The correct answer is 5.

Femoral shaft fractures are generally seen after severe direct trauma. Patients suffering traumatic fractures of the femoral shaft frequently present with signs of shock as a significant amount of blood can be lost into the thigh. On examination, the thigh is often deformed and ecchymotic. The preferred management for femoral shaft fractures is closed intramedullary fixation of shaft with medullary reaming and intramedullary nailing. This allows for early mobilization, improved knee and hip function during recovery and decreased hospital cost. In this technique, closed reduction of fracture segment is followed by intramedullary nail insertion through small skin insertion over the greater trochanter.

(Choice 1) Closed intramedullary nailing is preferred over open nailing in closed femoral shaft fractures as it is associated with a lower risk of infection, less soft tissue disruption and a lower risk of nonunion.

(Choice 2) External fixation is indicated in certain cases of open fracture where contamination of the wound is significant and the placement of indwelling hardware is contraindicated or when there is significant soft tissue loss around the fracture.

(Choice 3) Plaster casting is inappropriate for femoral shaft fractures because there is no traction to maintain femoral length and rotational position and weight bearing would be delayed for a prolonged period of time thereby increasing morbidity.

(Choice 4) Plate and screw fixation is reserved only for patients who cannot be treated with intramedullary nailing, such as victims of polytrauma who are unable to be placed on the fracture table.

The correct answer is 3.

The complaints of this patient are daytime fatigue, anorexia, significant weight loss, and visceral-type abdominal pain interfering with sleep. Physical examination reveals a tender, full epigastrium. This combination suggests a malignancy affecting the upper Gl tract or associated solid organs, such as the liver, gallbladder or pancreas. Among the choices listed, pancreatic carcinoma is the most likely diagnosis. Note that unlike the presentation in this case, early cancers of the periampullary region of head of the pancreas may present with progressive jaundice as well. Because pancreatic cancer most commonly occurs in the head of the pancreas, the most common presentation of this malignancy is a combination of constant epigastric pain radiating to the back, weight loss and jaundice. Another classic association is migratory thrombophlebitis.

(Choice 1) A peptic duodenal ulcer can cause epigastric burning pain, but this is typically periodic and relieved by meals. Anorexia need not be prominent, and because of the latter alleviating factor, weight loss is less common.

(Choice 2) A major depressive episode could be responsible for fatigue, anorexia, insomnia and weight loss. Abdominal pain and tenderness would not be typical. The latter findings suggest an organic lesion.

(Choice 4) Post-traumatic stress disorder consists of persistent reexperiencing of a previous traumatic event with recurrent attacks of anxiety, hyperarousal, nightmares, and/or flashbacks. It disturbs social and occupational functioning, but does not typically cause anorexia, weight loss or signs of organic disease such as abdominal pain and tenderness.

(Choice 5) Since this patient coincidentally has a history of recent blunt head trauma, a chronic subdural hematoma might have developed. This would be more likely in an elderly person and would typically cause headache, personality changes, seizures, confusion or hemiparesis. Abdominal pain and tenderness with anorexia and weight loss would not be expected.

The correct answer is 1.

There are two favorable findings in this patient: Her axillary lymph nodes do not have metastasis, and her tumor is strongly positive for hormonal receptors. However, everything else is unfavorable: The tumor is quite large, and the prognostic factors are all unfavorable. Clearly, the patient would benefit from chemotherapy, and she should be placed on hormonal therapy after chemotherapy and radiation therapy to take advantage of the positive hormonal receptors. The objective of the hormonal manipulations is to either block her receptors (with tamoxifen) or suppress the production of estrogens (with anastrozole). Randomized studies have shown that anastrozole is considerably more effective than tamoxifen in postmenopausal patients. Thus, it has become the drug of choice for that group.

(Choice 2) would be the best course of action for premenopausal patients, for whom anastrozole is not yet approved as the best drug. Chemotherapy and tamoxifen would have been the regimen for this patient before the advent of anastrozole.

(Choice 3) Adding estrogens and progesterone to the chemotherapy would be contraindicated. We want to deprive the tumor of the stimulation provided by those hormones.

(Choice 4) Completion of the operation to a more radical form of resection has no benefits. The patient has a very large margin of normal tissue around the tumor, all the margins are negative, and the patient has agreed to postoperative radiation. We do not cure breast cancer by cutting out more normal tissue. We do it by treating the systemic spread of the disease.

(Choice 5) Radiation therapy is focal in nature. It does not treat distant metastatic spread. The patient needs radiation to the breast that had the tumor to minimize the rate of local recurrence. Radiating the other breast and the axilla would not be helpful.

The correct answer is 1.

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%). 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.

The correct answer is 5.

The obvious clinical finding is a very large urinary output, which is neither in response to nor being matched by her fluid intake. With a history of surgery in the area of the pituitary gland, we have to suspect that damage to the posterior pituitary gland, or to the stalk, may have occurred and that diabetes insipidus has developed. If that is the case, we will see a significant increase in the serum sodium concentration, explaining the neurologic findings. (Choice 1) Blood glucose would not be increased by the fluids she is getting. It could be decreased if pituitary insufficiency and secondary adrenal insufficiency had developed, but in that case the presentation would have been one of otherwise unexplained shock.

(Choice 2) CT scan of the head would have been a good idea if she had a normal urinary output but had reported a horrible headache, followed by neurologic deterioration, suggesting intracranial bleeding.

(Choice 3) Creatinine clearance assumes that something is intrinsically wrong with the kidneys. Her kidneys are fine; they simply are not getting ADH and therefore are excreting high volumes of much diluted urine.

(Choice 4) Serum levels of ACTH follows the same line of reasoning as (Choice 1). Secondary adrenal insufficiency would have produced shock, hypoglycemia, and hyperkalemia in a patient who would be awake and not “peeing out a storm:’

The correct answer is 3.

Sensory fibers of the ninth (glossopharyngeal) nerve are in the vicinity of the digastric muscle, and can be damaged by retraction and dissection in the area. The lack of sensory input at the base of the tongue prevents the normal protective reflex that closes the glottis when swallowing liquids.

(Choice 1) Unilateral injury to the main trunk of the vagus in the neck would produce symptoms from the recurrent fibers that innervate the larynx, producing a hoarse voice but no change in swallowing.

(Choice 2) Injury to the mandibular branch of the facial nerve would produce drooping of the corner of the mouth and leaking of fluid at that level. Soup running out of the corner of the mouth is annoying, but swallowing is not affected.

(Choice 4) If the superior laryngeal branch of the vagus is damaged, the voice tires easily. Swallowing is not affected.

(Choice 5) The twelfth nerve is the most commonly damaged nerve during carotid endarterectomy because it crosses the internal and external carotids a short distance cephalad to the bifurcation. However, the outcome is deviation of the tongue to the affected side.

The correct answer is 5.

The patient described is suffering from acute pancreatitis with a secondary ileus. The most common causes of acute pancreatitis are gallstones, alcohol consumption, hypertriglyceridemia and recent ERCP. Treatment of pancreatitis is primarily supportive with intravenous fluids, NG tube suction, NPO and analgesia. In severe cases, antibiotics are indicated, and calcium and magnesium levels should be monitored and replaced as needed. A cause for the pancreatitis should also be sought. Choledocholithiasis is the most common cause of pancreatitis, and an ultrasound study early in the disease process may detect the offending stone before it is passed.

(Choice 1) The patient has evidence of a mild metabolic alkalosis (increased HCO 3 .) most likely due to vomiting. Bicarbonate is not indicated at this time.

(Choice 2) Evidence does not support the use of pancreatic protease inhibitors in acute pancreatitis.

(Choices 3 & 4) Carbachol is a cholinomimetic agent that stimulates contraction of the bowel musculature. As such, it may contract the sphincter of Oddi thereby worsening this patient’s pain. In fact, anticholinergics have been tested in the treatment of acute pancreatitis in an effort to relax this sphincter but have shown no benefit. This ileus is expected to resolve with the improvement of the pancreatitis.

The correct answer is 2.

The patient described is experiencing symptoms consistent with nephrolithiasis, which classically presents with flank pain and hematuria frequently accompanied by nausea and vomiting. Patients with Crohn disease, or any other small intestinal disorder resulting in fat malabsorption, are predisposed to hyperoxaluria. Oxalate is obtained from the diet and is a normal product of human metabolism. Symptomatic hyperoxaluria is classically the result of increased oxalate absorption in the gut. Under normal circumstances, calcium binds oxalate in the gut and prevents its absorption. In patients with fat malabsorption, calcium is preferentially bound by fat leaving oxalate unbound and free to be absorbed into the bloodstream. Failure to adequately absorb bile salts in states of fat malabsorption also cause decreased bile salt reabsorption in the small intestine. Excess bile salts may damage the colonic mucosa and contribute to increased oxalate absorption.

(Choice 1) Bile salt recycling and fatty acid absorption are decreased in Crohn disease. (Choices 3 & 4) Hypercalciuria, which may be idiopathic or may result from hyperparathyroidism, excessive calcium and vitamin D ingestion, dehydration or prolonged immobilization, predisposes to calcium stone formation.

(Choice 5) Recurrent urinary tract infections, particularly by Proteus species, predispose to struvite stone formation. Struvite stones may eventually grow to fill the entire renal pelvis, at which point they are known as “staghorn” calculi.

The correct answer is 2.

Shock is a condition in which peripheral blood flow is compromised, depriving cells of adequate oxygen supply. Several different conditions can cause shock, but there is commonality in the symptoms produced. By the time she is seen by the physician, the patient described is suffering from toxic shock syndrome (TSS) due to failure to remove the tampon over the course of 4 days. The early phase, including high temperature, rash, hypertension, and warm skin, reflects the inflammatory effects of toxins caused by bacteria growing in the tampon. In TSS, this phase generally lasts about 30 minutes and is then followed by the more typical symptoms of shock due to a toxin-induced shutdown of the vascular system. These typical shock symptoms include pale or gray skin that is cold and clammy to the touch; tachycardia with weak heart sounds; shallow, rapid breathing; hypotension; lack of focus with confusion; and possibly delirium. In the 1980s, a small epidemic of TSS was associated with a specific brand of “super-absorbant” tampons that allegedly could be left in place for an extended period. Since that brand was removed from the market, the condition has become much less common. TSS more often occurs in response to factors other than tampon use in menstruating women. The hypothesis regarding tampon-induced TSS is that, when women leave tampons in place for a long time, they may become infected with Staphylococcus aureus. This bacteria breeds in the tampons and produces toxins that induce septic shock. The tampons are a perfect growth medium, the environment is warm and moist, and the blood is a rich source of nutrients. Moreover, while in the tampon, the bacteria cannot be affected by normal physiologic defense mechanisms and are largely immune even to the influence of antibiotics.

(Choice 1) can be caused by loss of blood (either externally as by a wound or internally as in gastrointestinal bleeding or a fractured femur) or by dehydration from loss of fluid from extravascular compartments (as in vomiting or diarrhea). The symptoms are the same as those described for this patient, but the onset of shock would not be preceded by the early reaction to toxins.

(Choice 3) occurs when the supply of blood to peripheral tissues falls below a critical level because of inadequate pumping ability of the heart. The symptoms again are as those described, and the condition may be caused by a myocardial infarct, heart failure, cardiac arrhythmias, or cardiac tamponade.

(Choice 4) is caused by an allergic reaction to any of a host of potential allergins. As in TSS, shock is preceded by a brief inflammatory period. However, there is no reason to suspect an allergic reaction in the case presented.

(Choice 5) would represent classic septic shock, likely caused by an ingested pathogen or infection from gastrointestinal or urinary tract pathogens. As in TSS and anaphylactic shock, the onset of shock is preceded by a brief inflammatory period. However, gram-negative bacteria are rarely, if ever, associated with tampon-induced shock.

The correct answer is 3.

Perioperative or postoperative myocardial infarction (Ml) occurs in approximately 0.5% of patients undergoing non-cardiac surgery. This incidence increases to 5-1 0% in patients who are over the age of 70 or who have preexisting atherosclerotic conditions, cardiac conditions such as heart failure, or ischemia identifiable on cardiac stress testing. Major risk factors for perioperative cardiac ischemia include cardiac ischemia demonstrable by symptoms or noninvasive testing, heart failure, insulin-dependent diabetes mellitus, renal insufficiency, arrhythmias or AV block, history of stroke, advanced age, uncontrolled hypertension and low functional capacity. These risk factors can be used to determine a patient’s overall cardiac risk for a given procedure. Not all procedures carry the same cardiac risk. High risk procedures include emergency and major vascular operations; intermediate risk procedures include orthopedic, intraperitoneal and intrathoracic procedures; and low risk procedures include endoscopy and minor procedures of the skin or eye. The patient in the vignette is at intermediate risk for cardiac complications during or after surgery. Numerous studies have shown that administration of a P-adrenergic receptor antagonist before, during and after

surgery in at-risk patients significantly lowers the incidence of perioperative myocardial ischemic events. Beta-blockers exert this cardioprotective effect by decreasing cardiac work and causing a resultant decrease in myocardial oxygen demand.

The correct answer is 3.

For patients involved in motor vehicle accidents or falls from > 10 feet, physicians must have a high suspicion for blunt aortic injury. Blunt aortic injury carries a high mortality rate, making expeditious detection and treatment critical. Though clinical signs and symptoms are highly variable, anxiety, tachycardia and hypertension are common. Therefore, radiographic imaging is critical to diagnosis and should be obtained whenever the mechanism of injury raises suspicion for blunt aortic injury. Chest x-ray is an appropriate initial screening study. Mediastinal widening is the most sensitive finding for blunt aortic injury. Deviation of the trachea or nasogastric tube to the right or depression of the left mainstem bronchus may also be seen. Here the chest x-ray shows substantial mediastinal widening, sufficient for diagnosis. Where the history and chest x-ray findings are equivocal, chest CT and angiography are appropriate.

(Choice 1) Myocardial contusion may also result from blunt trauma. Tachycardia is a common sign, and chest x-ray may demonstrate rib fractures, a common cause of cardiac contusion. Mediastinal widening is not seen with myocardial contusion alone.

(Choice 2) Left ventricular (LV) aneurysm may present on chest x-ray as a prominence or bulge along the left heart border. LV aneurysm is most commonly seen as a complication of transmural myocardial infarction, and is not associated with trauma. It is best diagnosed by echocardiogram.

(Choice 4) Hemothorax is indistinguishable from pleural effusion on chest x-ray. Blunting of the costophrenic angle, or even partial to complete opacification of one hemithorax might be expected from a significant hemothorax.

(Choice 5) Pulmonary contusion is the most common finding after blunt chest injury. Chest x-ray reveals opacities caused by hemorrhage in the involved lung segments.

The correct answer is 4.

Acute mediastinitis with air in the tissues that occurs within a few hours of an upper gastrointestinal endoscopy is virtually diagnostic of instrumental, iatrogenic esophageal perforation.

(Choice 1) is also a form of esophageal perforation, but it is caused by protracted, forceful vomiting, which this patient did not have.

(Choice 2) A dissecting aneurysm of the thoracic aorta can mimic a myocardial infarction, but it would not fill the mediastinum with air.

(Choice 3) In upper gastrointestinal endoscopy, the esophagus, which has narrow lumen and a flimsy wall, can be perforated easily, but the stomach, which has ample lumen and a thick, strong wall, almost never is. Furthermore, other than looking, nothing was done that could damage the stomach (laser or electrocoagulation). Finally, a hole in the stomach gives an acute abdomen with free air under the diaphragm, rather than mediastinitis with air in the mediastinum.

(Choice 5) A real myocardial infarction is rare in a 32- year-old, and like the previous option, it produces pain but not mediastinitis with air.

The correct answer is 6.

This patient’s fever, leukocytosis, and parotid inflammation suggest acute bacterial parotitis. Dehydrated post-operative patients and the elderly are most prone to develop this infection. Acute bacterial parotitis presents with painful swelling of the involved parotid gland that is aggravated by chewing. Prominent physical exam findings are a tender, swollen and erythematous gland; with purulent saliva expressed from the parotid duct. The most common infectious agent is Staphylococcus aureus. Adequate fluid hydration and oral hygiene, both pre- and post-operatively, can prevent this complication.

(Choice 1) Incentive spirometry has been shown to reduce post-operative pulmonary complications by 50%. It will not prevent parotitis.

(Choice 2) Perioperative use of (3-blockers in patients with coronary artery disease decreases the likelihood of myocardial ischemia.

(Choice 3) Perioperative antibiotics should routinely be given to patients undergoing abdominal surgery.

(Choice 4) Tetanus toxoid is used to prevent tetanus. This illness presents with lockjaw, muscles spasms, and seizures.

(Choice 5) Polysaccharide vaccine is indicated in all patients over 65 to prevent illnesses caused by Streptococcus pneumoniae. The most common cause of parotitis is Staphylococcus aureus.

(Choice 7) Early ambulation is one of many proven methods of preventing post-operative complications, particularly deep venous thrombosis.

The correct answer is 2.

Acute arterial occlusion is an acute event typically caused by embolization. It can also be seen in thrombosis of an atheromatous plaque or in vascular trauma. Rapid intervention is required to avoid permanent sequelae. The diagnosis is made by physical exam and is characterized by the “six P’s”: pain, paralysis, pallor, paresthesia, poikilothermy, and pulselessness. The most appropriate immediate treatment consists of anticoagulation with IV heparin.

(Choice 1) A CT scan is an inappropriate choice for imaging because it does not evaluate peripheral arterial disease.

(Choice 3) An ankle brachial index (ABI) is used to evaluate arterial insufficiency. In this patient with no Doppler-able pedal signals, it will not assist in the diagnosis.

(Choices 4 & 5) A venous duplex and bedrest with lower extremity elevation would be more appropriate in patients with venous stasis, not in patients with arterial disease.

The correct answer is 3.

The patient has volume overload due to overzealous fluid resuscitation during and after surgery. Volume overload is the most common cause of congestive cardiac failure after surgery. A third heart sound is the first cardiac sign of left or right-sided congestive heart failure. Bibasilar inspiratory crackles indicate left-sided heart failure, and jugular venous distention and peripheral pitting edema are features of right-sided heart failure. Volume overload can be corrected by administration of a loop diuretic and by restricting fluid volume. It is always important to monitor fluid intake and output carefully in patients to avoid inadvertent fluid overload.

(Choices 1 & 2) Endotoxic shock and cardiogenic shock are incorrect responses because the patient has a normal blood pressure.

(Choice 4) is associated with tachycardia, dyspnea, thrombocytopenia, and petechiae over the chest. The latter two findings are not present in this patient.

(Choice 5) is not associated with peripheral pitting edema because it refers to retention of water without sodium. Serum sodium is usually less than 120 mEq/L; water restriction is the treatment of choice.

The correct answer is 3.

Respiratory complications are a common cause of postoperative morbidity and mortality. After upper abdominal surgery, a combination of factors can cause the vital capacity (VC) to fall 50% and the functional residual capacity (FRC) to fall 30%. First, postoperative pain promotes shallow, rapid breathing. Narcotic analgesics further decrease respiratory drive, deep inspirations and coughing. Some anesthetic agents depress mucociliary clearance and may promote bronchiolar obstruction as well. Additionally, obese patients will experience a Pickwickian-like syndrome when kept chronically supine following surgery. These factors together promote alveolar atelectasis, a major cause of FRC reduction. Atelectasis is the most common respiratory complication during the first 24 hours after surgery. It not only impairs gas exchange by decreasing the number of alveoli available for gas exchange, but it also predisposes to pneumonia. Chest physiotherapy, incentive spirometry, coughing and frequent repositioning/early ambulation are all methods that can be used to increase the FRC and prevent atelectasis in the immediate postoperative period. Simply moving the patient from supine to sitting reduces the intraabdominal pressure acting on the undersurface of the diaphragm thereby permitting greater alveolar expansion at end expiration and increasing the FRC.

(Choice 1) Bronchodilators do not significantly affect the FRC in patients without a history of obstructive lung disease. Bronchodilators may be used in normal individuals during the postoperative period to help prevent a fall in FRC secondary to bronchospasm, but they would not be expected to dramatically improve the FRC.

(Choice 2) Intermittent leg compression is important in the prevention of deep vein thromboses and pulmonary emboli, but does not affect the FRC directly.

(Choice 4) Opioid analgesics can suppress the respiratory drive. Decreasing the dosage of these medicines can help to prevent FRC reductions, but this would not alone dramatically increase the FRC, nor is it always possible in the immediate postoperative period as abdominal pain also limits lung expansion.

(Choice 5) Benzodiazepines can cause variable degrees of respiratory depression and would tend to favor the development of postoperative atelectasis and a consequent reduction in FRC.

The correct answer is 2.

The most common tumor of the appendix is a carcinoid tumor. Benign tumors, including carcinoids, are found in fewer than 5% of appendix specimens examined microscopically. They are most commonly found incidentally at the time of an appendectomy being performed for acute appendicitis. Tumors smaller than 2 cm in the tip of the appendix are unlikely to metastasize. Most authors recommend appendectomy for tumors less than 2 cm. Appendectomy alone is adequate treatment unless lymph nodes are visibly involved, the tumor is larger than 2 cm in diameter, mucinous elements are present in the tumor (adenocarcinoid), or the mesoappendix or base of the cecum is invaded.

(Choice 1) No staging is required due to the low probability of metastatic disease.

(Choice 3 & 5) Radiation therapy and chemotherapy have no role in the treatment of localized carcinoid tumors.

(Choice 4) For tumors larger than 2 cm or with more aggressive lesions, the patient should undergo a right hemicolectomy.

The correct answer is 2.

In evaluation of abdominal trauma, the retroperitoneum is divided into three zones. Zone I (the central zone) contains the majority of the vasculature within the abdomen (i.e., the aorta, vena cava, celiac trunk, and mesenteric arteries). This zone should always be explored in both penetrating and blunt trauma. Zone II (the lateral zone) lies on either side of Zone I. The kidneys and their vasculature are found within this area. Exploration should be undertaken in penetrating trauma, or in blunt trauma with a pulsatile expanding hematoma. Zone III consists of the pelvic retroperitoneum; the iliac vessels and the hypogastric plexus are found here.

This is a difficult area to explore, and obtaining hemostatic control is challenging. Mandatory exploration should occur in penetrating trauma cases. In cases involving blunt trauma, exploration should be undertaken if the hematoma is expanding or is pulsatile. Otherwise, no exploration is the best management choice.

(Choices 1 & 3) See the correct answer (Choice 2).

(Choices 4 & 5) There are only three zones of the retroperitoneum.

The correct answer is 1.

The patient has superior vena cava syndrome, which is most commonly secondary to extension of a primary lung cancer (usually a small-cell carcinoma) into the neck, with obstruction of superior vena caval blood flow. Clinical findings consist of puffiness and bluish discoloration of the face, arms, and shoulders, along with distention of the jugular veins. Collateral venous circulation results, as evidenced by dilated and tortuous veins over the anterior chest. In addition, there are central nervous system signs of dizziness, visual disturbances, and convulsions. Prompt administration of diuretics, fluid restriction, and radiation therapy are useful in restoring blood flow. Surgery is rarely indicated. The mean survival is 6-8 months.

(Choice 2) distends the neck veins but would not be associated with the degree of venous engorgement noted in this case.

(Choice 3) is uncommon and usually results from histoplasmosis.

(Choice 4) is associated with increased plasma volume and red blood cell mass, and a tendency for venous thrombosis. However, thrombosis of the superior vena cava is very unlikely.

(Choice 5) is not associated with the degree of venous engorgement noted in this patient.

The correct answer is 3.

The symptoms described in the case history clearly suggest a diagnosis of benign prostatic hypertrophy (BPH) since his PSA level is 3.5 ng/dl, below the 4.0 ng/dl level considered to be non malignant. Normally, the prostate is a walnut-sized gland situated just below the bladder and is wrapped around the urethra. With age, it tends to enlarge and constrict the urethra, making urination more difficult. BPH affects about 50% of men in their 50s and as many as 80% after the age of 70 years. Initially only a nuisance, if left untreated too long, BPH can become a serious medical problem: non-voided urine can lead to infection, and relentless back pressure can irreversibly damage bladder muscles and even the kidney. Normally, the first line of treatment is medical. Finasteride has proved to effectively reduce prostate size by as much as 20% and to effectively relieve mild to moderate symptoms over the long term, with few adverse effects. It is an inhibitor of 5a-reductase, the enzyme that converts testosterone to its more active derivative dihydrotestosterone, the hormone that promotes the abnormal growth of the prostate, causing BPH. The major shortcoming of finasteride is that it takes up to a year to become fully effective. As a consequence, a selective a-i -blocker such as doxazosin, terazosin, or prazosin often is also prescribed. The a r blocker acts more rapidly to relax prostatic smooth muscle tone, resulting in reduction of urethral resistance and permitting urine to flow more freely. Thus, the two classes of drugs act synergistically short term; however, it is not clear if that is also true long term.

(Choice 1) Transurethral resection of the prostate (TURP) remains the gold standard for treatment for BPH, against which other treatments are compared. It is relatively safe and effective about 80% of the time; however, as with any surgical procedure, complications, sometimes severe, may arise, and some patients are left with urinary incontinence and/or

impotence, and a smaller fraction with infection and other more serious problems. Therefore, it is not usually the first line of treatment and is generally reserved for cases more severe than the one described, such as chronic cases, and cases in which medical treatment is ruled out or has proved ineffective.

(Choice 2) Trimethoprim-sulfamethizole (TMP-SMX) is one of the several antibiotics that might be used to treat prostatitis. It has no role in treating BPH unless a secondary infection has set in.

(Choices 4 & 5) Radical prostatectomy, interstitial radiotherapy, or external beam radiotherapy are three of the more common therapies used to treat prostatic cancer.

Prostate carcinoma is the most common malignancy in males. The prevalence is estimated to be 30% for men in their 60s, close to 70% for those in their 80s, and approaching 100% for men in their 90s. However, because it often is slow growing, older men often die from causes other than problems arising from prostatic carcinoma. Early symptoms of BPH and prostatic cancer are similar. However, the digital rectal examination can often help distinguish between the two, since the cancerous prostate tends to be hard and nodular, not smooth and firm as in BPH. Although both conditions tend to elevate the PSA, the value in cancer is often above 10 ng/dL. Unfortunately, PSA values for both BPH and cancer can sometimes fall into a gray area, between 4 and 10 ng/dL, adding possible ambiguity to the diagnosis. The ultimate confirmatory test is biopsy.

The correct answer is 4.

The constellation of clinical findings in this patient is most consistent with esophageal perforation. First, the patient has chronic pancreatitis resulting from alcohol abuse. Exacerbations of chronic pancreatitis are frequently precipitated by alcohol consumption; such patients should be admonished to never consume alcohol. Exacerbation of the chronic pancreatitis has caused epigastric pain and tenderness as well as vomiting. Spontaneous rupture of the esophagus (Boorhave syndrome) can occur during episodes of vomiting, particularly when the patient is resisting the vomiting reflex. This results because high intraabdominal pressures are transmitted into the mediastinal esophagus where the transmural difference in pressure is large due to negative intrathoracic pressure. Esophageal rupture in this setting typically occurs a few centimeters above the gastroesophageal junction. The retrosternal pain and crepitus in the suprasternal notch are the result of pneumomediastinum, which commonly occurs following rupture of the esophagus within the mediastinum.

(Choice 1) Pneumomediastinum may accompany a pneumothorax, but pneumothorax would have decreased or absent breath sounds on the affected side.

(Choice 2) Acute pancreatitis causes epigastric pain radiating to the back but would not directly result in pneumomediastinum. It may, however, cause a left pleural effusion.

(Choice 3) A perforated duodenal ulcer would cause epigastric pain, and air would be visualized under the diaphragm on upright abdominal X-ray, but pneumomediastinum is not associated with duodenal perforation.

(Choice 5) A Mallory-Weiss tear is an incomplete mucosal tear at the gastroesophageal junction usually resulting from protracted vomiting. The common presentation is self-limited hematemesis. Pneumomediastinum does not occur in such tears because the rupture is incomplete.

The correct answer is 1.

Angiograms are done following neck trauma to rule out carotid artery injury. Angiograms are usually done for penetrating injury. Angiograms will evaluate the aortic arch and its branches. In the above patient, there is an intimal flap. Despite the patient being neurologically intact, exploration is mandatory, to prevent a stroke. The intimal flap may progress to complete obstruction of the vessel or may lead to emboli and stroke.

(Choice 2) Observation is not prudent in a vessel, which has an intimal flap. Observation may be indicated if the patient already has had a stroke and is in a poor condition to undergo surgery.

(Choice 3) Heparin is used as an anticoagulant if there is a thrombus or dissection of the carotid artery. It does not prevent thrombus formation in an intimal flap. The intimal flap may even get larger and completely obstruct the lumen of the vessel, causing a devastating stroke.

(Choice 4) Aspirin is indicated as a prophylactic agent to prevent thrombus formation in the carotid artery. Once an intimal flap has occurred, use of aspirin does not guarantee a stroke. (Choice 5) Ligation of the carotid artery is done only if there is uncontrolled hemorrhage from the vessel. Ligation may be done if the vessel is completely occluded. It is not recommended to ligate carotid artery in a dissection; it may produce an acute stroke.

The correct answer is 5.

The woman was stabbed in the heart, leading to cardiac tamponade (blood collecting in the pericardial sac). This causes impairment in heart function, leading to hypotension, distension of neck veins due to pump failure, and muffled heart sounds due to the collection of blood. The immediate concern is removing the blood from the pericardial sac by performing pericardiocentesis. All the other tests would lead to unnecessary delays in diagnosis and would result in death.

(Choice 1) is necessary for this patient to ultimately repair the damaged heart; however, the first step in saving this woman before the specialist arrives is pericardiocentesis.

(Choice 2) could aid in the diagnosis of pericardial effusion but would take too long to administer in such an emergent situation.

(Choice 3) would show a pericardial effusion, but there already are enough data to support the diagnosis, so x-ray would cause unnecessary delay in therapy.

(Choice 4) is used for pneumothorax and pleural effusions but would not be effective in the present scenario.

The correct answer is 3.

The patient described most likely has suffered a tear of the medial meniscus. Meniscal injuries often result from twisting injuries with the foot fixed. The medial meniscus is more commonly injured than the lateral meniscus. Patients generally complain of a popping sound followed by severe pain at the time of injury. Because the meniscus is not directly perfused, effusion following injury typically is not clinically apparent for many hours following the injury. Examination reveals localized tenderness on the medial side of the knee. Locking of the knee joint on extension is generally seen in “bucket handle” tears, while range of motion at the knee is limited by pain in all meniscal tears. Me Murray’s sign, which is indicative of a medial meniscus tear, refers to a palpable or audible snap occurring while slowly extending the leg at the knee from full flexion while simultaneously applying tibial torsion.

(Choice 1) In cases of anterior cruciate ligament tear, the patient gives a history of a forceful hyperextension injury to knee or a noncontact torsional injury of the knee during deceleration. Effusion is seen rapidly following injury. Lachman’s test, anterior drawer test and pivot shift test are used for clinical diagnosis.

(Choice 2) Posterior cruciate ligament injury is classically seen in the “dashboard injury”, which refers to forceful posterior-directed force on the tibia with the knee flexed at 90 degrees. The posterior drawer, reverse pivot shift and posterior sag tests will help in clinical diagnosis.

(Choice 4) Medial collateral ligament injury is associated with abduction injury to the knee. The valgus stress test will help in clinical diagnosis of this condition.

(Choice 5) Lateral collateral ligament injury is very rare and would be seen in adduction injury to the knee. The varus stress test will help in clinical diagnosis of these patients.

The correct answer is 2.

The clinical picture is that of acute-angle closure glaucoma. Treatment is urgent and consists of oral or intravenous carbonic anhydrase inhibitors, topical beta-blockers, and alpha-2-s elective adrenergic agonists. Osmotic diuretics may also be needed, and the definitive treatment is laser peripheral iridotomy.

(Choice 1) Copious irrigation is the emergency treatment for caustic burns of the eyes. It would not help in this case.

(Choice 3) Atropine drops would lead to mydriasis, which, as a rule, impedes, rather than enhances, aqueous outflow. The patient needs aqueous production to be diminished (which the carbonic anhydrase inhibitors do) and outflow to be improved.

(Choices 4 & 5) Topical antihistamines or mast cell inhibitors and topical corticosteroid- antibiotics are indicated in other ophthalmologic conditions, not in the treatment of glaucoma.

The correct answer is 4.

Acute small bowel infarction is indicated by the sudden onset of severe abdominal pain with vomiting and abdominal distention out of proportion with the physical findings, absent bowel sounds, a striking neutrophilic leukocytosis with left shift, lactic acidosis, hypotension, and increased serum amylase concentration of bowel origin. The increased serum amylase concentration is sometimes misinterpreted as representing acute hemorrhagic pancreatitis. Barium studies reveal “thumbprinting” of the mucosa due to submucosal hemorrhages and edema. Peritoneal signs (e.g., rebound tenderness) are generally late findings. These signs of acute infarction are often preceded by abdominal angina (also known as, mesenteric angina) 30 minutes after eating. Because of the pain, patients tend to have a fear of eating, and they lose weight. In 50% of cases, acute small bowel infarction occurs in elderly patients with atherosclerotic disease; usually, the pathogenesis relates to sudden occlusion of the superior mesenteric artery by thrombosis over an atherosclerotic plaque, less often to an embolism from the left heart (mitral valve disease, atrial fibrillation, or left ventricular mural thrombosis), and rarely from vasculitis. In about 25% of cases, nonocclusive infarction can occur from a low rate of blood flow, as in vasospasm or shock. Causes of vasospasm include ergot or cocaine poisoning and sympathomimetic drugs, such as digitalis. Shock can be induced by hypovolemia and hypotension, as may be caused by cardiac failure or loss of blood, as would occur with aortic aneurysm repair or dissections of the aorta (uncommon). The remaining 25% of cases of small bowel infarction may result from superior mesenteric vein occlusion related to hypercoagulable states, which could be associated with polycythemia rubra vera, oral contraceptives in females, malignancy, or one of the hereditary hypercoagulable states (e.g., antithrombin III deficiency, protein C and S deficiencies). Whatever the underlying mechanism, transmural, hemorrhagic infarctions damage the integrity of the mucosa, thus predisposing the bowel to secondary bacterial penetration and generalized peritonitis. The reestablishment of blood flow frequently results in further damage due to re-availability of oxygen, which may cause free radical formation. Treatment of the ischemic bowel must occur within 12 hours; otherwise, a 100% mortality rate can be expected. Surgery is always indicated if a grossly obvious hemorrhagic infarction has already occurred. Visible peristalsis is the best way to determine if the bowel is viable or dead. Embolectomy and intraarterial vasodilators are also used, depending on the cause of the ischemia.

(Choice 1) The symptoms presented in this case are unlikely clinical presentations for acute ulcerative colitis; moreover, ulcerative colitis is most often seen in young adults.

(Choice 2) Although hemorrhagic pancreatitis involves an elevated serum amylase concentration, it is not associated with diffuse abdominal pain and bloody diarrhea.

(Choice 3) An aortoenteric fistula is usually a late complication of repair of an abdominal aortic aneurysm.

(Choice 5) Toxic megacolons are associated with ulcerative colitis.

The correct answer is 1.

It is obvious that the patient is in shock, and the distended veins identify the type as cardiogenic. Given the location of the injury, pericardial tamponade is the obvious mechanism. Other possibilities are excluded as noted below.

(Choice 2) Tension pneumothorax is another form of extrinsic cardiogenic shock that can be seen with penetrating injuries of the chest. However, there would be respiratory distress and absent breath sounds on the affected hemithorax.

(Choice 3) Hemorrhagic shock is by far the most common reason for shock in the trauma victim, and thus it always has to be a consideration. However, his veins would have been empty rather than bulging.

(Choice 4) Intrinsic cardiogenic shock is seen with massive myocardial infarctions or fulminating myocarditis. The large distended veins would be there, but the setting would not be that of a penetrating injury.

(Choice 5) Vasomotor shock should not be overlooked, since a high spinal cord transection can produce it. But the patient would be pink and warm rather than pale and cold. Furthermore, this patient was neurologically intact.

The correct answer is 1.

This patient initially was admitted for acute pancreatitis. The patient is usually afebrile in uncomplicated pancreatitis. Alcohol abuse and gallstones account for over 80% of cases of pancreatitis; this patient likely abuses alcohol given his social history, his elevated MCV and his withdrawal-like tremulousness and formication. A well-known complication of acute pancreatitis is pseudocyst formation. Pancreatic pseudocysts are defined as collections of pancreatic secretions within a fibrous capsule, usually within the pancreas. Pseudocysts are typically diagnosed when a patient with acute pancreatitis fails to improve clinically with standard supportive care. Pseudocysts may uncommonly become infected resulting in a pancreatic abscess. Pancreatic abscess is typically accompanied by fever and leukocytosis and may result in bacteremia, as described in this patient. Treatment includes antibiotics and drainage of the abscess.

(Choice 2) Conservative management is indicated for uncomplicated pseudocysts. Pseudocysts may be complicated by infection, rupture or hemorrhage; these complications require intervention.

(Choice 3) Infective endocarditis in an intravenous drug abuser most commonly results from S. aureus colonization of the right heart valves. This is not the most likely cause of this patient’s bacteremia, so an echocardiogram is not indicated at this time.

(Choice 4) Pancreatic cancer is not a likely cause of the patient’s acute issues. CA 19-9 levels are not indicated in the acute management of this patient.

(Choice 5) His disorientation, tremor and hallucinations are probably due to alcohol withdrawal. There is no need for lumbar puncture at this time.

The correct answer is 4.

The profuse bleeding into the upper airway makes any approach through the mouth or nose doomed to failure, and will likely worsen the existing injuries. A direct route to the airway lower in the neck is needed, and the best option for quick use in the emergency department is a cricothyroidotomy.

(Choice 1) As pointed out above, attempted nasotracheal intubation would worsen existing nasal injuries, and visualization of the cords would not be possible with all the blood in the field.

(Choice 2) The same is true of orotracheal intubation: only blood would be seen as attempts are made to visualize the cords. Furthermore, rapid induction anesthesia would be quite redundant in an unconscious patient.

(Choice 3) Percutaneous transtracheal ventilation is the best alternate option but is not as good as the cricothyroidotomy. Contrary to what the name implies, one can oxygenate a patient through a small diameter catheter placed percutaneously into the trachea, but ventilation cannot be done very well by that route. In an unconscious patient, one may need better ventilation to help lower intracranial pressure.

(Choice 5) Emergency tracheostomy done in the emergency department is an absolute no- no. Tracheostomy is a formal operative procedure that should be done in the operating room, with all the help, light, instruments, and exposure appropriate for such an undertaking. To do so, an airway must have been previously secured in some other way. Attempting to operate in the neck without a secure airway, and in less than ideal conditions, can very quickly turn into a horror show.

The correct answer is 4.

The macula has the highest density of cones. Laser photocoagulation targeted at drusen may inadvertently damage cones. Unfortunately, this is not preventable. For this reason, it is important to advise the patient that deterioration in visual acuity would follow the procedure, and that the reason for recommending it is to slow progression of the disease, which if left unchecked, would soon leave her legally blind.

(Choices 1,2 & 3) are incorrect.

(Choice 5) is incorrect because peripheral vision remains relatively intact in macular degeneration, since drusen tiny, yellow or white hyaline bodies that are one of the most common precursor signs of age-related macular degeneration tend to accumulate in the macular area and a few are present elsewhere.

The correct answer is 2.

The clinical picture is that of embolic occlusion of the right common iliac at the aortic bifurcation (or possibly a similar process at the bifurcation of the common iliac into internal and external branches). The source is also obvious in the vignette: atrial fibrillation (manifested by the grossly irregular pulse). He needs an emergency embolectomy, which is done with the balloon tipped catheters invented by Fogarty. If he had been ischemic for a longer period of time, he might have required a fasciotomy of the lower leg as well. Clot- busters were not offered as an option. They can be used in highly selected cases, but the question did not offer all the necessary details that would have enabled a very experienced vascular surgeon to choose this approach. Of the choices offered, only the embolectomy is correct.

(Choice 1) Dacron prosthetic vascular conduits are appropriate for cases of arteriosclerotic occlusive disease blocking the iliacs, in which the native vessel cannot be opened and a graft has to go from the aorta to the femorals.

(Choice 3) Anticoagulants are an adjunct to vascular procedures, but are not the primary treatment for a clot that has already traveled from the atrial appendage to the lower extremity. Anticoagulants cannot dissolve existing clots.

(Choice 4) Saphenous vein bypass is the preferred way to deal with chronically occluded common femoral arteries, but it is not a choice when the native vessel is fine and can be unplugged.

(Choice 5) Sympathetic blocks are rarely used in vascular surgery. They are more appropriate for functional problems than for mechanical obstructions.

The correct answer is 3.

This is a patient of polytrauma with an abdominal injury and most likely a head injury. In trauma patients, immediate treatment must always include rigid fixation of the cervical spine and assessment of airway, breathing and circulation (the AB Cs of the primary survey). The patient is tachypneic, tachycardic and hypotensive suggesting significant blood loss. The first step in the management of hypotension is rapid administration of intravenous isotonic fluids. The patient described has not responded adequately to fluid administration as she continues to have hypotension and tachycardia. This is suggestive of continuing bleeding and is an indication of surgical intervention. This patient's abdominal distention, absent bowel sounds and abdominal bruising suggest that the hemorrhage is most likely intraabdominal. Emergent exploratory laparotomy is indicated.

(Choice 1) X-ray of the abdomen is not a sensitive test for intraabdominal trauma. Delaying surgery for further diagnostic studies may lead to the patient’s demise.

(Choice 2) Though the patient has a low Glasgow coma scale, intracranial bleeding can never cause enough blood loss to cause this degree of hypotension. Continued exsanguination and hypotension will cause death in this patient before head trauma would; therefore, treatment of the acute hemorrhage takes priority.

(Choice 4) Spine injury should be ruled out in patients with polytrauma but the first priority is to secure airway, breathing and circulation. The continued hemorrhage is a fault in circulation and must be addressed first. Rigid fixation of the cervical spine is done prophylactically as part of the primary survey.

(Choice 5) Delaying treatment of the patient’s acute hemorrhage for a chest x-ray is inappropriate. Lung sounds were normal in the patient, so severe intrathoracic injury is less likely to be the cause of the patient’s hemorrhage than abdominal injury.

The correct answer is 1.

An anal fissure is a disruption of the anoderm. It most commonly occurs in the posterior midline as a result of forceful dilatation of the anal canal, most often during defecation. Initially it is felt as a tearing pain upon defecation. This pain causes the patient to ignore the urge to defecate, resulting in constipation and further disruption to the anoderm upon defecation. A cycle of pain, poor sphincteric relaxation, and reinjury occurs. The patient presents with pain upon defecation and minimal bleeding on tissue of stool. Physical exam by simply separating the buttocks will reveal a tear in the anoderm in the posterior midline.

(Choice 2) Protrusion of an internal hemorrhoid usually results in anal fullness and discomfort along with bright red blood per rectum. Occasionally, an internal hemorrhoid can prolapse through the anus and incarcerate, requiring surgical intervention. Hemorrhoids can usually be distinguished from a fissure on physical exam.

(Choice 3) A fistula in ano presents as a draining site on the buttock skin, usually as a complication of an anorectal abscess. It presents with drainage, not extreme pain.

(Choice 4) Perirectal and anorectal abscesses most often arise from obstruction of an anal gland that subsequently becomes infected and overgrown with bacteria. These glands are located between the internal and external anal sphincters. If the infection tracks down this space toward the skin, an anorectal abscess occurs.

(Choice 5) Anal condylomas are caused by infection with human papillomavirus (HPV) types 6 and 11. Patients complain of a perianal growth that appears as a cauliflower-like lesion on physical exam. Minimal disease may be treated in the office with bichloracetic acid or podophyllum. Larger lesions may require surgical excision.

The correct answer is 2.

Progressive headache that is worse in the mornings and present for several months indicates a brain tumor. Furthermore, the papilledema and projectile vomiting leave no doubt about the presence of increased intracranial pressure, something that a brain tumor eventually will produce. Do not be fooled by the absence of other neurologic symptoms; that can happen when tumors press on a “silent area” of the brain.

(Choice 1) is also an intracranial mass that can do the same things described here, but the timetable would be shorter (days or weeks) and the source of infection would be described in the vignette (mastoiditis or frontal sinusitis, for instance).

(Choice 3) affects very old or alcoholic patients, who gradually lose their mental capacity after trivial trauma to the head.

(Choice 4) Degenerative diseases, like multiple sclerosis, typically have on and off neurologic deficits for years before they are diagnosed.

(Choice 5) Subarachnoid bleeding from an intracranial aneurysm can indeed strike a young person, but the presentation is an extremely intense headache of sudden onset, “like a thunderclap:’

The correct answer is 3.

This woman’s history is most consistent with a diagnosis of intraductal papilloma, a form of benign breast disease that is most common in perimenopausal women. The classic presentation is intermittent bloody discharge from one nipple. Most intraductal papillomas are situated beneath the areola, and are difficult to palpate on physical exam due to their small size (no larger than 2 mm) and soft consistency. Ultrasound is best at detecting masses greater than 1 cm in diameter; therefore, it is no surprise that the ultrasound finding was normal in this patient.

(Choice 1) Fibrocystic changes are also very common in premenopausal females. Patients present with bilateral breast pain associated with cystic changes of the breasts. The condition is benign, and symptoms vary cyclically with the menstrual cycle. On physical exam, lumpiness of the breasts is appreciated.

(Choice 2) A fibroadenoma is a solitary breast lesion, which presents as a painless, firm, and mobile breast lump, averaging about 2 cm in size. It occurs most often in women ages 15-25, and the condition is benign. Fibroadenomas do not change with the menstrual cycle.

(Choice 4) Ductal carcinoma in situ is most common in postmenopausal women. It is usually discovered as an incidental finding on mammography. In cases that do present symptomatically, nipple discharge and breast mass are the most frequent complaints. It is a histologic diagnosis, involving cellular abnormalities of the ductal epithelium that do not penetrate the basement membrane.

(Choice 5) Hyperprolactinemia can cause galactorrhea, but does not cause unilateral bloody nipple discharge.

The correct answer is 5.

The patient has deep venous insufficiency, as indicated by the history of venous symptoms stated in the vignette, including stasis dermatitis and superficial varicosities. Stasis dermatitis is a rusty discoloration of the skin, with or without ulceration, which usually is located behind the medial malleolus. Venous blood from the skin and superficial tissues that lie external to the deep fascia of the leg drains via perforators (communicating veins), into the deep veins in

the calf and is then returned to the right atrium. When the calf muscles contract, valves prevent retrograde flow into the superficial system. Incompetence of the venous valves leads to retrograde flow, increased venous pressure in the dorsal vein of the foot, and ensuing changes to the skin around the ankle. Persistently elevated venous pressure leads to capillary leakage. As a result, blood and fibrin is deposited in surrounding tissues. Breakdown of blood into hemosiderin leads to pigmentation of the skin, while fibrin deposition around capillaries leads to the formation of a barrier. Ischemia predisposes to ulceration of the skin. Finally, the retrograde blood flow from the deep to the superficial venous system causes varicosities as well.

(Choice 1) is incorrect; superficial thrombophlebitis presents with pain and erythema along the course of the superficial saphenous vein. Fever may be present. It is not associated with stasis dermatitis. Superficial thrombophlebitis may occur spontaneously in polycythemia or polyarthritis, or may herald the presence of a visceral tumor, such as carcinoma of the pancreas. The condition is known as thrombophlebitis migrans.

(Choice 2) is incorrect; in embolic disease, the history would suggest an embolus to the lungs and physical findings suggestive of deep venous thrombosis. Deep vein thrombosis may be asymptomatic, presenting as pulmonary embolus, or it may be symptomatic. In the latter case, the patient will have low-grade fever, pain, swelling, redness, and dilated superficial veins. Stasis dermatitis is not a feature.

(Choice 3) is incorrect; arterial insufficiency is not associated with stasis dermatitis. Flowever, varicose veins may coexist in patients with arterial insufficiency. The presence of normal arterial pulses and the lack of claudication pain that is characteristic of arterial insufficiency rules out this diagnosis.

(Choice 4) is incorrect; rheumatoid arthritis is three times more common in women than in men. Rheumatoid arthritis may be associated with vasculitis. However, varicosities, or stasis dermatitis, are absent. Furthermore, the patient would have evidence of joint involvement, which is absent in the case described.

The correct answer is 5.

The child has testicular torsion, one of the very few true urologic emergencies. He needs immediate de-torsion if the testis is to be saved. No time should be wasted doing further studies.

(Choice 1) Symptomatic care is fine for testicular trauma with scrotal hematomas. In this case, it would amount to malpractice.

(Choice 2) A sonogram is always done when the clinical diagnosis is epididymitis, and we want to be sure that torsion is not being overlooked. But when the clinical diagnosis screams “torsion:’ as in this vignette, time wasted confirming the diagnosis with the sonogram could lead to loss of the testicle.

(Choice 3) Antibiotics are effective therapy for acute epididymitis, the condition with which testicular torsion may be confused. But the patient with epididymitis is usually somewhat older (sexually active) and has fever, pyuria, a very tender cord, and a normally positioned testicle.

(Choice 4) Testicular biopsy is done when we think that the diagnosis is cancer, but the scenario would be a painless mass in a young male.

The correct answer is 2.

Injury to a number of different structures within the knee, including ligaments and cartilaginous menisci, can cause a popping or snapping sensation. Damage to the medial meniscus is a common knee injury that presents as described above. Meniscal injuries occur most commonly in patients in their thirties and forties while performing activities requiring axial loading and rotation. Classically the patient will report feeling a “pop” that is followed by pain. Meniscal injuries typically cause joint swelling over the following 12 to 24 hours, in contrast to ligamentous injuries, which cause rapid joint swelling due to hemarthrosis. (Ligaments have much greater vascular supply than menisci, which rely on diffusion for nourishment.) Physical exam may show joint line tenderness, decreased range of motion and a positive McMurray’s test. MRI provides the definitive diagnosis.

(Choice 1) An anterior cruciate ligament (ACL) tear would cause immediate swelling due to rapid development of hemarthrosis. Moreover, patients typically experience immediate inability to weight-bear and then lasting knee instability following such an injury.

(Choice 3) Osteoarthritis has an onset that does not necessarily directly follow a distinct precipitating injury; instead it tends to develop insidiously over years. Osteoarthritis typically causes recurrent use-dependent swelling and pain as well as crepitus with range of motion on physical examination.

(Choice 4) Chronic overuse, typically related to strenuous athletic activities, can cause patellar tendonitis, or “jumper’s knee.” Physical exam typically reveals point tenderness over the proximal patellar tendon.

(Choice 5) The anserine bursa underlies the conjoined tendons of the gracilis and semitendinosus muscles and separates them from the head of the tibia. Anserine bursitis causes tenderness over the medial aspect of the knee, and typically affects athletes and obese middle-aged to elderly women. A popping sensation is not typically reported.

The correct answer is 5.

Meconium ileus is an obstruction of the distal ileum from inspissated meconium and is often associated with cystic fibrosis. Approximately 10% to 15% of infants with meconium ileus have cystic fibrosis. Meconium ileus presents with failure to pass meconium within 48 hours of birth in conjunction with progressive abdominal distention and bilious emesis. Abdominal films show the classic “soap bubble” appearance in the proximal colon, and a contrast enema shows a microcolon with small plugs of meconium (note the arrows in the image).

(Choice 1) Budd-Chiari syndrome is hepatic veno occlusive disease, mostly seen in adults and not associated with meconium ileus.

(Choice 2) Down syndrome (trisomy 21) is most often associated with cardiac and renal abnormalities. Associated abdominal abnormalities include imperforate anus, duodenal or jejunal atresia, duodenal or jejunal stenosis, and Hirschsprung’s disease.

(Choice 3) Von Hippel-Lindau syndrome is associated with pancreatic, central nervous system, and renal tumors in adults.

(Choice 4) Eaton-Lambert syndrome is a paraneoplastic neurologic-myopathic syndrome that presents with symptoms similar to myasthenia gravis.

The correct answer is 1.

Torus palatinus is a benign bony mass (exostosis) located on the hard palate. The growth of bone arises from the midline suture in the hard palate. A patient with torus palatinus will usually give a history that the lesion has been present for some time and will deny tenderness. The thin epithelium overlying the bony growth will tend to ulcerate and be slow to heal due to poor vascularity. No medical or surgical therapy is required unless the mass becomes symptomatic. The cause of this mass is unknown and is unrelated to trauma. (Choice 2) Squamous cell carcinoma (SCC) is the most common malignancy of the head and neck. Oral SCC classically occurs in the setting of chronic alcohol or tobacco abuse or in cases of repeated oral trauma, such as may be caused by poorly fitting dentures. Inflammatory conditions such as oral lichen planus have also been associated with an increased risk of oral SCC.

(Choice 3) Surgical correction of torus palatinus is indicated only if the lesion causes symptoms or otherwise interferes with speech, eating or the fitting of dentures.

(Choice 4) Radiation therapy may be used as a primary or adjuvant therapy for many malignancies as well as for nonmalignant conditions, such as keloids. Torus palatinus is a benign growth and would not likely respond to radiation therapy.

(Choice 5) Candida infections do occur in the oral cavity but do not present as a hard mass. They are usually white and cheesy (“curd-like”) in appearance and often lie on an erythematous base.

The correct answer is 2.

This patient has acute epidural hematoma. Epidural hematoma is accumulation of blood in the potential space between the cranium and dura mater. It may be intracranial or spinal. Acute epidural hematoma generally occurs with moderate degree of trauma to the side of the head. It results from rupture of middle meningeal artery secondary to temporal bone fracture. Acute epidural hematoma has a classic presentation of unconsciousness followed by a lucid interval (Patient is perfectly normal) followed by gradual deterioration of consciousness. The dilation of pupil on the side of lesion along with contra lateral hemiparesis is considered very characteristic. CT scan is the diagnostic test of choice and it shows a biconvex hematoma. Emergency craniotomy should be done to relieve the increased intracranial tension.

(Choice 1) Acute subdural hematoma is secondary to intracranial venous bleeding in the subdural space due to severe head trauma. The CT scan characteristically shows a semi lunar hematoma and there is no lucid interval.

(Choice 3) Basilar skull fracture does not cause lucid interval, biconvex hematoma or unilateral pupillary dilatation; it is characterized by raccoon eyes, rhinorrhea and otorrhea. (Choice 4) Intracerebral hemorrhage is a grave emergency characterized by worsening coma and focal neurological signs. CT scan is diagnostic and it will not give lucid interval or biconvex hematoma. It is usually seen in elderly patients with hypertensive stroke.

(Choice 5) Subarachnoid hemorrhage is most commonly secondary to rupture of berry aneurism and characterized by severe headache and meningeal signs with or without focal signs. CT helps in diagnosis most of the times, but spinal fluid examination is diagnostic.

The correct answer is 4.

About 60% of the solitary coin lesions in the lung are benign. Of the benign causes, granulomas account for 95%, while the remaining 5% are due to hamartomas or mixed tumors. The patient’s mid-western origins strongly suggest histoplasmosis as the cause for the calcified granuloma. Calcification of a coin lesion is more commonly seen in granulomas than in cancer. Absence of growth within 2 years noted on serial radiography of the chest, target or popcorn calcifications, or concentric calcifications strongly favors a benign process. A malignancy would be suggested by indistinct margins, increased growth rate compared with previous films, flecks of calcium in the mass, and sizes greater than 3 cm in diameter. A history of living in an endemic granuloma area and not smoking, in conjunction with no cough, chest pain, weight loss, rhonchi, or hemoptysis all suggest that the lesion is not cancer. Its benign nature also is strongly supported by the fact that it is concentric, calcified, and less than 1 cm in diameter. However, follow-up radiography should be conducted (first yearly, then less regularly) for at least 10 years to make sure the lesion is not growing. (Choices 1,2,3 & 5) Mixed tumors, also known as bronchial hamartomas (Choice 2), are so called because they are pleomorphic and contain epithelial cells, cartilage, and mesenchymal cells. Malignant change is rare in them. Hamartomas are the result of faulty

development that results in tissue overgrowth. Indeed, the word hamartoma in Greek means fault and was the term used when spear throwers missed their mark. The remaining 40% of the causes of solitary coin lesions in the lung are primary lung cancer {35%; (Choice 1)} and metastatic lung cancer {5%; (Choice 3)}. A negative tuberculosis skin test result proves that it is not a calcified tuberculosis lesion (Choice 5).

The correct answer is 4.

A rib fracture can be a serious injury in the elderly, because the pain prevents full inspiration, atelectasis ensues, and eventually pneumonia develops and may cause significant morbidity and mortality. The key to the treatment is to eliminate the pain without interfering with ventilation. An intercostal nerve block will accomplish this goal.

(Choice 1) Although supplemental oxygen would not be directly injurious, it would neither eliminate the pain nor preserve ventilation.

(Choice 2) Systemic narcotic analgesics would diminish the pain but would also increase the probability of complications by depressing the respiratory drive, thus reducing ventilation. (Choice 3) Binding the chest diminishes the pain by limiting motion. In doing so, however, it limits ventilation.

(Choice 5) Open reduction and internal fixation to accelerate healing is totally unnecessary. The chest wall already is holding the rib in a good position for eventual healing. It will not happen faster if we intervene.

The correct answer is 3.

This man is not a surgical candidate, thus ruling out pneumonectomy (choices 4 and 5). With a central lesion, he would require a pneumonectomy rather than a lobectomy. After resectional pulmonary surgery is done, however, a patient must be left with at least 800 mL in the FEV1 to live a semi-decent life. Anything less than that would make him a pulmonary cripple, or outright kill him. Because of his COPD, this patient is already severely limited, with a total FEV 1 of 1100 mL. Were the bad lung to be removed, he would be left with only 40% of 1100 mL: 440 mL. The only option left is radiation and chemotherapy.

(Choices 1 & 2) CT scan of the upper abdomen to rule out liver metastasis and mediastinoscopy to biopsy carinal nodes are necessary steps to establish curability. There is no point in doing a pneumonectomy if there are liver or carinal node metastases. But if a pneumonectomy cannot be done for reasons of poor function, there is no point in finding out whether the other limiting factors are present.

The correct answer is 1.

Hyperkalemia is seen in cases involving renal failure, crush injuries, burns, blood transfusions, and iatrogenic potassium containing infusions, and secondary to some medication use. Potassium is critical to the electric physiology of the heart, and hyperkalemia can result in ventricular fibrillation and cardiac arrest. EKG findings include peaked T waves, prolongation of the PR interval, and widening of the QRS complex. Levels exceeding 6.5 mmol/L are considered critical and should be immediately addressed. Immediate treatment includes cardiac stabilization by administration of IV calcium gluconate.

(Choice 2) Metoprolol is a p-antagonist and causes potassium to leave the cells and enter circulation, thereby causing hyperkalemia.

(Choices 3 & 5) Following administration of IV calcium gluconate, you must take action to reduce the serum concentration of potassium. These steps include shifting potassium into the cells with infusion of insulin and glucose or administration of an albuterol nebulizer, diuresis of potassium with furosemide, and binding of potassium in the intestinal tract with sodium polystyrene (Kayexalate), resulting in excretion.

(Choice 4) Dialysis can be used if the measures described in the explanation for 3 and 5 are ineffective or contraindicated.

The correct answer is 4.

The differential diagnosis for unilateral hip pain in a middle-aged adult is broad, and includes infection, trauma, arthritis, bursitis, and radiculopathy. This particular patient’s presentation is most consistent with trochanteric bursitis. Trochanteric bursitis is inflammation of the bursa surrounding the insertion of the gluteus medius onto the femur’s greater trochanter. Excessive frictional forces secondary to overuse, trauma, joint crystals, or infection are responsible. Patients with this condition complain of hip pain when pressure is applied (as when sleeping) and with external rotation or resisted abduction.

(Choice 1) Slipped capital femoral epiphysis is a condition that primarily affects obese male children during late childhood or early adolescence.

(Choice 2) In Paget’s disease of the bone (osteitis deformans), bone turnover is accelerated in localized areas resulting in focal bony hypertrophy. Affected bone is weak and prone to pathologic fractures. This condition tends to affect elderly patients and is asymptomatic in up to 75% of cases.

(Choice 3) Aortoiliac peripheral vascular disease may cause buttock, thigh, or hip pain and claudication. In men it may also cause erectile dysfunction (Leriche syndrome). The pain in this condition is exercise induced and relieved by rest.

(Choice 5) Hip osteoarthritis causes pain localized deep within the joint (in contrast to the superficial tenderness here) that may be referred to the inguinal area or rarely to the knee. Hip osteoarthritis is uncommon before the age of 50. Classically, internal rotation of the hip worsens this pain.

The correct answer is 4.

This woman has bilateral pheochromocytoma (bilateral adrenal lesions), a parathyroid adenoma (hypercalcemia and ectopic calcium deposits), and an oversized thyroid (a palpable, nontender swelling in front of her neck). This by definition is an example of multiple endocrine neoplasias (MEN). There are three such multi gland syndromes, called MEN 1 (aka, Wermer syndrome), MEN 2a (aka, Sipple syndrome), and MEN 2b. All are inherited as autosomal dominant traits. MEN 1 is caused by a mutation in a tumor suppressor gene on chromosome 11; in this germline mutation, tumors form in cells in which the normal allele is suppressed. Both MEN 2a and 2b are due to mutations in a gene that codes for a protooncogene called RET, which is only expressed in cells with a neuro crest origin, such as medullary thyroid C-cells and chromaffin cells. (C-cells are sometimes also found in parathyroid tissue.) The RET gene is located on chromosome 10, and a given kindred will have a mutation in a specific codon that will correlate with a variation in clinical expression, such as age first expressed. This probably also accounts for the unique characteristics of MEN 2b, which include gastrointestinal and mucosal neuromas, a Marfan-like phenotype with skeletal abnormalities, as well as medullary carcinoma and pheochromocytoma. Genetic testing can identify 95% of persons with a mutated gene and is of value for genetic counseling and for identification of affected family members before symptoms arise; the latter permits a prophylactic thyroidectomy. Among adults worldwide, the prevalence of all three types of MEN is estimated to be between 0.2 and 2 cases per 105 individuals; about 90% of cases are MEN 1, and MEN 2a makes up almost all of the remainder (MEN 2b is extremely rare). There is a 2:1 male-to-female ratio. The approximate degree to which the various organs are affected is as follows: MEN 1, parathyroid more than 80%, pancreas 75%, pituitary, 60%; MEN 2a, medullary thyroid carcinoma more than 90%, parathyroid 20%-50%, pheochromocytoma 20%-35%; MEN 2b, mucosal and gastrointestinal gangliomas more than 90%; medullary thyroid carcinoma 80%, pheochromocytoma, 60%, and parathyroid, rarely. Accordingly, the woman described in the vignette has MEN 2a. Medullary carcinomas of the thyroid derive from C cells, which synthesize calcitonin. For MEN 2a, serum calcitonin is the best screen. A provocative stimulation test using omeprazole, pentagastrin, or calcium can be used on family members to identify those who are at risk for developing medullary carcinoma. Although medullary carcinomas of the thyroid arising from MEN 2a are usually not highly aggressive, eventually death will ensue unless the thyroid is removed; thus, early identification by genetic screening of children in affected families is important.

(Choices 2 & 3) Serum thyroid-stimulating hormone (TSH) and serum thyroxine (T 4 ) levels are normal in patients with medullary carcinoma.

(Choices 1 & 5) An iodine-123 ( 123 l) scan and measurement of the serum parathyroid hormone level are of no additional value in determining a diagnosis in this patient and would only identify half the cases.

The correct answer is 2.

Roux-en-Y gastric bypass surgery removes most of the stomach, leaving only a small pouch, which is attached directly to the small intestine at the level of the jejunum, bypassing most of the stomach and the duodenum. This leaves patients vulnerable to nutritional deficiencies, since many vitamins and minerals are normally absorbed from these missing areas. To avoid deficiency states, all persons who have had gastric bypass surgery are told consume specific vitamin and mineral supplements. Studies have shown that special

supplements, in addition to a standard multivitamin-mineral pill are required to prevent deficiencies of iron and vitamin B 12 . This patient did not take such supplements, and not too surprisingly, he demonstrated classic symptoms of B 12 (cobalamine) deficiency. Even individuals who have not had bariatric surgery are at some risk for cobalamine deficiency because of the way it is absorbed from the gut. Initially, it must be separated from the foods to which it is usually bound; once free, it must then bind to the “intrinsic factor,” a substance normally released from the parietal cells of the stomach; this normally occurs in the duodenum. This B 12 intrinsic factor complex is then absorbed in the ileum. The classic presentation of B 12 deficiency is pernicious anemia caused by a lack of intrinsic factor due to an autoimmune attack on the partial cells; similarly, in the Roux-en-Y process, the part of the stomach removed by the surgeon includes most of the partial cells; consequently, these patients will become B 12 deficient unless their diet is supplemented. Initially, it was thought this need be by intramuscular injections. However, more recently, it has been demonstrated that rather massive oral supplementation worked just as well. (The amount in a normal multivitamin pill is usually 2 meg, but in the oral supplements used for post Roux-en-Y patients the amount used is 1,000 to 2,000 meg). This is what this patient admits he did not take. In humans, only two reactions require a cobalamine cofactor. The first is a reaction catalyzed by homocysteine methyltransferase. When too little cobalamine is available to permit this reaction to occur, folate accumulates in the otherwise nonfunctional N 5 -methyl form making the N 5 -N 10 -methylene and the N 10 -formyl derivatives unavailable for synthesis of the nucleotides required for RNAand DNA metabolism. Consequently, in the absence of excess folate to form these derivatives, a vitamin B 12 deficiency causes a macrocytic (megaloblastic) anemia. However, if sufficient exogenous folate is available to form the N 5 - N 10 -methylene and the N 10 formyl derivatives, a vitamin B 12 deficiency does not cause an anemia. Since the multivitamin supplement used in the post Roux-en-Y gastric bypass surgery protocol supplies excess folate, this vitamin B 12 deficiency does not cause an anemia. The second reaction requiring cobalamine as a cofactor is methyl malonyl CoA mutase, a reaction required in a sequence in which fatty acids with an odd number of carbons can be converted into succinyl CoA. When this sequence is inhibited by a lack of vitamin B 12 , odd-numbered fatty acids accumulate and are incorporated into the myelin sheet of nerves. This leads to demyelination and symptoms of peripheral neuropathy, such as those described for this patient. It may also cause sensory ataxia due to loss of proprioception initiated by dysfunction of the dorsal and lateral columns of the spinal cord; this leads to the stomping gait described. If not treated in time, it will also bring about malfunctions in various parts of the brain.

(Choices 1,3,4 & 5) All these choices are incorrect. It may be that he also has an iron deficiency because a special iron supplement is also recommended for post-surgery patients. Since adult males require very little iron, this is most important for menstruating females; moreover, if he was iron deficient this would cause a microcytic anemia contributing to fatigue but not to the neurological problems this patient has. Most post Roux-en-Y patients have higher serum folate levels after surgery than before surgery without use of a special supplements. Thus, it is unlikely that this patient suffered a folate deficiency. Similarly, there is no reason to suspect either a zinc or copper deficiency.

The correct answer is 1.

Hip pathology often presents with knee pain, and in this case the problem is clearly in the hip. Age is the next clue. Avascular necrosis (also known as idiopathic aseptic necrosis or Legg- Calve Perthes disease) occurs typically in this age group, with preference for boys rather than girls.

(Choice 2) is present at birth (it used to be called congenital dislocation of the hip, a name that was changed for medico legal reasons) and, if untreated, would have caused problems earlier.

(Choice 3) Osteomyelitis is usually seen in peripheral bones, following a febrile illness in toddlers. Fever is also usually seen at the time that the osteomyelitis has developed. (Choice 4) The same is true of a septic hip, which should be suspected when a toddler with a recent febrile illness suddenly refuses to move a hip and has so much pain that he does not allow anyone to examine it.

(Choice 5) Slipped capital femoral epiphysis should be suspected when a chubby, 12- to 14- year-oldboy shows up with hip pain and inability to internally rotate the hip. Age, again, is the first due.

The correct answer is 1.

This patient has a tear of the quadriceps expansion, which may result from direct or indirect injury. It can occur within the muscle, at the tendon-muscular junction, within the tendon itself, or at the tendo-osseus junction (most common in the elderly). Tears of the quadriceps expansion are most common in older individuals who are overweight and in poor physical condition. The usual history is of missing a step and tripping while descending a staircase or suddenly jumping down from a height. Patients complain of severe pain, often feel or hear a snap, and fall to the ground. Physical examination reveals swelling and tenderness at the site of the tear, and a sulcus or gap is felt at the site of separation, especially if the tear is complete. If the tear is partial, the patient has difficulty extending the knee; if the tear is complete, the patient cannot extend the knee. Tears of the quadriceps expansion can also occur in athletes and young individuals. In athletes, the tears are most often at the insertion of the tendon into the tibial tubercle.

(Choice 4) Tears of the posterior cruciate ligament usually occur because of hyperextension and are associated with a positive sag sign. They are not associated with inability to straight- leg raise, swelling of the anterior aspect of the knee, or a gap between the fibers of the quadriceps expansion or tendon.

(Choice 2) Although it is true that a snapping sound is heard in tears of the anterior cruciate ligament, there is hemarthrosis and a positive Lachman’s test result. The inability to straight- leg raise, a gap felt at the site of the tear, and swelling confined to the anterior aspect of the knee are not features of this condition.

(Choice 3) is the main differential diagnosis. Fractures of the patella can result from direct or indirect trauma. In older individuals who are obese and in poor physical shape, an indirect injury resulting from tripping down stairs, jumping from a height, or even forcefully squatting can result in fracture of the patella. The patient complains of severe pain and falls to the ground. Difficulty in straight-leg raise, swelling over the knee, and hemarthrosis are seen. A gap can be felt in the patella, and the fragments can be moved, which distinguishes it from a pure tear of the quadriceps expansion.

(Choice 5) usually occurs in a younger individual. In teenagers, the epiphysis is weaker than the tendon, and it can be sheared off from its moorings. The gap is felt below the inferior pole of the patella. In the case presented, the gap is felt above the superior pole of the patella.