Ksurgery 900-1000

Front 1

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?

Back 1

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.

Front 2

Q901. A 45 year old lady with a history of a recent tooth infection shows up with a huge, hot, red, tender, fluctuant mass occupying the left lower side of her face and upper neck, including the underside of the mouth. The mass pushes up the floor of the mouth on that side. She is febrile. Dx?; Tx? (2 together)

Back 2

A901. Dx: Ludwigs’ Angina (An abscess of the floor of the mouth); Tx:; 1. Tracheostomy; 2. Incision & Drainage of the abscess

Front 3

Q902. A 29 year old lady calls your office at 10 AM with the history that she woke up that morning with one side of her face paralyzed. Dx?; Management?

Back 3

A902. Dx: Bell’s palsy; Management: Immediate anti-viral medication; (the process is idiopathic and will resolve spontaneously in most cases)

Front 4

Q903. A patient with multiple trauma from a car accident is being attended to in the emergency room. As multiple invasive things are done to him, he repeatedly grimaces with pain. The next day it is noted that he has a facial nerve paralysis on one side. Dx?

Back 4

A903. Dx: Paralysis from Edema; (Trauma to the temporal bone can certainly transect the facial nerve, but when that happens the nerve is paralyzed right there and then. Nothing needs to be done...it will correct itself)

Front 5

Q904. Your office receives a phone call from Mrs. Rodriguez. You know this middle aged lady very well because you have repeatedly treated her in the past for episodes of sinusitis. In fact, six days ago you started her on decongestants and oral antibiotics for what you diagnosed as frontal and ethmoid sinusitis. Now she tells you over the phone that ever since she woke up this morning, she has been seeing double. Dx? (2 possible); Management? (3 steps); Dx test?

Back 5

A904. Dx: Cavernous Sinus Thrombosis or Orbital Cellulitis; Management: This is a real emergency (fact that is most likely questioned). 1. Immediate Hospitalization,; 2. high dose IV Antibiotic treatment; 3. Surgical Drainage of the paranasal sinuses or the orbit. Dx Test: CT scan (which will also be needed to guide the surgery)

Front 6

Q905. A 10 year old girl has epistaxis. Her mother says that she picks her nose all the time. Dx?; Tx?

Back 6

A905. Dx: Bleeding from the Anterior part of the septum; Tx: Phenylephrine spray and local pressure

Front 7

Q906. An 18 year old boy has epistaxis. The patient denies picking his nose. No source of anterior bleeding can be seen by physical examination. Dx? (2 possible)

Back 7

A906. Dx:; 1. Septal perforation from cocaine abuse; 2. Posterior juvenile Nasopharyngeal Angiofibroma

Front 8

Q907. A 72, hypertensive male, on aspirin for arthritis, has a copious nosebleed. His blood pressure is 220/105 when seen in the E.R. He says he began swallowing blood before it began to come out through the front of his nose. Dx?; Management? (2)

Back 8

A907. Dx: Epistaxis secondary to hypertension; Management:; 1. Lower BP with Medication; 2. Involve ENT (These are serious problems that can end up with death)

Front 9

Q908. A 57 year old man seeks help for “dizziness”. On further Questioning he explains that the room spins around him; Dx?; Management?

Back 9

A908. Dx: Vestibular Apparatus; Management: Symptomatic treatment (meclizine, phenergan, diazepam), or an ENT workup

Front 10

Q909. During a school physical exam, a 12 year old girl is found to have a heart murmur. She is referred for further evaluation. An alert cardiology fellow recognized that she indeed has a pulmonary flow systolic murmur, but he also notices that she has a fixed split second heart sound. A history of frequent colds and upper respiratory infections is elicited. Dx?; Diagnostic test?; Tx?

Back 10

A909. Dx: Atrial septal defect; Diagnostic test: Echocardiography; Tx: Surgical closure of the defect

Front 11

Q910. A three month old boy is hospitalized for ‘failure to thrive”. He has a loud, pansystolic heart murmur best heard at the left sternal border. Chest X-Ray shows increased pulmonary vascular markings. Dx?; Diagnostic test?; Tx?

Back 11

A910. Dx: Ventricular septal defect; Diagnostic test: Echocardiography; Tx: surgical correction

Front 12

Q911. A three day old premature baby has trouble feeding and pulmonary congestion. Physical exam shows bounding peripheral pulses and a continuous, machinery-like heart murmur. Dx?; Diagnostic test?; Tx? (2 possible)

Back 12

A911. Patent Ductus Arteriosus; Diagnostic test: Echocardiography; Tx:; 1. Surgical closure; 2. Indomethacin

Front 13

Q912. A patient known to have a congenital heart defect requires extensive dental work. Management?

Back 13

A912. Management: antibiotic prophylaxis for subacute bacterial endocarditis

Front 14

Q913. A 6 year old boy is brought to the U.S. by his new adoptive parents, from an orphanage in Eastern Europe. The kid is small for his age, and has a bluish hue in the lips and tips of his fingers. He has clubbing and spells of cyanosis relieved with squatting. He has a systolic ejection murmur in the left third intercostal space. Chest X-Ray shows a small heart, and diminished pulmonary vascular markings. EKG shows right ventricular hypertrophy. Dx?; Diagnostic test?

Back 14

A913. Dx: Tetralogy of Fallot; Diagnostic test: Echocardiogram

Front 15

Q914. A 72 year old man has a history of angina and exertional syncopal episodes. He has a harsh midsystolic heart murmur best heard at the second intercostal space and along the left sternal border. Dx?; Diagnostic test?; Definitive Tx?; When is it indicated? (2)

Back 15

A914. Dx: Aortic Stenosis; Diagnostic test: Echocardiogram; Tx: Surgical Valvular replacement; Surgery indications:; 1. gradient of more than 50 mm.Hg. 2. indication of CHF, angina or syncope

Front 16

Q915. A 72 year old man has been known for years to have a wide pulse pressure and a blowing, high-pitched, diastolic heart murmur best heard at the second intercostal space and along the left lower sternal border with the patient in full expiration. He has had periodic echocardiograms, and in the most recent one there is evidence of beginning left ventricular dilatation. Heart Dx?; Diagnostic test?; Next step?

Back 16

A915. Dx: Chronic Aortic Insufficiency; Diagnostic test: Echocardiogram; Next step: Aortic valve replacement

Front 17

Q916. A 26 year old drug-addicted man develops congestive heart failure over a short period of a few days. He has a loud, diastolic murmur at the right, second intercostal space. A physical exam done a few weeks ago, when he had attempted to enroll in a detoxification program was completely normal. Heart Dx?; Management/Tx? (2 together)

Back 17

A916. Dx: Acute Aortic Insufficiency due to Endocarditis; Management:; 1. Emergency valve replacement; 2. Antibiotics for a long time

Front 18

Q917. A 35 year old lady has dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, cough and hemoptysis. She has had these progressive symptoms for about 5 years. She looks thin and cachectic, has atrial fibrillation and a low- pitched, rumbling diastolic apical heart murmur. At age 15 she had rheumatic fever. Heart disorder Dx?; Diagnostic test?; Tx?

Back 18

A917. Dx: Mitral stenosis; Diagnostic test: Echocardiogram; Tx: Eventually surgical mitral valve repair

Front 19

Q918. A 55 year old lady has been known for years to have mitral valve prolapse. She now has developed exertional dyspnea, orthopnea and atrial fibrillation. She has an apical, high pitched, holosystolic heart murmur that radiates to the axilla and back. Dx?; Diagnostic test?; Tx? (2 possible)

Back 19

A918. Dx: Mitral Regurgitation; Diagnostic test: Echocardiogram; Tx: eventually surgical repair of the valve (Annuloplasty) or possibly valve replacement

Front 20

Q919. A 55 year old man has progressive, unstable, disabling angina that does not respond to medical management. His father and two older brothers died of heart attacks before the age of 50. The patient stopped smoking 20 years ago, but still has a sedentary life style, is a bit overweight, has type two diabetes mellitus and has high cholesterol. Management?

Back 20

A919. It’s a heart attack waiting to happen... Management: Cardiac Catheterization; (to see if he is a suitable candidate for coronary revascularization)

Front 21

Q920. On a routine pre-employment physical examination, a chest X-Ray is done on a 45 year old chronic smoker. A “coin lesion” is found in the upper lobe of the right lung. Dx?; Next step?

Back 21

A920. Dx: Cancer of the lung; Next step: Find and older chest X-Ray if one is available (from one or more years ago). If an older X-Ray has the same unchanged lesion, it is not likely cancer. No further work up is needed now, but the lesion should be followed with periodic X-Rays.

Front 22

Q921. A 54 year old man with a 40 pack/year history of smoking gets a chest X-Ray because of persistent cough. A peripheral, 2cm “coin lesion” is found in the right lung. A chest X-Ray taken two years ago had been normal. CT scan shows no calcifications in the mass and no enlarged peribronchial or peritracheal lymph nodes. The man has good pulmonary function and is otherwise in good health. Dx?; Diagnostic test?; If first Dx test does not work, what are 2 others (in order)?

Back 22

A921. Dx: Cancer of the lung; Diagnostic test:; 1. Start with Bronchoscopy and washings,; 2. if unrewarding go to Percutaneous Needle Biopsy; 3. if still unsuccessful go to Open Biopsy (Thoracotomy and Wedge Resection)

Front 23

Q922. A 72 year old chronic smoker with severe COPD is found to have a central, hilar mass on chest X-Ray. Bronchoscopy and biopsy establish a diagnosis of squamous cell carcinoma of the lung. His FEV1 is 1100, and a ventilation/perfusion scan shows that 60% of his pulmonary functions comes from the affected lung. Management/Tx?

Back 23

A922. Management: It takes an FEV1 of at least 800 to survive surgery and not be a pulmonary cripple afterwards. If this fellow got a pneumonectomy (which he would need for a central tumor) he would be left with an FEV1 of 440. No way... Don’t do any more tests. He is not a surgical candidate. Tx: pursue Chemotherapy and Radiation

Front 24

Q923. A 62 year old chronic smoker has an episode of hemoptysis. Chest X-ray shows a central hilar mass. Bronchoscopy and biopsy establish a diagnosis of squamous cell carcinoma of the lung. His FEV1 is 2200, and a ventilation/perfusion scan shows that 30% of his pulmonary function comes from the affected lung. Diagnostic test?; Tx?

Back 24

A923. Diagnostic test: CT scan and Mediastinoscopy; (to ascertain if surgery has a decent chance to cure him); Tx: Pneumonectomy (can tolerate it due to high FEV1)

Front 25

Q924. A 33 year old lady is undergoing a diagnostic work-up because she appears to have Cushing’s syndrome. Chest X- Ray shows a central, 3cm round mass on the right lung. Bronchoscopy and biopsy confirm a diagnosis of small cell carcinoma of the lung. Management for cancer?

Back 25

A924. Management: Radiation and chemotherapy. (Small cell lung cancer is not treated with surgery, and thus we have no need to determine FEV1 or nodal status)

Front 26

Q925. A 54 year old right handed laborer notices coldness and tingling in his left hand as well as pain in the forearm when he does strenuous work. What really concerned him, though, is that in the last few episodes he also experienced transitory vertigo, blurred vision and difficulty articulating his speech. Angiogram demonstrates retrograde flow through the vertebral artery. Dx?; Management/Tx?

Back 26

A925. Dx: Subclavian Steal syndrome; (A combination of “claudication of the arm” with posterior brain neurological symptoms is classical for this); Management: Angiographic study (If you had been given the vignette without it), then Vascular surgery

Front 27

Q926. A 62 year old man is found on physical exam to have a 6cm pulsatile mass deep in the abdomen, between the xiphoid and the umbilicus; Dx?; Tx?

Back 27

A926. Dx: Abdominal Aortic Aneurysm; Tx: Elective surgical repair

Front 28

Q927. A 62 year old man has vague, poorly described epigastric and upper back discomfort. He has been found on physical exam to have a 6cm pulsatile mass deep in the abdomen, between the xiphoid and the umbilicus. The mass is tender to palpation. Dx?; Management?

Back 28

A927. Dx: Abdominal Aortic Aneurysm that is beginning to leak. Management: Get a consultation with the vascular surgeons today

Front 29

Q928. A 68 year old man is brought to the ER with excruciating back pain that began suddenly 45 minutes ago. He is diaphoretic and has a systolic blood pressure of 90. There is an 8cm pulsatile mass palpable deep in his abdomen, between the xiphoid and the umbilicus. Dx?; Tx?

Back 29

A928. Dx: Abdominal Aortic Aneurysm, rupturing right now. Tx: Emergency surgery

Front 30

Q929. A retired businessman has claudication when walking more than 15 blocks. Management?

Back 30

A929. Management: If he is smoking he should quit; otherwise he needs nothing; (Vascular surgery, or angioplasty and stenting are palliative procedures. They do not cure arteriosclerotic occlusive disease. Claudication has an unpredictable course, thus there is no advantage to an “early operation”)

Front 31

Q930. A 56 year old postman describes severe pain in his right calf when he walks two or three blocks. The pain is relieved by resting 10 or 15 minutes, but recurs if he walks again the same distance. He can not do his job this way, and he does not qualify yet for retirement, so he is most anxious to have this problem resolved. He does not smoke. Diagnostic test? (2 steps); Tx?

Back 31

A930. Diagnostic test:; 1. Start with Doppler studies; 2. If he has significant gradient, Arteriogram comes next; Tx: Bypass surgery or stenting

Front 32

Q931. A patient consults you because he “can not sleep”. On Questioning it turns out that he has pain in the right calf, which keeps him from falling asleep. He relates that the pain goes away if he sits by the side of the bed and dangles the leg. His wife adds that she has watched him do that, and she has noticed that the leg which was very pale when he was lying down becomes deep purple several minutes after he is sitting up. On physical exam the skin of that leg is shiny, there is no hair and there are no palpable peripheral pulses. Dx?; Diagnostic test? (2 steps); Tx?

Back 32

A931. Dx: Claudication; Dx test:; 1. Start with Doppler studies; 2. If he has significant gradient, Arteriogram comes next; Tx: Bypass surgery or stenting

Front 33

Q932. A 45 year old man shows up in the ER with a pale, cold, pulseless, paresthetic, painful and paralytic lower extremity. The process began suddenly two hours ago. Physical exam shows no pulses anywhere in that lower extremity. Pulse at the wrist is 95 per minute, grossly irregular. Dx?; Tx?

Back 33

A932. Dx: Embolization by the broken-off tail of a clot from the left atrium; Tx: Emergency surgery with use of Fogarty catheters to retrieve the clot

Front 34

Q933. A 74 year old man has sudden onset of extremely severe, tearing chest pain that radiates to the back and migrates down shortly after it’s onset. His blood pressure is 220/100, he has unequal pulses in the upper extremities and he has a wide mediastinum on chest X-Ray. Electrocardiogram and cardiac enzymes show that he does not have a myocardial infarction; Dx?; Management with high BP? (2); Normal BP?; Tx? (depends on area; 2 possible)

Back 34

A933. Dx: Dissecting aneurysm of the thoracic Aorta; Management:; 1. if high BP, beta-blockers or IV nitrates to lower BP (b/c forces that dissected the vessel plus the force of the dye injection could further shear the aorta); 2. Arteriogram (first if BP is normal); Tx:; Ascending Aorta = emergency surgery; Descending Aorta = intensive therapy (in the ICU) for the hypertension will be the preferable option.

Front 35

Q934. A 62 year old right handed man has transient episodes of weakness in the right hand, blurred vision, and difficulty expressing himself. There is not associated headache, the episodes last about 5 or 10 minutes at the most, and they resolve spontaneously. Fundoscopic examination reveals highly refractile crystals in the left retinal artery. Dx?; Diagnostic test?; Tx?

Back 35

A934. Dx: Transient Ischemic Attacks; in the territory of the left carotid artery (probably an ulcerated plaque at the left carotid bifurcation); Diagnostic test: Angiogram; Treatment: Carotid endarterectomy

Front 36

Q935. A 61 year old man presents with a one year history of episodes of vertigo, diplopia, blurred vision, dysarthria and instability of gait. The episodes last several minutes, have no associated headache and leave no neurological sequela. Dx?; Diagnostic test?; Tx?

Back 36

A935. Dx: Transient Ischemic Attacks (but now the vertebrals may be involved); Diagnostic test: Arteriogram that examines all the arteries going to the brain (i.e. an aortic arch study); Tx: Vascular surgery will follow

Front 37

Q936. A 60 year old diabetic male presents with abrupt onset of right third nerve paralysis and contralateral hemiparesis. There was no associated headache. The patient is alert, but has the neurological deficits mentioned. Dx?; Diagnostic test?

Back 37

A936. Dx: Stroke; (Neurological catastrophes that begin suddenly and have no associated headache are vascular occlusive); Diagnostic test: CT scan (Vascular surgery in the neck is designed to prevent strokes, not to treat them once they happen)

Front 38

Q937. A 64 year old black man complains of a very severe headache of sudden onset and then lapses into a coma. Past medical history reveals untreated hypertension and examination reveals a stuporous man with profound weakness in the left extremities. Dx?; Diagnostic test?; Tx?

Back 38

A937. Dx: Vascular Hemorrhagic stroke; (Neurological catastrophes of sudden onset with severe headache); Diagnostic test: CT scan; Tx: Supportive with eventual rehabilitation efforts if he survives.

Front 39

Q938. A 39 year old lady presents to the ER with a history of a severe headache of sudden onset that she says is different and worse than any headache she has ever had before. She is given pain medication and sent home. She improves over the next few days, but ten days after the initial visit she again gets a sudden, severe and singular diffuse headache and she returns to the ER. This time she has some nuchal rigidity on physical exam. Dx?; Diagnostic test? (2 steps); Tx?

Back 39

A938. Dx: Subarachnoid bleeding from an intracranial aneurysm. (the nuchal rigidity betrays the presence of blood in the subarachnoid space); Diagnostic test:; 1. CT scan to find bleeder; 2. Angiograms will eventually follow, in preparation for (Tx) Surgery to clip the aneurysm

Front 40

Q939. A 31 year old nursing student developed persistent headaches that began approximately 4 months ago, have been gradually increasing in intensity and are worse in the mornings. For the past three weeks, she has been having projectile vomiting. Thinking that she may need new glasses, she seeks help from her optometrist, who discovers that she has bilateral papilledema. Dx?; Diagnostic test?; Management until surgery? (3)

Back 40

A939. Dx: Brain Tumor; (Neurological processes that develop over a period of a few months and lead to increased intracranial pressure, spell out tumor); Diagnostic test: MRI (If not offered, settle for CT scan); Management: Measures to decrease intracranial pressure include Mannitol, Hyperventilation, and high dose Steroids (decadron).

Front 41

Q940. A 42 year old right handed man has a history of progressive speech difficulties and right hemiparesis for five months. He has had progressively severe headaches for the last two months. At the time of admission he is confused, vomiting, has blurred vision, papilledema and diplopia. Shortly thereafter his blood pressure goes up to 190 over 110, and he develops bradychardia. Dx?; Management? (3 together); Tx?

Back 41

A940. Dx: Brain tumor; (but now with two added features...there are localizing signs: left hemisphere, parietal and temporal area...and he manifests the Cushing’s reflex of extremely high intracranial pressure); Management: Emergent Decrease ICP with Mannitol, Hyperventilation and Steroids; Tx: Surgery

Front 42

Q941. A 12 year old boy is short for his age, has bitemporal hemianopsia and has a calcified lesion above the sella in X- Rays of the head. Dx?; Diagnostic test?; Tx?

Back 42

A941. Dx: Craniopharyngioma; Diagnostic test: MRI; Tx: Pituitary surgery

Front 43

Q942. A 23 year old nun presents with a history of amenorrhea and galactorrhea of six months duration. She is very concerned that other may think that she is pregnant, and she vehemently denies such a possibility. Dx?; Diagnostic test? (2 steps); Tx?; If Tx is not possible, what medication?

Back 43

A942. Dx: Prolactinoma; Diagnostic test:; 1. Measure Prolactin level (Every time you suspect a functioning tumor of an endocrine gland, you measure the appropriate hormone); 2. MRI to see tumor for surgery; Tx: Trans-nasal, trans-sphenoidal; If inoperable: Bromocriptine

Front 44

Q943. A 44 year old man is referred for treatment of hypertension. His physical appearance is impressive: he has big, fat, sweaty hands; large jaw and thick lips, large tongue and huge feet. He is also found to have a touch of diabetes. In further Questioning he admits to headaches and he produces pictures of himself taken several years ago, where he looks strikingly different. Dx?; Diagnostic test? (2 steps); Tx?

Back 44

A943. Dx: Acromegaly; Diagnostic test:; 1. Growth hormone levels; 2. MRI for surgery; Tx: Pituitary surgery

Front 45

Q944. A 15 year old girl has gained weight and become “ugly”. She shows a picture of herself a year ago, where she was a lovely young lady. Now she has a hairy, red, round face full of pimples; her neck has a posterior hump and her supraclavicular areas are round and convex. She has a fat trunk and thin extremities. She has mild diabetes and hypertension. Dx?; Diagnostic test? (3 steps); Tx? (3 possible)

Back 45

A944. Dx: Cushing’s syndrome; Diagnostic test:; 1. AM and PM cortisol levels; 2. Dexamethasone suppression test; 3. MRI of the sella; Tx:; 1. Cushings Dz: Trans-sphenoidal pituitary surgery; 2. Adrenal CA: Adrenalectomy; 3. Ectopic ACTH: remove Primary tumor

Front 46

Q945. A 55 year old lady is involved in a minor traffic accident where her car was hit sideways by another car that she “did not see” at an intersection. When she is tested further it is recognized that she has bitemporal hemianopsia. Ten years ago she had bilateral adrenalectomies for Cushing’s disease. Dx?; Diagnostic test?; Tx?

Back 46

A945. Dx: Nelson’s syndrome; (Years ago, before imaging studies could identify pituitary microadenomas, patients with Cushing’s were treated with bilateral adrenalectomy instead of pituitary surgery. In some of those patients the pituitary microadenoma kept on growing and eventually gave pressure symptoms); Diagnostic test: MRI will show the tumor; Tx: Trans-nasal, trans-sphenoidal surgery will remove it

Front 47

Q946. A 42 year old man has been fired from his job because of inappropriate behavior. For the past two months he has gradually developed very severe, “explosive” headaches that are located on the right side, above the eye. Neurologic exam shows optic nerve atrophy on the right, papilledema on the left and anosmia. Specific Dx?; Diagnostic test?; Tx?

Back 47

A946. Dx: Brain tumor in the right frontal lobe; (Foster-Kennedy syndrome); (A little knowledge of neuroanatomy can help localize tumors. The frontal lobe has to do with behavior and social graces, and is near the optic nerve and the olfactory nerve); Diagnostic test: MRI; Tx: Neurosurgery

Front 48

Q947. A 32 year old man complains of progressive, severe generalized headaches that began three months ago are worse in the mornings and lately have been accompanied by projectile vomiting. He has lost his upper gaze and he exhibits the physical finding known as “sunset eyes”. Specific Dx?; Diagnostic test?; Tx?

Back 48

A947. Dx: Tumor is in the pineal gland (Parinaud’s syndrome); Diagnostic test: MRI; Tx: Neurosurgery

Front 49

Q948. A six year old boy has been stumbling around the house and complaining of severe morning headaches for the past several months. While waiting in the office to be seen, he assumes the knee-chest position as he holds his head. Neurological exam demonstrates truncal ataxia. Specific Dx?; Diagnostic test?; Tx?

Back 49

A948. Dx: Tumor of the Posterior Fossa. (Most brain tumors in children are located there, and cerebellar function is affected); Diagnostic test: MRI; Tx: Neurosurgery

Front 50

Q949. A 23 year old man develops severe headache, seizures and projectile vomiting over a period of two weeks. He has low grade fever, and was recently treated for acute otitis media and mastoiditis. Dx?; Diagnostic test?; Tx?

Back 50

A949. Dx: Brain abscess; (Signs and symptoms suggestive of brain tumor that develop in a couple of weeks with fever and an obvious source on infection, spell out abscess); Diagnostic test: These are seen in CT as well as they would on MRI, and the CT is cheaper and easier to get...so pick CT if offered. Tx: Resected by the neurosurgeons

Front 51

Q950. An 18 year old street fighter gets stabbed in the back, just to the right of the midline. He has paralysis and loss of proprioception distal to the injury on the right side, and loss of pain perception distal to the injury on the left side. Dx?; Management?

Back 51

A950. Dx: Spinal cord Hemisection; (Brown-Sequard’s syndrome); Management: high dose corticosteroids soon after a spinal cord injury may help minimize the permanent damage.

Front 52

Q951. A patient involved in a car accident sustains a burst fracture of the vertebral bodies. He develops loss of motor function and loss of pain and temperature sensation on both sides distal to the injury, while showing preservation of vibratory sense and position sense. Dx?; Management?

Back 52

A951. Dx: Anterior cord syndrome; Management: high dose corticosteroids soon after a spinal cord injury may help minimize the permanent damage.

Front 53

Q952. An elderly man is involved in a rear end automobile collision where he hyperextends his neck. He develops paralysis and burning pain of both upper extremities while maintaining good motor function in his legs. Dx?; Management?

Back 53

A952. Dx: Central Cord syndrome; Management: high dose corticosteroids soon after a spinal cord injury may help minimize the permanent damage.

Front 54

Q953. A 52 year old lady has constant, severe back pain for two weeks. While working on her yard, she suddenly falls and can not get up again. When brought to the hospital she is paralyzed below the waist. Two years ago she had a mastectomy for cancer of the breast. Dx?; Diagnostic test?; Tx?

Back 54

A953. Dx: Canacer metastasis causing Spinal fracture; (Most tumors affecting the spinal cord are metastatic, extradural; the sudden onset of the paralysis suggests a fracture with cord compression or transection); Diagnostic test: MRI is the best imaging modality for the spinal cord. Tx: Neurosurgeons may be able to help if the cord is compressed rather than transected

Front 55

Q954. A 45 year old male gives a history of aching back pain for several months. He has been told that he had muscle spasms, and was given analgesics and muscle relaxants. He comes in now because of the sudden onset of very severe back pain that came on when he tried to lift a heavy object. The pain is “like an electrical shock that shoots down his leg ”, and it prevents him from ambulating. He keeps the affected leg flexed. Straight leg raising test gives excruciating pain. Dx?; Diagnostic test?; Management? (2 possible)

Back 55

A954. Dx: Lumbar disk Herniation; (The peak age incidence is 45, and virtually all of these are either L4-L5 or L5-S1); Diagnostic test: MRI; Management:; 1. Bed rest will take care of most of these; 2. Neurosurgical intervention only if there is progressive weakness or sphincteric deficits

Front 56

Q955. A 79 year old man complains of leg pain brought about by walking and relieved by rest. On further questioning it is ascertained that he has to sit down or bend over for the pain to go away. Standing at rest will not do it. Furthermore, he can exercise for long periods of time if he is “hunched over”, such as riding a bike or pushing a shopping cart. He has normal pulses in his legs. Dx?; Diagnostic test?; Tx?

Back 56

A955. Dx: Neurogenic Claudication; Diagnostic test: MRI; Tx: Eventually surgical decompression of this cauda equina

Front 57

Q956. A 60 year old man complains of extremely severe, sharp, shooting, “like a bolt of lighting”, pain in his face which is brought about by touching a specific area, and which lasts about 60 seconds. His neurological exam is normal, but it is noted that part of his face is unshaven, because he fears to touch that area. Dx?; Diagnostic test?; Tx?

Back 57

A956. Dx: Tic Doloreaux (Trigeminal neuralgia); Diagnostic test: Rule out organic lesions with MRI; Tx: Anticonvulsants

Front 58

Q957. Several months after sustaining a crushing injury of his arm, a patient complains bitterly about constant, burning, agonizing pain that does not respond to the usual analgesic medications. The pain is aggravated by the slightest stimulation of the area. The arm is cold, cyanotic and moist. Dx?; Management? (2 possible)

Back 58

A957. Dx: Causalgia (reflex sympathetic distrophy); Management:; 1. Sympathetic block is diagnostic; 2. Surgical sympathectomy will be curative

Front 59

Q958. In the newborn nursery it is noted that a child has uneven gluteal folds. Physical exam of the hips reveals that one of them can be easily dislocated posteriorly with a jerk and a “ click”, and returned to normal position with a “snapping”. Dx?; Management?

Back 59

A958. Dx: Developmental Dysplasia of the hip; Management: Abduction splinting; (Don’t order X-Rays in a newborn. Calcification is still incomplete and you will not see anything)

Front 60

Q959. A 6 year old boy has insidious development of limping with decreased hip motion. He complains occasionally of knee pain on that side. He walks into the office with an antalgic gait. Passive motion of the hip is guarded. Dx?; Diagnostic test?; Management?

Back 60

A959. Dx: Legg-Perthes disease; (avascular necrosis of the capital femoral epiphysis); [Remember that hip pathology can show up with knee pain]; Diagnostic test: AP and lateral X-Rays for diagnosis; Management: Contain the femoral head within the acetabulum by casting and crutches

Front 61

Q960. A 13 year old boy complains of pain in the groin (it could be the knee) and is noted by the family to be limping. He sits in the office with the foot on the affected side rotated towards the other foot. Physical examination is normal for the knee, but shows limited hip motion. As the hip is flexed, the leg goes into external rotation and it can not be rotated internally; Dx?; Diagnostic test?; Tx?

Back 61

A960. Dx: Slipped Capital Femoral Epiphysis; (Forget the details: a bad hip in this age group is slipped capital femoral epiphysis, an orthopedic emergency); Diagnostic test: AP and lateral X-Rays; Tx: The orthopedic surgeons will pin the femoral head in place

Front 62

Q961. A little toddler has had the flu for several days, but he was walking around fine until about two days ago. He now absolutely refuses to move one of his legs. He is in pain, holds the leg with the hip flexed, in slight abduction and external rotation and you can not examine that hip he will not let you move it. He has elevated sedimentation rate; Dx?; Management? (2 steps)

Back 62

A961. Dx: Septic Hip (orthopedic emergency); Management:; 1. Under general anesthesia the hip is aspirated to confirm the diagnosis, and; 2. Open arthrotomy is done for drainage

Front 63

Q962. A child with a febrile illness but no history of trauma has persistent, severe localized pain in a bone. Dx?; Diagnostic test?

Back 63

A962. Dx: Acute Hematogenous Osteomyelitis; Diagnostic test: Bone Scan; (don’t fall for the X-Ray option. X-Ray will not show anything for two weeks)

Front 64

Q963. A 12 year old girl is referred by the school nurse because of potential scoliosis. The thoracic spine is curved toward the right, and when the girl bends forward a “hump” is noted over her right thorax. The patient has not yet started to menstruate. Management? (3 steps)

Back 64

A963. Management:; 1. Baseline x-rays to monitor progression; 2. Bracing may be needed to arrest progression; 3. Pulmonary function could be limited if there is large deformity; (The point is that scoliosis may progress until skeletal maturity is reached. At the onset of menses skeletal maturity is about 80%, so this patient still has a way to go)

Front 65

Q964. A 16 year old boy complains of low grade but constant pain in his distal femur present for several months. He has local tenderness in the area, but is otherwise asymptomatic. X- Rays show a large bone tumor, with “sunburst” pattern and periosteal “onion skinning”. Dx? (2 possible); Management?

Back 65

A964. Dx: Osteogenic Sarcoma or Ewing’s Sarcoma; Management: The point of the vignette is that you do not mess with these. Do not attempt biopsy. Referral is needed, not just to an orthopedic surgeon (they see one of these every three years), but to a specialist on bone tumors

Front 66

Q965. A 66 year old lady picks up a bag of groceries and her arm snaps broken; Dx?; Diagnostic test? (3 steps)

Back 66

A965. Dx: A pathologic fracture (i.e: for trivial reasons) means bone tumor, which in the vast majority of cases will be metastatic. Diagnostic test:; 1. Get X-Rays to diagnose this particular broken bone,; 2. whole body Bone Scans to identify other metastasis,; 3. start looking for the primary cancer site; (In women, breast. In men, prostate. In heavy smokers, lung...and so on)

Front 67

Q966. A 58 year old lady has a soft tissue tumor in her thigh. It has been growing steadily for six months, it is located deep into the thigh, is firm, fixed to surrounding structures and measures about 8cm in diameter; Dx?; Diagnostic test?

Back 67

A966. Dx: Soft tissue sarcoma is the concern; Diagnositic test: MRI; (Leave biopsy and further management to the experts)

Front 68

Q967. A middle aged homeless man is brought to the ER because of very severe pain in his forearm. The history is that he passes out after drinking a bottle of cheap wine and he slept on a park bench for an indeterminate time, probably more than 12 hours. There are no signs of trauma, but the muscles in his forearm are very firm and tender to palpation, and passive motion of his fingers and wrist elicit excruciating pain. Pulses at the wrist are normal; Dx?; Tx?

Back 68

A967. Dx: Compartment syndrome; Tx: Emergency Fasciotomy

Front 69

Q968. A patient presents to the ER complaining of moderate but persistent pain in his leg under a long leg plaster cast that was applied six hours earlier for an ankle fracture; Management?

Back 69

A968. Management: Remove the cast; (The point of this vignette is that you never give pain medication and do nothing else for pain under a cast. The cast has to come off right away. It may be too tight, it may be compromising blood supply, it may have rubbed off a piece of skin)

Front 70

Q969. A young man involved in a motorcycle accident has an obvious open fracture of his right thigh. The femur is sticking out through a jagged skin laceration; Management?

Back 70

A969. Management: Reduction in the OR within 6 hours; (The point of this one is that open fractures are orthopedic emergencies. This fellow may need to have other problems treated first...abdominal bleeding, intracranial hematomas, chest tubes, etc, but the open fracture should be in the OR getting cleaned and reduced within six hours of the injury)

Front 71

Q970. A 55 year old lady falls in the shower and hurts her right shoulder. She shows up in the ER with her arm held close to her body, but rotated outwards as if she were going to shake hands. She is in pain and will not move the arm from that position. There is numbness in a small area of her shoulder, over the deltoid muscle. Dx?; Diagnostic test?; Tx?

Back 71

A970. Dx: Anterior Dislocation of the Shoulder, with Axillary nerve damage; Diagnostic test: Get AP and lateral X-Rays; Tx: Reduce

Front 72

Q971. After a grand mal seizure, a 32 year old epileptic notices pain in her right shoulder and she can not move it. She goes to the near-by “Doc in a Box”, where she has X-Rays and is diagnosed as having a sprain and given pain medication. The next day she still has the same pain and inability to move the arm. She comes to the ER with the arm held close to her body, in a “normal” (i.e., not externally rotated, but internally rotated) position; Dx?; Diagnostic test? (specific)

Back 72

A971. Dx: Posterior Dislocation of the Shoulder; (Very easy to miss on regular X-Rays); Diagnostic test: Get X-Rays again but order Axillary view or Scapular Lateral

Front 73

Q972. A front seat passenger in a car that had a head-on collision relates that he hit the dashboard with his knees, and complains of pain in the right hip. He lies in the stretcher in the ER with the right extremity shortened, adducted, and internally rotated. Dx?; Diagnostic test?; Tx?

Back 73

A972. Dx: Posterior Dislocation of the Hip. (Emergency: The blood supply of the femoral head is tenuous, and delay in reduction could lead to avascular necrosis); Diagnostic test: X-Rays; Tx: Emergency reduction

Front 74

Q973. A 77 year old man falls in the nursing home and hurts his hip. X-Rays show that he has a displaced femoral neck fracture; Dx?; Tx?

Back 74

A973. Dx: Hip fracture; Tx: Metal prosthetic surgery; (The point of this vignette is that blood supply to the femoral head is compromised in this setting and the patient is better off with a metal prosthesis put in, rather than an attempt at fixing the bone. With intertrochanteric fractures on the other hand, the broken bones can be pinned together and expected to heal)

Front 75

Q974. A football player is hit straight on his right leg and he suffers a posterior dislocation of his knee. Management? (3 steps)

Back 75

A974. Management:; 1. Check pulses; 2. Arteriogram; 3. Reduction; (The point here is that posterior dislocation of the knee can nail the popliteal artery. Attention to integrity of pulses, arteriogram and prompt reduction are the key issues)

Front 76

Q975. A young recruit complains of localized pain in his tibia after a forced march at boot camp. He is tender to palpation over a very specific point on the bone, but X-Rays are normal; Dx?; Management? (2 steps)

Back 76

A975. Dx: Stress Fracture; (The lesson here is that stress fractures will not show up radiologically until 2 weeks later); Management:; 1. Treat the guy as if he had a fracture (cast); 2. Repeat the X-Ray in 2 weeks

Front 77

Q976. A man who fell from a second floor window has clinical evidence of fracture of his femur. The vignette gives you a choice of X-Rays to order. What are the rules for ordering x-rays? (3)

Back 77

A976. Here are the rules:; 1. Always get X-Rays at 90 degrees to each other (for instance, AP and lateral); 2. Always include the joints above and below; 3. if appropriate (this case is) check the other bones that might be in the same line of force (here the lumbar spine)

Front 78

Q977. A healthy 24 year old man steps on a rusty nail at the stables where he works as a horse breeder. Three days later he is brought to the ER moribund, with a swollen, dusky foot, in which one can feel gas crepitation. Dx?; Management? (3 steps: 1 med, 1 surgery, 1 other)

Back 78

A977. Dx: Gas gangrene; Management:; 1. Tons of IV penicillin; 2. Immediate surgical debridement of dead tissue; 3. followed by a trip to the nearest hyperbaric chamber for hyperbaric O2 treatment

Front 79

Q978. A 55 year old, obese man suddenly develops swelling, redness and exquisite pain at the first metatarsal-phalangeal joint; Dx?; Diagnostic test?; Tx? (3 possible)

Back 79

A978. Dx: Gout; Diagnostic test: Serum Uric Acid; Tx: Colchicine, Allopurinol or Probenicid

Front 80

Q979. A 67 year old diabetic has an indolent, unhealing ulcer at the heel of the foot; Management? (3 steps)

Back 80

A979. Management:; 1. control the diabetes; 2. keep the ulcer clean; 3. keep the leg elevated...and be resigned to the thought that you may end up amputating the foot

Front 81

Q980. A 67 year old smoker with high cholesterol and coronary disease has an indolent, unhealing ulcer at the tip of his toe. The toe is blue, and he has no peripheral pulses in that extremity. Dx?; Diagnostic test? (2 steps); Tx?

Back 81

A980. Dx: Ischemic Ulcers; (usually are at the farthest away pint from where the blood comes); Diagnostic test:; 1. Doppler studies looking for pressure gradient; 2. Arteriogram. Tx: Revascularization may be possible, and then the ulcer may heal

Front 82

Q981. A 44 year old, obese woman has an indolent, unhealing ulcer above her right malleolus. The skin around it is thick and hyperpigmented. She has frequent episodes of cellulitis, and has varicose veins; Dx?; Management?; Tx?

Back 82

A981. Dx: Venous Stasis Ulcer; Management: Unna boot and Support stockings; Tx: Varicose vein surgery

Front 83

Q982. A 14 year old boy presents in the Emergency Room with very severe pain of sudden onset in his right testicle. There is no fever, pyuria or history of recent mumps. The testis is swollen, exquisitely painful, “high riding”, and with a “ horizontal lie”. The cord is not tender. Dx?; Tx?

Back 83

A982. Dx: Testicular Torsion (urological emergency); Tx: Emergency surgery to save the testicle

Front 84

Q983. A 24 year old man presents in the emergency room with very severe pain of recent onset in his right scrotal contents. There is fever of 103 and pyuria. The testis is in the normal position, and it appears to be swollen and exquisitely painful. The cord is also very tender. Dx?; Diagnostic test?; Tx?

Back 84

A983. Dx: Acute Epididimitis; Diagnostic test: Ultrasound (to rule-out torsion); Tx: Antibiotics; (The differential diagnosis is with testicular torsion. Torsion is a surgical emergency. Epididimitis is not. Don’t rush this guy to the OR. If the vignette is not clear-cut, i.e: and adolescent that looks like epidimitis, but could be torsion, pick a sonogram to rule out torsion before you choose the non-surgical option)

Front 85

Q984. A 72 year old man is being observed with a ureteral stone that is expected to pass spontaneously. He develops chills, a temperature spike to 104 and flank pain. What should be given to him?; What is initial Tx? (2)

Back 85

A984. Give: Massive IV Antibiotics; Tx:; Decompression by:; 1. Ureteral stent, or; 2. Percutaneous Nephrostomy; (Obstruction and Infection of the urinary tract: a true urological emergency. In a septic patient stone extraction would be hazardous)

Front 86

Q985. An adult female relates that five days ago she began to notice frequent, painful urination, with small volumes of cloudy and malodorous urine. For the first three days she had no fever, but for the past two days she has been having chills, high fever, nausea and vomiting. Also in the past two days she has had pain in the right flank. She has had no treatment whatsoever up to this time; Dx?; Management? (3 steps)

Back 86

A985. Dx: Pyelonephritis; Management:; 1. Hospitalization; 2. IV antibiotics; 3. Sonogram to make sure that there is no concomitant obstruction; (UTI should not happen in men or in children, and thus they should trigger looking for a cause. Women of reproductive age on the other hand, get cystitis all the time and they are treated with appropriate antibiotics without great fuss)

Front 87

Q986. A 62 year old male presents with chills, fever, dysuria, urinary frequency, diffuse low back pain and an exquisitely tender prostate on rectal exam; Dx?; Management? (2 steps)

Back 87

A986. Dx; Acute Bacterial Prostatitis; Management:; 1. I.V. antibiotics; 2. what should not be done is any more rectal exams or any vigorous prostatic massage...doing so could lead to septic shock

Front 88

Q987. You receive a call from a patient at 3:00 AM. His regular urologist retired five years ago, and he has not sought a replacement. At about 11:00 PM last night, the patient injected himself with papaverine directly into the corpora, as he had been instructed to do for his chronic, organic impotence. He achieved a satisfactory erection and had intercourse, but the erection has not gone away and he still has it at this time; Dx?; Managment? (2 steps)

Back 88

A987. Dx: Priapism (urological emergency); Management:; 1. Emergency Alpha Agonist (phenylephrine, epinephrine or terbutaline) into the corpora; 2. Once the crisis is over, the patient has to be switched from papaverine to Prostaglandin E1, which in now the agent of choice to achieve erection because it is less likely to produce priapism; (Continued erection beyond four hours begins to damage the corpora)

Front 89

Q988. You are called to the nursery to see an otherwise healthy looking newborn boy because he has not urinated in the first 24 hours of life. Physical exam shows a big distended urinary bladder. Dx? (2 possible); First step?; Diagnostic test?; Tx?

Back 89

A988. Dx: Urinary Obstruction secondary to; 1. Meatal Stenosis; 2. Posterior Urethral valves; First step: Drain the bladder with a catheter; (it will pass through the valves); Diagnostic test: Voiding cystourethrogram; Tx: Endoscopic Fulguration or Resection

Front 90

Q989. A bunch of newborn boys are lined up in the nursery for you to do circumcisions. You notice that one of them has the urethral opening in the ventral side of his penis, about mid- way down the shaft. Dx?; Next step?

Back 90

A989. Dx: Hypospadias; Next step: The point of the vignette is that you don’t do the circumcision. The foreskin may be needed later for reconstruction when the hypospadias is surgically corrected

Front 91

Q990. A 7 year old child falls off a jungle gym and has minor abrasions and contusions. When checked by his pediatrician, a urinalysis shows microhematuria; Dx?; Diagnostic test?

Back 91

A990. Dx: Congenital Anomaly; (Hematuria from the trivial trauma in kids means congenital anomaly of some sort); Diagnostic test: start with Sonogram (IVP may be needed later)

Front 92

Q991. A 9 year old boy gives a history of three days of burning on urination, with frequency, low abdominal and perineal pain, left flank pain and fever and chills for the past two days; Dx?; Management? (2 steps)

Back 92

A991. Dx: UTI; (Little boys are not supposed to get urinary tact infections. There is more than meets the eye here. A congenital anomaly has to be ruled out); Management:; 1. treat the infection; 2. Sonogram right away to begin the work up

Front 93

Q992. A mother brings her 6-year-old girl to you because “ she has failed miserably to get proper toilet training”. On questioning you find out that the little girl perceives normally the sensation of having to void, voids normally and at appropriate intervals, but also happens to be wet with urine all the time; Dx?; Management? (2 steps); Tx?

Back 93

A992. Dx: (classic vignette) Low implantation of one ureter; (In little boys there would be no symptoms, because low implantation in boys is still above the sphincter, but in little girls the low ureter empties into the vagina and has no sphincter. The other ureter is normally implanted and accounts for her normal voiding pattern); Management:; 1. PE might show the abnormal ureteral opening; 2. IVP; Tx: Surgical repair

Front 94

Q993. A 16 year old boy sneaks out with his older brother’s friends, and goes on a beer-drinking binge for the first time in his life. He shortly thereafter develops colicky flank pain; Dx?; Diagnostic test?; Tx?

Back 94

A993. Dx: (classic) Ureteropelvic Junction Obstruction; Diagnostic test: Ultrasound; Tx: Surgical Repair will follow

Front 95

Q994. A 62 year old male known to have normal renal function reports an episode of gross, painless hematuria. Further Questioning determines that the patient has total hematuria rather than initial or terminal hematuria; Dx? (2 possible); Diagnostic test?; If test is normal what is next step?

Back 95

A994. Dx: Either Infection or Tumor can produce hematuria. (The blood is coming anywhere from the kidneys to the bladder, rather than the prostate or the urethra. In older patients without signs of infection cancer is the main concern); Diagnostic test: IVP (“gold standard-first study” in urology, except in postential obstruction, then Ultrasound); If normal the next step: Cystoscopy

Front 96

Q995. A 70 year old man is referred for evaluation because of a triad hematuria, flank pain and a flank mass. He also has hypercalcemia, erythrocytosis and elevated liver enzymes; Dx?; Diagnostic test? (2 steps)

Back 96

A995. Dx: Renal cell carcinoma (also known as clear cell carcinoma, or hypernephroma); Diagnostic test:; 1. IVP first; 2. CT scan next would be the standard sequence. (In real life, if a urologist saw a patient with a palpable flank mass, he or she might go straight for the CT scan)

Front 97

Q996. A 61 year old man presents with a history of hematuria. Intravenous pyelogram shows a renal mass, and sonogram shows it to be solid rather than cystic. CT scan shows a heterogenic, solid tumor. Dx?

Back 97

A996. Dx: Renal cell carcinoma

Front 98

Q997. A 55 year old, chronic smoker, reports three instances in the past two weeks when he has had painless, gross, total hematuria. In the past two months he has been treated twice for irritative voiding symptoms, but has not been febrile and urinary cultures have been negative; Dx?; Diagnostic test? (2 steps)

Back 98

A997. Dx: Bladder Cancer; Diagnostic test:; 1. IVP; 2. Cystogram; (With this very complete presentation some urologist would go for the cystoscopy first, but the standard sequence of IVP first and cystoscopy next is the only correct answer for an exam. An option both IVP and cystoscopy would be OK)

Front 99

Q998. A 59 year old black man has a rock-hard, discrete, 1.5cm nodule felt in his prostate during a routine physical examination; Dx?; Diagnostic test?; Tx?

Back 99

A998. Dx: Cancer of the Prostate; Diagnostic test: Trans-rectal needle biopsy; Tx: Surgical resection after the extent of the disease has been established

Front 100

Q999. An 82 year old gentleman who has congestive heart failure and chronic obstructive pulmonary disease is told by his primary care physician that his level of prostatic specific antigen (PSA) is abnormally high. The gentleman has seen ads in the paper for sonographic examinations of the prostate, and he has one done. The examination reveals a prostatic nodule, which on trans-rectal biopsy is proven to be carcinoma of the prostate. The man is completely asymptomatic as far as this cancer is concerned. He has not evidence of metastasis either. Tx?

Back 100

A999. Tx: As a rule, asymptomatic prostatic cancer is not treated after age 75; (An example of technology running amock. This man should have never had the PSA in the first place, much less the sonogram and biopsy. After a certain age, most men get prostatic cancer...but die of something else)

Front 101

Q1000. A 25 year old man presents with a painless, hard testicular mass. Dx?; Diagnostic test? (2)

Back 101

A1000. Dx: Testicular cancer; Diagnostic test:; 1. Pre-op Alpha-fetoprotein and Beta-HCG; 2. Diagnosis is made by performing a radical orchiectomy by the inguinal route. (That irreversible, drastic step is justified because testicular tumors are almost never benign. Beware of the option to do a trans-scrotal biopsy: that is a definitive no-no)