremia eventually develops. She does not have “water intoxication” (choice A). This term denotes abnormal water retention due to excessive water infusion at a time when there is a high level of ADH in the blood. This patient is retaining water because she is desperately volume-depleted, not because high volumes of water are being forced into her. The hyponatremia is not due to the loss of hypertonic fluid (choice B). There are no hypertonic fluids in the gut, or anywhere else for that matter. The only hypertonic fluid that we can lose is highly concentrated urine, but we usually do so as a physiologic response to save water. Yes, we often see comatose and convulsing patients when they have this much hyponatremia (choice D), but that happens when water retention is massive and fast. Slow water retention allows the brain to adapt. One can see even lower serum sodium concentrations in patients with a clear sensorium. Volume deprivation leads to renal wasting of sodium (choice E) is plain wrong. What the kidney does when there is volume depletion is to increase reabsorption of sodium, not to dump it.

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
Explanation:
The correct answer is
E. The presence of an “acute abdomen,” which this woman has, is an indication for exploratory surgery and prompt repair of the injuries (probably affecting hollow viscera) that have produced the signs of peritoneal irritation. Continued clinical observation (choice A) would be irresponsible when it is clinically obvious that she already has an acute abdomen. What would one observe for? Development of septic shock? Death? CT scan (choice B) is ideal when the issue is potential intraabdominal bleeding in a hemodynamically stable patient who can be safely sent to the radiology department. CT scan might even be a good idea if the picture of acute abdomen were equivocal. But it is not needed here. Diagnostic peritoneal lavage (choice D) or sonogram done in the emergency department (choice C) are our options when we suspect intraabdominal bleeding and the patient is too unstable to be sent anywhere. As pointed out above, however, when an acute abdomen has clearly developed, it is time to operate.

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
Explanation:
The correct answer is
A. Truly sudden death, with no warnings whatsoever, brings to mind the possibility of air embolism. The mechanism in this case is suggested by the circumstances. The patient had deep penetrating injuries that may have involved a major vein and an adjacent bronchus. When he was placed on the respirator, the air was forced through from the tracheobronchial tree into the vein, and thus into the heart. Fat embolism (choice B) is seen with multiple long bone fractures, and the symptomatology is respiratory failure. Myocardial infarction (choice C) would be extremely unlikely in a young man who was never hypotensive, and never showed arrhythmias. Pulmonary embolus (choice D) is seen late in the postoperative period after several days of reduced mobility. This man would have had no opportunity to develop clots in major veins in such short clinical course. Tension pneumothorax (choice E) would be unlikely to develop with a chest tube in place. However, even if we assume the tube was clogged or kinked and thus not functioning properly, a tension pneumothorax does not cause sudden death: it causes progressive hemodynamic shock and respiratory distress.

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
Explanation:
The correct answer is
D. Slipped capital femoral epiphysis is an orthopedic emergency. The clinical picture is classic: a chubby male in his early teens who is limping and cannot rotate his leg internally. Part of the classic presentation is also the fact that often hip pathology produces knee pain, but the knee is normal on physical examination. Avascular necrosis (choice A) is seen in younger children, around the age of 6 years. Developmental dysplasia (choice B) is typically diagnosed at birth. If it is missed, the affected child develops significant sequelae early in life. Osteogenic sarcoma (choice C) happens in the late teens, but the clinical findings are different, with a bony mass at the area of tenderness and no limitation on the motion of the hip. Tibial torsion and foot inversion (choice E) would not limit hip motion.

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
Explanation:
The correct answer is
E. The combination of obstruction and infection in the urinary tract constitutes a dire emergency that requires, in addition to IV antibiotics, the immediate decompression of the urinary tract above the point of obstruction. Adding antibiotics without decompressing the urinary tract (choice A) is not enough. Rapid destruction of the kidney, and even death from septic shock, will ensue if decompression is not done. It is too late to crush and remove the stone (choice B) once the infection has occurred. Complicated instrumentation should not be done in these circumstances. Such steps should await resolution of the lethal infection-obstruction combination. The same can be said for the use of extracorporeal shock wave lithotripsy (choice C). If it is chosen as the way to manage the stone, it should be done when infection and obstruction are no longer present. Putting a catheter into the bladder (choice D) would provide decompression below the level of obstruction. The drainage of infected urine is needed above the obstructing point.

26) A 14-year-old boy dives into the shallow end of a swimming pool and hits his head against the bottom. When he is rescued, he shows a complete lack of neurologic function below the neck. He is still breathing on his own, but he cannot move or feel his arms and legs. The paramedics carefully immobilize his neck for transportation to the hospital, and they alert the emergency department to his impending arrival. Once there, which of the following would most likely have an immediate benefit for this patient?
A. Hyperbaric oxygenation
B. IV antibiotics
C. IV high-dose corticosteroids
D. Massive diuresis induced by loop diuretics.
E. Surgical decompression of the cord
Explanation:
The correct answer is
C. There is some evidence that high-dose corticosteroids administered as soon as possible after the injury will result in a better ultimate outcome. Although the true medical value of this observation may be debatable, there is a legal imperative to use the treatment, which offers some hope and has not been shown to be detrimental. Hyperbaric oxygenation (choice A) has no role in the acute management of neurologic injuries. Antibiotics (choice B) are likewise unlikely to affect the course of events in a case like this. Although diuresis (choice D) is part of the therapy used to decrease intracranial pressure, the agent of choice is mannitol, and the indications do not include spinal cord injury. Surgical decompression (choice E) might be done, but the decision is individualized depending on the findings on MRI. Not all patients are automatically and immediately taken to the operating room.

27) A 72-year-old man is scheduled to have elective sigmoid resection for diverticular disease. He has a history of heart disease, and had a documented myocardial infarction 2 years ago. He currently does not have angina, but he lives a sedentary life because “he gets out of breath” if he exerts himself. During the physical examination, it is noted that he has jugular venous distention. He has a hemoglobin of 12 g/dL. If surgery is indeed needed, which of the following should most likely be done prior to the operation?
A. Evaluate the patient as a candidate for coronary revascularization
B. Place the patient on intensive respiratory therapy
C. Order a transfusion to increase the patient’s hemoglobin to 14 g/dL
D. Treat the patient for congestive heart failure
E. If at all possible, wait 6 months before performing surgery
Explanation:
The correct answer is
D. Jugular venous distention in this setting is indicative of congestive heart failure, a condition that would make elective surgery very risky. Medical treatment for congestive heart failure can reduce the risk. Coronary revascularization (choice A) is a preoperative consideration for patients with progressive angina. Preoperative respiratory therapy (choice B) is needed for patients with chronic obstructive pulmonary disease (COPD) who have compromised ventilation. A hemoglobin of 12 g/dL should be sufficient, and bringing it up to 14 g/dL (choice C) by transfusions would aggravate the existing congestive failure. Waiting 6 months (choice E) is imperative before noncardiac surgery is done after a myocardial infarction. In this case, the infarction happened 2 years ago; thus, the waiting period has already taken place.

28) A group of illegal immigrants is smuggled across the border in a closed metal truck in the middle of summer. When apprised by radio that the border patrol is on their trail, the smugglers abandon their charges in the middle of the desert, in the locked truck, with little water to drink. The victims are found and rescued 5 days later. One of them is brought to the emergency department, awake and alert, with obvious clinical signs of severe dehydration and a serum sodium concentration of 155 mEq/L. Which of the following would be the best choice and rate of IV fluid administration?
A. 5 L of 5% dextrose in water (D5W) over 2-3 days
B. 5 L of D5W over 5-10 hours
C. 5 L of 5% dextrose in half normal saline (D5 1/2 NS) over 5-10 hours
D. 10 L of D5 1/2 NS over 5-10 hours
E. 10 L of normal saline over 2-3 days
Explanation:
The correct answer is
C. A rough guideline to quantify water loss is that every 3 mEq/L that the serum sodium concentration is above normal, represents about 1 L of water deficit. With a value of 155, we can assume a water deficit of about 5 L. There is no advantage to the patient in remaining severely volume contracted for several days, thus the replacement should aim for correction in a matter of 5-10 hours rather than 2 or 3 days. However, because his loses were incurred slowly (over 5 days), his brain has had a chance to adapt to the tonicity change (he is indeed awake and alert). Thus, the tonicity correction should not happen with the same speed with which the volume is going to be corrected. That delay is achieved by choosing a fluid that is not pure water, but one that has some sodium in it to dampen the effect on tonicity. Half normal saline is a good choice. 5 L of D5W over 2 or 3 days (choice A) would be safe from the viewpoint of slowly correcting the tonicity, but it would unnecessarily prolong the state of volume depletion. 5 L of D5W over 5-10 hours (choice B) could well be deadly, because it would revert the tonicity to normal at a rate too fast for the brain to follow. Choices D and E budget a volume replacement well beyond what is needed. Neither would be lethal, because D5W is not used, but neither of them is the best answer.

29) A 72-year-old man comes in complaining of persistent and nagging low back pain that he has had for several weeks. The pain seems to be increasing in intensity, is worse at night, is unrelieved by rest or positional changes, and is not exacerbated by coughing, sneezing, or straining to have a bowel movement. He is a chronic smoker, and for the past 3 months has had persistent cough with occasional bloody streaked sputum, as well as a 20-pound weight loss. On physical examination, he is distinctly tender to palpation at a particular spot over his lower thoracic spine. Which of the following is the most likely diagnosis?
A. Ankylosing spondylitis
B. Herniated disk
C. Metastatic tumor to the thoracic spine
D. Multiple myeloma
E. Primary malignant bone tumor
Explanation:
The correct answer is
C. The age, nature of the pain, physical findings, and associated symptoms are all highly suggestive of metastatic tumor, and the source is probably the lung. Ankylosing spondylitis (choice A) happens to younger patients (in their early 30s) who have pain and stiffness in the mornings, and relief as they become active during the day. Herniated disc (choice B) can virtually be excluded by the fact that the pain is not exacerbated by coughing, sneezing, or straining. Multiple myeloma (choice D) is also a disease of old men, but they get anemia and multiple lytic lesions throughout the skeleton. Primary malignant bone tumors (choice E) occur in much younger people, and the extremities are a more likely location.

30) The unrestrained front-seat passenger in a car that crashes at high speed is brought to the emergency department by paramedics. At the site of injury, the patient was unconscious and had gurgly respiratory sounds, and the EMTs successfully accomplished blind nasotracheal intubation. The initial survey in the emergency department shows normal vital signs, multiple facial lacerations, and an unresponsive, comatose patient with fixed dilated pupils. Preparations are made to do a CT scan of the head. It is imperative that which of the following should be obtained as well?
A. Base of the skull x-ray films
B. Extension of the CT to include the entire cervical spine
C. Radiographs of all the teeth
D. Separate CT scan of the abdomen
E. Special views of the maxillary sinuses
Explanation:
The correct answer is
B. Deceleration injury resulting in head trauma of sufficient magnitude to produce coma and multiple facial lacerations may very well have also produced injuries to the cervical spine. Although intubation in the field was very appropriate before the cervical spine was visualized (the patient was comatose and had signs of compromised airway), we need to know the status of the cervical spine before much more is done to the patient. Since CT is needed to evaluate his head injury, the most expeditious way to check his cervical spine is by extending the CT to include the neck. The base of the skull (choice A) will be very well visualized in the CT. No separate x-ray films are needed. Checking the status of the teeth (choice C) or the sinuses (choice E) are hardly the sort of emergencies that need to be addressed now. A separate CT scan of the abdomen (choice D) would have been indicated if he had been hypotensive. So far we have no indication of internal bleeding, and thus do not need to look for a source.

31) A 55-year-old woman has been known for years to have mitral valve prolapse. She has now developed exertional dyspnea, orthopnea, and atrial fibrillation. She has an apical, high-pitched, holosystolic heart murmur that radiates to the axilla and back. Because of her deterioration, surgery has been recommended. Which of the following is the most appropriate procedure?
A. Aortic valve replacement
B. Mitral commissurotomy
C. Mitral valve annuloplasty
D. Mitral valve replacement
E. Both aortic and mitral valve replacement
Explanation:
The correct answer is
C. The physical findings are classic for mitral valve insufficiency. Whenever possible, repair of the native mitral valve is preferable to replacement. The way to repair an insufficient valve is to tighten the annulus, bringing the leaflets closer to one another. There are no physical findings indicating involvement of the aortic valve; therefore, choices A and E are wrong. Mitral commissurotomy (choice B) is the preferred operation for mitral stenosis. This patient has no signs of stenosis, and no history of rheumatic heart disease to suggest that she might have it. Mitral valve replacement (choice D) is the choice when repair of the native valve cannot be done.

32) A 23-year-old woman seeks help for exquisite pain with defecation and blood streaks on the outside of her stools, which she has been having for several weeks. Because of the pain, she has avoided having bowel movements, and when she finally did the stools were hard and even more painful. When seen, she has no fever or leukocytosis. Physical examination has to be done under spinal anesthesia, because the patient was so afraid of the pain that she initially refused even inspection of the area. The examination confirms the suspected diagnosis, and she is placed on stool softeners and appropriate topical agents, but without success. She is willing to undergo more aggressive treatment. Which of the following is the most appropriate next step?
A. Excision of the lesion
B. Fistulotomy
C. Incision and drainage
D. Lateral internal sphincterotomy
E. Rubber band ligation
Explanation:
The correct answer is
D. The clinical picture is classic for anal fissure, which is perpetuated by the fact that the anal sphincter is “too tight.” Forceful dilatation under anesthesia, lateral sphincterotomy, or botulinum toxin injections are acceptable options to “break the cycle.” The only one of those choices given is the sphincterotomy. Excision (choice A) used to be done for this condition, before the role of the “too tight sphincter” was elucidated. Fistulotomy (choice B) is not the answer. She has a fissure, not a fistula. Incision and drainage (choice C) is another option that addresses a wrong diagnosis. We do that for perirectal abscess, which produces severe pain with fever and leukocytosis, but without blood streaks, and drains spontaneously after several days if not diagnosed and treated. Rubber band ligation (choice E) is the answer for internal hemorrhoids. Internal hemorrhoids can bleed, but typically do not hurt. Thrombosed external hemorrhoids can hurt tremendously, but those are not amenable to rubber band ligation.

33) An exploratory laparotomy for multiple intra-abdominal injuries has lasted 3 and a half hours. Multiple blood transfusions have been given, and several liters of Ringer’s lactate have been infused. When the surgeons are ready to close the abdomen, they find that the abdominal wall edges cannot be pulled together without undue tension. Both the belly wall and the abdominal contents seem to be swollen. Which of the following is the most appropriate management in this situation?
A. Approximate the skin only, using towel clips
B. Close the abdomen with heavy retention sutures
C. Give diuretics and close the abdomen in the usual way
D. Leave the abdomen and its contents open to the air
E. Provide temporary bowel coverage with an absorbable mesh
Explanation:
The correct answer is
E. This is a new entity known as the abdominal compartment syndrome, unknown in the days when severely traumatized patients died prior to, or during, surgery. The life-saving massive fluid infusions produce severe edema in the surgical field. Forced closure would compromise ventilation and venous return. A temporary plastic coverage, or a mesh, allows the bowel to be protected without undue pressure. Closing the skin only (choice A) can be life-saving when hypothermia develops during surgery. In this setting, however, the skin will not come together without undue tension. Forced closure (choice B) would compromise ventilation and produce acute renal failure due to pressure on the inferior vena cava. Diuretics (choice C) cannot selectively remove the fluid from the swollen tissues. Leaving the bowel exposed to the air (choice D) is not an option. In the short term, the patient would suffer severe heat loss; later, the bowel would dry out and perforate.

34) A 61-year-old man comes in because of colicky abdominal pain and vomiting of 3 days’ duration. On physical examination, he is moderately distended and has high pitched hyperactive bowel sounds and a 5-cm tender groin mass. On direct questioning, he explains that he has had that bulge for many years, but has always been able to “push it back in” when he lies down. For the past 3 days, however, he has been unable to do so. He has a temperature of 38.9 C (102 F) and a white blood cell count of 12,500/mm3. Which of the following is the most appropriate management at this time?
A. A sonogram of the mass
B. A trial of nasogastric suction and IV fluids for a few days
C. Insertion of a long rectal tube via sigmoidoscopy
D. Manual reduction of the hernia, followed by a period of observation
E. Urgent surgical intervention
Explanation:
The correct answer is
E. The clinical picture is that of a strangulated inguinal hernia. If he only had the tender mass without signs of intestinal obstruction, he might have omentum trapped. If he had the intestinal obstruction without fever, leukocytosis, and the tender mass, he could be obstructed but not strangulated. But, the combination that he has is clearly that of obstruction with strangulation. He needs urgent surgery. A sonogram to make a diagnosis (choice A) might be appropriate for a mass without signs of obstruction, if we could not clinically be sure that it was a hernia. Nasogastric suction and IV fluids (choice B) is the standard approach for obstruction due to adhesions, when there are no signs suggestive of strangulation. We do not operate for adhesions (they form again), but do so only to rescue the bowel that is trapped. In hernias, on the other hand, we want not only to rescue the bowel but also to repair the hernia. A long rectal tube (choice C) is used in Ogilvie’s syndrome or volvulus, but not in strangulated hernias. Manual reduction (choice D) would actually be dangerous in this case, as it might force a dead segment of bowel into the abdomen, increasing morbidity and delaying definitive treatment. If he had no fever, no leukocytosis, and no tenderness, such an approach might be justified to gain time for an elective, non-rushed hernia repair.

35) In a rollover car accident, a 42-year-old woman is thrown from the car. The car subsequently lands on her and crushes her. On physical examination in the emergency department, it is determined that she has a pelvic fracture, which is confirmed by portable x-rays done as she is being resuscitated. Her initial blood pressure is 50/30 mm Hg, and her pulse is 160/min and barely perceptible. Thirty minutes later, after 2 L Ringer’s lactate and 2 U packed cells have been infused, her pressure is only 70/50 mm Hg, and her pulse is 130/min. A sonogram done in the emergency department shows no intra-abdominal bleeding, and a diagnostic peritoneal lavage confirms that there is no blood in the abdomen (the recovered fluid is pink, but not grossly bloody). Rectal and vaginal exams show no injuries to those organs. There is no blood in her urine. Which of the following is the most appropriate next step in management?
A. Packing of the vagina and rectum
B. Angiographic embolization of torn veins
C. External fixation of the pelvis
D. Open reduction and internal fixation of the pelvis
E. Exploratory laparotomy with pelvic dissection and hemostasis
Explanation:
The correct answer is
C. This is actually a terrible situation, with no easy way out. Pelvic fractures can bleed massively, and often the source is torn veins that are not easily controlled. Minimizing the motion of the bone fragments by external fixation can be helpful, and it will not make the situation worse. Packing the vagina or rectum (choice A) would help if bleeding originated in those organs, but they cannot reach the source of bleeding in this case. Angiography (choice B) can be very helpful when arteries are torn. It cannot do the same for veins. Opening the fractured area (choice D) would lose the tamponade effect and would not help control the bleeding. And as for the surgeons coming to the rescue (choice E), this is one place in which the high and mighty are routinely humbled. Opening the pelvic hematoma loses the tamponade effect, and once into the thick of things, pelvic veins bleed massively and are not easily controlled. It is best to stay out of these situations.

36) A 52-year-old nurse seeks medical retirement because of a “heart condition.” She complains of disabling attacks of tachycardia and palpitations. The physical examination and ECG studies confirm that indeed her pulse is between 100 and 105/min at all times, and she is in and out of atrial fibrillation. It is also noted that she is fidgety and constantly moving, and various examiners remark that she arrives for tests lightly dressed when it is rather cold outside. Thyroid function studies show elevated free thyroxine (T4) and undetectable levels of thyroid stimulating hormone (TSH). Her thyroid gland is not clinically enlarged or tender. Which of the following is the most appropriate next step in diagnosis?
A. Fine needle aspiration cytology of the thyroid gland
B. MRI of the pituitary area
C. Radioactive iodine uptake
D. Serum levels of C peptide
E. Serum levels of triiodothyronine (T3)
Explanation:
The correct answer is
C. It has been established clinically and by the laboratory that this patient is hyperthyroid, but the thyroid gland does not seem to be abnormal. The circumstances suggest that self-administration of thyroid hormone for secondary gain (e.g., weight loss) is a possibility. Radioactive iodine uptake should be high if her gland is indeed hyperfunctioning, but it will be near zero if it is suppressed by the exogenous hormone. Malignancy is not an issue; thus, fine needle aspiration (choice A) does not have a role. High thyroid function with undetectable levels of TSH excludes the pituitary as the source of the problem. Thus, there is no reason to investigate it as suggested in choice
B. C peptide (choice D) is indeed used to ferret out hormonal self-administration, but it distinguishes endogenous from exogenous insulin, not thyroid hormone. T3 (choice E) needs to be determined when clinical signs of hyperthyroidism coexist with normal levels of T4.

37) A 59-year-old man is referred for evaluation because he has been fainting at his job, where he operates heavy machinery. He is pale and gaunt, but otherwise his physical examination is remarkable only for 4+ occult blood in the stool. Laboratory studies show a hemoglobin of 5 gm/dL with microcytosis, as well as decreased levels of serum iron and increased iron binding capacity. Which of the following will most likely establish the diagnosis?
A. Upper gastrointestinal series (swallowed barium studies)
B. Colonoscopy
C. Flexible sigmoidoscopy to 45 cm
D. Upper gastrointestinal endoscopy
E. Visceral angiogram
Explanation:
The correct answer is
B. Iron deficiency anemia in the adult is always due to chronic blood loss, and the source is obvious in this vignette: the gastrointestinal tract. In turn, the most likely site, in the absence of other symptoms, is a cancer of the right side of the colon, which is best seen by colonoscopy. Upper gastrointestinal series (choice A) would not be likely to reveal the source of this man’s anemia, since the cecum or ascending colon is the number one target. Flexible sigmoidoscopy (choice C) would not reach the likely site of the cancer. If the cancer were located in the left colon, he would likely have visible blood in his stools and a change in bowel habits. Upper gastrointestinal endoscopy (choice D) is the first test when someone vomits blood. It often will also reveal the source of occult blood loss (peptic ulcer disease or aspirin-related gastritis) when the colon is found to be normal. In this case, however, the cecum or ascending colon is the number one target. As for visceral angiogram (choice E), it would be great at the time of massive gastrointestinal bleeding (more than 2 mL/min), but in this example it would be a very expensive, invasive, and roundabout way to demonstrate the presence of a tumor (by tumor blush).

38) A 24-year-old woman is admitted to the hospital for a broken femur. The patient was in a motor vehicle accident 20 hours ago and was brought to the hospital by EMS. On the scene, she was found belted in her car in the drivers seat, and her only documented injury was the leg fracture. She had no loss of consciousness or altered mental status. On arrival to the hospital, radiographs confirmed a fracture of her femur. She was stabilized over night and scheduled for surgery the next day. Which of the following is the major surgical risk for this patient?
A. Air embolism
B. Cerebrovascular accident
C. Fat embolism
D. Osteomyelitis
E. Permanent disability
Explanation:
The correct answer is
C. If a transesophageal echo probe is placed in every patient undergoing femoral reaming for fracture repair, the incidence of fat and particle debris in the right atrium approaches 70%. In fact, a major risk of lower extremity orthopedic procedures is pulmonary embolism due to fat or clots. The intramedullary pressures generated during the repair are greater than 500 psi and are enough to cause venous extrusion of fat and other particulate matter into the circulation. Air embolism (choice A) is common with neurosurgical procedures but is not often seen with orthopedic procedures of the lower extremity. Although cerebrovascular accident (choice B) can occur in the absence of a patent foramen ovale, it is rare. Osteomyelitis (choice D) is a feared complication of orthopedic surgery, and precautions such as sterile preparations and antibiotics are taken to guard against it. Because of this, the complication of pulmonary embolism due to fat is much greater than that of bone infection. Permanent disability (choice E), although a vague term, would rarely be the result of a lower extremity fracture repair.

39) A 42-year-old woman hit her breast with a broom handle while doing housework. She noticed a lump in that area at the time, and 1 week later the lump was still present. She then sought medical advice. On physical examination, she has a 3-cm, hard mass deep inside the affected breast, and some superficial ecchymosis over the area. Which of the following is the most appropriate next step, or steps, in management?
A. Reassess in about 2 months, with no specific therapy
B. Hot packs, analgesics, and surgical evacuation of the hematoma
C. Mammogram, and no further therapy if the report does not identify cancer
D. Mammogram and biopsy of the mass
E. Mastectomy
Explanation:
The correct answer is
D. Although the history of trauma might suggest a hematoma or fat necrosis, it is well known that trivial trauma sometimes brings to the attention of the patient an area of the body that had not been examined before. A breast mass in a 42-year-old woman requires a mammogram and biopsy. Waiting 2 months (choice A) would be unacceptable for a potential cancer. Hot packs and analgesics (choice B) on the assumption that this is a hematoma would also delay the diagnosis if a cancer is present. Furthermore, if this is indeed a hematoma one would not necessarily want to drain it. Choice C is incorrect because the mammogram is an adjunct to the biopsy of a breast mass, not a substitute for it. The two studies are complementary. Mastectomy (choice E) is too radical a step before a diagnosis has been established.

40) The unrestrained front-seat passenger in a car that crashed at high speed arrives at the emergency department with signs of moderate respiratory distress. Physical examination shows no breath sounds at all on the left hemithorax. Percussion is unremarkable, and his vital signs are normal. A chest x-ray film shows a collapsed left lung and multiple air-fluid levels filling the left pleural cavity. A nasogastric tube that had been placed prior to taking the film shows the tube reaching the upper abdomen and then curling up into the left chest. Which of the following is the most likely diagnosis?
A. Blow out of pulmonary blebs
B. Esophageal rupture or perforation
C. Left diaphragmatic rupture
D. Left hemopneumothorax
E. Major injury to the tracheobronchial tree
Explanation:
The correct answer is
C. The left diaphragm can blow out with blunt injuries, allowing the bowel to move up into the chest. The multiple air-fluid levels suggest that bowel is indeed there, and the trajectory of the nasogastric tube confirms that the abdominal viscera (including the stomach) have been sucked up into the thoracic cavity. Pulmonary blebs (choice A) produce a pneumothorax when they rupture. The esophagus (choice B) virtually never ruptures with blunt abdominal trauma. You need a penetrating injury, or better yet an endoscopy, to perforate it. When that happens, the outcome is mediastinitis. A hemopneumothorax (choice D) can indeed happen in thoracic injuries, but the x-ray films would show one single large air-fluid level, and the nasogastric tube would be in the stomach, without curling up into the chest. The tracheobronchial tree (choice E) can indeed break as a consequence of deceleration injuries, but the outcome would be a pneumothorax and air in the mediastinum and the subcutaneous tissues.

41) On the 7th postoperative day after the pinning of a broken hip, a 76-year-old man suddenly develops severe pleuritic chest pain and shortness of breath. When examined, he is found to be anxious, diaphoretic, and tachycardic, with a blood pressure of 140/85 mm Hg. He has prominent distended veins in his neck and forehead. Blood gases show hypoxemia and hypocapnia. His chest x-ray film is unremarkable. The nurses have placed him on supplemental oxygen by face mask. Which of the following is the most appropriate next step in management?
A. Aortogram and emergency surgical repair
B. ECG and cardiac enzymes
C. Intubation and respirator, with hyperventilation and PEEP
D. Retinal examination looking for fat droplets
E. Ventilation-perfusion lung scan, or spiral CT scan of the chest
Explanation:
The correct answer is
E. The clinical picture is that of a pulmonary embolus. Although pulmonary angiogram is the “gold standard” diagnostic test, confirmation is usually obtained with the less invasive ventilation-perfusion scan. In some centers, the high-definition spiral CT scan has been found to be a better diagnostic modality, and it is noninvasive. Aortogram and surgical repair (choice A) assumes the pain is due to a dissecting aortic aneurysm. Had that been the case, the pain would have been more likely to radiate down toward the back, and the patient would have been severely hypertensive. ECG and cardiac enzymes (choice B) would probably be done in this patient, but only to rule out myocardial infarction with greater certainty. Clinically, we should be suspecting a pulmonary embolus, and negative ECG and negative enzymes would not specifically confirm the suspected diagnosis. Hyperventilation (choice C) is not needed on someone who already has hypocapnia. Looking for fat droplets (choice D) is not particularly useful, even when the clinical diagnosis suggests fat embolism. Fat embolism is more likely to be seen with multiple comminuted fractures of long bones (not just a broken hip), and the clinical manifestations are those of respiratory failure. There would be no chest pain.

42) A young man sustains a gunshot wound to the base of his neck. He was shot point blank with a .38 caliber revolver. The entrance wound is above the left clavicle, below the level of the cricoid cartilage, and just lateral to the sternomastoid muscle. The exit wound is just above the spinous process of the right scapula. He has normal breath sounds on both sides, is awake and alert, is talking with a normal tone of voice, is neurologically intact, and is hemodynamically stable. Portable x-ray films of the neck and chest taken in the emergency department show some air in the tissues of the lower neck, but are otherwise non-diagnostic. Which of the following is the most appropriate next step in management?
A. Observation for several hours
B. CT scan of the lower neck and upper chest
C. Angiogram, esophagogram, esophagoscopy, and bronchoscopy prior to surgical exploration
D. Immediate surgical exploration of the lower neck through a collar incision
E. Immediate surgical exploration of the upper chest through a median sternotomy
Explanation:
The correct answer is
C. Gunshot wounds to the base of the neck need exploratory surgery, but the exact approach and incision are determined by a more accurate knowledge of the location and extent of the injuries. Thus, if time permits, diagnostic studies should precede surgical intervention. The major vessels, the tracheobronchial tree, and the esophagus are the potential targets that have to be investigated. Observation (choice A) might be appropriate for a stab wound in a completely asymptomatic patient. In gunshot wounds, we have to expect that injuries will exist, and they should not be neglected waiting for overt clinical signs. CT scan (choice B) has done wonders for our assessment of closed head injuries and blunt abdominal trauma, but it is not the study that would tell us what has happened to the major vessels, the esophagus, or the tracheobronchial tree in a gunshot wound. Immediate surgical exploration, either through the neck or the chest, or in combination, might be forced by a rapidly deteriorating situation. In the absence of such imperative, a decision to open the neck (choice D) or the chest (choice E) is premature at this point.

43) A 67-year-old man shows up in the emergency department because he has not been able to void for the past 12 hours. He feels the need to, but he cannot do it. He gives a history that, for several years now, he has been getting up four or five times a night to urinate. It would take him a considerable time to get the urinary stream going, and the stream lacked force and often ended in a dribble. Because of a cold, 2 days ago he began taking an antihistamine, taking a decongestant, and drinking plenty of fluids. Physical examination shows a palpable, smooth, round mass arising from the pubis and reaching about half way toward the umbilicus. The mass is dull to percussion, and pushing on it accentuates the feeling of needing to void. Rectal examination reveals a large, boggy, non-tender prostate gland without nodules. This a classic presentation for which of the following acute conditions?
A. Bacterial prostatitis
B. Cystitis in a patient with bladder cancer
C. Renal failure
D. Urinary retention in a patient with benign prostatic hypertrophy
E. Urinary retention in a patient with prostatic cancer
Explanation:
The correct answer is
D. The history and rectal examination findings are classic for benign prostatic hypertrophy. The use of a decongestant has led to stimulation of alpha adrenergic receptors, which have further closed the bladder neck. A big, palpable bladder has resulted. Bacterial prostatitis (choice A) would produce pain, fever, and a very tender prostate on rectal examination. Cystitis and bladder cancer (choice B) could be expected to produce irritative symptoms and hematuria, but not painless retention. Renal failure (choice C) produces oliguria, not anuria. The bladder would be empty and thus not palpable. The patient would urinate small amounts and feel no need to urinate more. Prostatic cancer (choice E) is usually first felt as a stony hard nodule. It would be unusual for it to grow to a size at which complete obstruction is the first manifestation. If it did, though, the prostate would feel stony hard.

44) Several months after sustaining a crushing injury to his arm, a patient complains bitterly about constant, burning, agonizing pain in that arm, that does not respond to the usual analgesic medications. The pain in his arm is aggravated by the slightest stimulation of the area, such as rubbing from the shirt sleeves. The arm is cold, cyanotic, and moist, but it is not swollen. Pulses at the wrist are normal, and neurologic function of the three major nerves is intact. Which of the following is most appropriate to provide diagnostic confirmation of the nature of the problem and eventual therapy?
A. Angiogram and subclavian vein bypass
B. Cervical spine x-rays and cervical rib resection
C. Doppler studies and arterial reconstruction
D. Doppler studies and fasciotomy
E. Sympathetic block and surgical sympathectomy
Explanation:
The correct answer is
E. The description is that of causalgia, also known as reflex sympathetic dystrophy. If sympathetic block relieves the symptoms, permanent cure will be obtained with surgical sympathectomy. Venous occlusion (choice A) would produce swelling but not this kind of pain. Cervical ribs (choice B) can produce neurologic and vascular symptoms in the arm, but they are related to activity and position and do not have the nature described here. Normal pulses make arterial insufficiency (choice C) unlikely. Furthermore, there is no description of intermittent claudication. Compartment syndrome (choice D) might have happened at the time of injury, but if that were the case, it would be too late to do a fasciotomy.

45) A 57-year-old alcoholic man is being treated for acute hemorrhagic pancreatitis. He was in the intensive care unit for 1 week, where he required chest tubes for pleural effusions and was on a respirator for several days. Eventually, he improved sufficiently to be transferred to the floor. Three days after leaving the unit, and about 2 weeks after the onset of the disease, he spikes a fever and develops leukocytosis. Which of the following developments do these recent findings most likely suggest?
A. Chronic pancreatitis
B. Pancreatic abscess
C. Pancreatic pseudocyst
D. Pelvic abscess
E. Subphrenic abscess
Explanation:
The correct answer is
B. A very common complication of hemorrhagic pancreatitis, and often the reason for the demise of the patient, is the development of a pancreatic abscess. The timetable is usually about 10-14 days from the onset of the disease, and the initial manifestations are fever and leukocytosis. Chronic pancreatitis (choice A) develops after several years of recurrent attacks of pancreatitis, and is characterized by steatorrhea, diabetes, and constant pain. Pancreatic pseudocyst (choice C) is another potential complication of pancreatitis, but the manifestations are related to pressure symptoms from the fluid collection, there is no fever or leukocytosis, and the timetable for development is about 6 weeks from the onset of the disease. Pelvic abscess (choice D) and subphrenic abscess (choice E) are indeed in the differential diagnosis, as they also show up with fever and leukocytosis some 10-14 days from the original problem. But, the original problem for these patients is usually an infectious process in the abdomen, e.g., a ruptured appendix or a perforated viscus. If the problem began with pancreatitis, and then there are signs of sepsis, the pancreas is the logical place to harbor the pus.

46) A 31-year-old male immigrant from India is found on a routine physical examination to have a single, 2-cm nodule in the right lobe of his thyroid gland. The mass is firm, moves up and down with swallowing, and is not tender. The skin of his face and neck is pitted with multiple scars, which suggest smallpox; however, he explains that the scars are due to very severe acne that he had as a youngster, for which he eventually received external beam radiation therapy at the age of 14. His thyroid function tests are normal, and a fine needle aspiration (FNA) cytology of the mass is read by the pathologist as “indeterminate.” Which of the following is the most appropriate next step in management?
A. No further care is needed
B. Thyroid function tests should be repeated yearly
C. Thyroid scan and sonogram are needed
D. FNA should be repeated until it can be read as benign or malignant
E. Thyroid lobectomy
Explanation:
The correct answer is
E. The patient is at high risk for thyroid cancer (young, male, with a single nodule and a history of radiation), and a reading of “indeterminate” in an FNA is a surgical indication. No further care (choice A) is totally wrong. It assumes that normal thyroid function means there is nothing wrong with the thyroid, when in fact thyroid cancer almost never alters thyroid function. This choice also assumes that if an FNA is not read as cancer, the patient does not have that disease. Focusing on function (choice B) as the criterion to do something is wrong for the same reasons. Thyroid scan and sonogram (choice C) were formerly valuable criteria to select surgical candidates (cold solid nodules meant a high risk of cancer), but the FNA provides a higher yield of malignancy in resected specimens, and thus has rendered the other tests obsolete for this purpose. Repeating the FNA (choice D) assumes that, given more cells, the pathologist should be able to distinguish benign from malignant. The pathologist has no trouble recognizing malignant features in papillary, medullary, or anaplastic cancers of the thyroid, but cannot do so with follicular neoplasms. Follicular adenoma and follicular carcinoma require a look at the entire specimen to tell them apart.

47) A 33-year-old woman is involved in a high-speed automobile collision. She arrives at the emergency department gasping for breath. Her lips are cyanotic and she has flaring nostrils. There are bruises over both sides of the chest, and tenderness suggestive of multiple rib fractures. Her blood pressure is 60/45 mm Hg, pulse is 160/min and feeble, and central venous pressure is 25 cm H2O. Her neck and forehead veins are distended. She is diaphoretic and has a hint of subcutaneous emphysema in the lower neck and upper chest. Her left hemithorax has no breath sounds and is hyperresonant to percussion. The trachea is deviated to the right, as are the heart sounds. Which of the following is the most likely diagnosis?
A. Air embolism from tracheobronchial injuries
B. Flail chest due to multiple rib fractures
C. Massive intrapleural bleeding from torn intercostal vessels
D. Massive mediastinal bleeding from ruptured aorta
E. Tension pneumothorax caused by lung punctured by broken ribs
Explanation:
The correct answer is
E. Although we typically associate tension pneumothorax with penetrating chest wounds, a blunt injury can produce lung puncture, as the jagged edges of broken ribs are driven in at the time of impact. All the classic findings of a tension pneumothorax are given in the vignette. Tracheobronchial injuries (choice A) can indeed produce subcutaneous emphysema. They can also produce air embolism if major vessels and major elements of the airway are lacerated next to one another. When that happens, though, the clinical manifestation is sudden death, typically when the patient is placed on a respirator. Flail chest (choice B) is also likely to occur with multiple rib fractures, but the clinical clue is paradoxical breathing, and the eventual problem is respiratory distress but no hemodynamic decompensation. Massive bleeding, whether from torn intercostals or ruptured aorta (choices C and D) would indeed lead to hypovolemic shock, but the central venous pressure would be zero and breathing would not be particularly affected.

48) A 44-year-old woman complains bitterly of severe headache that has been present for several weeks and has not responded to the usual over-the-counter headache remedies. She locates the headache to the center of her head. It is pretty much constant but is worse in the mornings. She has no other neurologic signs or symptoms. She has had “tension headaches” in the past, but she says that those were located in the back of her head and felt different from the present pain. She is currently under considerable stress because she has been unemployed since undergoing modified radical mastectomy for T3, N1, M0 breast cancer 2 years ago. She had several courses of post-operative chemotherapy, which she eventually discontinued because of the side effects. Which of the following is the most appropriate next step in diagnosis?
A. CT scan of the head
B. Psychiatric evaluation
C. Skull x-rays
D. Aortic arch arteriogram
E. Lumbar puncture
Explanation:
The correct answer is
A. Persistent headache in a patient with recent history of breast cancer (particularly node-positive) is brain metastasis until proven otherwise. The only acceptable course of action is to take a look (radiologically, of course), and the cheapest and most reliable way would be a CT scan. For primary brain tumors, the MRI is favored; however, to show the presence of metastasis, an MRI is not needed. Despite the history of tension headaches and current job worries, psychiatric causes (choice B) are far down the line in the differential diagnosis. Skull x-rays (choice C) are almost a vanishing test. They may still show linear skull fractures when you are looking for them, but they would certainly not show intracranial masses. Vascular studies (choice D) were, at one time, the only reliable way to rule out intracranial tumor, but the CT scan displaced them. We still use them to define vascular lesions, which this vignette does not suggest. Lumbar puncture (choice E) would not diagnose a tumor and would subject the patient to the risk of herniation of the brainstem. Save that test for patients with meningitis.

49) A 59-year-old black man has a rock-hard, discrete, 1.5-cm nodule that is felt in his prostate during a routine physical examination. He is completely asymptomatic, and his prostatic specific antigen (PSA) done 3 months ago was normal for his age. His last rectal examination was performed a year earlier and was unremarkable. Which of the following will best establish the diagnosis?
A. Clinical follow-up during the ensuing year
B. Repeat determination of PSA
C. Transrectal needle biopsy of the mass
D. Transrectal sonogram of the prostate
E. Transurethral resection of the prostate
Explanation:
The correct answer is
C. Cancer of the prostate will be discovered early by either the discovery of a hard nodule (as in this case), or the identification of elevated PS
A. These are complementary examinations. One may be normal, while the other may be revealing. In this case, the recent normal PSA does not exclude the need to biopsy this mass. Clinical follow up (choice A) is inappropriate at this age, but it is not a completely stupid option: it would be the thing to do if the man had been 75. As pointed out above, regardless of PSA levels (choice B) we need to biopsy this mass. A sonogram (choice D) might be needed to identify a tumor that is not palpable, but has been discovered by the PS
A. In this case the tumor has been felt. It can be biopsied, guided by the finger or by a sonogram if you prefer. But, the sonogram will not establish the diagnosis, it will only help do the biopsy. Let us not resect the prostate (choice E) before we have a diagnosis. Depending on the results of the complete workup, one might elect a different surgical approach or a different treatment (radiation, for instance).

50) A 9-month-old infant is brought in by her parents because she has an umbilical hernia. Physical examination shows an umbilical defect about 1 cm in diameter, with a small bulge when the girl cries. The hernial contents can be easily reduced. The hernia is not painful, and the girl is otherwise asymptomatic. Which of the following is the most appropriate next step in management?
A. No therapy unless the hernia persists beyond the age of 2 years
B. Repeated injections of sclerosing agents
C. Elective laparoscopic surgical repair
D. Elective open surgical repair
E. Urgent surgical repair
Explanation:
The correct answer is
A. Small umbilical hernias can close spontaneously up to the age of 2 years. Therefore, if they are asymptomatic and not posing an immediate risk of strangulation, they should be left alone. Obviously, every other answer offered in this question is wrong, because they all advocate aggressive therapy. However, we shall also review other ways in which they might be incorrect. Sclerosing agents (choice B) are not appropriate to manage a hernial sac that communicates with the rest of the peritoneal cavity. Occasionally, if a surgical hernia repair is done when a large distal sac has to be left in place, it might be advisable to destroy the peritoneal lining with sclerosing agents so that it does not secrete fluid. Laparoscopic hernia repair (choice C) makes sense when the size of the incision or incisions can be significantly reduced by the use of laparoscopy (for instance a bilateral inguinal hernia repair). In this case, however, one would need bigger incisions to introduce a TV camera and operating instruments than one would need to directly close a 1-cm superficial defect. Elective open surgical repair (choice D) is what this little girl will need if she still has the hernia past her second birthday. Urgent repair (choice E) would have been indicated if the hernia were tender, or if the girl had been vomiting or getting distended at the same time that the hernia became irreducible.

O.B.G Q&A Paper – 3

admin — Fri, 13 Mar 2009 05:12:23 +0000

Block 19 Explanations

1) A 31-year-old woman comes to the physician because she has not had a menstrual period for 7 months. She previously had normal cycles. She also states that over the past year she has felt increasingly weak and tired. She notes that she always feels cold and that her hair has been thinning over the course of the year. She also complains of constipation, weight gain, and depression. Her temperature is 36.7 C (98 F), blood pressure is 100/60 mm Hg, pulse is 56/minute, and respirations are 10/minute. Examination is significant for brittle hair and delayed deep tendon reflexes. Urine human chorionic gonadotropin (hCG) is negative. Thyroid stimulating hormone (TSH) is 20 µU/mL. Prolactin is normal. Which of the following is the most likely cause of this patient’s amenorrhea?
A. Hyperprolactinemia
B. Hypothyroidism
C. Kallmann syndrome
D. Polycystic ovarian syndrome
E. Pregnancy
Explanation:
The correct answer is
B. Secondary amenorrhea is defined as the absence of menses for 6 cycle intervals or 12 months in a woman who previously had regular cycles. This patient, therefore, has secondary amenorrhea. She also has a constellation of signs and symptoms that are highly suggestive of hypothyroidism. Patients with hypothyroidism often complain of some combination of weakness, fatigue, cold intolerance, constipation, weight gain, depression, or thinning of the hair. Physical examination can reveal bradycardia and low blood pressure. Laboratory evaluation often shows an elevated TSH as the pituitary attempts to stimulate the underfunctioning thyroid. However, many patients with hypothyroidism will be asymptomatic and the thyroid abnormality is found by thyroid function tests. Hypothyroidism likely leads to amenorrhea through changes in GnRH production. Treatment with thyroid replacement will often return these patients to regular menses. Hyperprolactinemia (choice A) is the cause of secondary amenorrhea in approximately 20% of cases. This patient, however, has a normal prolactin level. Kallmann syndrome (choice C) is a rare cause of primary amenorrhea. This syndrome is characterized by gonadotropin deficiency, anosmia or hyposmia, cleft lip or palate, and minimal sexual development. This patient does not have primary amenorrhea. Polycystic ovarian syndrome (choice D) is often characterized by obesity, hirsutism, infertility, and oligomenorrhea. Thyroid dysfunction is not part of this syndrome. Pregnancy (choice E) is, by far, the most common cause of secondary amenorrhea. This patient has a negative urine hCG.

2) A 75-year-old woman comes to the physician because of irregular vaginal bleeding. She has been menopausal for the past 25 years, but has noted on-and-off spotting for the past 2 years, which she finds intolerable. She has a complicated past medical history including hypertension, diabetes, and severe chronic obstructive pulmonary disease. Examination is unremarkable. An endometrial biopsy is performed that demonstrates an endometrial polyp with atypical cells that are difficult to grade. Which of the following is the most appropriate next step in management?
A. Hormone replacement therapy
B. Oral contraceptive pill
C. Hysteroscopy
D. Laparoscopy
E. Hysterectomy
Explanation:
The correct answer is
C. This patient is likely having irregular spotting secondary to the polyp. Endometrial polyps are projections of endometrial tissue that protrude into the endometrial cavity. They can be seen in women of any age, but are most commonly seen in perimenopausal women. This problem should be addressed for 2 reasons: 1. The bleeding per vagina is distressing to the patient. 2. There are some atypical cells from the biopsy that may represent cancer and polyps can contain malignant cells within them. Therefore, the polyp should be removed. The question then becomes how best to remove it. A hysteroscopy can be performed under monitored anesthesia care (MAC), an approach that provides adequate anesthesia without requiring the patient to have general anesthesia. It would be preferable to avoid general anesthesia in a patient with so many medical conditions. Hysteroscopy would allow visualization of the entire uterine cavity and removal of the polyp. A curettage should be performed afterward to fully sample the cavity. Hormone replacement therapy (choice A) would not be the most appropriate next step. First, the polyp must be removed and histologic evaluation of the polyp and endometrial tissues performed to rule out malignancy prior to instituting hormone replacement therapy. The oral contraceptive pill (choice B) would not be appropriate management for a 75-year-old woman, as the dose of hormones is higher than necessary. Laparoscopy (choice D) would not be indicated. This patient is having spotting, which is an intrauterine process. Laparoscopy allows visualization of only the external, serosal uterine surface. Hysterectomy (choice E) would not be the most appropriate management. Hysterectomy would take care of the patient’s spotting and would provide tissue for pathologic diagnosis. However, in this patient with multiple medical problems, the same goals can be achieved with the less invasive procedure of hysteroscopy.

3) A 31-year-old woman, gravida 1, para 0, at 36-weeks’ gestation with twins comes to the physician for a prenatal visit. The patient has had no contractions, bleeding from the vagina, or loss of fluid, and the babies are moving well. An ultrasound that was performed today shows that the presenting fetus is vertex and the non-presenting fetus is breech. Both fetuses are appropriately grown and greater than 2000 g. The patient wants to know if she should have a vaginal or cesarean delivery. Which of the following is the proper counseling for this patient?
A. Both vaginal delivery and cesarean delivery are acceptable.
B. Cesarean delivery is mandated because the fetuses are > 2000g.
C. Cesarean delivery is mandated because the second twin is breech.
D. Vaginal delivery is mandated because the fetuses are > 2000g.
E. Vaginal delivery is mandated because the first twin is vertex.
Explanation:
The correct answer is
A. Mode of delivery with twin gestations is an area that has generated controversy over time. Patients with vertex-vertex twins are generally allowed to have a vaginal delivery. Patients with a presenting twin that is non-vertex are generally advised to have a cesarean delivery. Patients with the presenting twin vertex and the non-presenting twin non-vertex may decide which mode of delivery they would prefer. Once the presenting (vertex) twin has delivered, there are essentially 2 options for delivery of the second (non-vertex) twin. The first option is an external cephalic version, in which the head of the second twin is guided into the pelvis so that it becomes a vertex presentation. The second option is a breech extraction of the second twin. Breech extraction may be performed so long as there is an adequate pelvis, a fetal weight greater than 2,000g, an experienced physician, a flexed fetal head, and available general anesthesia. To state that cesarean delivery is mandated because the fetuses are > 2000g (choice B) is incorrect. The fact that the fetuses are > 2000g makes a vaginal delivery with a non-vertex second twin possible. To state that cesarean delivery is mandated because the second twin is breech (choice C) is incorrect. As explained above, vertex-nonvertex twins may be delivered vaginally so long as certain criteria are met. To state that vaginal delivery is mandated because the fetuses are > 2000g (choice D) is incorrect. Vaginal delivery is possible because the fetuses are > 2000g, but the mother may still choose to have a cesarean delivery. To state that vaginal delivery is mandated because the first twin is vertex (choice E) is incorrect. With the first twin vertex, vaginal delivery is possible, but with a non-vertex second twin, cesarean delivery would also be entirely appropriate.

4) A 27-year-old woman comes to the physician because of fevers and back pain. She states that a few days ago she had burning with urination. Over the next few days she developed fevers and chills and a pain on the right side of her back. She has no medical problems and takes no medications. Her temperature is 38.9 C (102 F), blood pressure is 110/70 mm Hg, pulse is 102/minute, and respirations are 16/minute. Examination shows a patient in mild distress with shaking chills and right costovertebral angle tenderness. Leukocyte count is 18,000/mm3. Urinalysis shows 100 leukocytes/high powered field. Which of the following is the most appropriate next step in management?
A. Observation only
B. Spinal magnetic resonance imaging (MRI) scan
C. Outpatient management with oral trimethoprim-sulfamethoxazole
D. Hospital admission and initiation of IV trimethoprim-sulfamethoxazole
E. Hospital admission and administration of a 2-week course of IV tetracycline
Explanation:
The correct answer is
D. This patient has a presentation that is most consistent with pyelonephritis. Patients with pyelonephritis typically complain of some combination of back pain, fevers, chills, dysuria, nausea, and vomiting. Examination will often show an elevated temperature, costovertebral angle tenderness, and an elevated leukocyte count. Urinalysis may demonstrate positive nitrite and leukocyte esterase testing. Urine sediment often reveals white blood cells, red blood cells, and white cell casts. Pyelonephritis can be managed on an outpatient basis if the patient is otherwise healthy, has no complicating factors, and is reliable to return if her condition worsens. A patient cannot be managed as an outpatient if there is any evidence of sepsis. This patient, with her high fevers, shaking chills, and elevated leukocyte count may have sepsis and should therefore be admitted to the hospital for intravenous antibiotics. Treatment is with IV trimethoprim-sulfamethoxazole, IV ceftriaxone, IV gentamicin with or without ampicillin, or an IV fluoroquinolone. Once the patient is afebrile, her condition is improving, and she is able to tolerate oral intake, she may be converted to an oral antibiotic regimen to complete a 14-day course. Observation only (choice A) would not be correct for this patient. This patient has pyelonephritis, which is unlikely to resolve without antibiotic therapy. Spinal MRI (choice B) is often used to evaluate patients with back pain. This patient, however, has back pain that is almost certainly related to a renal infection, therefore spinal MRI would not be necessary. Outpatient management with oral trimethoprim-sulfamethoxazole (choice C) is appropriate in some cases of uncomplicated pyelonephritis, as explained above. This patient, however, is quite ill and possibly septic. She, therefore, requires hospital admission. Hospital admission and administration of a 2-week course of IV tetracycline (choice E) would not be appropriate. Tetracycline is not a drug-of-choice in the treatment of pyelonephritis.

5) A 24-year-old patient comes to the doctor because she has concerns regarding her sexuality. She states that for as long as she can remember she has been sexually attracted to other women. She was raised in a family where homosexuality is considered “unacceptable,” so she has never discussed these feelings before. Now, however, she feels that she can no longer hide her feelings, but she is concerned that she will cause deep and irreparable harm to her relationship with her parents if she tells them. Which of the following is the most appropriate next step in the management of this patient?
A. Prescribe a benzodiazepine
B. Prescribe estrogen
C. Prescribe haloperidol
D. Reassure her that time will change her feelings
E. Refer her for psychological counseling
Explanation:
The correct answer is
E. Sexual orientation is an issue of tremendous importance in the life of an individual. Patients often come to physicians for advice and input regarding questions of sexual orientation. It is essential that the physician try to address these issues in an unbiased manner that will allow the patient to express her feelings. However, it is also essential that a physician realize his or her limitations in being able to deal with complex questions regarding sexuality, self-expression, and family dynamics. This patient has issues not only regarding her sexual orientation, but also her family and the impact her sexual orientation may have upon them. She would, therefore, be most likely to benefit from psychological counseling, where a full evaluation could be conducted encompassing the personal and family issues. To prescribe a benzodiazepine (choice A) would not be the most appropriate next step in management. This patient is not complaining of acute anxiety or sleep disturbance. Rather, she has complex issues regarding her sexuality and family dynamics. To simply prescribe an anxiolytic medication rather than address the deeper psychological issues would not be appropriate. To prescribe estrogen (choice B) would not be the most appropriate next step in management. This patient does not have a disease process that would require estrogen for therapy. To prescribe haloperidol (choice C) would not be appropriate. This patient does not require an anti-psychotic medication as she has no evidence of psychosis or psychotic behavior. To attempt to reassure her that time will change her feelings (choice D) would not be appropriate. First, her issues regarding sexual orientation may not change with time. Second, there is no indication that a change of feelings is what she needs. Her present feelings and issues must be addressed and this could be done appropriately with psychological counseling.

6) A 68-year-old woman comes to the physician because of a painful lump in her vagina. She states that the lump has been there for a few months, but has recently begun to cause her pain. She has hypertension, for which she takes a diuretic, but no other medical problems. Examination shows a 4 cm cystic mass near the patient’s introitus by the right labia. The mass is mildly tender. The remainder of the pelvic examination is normal. Which of the following is the most appropriate next step in management?
A. Expectant management
B. Sitz baths
C. Oral antibiotics
D. Biopsy of the mass
E. Word catheter placement
Explanation:
The correct answer is
D. This patient has findings that initially seem to be consistent with a Bartholin’s gland cyst or abscess. The Bartholin’s glands are paired glands found on the posterolateral aspect of the vagina at the introitus. These glands normally secrete mucus into the vagina, particularly with sexual stimulation. They grow rapidly during puberty and shrink after the menopause. In a young woman it would be reasonable to assume that this cystic mass represents a Bartholin’s cyst or abscess. However, one cannot make this assumption in a postmenopausal patient. A cystic mass on the vulva in a postmenopausal woman must be biopsied as there is a higher likelihood that this lesion represents a Bartholin’s gland carcinoma. Primary carcinoma of the Bartholin’s gland accounts for about 5% of vulvar malignancies. Delay in diagnosis is common because many clinicians and patients assume the mass is a benign cyst. Any persistent mass in this region, especially in women greater than 40 years of age, should be biopsied. Expectant management (choice A) would not be appropriate. First, the patient is symptomatic and therefore requires something for relief. Second, there is the possibility that this mass represents a malignancy and it, therefore, should be biopsied. Sitz baths (choice B) can be recommended to patients with certain vulvar lesions. However, this mass must first be biopsied to rule out malignancy. Oral antibiotics (choice C) would not be the most appropriate next step in management. To simply assume that this mass represents an infectious process without obtaining tissue for pathologic diagnosis would not be correct. Word catheter placement (choice E) would be acceptable in a young woman with this lesion. In a woman older than 40, however, the lesion must be biopsied first.

7) A 28-year-old primigravid woman at 8 weeks’ gestation comes to the physician for her first prenatal visit. A home pregnancy test was positive. She has no complaints. She is concerned, however, because she is a carrier of the fragile X mutation. Her husband is also known to be a carrier. This is a highly desired pregnancy. She wants to know whether there is a way to determine whether the fetus is affected. Which of the following is the most appropriate next step in management?
A. There is nothing to offer this couple
B. Offer testing of the parents
C. Offer MRI of the fetus
D. Offer 2nd trimester amniocentesis
E. Offer termination of the pregnancy
Explanation:
The correct answer is
D. Fragile X syndrome is the most common inherited form of mental retardation. Down syndrome may cause more absolute cases of mental retardation, but it results from a spontaneously occurring trisomy and most cases are not considered inherited. The gene for fragile X syndrome is located on the long arm of the X-chromosome. It has a complex inheritance pattern that is related to the number of repeating cytosine-guanine-guanine triplets. When greater than 200 repeats are present, a person will have the full mutation and have phenotypic fragile X syndrome. A patient with 50-200 repeats is phenotypically normal and is said to have a premutation. Along with mental retardation, related features of the fragile X syndrome include autistic behaviors, speech and language problems, facial anomalies, and macroorchidism in adult males. DNA-based molecular analysis can be used to diagnose fragile X syndrome. This can be performed on cultured amniocytes obtained at amniocentesis. Chorionic villus sampling is not considered to be reliable for the diagnosis of fragile X syndrome because of different methylation patterns in the trophoblast compared with the fetus. To state that there is nothing to offer this couple (choice A) is incorrect. As detailed above, amniocentesis can be used to allow for prenatal diagnosis of fragile X syndrome. To offer testing of the parents (choice B) would not be correct. Based on the history provided, the parents have already been tested and are known to be carriers. Their concern at this point is whether the fetus will have fragile X syndrome, and that can only be determined by genetic analysis of the fetus. To offer MRI of the fetus (choice C) would be incorrect. The diagnosis is made based on DNA-based molecular analysis and not an imaging study. To offer termination of the pregnancy (choice E) would be incorrect. This is a desired pregnancy. This patient is seeking prenatal diagnosis at this point, not termination.

A 17-year-old female comes to the physician because she has not yet had a menstrual period. She also complains of a lack of breast development. Past medical history is significant for anosmia and color blindness. Past surgical history is significant for a cleft palate that was repaired in childhood. She takes no medications and has no allergies to medications. Examination is significant for absent breast development, and a hypoestrogenic vulva and vagina. Urine hCG is negative. Which of the following is the most likely diagnosis?
A. Anorexia nervosa
B. Kallmann syndrome
C. Polycystic ovarian syndrome
D. Pregnancy
E. Testicular feminization syndrome
Explanation:
The correct answer is
B. Patients with Kallmann syndrome (i.e., isolated gonadotropin deficiency or familial hypogonadotropic hypogonadism) can present with primary amenorrhea. Primary amenorrhea is defined as the absence of menses in a female by the age of 16. Associated findings in Kallmann syndrome may include anosmia or hyposmia, color blindness, and cleft lip or cleft palate. These findings are attributable to the fact that during embryogenesis the GnRH neurons originally develop in the epithelium of the olfactory placode and normally migrate into the hypothalamus. Thus exists the link between the midline defects and the amenorrhea. Physical examination may reveal absent to minimal breast development. Treatment of the patient with Kallmann syndrome is with exogenous estrogen and progestin replacement therapy. If pregnancy is desired, ovulation induction can be brought about with the pulsatile administration of exogenous GnRH. Anorexia nervosa (choice A) can cause amenorrhea and a reduction in breast size, but it is not associated with anosmia, color blindness, and cleft palate. These features are associated with Kallmann syndrome. Polycystic ovarian syndrome (choice C) is characterized by oligomenorrhea, hirsutism, infertility, and obesity. This patient does not have a presentation consistent with polycystic ovarian syndrome. Pregnancy (choice D) should always be the first thought when a potentially fertile woman presents with amenorrhea. However, this patient has a negative urine pregnancy test and no findings consistent with pregnancy. Testicular feminization syndrome (choice E) represents complete androgen insensitivity. This syndrome occurs in individuals with a 46, XY karyotype. Affected males have a female appearance with breast development.

9) A 21-year-old woman, gravida 2, para 1, at 28 weeks’ gestation comes to the physician because of spotting after intercourse and a foul-smelling vaginal discharge. Her prenatal course has, up to now, been uncomplicated, and she has no medical problems. Speculum examination shows inflammation of the cervix with a mucopurulent cervical discharge. A gonorrhea and Chlamydia test is performed which comes back positive for chlamydia. Which of the following is the most appropriate pharmacotherapy?
A. Azithromycin
B. Doxycycline
C. Levofloxacin
D. Penicillin
E. Streptomycin
Explanation:
The correct answer is
A. This patient has Chlamydia cervicitis. Chlamydia is the most common sexually transmitted bacterial organism in the United States. It is essential to detect and treat chlamydial infection during pregnancy because maternal chlamydial infection is associated with several complications of pregnancy including preterm premature rupture of the membranes (PPROM) and preterm labor. Chlamydial infection is also associated with neonatal conjunctivitis, which results from the fetus passing through an infected birth canal. The partner of the patient must be treated as well as the patient herself in order to prevent reinfection. A test of cure (TOC) should be performed 4 to 6 weeks after treatment is given to ensure that the organism has been completely eradicated from the patient and her partner or partners. Azithromycin has a prolonged tissue half-life and therefore it can treat chlamydia in a single dose. This single dose treatment allows far greater compliance than the multiple doses that are required if erythromycin or amoxicillin is used. The single dose treatment with azithromycin also allows the treatment to be “observed” (i.e., the patient can be watched taking the medication). While the safety and effectiveness of azithromycin during pregnancy has not been as well proven as that of erythromycin or amoxicillin, it is believed to be safe and its single dose quality makes it the drug of choice. Doxycycline (choice B) is contraindicated during pregnancy because of its effects on fetal teeth and bone. Levofloxacin (choice C) and the other fluoroquinolones are contraindicated during pregnancy because of their association with arthropathies. Penicillin (choice D) is safe during pregnancy but is not considered to be as effective against Chlamydia as are azithromycin, erythromycin, and amoxicillin. Streptomycin (choice E) is contraindicated during pregnancy because of its relationship to eighth cranial nerve damage.

10) A 38-year-old woman comes to the physician because of burning with urination. She states that the burning started about 2 days ago and has been growing worse since. She has no frequency or urgency. She had one episode of pyelonephritis in the past but no other medical problems. On examination there is no costovertebral angle or abdominal tenderness. The examination is significant for a thick, white vaginal discharge with erythema and excoriations of the labia. Urinalysis is negative. KOH/Normal saline smear demonstrates pseudohyphae. Which of the following is the most likely diagnosis?
A. Candida vaginitis
B. Hemorrhagic ovarian cyst
C. Pelvic inflammatory disease
D. Pyelonephritis
E. Urinary tract infection
Explanation:
The correct answer is
A. A patient with candidiasis classically presents with complaints of a thick, white, “cottage cheese-like” discharge. Such patient may also complain of vulvar pruritus and burning. Dysuria is often seen in cases of candidiasis because there is pain when the acidic urine comes in contact with the inflamed vaginal mucosa. This dysuria is often confused for a urinary tract infection. The keys to distinguishing between the two are the examination and laboratory studies. Examination on a patient with candidiasis often shows a thick, white, discharge as well as erythema of the vagina and vulva, as this patient has. The excoriations that this patient has are likely present because the patient has been scratching the area. In a urinary tract infection, examination of the vagina and vulva will most often be unremarkable. The KOH preparation will demonstrate pseudo-hyphae in cases of candidiasis. The urinalysis should be negative in cases of candidiasis, although if there is contamination of the sample, abnormalities may be seen. A hemorrhagic ovarian cyst (choice B) typically causes abdominal pain and tenderness. It usually does not cause burning with urination. The diagnosis of pelvic inflammatory disease (choice C) is made when a sexually active female has abdominal tenderness, cervical motion tenderness, and adnexal tenderness along with a fever, an elevated white blood cell count, a positive gonorrhea or Chlamydia test, or a mucopurulent cervical discharge. This patient does not have these findings. This patient does have a history of pyelonephritis (choice D) and therefore, pyelonephritis and urinary tract infection (choice E) would be considerations. However, the patient has no fever, costovertebral angle tenderness, or abnormal urinalysis, the three findings most helpful for the diagnosis of pyelonephritis. Also, while dysuria can often be a symptom of a urinary tract infection, this patient’s negative urinalysis and findings consistent with another process (namely candidiasis) make UTI less likely.

11) A 23-year-old woman calls her physician for the results of her Pap test. She has a history of Chlamydia. She has never had an abnormal Pap. She occasionally has unprotected intercourse. The physician informs her that the Pap was normal. The patient is relieved, but wants to know whether this result could be wrong. The physician explains that a Pap test detects abnormal cells in roughly 4 of every 5 women who have abnormal cervical cells. Which of the following represents the sensitivity of the Papanicolaou test?
A. 0%
B. 1%
C. 20%
D. 80%
E. 100%
Explanation:
The correct answer is
D. The Pap test is an excellent method of screening for cervical cancer. It has a relatively low-cost and is noninvasive and effective. Use of the Pap for screening over the past 50 years has resulted in a 70% decrease in the mortality from cervical cancer. However, the test is not without its flaws. The primary drawback of the test is its high false-negative rate. In the case of the Pap, a false-negative is a woman who has abnormal cervical cells but is declared to have a normal Pap smear. These false-negative results can be caused by any of the steps in the process, including errors in sampling, preparation, screening, and interpretation. The larger the number of false-negative results, the lower is the sensitivity of a test. Sensitivity of a test is calculated by dividing the number of patients who have the disease and test positive for the disease by the total number of patients that have the disease. In the above example, four women who have abnormal cervical cells will test positive for abnormal cervical cells. This number (4) should then be divided by the total number of women with truly abnormal cells (5). This gives a result of 4/5 or 0.8 or 80%. To state that the sensitivity of the Pap test is 0% (choice A) or 1% (choice B) is incorrect. If this were the case, it would mean that the Pap test would correctly identify none or only 1 of every 100 women with truly abnormal cervical cytology. This would make the Pap test a very poor or completely meaningless screening test. A screening test that is 20% (choice C) sensitive is also a very poor screening test. A screening test should ideally have high sensitivity and specificity. A test that is has only 20% sensitivity would identify only 20 of every 100 women with a given disease. This would make it a very poor screening test. A screening test that has 100% (choice E) sensitivity for a disease would be ideal. If the Pap test were 100% sensitive, it would mean that every woman with abnormal cervical cells would be correctly identified. However, this is not the case because of the possible errors that were described above. Also, efforts to increase the sensitivity of a screening test often lead to a loss of specificity and an increases in the percentage of false positives.

12) A 34-year-old woman, gravida 3, para 2 at term comes to the labor and delivery ward with a gush of blood, abdominal pain, and irregular, painful contractions. Her prenatal course was significant for her being Rh negative and antibody negative. Her temperature is 37 C (98.6 F), pulse is 110/minute, blood pressure is 110/70 mm Hg, and respirations are 12/minute. Abdominal examination shows a tender abdomen and cervical examination shows the cervix to be closed and long with a significant amount of blood in the vagina. The fetal heart rate is in the 170s with moderate to severe variable decelerations with contractions. The diagnosis of placental abruption is made and an emergent cesarean delivery is performed. To determine the correct amount of RhoGAM (anti-D immune globulin) that should be given, which of the following is the most appropriate laboratory test to send?
A. Apt test
B. Complete blood count
C. Kleihauer-Betke
D. Partial thromboplastin time
E. Serum potassium
Explanation:
The correct answer is
C. Women that are Rh negative are at risk for developing Rh isoimmunization. Rh isoimmunization occurs when an Rh-negative mother becomes exposed to the Rh antigen on the red blood cells of an Rh-positive fetus. This exposure may lead the mother’s immune system to become sensitized to the Rh antigen such that in a future pregnancy with an Rh-positive fetus, the mother’s immune system may “attack” the Rh antigen on the fetal red blood cells. This immune response may lead to the development of fetal anemia, hydrops, and death. To prevent Rh isoimmunization from occurring, Rh-negative women who are not Rh alloimmunized should receive RhoGAM (anti-D immune globulin) at 28 weeks of gestation, within 72 hours after the birth of an Rh-positive infant, after a spontaneous abortion, or after invasive procedures such as amniocentesis. RhoGAM should also be strongly considered in cases of threatened abortion, antenatal bleeding, external cephalic version, or abdominal trauma. The amount that is usually given after the delivery of an Rh-positive fetus is 300 µg. This amount is sufficient to cover a fetal to maternal hemorrhage of 30 mL (or 15 mL of fetal cells). However, some women will have a fetal to maternal hemorrhage that is in excess of this 30 mL-especially in cases such as manual removal of the placenta or placental abruption (as this patient had). To determine the amount of fetal to maternal hemorrhage that occurred, it is necessary to perform a Kleihauer-Betke test which is an acid-dilution procedure that allows fetal red blood cells to be identified and counted. Knowing the amount of fetal to maternal hemorrhage that took place allows the correct amount of RhoGAM to be given. An apt test (choice A) is used to differentiate fetal from maternal blood. It can be used in the diagnosis of vasa previa or with neonatal melena. A complete blood count (choice B) will demonstrate the amount of maternal hemorrhage, but not the amount of fetal to maternal hemorrhage. Partial thromboplastin time (choice D), and serum potassium (choice E) do not allow for the determination of the amount of fetal to maternal hemorrhage.

13) A 32-year-old woman, gravida 4, para 3, at 39 weeks’ gestation comes the labor and delivery ward with painful contractions. Her prenatal course was unremarkable. Examination shows that her cervix is 5 cm dilated, 100% effaced and the fetal heart rate is in the 130s and reactive. She is given meperidine for pain control. She progresses rapidly and less than 2 hours later she delivers a 7-pound, 6-ounce (3,345g) male fetus. The one-minute APGAR score is 1 and the infant is making little respiratory effort. Which of the following is the most appropriate next step in management?
A. Blood transfusion
B. Glucose
C. Naloxone
D. Penicillin
E. Sodium bicarbonate
Explanation:
The correct answer is
C. Meperidine can be used as a systemic analgesic during labor. It is an opioid and readily crosses the placenta; therefore, the fetus is exposed to the medication. As an opioid, it causes respiratory depression. Neonates are at greatest risk for respiratory depression when delivery occurs approximately 2 to 3 hours after meperidine is administered to the mother. This neonate was born approximately 2 hours after maternal administration of meperidine, which makes neonatal respiratory depression likely. Naloxone is a pure opioid antagonist that displaces the opioid from its receptor sites and can help to reverse the opioid-induced respiratory depression. It has a short duration of action so repeat doses may be necessary. Blood transfusion (choice A) would not be indicated. Blood transfusions are used when there is evidence that the neonate is anemic. This neonate appears to have respiratory depression and not anemia. Therefore, naloxone, and not blood transfusion, would be indicated. Glucose (choice B) should be given when there is evidence that the neonate is severely hypoglycemic. This neonate, given that its mother received an opioid 2 hours ago, is most likely to have respiratory depression from the opioid and not hypoglycemia. Penicillin (choice D) is an antibiotic that may be given when there is evidence of infection. This neonate has a presentation that is most consistent with opioid-induced respiratory depression and not infection. Sodium bicarbonate (choice E) should be given to a neonate for documented metabolic acidosis. It is often used during a prolonged resuscitation. The first step for this neonate, however, would be to try to reverse the respiratory depression with naloxone.

14) A 38-year-old woman comes to the physician for an annual examination and Pap smear. She has no complaints. She has a regular period every month. She is sexually active with her husband. She has migraine headaches and is status post a tubal ligation. She states that she uses numerous alternative medications for mood, sleep, and disease prevention. Examination, including pelvic and breast examination, is unremarkable. Which of the following is an appropriate question to ask this patient?
A. Does your husband know you are using these alternative medications?
B. Do you realize how dangerous alternative medicines are?
C. Which alternative medications do you use?
D. Why don’t you stick with traditional medicines?
E. Why haven’t you revealed your use of alternative medications before?
Explanation:
The correct answer is
C. Some estimates indicate that roughly 50% of Americans use some forms of complementary and alternative medicine (CAM). The categories of these include mind-body interventions, such as yoga, alternative systems of medical practice such as Chinese medicine, pharmacologic treatments such as medicinal plants, herbal medicine such as St. John’s wort, diet therapies such as vegetarianism, manual healing methods such as massage, and bioelectromagnetic applications such as magnets for musculoskeletal pain. It is essential for the physician to work with the patient regarding the use of CAM. The first step is to find out which methods the patient uses. This patient has told the physician that she uses alternative medications. Many patients do not offer this information, assuming that the usual physician will not support CAM. It is therefore important to ask the patient whether she is using, or considering using, CAM. Because the field of CAM is so broad, it is essential to ask which types of CAM the patient uses. One cannot assume that all alternative therapies are equivalent. Thus, the most appropriate question to ask this patient is “Which alternative medications do you use?” This is a non-threatening question that will allow her to further detail her use. To ask, “Does your husband know you are using these alternative medications?” (choice A) is inappropriate. The physician’s role is to care for the patient. Whether the patient reveals her use of alternative medicines to her husband is not the prime concern to the physician. This question is more likely to create conflict than reveal needed information for the physician. To ask, “Do you realize how dangerous alternative medicines are?” (choice B) is incorrect. This question is confrontational and judgmental. Many alternative therapies are safe and effective. To ask, “Why don’t you stick with traditional medicines?” (choice D) is inappropriate. If a patient has a condition and there is a remedy from the conventional medical system (known as allopathy in North America) available, then it is reasonable to offer this remedy as a possibility for the patient. However, inquiring as to why the patient doesn’t “stick” with traditional medicine is likely to cause confrontation and a worsening of the patient-doctor relationship. To ask, “Why haven’t you revealed your use of alternative medications before?” (choice E) is also somewhat challenging and confrontational. Perhaps the patient did not think a conventional physician would be accepting of CAM. The important step at this point is to identify the medications and discuss their risks, benefits, and side effects with the patient, as one would with traditional medications.

15) A mother brings her 12-year-old daughter to the physician because the mother is concerned that her child has delayed physical development. In particular, the mother is concerned because her daughter has not yet had a menstrual period. The daughter began developing breasts at age 10, but has not had her first period. The daughter has no medical problems and takes no medications. Examination shows developing breasts and normal external female genitalia. Which of the following is the most appropriate response to the mother?
A. Breast development at age 10 is abnormally early.
B. Breast development at age 10 is abnormally late.
C. Evaluation for late menses should be started immediately.
D. Evaluation for late menses should be started at age 15.
E. Her child’s sexual development is none of her business.
Explanation:
The correct answer is
D. Sexual development is variable from woman to woman, although there are certain ranges of normal. Thelarche, also known as breast-budding, is usually the first sign of secondary sexual development and this occurs on average between the ages of 8 and 10 years of age. The growth spurt usually follows after breast budding and menarche is one of the last stages, occurring, on average, between the ages of 12 and 13. This young woman began developing breasts at age 10, which is entirely appropriate. That she has not had her first menstrual period yet is not abnormal. The general rule is that evaluation for delayed sexual development should be started if there is no breast development by the age of 13 or menses by the age of 15. This general rule can be adapted to fit the circumstances if there are tempo or sequence abnormalities. In this case, with breast development occurring normally and development appearing to proceed in a standard fashion, the mother can be reassured and evaluation for late menses delayed until age 15, if it has not come before that time. To state that breast development at age 10 is abnormally early (choice A) or that breast development at age 10 is abnormally late (choice B) is incorrect. In North America, thelarche occurs, on average, between ages 8 to 10. Therefore, this young woman, who began breast development at age 10, falls into the normal range. To state that evaluation for late menses should be started immediately (choice C) is incorrect. The general rule for evaluation of delayed puberty is that evaluation should take place if thelarche has not occurred by age 13 or menarche by age 15. These ages represent roughly a 2.5 standard deviation from the mean and therefore warrant evaluation. To tell this mother that her child’s sexual development is none of her business (choice E) would not be appropriate. While there are certain sexual issues where confidential discussion with an adolescent is appropriate, concerns regarding delayed sexual development are appropriate issues for a parent to be concerned with.

16) A 23-year-old woman, gravida 2, para 1, at 6 weeks’ gestation comes to the emergency department because of lower abdominal pain and fevers. She states that her symptoms began 2 days ago and have steadily worsened since. Past medical history is significant for 2 episodes of gonorrhea and 1 episode of chlamydia. Temperature is 38.9 C (102.1 F), blood pressure is 110/76 mm Hg, pulse is 102/min, and respirations are 12/minute. Abdominal examination demonstrates significant lower abdominal tenderness. Pelvic examination shows a mucopurulent cervical discharge and bimanual examination reveals cervical motion tenderness and adnexal tenderness. Complete blood count shows leukocytes 18,000/mm3. Pelvic ultrasound shows a 6-week intrauterine gestation with no adnexal findings. Which of the following is the most appropriate management?
A. No treatment is necessary
B. Intramuscular ceftriaxone, oral doxycycline, and discharge home
C. Intravenous cefotetan and doxycycline and hospital admission
D. Intravenous clindamycin and gentamicin and hospital admission
E. Laparoscopy
Explanation:
The correct answer is
D. Pelvic inflammatory disease rarely occurs during pregnancy. The incidence of PID during pregnancy is far lower than in the nonpregnant state, likely because of the relative protection that the pregnancy provides against ascending infection from the cervix. However, while PID during pregnancy is rare, it is not impossible. This patient has the findings that are most consistent with a diagnosis of PI
D. She has abdominal tenderness, cervical motion tenderness, and adnexal tenderness. She also has a fever, a mucopurulent cervical discharge, and an elevated white blood cell count. She also has a history of gonorrhea and chlamydia. The correct management of a pregnant woman with PID is hospital admission and treatment with intravenous medications. Clindamycin and gentamicin should be used. To state that no treatment is necessary (choice A) is absolutely incorrect. A patient with PID certainly needs treatment. And a pregnant patient with PID requires hospitalization and intravenous antibiotics. To give intramuscular ceftriaxone, oral doxycycline, and discharge home (choice B) would not be appropriate. Nonpregnant patients that develop PID may be treated with intramuscular ceftriaxone and an extended course of doxycycline (14 days). This is a standard outpatient treatment for PI
D. A pregnant patient, however, must be admitted to the hospital for intravenous antibiotics. To provide intravenous cefotetan and doxycycline and hospital admission (choice C) is incorrect. Doxycycline is a class D drug that should not be used during pregnancy. Laparoscopy (choice E) would not be the most appropriate next step in management. The diagnosis of PID in this patient’s case is reasonably certain given the presentation. The next step, therefore, is treatment with intravenous antibiotics. If these fail, surgical alternatives may be considered.

17) A 25-year-old woman, gravida 2, para 2, comes to the physician to discuss birth control options. She and her partner have tried to use condoms; however, they find it difficult to use them consistently and she would like to try another form of contraception. She has no medical problems, takes no medications, and has no family history of cancer. Her examination is within normal limits. After a discussion with the physician, she chooses to take the oral contraceptive pill (OCP). She stays on the pill for the next three years. She now has most significantly decreased her risk of developing which of the following malignancies?
A. Bone cancer
B. Breast cancer
C. Cervical cancer
D. Endometrial cancer
E. Liver cancer
Explanation:
The correct answer is
D. Numerous studies have demonstrated that use of the oral contraceptive pill significantly decreases a woman’s likelihood of developing endometrial cancer. Overall, use of the oral contraceptive pill appears to decrease the risk by approximately 50%, with greatest effects in those using the pill for more than 3 years. One theory to explain the decreased endometrial cancer risk in oral contraceptive users is that the oral contraceptive pill provides almost continuous exposure of the endometrium to progestins. The major factor in the development of endometrial cancer is estrogen exposure, whether endogenously (e.g., due to obesity or chronic anovulation) or exogenously (e.g., from unopposed estrogen replacement therapy). By providing almost daily exposure to progestins, the oral contraceptive pill works to counteract the effects of estrogens. Over time, women on the OCP develop thinner endometrial linings and have a lower risk of developing endometrial cancer. There is no clear relationship between bone cancer (choice A) and OCP use. The relationship between breast cancer (choice B) and oral contraceptives remains unclear at this time. There is some evidence that current users and those who have recently stopped may be at some increased risk of breast cancer. However, there is also evidence that when breast cancer is diagnosed in an oral contraceptive user, it tends to be more localized than in a nonuser. The relationship between cervical cancer (choice C) and the OCP also remains unclear at this time. Overall the results have been inconclusive. All sexually active patients should have regular screening for cervical dysplasia with a Pap smear starting at age 18 or with the onset of sexual intercourse. The OCP does not protect against liver cancer (choice E). The OCP is believed to increase the risk of certain benign liver tumors.

18) A 26-year-old primigravid woman at 35 weeks’ gestation comes to the labor and delivery ward because of painful uterine contractions and a gush of fluid. Sterile speculum examination reveals a pool of clear fluid in the vagina that is nitrazine positive. When the fluid is examined under the microscope, a “ferning” pattern is seen. Cervical examination shows the patient to be 4 cm dilated, 100% effaced, and at 0 station. Fetal fingers can be felt along side the fetal head. External uterine monitoring shows contractions every 2 minutes. External fetal monitoring shows the fetal heart rate to be in the 130s and reactive. Which of the following is the most appropriate next step in management?
A. Expectant management
B. Oxytocin augmentation
C. Forceps delivery
D. Vacuum delivery
E. Cesarean section
Explanation:
The correct answer is
A. This patient has a compound presentation, which happens when an extremity prolapses alongside the fetal presenting part. In this case, the compound presentation is the fetal vertex along with a fetal arm. Compound presentation occurs in approximately 1 in 1000 deliveries and is brought about when the pelvic inlet is not completely occluded by the fetal head. Most often this occurs with premature fetuses. A compound presentation can be allowed to undergo a normal labor and delivery. The prolapsed arm should be left alone, as it will not interfere with the labor and delivery in most cases. Often the arm will rise out the way as the vertex descends further. Oxytocin augmentation (choice B) would not be appropriate management. This patient is in active labor, with painful contractions every 2 minutes and 4 cm of cervical dilation. Oxytocin is used in cases in which there is a need to augment labor (e.g., when contractions are not adequate) or to induce labor (e.g., when there are no contractions present.) This patient has adequate contractions. Forceps delivery (choice C) is not indicated at this point. The patient’s cervix is not fully dilated, and the presence of the fetal arm, if it persists, would prevent proper application of the forceps. Vacuum delivery (choice D) would not be appropriate. As with forceps, vacuum is not used unless the cervix is fully dilated and the vertex is at +2 to +3 station. This patient is only 4 cm dilated, and the vertex is at 0 station. There is no fetal or maternal indication at this point for vacuum delivery. Cesarean delivery (choice E) is not indicated. As noted above, most women with a compound presentation, with a hand presenting by the fetal head, can undergo a normal labor and delivery.

19) A 25-year-old woman comes to the physician for an annual examination. She has been feeling well over the past year. Her past medical and surgical histories are unremarkable. Past obstetrical history is significant for the term vaginal delivery two years ago of a male infant with spina bifida. Examination is within normal limits. The patient states that she would like to try to become pregnant within the next few months and wants to know if she needs to start taking any vitamins or medications. Which of the following supplements should this patient take?
A. Folic acid, 4 mg/day starting preconceptionally
B. Folic acid, 4 mg/day starting in the first trimester
C. Vitamin A, 10,000 IU/day starting preconceptionally
D. Vitamin A, 10,000 IU/day starting in the first trimester
E. No supplements are needed
Explanation:
The correct answer is
A. Several studies have established a relationship between folic acid and the prevention of neural tube defects. The presence of adequate levels of maternal folate appears to play a role in the correct development and closure of the neural tube. Based on these studies, in 1992, the United States Centers for Disease Control recommended that all women of child-bearing age should consume 0.4 mg/day of folic acid starting preconceptionally and continuing for the first 3 months of pregnancy. Women who have already had a child with a neural tube defect, however, fall into a different category. This patient had a child with spina bifida 2 years ago. For a woman such as this, the recommendation is that 4.0 mg of folic acid be taken daily, starting one month before the planned time of conception and continuing on for the first 3 months of pregnancy. It is believed that this level of supplementation will decrease the risk of having another child with a neural tube defect by 60 to 70%. To recommend folic acid, 4 mg/day starting in the first trimester (choice B) would be incorrect. This patient, because she has had a prior child with a neural tube defect, should indeed be taking 4 mg/day during the first 3 months of pregnancy. However, she shouldn’t start when she is pregnant, rather, she should be taking this level of folic acid supplementation starting preconceptionally. It is important that the pregnant woman’s folate stores are being supplemented prior to the time of conception. To recommend vitamin A, 10,000 IU/day starting preconceptionally (choice C) or vitamin A, 10,000 IU/day starting in the first trimester (choice D) would be incorrect. First, vitamin A deficiency is very rare in the United States. Second, vitamin A supplementation with levels of 10,000 IU/day and above has been associated with birth defects. Supplements taken by pregnant women should contain 5,000 IU/day or less. To state that no supplements are needed (choice E) is incorrect. This patient has a previous child with a neural tube defect. She should therefore take 4.0 mg of folic acid/day starting one month before conception and continuing through the first 3 months of pregnancy to help prevent having another child with a neural tube defect.

20) A 25-year-old woman comes to the physician because of pain and burning with urination. She states that the symptoms started two days ago and have worsened since. She has no fever or chills and has never had these symptoms before. She has hypothyroidism for which she takes thyroid hormone replacement. Otherwise she has no medical problems. Her temperature is 37 C (98.6 F). Examination is unremarkable including a normal pelvic examination. A KOH and normal saline “wet prep” is performed on her vaginal discharge and is negative. Urinalysis reveals numerous white blood cells. Which of the following is the most likely pathogen?
A. Escherichia coli
B. Neisseria gonorrhoeae
C. Pseudomonas species
D. Staphylococcus saprophyticus
E. Trichomonas vaginalis
Explanation:
The correct answer is
A. This patient has findings that are most consistent with a lower urinary tract infection. A lower urinary tract infection refers to infection of the bladder (cystitis) or urethra (urethritis). The principal complaints for women with lower urinary tract infections are dysuria, urgency, and frequency. Most often examination will be unremarkable. Occasionally, suprapubic tenderness may be present. A urinalysis will often reveal a positive leukocyte esterase or nitrite test. The microscopic analysis will show white blood cells. The most significant risk factors are related to sexual activity and hypoestrogenism. These factors lead to invasion by pathogenic organisms.
E. coli is by far the most common causative organism in cases of acute uncomplicated cystitis. It is responsible for approximately 80% of these cases. N. gonorrhoeae(choice B) is often associated with cervicitis and pelvic inflammatory disease. Yet, it can also cause urethritis. However, N. gonorrhoeae is a far less frequent cause of acute uncomplicated cystitis than
E. coli. Pseudomonas species (choice C) can cause urinary tract infections. It is often seen in patients with metabolic or anatomic abnormalities. In a routine case of UTI, however, it is not the most common pathogen. Staphylococcus saprophyticus(choice D) is a somewhat common cause of acute, uncomplicated UTIs. It accounts for approximately 10% of cases. Trichomonas vaginalis(choice E) is an organism that is most often associated with vaginitis, but can also cause a urethritis. This patient, however, has a negative normal saline “wet prep.” Patients with trichomoniasis usually have visible organisms on the “wet prep.” Also, while Trichomonas vaginalis can cause urethritis, it is not nearly as common a cause as is
E. coli.

21) A 33-year-old woman comes to the physician because she has not had a menstrual period for 8 months. She had menarche at the age of 12 and, after a few years of irregular menses, has since had normal monthly menses. She has no medical problems and takes no medications. Examination reveals a normal-appearing female with no abnormalities noted. Urine human chorionic gonadotropin (hCG) is negative. Serum thyroid stimulating hormone (TSH) and prolactin are also normal. The patient is given a 10-day course of medroxyprogesterone acetate. Upon completing the 10 days, she has a heavy menstrual period. This patient’s withdrawal bleeding in response to the progesterone provides good evidence for which of the following?
A. Asherman syndrome
B. Endogenous estrogen production
C. Endometrial carcinoma
D. Menopause
E. Pregnancy
Explanation:
The correct answer is
B. Primary amenorrhea is defined as the lack of spontaneous uterine bleeding by the age of 16. Secondary amenorrhea is defined as the absence of a menstrual period for 6 months or more in a woman who previously had normal periods or the absence of menses for 12 months or more in women with previously irregular menstrual periods. This patient, given that she previously had normal menstrual periods, has secondary amenorrhea. The most common cause of missed menses in previously cycling women is pregnancy. Therefore, it is absolutely essential that a pregnancy test be performed on any woman with this complaint. Hyperprolactinemia is the cause of amenorrhea in 10 to 20% of cases, so it is also important that a prolactin level be checked. And, because thyroid dysfunction can also cause a loss of menses, a TSH should also be checked. This patient, however, is not pregnant and has normal TSH and prolactin levels. At this point, some physicians would perform a progesterone withdrawal test. This consists of giving a woman an intramuscular injection of progesterone or oral progesterone for 5 to 10 days and then checking to see if the patient has withdrawal menstrual bleeding. If withdrawal bleeding occurs within 7 days, then patients are assumed to have adequate levels of endogenous estrogen production. Most patients with amenorrhea, adequate endogenous estrogen production, and withdrawal bleeding after the administration of progestins will have some form of polycystic ovarian syndrome (PCOS). Asherman syndrome (choice A) describes the condition in which menstrual periods do not occur because the uterine cavity has become obliterated with adhesions. These adhesions result from trauma to the basal level of the endometrium, most often occurring at the time of dilation and curettage. Patients with this syndrome would not be expected to have menses in response to progesterone. Endometrial carcinoma (choice C) typically presents with heavy, irregular bleeding or as postmenopausal bleeding. Menopause (choice D) represents the loss of menstrual periods as ovarian function decreases. Postmenopausal patients would not be expected to have withdrawal menses after progesterone exposure. This patient’s bleeding does not provide good evidence of pregnancy (choice E). Her negative urine hCG and withdrawal bleeding after progesterone make it extremely unlikely that she is pregnant.

22) A 41-year-old woman, gravida 4, para 3, at term is admitted to the labor and delivery ward with regular contractions every 2 minutes. Examination shows that her membranes are grossly ruptured and that her cervix is 5 cm dilated. Over the following 3 hours, she progresses to full dilation and +2 station. A fetal bradycardia develops, and the decision is made to proceed with vacuum-assisted vaginal delivery. A 7 pound, 8 ounce boy is delivered. APGAR scores are 8 at 1 minute and 9 at 5 minutes. Which of the following best represents an advantage of vacuum extraction over the forceps for expediting delivery?
A. The vacuum can be used at higher stations
B. The vacuum can be used for fetuses in breech presentation
C. The vacuum can be used in face presentations
D. The vacuum can be used with intact membranes
E. The vacuum does not occupy space next to the fetal head
Explanation:
The correct answer is
E. Both forceps and the vacuum extractor can be used to expedite the delivery of a fetus. These instruments are most often used when there are fetal indications, such as a non-reassuring fetal heart rate tracing, or maternal indications, such as maternal exhaustion or maternal contraindications to pushing (such as maternal cardiac disease.) The choice of forceps or vacuum depends most on the experience and preference of the physician. In certain cases, one instrument is favored or mandatory. For example, forceps may be used in face presentation with a mentum anterior presentation; in such a case, vacuum is contraindicated. Those who favor vacuum delivery make several arguments. For example, as opposed to forceps, the vacuum extractor does not occupy space next to the fetal head; this should lead to less trauma to maternal tissues. Also, attempted delivery with the vacuum in a situation of true cephalopelvic disproportion (i.e., the fetus cannot be delivered through the maternal pelvis) will lead to a loss of suction and failure of the procedure; forceps do not necessarily dislodge and this could lead to continued efforts being made with increased likelihood of maternal or fetal morbidity or mortality. To state that the vacuum can be used at higher stations (choice A) is incorrect. Both the vacuum and forceps should preferably be used only in low- or outlet- situations (i.e., with the fetal vertex at +2 station or lower.) To state that the vacuum can be used for fetuses in breech presentation (choice B) is incorrect. Neither the vacuum nor forceps should be used when the fetus is presenting as a breech. To state that vacuum can be used in face presentations (choice C) is not correct. Vacuum cannot be used when the fetus is presenting face first. Forceps may be used as long as the fetus is in mentum-anterior position (i.e., with the chin facing toward the maternal pubic symphysis.) To state that the vacuum can be used with intact membranes (choice D) is incorrect. Neither forceps nor vacuum should be used with intact membranes.

23) A 23-year-old primigravid woman comes to the physician because of vaginal bleeding. Her last menstrual period was 6 weeks ago. She has no other symptoms. Examination shows a 10-week sized uterus, but is otherwise unremarkable. Pelvic ultrasound reveals a snowstorm pattern consistent with a complete mole. Serum beta-hCG is markedly elevated over normal pregnant values. A chest x-ray film is negative. A dilation and evacuation is performed and the pathologic diagnosis is complete hydatidiform mole. Which of the following is the most appropriate next step in management?
A. Evaluation in one year
B. Follow beta-hCG levels to 0
C. Dactinomycin
D. Methotrexate
E. Hysterectomy
Explanation:
The correct answer is
B. The term gestational trophoblastic disease encompasses a number of related diseases originating from the placenta. These diseases include complete and partial hydatidiform moles, invasive moles, placental site trophoblastic tumors, and choriocarcinomas. This patient presents with findings consistent with a complete mole. The most common symptom is vaginal bleeding and examination often demonstrates a uterus that is larger than expected for gestational dates. Laboratory evaluation often shows a significantly elevated beta-hCG and ultrasound reveals the absence of a fetus and the presence of a “snowstorm” pattern with multiple echogenic areas of villi and clots. Treatment is with dilation and evacuation of the mole. Once there is pathologic confirmation of the diagnosis, it is essential that the patient continued to be followed weekly until the beta-hCG value returns to 0. The patient should then be followed monthly for an additional year to ensure that the values stay at 0 and that there is no evidence of persistent or metastatic disease. Evaluation in one year (choice A) would not be appropriate. This patient may have malignant gestational trophoblastic disease, in which case the beta-hCG values will remain elevated and not return to 0 after the evacuation. To postpone further evaluation for one year risks a significant delay in diagnosis and management of persistent or malignant disease. Dactinomycin (choice C) is often used as an alternative therapy to methotrexate in patients with malignant gestational trophoblastic disease. As long as this patient’s beta-hCG values fall to 0 appropriately and stay at 0, there is no need to treat with Dactinomycin. Methotrexate (choice D) is used as the first-line agent in patients with malignant trophoblastic disease. Again, there will be no need for chemotherapy in this patient as long as the beta-hCG values fall to 0 and stay at 0. Hysterectomy (choice E) would not be indicated in a 23-year-old patient with benign gestational trophoblastic disease who desires future fertility.

24) A 22-year-old woman, gravida 3, para 2, at 22 weeks’ gestation comes to the physician because of an ulcer near her vagina. She noted this a few days ago and it has not improved. The ulcer is painless. The patient has no history of medical problems and takes no medications. She is allergic to penicillin. Examination is significant for a 22 week-sized uterus and a 1 cm, raised, nontender lesion on the distal portion of the vagina. A rapid plasma reagin (RPR) test is sent; the result is positive. A microhemagglutination assay for Treponema pallidum (MHA-TP) is also read as positive. Which of the following is the most appropriate management for this patient?
A. Administer erythromycin
B. Administer levofloxacin
C. Administer metronidazole
D. Administer tetracycline
E. Desensitize the patient and then administer penicillin
Explanation:
The correct answer is
E. This patient has a presentation that is consistent with primary syphilis. Syphilis is caused by the organism Treponema pallidum, which is a highly contagious spirochete. The incubation period for the organism is anywhere from 10 to 90 days, after which a chancre, which is a raised, painless ulcer, will appear. T. pallidum cannot be cultured, but it can be identified with darkfield microscopy or fluorescent antibody staining from obvious lesions. Serologic tests can also be used, such as the RPR and VDRL tests, which are not specific for T. pallidum infection and may be positive in patients with collagen vascular disease, intravenous drug abuse, bacterial and viral infections, a history of blood transfusions, and even pregnancy. Because the RPR and VDRL are not specific, a treponemal specific assay such as the FTA-ABS or MHA-TP should also be used for confirmation. When these are positive and the patient has no history of treatment, it is absolutely essential that treatment be given because syphilis in pregnancy is associated with a number of complications including fetal demise, IUGR, preterm delivery, and congenital infection. Treatment during pregnancy must be with penicillin as no other drug permits safe and effective treatment of the fetus as well as the mother. In a patient who is allergic to penicillin, oral desensitization must be performed first in a hospital setting with appropriate facilities. To administer erythromycin (choice A), levofloxacin (choice B), or metronidazole (choice C) would not be proper management. These are not drugs that will effectively treat syphilis in pregnancy. Furthermore, levofloxacin is contraindicated during pregnancy, as are all fluoroquinolones, because of the possible relationship between maternal use and arthropathies in the offspring. To administer tetracycline (choice D) would be appropriate in the non-pregnant patient with syphilis who is allergic to penicillin. Tetracycline is considered a reasonable alternative in that situation. However, in the pregnant patient, tetracycline cannot be used because of effects on the fetal teeth and bones. Only penicillin is considered adequate for the treatment of syphilis in pregnancy.

25) A 32-year-old woman comes to the physician because of recurrent painful outbreaks on her labia and vagina. Her first outbreak was six years ago. At that time she developed what she thought was a bad “flu” with malaise and a fever, along with a painful rash on her labia. This initial outbreak resolved, but since then she has had approximately 8 -10 outbreaks each year. Each outbreak is preceded by burning in her perineal area. A few days later she develops vesicles, then shallow, painful ulcers that resolve in about 10 days. Which of the following is the most appropriate pharmacotherapy?
A. Daily oral acyclovir
B. Daily oral estrogen
C. Daily topical estrogen
D. Daily oral ferrous sulfate
E. Daily oral penicillin
Explanation:
The correct answer is
A. This patient has a classic presentation of herpes genitalis, a venereal disease caused by herpes simplex virus type II (90% of cases) or type I (10%). Initial infection usually results in generalized illness including malaise, myalgias, and low-grade fever along with the perineal lesions. These lesions start out as clear vesicles that progress to ulcers over the following days. The ulcers may then coalesce to form a larger, shallow, painful ulcer. After the initial infection, the virus resides in the dorsal root sacral ganglia. From there it is periodically reactivated. Recurrent episodes are characterized by a prodrome of tingling, burning, or itching prior to the appearance of the lesions. There is no “cure” for herpes genitalis. Acyclovir can be used to shorten the duration of symptoms. In patients who have more than 6 outbreaks per year, daily oral acyclovir is recommended to prevent these frequent outbreaks. Daily oral estrogen (choice B) or daily topical estrogen (choice C) would not be appropriate pharmacotherapy for these outbreaks. Estrogen (oral and topical) is used for patients with atrophic vaginitis. Atrophic vaginitis is characterized by pale vaginal mucosa with a loss of rugae. It is associated with estrogen deficient states such as menopause. This patient has no evidence of estrogen deficiency and therefore estrogen would not be recommended. Daily oral ferrous sulfate (choice D) is appropriate pharmacotherapy for patients with iron-deficiency anemia. Sufficient iron stores are necessary for effective erythropoiesis. There is no evidence that this patient is iron deficient and the most appropriate pharmacotherapy to prevent recurrent herpes outbreaks is acyclovir, not ferrous sulfate. Daily oral penicillin (choice E) would not be appropriate pharmacotherapy for this patient. This patient has herpes genitalis and not a bacterial infection. Thus, acyclovir, and not penicillin, would be indicated.

26) A 34-year-old primigravid woman at 30 weeks’ gestation comes to the physician with regular contractions every 6 minutes. Her prenatal course was significant for type 1 diabetes, which she has had for 10 years. Over the course of 1 hour, she continues to contract, and her cervix advances from closed and long to a fingertip of dilation with some effacement. The patient is started on magnesium sulfate, penicillin, and betamethasone. Which of the following is the most likely side effect from the administration of corticosteroids to this patient?
A. Decreased childhood intelligence
B. Increased maternal insulin requirement
C. Maternal infection
D. Neonatal adrenal suppression
E. Neonatal infection
Explanation:
The correct answer is
B. Corticosteroids are known to lead to more difficult glucose control in diabetic women. To ensure that these patients do not develop diabetic ketoacidosis, blood glucose levels should be checked regularly, and elevated values treated with insulin. This will often require hospitalization, which is usually required by the condition for which they received the corticosteroids in the first place (e.g., preterm labor or preterm premature rupture of membranes). In patients who do not have diabetes, the hyperglycemic effect will last 2-3 days. Studies have been performed to determine whether antenatal treatment with corticosteroids leads to decreased childhood intelligence (choice A). There is no evidence that this relationship exists. Because of the immunosuppressive properties of corticosteroids, there has been concern that their use may increase rates of maternal infection (choice C) or neonatal infection (choice E). There is no definitive proof that corticosteroid use leads to higher rates of infection in either the mother or fetus. And, although there may be some instances of maternal or neonatal infection in some cases of corticosteroid administration, the increased maternal insulin requirement occurs almost without exception. Neonatal adrenal suppression (choice D) has not been proven to result from antenatal corticosteroid administration.

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