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101 Cards in this Set

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Q400. What causes a bluish discoloration of the periumbilical area?; What is another sign of this?
A400. Fox’s sign: Retroperitoneal Hemorrhage; (ex: acute hemorrhagic pancreatitis); another sign: Ecchymosis or discoloration of flank; (Grey Turner’s sign)
Q401. Dx for the triad of HTN, bradycardia and irregular respirations?
A401. Dx: increased ICP
Q402. Dx for calf pain on forced dorsiflexion of the foot in patient (Homan’s sign)
A402. Dx: DVT
Q403. What are the two signs of a basilar skull fracture?
A403. Raccoon Eyes and Battle’s sign (ecchymosis over the mastoid process)
Q404. What is Budd-Chiari syndrome?
A404. Thrombosis of hepatic veins
Q405. MC indication for surgery with Crohn’s Dz?
A405. Small Bowel Obstruction
Q406. MC vessel involved in a bleeding duodenal ulcer?
A406. Gastroduodenal artery
Q407. MC bacteria in stool?
A407. Bacteroides fragilis (“B. frag”)
Q408. MC electrolyte deficiency causing Ileus?
A408. Hypokalemia
Q409. MC cause of Large Bowel Obstruction
A409. Colon Cancer
Q410. MC type of Volvulus?
A410. Sigmoid volvulus
Q411. MC bacteria causing UTI?
A411. E. coli
Q412. MC benign tumor of the liver?
A412. Hemangioma
Q413. A 55-yo man presents with a 20-year History of heartburn. During endoscopy a Biopsy demonstrates a high-grade columnar dysplasia consistent with Barrett’s esophagus. What is the most appropriate Tx?
A413. Esophageal resection
Q414. What is the most important part of the surgical correction of Zenker’s diverticulum?
A414. Myotomy of the Cricopharyngeus muscle; (b/c the diverticulum results from the increased spasticity of this muscle)
Q415. What are two main causes of non-anion gap metabolic acidosis?; How can you tell which is the problem?
A415. Diarrhea and Renal Tubular Acidosis; calculate the Urine Anion Gap (Una – Ucl – Uk)
Q416. What is a common cause of post-op tachyarrhythmia?; What is the Tx?; What is the reason for the initial treatment?
A416. Atrial Fibrillation; Tx: Beta-agonist drip for Rate Control
Q417. What is the next step in a patient presenting with a confirmed Acute MI?; (2 possible); What if the patient is a post-op?
A417. Next:; 1. Thrombolytics; 2. Angioplasty; Post-op:; Angioplasty; (due to possibility of bleeding with thrombolytics; Stenting may be indicated)
Q418. A 60-yo female is post-op on mechanical ventilation. Her blood chemistry shows a Respiratory Acidosis. What initial change in the ventilator is most appropriate?; What (2) vent changes are used to improve the patient’s oxygenation?
A418. First: Increase Tidal Volume; (CO2 is determined by minute ventilation calculated as Ve = RR x Tidal volume [Vt]; CO2 is retained by decreasing the Ve, so to blow off the CO2, either RR or Vt needs to increase); Improve O2: Increase FiO2 or Increase PEEP; (Increasing the amount of O2 the patient receives, the Fraction of Inspired O2, or increasing the surface area and the amount of time O2 can diffuse into the capillaries [PEEP] improves oxygenation)
Q419. What do the thyroid labs look like in Graves Disease?
A419. Decreased TSH; Increased free T-4
Q420. How does Secondary Hyper- and Hypo- thyroidism present in labs of TSH and T-4?
A420. Hyper: Increased TSH; Increased free T-4; Hypo: Decreased TSH; Decreased free T-4
Q421. What is the most serious complication following surgical treatment for a Thyroidectomy?
A421. Recurrent Nerve Damage; (resulting in Abductor Laryngeal paralysis with affected cord assuming the midline. Unilateral results in hoarseness; Bilateral may lead to airway obstruction)
Q422. What is the first step in diagnosing a mass on the thyroid?; What is the difference between a Hot and Cold lesion?; What test can distinguish b/t Hot and Cold lesions?
A422. First test: Fine Needle Aspiration; Hot lesion: Functional; Cold lesion: Non-functional; Hot/Cold test: Radionucleotide thyroid scan
Q423. After performing a VMA for a pheochromocytoma, what imaging exam is most specific in localizing the lesion?
A423. MIBG (a NE analog)
Q424. A 42-yo female was victim of a MVA and has been in the ICU for 2 weeks. She has been stable and on a vent for ARDS. She then suddenly gets acute hypotension (80/42) in addition to WBC of 9,000, HCT = 33%, Na = 130, K = 5.3, Cl = 110. You give the patient 2L of crystalloids but the vitals remain unchanged. A NE drip is started and the BP remains in the 80s/40s. What is the likely cause of this patient’s hypotension?
A424. Acute Adrenal Insufficiency; (Addisonian crisis: considered in any patient with unexplained hypotension that does not respond to fluid or pressors; occurs when the normal response of glutocorticoid release is impaired, most often in patients with long-term steroid use experiencing the stress of illness or surgery)
Q425. What is the disasterous complication of a Supracondylar fracture of the Humerus?
A425. Volkmann’s Contracture; (ischemic injury to the deep tendon flexors of the forearm sustained during a supracondylar humeral fracture; muscle necrosis can begin in 4 – 6 hours after compromised circulation)
Q426. What nerve and artery travel along the mid-Humeral shaft and can be damaged in a fracture to that area?
A426. Radial nerve;; Brachial Profunda (deep brachial) artery
Q427. Where is the MC place for a Mallory-Weiss tear?
A427. In the Stomach near the GE junction
Q428. What is the most proven risk factor of Pancreas cancer?; What is the best initial diagnostic test?
A428. Smoking; Dx test: CT scan with oral and IV contrast
Q429. Why is a posterior hip dislocation an emergency?
A429. To avoid Posterior Avascular Necrosis
Q430. What is the ECG sign with Primary Hyperparathyroidism?
A430. Shortened QT on ECG
Q431. What is the required margin of resection for a melanoma of the following size:; 1. In situ; 2. < 1mm; 3. 1 – 4mm; 4. > 4mm
A431. In situ: 0.5cm; < 1mm: 1 cm; 1 – 4mm: 2cm; > 4mm: 2 – 3cm
Q432. What is used to Dx Achalasia?
A432. Esophageal Manometry
Q433. A 54-yo male presents with angina-like chest pain that is usually assoc with stress and is relieved by nitrates. He is worked-up for an MI, but his troponin and ECG are normal. Dx?
A433. Diffuse Esophageal Spasm; (another chest pain relieved by nitrates)
Q434. What is the MCC of an acute appendicitis?
A434. Lymphoid Hyperplasia; (not fecalith)
Q435. What type of portal system shunt decreases the risk of developing encephalopathy?
A435. Warren distal Splenorectal shunt
Q436. After undergoing a portal shunt procedure one week ago, the patient has become confused and combative. His breathing is unlabored and vitals are normal, but there is a foul smell to his breath and he has asterixis. Dx?; What is seen in the blood sample?
A436. Dx: Hepatic Encephalopathy; In Blood: Increased Ammonia; (blood does not pass liver first to clean it of the ammonia)
Q437. What is the cause of hypotension in Septic shock?
A437. Cytokines from the inflammatory response cause loss of systemic vascular resistance; (as well as fever and leukocytosis)
Q438. Infant presents with excessive salivation and repeated episodes of coughing, choking and cyanosis. Dx?
A438. Dx: Esophageal Atresia; (most common ends in a blind pouch with a distal tracheoesophageal fistula)
Q439. Infant is vomiting and on abdominal films there is a “soap bubble” sign in the ileum. Dx?; Tx?
A439. Dx: Meconium Ileus; Tx: Gastrografin enema; (draws water into the bowel to break-up the meconium plug)
Q440. What bacteria are worrisome after a spenectomy?
A440. Encapsulated bacteria; (Strep pneumonia, H. influnzae, Meningococcus)
Q441. What is a common cause of sudden or unexplained hyperglycemia on a post-op patient on TPN?
A441. Infection
Q442. What complication related to TPN may cause a patient to get a HCO3 of 30 and go into Respiratory Failure?
A442. Increased CO2 production; (due to increasing the daily caloric intake; overfeeding)
Q443. What is an appropriate test if you suspect Clostridium Difficile?
A443. Stool Toxin Assay
Q444. Aside from trauma, what are (2) other causes of Hypovolemic shock?
A444. Small Bowel Obstruction and Pancreatitis; (both due to Third Spacing)
Q445. What neurologic condition may develop if low sodium is corrected too rapidly?; What (2) problems can cause a greater risk of this occurring in the patient?
A445. Central Pontine Myelinolysis; Patient has History of: Malnutrition or Alcoholism
Q446. What can be a devastating outcome of correcting a Hypernatremic patient too rapidly?
A446. Cerebral edema; (by rapidly shifting fluid into cells)
Q447. A 12-yo child presents with pain and inflammation over the ball of his left foot and red streaks extending up the inner aspect of his leg. He removed a wood splinter from his foot the previous day. What is the most likely bug?
A447. Streptococcus; (streaks are lymphatic inflammation)
Q448. A 3-yo presents with a non-tender abdominal mass. What is the MCC of extracranial solid tumors seen in children?; First step?; Tx?
A448. Dx: Neuroblastoma; (from neural crest cells); Diagnostic test: Urine HVA and VMA; (tumor secretes catecholamines); Tx: Surgery, Chemo and Radiation
Q449. A 3-yo child presents with an abdominal mass, HTN and hematuria. Dx?; Diagnostic test?
A449. Dx: Wilm’s Tumor; (originates from kidney and may also present with aniridia); Diagnostic test: CT of abdomen
Q450. A 3-yo presents with abdominal distention and a RUQ mass that moves with respiration. Dx?; Diagnostic test?; Tx?
A450. Dx: Hepatoblastoma;; Diagnostic test: Serum Alpha-Fetoprotein;; Tx: Surgical removal
Q451. A 3-yo presents with a sacrococcygeal mass. Dx?
A451. Dx: Teratoma; (most common site in children, followed by mediastinum)
Q452. What is the leading cause of death following a carotid endarterectomy?
A452. MI
Q453. What drug is most beneficial in closing a Crohn’s fistula?
A453. Infliximab
Q454. A patient with a history of Ulcerative Colitis has fever, tachycardia, a distended abdomen and a dilated transverse colon. Dx?; Tx?
A454. Dx: Toxic Megacolon; Tx: NPO, Nasogastric decompression, IV antibiotic and IV steroids for 48 hours, then Surgery if problem persists; (colonic decompression should not be attempted b/c it can lead to perforation)
Q455. What is the MCC of a mediastinal tumor?; What systemic condition is classically assoc with it?
A455. MCC: Thymoma; Assoc w/: Myasthenia Gravis; (30 – 50% will have it)
Q456. Dx: patient presents with café au lait pigmentation and neurofibromas of the GI tract
A456. Von Recklinghausen Dz
Q457. MC site of sarcoma metastasis?
A457. Lungs
Q458. MCC of Acute Mesenteric Ischemia?; Chronic Mesenteric Ischemia?
A458. Acute: Emboli; Chronic: Atherosclerosis
Q459. A 43-yo male presents with acute onset of chest pain since an episode of vomiting 6 hours ago. He has decreased breath sounds on the left and a mild left pleural effusion. Dx?; Diagnostic test?; Tx?
A459. Dx: Spontaneous Esophageal Rupture; (Boerhaave syndrome); Diagnostic test: Water-soluble or Barium Esophagogram; Tx: Primary Surgical repair
Q460. What is the Chemotherapy treatment for Melanoma in Stage III?; Stage IV?
A460. Stage III: Interferon-2A; Stage IV: Interleukin-2
Q461. A 57-yo asymptomatic male is noted to have a prostate that is normal in shape and size on rectal examination. His PSA is 18 (nml < 2.5). What is the best next step for this patient?
A461. Transrectal US exam with prostate Biopsy
Q462. A 72-yo man has a lower abdominal mass and constantly dribbles urine. Dx?; What is the best next step?
A462. Dx: Overflow Incontinence; Next step: Foley catheter and hospitalization
Q463. What unusual lab value can be elevated with a Small Bowel Obstruction?
A463. Serum Amylase; (also increased with Acute Pancreatitis…both also cause Third Spacing and Hypovolemic shock)
Q464. A 67-yo male presents with N/V 25 days post- appendectomy. He is afebrile, the abdomen is tender and distended. His WBC is 18,00, Na is 140, K is 4.2, Cl is 105 and Bicarb is 14. Dx?; Diagnostic test?; Tx?
A464. Dx: Anion Gap Acidosis secondary to Lactic Acid reflecting Ischemic Bowel; Diagnostic test: CT confirming obstruction; Tx: Surgery
Q465. A 34-yo diabetic woman complains of a 6-month History of numbness and pain in her right hand and thumb that wakes her up at night. Dx?; Tx? (2 together)
A465. Dx: Carpal Tunnel Syndrome; Tx: Nighttime Splint and NSAIDs
Q466. A 42-yo woman presents with persistent epigastric and back pain, Leukocytosis and a serum amylase of 1,300. Dx?; Initial Tx?
A466. Dx: Biliary Pancreatitis; Initial Tx: Rest and IV hydration; (then a Lap Chole)
Q467. Dx: Fever, intermittent RUQ pain and Jaundice
A467. Cholangitis
Q468. Dx: Persistent abdominal pain, RUQ tenderness and leukocytosis
A468. Acute Cholecystitis
Q469. A 52-yo alcoholic with cirrhosis presents with acute hematemesis. Bleeding esophageal varicies are found on UGI endoscopy. Tx?
A469. Tx: Endoscopic Sclerotherapy
Q470. What is the management of a patient presenting with Melena?; (2 steps)
A470. 1. IV fluids and insuring hemodynamic stability; 2. NG tube to rule-out UGI bleed; (melena = tarry stool; is usually a UGI bleed)
Q471. A 75-yo man develops hematochezia and presents with hemodynamic instability. His vital improve slightly with PRBC. What is the next step in Management? (3 together)
A471. 1. NG tube; 2. Proctosigmoidoscopy; 3. Tagged RBC scan with or without Angiography; (these three are most appropriate for a patient that is unstable)
Q472. What is the most common site of occlusion with Claudication?
A472. Superficial Femoral Artery
Q473. A 22-yo hemodynamically stable, intoxicated man presents with stab wounds to the left throacoabdominal region and abdomen. What are the next steps in management? (4 steps)
A473. Initially Observe for 24 – 48 hours:; 1. CXR (to look for pneumothorax, hemothorax and free air in the abdomen); 2. Wound exploration and Peritoneal Lavage; 3. Then repeat the study in 6 hours to make sure no changes are seen; 4. if changes: Diagnostic Laparoscopy to insure bowel is not punctured
Q474. A 24-yo male complains of colicky intermittent umbilical and RLQ abdominal pain of 24 hours, anorexia and nausea. He is afebrile. Dx?
A474. Gastroenteritis; (not appendicitis, b/c appendicitis does not present with intermittent pain)
Q475. A 58-yo woman has acute chest pain and dyspnea post- operatively. The results from cardiopulmonary and abdominal exams are nonspecific. She has a minimally elevated leukocyte count and normal cardiac enzyme levels. Arterial blood gas studies indicate respiratory alkalosis and hypoxemia. CXR and ECG show no pathology. Dx?; Next step?
A475. Dx: Pulmonary Embolism; (sudden onset of chest pain and SOB in patient without pulmonary or cardiac pathology); Next step: Empiric anticoagulation (Heparin or Coumadin) with confirmatory Pulmonary Angiography
Q476. Ten days after undergoing liver transplantation, a patient's levels of gamma-glutamyl transferase (GGT), alkaline phosphatase, and bilirubin begin to rise. What is the most appropriate next step in diagnosis?
A476. Ultrasound of biliary tract and Doppler studies of the anastomosed vessels; (in all other transplants aside from the liver, it would be considered acute rejection and biopsies should be taken)
Q477. What are the (2) rules for Breast cancer in a pregnant woman?
A477. The treatment of breast cancer in a pregnant woman should be the same as that in a nonpregnant woman, except for two restrictions:; 1. no chemotherapy during the first trimester; 2. no radiation therapy during the pregnancy
Q478. A 62-year-old man reports an episode of gross, painless hematuria. There is no history of trauma. The man does not smoke and has had no other symptoms referable to the urinary tract. Physical examination, including rectal examination, is unremarkable. His serum creatinine is 0.8 mg/dL, and, except for the presence of many red cells, his urinalysis is normal and shows no red cell casts. His hematocrit is 46%. What are the most appropriate initial steps in the workup?; (2)
A478. 1. Intravenous pyelogram (IVP); 2. Cystoscopy; (Although most patients with hematuria have benign disease, silent hematuria can be due to renal, ureteral, or bladder cancer, and these malignant processes must be effectively ruled out. IVP will visualize kidney and ureteral tumors, but is not reliable enough to rule out bladder cancer. Direct visualization of the bladder mucosa by cystoscopy is the only way to rule out bladder cancer)
Q479. A 45-year-old man with alcoholic cirrhosis is bleeding from a duodenal ulcer. He has required 6 units of blood over the past 8 hours, and all conservative measures to stop the bleeding, including irrigation with cold saline, IV vasopressin, and endoscopic use of the laser have failed. At the time of admission, when he had received only one unit of blood, showed a bilirubin of 4.5 mg/dL, a prothrombin time of 22 seconds, and a serum albumin of 1.8 g/dL. He was mentally clear when he came in, but has since then developed encephalopathy and is now in a coma. What best describes his operative risk?
A479. Prohibitive regardless of attempts to improve his condition; (The studies show that extremely marginal liver function could be tipped into overt liver failure by an anesthetic and an operation. He is not a surgical candidate)
Q480. A 22-year-old convenience store clerk is shot once with a .38 caliber revolver. The entry wound is in the left midclavicular line, 2 inches below the nipple. There is no exit wound. He is hemodynamically stable. A chest x-ray film shows a small pneumothorax on the left, and demonstrates the bullet to be lodged in the left paraspinal muscles. In addition to the appropriate treatment for the pneumothorax, what will this patient most likely need?
A480. Any gunshot wound below the nipples involves the abdomen, and such is the case here. The management of all gunshot wounds of the abdomen requires Exploratory Laparotomy
Q481. A 68-year-old man is brought to the emergency department with excruciating back pain that began suddenly 45 minutes ago. The pain is constant and is not exacerbated by sneezing or coughing. He is diaphoretic and has a systolic blood pressure of 90 mm Hg. There is an 8-cm pulsatile mass deep in his epigastrium, above the umbilicus. A chest x-ray film is unremarkable. Two years ago, he was diagnosed with prostatic cancer and was treated with orchiectomy and radiation. At that time, his blood pressure was normal, and he had a 6-cm, asymptomatic abdominal aortic aneurysm for which he declined treatment. What is the most likely diagnosis?
A481. Rupturing abdominal aortic aneurysm; (Abdominal aortic aneurysms have a high incidence of rupture once they reach or exceed a size of 6 cm. Often, the first manifestation is excruciating back pain, as the blood leaks into the retroperitoneal space before the aneurysm blows out into the peritoneal cavity. The combination of a big aneurysm and sudden severe back pain should always lead to this presumptive diagnosis)
Q482. A 55-year-old woman has been known for years to have mitral valve prolapse. She has now developed exertional dyspnea, orthopnea, and atrial fibrillation. She has an apical, high-pitched, holosystolic heart murmur that radiates to the axilla and back. Because of her deterioration, surgery has been recommended. What is the most appropriate procedure?
A482. Mitral valve annuloplasty; (Whenever possible, repair of the native mitral valve is preferable to replacement. The way to repair an insufficient valve is to tighten the annulus, bringing the leaflets closer to one another)
Q483. A 23-year-old woman seeks help for exquisite pain with defecation and blood streaks on the outside of her stools, which she has been having for several weeks. She has no fever or leukocytosis. Physical examination done under spinal anesthesia, confirmed the suspected diagnosis, and she is placed on stool softeners and appropriate topical agents, but without success. She is willing to undergo more aggressive treatment. What is the most appropriate next step? (3 possible)
A483. 1. Lateral Internal Sphincterotomy; 2. Forceful Dilation under anesthesia; 3. Botulinum toxin Injections; (The clinical picture is classic for anal fissure, which is perpetuated by the fact that the anal sphincter is "too tight.")
Q484. A 42-year-old woman is thrown from the car which lands on her and crushes her. In the ER it is determined that she has a pelvic fracture, which is confirmed by portable x-rays done as she is being resuscitated. Her initial blood pressure is 50/30 mm Hg, and her pulse is 160/min and barely perceptible. Thirty minutes later, after 2 L Ringer's lactate and 2 U packed cells have been infused, her pressure is only 70/50 mm Hg, and her pulse is 130/min. A sonogram done in the emergency department shows no intra-abdominal bleeding, and a diagnostic peritoneal lavage confirms that there is no blood in the abdomen. Rectal and vaginal exams show no injuries to those organs. There is no blood in her urine. What is the most appropriate next step in management?
A484. External fixation of the pelvis; (Pelvic fractures can bleed massively, and often the source is torn veins that are not easily controlled. Minimizing the motion of the bone fragments by external fixation can be helpful, and it will not make the situation worse)
Q485. Several months after sustaining a crushing injury to his arm, a patient complains bitterly about constant, burning, agonizing pain in that arm, that does not respond to the usual analgesic medications. The pain in his arm is aggravated by the slightest stimulation of the area, such as rubbing from the shirt sleeves. The arm is cold, cyanotic, and moist, but it is not swollen. Pulses at the wrist are normal, and neurologic function of the three major nerves is intact. Dx?; Diagnostic test?; Tx?
A485. Dx: Causalgia; Diagnostic test: Sympathetic block; Tx: Sympathetectomy; (If sympathetic block relieves the symptoms, permanent cure will be obtained with surgical sympathectomy)
Q486. A 71-year-old West Texas farmer of Irish ancestry has a nonhealing, indolent, punched out, clean-looking 2-cm ulcer over the left temple. The ulcer has been slowly growing over the past 3 years. There are no enlarged lymph nodes in the head and neck. Next step?
A486. Full thickness biopsy of the EDGE of the lesion; (The edge of the lesion offers the best information for the pathologist. A biopsy of the center of the lesion deprives the pathologist of all the clues that are found at the interface between the tumor and the normal skin, and in large lesions it runs the risk of sampling necrotic tumor that has outgrown its blood supply)
Q487. A 35-year-old man falls on an outstretched hand and comes in complaining of wrist pain. He relates that he was not able to break the fall, and that the heel of his hand took the brunt of his full weight as it hit the pavement. On physical examination, he is distinctly tender to palpation over the anatomic snuff box. Anteroposterior and lateral x-rays are negative. What is the most likely diagnosis and most appropriate next step in management?
A487. Dx: Carpal Navicular fracture; Tx: Thumb Spica Cast; (Nondisplaced fractures of the carpal navicular are notorious for not showing up on x-ray films at the time of injury. The mechanism of injury plus the physical findings described in this vignette are sufficient to make a presumptive diagnosis and to indicate the use of a cast)
Q488. A 56-year-old man develops slow, progressive paralysis of the facial nerve on one side. It took several weeks for the full- blown paralysis to become obvious, and it has been present now for 3 months. It affects both the forehead and the lower face. He has no pain anywhere, and no palpable masses by physical examination. What is the most likely diagnosis?
A488. Facial nerve tumor; (Slowly developing paralysis on one side is suggestive of a tumor. Since there are no physical findings, such as pain or a mass, to place the tumor in the parotid gland, it must be impinging on the nerve itself at a more proximal location)
Q489. A young mother complains of pain along the radial side of the wrist and the first dorsal compartment. She relates that the pain is often caused by the position of wrist flexion and simultaneous thumb extension that she assumes to carry the head of her baby. On physical examination, the pain is reproduced by asking her to hold her thumb inside her closed fist, and then forcing the wrist into ulnar deviation. What is the most likely diagnosis?
A489. Tenosynovitis of the abductor or extensor tendons of the thumb; (De Quervain's tenosynovitis); (The clinical presentation is classic for De Quervain's tenosynovitis, including the positive Finkelstein sign: the pain reproduced by ulnar deviation to stretch the affected tendons)
Q490. A 44-year-old homeless woman presents to the emergency department because she is "bleeding from the breast." Physical examination shows a huge, fungating, ulcerated mass that occupies the entire right breast and is firmly attached to the chest wall. The right axilla is full of hard masses that are not movable either. Core biopsies of the breast are read as highly undifferentiated infiltrating ductal carcinoma, and assay for estrogen and progesterone receptors are negative. What is the most appropriate next step in management?
A490. Radiation and chemotherapy; (Although this is an impressive, very advanced cancer with a poor prognosis, it can be expected to shrink significantly with local radiation plus systemic chemotherapy. It may do so to the point at which a palliative mastectomy becomes technically feasible, something that cannot be done at this time)
Q491. A 54-year-old African American man, with a history of smoking and drinking, describes progressive dysphagia that began 3 months ago. He first noticed difficulty swallowing meat; it then progressed to other solid foods, then to soft foods, and now to liquids as well. He locates the place where the food "sticks" at the lower end of the sternum. He has lost 30 pounds. What is the most appropriate first step in diagnosis?
A491. Barium swallow; (The clinical picture is that of a cancer of the esophagus, and given his race and history of smoking and drinking, it is probably a squamous cell carcinoma. The description of where the dysphagia is felt suggests a low location, but such subjective feelings lack precision. The tumor will eventually be seen and biopsied by endoscopy, but the endoscopist will first want to know the exact location of the tumor and the degree to which the lumen is occluded. Otherwise, there is a high risk of instrumental perforation of the esophagus. The best way to obtain that information is to do a barium swallow)
Q492. A 45-year-old woman, who wears high-heeled, pointed shoes, complains of pain in the forefoot after prolonged standing or walking. Occasionally, she also experiences numbness, a burning sensation, and tingling in the area. Physical examination shows no obvious deformities and a very tender spot in the third interspace, between the third and fourth toes. There is no redness, limitation of motion, or signs of inflammation. What is the most likely diagnosis?
A492. Morton's Neuroma; (The location and circumstances are classic for Morton's neuroma, a benign neuroma of the third plantar interdigital nerve)
Q493. A 66-year-old woman picks up a bag of groceries out of the supermarket cart to place it in the trunk of her car. As she does so, she feels sharp, sudden pain in the middle of her arm, and her humerus suddenly breaks. She arrives at the emergency department cradling her arm; the deformity leaves no doubt that the bone is broken. What is the most likely reason for the fracture?
A493. Bony metastasis to the humerus from breast cancer; (A fracture from such trivial strain signifies a very weakened bone. In this age and gender, the most likely cause would be a lytic lesion from metastatic breast cancer. In a man, we would have suspected metastatic lung cancer - not prostate, because prostatic metastases are blastic rather than lytic)
Q494. A 62-year-old man has had gastroesophageal reflux disease diagnosed by pH monitoring, and present for several years. He has been less than totally compliant with medical management, which he follows when the pain is bad, but discontinues when he feels better. Endoscopy and biopsies show severe peptic esophagitis, with Barrett's esophagus and early dysplastic changes, but no overt carcinoma. Additional tests show good esophageal motility, with low pressure in the lower esophageal sphincter and normal gastric emptying. What is the most appropriate treatment at this time?
A494. Laparoscopic Nissen fundoplication; (Transthoracic resection of the lower esophagus would be the procedure if a very early cancer were to develop at the esophagogastric junction)
Q495. A pedestrian is hit by a car. The paramedics report that he was unconscious at the site, and he arrives at the emergency department in coma, strapped to a head board with sandbags on either side of his head. Initial survey shows stable vital signs, and his pupils are of equal size and reactive to light. He is rapidly intubated by the nasotracheal route over a flexible bronchoscope and then sent for CT scans of the head. As he is being positioned on the table, it is noted that there is a sizable hematoma behind his right ear and that clear fluid is dripping from the ear canal. What is most advisable, considering this new finding?
A495. Extend the CT scan to include his neck; (The clinical findings are indicative of a fracture of the base of the skull, and thus he has sustained very significant trauma to the head. The integrity of the cervical spine has to be ascertained, and the CT that he is already going to have can be extended to include that area)
Q496. During the performance of a supraclavicular node biopsy under local anesthesia, a hissing sound is suddenly heard, and the patient suddenly dies. At the time of the catastrophic event, the target node was under traction, and the final cut was being made blindly behind it to free it up completely. The patient, an otherwise healthy 24-year-old man, was inhaling at that moment. What has most likely caused this patient's death?
A496. Major Vein injury with Air Embolism; (Major veins at the base of the neck have negative pressure during inspiration and, if injured at that moment, will suck air rather than bleed. The air embolism then leads to sudden death)
Q497. A man who weighs 65 kg sustains second and third degree burns over both of his lower extremities when his pants catch on fire. When examined shortly thereafter, it is ascertained that virtually all of the skin from both groins to the tip of the toes, front and back, has been burned. According to the modified Parkland formula, what is the approximate total amount of IV fluid that he can be expected to require during the first 24 hours post-burn?
A497. 11,360 mL; (4 mL of Ringer's lactate per kilogram of body weight, times the percentage of the body surface that has been burned; plus an additional 2000 mL of dextrose 5% in water to cover MAINTENANCE fluid needs. In the "rule of nines," each lower extremity represents 18% of the body surface. Thus, this patient has sustained a 36% body burn: 4 × 65 × 36 = 9360, plus 2000 = 11,360)
Q498. A 49-year-old woman has a firm, 2-cm mass in the right breast that has been present for 3 months. Mammogram has been read as "cannot rule out cancer," but it cannot diagnose cancer either. A fine-needle aspiration of the mass (FNA) and cytology do not identify any malignant cells. What is the most appropriate next step in management?
A498. Core or Incisional Biopsies; (Negative findings do not have the same diagnostic value that positive findings have. If this had been a 19-year-old woman suspected of having a fibroadenoma, one would have been satisfied with negative imaging studies (in that age, a sonogram) or the negative FNA. But, at age 49, the risk of cancer is much higher. Given negative findings in the least invasive studies, one would feel compelled to move to more aggressive ways to obtain better tissue sampling)
Q499. A 44-year-old woman has a palpable nodule in the right lobe of her thyroid gland. The nodule measures 2 cm and is firm. The rest of the thyroid gland cannot be felt and is not tender. She also describes losing weight in spite of a ravenous appetite, palpitations, and heat intolerance. She is thin, fidgety, and constantly moving, with moist skin and a pulse of 105/min. She has no exophthalmos or pretibial edema. Her TSH is reported as much lower than normal, and she has elevated levels of free T4. What is the most appropriate next step in diagnosis?
A499. Radionuclide Thyroid Scan; (the patient is hyperthyroid. She has no clinical signs of acute thyroiditis, and none of the other findings seen in Graves disease; however, she has a thyroid nodule, which raises the possibility of a hyperfunctioning adenoma (a "hot" adenoma). If indeed she does, the scan will show that the nodule traps all the iodine, with suppression of the rest of the gland)
Q500. Patient hurts his knee, causing him the ability to bend his leg inward to a greater extent then normally possible. What structure is damaged?
A500. Lateral Collateral Ligament; (Varus test)