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* clinical mastery Surgery Form 3 & 4 Please help!
 #824482  
  coke170 - 03/27/16 02:11
 
  18. A 16-year-old girl is brought to the emergency department after being stabbed in the anterior neck 30 minutes ago. A large hematoma is evident and is pulsatile at the level of the thyroid cartilage. As the physician watches, the hematoma expands. Which of the following is the most appropriate initial step in management?
A) Barium esophagography to rule out esophageal injury
B) Endotracheal intubation
C) Esophagoscopy to rule out esophageal injury
D) Indirect laryngoscopy to determine vocal cord injury
WRONG E) Tracheostomy

For each patient with a bleeding disorder, select the most likely diagnosis.
A) Anticardiolipin antibodies
B) Antithrombin 111 deficiency
WRONG C) Fibrinogen abnormality
D) Hemophilia
E) Thrombasthenia
F) Thrombocytopenia
G) Thrombocytosis
H) von Willebrand disease
25. A 64-year-old man is undergoing an elective surgical repair of an abdominal aortic aneurysm. During the operation, a retroaortic renal vein is lacerated, and the patient subsequently loses a large amount of blood. In addition to 4 L of blood retained by the cell-saver autotransfusion device, 22 units of packed red blood cells are replaced. The patient is hemodynamically stable, but blood is oozing from every surface in the operative field and from the intravenous and arterial catheter sites.
26. A 22-year-old man comes to the emergency department because of a swollen, painful, and slightly plethoric right lower extremity. He has had two episodes of superficial thrombophlebitis of the right lower extremity; the first episode occurred 30 months ago and the second episode occurred 18 months ago. Venous duplex scan confirms deep venous thrombosis involving the infrapopliteal veins.

39. A 32-year-old woman comes to the emergency department because of a 10-hour history of increasingly severe, constant pain in her abdomen. She has nausea but has not vomited. She has systemic lupus erythematosus well controlled with prednisone. She takes no other medications. Her temperature is 38C (100.4 F), pulse is 11 O/min, respirations are 16/min, and blood pressure is 115/65 mm Hg. Examination shows no scleral icterus. The abdomen is soft and tender to palpation over the right upper quadrant; there is mild guarding without rebound. Laboratory studies show:
Hemoglobin 14 g/dL
Leukocyte count 12,000/mm3
Segmented neutrophils75%
Bands10%
Lymphocytes15%
Results of liver function tests are within the reference ranges. Abdominal ultrasonography shows a distended gallbladder with a thickened wall and a gallstone lodged in the neck of the gallbladder. Following administration of cefazolin and an intravenous infusion of lactated Ringer solution, the patient is taken to the operating room for laparoscopic cholecystectomy. On induction with propofol, her blood pressure abruptly decreases to 60/40 mm Hg and remains constant despite administration of an additional 500-mL bolus of lactated Ringer solution. Which of the following is the most appropriate next step in pharmacotherapy?
A) Administer diphenhydramine
B) Administer dopamine
C) Administer gentamicin
D) Administer hydrocortisone
WRONG E) Decrease the dose of propofol
40. A 28-year-old woman comes to the physician because of fatigue, increasing breast size and tenderness, and increased urinary frequency over the past 8 weeks. She has also had slight intermittent cramping in the midline. She is uncertain when her last menstrual period occurred. She is 152 cm (5 ft) tall and weighs 85 kg (187 lb); BMI is 37 kg/m2. Ultrasonography shows a viable pregnancy high in the uterus consistent with an 8-week gestation. Two weeks later, she has severe right-sided abdominal pain associated with right shoulder pain. Ultrasonography of the pelvis shows a viable pregnancy in the right cornual area of the uterus. Immediately after the ultrasonography, the patient's vital signs become unstable with a pulse of 140/min, respirations of 20/min, and blood pressure of 90/40 mm Hg. Which of the following is the most likely diagnosis?
A) Adenomyosis
B) Corpus luteum cyst
C) Ectopic pregnancy
D) Endometrioma
E) Endometriosis
F) Follicular cyst
G) Leiomyomata uteri
H) Pelvic inflammatory disease
WRONG I) Ruptured ovarian cyst
J) Spontaneous abortion

1. A previously healthy 37-year-old woman is brought to the emergency department immediately after her husband found her lying in bed in a deep stupor. She has no history of a seizure disorder, and she does not take any medications. Her temperature is 37.5C (99.5F), pulse is 54/min, and blood pressure is 180/100 mm Hg. Examination shows a dense left hemiparesis and early decerebrate posturing. There is no evidence of trauma. Which of the following is the most likely diagnosis?
WRONG A) Arteriovenous malformation
B) Brain abscess
C) Meningioma
D) Ruptured intracerebral aneurysm
E) Thrombosed middle cerebral artery

8. A previously healthy 37-year-old woman comes to the physician because of a 2-month history of intermittent, right upper abdominal pain that usually occurs after meals. She has not had fever, chills, vomiting, nausea, weight loss, or change in bowel movements. She takes no medications. Her temperature is 37C (98.6F), pulse is 68/min, respirations are 16/min, and blood pressure is 110/70 mm Hg. Examination shows no jaundice or scleral icterus. Abdominal examination shows no abnormalities. Her leukocyte count is 5000/mm3. Results of liver function tests are within the reference ranges. Abdominal ultrasonography shows a thickened gallbladder wall, cholelithiasis, and a 4.2-cm hepatic mass in the right lobe. An abdominal CT scan shows the mass to be 4.2 x 3.5 cm with a central scar. Which of the following is the most appropriate next step in diagnosis?
A) Measurement of serum a-fetoprotein concentration
B) Hepatitis B virus serology
C) Radionuclide liver scan
D) MRI of the liver
WRONG E) Fine-needle aspiration biopsy of the mass
F) No further testing is indicated

31. A 67-year-old man comes to the physician because of an ulcer on the glans penis that has been increasing in size over the past 6 months. He is sexually active with multiple partners and rarely uses a condom. Examination shows an uncircumcised penis with bilateral, firm inguinal adenopathy and a painless ulcer on the glans. A serologic VDRL test is nonreactive. Which of the following is the most likely diagnosis?
A) Chancroid
B) Epididymitis
C) Gonococcal urethritis
D) Herpes
E) Inguinal hernia
F) Nongonococcal urethritis
G) Penile cancer
H) Scrotal abscess
WRONG I) Syphilis

For each patient with a limp, select the most likely diagnosis.
A) Legg-Calve-Perthes disease
B) Osgood-Schlatter disease
C) Osteomyelitis
D) Recurrent sprain
WRONG E) Septic arthritis
F) Slipped capital femoral epiphysis
G) Stress fracture
H) Tibia vara
I) Toxic synovitis
38. A 3-year-old girl is brought to the physician because of a 2-day history of a limp. Two weeks ago, she had fever and upper respiratory symptoms that resolved spontaneously. She has no history of serious illness and takes no medications. Her temperature is 37C (98.6F). Examination of the left hip shows moderate pain to palpation. Her leukocyte count is 11 ,000/mm3 (60% segmented neutrophils, 2% eosinophils, 30% lymphocytes, and 8% monocytes), and erythrocyte sedimentation rate is 12 mm/h.

39. A previously healthy 25-year-old woman is brought to the emergency department 20 minutes after being struck by an automobile. On arrival, she has pelvic and left lower extremity pain. Her temperature is 36.8C (98.3F), pulse is 135/min, respirations are 26/min, and blood pressure is 90/48 mm Hg. Examination shows an unstable pelvis and an obvious deformity of the left thigh. X-rays show fractures of the left iliac wing and left midshaft femur. Ten units of packed red blood cells are administered, and her blood pressure stabilizes. Nine days after operative repair of her fractures, she develops jaundice. Abdominal examination shows no abnormalities. Serum studies show:
Bilirubin, total 5 mg/dl
Direct 2.3 mg/dl
Alkaline phosphatase150 U/L
y-GIutamyltra nsferase35 U/L (N=5-50)
Which of the following is the most likely underlying cause of these findings?
A) Decreased excretion of bilirubin into the bile
B) Decreased hepatic conjugation of bilirubin
C) Decreased hepatic uptake of bilirubin
WRONG D) Obstruction of common bile duct
E) Overproduction of bilirubin
 
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* Re:clinical mastery Surgery Form 3 & 4 Please help
#3286739
  coke170 - 03/30/16 20:08
 
  thank you fuser00,

I didn't know that toxic synovitis and transient synovitis are synonymous.

here's what I found on wiki for those who didn't know that toxic synovitis is also known as transient synovitis.

Toxic synovitis is a temporary condition that causes hip pain in children. It's also known as transient synovitis. It mainly occurs in children between 3 and 8 years old. It's two to four times more common in boys than girls.
 
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* Re:clinical mastery Surgery Form 3 & 4 Please help
#3286861
  monter - 03/31/16 11:04
 
  to fuser:

for 18 -- you chose C , can you explain, or it is a typo.

for 39 -- agree on LUPUS and steroid treatment. (it is more frequent than other rare reactions)

38. toxic synovitis -- diagnosis of exclusion. nice catch.


for 55YO -- 3. it is BOERHAAVE . 100% lethal if you don't do surgery.

for 42YO -- MVC (probably motor vehicle collision, waiting for Violetta to confirm)
because she is STABLE, then agree on CT choice 2.
 
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* Re:clinical mastery Surgery Form 3 & 4 Please help
#3286939
  fuser00 - 03/31/16 16:00
 
  yep was a tipo the fact is protect airway : b) Endotracheal intubation  
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* Re:clinical mastery Surgery Form 3 & 4 Please help
#3287092
  coke170 - 04/01/16 09:23
 
  thank you fuser00  
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* Re:clinical mastery Surgery Form 3 & 4 Please help
#3289848
  alta90 - 04/18/16 12:58
 
  A few more questions from form 4

37 yo F comes to physician because of a 2-day history of increasing shortness of breath and fatigue. At the age of 5 years, she underwent succesful repair of VSD. She has no other history of serious illness and takes no medications. She does not smoke cigarettes. her pulse is 110/min and irregularly irregular. Respirations are 28, BP is 110/60. Examination shows perioral cyanosis. Lungs are clear to auscultation. On cardiac exam, there is a grade 4/6 soft holosystolic murmur head best at the left sternal border. There is 3+ pretibial edema. Which of the following is the most likely explanation for this patients symptoms?

A) Decreased pulmonary artery flow
B) Decreased pulmonary vascular resistance
C) Decreased systemic vascular resistance
D) Increased pulmonary artery blood flow
E) Increased pulmonary vascular resistance
F) Increased systemic vascular resistance.

Its not D. Most likely A given perioral cyanosis and edema?


An unconscious 27 y/o M is brought to the emergency department immediately after being involved in a motor vehicle collision. he was the unrestrained driver of a vehicle that struck a tree. At the scene, he was unconscious. He was not breathing spontaneously and was intubated and mechanically ventilated. On arrival, his GSC was 9/15. He breathes spontaneously when mechanical ventilation is d/cd. Temp 98.6, pulse 125, RR: 16, palpable systolic bp of 100. Exam shows copious bleeding from a laceration over scalp. There is a pool of blood around his head. There is an obvious fracture of the left humerus. Breath sounds are heard bilaterally. The abdomen is soft. The pelvis is stable. In addition to IV administration of crystalloid, which of the following is the most appropriate next step?

A) Direct pressure to bleeding laceration
B) CT abdomen
C) IV administration of vasopressor
D) Transfusion of packed RBCs
E) Closed reduction of fracture.

Not B, I'm guessing A.


67 year old woman has required mechanical ventilation to maintain adequate tissue oxygenation since she sustained a severe head injury 2 weeks ago. Several x-rays of chest during hospitalization show findings consistent with ARDS. Culture of bronchial washings have grown numerous organisms for which she is receiving broad spectrum antibiotic therapy. A current xray of the chest shows a cavitary lesion in the right upper lobe of the lung. Which of the following is the most likely diagnosis?

A) Aspergillosis
B) Atelectasis
C) Lung Abscess
D) Pneumatocele
E) Tuberculosis.

D is wrong (I figured it might have been ventilator associated injury. I'm guessing C?
 
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* Re:clinical mastery Surgery Form 3 & 4 Please help
#3289865
  palivizumab - 04/18/16 15:32
 
  correct answers:
C) increased pulmonary vascular resistance
A) direct pressure on laceration--- you guessed it right!!
the last one could be C); not sure
 
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* Re:clinical mastery Surgery Form 3 & 4 Please help
#3289885
  alta90 - 04/18/16 16:47
 
  Thanks for the reply palivizumab. The letter and the response from the first one don't match up. If its increased pulmonary vascular resistance, does this mean that she just had primary pulmonary hypertension and all the other stuff about VSD was just filler?  
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* Re:clinical mastery Surgery Form 3 & 4 Please help
#3289891
  coke170 - 04/18/16 17:03
 
  E) Increased pulmonary vascular resistance: Tricuspid regurg 2/2 Pulm HTN(increased pulm vasc resistance)
A) Direct pressure to bleeding laceration
C) Lung Abscess
 
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* Re:clinical mastery Surgery Form 3 & 4 Please help
#3327835
  mayank - 02/13/17 13:14
 
  39- give hydrocortisone. H/o steroids and hypotensive.....need steroids again to pick up BP  
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