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101 Cards in this Set

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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?
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
Q801. A 28 year old male is brought to the office by his mother. Beginning four months ago he has had three operations, done elsewhere, for a perianal fistula, but after each one the area has not healed, but actually the surgical wounds have become bigger. He now has multiple unhealing ulcers, fissures all around the anus, with purulent discharge. There are no palpable masses. Dx?; Diagnostic test?; Top 3 medical Tx?
A801. Dx: Crohn's Disease; (The perianal area has fantastic blood supply and heals beautifully even though feces bathe the wounds. When it does not, you immediately think of Crohn’s disease); Diagnostic test: Flexible sigmoidoscopy with Biopsy; (You still have to rule out malignancy); Top 3 medical Tx:; 1. Sulfasalazine; 2. Metronidazole; 3. Prednisone
Q802. A 44 year old man shows up in the E.R. at 11 PM with exquisite perianal pain. He can not sit down, reports that bowel movements are very painful, and that he has been having chills and fever. Physical examination shows a hot, tender, red, fluctuant mass between the anus and the ischial tuberosity. Dx?; Management?
A802. Dx Ischiorectal abscess; Management: Exam under Anesthesia with Incision and Drainage; (The treatment for all abscesses is drainage. This one is no exception. But as always, cancer has to be ruled out)
Q803. A 62 year old man complains of perianal discomfort, and reports that there are streaks of fecal soiling in his underwear. Four months ago he had a perirectal abscess drained surgically. Physical exam shows a perianal opening in the skin, and a cord-liked tract can be palpated going from the opening towards the inside of the anal canal. Brownish purulent discharge can be expressed from the tract. Dx?; First step?; Tx?
A803. Dx: Anal Fistula; First:; Rule-out cancer with Proctosigmoidoscopy; Tx: elective Fistulotomy
Q804. A 55-year old, HIV positive man, has a fungating mass growing out of the anus, and rock hard, enlarged lymph nodes on both groins. He has lost a lot of weight, and looks emaciated and ill. Dx?; Diagnostic Test?; Eventual Tx?
A804. Dx: Squamous cell carcinoma of the anus; Diagnostic test: Biopsies of the fungating mass. Eventual treatment: Nigro protocol of pre-operative chemotherapy and radiation
Q805. A 33 year old man vomits a large amount of bright red blood. Where can the bleeding be from?; Diagnostic test?
A805. Bleeding from: Tip of the nose to the ligament of Treitz. Diagnostic test: for all upper G.I. bleeding, start with Endoscopy
Q806. A 33 year old man has had three large bowel movements that he describes as made up entirely of dark red blood. The last one was 20 minutes ago. He is diaphoretic, pale, has a blood pressure of 90 over 70 and a pulse rate of 110. Where is bleeding from?; Management?
A806. Bleeding from? Anywhere in GI tract; (The point of the vignette is that something needs to be done to define the area from which he is bleeding. With the available information it could be from anywhere in the G.I. tract); Management: The first diagnostic move here is to place a Nasogastric tube
Q807. A 33 year old man has had three large bowel movements that he describes as made up entirely of dark red blood. The last one was 20 minutes ago. He is diaphoretic, pale, has a blood pressure of 90 over 70 and a pulse rate of 110. A nasogastric tube returns copious amounts of bright red blood. Management?
A807. Management: Endoscopy; (Same as if he had been vomiting blood)
Q808. A 72 year old man had three large bowel movements that he describes as made up entirely of dark red blood. The last one was two days ago. He is pale, but has normal vital signs. A nasogastric tube returns clear, green fluid without blood. Diagnostic test? (2)
A808. Diagnostic test: Upper and Lower Endoscopies; (The clear aspirate is meaningless because he is not bleeding right now. So the guilty territory can be anywhere from the tip of the nose to the anal canal. Across the board, ¾ of all GI bleeding is upper, and virtually all the causes of lower GI bleeding are diseases of the old: diverticulosis, polyps, cancer and angiodysplasias. So, is old, the overall preponderance of upper is balanced by the concentration of lower causes in old people...so it could be anywhere)
Q809. A 7 year old boy passes a large bloody bowel movement. Dx?; Diagnostic test?
A809. Dx: Meckel’s diverticulum; (in this age group); Diagnostic test: Radioactively labeled Technetium scan; (not the one that tags reds cells, but the one that identifies gastric mucosa)
Q810. A 41 year old man has been in the intensive care unit for two weeks, being treated for idiopathic hemorrhagic pancreatitis. He has had several percutaneous drainage procedures for pancreatic abscesses, chest tubes for pleural effusions, and bronchoscopies for atelectasis. He has been in and out of septic shock and respiratory failure several times. Ten minutes ago he vomited a large amount of bright red blood, and as you approach him he vomits again what looks like another pint of blood. Dx?; Diagnostic test?; How could it have been prevented?; Tx?
A810. Tx: Stress Ulcer; Diagnostic test: Endoscopy; It should have been prevented by keeping the pH of the stomach above 4 with H2 blockers, antiacids or both; Treatment: Angiographic Embolization of the left gastric artery.
Q811. A 59 year old man arrives in the E.R. at 2 AM, accompanied by his wife who is wearing curlers on her hair and a robe over her nightgown. He has abdominal pain that began about one hour ago, and is now generalized, constant and extremely severe. He lies motionless in the stretcher, is diaphoretic and has shallow, rapid breathing. His abdomen is rigid, very tender to deep palpation, and has guarding and rebound tenderness in all quadrants. Dx?; Management?
A811. Dx: Acute Peritonitis (Acute Abdomen); Management: Emergency Exploratory Laparotomy
Q812. A 62 year old man with cirrhosis of the liver and ascites, presents with generalized abdominal pain that started 12 hours ago. He now has moderate tenderness over the entire abdomen, with some guarding and equivocal rebound. He has mild fever and leukocytosis. Dx?; Diagnostic test?; Tx?
A812. Dx: Primary Peritonitis; (Peritonitis in the cirrhotic with ascitis, or the child with nephrosis and ascitis, could be primary peritonitis – which does not need surgery!); Diagnostic test: Paracentesis with Cultures of the ascitic fluid will yield a single organism; Treatment: Antibiotics
Q813. A 43 year old man develops excruciating abdominal pain at 8:18 PM. When seen in the E.R. at 8:50 PM, he has a rigid abdomen, lies motionless in the examining table, has no bowel sounds and is obviously in great pain, which he describes as constant. X-Ray shows free air under the diaphragms. Dx?; Management?
A813. Dx: Acute abdomen plus perforated GI tract; (perforated duodenal ulcer in most cases); Management: Emergency exploratory laparotomy
Q814. A 44 year old alcoholic male presents with severe epigastric pain that began shortly after a heavy bout of alcoholic intake, and reached maximum intensity over a period of two hours. The pain is constant, radiates straight through to the back and is accompanied by nausea, vomiting and retching. He had a similar episode two years ago, for which he required hospitalization. Dx?; Diagnostic test?; If Dx is unclear?; Management? (3 together)
A814. Dx: Acute pancreatitis; Diagnostic test: Serum and Urinary Amylase and Lipase; If unclear: CT scan (or in a day or two if there is no improvement); Management: NPO, NG suction, IV fluids.
Q815. A 43 year old obese lady, mother of six children, has severe right upper quadrant abdominal pain that began six hours ago. The pain was colicky at first, radiated to the right shoulder and around towards the back, and was accompanied by nausea and vomiting. For the past 2 hours the pain has been constant. She has tenderness to deep palpation, muscle guarding and rebound in the right upper quadrant. Her temperature is 101 and she has a WBC of 16,000. She has had similar episodes of pain in the past, brought about by ingestion of fatty food, but they all had been of brief duration and relented spontaneously or with anticholinergic medications. Dx?; Diagnostic test?; Management?
A815. Dx: Acute cholecystitis; Diagnostic test: Ultrasound (If equivocal, an “HIDA” scan: radionuclide excretion scan); Management: “cool down” the process; Surgery will follow
Q816. A 52 year old man has right flank colicky pain of sudden onset that radiates to the inner thigh and scrotum. There is microscopic hematuria. Dx?; Diagnostic test? (2)
A816. Dx: Ureteral colic; Diagnostic test: Urological evaluation always begins with a Plain Film of the abdomen (a “KUB”); Ultrasound often is the next step; (but traditionally it has been intravenous pyelogram)
Q817. A 59 year old lady has a history of three prior episodes of left lower quadrant abdominal pain for which she was briefly hospitalized and treated with antibiotics. Now she has left lower quadrant pain, tenderness, and a vaguely palpable mass. She has fever and leukocytosis. Dx?; Diagnostic test?; Management?
A817. Dx: Acute diverticulitis; Diagnostic test: CT scan; (Colonoscopy is not safe in acute setting); Management: Elective Sigmoid resection; (for recurrent attacks, like this case or if she does not respond to medical Tx from initial attack or gets worse); (Treatment is medical for the acute attack: antibiotics, NPO)
Q818. An 82 year old man develops severe abdominal distension, nausea, vomiting and colicky abdominal pain. He has not passed any gas or stool for the past 12 hours. He has a tympanitic abdomen with hyperactive bowel sounds. X-Ray shows distended loops of small and large bowel, and a very large gas shadow that is located in the right upper quadrant and tapers towards the left lower quadrant with the shape of a parrot’s beak. Dx?; Management?
A818. Dx: Volvulus of the sigmoid; Management: Proctosigmoidoscopy should relieve the obstruction; (Rectal tube is another option. Eventually surgery to prevent recurrences could be considered)
Q819. A 79 year old man with atrial fibrillation develops and acute abdomen. He has a silent abdomen, with diffuse tenderness and mild rebound. There is a trace of blood in the rectal exam. He has acidosis and looks quite sick. X-Rays show distended small bowel and distended colon up to the middle of the transverse colon. Dx?; Tx if mild, moderate or severe?
A819. Dx: Emboli of Mesenteric vessels; (Acute abdomen present in the elderly who has atrial fibrillation, brings to mind embolic occlusion of the mesenteric vessels. Acidosis frequently ensues, and blood in the stool is often seen); Mild Tx: Observe only; Moderate Tx (fever and inc WBC only): IV Antibiotics; Severe Tx (Peritoneal signs): Exploratory Lap with Colostomy
Q820. A 53 year old man with cirrhosis of the liver develops malaise, vague right upper quadrant abdominal discomfort and 20 pound weight loss. Physical exam shows a palpable mass that seems to arise from the left lobe of the liver. Alpha feto protein is significantly elevated. Dx?; Diagnostic test?; Tx?
A820. Dx: Liver cell carcinoma; Diagnostic test: CT scan; Tx: If confined to one lobe, Resection.
Q821. A 53 year old man develops vague right upper quadrant abdominal discomfort and a 20 pound weight loss. Physical exam shows a palpable liver with nodularity. Two years ago he had a right hemicolectomy for cancer of the ascending colon. His carcinoembryogenic antigen (CEA) had been within normal limits right after his hemicolectomy, is now ten times normal. Dx?; Diagnostic test?; Tx?
A821. Dx: Metastasis to the liver from colon cancer; Diagnostic test: CT scan; Tx: If metastasis are confined to one lobe: Resection. (Otherwise, Chemotherapy if he has not had it)
Q822. A 24 year old lady develops moderate, generalized abdominal pain of sudden onset, and shortly thereafter faints. At the time of evaluation in the ER she is pale, tachycardic, and hypotensive. The abdomen is mildly distended and tender, and she has a hemogoblin of 7. There is no history of trauma. On inquiring as to whether she might be pregnant, she denies the possibility because she has been on birth control pills since she was 14, and has never misses taking them. Dx?; Management?; Tx?
A822. Dx: Bleeding from a ruptured Hepatic Adenoma, secondary to birth control pills. Management:; CAT scan; (will confirm bleeding and probably show the liver adenoma as well); Tx: Surgery
Q823. A 44 year old lady is recovering from an episode of acute ascending cholangitis secondary to choledocholithiasis. She develops fever and leukocytosis and some tenderness in the right upper quadrant. An ultrasound reveals a liver mass. Dx?; Management?
A823. Dx: Pyogenic abscess; Management: it needs to be drained (the radiologists will do it percutaneously)
Q824. A 29 year old migrant worker from Mexico develops fever and leukocytosis, as well as tenderness over the liver when the area is percussed. He has mild jaundice and an elevated alkaline phosphatase. Ultrasound of the right upper abdominal area shows a normal biliary tree, and an abscess in the liver. Dx?; Management?
A824. Dx: Amebic abscess; (very common in Mexico); Management: Serology for Amebic titers and start on Metronidazole; (This one Abscess that does not have to be drained. Get serology for amebic titers, and start the patient on Metranidazole. Prompt improvement will tell you that you are on the right track...serologies in 3 weeks will confirm. Don’t fall for an option that suggests aspirating the pus and sending it for culture, you can not grow the ameba from the pus)
Q825. A 42 year old lady is jaundiced. She has a total bilirubin of 6 and the laboratory reports that the unconjugated, indirect bilirubin is 6 and the direct, conjugated bilirubin is zero. She has no bile in the urine. Dx?; Management?
A825. Dx: Hemolytic Jaundice; Management: Try to figure out what is chewing her red cells.
Q826. A 19 year old college student returns from a trip to Cancun, and two weeks later develops malaise, weakness and anorexia. A week later he notices jaundice. When he presents for evaluation his total bilirubin is 12, with 7 indirect and 5 direct. His alkaline phosphatase is mildly elevated, while the SGOT and SGPT (transaminases) are very high. Dx?; Management?
A826. Dx: Hepatocellular jaundice; Management: Get serologies to confirm diagnosis and type of Hepatitis
Q827. A patient with progressive jaundice which has been present for four weeks is found to have a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated SGOT. The alkaline phosphatase was twice normal value couple of weeks ago, and now is about six times the upper limit of normal. Dx?; Management?
A827. Dx: Obstructive jaundice; Diagnostic test: Ultrasound; (looking for dilated intrahepatic ducts, possibly dilated extrahepatic ducts as well, and if we get lucky a finding of gallstones)
Q828. A 40 year old, obese mother of five children presents with progressive jaundice which she first noticed four weeks ago. She has a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated SGOT. The alkaline phosphatase is about six times the upper limit of normal. She gives a history of multiple episodes of colicky right upper quadrant abdominal pain, brought about by ingestion of fatty food. Dx?; Diagnostic test? (2); Tx?
A828. Dx: Obstructive jaundice; Diagnostic test: Ultrasound; (If you need more tests after that, ERCP is the next move, which could also be used to remove the stones from the common duct); Tx: Cholecystectomy
Q829. A 66 year old man presents with progressive jaundice which he first noticed six week ago. He has a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated SGOT. The alkaline phosphatase is about six times the upper limit of normal. He has lost 10 pounds over the past two months, but is otherwise asymptomatic. A sonogram shows dilated intrahepatic ducts, dilated extrahepatic ducts and a very distended, thin walled gallbladder. Dx?; Management? (2)
A829. Dx: Malignant obstructive jaundice. (“Silent” obstructive jaundice is more likely to be due to tumor. A distended gallbladder is an ominous sign: when stones are the source of the problem, the gallbladder is thick- walled, non-pliable); Management: CAT scan and ERCP
Q830. A 66 year old man presents with progressive jaundice which he first noticed six weeks ago. He has a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated SGOT. The alkaline phosphatase is about six times the upper limit of normal. He is otherwise asymptomatic. A sonogram shows dilated intrahepatic ducts, dilated extrahepatic ducts and a very distended, thin walled gallbladder. Except for the dilated ducts, CT scan is unremarkable. ERCP shows a narrow area in the distal common duct, and a normal pancreatic duct. Dx?; Next step?; Tx?
A830. Dx: Malignant, but lucky... probably Cholangiocarcinoma at the lower end of the common duct. Next step: get brushings of the common duct for cytological diagnosis. Tx: He could be cured with a pancreatoduodenectomy; (Whipple operation)
Q831. A 64 year old lady presents with progressive jaundice which she first noticed two weeks ago. She has a total bilirubin of 12, with 8 direct and 4 indirect, and minimally elevated SGOT. The alkaline phosphatase is about ten times the upper limit of normal. She is otherwise asymptomatic, but is found to be slightly anemic and to have positive occult blood in the stool. A sonogram shows dilated intrahepatic ducts, dilated extrahepatic ducts and very distended, thin walled gallbladder. Dx?; Diagnostic test?; Tx?
A831. Dx: Malignant Obstructive jaundice; (The coincidence of slowly bleeding into the GI tract at the same time that she develops obstructive jaundice points to an Ampullary carcinoma, another malignancy that can be cured with Radical surgery); Diagnostic test: Endoscopy
Q832. A 56 year old man presents with progressive jaundice which he first noticed six weeks ago. He has a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated SGOT. He alkaline phosphatase is about eight times the upper limit of normal. He has lost 20 pounds over the past two months, and has a persistent, nagging mild pain deep into his epigastrium and in the upper back. His sister died at age 44 from a cancer of the pancreas. A sonogram shows dilated intrahepatic ducts, dilated extrahepatic ducts and a very distended, thin walled gallbladder. Dx?; Diagnostic test? (2)
A832. Dx: Cancer of the head of the pancreas (Terrible prognosis); Diagnostic test: CAT scan –which may show the mass in the head of the pancreas;; then ERCP –which will probably show obstruction of both common duct and pancreatic duct
Q833. A white, fat, female, aged 40 and mother of five children gives a history of repeated episodes of right upper quadrant abdominal pain brought about by the ingestion of fatty foods, and relieved by the administration of anticholinergic medications. The pain is colicky, radiates to the right shoulder and around to the back, and is accompanied by nausea and occasional vomiting. Physical exam is unremarkable. Dx?; Diagnostic test?
A833. Dx: Gallstones, with biliary colic; Diagnostic test: Ultrasound; Tx: Elective cholecystectomy
Q834. A 43 year old obese lady, mother of six children, has severe right upper quadrant abdominal pain that began three days ago. The pain was colicky at first, but has been constant for the past two and a half days. She has tenderness to deep palpation, muscle guarding and rebound in the right upper quadrant. She has temperature spikes to 104 and 105, with chills. Her WBC is; 22,000, with a shift to the left. Her bilirubin is 5 and she has an alkaline phosphatase of 2,000 (about 20 times normal). She has had episodes of colicky pain in the past, brought about by ingestion of fatty food, but they all had been of brief duration and relented spontaneously or with anticholinergic medications. Dx?; Further test?; Management? (2)
A834. Dx: Acute Ascending Cholangitis; Further test: Ultrasound might confirm dilated ducts. Management:; Emergency decompression of the biliary tract... ERCP is the first choice, but PTC (percutaneous transhepatic cholangiogram) is another option
Q835. A white, fat, female, aged 40 and mother of five children gives a history of repeated episodes of right upper quadrant abdominal pain brought about by the ingestions of fatty foods, and relieved by the administration of anticholinergic medications. The pain is colicky, radiates to the right shoulder and around to the back, and is accompanied by nausea and occasional vomiting. This time she had a shaking chill with the colicky pain, and the pain lasted longer than usual. She has mild tenderness to palpation in the epigastrium and right upper quadrant. Laboratory determinations show a bilirubin of 3.5, an alkaline phosphatase 5 times normal and a serum amylase 3 times normal value. Dx?; Diagnostic test?; Management/Tx if she gets better?; If she gets worse?
A835. Dx: She passed a common duct stone and had a transient episode of Cholangitis (the shaking chill, the high phosphatase) and a bit of Biliary Pancreatitis (the high amylase). Diagnostic test: Ultrasound (It will confirm the diagnosis of gallstones); Management: If she continues to get well, elective Cholecystectomy. If she deteriorates, she may have the stone still impacted at the Ampulla of Vater, and may need ERCP and sphincterotomy to extract it
Q836. A 33 year old, alcoholic male, shows up in the E.R. with epigastric and mid-abdominal pain that began 12 hours ago shortly after the ingestion of a large meal. The pain is constant, very severe, and it radiates straight through to the back. He vomited twice early on, but since then has continued to have retching. He has tenderness and some muscle guarding in the upper abdomen, is afebrile and has mild tachycardia. Serum amylase is 1200, and his hematocrit is 52. Dx?; Management? (3)
A836. Dx: Acute edematous pancreatitis. Management: put the pancreas at rest...NPO, NG suction, IV fluids
Q837. A 56 year old alcoholic male is admitted with a clinical picture of acute upper abdominal pain. The pain is constant, radiates straight through to the back, and is extremely severe. He has a serum amylase of 800, WBC of 18,000 blood glucose of 150, serum calcium of 6.5 and a hematocrit of 40. He is given IV fluids and kept NPO with NG suction. By the next morning, his hematocrit has dropped to 30 the serum calcium has remained below 7 in spite of calcium administration, his BUN has gone up to 32 and he has developed metabolic acidosis and a low arterial PO2. Dx?; Management/test?
A837. Dx: Hemorrhagic Pancreatitis (In fact, he is in deep trouble, with at least eight of Ranson’s criteria predicting 80 to 100% mortality); Management/test: Very intensive support will be needed, but the common pathway to death from complication of hemorrhagic pancreatitis frequently is by way of pancreatic abscesses that need to be drained as soon as they appear. Thus serial CT scans will be required.
Q838. A 57 year old alcoholic male is being treated for acute hemorrhagic pancreatis. He was in the intensive care unit for one week, required chest tubes for pleural effusion, and was on a respirator for several days, but eventually improved enough to be transferred to the floor. Two weeks after the onset of the disease he begins to spike fever and to demonstrate leukocytosis. Dx?; Diagnostic test?; Tx?
A838. Dx: Pancreatic abscess; Diagnostic test: CT scan; Tx: Drainage
Q839. A 49 year old alcoholic male presents with ill-defined upper abdominal discomfort and early satiety. On physical exam he has a large epigastric mass that is deep within the abdomen, and actually hard to define. He was discharged from the hospital 5 weeks ago, after successful treatment for acute pancreatitis. Dx?; Diagnostic test?; Tx?
A839. Dx: Pancreatic pseudocyst; Diagnostic test: You could diagnose it on the cheap with an ultrasound, but CT scan is probably the best choice. Tx: It will need to be drained, and the radiologist will do it with CT guidance
Q840. A 55 year old lady presents with vague upper abdominal discomfort, early satiety and a large but ill-defined epigastric mass. Five weeks ago she was involved in an automobile accident where she hit the upper abdomen against the steering wheel. Dx?; Diagnostic test?
A840. Dx: Pancreatic pseudocyst, secondary to trauma; Diagnostic test: CT scan
Q841. A disheveled, malnourished individual shows up in the emergency room requesting medication for pain. He smells of alcohol and complains bitterly of constant epigastric pain, radiating straight through to the back that he says he has had for several years. He has diabetes, steatorrhea and calcifications in the upper abdomen in a plain X-Ray. Dx?; Diagnostic test?; Management? (3)
A841. Dx: Chronic pancreatitis; Diagnostic test: AXR visualizing calcifications; Management: Stop alcohol, replacement of pancreatic enzymes and control of the diabetes; ERCP
Q842. On the first post-operative day after an open cholecystectomy, a patient has a temperature of 101. Dx?; Diagnostic test?; Management? (2 together)
A842. Dx: Atelectasis; Diagnostic test: Chest X-ray; Management:; 1. Incentive Spirometry; 2. Encourage deep breathing and coughing
Q843. On the third post-operative day after an open cholecystectomy, a patient develops a temperature of 101. Dx?; Diagnostic test?; Tx?
A843. Urinary tract infection; Diagnostic Test: Urinalysis and Urinary culture; Tx: appropriate Antibiotics
Q844. On the fourth post-operative day after an open cholecystectomy, a patient develops a temperature of 101. There is tenderness to deep palpation in the calf, particularly when the foot is dorsiflexed. Dx?; Diagnostic test?; Tx?
A844. Dx: Deep Venous Thrombosis; Diagnostic test: Duplex ultrasound; (Doppler flow plus real time B-mode); Tx: Anticoagulation to prevent thrombus propagation
Q845. Seven days after an inguinal hernia repair, a patient returns to the clinic because of fever. The wound is red, hot and tender. Dx?; Management? (3 steps)
A845. Wound infection; Management:; 1. Open the wound; 2. Drain the pus; 3. Pack it and leave it open
Q846. Two weeks after an open cholecystectomy a patient develops fever and leukocytosis. The wound is healing well and does not appear to be infected. Dx?; Where is greatest possibility? (2); Diagnostic test?; Tx?
A846. Dx: Deep Abscess; Places: Subphrenic or Subhepatic; (Had the operation been an appendectomy, pelvic abscess would be the first pick); Diagnostic test: CT scan to find the abscess and to guide the radiologist for the (Tx) Percutaneous Drainage.
Q847. On the fifth post-operative day after a right hemicolectomy for cancer, the dressings covering the midline abdominal incision are found to be soaked with a clear, pinkish, salmon- colored fluid. Dx?; Management? (3 steps)
A847. Dx: Wound dehiscence Management:; 1. Keep the patient in bed; 2. Tape his belly together; 3. Schedule surgery for re-closure of the wound if the patient can take the re-operation. (If too sick, the development of a ventral incisional hernia may have to be accepted now and repaired later)
Q848. Following the discovery of the copious, salmon colored, pinkish clear fluid along the post-op abdominal incision, the patient gets out of bed, or sneezes forcefully, and you are confronted with a bucket-full of small bowel; Dx?; Management? (2 steps)
A848. Dx: Evisceration; Management:; 1. keep the bowel covered and moist with sterile dressings; 2. Rush the patient to the OR for re-closure
Q849. A 62 year old lady was drinking her morning cup of coffee at the same time she was applying her makeup, and she noticed in the mirror that there was a lump in the lower part of her neck, visible when she swallowed. She consult you for this and on physical exam you ascertain that she indeed has a dominant, 2cm mass on the left lobe of her thyroid as well as two smaller masses on the right lobe. They are all soft and she has no palpable lymph nodes in the neck. Diagnostic test?
A849. Diagnostic test: FNA
Q850. A 21 year old college student is found on a routine physical examination to have a single, 2cm nodule in the thyroid gland. The young man had radiation to his head and neck when he was thirteen years old because of persistent acne. His thyroid function tests are normal. Diagnostic test?; Tx?
A850. Diagnostic test: FNA; Tx: Surgical removal (due to radiation leading to cancer)
Q851. A 44 year old lady has a palpable mass in her thyroid gland. She also describes losing weight in spite of a ravenous appetite, palpitations and heat intolerance. She is a thin lady, fidgety and constantly moving, with moist skin and a pulse rate of 105. Dx?; Management/test? (3 steps); Tx?
A851. Dx: A “hot” Adenoma; Management/test:; 1. confirm hyperthyroidism by measuring Free T4; 2. Confirm source of the excessive hormone with Radioactive Iodine Scan; 3. give Beta-blocker; Tx: Surgery (after Beta blocking)
Q852. A 22 year old male has a 2 cm round firm mass in the lateral aspect of his neck, which has been present for four months. Clinically this is assumed to be an enlarged jugular lymph node and it is eventually removed surgically. The pathologist reports that the tissue removed is normal thyroid tissue. Dx?; Diagnostic test?; Tx?
A852. Dx: Follicular Carcinoma of the Thyroid (metastitic); (There is no such thing as “lateral aberrant thyroid”); Diagnostic test: Look for the primary with a Thyroid Scan. Tx: Eventually Surgery
Q853. An automated blood chemistry panel done during the course of a routine medical examination indicates that an asymptomatic patient has a serum calcium of 12.1 in a lab where the upper limit of normal is 9.5. Repeated determinations are consistently between 10.5 and 12.6. Serum phosphorus is low. Dx?; Diagnostic test? (2); Tx?
A853. Dx: Parathyroid Adenoma; Diagnostic test: PTH determination and Sistimibi scan to localize the adenoma; Tx: Surgical excision
Q854. A 32 year old woman is admitted to the psychiatry unit because of wild mood swings. She is found to be hypertensive and diabetic and to have osteoporosis. (she had not been aware of such diagnosis beforehand). It is also ascertained that she has been amenorrheic and shaving for the past couple of years. She has gross centripetal obesity, with moon fascies and Buffalo hump, and thin, bruised extremities. A picture from 3 years ago shows a person of very different, more normal appearance; Dx?; Diagnostic test? (3 steps); Tx?
A854. Dx: Cushings Dz; (The appearance is so typical, that you will probably be given a photograph on the test, with an accompanying brief vignette); Diagnostic test:; 1. AM and PM cortisol determinations; 2. Dexamethasone suppression tests; 3. MRI of the head looking for the pituitary microadenoma; Tx: removed by the trans-nasal, trans-sphenoidal route
Q855. A 28 year old lady has virulent peptic ulcer disease. Extensive medical management including eradication of H.Pylori fails to heal her ulcers. She has several duodenal ulcers in the first and second portions of the duodenum. She has watery diarrhea. Dx?; Diagnostic test? (2 steps); Tx?
A855. Dx: Gastrinoma (Zollinger-Ellison); Diagnostic test:; 1. Serum gastrin; 2. CT scans (or MRI) of the pancreas looking for the tumor; Tx: Surgical excision
Q856. A second year medical student is hospitalized for a neurological work-up for a seizure disorder of recent onset. During one of his convulsions it is determined that his blood sugar is extremely low. Further work-up shows that he has high levels of insulin in the blood with low levels of C- peptide. Dx?; Management?
A856. Dx: Exogenous administration of insulin; (If the C-peptide had been high along with the insulin level, the diagnosis would have been insulinoma); Management: Psychiatric evaluation and counseling; (He is faking the disease. If it had been insulinoma, CT scan or MRI looking for the tumor in the pancreas, to be subsequently removed surgically)
Q857. A 48 year old lady has had severe, migratory necrolytic dermatitis for several years, unresponsive to all kinds of “ herbs and unguents”. She is thin, has mild stomatitis and mild diabetes mellitus. Dx?; Diagnostic test? (2); Tx?; If this Tx is not possible, what can be done? (2)
A857. Dx: Glucagonoma; Diagnostic test:; 1. Determine Glucagon levels; 2. CT scan or MRI looking for the tumor in the pancreas. Tx: Surgery will follow If inoperable:; 1. Somatostatin can help symptomatically; 2. Streptozocin is the indicated chemotherapeutic agent
Q858. A 45 year old lady comes to your office for a “regular checkup”. On repeated determinations you confirm the fact that she is hypertensive. When she was in your office three years ago, her blood pressure was normal. Laboratory studies at this time show a serum sodium of 144 mEq/L, a serum bicarbonate of 28 mEq/L, and a serum potassium concentration of 2.1 mEq/L. The lady is taking no medications of any kind. Dx? (2 possible); Diagnostic test? (2 steps); Tx for each?
A858. Dx: Hyperaldosteronism or Adrenal Adenoma; Diagnostic test:; 1. Aldosterone and renin levels. 2. If confirmatory (aldo high, renin low) proceed with determinations lying down and sitting up, to differentiate Hyperplasia (not surgical) from Adenoma (surgical). Hyperplasia Tx: Aldactone; Adenoma Tx: Imaging studies (CT scan or MRI) and Surgery
Q859. A thin, hyperactive 38 year old lady is frustrated by the inability of her physicians to help her. She has episodes of severe pounding headache, with palpitations, profuse perspiration and pallor, but by the time she gets to her doctor ’s office she checks out normal in every respect. Dx?; Diagnostic test? (2 steps); Medication before surgery?
A859. Dx: Pheochromocytoma; Diagnostic test:; 1. 24hr urinary determination of metanephrine and VMA (Vanillylmandelic acid); 2. CT scan of adrenal glands; Meds before surgery: Alpha-blockers
Q860. A 17 year old man is found to have a blood pressure of 190/115. This is checked repeatedly in both arms and it is always found to be elevated, but when checked in the legs it is found to be normal. Dx?; Diagnostic test? (2 steps); Tx?
A860. Dx: Coarctation of the Aorta; Diagnostic test:; 1. Chest X-Ray, looking for scalloping of the ribs; 2. Aortogram; Tx: Surgery
Q861. A 23 year old lady has had severe hypertension for two years, and she does not respond well to the usual medical treatment for that condition. A bruit can be faintly heard over her upper abdomen. Dx?; Diagnostic test?; Tx? (2 possible)
A861. Dx: Renovascular Hypertension due to Fibromuscular Dysplasia; Diagnostic test: Arteriogram will precede (Tx) Surgical correction or Balloon dilatation
Q862. A 72 year old man with multiple manifestations of arteriosclerotic occlusive disease has hypertension of relatively recent onset, and is refractory to the usual medical therapy. He has a faint bruit over the upper abdomen. Dx?
A862. Dx: Renovascular Hypertension due to arteriosclerotic plaque at the origin of the Renal Artery…or arteries; (this is usually bilateral)
Q863. Within eight hours after birth, it is noted that a baby has excessive salivation. A small, soft nasogastric tube is inserted and the baby is taken to X-Ray to have a “babygram” done. The film shows the tube coiled back upon itself in the upper chest. There is air in the gastrointestinal tract. Dx?; Management?; Tx?
A863. Dx: Tracheo-esophageal fistula; (the most common type with proximal blind esophageal pouch and distal TE fistula); Management:; 1. Rule-out the associated anomalies (“VACTER”: vertebral, anal, cardiac, TE and renal/radial). The vertebral and radial will be seen in the same X-ray you already took, you need Echo for the heart, Sonogram for the kidneys and Physical Exam for the anus. Tx: Surgical repair
Q864. A newborn baby is found on physical exam to have an imperforate anus. Management? (2 steps)
A864. Management:; 1. This is part of the “VACTER” (vertebral, anal, cardiac, TE and renal/radial) group, so look for the others as mentioned. 2. For the imperforate anus, look for a fistula nearby (to the vagina in little girls, to the perineum in little boys), which will help determine the level of the blind pouch and the timing and type of surgery (primary repair versus colostomy and repair later).
Q865. A newborn baby is noted to be tachypneic, cyanotic and grunting. The abdomen is scaphoid and there are bowel sounds heard over the left chest. An X-Ray confirms that there is bowel in the left thorax. Shortly thereafter, the baby develops significant hypoxia and acidosis; Dx?; Management? (4 together); Tx?
A865. Dx: Congenital Diaphragmatic Hernia; Management:; 1. keep the kid alive with endotracheal intubation; 2. Hyperventilation (careful not to blow up the other lung); 3. Sedation; 4. NG suction; (Tx: The main problem is the hypoplastic lung. It is better to wait 36 to 48 hours to do Surgery to allow transition from fetal circulation to newborn circulation)
Q866. At the time of birth it is noted that a child has a large abdominal wall defect to the right of the umbilicus. There is a normal cord, but protruding from the defect there is a matted mass of angry looking, edematous bowel loops. Dx?; Tx?
A866. Dx: Gastroschisis; Tx: Pediatric Surgeon must get the bowel back into the belly; they may need to use a silicon “silo” to gradually close the abdominal wall defect.
Q867. A newborn baby is noted to have a shiny, thin, membranous sac at the base of the umbilical cord. Inside the sac one can see part of the liver, and loops of normal looking bowel. Dx?; Management?; Tx?
A867. Dx: Omphalocele; Management: Look for other congenital defects. These kids can have a host of other congenital defects; Tx: Repair is performed by a Pediatric surgeon
Q868. A newborn is noted to have a moist medallion of mucosae occupying the lower abdominal wall, above the pubis and below the umbilicus. It is clear that urine is constantly bathing this congential anomaly. Dx?; what is important regarding this repair?
A868. Dx: Exstrophy of the urinary bladder; Important: Repair must be done within the first 48 hours, or it will not have a good chance to succeed. It takes time to arrange for transfer of a newborn baby to a distant city that specializes in this repair. If a day or two are wasted before arrangements are made, it will be too late
Q869. Half an hour after the first feed, a baby vomits greenish fluid. The mother had polyhydramnios and the baby has Down’s syndrome. X-Ray shows a “double bubble sign”: a large air fluid level in the stomach, and smaller one in the first portion of the duodenum. There is no gas in the rest of the bowel. Dx? (2 possible); Management?; Tx?
A869. Dx: Duodenal Atresia or Annular Pancreas; (innocent vomit is clear-whitish. Green vomiting in the newborn is bad news. It means something serious); Management: Look for other congenital anomalies first; Tx: Emergency Surgery
Q870. Half an hour after the first feed, a baby vomits greenish fluid. X-Ray shows a "double bubble sign”: a large air fluid level in the stomach, and a smaller one in the first portion of the duodenum. There is air in the distal bowel, beyond the duodenum, in loops that are not distended. Dx? (3 possibilities); Diagnostic test?
A870. Dx:; 1. Incomplete obstruction from duodenal stenosis,; 2. Annular Pancreas,; 3. Malrotation of bowel; Diagnostic test: Contrast enema; (and if not diagnostic order a water-soluble gastrographin Upper GI study)
Q871. A newborn baby has repeated green vomiting during the first day of life, and does not pass any meconium. Except for abdominal distention, the baby is otherwise normal. X-Ray shows multiple air fluid levels and distended loops of bowel. Dx?; Cause?
A871. Dx: Intestinal atresia; Cause: Vascular accident in utero; (thus there are no other congenital anomalies to look for, but there may be multiple points of atresia)
Q872. A very premature baby develops feeding intolerance, abdominal distention and a rapidly dropping platelet count. The baby is four days old, and was treated with indomethacin for a patent ductus. Dx?; Management? (3 together); Reasons for surgical Tx? (3)
A872. Dx: Necrotizing Enterocolitis; Management:; 1. Stop all feedings; 2. Broad spectrum antibiotics; 3. IV fluids/nutrition; Tx: Surgical intervention if they develop abdominal wall erythema, air in the biliary tree or pneumoperitoneum
Q873. A three day old, full term baby is brought in because of feeding intolerance and bilious vomiting. X-Ray shows multiple dilated loops of small bowel and a “ground glass” appearance in the lower abdomen. The mother has cystic fibrosis. Dx?; Management? (3 steps)
A873. Dx: Meconium Ileus; Management:; 1. Gastrografin enema may be both diagnostic and therapeutic, so it is the obvious first choice. 2. If unsuccessful, surgery may be needed. 3. The kid has cystic fibrosis, and management of the other manifestations of the disease will also be needed
Q874. A three week old baby has had “trouble feeding” and it is not quite growing well. He now has bilious vomiting and is brought in for evaluation. X-Ray shows a classical “double bubble”, along with normal looking gas pattern in the rest of the bowel. Dx?; Diagnostic test?; Tx?
A874. Dx: Malrotation of the bowel (not all will show up on day one); Diagnostic test: Contrast enema to verify the malrotation; Tx: Emergency surgery
Q875. A 3 week old first-born, full term baby boy began to vomit three days ago. The vomiting is projectile, has no bile in it, follows each feeding and the baby is hungry and eager to eat again after he vomits. He looks somewhat dehydrated and has visible gastric peristaltic waves and a palpable “olive size” mass in the right upper quadrant. Dx?; Management? (2 steps); Tx?
A875. Dx: Hypertrophic Pyloric Stenosis; Management:; 1. Check electrolytes: hypokalemic, hypochloremic metabolic alkalosis may have developed (correct it). 2. Rehydrate; Tx: Ramsted Pyloromyotomy
Q876. An 8 week old baby is brought in because of persistent, progressively increasing jaundice. The bilirubin is significantly elevated and about two thirds of it is conjugated, direct bilirubin. Ultrasound rules out extrahepatic masses, serology is negative for hepatitis and sweat test is normal. Dx?; Diagnostic test? (2); Tx?
A876. Dx: Biliary Atresia; Diagnostic test:; 1. HIDA scan; 2. Percutaneous Liver Biopsy; Tx: Exploratory laparotomy
Q877. A two month old baby boy is brought in because of chronic constipation. The kid has abdominal distention, and plain X- Rays show gas in dilated loops of bowel throughout the abdomen. Rectal exam is followed by expulsion of stool and flatus, with remarkable improvement of the distention. Dx?; Diagnostic test? (2); Tx?
A877. Dx: Hirschsprungs’ disease (aganglionic megacolon); Diagnostic test:; 1. Barium enema will define the normal-looking aganglionic distal colon and the abnormal-looking thickness; 2. Biopsy of the rectal mucosa; Tx: Surgical excision of aganglionic segment
Q878. A 9 month old, chubby, healthy looking little boy has episodes of colicky abdominal pain that make him double up and squat. The pain lasts for about one minute, and the kid looks perfectly happy and normal until he gets another colick. Physical exam shows a vague mass on the right side of the abdomen, an “empty” right lower quadrant and currant jelly stools. Dx?; Management?; Tx?
A878. Dx: Intussusception; Management: Barium enema is both diagnostic and therapeutic in most cases. Tx: If reduction is not achieved radiologically, exploratory laparotomy and manual reduction will be needed
Q879. A one year old baby is referred to the University Hospital for treatment of a subdural hematoma. In the admission examination it is noted that the baby has retinal hemorrhages. Dx?
A879. Child Abuse
Q880. A one year old child is brought in with second degree burns of both buttocks. The stepfather relates that the child fell into a hot tub. Dx?
A880. Child Abuse
Q881. A three year old girl is brought in for treatment of a fractured humerus. The mother relates that the girl fell from her crib. X-Rays show evidence of other older fractures at various stages of healing in different bones. Dx?
A881. Child Abuse
Q882. A 4 year old boy passes a large bloody bowel movement. Dx?; Diagnostic test?; Tx?
A882. Dx: Meckel’s diverticulum; Diagnostic test: Radioisotope scan looking for gastric mucosa in the lower abdomen; Tx: Surgical excision
Q883. A 15 year old girl has a round, 1cm cystic mass in the midline of her neck at the level of the hyoid bone. When the mass is palpated at the same time that the tongue is pulled, there seems to be a connection between the two. The mass has been present for at least 10 years, but only recently bothered the patient because it got infected and drained some pus. Dx?; Tx?
A883. Dx: Thyroglossal Duct Cyst; Tx: Sistrunk operation; (removal of the mass and the track to the base of the tongue, along with the medial segment of the hyoid bone).
Q884. An 18 year old woman has a 4cm fluctuant round mass on the side of her neck, just beneath and in front of the sternomastoid. She reports that is has been there at least 10 years, although she thinks that it has become somewhat larger in the last year or two. A CT scan shows the mass to be cystic. Dx?; Tx?
A884. Dx: Branchial Cleft Cyst; Tx: Elective surgical removal
Q885. A 6 year old child has a mushy, fluid filled mass at the base of the neck, that has been noted for several years. The mass is about 6 cm. in diameter, occupies most of the supraclavicular area and seems by physical exam to go deeper into the neck and chest. Dx?; Diagnostic test?; Tx?
A885. Dx: Cystic hygroma; Diagnostic test: CT scan to see how deep this thing goes. (They can extend down into the chest and mediastinum); Tx: Surgical removal will eventually be done
Q886. A 22 year old lady notices an enlarged lymph node in her neck. The node is in the jugular chain, measures about 1.5cm, is not tender, and was discovered by the patient yesterday. The rest of the history and physical exam are unremarkable. Management?
A886. Management: Reschedule an appointment for 3 weeks to see its progress; (If the node has gone away by then, it was inflammatory and nothing further is needed. If it’s still there, it could be neoplastic and something needs to be done)
Q887. A 22 year old lady seeks help regarding an enlarged lymph node in her neck. The node is in the jugular chain, measures about 2cm, is firm, not tender, and was discovered by the patient six weeks ago. There is a history of low grade fever and night sweats for the past three weeks. Physical examination reveals enlarged lymph nodes in both axillas and in the left groin. Dx?; Diagnostic test?
A887. Dx: Lymphoma (most likely); Disgnostic test: Tissue diagnosis will be needed. You can start with FNA of the available nodes, but eventual node biopsy will be needed to establish not only the diagnosis but also the type of lymphoma
Q888. A 72 year old man has 4cm hard mass in the left supraclavicular area. The mass is movable, non tender and has been present for three months. The patient has had a 20 pound weight loss in the past two months, but is otherwise asymptomatic. Dx?; Management? (2)
A888. Dx: Malignant metastasis to a supraclavicular node from a primary tumor below the neck. Management:; 1. Look for the obvious primary tumors: lung, stomach, colon, pancreas, and kidney; 2. The node itself will eventually be Biopsied
Q889. A 69 year old man who smokes and drinks and has rotten teeth has a hard, fixed, 4cm mass in his neck. The mass is just medial and in front of the sternomastoid muscle, at the level of the upper notch of the Thyroid cartilage. It has been there for at least six months, and it is growing. Dx?; Diagnostic test?
A889. Dx: Metastatic squamous cell carcinoma to a jugular chain node, from a primary in the mucosa of the head and neck (oro-pharyngeal-laryngeal territory); Diagnostic test: Triple Endoscopy; (examination under anesthesia of the mouth, pharynx, larynx, esophagus and tracheobronchial tree); (Don’t biopsy the node! FNA is OK if Triple endoscopy not available)
Q890. A 69 year old man who smokes and drinks and has rotten teeth has hoarseness that has persisted for six weeks in spite of antibiotic therapy; Dx?; Diagnostic test?
A890. Dx: Squamous cell carcinoma of the mucosa of the head and neck; Diagnostic test: Triple endoscopy to find and biopsy the primary tumor
Q891. A 69 year old man who smokes and drinks and has rotten teeth has a painless ulcer in the floor of the mouth that has been present for 6 weeks and has not healed. Dx?; Diagnostic test?
A891. Squamous cell carcinoma of the mucosa of the head and neck; Diagnostic test: Triple endoscopy to find and biopsy the primary tumor
Q892. A 69 year old man who smokes and drinks and has rotten teeth has unilateral ear ache that has not gone away in 6 weeks. Physical examination shows serious otitis media on that side, but not on the other. Dx?; Diagnostic test?
A892. Dx: Squamous cell carcinoma of the mucosa of the head and neck; Diagnostic test: Triple endoscopy to find and biopsy the primary tumor
Q893. A 52 year old man complains of hearing loss. When tested he is found to have unilateral sensory hearing loss on one side only. He hoes not engage in any activity (such as sport shooting) that would subject that ear to noise that spares the other side. Dx?; Diagnostic test?
A893. Dx: Acoustic Nerve Neuroma; (Unilateral versions of common ENT problems in the adult suggest malignancy. Note that if the hearing loss had been conductive, a Cerumen Plug would be the obvious first diagnosis); Diagnostic test: MRI looking for the tumor
Q894. 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 three months. It affects both the forehead as well as the lower face. Dx?; Diagnostic test?
A894. Dx: Gradual, unilateral nerve paralysis suggests a neoplastic process; Diagnostic test: Gadolinium enhanced MRI
Q895. A 45 year old man presents with a 2cm firm mass in front of the left ear, which has been present for four months. The mass is deep to the skin and it is painless. The patient has normal function of the facial nerve. Dx?; Management?
A895. Dx: Pleomorphic adenoma (mixed tumor) of the parotid gland; Management: Referral to a head and neck surgeon for formal superficial parotidectomy; (FNA is appropriate, but the point of the question will be to bring out the fact that parotid masses are never biopsied in the office or under local anesthesia)
Q896. A 65 year old man present with a 4cm hard mass in front of the left ear, which has been present for six months. The mass is deep to the skin and it is fixed. He has constant pain in the area, and for the past two months has had gradual progression of left facial nerve paralysis. He has rock-hard lymph nodes in the left neck. Dx?; Management?
A896. Dx: Cancer of the parotid gland; Management: Referral to a head and neck surgeon for formal superficial parotidectomy; (Amateurs should not mess with parotid)
Q897. A two year old boy has unilateral ear ache. Dx?
A897. Dx: Unilateral versions of common bilateral ENT conditions in toddlers suggest Foreign Body
Q898. A two year old has unilateral foul smelling purulent rhinorrhea. Dx?
A898. Dx: Unilateral versions of common bilateral ENT conditions in toddlers suggest foreign body
Q899. A two year old has unilateral wheezing and the lung on that side looks darker on X-Rays (more air) than the other side. Dx?
A899. Dx: Unilateral versions of common bilateral ENT conditions in toddlers suggest foreign body
Q900. A 4 year old child is brought by his mother to the emergency room because “she is sure that he must have swallowed a marble”. The kid was indeed playing with marbles and apparently completely healthy when he was put to bed, but four hours later he had developed inspiratory stridor, a fever of 103 and obvious respiratory distress. The kid is sitting up, leaning forward, drooling at the mouth and looking very sick indeed. Dx?; Diagnostic test?; Management? (3); what if bradycardia develops?
A900. Dx: Acute Epiglotitis; Diagnostic test: Lateral X-ray of the neck; Management: A real emergency where expert help is needed!; 1. Ready to use bag and mask if needed. 2. OR for Nasotracheal Intubation. 3. Start IV antibiotics along the way for H.Pylori; Bradychardia develops: Atropine will help, but hypoxia is the problem.