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A 48-year-old female undergoes a left lumpectomy and sentinel lymph node biopsy for an invasive ductal carcinoma. Pathology reveals a 2.2 cm tumor with clear surgical margins. Immunohistochemistry shows Estrogen Receptor (ER) negative, Progesterone Receptor (PR) negative, and Human Epidermal Growth Factor Receptor 2 (HER2) strongly positive (3+ by immunohistochemistry). The sentinel node biopsy is negative for metastatic disease (0/2 nodes). What adjuvant systemic therapy regimen is most appropriate for this patient?

General Surgery Problems

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A 45-year-old diabetic female presents with a 24-hour history of severe, constant right upper quadrant pain, radiating to the right scapula, accompanied by nausea and low-grade fever (37.9°C). On examination, she has marked tenderness in the right upper quadrant with a positive Murphy's sign. Lab results show a white blood cell count of 14.8 x 10^9/L and mildly elevated C-reactive protein. Transabdominal ultrasound reveals a distended gallbladder with a thickened wall (5 mm), pericholecystic fluid, and multiple gallstones, with one impacted in the gallbladder neck. What is the most appropriate management?

General Surgery Problems

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A 78-year-old female with a history of recurrent biliary colic presents with a 3-day history of progressive abdominal distention, colicky abdominal pain, and obstipation. On examination, she is dehydrated and has a distended, tympanitic abdomen with hyperactive bowel sounds. Plain abdominal radiograph reveals dilated small bowel loops with air-fluid levels, pneumobilia (gas in the biliary tree), and an oval radiopaque shadow in the right iliac fossa. What is the diagnosis and the most appropriate surgical treatment?

General Surgery Problems

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A 52-year-old male with severe acute necrotizing pancreatitis secondary to gallstones remains in the intensive care unit. On day 21, he develops high fevers (39.0°C), worsening leukocytosis (22.5 x 10^9/L), and hemodynamically unstable septic shock. A contrast-enhanced CT scan of the abdomen reveals a large area of pancreatic necrosis (approximately 40%) in the pancreatic body and tail containing loculated gas bubbles. What is the most appropriate management strategy?

General Surgery Problems

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A 38-year-old male with a strong family history of colon cancer presents for genetic counseling. His father was diagnosed with colon cancer at age 42, and his paternal aunt was diagnosed with endometrial cancer at age 45. Microsatellite instability (MSI) testing of his father's stored tumor specimen shows high microsatellite instability (MSI-H), and immunohistochemistry reveals loss of MSH2 and MSH6 protein expression. Which genetic condition does this pedigree most likely represent, and what is the gene defect?

General Surgery Problems

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A 68-year-old male is admitted with severe left lower quadrant abdominal pain, high fever (38.8°C), and worsening tachycardia. On physical examination, he has diffuse abdominal tenderness with guarding and rebound tenderness. Lab investigations show severe leukocytosis and acute kidney injury. An emergent CT scan of the abdomen and pelvis shows pneumoperitoneum with extensive free fluid and inflammatory changes in the sigmoid colon, consistent with a perforated diverticulitis with purulent peritonitis (Hinchey Stage III). What is the most appropriate surgical intervention?

General Surgery Problems

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A 56-year-old male with a history of an open appendectomy 10 years ago presents with a 24-hour history of colicky abdominal pain, bilious vomiting, and abdominal distention. On examination, his abdomen is distended but soft, with mild diffuse tenderness and no signs of peritonitis. An abdominal X-ray shows dilated loops of small bowel with multiple air-fluid levels and no free gas. A CT scan of the abdomen confirms a mechanical small bowel obstruction with a transition point in the mid-ileum, likely due to adhesions, with no signs of bowel ischemia. What is the most appropriate initial management?

General Surgery Problems

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A 65-year-old diabetic male presents with a 2-week history of right upper quadrant pain, high spiking fevers, chills, and anorexia. On examination, he is febrile (38.9°C), tachycardic, and has marked right upper quadrant tenderness with hepatomegaly. Lab tests reveal a leukocytosis of 18.5 x 10^9/L, elevated alkaline phosphatase, and mild hyperbilirubinemia. An ultrasound of the abdomen reveals a 6.5 cm hypoechoic, thick-walled, multilocular collection in the right lobe of the liver. What is the most appropriate management?

General Surgery Problems

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A 50-year-old male presents to the emergency department with severe, sudden-onset retrosternal chest pain and shortness of breath following an episode of forceful vomiting after heavy alcohol consumption. On examination, he is diaphoretic, tachypneic, and tachycardic, with a blood pressure of 90/60 mmHg. Chest auscultation reveals decreased breath sounds on the left, and subcutaneous emphysema is palpable in the neck. What is the most likely diagnosis, and what is the best diagnostic investigation to confirm it?

General Surgery Problems

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A 28-year-old female with a 3-year history of ulcerative colitis is admitted with a severe flare-up. Despite 5 days of high-dose intravenous hydrocortisone, her clinical condition deteriorates. She develops abdominal distention, high fevers (39.2°C), tachycardia (130 bpm), and hypotension. Physical exam reveals a distended abdomen with diffuse tenderness and rebound tenderness. An abdominal radiograph shows a dilated colon with a transverse colonic diameter of 8.5 cm and mucosal islands. What is the diagnosis, and what is the most appropriate surgical treatment?

General Surgery Problems

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A 28-year-old male is brought to the emergency department after a motorcycle collision, sustaining a closed, displaced midshaft tibia fracture. He is stabilized, and a plaster splint is applied. Six hours later, he complains of severe, escalating pain in his calf that is completely out of proportion to the injury and unresponsive to intravenous morphine. On examination, there is tense swelling of the calf, and passive stretch of the toes causes excruciating pain. Sensation in the first web space is decreased, but distal pulses are still palpable. What is the most appropriate next step in management?

Orthopedic Urological Problems

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A 48-year-old male presents with severe lower back pain radiating down both legs, which started after lifting a heavy box. He complains of numbness in his buttocks and groin, and difficulty initiating urination. On examination, he has saddle anesthesia, lax anal sphincter tone, and bilateral foot drop. A bladder scan reveals a post-void residual volume of 650 mL. What is the most likely diagnosis, and what is the immediate management?

Orthopedic Urological Problems

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A 32-year-old male is brought to the trauma bay with a 5 cm open wound over the anterior aspect of his mid-shaft tibia, through which bone is visible, following a pedestrian-motorvehicle accident. He is hemodynamically stable. The wound is heavily contaminated with soil and road debris. Plain films show a comminuted tibia-fibula fracture with moderate soft tissue damage but no vascular compromise. How is this open fracture classified, and what is the most appropriate initial management?

Orthopedic Urological Problems

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A 55-year-old male presents with a 2-day history of acute, severe pain, swelling, and warmth in his left knee, accompanied by inability to bear weight. He has a history of gout and type 2 diabetes. On examination, he is febrile (38.2°C) and has a tense, erythematous knee effusion. Range of motion is severely limited by pain. What is the most appropriate diagnostic test to differentiate septic arthritis from an acute gout flare, and what is the threshold finding for septic arthritis?

Orthopedic Urological Problems

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A 62-year-old male with poorly controlled type 2 diabetes presents with rapidly progressive swelling, redness, and severe pain in his left lower leg over the past 24 hours. On examination, he is febrile (39.1°C), tachycardic, and hypotensive (92/58 mmHg). The leg is swollen, warm, and erythematous, with margins of redness extending rapidly. There is exquisite tenderness extending beyond the borders of erythema, along with patches of dusky blue skin, bullae containing hemorrhagic fluid, and fine crepitus on palpation. What is the most likely diagnosis, and what is the immediate treatment?

Orthopedic Urological Problems

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A 35-year-old male is brought to the emergency department after falling from a ladder, sustaining a closed midshaft fracture of the right humerus. Splinting is performed, and post-reduction radiographs show acceptable alignment. On neurological examination, the patient is unable to actively extend his right wrist or fingers, and has numbness over the dorsum of the first web space. What nerve is injured, and what is the appropriate initial management of this neurological deficit?

Orthopedic Urological Problems

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A 14-year-old boy presents to the emergency department with sudden-onset, severe pain in his left scrotum that woke him from sleep 4 hours ago, accompanied by nausea. On examination, the left hemiscrotum is erythematous and swollen. The left testis is extremely tender, high-riding, and oriented transversely. The cremasteric reflex is absent on the left, and elevating the scrotum does not relieve the pain. What is the most likely diagnosis, and what is the most appropriate next step in management?

Orthopedic Urological Problems

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A 68-year-old male with no significant medical history has a screening prostate-specific antigen (PSA) level of 5.8 ng/mL (normal: < 4.0 ng/mL). Digital rectal examination (DRE) reveals a firm, non-tender 1 cm nodule in the right lobe of the prostate. A transrectal ultrasound (TRUS) guided biopsy confirms adenocarcinoma of the prostate in 3 out of 12 cores, with a Gleason score of 3+4=7 (Grade Group 2). A bone scan and CT scan of the abdomen/pelvis show no evidence of metastasis. What is the most appropriate management option for this localized, intermediate-risk prostate cancer?

Orthopedic Urological Problems

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A 54-year-old diabetic male presents with severe pain, swelling, and redness in his scrotum and perineum over the past 2 days. On examination, he is febrile (38.8°C), tachycardic (115 bpm), and hypotensive (98/60 mmHg). The scrotum is grossly swollen, tense, and dark, with patches of black skin necrosis and crepitus on palpation. Pain is exquisite and extends to the perineal area. What is the diagnosis, and what is the most appropriate initial management?

Orthopedic Urological Problems

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A 72-year-old male is brought to the emergency department with sudden-onset, severe abdominal pain radiating to his back, accompanied by syncope. On examination, he is pale, diaphoretic, and hypotensive (85/50 mmHg). His abdomen is obese, but a tender, pulsatile midline mass is palpable. The emergency physician performs a bedside ultrasound, confirming a 6.8 cm abdominal aortic aneurysm with free retroperitoneal fluid. What is the most appropriate immediate management strategy?

Vascular Cardiothoracic Problems

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A 68-year-old male with a history of chronic atrial fibrillation presents with a 4-hour history of sudden, severe pain in his left leg. On examination, the left leg is cold and pale from the mid-calf distally. Active movement of the toes is preserved but weak, and sensation to light touch is reduced over the dorsum of the foot. The femoral pulse is palpable, but the popliteal and pedal pulses are absent. Doppler signals are absent in the pedal arteries but present in the veins. What is the classification of this acute limb ischemia, and what is the immediate treatment?

Vascular Cardiothoracic Problems

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A 58-year-old female presents with a chronic, painful ulcer on the medial aspect of her left ankle, just superior to the medial malleolus, which has been present for 4 months. On examination, the ulcer is shallow, has irregular borders, and is surrounded by hyperpigmented, indurated skin (lipodermatosclerosis). She has significant bilateral varicose veins. An arterial duplex ultrasound shows normal ankle-brachial indices (ABI of 1.0). What is the cornerstone of management for this ulcer?

Vascular Cardiothoracic Problems

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A 66-year-old male presents to the clinic 10 days after experiencing a transient episode of weakness in his right arm and difficulty speaking, which resolved completely within 1 hour. A carotid duplex ultrasound reveals a 75% stenosis of the left internal carotid artery with a calcified plaque. His medical history includes hypertension, hyperlipidemia, and smoking. What is the most appropriate management to prevent a future stroke?

Vascular Cardiothoracic Problems

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A 42-year-old female presents with sudden-onset, massive swelling and severe pain in her left lower extremity, extending from the groin to the toes. On examination, the left leg is intensely swollen, cyanotic (dusky blue), and cold to the touch. Distal pulses are not palpable, and venous Doppler signals are absent. She has a history of active breast cancer. What is the most likely diagnosis, and what is the immediate treatment?

Vascular Cardiothoracic Problems

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A 28-year-old female competitive swimmer presents with progressive pain, numbness, and paresthesia in her right arm and hand, which worsens during overhead activities. She also reports that her hand becomes pale and cold when swimming. On examination, there is weakness in her hand grip, and her radial pulse disappears when her arm is abducted and externally rotated with her head turned to the right (positive Adson's test). What is the diagnosis, and what is the definitive surgical treatment for refractory symptoms?

Vascular Cardiothoracic Problems

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