Explanation:

The Aster Coller modification of Duke´s staging system is commonly used to stage colon carcinoma. Stage A is when the tumor does not extend into the muscularis. Stage B1 is when the tumor extends into the muscularis without lymph node involvement, and stage C1 is stage B1 with lymph node involvement. Stage B2 is when the tumor extends past the muscularis without lymph node involvement, and stage C2 is stage B2 with lymph node involvement. Stage D is distant metastatic disease.

Explanation:

Interventions of unresponsive patients should always follow the ABCs of basic life support. An unresponsive state most likely occurs secondary to lack of oxygen to the brain or excess carbon dioxide. The first step in managing an unresponsive patient is to secure the airway and provide oxygenation. Only then does fluid resuscitation begin. Diagnostic studies follow once the initial life support measures are instituted.

Explanation:

Obtaining a series of skeletal radiographs in the initial evaluation of an individual with a newly discovered breast lump is not useful in the elucidation of the diagnosis. Mammography is very important to identify the size and presence of calcification in the mass. A physical examination by the physician is essential to independently document the lesion and to measure it. It is necessary to obtain a family history, since women who have first degree female relatives with breast cancer are at greater risk themselves. Determining the medications the patient has taken recently is necessary, since some, such as hormones, can be associated with breast lesions.

Explanation:

In the case of a patient in need of urgent surgery, fresh frozen plasma is the fastest and safest way to correct the prothrombin time. Non urgent surgery should be postponed, but urgent surgery, such as in this case where an abscess is suspected, should not be delayed. Protamine reverses heparin, although it has no effect on prothrombin time. Vitamin K will counteract the effect of coumadin, but it takes several days to work, and it makes anticoagulation after surgery extremely difficult. Packed red blood cell transfusion will not correct an abnormal prothrombin time

Explanation:

While radiation and chemotherapy are appropriate as adjuvant treatment of colonic carcinoma, they are inadequate alone. Local excision is also inadequate. Wide resection with drainage of regional lymphatics is the treatment of choice.

Explanation:

The major toxicity derived from Sterno is due to its methanol content. Methanol is metabolized in the body to formaldehyde and formic acid, which can damage the retina. The other symptoms listed are not side effects specific to Sterno.

Explanation:

Bariatric surgery is a major gastrointestinal procedure. Bariatric surgery in adolescents raises social, psychological and developmental issues, but adolescents are not excluded from surgery, and some hospitals have specialised programmes for younger patients. Potential candidates for surgery are those with a body mass index (BMI) exceeding 40, or BMI > 35 with serious co-morbidities (eg sleep apnoea, type 2 diabetes). Post-operative mortality ranges from 0.1-2 %. Vomiting is a risk associated with bariatric surgery, as is dumping syndrome and nutritional deficiencies. There is no evidence as yet; that bariatric surgery reduces cardiovascular mortality in patients.

Explanation:

The history is classical, with severe diarrhea, weight loss, and halitosis as a result of fecal contamination of the gastric contents. The setting for this fistula to develop is also well described in the vignette: an antecolic anastomosis that develops a marginal ulcer that is not properly treated. The ulcer eventually eats its way into the adjacent colon.
Diarrhea occurs in both the afferent loop syndrome (A) and the dumping syndrome (B) but in both cases the complication develops shortly after the original surgery. Neither of these problems would first show up nearly 20 years after surgery. Gastric cancer (D) can indeed develop in the remaining stomach after peptic ulcer surgery, and it happens a good many years later thus fitting the pattern of this vignette. But the manifestations would not include diarrhea and halitosis, and the history would not include the marginal ulcer as in this case. Gastrinoma (E) if responsible for the original ulcer would have led to continued peptic ulcer disease right away, not many years after the operation. The diarrhea of Zollinger Ellison is watery, and it occurs along with other manifestations of peptic ulcer disease, such as pain, peroration, or bleeding.

Explanation:

This patient has an epididymo-orchitis that is complicated by the development of a scrotal abscess. The appropriate treatment of an abscess anywhere in the body is drainage. The technique of drainage can vary, depending on the location of the abscess with a scrotal abscess, exploration and open drainage is the most appropriate. The location is easy to gain access to, the actual procedure is generally well tolerated, and this is the only technique that ensures all the purulent fluid is drained completely. Aspiration (A) carries the risk of not removing all the fluid; therefore, there is a risk for recurrence. Aspiration of an abscess should be reserved for collections that would require major surgical intervention to reach. A change in this patient´s antibiotics will not treat him completely (B). Management of a patient with presumptive epididymo-orchitis on admission with intravenous antibiotics is appropriate. Most patients with this diagnosis improve with antibiotics when a patient´s condition does not respond appropriately, however, it is necessary to investigate other possible diagnoses. As stated, this patient requires surgical drainage.
This patient has not improved from a clinical or laboratory standpoint. His ultrasound shows an abscess; therefore, continuing with the current regimen would be inappropriate (C). Fournier gangrene (D) is defined as a necrotizing fasciitis that presents as a progressive, fulminating infection of the male genitalia, initially, the patient may present with only induration of the penis or scrotal skin. Erythema and crepitus develops and quickly extends over the perineum and abdominal wall. Treatment requires immediate wide surgical debridement of the involved skin and subcutaneous tissue.

Explanation:

Administration of long term glucocorticoids suppresses the hypothalamic pituitary adrenal axis (CRH) by exerting a negative feedback control to suppress corticotropin-releasing harness (CRH) secretion and, consequently, adrenocorticotropic hormone (ACTH) secretion, which leads to tertiary adrenal insufficiency. The atrophic adrenal glands become incapable of producing the high quantity of steroids needed during times of stress, such as surgery. The major clinical manifestation of adrenal crisis is shock, but patients may also have nonspecific symptoms such as anorexia, nausea, vomiting, abdominal pain, diarrhea, lethargy, fever, confusion, or coma. Laboratory studies of this patient reveal hyponatremia, hyperkalemia due to mineralocorticoid deficiency, and hypoglycemia due to glucocorticoid deficiency. Other findings include lymphocytosis and eosinophilia. Adrenal crisis could have been prevented in this patient by increasing steroid doses on the day of the surgery and then tapering off to usual levels a few days after surgery. Adrenal hemorrhage may also cause an adrenal crisis. Causes include septicemia induced Waterhouse-Friderichsen syndrome (fulminant meningococcemia) or the over-anticoagulation of patients. Waterhouse Friderichsen syndrome is usually much more acute in onset and often diagnosed at autopsy. Moreover, this patient has a history of chronic steroid use, making tertiary adrenal insufficiency the most likely cause.

Explanation:

Explanation:

The clinical features are those of a herniated lumbar disc. The diagnosis should be confirmed with an MRI, and then the patient should be treated conservatively with short term bed rest (approximately a few days to a couple of weeks) and analgesics. Most patients get better with this simple approach. Giving antibiotics (B) assumes an infectious process. Infections can occur in the lumbar spine or the discs, but their symptoms do not start suddenly, like this vignette describes. A body cast (C) might be needed for fractures, scoliosis, or other spinal pathology, but casting is not needed for an extruded disc. Radiotherapy (D) assumes a neoplastic process. Although a weakened bone may indeed rupture suddenly, such patients are usually known to have had the kind of tumor that is likely to metastasize to bone (in women, breast cancer would lead the list), and would have been complaining of localized bony pain before the process gets to the point of fracture. Surgical decompression (E) would have been required if she had sphincteric deficits or perineal anesthesia.

Explanation:

This patient is suffering from fistula-in-ano. This is a chronic form of per anal abscess that is spontaneously or surgically drained, but in which the abscess cavity, does not heal completely. The cavity becomes an inflammatory track with a primary opening (internal opening) in the anal crypt at the dentate line and a secondary opening (external opening) in the perianal skin. They are classified according to the relation of the fistula to the sphincter muscle. Most of these patients have a history of anorectic abscess with intermittent drainage with fecal soiling and occasional perinea discomfort. The external opening is usually visible red elevation of granulation tissue with purulent or serosanguineous drainage on compression. Necrotic and draining tumor must be ruled out (with proctoscopy or sigmoidoscopy) and treatment is byway of fistulotomy to undo of the Fistula, eliminate the primary opening, and establish adequate drainage. An anal fissure (A) typically occurs in young women who have exquisite tenderness with defecation and blood streaks that cover the stool. Patients with an ischiorectal abscess (C) are febrile and complain of exquisite per rectal pain that does not allow them to sit down or have a bowel movement Examination is classic for an abscess (rumor, dolor, color, and tumor) that is lateral to the anus. Incision and drainage is the treatment of choice. A pilonidal sinus (D) is caused by infection of a hair follicle in the sacrococcygeal area. They may present as an acute abscess at the sacrococcygeal area that ruptures spontaneously, leaving an unhealed sinus with chronic drainage. If no abscess is present, then examination will reveal a pit or pits in the midline that represent infected hair follicles. Squamous cell carcinoma (E) of the anus is seen in HIV and homosexual men with receptive sexual practices. On examination, there is a fungating mass that grows out of the anus and metastatic inguinal nodes may be palpated.

Explanation:

The patient has a lower GI bleed, the differential of which includes colon cancer, diverticulosis, arteriovenous malformation, and hemorrhoids. The etiology is not initially s important as stabilizing the patient and preventing further bleeding. A blood transfusion would be first and foremost but is not an option. Reversing the coagulopathy, which is likely due to non- monitored warfarin use, is the next most crucial step. This can best be accomplished using fresh frozen plasma in the acute setting. It is always prudent to monitor elderly patients, especially those with a cardiac history, for volume overload when transfusing FFP; this is because it involves transfusing a large volume of fluid in a short period of time. Elderly patients should be diuresed, if necessary. Factor VII (A) has been approved for use in bleeding, but its limited testing in clinical trials and high expense limit its use to critical patients, typically in disseminated intravascular coagulopathy (DIC) in the operating room. It is used more in obstetric and gynecologic treatment than anywhere else.
Vitamin K (B) is always indicated in patients with an abnormal INR, and is particularly useful in coagulopathy due to nutritional Vitamin K deficiencies and liver disease. However, its effect is significantly less potent and slower than FFP, with no effect for about l2 hours. Therefore, it should also be given in this patient but it is the most critical agent to use in reversing her ongoing bleed.

Explanation:

The patient has a lower GI bleed, the differential of which includes colon cancer, diverticulosis, arteriovenous malformation, and hemorrhoids. The etiology is not initially s important as stabilizing the patient and preventing further bleeding. A blood transfusion would be first and foremost but is not an option. Reversing the coagulopathy, which is likely due to non- monitored warfarin use, is the next most crucial step. This can best be accomplished using fresh frozen plasma in the acute setting. It is always prudent to monitor elderly patients, especially those with a cardiac history, for volume overload when transfusing FFP; this is because it involves transfusing a large volume of fluid in a short period of time. Elderly patients should be diuresed, if necessary. Factor VII (A) has been approved for use in bleeding, but its limited testing in clinical trials and high expense limit its use to critical patients, typically in disseminated intravascular coagulopathy (DIC) in the operating room. It is used more in obstetric and gynecologic treatment than anywhere else.
Vitamin K (B) is always indicated in patients with an abnormal INR, and is particularly useful in coagulopathy due to nutritional Vitamin K deficiencies and liver disease. However, its effect is significantly less potent and slower than FFP, with no effect for about l2 hours. Therefore, it should also be given in this patient but it is the most critical agent to use in reversing her ongoing bleed.

Explanation:

Male factors account for infertility in approximately one third of cases (one third are female factors, one third are combined). Evaluation is warranted if no pregnancy occurs after 12 months of unprotected intercourse, which is the standard definition of in fertility. The physical examination should look for any features of hypogonadism and an evaluation of testicular size. The First laboratory step in male fertility analysis is semen analysis. If semen analysis reveals normal count, morphology, and volume, the next step should be evaluation for female factor infertility with assessment of ovulatory status by history and laboratory testing (A). If these are normal or equivocal, the next step would be to proceed with assessing tubal patency through a hysterosalpingogram (C). A hysterosalpingogram will also give evidence of any anatomic uterine abnormality. If the first semen analysis is abnormal, repeat testing in days to weeks is warranted because of significant variability. If repeat testing reveals oligozoospermia once again, then investigation of male serum FSH, LH, and testosterone (B) is the next step. Telling the couple that they require a sperm donor (E) to achieve pregnancy is not appropriate without further testing and repeat semen analysis.

Explanation:

Of the cases of breast cancer that are heritable, approximately 80% are due to mutations in BRCA1 and BRCA2. BRCA1 is associated with high risk for breast and ovarian cancer. BRCA2 is associated with a high risk of female and male breast cancer.

On the basis of our current understanding, however, less than 10% of all breast cancer cases can be considered to be heritable. Therefore, the total number of breast cancer cases associated with BRCA1 and BRCA2 mutations is a small percentage of the total number of breast cancer cases. Furthermore, there are numerous mutations that can occur in the BRCA1 and BRCA2 genes and can be related to an increased cancer risk. Some patients who have a mutation associated with cancer will not go on to develop cancer. Other patients may have a strong family history of breast cancer but no identifiable mutation. At present, therefore, screening of the general population is not recommended. This patient has no family history and is not in a high-risk group. Her prior breast tenderness was likely mastalgia related to the premenstrual phase. Therefore, BRCA1 and 2 screening would not be recommended for this patient. To state that BRCA1 and 2 screening should be performed after age 50 (choice B) is incorrect. As noted above, given the limitations of the testing for BRCA1 and 2 mutations, screening of the general population is not recommended. To state that BRCA1 and 2 screening should be performed if breast pain recurs (choice C) is incorrect. This patient does not need screening, not because her breast pain has resolved, but rather because BRCA1 and 2 screening is not appropriate for the general population at this time. As noted above, her breast pain was likely cyclic mastalgia secondary to hormonal changes prior to menses. To state that either BRCA1 screening (choice D) or BRCA2 screening (choice E) is recommended is not correct. As explained above, screening for neither of these is recommended.

Explanation:

This is an infiltrating carcinoma.
The lack of estrogen receptor staining suggests a poor response to hormonal therapy with tamoxifen.
The positive C-erb B2 (HER2/neu) staining suggest that trastuzumab (Herceptin) may be effective.

Explanation:

Explanation:

In transurethral resection of the prostate (TURP), a thin cylindrical instrument (resectoscope) is inserted through the urethra where it is surrounded by prostate tissue. An electrical loop cuts away excess prostate tissue to improve urine flow.
In a man with advanced age if the tissue shows low grade (Stage T1a-Incidental histologic finding in 5% or less of the tumor resected). It is ok to observe without any further aggressive intervention. Options for more advance cases of prostate carcinoma include prostatectomy and radiation.

Explanation:

hydrocele is fluid build-up around the testicle(s), while a varicocele occurs when blood backs up in the main vein that drains the scrotum. Varicocele is a condition in which the blood supply of the testis develops varicose veins. Veins contain valves that prevent blood from flowing backward. Faulty valves can result in a varicocele. Varicoceles usually develop on the left side of the scrotum and may produce no symptoms. Alternatively, varicoceles may cause pain and a sense of fullness that becomes bothersome. The varicocele feels like a bag of worms when the man is standing. However, the swelling usually disappears when he reclines because blood flow to the enlarged veins decreases. Rarely, a varicocele impairs fertility. During the transillumination test, a flashlight is shone through the enlarged portion of the scrotum. If a hydrocele is present, the scrotum will light up and the test will be positive. If it is a varicocele it will not light up. Germinoma occurs in females (dysgerminoma).

Explanation:

Enteral nutrition is feeding a patient with specially prepared liquid feeds through a tube into your stomach (PEG tube) or small intestine (PEJ tube). Different formulas are available. Your dietitian will choose the most appropriate one for you, depending on your own particular nutritional needs. Some people may need to take all their food and drink this way. While others can take some food by mouth and some fed through the tube. Enteral feeding is only suitable for people whose digestive tract (stomach and intestines) is working normally. This is because the feeds still go through the usual path of digestion. Enteral feeds can cause side effects. Because they are quite concentrated, some of the feeds can cause sickness and diarrhea. If this happens, you may need to have your feeds more slowly. It is common to start off slowly and then build up from there. You may also need extra fluids through a drip to prevent dehydration from severe diarrhea.

Explanation:

Enteral nutrition is feeding a patient with specially prepared liquid feeds through a tube into your stomach (PEG tube) or small intestine (PEJ tube). Different formulas are available. Your dietitian will choose the most appropriate one for you, depending on your own particular nutritional needs. Some people may need to take all their food and drink this way. While others can take some food by mouth and some fed through the tube. Enteral feeding is only suitable for people whose digestive tract (stomach and intestines) is working normally. This is because the feeds still go through the usual path of digestion. Enteral feeds can cause side effects. Because they are quite concentrated, some of the feeds can cause sickness and diarrhea. If this happens, you may need to have your feeds more slowly. It is common to start off slowly and then build up from there. You may also need extra fluids through a drip to prevent dehydration from severe diarrhea.

Explanation:

Hemorrhoids are dilated veins of the hemorrhoidal plexus in the lower rectum. Symptoms include irritation and bleeding. Thrombosed hemorrhoids are painful. Diagnosis is by inspection or anoscopy. Treatment is symptomatic or with endoscopic banding, injection sclerotherapy, or sometimes surgery.
External hemorrhoids may become thrombosed, resulting in a painful, purplish swelling. Rarely, they ulcerate and cause minor bleeding. Cleansing the anal region may be difficult.
Internal hemorrhoids typically present with bleeding following defecation; blood is noted on toilet tissue and sometimes in the toilet bowl. Internal hemorrhoids may be uncomfortable but are not as painful as thrombosed external hemorrhoids. Internal hemorrhoids sometimes cause mucus discharge and a sensation of incomplete evacuation. Strangulated hemorrhoids occur when protrusion and constriction occlude the blood supply. They cause pain that is occasionally followed by necrosis and ulceration.

Explanation:

Older patients with appendicitis are more likely to present without classic signs and symptoms. Elevated WBC counts, rebound tenderness, guarding, and fever are less reliably seen. Perforation is found in over 65% of elderly patients at the time of diagnosis. The causes are delay in diagnosis and because vascular supply is already compromised due to atherosclerotic disease, if infective thrombosis occures, it will ace the perforation.

Explanation:

Almost all glass is visible on radiographs if it is 2 mm or larger, and contrary to popular-belief, it doesn´t have to contain lead to be visible on plain films. Many common or highly reactive materials, such as wood, thorns, cactus spines, some fish bones, other organic matter, and most plastics, are not visible on plain films. Alternative techniques such as ultrasonography or CT scanning may be effective and necessary in those cases. Sea urchin spines, like many animal parts, have not been found to be easily detected by plain radiography.

Explanation:

Explanation:

The correct answer is B. Multinucleated giant cells originate from histiocytes and participate in specialized forms of inflammatory reaction to certain pathogenic stimuli. Multinucleated giant cells are found for example, in granulomas developing in response to mycobacterial and fungal infections, lung injury due to inhalation of airborne inorganic dust, or unknown stimuli in sarcoidosis. In addition, a multinucleated giant cell reaction may result from focal necrosis of fat with release of lipids into the interstitium. The latter mechanism accounts for a marked chronic inflammatory response with formation of multinucleated giant cells in fat necrosis of breast. Frequently, this develops as a result of trauma (which the patient may have forgotten) or following surgery. A poorly circumscribed nodule that must be differentiated from a neoplasm develops in the breast. Biopsy shows this nodule to consist of a central core of lipid filled macrophages, including numerous multinucleated histiocytes, admixed with acute and chronic inflammatory cells and surrounded by a peripheral rim of fibrous tissue.
Acute mastitis is an infection characteristic of the lactating breast, which is made vulnerable to bacterial invasion by microscopic lesions of the nipple. Through this portal of entry, Staphylococcus aureus penetrates into the breast, inciting a marked acute purulent inflammatory response with abscess formation.
Fibroadenoma is the most common benign tumor of the breast, occurring usually before age 30. It is composed of a mixture or fibrous stroma and glandular tissue. The current view is that the true neoplastic population is the fibroblastic component. It appears as a well circumscribed mobile nodule within the breast. There is no inflammatory or giant cell reaction. Fibrocystic changes include a wide spectrum of morphologic alterations in which formation of small cysts; increases in the number of acini, and fibrosis are the main components. Unless associated with proliferative changes of epithelial cells in the terminal duct-lobular unit, fibrocystic changes are benign and do not predispose to cancer. No giant cell formation is seen. Sclerosing adenosis is part of proliferative disease of the breast. It is characterized by proliferation of acini (adenosis) and fibrosis and is associated with a slightly increased risk of developing cance

Explanation:

The first step is to palpate the aorta to ensure that adequate blood pressure is being maintained. Once it is established that there is adequate pressure, attention can be turned to looking for an injury to the major organs. Little information can be gained from palpating the vena cava.

Explanation:

To prevent recurrent variceal bleeding, it is necessary to decompress the portal hypertension. Only shunt surgery effectively accomplishes this goal. Vasopressin, balloon tamponade, and sclerotherapy are effective treatments of acute bleeding, but recurrent bleeding is inevitable. Cimetidine is ineffective in preventing bleeding

Explanation:

Pancreatic carcinoma is a poorly treated and often deadly disease. Five-year survival is extremely poor. Ten to twenty percent of tumors are surgically resectable although this group does not demonstrate a significant increase in five-year survival. Palliative procedures are the mainstay of management. Stenting can be an effective adjuvant to relieve obstructive jaundice and cholangitis.

Explanation:

Pancreatitis can produce both a periumbilical hematoma (Cullen´s sign) and a flank ecchymoses (Grey-Turner´s sign). Homan´s sign refers to pain on dorsiflexion in the presence of a calf deep venous thrombosis, but is not very sensitive or specific. Abdominal pain under the right costal margin during simultaneous palpation and inspiration is Murphy´s sign, which can be found in acute cholecystitis. The psoas sign is when right leg extension produces abdominal pain, and is found in acute appendicitis (the appendix overlies the psoas muscle). Crohn´s disease, a subset of inflammatory bowel disease, is not commonly associated with any of these clinical signs.

Explanation:

Explanation:

In managing any unresponsive patient, maintenance of oxygenation and circulation is essential. This often requires oxygen support and IV fluids if the blood pressure is decreased. In post op patients, you must always be aware of the depressant effect of narcotics on respiratory rate, and treatment of an unresponsive patient with Narcan is appropriate. In the absence of diabetic ketoacidosis, IV administration of an ampule of 50% dextrose can be a life saving maneuver in the patient who is hypoglycemic. By the same token, the administration of insulin could kill this patient.

Explanation:

Breast cancer responds the best of all these tumors to the use of adjuvant chemotherapy after surgical resection.

Explanation:

In the case of a patient in need of urgent surgery, fresh frozen plasma is the fastest and safest way to correct the prothrombin time. Non urgent surgery should be postponed, but urgent surgery, such as in this case where an abscess is suspected, should not be delayed. Protamine reverses heparin, although it has no effect on prothrombin time. Vitamin K will counteract the effect of coumadin, but it takes several days to work, and it makes anticoagulation after surgery extremely difficult. Packed red blood cell transfusion will not correct an abnormal prothrombin time.

Explanation:

The Public Health Service working group suggests that chemoprophylaxis be started promptly (within one to two hours) after exposure and that it be continued for four weeks, if possible. Health care workers with occupational HIV exposure should be given follow up medical evaluation and counseling. The risk of seroconversion after percutaneous injuries averages 0.3%; after mucous membrane exposure, it is about 0.1%, and after skin exposure, less than 0.1%. The risk of seroconversion increases if there is visible blood on the device causing the injury and the in- jury is deep. HIV antibody tests should be given at baseline and thereafter for the next six months. It may be possible to lower the risk further by administering zidovudine in combination with lamivudine or a protease inhibitor.

Explanation:

The baby probably has congenital hypertrophic pyloric stenosis, which usually presents at several weeks of age. Partial surgical incision through the pylorus (pyloromyotomy) is usually curative. Antacids are beneficial in esophageal reflux and peptic ulcer disease. Barium enema can reverse intussusception in a child, but would not be therapeutic in this case. Gastric resection is not indicated since the much less invasive procedure of pyloromyotomy is actually more effective. Oral antibiotics are not indicated, since this is not an infectious process.

Explanation:

The patient has a femoral hernia. This hernia forms by passage of a loop of bowel into the saphenous opening of the fascia lata and then through the cribriform fascia, to bulge anteriorly under the skin over the saphenous opening. They occur below the inguinal ligament. Femoral hernias are much more common in women than in men. The major risk of this type (and most other types) of hernia is strangulation of the herniated small intestine, which may result in death of the involved tissue with significant risk of subsequent life threatening peritonitis and sepsis. A direct inguinal hernia represents intestinal structures passing through a gap in the abdominal wall between transversus abdominis and the internal oblique muscles; these structures do not pass through the deep ring.
A femoral aneurysm is a well recognized complication of angiography and vascular access performed from this approach. During catheterization, the vessel wall is weakened and an outpouching, or aneurysm, results. These are potentially very dangerous. Not only can they rupture, but they can clot and send thrombus to the extremity, resulting in gangrene. Treatment involves surgery or percutanous induction of thrombosis using a variety of sclerosing agents, such as thrombin injection. An incisional hernia occurs where a surgical incision has weakened the abdominal wall. An indirect inguinal hernia represents extrusion of abdominal contents through the deep ring, through the inguinal canal to emerge at the superficial inguinal ring. During physical examination, the hernia can sometimes be reduced by the patient lying on his/her back; if the physician applies pressure to the site of the deep ring, reherniation will temporarily be prevented verifying the diagnosis of indirect inguinal hernia.

Explanation:

The underlying pathology in this patient is most likely a single parathyroid adenoma, for which surgical removal is the only cure. However, estrogen-progestin therapy is beneficial in postmenopausal women with primary hyperparathyroidism because of its ability to reduce bone resorption and thus increase bone density and possibly lower serum calcium concentrations. Other drugs that inhibit bone resorption and thus can be used in primary hyperparathyroidism are bisphosphonates and raloxifene. Calcitonin (B) is useful in the acute treatment (after IV fluids and loop diuretics) of severe hypercalcemia or when the hypercalcemia is severely symptomatic. It effects are short lived and long-term therapy is not possible because resistance to its hypocalcemic effects develops within 1 or 2 days. Low calcium intake (C) is incorrect because it can result in increased hormone production and can accentuate bone disease. Calcium intake for this woman should be modest, but not low. Thiazides (D) are contraindicated because they can worsen hypercalcemia. When diuretics are used to control excessive or symptomatic hypercalcemia, furosemide is recommended, but never thiazides. Vitamin D analogs (B) are used in patients with hyperparathyroidism secondary to renal failure, in which case, the kidney can no longer add a hydroxyl group to vitamin D. This results in decreased calcium uptake from the GI tract In turn, PTH levels are elevated secondarily. Vitamin D analogs correct this problem. However, this patient has no problem with Vitamin D synthesis; giving her Vitamin D analogs would result in increased calcium absorption from the GI tract and would exacerbate the hypercalcemia.

Explanation:

In this setting, the clinical diagnosis is metastatic squamous cell carcinoma to a cervical lymph node, from a primary (or multiple primaries) somewhere in the mucosa of the aerodigestive tract. Endoscopy and biopsies should establish the diagnosis. Thyroid cancer could indeed metastasize to neck nodes, sometimes before the primary tumor is palpable. In this particular setting, however, a radionuclide scan (A) would be a very distant second choice. Sputum cytology and CT scan of the lungs (B) is another tempting thought for a smoker. But when lung cancer metastasizes to the cervical nodes, it affects the supraclavicular nodes, not the nodes higher up in the neck. Open biopsy of the neck mass is an absolute no-no, whether it is excisional (E) or incisional (D). Doing so will in fact confirm the diagnosis, but at the cost of contaminating the tissues and interfering with the placement of incisions for the definitive surgery. Furthermore, the location of the primary (or primaries) would not be established.

Explanation:

This question evaluates an important concept in medical treatment always try conservative managements first. In this case, the patient has already been prescribed local anesthetics and sitz baths, but he also needs high fiber diet since hemorrhoids are often caused by a history of constipation. Topical antibiotics are not necessary since the rectal and anal mucosa are highly vascularzed and have an extraordinary ability to heal (B). Hemorrhoids are classified as either internal or external, based on their location. They occur when the veins of either the internal or external hemorrhoid plexus become enlarged and the supporting muscles deteriorate. Both types are very common and are associated with increased hydrostatic pressure in the portal venous system, such as during pregnancy, straining at stool or cirrhosis (as in this case). The most common manifestation of internal hemorrhoids is painless, bright red rectal bleeding that occurs with bowel movements. Some complain of a feeling of incomplete evacuation. Definitive diagnosis is made by physical examination. If possible, the patient is asked to strain as if defecating and the anus is examined for relapsing veins. Anoscopy and proctoscopy may be performed to rule out coexisting pathology. The physician has an obligation to determine that there is nothing more serious going on with this patient. The patient did not offer these symptoms at his last physical, and waiting for 9 months (C) is unethical, since you have a diagnosis already. Because it will be necessary to rule out cancer, this patient will need a digital rectal examination, anoscopy, and flexible sigmoidoscopy. Once malignancy has been ruled out, conservative treatment with sitz baths, stool softeners, and stool-bulking agents may be used. Anal fissure (D) is not the correct diagnosis here because the patient does not present with the classic exquisite pain during defecation .Most of the time the bleeding presents as streaks on the stool surface. If anal fissure was the diagnosis, the analgesics might have easily controlled the pain. Thrombosis is one of the complications of hemorrhoids. This occurs when the hemorrhoid has prolapsed and the normal blood within the vein has become acutely thrombosed. This leads to severe pain. The treatment for an acutely thrombosed hemorrhoid is incision and extraction of the clot, followed by compression of the incised area (E). This patient´s pain does not seem this severe; so do not schedule surgery without trying medical treatment first.

Explanation:

Even though this patient has risk factors for organic impotence-atherosclerosis (A) and diabetes mellitus (B) the sudden onset and the continued presence of nocturnal erections point to a psychogenic problem. Gemfibrozil (C) is not associated with erectile dysfunction. Beta-blockers such as metoprolol (D) are associated with sexual dysfunction, but patients usually present with symptoms after having been treated for a long period of time. This patient has sudden onset dysfunction. Further, beta-blockers do not result in a loss of libido; they result in a loss of the ability to maintain/achieve erections.

Explanation:

Explanation:

The initial diagnosis was acute pancreatitis because of the symptoms of abdominal pain, nausea, vomiting and the finding of the Grey Turner sign (bruises on the flanks due to subcutaneous tracking of digested blood around the abdomen from the inflamed pancreas). A common complication of pancreatitis, and often the reason forth demise of patients, is the development of a pancreatic abscess. The timetable is usually about 10 to 14 days from the onset of the disease, and the initial manifestations are high-grade fever and leukocytosis (as observed in the laboratory studies). The next step in management would be CT scan of the abdomen to locate the abscess for drainage. Chronic pancreatitis (A) develops after several years of recurrent attacks of pancreatitis, and is characterized by steatorrhea, diabetes, and constant pain, which is not the case here. Pancreatic pseudo cyst (D) is another potential complication of pancreatitis. However, the manifestations are related to pressured symptoms from the fluid collection, there is no fever or leukocytosis, and the timetable for development is about 6 weeks from the onset of the disease. Pelvic abscess (D) and Subphrenic abscess (E) are indeed in the differential diagnosis, as they also present with fever and leukocytosis some 10 to 24 days from the original problem. But, the original problem for these patients is usually an infectious process in the abdomen, e.g., ruptured appendix or a perforated viscus. If the problem began with pancreatitis, and then there are signs of sepsis, the pancreas would be the logical place to harbor the pus.

Explanation:

The entire description is classic for anal cancer, but the clincher is the presence of metastasis in the inguinal nodes. Adenocarcinoma of the rectum (A) could look like this if it arose very low in the rectum, but it would not metastasize to inguinal nodes. Condyloma acuminatum (B) could give fungating masses, but it would not lead to cachexia and would not produce the rock hard inguinal nodes. Viral infections may precede the development of this kind of tumor (and could coexist with it), but it would be wrong to assume that all the patient has is the benign viral process. External hemorrhoids (C) are not fungating masses, and they are usually very painful. They do not lead to inguinal adenopathy or cachexia. Rectal prolapse (D) would produce a protruding mass with concentric mucosal folds, would come in and out with straining and would be a nuisance but it would not produce adenopathy and cachexia.

Explanation:

There is a marked hypernatraemia with elevated chloride but normal potassium and urea in a patient with severe head injuries. The likely cause of this presentation is diabetes insipidus. Urine osmolality is therefore likely to be low. You cannot say that she has a hyperchloraemic acidosis as you do not have her bicarbonate concentration but if you assume that the anion gap would be normal, that is 10-12, then this would suggest that the bicarbonate is elevated, suggesting either a metabolic alkalosis or respiratory acidosis with compensation. Although restoration of normal volume and osmolality is required, giving 5% dextrose may exacerbate any cerebral oedema and so correction should be gradual.

Explanation:

An inguinal hernia usually produces a painless bulge in the groin or scrotum. If the hernia can slide back and forth, the bulge may enlarge when a man stands or strains. The bulge may get smaller or disappear when the man lies down. If the hernia is incarcerated, the bulge does not get smaller or disappear. Strangulated hernias usually become very painful within minutes or hours.
To diagnose an inguinal hernia, a doctor examines the groin and the area around it. For the examination, a man may have to stand and cough or strain. Coughing or straining produces pressure in the abdomen and makes a hernia more obvious. To determine whether the hernia is reducible or incarcerated, the doctor usually tries to push the loop of intestine back into the abdomen by pushing on the upper part of the scrotum with a gloved finger

Explanation:

First-degree burns are the most shallow (superficial). They affect only the top layer of skin (epidermis). Second-degree burns extend into the middle layer of skin (dermis). Third-degree burns involve all three layers of skin (epidermis, dermis, and fat layer), usually destroying the sweat glands, hair follicles, and nerve endings as well.
As with more superficial burns, deep minor burns are treated with antibiotic cream. However, any dead skin and broken blisters must be removed before the antibiotic cream is applied. In addition, keeping a deeply burned arm or leg elevated above the heart for the first few days reduces swelling and pain. The burn may require frequent re-examination at a hospital or doctor´s office, possibly as often as daily for the first few days.

Explanation:

The absence of vital signs is the commonest mode of diagnosing death and entails absent heart sounds, respiratory arrest and loss of papillary light reflex. Brain stem tests are generally reserved for ventilated cases where organ transplantation may be required. Doctors most commonly diagnose death not the coroner who provides a verdict on the cause of death.

Explanation:

Terminally ill patients often report that they fear intractable pain more than they do dying. Patients frequently express the desire to have open and honest dialogue about pain and want to be involved fully in planning their pain management. A doctor must be able to get alongside the patient and their family and to spend time presenting options, answering questions and quelling fears. Having promised to keep the patient relatively pain-free, it is paramount to meet this promise to preserve trust. Pain is easier to prevent than it is to relieve and drugs should be prescribed on a prophylactic basis with no other consideration than maintaining the patient´s quality of life. Pain is a complex subjective phenomenon and is affected by the emotional context in which it is endured. Adequate psychological support is critical as removing the fear of pain in itself will help to optimize pain control. A patient who is fearful, withdrawn and depressed often appears to have a lower pain threshold than one who is still actively engaged in enjoying what is left of their lives, even though they may have same stage disease. Non-drug measures to help psychological or spiritual distress may be as important as medication in relieving pain and suffering.

Explanation:

Pre-operative antibiotics given prior to skin incision have significantly lowered surgical infection rates. Antibiotics should be given within two hours of surgery. There is no advantage to starting antibiotics 24 hours prior to surgery. Antibiotics can be continued 24 to 48 hours after surgery but should not be routinely continued for longer than this time period. Post-operative doses have not been shown to be as important as pre-op doses.

Explanation:

The lymph nodes of the groin are divided into superficial and deep groups. The superficial group is further divided into horizontal and vertical chains. It is worth remembering that tumors from the penis, vagina and anal canal can drain to the medial side of the horizontal chain of the superficial group of inguinal lymph nodes. Tumors from the ascending colon do not usually metastasize early to easily palpable lymph nodes; they instead metastasize to mesenteric nodes. Tumors from the duodenum do not usually metastasize early to easily palpable lymph nodes. They metastasize instead to the rich network of lymph nodes around the duodenum, pancreas, stomach, and liver. Tumors from the stomach can metastasize early to the easily palpable left supraclavicular nodes (also called Virchow´s nodes or sentinel nodes). They can also metastasize to nodes near the stomach. Tumors from the transverse colon do not usually metastasize early to easily palpable lymph nodes; they instead metastasize to mesenteric nodes.

Explanation:

Hernia following caesarean section is relatively common and may occur because of the increased elasticity and abdominal pressure that occurs during pregnancy. As long as the hernia remains easily reducible, it can be observed and electively repaired if symptoms dictate. There is no need to resect small bowel in a hernia without strangulation. Medication has no effect on the hernia. Emergent repair is only indicated in cases of incarceration and/or strangulation.

Explanation:

A direct blow to the bladder can lend to the extravasation of urine into the peritoneal cavity. This urine would have basically the same chemical characteristics of urine that is passed normally. Levels of urea, creatinine, and ammonia would be high. Amylase and lipase would below. In preparing for a peritoneal tap, it is important to ensure that, if possible, the bladder is empty. Accidental entry into the bladder would give similar results. Ascites from liver failure can have a straw colored appearance and be low in protein. The fluid would also be low in urea and creatinine. Depending on the serum ammonia levels, the ascitic fluid ammonia levels would range from low to elevated. Intestinal strangulation secondary to volvulus or hernia incarceration would lead to damage to the intestinal bowel wall. The fluid would be high in ammonia (and alkaline phosphatase) but low in creatinine and urea. Peritoneal effusions secondary to acute pancreatitis would have high levels of amylase and lipase. Perforated bile duct or for that matter, a perforated gallbladder, would give an effusion with a greenish hue. Urea and creatinine would not be elevated.

Explanation:

To prevent recurrent variceal bleeding, it is necessary to decompress the portal hypertension. Only shunt surgery effectively accomplishes this goal. Vasopressin, balloon tamponade, and sclerotherapy are effective treatments of acute bleeding, but recurrent bleeding is inevitable. Cimetidine is ineffective in preventing bleeding

Explanation:

A hernia is an abnormal protrusion of tissue through a fascial defect. A Spigelian hernia is an acquired hernia through the linea semilunaris (the lateral border of the rectus abdominus muscle). A Richter hernia occurs when part of the bowel becomes incarcerated in the defect. A direct hernia occurs because of a defect in the transversalis fascia in Hesselbach´s triangle, as opposed to an indirect inguinal hernia, in which the processus vaginalis fails to be obliterated. Littre´s hernia contains a Meckel´s diverticulum within it. A pantaloon hernia is a combined direct and indirect hernia.

Explanation:

The survival rate for patients with distant spread of gastric carcinoma is poor. Patients with distant spread should receive palliation treatment only for such conditions as obstruction. Radiation and chemotherapy are not effective. Subtotal and total gastrectomy are indicated for localized tumors.

Explanation:

Rapid bolus feedings in the supine position in a comatose patient can cause aspiration of the formula, and not diarrhea. Hypertonic feedings cause high osmolality and thus osmolar diarrhea. Bacterial contamination of feedings can cause infectious diarrhea. Refrigeration of formula and strict handwashing is necessary. Decrease in the acidity of the bowel by H2 blockers can alter the bowel flora and thus cause diarrhea. Antibiotics can also alter the bowel flora and cause C. difficile diarrhea.

Explanation:

Fractures of the femurs are known to be one of the few places in the body where enough occult blood loss may occur to lead to hypovolemic shock. Fat embolism (B) is also associated with long bone fractures, but the manifestations are those of respiratory failure, rather than hypovolemic shock. Neurogenic shock (C) would rarely occur from pain alone, being more common as a sequela of high spinal cord transaction. When it happens, the patient is hypotensive but looks warm and flushed rather than cold and pale. Intracranial bleeding (D) can lead to neurologic symptoms, but not to hypovolemic shock. There is not enough room within the head to accumulate the sizable blood loss required to go into shock. Pericardial temponade (E) would produce high central venous pressure.

Explanation:

The patient has fever, right upper quadrant pain, and jaundice (together known as Charcot triad, characteristic of cholangitis), along with elevated alkaline phosphatase. Ultrasound would show dilatation of the common bile duct along with the extra and intrahepatic biliary apparatus, which would indicate that there is some obstruction at the level of the common bile duct. This obstruction is most likely due to a common bile duct stone (known as choledocholithiasis). Biliary obstruction is the primary etiology in most patients with acute cholangitis. All patients with suspected cholangitis should be evaluated for biliary obstruction by an imaging study. ERCP is both diagnostic and therapeutic. Acute hepatitis should be suspected in all patients with abdominal pain. However, the patient´s normal enzyme values and the high LDH and amylase values would not be explained by acute hepatitis (B). This patient probably presented initially with a biliary colic (A). However, at this time, the case is most consistent with a cholangitis due to the presence of jaundice and the high fever, which are unlikely to be seen in a cholelithiasis or a cholecystitis case. This patient probably had a gallbladder stone that traveled to the common bile duct, partially obstructing it, and leading to an ascending infection. Choledocholithiasis and gallstones both predispose patients to acute pancreatitis. However, the patient has a normal lipase level, and it is unlikely that he has acute pancreatitis (C). Amylase can be elevated with inflammatory intraabdominal pathology, including acute cholangitis. Peptic ulcer disease (PUD) (E) causes epigastric pain, but fever, jaundice, and biliary obstruction would not be explained by PUD.

Explanation:

This question describes a patient with intracranial hemorrhage and evidence of increased intracranial pressure. Cushing´s Triad refers to the bradycardia, hypertension, and irregular respiratory patterns with which this patient presents-obvious bradycardia and BP of 130/80 mm Hg is relative hypertension in a recent trauma patient. Furthermore, failure to over breathe the ventilator by a patient for whom sedation is not mentioned is considered irregular. This diagnosis of Cushing´s triad can be made clinically based on this combination of symptoms or can be detected on fundus examination, with a CT scan showing edema or midline shift, or with the insertion of an intracranial pressure monitor. Regardless of the method of diagnosis, the treatment is reduction of the increased intracranial pressure, which includes several strategies-from least invasive, including raising the head of the bed, sedation with propofol, hyperventilation to a PaCO2 of 30-35 mm Hg, and administration of mannitol (osmotic diuretic); to fairly invasive procedures including surgical intervention with a Burr hole decompression; or craniotomy and evacuation. In this case, the diagnosis can be made clinically, although a CT scan should be obtained, as ordered, to assess for progression of the known bleed. Treatment, therefore, is aimed at decreasing intracranial pressure, with the best option being the administration of mannitol. Atropine (A) is useful for bradycardia via parasympathetic antagonism; it is also useful in cardiogenic bradycardia, but not when due to an intracranial process, in which it will simply elevate the heart rate not treat the underlying problem. Emergent craniotomy (C) may become necessary, but is the most invasive strategy and should only be performed if less invasive techniques fail. There is no indication for removal of the cervical collar (D), which would in no way manage the underlying problem of elevated intracranial pressure. Mechanical ventilation is indicated for patients with increased intracranial pressure, as they can be sedated to decrease cerebral perfusion and thereby intracranial pressure. Accordingly, extubation (E) would be contraindicated.

Explanation:

In this setting, the clinical diagnosis is metastatic squamous cell carcinoma to a cervical lymph node, from a primary (or multiple primaries) somewhere in the mucosa of the aerodigestive tract. Endoscopy and biopsies should establish the diagnosis. Thyroid cancer could indeed metastasize to neck nodes, sometimes before the primary tumor is palpable. In this particular setting, however, a radionuclide scan (A) would be a very distant second choice. Sputum cytology and CT scan of the lungs (B) is another tempting thought for a smoker. But when lung cancer metastasizes to the cervical nodes, it affects the supraclavicular nodes, not the nodes higher up in the neck. Open biopsy of the neck mass is an absolute no-no, whether it is excisional (E) or incisional (D). Doing so will in fact confirm the diagnosis, but at the cost of contaminating the tissues and interfering with the placement of incisions for the definitive surgery. Furthermore, the location of the primary (or primaries) would not be established.

Explanation:

He came in with mechanical intestinal obstruction due to adhesions, and has now developed signs of bowel strangulation. If the strangulated loop is still viable, it has to be freed immediately. If it is necrotic, it has to be respected with equal urgency to prevent continued peritoneal soiling. Antibiotics (A) will not provide viability to a compromised loop of bowel, nor prevent peritonitis if the loop is dead. Barium tag (B) is what we do in the postoperative period after abdominal surgery when we cannot decide whether a sluggish bowel has paralytic ileus or early mechanical obstruction. This is not the situation here. CT scan (C) is our universal answer when we do not know what is happening inside the belly. Here we do. Had he shown up with obstruction, and no reasonable etiology for it (no prior surgery, no hernias), we might have done CT. Endoscopy and a long tube (D) will not take care of dead or dying bowel.

Explanation:

This patient has stage l breast cancer clinically, based on the size of the lesion and the lack of nodal involvement. Lumpectomy (breast conservation) has been shown to be as efficacious as radical mastectomy when combined with radiation therapy. Lumpectomy alone (A) is associated with higher rates of recurrence in patients with breast cancer. Lumpectomy alone can be performed in some women who fear cosmetic deformity but it is not recommended, due to the high rate of recurrence. Tamoxifen ought to be used if the tumor is estrogen receptor-positive, as it is in this case. Tamoxifen works as a competitive inhibitor of estrogen. It has been shown to reduce the recurrence and mortality when combined with radiation and lumpectomy (C) in this population of patients. Anastrozole (B) is also approved for the treatment of breast cancer in postmenopausal women; however, it has been shown to increase the risk of fractures. Since this patient has a history of osteoporosis, anastrozole is not preferred. Raloxifene, another selective estrogen receptor modulator (SERM) approved for the treatment of breast cancer, has been shown to decrease the risk of fractures in postmenopausal women and therefore can also serve as a preventive agent.

Explanation:

Even though this patient has risk factors for organic impotence-atherosclerosis (A) and diabetes mellitus (B) the sudden onset and the continued presence of nocturnal erections point to a psychogenic problem. Gemfibrozil (C) is not associated with erectile dysfunction. Beta-blockers such as metoprolol (D) are associated with sexual dysfunction, but patients usually present with symptoms after having been treated for a long period of time. This patient has sudden onset dysfunction. Further, beta-blockers do not result in a loss of libido; they result in a loss of the ability to maintain/achieve erections.

Explanation:

The concern is that even though he is now normotensive, invasive steps might trigger a hypertensive crisis from the previously undiagnosed pheochromocytomas that he probably has. The presence of catabolites from epinephrine indicates that the tumor is in the adrenal glands, and not at an extra-adrenal site. Thus, the diagnosis of the pheochromocytomas can best be confirmed by MRI of the adrenals. Meningioma (A) and acoustic nerve tumors (C) occur in type 2 neurofibromatosis, not in type 1. Looking for pheochromocytomas outside of the adrenal glands (D) would have been a good idea if only elevated catabolites of nor epinephrine had been detected. The presence of high levels of epinephrine catabolites implicates the adrenal glands.
Radiation therapy (E) is a bad idea. Benign neurofibromas can be stimulated by radiation to undergo malignant transformation.

Explanation:

The diagnosis is a perforated esophagus, also known as Boerhaave syndrome, based on the presence of vomiting, pain, and subcutaneous emphysema (Meckles triad). Forceful vomiting results in a transmural tear and perforation of the esophagus, usually in the left lateral position of the distal esophagus 3-5 cm above the gastroesophageal junction. Full-thickness transmural perforation is in contradistinction to Mallory Weiss syndrome, which is a tear of the inner layer of the esophagus, is not transmural, and usually presents as an upper GI bleed and not chest pain or subcutaneous emphysema. Hartmann sign is the presence of mediastinum crunching on auscultation and indicates the presence of pneumomediastinum. Approximately 90% of cases of esophageal perforation are iatrogenic during upper endoscopy, with the name “Boerhaave syndrome” reserved for spontaneous rupture typically due to vomiting. Diagnosis of an esophageal perforation is made on a Gastrografin swallow study, demonstrating contrast extravagating from the esophageal lumen. Gastrografin, which is water soluble, is not toxic to mediastinum and thoracic structures; as opposed to barium (A), which is more radiopaque and therefore more sensitive but also more dangerous. Treatment depends on the patient´s clinical situation and can include immediate primary repair via left thoracostomy if there is no gross contamination; drainage alone; conservative management with NPO status, intravenous fluids, and antibiotics; or diversion with a cervical esophagostomy.
Insertion of a nasogastric tube (C) would be of little immediate benefit and risks further damage to the perforated esophagus. It may be useful for gastric decompression and even feeding, if necessary, but plays no role in the acute setting. If feeding is desired and an operative intervention is pursued, a gastrostomy tube would be indicated. Transthoracic echocardiogram (D) would be of little help in diagnosing an esophageal perforation. The presence of a murmur and a known ventricular sepal defect is a distracter and is unlikely to account for the chest pain in this patient´s condition, given the other findings on physical exam. A transesophageal echocardiogram would obviously be contraindicated in the presence of a possible esophageal perforation. Upper endoscopy (E) is much more invasive than radiologic studies and carries its own risk of perforation. Additionally, direct visualization of the perforation contributes little to the ultimate management of the patient.

Explanation:

The patient is remarkably stable for a gunshot wound to the abdomen, so one must wonder if, in fact, he did sustain such injury. Only one bullet hole is noted, presumably the entry wound. There is, however, no exit wound. Given the musculature of the back, it is possible that the bullet did not traverse the superficial layers and enter the peritoneum or even the retro peritoneum. This would be consistent with his presentation. Although CT scan of the abdomen (B) or exploratory laparotomy (D) would prove this theory, the least invasive and quickest test is a cross table X-ray (C). It would likely reveal the bullet in a posterior position. If the bullet were in fact anterior, it would indicate that the bullet had traversed the abdomen and warrant either further imaging (such as a CT scan) or exploration, depending on the patient has reassessed clinical condition. This patient should not be assigned autocritically to exploratory laparotomy for a gunshot wound to the abdomen until it either is known, clinically or radiographically, that the gunshot was indeed to the abdomen. The findings of the chest X-ray are negative and there are no hemodynamic or respiratory findings that would suggest a thoracic injury. CT scan of the chest (C) is therefore incorrect. Insertion of Foley catheter shows clear urine, so an IV pyelogram (E) is not indicated.

Explanation:

PSA is a glycoprotein produced only in the cytoplasm of prostate cells, and the serum level correlates with the volume of both benign and malignant tissue. As a first line screen, it is elevated in 10 to 15% of men self referred for screening. Prostatic cancer will be found in 18 to 30% of men with intermediate levels of elevation-4.1 to 10 g/L (normal is 4 g/L); 50 to 70% of those with levels 10 g/L will be found to have cancer. But 20% of patients who have radical prostatectomy for cancer will have a normal PSA. Treatment decisions in patients with untreated cancers cannot be made on the basis of PSA testing alone. Most cancers detected by digital rectal examination are advanced. Transrectal ultrasound should not be used as a first line screening tool because of its expense, and low specificity and, therefore, high biopsy rate. It increases the detection rate very little when compared with the combined digital rectal examination and PSA determination. PSA is not specific for cancer, and there is overlap of values in men with BPH and cancer. PSA detected cancers are more likely to be localized compared with those detected by rectal examination alone. The serial measurement of the PSA, called the PSA velocity, this may increase sensitively for cancer detection. Increased likelihood occurs with an increase of 0.75 g/L per year. A decrease in PSA velocity (A) is not usually associated with malignancy.
Further refinement may be done, however, in a patient with a normal rectal exam, and elevated PSA, and a normal transrectal ultrasound by calculating the PSA density. This is the serum PSA volume of the prostate as measured by ultrasound. Patients with high PSA densities are more likely to have cancer in spite of a normal rectal examination and ultrasound. The most recent refinement of PSA has been the measurement of free serum and protein-bound levels. Cancer patients have lower percentages of free serum PSA (C) as compared to protein bound PSA which is usually higher (D). Optimal cutoff levels have not yet been determined.

Explanation:

The situation described is that of a wound dehiscence that has not yet progressed to a wound evisceration. The former can be dealt with conservatively, like any other wound, by taping the wound securely maintaining moist environment pain reduction and promotion of granulation tissue. The patient will eventually require re-closure, but this can be done whenever it is most convenient Cultures and antibiotics (A) would be appropriate it there was a sign of infection. Assuming the pink fluid to be sign of infection is not correct. It is normal peritoneal fluid (with a trace of blood still in it from the recent surgery) that is seeping out through the unhealed wound. Probing (B) will not produce pus, but it might cause evisceration. The patient is afebrile and the wound is not red. Clear pink salmon-colored fluid means dehiscence, not infection. Betting the patient out or bed (C) is absolutely inadvisable. If this were done, the person helping the patient would soon be looking at a portions or small bowel extruding from the abdomen. Taking the patient to the OR immediately (D) would be appropriate if the patient had wound dehiscence with evisceration.

Explanation:

Ogilvie syndrome is a type of colonic dysfunction often seen in elderly patients who are not too active to begin with and are then further immobilized by extra-abdominal surgery. Colonoscopy should be done to rule out obstructing cancer (always a consideration in this age group) and allows the gas to be sucked out as the scope is advanced. A long tube is then left in place. Fecal impaction (A) is always a good thing to look for in old immobilized people with abdominal distention. However, the rectal vault would have been full, and the X-ray films might have shown the fecal column extending up into the sigmoid and descending colon. Neither mechanical intestinal obstruction (B) nor paralytic ileus (D) would develop from hip surgery. When these complications occur after abdominal surgery they affect primarily the small bowel, not the colon. Volvulus of the sigmoid (E) is another good thought in the distended old patient but the radiologic picture would have been different with a huge distended sigmoid way up into the right upper quadrant and tapering toward the left lower quadrant with the classic image of a parrot´s beak.

Explanation:

This patient has injured his femoral artery with a bone fragment from the fractured femur. Vascular injury can be a sequel of femoral fractures, posterior knee dislocation, or fracture of the proximal tibia and fibula. A thorough lower extremity pulse examination is required in case of any of these injuries. Angiography may reveal an area of active bleeding or vascular disruption that may be embolized or identified as site for a possible surgical bypass. An emergent fasciotomy (B) should be used in acute compartment syndrome; the compartment pressure should be above 30 to 40 mm Hg. Reduction of the fracture (C) can be performed after vascular integrity has been assessed. Right leg amputation (D) is unnecessary at this time, as the leg may be salvaged with an intervention after angiograph. Vigorous hydration (E) would be necessary in the case of hypovolemia.

Explanation:

Pinavarium is used to reduce the pain duration in irritable bowel syndrome (IBS). Carbamazepine is in use for the treatment of neuropathic pain of malignancy, diabetes and other disorders. Clodronate inhibits osteoclastic bone resorption and is used to treat malignant bone pain and the associated hypercalcaemia. The corticosteroids are used to treat pain from central nervous system tumours.
Reducing the inflammation and oedema relieves the pain caused by neural compression. Nifedipine helps relieve painful oesophageal spasm and tenesmus associated with gastrointestinal tumours. Painful bladder spasm may be relieved by oxybutinin.

Explanation:

Initial treatment of an acute coronary syndrome is aspirin 300 mg. This should be safe in the postsurgical patient with no signs of bleeding at 3 days post-operation. Clexane would also be given, but aspirin initially.
The dose of clopidogrel is 300 mg in an acute coronary syndrome. Diamorphine is used to treat anxiety and pain, neither of which is commented upon.
GTN would be reasonable to try, however the blood pressure is low. Remember that in the diabetic, chest pain may not be a feature of acute coronary syndrome due to autontmic dysfunction, and in most postsurgical patients myocardial infarct is silent.

Explanation:

A retrospective review of 650 patients with suspected appendicitis showed a sensitivity of 97% and a specificity of 98% for spiral CT. In patients in whom the clinical diagnosis was uncertain, sensitivity was 92% and specificity was 85%. Two prospective studies comparing ultrasonography with spiral CT have favored spiral CT. Ultrasonography is used in women who are pregnant and women in whom there is a high degree of suspicion of gynecologic disease. Abdominal radiography has low specificity and sensitivity for the diagnosis of acute appendicitis. Air contrast barium enema also has low accuracy. Limitations of MRI include increased cost, decreased availability, and increased examination time compared to CT

Explanation:

Varices are dilated veins in the distal esophagus or proximal stomach caused by elevated pressure in the portal venous system, typically from cirrhosis. They may bleed massively but cause no other symptoms. Diagnosis is by upper endoscopy (Esophagogastroduodenoscopy or EGD). Treatment is primarily with endoscopic banding and IV octreotide. Sometimes a transjugular intrahepatic portosystemic shunting procedure is needed.

Explanation:

The patient has a history and symptoms very suggestive of a compartment syndrome of the anterior compartment of the left leg. A common cause of this serious problem is limb compression during prolonged recumbency related to drug or alcohol overdose. Early diagnosis and treatment are essential in order to avoid permanent, severe disability.
The five “P´s” of compartment syndrome are pain, pallor, paresthesias, pulselessness, and paralysis. If distal pulses are reduced, then muscle necrosis has occurred and immediate surgical consultation is necessary. Duplex Doppler ultrasonography and impedance plethysmography are used to evaluate for deep venous thrombosis. Given the decreased pulses, however, this diagnosis is much less likely and such testing may needlessly delay urgent surgical treatment. Intravenous antibiotics would be appropriate for cellulites. This diagnosis is unlikely in this scenario given the absence of fever, erythema, and edema, and the presence of a diminished pulse. Rest, ice, and elevation are inappropriate treatment modalities for compartment syndrome.

Explanation:

Tumors within 5 cm of the anal verge should be treated with abdominal perineal resection with permanent colostomy. Hemicolectomy is indicated for right and left colon tumors. Anterior resection with anastomosis to the rectal stump is best reserved for sigmoid and upper rectal tumors. Total colectomy alone would not treat distal rectal disease. Palliation therapy is indicated for metastatic disease.

Explanation:

Suppurative cholangitis can result in life-threatening sepsis and requires IV fluids and antibiotics along with emergent drainage of the biliary tree. Observation and oral antibiotics are not effective and any delay in treatment can increase mortality which is as high as 50% in this disease.

Explanation:

While recent technological advances have led to earlier detection of breast cancer, this has not led to an absolute cure and a marked increase in survival. The major advance has been in demonstrating that lumpectomy with axillary node dissection offers about the same five-year survival as mastectomy The choice between these treatments should be determined on an individual treatment basis, with the psychological implications of mastectomy weighed against the fear of recurrence if the breast is not removed.

Explanation:

The most common breast mass in men, especially under 25 years of age, is gynecomastia, which is a benign proliferation of ductal and stromal elements of the breast. It is generally an idiopathic condition, probably related to pubertal hormonal changes. Gynecomastia can involve either one or both breasts and, if it arises during adolescence1wilI often resolve spontaneously with time. Fibrocystic changes in the breast, which reflect physiological responses in the breast to cyclical levels of sex hormones, are not observed in men. Fibrocystic changes are most common in the late reproductive years and include fibrosis cyst formation, and a variety of epithelial changes such as hyperplasia and apocrine metaplasia. Intraductal papillomas are benign neoplasms commonly evolving in the major lactiferous ducts beneath the nipple. They most commonly present with a bloody nipple discharge and are rare in men. Carcinoma of the male breast is rare and almost always develops in the breasts of elderly men. Male breast carcinomas have a somewhat worse prognosis than their female counterpart. Grossly and microscopically they usually resemble ductal carcinoma in the female. The male breast does not develop lobules and so carcinomas resembling lobular carcinoma are extremely rare in the male breast.

Explanation:

The patient most likely has a gastrointestinal bleed. While she may be bleeding from a site other than the Gl tract, the Gl tract should be the first place checked. Her unchanged hemoglobin despite two units of blood is suggestive of an active bleed. Observation and IV fluids do nothing to address the source of bleeding. Fresh frozen plasma is not indicated, as there is no evidence of a coagulation abnormality. As the patient is stable, there is no indication for surgical exploration.

Explanation:

In cases of blunt abdominal trauma, diagnostic peritoneal lavage is the correct intervention. Exploratory laparotomy is indicated if there are >l00,000 red blood cells. If lavage is negative, observation for 24 hours is indicated.

Explanation:

Etoposide and cisplatin typically represent the combination chemotherapy that is used for the treatment of testicular cancer. Fluorouracil with the adjuvant levamisole is used for colorectal carcinoma. Methotrexate and dactinomycin are used in the treatment of choriocarcinoma, while vincristine and dactinomycin are used in patients with Wilms tumor.

Explanation:

The most common clinical sign of pulmonary embolism is tachypnea. Other important features include chest pain, dyspnea, an accentuated S2 heart sound, pulmonary rales, apprehension, tachycardia, fever, phlebitis, hypotension/syncope, and cyanosis.

Explanation:

Wide resection is the treatment of choice for established soft tissue sarcomas. Wide resection consists of excision with a margin of normal tissue. Incision and excision are inadequate for malignant tumors. Marginal excision consists of excision through the reactive zone of tissue. This is not recommended for malignant tumors, although it is adequate for benign, but locally aggressive, tumors. Radical resection consists of resecting the entire compartment. This is overly aggressive and has not been shown to improve the outcome.

Explanation:

Laparotomy allows accurate staging and allows for transposition of the ovaries out of the radiation field, which is desirable if the patient wishes children in the future. Treatment should not be delayed, as this could lead to further spread of the disease. Chemotherapy will prevent a future healthy pregnancy. Progesterone will have no protective effect.

Explanation:

Indications for lumbar disc decompression include progressive weakness and loss of reflexes, which are indicative of severe nerve compression. An inability to control urination is indicative of cauda equina syndrome, which is a surgical emergency. The real surgical dilemma occurs in the management of patients with pain as the chief complaint. Isolated low back pain does not usually respond to lumbar disc decompression, as the pain is most often due to mechanical back pain. These patients should be managed conservatively for as long as possible with a minimum of three months of conservative management. Patients with leg pain worse than back pain may be appropriate candidates for decompression after an initial period of at least six weeks of conservative care.

Explanation:

A nonhealing ulcer is an indication for peripheral revascularization, as the ulcer will eventually become infected and can lead to partial amputation without an adequate blood supply. Vascular claudication alone is not an indication for surgery. Neurogenic claudication is a result of spinal stenosis and will not be treated by vascular surgery. Weakness of dorsiflexion is not a common symptom of peripheral vascular disease and loss of sensation in the foot should make you suspicious of a diabetic neuropathy which often occurs in association with peripheral vascular disease.

Explanation:

The history is classic for “congenital” pyloric stenosis, which typically presents from 3 to 6 weeks of life. A small mass can be felt deep to the right of the rectus abdomen is when the stomach is empty which is the hypertrophied pylorus. This problem can be easily surgically corrected with pyloromyotomy, in which the pyloric muscle is partially cut, relieving the obstruction. Barium enema is occasionally effective in reducing childhood intussusception, but would not be of value in pyloric stenosis. Duodenoduodenostomy is used to correct congenital duodenal obstruction, but is not required for congenital pyloric stenosis. Gastric resection would be completely unnecessary in this case. Volvulus usually involves the small intestine and can produce an “acute abdomen” secondary to infarction of the bowel.

Milk is vomited and it maybe curdled or not. Depends on the time difference between feed and vomitus. If enough time exists for milk to mix with acid, it will be curdled milk vomiting. Or otherwise.

Explanation:

Bariatric surgery is a major gastrointestinal procedure. Bariatric surgery in adolescents raises social, psychological and developmental issues, but adolescents are not excluded from surgery, and some hospitals have specialised programmes for younger patients. Potential candidates for surgery are those with a body mass index (BMI) exceeding 40, or BMI > 35 with serious co-morbidities (eg sleep apnoea, type 2 diabetes). Post-operative mortality ranges from 0.1-2 %. Vomiting is a risk associated with bariatric surgery, as is dumping syndrome and nutritional deficiencies. There is no evidence as yet; that bariatric surgery reduces cardiovascular mortality in patients.

Explanation:

Liver abscess complicating biliary tract disease is described as pyogenic abscess (to contrast it with amebic abscess), and it requires drainage. The percutaneous route is favored. The difference between amebic and pyogenic abscess may be radiographically indistinguishable. Clinical suspicion based on age and epidemiologic risk factors is therefore most important. Those who have pyogenic liver abscesses are most likely to have a greater degree of jaundice, bacteremia/sepsis, and history of gallbladder disease or surgery. Amebic abscess should be suspected in young male patients who have recently traveled to endemic areas or are immigrants of endemic areas. Amebic abscess, when suspected, does not require immediate percutaneous drainage; it should be treated empirically with metronidazole (C) and have serologic testing performed (for E. histolytica). If the patient does not improve over a course of days, percutaneous drainage may be required. Endoscopic retrograde cholangiopancreatogram (ERCP) (A) is often urgently needed to treat acute ascending cholangitis, but it does nothing for a liver abscess. Long term antibiotics (B) do not penetrate an existing abscess. Abscesses have to be drained for resolution to occur, except in the case of amebic abscess, as described. Open surgical drainage (D) is not preferred for a liver abscess. If this option had been open surgical drainage plus removal of the gall bladder, this would have been a good option. Open surgical drainage alone, however, is more invasive than percutaneous intervention.

Explanation:

Prostate cancer is the most common cancer detected in American men. Most of these cancers are small and contained within the prostate, and few are associated with regional or distant disease. Incidence increases with age. Obstructive voiding symptoms are most often due to benign prostatic hypertrophy (BPH), but large, locally extensive cancer can cause obstructive voiding symptoms. On digital rectal exam, prostate cancer may show as focal nodules or areas of induration; however, many are associated with normal palpation and so are detected on the basis of elevation of the serum PSA. Transrectal ultrasound guided biopsy is the best method for detection of prostatic cancer and allows for accurate grading. The biopsy is done in men with an abnormal digital examination or PSA. Early adenocarcinoma of the prostate represents disease that is localized to the gland without extension beyond the capsule or to distant sites. Following the establishment of the diagnosis, the patient should be prepared for a radical prostatectomy. Disease that includes or extends beyond the capsule is considered advanced carcinoma, and other treatment modalities should be sought (A, B, or C). Transurethral resection of the prostate (TURP) (E), is the most common surgical procedure to treat BPH. It has no use in the treatment of adenocarcinoma of the prostate.

Explanation:

Explanation:

The underlying pathology in this patient is most likely a single parathyroid adenoma, for which surgical removal is the only cure. However, estrogen-progestin therapy is beneficial in postmenopausal women with primary hyperparathyroidism because of its ability to reduce bone resorption and thus increase bone density and possibly lower serum calcium concentrations. Other drugs that inhibit bone resorption and thus can be used in primary hyperparathyroidism are bisphosphonates and raloxifene. Calcitonin (B) is useful in the acute treatment (after IV fluids and loop diuretics) of severe hypercalcemia or when the hypercalcemia is severely symptomatic. It effects are short lived and long-term therapy is not possible because resistance to its hypocalcemic effects develops within 1 or 2 days. Low calcium intake (C) is incorrect because it can result in increased hormone production and can accentuate bone disease. Calcium intake for this woman should be modest, but not low. Thiazides (D) are contraindicated because they can worsen hypercalcemia. When diuretics are used to control excessive or symptomatic hypercalcemia, furosemide is recommended, but never thiazides. Vitamin D analogs (B) are used in patients with hyperparathyroidism secondary to renal failure, in which case, the kidney can no longer add a hydroxyl group to vitamin D. This results in decreased calcium uptake from the GI tract In turn, PTH levels are elevated secondarily. Vitamin D analogs correct this problem. However, this patient has no problem with Vitamin D synthesis; giving her Vitamin D analogs would result in increased calcium absorption from the GI tract and would exacerbate the hypercalcemia.

Explanation:

The patient described is suffering from primary hyperthyroidism. The most common cause of primary hyperthyroidism is a parathyroid adenoma; parathyroid carcinoma and hyperplasia are much less common. This condition most commonly occurs in women over the age of 40 years as a solitary adenoma. Genetic syndromes such as MEN I, IIa, and IIb may also be associated with parathyroid adenomas, among other findings. Typical presenting complaints are those associated with hypercalcemia. These include recurrent urolithiasis, constipation, myalgias, bone pain, polyuria, fatigue, and psychologic changes. Patients may be asymptomatic at presentation, however, with the diagnosis made following discovery of an elevated calcium level on routine blood tests. Laboratory studies typically reveal an inappropriately elevated parathyroid hormone (PTH) level, hypercalcemia, hypophosphatemia, and elevated urine calcium. Chronically elevated PTH levels can cause defective bone mineralization and remodeling, leading to osteitis fibrosa cystica, a condition characterized by the formation of “brown tumors” in bone, particularly in the jaw. In cases in which the bone is significantly affected, the serum alkaline phosphatase is elevated, not decreased (E). Hypernatremia (A) typically occurs in the setting of excessive free water loss and is not associated with primary hyperparathyroidism. Hyperphosphatemia (B) and low levels of dihydroxy (24, 25(OH) 2) vitamin D occur in the setting of renal failure/renal osteodystrophy, one cause of secondary hyperparathyroidism. Hyponatremia (C) can occur in the syndrome of inappropriate antidiuretic hormone (SIADH), which is a paraneoplastic condition associated with small cell carcinoma of the lung. Another paraneoplastic syndrome associated with this malignancy is hypercalcemia caused by production of PTH related peptide by the malignant cells, resulting in hypercalcemia and low PTH levels.

Explanation:

The description is that of causalgia, also known as reflex sympathetic dystrophy. If sympathetic block relieves the symptoms, permanent cure will be obtained with surgical sympathectomy. Venous occlusion (A) would produce swelling but not this kind of pain. Cervical ribs (B) can produce neurologic and vascular symptoms in the arm, but they are related to activity and position and do not have the nature described here. Normal pulses make arterial insufficiency (C) unlikely. Furthermore, there is no description of intermittent claudicating. Compartment syndrome (D) might have happened at the time of- injury, but if that were the case, it would be too late to do a fasciotomy. Compartment syndrome is characterized by excruciating pain with passive extension, tenderness to palpation, and a “tense” feel to the affected extremely. Neurologic function is lost initially, followed by pulses.

Explanation:

he history and rectal examination findings are classic for urinary retention caused by a benign prostatic hyperplasia (BPH). The use of a decongestant has led to stimulation of alpha adrenergic receptors, which have further closed the bladder neck, producing a big, palpable bladder The next step by general consensus is to catheterize the bladder with a Foley catheter. But when resistance or obstruction is encountered, it is necessary to do a percutaneous suprapubic cystostomy to relieve bladder distention. Dilation of the urethra is a valid option, although this should be done by a specially trained physician. Culture and sensitivity of prostatic secretions (A) would be a valid option if a bacterial prostatitis is suspected, which will be characterized by pain, fever spikes, and a very tender and hot prostate on rectal examination. This patient has a mild temperature elevation that is not due to infection. Morphine IV stat (B) may relieve the pain, but the same result can be achieved by relieving the urine retention. Furthermore, remember that opioid may increase the tone of the sphincters, an undesirable effect in this patient. To obtain a serum PSA level (C) is not indicated at this time. The case presentation is typical for BPH, and the patient is in distress due to the urinary retention. Relieve the pain and the obstruction first then consider ordering a PEA level. Trans-rectal ultrasound of the prostate (E) is indicated for early diagnosis of carcinoma of the prostate, as follow-up of abnormal digital rectal examinations, elevated PSA levels, evaluation of azoospermia, etc. It is not necessary in a patient with BPH facing acute urinary retention. The priority here is to relieve the patient´s bladder distention.

Explanation:

The correct next step is to perform an urgent exploratory laparotomy this patient has pneumoperitoneum, and despite not knowing her clinical status (fever; hemodynamic, etc.), it needs to be surgically explored. Given the facts of her hospital admission, steroid use, and epigastric pain and vomiting, the diagnosis of a gastric ulcer should be obvious, and the presence of free air indicating perforation is an indication for urgent surgical exploration. Biopsies should also be taken to evaluate for Helicobacter pylori as well as a neoplastic process. Free air present on X-ray is almost ubiquitously an indication for exploration; further imaging with a CT scan (A) is not necessary this patient´s diagnosis should be recognized clinically and the decision to operate should be made on the basis of the plain X-ray findings. Concern for a peptic ulcer should be worked up with upper endoscopy (E), and H. pylori positive patients should be treated with triple therapy (D). However, that would be an option for the symptomatic but stable patient, not in the presence of known or suspected hollow bowel perforation. Endoscopy to evaluate the repair and triple therapy will likely be necessary for this patient in the future. NPO status and insertion of a nasogastric tube (C) will not help this patient in the long run. Gastric decompression and drainage are necessary to protect the repair, and a nasogastric tube must be placed under direct internal palpation in the operating room, but it is not the management of choice for this patient since it is not enough to repair the perforation.