Explanation:

Significant impact (eg, motor vehicle collision) can rupture a normal spleen. Rupture of the splenic capsule produces marked hemorrhage into the peritoneal cavity. The manifestations, including hemorrhagic shock, abdominal pain, and distention, are usually clinically obvious. However, splenic trauma can also produce a subcapsular hematoma, which may not rupture until hours or even months after the injury.
Rupture is generally preceded by left upper quadrant abdominal pain. Splenic rupture should be suspected in patients with blunt abdominal trauma and hemorrhagic shock or left upper quadrant pain (which sometimes radiates to the shoulder); patients with unexplained left upper quadrant pain, particularly if there is evidence of hypovolemia or shock, should be asked about recent trauma. The diagnosis is confirmed by CT scan (in the stable patient), ultrasound, or peritoneal lavage (in the unstable patient).
Treatment has traditionally been splenectomy. However, splenectomy should be avoided if possible, particularly in children, to avoid the resulting permanent susceptibility to bacterial infections.

Explanation:

Explanation:

Asplenic and functionally asplenic patients are susceptible to overwhelming infection from encapsulated organisms, and should be immunized with pneumococcal, meningococcal, and Hib vaccines. The vaccines´ immunogenicity may be reduced when given after splenectomy or during chemotherapy; thus, they should be given at least 2 weeks before performing elective splenectomy or starting chemotherapy if possible.

Explanation:

Esophaegal 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.
Treatment involves fluid resuscitation, endoscopic banding (sclerotherapy second choice) IV octreotide and possibly a transjugular intrahepatic portosystemic shunting (TIPS) procedure.
If bleeding continues or recurs despite these measures, emergency techniques to shunt blood from the portal system to the vena cava can lower portal pressure and diminish bleeding. A TIPS procedure is the emergency intervention of choice. TIPS is an invasive radiologic procedure in which a guidewire is passed from the vena cava through the liver parenchyma into the portal circulation.
The resultant passage is dilated by a balloon catheter, and a metallic stent is inserted, creating a bypass between the portal and hepatic venous circulations. Stent size is crucial. If the stent is too large, hepatic encephalopathy results because of diversion of too much portal blood flow from the liver. If the stent is too small, it is more likely to occlude.

Explanation:

This patient in all probability has the euthyroid-sick syndrome, also known as nonthyroid illness syndrome (NTI)-the association of severe nonthyroidal illness with biochemical parameters indicative of thyroid hypofunction. Low T3 with normal T4 and low T3 with low T4 are the most common variants of this syndrome. TSH is usually normal but may be high or low. A TSH level > 20 microU/mL would be inconsistent with NTI and ´indicates hypothyroidism. Replacement of T4 does not influence the outcome.

Explanation:

The accessory nerve (CN XI) runs through the posterior triangle, so it is likely to be injured in posterior neck triangle operations. If the accessory nerve is damaged there, the trapezius will be denervated, the tip of the shoulder will be drooping and the patient will have inability to raise her hand above her head.

Explanation:

When straw-colored or gray-green fluid is obtained by fine-needle aspiration of a breast nodule and the lesion completely disappears, the diagnosis is simple cyst. The fluid should not be sent for analysis because the risk for cancer is exceedingly small. If the fluid is bloody or otherwise unusual, it should be sent for cytologic examination because about 7% of bloodstained aspirates are associated with cancer.

Explanation:

The presence of free air under the diaphragm should be almost pathognomic for the diagnosis of secondary bacterial peritonitis, which most often results from the perforation of the bowel wall. Non-ruptured duodenal and gastric ulcers will not reveal free air under the diaphragm on a vertical chest x ray. In addition, the abdomen will not be dilated. All of the laboratory findings are consistent with the diagnosis of secondary peritonitis. Esophageal rupture is rarer as compared to bowel perforation and more likely to produce air in the chest cavity.

Explanation:

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:

Explanation:

Explanation:

Organic cases of impotence are uncommon. In this patient without history or evidence of diabetes or drug exposure, a pituitary tumor is the most common organic cause. Primary hypogonadism is rare and is usually accompanied by other complaints (e.g., weakness). Neuropathies, not secondary to diabetes mellitus, are rare and patients usually present with complaints of pain, numbness, or weakness.

Explanation:

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

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:

Similar to testicular tumors, ovarian tumors can be classified according to cell of origin. There are three main categories: tumors of surface epithelium, tumors of germ cell origin, and tumors of sex cord stromal origin. Ovarian surface epithelium (coelomic mesothelium) may differentiate along tubal (serous), cervical (mucinous), or endometrial lines giving origin to serous cystadenoma/cystadenocarcinoma, mucinous cystadenoma/cystadenocarcinoma and endometrioid tumors, respectively. Serous tumors represent 40% of all ovarian tumors, and serous cystadenocarcinoma is the most frequent serous tumor. Serous cystadenocarcinomas occur primarily in women aged 40 to 65 years. About two thirds of these tumors are bilateral. As the name suggests it is a cystic tumor containing clear fluid. The cystic wall is lined by malignant epithelial cells forming papillary fronds. Less frequent than serous cystadenocarcinoma, endometrioid adenocarcinoma and mucinous cystadenocarcinoma also derive from surface epithelium. Endometrioid carcinoma is histologically similar to endometrial adenocarcinoma, whereas mucinous cystadenocarcinoma is composed of mucin producing cells similar to cervical epithelium. Both these neoplasms have solid and cystic areas (mucinous cystadenocarcinoma more so than endometrioid carcinoma) and may be bilateral (endometrioid carcinoma more frequently than mucinous cystadenocarcinoma). Granulosa cell tumors originate from ovarian stroma and consist of variable mixtures of granulosa cells and theca cells. Since they frequently produce large amounts of estrogens, these tumors manifest with precocious puberty in preadolescent girls. On the contrary, mature women with granulosa cell tumors develop endometrial hyperplasia and fibrocystic change of breast. Histologically, these neoplasms are composed of uniform cuboidal cells, forming structures reminiscent of ovarian follicles (Call-Exner bodies). Mature cystic teratoma is the most frequent neoplasm derived from germ cells. Teratomas can be further classified into mature cystic, immature, and monodermal teratomas. The great majority of teratomas are mature cystic. Since they originate from more than one germ layer, these neoplasms contain an amazing mixture of mature tissue components, often including skin, teeth, neural epithelium, thyroid, cartilage, and intestinal tissue, for example.

Explanation:

The combination of the clinical history and macroscopic features of the surgical specimen is consistent with Crohn disease. Histologic examination of this segment would likely reveal transmural chronic inflammation and scattered noncaseating granulomas. This chronic inflammatory condition may affect the whole alimentary tract, from mouth to anus, but most commonly involves the terminal ileum. The most important clues to the correct choice (clues that also guide the clinical diagnosis) include sharp demarcation of involved segments of bowel and the involvement of the terminal ileum. The young age of the patient is also consistent with the epidemiologic features of Crohn disease. Adenocarcinoma of the colon develops most commonly alter 60 years of age. The small intestine is not usually involved. The gross picture would show either a fungating, often ulcerated mass protruding into the lumen; or a ring like infiltrating lesion that narrows the intestinal lumen. Diverticular disease is particularly prevalent in elderly people, and usually involves the distal colon. Involvement of the terminal ileum is unlikely. Asymptomatic cases are more frequent than those giving rise to clinical manifestations. Grossly, you would see outpouchings of the mucosa covered by a thin layer of serosa without a muscular layer. Intestinal tuberculosis is now a rare condition, occasionally encountered in immunosuppressed patients. Ulcerations of the mucosa are the predominant macroscopic features. Caseating granulomas are the most typical histologic features. Ulcerative colitis overlaps with Crohn disease in clinical and histopathologic features. This overlap justifies the “umbrella” designation of inflammatory bowel disease, used by clinicians and pathologists when differentiation between these conditions is not possible (10-15% of cases). However the presence of “skip” segments between involved intestinal loops and non necrotizing granulomas on histologic examination favors a diagnosis of Crohn disease over that of ulcerative colitis. The terminal ileum is only involved in ulcerative colitis if there is extensive disease through the whole length of the large bowel.

Explanation:

Mesenteric ischemia is caused by a reduction in intestinal blood flow, which most commonly arises from occlusion, vasospasm, and/or hypoperfusion of the mesenteric vasculature. A CT scan of the abdomen (or MRI, which was not offered as a choice) has excellent diagnostic yield when looking for mesenteric venous thrombosis. The clinical picture is indeed very suggestive for that condition. Colonoscopy (A) or sigmoidoscopy is often required to establish the diagnosis of ischemic colitis. They are usually performed without bowel preparation to avoid reducing blood flow from dehydrating cathartics), and with minimization of air insufflation in an effort to avoid overdistention and perforation. Colonoscopy is usually reserved for occasions where CT is inconclusive. Color Doppler ultrasound (C) also has excellent diagnostic capability if performed by an experienced sonographer, under ideal circumstances. Gas, however, is the “enemy´ of sonograms. Given the gas distention in this man, the circumstances are no longer ideal for the ultrasound. Exploratory laparotomy (D) is in order if there are signs of peritonitis (which this mar does not have). Surgical treatment is not necessarily imperative at this time. The peritonitis could still be managed with anticoagulants or thrombolytic agents. Laparoscopy (E) is less invasive than open laparotomy, but the necessary insufflation of the abdomen in an already distended individual, with marginal vital signs, is not a good idea particularly when the noninvasive CT scan can enable the physician to make the diagnosis.

Explanation:

The clinical diagnosis is chronic pancreatitis because of the history of intense epigastric pain and long-standing heavy alcohol intake. Steatorrhea and diabetes reflect the pancreatic insufficiency. ERCP (C) provides the most accurate visualization of the pancreatic ductal system and is regarded as the diagnosing criterion of chronic pancreatitis. ERCP is not the best initial test as it is invasive, expensive, and carries a risk (operator-dependent) of pancreatitis. CT scan (B) is the best initial step as it gives useful information about potentially correctable features of the disease, such as pseudocysts, dilated ducts, calculi, or areas amenable to resection. It is not the most accurate test because the subtle abnormalities of early to moderate chronic pancreatitis are beyond its resolution, and a normal finding on this study does not rule out chronic pancreatitis. This study is indicated to look for complications of the disease. Arteriogram (A) adds little to the diagnosis of chronic pancreatitis, and it is invasive and expensive. Sonogram (D) lacks the necessary detail for this evaluation. It is, however, an excellent way to follow the size of pseudocysts that are being observed. Upper gastrointestinal series (E) would give minimal information about the pancreas.

Explanation:

Fever that starts about 10 to 15 days after a contaminated abdominal surgical procedure is most likely due to a deep abscess, either pelvic or subphrenic, which is further supported by the elevated WBC. The former has been ruled out by the rectal exam performed as part of his postoperative physical examination; the latter can best be demonstrated by CT scan. A chest X-ray (A) could be helpful if an air-fluid level was to show up beneath the right diaphragm, but such finding is rare. An elevated hemidiaphragm with pleural effusion would also be suggestive, but not diagnostic. The lung itself should not be the source of this late post operative fever. Plain films of the abdomen (C) might show the same findings detailed above, but the chances are low. Pus alone will not be seen in a plain film.
Blood cultures (D) might identity a type of flora, which would suggest the source of the infection (in this case the gastrointestinal tract flora), but would not pinpoint the location of the abscess. X-ray studies of the bowel (E) might identify a leak in an anastomosis and might be a good idea if a gastric or a colonic suture line were suspected, which is not applicable here.

Explanation:

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:

Ninety percent of hepatic adenomas arise in women aged 20 to 40 years, most of whom use oral contraceptives. The risk of hepatic adenoma seems to be related to the dosage and duration of use of estrogens. It is also associated with glycogen storage disease type 1 and the use of anabolic steroids. It is important to know that these adenomas have a tendency to rupture and bleed massively inside the abdomen. CT scan is diagnostic and emergency surgery is required.
Acute cholecystitis (A) occurs with inflammation and gallbladder distention. Patients will complain of pain consistent with biliary, colic and may have a fever and mild tachycardia. They do not have anemia. Ascending cholangitis (B) is a potentially deadly disease in which gallstones have reached the common duct, producing partial obstruction and ascending infection. Patients are usually much older and very sick. Ectopic pregnancy (C) presents as lower abdominal pain and irregular or absent menstrual periods. This patient has neither. Perforated duodenal ulcer (D) is usually accompanied by sudden and severe epigastric pain with radiation to the right scapula. Physical examination reveals a low grade fever, diminished bowel sounds, and rigid abdominal muscles. Upright abdominal X-ray may reveal pneumoperitoneum, which is not present in this patient.

Explanation:

The patient described has a squamous cell carcinoma (SCC) of the pharynx. SCC of the head and neck has been associated with alcoholism, chronic tobacco use, and infection with the human papilloma virus (HPV), particularly monogenic HPV strains such as type 16. Oropharyngeal SCC most commonly affects men over the age of 50 years, though men may be more likely to abuse alcohol and tobacco, and the most commonly involved sites are the palate and tongue. Lesions classically begin as red or white plaques (erythroplakia and leukoplakia, respectively), but tumors in the nasopharynx and or pharynx often do not become clinically evident until disease is severe (stage III to IV). Lesions of the nasopharynx may occlude the Eustachian tube, causing accumulation of mucus in the middle ear, which is then predisposed to repeated, chronic infections. Aflatoxin (A) is produced by some species of Aspergillus and typically occurs in locations where crop grains are stored. It is associated with the development of hepatocellular carcinoma. Arsenic (C) exposure is associated with squamous cell carcinoma of the skin, but it does not cause oropharyngeal SCC. Obesity (E) is associated with a greater risk for diabetes, stroke, and coronary artery disease and has a detrimental effect on expected lifespan, but it is not directly associated with any particular malignancies.

Explanation:

This patient has abdominal compartment syndrome .The massive infusion of Ringer lactate, though life-saving, produces severe edema in the surgical field. Forced closure would increase the intra abdominal pressure, compressing the lungs, thus producing hypoxia, and the inferior vena cava, causing renal failure. Distension of the skin will cause the sutures to cut through the skin around them. To avoid this set of complications, a temporary plastic coverage or an absorbable mesh that can be left in place, should be placed at the time of the surgery to allow the bowel to be protected without the undue pressure. Closing the skin only (A) can be life-saving when hypothermia develops during surgery. In this setting, however, the skin will not come to gather without undue tension.
Forced closure (B) would compromise ventilation and produce acute renal failure due to pressure on the inferior vena cava. Diuretics (C) cannot selectively remove the fluid from the swollen tissues. Leaving the bowel exposed to the air (D) is not an option. In the short term, the patient would suffer severe heat loss; later, the bowel would dry out and perorate.

Explanation:

Gastrointestinal tract fluids have a sodium concentration very close to that of plasma; as they are lost (internally or externally), they should be replaced with isotonic, sodium containing fluids. But that is not what patients typically do at home. Thirsty and unable to eat solid (sodium-containing) foods, they drink water, Coke, and tea, fluids without significant amounts of sodium, which the body avidly retains because of the severe volume depletion. Endogenous water from catabolic activity is also retained. Dilutional hyponatremia eventually develops. She does not have “water intoxication” (A). This term denotes abnormal water retention due to excessive water infusion at a time when there is a high level of ADH in the blood. This patient is retaining water because she is desperately volume depleted, not because high volumes of water are being forced into her.
The hyponatremia is not due to the loss of hypertonic fluid (B). There are no hypertonic fluids in the gut or anywhere else for that matter. The only hypertonic fluid that we can lose is highly concentrated urine, but we usually do so as a physiologic response to save water. Yes, we often see comatose and convulsing patients when they have this much hyponatremia (D), but that happens when water retention is massive and fast. Slow water retention allows the brain to adapt. One can see even lower serum sodium concentrations in patients with a clear sensorial. Volume deprivation leads to renal wasting of sodium (E) is plain wrong. What the kidney does when there is volume depletion is to increase reabsorption of sodium, not to dump it.

Explanation:

The most likely diagnosis is deep venous thrombosis (DVT), for which this patient is high risk given her bed rest secondary to the orthopedic operation. She should have been on appropriate DVT prophylaxis, ideally with low molecular weight heparin. Although the question stem is certainly suggestive of this diagnosis, with the appropriate imaging, therapy should not be initiated, especially in an elderly postoperative patient. Although a venogram (E) would be the gold standard for the diagnosis, it is highly invasive; therefore, the appropriate diagnostic modality is a duplex venous flow study, as it is entirely non-invasive and has sensitivity and specifically greater than 90%.
Therapy would then entail systemic anticoagulation with either heparin or low molecular-weight heparin (C) followed by warfarin (D). It is crucial that warfarin not be started before adequate anticoagulation with a heparin product because of the well described initial pro-coagulopathy state after initiating warfare therapy due to its inhibition of proteins C and S. Administering IV furosemide (A) is based on this patient´s distracting cardiac history, making congestive heart failure (CHF) exacerbation a possibility; but there is no mention of any other physical exam findings consistent with this diagnosis, and the lower-extremity edema is unilateral, whereas congestive heart failure would present as bilateral edema. If CHF exacerbation were in fact the diagnosis, the administration furosemide would certainly be appropriate.

Explanation:

The man obviously has early obstruction of his billiary tract, of which he had not been clinically aware. He also has blood in the lumen of the gut, and has been bleeding sufficiently to become anemic. The only single lesion that could account for both of these findings is a cancer of the ampulla of Vater. Endoscopic examination should reveal it and allow biopsies to confirm the diagnosis. CT scan of the abdomen (A) can reveal sources of billiary obstruction if they are large (cancer of the head of the pancreas) or calcified (gallstones), but is unlikely to show a small ampullary cancer. Colonoscopy (B) would have been the thing to do if all he had was anemia and blood in the lumen of the gut, in which case the diagnostic suspicion would have been cancer of the right colon. But cancer of the colon could not account for the billiary obstruction. Percutaneous cholangiogram (D) is sometimes done to visualize the billiary tract but ERCP is usually preferred. In any event, we should be able to establish the diagnosis in this case by just doing the “E” of the ERCP (endoscopy). Upper gastrointestinal series (E) is a poor second choice to direct visualization when trying to confirm the presence of an ampullary cancer.

Explanation:

The laboratory picture is highly suggestive of obstructive jaundice. Patients who have sclerosing cholangitis are at high risk for developing cholangiocarcinoma (lifetime risk is estimated to be 10 to 15%). Sonogram is the best initial study, but it is often difficult to interpret. In these cases, a CT scan is expected to provide greater detail and might show the tumor. Based on the results, a good guess as to the anatomic location of the tumor can be made. Klatskin tumors are a subtype of cholangiocarcinoma that occur at the confluence of the right and left hepatic bile ducts with or without a thickened wall. This results in intrahepatic ducal dilation and a contracted gall bladder because of the obstruction to outward biliary flow. Obstruction to outward flow also leads to a predominantly conjugated hyperbilirubinema. Cholangiocarcinoma occurring at the ampulla of Vater (A) or the common bile duct (B) or a tumor in the head of the pancreas (E) large enough to compress the distal billiary tree would be expected to produce a distended gall bladder and dilation of the intrahepatic and extra hepatic billiary ducts proximal to the tumor. A distended gall bladder without intra or extra hepatic billiary duct dilation is suggestive of a cystic duct tumor (D) or stone.

Explanation:

Any malignant mass >4 cm in diameter exceeds the criteria to perform a lumpectomy; therefore, mastectomy is indicated. However, mastectomy alone is not sufficient. Axillary node sampling is required in all suspicious lesions in order to determine postoperative systemic therapy.
Lumpectomy alone (A) cannot be done because the tumor is >4 cm in diameter.
Lumpectomy, axillary sampling and postoperative radiation (B) would have been the correct answer for a tumor 4 cm. Total mastectomy alone (C) would have been a wise palliative choice if the patient had evidence of distant metastasis.
Radical mastectomy (E) is no longer used for the treatment of breast cancer. It offers no survival advantage over the less aggressive modified radical mastectomy.

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:

Esophaegal 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.
Treatment involves fluid resuscitation, endoscopic banding (sclerotherapy second choice) IV octreotide and possibly a transjugular intrahepatic portosystemic shunting (TIPS) procedure.
If bleeding continues or recurs despite these measures, emergency techniques to shunt blood from the portal system to the vena cava can lower portal pressure and diminish bleeding. A TIPS procedure is the emergency intervention of choice. TIPS is an invasive radiologic procedure in which a guidewire is passed from the vena cava through the liver parenchyma into the portal circulation.
The resultant passage is dilated by a balloon catheter, and a metallic stent is inserted, creating a bypass between the portal and hepatic venous circulations. Stent size is crucial. If the stent is too large, hepatic encephalopathy results because of diversion of too much portal blood flow from the liver. If the stent is too small, it is more likely to occlude.

Explanation:

Testicular torsion is the most common cause of spontaneous testicular pain in boys age 12 years and older and is uncommon before 10 years of age. There is inadequate fixation of the testis within the scrotum, resulting in excessive mobility. Shortly after torsion, there is acute pain and swelling of the scrotum, which is very tender. The normal cremasteric reflex is nearly always absent. The differential diagnosis includes strangulated inguinal hernia, which most often causes inguinal swelling, unlike torsion. There is no antecedent association of hydrocele with testicular torsion. Spermatogenesis can be lost within 6 hours of the loss of blood flow, making prompt diagnosis and surgical detorsion and fixation essential. Either a Technetium-99m pertechnetate flow scan of color Doppler Ultrasonography is 95 % accurate in determining flow, but results can be misleading if torsion is less that 360. These tests are reasonable, but should not delay surgical intervention given the small window of therapeutic opportunity.

Explanation:

ABC is a mnemonic for memorizing essential steps in dealing with an unconscious or unresponsive patient. It stands for Airway, Breathing and Circulation. If the patient´s airway is blocked, oxygen cannot reach the lungs and so cannot be transported round the body in the blood. Ensuring a clear airway is the first step in treating any patient. Common problems with the airway involve blockage by the tongue or vomit. Initial opening of the airway is often achieved by a “head tilt, chin lift” or jaw thrust technique, although further maneuvers such as intubation may be necessary. The patient is next assessed for breathing. Common findings during an assessment of breathing may include normal breathing, noisy breathing, gasping or coughing. The rescuer proceeds to act on these based on his/her training. Generally at this point it will become clear whether or not the casualty needs supportive care (such as the recovery position) or rescue breathing. Once oxygen can be delivered to the lungs by a clear airway and efficient breathing, there needs to be a circulation to deliver it to the rest of the body. This can be assessed in a number of ways, including a pulse check, ECG analysis, or capillary refill time.

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 falls to be obliterated. Littre´s hernia contains a Meckel´s diverticulum within it. A pantaloon hernia is a combined direct and indirect hernia.

Explanation:

Explanation:

Recurrent breast cancer is likely to produce small nodules in the scar tissue. Streptococcal infection is most likely to involve laryngeal, pharyngeal, or tonsillar tissue. Staphylococcal infections are most likely to occur within a few weeks after surgery. Candida Albicans prefers deeper locations where heat, moisture, and macerated tissue are available to promote growth. Erysipelas lesions are more likely to appear as vesicles than papules.

Explanation:

If appendicitis evolves slowly adjacent organs such as the terminal ileum, cecum, and omentum may wall off the appendiceal area, resulting in an abscess. Although obstruction of the appendiceal lumen with a fecalith is thought to be a primary initiating event in acute appendicitis, it cannot be identified in every case. Alternatively, mucosal ulceration has been demonstrated as another initiating event. Following obstruction of the lumen, mucous secretion is impaired, resulting in distention of the organ. Luminal bacteria multiply and invade the appendiceal wall as its veins become engorged and its arterial supply is compromised.

Explanation:

Splenectomy is always indicated in two conditions that result in primary hypersplenism: heriditary spherocytosis and primary splenic tumor. It may be indicated in causes of secondary splenism when the primary cause of illness cannot be cured. It is never indicated in hypersplenism secondary to infection, immune mediated reaction, or agranulocytosis. The treatment of portal hypertension is portal decompression, although splenectomy may rarely be indicated.

Explanation:

Initial treatment of varicose veins is noninvasive compression stockings, weight control, elevation of legs above the head, avoidance of high heels, and whirlpool baths. If conservative treatment fails after three to six months or if complications such as phlebitis develop, surgery or sclerotherapy would be the treatment of choice. All of the remaining statements regarding varicose veins are true.

Explanation:

Left shoulder pain and abdominal distention (due to hemoperitoneum) are findings in splenic rupture, due to the distribution of the nerve endings supplying the spleen. Cardiac tamponade would present as an acute cardiovascular emergency; intussusception is not associated with acute trauma; a humeral fracture would not cause abdominal distention; and fracture of the thoracic spine also would not lead to abdominal distention.

Explanation:

In adults, inguinal lymph nodes are often palpable and are less than two centimeters in size. Lymph node enlargement may result from an increase in the number of benign lymphocytes and macrophages in response to antigenic stimulation. Virtually any disease characterized by immune cell activation, such as systemic lupus erythematosis, rheumatoid arthritis, serum sickness, or angioimmunoblastic lymphadenopathy, will produce lymphadenopathy. In amyloidosis, deposition of fibrillar material in lymph nodes results in lymphadenopathy. Infiltration of lymph nodes by inflammatory cells or hyperplasia of the lymphoid or phagocytic cells produces lymphadenopathy in infectious diseases. In situ proliferation of malignant lymphocytes or macrophages, such as occurs in lymphomas, Hodgkin´s disease, or leukemias, also results in enlargement of lymph nodes.

Explanation:

Non-absorbable oral antibiotics are of no use in the management of diverticulitis. IV broad spectrum antibiotics are definitely indicated. Patients should be kept from eating or drinking (A), started on IV fluids (C), and pain should be controlled with narcotics (D) if necessary Morphine should be avoided, as it increases colonic contraction. Patients should undergo a barium enema (E) one week after the attack.

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:

Mammograms alone should not serve as the only screen for the development of breast cancer. Women should be instructed in, and encouraged to perform, breast self examination, since this can identify a lesion before the annual or biannual mammography exam. Breast ultrasonography should not be a routine exam in addition to mammography, but should only be perfumed to demonstrate cystic changes when a suspicious lesion is found at a mammogram. Mammography is not advised in most women before the age of 40, unless they have detected lumps or there is another compelling reason for earlier studies. The amount of radiation in a mammogram is too high to justify using it routinely in all women beginning at the onset of puberty. Mammography can detect lesions that are not palpable and, thus, should not be reserved only for those with lumps.

Explanation:

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:

Explanation:

In liver transplants, technical problems with the biliary and vascular anastomosis are the most common cause of early functional deterioration, and are therefore, the first anomalies to be sought. Antigenic reactions are less common in liver transplants than in other solid organ transplants, in which deterioration of function after 10 days would suggest an acute rejection episode, and appropriate biopsies would be needed to confirm the diagnosis. Options A, B, and C are centered on liver biopsy, which would be done only after technical problems with the biliary and vascular anastomosis have been ruled out. Preformed antibodies (D) are responsible for hyperacute rejection, which would be evident within minutes of establishing blood flow to the graft.

Explanation:

This patient presents with a classic case of Meckel diverticulitis, an inflammation of the remains of the embryonic omphalomesenteric duct that is usually located approximately 50 cm from the ileocecal valve. The “rule of 2´s” refers to:

• the location within 2 feet of the ileocecal valve 4 its presence in 2% of the population
• That it is symptomatic in only 2% of those in which it occurs
• That it consists of two types of mucus (usually intestinal and gastric)

Most of the time, bleeding occurs without warning and stops spontaneously.
In asymptomatic patients, or those presenting without complications diverticulectomy alone is usually enough (A) However, cases that present with complications, such as bleeding, perforation, obstruction, and strangulation, need to be treated with resection of the diverticulum and the adjacent bowel segment (B), which is curative (D). Bowel rest and intravenous antibiotics (C) are part of the conservative management of this condition; however, this is not likely to be enough treatment for patients presenting with bleeding and other complications
Technetium-99m pertechnetate scintigraphy, or Meckel scan, is an important diagnostic modality in which the insertion of a radioisotope with high affinity for the gastric mucosa (not colonic mucosa, E), allows for visualization of the ectopic tissue in the ectopic diverticulum, which is likely producing the mucosal erosions and the bleeding.

Explanation:

The question points out that resolving urosepsis did not affect this man´s mental status, implying another etiology. His history of frequent falls is a predisposing factor for head trauma, and previous or ongoing cerebrovascular ischemia or hemorrhage must be ruled out with a CT scan of the head. A recent change in mental status could be due to more common causes that need to be ruled out before proceeding with more expensive testing; these include hypoxemia, hypoglycemia, electrolyte abnormalities, toxins and polypharmacy fever, psychiatric disorders, brain infections, and brain injury such as an acute or chronic subdural herntoma, which is frequently found in patients with a history of multiple falls. The etiology of this patient´s altered mental status should be explored outside the genitourinary tract, based on the specific mention that his urinary tract infection is improved. This makes renal ultrasound (D) unlikely to reveal further detail on the cause of the patient has altered mental status. Duplex ultrasound of the leg (B) in order to rule out deep venous thrombosis is unlikely to reveal the real cause of this patient has altered mental status. There are no signs or symptoms related to deep venous thrombosis or pulmonary embolism that may suggest the need for this diagnostic procedure. Stopping all medications, (C) is not the appropriate step in this scenario. Even though polypharmacy is one of the common causes of altered mental status in geriatric patients, this man is on few medications; stopping them is more likely to harm him than to alleviate his current problem. Water restriction (E) is likely to dehydrate this patient and further increase his serum sodium level, which is normal at the moment and is an unlikely cause of his altered mental status. Therefore, this is not the appropriate step to be taken at the moment.

Explanation:

Explanation:

Allergenic bone marrow transplantation has become a frequent therapeutic approach to a variety of conditions, including leukemic diseases. The patient undergoing bone marrow transplantation is profoundly immunosuppressed and prone to developing opportunistic infections. The clinical picture described in this case is consistent with graft versus host disease (GVHD), in which T cells (both helper and suppressor cells) of the engrafted marrow react against the recipient´s antigens, thus triggering inflammation and injury to the host tissues. The most severely affected organs include the immune system, gastrointestinal tract liver, skin, and lungs. This complication may be acute (this case) or chronic. CMV pneumonia is a frequent fatal complication in the acute stage. The chronic stage is characterized by progressive fibrosis of affected organs.
B-lymphocytes of a bone marrow grail (A) do not play a significant role in GVHD. Leukemic cells (B) may give rise to recurrence of the original disease, which must be distinguished from GVHD. The combination of skin rash and opportunistic infections strongly favor GVHD. In addition, single cell necrosis in the epithelia of skin, GI tract and liver is highly characteristic of GVHD.
Natural killer cells of the recipient (C) and T-lymphocytes of the recipient (E) play a crucial role in mediating rejection of allergenic marrow transplants.

Explanation:

All of the choices listed are used in the treatment of organic erectile dysfunction. However, to answer this question you must first recognize that this patient is being treated with nitroglycerin for his pulmonary hypertension secondary to his COPD. Sildenafil citrate is contraindicated in patients who use nitrate containing medication. Sildenafil citrate works by inhibiting the type 5 cGMP phosphodiesterase enzyme, which is primarily located in the corpus cavernous smooth muscle. This inhibition leads to an increase in cGMP, which causes a decrease in intracellular calcium and ultimately relaxation of cavernously smooth muscle. This results in erection. Nitroglycerine is converted to nitric oxide (NO) in the blood through a mechanism that is poorly understood. NO is a potent vasodilator; its effect on veins is more than that on arteries, thus leading to pooling of blood in the lower extremities and causing orthostatic hypotension secondary to the reduced preload. Sildenafil citrate differs from the other medications listed in that it will not generate an erection by itself; therefore, stimulation must occur. Because of its mechanism of action, it potentiates the effect of nitrate containing medications that may cause life threatening hypotension. Sildenafil has also been used in patients with primary pulmonary hypertension; however, it has not been shown to have satisfactory results in secondary pulmonary hypertension, which is the case in this question.
Epoprostenol (A) is an analogue or prostacyclin (PGI 2) which is an eicosanoid that primarily prevents platelet aggregation and clumping in the clotting cascade. PGI2 also causes vasodilatation and is administered as a continuous infusion that requires a semi-permanent central line catheter. Bosentan (B) is an endothelin receptor antagonist. Endothelin is a very potent vasoconstrictor that binds to smooth muscle endothelial receptors. Bosentan blocks these receptors, producing vasodilatation. Combination therapy with nitroglycerin has been approved for refractory cases of pulmonary hypertension and has shown a decrease in mortality. A penile prosthesis (D) is typically the final treatment modally offered to patients suffering from impotence. It is invasive, requires anesthesia, and because it is a prosthetic implant carries the risk for infection and malfunction. All of these factors increase the morbidity of the patient. This patient not a good candidate for a surgical procedure, primarily due to his COPD and pulmonary hypertension. Once all other options have been exhausted, then a penile prosthesis may be offered to this patient. Vacuum erection devices (E) work by placing a cylinder over the penis and having a vacuum pump draw blood into the penis. An occlusive band is placed around the base of the penis to maintain the erection. These devices are contraindicated in patients with a predisposition to priapism, significant angulations or fibrosis of the penis, penile implant, bleeding disorder, or on anticoagulation medications.

Explanation:

The patient described has a squamous cell carcinoma (SCC) of the pharynx. SCC of the head and neck has been associated with alcoholism, chronic tobacco use, and infection with the human papilloma virus (HPV), particularly monogenic HPV strains such as type 16. Oropharyngeal SCC most commonly affects men over the age of 50 years, though men may be more likely to abuse alcohol and tobacco, and the most commonly involved sites are the palate and tongue. Lesions classically begin as red or white plaques (erythroplakia and leukoplakia, respectively), but tumors in the nasopharynx and or pharynx often do not become clinically evident until disease is severe (stage III to IV). Lesions of the nasopharynx may occlude the Eustachian tube, causing accumulation of mucus in the middle ear, which is then predisposed to repeated, chronic infections. Aflatoxin (A) is produced by some species of Aspergillus and typically occurs in locations where crop grains are stored. It is associated with the development of hepatocellular carcinoma. Arsenic (C) exposure is associated with squamous cell carcinoma of the skin, but it does not cause oropharyngeal SCC. Obesity (E) is associated with a greater risk for diabetes, stroke, and coronary artery disease and has a detrimental effect on expected lifespan, but it is not directly associated with any particular malignancies.

Explanation:

The story is classic for an iatrogenic stricture of the common bile duct (CBD). It presents with biliary colic and obstructive jaundice (very high alkaline phosphates, direct hyperbilirubinemia). This CBD stricture got infected and has led to cholangitis due to partial or complete obstruction of the CBD, with increased intra-luminal pressures, bacterial infection of the bile with multiplication of the organisms within the duct, and seeding of the bloodstream with bacteria or end toxin. Cholangitis can rapidly become life threatening condition. Clinical presentation of cholangitis is the Charcot triad of fever and chills, jaundice, and right upper quadrant abdominal pain in most patients. Hepatic abscess (A) would have been seen in the sonogram, and would not have produced dilated intrahepatic ducts. Hepatitis (B) would show high transaminases and minimally elevated alkaline phosphatase. The ducts would have been of normal size in the sonogram. Retained stones (D) are a possibility, but it is far less likely than stricture. Had the second surgery been done to retrieve stones and some left behind, the obstruction would typically be near the ampulla, and the common duct would have been dilated in the sonogram. Subphrenic abscess (E) would produce fever, but would not change liver function tests or affect the size of the intrahepatic ducts. Furthermore, the sonogram would have easily detected the abscess.

Explanation:

The presence of an “acute abdomen,” which this woman has, is an indication for exploratory surgery, and prompt repair of the injuries (probably affecting hollow viscera that have produced the signs of peritoneal irritation. Continued clinical observation (A) would be irresponsible when it is clinically obvious that she already has an acute abdomen. CT scan (B) is ideal when the issue is potential intra abdominal bleeding in a hermodynamically stable patient who can be safely sent to the radiology department. CT scan might even be a good idea if the picture of acute abdomen were equivocal. However it is not needed here. Diagnostic peritoneal lavage (D) or sonograms done in the emergency department (C) are our options when we suspect intra abdominal bleeding and the patient is too unstable to be sent anywhere. As pointed out above, however, when an acute abdomen has clearly developed, it is time to operate.

Explanation:

Cancer of the esophagus shows the classic progression of dysphagia starting with meat then other solid foods, eventually liquids, and finally saliva. Significant weight loss is also seen. Smoking and drinking are risk factors for squamous cell carcinoma, and blacks are affected more commonly than whites. Achalasia (A) is seen more commonly in women. There is dysphagia also, but it is worse for liquids. There is occasional regurgitation of undigested food. Colon cancer (B) does not present with swallowing problems, although guaiac positive stools are present. If the cancer is present on the left side, there may be bloody bowel movements. Adenocarcinoma of the esophagus (C) is seen in people who have longstanding gastroesophageal reflux. Carcinoma of the stomach (D) is usually seen in elderly patients. There is anorexia and weight loss; however, there is vague epigastria distress and early satiety, rather than dysphasia. Hematemesis is possible.

Explanation:

Open appendectomy via lower midline laparotomy incision. The diagnosis of perforated appendicitis is given in the question, and the goal of the question is straightforward: what is the proper management of perforated appendicitis? The first decision in any scenario is how aggressive to be, i.e. conservative medical management vs. aggressive surgical management. In this scenario, the patient is obviously sick-fever, tachycardia and early hypotension in an immunocompromised patient is self explanatory for not choosing conservative management. Therefore, (A) and (B) are wrong, although they retain a place in the management of non perforated acute appendicitis. If there is known pelvic fluid, the goal of the operation, in addition to removal of the appendix, is to prevent a post-operative, intra-abdominal abscess, i.e. source control. This is done with extensive irrigation of the entire intra-abdominal cavity and breaking up any purulent ovulations that may already exist. This is best done through a midline incision (C) to adequately access both lower quadrants and deep in the pelvis. Alternatively, the laparoscopic approach is excellent for full abdominal visualization and irrigation, but not yet standard of care enough for the purposes of this exam. A standard Mc Burney´s (D) or Pfannesteil incision (E) would severely limit exposure and therefore sufficient irrigation of the abdomen.

Explanation:

This man may have a cardiac cause for his dizziness.The highest prevalence of myocardial infarction (MI) is 72 hours post-operation. Patients with diabetes may not have chest pain due to autonomic dysfunction.
The differential diagnosis would include pulmonary embolus.
It may also include diabetic ketoacidosis, but this would be unlikely with his glucose at 18nmol/L and would not directly explain his hypotension. Also, he would be expected to have a slightly higher respiratory rate than 24/min.
The most appropriate immediate investigation in this scenario would be ECG

Explanation:

Transurethral Catheterization is contraindicated in patients who have urethral injuries. Trauma to the urethra should be suspected when a patient has blood at the urethral meatus. A patient who presents with this should be investigated with a retrourethrogram.

Explanation:

This patient has just had a motor vehicle accident with obvious chest trauma. Any such patient that presents with symptoms of extreme dyspnea, restlessness, anxiety, agitation and decreased breath sounds should be evaluated immediately for a tension pneumothorax with a chest x-ray.
A tension pneumothorax occurs secondary to blunt or penetrating injury of the lung which results in a one-way valve being created. Air leaks from the lung out into the pleural space and is unable to escape, resulting in increased intrapleural pressure. The most immediate goal in the treatment of tension pneumothorax is to alleviate the increased intrapleural pressure. This is most quickly accomplished by performing thoracocentesis using a 20 g needle in the 7th or 8th intercostal space. Once the pleural space has been evacuated, if pneumothorax recurs or is persistent, a tube thoracostomy should be performed.

Explanation:

Bier block anesthesia involves lidocaine and a tourniquet. It is indicated for fractures of the forearm, wrist and hand. Bier block is not appropriate for fractures about the elbow, and may not be appropriate in patients with excessive obesity (w/ a large fatty arm).
In this procedure, torniquet is placed on the arm and lidocaine is injected into the dorsal vein in hand, distal to the fracture site. After 30-45 min, most of the lidocaine has been bound to tissues in forearm; therefore, removing the tourniquet at this time does not release a large dose of lidocaine into the general circulation.
Bupivacaine can last for up to 20 hours after surgery and would not be appropriate since after the tourniquet is removed the drug would go into the circulation. A shorter acting drug such as lidoocaine is appropriate as it lasts only 1-5 hours.

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:

Esophaegal 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.
Treatment involves fluid resuscitation, endoscopic banding (sclerotherapy second choice) IV octreotide and possibly a transjugular intrahepatic portosystemic shunting (TIPS) procedure.
If bleeding continues or recurs despite these measures, emergency techniques to shunt blood from the portal system to the vena cava can lower portal pressure and diminish bleeding. A TIPS procedure is the emergency intervention of choice. TIPS is an invasive radiologic procedure in which a guidewire is passed from the vena cava through the liver parenchyma into the portal circulation.
The resultant passage is dilated by a balloon catheter, and a metallic stent is inserted, creating a bypass between the portal and hepatic venous circulations. Stent size is crucial. If the stent is too large, hepatic encephalopathy results because of diversion of too much portal blood flow from the liver. If the stent is too small, it is more likely to occlude.

Explanation:

Diverticulitis is inflammation of a diverticulum, which can result in phlegmon of the bowel wall, peritonitis, perforation, fistula, or abscess. The primary symptom is abdominal pain. Diagnosis is by CT scan. Treatment is with antibiotics (ciprofloxacin, or a 3rd-generation cephalosporin plus metronidazole) and occasionally surgery.
Surgery is required immediately for patients with free perforation or general peritonitis and for patients with severe symptoms that do not respond to nonsurgical treatment within 48 hours. Increasing pain, tenderness, and fever are other signs that surgery is needed. Surgery > should also be considered in patients with any of the following: 2 2-previous attacks of mild diverticulitis (or one attack in a patient < 50); a persistent tender mass; clinical, endoscopic, or x-ray signs suggestive of cancer; and dysuria associated with diverticulitis in men (or in women who have had a hysterectomy), because this symptom may presage perforation into the bladder.

Explanation:

Explanation:

The accessory nerve (CN XI) runs through the posterior triangle, so it is likely to be injured in posterior neck triangle operations. If the accessory nerve is damaged there, the trapezius will be denervated, the tip of the shoulder will be drooping and the patient will have inability to raise her hand above her head.

Explanation:

Coarctation of the aorta is localized narrowing of the aortic lumen that results in upper-extremity hypertension. Treatment is balloon angioplasty with stent placement, or surgical correction.
Renal artery occlusion is acute or chronic interruption of blood flow through one or both of the main renal arteries or its branches, usually due to thromboemboli, atherosclerosis, or fibromuscular dysplasia.
Chronic, progressive occlusion causes refractory hypertension and may lead to chronic renal failure. Treatment of chronic, progressive occlusion includes angioplasty with stenting, surgical bypass, and removal of an infarcted kidney.
A pheochromocytoma is a catecholamine-secreting tumor of chromaffin cells typically located in the adrenals. It causes persistent or paroxysmal hypertension. Treatment involves surgical removal of the tumor when possible.
Essential hypertension, which comprises 90-95% of all cases of hypertension, occurs through no secondary cause. It is treated with lifestyle modifications, diet, exercise and medications.

Explanation:

Treatment of ischemic ulcerations is mainly supportive through conservative debridement of only necrotic tissue and local wound care to help prevent infection. The prognosis for healing of the ulceration is poor, however, if the arterial perfusion to the area cannot be improved through vascular surgery. Other adjunctive procedures that have been employed with variable success are hyperbaric oxygen therapy and the use of local and systemic vasodilators. These modalities usually are not effective in occlusive disease because the affected area usually is maximally vasodilated secondary to the presence of the local by-products of ischemia.

Explanation:

Approximately 70- 80% of intestinal gas consists of swallowed air. This air consists primarily of nitrogen, which is poorly absorbed by the intestinal lumen. Impairment of venous return results in severe intestinal congestion, with blood seepage into the intestinal lumen. Accumulation of fluid proximal to an obstructing lesion results from ingested fluid, swallowed saliva, gastric juice, biliary and pancreatic secretions, as well as from interference with normal sodium and water transport. A closed-loop obstruction, such as occurs with an adhesive band, results when the lumen is occluded at two points by the same mechanism.

Explanation:

The patient has developed large hydrocele, in which there is accumulation of clear fluid (that probably communicates with ascites fluid in the abdomen) in the tunica vaginalis. Other causes of hydrocele include infection, tumor and systemic edema related to renal disease. Infants with congenital hydrocele usually have a failure of closure of the process vaginalis, but adults who develop a “new” hydrocele typically have a previously normal or near normal process vaginalis that is “dissected” by the fluid. Blood in the tunica vaginalis (due to trauma or hemorrhagic disease) causes a hematocele. Lymphatic fluid in the tunica vaginalis causes a chylocele, which produces the massively enlarged scrotum observed in patients with elephantisis. Hydrocele can compress the epididymis (choice A) or testes (choice C), but does not usually directly involve these structures. The more distant prostate (choice B) and seminal vesicle (choice E) are usually not affected by hydrocele.

Explanation:

This woman has pheochromocytoma, which can be sporadic or familial. Hypertension is paroxysmal in 50% of cases and other symptoms are labile also. The cause of symptoms is excess catecholamines secreted by the tumor, which is usually located in the adrenal glands. Surgical option requires prior treatment with the non-specific and irreversible alpha adrenoceptor blocker Phenoxybenzamine (Irreversible blockade is important because a massive release of catecholamines from the tumor may overcome a reversible blockade). Doing so permits the surgery to proceed while minimizing the likelihood of severe intraoperative hypertension (as might occur when the tumor is manipulated). Some authorities would recommend that a combined alpha/beta blocker such as labetalol also be given in order to slow the heart rate. Regardless, a “pure” beta blocker such as atenolol must never be used in the presence of a pheochromocytoma due to the risk of such treatment´s leading to unopposed alpha agonism and, thus, severe and potentially refractory hypertension. It can only be done after prior alpha antagonization. Clonidine suppression tests are one of the diagnostic tests of choice to rule out pheochromocytoma. 0.3 mg of clonidine given to a patient with pheochromocytoma will cause a rise in catecholamines. Imaging studies, such as CT scan or MRI of the abdomen, can detect as many as 90% of the tumors if the tumors are at least 1 cm in size.

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:

Cyanocobalamin, or vitamin B12, is absorbed in the terminal ileum and, therefore, is the most likely vitamin deficiency to develop in this patient. The other vitamins are less likely to be deficient.

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:

Doxorubicin is an anthracycline. It is associated with myofibrillar loss and subsequent cardiomyopathy if given for a cumulative dose of 450 mm2 body surface area. Cardiotoxicity can be prevented by dexrazoxane. An echocardiogram and MUGA scan can evaluate the extent of systolic ventricular dysfunction. This patient has congestive heart failure secondary to cardiomyopathy from doxorubicin toxicity. Cisplastin is given for ovarian cancer and it causes renal toxicity as well as bone marrow toxicity. Cyclophosphamide is an alkylating agent used for many leukemias and solid tumors. It causes severe neutropenia but it is known to cause bladder toxicity (hemorrhagic cystitis). Bladder toxicity can be blocked by administration of the uroprotective agent mesna. Amphotericin B is used to treat fungal infections, and it causes renal toxicity. Methotrexate causes liver toxicity.

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:

Explanation:

A child who is brought to an emergency department multiple times with trauma is likely to be the victim of child abuse. Emergency room personnel must be aware of this possibility and evaluate it appropriately. A bone marrow biopsy would not be helpful. Individuals with osteogenesis imperfecta do not usually present in this fashion. Myeloma is very unlikely in a child. Casting a child such as this and sending her home puts her at risk for more abuse, unless the issue of child abuse has been evaluated and ruled out.

Explanation:

Phosphodiesterase inhibitors such as sildenafil (C) are the first line therapy for erectile dysfunction (ED). However, this patient cannot take sildenafil because of the concurrent use of nitrates. The second line therapy for ED that should be employed in this patient is a vacuum device. Penile implants (A) should be used as a last resort for those who fail all other conventional therapy. Sertraline (B) is an antidepressant. This patient´s history is not suggestive of depression; furthermore, sertraline can cause sexual problems, including erectile dysfunction and retarded ejaculation, which makes it contraindicated in this case. Testosterone (D) is not necessary, as the patient´s testosterone level is normal.

Explanation:

Pancreatic cancer has very high mortality. . When associated with metastasis, the mortality rate is 100%. In the setting of metastasis, aggressive management by doing surgery is not recommended. Instead, treatment should be supportive with:
Pain management
Control of other symptoms like diarrhea
Placement of a biliary stent in case of biliary obstruction resulting in pruritus Symptomatic relief with cholecystectomy
Chemotherapy (A) and radiotherapy (B) are generally used as adjuvant therapies after surgery in patients with resectable pancreatic cancer. They have also been used in combination in locally invasive disease. However, they do not have a role in treatment of metastatic pancreatic cancer. A Whipple procedure (D) (pancreatico-duodenectomy) is performed only if the pancreatic cancer is resectable and there is no metastasis in patients who are considered to be fit for surgery. It should be noted that a Whipple procedure is associated with a high intraoperative mortality and is generally not performed in patients with a lot of comorbidities. A Whipple procedure is generally not performed when there is evidence of metastasis. Therefore, resection of part of the liver (E) in combination with a Whipple procedure is not done.

Explanation:

This one should be obvious. There is no question that the femoral vessels are injured, and the expanding hematoma plus absent pulses indicate that the femoral artery is involved (the vein may or may not be injured). Surgical exploration starts with proximal and distal control. Once the hematoma is safely entered, the extent of the injuries can be ascertained and the proper repair done. Doppler studies (A) are wonderful when we are trying to ascertain whether blood is flowing through a vessel. The clinical findings here are obvious. No fancy technology is needed. Venograms (B) are not needed prior to surgery. We can look at the vein during the operation. Arteriograms (C) are very often used in vascular trauma, but are not needed here. We would use an arteriogram if the anatomic location of the injury suggested vascular involvement, but the clinical signs did not confirm such suspicion. Arteriograms are also used when the specific surgical approach is dictated by precise knowledge of the site of extravasation, a situation that does not apply here. An embolectomy (D) will probably be done at the end of the surgical procedure, as a routine part of removing debris from the lumen of a vessel that has been repaired or re-anastomosed. However, embolectomy alone is the wrong answer for this vignette. The absent pulses are due to disruption of the artery, not to embolization from a distant source

Explanation:

Obstructive jaundice is evident by the high alkaline phosphatase and the dilated biliary ducts. Malignancy is suggested by the dilated, thin walled gallbladder without stones. If there is a cancer of the head of the pancreas, CT scan has a good chance of showing it in a noninvasive manner. Endoscopic retrograde cholangiopancreatography (ERCP) (B) or percutaneous transhepatic cholangiogram (PTC) (D) would be the next step if the CT scan were negative. A smaller tumor at the ampulla, the common duct itself, or even the head of the pancreas could escape detection by the CT scan and would necessitate a more invasive study to show up. Either of these could be used, although ERCP is favored by most practitioners. Exploratory laparotomy (C) would be premature at this point. Serologies (E) would have been called for if he had very high transaminases, normal or near normal alkaline phosphatase, and an unremarkable sonogram.

Explanation:

The patient has a simple cyst in the head of his right epididymis. The differential diagnosis is limited, and consists of a spermatocele versus an epididymis cyst. The difference is the presence or absence of sperm within the cyst. As long as the patient is asymptomatic, no further follow-up or management is necessary, as the cyst will eventually involute. Fine-needle aspiration (A) is unnecessary and potentially dangerous, as spilled sperm within the scrotum can incite an inflammatory response. Follow-up with future ultrasounds (B) is unnecessary, as the lesion is benign. Staging CT scan (D) is also unnecessary, as the lesion is benign. Surgical excision (E) is incorrect. If the cyst was causing pain, then surgical excision would be appropriate.

Explanation:

Gastrointestinal tract fluids have a sodium concentration very close to that of plasma; as they are lost (internally or externally), they should be replaced with isotonic, sodium containing fluids. But that is not what patients typically do at home. Thirsty and unable to eat solid (sodium-containing) foods, they drink water, Coke, and tea, fluids without significant amounts of sodium, which the body avidly retains because of the severe volume depletion. Endogenous water from catabolic activity is also retained. Dilutional hyponatremia eventually develops. She does not have “water intoxication” (A). This term denotes abnormal water retention due to excessive water infusion at a time when there is a high level of ADH in the blood. This patient is retaining water because she is desperately volume depleted, not because high volumes of water are being forced into her.
The hyponatremia is not due to the loss of hypertonic fluid (B). There are no hypertonic fluids in the gut or anywhere else for that matter. The only hypertonic fluid that we can lose is highly concentrated urine, but we usually do so as a physiologic response to save water. Yes, we often see comatose and convulsing patients when they have this much hyponatremia (D), but that happens when water retention is massive and fast. Slow water retention allows the brain to adapt. One can see even lower serum sodium concentrations in patients with a clear sensorial. Volume deprivation leads to renal wasting of sodium (E) is plain wrong. What the kidney does when there is volume depletion is to increase reabsorption of sodium, not to dump it.

Explanation:

Dual positivity for estrogen and progesterone receptors predicts improved response to endocrine treatment, time to relapse, and overall survival. The presence of the estrogen receptor on the tumor allows for treatment with tamoxifen, a competitive inhibitor of estrogen, which significantly reduces mortality and risk for recurrence. The accepted prognostic markers that provide critical information necessary for treatment decisions are TNM stage, axillary lymph node status, tumor size and grade, and hormone receptor status. Other good prognostic factors include:
1. Stage I cancer (less than 2 cm in size and has not spread from the breast)
2. No lymph node involvement. The status of the axillary lymph nodes is one of the most useful prognostic indicators for breast cancer, with average 10 year survival rates dropping drastically in node-positive patients.
3. Carcinoma in situ
4. Medullary, lobular, and mucinous carcinomas have a slightly better prognosis then invasive ductal carcinoma (B)
5. Positivity for ER and PR hormone receptors
The poor prognostic factors include:
l. Large size tumors (D)
2. Carcinoma with axillary lymph node involvement
3. Higher grade carcinoma
4. ER or PR negativity (C) on immunohistochemical staining
5. Overexpression of HER2/neu
Among all the choices given, (E) has the best prognosis for this patient

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:

This is a difficult question as all the answers seem reasonable! His observations could be caused by pain. However in the face of a falling haemoglobin, a rising pulse rate and an increasing loss into his drains this patient needs to return to theatre. However his raised pulse rate and a low haemoglobin suggest resuscitation and they are not severe enough to warrant going straight to theatre without intervention. His blood pressure is not critically low and although many would give crystalloid, it is not unreasonable in an elderly man with ischaemic heart disease to get blood if it is easily available.

Explanation:

Sedation occurring in the first few days typically wears off.
A laxative should be used along and started in conjunction with narcotics to avoid distressing constipation.
If pain relief is inadequate the dose should be increased; cocaine may produce hallucinations.
Addiction is not an issue in the terminally ill.
IM is 3 times more effective than the same oral dose.

Explanation:

The most common cause of SBO is postsurgical adhesions. Postoperative adhesions can be the cause of acute obstruction within 4 weeks of surgery or of chronic obstruction decades later. The incidence of SBO parallels the increasing number of laparotomies performed in developing countries.
The second most common identified cause of SBO is an incarcerated groin hernia. Other etiologies of SBO include malignant tumor (20%), hernia (10%), inflammatory bowel disease (5%), volvulus (3%), and miscellaneous causes (2%). The causes of SBO in pediatric patients include congenital atresia, pyloric stenosis, and intussusception.

Explanation:

Hydration status can be evaluated by various measures. For example checking the eyeballs for sunkenness, mucous membranes, heart rate, skin turgor, capillary refill time, and urine output. Close monitoring of urine output is most essential and should be maintained in the early post-operative period.

Explanation:

In a trauma case it is always essential to keep the airway clear. It may be necessary to carry out procedures to do this under various conditions. The cricothyroid membrane. A large calibre needle may be passed though the cricothyroid membrane to provide an essential airway when the upper airway is obstructed. The cricothyroid membrane fills in the space between the anterior cricoid cartilage and the thyroid cartilage. This and other procedures on the larynx and trachea must be performed strictly in the mid-line to avoid large blood vessels.

Explanation:

This patient in all probability has the euthyroid-sick syndrome, also known as nonthyroid illness syndrome (NTI)-the association of severe nonthyroidal illness with biochemical parameters indicative of thyroid hypofunction. Low T3 with normal T4 and low T3 with low T4 are the most common variants of this syndrome. TSH is usually normal but may be high or low. A TSH level > 20 microU/mL would be inconsistent with NTI and ´indicates hypothyroidism. Replacement of T4 does not influence the outcome.

Explanation:

Splenic rupture generally results from blunt abdominal trauma. Significant impact (eg, motor vehicle collision) can rupture a normal spleen. Rupture of the splenic capsule produces marked hemorrhage into the peritoneal cavity. The manifestations, including hemorrhagic shock, abdominal pain, and distention, are usually clinically obvious. However, splenic trauma can also produce a subcapsular hematoma, which may not rupture until hours or even months after the injury.
Rupture is generally preceded by left upper quadrant abdominal pain. Splenic rupture should be suspected in patients with blunt abdominal trauma and hemorrhagic shock or left upper quadrant pain (which sometimes radiates to the shoulder); patients with unexplained left upper quadrant pain, particularly if there is evidence of hypovolemia or shock, should be asked about recent trauma. The diagnosis is confirmed by CT scan (in the stable patient), ultrasound, or peritoneal lavage (in the unstable patient). Treatment has traditionally been splenectomy. However, splenectomy should be avoided if possible, particularly in children, to avoid the resulting permanent susceptibility to bacterial infections. In this case, treatment is transfusion as needed.

Explanation:

In the ideal setting, the accuracy of fine-needle aspiration may be over 90%. Clinical information is critical in interpreting the results of fine- needle aspiration – more so than with a tissue biopsy because of the more limited sampling. It is crucial to determine whether the findings on fine-needle aspiration explain the clinical findings. Although the report from the mammogram and the biopsy are not ominous, they do not explain the clinical findings in this case. Immediate repeat fine-needle aspiration or, even better, a tissue biopsy is indicated. Proceeding directly to therapy, whether surgery or irradiation, is inappropriate because the diagnosis is not clearly established. Likewise, any delay in establishing the diagnosis is not appropriate.

Explanation:

The most likely cause of fever in this patient is post operative atelectasis, which can be effectively treated with good pulmonary toilet, i.e., incentive spirometry and deep breathing. Urinary tract infection usually will not become apparent until post operative day three. This commonly occurs as a result of catheterization preoperatively or colonization of the catheter post-operatively.

Explanation:

While Sertoli and Leydig cell tumors may present with testicular mass and gynecomastia, only Leydig cell tumors exhibit crystals of Reinke within the cytoplasm of tumorigenic cells. None of the other choices typically present with palpable testicular neoplasms as the first symptoms.

Explanation:

Cecostomy is a relatively minor procedure and is the treatment of choice in unstable patients with large bowel obstruction. Delaying surgery could result in perforation. Hemicolectomy, staged or unstaged and ilea rectal anastomosis are major surgical procedures and should not be undertaken in unstable patients.

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.