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Fluids, Electrolytes and Acid/Base Balance PROBLEM 1 A 45 year old man with previously known duodenal ulcer disease presents with complaints of persistent vomiting for the past 36 hours. The vomit is clear-looking and acidic in taste. He has no abdominal pain. Prior to the vomiting, he had difficulty with solid foods causing "fullness" in the stomach and he had been taking only liquids for one week. His heartburn had been aggravated at the time of the "fullness", but antacids did not help and he did not seek medical attention until today. He complains of being dizzy when he stands up. His blood pressure changes from 120/70 when lying to 105/55 when standing, his pulse changes from 100 to 130. Study
Questions:
PROBLEM 2 A 72 year old man is admitted with painless jaundice of two weeks duration. Ultrasound demonstrates markedly dilated bile ducts with no gallstones. He undergoes transhepatic cholangiography which demonstrates an obstructing lesion in the distal common bile duct. A decision is made to leave a catheter in the duct to drain the bile pending surgical evaluation. the first 48 hours after the catheter is placed it drains 1000 cc/24 hours. Study
Questions:
PROBLEM 3
A 36 year old man has undergone a total colectomy and proctectomy
for ulcerative colitis two years previously, and has an ileostomy
which usually drains about 800 cc per day. Two days before coming
to the hospital he developed crampy abdominal pain, bloating, and
began draining large quantities of liquid from his ileostomy.
Because of nausea and two episodes of vomiting he did not
take any food or liquids over the past 24 hours. Study
Questions:
PROBLEM 4
A postoperative patient is noted to be oliguric with urine output
of 10-15 cc/hr for the past eight hours. BUN and creatinine measurements reveal and increase from BUN
15 and creatinine of 1.0 to BUN of 40 and creatinine of 1.5.
The urine specific gravity is 1.030 and urine electrolytes
reveal a sodium of 2 Meq/1, potassium of 40 mEq/1. Study
Questions:
PROBLEM 5
A 65 year old man with known congestive heart failure treated with
digoxin and a diuretic undergoes an uneventful abdominal aortic
aneurysm repair with 1,000 cc of blood loss. During the four hours
of surgery he is administered 4,000 cc of lactated Ringer's solution.
During his first eight hours after surgery he is administered
1,000 cc of lactated Ringer's, has made 250 cc of urine and has
drained 200 cc from a nasogastric tube. Study
Questions:
PROBLEM 6 A 75 year old woman who lives alone was discovered lying on the floor of her apartment by her landlady. She is brought to the emergency room by ambulance, and does not respond to commands. Her blood pressure is 120/70, pulse is 110, respirations 30 and temperature is 37oC. She is moving all extremities. Her abdomen reveals a lower midline scar and a stoma in the left lower quadrant with dark yellow fluid in a stoma bag. Her past history is not available. Arterial blood gases are as follows: pH 7.25, p0285, pC0225. Serum electrolytes are Na 145, Cl 123, K 6.5, PC02 15, glucose 106. Study
Questions:
PROBLEM 7 An 18 year old man was in a motorcycle accident; he was not wearing his helmet. He suffered a severe closed head injury with diffuse swelling of both cortices. He remains comatose three days after injury and is noted to have a urine output of 500 cc per hour. The specific gravity of the urine is 1.000 and his serum electrolytes demonstrate a sodium of 155, chloride of 125, potassium of 4.5 and PC02 of 25 Study
Questions:
PROBLEM 8
A 55 year old woman with alcoholic cirrhosis and ascites is
admitted for upper intestinal bleeding.
Upper endoscopy reveals gastritis which is not actively bleeding.
She is admitted and given an intravenous of 5% dextrose and
0.2% NaCl at 125 cc/hr. Over
the next 24 hours her abdomen becomes tense and her urine output
is 15 to 20 cc per hour. Her
serum sodium has decreased from 132 on admission to 122 and she
is less responsive to verbal stimuli. Study
Questions:
PROBLEM 9
A 55 year old man fell from a scaffold which was toppled by a large
concrete block as it fell from a crane. His left leg was pinned under the concrete.
After extrication, his leg below the knee was pale and motionless
with moderate pain. The
patient was transported to your emergency room with a blood pressure
of 110/60, pulse 120, temperature 37.5oC, and respirations
of 25 noted on admission.
Insertion of a Foley catheter revealed dark brown colored
urine. EKG monitoring revealed peaked T waves. Serum electrolytes were Na 142, K 6.8, C1 106, PCO2
18. Serum BUN was 25,
creatinine 2.0. Study
Questions:
PROBLEM 10
A 66 year old woman with a history of asthma undergoes laparoscopic
cholecystectomy using narcotic anesthesia.
Her preoperative blood gases on room air are pH 7.42, p0275,
PCO245. Thirty
minutes after extubation the patient is noted to be somnolent with
shallow respirations and a pulse of 110.
A blood gas at this point reveals pH7.32, p02
225 on 50% face mask, pC0250. Study
Questions:
PROBLEM 11
A 74 year old presents to the Emergency Room with a chief complaint
of colicky abdominal pain of three days duration.
The patient has repeatedly vomited a foul-smelling fluid
for the past 48 hours. The
patient feels weak and is unable to get out of bed since today.
She has been unable to retain any water or fruit juice.
She has not voided for 12 hours.
She underwent total abdominal hysterectomy at age 60 for
a fibroid uterus. Physical examination:
weight is 143 lbs; height is 65"; blood pressure is 100
systolic; pulse is 114/minute; temperature is 99.2oF,
respirations 24/minute. The
abdomen is distended with a lower midline scar and tympanic. Bowel
sounds are hyperactive. There
is percussion tenderness in the left lower quadrant, as well as
involuntary guarding. The rectal ampulla is empty.
Laboratory studies: Hemoglobin = 16.8 gms, Hematocrit = 57%; WBC = 11,000; Na++=126 mEq/1 (N-135-154); K+3.4 mEq/1(N-3.5-5.0); C1-92 mEq/1(N-95-106); Anion gap 22 mEq/1(N-8-16), BUN 50 mg/dl(N-7-19); Creatinine 3.2 mg/dl(N-0.7-1.4); Arterial blood gases-pH 7.28(N-7.35-7.45); PaO288mmHg(N-75-100); PaCO238 mmHg(N-38-42); HCO3 12 mEq/1(N-16-24); Base excess-5; urine sp. gr. 1.031(N-1.003-1.025); urine pH 4.5(N-4.6-8.0). Study
Questions:
PROBLEM 12
A 64 year old man has surgical resection of an abdominal aortic
aneurysm with graft interposition.
The operation is difficult and six units of packed cells
are infused during the surgery.
The patient's blood pressure twice fell to 70 systolic during
the four-hour operation. Eight
liters of crystalloid were administered, 500 cc of fresh frozen
plasma, and 1,000 cc of Hetastarch.
The patient came to the intensive care unit with a systolic
blood pressure of 60 mmHG.
Three additional units of blood were given before his pressure
is over 100 mmHg systolic.
The patient made 100 cc of urine output during the case but
in the ICU is noted to be oliguric, with 5 to 10 cc of urine output
during the first four postoperative hours.
Mannitol, which was given in the operating room, was repeated
with no increase in urine output. During the next twelve hours six liters of crystalloid and
500 cc of packed red cells are administered resulting in 75 cc of
dark yellow urine. By
this time his hemoglobin and hematocrit have stabilized at 9.6 gms
and 27.8%. Laboratory
values are:
WBC
11,800 Urinalysis= Study
Questions:
PROBLEM 13
A 71 year old man is subjected to an open cholecystectomy.
After surgery he is extubated in the operating room and moved
to the recovery room. There
he becomes restless and arterial blood gases are drawn.
Blood gases are reported: PaO2 55 mmHg Study
Questions:
PROBLEM 14
A 24 year old man who weighs 60 kgm has a three year history
of Crohn's disease. At
the onset of his disease a distal small bowel resection and appendectomy
were performed for perforation of the terminal ileum and abscess.
Over the past two weeks he has developed fever, crampy, abdominal
pain, diarrhea and occasional vomiting, and he has lost 10 pounds
during this time. Physical exam reveals a
pulse of 100, a temperature of 38.5oC, a blood pressure of
120/70. His abdomen is
distended with active bowel sounds and minimal tenderness in the right
flank.
His laboratory studies reveal: Hb
13.5 Study
Questions:
PROBLEM 15
A 68 year old man underwent an elective sigmoid resection for carcinoma
seven days ago. On
day six a temperature to 39oC and lower abdominal pain
prompted a CT scan of the abdomen which revealed a left lower quadrant
abscess. The following
day the abscess was drained percutaneously and 100 cc of foul smelling
purulent material was removed.
His abdomen is distended with few bowel sounds.
He is anorectic. He
has not had anything more than clear liquids by mouth since his
operation. His albumin
is 2.5 gm/dl. Study
Questions:
PROBLEM 16
A 68 year old woman with a history of a 20 pound weight loss over
the past six months presents to the emergency room with a history
of passing bright red blood per rectum.
Her pulse is 95, her blood pressure 120/70. She has not seen a physician in 40 years. Study
Questions:
PROBLEM 17
A 24 year old man is in the operating room for a massive liver
injury sustained when his motorcycle hit a truck.
After one hour of surgery he has received 15 units of packed
cells and has developed diffuse oozing from the surface of his liver.
Clots are no longer forming.
His body temperature is 34oC. Study
Question:
PROBLEM 18
A 45 year old man is receiving the second of two units of packed
red cells 48 hours after elective hip surgery. After 50 cc of blood has been given, he develops a temperature
to 38.5oC and a pulse to 110. Study
Questions:
PROBLEM 19
A 22 year old man was driving drunk and without his seatbelt
fastened when he was involved in a single-vehicle automobile accident.
When attended by EMT personnel, no information was available
about the time of the accident.
He was found agitated and complaining of abdominal pain.
His airway was patent.
At the scene, he was breathing at 20 per minute with a blood
pressure of 90/60 and a pulse of 130.
He was placed in a hard cervical collar and on a back board
and transported to your emergency room.
Upon arrival his vital signs are the same, with a temperature
of 36oC. His
abdomen is markedly distended.
His hands and feet are cold, his legs mottled. A nasogastric tube reveals green liquid.
A urinary catheter reveals dark yellow urine.
His hemoglobin is 7.
His abdominal lavage reveals gross blood. Study
Questions:
PROBLEM 20
A 65 year old man with known coronary artery disease (myocardial
infarct three years earlier, currently taking a beta blocker) is
admitted with acute left lower quadrant pain of six hours duration.
His blood pressure is 90/50, pulse 120, respirations 18,
temperature 39oC.
He is flushed with warm hands and warm feet, his legs are
pink. Physical examination
reveals findings consistent with peritonitis in the left lower quadrant. Study
Questions:
A 55 year old man with stable angina which occurs twice a week
while walking uphill and is treated with nitroglycerin undergoes
an uneventful sigmoid resection for diverticular disease.
On postoperative day four he develops severe substernal chest
pain, sudden hypotension (85/55), tachycardia (120), and becomes
agitated. Physical
exam reveals total body mottling, cold hands and feet, distended
neck veins and an S3 gallop.
ECG demonstrates elevated ST-T wave segments in all of the
anterior leads. Study
Questions:
PROBLEM 22 A 35 year old man dove into three feet of water at a swimming pool,
did not emerge and was rescued by friends who performed CPR.
When the EMTs arrived they found the patient to have a blood
pressure of 80/50, pulse 100, and no spontaneous respirations, although
he was opening his eyes. They began ambu bag assistance of respiration and placed a
hard cervical collar. He
was placed on a back board and transported to your emergency room. Upon arrival he has the same vital signs with warm hands and
feet and pink extremities. Study
Questions:
PROBLEM 23 A 55 year old man who is steroid dependent, asthmatic, and diabetic
underwent a sigmoid resection and end sigmoid colostomy for perforated
sigmoid diverticulitis. There
was gross contamination of the entire abdominal cavity with large
intestine contents. During
the operation his blood pressure fell to 80 systolic.
After irrigation of the abdomen to clear debris, the abdominal
fascia was closed with running #2 nylon suture material and the
skin and subcutaneous tissue left open and packed with saline-moistened
gauze. Study
Questions:
Surgical
Infections/Antibiotics PROBLEM 24 A 55 year old woman undergoes an emergency cholecystectomy and common
duct exploration for acute cholecystitis and cholangitis.
E. coli, Klebsiella, and enterococcus grow out of the intraoperative
bile cultures. She
receives ampicillin and gentamicin preoperatively and this is continued
in the postoperative period through day four.
On day five she complains of increased pain in the stapled
skin closure site. She
has an increase in temperature from 38oC to 39oC,
and erythema and warmth are noted in the mid portion of the wound. Study
Questions:
PROBLEM 25 A 65 year old male diabetic has had pain in the perianal region for
three days. This morning
his wife found him unresponsive and called an ambulance. Upon arrival to the emergency room he has a blood pressure
of 90/50, pulse of 130, a temperature of 40oC and is
foul-smelling. Examination
of his perianal region reveals crepitus, bullae, and foul-smelling
liquid draining from a spontaneously draining abscess just lateral
to the right anal opening.
A pelvic x-ray demonstrates air in the soft tissues of the
perineum. Study
Questions:
PROBLEM 26 A 35 year old woman who was involved in a motor vehicle accident undergoes
a splenectomy for a severely injured spleen.
On postoperative day one she has a temperature to 38.5oC,
with physical exam demonstrating tubulo-vesicular breath sounds
and egophony at her left base.
Preoperatively administered cephazolin is discontinued after
two doses. Her temperature
over the next four days never goes below 38oC and on
day five increases to 39oC.
Her physical exam is unchanged.
Her abdomen is as distended as it was immediately postoperatively,
and she has passed little flatus.
Her wound looks normal.
She has little appetite and still requires intravenous fluid.
A urinary catheter is still in place.
Her WBC fell from 15,000 immediately postoperatively to 10,000
on day three. On day
five it is 18,000. Study
Questions:
PROBLEM 27 A 68 year old man with known COPD (FEV1 1.5 liters, pCO2
48 on room air) undergoes an uneventful resection of a 6cm abdominal
aortic aneurysm. However,
intubation was difficult and required three attempts.
One dose of preoperative cephazolin was given. Central vascular access wad placed during surgery but a pulmonary
artery catheter was not used.
On postoperative day one he fails extubation because of vocal
cord swelling and is urgently reintubated.
Despite the presence of a nasogastric tube, some gastric
contents are suctioned from the endotracheal tube.
He had been on H2 blockers since surgery.
His repeat chest x-ray shows bilateral pulmonary infiltrates. Blood gases on 50% FIO2, tidal volume 1000 and rate
12 are pO2 95 and pCO2 42.
No antibiotics are given.
Four days later he develops a temperature to 39oC
with no drop in blood pressure but an increase in pulse to 120.
His chest x-ray shows resolution of most of the infiltrates
except for those in the right lower lung field.
The central venous catheter is still in place. Urine output measured throughout with a bladder catheter is
30 cc to 40 cc per hour. His
blood gases drawn through the arterial line placed in the operating
room on 40% FIO2 and an IMV of 6 are pO2 of
105, pCO2 45. Study
Questions:
PROBLEM 28 A 19 year old man is brought into the emergency department following
a motorcycle accident in which he was thrown 20 feet.
Vital signs on admission to the emergency room are blood
pressure 90/60, pulse 140, respirations 24 and noisy.
He is unconscious, has a bruise over his forehead, there
is fresh blood flowing from a laceration in his right groin, and
his left leg is twisted in a deformed angle. Study
Questions:
PROBLEM 29
A 26 year old man sustained a stab wound to the left chest just
below the mid-clavicle. His
blood pressure is 70/50. He
is cyanotic. His neck
veins are markedly distended, and there is minimal external bleeding. Study
Questions:
PROBLEM 30 A 45 year old woman who was wearing a lap seat belt is involved in
a head-on automobile collision.
She is awake and complains of abdominal pain. She is slightly pale and has a blood pressure of 110/80.
There is a bruise across her upper abdomen, with slight guarding
and moderate tenderness to palpation. Study
Questions:
PROBLEM 31 A 16 year old boy falls from a tree and lands on his head.
He is found unconscious at the scene with vital signs of
blood pressure 120/80, pulse 90, and spontaneous respirations at
16. In the emergency
room his vital signs are the same, but he is mumbling incoherently
and there is an enlarging hematoma on his forehead.
He does not respond to verbal stimuli.
He opens his eyes to painful stimuli and has a flexion response
in both upper extremities.
There are no other apparent injuries on physical examination,
and there are no focal neurological signs. Study
Questions:
PROBLEM 32
Study
Questions: Part
B Study
Questions: Part
C Study
Questions: Part
D Study
Questions:
PROBLEM 33
You are called to the emergency room of your 70 bed community
hospital because there has been an explosion at the chemical plant
which is your community's sole industry.
The first patient's you see are described below:
The major medical center to which your hospital normally refers complicated cases is located approximately 30 miles away. Study Questions:Which of these patients may be treated appropriately as an outpatient? Which of these patients may be treated appropriately in your own hospital? Which of these patients should be referred to the burn center? What therapeutic steps will you take before transferring any patient to the burn center?
PROBLEM 34 Head Trauma Study
Questions:
PROBLEM 35 Brain Death Part
A Study
Questions: Part
B Study
Questions:
PROBLEM 36 A 25 year old asymptomatic woman
on routine physical examination is referred to a surgeon with a
firm 1 cm nodule in the lower neck just to the right of the midline.
It was nontender and moved up and down with swallowing. Study
Questions:
PROBLEM 37 A
young woman presents with complaints of palpitations, insomnia,
weight loss and irritability.
She further reveals heat intolerance and increased swelling.
Physical examination reveals hand tremor, a pulse of 110,
and a smoothly enlarged thyroid.
Her T4 level is twice normal. Study
Questions:
PROBLEM 38 A 50 year old woman is admitted
with renal colic and investigation reveals hypercalcemia. Study
Questions:
PROBLEM 39
A 35 year old man has blood chemistries drawn at
the time of a yearly physical examination.
His calcium was noted to be elevated and a parathyroid hormone
level is increased. Study
Questions:
PROBLEM 40 A 30 year old woman with hypercalcemia
is referred to you. She
has a very high PTH level.
The serum phosphatase level is decreased.
The patient's mother had parathyroid surgery for hypercalcemia. Study
Questions:
PROBLEM 41 A 69 year old man presents who
has difficulty swallowing solid foods, some substernal discomfort
and a 15 pound weight loss.
All of these symptoms have been present for six weeks.
His physician is most concerned that these symptoms are secondary
to esophageal carcinoma. Study
Questions:
PROBLEM 42 A 46 year old woman is seen with
a history of hiatus hernia and esophageal reflux treated medically
1 year ago with relief of symptoms.
Over the year she gained 20 pounds and over the past several
weeks has noted a return of symptoms. Study
Questions:
PROBLEM 43 A 75 year old man complains of
severe halitosis and the regurgitation of undigested food hours
after eating. He has had this problem progress over the past two years and
over the past six months has lost 10 pounds. Study
Questions:
PROBLEM 44 A 24 year old woman, who is highly
anxious, visits your office with her mother.
The mother states that her daughter has had considerable
difficulty swallowing both liquids and solids resulting in a drop
in weight from 120 to 105 pounds in six months.
Neither substance seems to pass easily from mouth to stomach.
They visited another doctor who prescribed "nerve pills"
without relief. Study
Questions:
PROBLEM 45 A 40 year old woman with no family
history of breast disease comes to your office with a complaint
of a left breast mass of one month duration.
She has regular periods, and no change in the mass was noted
through one menstrual cycle.
The mass is located in the upper outer quadrant of the left
breast. It is smooth,
non-tender with no skin retraction, no fixation to the chest wall,
and the axilla is negative. Study
Questions:
PROBLEM 46 A 35 year old woman with a previously
removed fibroadenoma of the right breast comes to your office complaining
of a similar-feeling mass in the left breast.
The referring physician did a needle aspiration which revealed
no fluid and non-diagnostic material on cytologic examination. Physical exam reveals a rubbery, freely mobile 1-cm mass just
to the left of the areola in the left breast.
The mass is nontender. Study
Question:
PROBLEM 47 A 48 year old woman with irregular
menses has noted a painful mass in the upper outer quadrant of the
right breast which is particularly painful during her periods.
On physical exam there is a tender 3-cm mass which is not
fixed to the chest wall. Study
Question:
PROBLEM 48 A 70 year old woman with a 2-cm
mass in the right breast of three months duration has a needle aspiration
cytology positive for malignant cells. Study
Questions:
PROBLEM 49
An 80 year old woman with a breast mass of
undetermined duration is brought to your office because of a foul-smelling
growth in the left breast.
Examination reveals a necrotic 6-cm mass in the left breast
with a foul-smelling exudate.
The mass is fixed to the chest wall and is an obvious malignancy.
The left axilla contains a 3 to 4 cm mass of matted lymph
nodes. Study
Questions:
BILIARY
TRACT PROBLEM 50 A 19 year old woman presents with
history of intermittent epigastric and right upper quadrant pain
which occurs about 15 minutes after eating and lasts for one to
two hours. This pain has been happening for about one month, two
to three times a week, especially after eating french fries.
She is 5 ft. 4 inches tall and weighs 130 pounds.
She has never been pregnant and is currently taking birth
control pills. Physical examination is normal.
An ultrasound of the gallbladder demonstrates multiple small
stones. Study
Questions: What factors predispose to the formation of gallstones?
PROBLEM 51 A 36 year old woman presents to
the emergency room with a history of right upper quadrant pain,
shaking chills, and jaundice.
This pain came on suddenly six hours earlier and has been
progressing. She took
her temperature at home and it was 102.
She vomited once at the onset of the pain.
She has had intermittent episodes of epigastric and right
upper quadrant pain after eating for the past six months.
The pain always abated after thirty to sixty minutes.
Her blood pressure is 110/60, her pulse 110, and her temperature
39 in the emergency room. Study
Questions:
PROBLEM 52 A 74 year old woman presents with
a complaint of jaundice which her husband noticed two days before.
She has had no specific pain but has noted post prandial
epigastric discomfort which has not responded to antacids. She has lost 20 pounds over the past three months, but is on
a diet. Physical exam
reveals an obviously icteric woman with a non-tender globular mass
in the right upper quadrant. Study
Questions:
PROBLEM 53 A 44 year old woman who weighs
160 pounds and has four children comes to the emergency room complaining
of severe epigastric pain, which has lasted for three hours and
radiates straight to the back.
The pain began suddenly, but was less severe at the beginning.
She has vomited clear material three times.
She drank five to six mixed drinks earlier, with the last
drink about two hours before the pain began.
She has been on a diet and has been told that she has elevated
fat in her blood but has not taken any medicines.
Her 38 year old sister had her gallbladder removed. Physical
exam reveals a pulse of 110, blood pressure of 120/70, respirations
16 and temp of 38.3. Her
abdomen is distended in the epigastrium, bowel sounds are hypoactive,
she has percussion tenderness, involuntary guarding, and referred
tenderness in the epigastrium.
A flat and upright abdomen x-ray reveals a dilated transverse
colon with no free air. Her
hemoglobin is 15, her WBC 15,000.
Her serum amylase is 2,000.
She is admitted with a diagnosis of acute pancreatitis. Study
Questions:
PROBLEM 54
A 50 year old male alcoholic presents
to your office with chronic, nagging epigastric pain.
It has been recurrent several times within the last decade.
He denies hematemesis, diarrhea or jaundice, but admits to
weight loss (about 20 pounds in the last six months) and continuing
alcohol intake. Flat
plate of the abdomen reveals pancreatic calcifications. White count and amylase are normal. Study
Questions:
PROBLEM 55
A 35 year old male alcoholic is seven days into an episode of moderately
severe pancreatitis (four Ranson's criteria).
His fluid sequestration has resolved and his serum amylase
has fallen from 1000 on admission to 250 on day 7 (normal up to
200). His nasogastric
tube drains 750 to 1000 cc per day.
He has a low grade temperature (38), a pulse of 100, and
fullness in the epigastrium which is slightly tender.
The severe epigastric pain and peritonitis present on admission
have disappeared. The
rest of his abdomen is soft with normoactive bowel sounds present.
His WBC has fallen from 15,000 on admission to 10,000. An abdominal CT scan shows better definition of the pancreas
compared to the CT on admission with an apparent fluid collection
in the lesser sac. Study
Questions:
PROBLEM 56
A 40 year old female alcoholic with known
chronic pancreatitis and pain treated with intermittent courses
of narcotics comes to your office complaining of increased pain
and a tender fullness in her left upper quadrant which has been
present for about a week. Her appetite is diminished and she complains of early satiety.
She has lost 15 pounds over the last month. She
is afebrile with a pulse of 80 and blood pressure 120/80.
Her abdominal exam reveals a mass about 5 cm in diameter
in the left upper quadrant which is slightly tender.
Her WBC is 7000, her hemoglobin 12. Study
Questions:
PROBLEM 57
A 65 year old retired executive presents with jaundice, epigastric
pain, mid-back pain and weight loss. Physical exam demonstrates obvious jaundice and a globular
mass in the right upper quadrant. Study
Questions:
PROBLEM 58 A 27 year old woman was involved in a motor vehicle accident; she was
driving the vehicle and was not wearing her seatbelt.
On arrival to the emergency department, she is mildly disoriented,
her blood pressure is 120/60 mm Hg, and her heart rate is 100 per
minute. She has alcohol
on her breath. Physical
examination reveals ecchymosis and tenderness in the left lower
chest area. Her abdomen
is non-tender. Chest
x-ray shows 7th, 8th and 9th rib fractures on the left. Study
Questions:
PROBLEM 59 A 24 year old man sees an internist for complaints of fatigue and jaundice. He has noted intermittent right upper quadrant pain, usually after eating fatty foods. His urine turned dark three days ago. He has no pain or fever at present. On physical examination there is scleral icterus and his spleen is noted to be enlarged enough to feel just below the costal margin. His hemoglobin is 8.0 and white blood count 7,000. The platelet count is 170,000. Study
Questions:
PROBLEM 60
A 35 year old woman sees her gynecologist for increased menstrual
bleeding. She complains
of bruises which come following minimal trauma.
On physical examination her gynecologist notices petechiae
on her legs and arms. Her
uterus and ovaries feel normal.
She is not pregnant.
Her hemoglobin is 11 and her platelet count is 20,000.
Her prothrombin time and partial thromboplastic time are
normal. Study
Questions:
PROBLEM 61
A 65 year old man sees his internist for complaints of fatigue,
weakness, and increasing abdominal size. On physical examination his spleen is markedly enlarged, extending
to the left iliac crest. His
liver is palpated two fingerbreaths below the costal margin.
His hemoglobin is 9.9, white blood count 4,500, and his platelets
100,000. Study
Questions:
PROBLEM 62
A 25 year old man presents to your office with a complaint of an
intermittent bulge in his right groin, which occurs with heavy lifting,
but which goes back in easily. Study
Questions:
PROBLEM 63 An
80 year old woman presents to the emergency room with a three-day
history of intermittent abdominal distension and vomiting.
On physical exam she appears slightly dehydrated.
Her abdomen is distended and tympanitic to percussion but
without evidence of peritonitis.
A bulge is noted in the right groin, slightly inferior to
the inguinal ligament. Study
Questions:
PROBLEM 64 You perform surgery for a perforated
duodenal ulcer in a 70 year old man who has a history of steroid-dependent
chronic obstructive pulmonary disease.
Postoperatively, he develops an infection of his upper midline
abdominal incision. After
the wound is fully healed, the patient presents back to your office
with complaint of a bulge in the incision, with straining.
You make a diagnosis of incisional hernia. Study
Questions:
PROBLEM 65 A woman brings her two month old
infant to your office with complaint of a umbilical hernia.
The child is otherwise healthy.
On physical examination you find a 1 x 1 cm bulge at the
umbilicus. This is
easily reducible and you palpate a fascial defect the size of your
small finger. Study
Questions:
PROBLEM 66 Patient A:
A 44 year old woman comes to the emergency room with a complaint
of upper abdominal pain of four hours duration.
The pain came on 30 minutes after eating a hamburger and
french fries. She vomited
once at the beginning of the pain and at present still has nausea.
The pain has been gradually getting worse, yet has periods
when it seems to subside, but not disappear.
She points to the entire upper abdomen to describe the location
of the pain. The region
of her right shoulder blade hurts.
She cannot seem to find a comfortable position and is continuously
moving. Patient
B: A 50 year old male
alcoholic was drinking whiskey this morning when he developed upper
abdominal pain. He
vomited the alcohol and could not drink anything further.
The pain increased steadily with no periods of relief.
The pain is most severe in one spot, high in the epigastrium.
The pain travels through to his back and he feels better
when sitting up and leaning forward.
Otherwise, he does not want to move. Study
Questions:
PROBLEM 67 Patient A:
A 70 year old man with a complaint of left lower quadrant
pain exhibits the following physical examination:
Blood pressure 120/80, pulse 100, temperature 38.5o,
respirations 16. He
is lying still with his left leg flexed at the hip.
He is silent. Inspection
of the abdomen reveals lower abdominal distention with no masses
and no scars. Auscultation reveals diminished bowel sounds.
Percussion is tender in the left lower quadrant.
Palpation demonstrates involuntary guarding in the left lower
quadrant. Palpation
in the right lower quadrant produces discomfort in the left lower
quadrant. Rectal exam is tender on the left with stool hemetest negative. Patient
B: A 55 year old
woman who complains of abdominal pain and vomiting exhibits the
following physical examination:
blood pressure is 120/70, pulse is 90, temperature 37o,
respirations 12. She
sits up, then lays down, then moves on one side, then the other.
She periodically moans with increased pain, then seems relieved.
Inspection reveals diffuse abdominal distention with a scar
in her lower midline. Auscultation
reveals hyperactive bowel sounds. Percussion demonstrates tympany throughout with no tenderness.
Palpation reveals diffuse voluntary guarding.
Rectal exam is non-tender, there is no stool in the vault. Study
Questions:
PROBLEM 68 A 55 year old man who is in general
good health arrives by ambulance with a complaint of severe, progressing
abdominal pain which came on suddenly three hours earlier.
His blood pressure is 90/50, pulse 130, temperature 38oC,
respirations 16. His
physical examination reveals abdominal distention, no bowel sounds,
and involuntary guarding throughout, a "board-like abdomen."
An upright chest x-ray reveals free air under the diaphragm.
Study
Question:
PROBLEM 69
A 64 year old man presents to the emergency room complaining of
having passed a cup of blood per rectum into the toilet.
He has had no pain, but was frightened by the blood.
He denies previous bleeding but has a history of hemorrhoids.
His medical history is significant for stable angina for
which he takes an occasional nitroglycerin and chronic obstructive
lung disease for which he uses an inhaler. Study
Questions:
PROBLEM 70 You find hemetest positive stool
in a 57 year old man during his yearly office visit.
The prostate was smooth and slightly enlarged.
No mass was palpated in the rectum.
He had smoked for 40 years, but stopped three years ago because
of progressing COPD. He
currently uses theophylline and inhalers.
Twice in the past year he has required steroids for exacerbations
of bronchospasm. He
is on quinidine for a supraventricular arrhythmias. He has been
depressed since losing his wife to cancer eight months ago. Study
Questions:
PROBLEM 71 A 45 year old Native American
woman presents with her first episode of hemetemesis.
At the Indian Health Service Hospital she is noted to have
a blood pressure of 80/40 and a pulse of 120.
After initial irrigation of blood and clots, nasogastric
tube drainage continues to demonstrate active bleeding.
She is transferred 30 miles to your hospital because of the
acuteness and severity of her illness.
Upon arrival to your emergency room, her blood pressure and
pulse are still 80/40 and 120, respectively, despite the administration
of two units of packed cells during transfer. Study
Questions:
PROBLEM 72 A 40 year old male business executive, with a history of ethanol consumption consisting of one mixed drink a day, and two pack-per-day smoking habit, presents to your office with a history of intermittent epigastric pain. The pain is burning in character, usually occurs three to four hours after eating and is relieved by food intake. The physical examination is normal. Workup includes an upper GI series which reveals a duodenal ulcer. You
institute therapy on this patient.
He does not come back for his scheduled appointment in two
weeks, but instead presents three weeks later to the emergency room
with hematemesis. His
blood pressure is 110/70 with a pulse of 100 lying down. This changes
to 90/50 and 130 when sitting and he complains of being lightheaded. Study
Questions:
PROBLEM 73
A 70 year old woman presents to your office
with a history of weight loss, decreased appetite and epigastric
discomfort. Examination
reveals her to be thin but ne cachectic and the stools to be positive
for occult blood. An
upper GI series reveals a gastric ulcer on the greater curvature. Study
Questions:
PROBLEM 74 A 70 year old woman presents to
your office with a history of weight loss, decreased appetite and
epigastric discomfort. Examination
reveals her to be thin but not cachectic and the stools to be positive
for occult blood. An
upper GI series reveals a gastric ulcer on the greater curvature.
Upper endoscopy reveals an ulcer with an irregular border. Biopsies are positive for adenocarcinoma. Study
Questions:
PROBLEM 75 A 30 year old woman comes to your
office complaining of epigastric pain and vomiting which have been
present for six months. Food
relieves some of the discomfort.
She underwent an upper GI series three months ago which demonstrated
a large duodenal ulcer and accentuated rugal folds.
Therapy with cimetidine and ranitidine have not relieved
the symptoms. She has
lost 15 pounds in the last month and has loose bowel movements three
times a day. There
has been no blood in the bowel movements or black stools.
Physical examination demonstrates a thin female with mild
tenderness to palpation in the epigastrium.
Stool is negative for occult blood. Study
Questions:
PROBLEM 76 A 60 year old male diabetic on dialysis for chronic renal failure develops severe, sudden epigastric pain while on dialysis. His blood pressure drops from 110/80 to 90/60 and his pulse increases to 120 from 90. Dialysis is stopped and he is given 1000 cc of normal saline with increase in blood pressure to 120 systolic and pulse decrease to 100. He refuses to move and wants to stay flat in bed. Physical exam reveals mild distention, absent bowel sounds, and diffuse involuntary guarding. A flat plate x-ray of the abdomen is unremarkable. A left side down lateral decubitus x-ray demonstrates free air over the liver. Study
Questions:
PROBLEM 77 A 22 year old woman presents with
a two-day history of increasingly severe abdominal pain.
The pain began in the periumbilical region, and after 24
hours migrated to the right lower quadrant where it has remained.
She has vomited three times and has had a poor appetite.
Bowel movements are normal.
There are no urinary symptoms.
Her last menstrual period was two weeks ago.
She is sexually active, and she has noted a foul-smelling
vaginal discharge during the past week. On physical examination, the patient has a temperature of 101oF and is in moderate abdominal stress. There is significant guarding and tenderness in the right lower quadrant, and slight tenderness without guarding in the left lower quadrant. On bimanual vaginal examination there is mild tenderness on motion of cervix; no adnexal masses are palpable. Study
Questions:
PROBLEM 78 A five year old boy presents with
abdominal pain of four days duration.
Three days ago his parents took him to his pediatrician because
he had a fever of 102oF, was complaining of a "bellyache,"
and was vomiting. The
parents were told that the boy probably had gastroenteritis, that
he should be given a clear liquid diet and that the symptoms would
resolve. Instead, the
boy has become increasingly ill with worse abdominal pain.
He continues to vomit and his temperature has reached 104oF. On
examination, the child appears to be dehydrated and he lies on his
side quite still with his knees drawn up. The abdomen is distended, with a diffuse guarding and tenderness.
Rectal examination reveals tenderness and fullness anteriorly.
A surgeon is consulted and takes the child to the operating
room with a preoperative diagnosis of perforated appendicitis. Study
Questions:
PROBLEM 79 A 14 year old boy presents with
a two-day history of suprapubic and right lower quadrant pain.
He has localized guarding and tenderness, and surgery is
performed for suspected appendicitis.
At operation the appendix appears to be normal, but an acutely
inflamed Meckel's diverticulum is noted. Study
Questions:
PROBLEM 80 A 54 year old man is admitted
to the hospital because of crampy abdominal pain and bilious vomiting
that has lasted for three days.
He has not had a bowel movement or flatus for two days.
Ten years ago he had an appendectomy for a perforated appendicitis,
with no postoperative complications.
Physical examination reveals a pulse of 100, blood pressure
of 110/60, temperature 37.5oC.
His abdomen is distended with hyperactive bowel sounds and
tympany throughout. There
is no abdominal tenderness to palpation. His hemoglobin is 15.4, WBC 10,000. Study
Questions:
PROBLEM 81 A
65 year old man presents to the emergency room with a five-day history
of left lower quadrant pain and a 24 hour history of fever.
He has a long history of constipation for which he occasionally
takes a laxative. He
has not had any recent change in his bowel habits.
He saw his private MD three days ago and was started on an
unknown antibiotic, taken orally.
On physical examination his temperature is 38.5oC,
heart rate is 78, blood pressure is 145/85.
He is moderately tender in the left lower quadrant but has
no peritoneal signs. WBC
count is 14,500 with five bands. Study
Questions:
PROBLEM 82 A 55 year old obese man with known
diverticular disease discovered at a colonoscopy for hemetest positive
stool, comes to the emergency room complaining of severe left lower
quadrant pain of four hours' duration.
Prior to the severe pain he had crampy, poorly localized
lower abdominal pain and nausea which progressed to severe, well
localized left lower quadrant pain. His temperature is 38.5, his pulse 100, his blood pressure
120/70. He is distended
with decreased bowel sounds and tympany.
He demonstrates percussion tenderness and involuntary guarding
in the left lower quadrant.
Rectal exam reveals hemetest negative stool and tenderness
on the left. His WBC
is 15,000. Study
Questions:
PROBLEM 83 A 60 year old woman presents in
the emergency room with a complaint of sudden onset of painless
bright red blood per rectum which has occurred three times in two
hours and is associated with feeling faint when standing.
She has no previous significant medical or surgical history
and is not taking aspirin or anticoagulants.
Physical exam reveals a pulse of 110 supine with a blood
pressure of 100/60. These
change to a pulse of 130 and a blood pressure of 90/50 when sitting.
Her temperature is 37.
Her abdomen is not distended nor tympanic.
There is no abdominal tenderness.
Rectal exam demonstrates frank blood with clots with no obvious
hemorrhoidal disease. Study
Questions:
PROBLEM 84 A 72 year old man presents to
your office for a routine physical.
On physical examination you find guaiac positive stool but
are unable to feel any masses. He has no history of ulcer disease. Study
Questions:
PROBLEM 85 A 65 year old man has a complaint
of crampy lower abdominal pain and constipation.
His physician finds hemetest positive stool with no rectal
mass and recommends a colonoscopy.
At colonoscopy a large, friable mass partially obstructing
the sigmoid colon at 35 cm is biopsied and is positive for adenocarcinoma.
No other colonic lesions are noted. Study
Questions:
PROBLEM 86 A 45 year old woman has just moved
to town and has a 18 year history of "colitis".
She comes to your office because she's been told that she
needs close follow-up. She
does not know if she has Crohn's colitis or ulcerative colitis,
but she is fairly sure it is one of the two.
She complains of two to three loose bowel movements per day
that occasionally contain mucous and/or blood.
Her medical history is otherwise negative. Study
Questions:
PROBLEM 87
A 95 year old woman is sent to the emergency
room from a nursing home with complaints of abdominal pain and distention.
It is unclear, but staff at nursing home think it has been
about four days since she had a bowel movement.
On examination, the woman has an expressive aphasia and a
right hemiparesis from a previous stroke.
Her vital signs are pulse 90, blood pressure 120/80, and
she is afebrile. Her
abdomen is markedly distended with hyperactive bowel sounds and
tympany throughout. There
is no abdominal tenderness. Rectal
exam reveals large quantities of soft, brown, guaiac negative stool.
KUB and upright reveal marked dilated colon consistent with
obstruction. Study
Questions:
PROBLEM 88 A 21 year old man complains of
severe pain in his anal area, especially after a bowel movement.
He reports no history of trauma or anal intercourse.
He has no history of fever. He is otherwise healthy. Study
Questions:
PROBLEM 89 A 65 year old man, in previous
good health, has undergone an uneventful sigmoid resection for colon
carcinoma. During the operation his blood pressure fell into the 90's
systolic despite only 250 cc of blood loss, and he required five
liters of crystalloid to maintain a systolic pressure above 100
and a urine output of 50 cc per hour.
During the first 18 hours after surgery he has required an
additional 8 liters of fluid.
His temperature is 38.8 the morning after surgery.
After this eighteen hour period his hemoglobin is 12.2 (13.5
pre op), his sodium is 130, potassium 5.5., chloride 105, PCO2
24. His WBC is 14,000
with 65 polys, 10 bands, 15 lymphs, and 10 eosinophils. Study
Questions:
PROBLEM 90 A 24 year old man with a three
year history of Crohn's disease of the terminal ileum comes to the
hospital complaining of nausea, vomiting, and diarrhea of three
days duration. He had
been exposed to friends with a viral gastroenteritis seven days
earlier. His symptoms
of Crohn's disease has been crampy abdominal pain and loose bowel
movements for which he intermittently received up to 30 mg of prednisone
a day. His last prednisone
therapy was six months ago.
At this time the diarrhea is more severe than his usual and
he has felt lightheaded. His
blood pressure is 90/60 sitting, 110/70 lying flat.
Corresponding pulses are 120 and 105.
His temperature is 38.
His abdomen is slightly distended with hyperactive bowel
sounds and is nontender. His
hemoglobin is 15, WBC 12,000 with 75 polys 10 bands, 8 lymphs and
7 eosinophils. His
serum sodium is 130, potassium 5.5, chloride 105, and pCO2 22. His BUN is 30 with a creatinine of 1.2. Study
Questions:
PROBLEM 91 A 37 year old woman with a diagnosis
of hypertension for one year treated with salt restriction comes
to your office complaining of fatigue and weakness.
Her menstrual bleeding has been increased for the last three
months. Physical exam
demonstrates a blood pressure of 150/90.
Her BUN is 25 with a creatinine of 1.0
Her sodium if 140, potassium 2.7, chloride 100, and pCO236. Study
Questions:
PROBLEM 92 A 16 year old woman is referred
to you for a thyroid nodule discovered during a routine physical
examination. Her mother
died at age 38 of thyroid cancer.
The patient has a blood pressure of 140/80.
You perform needle aspiration cytology on the thyroid nodule
which is consistent with medullary carcinoma. Study
Questions:
PROBLEM 93 A 67 year old man presents in
the ER with the sudden onset of severe back and abdominal pain and
a syncopal episode. BP
100/60, P 110, R 24. Physical examination reveals a pale, disphorectic
anxious man with a tender pulsatile abdominal mass. Study
Questions:
PROBLEM 94 A 64 year old woman presents in
the ER with a one-hour history of severe left leg pain and numbness.
Examination shows a pale, cool leg without palpable pulses.
The right leg is normal with palpable pulses. Study
Questions:
PROBLEM 95
A 44 year old lawyer is referred to you for a chronic ulcer
over his right lateral malleolus.
He is an obese, non insulin-dependent diabetic who smokes
1.5 packs of cigarettes per day.
The ulcer has been present for six months and is painful,
especially at night. He
has a two year history of progressive calf, thigh and buttock claudication
to the point that he can now walk only 200 yards before having to
stop and rest. Physical
examination reveals an obese male in no distress.
BP 180/100 in both arms.
A left carotid and bilateral femoral bruits are noted.
No peripheral pulses are palpable in the lower extremities
below weak femorals. A
1.5 cm ulcer is present over the later malleolus of the right ankle. Study
Questions:
PROBLEM 96 A
72 year old woman complains of a sudden episode of left-arm and
left-hand weakness which lasted only a few minutes on the previous
evening. She also reports
several episodes of transient partial blindness in her right eye
over the past few months.
On physical examination she has bilateral carotid bruits.
The remainder of her vascular examination and a careful neurologic
examination are normal. Study
Questions:
PROBLEM 97 You are called to see 32 year
old man who complains of the sudden onset of respiratory distress
six days following open reduction and internal fixation of a right
femoral and bilateral tibial fractures sustained in an auto accident.
On examination the patient is cyanotic, dyspneic, tachypneic,
and hypotensive with a BP of 90/60. Study
Questions:
PROBLEM 98 A 44 year old woman presents with
a swollen ulcerated left leg.
She has had a moderately swollen leg for many years following
a knee injury. The ulcer began with an abrasion from a minor injury six months
ago, which has progressed to a large infected ulcer measuring 8
x 15 cm over the lower medial aspect of the leg.
In addition to the ulcer, there are numerous varicose veins
in the left leg which is 5 cm greater in circumference compared
to the right leg at both the ankle and calf level. Study
Questions:
PROBLEM
99 A
48 year old woman with mild hypertension was in a motor vehicle
accident and sustained chest wall contusion and a severe head injury.
There are no abdominal or extremity injuries noted.
The patient has been managed by the neurosurgical service
with Mannitol, hyperventilation and fluid restriction.
Heart rate is 118, blood pressure is 105/55, urine output
has been > 200 cc per hour. Study
Questions:
PROBLEM
100 A
28 year old man comes to your office.
He underwent an orthotopic liver transplant eight weeks prior,
and has noticed a feeling of lethargy, joint aches, low-grade temperatures
to 38.1oC, and has been eating normally.
The patient is currently on Cyclosporin, Imuran and Medrol
for immunosuppression. Labs
on admission show a creatinine that has risen to 3.2, bilirubin
that has risen from a baseline of 1.8 to 2.1, and a white count
of 4.8. Study
Questions:
PROBLEM 101
A 72 year old man presents with a firm mass measuring 4 cm, located
approximately 3 cm superior to the gluteal crease over the sacrum.
Ten years previously, he had a colon carcinoma resected and
then underwent a full course of radiation therapy to his pelvis. Study
Questions:
PROBLEM 102 A 16 year old woman presents with
a non-tender 2 cm mass in her left anterior neck. This mass had
been present for several weeks and has not changed. Study
Questions:
PROBLEM 103
A 22 year old man with left axillary adenopathy, night sweats, and
a five-pound weight loss, has had an axillary lymph node removed
which revealed Hodgkin's disease. Study
Questions: |
