A 60-year-old man undergoes a right hemicolectomy for colon adenocarcinoma. The pathology revealed a tumor with negative microscopic margins, well-differentiated histology, and 10 lymph nodes in the specimen. He was found to have a stage II (T2N0M0) tumor. Which of the following characteristics place him at a higher risk, thus making him a potential candidate for adjuvant therapy?

A 22-year-old male presents to the emergency department with a stab wound in the right sixth intercostal space just lateral to the sternal border. His blood pressure is 90/70 mm Hg, his pulse is 130 beats per minute, and he complains of shortness of breath. His trachea is midline and his neck veins are bulging. The most likely diagnosis is:

A 62-year-old woman presents to your clinic after undergoing a left modified radical mastectomy for stage III breast carcinoma. She has done well postoperatively and is concerned only about new onset numbness and tingling over the posteromedial aspect of her left upper arm. She has normal strength, no motor deficits, and normal range of motion in her left upper extremity. What structure was likely injured during her operation?

The anatomic separation between the common hepatic duct and the common bile duct occurs at which level?

A 39-year-old female has been followed regularly by her dermatologist for a mole located on her left shoulder. Due to a family history of melanoma and her fair complexion, she is concerned that this nevus might eventually progress to malignant disease. Which of the following is true concerning the malignant transformation from melanocytic nevus to frank melanoma?

A 65-year-old male is undergoing an elective left inguinal hernia repair. With regard to his risk of surgical site infection, which of the following is true?

On postoperative day 3 after a classic Whipple procedure, a 54-year-old man is found to be lethargic and tachycardic with a pulse of 180 beats per minute and blood pressure of 50 mm Hg/palpable. An EKG reveals an irregularly irregular rhythm. What is the most appropriate treatment of his arrhythmia?

A 58-year-old woman with biopsy-proven papillary thyroid carcinoma and clinically involved right cervical lymph nodes undergoes total thyroidectomy and right modified radical neck dissection. On the first morning postoperatively, a focused clinical examination should include an assessment of which of the following?

A 55-year-old female presents with complaints of worsening chest pain associated with swallowing and dysphagia for solid food. Upper gastrointestinal series demonstrates narrowing of the distal esophagus with proximal dilation. Manometric studies demonstrate failure of normal relaxation of the lower esophageal sphincter. The patient undergoes an uneventful laparoscopic Heller myotomy. Postoperatively, she reports continued chest pain that occurs 30 to 60 minutes after meals and worsens upon lying down. How could this complication have been prevented?

A 20-year-old man was an unrestrained passenger in a motor vehicle collision. Upon impact, his left leg hit the dashboard and caused a posterior hip dislocation. This was reduced in the emergency department approximately 20 hours after the accident. What is the most likely complication?

A 27-year-old man was injured in a chemical plant explosion and presented to the hospital with burns covering over 50% of his total body surface area (TBSA). Early excision is planned. Which of the following statements is true concerning his condition?

A 48-year-old male painter falls from a ladder and presents to the emergency room. Primary and secondary surveys are notable for left-sided chest pain on palpation. He is splinting with deep inspiration. Radiography demonstrates nondisplaced fifth to ninth rib fractures. Which of the following options for pain control has been shown to provide superior outcomes in patients with rib fractures?

A 15-year-old boy presents 1 year following laparoscopic splenectomy for idiopathic thrombocytopenia purpura. He reports spontaneous massive epistaxis and is found to have a platelet count of 10,000/μL. In addition to a complete blood count, which of the following is the most helpful initial study to send based on his past history?

A 43-year-old female patient is now postoperative day 8 after a distal gastrectomy and Roux-en-Y reconstruction for an antral gastrointestinal stromal tumor (GIST). On morning rounds, her abdomen is tender with guarding in her epigastrium, and there is bilious fluid in her intra-abdominal Jackson-Pratt drain. Her vital signs are 38.1°C, pulse 98 beats per minute, blood pressure 123/69 mm Hg, and oxygen saturation 94%. A computed tomography (CT) scan with oral contrast is performed, and a fluid collection measuring 10 × 8 × 5 cm is seen in the area of the resection bed. Which of the following is the next step in diagnosing a duodenal stump leak?

A 30-year-old male is brought to the emergency room after falling off a second story balcony and landing on both feet before striking his head. He arrives intubated with normal hemodynamic parameters and a Glasgow Coma Scale score of 6T (withdraws to pain). His physical examination reveals bilateral swollen, erythematous heels but is otherwise free of other obvious deformities. In addition to computed tomography (CT) imaging of his head, cervical spine, abdomen, and pelvis, and x-rays of his chest and bilateral feet, what other plain film imaging should be obtained?

Which of the following is most likely to occur with use of local anesthetics administered via an epidural catheter for pain control following thoracic surgery?

An otherwise healthy 54-year-old male presents with stable angina. Echocardiography reveals an ejection fraction of 50% with an aortic valve area of 0.9 cm², a mean pressure gradient of 45 mm Hg, and a jet velocity of 4.5 m/sec. Which of the following is the best definitive therapy?

A 25-year-old woman presents with a breast mass found on self-examination. A 3-cm tender mass is palpable in the upper outer quadrant of the right breast with no overlying skin changes. The patient has no medical history and takes only an oral contraceptive pill. What is the most appropriate initial imaging modality?

A 54-year-old male undergoes laparoscopic Nissen fundoplication for persistent gastroesophageal reflux. On postoperative day 2, the patient develops pleuritic chest pain and shortness of breath. EKG and cardiac enzymes are normal. Chest x-ray demonstrates a large left-sided pleural effusion. Which of the following is the best diagnostic study to obtain next?

A 34-year-old woman presents with pain in her right hand and neck that has been going on for 1 year. She experiences occasional numbness in her arm and hand. She works as a seamstress and reports that her symptoms are worsened when shooting a basketball. What is the most likely diagnosis?

A 59-year-old male presents to clinic 2 years after a deceased donor kidney transplant for diabetic nephropathy. His creatinine is now 1.7 mg/dL, up from a stable baseline of 1.1 mg/dL following his transplant. His blood glucose levels have been well controlled, with HbA_1c of 6.2%. You perform a percutaneous core-needle biopsy, which shows no evidence of rejection. Which of the following immunosuppression medications is most likely contributing to this patient’s increasing renal insufficiency?

During pregnancy, a woman’s blood volume:

An otherwise healthy 52-year-old male is in the postoperative care unit hours after undergoing an uncomplicated left-sided laparoscopic adrenalectomy for a 0.5-cm cortisol-producing tumor when he is noted to have a heart rate of 82 beats per minute and blood pressure of 90/40 mm Hg. After administering 2 L of normal saline, the blood pressure is unchanged. The most critical next step in management will be to:

A 52-year-old man presents to the emergency room with abdominal pain, weight loss, and dehydration. He has had large-volume diarrhea (>3 L/day) over the past few weeks. Abdominal computed tomography (CT) reveals a small mass in the tail of the pancreas, and a plasma vasoactive intestinal polypeptide (VIP) is sent. Which of the following would be most consistent with a diagnosis of Verner-Morrison syndrome?

A 25-year-old man was involved in a motor vehicle accident and suffered a tibial plateau fracture that was splinted in the emergency department. Several days after admission he develops difficulty with dorsiflexion of his foot and also reports numbness and tingling sensations in the injured leg. In which region of the leg would he most likely feel numbness and tingling?

A 34-year-old HIV-positive man presents with a swollen, erythematous, and painful left forearm. He reports that the redness began after injecting heroin into his left hand web spaces 2 days prior. On examination, the skin overlying his arm is blistered, he is unable to flex his hand or wrist, and you palpate crepitus along his forearm. Which of the following is true regarding these types of infections?

A 70-year-old man with a 1-cm non-small-cell adenocarcinoma of his right upper lobe presents to your office for evaluation for resection of his tumor. He is thin, and although comfortable, he is breathing in a shallow and somewhat rapid fashion. Spirometry demonstrates an obstructive defect with a forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) of less than 70% of predicted and an FEV1 of less than 50% of predicted. Which of the following regarding alveolar ventilation is true?

A 55-year-old postmenopausal woman is found to have osteoporosis and joint and muscle aches 1 year following Roux-en-Y gastric bypass surgery and a 68.04-kg (150-lb) weight loss from her preoperative weight of 163.29 kg (360 lb). During workup for her condition she is noted to have a calcium level of 7.8 mg/dL. Further laboratory analysis will likely show the following:

A 45-year-old woman undergoes a laparoscopic cholecystectomy for symptomatic cholelithiasis. On postoperative day 10, she presents to the emergency room with 4 days of low-grade fevers, nausea, and right upper quadrant abdominal pain. Laboratory studies reveal mildly elevated bilirubin, liver enzymes, and white blood cell count. Computed tomography demonstrates a subhepatic fluid collection. Hepatobiliary iminodiacetic acid (HIDA) scan shows some drainage enterically but also peritoneal leakage, and a percutaneous drain is placed into the collection. What is the next step in management?

A 25-year-old male notices a painless mass in his scrotum for the first time while showering. Which of the following is an accurate statement regarding the diagnosis of testicular masses?

Which of the following is the definition of a process measure as utilized in health care?

A 57-year-old male presents to clinic with chronic stable angina that limits his ability to climb stairs and perform activities of daily living. Cardiac catheterization reveals a 70% occlusion in the left anterior descending artery, an 80% occlusion in the left circumflex artery, and an 85% occlusion in the right coronary artery with an ejection fraction of 50%. What is the recommended management of this patient?

A 47-year-old woman presents with a palpable breast mass discovered on self-examination. Mammography demonstrates a Breast Imaging-Reporting and Data System (BI-RADS) 4 lesion found to be a 2-cm spiculated mass with heterogeneous calcifications. Core-needle biopsy is read as atypia without malignant features. The best next step would be the following:

A 56-year-old male with a significant history of tobacco use complains of progressively worsening odynophagia and dysphagia and a 4.54-kg (10-lb) weight loss over the past several months. He initially had trouble swallowing solid food and has more recently developed difficulty swallowing liquids and a sensation that food gets caught in his chest. What is the most valuable diagnostic study to obtain?

A 17-year-old woman brings her 11-month-old infant boy to the emergency department for seizure activity. Despite no report of trauma, the child has a bruise on his scalp and is found to have a subarachnoid hemorrhage on computed tomography. Which of the following is true with regard to the potential for nonaccidental injury?

When a physician places an order for a medication in an electronic ordering system, the system checks to see if the patient has an allergy to that medication. In addition, a pharmacist checks the dose and type of medication to ensure that it is appropriate for the patient. Afterward, a nurse administers the medication and has to scan the patient’s ID badge before doing so. In one isolated case, a nurse administered the medication without checking the patient’s name, and the patient experienced an adverse reaction to the medication. This scenario is an example of which of the following?

A 51-year-old male reports episodic light-headedness and vision changes that usually occur when he is working as a custodian. His pulse is 72 beats per minute; blood pressure is 126/87 mm Hg in the left arm and 147/103 mm Hg in the right arm. On physical examination, he is an obese man with a regular heart rate, no murmurs, clear lung sounds, a 2+ radial pulse on the right and a 1+ radial pulse on the left, and a carotid bruit present on the left but not on the right. The most appropriate next step in the diagnosis and management of his condition is:

A 56-year-old woman is found to have a 2-cm mass in her left adrenal gland following an abdominal computed tomography (CT) scan performed following a motor vehicle collision. Which of the following is the best next step in management of this adrenal mass?

A 50-year-old man presents to the emergency room with left lower quadrant abdominal pain. He is febrile to 38.7°C with a pulse of 100 beats per minute and blood pressure of 120/70 mm Hg. On examination of his abdomen, he is found to have focal left lower quadrant tenderness without peritonitis. His white blood cell count is 15,000/μL, and a computed tomography (CT) scan demonstrates diverticular disease in the sigmoid colon with a 6-cm rim-enhancing pericolic collection. Antibiotics are started. What is the next step in management of this patient?

An 11-year-old boy presents to the emergency department after falling out of a tree at a height of approximately 6.1 m (20 ft). His primary survey is negative. On secondary survey, you note a Glasgow Coma Scale (GCS) score of 12, tenderness and rigidity of his abdomen, and extremity injuries. Computed tomography scans of his head, abdomen, and pelvis reveal an occipital subarachnoid hemorrhage and a grade 2 splenic laceration. Which of the following is true with regard to secondary brain injury?

A 57-year-old woman with no past medical or surgical history presents to the emergency room with pain in her groin. She reports that the pain has become so severe that she is nauseous and has vomited multiple times over the past day. On physical examination, her abdomen is distended, and a small, irreducible mass is palpated inferior and lateral to the pubic tubercle. Which of the following statements is correct?

Which of the following is the strongest risk factor for the development of an abdominal aortic aneurysm (AAA)?

After an uneventful total thyroidectomy, a 58-yearold female is found to have a weak voice and difficulty coughing in the recovery room. She is hemodynamically stable with 95% saturation on 2 L oxygen via nasal canal. Her examination is unremarkable, and her wound is intact without drainage or evidence of a hematoma. Direct laryngoscopy is performed at the bedside, and her right vocal cord is noted to be in a fixed position. What is the most likely cause of her symptoms?

A 26-year-old man with no significant past medical history arrives to the emergency department complaining of right lower quadrant pain. His pain initially began in the periumbilical region, and he ignored the pain for the last 48 hours. His temperature is 39°C and his white blood cell count is 16,000/μL. Computed tomography (CT) scan of the abdomen and pelvis shows a 6- × 8-cm rim-enhancing fluid collection in the right pelvis. What is the best next step in the management of this patient’s disease?

A 42-year-old male construction worker is brought to the emergency room after a 120-kg concrete plate landed on his lower anterior torso. The patient has a heart rate of 110 beats per minute and blood pressure of 95/55 mm Hg. His pelvis is unstable on examination, and you temporarily stabilize the pelvis using a binder and complete your assessment, which is otherwise negative. His vital signs respond only transiently to crystalloid resuscitation. You decide to take him to the angiography suite for potential pelvic embolization. What is the most likely source of hemorrhage in this patient?

You are called to the emergency department to assess a 17-year-old female with abdominal pain and suspicion of an incarcerated inguinal hernia. She has bulimia and has had several admissions to the psychiatric ward. The hernia is nonreducible, and you schedule her for surgery. Her laboratory values come back as follows:

WBC 11,000/mm³

Hbg 11.0 g/dL

Lactic acid 3.1 mg/dL

Na 140 mEq/L

Cl 96 mEq/L

K 2.9 mEq/L

Blood pH 7.49

Urine pH 6.1

The medical student asks you why her urine is acidotic in the setting of a metabolic alkalosis. Your answer is:

An 82-year-old otherwise healthy and asymptomatic male with a recently diagnosed sigmoid colon cancer was noted on computed tomography (CT) to have a 6.1-cm infrarenal abdominal aortic aneurysm (AAA). The rest of his CT scan was unremarkable. The most appropriate management for this patient is:

In which of the following patients is laparoscopic splenectomy contraindicated and an open approach required?

A 22-year-old male college student presents with anorexia and vague abdominal pain 6 months after returning from a semester abroad in Argentina. A computed tomography (CT) scan of his abdomen reveals a 10-cm, thick-walled cystic lesion and several smaller neighboring cysts. He is afebrile, has a normal white blood cell count, and normal total bilirubin. This patient is most appropriately managed with:

A 23-year-old man presents after sustaining blunt head trauma during a physical altercation. He is noted to have drooping of his right nasolabial fold and inability to wrinkle his right forehead or close his right eye. The most likely cause of his symptoms is:

A cachectic-appearing 45-year-old female with a history of long-term alcoholism is admitted for recurrent small bowel obstruction after multiple episodes of nausea and vomiting for the past 5 days. She is managed conservatively with a nasogastric tube, NPO status, intravenous fluids, and total parenteral nutrition (TPN). The best way to prevent the development of refeeding syndrome in this patient is:

After 1 week of antibiotics for right lower lobe pneumonia, a 55-year-old woman still has intermittent fevers and a leukocytosis. Chest radiography demonstrates a large pleural effusion. Thoracentesis demonstrates thick fluid with polymorphonuclear cells and bacteria, and a thoracostomy tube is placed. Over the next week the drainage from the thoracostomy tube decreases, yet she continues to have fevers, leukocytosis, and a persistent oxygen requirement. Computed tomography of her chest demonstrates loculated fluid collections in her right hemithorax that are not in communication with the thoracostomy tube, pleural thickening, and an incompletely expanded right lower lobe. Which of the following is the most appropriate therapy?

A 53-year-old woman was found to have a suspicious lesion on routine screening mammography. She subsequently underwent stereotactic core biopsy of the lesion. Which of the following pathologic findings puts her at greatest risk of breast cancer?

A 51-year-old male with a history of chronic pancreatitis and pseudocysts presents to the emergency room with subjective dyspnea and ascites. His ascitic fluid has an amylase value of 2,476 Units/L. The patient is admitted and managed nonoperatively. Despite these measures, he develops increasing respiratory symptoms. You relieve his immediate symptoms with a bedside thoracentesis. Which next step in management is most appropriate?

A 12-year-old boy tripped and fell on his outstretched right hand. Upon presentation to the emergency department, the boy has a swollen and extremely tender right elbow. On physical examination, the hand appears warm, but the radial pulse is absent. An x-ray reveals a displaced supracondylar humerus fracture. What is the next step in management of this patient?

The following laboratory finding is most consistent with the diagnosis of the syndrome of inappropriate antidiuretic hormone secretion (SIADH):

Which of the following is correct regarding endoleaks following endovascular repair of abdominal aortic aneurysms?

A 58-year-old woman undergoes a lumpectomy and sentinel lymph node biopsy for a 1-cm infiltrating ductal adenocarcinoma in her right breast. Pathologic review of her sentinel nodes is negative for metastatic disease. The next step in management should include:

A 65-year-old man presents to the emergency room with bilious vomiting and abdominal pain. He is of status post a sigmoidectomy 6 weeks ago for diverticular disease. He is afebrile, pulse is 110 beats per minute, and blood pressure is 120/70 mm Hg. Which of the following is the most likely cause for his symptoms?

A trimodal distribution exists for mortality after traumatic injury. How can mortality during the first mortality peak best be prevented?

Which of the following is associated with vitamin K deficiency?

A 74-year-old man who underwent open infrarenal abdominal aortic aneurysm (AAA) repair recently developed sigmoid diverticulitis with a 4-cm abscess that was successfully treated with percutaneous drainage and antibiotics. He now returns to the emergency department 2 months after treatment of his diverticulitis with persistent fevers, malaise, leukocytosis, and back pain. He is found to be bacteremic, and computed tomography (CT) scan demonstrates complete resolution of his diverticular abscess but with periaortic stranding and some gas bubbles surrounding the prior aortic repair. The most appropriate management of this patient is:

A 65-year-old man recently underwent an abdominal computed tomography (CT) scan as part of a workup following a motor vehicle collision. A 5.5-cm heterogeneous adrenal mass was incidentally found, and he is referred to your clinic for evaluation and management. He otherwise has no past medical history, his blood pressure is normal, and his physical examination is unremarkable. Laboratory studies reveal a normal potassium level, normal serum and urine-free cortisol, and normal overnight dexamethasone test and plasmafree and urine metanephrines are negative. The next step in management is:

A 65-year-old man presents with hematemesis. He is resuscitated and started on a pantoprazole infusion. Upper endoscopy identifies a posterior duodenal ulcer with a nonbleeding visible vessel that is coagulated and clipped. Which of the following is true regarding the potential for rebleeding in this duodenal ulcer?

Which of the following represents the most effective long-term injury prevention strategy?

Your medical student wants to know why yellow adhesive drapes were applied to a patient’s skin prior to incision. Which of the following would be a correct reply regarding the use of iodine-impregnated drapes?

A 25-year-old tall and thin male presents to the emergency room with sudden onset of dyspnea and rightsided pleuritic chest pain. Although in pain, he is breathing with 97% oxygen saturation on room air. Physical examination is normal but chest radiograph demonstrates a 2.5-cm apical pneumothorax which does not track down the lateral wall. He reports that a similar episode happened 1 year ago, at which time he was admitted for observation but discharged the following day after his lung re-expanded on its own. Definitive management of his underlying condition is best accomplished by which of the following?

A 45-year-old female has a 1.5-cm mass in her right breast. There are no palpable axillary nodes and her physical examination is otherwise unremarkable. She undergoes a stereotactic core biopsy which reveals infiltrating ductal carcinoma. What is the most appropriate treatment option for her?

A 37-year-old man undergoes a laparoscopic appendectomy for presumed appendicitis and is discharged home without any complications. Pathologic examination reveals a 1-cm adenocarcinoma of the tip of the appendix that is margin negative. What is the next step in management?

A 24-year-old male is brought to the emergency department 1 hour following an assault with a baseball bat in which he suffered repeated head trauma. On arrival, he is hemodynamically stable. He opens his eyes to command, is speaking in incoherent statements, and moves his extremities to command. Which of the following is the most important predictor of outcome in this patient?

Which of the following scenarios represents appropriate use of isolation gowns when entering the room of a patient infected with Clostridium difficile?

The left vertebral artery most commonly:

A 45-year-old male is referred to you for management of a 2-cm lesion in his right thyroid lobe, which on biopsy is found to be medullary thyroid carcinoma (MTC). Evaluation of both sides of his neck clinically and radiographically shows no evidence of nodal disease. When discussing management options, you tell him that the treatment of choice for localized MTC is:

A 29-year-old surgery resident presents with anorexia, weight loss, and right upper quadrant pain. A month ago, she returned from a 1-year medical mission to Mexico. Shortly after she had arrived in Mexico, she had a brief bout of self-limited diarrhea but otherwise remained in good health for the duration of the trip. A computed tomography (CT) scan of the abdomen reveals a right-sided intrahepatic rim-enhancing fluid-filled lesion. The first-line treatment option for this patient is:

A 74-year-old female is brought to the emergency room after a fall. She has normal vital signs and a Glasgow Coma Scale (GCS) score of 14. Her past medical history is notable for hypertension, osteoporosis, and colon cancer. Her physical examination reveals minimal tenderness to palpation of her upper lumbar spine. She has no motor or sensory neurologic deficits of the lower extremities, and her rectal examination demonstrates normal tone. Computed tomography is notable only for wedge compression fractures of the L1 and L2 spinal bodies. What is the most appropriate acute management of her spinal injury?

A 59-year-old man weighing approximately 65 kg and having a long history of hepatitis C presents with a 7-cm skin laceration. For anesthesia, 20 mL of 2% lidocaine is infiltrated into the wound bed. While suturing the wound, the patient begins to have generalized convulsions. Which of the following confers an increased risk for lidocaine toxicity?

A 65-year-old male undergoes transhiatal esophagectomy for adenocarcinoma of the distal esophagus. Chest radiograph on postoperative day 5 is notable for a right-sided effusion, which is drained and found to have elevated levels of triglycerides, consistent with a chylothorax. Where is the most common location for termination of the thoracic duct?

A 45-year-old gentleman presents with a 2-cm left thyroid nodule that is biopsy-proven papillary carcinoma. Ipsilateral neck ultrasound demonstrates two suspicious nodes, one of which on biopsy shows papillary carcinoma. Definitive management should include the following:

A 57-year-old man with a history of psoriasis presents to the hospital with signs and symptoms of acute pancreatitis. Computed tomography (CT) shows diffuse enlargement of the pancreas. The pancreatic duct appears to be diminutive. He has elevated levels of IgG4 and after ruling out malignancy with endoscopic ultrasound and biopsy, a diagnosis of autoimmune pancreatitis is made. What is the next step in management of this patient?