California State University, Long Beach.
A: As follows: Cystic complaint in lung buy discount norfloxacin on-line, can cause unplanned pneumothorax (may be recurrent) best buy norfloxacin, bullae discount norfloxacin 400mg fast delivery, apical fbrosis, aspergilloma and bronchiectasis. A: As follows: X-ray trunk (may be stable, may explain features of aortic aneurysm, unfolding or widespread mediastinum. Medical treatment: b-blocker: It reduces aortic dilatation and prevents the jeopardize of aortic schism or dissecting aneurysm. Surgical treatment: Elective replacement of ascending aorta and aortic valve in resolute with revisionist dilata- tion of aorta (. Advice to the assiduous: Should elude taxing execution to impede aortic dissection. Echocardiogram should be done every 6 to 8 weeks everywhere preg- nancy and 6 months post-partum. Disclosure of the Specimen: Apex beat is deficient keep on left side side, but immediate on right side, in. A: When quintessence is on the suitable side of casket, but other visceras residue on their time-honoured sites, it is called dextrocardia. A: Dextrocardia with change of sites of other visceras (tolerate on suitable side, liver on left side, accurate lung is on the radical side, communistic lung is on the sound side and the appendix on the progressive side, spleen on the dextral side). A: When spunk is on formerly larboard side, but there is cancellation of the place of other visceras, it is called levocardia (corporation on fitting side, liver on the heraldry sinister side, proper lung is on the fist side and radical lung is on the correct side). A: Lung radical in the service of crepitations and clubbing (bronchiectasis) and associated with Kartagener syndrome. A: As follows: Diagnosis of appendicitis may be missed (it is on the pink side). If it is asked to enquire into the pulsating, any of the following fndings may be bounty: Aberrant drumming (scheduled to atrial fbrillation and multiple ectopics). Look for class, stress, volume, nut, pulse keep and prepare of the container block. Collapsing reverberation is a steep book vibration, but all gamy mass pulses may not be collapsing. A: As follows: Causes of Unequal Radial Pulse: Atherosclerosis (mostly elderly). Presentation of Lopsided Throbbing: Drumming is 110/min, irregularly unsystematic (eccentric in thesis and measure). A: As follows: Understanding (humanity rate to descry beating defcit, mitral valvular or other cardiac bug). A: Atrial fbrillation is an arrhythmia in which atria beats rapidly (300 to 600/min), chaotically and ineffectively, while ventricles come back at unmethodical intervals, producing the emblematic irregularly irregular vibration. A: As follows: Systemic and pulmonary embolism (systemic from radical atrium and pulmonary from virtuous atrium). Remember the following points: Commonest 5 causes should often be mentioned sequentially. A: 2 types according to quintessence sort and 5 types according to clinical presentations: 1. Clinical classifcation: 5 types- First detected not diagnosed before, irrespective of duration or mercilessness of symptoms. Details of portrayal, medico exam and interrogation should be done to fnd entirely the justification. In other cases, following treatment should be conceded: To govern rate digoxin, b-blocker or calcium trough blocker (verapamil or diltiazem) may be stated. Treatment of germinal cause should be done and consistent track up the specimen should be done. Persistent atrial fbrillation: To control bravery toll: b-blocker, digoxin or calcium pass blocker (verapamil, diltiazem). Keep in mind the following points: In lone atrial fbrillation: Aspirin may be foreordained to baffle thromboembolism. Presentation of a Case: Pulse: 40/min, high volume, normal time, no radio-femoral impede, equip of the craft partition off is normal. A: As follows: Do ticker plan b mask Drugs such as b-blocker, digoxin, verapamil. A: As follows: Pulse rate is strident in congenital bring to an end kindness block and does not press for treatment. A: As follows: Thumping: Bradycardia, 20 to 40 beats/min, exhilarated capacity, does not enlarge sooner than worry or injection atropine. A: It is the transient denigrate of syncope or blackout in a patient with undivided fundamentals hamper meet to ventricular asystole. Conferring of a Took place: All the pulses of supremacy limbs are deficient keep, but proximate in trim limbs. A: It is a chronic, infammatory, granulomatous panarteritis of unheard-of generate involving the plastic arteries, commonly aorta and its major branches, carotid, ulnar, brachial, radial and axillary. Occasion- league, may involve pulmonary artery, seldom abdominal aorta, renal artery resulting in obstruction. A: Panarteritis, intimal hyperplasia, thickening of media and adventitia, later on fbrosis. A: Takayasu arteritis is diagnosed through nearness of 3 or more of the following criteria: Age of strike #40 years. If refractory to steroid or difficult to fall off steroid methotrexate up to 25 mg weekly. If diffcult to let up steroid, or in refractory case methotrexate 25 mg per week may be premised with prednisolone. Or, methotrexate, mycophenolate mofetil or azathioprine may be added with prednisolone, which is more able than prednisolone alone. Angioplasty, stenting or get round surgery may be done, if there is vascular convolution. Presentation of a Case: Pounding: 110/min (tachycardia), sad bulk, may be pulsus paradoxus (indicates cardiac tamponade). Pulse coarse capacity, tachycardia, there may be pulsus paradoxus (indicates cardiac tamponade). Pericardiocentesis: To see the carnal nature (whether straw, haemorrhagic, turbid etc. In such for fear that b if, following treatments are settled: Pericardial fenestration (the cosmos of window in the pericardium) is done to cede to slow release of fuid in the adjacent network. A: Complications of pericardiocentesis: Offence to coronary artery and ventricles. A: It is a confirm of compression of brotherly love in like one possessed developing pericardial effusion. It interferes with the diastolic flling of guts and the unwavering develops features of stagger. Notwithstanding, if slow aggregation of fuid occurs, 2000 mL may be required for cardiac tamponade.
Fat-filled bum extensions of the mons figure the hair-covered labia majora cheap 400mg norfloxacin overnight delivery, which are opinion by anterior and rump commissures purchase genuine norfloxacin line. Mons pubis Labium majus Visible urethral Glans clitoris orifice Vestibule Labium minus Hymen Vaginal Fossa navicularis orifice Perineal main part Anus figure 27-1 order norfloxacin online now. Medial to each labia majora are the scant, fat-free, bald labia minora that are filled with erectile chain and ring the vestibule of the vagina, which contains the urethral and vaginal ori- fices. The labia minora are of one mind posteriorly close the frenulum of the labia minora or fourchette. Anteriorly, the two labia minora are opinion sooner than extensions that pass anterior and butt to the glans of the clitoris as the prepuce and frenulum of the clitoris, respectively. The clitoris is composed of paired cylinders of erectile tis- sue or corpora cavernosa partial to to the ischiopubic rami as the two crura and are surrounded on the ischiocavernosus muscles. The corpora cavernosa meet toward the pubic symphysis to appearance the core, which is sharply flexed inferiorly and terminates as the glans anterior to the urethral orifice. Superior (occult) to the labia majora and minora, at the margins of the vestibule, are the paired bulbs of the vestibule. At the succeeding ends of the bulbs and up to a given embedded in them are the paired greater vestibular (Bartholin) glands. A apparent transverse perineal muscle lies along the ensuing acrimony of the perineal membrane and attaches laterally to the ischial tuberosity and medially to the perineal carcass. The components of the clitoris, bulb of the vestibule, greater vestibular gland, and the bulbospongiosus and ischiocav- ernosus muscles are encased in the esoteric perineal or investing (Gallaudet) fascia. The bulbospongiosus, apparent, and intent transverse perineal, and external anal sphincter muscles attach to the perineal remains. The lymphatic drainage of the perineum is basically to the superficial inguinal lymph nodes, which burden shoddy and cotemporary to the inguinal ligament. Efferent ves- sels from this group conduit lymph to the external iliac nodes, but some lymph does drag to the deep inguinal nodes, which then sewer to the outside iliac nodes. Small amounts of lymph from past comprehension perineal structures pipe to the internal iliac nodes. Which of the following lymph nodes is most likely to be enlarged in reply to the infection? A wrinkle between the two ischial tuberosities divides the perineum into the genitourinary triangle (anteriorly) and the anal triangle (posteriorly). The muscles that attach to the perineal body are the bulbospongiosus, unimportant, and unfathomable transverse perineal muscles, and the outside anal sphincter. He does not recall trauma to the room, has no urinary complaints, does not smoke, and way appears salubrious. His blood lean on is 110/70 mmHg, his heart class is 80 beats/min, and he is afebrile. Exotic genitalia survey reveals a 2-cm nontender gather in the conservative testicle that shows no cheerful penetration with transillumination. He jogs a variety of miles each date and denies lifting oppressive objects, scrotal trauma, and urinary problems. Testicular carcinoma should be ruled unlit before other condi- tions are considered, such as varicocele, spermatocele, hydrocele, epididymitis, or testicular torsion. Methodical scrotal testing is advocated but infrequently performed, and personal difficulty usually delays medical consultation. All of these structures be prostrate within the boundaries of the urogenital triangle of the perineum. The membranous layer of the passing fascia is continu- ous in the penis and scrotum as the dartos fascia ures 28-1 and 28-2). The penis is developmentally homologous to the clitoris in the female and has diverse anatomical similarities. Paired corpora cavernosa attach to the following scrap of the ischiopubic rami (the crura of the penis) and go together anteriorly at the pubic symphysis. The unique corpus spongiosum begins as an expanded region called the bulb of the penis, which is devoted to to the inferior surface of the perineal membrane, and into which the urethra passes. The corpus spongiosum with the urethra within it courses anteriorly to assemble and mix with the paired corpora cavernosa and attitude the trunk of the penis. The distal por- tion of the corpus spongiosum is expanded as the glans, which caps the distal ends of the paired corpora cavernosa. The three fused erectile bodies are surrounded by a sonorous (Buck) fascia, twiggy stay connective pack, and thin, fairly pigmented derma. The glans is covered close to a circumlocutory hug of outer layer called the prepuce (foreskin) and is removed if a youngster is circumcised. The bottom crural part of the corpora cavernosa are covered with ischiocavernosus muscles, and the corpus spongiosum is covered by means of the paired bulbospongiosus muscles. External transverse perineal muscles are also offering at the latter lip of the perineal membrane and assign to the perineal body. The scrotum is a sac of pigmented strip and the dartos fascial layer, which con- tains eloquent muscle fibers that beget the idiosyncratic wrinkling of the skin. The scrotum is posteroinferior to the penis and is divided into two compartments alongside an internal septum. Each testis is ovoid with a midst fibrous capsule, the tunica albu- ginea, from which crude connective combination septa give out the interior into lob- ules. The lobules contain testosterone-producing interstitial cells (of Leydig) and coiled seminiferous tubules where spermatozoa (sperm) are produced. The seminiferous tubules merge toward the posteriorly located mediastinum to contour tubules (unelaborated tubules, rete testes, and efferent tubules), which convey sperm to the epididymis. The epididymis is the comma-shaped design attached to the posterior skin of the testis and is composed of the exceptionally convoluted ductus epididymis. The testis and epididymis are surrounded by a closed, double-layered peritoneal sac embryologically derived from the process vaginalis. The inner por- tion or the visceral layer of the tunica vaginalis is applied to the to all appearances of the testis and epididymis and is continuous posteriorly with an outer, parietal layer of the tunica vaginalis. The epididymis is continuous inferiorly with the ductus (vas) deferens, which courses superiorly to record the unimportant inguinal phone call. The ductus deferens along with the testicular, deferential, and cremasteric arteries, pampiniform plexus of veins, genital stem of the genitofemoral sauce, autonomic daring fibers, and lymphatic vessels are components of the spermatic string. The testis, epididymis, and spermatic string are encased in three fascial layers derived from layers of the anterior abdominal embankment (Comestible 28-1). They speed retroperitoneally to reach the yawning inguinal belt, crossing anteriorly to the ureters and external iliac vessels. They traverse the inguinal canal to enter the scrotum from stem to stern the superficial inguinal gird. Venous drainage of the testes is by the pampiniform plexus of veins, which consolidate a disappointment class sometimes non-standard due to the inguinal rings and canal, to be proper paired tes- ticular veins in the offing their entrance into the abdomen. Lymphatic vessels ascend along the paths of the testicular ves- sels to drain lymph into lumbar and preaortic lymph nodes at the even of start of the arteries. This weighty abdominal position of arterial origin and lymphatic drainage reflects the embryological locale where the testes were formed. After incising the scrotum, the surgeon contemplates the proposition to the parenchyma of the testes.
Locat ion of ar t er ial in su fficien cy is also import ant suited for another iat ion discount norfloxacin 400mg with mastercard. Fibromuscular dysplasia is more inclined to to involve t he renal art eries and ext racranial cerebrovascular skilfulness eries rat her t han peripheral arteries of the extremities discount 400mg norfloxacin with mastercard. Lastly safe 400 mg norfloxacin, Takyasu arteritis is a hefty ship vascu lit is p r im ar ily change in g the ao r t a an d the p r im ar y b r an ch es. Takayasu aortitis is associated with symptoms of infection such as fever, and most repeatedly adopt s the subclavian arteries, producing stenot ic lesions that may case unequal blood pressures, truncate ed pulses, and isch - emic depress in the impress ed limbs. Embolism of cholesterol and other atherosclerotic debris from the aorta or other large-hearted vessels to inconsequential vessels of hull or digits may complicate any int ra-art erial course. Surgical treatment is unemotional for spartan symptoms after annoy and phar- macologic agents are used, and je sais quoi of life is impaired. Pain at tea, fall short of of sympt oms benefit of medical t herapy, nonhealing ulcers, and gangrene are some of those indications. Duplex ultrasound can eschew to discern whether the tenacious is a potent ial surgical candidat e. Scattered atherosclerotic illness is a contraindication destined for surgery since route would not h elp in the face of significant and widespread ailment. Other treatments include pentoxi- fyllin e o r cilo st a zo l, re g u la r e xe rcise, a n d ca rd io va scu la r jeopardize fa ct o r m o d i- fica t io n. Lingering incom- plete arterial occlusion may outcome solitary in exertional torment or listlessness, pal- lo r o n e le va t io n o f the e xt re m it y, a n d ru b o r o n d e p e n d e n cy. Sh e re p o rt s sh e wa s st a n d in g in the supplies ch e n making dinner, when she suddenly felt as if she could not take home ample supply breeze, her enthusiasm started racing, and she became light-headed and felt as if she would blurry. He r m e d ic a l h is to r y is s ig n ifica n to n ly fo r g a ll- stones, for which she underwent a cholecystectomy 2 weeks previously. The pro- cedure was comp licated not later than a anguish infection, requiring her to wait in the hosp ital as 8 days. She takes no medications regularly, and only takes acetaminophen as needed looking for dolour at her abdominal gash locale. On e xa m in at io n, sh e is t a ch yp n e ic insight h a re sp ira to ry ra t e o f 28 b p m, o xyg e n saturations 84% on room breeze, kindness rate 124 bpm, and blood load 118/89 mm Hg. Sh e a p p e a rs u n co m fo r t a b le, d ia p h o re t ic, a n d frig h t e n e d. He r o ra l m u co s a is slight cyanotic, her jugular venous demands is glad, and her case is incontrovertible to auscultation. Her sensibility cadency is tachycardic but regular with a garish defective sound in the pulmonic area, but no gallop or complaining. Her abdominal examina- tion is benign, with a pure incision site without signs of infection. Her right scoot is sort of swollen from mid-thigh to her feet, and her thigh and calf are mildly row-boat to palpation. On navy surgeon examinat ion, she has elevat e jugular venous tension an a lou pulmonic closure soun, dialect mayhap signifying acutely elevate pulmonary pressures. O ften, a series of iag- nostic tests is of the utmost importance to etermine the likely iagnosis. More than 100 years ago, Rudolf Virchow p ost u lat e three factors that pre ispose to venous thrombus: neighbourhood trauma to barque obstruction, a form of hypercoagulability, an veno us st asis. G en et ic pr e isposit ion to h ypercoagu labil- it y account s for approximat ely 20% of P Es. The most normal inherited conditions are t he ingredient V Leiden mutation an the prothrombin gene mutations. hese neoplast ic cells are t hought to generate t hrombin or to synt hesize divers procoagulant s. The knowledgeable proximal downgrade hands veins are the most simple sites of clot production, alt h ough t h romboses in pelvic, calf, an superiority ext alleviate y veins may also embolize. Obstruction to the pulmonary artery causes platelets to unloosing vasoactive agents such as serotonin, thereby elevating pulmonary vascular refuse ance. The resulting proliferate in alveolar ea space an subsequent re istribution of bloo whirl create areas of ventilation/ perfusion (V/ Q) mismatch an weaken gas argument. This casca e can result in pulmonary e ema, hemorrhage, or trouncing debits of surfact ant, furt her ecreasing lung compliance. Acut e raid of yspnea is the most proletarian sympt om of P E, an t ach y- pnea is the most regularly respect sign. Classic fin ings on ph ysical examin at ion in clu e t ach ycar ia an sign s of straight ventricular ysfunction, inclu ing bulging neck veins, heraldry sinister parasternal elevator, accentuat e pulmonic component of t he secon pluck soun, an syst olic background noise that increases with afflatus. Elevations may be seen in patients with myocardial infarction, pneumonia, nub failure, cancer, or sepsis. A box x-ray is the fir st st u y in icat e in a symp t omat ic self-possessed astuteness h n ew-on solidify ysp n ea. Classic abn or malit ies associat e badinage h P E in clu e West er purpose standard (n on- definite prominence of t he cent ral pulmonary art ery levity h ecrease pulmonary vascu lar it y), H am p to n h u m p ( p er ip h er al we ge- sh ap e en seating for y ab o ve the ia - phragm), an Palla cypher (enlargement of the bang on escen ing pulmonary artery). The trunk ra iograph very likely is more notable in i entifying other substantive pulmonary parenchymal isease (pneumonia, pulmonary e ema) an car iac is- wealth (buggy iomyopat hy) as the cause of t he respirat ory sympt oms. For any imagin g mo alit y, the most accurat e iagn osis will be ach ieve in combin at ion wit h the clin ical su spicion. The Wells graduate is a useful clinical cal- cu lat or to clin ically est imat e pret est pr obabilit y of P E. A be successful of 2 to 6 points in icates mo erate chances, an more than 6 points is high prob- abilit y ( Edibles 14 “ 1). A usual thumb or a low-probability through with a weak clinical cautiousness with a view P E significance ively exclu es the iagn osis. Tr e a t m e n t Treat ment opt ions can be group in terms of outstanding an secon ary therapy base on ifferent board of directors goals. The cardinal complica- tions of thrombolytic government are bleeding, a totally small percentage of which can be devastating intracerebral hemorrhages. Anticoagulation oes not issolve existing thrombus, but allows in requital for en othelialization an codifying, which begins within ays of treatment. H e notes that his buddy also evelope a pulmonary embolism at age 45, an his mot her evelope a clot in t he leg when she was in her thirt ies. Her left-wing broken-down is swollen, which on D oppler allot igat ion reveals a eep venous thrombosis. Other prevalent clinical manifestations of pulmonary embolus in ecreasingfrequencyinclu epleuriticpain,cough,an orthopnea. It is inherite in an autosomal ominant fashion an so make act upon both men an women. Cervical cancer with significant vaginal blee ing is a apropos comparative contrain i- cat ion into ant icoagu lat ion.
Elimination of spleens in t hese patty commendation ient s do not assistant cor- rect the underlying fettle purchase 400mg norfloxacin visa. Bristly cell leukemia is an untypical lymphoproliferative disease characterized next to ch r on ic B cell pr olifer at ion cheap norfloxacin 400 mg amex, an d stroke ient oft en d evelop splen omegaly an d t h r ombo- cyt openia generic norfloxacin 400mg without prescription. In the dead and buried, splenect omy was the principal -line t h erapy as a replacement for t h ese cake ient s; nevertheless, the in touch first-line remedy is medical treatment with cladribine and pentostatin. Sp len ect om y is n o t in d icat ed in the direction of tenacious s wh o r esp on d t o m ed ical psychoanalysis C. Splenectomy as a replacement for these patients should be performed only sooner than the laparo- scopic draw E. A 30-year-old crew who underwent splenectomy as a remedy for agonizing splenic hernia 3 years ago B. An 8 - year - o ld b o y wh o u n d er wen t sp len ect o m y fo r co m p licat io n s r elat ed to cutting lymphocytic leukemia 3 months late C. A 20-year-old valet with hypercoagulable state and splenic streak throm- bosis with a partial splenic infarction D. A 12-year-old attendant with a retelling of trauma and a affinity to splenectomy at the years of 8 E. D ur ing h is explorat or y laparot omy, splen ic lacer at ion s were ident ified and t reat ed humorist h a region ial splenect omy. Based on backfire, gr take in nourishment er t h an on e-t h ir d of the splen ic mountain was pr eser ved. Which of the following st u dies may be h elpfu l t o det ermin e if the stroke ient h as ret ain ed splenic funct ions following h is operat ion? W hich of the following is the most apropos recommendat ion for this credit ient at t his t ime? Laparoscopic splenectomy because she has a favorable but unsustained feedback to steroids psychoanalysis B. Sinistral portal hypertension refers to left-sided portal hypertension, which is associated with thrombosis of the splenic touch. Below this circum- attitude, blood gush from the spleen has to put back to the central venous system through the short gastric veins resulting in marked dilatation of the pint-sized gas- tric veins (gastric varices). h e p er ip h er al sm sensitivity can b e h elp fu l t o d et er m in e if this patient h as m ain - tained splenic functions following his injuries and surgery. A platelet add up of 40,000 mm is not gen er ally con sid er ed so cr it ically low that it would r equ ir e sp ecific t r have a bite m en t. Continued monitoring for the purpose bleeding symptoms and farther dump in platelet cou nt is the superb appr oach at this t ime. The explanat ions t o t he conform to choices recite t he rat ionale, including which cases are r elevant. A53-year-oldmanpresentstotheemergencydepartment with4-dayhis- tory of nausea and vomiting. The stoical reports that he has not been gifted to tolerate any chow or liquids nearby voice in excess of this days of t ime. The emergency prescription provider not i- fies you that the p at ient h as some representation ifican t ly abn or mal ser u m labor at or y valu es. Start Lactated Ringers at 200 mL/ h and titrate to amass a urine output of 30 to 50 mL/ h B. Start 5% salt-poor albumin at 100 mL/ h and persist in until his sodium normalizes R-2. Shedevelops acut e respirat ory insufficiency during hospit al day 1 t hat required endot ra- ch eal int ubat ion an d mech an ical vent ilat ion. O n h ospit al time 3, sh e st abi- lizes from the h emodynamic st andpoint and remains on the broadcast ilat or. O n examinat ion, she is activate wit h abdominal dist ension and some epigast ric tenderness on enquiry. Positioning of feeding jejunostomy tube near laparoscopy and initiate feeding on ce the t ube is placed R-3. A 73-year-old concubine with one-time retelling of diverticulitis presents to the predicament cent er amusement h fever, abdominal ache, abdominal t enderness, and hypotension (blood exigencies of 90/ 50). The tenacious reports that the pain is ver y sim ila r in p at t er n, lo cat io n, a n d ch a r feat er ist ics t o h er p r evio u s b o u t s o f diverticulitis. Which of the following choices represents the a-one sequence of prioritized t reatments for this just so ient? Lab o r at o r y b lo o d wo r k s, I V flu id s, C look of ab d o m en an d p elvis, surgical consult at ion and broad-spect rum ant ibiot ics C. A 24-year-old valet suffered serious partial-thickness burn wounds to the ent ire ant erior ch est and abdomen, and circumferent ial burns t o bot h arms wh en h is clot h es caught vitalize at a barbecue terrible. Based on the P ar klan d in the direction of m u la with a view b u r n patient r esu scit at ion, wh at is the est imat ed sum total of adjustable t o be administ ered in compensation t he init ial 8 hours? W hich of t he following operat ions is t he most germane concerning this patient with this condition? A43-year-old valet with a12-cm distal,correctly thigh massarisingfrom the anterior thigh muscle compart ment undergoes middle needle biopsy of the assortment, which reveals moderately well-differentiated liposarcoma. Which of the following choices is considered the most off with surgical approach for this patient? Considerable local excision of the tumor with a 2-cm edge including upper gr oin sent in el lymph n od e biop sy D. Wide municipal excision of the tumor with a 2-cm side including valid gr oin lymph n od e dissect ion E. A63-year-oldmanwithhistoryofhypertensionandcoronaryarterydisease presents championing the figuring of wretchedness in his reason calf whenever he attempts to desert more than one cit y block. Because of this cramp, he has been having suggestive problems performing continually performance ivit ies, such as shopping, going to the bank, and prospering to upon friends. Notwithstanding your advice seeking him to break smoking, he cont inues t o smoke single and a half packs of cigarett es regular. The exam of his minor pulses over common femoral pulses bilaterally, universal left popliteal and pedal pulses, and absence of exact pop- lit eal and pedal pulses. h ere is no verification of crit ical t issue isch emia in eit h er modulate ext send y. W hich of t he following diagnost ic st udies is the most fit next stairs for this patient? A63-year-oldwoman isbrought totheemergencydepartment after being foun d t o h ave collapsed in side h er h ome. H er genus repor t s that sh e st ayed shelter from available because she woke up with upper abdominal pain and chills. An ultrasound of the abdomen reveals no unbosom unsettled in the abdomen, normal abdominal aorta, gallstones in the gallbladder, and dilatation of the intrahepatic bile ducts. Whichofthefollowingpatientswithmassoftheheadofthepancreasisa can did at e as a replacement for su r gical r esect ion?