This patient likely has an abdominal aortic aneurysm. Ninety-five percent of aneurysms of the abdominal aorta are associated with atherosclerosis. This condition is responsible for approximately 15,000 deaths per year. Men are affected nearly 10 times more than women. Marfan syndrome can be associated with increased protease activity on histologic evaluation of the aneurysm wall. Syphilitic aneurysms occur in late-stage syphilis. Meningococcal infection is rarely associated with aneurysm formation. Trauma is a rare cause of abdominal aortic aneurysm.
This patient likely has acute mesenteric ischemia. Patients complain of sudden onset of abdominal pain with severe nausea, diarrhea, and/or vomiting. Pain is out of proportion to physical findings. Treatment involves surgical resection of infracted bowel as soon as possible. Aggressive surgical intervention should not be delayed because of the high index of suspicion of infracted bowel. Angiographic embolization may be diagnostic and therapeutic but is not considered a first-line therapy. Antibiotic therapy is considered an adjunctive therapy. Heparinization is not a first-line therapy for this condition.
A major portion of circulation for the lower extremity begins with the superficial femoral artery, which forms the popliteal artery passing behind the knee joint. This vessel then branches into the anterior tibial, posterior tibial, and peroneal arteries. There is no evidence to suggest rupture, hematoma, or spasm in these vessels. With knee injuries, the popliteal artery may go into spasm because of its location just posterior to the joint. It is important for practitioners to always palpate for a pulse in this artery in all patients with knee injuries. This vessel is also important, as it determines vascular supply to the distal leg.
Younger women have more fibrous tissue, which makes mammograms harder to interpret. Thus ultrasound is a useful testing modality. As women age, breast tissue transforms from fibrous tissue to adipose tissue. This change makes it easier for mammography to detect masses. Thus this modality is more useful in patients over the age of 35 years. Watchful waiting may be considered if the lesion is benign. Testing for the BRCA gene may be considered if the patient is suspect to a family history of breast cancer.
Women with mastitis need close follow-up for inflammatory breast disease. If a breast abscess developed, she would need antibiotics. If her breast abscesses were recurrent, the physician should consider resection of the involved ducts. If a patient with fibrocystic disease has straw-colored fluid on aspiration, she would need to be observed closely. If the patient had spontaneous galactorrhea, the physician would need to rule out a prolactinoma.
This patient should be treated with multiagent chemotherapy. This is the treatment of choice for a premenopausal patient with stage I or II breast cancer (size <1 cm), negative lymph nodes, and estrogen receptor—negative status. Watchful waiting may be appropriate for patients with small tumors and negative lymph nodes. External-beam radiotherapy is not indicated for this patient. High-energy focused ultrasound therapy is not indicated for the treatment of breast cancer. Tamoxifen is considered in patients who are estrogen receptor positive and have tumor size >1 cm.
This patient likely has ulcerative colitis. Colonoscopy may reveal thickened, friable mucosa. Fissures and pseudopolyps
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may also be present. This disease almost always involves the rectum and extends backward toward the cecum to varying degrees. Anoscopy is a limited procedure and will not allow visualization of the entire colon. Flexible or rigid sigmoidoscopy will allow visualization of the rectum and sigmoid colon but will miss higher levels of the colon. This patient requires further testing to establish a definitive diagnosis.
This patient has diverticulosis as a result of the presence of outpouchings in the wall of the colon that occur where the arterial supply penetrates the bowel wall. Patients who stop bleeding and are asymptomatic require no further treatment. Elective colectomy is not recommended at the first episode; thus right hemicolectomy, left hemicolectomy, or subtotal colectomy are not required. Intravenous antibiotic therapy is not required in this patient, because there is no evidence of infection.
This patient has sigmoid volvulus. This condition can be reduced with a rectal tube, which is the treatment of choice. In addition, one can consider decompression with enema. Cecal calculus is treated with surgical intervention. High-fiber diet has no role in the treatment of volvulus. Lactulose is unlikely to be of benefit in the management of this patient.
This patient likely has a prolactinoma, the most common type of pituitary neoplasm. Women may present with headaches, irregular menses, amenorrhea, or galactorrhea. A serum prolactin level of >300 µg/L suggests the diagnosis of pituitary adenoma. This can be confirmed with MRI. Ferritin levels would likely be normal in this patient. Hemoglobin and hema-tocrit levels should be normal in this patient. Iron levels should be normal in this patient.
This patient would be expected to have fibroblast dysfunction. Patients with inflammatory bowel disease may require treatment with exogenous corticosteroids. These agents suppress the immune system and impair inflammatory cell migration. Antibody production is impaired. This is appropriate in Crohn's disease. Other effects of corticosteroids include fibroblast dysfunction and impaired wound healing.
Renal failure is the most common cause of secondary hyperparathyroidism. This patient, who has had severe uncontrolled diabetes and lab values consistent in patients with diabetes, is most likely to have renal failure as the cause of his hypercalcemia. Whenever the kidney loses its ability to reabsorb calcium and hydroxylate vitamin D for calcium absorption from the gut, hypocalcemia triggers the parathyroid glands to increase their production of parathyroid hormone. Milk-alkali syndrome can cause hypercalcemia in patients who eat many antacids or drink an excessive amount of milk. This condition is more commonly found in patients who have gastric ulcers and frequently depend on milk and antacids for relief. Lithium can cause hypercalcemia by causing hyperparathyroidism. Parathyroid adenomas can cause hypercalcemia by increasing parathyroid hormone secretion.
The arcuate ligament does not inhibit gastroesophageal (GE) reflux and will not protect the esophageal mucosa from erosion. The esophagus limits its exposure to acid by several mechanisms, including salivation, gravity, gastric emptying, and the activity of peptic acid. Also important is the maintenance of a critical esophagogastric angle and appropriate diaphragmatic location of the GE junction.
This patient has diffuse esophageal spasm. Patients present with chest pain and dysphagia. Manometric studies reveal high-amplitude contractions and normal relaxation of the lower esophageal sphincter. Cricopharyngeal spasm occurs because of muscular dysfunction. Scleroderma is a collagen vascular disease that can affect the esophagus and cause motility dysfunction. Tuberculosis can be associated with esophageal diverticula of the traction type. This patient has no evidence to suggest a psychogenic swallowing disorder.
This child ingested a caustic alkaline substance. The child has difficulty breathing and has stridor. Airway edema is likely. Thus tracheostomy should be performed first. Antibiotics and corticosteroids are secondary to the important primary survey of airway, circulation, and breathing in this patient. Vomiting should not be induced for a patient with a caustic ingestion. Likewise, placement of a nasogastric tube should be deferred.
This patient likely has cancer of the gallbladder. Eighty percent of cases are due to adenocarcinoma. Approximately 10% are anaplastic carcinoma, whereas 5% are squamous cell carcinoma. A right upper quadrant mass may be palpable. Signs of jaundice are also possible. This lesion is unlikely to be a sarcoma. Transitional cell carcinoma occurs in the urinary tract. Tuberculosis granuloma is found in the lung.
This patient has a type II cholesterol stone. This is produced as a result of homogeneous nucleation and can produce large gallstones. This type of gallstone represents 5% to 20% of all
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gallstones. Type I cholesterol stones are small in size and often multiple. Calcium oxalate stones are often found in the kidney. Black and brown gallstones are smaller in size and multiple in number.
This patient has the Charcot triad of fever, jaundice, and upper quadrant pain. This triad is seen with acute cholangitis. Initial treatment consists of fluid resuscitation and antibiotics. Patients who do not respond to this therapy need to be decompressed with percutaneous transhepatic drainage. T-tube decompression can also be considered if there is failure to respond to antibiotics. Choledochojejunostomy is considered when the bile duct is dilated.
This patient has evidence of aortic stenosis. Progressive degeneration and calcification of the valve leaflets occur. Patients can complain of angina, syncope, and dyspnea. A crescendo-decrescendo murmur can be heard best in the second right intercostal space. Electrocardiogram reveals left ventricular hypertrophy. Bundle branch block is uncommon, as is T-wave inversion.
This patient has evidence of coronary artery disease that ultimately led to death. This is confirmed with the autopsy findings of myocardial necrosis and rupture of the left ventricle. Risk factors for coronary artery disease include hypertension, smoking, hypercholesterolemia, family history of heart disease, personal history of diabetes mellitus, and obesity. Atherosclerosis is the predominant pathogenic mechanism underlying obstructive disease of the coronary arteries.
This patient likely has a metastatic tumor to the heart. In this case, lymphoma is likely because of the following symptoms: fever, fatigue, weight loss, and an elevated white blood cell count beyond what would be expected with infection. Atrial myxoma would manifest as a mass lesion detectible with echocardiogram. Atrial fibrillation is unlikely given the findings presented. This patient has no colorectal symptoms; thus metastatic colorectal carcinoma is unlikely. Pericarditis is unlikely given the presenting findings in this patient.
This newborn has omphalocele, an opening in the abdominal wall at the umbilicus that is due to incomplete closure of the somatic folds of the anterior abdominal wall in the fetus. The omphalocele can be a part of the pentalogy of Cantrell, which is associated with a diaphragmatic hernia, cleft sternum, absent pericardium, intracardiac defects, and exstrophy of the bladder. Cleft lip and palate are not present in these patients.
The optimal time of convalescence after hernia repair is unknown. After traditional open surgery, patients have been asked to convalesce for 6 to 8 weeks. However, after laparoscopic mesh repair, patients may return to strenuous activity in 2 to 3 weeks. However, the true optimal time of convalescence is not known.
Femoral hernias are located in the femoral canal. The entrance to the canal is bounded superiorly and medially by the iliopubic tract, inferiorly by Cooper ligament, and laterally by the femoral vein. The inguinal ligament is more superficial. The ischial spine is not part of the femoral triangle. The lacunar ligament is not part of the femoral triangle. The femoral vein, not the femoral nerve, forms the lateral boundary of the triangle.
Although preservation of the bladder neck, nervi erigentes, and the size of the bladder neck have all been associated with continence, the only factor that is generally accepted as being related to urinary control after radical prostatectomy is preservation of the external sphincter.
This patient presents with a residual bulky mass after three courses of platinum-based chemotherapy. Although the chest x-ray and β-hCG are normal, the serum AFP remains slightly elevated. AFP production is usually attributed to yolk sac elements in a mixed germ cell tumor. It is also seen with a number of other conditions, such as hepatocellular carcinomas and benign hepatic disease, including alcohol hepatitis, as is probable in this case. Patients with persistent marker elevations after chemotherapy are usually considered very likely to harbor residual carcinoma and probably best managed by further chemotherapy. However, the AFP elevation seen in this case is more likely due to benign liver disease. Consequently, this patient would be best managed by retroperitoneal lymph node dissection instead. The most likely finding at retroperitoneal lymph node dissection would be either fibrosis or residual teratoma. CT scan–directed percutaneous needle biopsy would have considerable sampling error, and external-beam radiotherapy has no efficacy, particularly in the management of teratoma. Further observation is usually not warranted in patients who have residual retroperitoneal masses in excess of 2 to 3 cm.
The frequency of development of metachronous upper tract tumors in patients with superficial transitional cell carcinoma (TCC) of the bladder is not exactly known but has been estimated to be very low (1% to 3%). The incidence is higher in patients with higher stage (T2) primary lesions (2% to 8%).
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Patients treated for high-risk superficial TCC with BCG demonstrate a higher rate (13% to 18%) of upper tract tumors over 3 years of follow-up. The best follow-up approach in patients treated with BCG is, therefore, the addition of upper tract imaging in the form of an intravenous pyelogram or CT urogram. Selective cytology as a routine practice is not recommended.
This patient likely has adenocarcinoma of the gallbladder, the most common pathology of gallbladder carcinoma. Ninety percent of patients have cholelithiasis. Metastases can occur to the lymph nodes and to the liver. Prognosis is poor and has a 5-year survival rate ranging from 0% to 10%. There are several rare benign tumors of the gallbladder, including fibroma, lipoma, myxoma, and myoma.
This patient has a congenital malformation of the pancreaticobiliary tree. Specifically, this is a type U choledochal cyst, which is a fusiform dilation of the common bile duct. The type II cyst is a diverticulum of the common bile duct. The type III cyst is a choledochocele involving the bile duct within the liver. The type IV cyst is a cystic celation of the intrahepatic ducts. The type V cyst does not exist.
This patient has sustained a penetrating injury. Gallbladder injuries are uncommon but are seen after such trauma, as in this patient. When the gallbladder is injured, one must search for other injuries. The most frequent associated injury, in 72% of cases, is to the liver. Aortic injuries are less common than are liver injuries. Colon injuries are less common than are liver injuries. Kidney injuries are commonly associated with penetrating trauma. Urinary bladder trauma is often associated with pelvic fractures.
The combination of cough, hemoptysis, wheezing, and smoking history suggests the diagnosis of lung cancer. Of the two lung cancers listed, squamous cell carcinoma is the one that may produce parathyroid hormone (PTH)–related peptide protein. PTH receptor leads to hypercalcemia. Small-cell carcinomas commonly produce antidiuretic hormone or adrenocorticotropin hormone. In a patient with Goodpasture, hemoptysis may present before hematuria, but because of the other symptoms, squamous cell carcinoma is the better choice. Renal cell carcinoma, not renal adenoma, may produce ectopic PTH-related protein, and smokers do have an increased risk, but these patients present with hematuria, a palpable mass, flank pain, and a fever. The lack of an immunoglobulin G or A spike on serum protein electrophoresis should rule out multiple myeloma.
Laryngeal papillomas are benign neoplasms usually located on the true vocal cords. In children, they present as multiple lesions and are usually caused by human papilloma virus. In adults, they occur as single lesions and sometimes undergo malignant change. A singer's nodule is a small benign laryngeal polyp associated with chronic irritation from excessive use or heavy cigarette smoking and is usually found on the true vocal cords. Thyroid carcinoma is unlikely in children.
Squamous cell carcinoma is the most common type of cancer of the larynx. Cigarette smoking is the most important risk factor. Laryngeal polyps are small and benign. They are usually associated with chronic irritation from excessive use or heavy cigarette smoking. Mucoepidermoid and adenocarcinoma of the larynx are not as common as squamous cell carcinoma and don't have dysplasia as a precursor. Laryngitis is acute inflammation of the larynx, trachea, and epiglottis and is most often caused by a viral infection.
Phimosis is an acquired or congenital condition in which the foreskin cannot be pulled back behind the glans penis. In acquired phimosis, there likely is a history of poor hygiene, chronic balanoposthitis, or forceful retraction of a congenital phimosis. Balanitis is inflammation of the glans of the penis. Hypospadias is an anomaly in which the urethral meatus opens on the ventral surface of the penis. Epispadias is an anomaly in which the urethral meatus opens on the dorsal surface of the penis. Paraphimosis is an emergency condition in which the foreskin, once pulled back behind the glans penis, cannot be brought down to its original position.
Dutasteride is 5-alpha reductase inhibitor used in the symptomatic treatment of benign prostatic hyperplasia that blocks the conversion of testosterone to dihydroxy testosterone (DHT) in target tissues. Because DHT is the major intracellular androgen in the prostate, dutasteride is effective in suppressing DHT and, subsequently, stimulation of prostatic growth and secretory function. Prostate size will decrease by approximately 25%. Ejaculatory dysfunction occurs in 5% to 8% of patients. Serum prostate-specific antigen will decrease by 50%. American Urological Association symptom scores typically improve by 5 to 7 points.
More than 90% of testicular tumors derive from germ cell tumors; the remainder are gonadal stromal tumors or metastatic from another site. The most common solid tumor
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in men between the ages of 15 and 40 is a seminoma. These tumors are typically confined to the testicle and associated with a hypoechoic area on ultrasound. This is an important feature, as most other testis tumors are associated with mixed echogenicity on ultrasound. Nonseminomatous germ cell tumors include embryonal carcinoma, choriocarcinoma, endodermal yolk sac tumor, and teratoma.
Arachnoid villi open at a pressure of 5 mm Hg. They act as one-way valves. Cerebrospinal fluid can be absorbed around the spinal nerve roots. Cerebrospinal fluid flows through the ventricles and exits by the foramen of Magendie. The total volume of cerebrospinal fluid is 150 mL.
Epidural hematoma results from hemorrhage into the potential space between the dura and the skull. The hemorrhage most likely results from rupture to a meningeal artery, which travels within this plane; the middle meningeal artery, which branches off the maxillary artery in the temporal area, is most common. Normally, the patient experiences a lucid interval, defined as an asymptomatic period of a few hours after the trauma. A Berry aneurysm results from a defect in the media of arteries and is usually located at bifurcation sites. Berry aneurysms are most commonly found in the circle of Willis. The source of bleeding due to subdural hematoma is from bridging veins; these often occur in older adults as a result of minor trauma, and symptoms usually occur slowly—days to weeks. Bacterial meningitis diagnosis is confirmed with lumbar puncture and demonstrates increased neutrophils/protein and decreased glucose in the cerebrospinal fluid.
This patient may have an acoustic neuroma. These lesions arise from the vestibular portion of cranial nerve VIII. MRI has now become the method of choice for evaluation of posterior fossa and cerebellopontine angle tumors, because they are better seen on MRI as compared with CT. Audiometric testing is useful for lesions of cranial nerve VIII. Brainstem-evoked potential testing is useful for lesions of cranial nerve VIII. Nystagmography is useful for evaluation of vestibular disorders.
The most appropriate incision for a single lung transplant is via lateral thoracotomy. Double lung transplants are usually performed through a transverse anterior thoracotomy incision. Chevron incisions are useful for renal surgery. Midline abdominal incisions are appropriate for abdominal surgeries, not thoracic surgeries. Pfannenstiel incisions are appropriate to approach the female genitourinary tract.
One thing to consider after lung transplantation is survival. It is similar when comparing single with double lung transplantation. It is also related to diagnosis. The best survival is with obstructive lung disease. This is followed by cystic fibrosis. The worst survival is associated with pulmonary hypertension. Bronchogenic carcinoma also has a poor survival rate. Patients with lung cancer are not considered candidates for lung transplantation.
Most candidates for liver transplantation have end-stage liver disease and are likely to die in 1 to 2 years. Children who require liver transplantation often have biliary atresia (in 50% of cases). In adults, postnecrotic cirrhosis accounts for 55% of cases, of which most are due to alcoholism or chronic hepatitis B. Approximately 15% of cases involve primary biliary cirrhosis and primary sclerosing cholangitis.
Pancreatic insufficiency, which is commonly seen in patients with cystic fibrosis, presents with malabsorptive issues and severe steatorrhea. Proper advice is to limit fat intake, as well as to increase ingestion of fat-soluble vitamins. Glucose malabsorption would not have such effects upon stooling. Menstrual loss could incur an anemic condition but not odorous stools. Bleeding ulcers can also cause anemia and black tarry stools, without the odor issues.
The exocrine pancreas is anastomosed to the bladder, and by measuring amylase, the exocrine product of the pancreas, one can monitor the functioning of the graft. Unless the patient had a pancreatectomy, the native pancreas may be making amylase. For the first several days postoperative, the serum glucose may not stabilize, and insulin may be required. The native pancreas may make a variably small amount of insulin, so direct measurement of the graft is not possible. The graft may have good blood flow but not be functioning well as a result of microvascular damage.
Ranson developed 11 criteria to determine the severity of pancreatitis. These factors are divided into admission criteria and initial 48 hours criteria. This patient's age of <55 years is reassuring. His blood glucose level is worrisome. His serum lactate dehydrogenase (LDH) level is worrisome. His serum calcium level is also worrisome. His serum calcium level is low and is also worrisome.
The superior parathyroid glands are located at the junction of the upper and middle third of the thyroid gland on the
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posteromedial aspect. The inferior parathyroids are located near the junction of the inferior thyroid and the recurrent laryngeal nerve. The carotid sinus is not near the location of the superior parathyroid glands.
Ultrasonography will define an enlarged parathyroid gland in 70% to 80% of cases. Dual tracer imaging can localize adenoma or hyperplasia in 70% of cases. Thyrocervical angiography is reserved for patients with recurrent hyperparathyroidism after surgical neck exploration. CT and MRI are helpful to locate enlarged parathyroid glands that are in the mediastinum.
This patient has tertiary hyperparathyroidism, which occurs in patients with chronic renal disease despite successful renal transplantation. Patients will have hypercalcuria (elevated urine calcium). There is no change in LDH levels. Serum phosphate levels are decreased. Serum and urine calcium levels are increased.
Melanocytes produce melanin and are chiefly responsible for pigmentation of the skin. They are of neural crest origin. One of the diseases associated with melanocytes is vitiligo, which is characterized by flat, well-demarcated zones of pigment loss. Keratinocytes produce keratin, which forms a waterproof layer. Langerhans cells are antigen-presenting cells. Merkel cells are epidermal cells that function in cutaneous sensation. Adipocytes are fat storage cells.
Basal cell carcinomas are the most common skin tumors. They tend to involve skin-exposed areas, most often in the head and neck. Grossly, they are characterized by a pearly papule with overlying telangiectatic vessels. The lower lip is actually the most common site for a tobacco user to develop squamous cell carcinoma. Malignant melanomas are the most likely primary skin tumors to metastasize systemically. Histiocytosis X (Langerhans cell histiocytosis) is caused by a proliferation of Langerhans cells, which are normally found in the epidermis. Seborrheic keratosis is a benign squamoproliferative neoplasm, associated with sunlight exposure. Fair-skinned persons are at increased risk. Depth of tumor correlates with risk of metastases.
A keloid is an abnormal proliferation of connective tissue with an abnormal arrangement of collagen. This abnormal proliferation looks very similar to a tumorlike scar. Keloids are much more common in African American individuals and usually follow some sort of trauma—in this case, the ear piercing. The Spitz nevus can be confused with malignant melanoma. However, the lack of color change or change in size would make melanoma a little less likely. Also, this patient is much younger than the average age of patients who present with melanomatous lesions. Spitz nevus is also known as juvenile melanoma; because of its benign nature, this name is falling out of use. It is important to always think of melanoma when this type of lesion is seen and to order appropriate tests to rule it out. Molluscum contagiosum is a viral disease caused by the DNA poxvirus. It is contracted via direct contact, and its lesions are characteristically pink, umbilicated, and dome-shaped.
Ovarian cancer is an associated risk for women with Peutz-Jegher's syndrome. Granulosa cell tumor is the most common. This condition is not associated with cervical carcinoma. Hereditary renal cell carcinoma can be associated with Von Hippel-Lindau disease. Hamartomas are not associated with liver carcinoma or pancreatic carcinoma.
This patient has carcinoid syndrome, which is caused by the release of substances from a carcinoid tumor. The medical treatment for carcinoid syndrome is octreotide, a somatostatin analog. Topical or intravenous corticosteroids are not beneficial for this patient. Furosemide is a loop diuretic used to treat fluid overload states. Tetracycline is an antibiotic and is not indicated in the treatment of carcinoid syndrome.
Appendicitis is predominantly seen in young adults. It causes right lower quadrant pain, nausea, vomiting, mild fever, and leukocytosis. The inflamed appendix may become gangrenous and perforate in 24 to 48 hours. Therefore, immediate appendectomy is standard treatment. Pancreatitis typically presents with epigastric pain radiating into the back, nausea, vomiting, and fever. Crohn's disease and ulcerative colitis are inflammatory bowel diseases that typically present with long-standing diarrhea. They do not typically present in an acute fashion, as in this patient. Diverticulitis is predominantly found in older adults and typically presents with left lower quadrant pain.
The left gastroepiploic artery runs through the gastrosplenic ligament to reach the greater omentum. The gastroduodenal artery and the right gastric artery branch off of the common hepatic artery. The gastroduodenal artery descends behind the first part of the duodenum. The right gastric artery runs to the pylorus and then along the lesser curvature of the stomach. The left gastric artery and the splenic artery arise from the celiac trunk. The left gastric artery runs upward and to the left toward the cardia, giving rise to esophageal and hepatic branches, and then turns right and runs along the lesser curvature within the lesser omentum to anastomose with the right gastric artery.
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This child has a Meckel's diverticulum, which is a congenital anomaly resulting from an unobliterated yolk stalk. More specifically, it is a vestigial remnant of the omphalomesenteric duct. It presents as an ileal outpouching typically located close to the ileocecal valve. The presence of inflammation, ulceration, and gastrointestinal bleeding due to the presence of ectopic acid–secreting gastric epithelium is seen in approximately half of these patients. Remember the rule of 2s with Meckel's diverticulum: It occurs in approximately 2% of children, occurs within approximately 2 ft of the ileocecal valve, contains 2 types of ectopic mucosa (gastric and pancreatic), and its symptoms usually occur by age 2.
Because of the symptoms of decreased burning with food intake and weight gain, a preliminary differential diagnosis of Helicobacter pylori would be appropriate. Treatment with the triple therapy of bismuth salicylate, metronidazole, and an antibiotic such as amoxicillin would be in order. The presentation of Escherichia coli tends to be a more acute infection.E. coli is associated with bloody diarrhea, and Shigella with abdominal cramping and diarrhea.
Thrombocytopenia is not a complication of a splenectomy. Thrombocytosis is a possible complication postsplenectomy. Anemia is not a direct result of splenectomy. Patients are unlikely to have basophilia or eosinophilia. Subphrenic abscess, atelectasis, pancreatitis, gastric dilation, and sepsis are the possible complications of splenectomy.
The peripheral blood smear in a postsplenectomy patient will show Pappenheimer bodies, Howell-Jolly bodies, and Heinz bodies. Nucleated red blood cells are found in the blood of sickle cell patients. Basophilic stippling is found in the blood of patients with lead poisoning. Spherocytes are found in patients with hemolytic anemia. Blister cells are found in the blood of patients with glucose-6-phosphate deficiency.
Postsplenectomy patients should receive vaccinations against encapsulated organisms. The common encapsulated organisms are Streptococcus pneumoniae, Neisseria meningitides,and Haemophilus influenzae. The best time to vaccinate these patients is preoperatively.
This patient likely has Hashimoto thyroiditis. Patients have mild thyroid tenderness and fatigue. Laboratory features include the presence of thyroid autoantibodies. Frequently, no treatment is necessary for this condition. Acute thyroiditis is associated with fever, chills, and dysphagia. Papillary carcinoma is associated with a palpable thyroid nodule. Riedel thyroiditis is associated with thyroid fibrosis. Symptoms of tracheal and esophageal compression are possible.
This patient has evidence of papillary carcinoma of the thyroid. Only 5% of patients with papillary carcinoma of the thyroid present with distant metastases. For tumors that are <1.5 cm and that are disease-confined to one lobe and no extracapsular extension, treatment with thyroid lobectomy is appropriate. External-beam radiotherapy is not required for this patient. Multiagent chemotherapy is not required for this patient. Subtotal and total thyroidectomy are not required for this patient.
Injury to the nerve causes bowing of the vocal cords during phonation. This can be a problem in singers who have difficulty reaching high-pitched notes. The nerve can be at risk during thyroid surgical procedures because of its proximity to the superior thyroid artery. The nerve is both sensory and motor to the larynx.
This patient is apneic. An airway must be established for this patient. However, he may also have fractures of the cervical spine. Thus the best treatment for this patient in terms of airway management is a tracheostomy. Nasotracheal intubation is inappropriate for a patient who is totally apneic. Oral intubation and oral intubation with head-chin lift is inappropriate because it requires some hyperextension of the neck. Intubation is necessary for a patient who is apneic.
It is unlikely that this patient has an open pneumothorax. Patients with pneumothorax are in obvious respiratory distress. They often have an obvious "sucking" chest wound. This patient has neither of the above findings. Left pneumothorax is possible in this patient and needs evaluation with a chest x-ray. Cardiac tamponade is possible in this patient, as is rupture of the main stem bronchus. Tension pneumothorax is also a consideration for this patient.
An amputated upper extremity body part can be replanted if properly recovered and transported with the patient. Cooling the body part in a chest filled with crushed ice and water may preserve the body part for up to 18 hours. The body part should not be placed in dry gauze or packed with dry ice. In addition, the body part should not be placed in warm water.
An ulcer will appear as a fluorescein-stained epithelial defect with a local corneal infiltrate. This patient appears to have no
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evidence of an ulcer. However, this form of testing does not rule out the presence of bacterial infection, iritis, trauma, or viral infection. This patient will benefit from treatment with quinolone eyedrops and avoidance of eye patching. Close follow-up with a physician is also recommended.
This patient has suffered a metallic foreign body to the eye with an epithelial rust ring. These should be removed immediately with an eye burr. Foreign bodies of the cornea can also be approached with a fine needle tip or an eye spud. Sterile water may be used, but alcohol exposure to the eye should be avoided. Cyanoacrylate glue adheres to the eyes and should also be avoided.
This patient has sustained a chemical burn to the eye. The eye should be immediately flushed at the scene with 1 to 2 L of normal saline, which should be continued in the emergency department. A topical anesthetic and a Morgan lens will facilitate flushing. Eye patch placement is not indicated. Placement of the eye under direct sunlight may damage the eye. Watchful waiting is not recommended; this patient needs eye lavage as soon as possible.
This patient likely has a compartment syndrome, which is caused by an increase in interstitial fluid pressure within an osteofascial compartment, leading to compromise of the microcirculation and myoneural necrosis. Diagnosis is confirmed by an intracompartmental pressure of 30 mm Hg or higher. Treatment of this condition is surgical fascial release.
Bursae are fluid-filled sacs that cushion areas of friction between tendon and bone or skin. Bursae are lined with special cells called synovial cells, which secrete a fluid rich in collagen and proteins. This synovial fluid acts as a lubricant when parts of the body move. When this fluid becomes irritated because of too much movement, the painful condition known as bursitis results. Rheumatoid arthritis is a multisystem disorder that results in symmetrical joint inflammation, articular erosions, and extra-articular complications. Infectious arthritis is unlikely in the absence of joint fluid aspiration that reveals an organism. Septic thrombophlebitis is unlikely given the history of this patient. Trauma is also unlikely given the history of this patient.
This patient may have suffered a tear of the rotator cuff. Most tears are small and may be treated symptomatically with rest, elevation, and anti-inflammatory agents. If the shoulder still demonstrates pain after a trial of conservative therapy, surgical repair should be considered. Injection of corticosteroids or intravenous corticosteroids is not considered to be first-line therapy for this patient.
Multiple randomized controlled studies have demonstrated decreased mortality and morbidity with intraoperative beta blockade in high-risk patients. This is one of the few interventions that has been clearly shown to improve outcomes.
In the setting of a normal history and physical, it is not necessary to obtain preoperative labs for minor surgery, though many surgeons and institutions will do this.
Lactated Ringer's solution is a bicarbonate-rich solution with an electrolyte composition similar to stool output.
Although all of the options contain important principles of wound closure, the most relevant here is gentle handling of the tissue and closure without tension to prevent further damage that can result in poor healing, infection, or hypertrophic scar formation. Although debridement of devitalized tissue is important, in this type of injury, the surrounding tissue is generally healthy and well vascularized.
This patient has signs and symptoms of an abdominal aortic aneurysm. This is suggested by the mentioned risk factors and physical examination findings. CT scan will provide precise anatomical detail and location of the aneurysm. This is particularly important for consideration of stent graft repair. Aortogram may be useful as a secondary test to prepare for surgical resection. Ultrasound could be performed to determine the presence of clot in the aortic lumen. The ultrasound choices given in this question would be unlikely to determine clot in the lumen because they are focusing on the upper quadrants and not the midline.
Younger women have more fibrous tissue, which makes mammograms harder to interpret. Thus ultrasound is a useful testing modality. This patient has a family history of breast cancer. Therefore, ultrasound and consideration for breast biopsy would be most prudent. As women age, breast tissue transforms from fibrous tissue to adipose tissue. This change makes it easier for mammography to detect masses. Thus this modality is more useful in patients older than 35 years. Watchful waiting may be considered if the lesion is benign. Testing for
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the BRCA gene may be considered if the patient is suspect to a family history of breast cancer.
This patient likely has ulcerative colitis. Patients complain of bloody diarrhea, fever, and weight loss and have frequent attacks of symptoms. Colonoscopy often reveals thickened, friable mucosa. Fissures and pseudopolyps are also common. Diverticulosis is rare in a patient younger than 30 years. Although internal hemorrhoids are a possible cause of bleeding in this patient, they do not present with the associated findings of abdominal pain and weight loss.
This patient has a glucagonoma, a tumor produced by pancreatic alpha cells that increases glycogenolysis and gluconeogenesis and leads to increased blood glucose levels. Glucagonomas are associated with necrolytic migratory erythema, a characteristically red, scaly rash usually located on the face but also occurring in other locations. Typical patients are thin and have an insidious onset of symptoms. Insulinoma would produce dizziness, diaphoresis, anxiety, and tremor because of the increased production of insulin and resulting hypoglycemia. Patients with type II diabetes mellitus are often obese and have a gradual onset of symptoms. Patients with Verner Morrison disease often complain of watery diarrhea, hypokalemia, and achlorhydria.
This patient likely has esophageal cancer by history. Any older patient with dysphagia should be assumed to have esophageal cancer until proven otherwise. This patient is a smoker with progressive dysphagia and lymphadenopathy, placing him at high risk. Definitive diagnosis requires biopsy at the time of esophagogastroscopy. CT and MRI may evaluate the presence of regional lymphatic spread. Barium study will detect lesions in more than 90% of patients but will not provide tissue for pathologic examination.
This patient likely has sickle cell anemia. Calcium bilirubinate stones are found in association with the following conditions: chronic biliary infection, cirrhosis, and hemolytic processes such as sickle cell anemia. A high-cholesterol diet has a role in the pathogenesis of cholesterol stones.
Atrial septal defects are often mild until later in life. As a result of the low pressures of both atria, only a small left-to-right shunt will occur. Over time, this increase in blood return to the right heart leads to pulmonary hypertension and right ventricular hypertrophy. Ventricular septal defect is associated with late cyanosis because of the left to right shunt. Patent ductus arteriosis is also associated with a left-to-right shunt and late cyanosis. The posterior descending artery can close with indomethacin treatment. Tetralogy of Fallot is the most common cause of early cyanosis. It is the result of a right-to-left shunt and results in early cyanosis.
Umbilical hernias are the result of a patent umbilical ring at birth. Some of the other choices in this question, such as patent omphalomesenteric duct, are seen in association with umbilical hernias, but this is likely coincidence as opposed to causality. Most of these hernias will resolve without the need for operation.
This patient has a uric acid stone. These stones are visible on CT scan but not on KUB x-rays. Calcium and struvite stones, on the other hand, are visible on both CT scan and on KUB x-rays. Knowing the visibility of stones on imaging modalities assists with treatment decisions.
Recurrent pancreatitis occurs within 6 weeks in nearly 50% of patients. When this occurs, complications of pancreatitis can be severe. Although the other choices are possible, they are not nearly as common.
Angioma is a benign tumor that frequently regresses, and simple observation (watchful waiting) with serial examinations and imagines studies is recommended. There is no need for other treatments such as corticosteroids, antibiotics, or lobectomy.
This patient likely has transitional cell carcinoma of the bladder. This is a common cause of painless gross hematuria in patients older than 50 years. This consideration is strengthened by the CT scan findings in this question (hydronephrosis and bladder mass). Both renal cell carcinoma and advanced prostate cancer can present with hematuria, but it is less likely. Urinary tract infections are also a cause of hematuria, but are not common in men. Nephrolithiasis can cause hematuria, but are more likely to cause flank pain.
This man most likely has adult polycystic kidney disease, an autosomal dominant disease. It is the most common inherited disorder of the kidney. Adult polycystic kidney disease is often associated with berry aneurysm in the circle of Willis. These aneurysms
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are prone to rupture, leading to subarachnoid hemorrhage. Cerebellar hemangioma is associated with von Hippel-Lindau disease, an autosomal dominant disease of chromosome 3.
Acute rejection typically occurs days to months after transplantation and is characterized by significant inflammation. Acute rejection is primarily T-cell mediated. These patients typically present with symptoms of acute renal failure. Hyperacute rejection occurs within minutes or hours of the transplantation and is due to preformed antibodies against the donor. In a hyperacute kidney rejection, the graft would rapidly become cyanotic, mottled, and flaccid and does not produce urine. Chronic rejection is probably more correctly termed chronic allograft nephropathy and presents years after transplantation with chronic changes on biopsy. Patients typically present clinically with a progressive increase in serum creatinine levels over a 4-to 6-month period.
This patient has suffered from chronic pain which is presumed to be of pancreatic origin. This can initially be treated with oral analgesics. For patients for whom this treatment fails, operative drainage is considered next. All of the above steps have failed, and therefore, this patient would best benefit from interruption of sympathetic nerve fibers (splanchnicectomy).
Patients with primary hyperparathyroidism can have renal stones. Typically, patients have multiple and bilateral stones. Thus a patient with 1-mm, 2-mm, and 3-mm stones bilaterally and visible on KUB suggests calcium stones.
Histologically, the epidermis has five layers, which are demarcated on the basis of microscopic morphology. The most superficial layer, the stratum corneum, is characterized by anucleate cells filled with keratin filaments. Beneath the stratum corneum is the stratum lucidum, which is only seen well in thick skin and is considered to actually be a subdivision of the stratum corneum. The stratum granulosum is beneath the stratum lucidum and contains keratohyalin granule-containing cells. The stratum spinosum, beneath the stratum granulosum, is composed of spiny-looking cells. Finally, the stratum basale, the deepest layer of the epidermis, is composed of a single layer of stem cells from which keratinocytes arise.
Because of the presence of granulomas in the colon, mycobacterial infection is thought to be the causative agent. Thus if one were to consider antibiotic therapy in such a patient, it should be directed toward this agent. However, no specific immunologic disturbance has been described for this disease.
This patient has postcricoid carcinoma, which is associated with Plummer-Vinson syndrome. Dysphagia is nearly always a symptom of organic disease rather than a functional complaint. Lymphoma and leukemia are rarely associated with iron deficiency anemia. Rheumatoid arthritis is associated with arthralgias of joints of the hands. Iron deficiency anemia is uncommon with this condition.
Accessory spleens are present in approximately 25% of patients. They are most often found in the splenic hilum. The second most common location is the splenic ligaments and greater omentum. Accessory spleens are almost never found in the right upper or lower quadrants.
This patient has a thyroglossal duct cyst. These are most commonly seen in children and appear as a single painless lump in the midline that moves with swallowing. Thyroid carcinoma is rare in children. Leukemia and lymphoma would be associated with palpable lymphadenopathy in the neck.
There are two ophthalmic injuries that require immediate treatment: acid/alkali burns and an unremovable corneal or conjunctival foreign body. The other choices should be referred immediately and do not require immediate on site treatment.
Primary closure is the simplest and most common method of wound closure. Surgical wounds created during a procedure are typically closed in this fashion. Delayed primary closure is considered if the wound is contaminated or requires debridement.
Bursae are fluid-filled sacs that cushion areas of friction between tendon and bone or skin. Bursae are lined with special cells called synovial cells, which secrete a fluid rich in collagen and proteins. This synovial fluid acts as a lubricant when parts of the body move. When this fluid becomes irritated because of too much movement, the painful condition known as bursitis results. Rheumatoid arthritis is a multisystem disorder that
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results in symmetrical joint inflammation, articular erosions, and extra-articular complications. Gonococcal arthritis is unlikely in the absence of joint fluid aspiration that reveals Gram-negative diplococci. Rheumatoid arthritis is an autoimmune disease that affects the synovial joints, with pannus formation in the joints (metacarpophalangeal, proximal interphalangeal), subcutaneous rheumatoid nodules, ulnar deviation, and subluxation. Septic bursitis is unlikely in the absence of a joint fluid aspiration that reveals organisms on Gram stain. Trauma is unlikely given the history in this patient.