General Surgery Smarty PANCE

An 18-year-old patient has a tibia/fibula fracture following a motorcycle crash. Twelve hours later the patient presents with increased pain despite adequate doses of analgesics and immobilization. Which of the following is the most likely diagnosis?

A avascular necrosis

B myositis ossificans

C compartment syndrome

D reflex sympathetic dystrophy

Compartment syndrome is characterized by a pathological increase of pressure within a closed space and results from edema or bleeding within the compartment. It may occur as an early local complication of fracture.

A 38 year-old male sustained a fracture of the left distal tibia following a 25-foot fall and is taken to the operating room for an open reduction internal fixation of the distal tibia. Sixteen hours post-op, the patient develops sustained pain, which is not relieved with narcotics. On passive range of motion of the toes the patient "yells" in agony. The patient also states that the top of his foot has decreased sensation. On physical examination the physician assistant notes that the leg is swollen and the foot is cool to touch. Based upon this information what diagnostic testing should be done?

A X-ray of the lower leg and ankle

B Doppler studies

C Bone scan.

D Compartment pressure

Compartmental pressures should be obtained as soon as possible. If they are elevated this is a surgical emergency

A 23-year-old patient presents to the emergency department after a motor vehicle accident. The patient was an unrestrained driver involved in a head-on collision. The patient is heavily intoxicated on what he claims is only alcohol. An initial trauma assessment is performed and is notable for significant bruising of the right forearm. The patient is in the trauma bay and complains of severe pain in his right forearm. A physical exam is performed and is notable for pallor, decreased sensation, and cool temperature of the skin of the right forearm. Pain is elicited upon passive movement of the right forearm and digits. A thready radial pulse is palpable. A FAST exam is performed and is negative for signs of internal bleeding. The patient's temperature is 99.5°F (37.5°C), pulse is 100/min, blood pressure is 110/70 mmHg, respirations are 12/min, and oxygen saturation is 98% on room air. Radiography of the right forearm is ordered. The patient is still heavily intoxicated. Which of the following is the best next step in management?

A Detoxification

B IV fluids

C Analgesics

D Fasciotomy

E Pressure measurement

Compartment syndrome presents with the 6 P's: Pain, Paresthesias, Poikilothermia, Pallor, Pulselessness, and increased Pressure, and the best initial step in management is a fasciotomy

25 year-old male presents to the ED with left calf pain and cramping, as well as nausea and vomiting. He admits to "partying with cocaine all night". He describes his urine as a dark brown color. Serum creatinine kinase (CK) is 1325 IU/L (Normal Range 32-267 IU/L). Which of the following is the initial mainstay of therapy for this condition?

A IV rehydration

B Fasciotomy

C Toradol (Ketorlac)

D Hydrotherapy

IV rehydration with crystalloids for 24 to 72 hours is the mainstay of therapy for rhabdomyolysis

A 42 year-old male presents complaining of a sudden onset of a severe intermittent pain originating in the flank and radiating into the right testicle. He also complains of nausea and vomiting. On examination the patient is afebrile, but restless. Examination of the abdomen reveals tenderness to palpation along the right flank with no rebound or direct testicular tenderness. Urinalysis reveals a pH of 5.4 and microscopic hematuria, but is otherwise unremarkable. Which of the following is the most likely diagnosis?

A Bladder cancer

B Nephrolithiasis

C Acute appendicitis

D Acute epididymitis

A sudden onset of severe colicky flank pain associated with nausea and vomiting as well as the absence of rebound or direct testicular tenderness makes nephrolithiasis the most likely diagnosis. This is further supported by the presence of hematuria on the urinalysis.

Which of the following pathophysiological processes is believed to initiate acute appendicitis?

A Obstruction

B Perforation

C Hemorrhage

D Vascular compromise

Obstruction of the appendiceal lumen by lymphoid hyperplasia, a fecalith or foreign body initiates most cases of appendicitis

What is the term for blue discoloration about the umbilicus?

A Cullen's sign

B Murphy's sign

C Rovsing's sign

D Turner sign

Cullen's sign is a blue discoloration about the umbilicus and can occur in hemorrhagic pancreatitis and results from hemoperitoneum.

A patient presents with abdominal pain in the right lower quadrant, examination reveals increased pain in the right lower quadrant on deep palpation of the left lower quadrant. This commonly known as which of the following?

A Psoas sign

B Murphy's sign

C Rovsing's sign

D Obturator sign

A positive Rovsing's sign can be elicited in a patient with appendicitis when increased pain occurs in the right lower quadrant upon palpation of the left lower quadrant. Psoas sign is right lower quadrant pain with right leg extension. Murphy's sign is seen in liver and gallbladder disease in which the patient abruptly halts deep inspiration due to discomfort as the examiner's hand applies pressure to the right upper quadrant. Obturator sign is right lower quadrant pain with internal rotation of the hip.

A 25 year-old female presents with right lower quadrant pain, right flank pain, nausea, and vomiting. Her temperature is 39.6 degrees C. There is right CVA tenderness and RLQ tenderness. Pelvic exam is unremarkable. Urinalysis reveals pH 7.0, trace protein, negative glucose, negative ketones, positive blood, and positive nitrates. Specific gravity is 1.022. Microscopic shows 102 RBCs/HPF, 50-75 WBCs/HPF, rare epithelial cells, and WBC casts. The most likely diagnosis is

A acute salpingitis

B nephrolithiasis.

C acute pyelonephritis

D appendicitis

Acute pyelonephritis presents with flank pain, fever, and generalized muscle tenderness. Urinalysis shows pyuria with leukocyte casts.

A 26 year-old gravida 0 sexually active female presents to the emergency room complaining of colicky pain in her lower abdomen for the past 12 hours. She passed out earlier in the day while trying to have a bowel movement. Her last menstrual period was 6 weeks ago. She has noted vaginal spotting over the last 24 hours. Vital signs show Temp 37 degrees C, BP 96/60mmHg, P 110, R 16, Oxygen Sat. 98%. Abdominal exam is positive for distension and tenderness. Bowel sounds are decreased. Pelvic exam shows cervical motion and adnexal tenderness. Which of the following is the most likely diagnosis?

A Ectopic pregnancy

B Appendicitis

C Crohn's disease

D Pelvic inflammatory disease

High suspicion for ectopic pregnancy should be maintained when any possible pregnant woman presents with vaginal bleeding or abdominal pain

A 22 year-old male presents to the clinic complaining of scrotal pain that radiates into the groin. Patient admits to being a weightlifter and was lifting 24 hours prior to this pain developing into the scrotum. The patient admits to being sexually active with only his male partner. Examination reveals a reddened scrotum and it is difficult to distinguish the epididymis from the testes on the right side. Elevation of the right testicle brings relief of the pain. This is known as a positive

A Prehn's sign.

B Cullen's sign.

C Rovsing's sign.

D Murphy's sign.

Prehn's sign is seen in epididymitis when elevation of the scrotum with the affected epididymis to the level of the symphysis pubis brings relief from the pain.

Which of the following conditions is most suggestive of a symptomatic abdominal aortic aneurysm?

A abdominal mass

B hypertension

C chest pain

D syncope

Symptomatic abdominal aortic aneurysm presents with pulsating upper abdominal mass

A 12-year-old boy presents to the office with pain in his legs with activity gradually becoming worse over the past month. He is unable to ride a bicycle with his friends due to the pain in his legs. Examination of the heart reveals an ejection click and accentuation of the second heart sound. Femoral pulses are weak and delayed compared to the brachial pulses. Blood pressure obtained in both arms is elevated. Chest x-ray reveals rib notching. Which of the following is the most likely diagnosis?

A abdominal aortic aneurysm

B pheochromocytoma

C coarctation of the aorta

D thoracic outlet syndrome

Coarctation is a discrete or long segment of narrowing adjacent to the left subclavian artery. As a result of the coarctation, systemic collaterals develop. X-ray findings occur from the dilated and pulsatile intercostal arteries and the "3"is due to the coarctation site with proximal and distal dilations.

A 19 year-old female presents with complaint of palpitations. On examination you note the patient to have particularly long arms and fingers and a pectus excavatum. She has a history of joint dislocation and a recent ophthalmologic examination revealed ectopic lentis. Which of the following echocardiogram findings would be most consistent with this patient's physical features?

A right atrial enlargement

B aortic root dilation

C pulmonic stenosis

D ventricular septal defect

This patient has the signs and symptoms consistent with Marfan's syndrome. Ectopia lentis, aortic root dilation and aortic dissection are major criteria for the diagnosis of the disease.

A 56 year-old male presents to the office with a history of abdominal aortic aneurysm. He was told that he will need on going evaluation to assess whether the aneurysm is expanding. What is the recommended study to utilize in this situation?

A plain film of the abdomen

B serial abdominal exam

C ultrasound of the abdomen

D angiography of the abdominal aorta

An abdominal ultrasound can delineate the transverse and longitudinal dimensions of an abdominal aortic aneurysm and may detect mural thrombus. Abdominal ultrasound is best used to screen patients at risk for the development of this condition.

Which of the following is a proven risk factor for the development of abdominal aortic aneurysm?

A Infective endocarditis

B Diabetes mellitus

C Cigarette smoking

D Alcohol abuse

Cigarette smoking is the primary risk factor for the development of aortic aneurysms.

Postmenopausal patient is diagnosed with grade I breast cancer. The tumor is 0.7 cm in size, estrogen-receptor positive, and axillary nodes are negative. After undergoing a lumpectomy, which of the following adjuvant therapy is indicated for this patient?

A chemotherapy

B tamoxifen

C ovarian ablation

D bisphosphonate therapy

Tamoxifen is the adjuvant therapy of choice in post-menopausal estrogen receptor positive axillary node negative breast cancer.

A 28 year-old female with diabetes mellitus type 2 sustains a partial thickness burn to her left upper arm and her chest when hot grease spilled on her at home. The burn to her arm is circumferential and the estimated total body surface burned is 18%. She has no allergies. The most appropriate treatment of this patient would include

A outpatient application of silver sulfadiazine.

B debridement of all intact blisters.

C IV cefazolin (Ancef, Kefzol).

D transfer to a burn center.

Reasons for transfer to a burn center include a partial thickness burn covering greater than 10% of total body surface area. In addition, burns in patients with pre-existing medical conditions, such as diabetes, that could complicate their management, prolong recovery, or affect their outcome, is also a reason for transfer to a burn center.

A 72 year-old female is being evaluated for recurrent kidney stones. PE reveals no abnormal findings. Laboratory findings show elevated calcium and decreased phosphate levels. Which of the following is the most likely diagnosis?

A Pheochromocytoma

B Adrenal insufficiency

C Hyperparathyroidism

D Breast cancer

The majority of patients with hyperparathyroidism are asymptomatic. Recurrent nephrolithiasis may be one of the presentations of primary hyperparathyroidism. Measurement of parathyroid levels would be the initial laboratory test for the evaluation of hypercalcemia.

A 56 year-old female four days post myocardial infarction presents with a new murmur. On examination the murmur is a grade 3/6 pansystolic murmur radiating to the axilla. She is dyspenic at rest and has rales throughout all her lung fields. Blood pressure is 108/68 mmHg, pulse 70 bpm. Which of the following would be the definitive clinical intervention?

A Intra-aortic balloon counterpulsation

B Mitral valve replacement

C Coronary artery bypass surgery

D Immediate fluid bolus

MVR is the definitive intervention to correct MR caused by papillary muscle rupture.

28 year-old male presents with burns sustained from hot grease splashed on his left hand earlier this afternoon. The burn extends from his palm to the volar aspect of his wrist and has an erythematous base, covered by an intact blister. There are a few small scattered blisters over the dorsum of the left hand. Which of the following is the initial intervention of choice?

A Tetanus prophylaxis

B Admission to a burn unit

C Intravenous fluid administration

D Debridement of blisters

Tetanus prophylaxis should be initially considered in all burn patients.

Which of the following hyperthyroid patients would be the best candidate for radioiodine therapy?

A A 30-year-old patient with toxic adenoma.

B A 50-year-old man with subacute thyroiditis.

C A patient over age 65 with Grave's disease.

D A pregnant woman with Hashimoto's thyroiditis

Radioactive iodine is the recommended treatment for overactive thyroid tissue in patients without risk for subsequent thyroid cancer, leukemia, or other malignancies.

A 40-year-old male is hit in the face with a baseball. There is nasal deformity with bleeding. The most appropriate initial management is to

A treat the hematoma with I&D and antibiotics.

B consult with an ENT for immediate reconstructive nasal surgery.

C reduce septal defect using open technique.

D maintain nasal patency and nasal cosmesis

(u) A. Septal hematoma is less likely due to the finding of epistaxis, and is not of highest priority.

(u) B. Reconstructive nasal surgery is a delayed procedure.

(u) C. Open reduction is not indicated for nasal trauma.

(c) D. Maintain nasal patency until closed reduction can be attempted in 1 week

Which of the following is the selected method for the prevention of venous thromboembolism in a 38-year-old male undergoing an inguinal hernia repair?

A early ambulation

B elastic stockings

C intermittent pneumatic compression

D low-molecular weight heparin

Early ambulation is recommended for prophylaxis of venous thromboembolism in low-risk, minor procedures when the patient is under 40 years of age and there are no clinical risk factors.

A 16-year-old male presents with increasing pain and swelling of his right scrotum. The right testicle is extremely tender to palpation on examination. A Doppler ultrasound demonstrates decreased blood flow. Which of the following is the most appropriate intervention?

A oral doxycycline

B emergent surgery

C incision and drainage

D scrotal elevation and ice packs

Once a diagnosis of testicular torsion is suspected, emergent surgery is indicated to have the best possible chance of salvaging the testicle (85-97% chance if less than 6 hours). Any other treatment measures delay the definitive treatment and increase the risk of testicular ischemia and infarction.

Which of the following is the most appropriate intervention for a stage I testicular seminoma?

A Watchful waiting

B Chemotherapy initially

C Orchiectomy and radiation

D Orchiectomy and chemotherapy

Inguinal orchiectomy followed by retroperitoneal radiation therapy cures about 98% of patients with stage I seminoma.

Which of the following beta-adrenergic blocking agents has cardioselectivity for primarily blocking beta-1 receptors?

A Propranolol (Inderal)

B Timolol (Blocadren)

C Metoprolol (Lopressor)

D Pindolol (Visken)

Metoprolol is selective for beta-1 antagonists

A 55-year-old male presents complaining of episodic substernal chest pain that occurs especially during strenuous exercise. Suspecting coronary artery disease (CAD), an exercise stress test is ordered. The test is considered to be abnormal if which of the following occurs?

A Systolic blood pressure increases during exercise.

B The heart rate reaches maximal value during exercise.

C Random premature ventricular beats occur at peak exercise.

D A 2 mm ST-segment depression is seen on the ECG at peak exercise.

(u) A. An increase in systolic blood pressure is an expected normal response during this test.

(u) B. Heart rate should reach maximal value during exercise.

(u) C. Random premature ventricular beats are not uncommon during peak exercise and do not indicate CAD.

(c) D. A 2 mm ST-segment depression is suggestive of cardiac ischemia and is considered to be an abnormal finding

The treatment of choice for a patient with WPW (Wolff-Parkinson-White Syndrome) who has recurrent episodes of supraventricular tachycardia is which of the following?

A IV Verapamil (Calan, Isoptin)

B Digoxin (Lanoxin)

C Surgical ablation of the accessory pathway

D Radiofrequency ablation of bypass tracts

Catheter ablation of bypass tracts is possible in more than 90% of patients and is the treatment of choice in patients with symptomatic arrhythmias. It is safer, more cost-effective, and just as successful as surgery.

A 60 year-old female presents for pre-op evaluation for surgical treatment of a tri-malleolar fracture of the left ankle. Which of the following puts her at an increased risk for infection post-surgery?

A Recent URI

B Diabetes mellitus

C Heart murmur

D Swelling of the ankle

Diabetes mellitus puts her at risk for infection post surgery

A patient with renal artery stenosis is unresponsive to medical therapy. Which of the following is the next most appropriate intervention?

A Stenting of the renal artery

B Nephrectomy

C Radioactive iodine

D Lifestyle modifications

Stenting of the renal artery will dilated the narrowed area interfering with blood supply to the kidney.

Patient with chronic rheumatoid arthritis on maintenance prednisone and methotrexate undergoes surgery. She develops hyponatremia, hypoglycemia, and hypotension. In addition to IV fluid therapy, which of the following is the best initial therapy?

A Epinephrine

B Fludrocortisone (Florinef)

C Hydrocortisone

D Glucagon

Question 32 Explanation: The acute phase of adrenal crisis is treated with IV saline and hydrocortisone.

Which of the following is the most common indication for operative intervention in patients with chronic pancreatitis?

A Weight loss

B Intractable pain

C Exocrine deficiency

D To decrease risk of cancer

Indications for surgical treatment of chronic pancreatitis include severe pain that limits the patient's functioning or intractable pain despite the use of non-narcotic analgesics and absence of alcohol intake.

A patient with prostate cancer has a nonpalpable, focal lesion, and the patient is reluctant to have surgery at this time. Which of the following would best monitor disease progression?

A Periodic rectal exams

B Transrectal ultrasonography

C Measurements of serum acid phosphatase

D Measurements of prostate-specific antigen

PSA measurement correlates well with volume and stage of disease and is the recommended examination formonitoring disease progression.

52-year-old male with a history of hypertension and hyperlipidemia presents with an acute myocardial infarction. Urgent cardiac catheterization is performed and shows a 90% occlusion of the left anterior descending artery. The other arteries have minimal disease. Ejection fraction is 45%. Which of the following is the treatment of choice in this patient?

A Coronary artery bypass grafting (CABG)

B Streptokinase

C Percutaneous coronary intervention (PCI)

D Warfarin (Coumadin)

Class I indications for CABG from the American College of Cardiology (ACC) and the American Heart Association (AHA) are as follows

Over 50% left main coronary artery stenosis

Over 70% stenosis of the proximal left anterior descending (LAD) and proximal circumflex arteries

Three-vessel disease in asymptomatic patients or those with mild or stable angina

Three-vessel disease with proximal LAD stenosis in patients with poor left ventricular (LV) function

One- or two-Vessel disease and a large area of viable myocardium in high-risk area in patients with stable angina

Over 70% proximal LAD stenosis with either an ejection fraction (EF) below 50% or demonstrable ischemia on noninvasive testing

78 year-old male with history of coronary artery disease status post CABG and ischemic cardiomyopathy presents with complaint of progressive dyspnea and orthopnea. He also complains of lower extremity edema. The patient denies fever, chest pain, or cough. On physical examination, vital signs are BP 120/68, HR 75 and regular, RR 22, afebrile. You note the patient to have an S3 heart sound, jugular venous distention, and 2+ lower extremity edema. The patient is admitted and treated. Upon discharge from the hospital, the patient should be educated to monitor which of the following at home?

A Daily weights

B Daily spirometry

C Daily blood glucose

D Daily fat intake

Home monitoring of daily weights can alert the health care provider to the early recognition of worsening heart failure.

A 59 year-old otherwise healthy female develops acute dyspnea and chest pain one week post total abdominal hysterectomy. Echocardiogram demonstrates normal heart size with normal right and left ventricular function. Lung scan demonstrates two segmental perfusion defects. Which of the following is the next step in the management of this patient?

A Anticoagulation

B Embolectomy

C Thrombolysis

D Inferior vena cava filter

Anticoagulation is the treatment of choice in patients with pulmonary embolism with normal ventricular function and no absolute contraindications.

Lab results for a post-operative oliguric patient reveals an increased BUN to creatinine ratio. The patient has a low fractional excretion of sodium (less than 1%). Which of the following is the most likely diagnosis?

A prerenal azotemia

B acute tubular necrosis

C acute glomerulonephritis

D obstructive uropathy

Patients who have prerenal azotemia with otherwise normal kidneys will have severe sodium retention in order to help to save fluid. The amount of sodium in the urine is therefore very low.

A 60 year-old patient returned from the recovery room to the floor following a subtotal gastrectomy. At 3 AM the next morning, the patient's temperature is 102° F (39° C) and pulse is 112/min. Which of the following is the most likely cause?

A wound infection

B atelectasis

C phlebitis

D shock

Atelectasis is the most common pulmonary complication, affecting 25% of patients with abdominal surgery. It is more common in elderly and overweight patients and occurs within the first 12 to 24 hours postoperatively.

A 54 year-old female who has diabetes presents with rubor, absence of hair, and brittle nails of her left foot. She complains of leg pain that awakens her at night. Examination reveals a femoral bruit with diminished popliteal and pedal pulses on the left side. The most appropriate therapy would be

A vasodilator therapy

B bypass surgery.

C exercise program.

D embolectomy

Bypass surgery is indicated in the presence of rest pain and provides relief of symptoms in 80 to 90% of patients.

The first step in the treatment of a patient with an intestinal obstruction and no comorbid diseases is

A nasogastric decompression.

B invasive hemodynamic monitoring.

C abdominal exploration.

D administration of antibiotics

Nasogastric decompression is indicated in all but mild cases of obstruction to prevent distal passage of swallowed air and minimize distension.

Which of the following treatments will most benefit the diabetic patient with two vessel coronary disease?

A Stent placement

B Percutaneous balloon angioplasty

C Medical management

D Coronary artery bypass graft

CABG is the treatment of choice in a diabetic with two or three vessel disease.

Patient presents to the emergency department with right upper quadrant pain over eight hours, nausea, and vomiting. On exam there is a fever of 101.2 degrees F. Ultrasound shows a distended gallbladder. What is the most appropriate management of this patient?

A Oral analgesics

B Diagnostic peritoneal lavage

C Proton pump inhibitors

D Laparoscopic cholecystectomy

The proper treatment for acute cholecystitis is IV fluids, antibiotics, pain control, and surgery. Cholecystectomy is the definitive treatment for acute cholecystitis and laparoscopic cholecystectomy is the procedure of choice.

A 57 year-old male presents with acute bilateral lower extremity weakness and urinary incontinence that began after he fell earlier today. His examination is significant for bilateral lower extremity sensory deficits and weakness along with decreased rectal sphincter tone. Which of the following is the most appropriate intervention?

A Epidural steroids

B Oral NSAIDs

C Physical therapy

D Surgery

Cauda equina syndrome is a rare but serious surgical emergency because the duration of nerve compression is inversely correlated with the likelihood of full neurologic recovery

A patient with a history of severe peptic ulcer disease is 5 weeks status post Billroth I surgery. One week ago he restarted his normal diet and has had the onset of severe nausea, abdominal cramping, and light-headedness that occur approximately thirty minutes after eating. The abdominal exam reveals a healing surgical scar without areas of unusual tenderness or any palpable masses. Which of the following is the most likely diagnosis?

A Anxiety disorder

B Celiac sprue

C Dumping syndrome

D Irritable bowel syndrome

Dumping syndrome typically occurs after Billroth type I surgeries as well as gastric bypass surgeries when the patient attempts to eat a large amount of simple sugars.

In patents with diabetic retinopathy, what clinical intervention is most successful in preserving vision?

A Panretinal laser photocoagulation

B Iridectomy

C Radial keratotomy

D Vitrectomy

Panretinal laser photocoagulation is indicated for preservation of vision in patients with diabetic retinopathy.

A 20 year-old presents 30 minutes after being struck by a hockey puck in the mouth. On physical examination a central incisor is missing from its socket. The patient has the tooth wrapped in tissue paper and the root appears intact. Which of the following is the most appropriate next step in the treatment of this patient?

A Administration of IM penicillin

B No treatment is warranted

C Place tooth in saline and refer to plastic surgery for reimplantation

D Immediately reimplant the tooth and refer to an oral surgeon

Avulsed permanent teeth should be cleansed, transported in Hanks solution or saline and reimplanted by an oral surgeon within one hour.

A 62 year-old male presents with a right hilar mass. Needle-biopsy of the mass reveals the presence of small-cell carcinoma and a bone scan reveals the presence of scattered hot spots throughout the skeleton. Which of the following is the most appropriate treatment?

A Lobectomy

B Pneumonectomy

C Thoracic radiation therapy

D Combination chemotherapy

Combination chemotherapy is the treatment of choice for a patient with small-cell carcinoma of the lung.

A 60 year-old male has unstable angina, but is otherwise healthy. A 90% lesion is found in the left main coronary artery. Which of the following interventions is most appropriate?

A Thrombolysis with t-PA

B Medical management with nitrates

C Coronary artery bypass graft (CABG)

D Percutaneous transluminal coronary angioplasty

CABG is indicated in patients with stenosis of the left main coronary artery and those with three-vessel CAD

Patient with adrenal insufficiency is taking hydrocortisone 25 mg daily. What should the patient do with the hydrocortisone dose when they develop a minor illness such as a cold?

A Stop the hydrocortisone until the illness resolves.

B Continue the current dose that the patient is taking.

C Increase the dose to 50 mg daily until the illness resolves.

D Increase the dose to 250 mg daily until the illness resolves

To better mimic the normal physiologic response the baseline dose should be doubled for the duration of the illness. Doses should be increased 5-10 fold with major events such as surgery.

45 year-old type 2 diabetic female with history of cholelithiasis presents to the clinic with 2-3 episodes of sudden, severe epigastric pain that radiates to her shoulder. She has associated nausea and vomiting. Temperature is 101 degrees F and she is experiencing chills. Today her eyes appear yellow in color. Which of the following is the most likely diagnosis for this patient?

A Postcholecystectomy syndrome

B Cholangitis

C Gastroesophageal reflux disease

D Pancreatic cancer

Cholangitis is characterized by a history of biliary pain, fever, chills, and jaundice associated with episodes of abdominal pain.

A 52-year-old female presents with diffuse abdominal pain accompanied by distention and visible peristalsis. Ausculation reveals hyperactive bowel sounds. Percussion is tympanic throughout. Palpation reveals mild diffuse tenderness without masses. The most likely diagnosis is

A intra-abdominal abscess.

B intestinal obstruction.

C paralytic ileus.

D cholecystitis.

Intestinal obstruction without complications is suggested by crampy pain, abdominal distention, hyperactive bowel sounds, visible peristalsis, and minimal tenderness.

Which of the following is the most consistent physical examination finding in a patient with duodenal ulcer?

A Flank tenderness

B Right upper quadrant tenderness

C Epigastric tenderness

D Rebound tenderness

Epigastric tenderness is a key feature of duodenal ulcer.

A 29 year-old female G4P2Ab1 at 20 weeks gestation complains of nausea and vomiting with tenderness in the RUQ. Vital signs reveal the patient to be febrile. On physical examination, the abdominal examination reveals positive bowel sounds in all quadrants with a positive Murphy's sign. Fundus can be palpated at the level of the umbilicus. The skin is warm and dry with slight tenting. Oral mucosa is dry as well. What is the most likely diagnosis?

A Peptic ulcer disease

B Hyperemesis gravidarum

C Cholecystitis

D Viral gastroenteritis

Gallbladder disease represents one of the most common medical and surgical conditions seen during pregnancy. This is thought to be due to a decrease in gallbladder contractility and lithogenicity of the bile. There is an increased risk in multiparous women.

A 70-year-old man complains of abdominal pain of four hours duration. He states that he has vomited twice since the onset of pain. He also complains of three days of constipation. He is afebrile and the physical examination is noteworthy for a distended, diffusely tender abdomen with normoactive bowel sounds. His rectal exam reveals hemoccult positive brown stool. Medications include omeprazole (Prilosec) for GERD, digoxin and warfarin (Coumadin) for atrial fibrillation, OTC multivitamins and stool softeners. The abdominal and chest x-rays show no abnormalities. Which of the following is the most likely diagnosis?

A Acute cholecystitis

B Mesenteric infarction

C Perforated duodenal ulcer

D Small bowel obstruction

Acute onset of severe diffuse abdominal pain in a person with atrial fibrillation warrants the suspicion of mesenteric infarction. Vomiting and constipation may be seen, along with occult blood in the stool. Bowel sounds may be normal.

A 62 year-old male presents with complaints of vague epigastric abdominal pain associated with jaundice and generalized pruritus. Physical examination reveals jaundice and a palpable non-tender gallbladder, but is otherwise unremarkable. Which of the following is the most likely diagnosis?

A Viral hepatitis

B Pancreatic cancer

C Acute cholecystitis

D Gilbert's syndrome

Pancreatic cancer is suggested by the vague epigastric pain with the jaundice resulting from biliary obstruction due to cancer involving the pancreatic head. The presence of a palpable non-tender gallbladder (Courvoisier's sign) also indicates obstruction due to the cancer.

50 year-old male with history of alcohol abuse presents with acute, severe epigastric pain radiating to the back. The patient admits to an episode of coffee ground emesis. On examination he is ill-appearing with a rigid, quiet abdomen and rebound tenderness. Which of the following is the most likely diagnosis?

A Abdominal aortic aneurysm

B Perforated duodenal ulcer

C Acute myocardial infarction

D Cholecystitis

Perforation of a duodenal ulcer causes sudden, severe pain, with rebound tenderness and rigid abdomen on physical examination. It is often associated with coffee ground emesis.

A 65 year-old homeless male with a history of pancreatitis is seen in the emergency department for vomiting, upper abdominal pain, back pain and weakness. He is cachetic, pale and jaundiced. A 4-5 cm mass is palpable in the mid to right hypochondrium. What is the most likely diagnosis?

A Chronic cholecystitis

B Carcinoma of head of pancreas

C Fibrolipoma

D Primary biliary cirrhosis

Seventy-five percent of pancreatic cancers are in the head. Risk factors include age, tobacco use, obesity, chronic pancreatitis, family history and previous abdominal radiation.

A 16-year-old male is found on physical examination to have a history of cryptorchidism of the right testes. This was surgically corrected at age 18 months. This patient should be monitored for the development of

A prostatic cancer

B testicular cancer.

C bladder cancer.

D penile cancer.

Cryptorchidism increases the risk of testicular cancer. In fact, the major predisposing risk factor is cryptorchidism unrepaired until after age two and Caucasian men at highest risk.

A 60-year-old male presents with a recent history of change of bowel habits, weight loss, and blood and mucus in his stools. The most likely diagnosis is

A hemorrhoids

B colorectal carcinoma.

C acute diverticulitis.

D fistula-in-ano.

(u) A. Hemorrhoids may present with blood noted in the stool, but is not accompanied by weight loss.

(c) B. Colorectal cancer presents with weight loss, change of bowel habits, and blood in stool. (u) C. Acute diverticulitis presents with abdominal pain and tenderness, fever, and peritoneal findings.

(u) D. Patients with fistula-in-ano presents with severe pain, and there may be blood in the stool, but weight loss is not seen.

A 76-year-old female presents to the ED with the worst abdominal pain in her life. The pain began following a large meal and is located periumbilically. Although she is writhing in pain, she does not have an exacerbation of the pain on palpation of the abdomen. She has a history of coronary artery disease, asthma, and atrial fibrillation. Which of the following is the most likely diagnosis?

A Toxic megacolon

B Mesenteric thrombosis

C Fulminant hepatitis

D Acute diverticulitis with perforation

This patient is at risk for mesenteric ischemia due to advanced age, atherosclerosis and atrial fibrillation. This is the classic presentation for this condition with pain out of proportion to physical examination findings.

Ulcerative colitis usually presents with which of the following?

A bloody diarrhea

B toxic megacolon

C fever and left quadrant pain

D alternating constipation and diarrhea

Ulcerative colitis typically presents with episodic bloody diarrhea, lower abdominal cramps, and urgency to defecate

Which of the following is the most common type of skin cancer?

A basal cell

B melanoma

C atypical nevi

D squamous cell

Basal cell cancer is the most common cause of skin cancer usually occurring on sun-exposed areas

A 72 year-old man presents with acute left lower quadrant abdominal pain. He has nausea, vomiting, and constipation. He has a fever of 101° F and guarding and rebound tenderness in his left lower quadrant. His white blood cell count is elevated. He has no prior history of gastrointestinal disease. Which of the following is the most likely diagnosis?

A Inflammatory bowel disease

B Irritable bowel syndrome

C Viral gastroenteritis

D Acute diverticulitis

Acute abdominal pain, fever, left lower abdominal tenderness, and leukocytosis are hallmark signs of acute diverticulitis.

A 62 year-old male is brought to the emergency department with acute hematemesis. The patient denies a previous history of vomiting. His wife states he has chronic liver disease. Physical examination reveals a distended abdomen without rebound, guarding or organomegaly. There is a fluid wave. Which of the following is the most likely diagnosis?

A Esophageal varices

B Mallory-Weiss tear

C Arteriovenous malformation

D Perforated duodenal ulcer

Esophageal varices are dilated submucosal veins that develop in a patient with underlying portal hypertension. The most common cause of portal hypertension is cirrhosis.

An 18 month-old female presents to the Emergency Department having possibly swallowed a hearing aid battery within the past hour. She is drooling and appears anxious but parents have noticed no stridor or dyspnea. She has no history of previous esophageal injury. Physical examination is unremarkable. Chest radiograph reveals a radiopaque round object at the distal esophagus. Which of the following is the most appropriate treatment option?

A Observation for 24 hours

B Esophagoscopy for removal

C Barium swallow

D Bronchoscopy

Esophagoscopy is the procedure of choice for acutely ingested foreign bodies.

A patient diagnosed with Barrett's esophagus is at an increased risk for the development of what type of cancer?

A Squamous cell

B Transitional cell

C Adenocarcinoma

D Atypical carcinoid

The most serious complication of Barrett's esophagus is esophageal adenocarcinoma.

A 41 year-old female presents to you for medical screening advice. Her 44 year-old sister passed away recently 18 months after diagnosis of metastatic colon cancer. Which of the following is the most appropriate advice for this patient?

A Double contrast barium enema now and repeat every 5 years if normal

B Rectal occult blood testing annually until age 50 then sigmoidoscopy every 3 years

C Rectal occult blood testing annually until age 50 then screening colonoscopy every 5 years

D Screening colonoscopy now and repeat every 3-5 years if normal

Hereditary factors are believed to contribute to up to 30% of colorectal cancers. Relative risk is 3.8 times if the family member's cancer was diagnosed at less than 45 years of age. Recommended screening in a single first degree relative with colorectal cancer diagnosed before age 60 is beginning colonoscopy at age 40 or ten years younger than age at diagnosis of youngest affected first-degree relative. Then if negative, every 5 years

Which of the following is the most appropriate study for diagnosing Hirschsprung disease?

A Rectal biopsy

B Stool leukocyte test

C CT of the abdomen and pelvis

D Fecal occult blood test

A rectal biopsy showing the absence of ganglion cells in both the submucosal and muscular layers of the involved bowel is the most appropriate diagnostic study for Hirschsprung disease.

What is the pathologic mechanism of Hirschsprung's disease?

A Pyloric circular muscle hypertrophy causing gastric outlet obstruction

B Absence of ganglion cells in the mucosal and muscular layers of the colon

C A defect in the diaphragm leading to protrusion of the abdominal viscera into the thoracic cavity

D Absence of relaxation of the lower esophageal sphincter and lack of peristalsis in the esophageal body

Hirschsprung's disease results from an absence of ganglion cells in the mucosal and muscular layers of the colon.

A person presenting with bleeding esophageal varicies should be treated with which of the following while awaiting arrival of endoscopy?

A Carafate (Sucralfate)

B Octreotide (Sandostatin)

C Omeprazole (Prilosec)

D Enoxaparin (Lovenox)

Octreotide is a vasoacctive drug used in the treatment of GI bleeding as well as somatostatin, vasopressin, and terlipressin. Somatostatin and octreotide are preferred due to safety and less incidence of serious side effects.

A pregnant female presents at 32 weeks gestation with painless rectal bleeding and a bulging perianal mass when straining which goes away. Which of the following is the most appropriate management of this patient?

A Hemorrhoidectomy

B Metronidazole (Flagyl)

C Psyllium (Metamucil)

D Sclerotherapy

Dietary fiber or psyllium bulk laxatives can be used to decrease straining with defecation.

The main complication with the use of transjugular intrahepatic portosystemic shunt (TIPS) procedure is which of the following?

A increased portal pressures resulting in further esophageal varices

B increased portal pressures resulting in a worsening of cirrhosis

C Budd-Chiari syndrome

D increased risk of encephalopathy

TIPS procedures involve the placement of a stent in the liver in order to shunt blood away from the portal vein into the hepatic vein which bypasses the cirrhotic liver parenchyma. Its main complication is encephalopathy from the accumulation of toxic substances in the brain since the liver no longer acts as a filter.

A 65 year-old patient with known history of alcohol and tobacco abuse presents with solid food dysphagia. The patient also has a 24 lb weight loss over the past 6 months. Which of the following is the most appropriate intervention?

A endoscopy with biopsy

B chest x-ray

C barium esophagogram

D CT scan of the thorax

Endoscopy with biopsy establishes the diagnosis of esophageal cancer with a high degree of reliability

A 65 year-old patient with adenocarcinoma of the colon in remission presents for follow-up. Which of the following tumor markers should be monitored?

A AFP

B CEA

C CA 19-9

D CA-125

CEA is used to monitor recurrence of colon carcinoma.

A 42 year-old patient who is being treated for colon cancer with chemotherapy develops nausea and vomiting. Which of the following drugs would be the most effective in controlling the nausea and vomiting?

A scopolamine (Scopace)

B meclizine (Antivert)

C ondansetron (Zofran)

D loperamide (Imodium)

Ondansetron selectively blocks 5-HT3 receptors in the periphery (visceral afferent fibers) and in the brain (chemoreceptor trigger zone). It is indicated for use in chemotherapy induced nausea and vomiting.

A patient presents complaining of vague anal discomfort. On examination, the patient is noted to have a few small external hemorrhoids and edema in the anal region. Which of the following is the most appropriate intervention?

A proctoscopy followed by a hemorrhoidectomy

B increased dietary fiber and sitz baths

C hemorrhoidal banding

D inject a sclerosing agent

Most hemorrhoids respond well to conservative treatment such as fiber and sitz baths.

A 42 year-old male with a history of constipation presents with complaints of severe pain with defecation described as feeling like he is "tearing apart." He has also noted occasional small amounts of blood on toilet paper. External examination of the rectum is unremarkable and an internal rectal exam cannot be performed due to severe pain when attempted. Which of the following is the most likely diagnosis?

A Proctitis

B Anal fissure

C Rectal prolapse

D Internal hemorrhoids

Anal fissures are easily diagnosed from history alone with the classic finding of severe pain upon defecation. Constipation is also a common cause of the trauma that leads to development of a fissure.

A patient presents complaining of periumbilical pain. Which of the following anatomical sites is this finding associated with?

A Bladder

B Stomach

C Pancreas

D Small bowel

Pain from the small intestine, appendix, or proximal colon causes periumbilical pain

25 year-old female presents to the ED with an open fracture of the left fibula sustained from an auto accident. The patient has no neurological findings. In addition to stabilization of the patient which of the following should be immediately initiated?

A Antibiotic therapy

B Apply a bi-valve cast

C Reduce the fracture

D Surgical debridement

Antibiotic therapy should be started immediately along with tetanus if needed.

Congenital absence of ganglionic nerve cells innervating the bowel wall is seen in which of the following conditions?

A Hirschsprung's disease

B Meckel's diverticulum

C Chagas disease

D Hashimoto's hypothyroidism

Hirschsprung disease, also termed congenital aganglionic megacolon, results from a lack of ganglion cells in the bowel wall.

Which of the following laboratory markers are helpful in establishing the diagnosis of ovarian cancer in a 55 year-old post-menopausal women?

A Ca-125

B CEA

C LDH

D AFP

Ca-125 is one of the best tumor markers in epithelial ovarian cancer

Which of the following is better visualized with transesophageal echocardiogram (TEE) than transthoracic echocardiogram?

A Ventricular wall motion

B Pulmonary arteries

C Right ventricle

D Left atrial appendage

TEE allows 2-D and Doppler imaging of the heart through the esophagus. Given the close proximity of the esophagus to the heart, high-resolution images can be obtained, especially of the left atrium, mitral valve apparatus, and aorta

Which of the following is the therapy of choice for long-term management of esophageal varices in a patient who cannot tolerate beta blocker therapy?

A Octreotide (Sandostatin)

B Sclerotherapy

C Transjugular intrahepatic portosystemic shunt

D Sengstaken-Blakemore tube

Sclerotherapy is effective in decreasing the risk for rebleeding in a patient with esophageal varices.

A 72 year-old male with a new diagnosis of congestive heart failure and atrial fibrillation, develops episodes of hemodynamic compromise secondary to increased ventricular rate. A decision to perform elective cardioversion is made and the patient is anticoagulated with heparin. Which test should be ordered to assess for atrial or ventricular mural thrombi?

A Electrocardiogram

B Chest x-ray

C Transesophageal Echocardiogram

D C-reactive protein

Transesophageal echocardiography allows for determination of mural thrombi that may have resulted from atrial fibrillation.

Primary hyperparathyroidism is characterized by which of the following?

A decreased serum magnesium

B decreased serum phosphate

C increased hematocrit

D increased bone density

Parathyroid hormone stimulates the osteoclasts to increase bone resorption, leading to elevated calcium levels. It works in the kidney to increase calcium reabsorption and increase renal excretion of phosphorous. Hematocrit is not affected by parathyroid hormone.

A 20-year-old male presents with a mass in the groin. On inspection with the patient standing a symmetric, round swelling is noted at the external ring. When the patient lies down the mass disappears. The patient denies any trauma. The most likely diagnosis is

A an indirect inguinal hernia

B a direct inguinal hernia

C an obturator hernia

D a femoral hernia

A direct inguinal hernia is symmetrical, round and disappears easily with the patient lying down. An indirect inguinal hernia is typically elliptic that does not reduce easily. An obturator hernia is more commonly seen in elderly women and are rarely palpable in the groin. Femoral hernias are rare in males and do not typically reduce with lying down.

65 year-old female presents to the office with a six-month history of back pain. The patient states that she is shrinking and thinks she is about an inch shorter than she was a year ago. Serum parathyroid hormone, calcium, phosphorus, and alkaline phosphatase are all normal. Which of the following would you most likely see on the x-ray of her spine?

A Radiolucent lesions

B Demineralization

C Chondrocalcinosis

D Subperiosteal resorption

Osteoporosis presents with varying degrees of back pain and loss of height is common. The serum calcium, parathyroid hormone, phosphorus, and alkaline phosphatase are normal. Xray findings demonstrate demineralization in the spine and pelvis.

A 35 year-old female who was a back seat passenger in a vehicle which was involved in a head-on collision is brought to the ED. She is able to tell you that she is having difficulty moving both of her legs and is experiencing bilateral leg pain as well. She is embarrassed because she has "wet myself." Physical examination reveals markedly diminished sensory and motor function of both legs and decreased rectal sphincter tone. Which of the following is the most likely diagnosis?

A Herniated disc at L5-S1 and L4-L5

B An anterior cord lesion

C Cauda equina syndrome

D An L2 lesion

Cauda equina syndrome is a massive central disc protrusion that causes variable degrees of paralysis. Bowel and bladder function may be impaired with saddle anesthesia. This condition is a surgical emergency.

Which of the following is the most consistent physical examination finding associated with a hydrocele?

A Tender and swollen testicle

B Palpable painless mass on the testicle

C Nontender scrotal mass that transilluminates

D Inability to get exam finger above scrotal mass

A hydrocele is a fluid-filled mass that is nontender to palpation. Diagnosis is readily made by transillumination, however evaluation is still warranted as 10% of testicular tumors may have an associated hydrocele.

Trousseau's sign is usually associated with which of the following?

A Hypocalcemia

B Hypokalemia

C Osteomalacia

D Hyperparathyroidism

Trousseau's sign is associated with hypocalcemia.

A 43 year-old male is found to have an elevated serum calcium on routine pre-employment laboratory testing. Further laboratory testing demonstrated: Calcium 11.3 mg/dL (8.8 - 10.2 mg/dL) Ionized Calcium 6.2 mg/dL (4.6 - 5.3 mg/dL) Phosphorus 2.1 mg/dL (3.0 - 4.5 mg/dL) What is the most likely diagnosis?

A Adrenal insufficiency

B Hyperparathyroidism

C Osteoporosis

D Paget's disease

The presence of elevated total and ionized calcium are consistent with hyperparathyroidism.

Which of the following is a cause of prerenal azotemia?

A Infection

B Renal toxins

C Poor renal perfusion

D Urinary tract obstruction

Renal hypoperfusion is the cause of prerenal azotemia, which may be rapidly reversible when renal blood flow and glomerular ultrafiltration pressure are restored.

A patient presents to the office with worsening fatigue, weight loss, and weakness. She notes that she is having recurrent bouts of abdominal pain and has been losing her pubic hair. Patient is found to have orthostatic hypotension. Which of the following conditions is most likely?

A Cushing's syndrome

B Pheochromocytoma

C Primary hyperparathyroidism

D Addison's disease

Patients with Addison's disease have primary adrenal failure from an autoimmune problem in the adrenal gland or due to hemorrhage into the adrenal gland. These patients are not able to make glucocorticoids, mineralocorticoids, or sex hormones which result in hypotension, hyperpigmentation (from an increase in the ACTH and MSH hormones) and are hyponatremic.

Which of the following is the most common presentation for an elderly female patient with primary hyperparathyroidism?

A Abdominal pain

B Renal lithiasis

C Acute pancreatitis

D Asymptomatic

Patients with primary hyperparathyroidism are most commonly found to have this disease by an incidental finding of hypercalcemia on routine laboratory testing as a result of screening. Up to 0.1% of the adult population has this condition which is most commonly seen in females over age 50.

What is considered the most common physical examination finding for intestinal obstruction?

A Distention

B Fluid wave

C Rigidity

D Tenderness

Abdominal distention is the most common hallmark of all kinds of intestinal obstructions though its presence can be variable depending on the duration and exact location of the obstruction.

An adult presents with a three month history of progressive severe muscle cramps, extremity paresthesias and lethargy which began shortly after a thyroidectomy for a malignant thyroid lesion. Which of the following is the most likely diagnosis?

A Hypoparathyroidism

B Hypothyroidism

C Hyperparathyroidism

D Hyperthyroidism

Hypocalcemia secondary to hypoparathyroidism is commonly seen as a complication of thyroidectomy.

A 22-year-old patient complains of sudden onset of chest pain accompanied by shortness of breath. The patient appears dyspneic. On examination, the trachea is deviated to the left, breath sounds are faint on the right, and the right chest is hyperresonant to percussion. The preferable treatment for this patient would be

A Tracheostomy

B Insertion of a chest tube with an underwater seal, left 2nd intercostal space

C Needle thoracostomy right 2nd intercostal space

D Lung scan for pulmonary embolism and begin heparin sodium (Heparin) therapy

Decreased breath sounds and hyperresonance are noted on the side of the pneumothorax; tracheal deviation to the opposite side indicates the development of a tension pneumothorax. In this case, the patient has a RIGHT sided pneumothorax. This is a medical emergency and treatment consists of inserting a large bore needle through the chest wall to allow air to move out of the chest followed by insertion of a chest tube on the side of the pneumothorax following decompression.

Post-infarction syndrome (Dressler's syndrome) occurs after acute myocardial infarction presenting as

A ventricular aneurysm.

B pericarditis and pleuritis.

C cardiac tamponade.

D pleural effusion and rash.

Dressler's syndrome is the occurrence of pericarditis and pleuritis several days to weeks following an MI

In suspected subarachnoid hemorrhage with a negative head CT, which of the following studies should be used to help establish the diagnosis of subarachnoid hemorrhage?

A complete blood count

B lipid profile

C lumbar puncture

D electrocardiogram

Although 95% of subarachnoid hemorrhages show blood on head CT, the remaining do not show evidence of hemorrhaging. A lumbar puncture should then be performed and the fluid examined for red blood cells or xanthochromia.