The Correct Answer is BA felon, also called a whitlow, is an infection of the digital pulp of the terminal phalanx. The anatomic characteristics of this region compartmentalize infection, resulting in exquisite pressure and pain in the pulp spaces. As with all abscesses, incision and drainage is the single most important therapy.
Paronychial and eponychial infections occur in the dorsal surface of the finger about the nail. Bacterial tenosynovitis is an extension of a deep space infection along the tendons. Digital cellulitis is a nonspecific term and does not adequately describe the infection depicted. The presence of fluctuance with this infection suggests abscess formation rather than a simple cellulitis.
Ref: Schwartz SI (ed): Principles of Surgery, ed 7. McGraw-Hill, 1999, p 126.
The Correct Answer is E
The patient has acute suppurative sialadenitis which is caused by coagulase-positive Staphylococcus aureus, Streptococcus pneumoniae, and other bacteria. The patient therefore needs treatment with antibiotics. Tuberculosis is a rare cause. Cat scratch disease involves the lymph glands, not the salivary glands. A CT scan may be indicated if there is no improvement, or if a tumor is suspected.
Ref: Rice DH: Salivary gland disorders: Neoplastic and non neoplastic. Med Can North Am 1999; 83(1): 197-218.
The Correct Answer is A
At birth about 4% of foreskins are retractable, at 6 months it is 20%, at one year 50% and by 3 years it is 90%. If left untreated phimosis may ultimately lead to problems with micturition and sexual function. Inability to clean under the foreskin is associated with stones in the preputial sac and the development of cancer of the penis. Circumcision has a low rate of complications and is reported to be the safest surgical procedure in childhood.
The Correct Answer is B
Long term follow up in hospital does not favour outcome and is probably an inappropriate use of resources. Psychological support is best effected by the primary health care team. Tamoxifen if given for 5 years has shown to improve survival and decrease the risk of recurrence. Cancer in the opposite breast is 6 fold greater in those already having a malignancy, it is especially greatest for those who develop their first tumour under 40 years of age. Hormone manipulations often used first because of the decreased incidence of side effects. However the response rate is only 30% compared to 60% for chemotherapy.
The Correct Answer is B
The symptoms and signs of colorectal cancer vary depending upon the site of the tumour. Right sided lesions typically are painful with a palpable mass in 70%, rectal bleeding only occurs in 20%. In the left colon pain occurs less frequently but 60% have a change in bowel habit. 40% have a palpable mass. In the rectum, change in bowel habit is the commonest symptom, bleeding occurs in 60% and pain in only 5%
The Correct Answer is C
Stress and urgency incontinence require different treatments and are often confused. Stress incontinence is typically associated with leaking of urine on coughing, sneezing or laughter, leaking on playing sport or sudden movement. Urgency incontinence or detrusor instability is more likely with a history of frequency of 6 or more times per day and 3 or more times at night, leaking at night and having to rush to the toilet. Dribbling is a symptom of overflow incontinence.
The Correct Answer is A
For women who can comply indefinitely, pelvic muscle exercises are an option for mild to moderate stress incontinence; if not contraindicated, an alpha-adrenergic agonist (e.g., phenylpropanolamine) is also helpful in such cases, especially if combined with oestrogen. Occasionally, a pessary or even a tampon (for women with vaginal stenosis) provides some relief.
Mild stress incontinence can be treated nonoperatively with medications, hormonal supplementation, or biofeedback techniques. Modalities such as urethral plugs and anterior vaginal wall prostheses are under investigation.
The Correct Answer is D/ ?CStress incontinence, the second most common cause of established incontinence in older women (it is rare in men), is characterized by symptoms and evidence of instantaneous leakage of urine in response to stress. Leakage is worse or occurs only during the day unless another abnormality (e.g., detrusor overactivity) is also present. On examination, with the bladder full and the perineum relaxed, instantaneous leakage upon coughing strongly suggests stress incontinence, especially if it reproduces symptoms and if urinary retention has been excluded by a post voiding residual determination; a several-second delay suggests that leakage is instead caused by an involuntary bladder contraction induced by coughing.
Surgery is the most effective treatment with a cure rate of 75 to 85 percent. For women who can comply indefinitely, pelvic muscle exercises are an option for mild to moderate stress incontinence; if not contraindicated, an alpha-adrenergic agonist (e.g., phenylpropanolamine) is also helpful in such cases, especially if combined with oestrogen. Occasionally, a pessary or even a tampon (for women with vaginal stenosis) provides some relief.
Mild stress incontinence can be treated nonoperatively with medications, hormonal supplementation, or biofeedback techniques. Modalities such as urethral plugs and anterior vaginal wall prostheses are under investigation. Moderate to severe stress incontinence responds to surgical procedures aimed at supporting the anterior vaginal wall (vaginal, laparoscopic, or abdominal operations) or enhancing urethral closure when stress incontinence is secondary to internal sphincter deficiency (periurethral injection of teflon or collagen or insertion of an artificial urinary sphincter).
The correct answer is D.Breast lumps are a common complaint in women. Many of these masses are benign processes. Benign conditions of the breast include fibrocystic disease, fibroadenomas, galactoceles, abscesses, and necrosis. It is appropriate to aspirate a palpable macrocyst in the breast; the fluid should be placed on a slide and sent for cytologic evaluation. If the cytology is negative, no further treatment is needed. Some would argue that if the cyst recurs, it may be aspirated again. However, when a lesion recurs twice, as has occurred in this patient, open biopsy is warranted.
To wait to perform mammography in 1 year (choice A) or ultrasound in 1 year (choice B) would be incorrect management. First, if a malignancy is present, waiting another year will allow progression of the cancer. Second, the mammogram is not definitive. Imaging can contribute information to the workup of a breast mass, but the definitive diagnosis rests on histologic evaluation.
Tamoxifen therapy (choice C) is used to both prevent and treat breast cancer. However, this patient does not yet have a diagnosis. She has a cystic mass that has been aspirated twice and has recurred twice. She therefore requires a biopsy to establish a diagnosis prior to the institution of any treatment.
Mastectomy (choice E) would not be indicated for this patient. Again, this patient does not have a diagnosis, and to perform a mastectomy for a recurrent cyst would be inappropriate.
The correct answer is A.Of the cases of breast cancer that are heritable, approximately 80% are due to mutations in BRCA1 and BRCA2. BRCA1 is associated with high risk for breast and ovarian cancer. BRCA2 is associated with a high risk of female and male breast cancer. On the basis of our current understanding, however, less than 10% of all breast cancer cases can be considered to be heritable. Therefore, the total number of breast cancer cases associated with BRCA1 and BRCA2 mutations is a small percentage of the total number of breast cancer cases.
Furthermore, there are numerous mutations that can occur in the BRCA1 and BRCA2 genes and can be related to an increased cancer risk. Some patients who have a mutation associated with cancer will not go on to develop cancer. Other patients may have a strong family history of breast cancer but no identifiable mutation. At present, therefore, screening of the general population is not recommended.
This patient has no family history and is not in a high-risk group. Her prior breast tenderness was likely mastalgia related to the premenstrual phase. Therefore, BRCA1 and 2 screening would not be recommended for this patient.
To state that BRCA1 and 2 screening should be performed after age 50 (choice B) is incorrect. As noted above, given the limitations of the testing for BRCA1 and 2 mutations, screening of the general population is not recommended.
To state that BRCA1 and 2 screening should be performed if breast pain recurs (choice C) is incorrect. This patient does not need screening, not because her breast pain has resolved, but rather because BRCA1 and 2 screening is not appropriate for the general population at this time. As noted above, her breast pain was likely cyclic mastalgia secondary to hormonal changes prior to menses.
To state that either BRCA1 screening (choice D) or BRCA2 screening (choice E) is recommended is not correct. As explained above, screening for neither of these is recommended.
The Correct Answer is AThe classic teaching that pulmonary atelectasis is a cause of fever after abdominal surgery has been refuted. A study to determine the connection between postoperative fever and atelectasis found no relationship. The incidence of atelectasis increased daily after surgery, whereas the incidence of fever decreased. Wound infection is statistically the most common cause of postoperative fever.
Pneumonia, urinary tract infection, and pyogenic response to medication are all possible causes of postoperative fever. Thrombophlebitis is one of the most common causes of fever after the third postoperative day.
Ref:
- Perlino CA: Postoperative fever. Med Clin North Am 2001; 85(5):1141-1149. 2)
- Townsend CM Jr: Sabiston Textbook of Surgery, ed 16. WB Saunders Co, 2001, pp 179,204.
The Correct Answer is CAortic injury is one of the deadliest injuries and often is difficult to diagnose. It is being seen with increasing frequency in motor vehicle accidents due to the increase in traveling speed over the years. Of the trauma victims with an aortic injury who survive the accident to be transported to the hospital, about 70% will survive if the diagnosis is made promptly and intervention is available without delay.
The majority of aortic ruptures occur in the descending aorta (80-90%) just distal to the origin of the left subclavian artery. Even though only 9-10% of aortic ruptures occur in the ascending aorta, they are identified as a lethal injury 70-80% of the time. Blunt force injury to the chest can cause a "shearing" force to the aorta due to sudden deceleration. Lacerations to the aorta from this shearing force can be small, or may cause a complete fracture of the aorta. The patient who has suffered blunt chest or thoracic trauma must be considered to have an undiagnosed aortic injury until fully evaluated at the trauma center.
Upon initial examination the patient may present with upper extremity hypertension and pulse discrepancies. Femoral pulses will probably be absent.
Chest radiographs typically show:
- Widened mediastinum
- Displacement of the left mainstem bronchus
- Aortic knob distortions
If a nasogastric tube has been inserted, a displacement of the esophagus may also be visualized.
Thoracic CAT scans and aortography are useful in diagnosis of this phenomenon, but often the patient is too unstable to tolerate these procedures. Once the diagnosis is confirmed, the patient will need immediate surgical repair of the aortic laceration. If it is believed that the patient will not survive long enough to reach the operating suite, emergency thoracotomy is necessary in the emergency department.
The Correct Answer is CIntussusception is the telescoping or prolapse of one portion of the bowel into an immediately adjacent segment. Contrast enema can reduce the intussusception in approximately 75% of cases.
Pathophysiology- Most commonly occurs at the terminal ileum.
- The telescoping proximal portion of bowel invaginates into the adjacent distal bowel.
- The mesentery of the intussusceptum is compressed, and the ensuing swelling of the bowel wall quickly leads to obstruction.
- Venous engorgement and ischemia of the intestinal mucosa cause bleeding and an outpouring of mucous, which results in the classic description of red “currant jelly” stool.
- Most cases (90%) are idiopathic.
Intussusception is the predominate cause of intestinal obstruction in persons aged 3 months to 6 years. The estimated incidence is 1-4 per 1000 live births.Overall, the male-to-female ratio is approximately 3:1. With advancing age, gender difference becomes marked; in patients older than 4 years, the male-to-female ratio is 8:1.
The typical presentation is a previously healthy infant boy aged 6-12 months with sudden onset of colicky abdominal pain with vomiting.
The correct answer is C
Fibroadenoma is a common benign tumor found in the breast of adolescent girls. It is also considered the
most common discrete solid mass found within the adolescent breast tissue.
Most girls harboring a fibroadenoma have between thirteen and 16 years of age, the tumor is slow growing, tends to develop in the upper outer quadrant and is more common in African-American race.
Though females may develop breast masses early in life, the risk of malignancy is extremely low. The tumor is usually solitary, with an average diameter of two to 4 cm, characterized by rich cellular stroma and prominent glandular epithelium.
At physical exam the mass feels like a well-circumscribed movable nodule. Fibroadenomas may be related to an exaggerated local response to the estrogenic effects of puberty.
The tumor looks well-circumscribe, hyperechoic and homogenous on ultrasound.
The correct answer is CRisk factors- Age
- Exposure to exogenous estrogen
- Family history
- Pregnancy
- Genetics
AGE
- 85% of breast cancers occur in women over 50yrs
- 10% in women in their 40’s
Family history
- first degree relatives is most important
- number of affected family members-increased risk with closer the relation and earlier the age of diagnosis
Endogenous estrogen
- Prolonged exposure to endogenous estrogen.
- Look at early onset of menarche-age <12yrs
Pregnancy
- Pregnancy- first life birth before 30yrs
- Risk increases for live births after 35yrs
- Risk again increases for nulliparous women
- Also there is an increased risk with lower cumulative months of lactation
- All of these prolong lifetime exposure to estrogen peaks of menstrual cycle
Prolonged exposure to exogenous estrogen
- After menopause –initiation of estrogen replacement therapy ( ERT)
- Delays onset of osteoporosis
- Protective against heart disease and stroke
- Studies have shown an increased risk of breast cancer after 5yrs
- Consensus that benefits outweigh risks
Also implicated is oral Contraceptives-suspected increased risk but evidence is contradictory,newer formulas combo of low dose estrogen and progesterone are thought to be better
The correct answer is C
Pancreatic endocrine tumor, functional
Somatostatin-secreting (somatostatinoma) (diabetes mellitus, cholelithiasis, steatorrhea, hypochlorhydria)
Adrenocorticotropic hormone-producing (Cushing’s syndrome: central obesity, muscle weakness, glucose intolerance, hypertension)
- Insulinoma
- Most common islet cell tumor
- May secrete enough insulin to cause hypoglycemia
- Sxs: confusion, stupor, loss of consciousness
- Morphology
- most are solitary adenomas, 10% are multiple, 10% are metastatic
- See diffuse islet hyperplasia, with normal β cells (rectangular granules)
- Gastrinoma (Zollinger-Ellison syndrome)
- Triad of disease: peptic ulcers, gastric hypersecretion, endocrine gastrin-secreting tumor
- 60% are malignant
- Histology is similar to normal G cells
- Pts present with severe diarrhea, fluid/electrolyte imbalance and malabsorption
- Glucagonoma
- sxs similar to diabetes mellitus; have migratory skin erythema and anemia
- Somatostatinoma
- sxs: diabetes mellitus, cholelithiasis, steatorrhea, hypochlorhydria
- VIPoma
- sxs: watery diarrhea, hypokalemia, achlorhydria; associated with neural crest tumors
The Correct Answer is AThe gastrinoma syndrome, or Zollinger-Ellison syndrome, has traditionally been associated with a severe, fulminant ulcer diathesis, often with multiple ulcers, and ulcers in unusual locations such as the post-bulbar region of the duodenum and proximal jejunum.
The vast majority of Zollinger-Ellison syndrome (ZES) patients will develop ulcers, usually in the duodenal bulb, but sometimes also in the postbulbar duodenum or jejunum. An elevated serum gastrin concentration in a patient who is not achlorhydric is pathognomonic of the disease. Secretin testing adds little but may be positive on occasion in the rare patient with only minimally elevated serum gastrin. Extremely elevated serum gastrin levels (>1000 pg/ml) are not diagnostic of ZES as similar elevations do occur in patients who are achlorhydric. Therefore it is generally necessary to document the presence of gastric acid production when evaluating very elevated serum gastrin concentrations with gastric pH measurements or formal gastric analysis.
The correct Answers are: B,C
Crohn's disease of the colon is a patchy, segmental, chronic, transmural inflammatory process that penetrates the bowel wall to form fistulas but seldom causes rectal bleeding. In contrast, ulcerative colitis is a mucosal ulcerating process that extends continuously from the rectum to the more proximal colon and frequently bleeds. Both diseases can develop toxic megacolon, and both predispose the patient to increased risk of malignancy of the large intestine over the long term.
The correct answer is
ABD DISCUSSION:
Patients with colonic Crohn's disease who have minimal or mild rectal involvement can be treated by colectomy and ileorectostomy or by colectomy, closure of the rectal stump, and ileostomy. When severe rectal involvement is also present, proctocolectomy with permanent ileostomy is required. The Kock pouch (continent ileostomy) and the ileal pouch–anal canal operation are not performed for Crohn's disease because of the risk of recurrence of Crohn's disease in the ileal pouch in the postoperative period.
The correct answer is E.
The patient is suffering from hyperacute rejection due to the preformed anti-B ABO blood group antibody found in all type A positive individuals. Hyperacute rejection occurs within minutes to a few hours of the time of transplantation, and is due to the destruction of the transplanted tissue by preformed antibodies reacting with antigens found on the transplanted tissue that activatecomplement and destroy the target tissue. Preformed antibodies can also be due to presensitization to a previous graft, blood transfusion, or pregnancy.
Acute rejection due to antibody-mediated immunity (choice A) is incorrect because this patient suffered from hyperacute rejection (immediate) occurring within minutes to hours, rather than days.
Acute rejection due to cell-mediated immunity (choice B) will not occur until several days or a week following transplantation. Acute rejection is due to type II and type IV reactions. Chronic rejection, due to the presence of cell-mediated immunity to minor HLA antigens (choice C), occurs in allograft transplantation months to even years after the transplant. Chronic rejection is generally caused by both humoral and cell-mediated immunity. An accelerated acute rejection, occurring in 3-5 days, can be caused by tissue infiltration and destruction by presensitized T lymphocytes and macrophages (choice D) and/or antibody-dependent, cell-mediated cytotoxicity (ADCC). Note that this is not a hyperacute reaction.
The correct answer is D. The lesion is a malignant melanoma. Melanomas can develop either de novo or in an existing mole. Sunlight exposure is a significant risk factor and fair-skinned persons are at increased risk of developing melanoma. The most significant factor for long term prognosis is the depth of the lesion, since the superficial dermis lies about 1 mm under the skin surface, and penetration to this depth is associated with a much higher incidence of metastasis than is seen with a more superficial location.
The circumference of the lesion (choice A) is much less important than depth , since one form of melanoma (superficial spreading) can still have good prognosis despite large size, if it has not extended to the depth of the superficial dermal lymphatic bed.
The darkness (choice B) or degree of variation in color (choice C) do not have prognostic significance once melanoma is diagnosed.
Irregularity, or fuzziness at the border (choice E) of a mole-like lesion is a good clue to potential malignancy, but does not affect prognosis once a melanoma is diagnosed.
The correct answer is E.
The baby probably has congenital hypertrophic pyloric stenosis, which usually presents at several weeks of age. Partial surgical incision through the pylorus (pyloromyotomy) is usually curative.
Antacids (choice A) are beneficial in esophageal reflux and peptic ulcer disease.
Barium enema (choice B) can reverse intussusception in a child, but would not be therapeutic in this case.
Gastric resection (choice C) is not indicated, since the much less invasive procedure of pyloromyotomy is actually more effective.
Oral antibiotics (choice D) are not indicated, since this is not an infectious process.
