Practice test 2 Flashcards
5d after undergoing an emergency colon resection for an obstructing carcinoma in the rectosigmoid, an 87yo man has the sudden onset of SOB. he has a 15y h/o coronary artery disease. he is agitated and slighly confused. his temp is 100F, pulse is 104, respirations are 32 and labored and BP is 88/59. exam shows jugular venous distension. crackles are heard over the midlung fields. cardiac exam shows no murmurs or rubs. the abdomen is slightly distended. BS are decreased. the liver span is 13cm. pulse ox on RA shows an O2 sat of 92%. An ECG shows ST segment elevation in the anterior leads. which of the following is the most likely diagnosis?
a. ARDS
b. cardiogenic shock
c. hypovolemic shock
d. PE
e. septic shock
B
52yo woman with well-controlled T2DM is brought to the ED 24h after the onset of abd pain. she has vomited 3x in the ED. she appears toxic. she is 5'2" and weighs 210lb. BMI is 38. her temp is 103.1, pulse is 120, respirations are 28, and BP is 160/90. exam shows scleral icterus. breath sounds are decreased over the lower lung fields b/l. the abdomen is mildly tender, BS are normal. rectal examination shows no abnormalities. lab studies show:
Hgb 12.6
Leuk 16,000
segmented neut 70%
bands 10%
lymphocytes 20%
Serum
Na 130
Cl 90
K 5
HCO3 14
Glucose 600
bilirubin
total 5.2
direct 2.0
alkaline phosphatase 350
AST 300
amylase 100
which of the following is the most likely diagnosis?
a. acute pancreatitis
b. amebic liver abscess
c. biliary cirrhosis
d. cholangitis, ascending
e. chronic cholecystitis
f. hepatitisD
130-14-90
130-104 = 26
Charcot’s triad = RUQ pain, jaundice, fvever
Reynolds = + MS changes, hypotension
47yo man comes ot the physician for evaluation prior to undergoing an abd perineal resection for rectal cancer. over the past 6y he has had L ankle swelling. exam shows mild edema of the L ankle w/out prominent veins. Venous duplex ultrasonography shows chronic occlusion of the L iliac and femoral veins. immediately prior to the procedure, which of the following is the most appropriate management of the pt’s venous disease?
a. aspirin prophylaxis
b. low dose heparin prophylaxis
c. therapeutic heparin therapy
d. warfarin therapy
e. thrombolysis
B
venous stasis and concerns for DVT
no warfarin; thrombolysis - c/i in surgery
77yo man comes to the ED 30min after the onset of severe nosebleed. he has collected 500 mL of blood and clots. he has a h/o of athersclerotic cardiac disease, HTn, and peripheral vascular disease. his meds include lisinopril and daily aspirin. his pulse is 110, RR 18, BP 110/80. anterior rhinoscopy shows no obvious source of the bleeding. anterior nasal packing does not stop the bleeding. he now spits blood and clots out of his mouth . which of the following vessels is the most likely source of this pt's bleeding? a ascending palatine artery b. caverous sinus c. infraorbital artery d. internal carotid artery e. internal jugular artery f. middle meningeal artery g. sphenopalatine artery
G
responsible for most posterior nosebleeds
12h after rod stabilization of a femoral shaft fracture, a 27yo homeless man has the sudden onset of combativeness and disorientation. his pulse is 120, RR 24, BP 140/85. exam show petechiae over the axilla. the remainder of the exam shows no abnormalities. which of the following is the most likely cuase of these findings?
a. EtOH withdrawal
b. aspiration pneumonia
c. fat embolism
d. intracranial hemorrhage
e. pulmonary embolism
f. splenic rupture
C
36h after admission to the hospital for evaluation of mild-to-moderate diffuse abdominal pain, a 42 yo woman remains obstipated despite treatment with multiple laxatives. her last BM was 6d ago. she has a 9y hx of systemic sclerosis (scleroderma) and has chronic constipation. she has a 1y hx of progressive abdominal distension. her current temp is 100.4F, pulse is 110, RR 22 and BP is 110/0. the abd is distended and tympanitic with diffuse tenderness to deep palpation. there is involuntary guarding and rebound. her hgb conc. is 12, and leuk is 14,000. an abd x-ray shows dilation of the colon and a 12cm ccum. there is no distension of the small bowel. which oft the following most appropriate next step in the management?
a. metoclopramide therapy
b. octreotide therapy
c. colonoscopy
d. sigmoidoscopy
e. laparotomy
E
toxic megacolon.
colonoscopy is contraindicated b/c of impaction –> you won’t be able to see it anyway
abd pain, bloating, tenderness
fever, tachy
scleroderma –> likely that she has adhesions that you will need to take donw
LAPAROTOMY = go in and take a look at it.
Following diagnosis of ectopic pregnancy in a married 25yo woman, an abdominal operation is performed. however, exam of the abdoment shows a normal uterine pregnancy but an acutely inflamed appendix. an appendectomy is performed despite the fact that the operative permit authorized only a surgical procedure for ectopic pregnancy. which of the following best describes the surgeon’s conduct?
a. appropriate in view of the medical necessity to remove the inflamed appendix
b. appropriate only if consent was obtained from the spouse
c. inappropriate b/c it constituted an unauthorized extension f the field of srugery
d. inappropriate, b/c the pt had not previously been informed of the risks associated w/ an appendectomy
e. inappropriate b/c the pt had not previously been informed
A
if get in there and find a bad thing, you are required to get it.
a previously healthy 8yo boy is brought to the physician b/c of intermittent pain of his R anterior thigh over the past 3w. his activity level is high and has remained unchanged during this period, but his mother notes that he limps intermittently. he is at the 25th percentile for height and weight. his temp is 93.2F, pulse is 76, RR 24. and BP 95/70 exam shows an antalgic gait. abduction and internal rotation of the femur is limited. xrays of the hip show punched out areas of the femoral neck. which of the following is the most likely mechanism of this child’s condition?
a. avascular necrosis of the femoral head
b. bacterial infection of the bone
c. chronic inflammation of the synovium
d. congenital defect of the femoral head
e. malignant infiltration
f. mechanical slippage of the femoral head
A
classic presentation
- can’t internally rotate
- punched out holes in the femor ==> leading to AVN.
62yo womn comes to the physician b/c of a 3w history of progressive SOB, mild pain in her R chest wall, and a nonproductive cough. he has had a 12lb weight loss during the past 3mo. she received the diagnosis of carcinoma of teh R breast 6y ago, and underwent lympectomy followed by a radiotrherapy and chemotherapy. she has no other history of serious illness. she currently takes no meds. she is in mild respiratory distress and appears cyanotic and cachectic. she is 5’4” tall and weighs 116lb. BMI is 20. her pulse is 88, RR 24, and BP 114/80. pulse oximetry on RA shows an O2 sat of 90%. tenderness to palpation over the R chest. breath sounds are decreased on the R with dullness to percussion. a friction rub is heard at the R. heart sounds are normal. which of the following is the most likely diagnosis?
a. chest wall recurrence
e. empyema
c. pericardial effusion
d. pulmonary embolism
e. malignant pleural effusion
E
- hx of cancer, along with sxs of unintended weight loss
- sxs of respiratory distress; decreased breath sounds
- tenderness over R chest
12h after undergoing drainage of a pancreatic abscess, a 52yo man with alcoholism becomes bradycardic and hypoxic and requires intubation and mechanical ventilation. he weighs 154lb. the ventilation is set at a FiO2 = 100%, tidal volume of 1000mL, and positive end-expiratory pressure of 2.5cm H2O. arterial blood gas analysis shows pH 7.36 PCO2 40 PO2 48 which of the following is the most appropriate next step in management? a. begin IV acetaloamide therapy B. begin IV furosemide therapy c. begin IV heparin therapy d. begin IV sodium bicarbonate therapy e. begin IV urokinase therapy f. decrease FiO2 G. decrease tidal volume h. increase positive end-expiratory pressure i. increase tidal volume.
H
FiO2 = max
Tidal volume = max
PO2 still needs help
the driver of an automobile is brought to the ED following a head-on collision at 50mph. he was wearing a seat belt. his only symptom is mild tenderness over the chest. all diagnostic tests show normal findings, except an xray of the chest that shows a somewhat widened mediastinum. which of the following is the most appropriate next step in management?
a. aortic arteriography
b. bronchoscopy
c. discharge with a followup appointment in 24h
d. exploratory thoracotomy
e. observation in the hospital and another xray of the chest in 6h.
A
pulmonary contusion –> after 24h
? cardiac contusion
concerns about aortic aneurysm
1) CTA
2) arteriography
a 52yo woman is brought to the ED b/c of a 4d history of progressive back pain and weakness and numbness in the legs. she has not urinated in the past 12h. she underweight a left mastectomy for breast Ca 5y ago. cranial nerves are intact. muscle strength is full in the upper extremities and 3/5 to 4/5 diffusely in the lower extremities. deep tendon reflexes are 2+ in the upper extremities and 3+ in the knees and ankles. babinski sign is present b/l. sensation to pinprick is decreased below the nipples, and sensation to vibration is absent in the lower extremities. she is unable to walk. mental status examination shows no abnormalities. insertion of a catheter yields 400 mL of urine. which of the following is the most likely location of the abnormality? a. cauda equina b. cerebral hemispheres c. cervical spinal cord d. lumbar spinal cord e. medullaf. midbrain g. pons h thalamus i. thoracic spinal cord
D
cauda eqina syndrome (at the level of the lumbar spine).likely from breast Ca mets.
==> loss of muscle strength. saddle anaesthesia. loss of bladder / bowel control
red herring = loss of sensation over nipples. likely d/t L mastectomy
45yo man has had daily temp to 100.9F and a 15lb weight loss over the last 3 mo. he has pallor. his pulse is 84, RR 16, and Bp 120/80. lunges are clear to auscuultation and the precordium appears normal. carotic upstroke is normal and equal b/l, S1 is normal and S2 is physiologically split. a low-pitched rumbling diastolic murmur is heard int he apex, the murmur disappears when the pt lies on his R side. the remainder of the exam is normal. Hgb is 10. which of the following is the most likely diagnosis?
a. aortic insufficiency
b. aortic stenosis
c. atrial myxoma
d. pericarditis
e. ventricular septal defect
C
myxoma changes with position
sxs = SOB upright –> ; PND; mitral stenosis - pulmonary edema.
47yo man comes to the physician b/c of a 2d history of fever and increasingly severe rectal pain. he has T2DM treated with metformin. his temp is 102.4F, pulse is 90 RR 14, and dBp 130/80. exam shows a tender mass at the anal verge to the L. his hgb is 9.6, leuk is 18,000 and serum glucose conc. is 350. which of the folowing is the most appropriate next step in management?
a. sitz bath
b. CT scan of the abdomen and pelvis
c. oral metronidazole therapy
d. flexible sigmoidoscopy
e. incision and drainage of the lesion
E
it’s an abscess. it needs to be drained
he has a fever & symptomatic from the infection
sitz bath only if he was otherwise healthy
62 yo man comes to the physician b/c he has been coughing up blood during the pat week. he has a 5y hx of a daily productive cough. he has a 20hx of HTN well -controlled with metoprolol. he has smoke 2 packs of cigarettes daily for 44y. his bp is 136/84. he is no distress. exam shows a barrel-shaped chest. his serum Ca is 11. a CXR shows a 4cm lesion on the R lung. a biopsy specimen is most likely to show which of the following?
a. adenocardinoma
b. mesotheilioma
c. small cell lung carcinoma
d. squamous cell carcinoma
e. undifferentiated large cell carcinoma.
D
smoker, central
b. mesotheilioma –> after MANY years
c. small cell lung carcinoma –> SIADH, lambert eaton
d. squamous cell carcinoma –> PTHrp/calcitriol (breast CA, SCC, MM)
67yo
67yo postal worker come s to the physician 1d after a 5min episode of weakness and numbness in his R (dominant) hand while at work. He did not have visual problems, HA, or weakness/numbness of the lower extremities. he is currently asymptomatic. he has smoked 1PPD for 45 years. he has not seen a physician in 40y. his pulse is 85 & irregular and BP is 140/90. the lungs are CTA. pulses are palpable. carotid bruits are heard b/l. heart sounds ar enormal except for frequent premature beats. neurologic exam shows no abnormalities. an ECG shows a normal sinus rhythm with multiple atrial premature contractions. which of the following is the most appropriate next step in management?
a. echo
b. carotic duplex ultrasonography
c. heparin therapy
d. tissue plasminogen activator theray
e. warfarin therapy
B
don’t treat yet –> it really could just be carpel tunnel. but he’s got a bunch of other atherosclerosis (carotid bruits)
1) carotid duplex to determine degree of stenosis & indications to treat
2) Echocardiogram - to then look for A fib
6yo boy is brought to the ED 30min after being involved in an MVA. on arrival he is awake and alert. there is an obvious scalp laceration over the L frontopareital area. there are no neurologic deficits. a CT scan of the head shows a linear temporal skull fracture. which of the following findings on CT scan is most likely in this pt?
a. epidural hematoma
b. subdural hematoma
c. intraventricular hemorrhage
d. subarachnoid hemorrhage
e. meningitis
A
b/c the lac is in that area (lateral skull) superficially can sever the middle meningeal artery
previously healthy 37yo woman comes to the physician b/c of bruising on her arms and abdomen for 3w. she takes ibuprofen as needed for occasional HA. her temp is 98.4F. exam shows ecchymoses over the upper extremities and trunk. the lungs are CTA. cardiac & abd exams show no abnormalities. alb studies show Hgb 13.5 leuk 6800 plt 45,000 bleeding time 11 prothrombin time 15 sec (INR=4) exam of bone marrow aspirate shows increased megakaryocytes.w hich of the following is the most likely explanation for these findings? a. adverse effect of NSAIDs b.bone marrow sequestration of plts c. circulating rheumatoid factor d. formation of antiplatelet Abx e. previous cytomegalovirus infection
D
ITP –> bleeding time is prolonged; decreased platelets –> petechiae.
increased megakaryocytes
–> treatment = (1) steroids; (2) splenetomy
23yo woman has pain in the L shoulder 12h after falling down stairs. exam shows diffuse abd tenderness. Hgb conc. is 10 and leuk is 11,000. which oft he following is the most likely diagnosis? a. acute traumatic pancreatitis B. diaphragmatic tear c. ruptured spleen d. shoulder separation e. supracondylar fracture
C
Kehr sign on L shoulder after trauma –> ruptured spleen
27yo woman who is HIV+ comes to the ED 4h after the onset of bloody diarhea. she has intermittent nonbloody diarrhea over the past 6mo. she has a 4d hx of abdominal cramps. she has decreased appetite resulting in a 15lb weight loss during the past week. she has had 2 hospitalization for Pneumocystis jiroveci (P. carinii) pneumonia during the last year. current meds include didanosine, indinavir, stavudine, and trimethoprim-sulfamethoxazole. her temp is 103F, pulse is 130, RR are 24, and BP is 80/60. diffuse crackles are heard b/l. exam shows a rigid, tympanitic, distended abdomen with diffuse rebound tenderness. BS are decreased. rectal exam shows gross blood. her Hgb conc is 8, Hct is 24% and leuk is 3500. after fluid resuscitation with 0.9% saline & transfusion of 2U of pRBCs, she undergoes total abd colectomy with ileostomy for a perforated cecum. pathologic examination of the excise colon shows difffuse mucosal inflammation w/ nuclear inclusion bodies. which ofthe following is the most likely causal organism.?
a. campylobacter jejuni
b. cryptosporidiium parvum
c. cytomegalovirus
d. entamoeba histolytica
e. mycobacterium avium-intracellulare
C. CMV is the only one with intranuclear inclusion bodies
CMV colitis
- bloody stool
- intranuclear inclusion bodies
at risk
- IBD pts taking steroids
- chemo pts
- HIV/AIDs
Tx = total colectomy
