The correct answer is 2.

The patient described is most likely suffering from acalculous cholecystitis. This condition is most often seen in patients chronically hospitalized in the intensive care unit with any of the following conditions: multiorgan failure, severe trauma, surgery, burns, sepsis or prolonged parenteral nutrition. The pathogenesis of this condition is unclear, but it is most likely the result of cholestasis and gall bladder ischemia leading to secondary infection by enteric organisms, edema of the gall bladder serosa and necrosis of the gall bladder. Most patients affected by this condition have no prior history of gall bladder disease. Acalculous cholecystitis is a serious condition that can lead to sepsis and death if undetected. The clinical signs of disease, such as fever and leukocytosis, are vague, and patients most vulnerable to this condition are typically non-com municative due to their general medical condition. The best way to make the diagnosis is to have a high degree of clinical suspicion and to confirm the diagnosis with imaging studies that demonstrate gallbladder distention, thickening of the gall bladder wall and the presence of pericholecystic fluid. The immediate treatment is cholecystostomy, which may be followed by cholecystectomy when the patient’s medical condition improves.

(Choice 1) Mechanical bowel obstruction typically is associated with high-pitched hyperactive bowel sounds and dilated loops of bowel with air-fluid levels on abdominal imaging. The bowel distention in this patient is due to paralytic ileus, which is not uncommon after major trauma.

(Choice 3) Pancreatitis would not cause a distended gall bladder and pericholecystic fluid. CT findings consistent with pancreatitis would be pancreatic phlegmon, pseudocyst or abscess formation or pancreatic necrosis.

(Choice 4) Mesenteric contusion may be the cause of the patient’s paralytic ileus, but it does not explain the gall bladder findings on imaging.

(Choice 5) This patient most likely did suffer a pulmonary contusion in his initial traumatic insult. Pulmonary contusion frequently occurs when multiple ribs are fractured, and such an injury may have contributed to his hemothorax. A pulmonary contusion would not cause the gall bladder findings on imaging.

The correct answer is 4.

The patient most likely has a postoperative wound infection, which occurs in 2%-5% of patients who have had biliary tract Surgery. The infections are usually the result of contamination of the wound either during or after Surgery; there rarely is an infection prior to Surgery. Although infections can become evident within 1 day in a grossly contaminated wound, they generally first emerge 5-10 days postoperatively. Operative wounds are classified as clean (no gross contamination), clean-contaminated (e.g., in gastric or biliary tract Surgery), contaminated (e.g., in unprepared colon Surgery), or dirty and infected (infection encountered during the Surgery). The risk for wound infection increases if the wound is located in the abdomen, the Surgery lasts longer than 2 hours, or contamination of the wound is encountered during Surgery. One of the key factors that predisposes to

infection is decreased oxygen tension in the tissues. Attention to careful surgical techniques (reduced trauma to tissue, less suture material, removal of foreign bodies) and prophylactic use of antibiotics in certain types of surgeries reduce the chance of infection. Cefazolin is the drug of choice for prophylaxis during Surgery when both aerobes and anaerobes are a concern. Antibiotic prophylaxis is only given in selected clean or clean-contaminated procedures because antibiotic use in contaminated and dirty wounds is considered therapeutic. A single preoperative dose should be administered intravenously at the time of induction of anesthesia. Additional doses may be given after Surgery but are usually discontinued within 24 hours. Treatment of wound infection involves opening the wound and allowing drainage. Antibiotics are reserved for invasive infections.

(Choice 1) is not associated with fever.

(Choice 2) would be accompanied by warm shock, due to vasodilation of peripheral vessels, and would be an unlikely cause of this woman’s fever.

(Choice 3) is the most common cause of fever within 24 hours of Surgery.

(Choice 5) is associated with oliguria, not fever.

The correct answer is 3.

The clinical picture is that of mitral stenosis, with the apical diastolic murmur plus all the typical symptoms for that condition. As a rule, cardiovascular surgeons prefer to repair the patient’s own mitral valve, rather than replacing it. Stenosis is due to fusion at the commissures, which commissurotomy can correct.

(Choice 1) A ventricular septal defect would produce a systolic murmur and, if uncorrected by age 35, would have produced pulmonary vascular damage, with a potential reversal of the shunt and even cyanosis.

(Choice 2) Although mitral annuloplasty targets the correct valve, it assumes that the problem is insufficiency rather than stenosis. Had that been the case, the apical murmur would have been systolic, rather than diastolic.

(Choice 4) Replacement of the aortic valve would be correct if the patient had a deformed aortic valve, as these cannot be easily repaired. In this case, however, the sick valve is the mitral (with an apical murmur) rather than the aortic, who would have produced a murmur best heard at the base.

(Choice 5) Replacement of the mitral valve can be done, and is indeed done, but not as the first choice if repair is possible.

The correct answer is 4.

The correlation between ureteropelvic junction obstruction and profuse diuresis is classic. A congenital narrowing at the ureteropelvic junction allows normal passage of urine at a normal flow rate, but the lumen cannot accommodate a suddenly increased flow rate. Beer is a wonderful diuretic; if he had never been exposed to it, his congenital anomaly could have remained hidden.

(Choice 1) would give suprapubic pain and symptoms of an irritative bladder.

(Choice 2) is typically asymptomatic in the male but could lead to incontinence in the female.

(Choice 3) is a good second choice, and it could cause flank pain radiating to the inner thigh and scrotum. However, the youngster who develops colicky flank pain when first exposed to beer is so classic for ureteropelvic junction obstruction that urologists can make the correct diagnosis over the telephone.

(Choice 5) gives a febrile picture along with flank pain. It is typically seen in younger children, who eventually outgrow their problem.

The correct answer is 5.

Indications for exploratory laparotomy in trauma patients include those with intra-abdominal bleeding that has been demonstrated by appropriate tests, but also those with an acute abdomen (severe pain, tenderness, guarding, and rebound tenderness) following abdominal trauma. This woman is probably bleeding into her abdomen (she has no other obvious source). Even if that were not the case, however, she needs an exploratory laparotomy to deal with the source of the acute abdomen, which is bound to be injuries of hollow viscera. (Choice 1) Sonogram is used extensively to diagnose intra-abdominal bleeding, but it does not tell us what to do, or not to do, for the acute abdomen.

(Choice 2) X-ray films would add little to our decision. Free air under the diaphragm would prove visceral disruption, but the absence of such a finding would not exclude it.

(Choice 3) CT scan is excellent in the hemodynamically stable patient in whom the only question is intraabdominal bleeding. In this case, we are also contending with the acute abdomen. Furthermore, with a systolic blood pressure of 75 mm Hg, this woman cannot afford a trip to the CT scanner.

(Choice 4) Diagnostic peritoneal lavage is excellent to prove intra-abdominal injury, and is also extensively used to diagnose peritoneal contamination from ruptured hollow viscera. However, the latter is required only when the abdomen cannot be examined reliably (e.g., the drunk or the unconscious patient). This woman is telling us that her belly hurts, and our physical exam is diagnostic.

The correct answer is 3.

This patient has a mechanical small bowel obstruction (SBO). This disorder may be further categorized by anatomic location (i.e., proximal versus mid/distal) or simple versus strangulated. Complete proximal obstructions are characterized by vomiting, abdominal discomfort, and abnormal contrast filling on x-ray. Mid or distal obstructions typically present as colicky abdominal pain, vomiting, abdominal distention, constipation obstipation, and dilated loops of bowel on abdominal x-ray. Simple obstruction refers to luminal occlusion, whereas strangulation refers to a loss of blood supply to the bowel wall. Patients with strangulated obstructions may present with a rigid abdomen and signs of shock. Fever, tachycardia, and elevated WBC count are late findings. The patient in this vignette most likely has a simple mid or distal SBO. Adhesions are by far the most common cause of SBO.

They may be congenital in children (e.g., Ladd’s bands), but typically result from abdominal operations or inflammatory processes. Thus, this adult patient with an SBO is likely to have had an abdominal surgery in the past, such as an appendectomy.

(Choice 1) High alcohol consumption can be associated with acute pancreatitis or alcoholic hepatitis. Pancreatitis can cause an ileus and a tympanic abdominal exam. However, an AST/ALT ratio of more than 2 is typically observed if the patient is a heavy alcohol drinker. In addition, abdominal pain in pancreatitis is usually epigastric, constant, and radiates to the back.

(Choice 2) Occasional black or tarry stools (i.e., melena) are suggestive of a Gl bleed originating above the ligament of Treitz. The most common causes of melena in a man this age are peptic ulcer disease (PUD), gastritis, esophagitis, and Mallory-Weiss tear. PUD is a rare cause of proximal but not mid-distal SBO. The other etiologies are not associated with bowel obstruction.

(Choice 4) Ingestion of fatty foods precipitates biliary colic and acute cholecystitis, which usually cause right upper quadrant abdominal pain. Acute cholecystitis is accompanied by fever, leukocytosis, and sometimes abnormal liver function tests.

(Choice 5) Recent weight loss can be a sign of neoplasm, an endocrine disorder, or an inflammatory condition. Neoplasms and inflammatory conditions can cause SBO but are much less common causes than post-operative adhesions, especially in a younger patient.

The correct answer is 2.

Abdominal pain that refers to the shoulder suggests an intraabdominal pathology that is causing peritonitis and irritation of the diaphragm (Kehr sign). Pain sensation resulting from irritation of the parietal peritoneum covering the undersurface of either hemidiaphragm can be referred to the ipsilateral shoulder because the phrenic nerve originates from the C3 through C5 spinal levels, which also mediate sensation for the shoulder region. In the setting of blunt abdominal trauma, hemoperitoneum or spillage of bowel contents, bile, pancreatic secretions or urine can cause an acute chemical peritonitis. The choices given indicate that a bladder or urethral injury is the cause of this patient’s symptoms. Intraperitoneal rupture of the bladder occurs in blunt trauma to a full, distended bladder. The dome of the bladder is the only region covered by peritoneum; thus, it is the only injury that would permit leakage of urine into the peritoneum. Additionally, the dome of the bladder has a developmental hiatus where the urachus originates during embryonic life. Since the dome is attenuated in this region, it is also the segment of the bladder wall which is most susceptible to rupture caused by sudden increases in intravesical pressure.

(Choices 1,3,4 & 5) The other lower urinary tract structures listed in the answer choices are all extraperitoneal. Any possible blunt traumatic injury to each of these structures would not, by itself, cause peritonitis. Injury to any of these structures is classically associated with severe trauma and pelvic fracture. The most common site of extraperitoneal bladder rupture is the bladder neck.

The correct answer is 5.

Phimosis is an acquired or congenital condition in which the foreskin cannot be pulled back behind the glans penis. In acquired phimosis, there likely is a history of poor hygiene, chronic balanoposthitis, or forceful retraction of a congenital phimosis. Balanitis is inflammation of the glans of the penis. Hypospadias is an anomaly in which the urethral meatus opens on the ventral surface of the penis. Epispadias is an anomaly in which the urethral meatus opens on the dorsal surface of the penis. Paraphimosis is an emergency condition in which the foreskin, once pulled back behind the glans penis, cannot be brought down to its original position.

The correct answer is 2.

The relationship between smoking and bladder cancer is even more significant than the well- known relationship between smoking and lung cancer. This man is a prime candidate for bladder cancer. His workup has been appropriate until now because the intravenous pyelogram (IVP) is often the first test done in patients with hematuria. This study diagnoses renal cell carcinomas and ureteral tumors, but it is notoriously inaccurate for early bladder cancers. Thus, the patient’s workup has not been completed, and he now needs a cystoscopy.

(Choice 1) is also an excellent study for diagnosing renal cell carcinoma, but this diagnosis has already been excluded with the IVP, and the CT scan is not the best test to find early bladder cancers.

(Choice 3) We are not ready to prescribe medications. Valuable time will be wasted if we assume that the patient has a urinary tract infection or prostatitis (for which we have no convincing findings) and we go for a trial of therapy. The patient will not respond to it, and, eventually, we will have to look into his bladder. A 65- year-old man with hematuria, a normal IVP, and a very strong history of smoking needs an immediate cystoscopy.

(Choice 4) Hematuria is not the typical presentation for prostatic cancer. Prostatic cancer is found by discovering a hard nodule on rectal exam, or by being alerted by a high PSA, neither of which is present here. Thus, there is nothing to biopsy in that organ.

(Choice 5) is used to rule out bladder injuries in trauma patients. It is not the best test for early bladder cancer. In fact, we have already injected radio opaque dye in this patient’s bladder (as part of the IVP), and it failed to outline the tumor.

The correct answer is 4.

An emergent exploratory laparotomy is required for all blunt abdominal trauma patients with signs of peritoneal irritation and/or hemodynamic instability. The patient described in this question has suffered severe blunt abdominal trauma and has diffuse abdominal tenderness, guarding and rigidity on physical examination, all indicators of peritonitis. The most common causes of peritonitis in blunt abdominal trauma patients are hollow viscus rupture and pancreatic damage. This patient also has tachycardia, hypotension, collapsed neck veins and altered mental status, signs of hemorrhage leading to hypovolemic shock. Physical examination of his thorax is comparatively benign, making the abdomen the most likely location of his blood loss. Emergent exploratory laparotomy will allow for rapid identification and treatment of the hemorrhage as well as direct assessment of the abdominal viscera for perforation or other damage.

(Choice 1) Diagnostic laparoscopy is not ideal for hemodynamically unstable patients. (Choice 2) It is reasonable to presume that the source of bleeding in this patient is the abdomen based on clinical examination findings. Laparotomy should not be delayed for imaging studies.

(Choice 3) CT scan of the abdomen to diagnose intraabdominal or retroperitoneal bleeding should only be done in hemodynamically stable patients. The FAST (Focused Assessment with Sonography for Trauma) ultrasound examination may be used in the acute setting to assess for free fluid in four regions within the peritoneum.

(Choice 5) Diagnostic peritoneal lavage is done in blunt abdominal trauma patients to determine if intraperitoneal bleeding has occurred. This procedure has largely been replaced by the FAST exam. The presence of intraabdominal pathology is evident based on physical examination in this case, and further diagnostic studies are not required to corroborate this.

The correct answer is 2.

Duodenal hematomas most commonly occur following direct blunt abdominal trauma and are more commonly seen in children. Fallowing trauma, blood collects between the submucosal and muscular layers of the duodenum causing obstruction. Patients classically present with epigastric pain and vomiting due to the failure to pass gastric secretions past the obstructing hematoma. Most hematomas will resolve spontaneously in 1-2 weeks, and the intervention of choice is nasogastric suction and parenteral nutrition. Surgery may be considered to evacuate the hematoma if this more conservative method fails.

(Choice 1) Exploratory laparotomy is indicated only if there are other intraabdominal injuries following trauma such as hemorrhage or bowel perforation. Duodenal hematoma is best treated conservatively. If surgical intervention is required, it will be a focused laparotomy or a laparoscopic procedure to evacuate the hematoma.

(Choice 3) Antibiotics are not indicated in this patient as he is afebrile and has no symptoms suggestive of infection.

(Choice 4) Surgical removal of the hematoma is only attempted after conservative measures have failed. Laparotomy or laparoscopy is accepted methods of accomplishing evacuation of the hematoma.

(Choice 5) MRI will not provide any additional information relevant to this patient’s condition. CT with oral contrast is the investigation of choice for evaluating the duodenal hematomas.

The correct answer is 4.

Fractures of the shaft of the humerus involve the radial nerve, which winds around its posterior aspect, in the radial groove. As a result, a wrist drop may be present.

(Choice 1) Dislocations of the shoulder or fractures involving the surgical neck of the humerus may be associated with trauma to the axillary nerve. In such an event, sensations over the lateral aspect of the shoulder will be impaired.

(Choice 2) may be traumatized in supracondylar fractures of the humerus. The brachial artery may be compressed as well.

(Choice 3) can be injured after posterior dislocation of the elbow.

(Choice 5) is not injured in fractures of the upper extremities. Acute lateral flexion of the neck (e.g., after a fall) can damage the lower cord of the brachial plexus.

The correct answer is 2.

This patient has suffered rapid deceleration chest trauma, likely in association with forceful impact with his vehicle’s steering wheel. Chest radiography is the most important initial diagnostic study in all stabilized patients (airway, breathing and circulation secure) following blunt chest trauma. This patient’s chest x-ray shows a persistent pneumothorax despite chest tube placement and pneumomediastinum, and he has subcutaneous emphysema (palpable crepitus below the skin) on physical examination. Though rare, the most likely explanation for these radiographic and clinical findings is tracheobronchial perforation secondary to blunt thoracic trauma. The right main bronchus is most commonly injured in these cases. The diagnosis can be confirmed with high-resolution CT scanning, bronchoscopy, or surgical exploration. Operative repair is indicated.

(Choice 1) Myocardial contusion classically causes tachycardia, new bundle branch blocks or arrhythmia. Sternal fracture is a commonly associated injury.

(Choice 3) Myocardial rupture causes cardiac tamponade, which manifests with muffled heart sounds, hypotension and distended neck veins. The diagnosis can be made rapidly with ultrasound, and emergent surgical repair is warranted.

(Choice 4) Esophageal rupture following blunt trauma is rare. Iatrogenic (e.g., with endoscopy) and esophagitis-related etiologies are more common. Manifestations of esophageal rupture include pneumomediastinum and pleural effusions.

(Choice 5) Patients suffering diaphragmatic rupture may experience abdominal pain, pain referred to the shoulder, shortness of breath, and/or vomiting. Radiographic studies may show abdominal viscera above the diaphragm and/or loss of the diaphragmatic contour.

The correct answer is 3.

You probably had no trouble discerning that bacterial endocarditis, triggered by the use of non sterile N drugs, damaged a heart valve in this man. Although we usually think of the right- sided valves as the ones that are first in line to catch the bugs, any valve can become the seat of infection. The clinical presentation leaves no doubt that the aortic valve is the one that has been destroyed: the murmur is diastolic, at the right base, and the very low diastolic pressure reveals the incompetence of the aortic valve. Furthermore, this was not a slow process allowing for compensation: he is in failure and close to death. He needs a new valve, pronto.

(Choice 1) would have been more appropriate for a massive myocardial infarction producing a septal defect. The clinical presentation would have been different, with a systolic murmur and normal diastolic pressure.

(Choice 2) is wrong for at least two reasons: it would not address an acute problem, and the criteria given were those for long-standing aortic stenosis (not insufficiency).

(Choice 4) does not produce the symptoms described.

(Choice 5) is not the culprit either. If it were destroyed, it would give few manifestations (it is almost a “disposable” valve).

The correct answer is 4.

The patient described is experiencing colonic ischemia and infarction following surgical repair of an abdominal aortic aneurysm. Colonic ischemia follows up to 7% of such procedures due to interference of blood flow to the distal left colon. Common causes include loss of collateral circulation, manipulation of vessels with surgical instruments, prolonged aortic clamping and impaired blood flow through the inferior mesenteric artery. Patients classically present acutely following the procedure with dull abdominal pain in the area overlying the ischemic bowel and bloody diarrhea. X-rays of colonic ischemia are usually nonspecific except in cases of advanced disease. CT scan will show thickening of the bowel wall. Colonoscopy characteristically shows cyanotic mucosa with hemorrhagic ulcerations. There is typically a sharp transition from affected to unaffected mucosa with only a segment of bowel affected by ischemia.

(Choice 1) Acute diverticulitis would cause left lower quadrant pain, and diverticulae may cause rectal bleeding, but frequently rectal bleeding does not occur in the setting of acute diverticulitis. Additionally, colonoscopy would reveal diverticulae in this condition.

(Choice 2) Radiation proctitis is characterized clinically by diarrhea, rectal bleeding, tenesmus and incontinence. Later, strictures and fistulae may form.

(Choice 3) Clostridium difficile colitis (pseudomembranous colitis) typically causes abdominal pain, fever and watery diarrhea. The diagnosis can be confirmed with colonoscopy or, more commonly, by detecting toxin in the stool with ELISA.

(Choice 5) Inflammatory bowel disease (180) can be differentiated from colonic ischemia both by the acute onset of the latter as well as differences in appearance on colonoscopy. Namely, ischemia typically spares the rectum and involves only a segment of the colon while 180 does not.

The correct answer is 5.

This patient has a varicocele involving the pampiniform plexus of veins. The classic description of this is that it feels like a bag of worms. Varicoceles are benign conditions and may be associated with a small hydrocele. However, the main concern on the left side is the presence of a latent renal carcinoma that can herald itself by presenting as a varicocele. This is because, whereas the right testicular vein drains directly into the inferior vena cava, in contrast, the left testicular vein drains into the left renal vein. As a consequence, renal carcinoma can infiltrate into the left renal vein and block the inflow of blood from the left testicular vein, leading to backup and dilated veins in the scrotum. In such instances, the varicocele will not decompress when the patient is lying supine. Hence, the presence of renal carcinoma should be excluded at the earliest, rather than just dealing with the varicocele itself.

(Choice 1) is an unlikely diagnosis. This is usually associated with severe lower abdominal pain, retching, and vomiting, and the testis will be exquisitely tender. Moreover, the testis will be lying in a horizontal position.

(Choice 2) This man also does not have an incarcerated inguinal hernia. An incarcerated inguinal hernia will usually extrude from the inguinal canal into the scrotum. The scrotum will be swollen and tender. Dilated veins will not be found. The hernia will be distinct from the testis and will fail to reduce. Furthermore, one will not be able to “get above the swelling.” (Choice 3) Fournier’s gangrene, also known as idiopathic scrotal edema, is a rare condition. Scrotal inflammation occurs suddenly, followed by rapid onset of gangrene. This leads to sloughing of the scrotal skin. Patients usually have severe scrotal pain, fever, prostration, and pallor. Treatment involves antibiotics and analgesics.

(Choice 4) Epididymitis in young men most commonly results from sexually transmitted disease. Chlamydia is the leading cause, followed by gonorrhea. The epididymis is tender to palpation; however, no dilated veins or scrotal swelling is noted. If it spreads to the testis, the resultant disorder is called epididymo-orchitis.

The correct answer is 2.

As a rule, internal hemorrhoids bleed but do not hurt, whereas external hemorrhoids hurt but do not bleed. This is the typical symptomatology of external hemorrhoids.

(Choice 1) occurs in young women, who have excruciating pain when they have a bowel movement and blood streaks on the toilet paper.

(Choice 3) occurs in people who have had a perirectal abscess drained. The typical complaint is soiling of the underwear from the drainage of the fistula.

(Choice 4) As pointed out above, internal hemorrhoids tend to bleed, but they have no innervation for pain.

(Choice 5) would cause very intense pain, along with fever, and would have a short clinical course ending with spontaneous drainage of pus, if not surgically drained first.

The correct answer is 1.

Asternal fracture is very likely to be complicated by myocardial contusion, which may not be evident immediately but will show up in serial ECGs with signs very similar to those of a myocardial infarction.

(Choice 2) would not add to our present information. If he had free air under the diaphragms, or had a diaphragmatic rupture with bowel in the chest, both would be seen in his chest x-ray films.

(Choice 4) An injury of the tracheobronchial tree would produce pneumothorax, mediastinal air, or subcutaneous emphysema, so bronchoscopy would not be warranted.

(Choices 3 & 5)The esophagus typically gets injured during instrumentation or by penetrating injuries. Blunt trauma does not disrupt it, so a Gastrografin swallow or esophagoscopy would not be necessary.

The correct answer is 5.

As a result of sustaining a spontaneous fracture of the neck of the femur, this patient is in hemorrhagic shock. Among the choices offered to account for this fracture, metastatic bone disease is the most probable. Metastases in bone cause lytic lesions, thereby weakening the bone and possibly leading to a spontaneous fracture. The primary cancer may arise in any of several tissues, including breast, small-cell carcinoma of the lung, and follicular carcinoma of the thyroid. Lytic lesions are also found in multiple myeloma, which is the most common primary hematologic malignancy of bone, and in osteosarcoma, the most common primary cancer of bone. Nonmalignant diseases causing pathologic (spontaneous) fractures include bone cysts, Paget’s disease of bone (in which the fractures are usually transverse and usually involve the femur or the tibia), osteogenesis imperfecta, and osteoporosis.

(Choice 1) Chronic (not acute) osteomyelitis results from acute hematogenous infection to the bone that may or may not have been treated adequately. The condition is usually quiescent for several months or even years before it flares up. The patient has fever, prostration, local inflammation, and a draining sinus. This patient had a furuncle on her thigh, not a draining sinus. Fractures are unusual in a setting of chronic osteomyelitis. Treatment is surgical, and cure is difficult. The goal is to remove the sequestrum (dead bone), which is a continual nidus for infection.

(Choice 2) is unlikely. Notwithstanding the hot flushes that she has been experiencing recently, the patient is still premenopausal. Declining bone density in women usually commences shortly after menopause, but frank osteoporosis is rare before the age of 65. Colles’ fracture, fracture of the proximal humerus, neck of the femur, and collapse of the vertebra are the most common fractures associated with osteoporosis. Only femoral neck fracture and vertebral collapse are not preceded by a history of fall.

(Choice 3) are caused by repetitive excessive load on the bones. This can involve the second and third metatarsals (march fracture), which was initially noted in infantrymen during long marches, and femoral neck in the case of young soldiers who have to march for great distances carrying a full, heavily loaded backpack. Stress fractures can also involve the tibiae in runners, especially when they run over uneven surfaces. Physical examination usually reveals localized tenderness without deformity. A radiograph may not show the fracture,

especially in the early stages. A bone scan using 99m Tc-labeled bisphosphonate will clinch the diagnosis, by demonstrating increased uptake at the site. Most stress fractures resolve with rest.

(Choice 4), also known as brittle bone disease, presents itself in four forms, of varying severity. Type I is the most common form and is associated with a blue sclera 98% of the time (not blue irises, as in this woman); typically, fractures are not excessive and primarily occur prior to puberty. Type II manifests in utero or in infancy and is lethal. Type III is relatively rare; fractures abound, causing bone deformities such as scoliosis and deformed limbs and may result in dwarfism. Blue sclera is also a prominent symptom in types II and III. Type IV is similar to type I but much rarer and differs in that blue sclera are not seen. Both types I and IV are associated with childhood fractures after minimal trauma and are easily mistaken for child abuse, particularly type IV, in which blue sclera are not present. Although in both type I and IV fractures become less frequent after growth ceases, the bone structure remains less dense than normal, making then susceptible to fractures throughout life and to osteoporosis as the patients age. Types I and IV are autosomal dominant, and commonly, cases can be traced back several generations. In contrast, type II and III cases lack a family history and are either autosomal recessive conditions or new mutations.

The correct answer is 1.

Developmental dysplasia of the hip (DOH) comprises a group of disorders that involves any abnormal relationship between the proximal femur and the acetabulum. Proper formation of the femoral head and acetabulum depends on the proper articulation of these bony structures. Failure of these bony elements to contact one another properly may cause defects in maturation of both structures. Such errors in contact between the femoral head and acetabulum result in hips that are subluxable, dislocated, dislocatable or dysplastic.

DOH has been associated with the following factors: Caucasian race, female gender, first- born infants, breech position, family history of DOH and other congenital abnormalities. The maneuvers used to screen for DOH in the newborn are the Barlow and Ortolani tests, which act to dislocate and relocate affected infants’ hips, respectively. Ancillary tests to aid in the diagnosis are ultrasound in patients less than 4 months old and radiographs in patents over 4 months old. Ultrasound is preferred in patients less than 4 months of age because at that age the femoral head and acetabulum have not yet ossified, so plain x-rays are poorly capable of illustrating the patient’s anatomy. Treatment may involve use of a hip (Pavlik) harness, spica cast or surgical reduction.

(Choice 2) Reassurance in the setting of an abnormal physical exam, such as a positive Ortolani test, is not the best option.

(Choices 3 & 5) The lesions on the patient’s lumbosacral region are most likely Mongolian spots, which are normally seen in some newborns. Imaging studies of the lumbosacral area are indicated when a midline defect, such as spina bifida, meningocele or myelomeningocele, is suspected. Classic cutaneous findings associated with spinal dysraphism include a midline dimple or tuft of hair.

(Choice 4) X-ray is used as a diagnostic test for DOH when the patient is more than 4 months old. At that age, the acetabulum has begun the process of ossification and can thus be visualized with radiography.

The correct answer is 2.

The patient has volvulus of the sigmoid colon. Volvulus is a twisting of the bowel around the mesenteric root. It is most common in the sigmoid colon (65%) and is most often seen in the elderly population. Obstruction and strangulation with infarction are potential sequelae. Clinical signs include colicky abdominal pain, abdominal distention, and vomiting. In sigmoid volvulus, there is a single dilated loop of bowel resembling a “coffee bean” rising up out of the pelvis. The concavity of the coffee bean points toward the left lower quadrant. Barium studies reveal a “bird’s beak” or “ace of spades” appearance, with the lumen of the bowel tapering toward the volvulus. A volvulus can frequently be decompressed with a flexible colonoscope, but it often recurs. If it cannot be decompressed, then surgery should be performed with resection of the redundant bowel.

(Choice 1) is uncommon in adults. It refers to the telescoping of one segment of proximal bowel into the distal bowel. In adults, it commonly results from an underlying mucosal lesion that serves as the nidus for the intussusception, producing obstruction and strangulation of the bowel. Bloody diarrhea and a palpable mass are usually present.

(Choice 3) is associated primarily with ulcerative colitis. The diameter of the descending colon exceeds 6 cm. Perforation is a common complication. The patient does not have a history compatible with ulcerative colitis (e.g., intermittent bouts of bloody diarrhea).

(Choice 4) is a pseudo-obstruction of the ascending colon in elderly persons. There is a sudden, massive distention of the colon without pain or tenderness. The right colon is distended with a cutoff at the splenic flexure. Barium studies are negative for obstruction. (Choice 5) would not likely result in complete obstruction.

The correct answer is 2.

The patient obviously has developed a fistula at the operative site, but there are no signs that the gastrointestinal contents are spilling into the abdomen (no signs of an acute abdomen) or collecting inside a pocket (no fever).Thus, we can provide general support and wait for the fistula to dose. He is already getting two of the essential components of therapy: the skin is well protected, and he is getting good nutritional support distal to the fistula, with a feeding solution that does not stir up enzymatic activity(elemental diet) and that is rich in protein (a calorie-nitrogen ratio lower than 150). But he needs replacement of the fluids and electrolytes pouring out through the fistula. The green fluid indicates a duodenal origin (alkaline fluid), so Ringer’s lactate is a suitable replacement fluid. Cramming 6 L a day via the jejunostomy might be too much; thus, the IV route is better for the additional fluid.

(Choice 1) No change in therapy would lead to prompt dehydration and electrolyte depletion. He needs the 3 L per day of jejunal feeding for his own needs. The fistula losses have to be replaced separately.

(Choice 3) Stopping the nutritional support would not help the fistula to dose. If he had been eating meat and potatoes by mouth, they would have had to be stopped. As he is, however, the feeding does not disturb the fistula. Furthermore, 5% dextrose (D5)-half normal saline would be a poor choice of IV fluid to replace alkaline loses from the duodenum.

(Choice 4) Surgical drainage addresses a nonexistent problem. The gastrointestinal fluid is already coming out, not pooling inside.

(Choice 5) As for surgical reconstruction, it might have to be done if conservative management does not lead to fistula closure. But one does not begin with such a high-risk, technically difficult step. Most fistulas close if there is no foreign body, epithelialization, tumor, infection, or distal obstruction to prevent it.

The correct answer is 5.

This patient has adult onset polycystic kidney disease (APKD). APKD is an autosomal dominant disease that presents with hypertension, renal cysts, hematuria, and possible renal failure, usually after age 30. There is a 10 to 20% incidence of berry aneurysms in these patients, and they need to be screened with angiography to determine the presence or absence of these malformations. A magnetic resonance angiogram (MRA) of the brain is the standard option for such imaging in most medical centers.

(Choice 1) is not indicated since clinical history and renal ultrasound alone can make the diagnosis of APKD. The concern here is to screen for the concomitant presence of intracranial pathology.

(Choice 2) is incorrect. Unless these lesions were mistaken for renal cell carcinoma, there is no indication to scan a distant site like the lungs as this disease has no malignant potential. (Choice 3) is not useful for detecting circulatory malformations without the aid of angiographic contrast material.

(Choice 4) is used to evaluate the collecting system of the urinary tract and is not indicated in this case, as the diagnosis of APKD is almost certainly based on the ultrasound and clinical presentation. This study adds no diagnostic information to the results of the ultrasound already obtained.

The correct answer is 5.

This adolescent has a slipped capital femoral epiphysis (SCFE). SCFE is characterized by displacement of femoral head on the femoral neck due to disruption of the proximal femoral growth plate. This condition is commonly seen in obese adolescent boys. The physis, the physical junction between the femoral head and neck weakens during early adolescence because it is rapidly expanding and composed primarily of cartilage, which does not possess the strength of bone. When exposed to excessive shear stress, which is magnified by obesity, the physis fractures and the femoral head slips posteriorly and medially relative to the femoral neck. Patients typically present with hip or knee pain of insidious onset causing limping. Acute presentations may occur. Diagnosis requires a high degree of clinical suspicion because knee pain, not hip pain, is a common presenting complaint with this condition. Physical examination shows loss of abduction and internal rotation of the hip, and patients hold the thigh in external rotation while the hip is being flexed. A frog-leg lateral view x-ray of the hip is the diagnostic imaging technique of choice. SCFE should be treated promptly with surgical pinning of the slipped epiphysis where it lays (in situ) in order to lessen the risk of avascular necrosis of femoral head and chondrolysis.

(Choice 1) Joint aspiration and microscopic analysis would be useful in the diagnosis of a septic joint or a crystal-induced arthropathy.

(Choice 2) Conservative management with rest and analgesics is indicated for the treatment of tendinous or ligamentous strains.

(Choice 3) Closed reduction is not advised due to the risk of further damage to the tenuous blood supply of femoral head, which may lead to avascular necrosis.

(Choice 4) Corrective osteotomies may cause a vascular necrosis and may not correct the exact anatomic deformity. They are usually undertaken later in treatment if a patient experiences persistent pain and limitation of range of motion after initial repairs and attempted rehabilitation.

The correct answer is 4.

Nowadays, when thousands of patients are awaiting transplants and many die before they get them, every potential donor should be evaluated by the experts. They may indeed reject some, but probably very few. For instance, corneas can be harvested even from people with cancer, and donors with chronic viral infections can be used for patients who have the same viral disease.

All the other options were at one time or another used to exclude donors. These situations still make solid organs less attractive, but not to the extent that evaluation should be precluded.

The correct answer is 3.

The rule is that lymph nodes that progressively enlarge over several months are malignant. Furthermore, when they are in the supraclavicular area, they typically harbor metastasis from a primary tumor below the clavicles (i.e., not in the head and neck). In this case, gastric cancer was the only choice offered that fit the rule, and the rest of the vignette is actually suggestive of that particular malignancy. Don’t be put off by the inability to feel it by palpation; gastric cancers are seldom palpable.

(Choice 1) Inflammatory nodes typically have a timetable of weeks rather than months, and they would not explain weight loss, epigastric discomfort, and occult blood in the gastrointestinal tract.

(Choice 2) would have been an excellent choice in a young person with fever, night sweats, and multiple enlarged lymph nodes at several locations.

(Choice 4) would have been perfect for an old man who smokes and drinks and has rotten teeth, if the node had been higher up in the neck.

(Choice 5) would likewise metastasize to the jugular nodes before it would involve the supradavicular area.

The correct answer is 4.

Bowel ischemia is one known complication (1- 7% incidence) of abdominal aortic aneurysm repair. It results from inadequate colonic collateral arterial perfusion to the left and sigmoid colon after loss of the inferior mesenteric artery during aortic graft placement. Patients present with abdominal pain and bloody diarrhea. Fever and leukocytosis may also be present. This adverse effect can be minimized by checking sigmoid colon perfusion following placement of the aortic graft.

(Choice 1) C. difficile is the most common cause of nosocomial diarrhea. Pseudomembranous colitis occurs following antibiotic treatment and most commonly causes a voluminous watery diarrhea in addition to abdominal pain and fever. Bloody diarrhea is rare. Also, it is uncommon to develop C. difficile infection so early after the antibiotic use (typically takes 4-5 days).

(Choice 2) Invasive diarrhea, such as that caused by E. coli (EEC) or Shigella manifests with bloody, purulent diarrhea and tenesmus. These are less likely in this setting.

(Choice 3) Aortoenteric fistula is a rare and late complication where the duodenum erodes into the proximal part of the aortic graft.

(Choice 5) Iatrogenic bowel perforation may be suspected after any abdominal operation. Signs of peritoneal irritation are usually present. Bloody diarrhea is usually not a feature of perforation.

The correct answer is 5.

This question simply requires a basic understanding of the anatomy of the brachial plexus. In every medical specialty, general medicine included, knowledge of key anatomic loci is crucial for patient care. Classic examples of this include placement of central venous lines or needle thoracentesis. In this case, the ulnar nerve, the end-terminal branch of the medial cord (posterior to the axillary artery) of the brachial plexus, is in jeopardy. Although the posterior cord is posterior to the axillary artery at lower levels, at this level the medial cord is interposed between the posterior cord and the artery. This is the so-called “region two of the axillary artery (posterior to the pectoralis minor muscle):’ where the axillary block is performed. (Choice 1) The axillary nerve is a branch of the posterior cord, but arises very high in the plexus and immediately exits the axilla via the teres muscle groups.

(Choice 2) The median nerve is formed from the medial and the lateral cords, is very low in the brachium, and is not in danger from an axillary block.

(Choice 3) The musculocutaneus nerve is a branch of the lateral cord and is in no danger, as it is buried in muscle tissue from its origin.

(Choice 4) The radial nerve, also a branch of the posterior cord, is in no danger of injury since it exits the axilla via the radial groove on the humerus, very deep to muscle. This nerve is most often injured during spiral fractures of the humerus.

The correct answer is 2.

Post-surgical patients generally have moderate to severe derangement in fluid balance. They have been fasted before the procedure and then had a variety of sensible and insensible losses during the procedure. In this case, the idea of severe dehydration causing pre-renal azotemia would be supported by an elevated BUN and creatinine, but in a ratio of greater than 20: 1 . This is due to the heightened reabsorption and retention of solute by the kidney that is reflected by the elevated BUN.

(Choice 1) is incorrect. In conditions of volume depletion, the renin-angiotensin-aldosterone axis is activated with high levels of each hormone. In this case, aldosterone is acting on the distal tubules to affect sodium reabsorption.

(Choice 3) is incorrect because in the case of volume depletion, the urine should be maximally or near maximally concentrated, reflecting retention of nearly all filtered water. (Choice 4) is not correct. With volume depletion, the urine sodium should be quite low ( <20 mEq/L), reflecting retention of nearly all filtered water and sodium.

(Choice 5) is the opposite of what is expected. As with osmolality, this parameter should reflect maximal concentration of the urine, which is equivalent to minimal free water excretion.

The correct answer is 4.

This patient has an injury to medial collateral ligament of the knee. The medial collateral ligament is the most commonly injured ligament of the knee. Forceful abduction of the knee, often with a torsional component of motion causes most injuries to this ligament. On examination, the knee joint is swollen due to effusion with tenderness over medial aspect of the knee. Because the medial collateral ligament resists valgus angulations (abduction) at the knee, injury to this ligament leads to increased angulation of the effected knee on valgus stress. MRI is the investigation of choice for assessment of soft tissue injuries of the knee. MRI is able to detect complete and partial tears, the exact site of ligamentous injury and associated injuries to other ligaments or the meniscus.

(Choice 1) CT scan does not visualize the soft tissue of the knee joint (tendons, ligaments, and meniscus) as well as MRI.

(Choice 2) Swelling in this patient is due to effusion associated with ligamentous injury; fluid examination is not needed. Joint aspiration is useful in the diagnosis of septic arthritis and crystal-induced arthritis.

(Choice 3) Arthroscopy is an invasive procedure and is reserved for cases where MRI is inconclusive or surgical treatment of lesion is necessary.

(Choice 5) Plain radiographs are of limited use in confirming the diagnosis of ligamentous injury though they should be obtained for all patients with traumatic knee injury.

The correct answer is 4.

This patient has a classic presentation of fat embolism. Fat embolism is common in patients with polytrauma, especially with multiple fractures of long bones. It is characterized by severe respiratory distress, petechial rash, subconjunctival hemorrhage, tachycardia, tachypnea, and fever. Diagnosis can be confirmed by presence of fat droplets in urine or presence of intra-arterial fat globules on fundoscopy. It may occur from 12 to 72 hours after the injury. Central nervous system dysfunction initially manifests as confusion and agitation but may progress to stupor, seizures, or coma and frequently is unresponsive to correction of hypoxia. Thrombocytopenia, anemia, and hypofibrinogenemia are nonspecific findings. Serial x-rays shows increasing diffuse bilateral pulmonary infiltrates within 24-48 hours of onset of clinical findings.

(Choice 4) Treatment should include prompt respiratory support. Use of heparin, steroids, and low molecular weight dextran is controversial.

(Choice 1) An air embolism can occur in a trauma patient who is on a respirator. It can also occur with subclavian vein access. It can result in sudden collapse and cardiac arrest. (Choice 2) Amniotic fluid embolism occurs immediately after the rupture of membranes; it is not usually seen during this period of pregnancy.

(Choice 3) Thromboembolism can cause pulmonary embolism in bed-ridden patient; however it is rare at this young age. Also it would not cause the petechial rash. Such patients would have some signs of deep venous thrombosis or congenital thrombophilia.

(Choice 5) Acute respiratory distress is characterized by severe pulmonary distress. Again they do not have this classic rash.

The correct answer is 1.

This patient’s history of motor vehicle accident and hypotension with no obvious source of external bleeding indicates possible internal bleeding. In hemodynamically unstable patients who have suffered blunt abdominal trauma and pelvic fracture, both intraperitoneal and retroperitoneal bleeding must be ruled out. This patient has already had an ultrasonogram and diagnostic peritoneal lavage performed to investigate his blunt abdominal trauma, both of which showed no intraperitoneal bleeding. The next investigation should be aimed at identifying any retroperitoneal bleeding caused by pelvic fractures. Not only does pelvic angiography provide the best means for identifying the source of retroperitoneal hemorrhage, but it can also be used to treat it. By embolizing the offending vessel, the bleeding can be stopped and the hemodynamics can be stabilized.

(Choice 2) A CT scan of the abdomen is the appropriate assessment for hemodynamically stable victims of blunt abdominal trauma and is contraindicated in unstable patients. This patient is hemodynamically unstable, and while a CT scan would identify the retroperitoneal bleeding, it would not help in treatment and would cost precious time.

(Choice 3) A CT scan of the chest would not be appropriate at this stage in the patient’s management. His chest x-ray showed a fractured rib, but no pneumothorax, aortic dissection or other potential source for his hypotension. A CT scan of the chest would cost valuable time and not elucidate the source of hemodynamic instability.

(Choice 4) Laparotomy is the appropriate treatment for intraperitoneal bleeding confirmed on either ultrasound or diagnostic peritoneal lavage. However, pelvic angiography is the appropriate diagnostic and therapeutic option for retroperitoneal hemorrhage associated with pelvic fracture.

(Choice 5) Chest tube placement would be appropriate for managing a pneumothorax. This patient’s chest x-ray did not reveal pneumothorax.

The correct answer is 2.

This child suffered first and second-degree burns on her hand and fingers. The first-degree burns are indicated by the reddened area, second-degree burns by the blisters. The primary treatment should be gently cleaning the burned area with a cool, not cold, antiseptic solution, applying a topical antibiotic, and dressing the injured area with a nonadherent dressing. Following that, a conforming protective material should be applied. The mother suffered from shock at seeing her child suffer and guilt at leaving her unattended and needs to be reassured that, luckily, the child’s burns are minor and should heal without scarring in the course of a couple of weeks. She should also be informed that application of butter or any other greasy substance is not suitable treatment because it traps the heat of the burn, possibly making it worse. She ought to also be advised that a better course of action in the event of any serious accident is to call 911 rather than rush off to a walk-in clinic.

(Choice 1) introduces a risk of compromising circulation to marginally surviving areas of the burn and should not be done for any burn more serious than a first-degree one. In addition, for burns covering an extensive area such cooling also creates a risk of hypothermia. On the other hand, washing relatively nonextensive first or second-degree burns with cool water, about 60-80°F (15-25°C), eases the pain.

(Choices 3 & 4) Most authorities believe the blister should be left intact as long as possible because the skin of a blister may act as a natural dressing, protecting the wound against infection and reducing the amount of pain; consequently, (aspirate the fluid underneath the blister) and (debride the wound, aspirate the fluid, and apply an antibiotic cream) are incorrect. In addition to cooling to reduce pain, an oral analgesia such as acetaminophen (not aspirin) should be provided.

(Choice 5) is important in all patients with burns in whom the skin is or may be broken. Thus, if this child’s tetanus immunization is not up to date, it should be brought up to date. The best course of action in this particular case would be to contact and inform the child’s regular physician of the accident and treatment, to determine the child’s immunization status, and to arrange for a follow-up appointment either at the walk-in clinic or better yet with the child’s usual physician. In any case, the child should be seen again within 48 hours to make sure that there is no secondary infection.

The correct answer is 3.

Rib fractures should be suspected in all patients with localized chest wall tenderness following trauma; up to half of rib fractures will not be evident on initial chest x-ray. Rib fracture is associated with significant pain, which causes hypoventilation that may ultimately result in atelectasis and pneumonia. Thus, pain management and respiratory support are the priorities in the management of rib fractures. Oral agents, such as opiates and/or NSAIDS are most commonly utilized, but an intercostal nerve block with a long-acting local anesthetic can be used if oral or systemic analgesics are not sufficiently effective. Intercostal nerve blocks provide pain relief without affecting respiratory function, as opiate analgesics may, but it does carry some risk of pneumothorax.

(Choice 1) The cause of hypoventilation in patients with rib fracture is severe pain. Pain relief will correct the hypoventilation and intubation is not needed unless respiratory decompensation occurs.

(Choice 2) Use of colloids or crystalloid has no role in management of rib fracture unless the patient has hypotension or blood loss.

(Choice 4) Mechanical stabilization of chest wall is not required in rib fractures. In fact, the external compression caused by such devices may further impair adequate ventilation. (Choice 5) Prophylactic antibiotics are not indicated routinely in management of rib fracture unless an open fracture has occurred.

The correct answer is 5.

Renal failure is the most common cause of secondary hyperparathyroidism. This patient, who has had severe uncontrolled diabetes and lab values consistent in patients with diabetes, is most likely to have renal failure as the cause of his hypercalcemia. Whenever the kidney loses its ability to reabsorb calcium and hydroxylate vitamin D for calcium absorption from the gut, hypocalcemia triggers the parathyroid glands to increase their production of parathyroid hormone. Milk-alkali syndrome can cause hypercalcemia in patients who eat many antacids or drink an excessive amount of milk. This condition is more commonly found in patients who have gastric ulcers and frequently depend on milk and antacids for relief. Lithium can cause hypercalcemia by causing hyperparathyroidism. Parathyroid adenomas can cause hypercalcemia by increasing parathyroid hormone secretion.

The correct answer is 2.

Acute blood loss is an indication for transfusion in patients who have lost 25-30% of their blood volume (1500ml in 70 kg man). Crystalloid resuscitation is generally adequate for blood loss that is less than 25% of the patient’s blood volume though patients with concomitant heart disease and other comorbidities may require transfusion with lesser blood losses. An effective general guideline for treating a bleeding patient is to initially resuscitate with crystalloids. 2L are administered very quickly. If the patient continues to show signs of hemodynamic instability after infusion of 2L of crystalloid, blood transfusion should be initiated.

(Choice 1) The hematocrit is not a good indicator in acute blood loss because acute blood loss results in a proportional loss of both erythrocytes and plasma. Acutely, physiologic responses to depletion of intravascular volume, such as increased renal retention of water, have not had an opportunity to dilute the blood and cause a drop in hematocrit.

(Choice 3) Hypoxia in a trauma patient could be due to pneumothorax, hemothorax, cardiac tamponade, pulmonary contusion etc. Hypoxia alone is not an indication for blood transfusion.

(Choices 4 & 6) Acidosis in trauma patients is most likely due to inadequate tissue perfusion. This could be from any reason and need not be from blood loss. For example cardiac tamponade or pneumothorax can cause hypotension and resultant lactic acidosis. Decreased urine output is to the result of inadequate renal perfusion, which may be corrected in many patients with crystalloids alone.

(Choice 5) Even though a femoral fracture may be associated with a potential hemorrhage, the presence of a fracture alone is not an indication for blood transfusion.

The correct answer is 1.

Pulmonary artery (Swan Ganz) catheters are ubiquitous in critical care settings; a basic ability to interpret data from them is vital to the practice of inpatient hospital medicine. This patient has a low cardiac output and a high filling pressure ( > 18 mm Hg) and is hypotensive. Therefore, this patient’s shock syndrome is cardiogenic. Cardiogenic shock is caused by a number of underlying problems, but the end result is left ventricular failure. This also accounts for the secondarily high right-sided pressures and filling pressures (left heart failure causes right heart failure).

(Choice 2) is a possibility in this case. At first glance, acute MR could account for all of the patient’s findings, both on physical examination and pulmonary artery catheter. However, unless the acute MR occurred in the setting of acute ischemia, there is no way to account for the severely depressed cardiac output (LV function). Therefore, isolated acute MR from a papillary muscle rupture or chordae rupture could not alone account for all of this patient’s findings.

(Choice 3) is incorrect because it fails to explain the elevated left-sided filling pressures. (Choice 4) would acutely produce elevated pulmonary artery pressures and possibly right heart failure over the long term, but not in an acute manner.

(Choice 5) is defined as hyperdynamic cardiac output (supraphysiologic) with systemic hypotension. This patient has a depressed output, not compatible with sepsis.

The correct answer is 4.

Chronic pancreatitis produces steatorrhea (increased fat in the stool) because the intestine is lipase deficient. Consequently, undigested lipid and fat-soluble vitamins are lost in the stool. Oral pancreatic enzyme preparations have high lipase activity; thus, administration before, during, and after a meal, will help hydrolyze ingested fats, thereby facilitating their absorption. Concurrent administration of a histamine (H 2 ) antagonist will assist this process by blocking inactivation of the enzyme by acid. In addition, the patient should be on a low-fat diet.

(Choice 1) is a treatment option in chronic pancreatitis if intractable pain is present and is not amenable to medical therapy. However, normally the patient's pain is controlled with medical therapy. A

(Choice 2) does not enhance lipid absorption because bacterial overgrowth is not part of the pathophysiology of chronic pancreatitis. Bacterial overgrowth produces bile salt deficiency, which leads to steatorrhea.

(Choice 3) is the therapy of choice for celiac disease, which is an autoimmune disease that has antibodies directed against the gliadin fraction in gluten. These antibodies are not present in the patient.

(Choice 5) is a synthetic sugar used to treat constipation and to lower blood ammonia levels resulting from hepatic encephalopathy; it has no role in the treatment of steatorrhea.

The correct answer is 2.

All patients with traumatic wounds should be considered for tetanus immunoglobulin (TIG) or tetanus toxoid (TT) administration. Tetanus immunoglobulin provides passive, temporary and immediate immunity and tetanus toxoid provides active, prolonged but delayed immunity. The current recommendations are as follows:

History of tetanus toxoid ,

Clean minor wounds High-risk wounds

immunization

< 3 doses > 3 doses

TT: Yes TIG: No

TT: Yes if last dose >10 years ago TIG: No

TT: Yes TIG Yes

TT: Yes if last dose> 5 years ago TIG: No

Wounds at high risk for vegetative Clostridium tetani growth are those that provide an anaerobic environment for growth, such as puncture wounds, projectile wounds, wounds containing foreign bodies, sites of active infection by other organisms, and wounds containing necrotic tissue. The patient described in the vignette needs tetanus toxoid only, as he has already received at least 3 doses of the tetanus vaccine with his childhood vaccine series.

(Choice 1) This patient requires a booster (toxoid) vaccination as it has been more than 10 years since his last vaccination.

(Choices 3 & 4) Tetanus immunoglobulin is indicated in patients who have wounds suspicious for C. tetani contamination and who have had less than 3 vaccinations. Additionally, TIG is used in the treatment of symptomatic tetanus disease in an effort to eliminate any unbound toxin.

The correct answer is 5.

This patient has developed a compression fracture of the vertebra. She probably has osteoporosis, which makes it possible for a compression fracture to occur. Sudden onset of pain that radiates to the front of the abdomen like a belt is a characteristic presentation. This, together with tenderness in the vertebra to palpation, should suggest the diagnosis. Additional features include neurologic deficits secondary to spinal cord compression. The sensory deficits in the legs of this patient and the absent ankle jerks are due to diabetic neuropathy. (Choice 1) is usually associated with chronic pain, and there may be tenderness on palpation of the vertebra. Clonus has to be sustained to be pathologic and signifies involvement of the corticospinal pathway. Thus, there are no neurologic findings in this patient to support a spinal cord tumor.

(Choice 2) can present with pain over a few days and tenderness in the spine, together with pyrexia, which is absent in this patient. Furthermore, the patient may have neurologic deficits as well.

(Choice 4) is associated with radicular pain (i.e., pain going down one lower extremity) together with sensory loss over the distribution of the appropriate dermatome in the leg.

There may be motor weakness, either weak dorsiflexion or weak plantar flexion of the appropriate foot, depending on which nerve root is involved. No spinal tenderness will be elicited.

(Choice 5) is associated with saddle anesthesia and an absent or weakened anal wink reflex, or weakness of the lower extremity with partial saddle anesthesia. The former is due to involvement of the conus medullaris, whereas the latter is due to involvement of the cauda equina. In neither case will there be tenderness of the vertebral spine.

The correct answer is 4.

In blocking his opponent’s shot, this athlete has sustained forceful abduction and external rotation of his right arm, resulting in anterior dislocation of the humeral head from the glenoid fossa. In anterior shoulder dislocations, the humeral head is displaced anteriorly relative to the glenoid fossa and the anterior capsule of the glenohumeral joint is often torn. Physical exam will reveal prominence of the acromion with an abnormal subacromial space where the humeral head normally resides. Fullness of the anterior shoulder is noted on palpation. Anterior shoulder dislocations warrant neurologic examination of axillary nerve function, as the axillary nerve courses around the medial undersurface of the humeral head through the quadrangular space and can be injured by anteroinferior shoulder dislocations. Axillary nerve injury can cause paralysis of the deltoid and teres minor muscles as well as loss of sensation over the lateral upper arm.

(Choice 1) Classic causes of radial nerve injury include fracture of the humeral midshaft and use of improperly fitted crutches. Symptoms include wrist drop and sensory loss on the posterior arm, forearm, and lateral dorsal hand.

(Choice 2) The ulnar nerve may be injured by fracture of the medial epicondyle of the humerus or more distally by deep lacerations of the anterior wrist. Symptoms include “claw hand” resulting from paralysis of most of the intrinsic muscles of the hand as well as sensory loss on the dorsal and ventral lateral hand.

(Choice 3) The musculocutaneous nerve arises from the lateral cord of the brachial plexus and innervates the biceps, brachialis and coracobrachialis muscles. It is not frequently injured by common forms of upper extremity trauma.

(Choice 5) The long thoracic nerve innervates the serratus anterior muscle. Deep lacerations to the axillary region and axillary lymphadenectomy are common causes of long thoracic nerve injury. Damage causes scapular winging.

The correct answer is 2.

Although several procedures provide clues concerning whether a thyroid nodule is benign or cancerous, a definitive answer requires a biopsy and histological analysis by a pathologist; thyroid fine needle aspiration (FNA) biopsy is a nonsurgical method that usually can definitely differentiate between benign and malignant nodules. Consequently, it commonly is the first and only test used to evaluate the potential malignancy of a nodule. Performing a successful fine needle aspiration biopsy early in the workup of a nodule typically provides a rapid and unambiguous diagnosis, thus reducing cost and saving the patient anxiety. That she immigrated from the Ukraine is relevant because of the accident at Chernobyl.

(Choices 1 & 3) Analyzing the results of an ultrasound scan and/or a thyroid nuclear scan using 123 l are generally reserved for the approximately 5% of fine needle aspiration biopsies that are reported to be nondiagnostic or the approximately 10% of results categorized as suspicious. A report of nondiagnostic biopsy generally results from an inability to obtain a sufficient number of thyroid cells using FNA, whereas about 75% of the nodules identified as suspicious are benign follicular adenomas that cannot be distinguished from follicular or Hurthle cell cancers. A solid or complex ultrasound scan result implies that the nodule is malignant, and a cold area after a thyroid scan (i.e., where 123 l is not taken up) indicates possible malignancy since about 95% of hot nodules are benign. Consequently, a cold nodule found suspicious by FNA is generally removed surgically. In addition to being an aid in diagnosis, an ultrasound scan is also carried out to help in the placement of the needle while performing FNA.

(Choice 4) is generally an early test done to obtain an overview of the patient’s thyroid function, but it is not able to diagnose the potential malignancy of a nodule.

(Choice 5) is reserved for the diagnosis of nodules labeled non-diagnosable or suspicious after FNA.

The correct answer is 3.

Survival after ruptured AAA is dependent on rapid diagnosis and immediate surgical exploration for repair. A ruptured AAA carries a 90% overall mortality rate, which can be reduced to 50% for patients who reach a hospital that is capable of providing appropriate

care via immediate exploration and repair. Figure 5-180 is an abdominal CT showing a rim of calcium at the borders of the AAA and surrounding retroperitoneal hematoma from rupture (note the arrow).

(Choice 1) While fluid resuscitation for hypovolemic shock is needed, once the diagnosis of AAA rupture is made, surgical exploration and repair should not be delayed for attempts at stabilization.

(Choice 2) An acute AAA rupture, as described in this case, usually consists of a rupture with the surrounding hematoma contained within the retroperitoneum. Paracentesis in an effort to find evidence of rupture would therefore be fruitless and needlessly delay the proper surgical treatment.

(Choice 4) The CT scan is an excellent diagnostic tool for evaluating patients suspected of having an AAA. However, in the setting of suspected ruptured AAA, obtaining a CT scan would merely delay the move to immediate surgical care.

(Choice 5) While abdominal angiography is a test for work-up of some aortic aneurysms, it should not be used to confirm a ruptured AAA. Time wasted in obtaining the study could potentially be lethal due to delay in definitive surgical care.

The correct answer is 5.

This patient is experiencing acute compartment syndrome secondary to supracondylar fracture of humerus. Supracondylar fracture of humerus is common in young children and

adolescents secondary to fall on an outstretched hand. Compartment syndrome results from increased pressure within a limited anatomic space, acutely compromising the circulation and ultimately threatening the function of the tissue within that space. Diagnosis of compartment syndrome is made predominantly on clinical findings of pain, pallor, pulselessness, paralysis and paresthesia. Treatment consists of immediate fasciotomy. Volkmann’s ischemic contracture is the final sequel of compartment syndrome in which the dead muscle has been replaced with fibrous tissue.

(Choice 1) Malunion with alteration of carrying angle is another common complication of supracondylar fracture of humerus; however it is not a sequel of compartment syndrome. (Choice 2) Non-union is not a common complication of supracondylar fracture of humerus and does not occur as a sequel of acute compartment syndrome.

The correct answer is 5.

The clinical scenario described is suggestive of acute adrenal insufficiency. Acute onset of nausea, vomiting, abdominal pain, hypoglycemia, and hypotension after a stressful event (e.g., surgical procedure) in a patient who is steroid-dependent is typical. Avery important clue to the correct diagnosis in this patient is the past medical history (lupus) indicative of preoperative steroid use. Exogenous steroids depress pituitary-adrenal axis and a stressful situation can precipitate an acute adrenal insufficiency.

(Choice 2) Diabetic ketoacidosis is also manifested by nausea, vomiting, and abdominal pain; however, you will see hyperglycemia, and you usually do not see hypotension.

(Choice 3) An abscess is a late postoperative complication.

(Choice 4) Intestinal obstruction is not accompanied by hypoglycemia and hypotension, even though you can see all the rest.

The correct answer is 2.

The differential diagnosis of a widened mediastinum as a solitary finding includes processes as diverse as anthrax, various tumors, mediastinitis, aortic dissection, hemorrhage and large

pericardial effusion among others. Because this patient has just undergone a surgical procedure involving the mediastinum and has laboratory and clinical findings suggestive of an infection, acute mediastinitis is the most likely diagnosis. Mediastinitis complicates up to 5% of sternotomies. Like an abscess, the treatment of mediastinitis requires drainage, debridement and antibiotic therapy. One in five patients with acute mediastinitis will not survive despite treatment.

(Choices 1 & 4) Fever, leukocytosis, tachycardia and chest pain might be the signs of postpericardiotomy syndrome. This syndrome is autoimmune in nature and classically occurs a few weeks following any procedure where the pericardium is incised. Treatment is with pericardial puncture if tamponade occurs, and with aspirin or corticosteroids to address the inflammation.

(Choice 3) Postoperative mediastinal hemorrhage is less likely to become symptomatic on the 10th day; most hematomas occur within the first 48 hours of a procedure. Moreover hemorrhage would not likely cause fever and leukocytosis.

(Choice 5) Antibiotic therapy alone is not sufficient for this disease.

The correct answer is 3.

The patient described most likely suffered appendicitis during the 24-hour period where he felt abdominal pain 10 days prior to admission. Subsequent rupture of the inflamed appendix in this case led to formation of a pelvic abscess due to drainage of fluid into the dependent rectovesical pouch. In males, appendicitis is a common cause of pelvic abscess while gynecologic issues more commonly cause pelvic abscess in females. The finding of a tender, fluctuant mass palpable only with the tip of the examining finger on rectal examination indicates an abscess in the rectovesical pouch as the prostate is much more readily palpable and would cause different symptoms. Patients with pelvic abscesses typically present with fever, leukocytosis, painful defecation and diarrhea resulting from bowel irritation by the intraabdominal infection. Drainage of the abscess is the usual treatment in such cases.

(Choice 1) Anorectal abscesses cause perineal pain with a fluctuant mass palpable on the perineum. Pain with ambulation and defecation is common as well as urinary retention. (Choice 2) Invasive diarrhea would not cause a fluctuant swelling on rectal exam and the patient would most likely have generalized abdominal pain, tenesmus and bloody diarrhea. (Choices 4 & 5) Colon cancer and diverticulitis can be complicated by pelvic abscess, but these disease processes are less likely in this age group. Additionally, diverticulitis would most classically cause left lower quadrant pain rather than right lower quadrant pain.

The correct answer is 1.

This case is a classic example of lower extremity compartment syndrome. Patients are at risk when reperfusion follows an extended period of ischemia. Early signs of compartment syndrome include pain out of proportion to exam, decreased sensation in the first web space, and increased pain with passive dorsiflexion of the foot. The diagnosis can be confirmed by measurement of compartment pressures; any value higher than 30 mm Hg is considered diagnostic. Patients with compartment syndrome may not lose peripheral pulses, as the pressures would have to be elevated above systolic arterial pressure to compromise arterial perfusion. Emergent four-compartment fasciotomies is the appropriate treatment.

(Choice 2) Inadequate pain control is not the issue in this patient. The pain associated with compartment syndrome is significant, and trying a different narcotic will not resolve the problem.

(Choice 3) There is no evidence of thrombosis formation in this case.

(Choice 4) A duplex Doppler scan would show evidence of arterial flow but would miss the problem of decreased tissue perfusion.

(Choice 5) Pulses may be palpable despite the presence of compartment syndrome.

The correct answer is 4.

This patient has a mechanical obstruction of the bowel caused by a large gallstone (>2.5 cm) lodged within the lumen of the ileus: i.e., gallstone ileus. These stones are usually radiopaque. Gallstone ileus is most commonly seen in elderly women who have a chronically inflamed gallbladder that adheres to the bowel. This results in a cholecystenteric fistula, which connects the gallbladder with either the duodenum or hepatic flexure of the colon, both of which are in the vicinity of the gallbladder. In 40% of cases, air is seen in the biliary tree because bowel air is transported to that location via the fistula. Emergency laparotomy and enterotomy to remove the stone should be undertaken. A second stone may be present proximally and should be removed to avoid recurrence. The fistula should be left alone, because it is not the cause of this patient’s symptoms, and it closes off by itself. Cholecystectomy might be undertaken at a later date, if the patient has symptoms.

(Choice 1) Tumors of the small bowel (e.g., lymphoma of the small bowel) are rare. The most common location is the terminal ileum, and they are not radiopaque. Lymphoma is the most common primary malignant tumor of the small intestine. It may present with rectal bleeding or intussusception.

(Choice 2) presents as an acute abdomen, but it is not associated with a radiopaque mass in the small bowel. It is more common in males and in a younger age group. A plain abdominal x-ray film shows a sentinel loop, which represents a dilated proximal loop of jejunum adjoining the pancreas.

(Choice 3) Acute appendicitis with radiopaque fecalith has a different clinical presentation. The patient would complain of nausea, vomiting, constipation, and periumbilical pain that radiates and settles in the right lower quadrant. Physical examination would elicit tenderness and guarding in the right lower quadrant. Finally, fecaliths are not radiopaque.

(Choice 5) is a telescoping of a segment of the bowel into the adjacent segment. This usually involves the terminal ileum telescoping into the proximal large bowel. It is the most common cause of intestinal obstruction in children. It is associated with a sausage-shaped mass in the mid-abdomen and red, currant-jelly stool. If it cannot be reduced by barium enema, Surgery is required.

The correct answer is 4.

Colicky or paroxysmal abdominal pain with episodic hyperactive bowel sounds attributable to peristaltic rushes, abdominal distension, and diffuse abdominal tenderness are signs and symptoms of a mechanical intestinal obstruction. Nausea and vomiting may be more frequent with small bowel obstruction (SBO) as compared to large bowel obstruction (LBO) where the ileocecal valve is competent. The contents of the vomitus are typically bilious in proximal SBO and feculent with more distal obstructions. Failure to pass stool or flatus ( obstipation) indicates that a complete obstruction has occurred. The patient described is most likely suffering from a complete SBO. A mild leukocytosis and modest increase in amylase are expected with any bowel obstruction.

Whereas a partial SBO may be managed conservatively with nasogastric tube decompression and observation, complete SBO requires surgical correction. This patient’s metabolic acidosis, in this setting most likely representing lactic acidosis due to ischemia of a strangulated loop of small bowel, is a further indication for laparotomy. Strangulation leading to ischemic necrosis and perforation of a SB segment is the major life-threatening complication of SBO. The absence of peritoneal signs in this patient suggests that frank bowel necrosis has not yet occurred, but there are signs of ischemia that warrant emergent abdominal exploration to reverse the cause of his mechanical bowel obstruction.

(Choice 1) Analgesics may alleviate some of this patient’s abdominal pain, and pain control should be one goal of therapy. Laxatives, however, are not appropriate therapy for bowel obstruction as they do not address the primary pathology and may worsen the patient’s condition.

(Choice 2) A barium enema (BE) would not assist in the diagnosis or treatment of SBO. A BE may be useful in cases colonic obstruction (LBO) resulting from sigmoid volvulus, wherein a “bird’s beak” sign would be seen. Decompression of a sigmoid volvulus may be accomplished with sigmoidoscopy.

(Choice 3) IV fluids would be appropriate to treat intravascular volume depletion associated with SBO, but long intestinal tubes are rarely effective in relieving a SBO, and surgery should not be delayed with attempts to utilize such tubes.

(Choice 5) Because this patient shows signs of small intestinal ischemia due to strangulation, he is at risk for intestinal bacterial translocation and sepsis. Broad spectrum IV antibiotics may be indicated, but the most urgent issue is surgical decompression of the bowel obstruction.