Day 26 Flashcards
Q1-A 42-year-old man with hepatitis C cirrhosis presents with a large umbilical hernia with intermittent pain. On examination he has large amounts of ascites. Surgical intervention is being considered. His bilirubin is 3.0, his prothrombin time is 32 seconds, INR 2.2, and his serum albumin is 1.9. Which of the following is the best next step in management?
A-Proceed to emergency surgery
B-Proceed with surgery after first giving vitamin K
C-Proceed with surgery after total parenteral nutrition (TPN)
D-Do not performs surgery
E-Proceed with surgery after albumin infusion
Ans: D. Do not do surgery in any patients with multiple derangements in hepaticrisk factors. Any 1 of the hepatic risks alone—bilirubin above 2, albumin below 3, prothrombin above 16, and encephalopathy (as suggested by altered mental status)—predicts a mortality of over 40 percent. If 3 of them are present, the risk is 85 percent; all 4 risks constitute almost 100 percent risk of mortality
Q2-A 59-year-old man is scheduled for prostatectomy. He has a history of HTN, COPD, and diabetes mellitus. He takes atenolol for blood pressure, tiotropium and albuterol for COPD, and glipizide for diabetes. Vitals stable.and HgbA1c is 7.2. Recent pulmonary tests document FEV1 1.3. Blood CO2 is 47. Which of the following is this patient most at risk of developing?
A-Intraoperative myocardial infarction
B-Pneumothorax
C-Postoperative pneumonia
D-Hypercapnic failure
Ans: C. Severe COPD (FEV1 < 1.5 L) increases surgical risk, mainly because patients have an ineffective cough and cannot clear secretions. They are subsequently at risk for postoperative pneumonia.
Q3-Child with in toeing and the knee and leg goes inside when he is walking, with W shape position while sitting. Abnormality is:
A-Metatarsus vareus
B-Metatarsusadductus
C-Medial femoral torsion
Ans: C
Q4-A 46-year-old woman with medical history significant for large fibroids and anemia becomes disoriented 16 hours after an uncomplicated hysterectomy. What is the next step in management?
A-Obtain arterial blood gas B-Obtain CT scan of the pelvis C-Give intravenous fluids D-Give lorazepam E-Give blood transfusion
Ans: A. There is a long list of causes for post-op disorientation; however, the most lethal one if not recognized and treated early is hypoxia. Unless the vignette clearly identifies other possible metabolic causes of disorientation—uremia, hyponatremia, hypernatremia, ammonium, hyperglycemia, delirium tremens (DTs), or iatrogenic medications-the safest thing is to obtain a blood gas first.
Q5-A 52-year-old woman is found to have brown feculent fluid draining from her wound drain 9 days after a sigmoid resection for colorectal cancer. The patient is afebrile, has stable vital signs, and is without complaints. What is the next step in management?
A-Administer intravenous antibiotics B-Order a CT of the abdomen C-Flush the drain with normal saline D-Observation only E-Perform an urgent laparotomy
Ans: D. Observation is all that is needed. A fecal fistula, if draining to the outside, is not serious. It will close eventually with little or no therapy. If feces were accumulating on the inside, the patient would be febrile and would have other systemic signs. This would require drainage and probably a diverting colostomy.
Q6-A newborn is vomiting greenish liquid material. A “double-bubble” is seen on x-ray. What is the diagnosis?
A-Annular pancreas B-Congenital diaphragmatic hernia C-Gastroschisis D-Imperforated anus E-Intestinal atresia
Ans: A. don’t be everytime thinking that only duodenal atresia presents with double-bubble sign. Annular pancreas and malrotation also present with double-bubble sign. All of these anomalies require surgical correction, but malrotation is the most dangerous because the bowel can twist on itself, cut off its blood supply, and become necrotic.
Q7-A 30-year woman with a known seizure disorder has a grand mal seizure. She complains of left shoulder pain. PA and lateral x-rays are obtained and fail to reveal fracture or dislocation. She is given ibuprofen for pain. She returns 3 days later with persistent pain with her arm held close to her side. She reports that she is unable to move the left arm. What is the next step in management?
A-Axillary radiograph of the left shoulder
B-Change analgesic to Percocet
C-CT of the left shoulder
D-MRI of the left shoulder
Ans: A. Although anterior shoulder dislocations are easily seen on erect posteroanterior (PA) and lateral films—look for adducted arm and externally rotated forearm with numbness over deltoid (axillary nerve is stretched)—posterior shoulder dislocations are commonly missed on these views. Posterior shoulder dislocations should be suspected in a patient with a recent seizure or electrical burn and shoulder injury or pain. Order axillary or scapular views of the affected shoulder.
Q8-A 45-year-old man with a history of back pain for several months presents with sudden-onset severe back pain that came on when he was moving a television. He describes an “electrical shock” that shoots down his leg, which is worse when he coughs or strains and is partially relieved by flexing his legs. The pain has prevented him from ambulating. Straight leg raising gives excruciating pain. What is the next step in management?
A-MRI of the spine
B-Dexamethasone
C-Immediate surgery
D-Ibuprofen and brief bed rest
Ans: D. This is the classic presentation of lumbar disc herniation. It occurs almost exclusively at L4–L5 or L5–S1. Peak age is 43–46. Anti-inflammatories and a brief period of bed rest is all that is needed at this stage. Immediate surgical compression is needed if the history suggests cauda equina syndrome (look for bowel/bladder incontinence, flaccid anal sphincter, and saddle anesthesia). MRI can confirm both disc herniation and cauda equina, but do not answer MRI in classic cases of disc herniation. Trial of antiinflammatories is also the first step in management.
Q9-A 24-year-old man presents in the emergency room with very severe pain. His temperature on presentation is 102.3°F. His testes appear swollen and are tender to palpation. Urinalysis reveals 50 white blood cells, 0 red blood cells. Which of the following is the next step in management?
A-Antibiotics
B-Culture and sensitivity
C-Inguinal lymph node biopsy
D-Testicular ultrasound
Ans: A. The most likely diagnosis is orchitis/epididymitis, so starting antibiotics is the best next step in management.
Q10-A 72-year-old man is being observed; he has a ureteral stone that is expected to pass spontaneously. He develops chills, a temperature of 102.9°F, flank pain, and elevated creatinine. Which of the following is the next step in management?
A-Prescribe oral antibiotics B-Prescribe loop diuretics C-Perform lithotripsy D-Place percutaneous stent E-Place Foley catheter
Ans: D. Place a percutaneous stent to relieve the obstruction.
Q11-A 48-year-old laborer complains of coldness and tingling in his left hand as well as pain in the forearm when he does strenuous work. Recently he is complained of dizziness, with blurred vision and trouble keeping steady during these episodes.
Which of the following is the most important management?
A-Aspirin B-Clopidogrel C-Warfarin D-Bypass surgery E-Carotid endarterectomy
Ans: D. Bypass surgery is needed for subclavian steal syndrome.
Q12-A 66-year-old man has vague, poorly described epigastric and upper back discomfort. He is found on physical examination to have a pulsatile mass, which is very tender to palpation. Ultrasound reveals a 6-cm abdominal aneurysm. What is the next step in management?
A-ACE inhibitors
B-Urgent surgery
C-Elective repair
D-Repeat abdominal ultrasound in 6 months
Ans: B. Urgent surgery within the next day is the most appropriate management in a patient with asymptomatic abdominal aortic aneurysm. Signs (hypotension) and symptoms (excruciating abdominal pain radiating to the back) suggest leaking or ruptured aneurysm and necessitate emergency surgery.
Q13-A 32-year woman suffers an episode of severe occipital headache with vomiting and loss ofconsciousness. She is brought to the hospital where she is found to be conscious and completelyalert. Exam: normal pulse & BP. No abnormal neurological signs. What is the next step inmanagement?
A-Admission for observation B-CT brain C-MRI head D-Reassurance and discharge E-XRay skull
Ans: B. CT brain. Basilar migraine can cause severe headache and LOC. But there occurs noneurological deficit and recovering from unconsciousness becomes completely alert. But to diagnosebasilar migraine there should at least history of two migraine attacks with aura. As here diagnosticcriteria of basilar migraine is not fulfilled we can not discharge the patient without neuroimaging like CTor MRI.
Q14- A 10 y/o boy suddenly falls down without losing consciousness. P/E finds decreased muscle tone on the limbs. There are no other abnormal findings. He does not have a special medical history. The most likely cause is
A-Sleep paralysis B-Cataplexy C-Syncope D-Hypoglycemia E-Sleep attack
Ans: B.Cataplexy: sudden loss of muscle tone without sleep. Sleep attacks: falling asleep quickly at night. Sleep paralysis: patient is unable to move while awakening.
Q15-An infant boy is born at 39 weeks’ gestation by way of spontaneous vaginal delivery to a healthy, 32-year-old primigravid woman. Prenatal care was appropriate and there were no problems at the time of delivery. Physical examination by the staff pediatrician is normal, with
the exception of the genital examination. She observes that the urethral meatus is located on the ventral aspect of the penile shaft. Which of the following is the most correct statement about this condition?
A-Circumcision should be delayed
B-The infant may have a circumcision now
C-The infant may never have a circumcision
D-A urine culture should be obtained at this time
E-A voiding cystourethrogram should be ordered
Ans: A. Instruct the patient or caregiver on the use of intermittent catheterization.
