Sur 2017-2018

A 29-year-old woman presents with a 6-month history of erythema and edema of the right breast with palpable axillary lymphadenopathy. A punch biopsy of the skin reveals neoplastic cells in the dermal lymphatics. Which of the following is the best next step in her management?

A 42-year-old man comes to the physician because of a 3-month history of substernal chest pain after every meal. He has chronic alcoholism and a long history of heartburn. Upper endoscopy shows mucosal irregularity and ulceration of the squamocolumnar junction above the lower esophageal sphincter (LES). Multiple biopsies were taken. 4 hours later he is complaining of worsening substernal pain radiating to the back, left chest pain, and shortness of breath. His temperature is 37.10C (98.90F), blood pressure is 110/70 mm Hg, pulse is 140/min, and respirations are 34/min. An x-ray film of the chest shows minimal left pleural effusion. Which of the following is the most appropriate next step in management?

A 61-year-old man with severe three-vessel coronary disease and diabetes mellitus is scheduled for abdominal surgery. The patient has a long history of coronary disease and had a q-wave myocardial infarction 2 years ago. He has had type 1 diabetes mellitus for 12 years. His medications include atenolol, insulin, and captopril. His last hemoglobin Alc, 3 months ago, was 9.2%. Which of the following is the most predictive of a perioperative complication in this patient?

On assessment of a patient in the outpatients department you identify that they are Trendelenburg’s test positive. This indicates a possible palsy of which nerve?

A 68-year-old woman underwent an amputation of her right leg following severe crush injury. Three days postoperatively she has pyrexia and tachycardia and looks toxic. The amputation site looks red and brawny with the limb swollen with crepitus in the intermuscular planes. The diagnostis of this patient is?

A man involved in a high-speed, head-on automobile collision arrives at the emergency department in a deep coma. His pupils react poorly to light but are of equal size. An airway is placed, and the patient is sent for CT scan of the head with extension to the neck. The study shows no cervical spine fractures, but does reveal a small, crescent-shaped hematoma on the right side, with no deviation of the midline structures. Which of the following is the most appropriate next step in management?

A 71-year-old man returns from the operating room (OR) after undergoing a triple coronary bypass. His initial cardiac index is 2.8 L/ (min•m2). Heart rate is then noted to be 55 beats per minute, BP is 110/80 mm Hg, wedge pressure is 15, and his cardiac index has dropped to 1.6 L/(min•m2). He has a normal left ventricle. Which of the following maneuvers will increase his cardiac output?

A 45-year-old man presents with thunderclap headache. He gives a history of longstanding right-side headaches and a rushing sound in the right ear in time with his pulse. What is the most likely diagnosis of this patient?

A 12-year-old boy is brought to the emergency department after falling from a tree. Examination shows tenderness and swelling over the left lower arm. An x-ray film of the arm shows a fracture of the distal end of the humerus with proximal and posterior displacement of the distal fracture segment. Closed reduction of the fracture is performed. However, postoperatively the patient complains of increasing pain in the left arm and forearm. Twelve hours postoperatively his forearm is pale and cold. There is marked pain on passive extension of the fingers. Which of the following is the potential dreaded complication of this condition?

A 30-year-old victim of a road-traffic accident is GCS E1 V1 M4 with midsize reactive pupils at admission; the left fixes and dilates in the CT scanner. A diffuse concave extra-axial bleed is evident over the surface of the left hemisphere. What is the most likely diagnosis of this patient?

A 32 year-old woman who plays football on weekends complains of pain over the medial aspect of the left knee and intermittent problems with an inability to straighten her leg. She has positive McMurray’s test. What is the most likely diagnosis?

A 69-year-old man, who smokes and drinks heavily, complains of an earache on his left side. The earache has been present for 6 weeks and is not getting any better despite systemic antibiotics and ear drops. On physical examination, he is found to have very poor oral hygiene, only a few remaining stumps of rotten teeth, and big tonsils that are hard to see because he gags easily. Otoscopic examination shows a perfectly normal right tympanic membrane, although the left is distorted by what appears to be a serous otitis media. Tuning fork testing shows conductive hearing loss on the left but equal bone conduction on both sides. He is afebrile. Which of the following will most likely confirm the diagnosis?

A 62-year-old man is admitted to the emergency department with abdominal pain. The patient has a past history of ischaemic heart disease and atrial fibrillation. Computed tomography scan features are highly suggestive of ischaemic bowel. The patient's blood gases are as follows: pH = 7.25, paO2 = 10, paCO2 = 2.8, HCO3 = 18, Base excess = –8. Which of the following best describes the patient's acid–base status?

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 43-year-old male complains of right shoulder pain and weakness after falling on his outstretched hands two days ago. He denies shoulder deformity. The physician passively abducts both his arms above his head and then asks him to bring his arms down slowly in an adducting motion. The right arm drops rapidly at the midpoint of its descent. What is the most likely diagnosis?

A 68-year-old Caucasian man presents with a 3-week history of a swelling at the angle of the right jaw. He denies pain or any other symptoms of note. On further enquiry, he has felt lethargic for the past few months but denies weight loss. On physical examination, he has a 4 cm × 3 cm firm irregular swelling arising from the right parotid gland. He has an asymmetrical smile and is unable to purse his lips to whistle. The most likely diagnosis is?

A 1-month-old female infant presents with persistent jaundice. A serum direct bilirubin is 4.0 mg/dL and an ultrasound of the abdomen shows a shrunken gallbladder and inability to visualize the extrahepatic bile ducts. Which of the following is the most appropriate initial management of this patient?

A 68-year-old man is 6 days following open anterior resection with defunctioning ileostomy. The patient is afebrile at 36.7 °C. He is eating and drinking normally. The nursing staff informs you the stoma output is 3 L/day. His mucous membranes are dry and the patient feels thirsty. Which one of the following statements regarding fluid therapy is most correct?

A 36-year-old woman presents with palpitations, anxiety, and hypertension. Workup reveals a pheochromocytoma. Which of the following is the best approach to optimizing the patient preoperatively?

A patient sustained third-degree burns on both his arms when his shirt caught on fire while he was lighting the backyard barbecue. The burned areas are dry, white, leathery, anesthetic, and circumferential all around the arms and forearms. Which of the following parameters should be very closely monitored?

A 62-year-old man is awaiting an elective femoropopliteal bypass for peripheral vascular disease. He is a smoker of 60 pack years and is being treated for hypertension and hypercholesterolaemia with ramipril 5 mg each morning and simvastatin 10 mg orally at night. Three weeks ago he was admitted following an ST elevation myocardial infarction. His current blood pressure is 170/110 mmHg. Which of the following best describes the preoperative strategy?

A 42-year-old homeless man presents with a 3-week history of shortness of breath, fevers, and pleuritic chest pain. Chest x-ray (CXR) reveals a large left pleural effusion. Thoracentesis reveals thick, purulent-appearing fluid, which is found to have glucose less than 40 mg/dL and a pH of 6.5. A chest tube is placed, but the pleural effusion persists. Which of the following is the most appropriate management of this patient?

A patient presents having fallen on his head from a height. The atlas is fractured and expanded. What is the most likely diagnosis of this patient?

A 57-year-old man is undergoing a femoral-popliteal bypass of his right lower extremity because of severe peripheral vascular disease. This patient has a longstanding history of claudication and shortness of breath. He had a myocardial infarction 3 years ago and has had progressive limitation of his exercise capacity because of his peripheral vascular disease. He has not had any risk stratification after his infarction. Two weeks ago, he underwent a lower extremity arterial study that showed severe diffuse disease of his right leg arterial system. The patient is brought to the operating room, and, during the procedure, his right lower extremity is made bloodless by application of a thigh tourniquet for 1.5 hours. The surgeons complete their bypass and are preparing to restore blood flow. Which of the following is an expected consequence of this maneuver?

A 25-year-old man presents with a painless, hard, 3-cm testicular mass that he discovered serendipitously while taking a shower. Physical examination confirms that the mass arises from the testicle itself, is not part of the epididymis, and is solid rather than a fluid collection. The rest of the physical examination is unremarkable. Which of the following would be the most appropriate next step?

You are called to see an 85-year-old female patient as the nursing staff is concerned that the patient has not passed stool for 4 days. The patient has been admitted after family members became increasingly concerned regarding her general deterioration in health and level of function. She is orientated but frail and complains of increasing abdominal discomfort. On examination bowel sounds are increased. The abdomen is distended with generalized tenderness, but no rebound or guarding. There is a firm palpable mass in the left iliac fossa. Digital rectal examination shows an empty rectum. What diagnosis must be excluded?

A 65-year-old man presents to the emergency department with sudden onset of pain and weakness of the left lower extremity of 2-hour duration. Past history reveals chronic atrial fibrillation following a myocardial infarction 12 months ago. On examination, he is found to have a cool, pale left lower extremity with decreased strength and absent popliteal and pedal pulses. The opposite leg has a normal appearance with palpable pulses. Which of the following is the treatment of choice for this patient?

A fit 30-year-old woman while gardening suddenly became very short of breath, had intense itching with rash and complained of a painful red spot on her arm. She has been brought to the A&E department and is hypotensive, hypoxic with warm peripheries. The diagnostic of this patient is?

In the first postoperative day after an open abdominal procedure, a patient develops a temperature of 38.9 C (102 F). He is encouraged to ambulate, cough, and breathe deeply, but he is noncompliant. On the second day, he is still febrile. Incentive spirometry and postural drainage are instituted, but his participation is less than enthusiastic. He lies in bed all day and hardly moves. By the third day, he is still spiking fevers in the same range, although efforts to improve his ventilation continue, resolution of his problem will most likely require which of the following?

A 36-year-old woman presents to the emergency department with severe epigastric pain and right shoulder pain of about two hours duration. She also reports having one episode of emesis. When asked about her diet, she explains that she unintentionally fasted yesterday and had a large meal two hours ago. Her past medical history is significant for frequent heartburn for which she takes ranitidine. Several hours after presenting, the patient's pain resolves completely. Which of the following best explains this episode?

A 40-year-old Caucasian man presents complaining of pain in his left eye. Earlier that day he was working in his house, attempting to put up a shelf with nails. He felt a sensation of ‘some material entering his eye’. He does not wear contact lenses. His eye has been extremely watery and he has been unable to open it properly, fluorescein assessment under the blue light slit lamp reveals a discrete green region at the lateral corneal margin. Which one of the following statements best describes the management for corneal abrasion following foreign body injury?

You see a 50-year-old woman, admitted with colicky central abdominal pain, and passing blood-stained diarrhoea and mucus per rectum. She has a marked fever and tachycardia. Abdominal plain film radiography appears normal. The white cell count is raised and stool analysis reports reveal the presence of Clostridium difficile cytotoxins. What is the most likely diagnosis?

A 60-year-old man complains of anal itching and discomfort, particularly toward the end of the day. He works as a salesman in a department store, where he has to be on his feet all day. When he goes home in the evening, he finds himself sitting sideways to avoid the discomfort. He has no fever, rectal bleeding, or soiling of his underwear, and he has never had surgery in that area. Which of the following is the most likely diagnosis?

A 45-year-old woman is diagnosed with a submandibular calculus, having presented with a tender lump below the jaw on eating. Which structure is likely to be obstructed?

A 46-year-old man is diagnosed with an oestrogen receptor positive invasive ductal carcinoma of the right breast after having discovered a lump 3 months before. The patient is found to have multiple involved axillary lymph nodes and the tumour is of an aggressive phenotype. The most appropriate treatment option for this patient is?

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?

Six months ago at the time of lumpectomy for breast cancer, a 60-year-old female attorney quit a 30-year smoking habit of 2 packs per day. She had the chest radiograph shown here as part of her routine follow-up examination. Based on her age and history of smoking, you are concerned for either a new primary lung or metastatic breast malignancy. Which of the following is the most appropriate next step in the management of this lesion?

A 45-year-old man was an unhelmeted motorcyclist involved in a high-speed collision. He was ejected from the motorcycle and was noted to be apneic at the scene. After being intubated, he was brought to the ER, where he is noted to have a left dilated pupil that responds only sluggishly. What is the pathophysiology of his dilated pupil?

A 6-year-old boy has insidious development of limping with decreased motion in one hip. He complains occasionally of knee pain on that side. He walks into the office with an antalgic gait. Examination of the knee is normal, but passive motion of the hip is guarded. The child is afebrile, and the parents indicate that his gait and level of activity were completely normal all his life until this recent problem. He has not had a recent febrile illness. Which of the following is the most likely diagnosis?

A 46-year-old man comes to the physician because of a two day history of worsening abdominal discomfort and persistent vomiting. He has not had a bowel movement or passed flatus for 3 days. He had an appendectomy for appendicitis 20 years ago. Examination shows a distended abdomen that is tympanic on percussion. High-pitched bowel sounds and splashing are heard on auscultation. The abdomen is diffusely tender on palpation without rebound or guarding. An x-ray film of the abdomen shows distended small bowel loops with airfluid levels; no gas is seen in the colon. IV rehydration is started. Which of the following is the most appropriate next step in management?

A 63-year-old woman presents to the emergency department with episodes of difficulty breathing coupled with flushing and diarrhoea. On taking the history you ascertain that these episodes are precipitated by stress and alcohol. On examination, her blood pressure is 129/83 mmHg and heart rate is 80 beats/min. Based on this patient's history, select the best distinguishing investigation from the list below?

A 22-year-old college student notices a bulge in his right groin. It is accentuated with coughing, but is easily reducible. Which of the following hernias follows the path of the spermatic cord within the cremaster muscle?

A 34-year-old man has isolated medial compartment osteoarthritis following a previous complex tibial plateau fracture. He has severe pain, but with a reasonable range of movement, and a varus deformity. What is the best next step in management?

A 68-year-old man is diagnosed with lung cancer. In preparation for pulmonary resection he undergoes pulmonary function tests. Which of the following results indicate a favorable prognosis?

A 78-year-old diabetic man has undergone surgical repair of a large abdominal aortic aneurysm. Postoperatively, he develops left lower quadrant abdominal pain followed by bloody diarrhea. He has a history of prostate cancer and received radiation therapy several years ago. He eats a low fiber diet. He quit smoking recently. Vital signs show a low grade fever. Examination shows tenderness in the left lower quadrant and rectal examination reveals blood in the stool. CT scan of the abdomen demonstrates thickening of the colon at the rectosigmoid junction. On colonoscopy, ulcerations are seen in the same area while the colon above and below the lesions is completely normal. Which of the following is the most likely cause of his symptoms?

A homeless man is admitted unresponsive after being found by police on a park bench. He has no external signs of injury. An oesophageal temperature probe records his core body temperature to be 34 °C. Which of the following management options is not routinely indicated in this case?

A 60-year-old woman has been admitted as an emergency with a 4-day history of severe right upper quadrant pain, vomiting, jaundice and intense pruritus and is very toxic – high temperature with rigors and hyperdynamic circulation. The diagnostic of this patient is?

A 72-year-old retired banker is brought to the ED by his daughter for increasing confusion, lethargy, cough, and fever. You remember the patient because he was discharged just 3 days earlier after being treated for urinary retention secondary to benign prostatic hypertrophy (BPH). The patient’s cough has been present since discharge and is accompanied by dark green sputum. He has not returned to work, and he has not been able to ambulate. His vital signs: BP 86/40 mm Hg, R 32 beats/min, P 121 beats/min, T0 101.90F (39.190F). What is the best next step in the management of this patient?

Which of the following investigations are not used in staging of oesophageal malignancy?

A 22-year-old man is admitted following a stab injury to the right groin. He is bleeding profusely from the wound. His blood pressure is 80/40 mmHg and his pulse is 140 beats/min. He is agitated and mildly confused. His skin is cool and mottled, which one of the following statements regarding fluid resuscitation is most correct?