Ksurgery 700-800

Front 1

Q700. A 17 year old girl is stung by a swarm of bees…or a man of whatever age breaks out with hives after a penicillin infection …or a patient undergoing surgery under spinal anesthetic… eventually develop BP of 75 over 25, pulse rate of 150, but they look warm and flushed rather than pale and cold. CVP is low. Dx?; Management? (2)

Back 1

A700. Dx: Vasomotor shock; (massive vasodilation, loss of vascular tone); Management: Vasoconstrictors and Volume replacement as needed

Front 2

Q701. A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has stable vital signs. No breath sounds on the right. Resonant to percussion. Dx?; Diagnostic Test?; Tx (specific)?

Back 2

A701. Dx: Plain pneumothorax; Diagnostic Test: There is time to get a chest X-Ray if the option if offered; Treatment: Chest tube to underwater seal and suction, high in the pleural cavity

Front 3

Q702. A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has stale vital signs. No breath sounds on at the base on the right chest, faint distant breath sounds at the apex. Dull to percussion. Dx?; Diagnostic Test?; Tx?

Back 3

A702. Dx: Hemothorax; Diagnostic Test: Chest X-Ray; Treatment: Chest tube on the right, at the base of the pleural cavity

Front 4

Q703. A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has stable vital signs. No breath sounds on at the base on the right chest, faint distant breath sounds at the apex. Dull to percussion. A chest tube placed at the right pleural base recovers 120 cc of blood, drains another 20 c in the next hour. Dx?; Further Tx?

Back 4

A703. Dx: Hemothorax; Further treatment: The point of this one is that most hemothoraxes do not need exploratory surgery. Bleeding is from lung parenchyma (low pressure), stops by itself. Chest tube is all that is needed. Key clue: little blood retrieved, even less afterwards

Front 5

Q704. A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has blood pressure is 95 over 70, pulse rate of 100. No breath sounds on at the base on the right chest, faint distant breath sounds at the apex. Dull to percussion. A chest tube placed at the right pleural base recovers 1250 cc of blood…(or it could be only 450 cc at the outset, but followed by another 420 cc in the next hour and so on). Dx?; Further Tx?

Back 5

A704. Dx: Hemothorax; Further treatment: The rare exception who is bleeding from a systemic vessel (almost invariably intercostal) will need Thoracotomy to ligate the vessel

Front 6

Q705. A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has stable vital signs. No breath sounds on the right. Resonant to percussion at the apex of the right chest, dull at the base. Chest X-Ray shows one single, large air-fluid level. Dx?; Tx?

Back 6

A705. Dx: Hemo-pneumothorax; Tx: Chest tube, surgery only if bleeding a lot

Front 7

Q706. A 33-year-old lady is involved in a high-speed automobile collision. She arrives at the E.R. gasping for breath, cyanotic at the lips, with flaring nostrils. There are bruises over both sides of the chest, and tenderness suggestive of multiple fractured ribs. Blood pressure is 60 over 45. Pulse rate 160, feeble. She has distended neck and forehead veins, is diaphoretic. Left hemithorax has no breath sounds, is tympanic to percussion. Dx?; Where is the trauma?; Management?

Back 7

A706. Dx: Tension Pneumothorax; Where is the penetrating trauma? The fractured ribs can act as a penetrating weapon. Management: Chest Tube to the left immediately!

Front 8

Q707. A 54-year-old lady crashes her car against a telephone pole at high speed. On arrival at the E.R. she is in moderate respiratory distress. She has multiple bruises over the chest, and multiple site of point tenderness over the ribs. X-Rays show multiple rib fractures on both sides. On closer observation it is noted that a segment of the chest wall on the left side caves in when she inhales, and bulges out when she exhales. Dx?; Next step if she is going to OR?; Next step if not doing well?

Back 8

A707. Dx: Flail Chest; (paradoxical breathing); to OR:; prophylactic Bilateral Chest Tubes; (because she is at high risk to develop tension pneumothorax when under the positive pressure breathing of the anesthetic); not well:; Intubate and give Positive Pressure ventilation; (Flail chest is usually assoc with pulmonary contusion, leading to inadequate respiration from pain)

Front 9

Q708. A 54-year-old lady crashes her car against a telephone pole at high speed. On arrival at the E.R. she is breathing well. She has multiple bruises over the chest and multiple sites of point tenderness over the ribs. X-Rays show multiple rib fractures on both sides, but the lung parenchyma is clear and both lungs are expanded. Two days later her lungs “white out ” on X-Rays and she is in respiratory distress. Dx?; Management? (2 together)

Back 9

A708. Dx: Pulmonary contusion. It does not always show up right away, may become evident one or two days after the trauma. Management:; 1. Fluid restriction (using colloids) and diuretics,; 2. Respiratory support:; (intubation, mechanical ventilation and PEEP if needed)

Front 10

Q709. A 54-year-old lady crashes her car against a telephone pole at high speed. On arrival at the E.R. she is breathing well. She has multiple bruises over the chest, and is exquisitely tender over the sternum at a point where there is a crunching feeling of crepitation elicited by palpation. Dx?; Further Tests?

Back 10

A709. Dx: Sternal fracture; (but the point is that she is at high risk for myocardial contusion and for traumatic rupture of the aorta); Further tests:; Most important:; 1. CT scan; 2. Transesophageal echo; (or arteriogram looking for aortic rupture); Also work-up for MI:; 1. EKG; 2. Cardiac enzymes

Front 11

Q710. A 53-year-old man is involved in a high-speed automobile collision. He has moderate respiratory distress. Physical exam shows no breath sounds over the entire left chest. Percussion is unremarkable. Chest X-Ray shows air fluid levels in the left chest. Dx?; Management?

Back 11

A710. Dx: Diaphragmatic rupture; (It is always on the left); Management: Surgical repair

Front 12

Q711. A motorcycle daredevil attempts to jump over the 12 fountains in front of Caesar’s Palace Hotel in Las Vegas. As he leaves the ramp at very high speed his motorcycle turns sideways and he hits the retaining wall at the other end, literally like a rag doll. At the ER he is found to be remarkably stable, although he has multiple extremity fractures. A chest X-Ray shows fracture of the left first rib and widened mediastinum. Dx?; Diagnostic Test?; Tx?

Back 12

A711. Dx: traumatic rupture of the aorta; (King size trauma, fracture of a hard-to-break bone...it could be first rib, scapula or sternum...and the tell-tale hint of widened mediastinum); Diagnostic Test: Arteriogram (aortogram); Treatment: Emergency surgical repair

Front 13

Q712. A 34-year-old lady suffers severe blunt trauma in a car accident. She has multiple injuries to her extremities, has head trauma and has a pneumothorax on the left. Shortly after initial examination it is noted that she is developing progressive subcutaneous emphysema all over her upper chest and lower neck. Dx?; Test for additional findings?; Diagnostic test?; Tx?

Back 13

A712. Dx: Traumatic rupture of the trachea or major bronchus; Additional findings: Chest X-Ray would confirm the presence of air in the tissues; Diagnostic test: Fiberoptic bronchoscopy; (to confirm diagnosis and level of injury and to secure an airway); Tx: Surgical repair

Front 14

Q713. A 26-year-old lady has been involved in a car wreck. She has fractures in upper extremities, facial lacerations and no other obvious injuries. Chest X-Ray is normal. Shortly thereafter she develops hypotension, tachycardia and dropping hematocrit. Her CVP is low. Dx?; Diagnostic Test if stable?; Unstable? (2 possible); Tx?

Back 14

A713. Dx: Abdominal bleed; Diagnostic test:; Patient is stable: CT scan; Unstable:; 1. Diagnostic Peritoneal Lavage; or; 2. Ultrasound in ER; Tx: Exploratory Lap

Front 15

Q714. A 19 year old gang member is shot in the abdomen with a 38 caliber revolver. The entry wound is in the epigastrium, to the left of the midline. The bullet is lodged in the psoas muscle on the right. He is hemodynamically stable, the abdomen is moderately tender. Management (specific)?

Back 15

A714. Management:; A penetrating wound of the abdomen gets exploratory laparotomy every time. preparations prior to surgery:; an indwelling bladder catheter, a big bore venous line for fluid administration and a dose of broad spectrum antibiotics.

Front 16

Q715. A 19 year old gang member is shot once with a 38 caliber revolver. The entry wound is in the left mid-clavicular line, two inches below the nipple. The bullet is lodged in the left paraspinal muscles. He is hemodynamically stable, but he is drunk and combative and physical exam is difficult to do. Management?

Back 16

A715. Management:; The point here is to remind you of the boundaries of the abdomen. Although this sounds like a chest wound, it is also abdominal. The belly begins at the nipple line. The chest does not end at the nipple line, though. Belly and chest are not stacked up like pancakes, they are separated by a dome. This fellow needs all the stuff for a penetrating chest wound (chest X-Ray, chest tube if needed), plus the exploratory lap

Front 17

Q716. A 27 year old intoxicated man smashes his car against a tree. He is tender over the left lower chest wall. Chest X-Ray shows fractures of the 8th, 9th and 10th ribs on the left. He has a blood pressure of 85 over 68 and a pulse rate of 128. Dx?; Diagnostic test if stable?; Diagnostic test if crashing? (2); Tx?

Back 17

A716. Dx: Ruptured spleen; Management if Stable: CT Scan; (if he responds promptly to fluid administration, and does not require blood; further management in that case may well be continued observation with serial CT scans); Management if “crashing”: Peritoneal Lavage or Sonogram followed by (Tx)Exploratory Laparotomy

Front 18

Q717. A 27 year old intoxicated man smashes his car against a tree. He is tender over the left lower chest wall. Chest X-Ray shows fractures of the 8th, 9th and 10th ribs on the left. He has a blood pressure of 85 over 68 and a pulse rate of 128, which do not respond satisfactorily to fluid and blood administration. He has a positive peritoneal lavage and an exploratory laparotomy where a ruptured spleen is found and it is not salvagable. Further Management?

Back 18

A717. Further Management:; administration of Pneumovax and some would also Immunize for Hemophilus Influenza B and Meningococcus

Front 19

Q718. A 31 year old lady smashes her car against a wall. She has multiple injuries including upper and lower extremity fractures. Her blood pressure is 75 over 55, with a pulse rate of 110. On physical exam she has a tender abdomen, with guarding and rebound on all quadrants. Dx?; Management?

Back 19

A718. Dx: Blood (and possible feces) in the belly; Management: Exploratory lap

Front 20

Q719. A 31 year old lady smashes her car against a wall. Her abdomen is tender with guarding and rebound tenderness present in all quadrants; Dx?; Management?

Back 20

A719. Dx: Ruptured bowel; Management: Exploratory lap, and repair of the injuries

Front 21

Q720. A patient involved in a high speed automobile collision has multiple injuries, including a pelvic fracture. On physical exam there is blood in the meatus. Dx? (2 possible); Diagnostic test?

Back 21

A720. Dx: Bladder or Urethral injury; (pelvic fracture plus blood in the meatus); Diagnostic test: Retrograde Urethrogram; (because urethral injury would be compounded by insertion of a Foley catheter)

Front 22

Q721. A 19 year old male is involved in a severe automobile accident. Among many other injuries he has a pelvic fracture. He has blood in the meatus, scrotal hematoma and the sensation that he wants to urinate but can not do it. Rectal exam shows a “high riding prostate”. Dx?; Diagnostic Test?; Management?

Back 22

A721. Dx: Posterior Urethral injury. Diagnostic test: Retrograde Urethrogram; Management:; Suprapubic catheter; (and the repair is delayed 6 months)

Front 23

Q722. A 19 year old male is involved in a motorcycle accident. Among many other injuries he has a pelvic fracture. He has blood in the meatus and scrotal hematoma. Retrograde urethrogram shows an anterior urethral injury. Management?

Back 23

A722. Management: Anterior urethral injuries are repaired right away

Front 24

Q723. A patient involved in a high speed automobile collision has multiple injuries, including a pelvic fracture. Insertion of a Foley catheter shows that there is gross hematuria. Dx?; Diagnostic test?

Back 24

A723. Dx: Bladder injury; (Presumably there was no blood in the meatus to warn against the insertion of an indwelling catheter, and since the latter was accomplished without problem, the urethra must be intact); Diagnostic test: Retrograde Cystogram

Front 25

Q724. A patient involved in a high speed automobile collision has multiple injuries, including rib fractures and abdominal contusions. Insertion of a Foley catheter shows that there is gross hematuria, and retrograde cystogram is normal. Dx?; Diagnostic Test?

Back 25

A724. Dx: Kidney injury; (Lower injuries have been ruled out); Diagnostic test: CT scan; (They will not ask you for fine-judgment surgical decisions, but the rule is that traumatic hematuria does not need surgery even if the kidney is smashed. They operate only if the renal pedicle is avulsed or the patient is exsanguinating)

Front 26

Q725. A 35 year old male is about to be discharged from the hospital where he was under observation for multiple blunt trauma sustained in a car wreck. It is then discovered that he has microscopic hematuria. Management?

Back 26

A725. Management: Gross traumatic hematuria in the adult always has to be investigated

Front 27

Q726. A 4 year old falls from his tricycle. In the ensuing evaluation he is found to have microscopic hematuria. Management?

Back 27

A726. Management: Microhematuria in kids needs to be investigated, as it often signifies congenital anomalies… particularly if the magnitude of the trauma does not justify the bleeding. Start with a Sonogram

Front 28

Q727. A 14 year old boy slides down a banister, not realizing that there is a big knob at the end of it. He smashes the scrotum and comes in to the E.R. with a scrotal hematoma the size of a grapefruit. What should be the physician's concern?; Diagnostic test?; Management?

Back 28

A727. Concern: The issue in scrotal hematomas is whether the testicle is ruptured or not. Diagnostic test: Sonogram; Management: If ruptured, surgery will be needed. If intact, only symptomatic treatment

Front 29

Q728. A 41 year old male presents to the E.R. reporting that he slipped in the shower and injured his penis. Exam reveals a large penile shaft hematoma with normal appearing glans. Dx?; Tx?

Back 29

A728. Dx: Fracture of the tunica albuginea; (including the usual cover story given by the patient. These always happen during sexual intercourse with woman on top); Tx: this is one of the few urological emergencies. Surgical repair is needed

Front 30

Q729. You get a phone call from a frantic mother. Her 7 year old girl spilled Drano all over her arms and legs. You can hear the girl screaming in pain in the background. Management?

Back 30

A729. Management:; The point of this question is that chemical injuries – particularly alkalis-need copious, immediate, profuse irrigation. Instruct the mother to do so right at home with tap water, for at least 30 minutes before rushing the girl to the E.R

Front 31

Q730. While trying to hook up illegally to cable TV, an unfortunate man comes in contact with a high tension electrical power line. He has an entrance burn wound in the upper outer thigh and an exit burn lower down on the same side. Tx?; What can occur from this event?; Management of this? (3)

Back 31

A730. Management: Extensive surgical Debridement; (there is deep tissue destruction); What can occur? Myoglobinemia; (leading to myoglobinuria and to Renal Failure); Management:; 1. lots of IV fluids,; 2. Osmotic Diuretics (Mannitol),; 3. Alkalinization of the urine

Front 32

Q731. A man is rescued by firemen from a burning building. On admission it is noted that he has burns around the mouth and nose, and the inside of his mouth and throat look like the inside of a chimney. Dx?; Diagnostic Test?; Management?

Back 32

A731. Dx: Inhalation burns; Diagnostic test: Bronchoscopy; Management: Respiratory support

Front 33

Q732. A patient has suffered third degree burns to both of his arms when his shirt caught on fire while lighting the back yard barbecue. The burned areas are dry, white, leatherly anesthetic, and circumferential all around arms and forearms. What is main problem?; Management? (2)

Back 33

A732. Problem: Circumferential burns; (The leatherly eschar will not expand, while the are under the burn will develop massive edema, thus circulation will be cut off or in the case of circumferential burns of the chest, breathing will be compromised); Management: Compulsive monitoring of peripheral pulses and capillary filling. Escharotomies at the bedside at the first sign of compromised circulation

Front 34

Q733. A toddler is brought to the E.R. with burns on both of his buttocks. The areas are moist, have blisters and are exquisitely painful to touch. The story is that the kid accidentally pulled a pot of boiling water over himself. what type of burn?; What should the physician question?; Management? (2)

Back 34

A733. Dx: Second degree burn; (Note that in kids third degree is deep bright red, rather than white leatherly as in the adult); Question: How did it really happen? Burns in kids always bring up the possibility of child abuse, particularly if they have the distribution that you would expect if you grabbed the kid by arms and legs and dunked him in a pot of boiling water. Management: Silvadene cream. Possibly reporting to authorities for child abuse

Front 35

Q734. An adult male who weight “X” Kgs. Sustains second and third degree burns over ---whatever--- The burns will be depicted in a drawing, indicating what is second degree (moist, blisters, painful) and what is third degree (white, leatherly, anesthetic). What is the equation for proper fluid resuscitation management?; What fluid and how much in first 8 hours?

Back 35

A734. Management:; 4cc per Kg. of body weight per percentage of burned area; (up to 50%); (if patient is 70kg and 18% burned, then 70x4x18); Fluid: Ringers Lactate; (half of the calculated dose goes in during first 8 hours)

Front 36

Q735. A 42 year old lady drops her hot iron on her lap while doing the laundry. She comes in with the shape of the iron clearly delineated on her upper thigh. The area is white, dry, leatherly, anesthetic. Tx?

Back 36

A735. Tx: Early excision and skin grafting; (in very small third degree burns)

Front 37

Q736. A 22 year old gang leader comes to the E.R. with a small, 1 cm. deep sharp cut over the knuckle of the right middle finger. He says he cut himself with a screwdriver while fixing his car. Dx?; Management?

Back 37

A736. Dx: The description is classical for a human bite. No, nobody actually bit him, he did it by punching someone in the mouth...and getting cut with the teeth that were smashed by his fist. The imaginative cover story usually comes with this kind of lesion. Management: human bites are bacteriological the dirtiest that one can get. Rabies shots will not be needed, but surgical exploration by an orthopedic surgeon will be required.

Front 38

Q737. A 65 year old West Texas farmer of Swedish ancestry has an indolent, raised, waxy, 1.2 cm skin mass over the bridge of the nose that has been slowly growing over the past three years. There are no enlarged lymph nodes in the head and neck. Dx?; Diagnostic Test?; Tx?

Back 38

A737. Dx: Basal cell carcinoma; Diagnostic test: Full thickness biopsy at the edge of the lesion (punch or knife); Treatment: Surgical excision with clear margins, but conservative width

Front 39

Q738. A 71 year old West Texas farmer of Irish ancestry has a non- healing, indolent, punched out, clean looking 2 cm ulcer over the left temple, that has been slowly becoming larger over the past three years. There are no enlarged lymph nodes in the head and neck. Dx?; Diagnostic Test?; Tx?

Back 39

A738. Dx: Basal cell carcinoma; Diagnostic Test: Full thickness biopsy at the edge of the lesion (punch or knife); Tx: Surgical excision with clear margins, but conservative width

Front 40

Q739. A blond, blue eyed, 69 year old sailor has a non-healing, indolent 1.5 cm. ulcer on the lower lip, that has been present, and slowly enlarging for the past 8 months. He is a pipe smoker, and he has no other lesions or physical findings. Dx?; Diagnostic Test?; Tx? (2 possible)

Back 40

A739. Dx: Squamous cell carcinoma; Diagnostic test: Biopsy; Treatment: Surgical resection with wider (about 1 cm) clear margins. Local radiation therapy is another option

Front 41

Q740. A red headed 23 year old lady who worships the sun, and who happens to be full of freckles, consults you for a skin lesion on her shoulder that concerns her. She has a pigmented lesion that is asymmetrical, with irregular borders, of different colors within the lesion, and measuring 1.8 cms; Dx?; Diagnostic Test?

Back 41

A740. Dx: Melanoma or Dysplastic Nevus; Diagnostic test: full thickness biopsy at the edge of the lesion; margin free local excision if superficial melanoma; (Clarks’ levels one or two, or under 0.75 mm); wide local excision with 2 or 3 cm margin if deep melanoma

Front 42

Q741. A 35 year old blond, blue eyed man left his native Minnesota at age 18, and has been living the life as a crew member for a sailing yacht charter operation in the Caribbean. He has multiple nevi all over his body, but one of them has changed recently. Dx?; Management?

Back 42

A741. Dx: Melanoma; (Change in a pigmented lesion is the other tip off to melanoma...It may be growth, or bleeding, or ulceration, or change in color); Management: Full-thickness biopsy at the edge of the lesion; margin free local excision if superficial melanoma; (Clarks’ levels one or two, or under 0.75 mm); wide local excision with 2 or 3 cm margin if deep

Front 43

Q742. A 44 year old man has unequivocal signs of multiple liver metastasis, but no primary tumor has been identified by multiple diagnostic studies of the abdomen and chest. The only abnormality in the physical exam is a missing toe, which he says was removed at the age of 18 for a black tumor under the toenail. Dx?; Diagnostic Test for initial problem?

Back 43

A742. Dx: Malignant Melanoma; (the alternate version has a glass eye, and history of enucleation for a tumor. No self-respecting malignant tumor would have this time interval, but melanoma will); Diagnostic Test: full thickness biopsy at the edge of the lesion; margin free local excision if superficial melanoma; (Clarks’ levels one or two, or under 0.75 mm); wide local excision with 2 or 3 cm. margin if deep melanoma

Front 44

Q743. A 32 year old gentleman had a Clark’s level 5, 3.4 mm. Deep, melanoma removed from the middle of his back three years ago. He now has…(a tumor in a weird place, like his left ventricle, his duodenum, his ischiorectal area...anywhere!); Dx?

Back 44

A743. Dx: Melanoma; (The point of this vignette is that invasive melanoma...it has to be deep...metastasizes to all the usual places [lymph nodes plus liver-lung-brain-bone] but it is also the all-time- champion in going to weird places where few other tumors dare to go)

Front 45

Q744. An 18 year old lady has a firm, rubbery mass in the left breast that moves easily with palpation. Dx?; Diagnostic Test?; Imaging technique for young patient?

Back 45

A744. Dx: Fibroadenoma; Diagnostic Test: Tissue diagnosis...(choices in order); 1. FNA; 2. Core Biopsy; 3. Excisional Biopsy; (The only safe answer, even if the presentation favors benign disease, is to get tissue diagnosis); Sonogram is the only imaging technique suitable for the very young breast

Front 46

Q745. A 27 year old immigrant from Mexico has a 12 x 10 x 7 cm. mass in her left breast. It has been present for seven years, and slowly growing to its present size. The mass is firm, rubbery, completely movable, is not attached to chest wall or to overlying skin. There are no palpable axillary nodes. Dx?; Diagnostic Test?

Back 46

A745. Dx: Cystosarcoma Phyllodes; (basically same presentation as Fibroadenoma, but >25yo); Diagnostic test: given the size best done with core or incisional biopsy; (no need for axillary node dissection with phyllodes...metastasis is rare)

Front 47

Q746. A 35 year old lady has a ten year history of tenderness in both breasts, related to menstrual cycle, with multiple lumps on both breasts that seem to “come and go” at different times in the menstrual cycle. Now has a firm, round, 2 cm. mass that has not gone away for 6 weeks. Dx?; Diagnostic Test?

Back 47

A746. Dx: Fibrocystic disease; Diagnostic test: Aspiration of the Cyst; (tissue diagnosis [i.e: biopsy] becomes impractical when there are lumps every month); If the mass goes away and the fluid aspirated is clear, that’s all. If the fluid is bloody it goes to cytology. If the mass does not go away, or recurs she needs biopsy. (Answers that offer mammogram or sonogram in addition to the aspiration would be OK, but not as the only choice)

Front 48

Q747. A 34 year old lady has been having bloody discharge from the right nipple, on and off for several months. There are no palpable masses. Dx?; Diagnostic Test?; if test is inconclusive?

Back 48

A747. Dx: Intraductal papilloma; Diagnostic test: Mammogram; (the way to detect breast cancer that is not palpable); (If negative, one may still wish to find an resect the intraductal papilloma to provide symptomatic relief. Resection can be guided by galactogram, or done as a retroareolar exploration)

Front 49

Q748. A 26 year old lactating mother has cracks in the nipple and develops a fluctuating, red, hot, tender mass in the breast, along with fever and leukocytosis. Dx?; Management?

Back 49

A748. Dx: Abscess; (However, only lactating breasts are “entitled” to develop abscesses. On anybody else, a breast abscess is a cancer until proven otherwise.); Management: Incision and Drainage; (if an option includes drainage with biopsy of the abscess wall, go for that one)

Front 50

Q749. A 49 year old has a firm 2cm mass in the right breast that has been present for 3 months. Dx?; Management?

Back 50

A749. Dx: This could be anything. (Age is the best determinant for Cancer of the breast. If she had been 72, you go for cancer. At 22, you favor benign. But they will not ask you what this is, they will ask what do you do.); Management: You have to have tissue. Core biopsy is OK, but if negative you don’t stop there. Only excisional biopsy will rule out cancer

Front 51

Q750. A 69 year old lady has a 4 cm hard mass in the right breast, with ill defined borders, movable from the chest wall but not movable within the breast. The skin overlying the mass is retracted an has an “orange peel” appearance…or the nipple became retracted six months ago. Dx?; Diagnostic Test?

Back 51

A750. Dx: Cancer of the Breast; Diagnostic test: Core or Excisional Biopsy

Front 52

Q751. A 62 year old lady has an eczematoid lesion in the areola. It has been present for 3 months and it looks to her like “some kind of skin condition” that has not improved or gone away with a variety of lotions and ointments; Dx?; Diagnostic Test?

Back 52

A751. Dx: Paget’s disease of the breast; (which is a cancer under the areola); Management: Full thickness punch biopsy of the skin would be OK, but core biopsy or incisional biopsy of the tissue underneath would be OK also

Front 53

Q752. A 42 year old lady hits her breast with a broom handle while doing her housework. She noticed a lump in that area at the time, and one week later the lump is still there. She has a 3 cm hard mass deep inside the affected breast, and some superficial ecchymosis over the area; Dx?

Back 53

A752. Dx: Cancer, until proven otherwise; (A classical trap for the unwary. Trauma often brings the area to the attention of the patient...but is not cause of the lump.)

Front 54

Q753. A 58 year old lady discovers a mass in her right axilla. She has a discreet, hard, movable, 2cm mass. Examination of her breast is negative, and she has not enlarged lymph nodes elsewhere; Dx?; Diagnostic Test? (2)

Back 54

A753. Dx: Cancer, until proven otherwise; (A tough one, but another potential presentation for cancer of the breast. In a younger patient you would think lymphoma. It could still be lymphoma on her.); Diagnostic test:; 1. Mammogram; (we are now looking for an occult primary); 2. Biopsy Node

Front 55

Q754. A 60 year old lady has a routine, screening mammogram. The radiologist reports an irregular area of increased density, with fine microcalcifications, that was not present two year ago on a previous mammogram; Dx?; Further Management?

Back 55

A754. Dx: Cancer of the Breast; Further management: Stereotactic Radiologically guided Core Biopsy; (If unsatisfactory, the next move would be needle localized excisional biopsy)

Front 56

Q755. A 44 year old lady has a 2cm palpable mass in the upper outer quadrant of her right breast. A core biopsy shows infiltrating ductal carcinoma. The mass is freely movable and her breast is of normal, rather generous size. She has no palpable axillary nodes; Tx? (2 steps)

Back 56

A755. Tx:; 1. Segmental Resection (Lumpectomy) and axillary node dissection; 2. followed by Radiation Therapy to the remaining breast; Axillary node dissection is to help determine the need for adjuvant systemic therapy

Front 57

Q756. A 62 year old lady has a 4 cm hard mass under the nipple and areola of her rather smallish left breast. A core biopsy has established a diagnosis of infiltrating ductal carcinoma. There are no palpable axillary nodes. Management?

Back 57

A756. Management: Modified Radical Mastectomy; (A Lumpectomy is an option only when the tumor is small [in absolute terms and in relation to the breast] and located where most of the breast can be spared.) A modified radical mastectomy is the choice here. Why go after the axillary nodes when they are not palpable?: Because palpation is notoriously inaccurate in determining the presence or absence of axillary metastasis.

Front 58

Q757. A 44 year old lady shows up in the Emergency Room because she is “bleeding from the breast”. Physical exam shows a huge, fungating, ulcerated mass occupying the entire right breast, and firmly attached to the chest wall. The patient maintains that the mass has been present for only “a few weeks”, but a relative indicates that it has been there at least two years, maybe longer. Dx?; Diagnostic Test?; Management?

Back 58

A757. Dx: Advanced Cancer of the Breast; Diagnostic Test: Core or an Incisional biopsy; Management: currently inoperable, and incurable as well...but palliation can be offered. Chemotherapy is the first line of treatment. (In many cases the tumor will shrink enough to become operable)

Front 59

Q758. A 37 year old lady has a lumpectomy and axillary dissection for a 3cm infiltrating ductal carcinoma. The pathologist reports clear surgical margins and metastatic cancer in 4 out of 17 axillary nodes. Management?

Back 59

A758. Management: Chemotherapy; (Only very small tumors with negative nodes and very favorable histological pattern are “cured” with surgery alone. More extensive tumors need adjuvant systemic therapy, and the rule is that premenopausal women get chemotherapy and postmenopausal women get hormonal therapy.)

Front 60

Q759. A 66 year old lady has a modified radical mastectomy for infiltrating ductal carcinoma of the breast. The pathologist reports that tumor measures 4 cm. in diameter and that 7 out of 22 axillary node are positive for metastasis. The tumor is estrogen and progesterone receptor positive. Management?

Back 60

A759. Management: Hormonal therapy; (The agent used is Tamoxifen)

Front 61

Q760. A 44 year old lady complains bitterly of severe headaches that have been present for several weeks and have not responded to the usual over-the-counter headache remedies. She is two years post-op. from modified radical mastectomy for T3, N2, M0 cancer of the breast, and she had several courses of post-op chemotherapy which she eventually discontinued because of the side effects. Dx?; Diagnostic Test?

Back 61

A760. Dx: Brain metastasis (until proven otherwise); (Don’t get hung up on the TNM classification, if the numbers are not 1 for the tumor and zero for the nodes and metastasis, the tumor is bad.); Diagnostic Test: CT scan of the brain

Front 62

Q761. A 39 year old lady completed her last course of postoperative adjuvant chemotherapy for breast cancer six months ago. She comes to the clinic complaining of constant back pain for about 3 weeks. She is tender to palpation over two well circumscribed areas in the thoracic and lumbar spine. Dx?; Diagnostic Test?

Back 62

A761. Dx: Bone metastasis until proven otherwise; Diagnostic test: Bone Scan; (the most sensitive test for bone metastasis); If positive, X-Rays are needed to rule out benign reasons for the scan to “light up”.

Front 63

Q762. A young mother is visiting your office for routine medical care. She happens to have her 18 month old baby with her, and you happen to notice that one of the pupils of the baby is white, while the other one is black. Dx Differential? (2)

Back 63

A762. Dx Diff: Retinoblastoma or Cataracts; (An ophthalmological and potentially life-and-death emergency. A white pupil (leukocoria) at this age can be retinoblastoma. This kid needs to see the ophthalmologist not next week, but today or tomorrow. If it turns out to be something more innocent, like a cataract, the kid still needs it corrected to avoid amblyopia.)

Front 64

Q763. Your distant cousins that you have not seen for years visit you and brag about their beautiful baby with “huge, shiny eyes”. They show you a picture that indeed proves their assertion (or the exam booklet will have such a picture). Dx?

Back 64

A763. Dx: Huge eyes in babies can be Congenital Glaucoma. (Tearing will indeed make them shine all the time. If undiagnosed, blindness will ensue.)

Front 65

Q764. A 53 year old lady is in the ER complaining of extremely severe frontal headache. The pain started about one hour ago, shortly after she left the movies where she watched a double feature. On further questioning, she reports seeing halos around the lights in the parking lot when leaving the theater. On physical exam the pupils are mid-dilated, do not react to light, the corneas are cloudy and with a greenish hue, and the eyes feel “hard as a rock”. Dx?; Management?; Medicine Tx? (3 possible)

Back 65

A764. Dx: Acute glaucoma; (most are asymptomatic); Management: An ophthalmologist is needed stat; Tx:; 1. Diamox; 2. Pilocarpine drops; 3. Mannitol

Front 66

Q765. A 32 year old lady presents in the E.R. with swollen, red, hot, tender eyelids on the left eye. She has fever and leukocytosis. When prying the eyelids open, you can ascertain that her pupil is dilated and fixed and that she has very limited motion of that left eye. Dx?; Management?; Tx?

Back 66

A765. Dx: Orbital Cellulitis; Management: CT scan; (Ophthalmological emergency that requires immediate consultation); Tx: Surgical drainage

Front 67

Q766. A frantic mother reaches you on the phone, reporting that her 10 year old boy accidentally splashed Drano on his face and is screaming in pain complaining that his right eye hurts terribly. Management?

Back 67

A766. Management: The key is immediate irrigation. Instruct the mother to pry the eye open under the cold water tap at home, and irrigate for about ½ hour before she brings the kid to the hospital.

Front 68

Q767. A 59 year old, myopic gentleman reports “seeing flashes of light” at night, when his eyes are closed. Further questioning reveals that he also sees “floaters” during the day, that they number ten or twenty, and that he also sees a cloud at the top of his visual field. Dx?; Management and Tx?

Back 68

A767. Dx: Retinal Detachment; (that “cloud” at the top of the visual field is hemorrhage settling at the bottom of the eye); Management: Another Ophthalmological emergency. The retina specialist will use Laser treatment to “spot weld” the retina back in place

Front 69

Q768. A 77 year old man suddenly loses sight from the right eye. He calls you on the phone 10 minutes after the onset of the problem. He reports no other neurological symptoms. Dx?; Management?

Back 69

A768. Dx: Embolic occlusion of the retinal artery; Management: Another ophthalmological emergency...although little can be done for the problem. He has to get the ER instantly and it might help for him to breathe into a paper bag on route, and have someone press hard on his eye and release repeatedly

Front 70

Q769. A 55 year old man is diagnosed with type two diabetes mellitus. On questioning about eye symptoms he reports that sometimes after a heavy dinner the television becomes blurry and he has to squint to see it clearly. Dx?; Management?

Back 70

A769. Dx: Simply DM-related changes in eye; (no big deal: the lens swells and shrinks in response to swings in blood sugar); Management: regular ophthalmological follow up for retinal complications

Front 71

Q770. A 54 year old obese man gives a history of burning retrosternal pain and “heartburn” that is brought about by bending over, wearing tight clothing or lying flat in bed at night. He gets symptomatic relief from antiacids, but the disease process seems to be progressing since it started several years ago. Dx?; Management?

Back 71

A770. Dx: Gastroesophageal reflux; Management: Endoscopy and biopsies; (to assess the extent of esophagitis and potential complications before medication)

Front 72

Q771. A 62 year old man describes severe epigastric and substernal pain that he can not characterize well. There is a history suggestive of gastroesophageal reflux, and EKG and cardiac enzymes have been repeatedly negative. Diagnostic test?

Back 72

A771. Diagnostic test: Acid Perfusion (Bernstein) test; (it reproduces the pain when the lower esophagus is irrigated with an acid solution to tell if it is only GERD)

Front 73

Q772. A 44 year old black man describes progressive dysphagia that began 3 months ago with difficulty swallowing meat, progressed to soft foods and is now evident for liquids as well. He locates the place where food “sticks” at the lower end of the sternum. He has lost 30 pounds of weight. Dx?; Diagnostic tests? (3 in order)

Back 73

A772. Dx: Carcinoma of the Esophagus; Diagnostic test:; 1. Barium swallow; 2. Endoscopy with biopsies; 3. CT scan

Front 74

Q773. A 47 year old lady describes difficulty swallowing which she has had for many years. She says that liquids are more difficult to swallow than solids, and she has learned to sit up straight and wait for the fluids to “make it through”. Occasionally she regurgitates large amounts of undigested food. Dx?; Diagnostic test? (3); Tx? (3 possible)

Back 74

A773. Dx: Achalasia; Diagnostic test:; 1. Manometry studies (gold standard); 2. CXR with barium swallow; 3. Endoscopy; Tx:; 1. Pneumatic dilation; 2. Surgical Myotomy; 3. Botox injection (if patient >50 yo is first Tx)

Front 75

Q774. A 24 year old man spends the night cruising bars and drinking heavily. In the wee hours of the morning he is quite drunk and he starts vomiting repeatedly. He initially brings up gastric contents only, but eventually he vomits bright red blood. Dx?; Diagnostic test?

Back 75

A774. Dx: Mallory Weiss tear; Diagnostic test: Endoscopy; (Photocoagulation may be used if needed)

Front 76

Q775. A 24 year old man spends the night cruising bars and drinking heavily. In the wee hours of the morning he is quite drunk and starts vomiting repeatedly. Eventually he has a particularly violent episode of vomiting and he feels a very severe, wrenching epigastric and low sternal pain of sudden onset. On arrival at the E.R. one hour later he still has the pain, he is diaphoretic, has fever and leukocytosis and looks Quite ill. Dx?; Diagnostic test?; Tx?

Back 76

A775. Dx: Boerhave’s syndrome; Diagnostic test: Gastrographin swallow; Treatment: Emergency surgical repair; (Prognosis depends on time elapsed between perforation and treatment)

Front 77

Q776. A 55 year old man has an upper G.I. endoscopy done as an outpatient to check on the progress of medical therapy for gastric ulcer. Six hours after the procedure, he returns complaining of severe, constant, retrosternal pain that began shortly after he went home. He looks prostrate, very ill, is diaphoretic, has a temperature of 104 and respiratory rate of 30. Dx?; Diagnostic test?

Back 77

A776. Dx: Instrumental perforation of the esophagus; Diagnostic test: Gastrographin swallow

Front 78

Q777. A 72 year old man has lost 40 pounds of weight over a two or three month period. He gives a history of anorexia for several months, and of vague epigastric discomfort for the past 3 weeks. Dx?; Diagnostic test?

Back 78

A777. Dx: Cancer of the stomach; Diagnostic test: Endoscopy and biopsies

Front 79

Q778. A 55 year old patient with known PUD presents with sudden onset of severe epigastric pain. Physical exam reveals guarding and rebound tenderness. Dx?; Diagnostic test?

Back 79

A778. Dx: Anterior Perforated ulcer; Diagnostic test: Chest or Abdominal x-ray to show free air under diaphragm

Front 80

Q779. A 52 year old woman presents due to 3 months of early satiety, weight loss and non-bilious vomiting. Dx?

Back 80

A779. Dx: Gastric Outlet Obstruction

Front 81

Q780. A 55 year old patient with known PUD presents with sudden onset of severe epigastric pain that radiates to the back. Physical exam reveals guarding and rebound tenderness. An Abdominal x-ray does not show free air under diaphragm. Dx?

Back 81

A780. Dx: Posterior Perforated ulcer; (An Abdominal x-ray will not show free air under diaphragm if it is a posterior perforation)

Front 82

Q781. A 45 year old Japanese male smoker presents with weight loss and epigastric pain exacerbated by eating. Dx?; Diagnostic test?

Back 82

A781. Dx: Gastric Ulcer; Diagnostic test: Endoscopy with Biopsy

Front 83

Q782. A 24 year old patient who was recently a burn victim over 36% of his body presents with epigastric pain exacerbated by eating. Dx?

Back 83

A782. Dx: Curling’s Ulcers; (Gastric stress ulcers with severe burns. “Burnt paper CURLS”)

Front 84

Q783. A 72 year old recent stroke patient begins to have severe epigastric pain that is exacerbated by eating. Dx?

Back 84

A783. Dx: Cushing’s Ulcers; (Gastric ulcer related to severe CNS damage)

Front 85

Q784. A 58 year old woman who is 6 days post-op from a gastrojejunostomy for PUD presents with postprandial RUQ pain and nausea. She reports that vomiting relieves her suffering. Dx?; Diagnostic test?; Tx?

Back 85

A784. Dx: Afferent Loop syndrome; Diagnostic test: UGI series with contrast; (will show afferent loop without contrast); Tx: Endoscopic Balloon dilatation or Surgical revision

Front 86

Q785. (5) causes for an Upper GI Hemorrhage

Back 86

A785. Mallory’s Vices Gave (her) An Ulcer:; Mallory-Weiss Tear;; Varices;; Gastritis;; AV malformation;; Ulcer

Front 87

Q786. A 54 year old man has had colicky abdominal pain and protracted vomiting for several days. He has developed progressive moderate abdominal distention, and has not had a bowel movement or passed any gas for five days. He has high pitched, loud bowel sounds that coincide with colicky pain, and X-Rays that show distended loops of small bowel and air-fluid levels. Five years ago he had an exploratory laparotomy for a gunshot wound of the abdomen. Dx?; Management?

Back 87

A786. Dx: Mechanical Intestinal Obstruction, due to adhesions; Management: Nasogastric suction, I.V. fluids and careful observation

Front 88

Q787. A 54 year old man has had colicky abdominal pain and protracted vomiting for several days. He has developed progressive moderate abdominal distention, and has not had a bowel movement or passed any gas for five days. He has high pitched loud bowel sounds that coincide with the colicky pain, and X-Rays that show distended loops of small bowel and air-fluid levels. Five years ago he had an exploratory laparotomy for a gunshot wound of the abdomen. Six hours after being hospitalized and placed on nasogastric suction and I.V. fluids, he develops fever, leukocytosis, abdominal tenderness and rebound tenderness; Dx?; Management?

Back 88

A787. Dx: Strangulated Obstruction; (a loop of bowel is dying –or dead- from compression of the mesenteric blood supply); Management: Emergency surgery

Front 89

Q788. A 54 year old man has had colicky abdominal pain and protracted vomiting for several days. He has developed progressive moderate abdominal distention, and has not had a bowel movement or passed any gas for five days. He has high-pitched, loud bowel sounds that coincide with the colicky pain, and X-Rays that show distended loops of small bowel and air-fluid levels. On physical exam a groin mass is noted, and he explains that he used to be able to “push it back” at will, but for the past 5 days has been unable to do so. Dx?; Management?

Back 89

A788. Dx: Mechanical Intestinal Obstruction, due to an incarcerated (potentially strangulated) Hernia. Management: After suitable fluid replacement needs urgent surgical intervention

Front 90

Q789. A 55 year old lady is being evaluated for protracted diarrhea. On further questioning she gives a bizarre history of episodes of flushing of the face, with expiratory wheezing. A prominent jugular venous pulse is noted on her neck. Dx?; Diagnostic test? (2 steps); Tx? (3 depending on position)

Back 90

A789. Dx: Carcinoid syndrome. Diagnostic test:; 1. 24 hour Serum determinations of 5-hydroxy-indoleacetic acid (5-HIAA) or 5-HTP;; 2. CT scan of abdomen; Tx: Serotonin antagonists;; then... If Appendiceal < 2cm = Appendectomy. If Appendiceal > 2cm = Right hemicolectomy;; Small intestinal = resect tumor with mesenteric LN

Front 91

Q790. A 22 year old man develops vague periumbilical pain that several hours later becomes sharp, severe, constant and well localized to the right lower quadrant of the abdomen. On physical examination he has abdominal tenderness, guarding and rebound to the right and below the umbilicus. He has a temperature of 99.6 and a WBC of 12,500, with neutrophilia and immature forms. Dx?; Management?

Back 91

A790. Dx: Acute Appendicitis; Management: Exploratory laparotomy and appendectomy

Front 92

Q791. A 70 year old male with a history of peripheral vascular disease and hyperlipidemia presents to the ER with diffuse abdominal pain. His BP is 170/100 and his pulse is 90bpm. Supine abdominal radiographs shows air in the wall of the small intestine. Dx?

Back 92

A791. Dx: Small bowel Infarction

Front 93

Q792. A patient presents with pigmented spots on his lips and a history of recurrent colicky abdominal pain. Dx?

Back 93

A792. Dx: Peutz-Jeghers syndrome

Front 94

Q793. A 5 year old child presents with increasing irritability, colicky abdominal pain and rectal bleeding with stools that have a currant jelly appearance. A mass is palpated in the right lower quadrant. Dx?; Diagnostic test? (2)

Back 94

A793. Dx: Intussusception; Diagnostic test: Abdominal x-ray showing air-fluid levels with a stepladder pattern;; Barium enema (which is also therapeutic)

Front 95

Q794. A 59 year old is referred for evaluation because he has been fainting at his job where he operates heavy machinery. He is pale and gaunt, but otherwise his physical exam is remarkable only 4+ occult blood in the stool. Lab studies show a hemogoblin of 5. Dx?; Diagnostic test?; Tx?

Back 95

A794. Dx: Cancer of the right colon; Diagnostic test: Colonoscopy and biopsies; Treatment: Blood transfusions and eventually Right Hemicolectomy

Front 96

Q795. A 56 year old man has bloody bowel movements. The blood coats the outside of the stool, and has been constipated, and his stools have become of narrow caliber. Dx?; Diagnostic test?

Back 96

A795. Dx: Cancer of the distal, left side of the colon; Diagnostic test: Endoscopy and biopsies; (If given choices start with Flexible Sigmoidoscopy)

Front 97

Q796. A 42 year old man has suffered from chronic ulcerative colitis for 20 years. He weights 90 pounds and has had at least 40 hospital admissions for exacerbations of the disease. Due to a recent relapse, he has been placed on high dose steroids and immuran. For the past 12 hours he has had severe abdominal pain, temperature of 104 and leukocytosis. He looks ill, and “toxic”. His abdomen is tender particularly in the epigastric area, and he has muscle guarding and rebound. X-Rays show a massively distended transverse colon, and there is gas within the wall of the colon. Dx?; Management?

Back 97

A796. Dx: Toxic megacolon; Management: Emergency surgery for the toxic megacolon and removal of the rectum; (but the case illustrates many other indications for surgery: chronic malnutrition, “intractability” and risk of developing cancer)

Front 98

Q797. A 27 year man is recovering from an appendectomy for gangrenous acute appendicitis with perforation and periappendicular abscess. He has been receiving Clindamycin and tobramycin for seven days. Eight hours ago he developed watery diarrhea, crampy abdominal pain fever and leukocytosis; Dx?; Diagnostic test?; Management?

Back 98

A797. Dx: Pseudomembranous colitis from overgrowth of Clostridium Difficile; Diagnostic test: Stool cultures (but proctosigmoidoscopy can show a typical picture before the cultures are back); Management: Stop the clindamycin, give either Vancomycin or Metronidazole, and avoid lomotil

Front 99

Q798. A 60 year old man known to have hemorrhoids reports bright red blood in the toilet paper after evacuation. Dx?; Management?

Back 99

A798. Dx: Internal hemorrhoids; Management: Proctosigmoidoscopic Examination; (It is not reassurance and hemorrhoid remedies prescribed by telephone. In all these cases, cancer of the rectum has to be ruled out)

Front 100

Q799. A 60 year old man known to have hemorrhoids complains of anal itching and discomfort, particularly towards the end of the day. He has perianal pain when sitting down and finds himself sitting sideways to avoid the discomfort. He is afebrile. Dx?; Management?

Back 100

A799. Dx: External hemorrhoids; Management: Proctosigmoidoscopic Examination; (It is not reassurance and hemorrhoid remedies prescribed by telephone. In all these cases, cancer of the rectum has to be ruled out)

Front 101

Q800. A 23 year old lady describes exquisite pain with defecation and blood streaks on the outside of the stools. Because of the pain she avoids having bowel movements and when she finally does, the stools are hard and even more painful. Physical examination can not be done, as she refuses to allow anyone to even “spread her cheeks” to look at the anus for fear of precipitating the pain. Dx?; Management?; Surgical Tx?

Back 101

A800. Dx: Anal Fissure; Management: Exam under Anesthesia; (Even though the clinical picture is classical, cancer still has to be ruled out); Tx: Lateral Internal Sphincterotomy