7/23/08

KTB

USMLE WORLD QUESTIONS

1. A 20-year-old female is brought to the ER after she fell from a

bicycle. She is c/o epigastric pain and nausea. You do a detailed
examination and investigation on the patient , which shows
duodenal obstruction secondary to duodenal hematoma. Her
vitals are stable. What is the most appropriate management of
this patient?
a. Exploratory Laparotomy
b. Nasogastric suction w/ parenteral nutrition
c. Nasogastric suction w/ IVF
d. Concervative management with rest and antibiotics
e. Endoscopic removal of the hematoma

2. A 60-year-old male underwent laparotomy for intestinal

obstruction due to postoperative adhesions. PMH is significant for
DM type 2 and HTN. He underwent cholecystectomy two years
ago. His current medications include insulin, HCTZ, enalapril and
pravastatin. On the fifth day after surgery, he complains of
intensive pain around the wound. His temperature is 38.3 C (101
F), blood pressure is 120/76 mmHg, pulse is 100/min, and
respirations are 16/min. Local inspection reveals cloudy-gray
discharge and single crepitus. The sensitivity at the edges of the
wound is decreased. What is the most important next step in the
management of this patient?
a. Surgical exploration
b. Anti-staphylococcal antibiotics
c. Culture the discharge
d. Improve glycemic control
e. Observation

3. A 12-year-old boy was involved in a motor vehicle accident. He

was in the rear seat and thrown out of the car. He was
immediately resuscitated and the trauma workup turned out to
be negative. His discharge was uneventful. Two months later, he
was seen in the ER complaining of vague chest pain and
discomfort. Auscultation revealed decreased air entry into the
left lower bases. CXR showed deviated mediastinum and mass in
left lower chest cavity. The next step in management is?
a. Place chest tube
b. Bronchoscopy
 c. Start antibiotics
d. Barium swallow
e. Angiogram

4. During the performance of a supraclavicular node biopsy under

local anesthesia, a hissing sound is suddenly heard, and the
patient suddenly dies. At the time of the catastrophic event, the
target node was under traction, and the final cut was being made
blindly behind it to free it up completely. The patient, an
otherwise healthy 24-year-old man, was inhaling at that moment.
Which of the following most likely caused this patient’s death?
a. Arterial injury w/ air embolization
b. Major vein injury with air embolism
c. Sudden pneumothorax with lung collapse
d. Sympathetic discharge
e. Tracheal injury

5. A 19-year-old man is brought to the emergency department after

sustaining multiple injuries in a high speed automobile collision.
There is a pneumothorax on the left side, for which he has a
chest tube placed. Over the next several days, a large amount of
air drains continuously through the tube, and daily chest x-rays
show that his collapsed left lung is not expanding. The patient is
not on a respirator. All of his other injuries have been treated
appropriately. Which of the following is the most likely cause of
these findings?
a. Air embolism
b. Injury to lung parenchyma
c. Injury to major bronchus
d. Insufficient suction being applied to the chest tube
e. Tension pneumothorax

6. During a screening colonoscopy a 70-year-old man is discovered

to have colon cancer. As part of his preop evaluation he receives
an abdominal CT to evaluate for metastatic disease. Although no
lesions consistantw/ metastatic disease are seen, the radiologist
reports that the gallbladder has significant intramural
calcification. The calcified wall appears thickened, though there
is no pericholecysticfluid present. The man denies any
complaints of abdominal pain and reports feeling healthy. Vital
signs and physical examination, including careful abdominal
exam are within normal limits. In addition to surgical resection of
patient’s colon cancer, which of the following is an appropriate
treatment for this patient’s calcified gallbladder?
a. Laparoscopic biopsy of gallbladder wall
b. Medical treatment with ursodeoxycholic acid
 c. Prophylactic open cholecystectomy
d. Reassurance that finding is inconsequential
e. Repeat CT scans in 6 months and 1 year

7. A 36-year-old white male was admitted for upper GI bleeding. He

has a 2-year history of cirrhosis and 10 year history of
alcoholism. He was on propranolol, spiranolactone, and
furosemide. His vital signs were, HR: 120; BP:90/50; RR 30; Temp
36.3C(97.4F). endoscopy revealed bleeding from esophageal
varices but failed to control it with sclerotherapy. Treatment with
vasopressin every 4 hours was started and a Sengstaken-
Blakemore tube was placed. 24 hours later bleeding persists.
Meanwhile 6 units of blood have been transfused. Vital signs now
are HR: 100, BP: 105/60; RR: 16; Temperature: 36.3C (97.4). The
patient is distressed but alert and oriented. Abdomen is
distended with evidence of splenomegaly and ascites on
ultrasound. Abdominal x-ray shows no air-fluid levels. What
should be done next?
a. Continue the pharmacotherapy and leave the tube for
another 24 hours.
b. Continue the pharmacotherapy but remove the tube.
c. Ligation of the varices
d. Meso-caval shunt
e. Transjugular intrahepatic portosystemic shunt

8. A 32-year-old male presents with recurrent abdominal pain. A

small bowel study reveals several strictures in the small bowel.
He was diagnosed with Crohn’s disease. He underwent a small
bowel resection. Two months later, he presents with colicky left
flank pain with mild hematuria. He was admitted and IV
hydration was given. An IVP shows a kidney stone. The type of
kidney stone that occurs after rection of small bowel is:
a. Calcium phosphate
b. Oxalate
c. Struvite
d. Urate
e. Cystine

9. A 38-year-old woman had severe, stabbing, mid gastric pain of

sudden onset, 30 minutes ago. Now she has lower abdominal
pain. Her past medical history is remarkable for peptic ulcer
disease. Her LMP was 30 days ago. Her entire abdomen is tender
to palpation with guarding and marked rebound. There is no
shifting dullness. The bowel sounds are absent. Her vital signs
are, HR: 110, BP: 160/90; RR: 25; Temperature: 36.8C (98.1F).
Lab values: Hb: 13.1; Hct: 43%; WBC: 10.9.
 a. Pregnancy test
b. DPL
c. Pelvic ultrasound
d. Upright abdominal x-ray
e. Abdominal CT

10.A 45-year-old woman underwent elective surgery for an inguinal

hernia. In the post-op recovery room, she developed nausea,
vomiting, and acute abdominal pain. Her other medical condtions
include SLE, pernicious anemia, IDDM, chronic low back pain and
uterine fibroids. Her preop medications include monthly vitamin
B-12 injections, insulin, prednisone, hydroxychloroquine, and
acetaminophen. Her blood pressure is 70/40 and HR 110. Initial
labs showed blood glucose of 50. What is the most probable
cause of the patient’s condition?
a. Postop bleeding
b. DKA
c. Intra-abdominal abscess
d. Intestinal obstruction
e. Adrenal insufficiency
f. Allergic reaction
g. Insulin-induced hypoglycemia
h. Atelectasis
i. Bleeding into uterine fibroid.

11.A 38-year-old woman had undergone a parietal cell vagotomy for

persisting duodenal ulcer. 3-months later, she experienced an
upper gastrointestinal hemorrhage and a recurrent ulcer was
diagnosed. Distal gastrectomy with Billroth II and truncal
vagotomy was performed. 2-days after the operation she has
severe epigastric and back pain. Her vital signs are, PR: 110/min;
BP: 120/80mm Hg; RR: 16/min; Temperature: 37C(98.6F).
Abdominal ultrasound shows some swelling of the pancreas.
Laboratory results are:
Hb 13.8gm/dL; WBC 12,300/cmm; Na 142; Cl 110; K 4.1;
HCO3 25; Ca 11.4; pH 1.1 mmol/L; Amylase 772
Which of the following studies is the most appropriate?
A. Acid ouput studies
B. Gastrin and calcitonin levels
C. Parathyroid hormone and gastrin levels
D. Parathyroid hormone and calcitonin levels
E. Calcitonin and urinary vanillymandelic acid (VMA) levels

12.A 34-year-old male patient is brought to you after his friend’s car
was involved in a collision. The patient was in front passenger
seat, wearing a seat belt, and complains of epigastric pain since
 the event. He is hemodynamically stable with no obvious injury
or complaint, other than epigastric pain. X-ray of the abdomen
shows retroperitoneal air. Which of the following is the
investigation of choice to confirm the suspected diagnosis?
A. Plain CT scans of abdomen
B. Diagnostic peritoneal lavage
C. Exploratory laparotomy
D. CT scans of abdomen with oral contrast
E. USG of abdomen

13.A 65-year-old Caucasian male presents to your office with a four

week history of weakness and vague postprandial epigastric
pain. His past medical history is insignificant. He is not taking
any medications. He smokes 1½ packs a day and consumes
alcohol occasionally. Stool is positive for occult blood. A
gastroduodenoscopy is performed that reveals an antral ulcer.
Four of seven biopsies taken from the margins of the ulcer
returned positive for malignancy. Which of the following is the
best next step in the management of this patient?
A. Serum albumin
B. Serologic markers
C. A CT scan
D. Laparoscopy
E. Exploratory laparotomy

14.A 72-year-old man underwent double bypass grafting for

unstable angina. On the 1st postoperative day his vital signs
were, PR: 80/min; BP: 120/70mm of Hg; RR: 12/min;
Temperature: 36.6C(97.9F). On postoperative day 10 he is
complaining of worsening retrosternal pain, despite continuing
analgesia with morphine. He also has dyspnea at rest. His vital
signs currently are, PR: 100/min; BP: 110/70mm of Hg; RR:
24/min; Temperature: 37.9C(100.1F). He has clear heart sounds,
without murmurs or rubs on auscultation. EKG shows no acute
changes compared to the EKG on the 1st postoperative day.
Chest x-ray reveals widening of the mediastinum.
Echocardiography is positive for a small amount of pericardial
fluid.

His laboratory results are:

Hb 16.7; Hct 41%; WBC 18,700cmm with 7% bands

Platelets 260,000; PT 14; PTT 32; CK 80; CK-MB 2

AST 84; LDH 180;

 Most probably this patient will require?

A. Aspirin or steroid therapy

B. Thoracotomy for debridement , drainage, and antibiotic

therapy

C. Thoracotomy for hemostasis

D. Pericardial puncture and aspirin or steroid therapy

E. Antibiotic therapy alone