Exam 4: Surgery

A 75-year-old woman comes to the emergency department due to fever, chills, abdominal pain, nausea, and vomiting for the past 2 days.  She did not eat anything unusual, and no one else at her home is sick.  The patient has no diarrhea, dysuria, or urinary frequency.  Medical issues include type 2 diabetes mellitus, hypertension, obstructive sleep apnea, and coronary artery disease.  Temperature is 38.9 C (102 F), blood pressure is 130/80 mm Hg, pulse is 104/min, and respirations are 18/min.  Oxygen saturation is 94% on room air.  BMI is 32 kg/m².  On physical examination, the patient appears acutely unwell.  The oropharynx has dry mucous membranes, and dentition is poor.  Cardiopulmonary examination shows normal lung and heart sounds.  Abdomen is mildly distended.  There is marked tenderness over the epigastrium and right upper quadrant with guarding.  Bowel sounds are decreased.  The extremities have no cyanosis or edema.  Laboratory studies are as follows. Abdominal ultrasonogram reveals thickening of the gallbladder wall, pericholecystic fluid, and multiple hyperechoic calculi.  Air is noted within the gallbladder wall, and the common bile duct is not dilated.  Intravenous fluids, insulin, analgesics, and broad-spectrum antibiotics are initiated.  Which of the following additional intervention is most appropriate in the management of this patient?

A 54-year-old woman comes to the emergency department due to bright red blood per rectum.  She reports passing 3 large, bloody stools over the past 2 days, which have been associated with mild abdominal cramps.  The patient has no melena, fever, vomiting, or unexpected weight changes.  She underwent a radical hysterectomy and adjuvant radiation therapy for cervical cancer over 12 months ago.  The patient has no other medical conditions and takes no medication.  Temperature is 37.5 C (99.5 F), blood pressure is 140/80 mm Hg, pulse is 80/min, and respirations are 12/min.  Cardiopulmonary examination is unremarkable.  The abdomen is nontender and nondistended.  Extremities are warm and well perfused.  Laboratory results are as follows: A colonoscopy is performed and shows mucosal pallor, friability, and multiple telangiectasias, all of which are confined within the rectum.  Scattered diverticula are present but limited to the descending and transverse colon.  Which of the following is the most likely diagnosis?

A 35-year-old man comes to the office due to a progressive increase in breast size over the past 6 months.  He is sexually active, has no chronic medical conditions, and takes no medications.  The patient does not use tobacco, alcohol, or illicit drugs.  Vital signs are normal.  BMI is 28 kg/m².  Gynecomastia with mild bilateral breast tenderness is present.  Genitourinary examination reveals a 1-cm nodule in the right testis.  The examination is otherwise normal.  Laboratory results are as follows: Which of the following is the most likely diagnosis in this patient?