Professional Documents
Culture Documents
1)
0/1
You are seeing an otherwise-healthy 28-year-old man who is presenting with a 4-month
history of epigastric discomfort and heartburn symptoms that are usually exacerbated
after meals, especially after eating spicy foods. He denies dysphagia, weight loss, or
decreased appetite. He has an active lifestyle and takes no medications. His vital signs or
normal and physical examination is normal except for mild epigastric tenderness to deep
palpation. Routine laboratory studies are normal including liver function studies and
lipase. Bedside ultrasound shows no evidence of gall stones. What is most appropriate
treatment at this time?
Upper Endoscopy
Esophageal manometry
The answer is D, Typical GERD symptoms include chest discomfort (heartburn) and
regurgitation. Symptoms occur most often after meals, especially fatty meals. Lying
down, bending, or physical exertion often aggravate symptoms, and antacids provide
relief. Patients with classic symptoms rarely require testing to confirm the diagnosis
because of the high positive predictive value of classic symptoms (1). When heartburn
(89% specificity, 81% positive predictive value) and regurgitation (95% specificity, 57%
positive predictive value) occur together, a physician can diagnose GERD with greater
than 90% accuracy.
Performing diagnostic tests for all patients presenting with symptoms that might indicate
GERD would be costly and is not necessary to arrive at a sufficiently accurate diagnosis.
Response to an empirical trial of acid-suppression therapy is considered a sufficiently
sensitive and specific method for establishing a GERD diagnosis among patients with
classic symptoms of heartburn or regurgitation. read more
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2)
0/1
You are consulted to see a 22-year-old black female in the ER who has a history of sickle
cell anemia. She presented with worsening lower back and leg pains along with some
shortness of breath that has progressively worsened since she was discharged 5 days ago
following an RBC transfusion ( 2 units of matched RBCs) for anemia following a prior
sickle cell crisis 1 week ago. Her current medications are hydroxyurea and folic acid.
On physical examination, she is in obvious distress and appears jaundiced. Her oral
temperature is 36.5°C, blood pressure is 125/80 mm Hg, pulse rate is 110/min, and
respiration rate is 22/min. Chest X-ray is shows normal lung fields and cardiac size. Her
labs are below. Which of the following laboratory findings would best explain this
patient's current clinical presentation?
Laboratory studies:
Antineutrophil antibodies
HLA antibodies
IgA deficiency
New alloantibodies
The answer is D, Delayed hemolytic transfusion reactions (DHTR) are potentially life-
threatening complications observed in patients with sickle cell disease. The clinical
presentation of a DHTR in SCD may be quite similar to that of a sickle cell pain crisis,
with or without features of an “aplastic crisis. The manifestations of acute or delayed
hemolysis, patients typically exhibit symptoms of a pain crisis, marked reticulocytopenia
(a decrease from the patient’s usual absolute reticulocyte count), and may develop a more
severe anemia following transfusion than was present before. is almost always a result of
complement-mediated intravascular hemolysis caused by preformed antibodies in the
recipient's plasma to the donor's red blood cells (RBCs). This medical emergency results
from the rapid destruction of donor RBCs by preformed recipient antibodies, usually anti-
A or anti-B but occasionally anti-Rh or anti-Jka, capable of fixing complement. Rapid
intravascular hemolysis may lead to disseminated intravascular coagulation (DIC), shock,
and acute renal failure due to acute tubular necrosis.
The presence of antibodies against recipient neutrophils present in donor plasma is
known to cause transfusion-related acute lung injury (TRALI), which may mimic
noncardiogenic pulmonary edema, including radiographic evidence of pulmonary edema
and pulmonary infiltrates. Patients may also have fever and hypotension. This
constellation of symptoms and findings is not consistent with this patient's presentation,
which is most characteristic of a pain crisis. In addition, TRALI occurs during or soon
after a transfusion, and this patient's findings were delayed several days after the
transfusion.
Platelet refractoriness is an inappropriately low increment in the platelet count following
a transfusion, generally defined as an increment of less than 10,000/µL (10 × 109/L).
HLA alloimmunization can cause platelet refractoriness, but this patient did not receive
platelets, and HLA alloimmunization would not explain her current findings. Read
more here or more from Up to Date
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3)
0/1
You are seeing a 45-year old male who presents with acute abdominal pain following a
high speed motor vehicle collision. On exam he has a seat belt mark on his abdomen.
How much more likely does having a seat belt sign on physical exam increase
the likelihood of having an underlying abdominal injury?
1 x higher
5-10 x higher
10-20 x higher
The answer is B, 5x higher. This sign increases the likelihood of having some intra-
abdominal injury .
According to a systematic review of 12 studies involving 10,757 patients, the physical
examination findings most strongly associated with intra-abdominal injury following
BAT are the following [1]:
●Seat belt sign (likelihood ratio (LR) range 5.6 to 9.9)
●Rebound tenderness (uncommon but substantially increases risk when present; LR 6.5,
95% CI 1.8-24)
●Hypotension (defined as SBP <90 mmHg; LR 5.2, 95% CI 3.5-7.5)
●Abdominal distension (LR 3.8, 95% CI 1.9-7.6)
●Abdominal guarding (LR 3.7, 95% CI 2.3-5.9)
●Concomitant femur fracture (LR 2.9, 95% CI 2.1-4.1) (femur fractures are significant
distracting injuries, and may indicate BAT among pedestrians stuck by
automobiles). read more
<2%
3%-5%
10%-30%
25%-50%
The answer is C. Plain radiographs have little role in the diagnosis of gallstones or
gallbladder disease. Cholesterol and pigment stones are radiopaque and visible on
radiographs in only 10%-30% of instances, depending on their extent of calcification.
For more on the work-up of a patient with gallstones, read here.
On exam she is diffusely tender in both upper quadrants and is guarding. Her chest xray
is shown below. Her labs show a normal lipase and slightly elevated amylase. Her NG
lavage showed clear fluid on aspirate without blood or bile. What is this patient's
definitive treatment?
Admit, keep NPO and put on IV Proton Pump Inhibitor and IV Octreotide
To the OR for closure with a piece of omentum (Graham patch) for a
perforated gastric ulcer
The answer is D. She has a duodenal ulcer that has perforated, the tip off in this scenario
is that the NG lavage should no blood or bile. Also the xray shows free air. There are
some non operative treatment pathways for patients but in this case our patient needs
surgery. Perforation occurs in 2–10% of patients with PUD and accounts for more than
70% of deaths associated with PUD. Perforation is often the first clinical presentation of
PUD. The incidence of duodenal perforation is 7–10 cases/100,000 adults per year . The
perforation site usually involves the anterior wall of the duodenum (60%), although it
might occur in antral (20%) and lesser-curvature gastric ulcers (20%) . Duodenal ulcer is
the predominant lesion of the western population, whereas gastric ulcers are more
frequent in oriental countries, particularly in Japan. Gastric ulcers have a higher
associated mortality and a greater morbidity resulting from hemorrhage, perforation and
obstruction . PPU used to be a disorder mainly of younger patients (predominantly
males), but recently the age of PPU patients is increasing (predominantly females). The
current peak age is 40–60 years . The need for surgery for PPU has remained stable or
even increased and the mortality of peptic ulcer surgery has not decreased since the
introduction of H2 receptor antagonists and peptic ulcers are still responsible for about
20,000–30,000 deaths per year in Europe . This may be due to an increase in use of
aspirin and/or NSAIDs . One can say that nonoperative treatment is limited to patients
<70 years of age who are not eligible for surgical repair due to associated morbidity, with
documented contrast studies showing that the perforation has sealed completely. When
the patient is in shock or when the time point between perforation and ‘start of treatment’
is >12 h, simple closure should be the first treatment of choice. Perforated Peptic Ulcer
Disease: A Review of History and Treatment
Visceral Pain
•Caused by the stretching of fibers innervating the walls or capsules of hollow or solid
organs
•A steady ache or vague discomfort to excruciating or colicky
•Visceral afferents follow a segmental distribution and pain is localized by the sensory
cortex to an approximate spinal cord level determined by embryological organ of the
organ involved.
•Biliary, duodenum, stomach produce epigastric pains
•Most small bowel, appendix, cecum cause periumbilical pain
•Hindgut structures, such as the bladder, distal two-thirds of the colon, and pelvic
genitourinary (GU) organs, usually cause pain in the suprapubic region.
•Pain is often reported in the back for retroperitoneal structures, such as the aorta and
kidneys
•Deep musculoskeletal structures (especially of the back) are innervated by visceral
sensory fibers with similar qualities to those arising from intra-abdominal organs.
•Intraperitoneal organs are bilaterally innervated causing pain to be located in the midline
regardless of which side it is coming from. Classic example is early appendicitis causing
periumbilical pain
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7)
0/1
What is the most common surgical cause of abdominal pain in adults?
(Select 1)(1pts)
Appendicitis
Cholecystitis
Wilso Brew
n et er et
OMGE23( Irvin13( de
Diagno al (N
82 al12(N Hawthorn83
N= N= Dombal1(
sis = = (N = 496)
10,320) 1,190) N = 552)
1,196 1,000
) )
Nonspecifi
c
34.0 45.6 34.9 41.3 50.5 36.0
abdominal
pain
Acute
appendicit 28.1 15.6 16.8 4.3 26.3 14.9
is
Acute
cholecysti 9.7 5.8 5.1 2.5 7.6 5.9
tis
Small
bowel
4.1 2.6 14.8 2.5 3.6 8.6
obstructio
n
Acute
gynecolog 4.0 4.0 1.1 8.5 — —
ic disease
Acute
pancreatiti 2.9 1.3 2.4 — 2.9 2.1
s
Urologic
2.9 4.7 5.9 11.4 — 12.8
disorders
Perforated
pepticulce 2.5 2.3 2.5 2.0 3.1 —
r
Diverticula
1.5 1.1 3.9 — 2.0 3.0
r disease
Gastroenter
— — 0.3 6.9 — 5.1
itis
Inflammato
ry bowel — — 0.8 — — 2.1
disease
Mesenteric
— 3.6 — — — 1.5
adenitis
Constipatio
— 2.4 — 2.3 — —
n
Amebic
hepatic 1.2 — 1.9 — — —
abscess
Miscellane
6.3 1.3 5.2 15.5 4.0 8.0
ous
(Select 1)(1pts)
Subdural Hematoma
Epidural Hematoma
Subarachnoid Hemorrhage
Spontaneous Pneumothorax
Esophageal Perforation
The answer is D. This patient has evidence subcutaneous air (crepitus) and has likely
ruptured his esophagus. Effort rupture of the esophagus or Boerhaave's syndrome is a
spontaneous perforation of the esophagus that most commonly results from a sudden
increase in intraesophageal pressure combined with negative intrathoracic pressure
caused by straining or vomiting. It was first described by Dr. Herman Boerhaave, a
physician from Leiden, the Netherlands.
The answer is E, Consider surgery as an option for patients with well-documented GERD
who require long-term PPI maintenance therapy but show satisfactory relief of symptoms
and who:
Are older than 50 years
Consider long-term medication a financial burden
Are noncompliant with drug therapy
Prefer a single surgical intervention to long-term drug treatment
Experience prominent symptoms of regurgitation, even with medical
control of heartburn symptoms
Nissen fundoplication is the most common surgical intervention for GERD. This
procedure aims to restore the physiology and anatomy of the gastroesophageal junction
by wrapping the gastric fundus around the distal esophagus. The FDA has also approved
several endoscopic procedures for treatment of GERD, including endoscopic suturing and
radiofrequency ablation of the lower esophageal sphincter. Read more
Cigarette smoking
Obesity
Answer D is not correct. Esophageal cancer has two main subtypes — esophageal
squamous-cell carcinoma and esophageal adenocarcinoma; their precursor lesions are
esophageal squamous dysplasia and Barrett’s esophagus, respectively. Although
squamous-cell carcinoma accounts for about 90% of cases of esophageal cancer
worldwide, the incidence of and mortality rates associated with esophageal
adenocarcinoma are rising and have surpassed those of esophageal squamous-cell
carcinoma in several regions in North America and Europe. In the United States, more
than 18,000 new cases of esophageal cancer and more than 15,000 deaths from
esophageal cancer were expected in 2014. Esophageal carcinoma is rare in young people
and increases in incidence with age, peaking in the seventh and eighth decades of life.
The main risk factors for esophageal adenocarcinoma are gastroesophageal reflux
disease, obesity, and cigarette smoking; H. pyloriinfection is associated
with a reduced risk. Cigarette smoking and alcohol consumption constitute the
main risk factors for esophageal squamous-cell carcinoma. High intake of red meats, fats,
and processed foods is associated with an increased risk of both types of esophageal
cancer, whereas high intake of fiber, fresh fruit, and vegetables is associated with a lower
risk.
N Engl J Med 2014; 371:2499-2509December 25, 2014DOI:
10.1056/NEJMra1314530
(Select 1)(1pts)
Pneumomediastinum
Pneumoperitoneum
Intestinal Malrotation
Pneumothorax
The answer is B, Pneumoperitoneum which describes gas within the peritoneal cavity,
and is often the harbinger of a critical illness. The most common cause of a
pneumoperitoneum is from the disruption of the wall of a hollow viscus. Read more
An erect chest x-ray is probably the most sensitive plain radiograph for the detection of
free intraperitoneal gas. If a large volume pneumoperitoneum is present, it may be
superimposed over normal aerated lung with normal lung markings.
subdiaphragmatic free gas
cupola sign (in supine film)
Free gas within the peritoneal cavity can be detected on an abdominal radiograph. These
signs can be further divided by anatomical compartments in relation to the
pneumoperitoneum:
bowel related signs
double wall sign (also known as Rigler's sign or bas-relief
sign)
telltale triangle sign (also known as triangle sign)
peritoneal ligament related signs
football sign
falciform ligament sign
lateral umbilical ligament sign (also known as inverted
"V" sign)
urachus sign
right upper quadrant signs
lucent liver sign
hepatic edge sign
fissure for ligamentum teres sign
Morison's pouch sign
cupola sign
The patient above likely has a perforated ulcer from underlying NSAID use. Ulcer
perforation should be suspected in patients who suddenly develop severe, diffuse
abdominal pain. Perforations complicate 2 to 10 percent of peptic ulcers [70]. Duodenal,
antral, and gastric body ulcers account for 60, 20, and 20 percent of perforations due to
peptic ulcer disease (PUD), respectively. If imaging is required, plain x-rays are typically
obtained first. Careful interpretation of upright chest and abdominal films can detect
diagnostic free air in many cases of perforated gastric and duodenal ulcers [76]. The
presence of free air on abdominal imaging is highly indicative of a perforated viscus
(image 1 and image 2 and image 3), although about 10 to 20 percent of patients
with a perforated duodenal ulcer will not have free air [76]. If free air is found, no other
diagnostic studies are necessary. Leakage of water soluble oral contrast may be useful in
selected cases. Once the oral contrast is given, the patient should be rotated 360 degrees
and placed on the right side to fill the antrum and duodenum with contrast. However,
many perforations have already sealed spontaneously by the time of presentation [77], so
the absence of a leak does not exclude the diagnosis of a perforated ulcer. Read More
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13)
0/1
You are seeing a 45-year old male in clinic who has a past medical history of
osteoarthritis for which he takes daily alleve. He denies tobacco use or alcohol use. He
has been having recent early satiety, bloating and epigastric discomfort over the last
month. You suspect peptic ulcer disease. Which of the following ulcer locations is more
associated with H. Pylori infection?
(Select 1)(1pts)
Duodenal
Gastric
Esophageal
Jejunal
(Select 1)(1pts)
Gastric
Duodenal
Jejunal
Esophageal
NSAID use confers around a 40 fold increase in the development of gastric ulcers and an
8 fold increase risk for the development of duodenol ulcers and . Therefore in this patient
you would expect gastric ulcer more likely than a duodenal ulcer.
The use of NSAIDs is the most commonly identified risk factor for peptic ulcer bleeding,
especially in the elderly. Studies have found relative risks for bleeding ranging from 2.7
to 33.9 [11]. Studies have also shown that the risk is drug-specific and dose-dependent.
As an example, in a study of 2777 patients, the overall relative risk (RR) of bleeding
associated with NSAID use was 5.3 (95% CI 4.5-6.2). However, the risk varied by drug
and was lowest for aceclofenac (RR 3.1, 95% CI 2.3-4.2) and was highest for ketorolac
(RR 14.4, 95% CI 5.2-39.9) [18]. The risk was higher in patients taking high-dose
NSAIDs compared with those taking medium- or low-dose NSAIDs (RR 6.8, 95% CI
5.3-8.8 versus 4.0, 95% CI 3.2-5.0). There was also an increased risk of bleeding with
aspirin use (RR 5.3) that again was dose-dependent (RR 7.5 with 500 mg per day versus
2.7 with 100 mg per day). The concurrent use of aspirin and NSAIDs conferred an even
greater risk of bleeding than was seen with either agent alone (RR 12.7). Finally, the risk
was highest in the first 30 days of NSAID use, with a RR of 7.6 (95% CI 6.0-9.5). The
risk remained high between days 31 and 90 days (RR 7.3, 95% CI 4.0-13.2), but dropped
after 91 days (RR 2.6, 95% CI 1.6-4.1).
NSAID use has also been identified as a risk factor for ulcer perforation [16,19]. In a
study of 176 patients from Spain, NSAID use was the only risk factor that was
significantly associated with perforation (odds ratio [OR] 3.6). Read more
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15)
0/1
What is the most common complication of peptic ulcer disease?
(Select 1)(1pts)
Perforation
Bleeding
Cancer
The answer is B, Bleeding. Bleeding is the most common complication of peptic ulcer
disease requiring hospitalization. In a study of the National Inpatient Sample (NIS),
bleeding occurred in 73 percent, perforation in 9 percent, and obstruction in 3 percent
[4]. H. pylori, nonsteroidal antiinflammatory drugs (NSAIDs), and the use of low dose
aspirin are the most common etiologies of ulcer bleeding [7] and ulcer perforation [8-
10]. In observational studies, duodenal, antral/pyloric, and gastric body ulcers
account for 60, 20, and 20 percent of perforations, respectively [8,9]. Among these
complications, perforation had the highest mortality rate, followed by obstruction, then
hemorrhage.
Bleeding peptic ulcer — Upper gastrointestinal bleeding due to peptic ulcer disease
is a common indication for emergency management of peptic ulcer disease [11]. Most
patients with acute bleeding can be managed with fluid resuscitation and transfusion, acid
suppression therapy, and endoscopic intervention. For those who fail these efforts,
surgery may become necessary. The specific indications for surgery for patients with
bleeding peptic ulcer are reviewed separately.
Perforated peptic ulcer — Ulcer perforation may be suspected in patients with a
history consistent with peptic ulcer disease who develop the sudden onset of severe,
diffuse abdominal pain. Once a diagnosis of perforation is established, surgical
intervention is indicated.
Gastric outlet obstruction — Gastric outlet obstruction is the least frequent ulcer
complication in developed countries. Most cases are associated with duodenal or pyloric
channel ulceration; gastric ulceration accounts for only five percent of cases.
Surgical consultation should be obtained for patients with chronic partial gastric outlet
obstruction that is refractory to medical treatment, and those found to have complete
gastric outlet obstruction, or those readmitted with gastric outlet obstruction after recent
“successful treatment.” Surgery is indicated if the patient fails to respond to conservative
medical management and endoscopic therapy.
Surgical treatment of gastric outlet obstruction is almost never an emergency. Because
most patients present with some degree of malnutrition and frequently have electrolyte
imbalances (ie, hypokalemic, hypochloremic metabolic alkalosis secondary to vomiting
or nasogastric suctioning), it is important to correct any derangements and optimize the
patient’s medical status prior to proceeding with surgery. Failure to identify and correct
these issues increases perioperative morbidity.
It may also be reasonable to try and improve the patient’s overall nutritional status with
nutritional support, as these patients are frequently malnourished and can have significant
postoperative delayed gastric emptying due to their atonic stomach.
Many experienced gastric surgeons advocate preoperative nasogastric sump
decompression to decrease gastric dilation and, hopefully, gastric atony. Read more
<1%
5-11%
15-21%
24-30%
The answer is B, 5-11%. Given the low predictive value of the signs and symptoms of
PUD, the diagnosis of uncomplicated peptic ulcers is difficult to make solely on a clinical
basis. The diagnosis of PUD is typically made by endoscopy and upper gastrointestinal
(UGI) radiography. Endoscopy is the most accurate method of establishing the diagnosis
of peptic ulcers, with a reported sensitivity of 92% and specificity of 100%.7 In addition
to identifying the ulcer and its features, location, and size, endoscopy provides an
opportunity for biopsies to test for H. pylori and exclude malignancy and for therapeutic
interventions for bleeding ulcers. Duodenal ulcers are most often benign and do not
require routine biopsy. Multiple biopsies are indicated for all gastric ulcers as even
lesions with a benign appearance harbor malignancy in 5 to 11% of cases. Read more
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Unit 5
17)
0/1
You are seeing a 27-year old male in the trauma bay shortly after being stabbed in this
back with a 6 cm buck knife by his disgruntled neighbor after an argument.
He arrived via EMS sitting up, awake and alert with a GCS of 15. His BP is 140/90, HR
120 and O2 sat is 85% on a non re-breather.
On physical exam there is a 3 cm non bleeding wound just left of his mid thoracic spine.
Upon auscultation there is decreased breath sounds on his left side. There are no signs of
tracheal deviation or JVD.
What is the next best step in management?
(1pts)
The answer is A, Upright Chest Xray followed by a chest tube. This patient is awake and
talking. He is stable enough for a chest xray followed by chest tube placement. A needle
thoracotomy to should be done if he has evidence of tension pneumothorax which would
be respiratory distress and hypotension. He will likely then need a chest tube and can be
further managed. Read More
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18)
0/1
What is the most common abdominal organ injured in the setting of blunt abdominal
trauma?
(Select 1)(1pts)
Spleen
Liver
Kidneys
Small Intestines
The liver is the most commonly injured solid organ in blunt trauma, comprising 5% of all
trauma admissions, and because of its size is frequently involved in penetrating trauma.
Following blunt trauma, the most commonly injured structures are the parenchyma and
hepatic veins. Blunt forces dissipate along segments of the liver and along the fibrous
coverings of the portal triad structures; the hepatic veins, however, are not so insulated.
Given its size and location within the abdomen, the liver is also commonly involved in
penetrating trauma. Stab wounds typically result in direct linear tears, whereas gunshot
wounds or shotgun wounds result in significant cavitary injuries attributable to blast
effect and the "tumbling" of the missile within the liver parenchyma. Thus, arterial injury
is more common with penetrating trauma.
Over the past 20 years, nonoperative management (NOM) of liver injuries has evolved to
become the prevailing therapeutic strategy for blunt hepatic trauma. Several concurrent
changes resulted in this paradigm change. First was the realization that diagnostic
peritoneal lavage (DPL) was sensitive but not specific for identifying intraperitoneal
hemorrhage that necessitated operative management. Surgeons recognized that many
laparotomies undertaken for a positive DPL were associated with liver injuries that did
not require intervention for bleeding.1Second, trauma surgeons noted that nonbleeding
hepatic venous injuries, if manipulated at laparotomy, often resulted in more hemorrhage
and sometimes even death.2 Furthermore, it became conspicuous that with hemostasis
achieved in the operating room, recurrent postoperative bleeding was rare. Therefore,
surgeons queried whether hepatic venous injuries, which are low-pressure system
injuries, could heal without intervention. Finally, computed tomography (CT) provided a
reliable method for diagnosing and grading liver injuries.
The spleen is the second most commonly injured abdominal organ in blunt trauma
patients. Historical studies have reported a 10% mortality with all splenic injuries;
however, isolated splenic injury mortality is less than 1%. The mechanisms of injury are
similar to those seen with liver injuries: motor vehicle collisions, autopedestrian
accidents, and falls. Similar to penetrating trauma to the liver, stab wounds to the spleen
typically result in direct linear tears, whereas gunshot wounds result in significant
cavitary injuries.
Until the 1970s, splenectomy was considered mandatory for all splenic injuries.
Recognition of the immune function of the spleen refocused efforts on splenic salvage in
the 1980s.38,39Following success in pediatric patients, NOM of splenic injuries was
adopted in the adult population and has become the prevailing strategy for blunt splenic
trauma.
Duodenal and pancreatic injury continues to challenge the trauma surgeon. The relatively
rare occurrence of these injuries, the difficulty in making a timely diagnosis, and high
morbidity and mortality rates justify the anxiety these unforgiving injuries invoke.
Mortality rates for pancreatic trauma range from 9 to 34%, with a mean rate of 19%.
Duodenal injuries are similarly lethal, with mortality rates ranging from 6 to 25%.
Complications following duodenal or pancreatic injuries are alarmingly frequent,
occurring in 30 to 60% of patients.1-3 Recognized early, the operative treatment of most
duodenal and pancreatic injuries is straightforward, with low morbidity and mortality.
2014. Scientific American Surgery. Hamilton, Ontario & Philadelphia, PA. Decker
Intellectual Properties Inc. ISSN 2368-2744. STAT!Ref Online Electronic Medical
Library. http://online.statref.com/Document.aspx?fxId=61&docId=2329. 10/27/2014
1:39:15 PM CDT (UTC -05:00).
Thoracoscopy
Laparotomy
The answer is D. This patient suffered a ruptured diaphragm and chest tube placement
appears to have ruptured the bowel as evidence from the greenish fluid that was returned.
She needs an emergent laparotomy to control bleeding and repair her diaphragm. Read
More
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Unit 6
20)
0/1
A 46-year obese black female presents to you with 2 days of worsening of right upper
abdominal pain and vomiting. She feels hot and cold chills and says that she sometimes
feels this pain after eating but now its much worse.
Vitals: Temp is 39.0 C, heart rate 125 beats/min, blood pressure 124/90. Physical exam
reveals inspiratory arrest upon palpation of her RUQ to deep palpation.
Her labs show a WBC of 17,000. Her ALT, AST, bilirubin, and lipase are within normal
limits. What is the most likely diagnosis?
(Select 1)(1pts)
Cholelithiasis
Choledocholithiasis
Klatskin Tumor
Acute Cholecystitis
The patient presents with the triad of acute cholecystitis which is fever, vomiting,
jaundice and RUQ pain. This triad has been reported to be present in as high 70% present
of cases to as little as 20% of cases. Acute cholecystitis is the result of cystic duct
obstruction leading to gallbladder edema, mucosal sloughing, and, potentially, ischemia.
Signs and symptoms of acute cholecystitis include right upper quadrant pain, nausea, and
vomiting. Unlike the self-limited pain associated with biliary colic, pain associated with
acute cholecystitis generally lasts more than 6 to 8 hours. In addition to the signs of local
inflammation (pain and tenderness in the right upper abdomen or epigastric area),
patients also exhibit signs of systemic inflammation, including fever, leukocytosis, and
elevated C-reactive protein. Mild elevations in bilirubin and liver enzymes may be
present. A positive Murphy sign on physical examination is suggestive of a diagnosis of
cholecystitis (likelihood ratio of 2.8). Necrosis of the gall-bladder wall can occur due to
prolonged inflammation and decreased gallbladder perfusion. Gallbladder perforation
occurs in 5 to 10% of patients with acute cholecystitis.
Renoylds pentad adds sepsis and altered mental status to the triad and is less common and
can be easily missed. A Klatskin tumor presents with painless jaundice. While she might
have cholelithiasis and choledocholithiasis her symptoms are more indicative of acute
cholecystitis. Some cases of acute cholecystitis have mildly elevated bilirubin but severe
elevation suggests either Choledocholithiasis, cholangitis, or obstruction of the CBD.
2014. Scientific American Surgery. Hamilton, Ontario & Philadelphia, PA. Decker
Intellectual Properties Inc. ISSN 2368-2744. STAT!Ref Online Electronic Medical
Library. http://online.statref.com/Document.aspx?fxId=61&docId=942. 10/20/2014
8:07:24 PM CDT (UTC -05:00).
Which of the following imaging studies is most sensitive for the diagnosis of acute
cholecystitis?
(1pts)
Ultrasound
HIDA scan
CT scan
MRI
The answer is B, HIDA scan. US is about 88% sensitive where as HIDA Scanning is
slightly better and more senstive but US is still the recommended as the first line
diagnostic imaging study. Cholescintigraphy using 99mTc-hepatic iminodiacetic acid
(generically referred to as a HIDA scan) is indicated if the diagnosis remains uncertain
following ultrasonography. Technetium labeled hepatic iminodiacetic acid (HIDA) is
injected intravenously and is then taken up selectively by hepatocytes and excreted into
bile. If the cystic duct is patent, the tracer will enter the gallbladder, leading to its
visualization without the need for concentration. The HIDA scan is also useful for
demonstrating patency of the common bile duct and ampulla. Normally, visualization of
contrast within the common bile duct, gallbladder, and small bowel occurs within 30 to
60 minutes (image 3). The test is positive if the gallbladder does not visualize. This
occurs because of cystic duct obstruction, usually from edema associated with acute
cholecystitis or an obstructing stone (image 4).
Cholescintigraphy has a sensitivity and specificity for acute cholecystitis of
approximately 90 to 97 percent and 71 to 90 percent, respectively [23,26,28,29].
Cystic duct obstruction with a stone or tumor in the absence of acute cholecystitis can
cause a false positive test. Conditions that can cause false positive results despite a non-
obstructed cystic duct include:
Severe liver disease, which may lead to abnormal uptake and excretion of
the tracer.
Fasting patients receiving total parenteral nutrition, in whom the
gallbladder is already maximally full due to prolonged lack of
stimulation.
Biliary sphincterotomy, which may result in low resistance to bile flow,
leading to preferential excretion of the tracer into the duodenum without
filling of the gallbladder.
Hyperbilirubinemia, which may be associated with impaired hepatic
clearance of iminodiacetic acid compounds. Newer agents commonly
used in cholescintigraphy (diisopropyl and m-bromotrimethyl
iminodiacetic acid) have generally overcome this limitation.
False negative results are uncommon since most patients with acute cholecystitis have
obstruction of the cystic duct. When they occur, they may be due to incomplete cystic
duct obstruction. Rear more
Cholecystitis
Cholangitis
Pancreatitis
(1pts)
The answer is B, The use of plasma from male donors only. Transfusion of blood
products is not without risk. According to the Annual Summary of the FDA for 2012,
there were 38 transfusion-related fatalities in the United States, as opposed to 46 in
2008. Since the number of adverse outcomes is small in comparison to the overall
number of transfusions (an estimated 24 million in 2008), many emergency physicians
are unfamiliar with the potential complications of blood product administration. As an
example, TRALI is unfamiliar to many physicians and not universally discussed with
patients during the consent process,63 despite the fact that it was the leading cause of
transfusion-related fatality in both 2008 and 2012.
As early as the 1950s, noncardiogenic pulmonary edema was recognized as a potential
complication of blood transfusion, although it was not until 1983 that Popovsky and
colleagues coined the term “transfusion-related acute lung injury.” These investigators
reported that transfusion of whole blood, RBCs, and plasma from multiparous women
was found to be associated with the rapid onset of hypoxemia and pulmonary infiltrates,
either during transfusion or within several hours of administration. The association with
multiparous donors suggested as the mechanism of lung injury the passive transfer of
antibodies in the transfused blood product, with subsequent activation of recipient white
blood cells. Just as pregnant women can become immunized to Rh antigen present on the
RBCs of the fetus during periods of feto-maternal hemorrhage, exposure to fetal white
blood cells can give rise to antileukocyte antibodies. This idea has been supported by the
identification of antileukocyte antibodies in transfused blood products derived from
multiparous women. Although other factors may contribute to the pathogenesis of
TRALI, exposure to plasma or plasma-containing blood products containing
antileukocyte antibodies is still believed to be the primary mechanism for this
transfusion-related syndrome. Both the American Association of Blood Banks and the
American Red Cross have implemented changes to reduce this risk, including the
preferential use of male plasma, especially in high-plasmacontent products (FFP and
platelets). A national survey in 2008 revealed that > 90% of blood banks had instituted
collection of male-only, malepredominant, or never-pregnant female plasma.
Retrospective studies support these practices, confirming a significant reduction in rates
of TRALI following their adoption.67 Unified definitions of TRALI have been proposed
by the National Institutes of Health (NIH) and a Canadian Consensus Panel. The
Consensus Panel defined 4 criteria, as well as a separate diagnostic category, “possible
TRALI,” for patients in which the development of acute lung injury is temporally related
to both transfusion and another potential cause of acute lung injury. Read more
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24)
0/1
When geographically and logistically feasible, critically injured patients should be taken
directly to a designated level I trauma center or to a level II trauma center if a level I
trauma center is more than 30 minutes away. The currently available field trauma scores,
however, are not reliable in making this triage decision. Because the potential harm
associated with undertriage is high and could result in death or substantial morbidity and
disability, criteria were initially chosen to err on the side of minimizing undertriage rather
than minimizing overtriage. What are the target levels for undertriage rates within a
trauma system to a level I or II trauma center?
(Select 1)(1pts)
<5%
5-10%
10-15%
15-20%
The answer is A, <5%. When geographically and logistically feasible, critically injured
patients should be taken directly to a designated level I trauma center or to a level II
trauma center if a level I trauma center is more than 30 minutes away. The currently
available field trauma scores, however, are not reliable in making this triage decision.
The development of field triage criteria has paralleled the development of trauma centers.
The decision is based on a practice algorithm called a "decision scheme." The first field
triage decision scheme was published by the American College of Surgeons in 1986, with
subsequent updates in 1990, 1993, 1999, 2006, and 2011.6 The decision scheme has four
steps that the emergency medical service (EMS) provider proceeds through after
measuring vital signs and level of consciousness to decide if the patient should be
transported to a higher-level trauma center [see Table 2]. Because the potential harm
associated with undertriage is high and could result in death or substantial morbidity and
disability, criteria were initially chosen to err on the side of minimizing undertriage rather
than minimizing overtriage. However, overtriage results in an overuse of financial and
human resources, overcrowding of trauma centers, and increased EMS transport times.
Target levels for undertriage rates within a trauma system range from 0 to 5% of patients
requiring level I or level II trauma center care, whereas levels of overtriage vary from 25
to 50%. As field triage continues to evolve on the basis of new research findings,
overtriage rates might be reduced while maintaining low undertriage rates. Read more
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25)
0/1
In the absence of a major surgical insult or concomitant coagulopathy, what platelet count
is required for normal coagulation?
(1pts)
10,000/μL
20,000/μL
50,000/μL
100,000/μL
The answer is B, Patients with a normal INR and a normal aPTT who exhibit unexpected
bleeding may have impaired platelet activity. Inadequate platelet activity is frequently
manifested as persistent oozing from wound edges or as low-volume bleeding. Such
bleeding is rarely the cause of exsanguinating hemorrhage, although it may be life-
threatening when it occurs in certain locations (e.g., inside the cranium or the
pericardium). Inadequate platelet activity may be attributable to an insufficient number of
platelets, platelet dysfunction, or a platelet inhibitor. In the absence of a major surgical
insult or concomitant coagulopathy, a platelet count of 20,000/μL or higher is usually
adequate for normal coagulation.14,15 There is some disagreement regarding the
threshold for platelet transfusion in the absence of active bleeding. Patients undergoing
procedures in which even small-vessel oozing is potentially life-threatening (e.g.,
craniotomy) should be maintained at a higher platelet count (i.e., > 20,000/μL). Patients
without ongoing bleeding who are not specifically at increased risk for major
complications from low-volume bleeding may be safely watched with platelet counts as
low as 10,000/μL. Read more
Unit 1
1)
1/1
You are seeing a 26-year old college student in the ER following a roll over MVC. He
was wearing a seat belt and was not ejected. Upon arrival his complaining of abdominal
pain. His vital signs show a heart rate of 120/min, blood pressure is 134/98, RR 20/min,
O2 98% on room air. Physical exam shows he has a seat belt sign across his abdomen and
has tenderness greatest in his upper abdomen with no guarding. His CT scan of the
abdomen/pelvis with IV contrast only shows a liver laceration.
True
False Correct
False: The current approach to hepatic trauma has evolved to nonoperative management
in more than 80% of cases. Several contributing factors have been recognized: realization
that more than 50% of liver injuries stop bleeding spontaneously, the precedent of
successful nonoperative management in pediatric patients, knowledge that the liver has
tremendous capacity to heal after injury, and improvements in liver imaging with CT.
Criteria for nonoperative management include foremost, hemodynamic stability, absence
of other abdominal injuries that require laparotomy, immediate availability of resources
including a fully staffed operating room, and a vigilant surgeon. In general, any patient
who is stable enough to have a CT scan performed is likely to be successfully managed
nonoperatively. Grade I and II hepatic injuries should be observed in a monitored setting
with serial hematocrit evaluations and bed rest. Higher-grade injuries in stable patients
should be observed in an intensive care unit setting with optimization of all coagulation
factors. Read More
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2)
0/1
A 55-year-old white female presents with pain and redness to her right breast at the scar
site from a lumpectomy that was performed for stage I cancer four months ago. She has
also since completed multiple rounds of radiation treatments to her breast as well.
Currently her vitals are normal and she is afebrile. Physical exam reveals 5-6 cm of
erythema surrounding her surgical scar that is painful to touch, there is no axillary
adenopathy, no wound drainage, crepitance, or bullous lesions. Which one of the
following organisms would be the most likely cause of cellulitis in this patient?
Pneumococcus pneumoniae
Clostridium perfringens
Escherichia coli
Ovarian
Lung
Colon
Breast
The answer is D, Breast Cancer. Approximately 230,480 American women are diagnosed
with breast cancer annually, and 39,520 women die from this disease. Global cancer
statistics show that breast cancer is the most frequently diagnosed cancer and the leading
cause of cancer death among females, accounting for 23 percent of total cancer cases and
14 percent of cancer deaths. Breast cancer is now also the leading cause of cancer death
among females in economically developing countries.
Globally, breast cancer is the most frequently diagnosed cancer and the leading cause of
cancer death in women. In the United States, breast cancer is the most commonly
diagnosed cancer and the second most common cause of cancer death in women. In
addition, breast cancer is the leading cause of death in women ages 40 to 49 years.Breast
cancer is treated with a multidisciplinary approach involving surgical oncology, radiation
oncology, and medical oncology, which has been associated with a reduction in breast
cancer mortality. Read more from Up to date
Nonpuerperal mastitis
The answer is B, Intraductal papilloma. The old concern over cancer is the issue, and the
way to detect cancer that is not palpable is with a mammogram. That should be the first
choice. If negative, one may still wish to find an resect the intraductal papilloma to
provide symptomatic relief. Intraductal papillomas consist of a monotonous array of
papillary cells that grow from the wall of a cyst into its lumen. Although they are not
concerning in and of themselves, they can harbor areas of atypia or ductal carcinoma in
situ (DCIS). Papillomas can occur as solitary or multiple lesions. The standard approach
to a papilloma diagnosed by core needle biopsy (CNB) is to perform a surgical excision,
particularly if atypical cells are identified [14,16-21]. In a meta-analysis of 34 studies
that included 2236 non-malignant breast papillary lesions, 346 (15.7 percent) were
upgraded to malignancy following a surgical excision [21]. Because of a risk of
malignancy, these require surgical excision.Read More
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5)
0/1
You are seeing a 31-year-old woman who presents with worsening sore throat, dry
cough, fever, and severe neck pain over the last week. She is otherwise healthy and takes
no medications.
Her vitals show a temperature is 102.5 °F, blood pressure is 99/68 mm Hg, pulse rate is
125/min, and respiration rate is 24/min. On exam she appears ill and her neck is tender to
palpation along the left side with overlying erythema, mild induration, without
lymphadenopathy. Her pharynx is erythematous, with tonsillar enlargement and no
exudates or ulcers. Her lungs are clear to auscultation. The remainder of the examination
is normal. Her chest x-ray shows multiple bilateral infiltrates. Labs show a leukocyte
count is 19,700/µL with 16% band forms. Hgb 10.8 g/dl, BUN 34 mg/dL, serum
creatinine level is 1.8 mg/dL. Which of the following tests is most likely to establish the
diagnosis?
The answer is B, The patient should undergo computed tomography (CT) of the neck
with contrast. She has fever, leukocytosis, sore throat, unilateral neck tenderness, and
multiple densities on chest radiograph, suggestive of septic emboli. The combination of
these factors points strongly toward Lemierre syndrome, which is septic thrombosis of
the internal jugular vein. The diagnosis should be suspected in anyone with pharyngitis,
persistent fever, neck pain, and septic pulmonary emboli. CT of the affected vessel with
contrast would confirm the diagnosis. Treatment includes intravenous antibiotics that
cover streptococci, anaerobes, and β-lactamase-producing organisms. Penicillin with a β-
lactamase inhibitor and carbapenem are both reasonable choices (eg, ampicillin-
sulbactam, piperacillin-tazobactam, ticarcillin-clavulanate).
Chest CT would better characterize the pulmonary infiltrates, but this information would
not provide specific diagnostic information that would guide therapy.
Soft tissue radiography of the neck cannot detect jugular vein filling defects or
thromboses, which are diagnostic of septic thrombophlebitis.
Echocardiography would be helpful to exclude right-sided endocarditis as a cause of
septic emboli. However, there is nothing in the history or on cardiac examination to
suggest a cardiac source of septic emboli. Centor RM, Samlowski R. Avoiding sore
throat morbidity and mortality: when is it not “just a sore throat?” Am Fam Physician.
2011;83:26, 28. PMID: 21888123
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Unit 2
6)
0/1
Nonoperative Management of solid-organ injuries can be pursued in hemodynamically
stable patients who do not have overt peritonitis or other indications for laparotomy.
According to contemporary data, what percentage of patients with splenic injuries are
candidates for nonoperative management?
(Select 1)(1pts)
<10%
25%
45%
60%
<1%
5-10-%
10-20%
20-30%
The answer is A, The spleen is one of the most commonly injured abdominal organs in
blunt trauma patients. Historical studies have reported 10% mortality with all splenic
injuries; however, isolated splenic injury mortality is less than 1%. The mechanisms of
injury are similar to those seen with liver injuries: motor vehicle collisions, automobile-
pedestrian collisions, falls, and any type of penetrating injury. Stab wounds to the
abdomen are less likely to cause spleen injury compared with liver injury due to the
spleen's protected location. Stab wounds to the abdomen are less likely to cause injury to
the spleen than to the liver, due to its protected location.
Until the 1970s, splenectomy was considered mandatory for all splenic injuries.
Recognition of the immune function of the spleen refocused efforts on splenic salvage in
the 1980s.1,2 Following success in pediatric patients, nonoperative management (NOM)
of splenic injuries was adopted in the adult population and has become the prevailing
strategy for blunt splenic trauma. Read more
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8)
0/1
In cases of blunt trauma to the diaphragm, the injury is on the ____ side __% of the time?
(Select 1)(1pts)
Right; 90%
Left; 75%
Left; 25%
Right; 10%
The answer is B, left;75%. In cases of blunt trauma to the diaphragm, the injury is on the
left side 75% of the time, presumably because the liver diffuses some of the energy on
the right side. Blunt diaphragmatic injuries result in a linear tear in the central tendon,
whereas penetrating injuries are variable in size and location depending on the weapon. It
is important to identify the trajectory of penetrating injuries to determine the likelihood of
diaphragm injuries. With blunt and occasionally with penetrating injuries, the diagnosis is
suggested by an abnormality of the diaphragmatic shadow on a chest radiograph [see
Figure 5]. In patients without clear imaging results in the trauma bay, a CT scan may
identify a diaphragmatic injury.
Regardless of the etiology, acute injuries are repaired through an abdominal incision.
Thoracoscopy or laparoscopy may be used if concomitant injuries requiring laparotomy
have been ruled out. Following delineation of the injury, the chest should be evacuated of
all blood and particulate matter, and tube thoracostomy should be placed if not previously
done. Using Allis clamps to approximate the diaphragmatic edges, the defect can be
closed with a running permanent suture [see Figure 6]. Occasionally, large avulsions or
shotgun wounds with extensive tissue loss will require mesh to bridge the defect.
Alternatively, transposition of the diaphragm cephalad one to two intercostal spaces may
allow repair without undue tension. Read more
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9)
1/1
You are seeing a 20-year-old male in hospital 12 hours after he was admitted for
observation following an MVC. Initially he was complaining of left sided chest wall pain
after his car was t-boned on the passenger side. His initial physical examination showed
bruises on the anterior chest wall and upper abdominal wall. X-rays revealed fractures
of his sixth and seventh ribs on the left (but no pneumothorax or pleural effusion). A
FAST Exam did not show any free intraperitoneal fluid. Currently, he complains of
worsening epigastric pain, left shoulder pain and mild nausea. His current vitals show his
blood pressure is now 95/60 and pulse rate 115 beats/min, and O2 saturation is 96% on
room air. Which of the following is the next best step in treatment?
(Select 1)(1pts)
Transesophageal echocardiogram
This patient presents with blunt abdominal trauma with the delayed onset of hypertension
and signs and symptoms worrisome for likely splenic injury. Most common injuries are
to the spleen, liver, and less common injuries are to the hollow viscous organs in the
abdomen. Symptoms and signs suggesting splenic injury include left upper quadrant pain,
abdominal wall contusion, left lower chest wall tenderness, hypotension, and left
shoulder. Pain referred from splenic hemorrhage, hitting the phrenic nerve and diaphragm
(Kehr sign). The initial examination after blunt abdominal trauma can be unremarkable
and the symptoms can occur hours later, indicating ongoing splenic injury. The best
choice here would be an abdominal CT scan with intravenous contrast, only (no oral
contrast is needed because as little utility). This will define organ injury, assess for
presence of bleeding in all abdominal compartments, determine the need for surgery.
The spleen is the second most commonly injured abdominal organ in blunt trauma
patients. Historical studies have reported a 10% mortality with all splenic injuries;
however, isolated splenic injury mortality is less than 1%. The mechanisms of injury are
similar to those seen with liver injuries: motor vehicle collisions, autopedestrian
accidents, and falls. Similar to penetrating trauma to the liver, stab wounds to the spleen
typically result in direct linear tears, whereas gunshot wounds result in significant
cavitary injuries.
Until the 1970s, splenectomy was considered mandatory for all splenic injuries.
Recognition of the immune function of the spleen refocused efforts on splenic salvage in
the 1980s.38,39Following success in pediatric patients, NOM of splenic injuries was
adopted in the adult population and has become the prevailing strategy for blunt splenic
trauma.40
Addressing the patient's ABC's, examining the patient's abdomen, and performing
adjunctive imaging with FAST and CT are the initial steps of diagnosing a patient's
splenic injury. Hypotension with a positive FAST scan should prompt emergent
laparotomy. For patients with an identified blunt splenic injury on a CT scan, the injury
should be graded according to the AAST injury grading scale [see Table 1].3
Similar to liver injuries, the grade of splenic injury predicts failure rates and complication
rates of NOM. Other findings that should be searched for on a CT scan include contrast
extravasation (is the contrast blush contained within the spleen, or does it spill into the
peritoneum?), the amount of intra-abdominal hemorrhage (is it isolated to the splenic
fossa, or does blood extend into the pelvis?), and the presence of pseudoaneurysms.
NONOPERATIVE MANAGEMENT
It is clear, however, that 20 to 30% of patients with splenic trauma deserve early
splenectomy and that failure of NOM often represents poor patient selection.53,54 In
adults, indications for prompt laparotomy include initiation of blood transfusion within
the first 12 hours considered to be secondary to the splenic injury or hemodynamic
instability. In the pediatric population, blood transfusions up to half of the patient's blood
volume are used prior to operative intervention. Following the first 12 postinjury hours,
indications for laparotomy are not as black and white. Determination of the patient's age,
comorbidities, current physiology, degree of anemia, and associated injuries will
determine the use of transfusion alone versus intervention with either embolization or
operation. Unlike hepatic injuries, which rebleed in 24 to 48 hours, delayed hemorrhage
or rupture of the spleen can occur up to weeks following injury. Algorithms for the
management of pediatric splenic injuries exist,55 and the patient's physiologic status is
the key determinant. Rapid mobilization in patients who are hemodynamically stable with
a stable hematocrit and no abdominal pain is generally successful. Overall, nonoperative
treatment obviates laparotomy in more than 90% of cases.
Follow-up Imaging
Out of concern over the risk of delayed hemorrhage or other complications, follow-up CT
scans have often been recommended; unfortunately, there is no consensus as to when or
even whether they should be obtained. Patients with grade I or II splenic injuries rarely
show progression of the lesion or other complications on routine follow-up CT scans; it is
reasonable to omit such scans if patients' hematocrits remain stable and they are
otherwise well. Patients with more extensive injuries often have a less predictable course,
and CT may be necessary to evaluate possible complications. Routine CT before
discharge, however, is unwarranted. Outpatient CT, however, in patients who participate
in vigorous or contact sports should be performed at 6 weeks to document complete
healing before resuming those activities. A more convenient and less expensive
alternative to follow-up CT is ultrasonographic monitoring of lesions.
In penetrating abdominal injuries not suitable for NOM and in blunt abdominal injuries
when NOM is contraindicated or has failed, exploratory laparotomy is performed.
To ensure safe removal or repair, the spleen should be mobilized to the point where it can
be brought to the surface of the abdominal wall without tension. An incision is made in
the peritoneum and the endoabdominal fascia, beginning at the white line of Toldt along
the descending colon and continuing cephalad 1 to 2 cm lateral to the posterior peritoneal
reflection of the spleen; this plane of dissection is continued superiorly until the
esophagus is encountered [see
Figure 15a]. Posteriorly, blunt dissection is performed to mobilize the spleen and
pancreas as a composite away from Gerota fascia and up and out of the retroperitoneum;
this posterior plane may be extended to the aorta if necessary [seeFigure 15b].
Additionally, the attachments between the spleen and the splenic flexure of the colon may
be divided to avoid avulsion of the inferior splenic capsule. Care must be taken not to
pull on the spleen; otherwise, it will tear along the posterior peritoneal reflection, causing
significant hemorrhage. It is often helpful to rotate the operating table 20° to the patient's
right so that the weight of the abdominal viscera facilitates viscera retraction. Any
ongoing hemorrhage from the splenic injury may be temporarily controlled with digital
occlusion of the splenic hilar vessels. Once mobilization is complete, the spleen can be
repaired or removed without any need to struggle to achieve adequate exposure.
Figure 16] for partial immunocompetence in younger patients.56 Drains are not used.
Partial splenectomy can be employed in patients in whom only the superior or inferior
pole has been injured. Hemorrhage from the raw splenic edge is controlled with a
horizontal mattress suture, with gentle compression of the parenchyma [see
Enthusiasm for splenic salvage was driven by the rare but often fatal complication of
overwhelming postsplenectomy sepsis (OPSS). OPSS is caused by encapsulated
bacteria,Streptococcus pneumoniae, Haemophilus influenzae,
and Neisseria meningitidis, which are resistant to antimicrobial treatment. In
patients undergoing splenectomy, prevention against these bacteria is provided via
vaccines administered optimally at 14 days but definitely prior to hospital
discharge.57 Vaccines to be administered include Pneumovax (Merck & Co., Inc.,
Whitehouse Station, NJ), Menactra (Sanofi Pasteur, Swiftwater, PA), and Fluvirin
(Novartis, East Hanover, NJ). Revaccination remains open to debate, but some argue for
revaccination every 6 years.
An immediate postsplenectomy increase in platelets and white blood cells (WBCs) is
normal; however, beyond postoperative day 5, a WBC count above 15,000/μL and a
platelet to WBC ratio less than 20 are highly associated with sepsis and should prompt a
thorough search for underlying infection.58,59 A common infectious complication
following splenectomy is a subphrenic abscess, which should be managed with
percutaneous drainage. Following splenectomy or splenorrhaphy, postoperative
hemorrhage may be attributable to loosening of a tie around the splenic vessels, a missed
short gastric artery, or recurrent bleeding from the spleen if splenic repair was used.
Additional sources of morbidity include a concurrent but unrecognized iatrogenic injury
to the pancreatic tail during rapid splenectomy, resulting in pancreatic ascites or fistula.
2014. Scientific American Surgery. Hamilton, Ontario & Philadelphia, PA. Decker
Intellectual Properties Inc. ISSN 2368-2744. STAT!Ref Online Electronic Medical
Library. http://online.statref.com/Document.aspx?fxId=61&docId=2297. 10/17/2014
4:45:39 AM CDT (UTC -05:00).
<10%
25%
50%
>80%
The answer is D, > 80%. Over 80% of patients with liver injuries may be managed
nonoperatively. The liver is the most commonly injured solid organ in blunt trauma,
comprising 5% of all trauma admissions, and because of its size is frequently involved in
penetrating trauma. Following blunt trauma, the most commonly injured structures are
the parenchyma and hepatic veins. Blunt forces dissipate along segments of the liver and
along the fibrous coverings of the portal triad structures; the hepatic veins, however, are
not as resilient. Stab wounds typically result in direct linear tears, whereas gunshot
wounds or shotgun wounds result in significant cavitary injuries attributable to blast
effect and the "tumbling" of the missile within the liver parenchyma. Thus, arterial injury
is more common with penetrating trauma. Biliary trauma is more common with
central/hilar trauma, either blunt or penetrating.
Nonoperative management (NOM) of liver injuries is now the prevailing therapeutic
strategy for blunt hepatic trauma and can be employed for isolated right subcostal
penetrating wounds. Several concurrent changes resulted in this paradigm change. Over
80% of patients with liver injuries may be managed nonoperatively. One of the early
studies to test the application of NOM in 1995 supported its broad application, with an
overall success rate greater than 85% in hemodynamically stable patients, despite
substantial hemoperitoneum documented by CT.11 Of the 8% of patients who failed
NOM, half required operation as a result of associated injuries (i.e., enteric or pancreatic
injuries), whereas half underwent laparotomy for hepatic-related hemorrhage. Patients
who require intervention for hemorrhage typically fail NOM in the first 24 to 48
hours.2,11,17 Patients who fail NOM due to associated enteric or pancreatic injury have a
more variable time frame to presentation17; half manifested symptoms within 48 hours,
with the remainder becoming symptomatic up to 3 weeks later. Perhaps not surprisingly,
those patients who failed NOM had failure rates associated with increasing grades of
hepatic injury, with grade V injuries having a greater than 20% failure rate. Subsequent
studies have reported failure rates of 14% in grade IV injuries and 23% in grade V
injuries.12 The most recent analysis of the National Trauma Data Bank of severe blunt
liver injuries (grade IV and V) identified that initial NOM occurred in 73%, with a failure
rate of 7%.16 Interestingly, failure of NOM was associated with higher mortality.
Predictors of failure of NOM included increasing age, male sex, increasing Injury
Severity Score, decreasing Glasgow Coma Scale score, and hypotension. A similar study
of high-grade liver injuries identified a similar pattern with NOM initiated in 66%
patients with a failure rate of 9%.18 The amount of hemoperitoneum evident on a CT
scan appears to correlate with successful management; patients with a large amount of
hemoperitoneum (i.e., blood extending into the pelvis) are more likely to fail NOM.
However, predicting which patients will ultimately require laparotomy has yet to be
accomplished. Read more
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11)
0/1
The liver is the most commonly injured solid organ in blunt trauma, comprising 5% of all
trauma admissions. With that being said, over 80% of patients with liver injuries may be
managed nonoperatively. Which of the following is not a predictor of nonoperative
management?
(1pts)
Female sex
Increasing age
Hypotension
Increasing Injury Severity Score
The answer is A, female sex. Over 80% of patients with liver injuries may be managed
nonoperatively. One of the early studies to test the application of NOM in 1995 supported
its broad application, with an overall success rate greater than 85% in hemodynamically
stable patients, despite substantial hemoperitoneum documented by CT.11 Of the 8% of
patients who failed NOM, half required operation as a result of associated injuries (i.e.,
enteric or pancreatic injuries), whereas half underwent laparotomy for hepatic-related
hemorrhage. Patients who require intervention for hemorrhage typically fail NOM in the
first 24 to 48 hours.2,11,17 Patients who fail NOM due to associated enteric or pancreatic
injury have a more variable time frame to presentation17; half manifested symptoms
within 48 hours, with the remainder becoming symptomatic up to 3 weeks later. Perhaps
not surprisingly, those patients who failed NOM had failure rates associated with
increasing grades of hepatic injury, with grade V injuries having a greater than 20%
failure rate. Subsequent studies have reported failure rates of 14% in grade IV injuries
and 23% in grade V injuries.12 The most recent analysis of the National Trauma Data
Bank of severe blunt liver injuries (grade IV and V) identified that initial NOM occurred
in 73%, with a failure rate of 7%.16 Interestingly, failure of NOM was associated with
higher mortality. Predictors of failure of NOM included increasing age, male sex,
increasing Injury Severity Score, decreasing Glasgow Coma Scale score, and
hypotension. A similar study of high-grade liver injuries identified a similar pattern with
NOM initiated in 66% patients with a failure rate of 9%.18 The amount of
hemoperitoneum evident on a CT scan appears to correlate with successful management;
patients with a large amount of hemoperitoneum (i.e., blood extending into the pelvis) are
more likely to fail NOM. However, predicting which patients will ultimately require
laparotomy has yet to be accomplished. Read more
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12)
0/1
What is the most common abdominal organ injured in the setting of blunt abdominal
trauma?
(Select 1)(1pts)
Spleen
Liver
Kidneys
Small Intestines
The liver is the most commonly injured solid organ in blunt trauma, comprising 5% of all
trauma admissions, and because of its size is frequently involved in penetrating trauma.
Following blunt trauma, the most commonly injured structures are the parenchyma and
hepatic veins. Blunt forces dissipate along segments of the liver and along the fibrous
coverings of the portal triad structures; the hepatic veins, however, are not so insulated.
Given its size and location within the abdomen, the liver is also commonly involved in
penetrating trauma. Stab wounds typically result in direct linear tears, whereas gunshot
wounds or shotgun wounds result in significant cavitary injuries attributable to blast
effect and the "tumbling" of the missile within the liver parenchyma. Thus, arterial injury
is more common with penetrating trauma.
Over the past 20 years, nonoperative management (NOM) of liver injuries has evolved to
become the prevailing therapeutic strategy for blunt hepatic trauma. Several concurrent
changes resulted in this paradigm change. First was the realization that diagnostic
peritoneal lavage (DPL) was sensitive but not specific for identifying intraperitoneal
hemorrhage that necessitated operative management. Surgeons recognized that many
laparotomies undertaken for a positive DPL were associated with liver injuries that did
not require intervention for bleeding.1Second, trauma surgeons noted that nonbleeding
hepatic venous injuries, if manipulated at laparotomy, often resulted in more hemorrhage
and sometimes even death.2 Furthermore, it became conspicuous that with hemostasis
achieved in the operating room, recurrent postoperative bleeding was rare. Therefore,
surgeons queried whether hepatic venous injuries, which are low-pressure system
injuries, could heal without intervention. Finally, computed tomography (CT) provided a
reliable method for diagnosing and grading liver injuries.
The spleen is the second most commonly injured abdominal organ in blunt trauma
patients. Historical studies have reported a 10% mortality with all splenic injuries;
however, isolated splenic injury mortality is less than 1%. The mechanisms of injury are
similar to those seen with liver injuries: motor vehicle collisions, autopedestrian
accidents, and falls. Similar to penetrating trauma to the liver, stab wounds to the spleen
typically result in direct linear tears, whereas gunshot wounds result in significant
cavitary injuries.
Until the 1970s, splenectomy was considered mandatory for all splenic injuries.
Recognition of the immune function of the spleen refocused efforts on splenic salvage in
the 1980s.38,39Following success in pediatric patients, NOM of splenic injuries was
adopted in the adult population and has become the prevailing strategy for blunt splenic
trauma.
Duodenal and pancreatic injury continues to challenge the trauma surgeon. The relatively
rare occurrence of these injuries, the difficulty in making a timely diagnosis, and high
morbidity and mortality rates justify the anxiety these unforgiving injuries invoke.
Mortality rates for pancreatic trauma range from 9 to 34%, with a mean rate of 19%.
Duodenal injuries are similarly lethal, with mortality rates ranging from 6 to 25%.
Complications following duodenal or pancreatic injuries are alarmingly frequent,
occurring in 30 to 60% of patients.1-3 Recognized early, the operative treatment of most
duodenal and pancreatic injuries is straightforward, with low morbidity and mortality.
2014. Scientific American Surgery. Hamilton, Ontario & Philadelphia, PA. Decker
Intellectual Properties Inc. ISSN 2368-2744. STAT!Ref Online Electronic Medical
Library. http://online.statref.com/Document.aspx?fxId=61&docId=2329. 10/27/2014
1:39:15 PM CDT (UTC -05:00).
Sub capsular hematoma, > 50% surface area, or ruptured with active
bleeding
Engorgement
Mastitis
Candida infection
The answer is D, Candida infection. In breastfeeding women, bilateral nipple pain with
and between feedings after initial soreness has resolved is usually due to Candida. Pain
from engorgement typically resolves after feeding. Mastitis is usually unilateral and is
associated with systemic symptoms and wedge-shaped erythema of the breast tissue.
Improper latch-on is painful only during feedings. Eczema isolated to the nipple, while a
reasonable part of the differential, would be much more unusual.
Fibroadenoma
Intraductal papilloma
Cystosarcoma Phyllodes
Mammary dysplasia
The answer is B, Intraductal papilloma. The old concern over cancer is the issue, and the
way to detect cancer that is not palpable is with a mammogram. That should be the first
choice. If negative, one may still wish to find an resect the intraductal papilloma to
provide symptomatic relief. Intraductal papillomas consist of a monotonous array of
papillary cells that grow from the wall of a cyst into its lumen. Although they are not
concerning in and of themselves, they can harbor areas of atypia or ductal carcinoma in
situ (DCIS). Papillomas can occur as solitary or multiple lesions. The standard approach
to a papilloma diagnosed by core needle biopsy (CNB) is to perform a surgical excision,
particularly if atypical cells are identified [14,16-21]. In a meta-analysis of 34 studies
that included 2236 non-malignant breast papillary lesions, 346 (15.7 percent) were
upgraded to malignancy following a surgical excision [21]. Because of a risk of
malignancy, these require surgical excision.Read More
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16)
1/1
A 25 -ear obese black female presents to you with a painful breast lump along with
tenderness in both her breasts. She notes recurrent pain and multiple lumps on both
breasts that seem to “come and go” at different times during her menses. Now she has a
firm, round, mass that has not gone away for the last 5 weeks. What is the most likely
diagnosis?
(Select 1)(1pts)
Cystosarcoma Phyllodes
Intraductal papilloma
Fibrocystic disease
Fibroadenoma
The answer is C. This patient has fibrocystic disease which is a nonproliferative epithelial
lesions that are generally not associated with an increased risk of breast cancer [1]. It
should be noted that terms such as fibrocystic changes, fibrocystic disease, chronic cystic
mastitis, and mammary dysplasia refer to nonproliferative lesions and are not useful
clinically, as they encompass a heterogeneous group of diagnoses [5,11]. The most
common nonproliferative breast lesions are breast cysts. Other nonproliferative lesions
include papillary apocrine change, epithelial-related calcifications, and mild hyperplasia
of the usual type [5]. Apocrine metaplasia (also referred to as a "benign epithelial
alteration") is also a nonproliferative change that is secondary to some form of irritation,
typically associated with a breast cyst. Read More
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17)
1/1
A 30-year old white female presents to your office with right breast pain. She is currently
breast feeding her healthy 4-week old infant and has been having focal tenderness,
swelling and redness to her right breast near the nipple over the last 2 days. She reports
no past medical history and is a non smoker. Given the patient’s history and physical,
which of the following inflammatory disorders is the most likely diagnosis?
(Select 1)(1pts)
Acute mastitis
Granulomatous mastitis
Medullary carcinoma
Mucinous carcinoma
True Correct
False
True: Algorithms for clinical and imaging evaluation of palpable masses are stratified by
the age of the woman. Even in the setting of palpable masses, image guidance may
improve diagnostic accuracy. A clinically suspicious mass should be biopsied regardless
of imaging findings, as 10 to 15 percent of such lesions can be mammographically
occult. Read more
(Select 1)(1pts)
Fibroadenoma
Fibrocystic disease
Intraductal papilloma.
Cystosarcoma Phyllodes
True Incorrect
False
Clindamycin
Flagyl
Oxacillin
Augmentin
Fewer than 40% of patients with Patients with Necrotizing Soft Tissue
Infections exhibit the classic symptoms and signs described
The answer is B, crepitus is noted in only 30% of patients with necrotizing soft tissue
infections. Patients with necrotizing soft tissue infections often complain of severe pain
that is out of proportion to their physical findings. Compared with patients who have
nonnecrotizing infections, they are more likely to have fever, bullae, or blebs [see Figure
1]; signs of systemic toxicity; hyponatremia; and leukocytosis with a shift in immature
forms. Physical findings characteristic of a necrotizing infection include tenderness
beyond the area of erythema, crepitus, cutaneous anesthesia, and cellulitis that is
refractory to antibiotic therapy.6 Tenderness beyond the borders of the erythematous area
is an especially important clinical clue that develops as the infection in the deeper
cutaneous layers undermines the skin. Early in the course of a necrotizing soft tissue
infection, skin changes may be minimal despite extensive necrosis of the deeper
cutaneous layers. Bullae, blebs, cutaneous anesthesia, and skin necrosis occur as a result
of thrombosis of the nutrient vessels and destruction of the cutaneous nerves of the skin,
which typically occur late in the course of infection.
Clinicians should be mindful of certain diagnostic barriers that may delay recognition and
treatment of necrotizing soft tissue infections.7 In particular, these infections have a
variable clinical presentation. Although most patients present with an acute, rapidly
progressive illness and signs of systemic toxicity, a subset of patients may present with a
more indolent, slowly progressive infection. Patients with postoperative necrotizing
infections often have a more indolent course. Moreover, in the early stages, underlying
necrosis may be masked by normal-appearing overlying skin. As many as 20% of
necrotizing soft tissue infections are primary (idiopathic) and occur in previously healthy
patients who have no predisposing factors and no known portal of entry for bacterial
inoculation. Finally, crepitus is noted in only 30% of patients with necrotizing soft tissue
infections. Overall, fewer than 40% of patients exhibit the classic symptoms and signs
described.7,8Accordingly, it is imperative to maintain a high index of suspicion for this
disease in the appropriate setting.Read More on Soft Tissue Infection
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24)
0/1
You are seeing a 30-year-old male wrestler who is presenting with a painful lesion on his
upper back. He first noted a small painful area a few days ago, and the lesion has since
enlarged and became more red. He notes that others on his wrestling team have similar
lesions and have sought care elsewhere. He has no past medical history and takes no
medications.
Physical Examination of the upper back reveals a 1 × 1 cm erythematous, raised pustule
that is tender to palpation, with a 4 × 4 cm area of surrounding erythema. The remainder
of the physical examination is normal. You elect to perform an incision and drainage, and
culture. Of the following, which is the most appropriate empiric treatment?
(Select 1)(1pts)
Levofloxacin
Doxycycline
Dicloxacillin
Cephalexin
Ciprofloxacin
Presence of fever
Presence of leukocytosis
Depth of inflammation
Presence of purulence
The answer is C, depth of inflammation. Cellulitis and erysipelas are diffuse spreading
skin infections that not associated with underlying suppurative foci. Clinically, there is
often some degree of overlap between the two different entities. Erysipelas is
differentiated from cellulitis by the depth of inflammation; erysipelas affects the upper
dermis, including the superficial lymphatics, whereas cellulitis affects the deeper dermis
and subcutaneous fat (Mayo Clin Proc, Vol. 89;1436). Read More onCellulitis and
erysipelas from Up to Date
Unit 1
1)
0/1
You are seeing a 42-year old male who is presenting with flank pain following
an MVC. On physical exam he has a large degree of flank ecchymosis along with gross
hematuria. You are suspecting a kidney injury and he appears stable for CT at this time.
What renal injuries in the setting of trauma require surgical management?
Vascular Injury
Expanding Hematoma
Shattered Kidney
The answer is D. All of the above. Generally about 80-90% renal injuries treated
conservatively with remarkable resolution! Injuries requiring surgery: vascular injury,
shattered kidney and an expanding hematoma.
The goal in the management of renal trauma is to safely preserve the maximal number of
renal units, avoiding unnecessary explorations, repairs, and nephrectomies. Increasing
numbers of renal injuries, including grade IV and V injuries, are being been managed
nonoperatively. The accuracy and rapidity of helical CT, combined with the
improvements achieved in resuscitation methods, have reduced the number of renal
explorations performed.8 Currently, 36% of all penetrating renal injuries and fewer than
5% of blunt injuries necessitate operative management.9 All grade I and II renal injuries,
regardless of the mechanism of injury, can be managed with observation alone because
the risk of delayed bleeding is extremely low. Most grade III and IV injuries, including
those with devitalized parenchymal fragments and urinary extravasation, can be managed
nonoperatively with close monitoring, serial hematocrit measurement, and repeat imaging
in selected cases. Active arterial bleeding, in the absence of other associated injuries, can
be treated with emergency arteriography and selective angioembolization.
The only absolute indications for renal exploration are pedicle avulsion, pulsatile or
expanding hematoma, and hemodynamic instability resulting from renal
injury.6 Significant numbers of shattered kidneys (grade V) and renal vascular injuries
(grades IV and V) are now managed nonoperatively. The strongest predictor for
nephrectomy is severity of renal injury; however, roughly one third of all penetrating and
44% of blunt grade IV and V renal injuries are now managed nonoperatively.9,13,14In
patients who require laparotomy for associated injuries, renal exploration and
reconstruction of grade III and IV injuries may reduce the likelihood of delayed
complications. However, the need for laparotomy and surgery for other intra-abdominal
organs is associated with a higher likelihood of nephrectomy. Thus, exploration of
suspected kidney injuries (as determined by previous imaging or on-table evaluation) in
patients undergoing laparotomy for major splenic or bowel injury should be attempted by
surgeons experienced in repairing an injured kidney.9 In reality, the success of
nonoperative management for most grade III and IV injuries means that operative
intervention in cases of blunt trauma is typically limited to patients with the most severe
renal injuries, in whom conservative management fails either because of bleeding or
because of ongoing urinary extravasation despite ureteral stenting.15
A significant number of patients with a penetrating injury and a minority of those with
blunt trauma require immediate laparotomy before radiographic
evaluation.9,13 Hematuria should alert the surgeon to the possibility of renal injury, and
the presence of a perinephric hematoma visible through the mesocolon should prompt
further evaluation. If a major renal injury is suspected on the basis of the size of the
hematoma or an abnormal intraoperative intravenous pyelogram (IVP), exploration is
indicated.
2014. Scientific American Surgery. Hamilton, Ontario & Philadelphia, PA. Decker
Intellectual Properties Inc. ISSN 2368-2744. STAT!Ref Online Electronic Medical
Library. http://online.statref.com/Document.aspx?fxId=61&docId=2366. 10/20/2014
1:04:32 PM CDT (UTC -05:00).
Grade I
Grade II
Grade III
Grade IV
Intercostal block
Surgical fixation
<5%
20%
35%
50%
The answer is B, 20%. The decision to image is challenging in the wellappearing patient
with a concerning mechanism or intermediate examination. Approximately 20% of
patients with no physical evidence of chest trauma but a concerning mechanism will have
injuries on thoracic CT. Alternatively, patients with a NEXUS chest score of 0 (see Table
2, page 5) have a much lower incidence of significant findings on CT
Some 10% to 23% of patients with minimal findings on examination may still have
significant thoracic injuries.54,59 However, it is unclear what percentage of these injuries
is clinically important. Point tenderness and ecchymosis on the chest wall should raise the
concern for intrathoracic injury; however, these findings are nonspecific.55 Injuries to the
lower ribs may also indicate the presence of intra-abdominal injuries. In a 2005
prospective observational study, 3% of patients with “isolated” subjective pain or point
tenderness to the lower left ribs as the only indication for computed tomography (CT) had
splenic injuries. If patients had other indications for CT (hypotension, abdominal or flank
tenderness, pelvic or femur fractures, or gross hematuria) the rate of splenic injury was
9.4%.Read more
Foley catheterization
The answer is B. This patient exhibits a classic presentation of penile fracture. The penis,
due to its mobility in the flaccid state, is typically not injured in cases of blunt trauma. It
is far more vulnerable to trauma in a T Rex state, such as during sexual intercourse, and
this is the setting where penile fractures most commonly countered. This injury most
often occurs during intercourse with a woman is situated on top of the man because the
penis may emerge from the vagina in this position can be subsequently injured in a
bending passion between its rigid fixation of the male in the downwardly moving female
perineum. Patients typically complain of the snapping sensation and/or sound when the
injury occurs, followed by severe pain. The injury and associated snapping sensation
results from tearing of the tunica albuginea, which invests the corpus cavernous. A
hematoma rapidly forms at the site of injury causing bending of the shaft of the penis at
the site of the fracture. Treatment is with an emergent urethrogram to assess for urethral
injury, as well as emergent surgery to evacuate the hematoma and repair the torn tunica
albuginea. Read more
12-24 hours
1-2 days
3-5 days
7-14 days
The answer is D, 7-14 days. CEA remains the prototypical solid tumor marker. Despite
its lack of specificity, if used correctly, CEA testing is a valuable addition to the process
of clinical decision making in patients diagnosed with colon or rectal carcinoma.
However, it is not an appropriate screening test. Whether sampled once or serially, CEA
cannot be used in the differential diagnosis of an unknown-but-suspected bowel problem
or malignancy. Nevertheless, when CEA concentrations are determined before primary
tumor resection, they may be of additional prognostic value; this is particularly true in
patients with stage II disease, for whom elevated preoperative CEA is a poor prognostic
marker and may influence the decision regarding whether to administer adjuvant
chemotherapy.
Serial CEA values obtained postoperatively are a potentially effective means of
monitoring response to therapy. A postoperative CEA titer serves as a measure of the
completeness of tumor resection. It should be remembered, however, that the half-life of
CEA is 7 to 14 days; therefore, postoperative baselines are best established several weeks
after resection. If a preoperatively elevated CEA value does not fall to normal within 2 to
3 weeks after surgery, it is likely that (1) the resection was incomplete or (2) occult
metastases are present. A rising trend in serial CEA values from a normal postoperative
baseline (< 5 ng/mL) may predate any other clinical or laboratory evidence of recurrent
disease by 6 to 9 months. Read more
Radiation
CRC ranks as the third most common malignancy in the United States
Answer D is false. Worldwide, over 1 million people are diagnosed with CRC annually,
and there are more than 500,000 associated deaths.1 The highest rates of colorectal
carcinoma are found in industrialized countries. The rates are significantly lower in
eastern Europe, Asia, Africa, and South America.2 However, studies of Japanese
migration to the United States, Asiatic Jewish migration to Israel, and eastern European
migration to Australia show that migrants acquire the high rates of CRCs prevalent in
their adopted countries. There is little question that environmental factors, most likely
dietary, account for this.
Colon cancer is three times more common than rectal cancer. Interestingly,
epidemiologic studies indicate a rising proportion of right-sided colonic lesions. The
proximal migration of colon cancer may be associated with changing environmental
factors; however, there is no doubt that increased screening successfully detects early
lesions in an aging population. CRC ranks as the third most common malignancy in the
United States (behind prostate and lung cancer in men and breast and lung cancer in
women) and the second leading cause of cancer-related mortality. Approximately
143,000 patients are diagnosed with CRC in the United States each year, and 51,000 die
of disease.4,5 The probability of CRC developing during an individual's lifetime is about
6%. In contrast to the three previous decades, however, the overall incidence and
mortality of CRC have declined for both men and women. Age-adjusted incidence and
mortality are associated with race and ethnicity; however, the relationships are complex,
influenced by social and economic confounding factors more than tumor biology.
Clearly, CRC is associated with genetic and environmental influences. Overt risk factors
include a personal or family history of CRC or colorectal adenoma(s), a personal history
of colorectal polyps, inflammatory bowel disease (IBD), and age greater than 50. Age is
the most common risk factor. The risk of CRC increases after the fourth decade of life.13
Most individuals present with disease after the age of 60, and only 10% of CRCs are
diagnosed in individuals younger than 40.
Nonhereditary CRCs are referred to as "sporadic" and comprise 75 to 80% of all CRCs.
Genetic etiology may be identified in the remaining 20 to 25% of patients, including
family history (15 to 20%), Lynch syndrome (5%), and FAP (< 1%). Cancer can arise
within a polyp or at another site in the colon or rectum. Read more
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Unit 3
10)
0/1
You are seeing a 61-year old female who presents with worsening shortness of breath
for two days. The day preceding her symptoms she was involved in an MVC and was
seen in your facility and diagnosed with 3 non displaced rib fractures on the right. Her x-
ray today is shown below. What is the most likely diagnosis?
(Select 1)(1pts)
Pneumothorax
Pulmonary Contusion
Fat embolism
Pneumonia
The answer is B. Severe blunt trauma to the chest can cause rib fractures and other
immediate injuries but sometimes pathology doesn't show up until days later such as a
pulmonary contusion and myocardial contusion. The contused lung is very sensitive to
fluid overload which can lead to respiratory distress. Pulmonary contusions generally
develop over the first 24 hours and resolve in about one week. Irregular, nonlobular
opacification of the pulmonary parenchyma on chest radiograph is the diagnostic
hallmark. About one-third of the time the contusion is not evident on initial radiographs.
Chest CT provides better resolution, but rarely alters management, unless other injuries
are found. Contusions evident on CT but not plain radiograph have better outcomes.
Pain control and pulmonary toilet are the mainstays of treatment. Prophylactic
endotracheal intubation is unnecessary, but patients with hypoxia or difficulty ventilating
require airway management. While opinions vary, fluid resuscitation with crystalloid to
euvolemia appears appropriate. Common complications include pneumonia and acute
respiratory distress syndrome (ARDS). Read more
The answer is A, Upright Chest Xray followed by a chest tube. This patient is awake and
talking. He is stable enough for a chest xray followed by chest tube placement. A needle
thoracotomy to should be done if he has evidence of tension pneumothorax which would
be respiratory distress and hypotension. He will likely then need a chest tube and can be
further managed. Read More
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12)
0/1
A 65-year-old male comes in the emergency Department because of severe right-sided
chest pain following a fall off his ladder 10 feet high.
Examination shows decreased respiratory movements on the right side of the chest and
tenderness on palpation over the right mentions, his abdomen is soft and non tender.
An x-ray film of his chest shows a non displaced fracture of the right 6th and 7th ribs on
the right without signs of pneumothorax.
Which of the following is the most appropriate goal in management of the rib fracture in
this patient?
(1pts)
The answer is B. Once significant associated injuries have been evaluated and treated, the
cornerstone of rib fracture management is pain control [36-38]. Early and adequate pain
relief is essential to avoid complications from splinting and atelectasis, primarily
pneumonia. The choice of analgesia depends upon the injury, the clinician's comfort
performing nerve blocks with their potential complications, and the ease with which more
invasive treatments can be performed. Analgesia for severe and multiple rib fractures and
monitoring of admitted patients are discussed separately.
For isolated injuries (ie, single rib fracture), clinicians generally begin treatment with
nonsteroidal anti-inflammatory drugs (NSAIDs) with or without opioids. For more severe
injuries, particularly if ventilation is compromised, admission and invasive treatments,
such as intercostal nerve blocks, may be needed.
Respiratory care, including use of incentive spirometry to prevent atelectasis and its
complications, is often important. We do not recommend rib belts or binders because
they compromise respiratory function. Studies of rib belts involve small numbers of
patients and have reached contradictory conclusions [39,40]. Patients with a rib fracture
who are discharged home can also use incentive spirometry throughout the day, after
analgesics have taken effect. Holding a pillow or similar soft brace against the fracture
site reduces discomfort while using the spirometer, or when coughing.
Disposition — Several researchers recommend hospital admission for any patient with
three or more rib fractures, and ICU care for elderly patients with six or more rib
fractures [14,15]. They cite the significant correlation between these findings and
serious internal injuries, such as pneumothorax and pulmonary contusion. We suggest
hospitalization for the majority of patients with three or more rib fractures. Patients with
multiple rib fractures sustained from high-energy trauma are best evaluated at a trauma
center. Transfer should be arranged expeditiously.
Displaced rib fractures likely increase the risk of injury to the lung and proximate
intercostal blood vessels. Bleeding from such fractures can be delayed, and admission or
close observation and follow-up should be arranged for patients with displaced fractures,
depending upon clinical and social circumstances. Multiple case reports indicate that
delayed bleeding from intercostal vessels or other injuries can be life-threatening,
particularly in older patients [20,41,42].
Surgical fixation may be of benefit with some types of rib fractures, particularly those
associated with chest wall deformity, flail chest, or symptomatic nonunion. The
appropriate role of surgical fixation is discussed separately. (See "Inpatient
management of traumatic rib fractures", section on 'Surgical
management'.)
Rarely, younger healthy individuals with three rib fractures, having undergone a thorough
clinical and radiographic evaluation by clinicians experienced in trauma management,
and an appropriate period of observation (a minimum of six hours of observation,
including a follow-up chest radiograph, is needed to rule out pneumothorax), may be
discharged from the emergency department. Clinicians must also consider patient
comorbidities and clinical and social circumstances when determining disposition.
Patients with one or possibly two isolated rib fractures and no complicating factors may
be discharged home with appropriate follow-up and adequate analgesia. Uptodate
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13)
0/1
You are seeing a 20-year old female that was stabbed in the chest by an attacker 15
minutes prior to arrival. EMS noted she was initially awake and talking but has since
become less talkative and more lethargic. Vitals signs show her blood pressure is
60/palp, heart rate 120 beats/min, respiratory rate 28/min and O2 92% on a non re-
breather. On physical exam her eyes are closed but arouses to painful stimuli and loud
voice. She has distended neck veins and muffled heart sounds. Chest exam reveals a 2-cm
wound just to left of her sternum. What is the next best step in management?
(Select 1)(1pts)
Pericardiocentesis
This young lady has been stabbed in the heart and has evidence of cardiac tamponade.
She needs an immediate percicardiocentesis. A chest tube will not help with this problem
and she is too unstable for an emegent echo or upright xray.Read more on the
initial evaluation of chest trauma
MRI abdomen/pelvis
Ultrasound
Intravenous pyelography
Cystography
Intravenous pyelography
The answer is A. This injury often follow pelvic fractures and classically present with
blood at the urethral meatus, an ability to void and a high riding or a non palpable
prostate to an intern. If you suspect urethral injury a retrograde urethrogram needs to be
performed prior to foley insertion. This procedure will locate the damage of the urethra, if
present. Inserting a Foley before this procedure is contraindicated as this can worsen the
urethral tear and potentially cause infection or a hematoma (you do not want to cause or
worsen the chance of a urethral stricture). These injuries often need surgical repair,
especially anterior urethral injuries. Some are treated with urinary diversion via
suprapubic catheter while the primary injury heals. Read more
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16)
0/1
You are seeing a 48-year old male in the trauma bay after shooting himself in his right
thigh while it was in its holster.
On exam there is one wound that is about 2cm in diameter on his posterolateral right
thigh. It has since stopped bleeding after pressure was applied. His pulses are equal and
symmetrical and his neuro exam in normal. You obtain an xray which shows bullet
fragments in his thigh without evidence of fracture.
What is the next best step in treatment?
(1pts)
This patient shows no sign of arterial injury as he has no hard or soft signs of vascular
injury (see below). He has a normal neuro exam and has no fracture on xray. The only
thing that this patient needs is a tetanus update and wound irrigation.
True
False Correct
The answer is False: In the setting of renal trauma, gross or microscopic hematuria is
absent in up to 5% of cases and this finding alone should not be used to preclude in those
you are suspicious of renal trauma. Read more on renal trauma
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Unit 5
18)
0/1
According to a large, randomized, multicenter Veterans Affairs (VA) study comparing
laparoscopic or open approach for the treatment of inguinal hernias, what was the overall
recurrence rate at 2 years for laparoscopic vs open mesh repair respectively?
(Select 1)(1pts)
10%/4%
20%/10%
4%/10%
10%/20%
20
50
75
120
Direct
Femoral
Richter
This patient most likely has an indirect hernia as it is the most common hernia and given
the lack of other findings in the stem that is the best answer and most likely. Although a
sports hernia may lead to a traditional, abdominal hernia, it is a different injury. A sports
hernia is a strain or tear of any soft tissue (muscle, tendon, ligament) in the lower
abdomen or groin area. Because different tissues may be affected and a traditional hernia
may not exist, the medical community prefers the term "athletic pubalgia" to refer to this
type of injury.
An indirect inguinal hernia is one of the most common abdominal hernias. It is
five times more common than a direct inguinal hernia, and is seven times more frequent
in males, due to persistence of the process vaginalis during testicular descent. An indirect
hernia enters the inguinal canal at the deep ring, lateral to the inferior epigastric vessels.
It passes infromedially to emerge via the superficial ring and, if large enough, extend into
the scrotum. In children, the vast majority of inguinal hernias are indirect (see Case 3).
Incarceration represents the most common complication associated with inguinal hernias,
the incidence could be as high as 30% for infants younger than 2 months.
A direct inguinal hernia arises from protrusion of abdominal viscera through a
weakness of the posterior wall of the inguinal canal medial to the inferior epigastric
vessels, specifically through the Hasselbach's triangle. This type of hernia is termed
direct as the hernial sac directly protrudes through the inguinal wall in contrast to indirect
ones which arise through the deep ring and enter the inguinal canal. Since direct hernias
do not have a guiding path, they seldom extend into the scrotum unless very large and
chronic. Direct hernias arise usually as acquired weakness of the Hasselbalch's triangle.
Therefore, they are seen in the elderly with chronic conditions which increase intra-
abdominal pressure over a long period, e.g. COPD, bladder outflow obstruction, chronic
constipation etc. Increased abdominal pressure is transmitted to both sides and as a result,
direct hernias are usually bilateral. Compared to indirect hernia, they are less susceptible
to strangulation as they have a wide neck.
In contrast to the indirect hernia, a direct hernia is most often an acquired lesion. It
occurs when a weak spot develops in the lower abdominal musculature (the posterior
floor of the inguinal canal) due to the normal and/or abnormal stresses inflicted by living
and aging. In adults, stresses such as lifting heavy of objects, frequent coughing or
straining, pregnancy, and constipation can instigate hernia. Unlike indirect hernias, direct
hernias traverse medial to the inferior epigastric vessels and are not associated with the
processus vaginalis. The hernia consists primarily of retroperitoneal fat. Only rarely is a
peritoneal sac containing bowel encountered. Because there is typically no involvement
of a sac, they do not protrude with the spermatic cord, and as such, have a lower
incidence of incarceration or strangulation. Like indirect inguinal hernia, direct inguinal
hernias typically cause a bulge in the groin (at the top of or within the scrotum) and
usually with increased abdominal pressure. Like indirect hernias, they may or may not be
painful (usually not). By palpating the inguinal canal and asking the patient to cough
while standing, one can usually elicit the hernia. In fact, one can often times palpate an
inguinal hernia without invaginating the scrotum (as is typically taught in medical
school). Rather, by placing one's fingers over the inguinal canal and asking the patient to
cough, one can often feel the bulge against the lower abdominal wall. As direct and
indirect hernias are unreliably differentiated by physical exam alone, the need to
invaginate the scrotum to feel into the inguinal canal is often more uncomfortable to the
patient, than telling to the physician. Rarely, palpation is not even necessary, as the
hernia is large enough to be visualized. Read more on Inguinal hernias: A Brief
review
In female patients, indirect inguinal hernias are the most common type
In male patients, direct inguinal hernias are the most common type
Femoral hernias account for fewer than 10% of all groin hernias; however,
40% present as emergencie
Answer C is the only false statement as No laboratory findings are particularly specific
for duodenal or pancreatic injury. Amylase has been proposed for both pancreas and
duodenal injuries but is not specific for either one. Some have noted that amylase can be
elevated in as many as 50% of duodenal injuries, but this has not been a consistent
finding.9 An elevated amylase should prompt an evaluation of the duodenum for injury
but alone is not diagnostic. Although the highest concentration of amylase in the human
body is in the pancreas, hyperamylasemia is also not a reliable indicator of pancreatic
trauma. In one series, only 8% of blunt abdominal injuries with hyperamylasemia had
pancreatic injury.10 Furthermore, as many as 40% of patients with a pancreatic injury
may initially have a normal serum amylase.
The history of a patient with a possible blunt pancreatic or duodenal injury usually
consists of a direct blow to the epigastrium. In children, this commonly involves a bicycle
handlebar to the epigastrium; in adults, more commonly the steering wheel or a motor
cycle handle bar is involved. However, any direct blow should raise suspicion. The
patient may complain of abdominal, back, or flank pain.
Outside of the pelvis x-ray, plain abdominal radiographs to evaluate blunt abdominal
trauma are less common in the era of focused abdominal sonography for trauma (FAST)
and computed tomographic (CT) scans. Reports suggest that signs of duodenal injury on
plain radiographs are identified less than one third of the time. Retroperitoneal air, free
intraperitoneal air, or obliteration of the psoas shadow should raise suspicion for
duodenal and other hollow viscous trauma.9 Upper gastrointestinal series have also been
used to evaluate the duodenum for injury and can add to the sensitivity and specificity of
plain films, but more recently, CT has become the primary diagnostic modality.
For optimal duodenal evaluation, intraluminal contrast administered via a nasogastric
tube soon but not immediately prior to the CT scan may aid by opacification of the lumen
of the duodenal "C loop." Visualization of contrast extravasation, retroperitoneal air,
adjacent fat stranding, and unexplained fluid, as well as duodenal wall thickening, are CT
findings suggestive of potential duodenal injury. The sensitivity of CT for duodenal
injury is related to the technology of the scanner (i.e., "number of slices") and the time
interval from the injury to imaging. In a recent review, CT was considered to have an
overall sensitivity of around 76% with new-generation scanners (16- or 64-slice), having
a higher sensitivity of around 82%. Additionally, if clinical suspicion remains high after
an initial negative CT scan, then repeat imaging is warranted and may improve diagnostic
yield.
At times, duodenal hematomas can cause duodenal obstruction. This usually presents 2 to
3 days after the trauma with evidence of gastric outlet obstruction. The common
nonoperative treatment of isolated obstructing duodenal hematomas is nasogastric tube
decompression of the stomach and duodenum, nutritional support, and time.38 Repeat
imaging in 7 to 14 days is reasonable to evaluate improvement or an unexpected finding
as most duodenal hematomas will have resolved after 7 to 14 days, and continued
obstruction may reveal additional injury, prompting intervention.39-41 Enteral nutrition
is preferred to parenteral nutrition, but in the setting of a duodenal obstruction, the
parenteral route (total parenteral nutrition [TPN]) is often required as passing a feeding
tube beyond the obstruction can be difficult and surgical feeding access defeats the
purpose of "nonoperative" care.
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23)
0/1
Which of the following statements regarding hollow viscus injuries in patients suffering
from blunt trauma is not true?
(Select 1)(1pts)
Answer D is false. Unexplained intraperitoneal fluid (i.e., fluid appearing in the absence
of solid-organ injury) was the most common radiographic finding associated with blunt
bowel or mesenteric injury but often proved to be a false positive finding.
Hollow viscus injury after blunt trauma, although uncommon, can have serious
consequences if the diagnosis is missed or delayed. In a multi-institutional study of 198
patients with blunt small bowel injury, delay of as little as 8 hours in making the
diagnosis resulted in increased morbidity and mortality.2 Mortality increased in parallel
with time to operative intervention (< 8 hours to operation, 2% mortality; 8 to 16 hours,
9%; 16 to 25 hours, 17%; > 24 hours, 31%), as did the complication rate. Consequently,
it is important to have an expedient approach to the diagnosis of blunt bowel injury.
Physical examination findings such as abdominal tenderness or tachycardia may suggest
the presence of hollow viscus injury. Distracting chest or long bone injury, closed-head
injury, spinal cord injury, or intoxication, however, may compromise reliability of the
examination. In addition, it is not uncommon for blunt bowel injury to have a latent
period from the time of injury, whereby the expected signs and symptoms of such injuries
take some time to develop. Laboratory abnormalities, including elevations in white blood
cell (WBC) count, amylase, and/or lactic acid, may also point toward the presence of
hollow viscus injury but are relatively nonspecific. Provided that the patient has suffered
a low-risk mechanism of injury (such as a fall from standing or a low-speed motor
vehicle collision), hollow viscus injury is extremely unlikely in the face of a normal,
reliable physical examination and normal laboratory results. With these conditions
present, the presence of blunt bowel injury can be effectively excluded. However, the
presence of abdominal complaints, an abnormal or unreliable physical examination,
abnormal laboratory results, or a high-risk mechanism of injury (such as a high-speed
motor vehicle collision) warrants further evaluation by imaging for the presence of bowel
injury.
Particular consideration should be given to lap-and shoulder-restraint injuries, which may
be associated with an increased risk of hollow viscus injury. The "seat-belt" sign (i.e.,
ecchymosis of the abdominal wall secondary to the compressive force of the lap belt) is
associated with a more than doubled relative risk of small bowel injury.3,4 Flexion-
distraction fractures of the spine (Chance fractures) are also associated with lap-belt use,
and the presence of such fractures should raise the index of suspicion for associated
hollow viscus injury.
Ultrasonography is routinely performed early in the evaluation of blunt abdominal
trauma. It is highly specific and moderately sensitive in identifying intra-abdominal fluid,
the presence of which in a hemodynamically unstable patient is an indication for
laparotomy (in that it strongly suggests the presence of significant intra-abdominal
hemorrhage).5 Ultrasonography does not, however, reliably distinguish solid-organ
injury from hollow viscus injury—a distinction that is critical for determining subsequent
management (i.e., operative versus nonoperative) in a hemodynamically stable patient.
Computed tomography (CT) is the imaging modality of choice in stable patients who
warrant evaluation by imaging as described above. We reviewed over 8,000 CT scans
performed to evaluate cases of blunt abdominal trauma and found that the number of
abnormal radiologic findings suggesting blunt injury to the bowel, the mesentery, or both
was correlated with the true presence of injury [see Table 1].6 A CT scan
demonstrating a solitary abnormality was associated with a true positive rate of 36%,
whereas a scan demonstrating more than one abnormality was associated with a true
positive rate of 83%. Unexplained intraperitoneal fluid (i.e., fluid appearing in the
absence of solid-organ injury) was the most common radiographic finding associated
with blunt bowel or mesenteric injury but often proved to be a false positive finding. On
the basis of this experience, we developed an algorithm for the evaluation of blunt hollow
viscus injury in patients with unreliable physical examinations [see Figure 1].
Most CT scans performed in this clinical setting, however, will be negative for evidence
of intra-abdominal injury. A prospective multi-institutional trial involving 3,822 blunt
trauma patients demonstrated that the negative predictive value of a normal abdominal
CT scan was 99.63%, leading the authors to conclude that patients with a normal scan do
not benefit from hospital admission and prolonged observation.7 However, a multi-
institutional review of 2,457 cases carried out by the Eastern Association for the Surgery
of Trauma (EAST) reported a 13% incidence of blunt small bowel injury in patients with
an initial negative CT scan. These results indicate that caution should be exercised in
dismissing the presence of hollow viscus injury on the basis of a negative scan.3 This
concern is echoed by our own institutional experience, in which the incidence of injury in
patients with an initial negative CT scan was 12%.6 If CT scanning demonstrates no
suspicious findings, no further diagnostic workup of hollow viscus injury is necessary,
but the duration of the observation period depends on both the overall condition of the
patient and clinical judgment. Most patients, as supported by the negative predictive
value of the study above, will not require ongoing further observation.
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24)
0/1
What is the mean mortality rate of patients suffering from pancreatic trauma?
(Select 1)(1pts)
<3%
9%
19%
31%
The answer is C, 19%. Duodenal and pancreatic injury continues to
challenge the trauma surgeon. The relatively rare occurrence of these
injuries, the difficulty in making a timely diagnosis, and high morbidity
and mortality rates justify the anxiety these unforgiving injuries
invoke. Mortality rates for pancreatic trauma range from 9 to 34%,
with a mean rate of 19%. Duodenal injuries are similarly lethal, with
mortality rates ranging from 6 to 25%. Complications following
duodenal or pancreatic injuries are alarmingly frequent, occurring in
30 to 60% of patients.1-3 Recognized early, the operative treatment
of most duodenal and pancreatic injuries is straightforward, with low
morbidity and mortality. Read more
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25)
0/1
What percentage of patients suffering from blunt abdominal trauma develop hollow
viscus injury?
(Select 1)(1pts)
1.2%
4.8%
8.9%
13.4%
The answer is A, 1.2%. Hollow viscus injury after blunt trauma, although
uncommon, can have serious consequences if the diagnosis is missed
or delayed.Hollow viscus injury is most often the consequence of
penetrating abdominal trauma. As a result of blunt force trauma,
bowel injury occurs with relative infrequency: in one multi-institutional
analysis, only 1.2% of blunt trauma admissions had an associated
hollow viscus injury. Read more
Unit 1
1)
0/1
What is the most common cancer among woman?
(Select 1)( 1pts extra credit)
Ovarian
Lung
Colon
Breast
The answer is D, Breast Cancer. Approximately 230,480 American women are diagnosed
with breast cancer annually, and 39,520 women die from this disease. Global cancer
statistics show that breast cancer is the most frequently diagnosed cancer and the leading
cause of cancer death among females, accounting for 23 percent of total cancer cases and
14 percent of cancer deaths. Breast cancer is now also the leading cause of cancer death
among females in economically developing countries.
Globally, breast cancer is the most frequently diagnosed cancer and the leading cause of
cancer death in women. In the United States, breast cancer is the most commonly
diagnosed cancer and the second most common cause of cancer death in women. In
addition, breast cancer is the leading cause of death in women ages 40 to 49 years.Breast
cancer is treated with a multidisciplinary approach involving surgical oncology, radiation
oncology, and medical oncology, which has been associated with a reduction in breast
cancer mortality. Read more from Up to date
Linear calcifications
Round calcifications
Pneumococcus pneumoniae
Clostridium perfringens
Escherichia coli
Transthoracic echocardiography
The answer is B, The patient should undergo computed tomography (CT) of the neck
with contrast. She has fever, leukocytosis, sore throat, unilateral neck tenderness, and
multiple densities on chest radiograph, suggestive of septic emboli. The combination of
these factors points strongly toward Lemierre syndrome, which is septic thrombosis of
the internal jugular vein. The diagnosis should be suspected in anyone with pharyngitis,
persistent fever, neck pain, and septic pulmonary emboli. CT of the affected vessel with
contrast would confirm the diagnosis. Treatment includes intravenous antibiotics that
cover streptococci, anaerobes, and β-lactamase-producing organisms. Penicillin with a β-
lactamase inhibitor and carbapenem are both reasonable choices (eg, ampicillin-
sulbactam, piperacillin-tazobactam, ticarcillin-clavulanate).
Chest CT would better characterize the pulmonary infiltrates, but this information would
not provide specific diagnostic information that would guide therapy.
Soft tissue radiography of the neck cannot detect jugular vein filling defects or
thromboses, which are diagnostic of septic thrombophlebitis.
Echocardiography would be helpful to exclude right-sided endocarditis as a cause of
septic emboli. However, there is nothing in the history or on cardiac examination to
suggest a cardiac source of septic emboli. Centor RM, Samlowski R. Avoiding sore
throat morbidity and mortality: when is it not “just a sore throat?” Am Fam Physician.
2011;83:26, 28. PMID: 21888123
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5)
0/1
You are seeing a 26-year old college student in the ER following a roll over MVC. He
was wearing a seat belt and was not ejected. Upon arrival his complaining of abdominal
pain. His vital signs show a heart rate of 120/min, blood pressure is 134/98, RR 20/min,
O2 98% on room air. Physical exam shows he has a seat belt sign across his abdomen and
has tenderness greatest in his upper abdomen with no guarding. His CT scan of the
abdomen/pelvis with IV contrast only shows a liver laceration.
True Incorrect
False
False: The current approach to hepatic trauma has evolved to nonoperative management
in more than 80% of cases. Several contributing factors have been recognized: realization
that more than 50% of liver injuries stop bleeding spontaneously, the precedent of
successful nonoperative management in pediatric patients, knowledge that the liver has
tremendous capacity to heal after injury, and improvements in liver imaging with CT.
Criteria for nonoperative management include foremost, hemodynamic stability, absence
of other abdominal injuries that require laparotomy, immediate availability of resources
including a fully staffed operating room, and a vigilant surgeon. In general, any patient
who is stable enough to have a CT scan performed is likely to be successfully managed
nonoperatively. Grade I and II hepatic injuries should be observed in a monitored setting
with serial hematocrit evaluations and bed rest. Higher-grade injuries in stable patients
should be observed in an intensive care unit setting with optimization of all coagulation
factors. Read More
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Unit 2
6)
0/1
In cases of blunt trauma to the diaphragm, the injury is on the ____ side __% of the time?
(Select 1)(1pts)
Right; 90%
Left; 75%
Left; 25%
Right; 10%
The answer is B, left;75%. In cases of blunt trauma to the diaphragm, the injury is on the
left side 75% of the time, presumably because the liver diffuses some of the energy on
the right side. Blunt diaphragmatic injuries result in a linear tear in the central tendon,
whereas penetrating injuries are variable in size and location depending on the weapon. It
is important to identify the trajectory of penetrating injuries to determine the likelihood of
diaphragm injuries. With blunt and occasionally with penetrating injuries, the diagnosis is
suggested by an abnormality of the diaphragmatic shadow on a chest radiograph [see
Figure 5]. In patients without clear imaging results in the trauma bay, a CT scan may
identify a diaphragmatic injury.
Regardless of the etiology, acute injuries are repaired through an abdominal incision.
Thoracoscopy or laparoscopy may be used if concomitant injuries requiring laparotomy
have been ruled out. Following delineation of the injury, the chest should be evacuated of
all blood and particulate matter, and tube thoracostomy should be placed if not previously
done. Using Allis clamps to approximate the diaphragmatic edges, the defect can be
closed with a running permanent suture [see Figure 6]. Occasionally, large avulsions or
shotgun wounds with extensive tissue loss will require mesh to bridge the defect.
Alternatively, transposition of the diaphragm cephalad one to two intercostal spaces may
allow repair without undue tension. Read more
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7)
1/1
Nonoperative Management of solid-organ injuries can be pursued in hemodynamically
stable patients who do not have overt peritonitis or other indications for laparotomy.
According to contemporary data, what percentage of patients with splenic injuries are
candidates for nonoperative management?
(Select 1)(1pts)
<10%
25%
45%
60%
Transesophageal echocardiogram
This patient presents with blunt abdominal trauma with the delayed onset of hypertension
and signs and symptoms worrisome for likely splenic injury. Most common injuries are
to the spleen, liver, and less common injuries are to the hollow viscous organs in the
abdomen. Symptoms and signs suggesting splenic injury include left upper quadrant pain,
abdominal wall contusion, left lower chest wall tenderness, hypotension, and left
shoulder. Pain referred from splenic hemorrhage, hitting the phrenic nerve and diaphragm
(Kehr sign). The initial examination after blunt abdominal trauma can be unremarkable
and the symptoms can occur hours later, indicating ongoing splenic injury. The best
choice here would be an abdominal CT scan with intravenous contrast, only (no oral
contrast is needed because as little utility). This will define organ injury, assess for
presence of bleeding in all abdominal compartments, determine the need for surgery.
The spleen is the second most commonly injured abdominal organ in blunt trauma
patients. Historical studies have reported a 10% mortality with all splenic injuries;
however, isolated splenic injury mortality is less than 1%. The mechanisms of injury are
similar to those seen with liver injuries: motor vehicle collisions, autopedestrian
accidents, and falls. Similar to penetrating trauma to the liver, stab wounds to the spleen
typically result in direct linear tears, whereas gunshot wounds result in significant
cavitary injuries.
Until the 1970s, splenectomy was considered mandatory for all splenic injuries.
Recognition of the immune function of the spleen refocused efforts on splenic salvage in
the 1980s.38,39Following success in pediatric patients, NOM of splenic injuries was
adopted in the adult population and has become the prevailing strategy for blunt splenic
trauma.40
Addressing the patient's ABC's, examining the patient's abdomen, and performing
adjunctive imaging with FAST and CT are the initial steps of diagnosing a patient's
splenic injury. Hypotension with a positive FAST scan should prompt emergent
laparotomy. For patients with an identified blunt splenic injury on a CT scan, the injury
should be graded according to the AAST injury grading scale [see Table 1].3
Similar to liver injuries, the grade of splenic injury predicts failure rates and complication
rates of NOM. Other findings that should be searched for on a CT scan include contrast
extravasation (is the contrast blush contained within the spleen, or does it spill into the
peritoneum?), the amount of intra-abdominal hemorrhage (is it isolated to the splenic
fossa, or does blood extend into the pelvis?), and the presence of pseudoaneurysms.
NONOPERATIVE MANAGEMENT
It is clear, however, that 20 to 30% of patients with splenic trauma deserve early
splenectomy and that failure of NOM often represents poor patient selection.53,54 In
adults, indications for prompt laparotomy include initiation of blood transfusion within
the first 12 hours considered to be secondary to the splenic injury or hemodynamic
instability. In the pediatric population, blood transfusions up to half of the patient's blood
volume are used prior to operative intervention. Following the first 12 postinjury hours,
indications for laparotomy are not as black and white. Determination of the patient's age,
comorbidities, current physiology, degree of anemia, and associated injuries will
determine the use of transfusion alone versus intervention with either embolization or
operation. Unlike hepatic injuries, which rebleed in 24 to 48 hours, delayed hemorrhage
or rupture of the spleen can occur up to weeks following injury. Algorithms for the
management of pediatric splenic injuries exist,55 and the patient's physiologic status is
the key determinant. Rapid mobilization in patients who are hemodynamically stable with
a stable hematocrit and no abdominal pain is generally successful. Overall, nonoperative
treatment obviates laparotomy in more than 90% of cases.
Follow-up Imaging
Out of concern over the risk of delayed hemorrhage or other complications, follow-up CT
scans have often been recommended; unfortunately, there is no consensus as to when or
even whether they should be obtained. Patients with grade I or II splenic injuries rarely
show progression of the lesion or other complications on routine follow-up CT scans; it is
reasonable to omit such scans if patients' hematocrits remain stable and they are
otherwise well. Patients with more extensive injuries often have a less predictable course,
and CT may be necessary to evaluate possible complications. Routine CT before
discharge, however, is unwarranted. Outpatient CT, however, in patients who participate
in vigorous or contact sports should be performed at 6 weeks to document complete
healing before resuming those activities. A more convenient and less expensive
alternative to follow-up CT is ultrasonographic monitoring of lesions.
In penetrating abdominal injuries not suitable for NOM and in blunt abdominal injuries
when NOM is contraindicated or has failed, exploratory laparotomy is performed.
To ensure safe removal or repair, the spleen should be mobilized to the point where it can
be brought to the surface of the abdominal wall without tension. An incision is made in
the peritoneum and the endoabdominal fascia, beginning at the white line of Toldt along
the descending colon and continuing cephalad 1 to 2 cm lateral to the posterior peritoneal
reflection of the spleen; this plane of dissection is continued superiorly until the
esophagus is encountered [see
Figure 15a]. Posteriorly, blunt dissection is performed to mobilize the spleen and
pancreas as a composite away from Gerota fascia and up and out of the retroperitoneum;
this posterior plane may be extended to the aorta if necessary [seeFigure 15b].
Additionally, the attachments between the spleen and the splenic flexure of the colon may
be divided to avoid avulsion of the inferior splenic capsule. Care must be taken not to
pull on the spleen; otherwise, it will tear along the posterior peritoneal reflection, causing
significant hemorrhage. It is often helpful to rotate the operating table 20° to the patient's
right so that the weight of the abdominal viscera facilitates viscera retraction. Any
ongoing hemorrhage from the splenic injury may be temporarily controlled with digital
occlusion of the splenic hilar vessels. Once mobilization is complete, the spleen can be
repaired or removed without any need to struggle to achieve adequate exposure.
Figure 16] for partial immunocompetence in younger patients.56 Drains are not used.
Partial splenectomy can be employed in patients in whom only the superior or inferior
pole has been injured. Hemorrhage from the raw splenic edge is controlled with a
horizontal mattress suture, with gentle compression of the parenchyma [see
Enthusiasm for splenic salvage was driven by the rare but often fatal complication of
overwhelming postsplenectomy sepsis (OPSS). OPSS is caused by encapsulated
bacteria,Streptococcus pneumoniae, Haemophilus influenzae,
and Neisseria meningitidis, which are resistant to antimicrobial treatment. In
patients undergoing splenectomy, prevention against these bacteria is provided via
vaccines administered optimally at 14 days but definitely prior to hospital
discharge.57 Vaccines to be administered include Pneumovax (Merck & Co., Inc.,
Whitehouse Station, NJ), Menactra (Sanofi Pasteur, Swiftwater, PA), and Fluvirin
(Novartis, East Hanover, NJ). Revaccination remains open to debate, but some argue for
revaccination every 6 years.
Thoracoscopy
Laparotomy
The answer is D. This patient suffered a ruptured diaphragm and chest tube placement
appears to have ruptured the bowel as evidence from the greenish fluid that was returned.
She needs an emergent laparotomy to control bleeding and repair her diaphragm. Read
More
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Unit 3
10)
0/1
Roughly what percentage of patients with blunt liver injury initially managed non-
operatively will go on to need surgical intervention?
(1pts)
<10%
25%
50%
75%
The answer is A, During the last century, the management of blunt force trauma to the
liver has changed from observation and expectant management in the early part of the
1900s to mainly operative intervention, to the current practice of selective operative and
nonoperative management. A 2008 study by Tinkoff et al.4 showed that 86.3% of hepatic
injuries are now managed without operative intervention. The current reported success
rate of nonoperative management of hepatic trauma ranges from 82% to 100%. Most
blunt liver trauma (80% in adults, 97% in children) patients are currently treated
conservatively. The success of non-operative management depends upon proper selection
of the patient. The patients, who are managed non-operatively, usually have grade I and
II liver injuries, hemoperitoneum less than 900 ml and blood transfusion of less than 3
units. The contraindications to non-operative management include refractory
hypotension, signinficant fall in haematocrit, the extravasations of intravenous contrast
agent, expanding haematoma and grade IV and V liver injury on CECT abdomen. The
patients of grade III liver injuries need very close observation as they may require
surgical intervention during first 24 hours. The failure rate of non-operative management
is not more than 5% inmost studies. It seems that patients with grade VI injuries rarely
reaches to the hospital alive and are not salvageable. Therefore, such injuries are usually
documented on autopsy. Mortality from blunt hepatic trauma is about 5% and is related
to uncontrolled hemorrhage.
Interventional radiology may be needed to perform an angiogram and embolization for
bleeding or to percutaneously drain an abscess or b iloma. An endoscopic retrograde
cholangiopancreatogram (ERCP) and stent placement may be required for biliary leak.
Even when such complications of the liver injury develop, only 15% require operative
intervention. Hepatic artery angiography with embolization is an important tool for the
stable patient with contrast extravasation who is being managed nonoperatively. It can
also be invaluable for the postoperative patient who has been stabilized by perihepatic
packing or who has rebled after an initial period of stability. Angioembolization has a
greater than 90% success rate in the control of bleeding with a low risk of rebleeding and
a reduction in required volume of transfusion. Read More
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11)
0/1
The liver is the most commonly injured solid organ in blunt trauma, comprising 5% of all
trauma admissions. With that being said, over 80% of patients with liver injuries may be
managed nonoperatively. Which of the following is not a predictor of nonoperative
management?
(1pts)
Female sex
Increasing age
Hypotension
The answer is A, female sex. Over 80% of patients with liver injuries may be managed
nonoperatively. One of the early studies to test the application of NOM in 1995 supported
its broad application, with an overall success rate greater than 85% in hemodynamically
stable patients, despite substantial hemoperitoneum documented by CT.11 Of the 8% of
patients who failed NOM, half required operation as a result of associated injuries (i.e.,
enteric or pancreatic injuries), whereas half underwent laparotomy for hepatic-related
hemorrhage. Patients who require intervention for hemorrhage typically fail NOM in the
first 24 to 48 hours.2,11,17 Patients who fail NOM due to associated enteric or pancreatic
injury have a more variable time frame to presentation17; half manifested symptoms
within 48 hours, with the remainder becoming symptomatic up to 3 weeks later. Perhaps
not surprisingly, those patients who failed NOM had failure rates associated with
increasing grades of hepatic injury, with grade V injuries having a greater than 20%
failure rate. Subsequent studies have reported failure rates of 14% in grade IV injuries
and 23% in grade V injuries.12 The most recent analysis of the National Trauma Data
Bank of severe blunt liver injuries (grade IV and V) identified that initial NOM occurred
in 73%, with a failure rate of 7%.16 Interestingly, failure of NOM was associated with
higher mortality. Predictors of failure of NOM included increasing age, male sex,
increasing Injury Severity Score, decreasing Glasgow Coma Scale score, and
hypotension. A similar study of high-grade liver injuries identified a similar pattern with
NOM initiated in 66% patients with a failure rate of 9%.18 The amount of
hemoperitoneum evident on a CT scan appears to correlate with successful management;
patients with a large amount of hemoperitoneum (i.e., blood extending into the pelvis) are
more likely to fail NOM. However, predicting which patients will ultimately require
laparotomy has yet to be accomplished. Read more
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12)
0/1
You are seeing a 34-year old female in the trauma following an MVC. He is complaining
intense diffuse abdominal pain after his car was hit from behind causing him to spin out
and crash into a wall. Initially he had a GCS of 15. His vitals showed a BP of 125/76, HR
95, RR 18, O2 of 98% on room air. On physical exam his lungs are clear and his
abdomen shows diffuse tenderness to light palpation and ecchymosis over his
epigastrium. His initial fast exam is negative but technically limited and you order a CT
scan with IV contrast of his abdomen and pelvis as you suspect a possible liver
injury. What description from the options below accurately describes a grade IV liver
laceration on CT imaging?
(Select 1)(1pts)
Sub capsular hematoma, > 50% surface area, or ruptured with active
bleeding
Spleen
Liver
Kidneys
Small Intestines
The liver is the most commonly injured solid organ in blunt trauma, comprising 5% of all
trauma admissions, and because of its size is frequently involved in penetrating trauma.
Following blunt trauma, the most commonly injured structures are the parenchyma and
hepatic veins. Blunt forces dissipate along segments of the liver and along the fibrous
coverings of the portal triad structures; the hepatic veins, however, are not so insulated.
Given its size and location within the abdomen, the liver is also commonly involved in
penetrating trauma. Stab wounds typically result in direct linear tears, whereas gunshot
wounds or shotgun wounds result in significant cavitary injuries attributable to blast
effect and the "tumbling" of the missile within the liver parenchyma. Thus, arterial injury
is more common with penetrating trauma.
Over the past 20 years, nonoperative management (NOM) of liver injuries has evolved to
become the prevailing therapeutic strategy for blunt hepatic trauma. Several concurrent
changes resulted in this paradigm change. First was the realization that diagnostic
peritoneal lavage (DPL) was sensitive but not specific for identifying intraperitoneal
hemorrhage that necessitated operative management. Surgeons recognized that many
laparotomies undertaken for a positive DPL were associated with liver injuries that did
not require intervention for bleeding.1Second, trauma surgeons noted that nonbleeding
hepatic venous injuries, if manipulated at laparotomy, often resulted in more hemorrhage
and sometimes even death.2 Furthermore, it became conspicuous that with hemostasis
achieved in the operating room, recurrent postoperative bleeding was rare. Therefore,
surgeons queried whether hepatic venous injuries, which are low-pressure system
injuries, could heal without intervention. Finally, computed tomography (CT) provided a
reliable method for diagnosing and grading liver injuries.
The spleen is the second most commonly injured abdominal organ in blunt trauma
patients. Historical studies have reported a 10% mortality with all splenic injuries;
however, isolated splenic injury mortality is less than 1%. The mechanisms of injury are
similar to those seen with liver injuries: motor vehicle collisions, autopedestrian
accidents, and falls. Similar to penetrating trauma to the liver, stab wounds to the spleen
typically result in direct linear tears, whereas gunshot wounds result in significant
cavitary injuries.
Until the 1970s, splenectomy was considered mandatory for all splenic injuries.
Recognition of the immune function of the spleen refocused efforts on splenic salvage in
the 1980s.38,39Following success in pediatric patients, NOM of splenic injuries was
adopted in the adult population and has become the prevailing strategy for blunt splenic
trauma.
Duodenal and pancreatic injury continues to challenge the trauma surgeon. The relatively
rare occurrence of these injuries, the difficulty in making a timely diagnosis, and high
morbidity and mortality rates justify the anxiety these unforgiving injuries invoke.
Mortality rates for pancreatic trauma range from 9 to 34%, with a mean rate of 19%.
Duodenal injuries are similarly lethal, with mortality rates ranging from 6 to 25%.
Complications following duodenal or pancreatic injuries are alarmingly frequent,
occurring in 30 to 60% of patients.1-3 Recognized early, the operative treatment of most
duodenal and pancreatic injuries is straightforward, with low morbidity and mortality.
2014. Scientific American Surgery. Hamilton, Ontario & Philadelphia, PA. Decker
Intellectual Properties Inc. ISSN 2368-2744. STAT!Ref Online Electronic Medical
Library. http://online.statref.com/Document.aspx?fxId=61&docId=2329. 10/27/2014
1:39:15 PM CDT (UTC -05:00).
Acute mastitis
Granulomatous mastitis
(Select 1)(1pts)
Cystosarcoma Phyllodes
Intraductal papilloma
Fibrocystic disease
Fibroadenoma
The answer is C. This patient has fibrocystic disease which is a nonproliferative epithelial
lesions that are generally not associated with an increased risk of breast cancer [1]. It
should be noted that terms such as fibrocystic changes, fibrocystic disease, chronic cystic
mastitis, and mammary dysplasia refer to nonproliferative lesions and are not useful
clinically, as they encompass a heterogeneous group of diagnoses [5,11]. The most
common nonproliferative breast lesions are breast cysts. Other nonproliferative lesions
include papillary apocrine change, epithelial-related calcifications, and mild hyperplasia
of the usual type [5]. Apocrine metaplasia (also referred to as a "benign epithelial
alteration") is also a nonproliferative change that is secondary to some form of irritation,
typically associated with a breast cyst. Read More
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16)
0/1
You are seeing a 25-year old white female who is presenting to your clinic with bloody
nipple discharge over the last 3 days. She denies any history of a breast lump, she is not
breast feeding and denies family history of breast cancer. Her exam shows no palpable
masses but there is scant bloody discharge coming from her left nipple. You order a
mammogram that does not show any suspicious lesions. What is the most likely
diagnosis?
(Select 1)(1pts)
Fibroadenoma
Intraductal papilloma
Cystosarcoma Phyllodes
Mammary dysplasia
The answer is B, Intraductal papilloma. The old concern over cancer is the issue, and the
way to detect cancer that is not palpable is with a mammogram. That should be the first
choice. If negative, one may still wish to find an resect the intraductal papilloma to
provide symptomatic relief. Intraductal papillomas consist of a monotonous array of
papillary cells that grow from the wall of a cyst into its lumen. Although they are not
concerning in and of themselves, they can harbor areas of atypia or ductal carcinoma in
situ (DCIS). Papillomas can occur as solitary or multiple lesions. The standard approach
to a papilloma diagnosed by core needle biopsy (CNB) is to perform a surgical excision,
particularly if atypical cells are identified [14,16-21]. In a meta-analysis of 34 studies
that included 2236 non-malignant breast papillary lesions, 346 (15.7 percent) were
upgraded to malignancy following a surgical excision [21]. Because of a risk of
malignancy, these require surgical excision.Read More
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17)
0/1
You are seeing a 24-year old female who is 4-weeks post postpartum in your clinic. She
is complaining of bilateral nipple pain over the last two days along with a nipple rash.
She notes pain both with breastfeeding and even when she is not feeding. The pain is so
bad that she didn't breastfeed her baby this morning because of the pain. Physical exam
shows erythema to both breasts along with cracking around both areolas. There are no
signs of an abscess and no induration present. What is the most likely cause of this
patient's symptoms?
(Select 1)(1pts)
Engorgement
Mastitis
Candida infection
The answer is D, Candida infection. In breastfeeding women, bilateral nipple pain with
and between feedings after initial soreness has resolved is usually due to Candida. Pain
from engorgement typically resolves after feeding. Mastitis is usually unilateral and is
associated with systemic symptoms and wedge-shaped erythema of the breast tissue.
Improper latch-on is painful only during feedings. Eczema isolated to the nipple, while a
reasonable part of the differential, would be much more unusual.
Medullary carcinoma
Mucinous carcinoma
The answer is A, Cancer that is confined to the lumen of the duct or
lobule of the breast and has not penetrated the basement membrane
is termed in situ cancer. This generally refers to ductal carcinoma in
situ (DCIS) but also encompasses a benign entity called lobular
carcinoma in situ (LCIS). Small uniform cells confined to the lobule of
the breast characterize LCIS. It is generally a clinically and
mammographically occult lesion that is identified only incidentally
when a biopsy is performed for calcifications or a mass that proves to
be some other benign lesion. LCIS is actually not cancer but rather is a
benign lesion and does not require cancer treatment. The primary
issue with LCIS is that it conveys an increased lifelong risk of
subsequent invasive cancer quantified at 0.5 to 0.75% per year. In
addition, when LCIS is identified on a core-needle biopsy, there is a 10
to 20% chance of DCIS or invasive cancer in the surrounding tissue;
therefore, surgical excision is warranted. Long-term follow-up shows
that the large majority of women with LCIS never develop invasive
breast cancer. Therefore, ablative surgical therapy and radiation for
LCIS are not necessary. Previously, LCIS was considered in and of
itself an indication to consider bilateral mastectomy. However,
mastectomy is generally not indicated in women with LCIS and should
be performed only in the context of risk reduction for those at very
high risk related to factors such as inherited susceptibility. Because
women with a diagnosis of LCIS are at increased risk for subsequent
invasive cancer, they should be counseled regarding that risk and may
benefit from consultation with genetics professionals if they have a
family history of breast or ovarian cancer. Women with a biopsy
showing LCIS may also consider risk-reducing chemoprevention with
one of the selective estrogen receptor modulators (SERM's), tamoxifen
or raloxifene. These reduce the risk of subsequent invasive cancer by
about 50%, with an acceptable toxicity profile.20,21 Raloxifene is the
preferred agent in postmenopausal women. Read more on Breast
Cancer
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19)
1/1
True or False: When approaching a patient with an abnormal mammogram for a
suspicious breast mass the next best step is a surgical excision is preferred over
percutaneous needle biopsy.
(1pts)
True
False Correct
False: Breast lesion suspicious for malignancy requires tissue biopsy.
Percutaneous needle biopsy is preferred over surgical excision in all
circumstances. Surgical excision as a diagnostic procedure is not a
justifiable alternative simply because of "patient choice" and should be
performed only when needle biopsy cannot be performed for specific
technical reasons, when a needle biopsy is either nondiagnostic, the
result is not concordant with the imaging findings (i.e., the needle
biopsy is benign, but the lesion is of high suspicion), or in highly select
other cases. Technical reasons that may preclude needle biopsy
include anatomic location of the lesion on mammography directly
opposed to the chest wall or in the far periphery of the breast so that
it cannot be visualized on stereotactic imaging devices. Breast Cancer
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20)
0/1
You are seeing a 75-year old female in clinic because of an enlarging breast mass the
last two months. On examination of her right breast you palpate a firm 3cm non tender
firm non-mobile mass lateral to her right nipple. She denies past medical history and
takes no medication. What is the next best step?
(Select 1)(1pts)
Mammogram
Breast Ultrasound
Core Biopsy
Excisional Biopsy
(Select 1)(1pts)
Fibroadenoma
Fibrocystic disease
Intraductal papilloma.
Cystosarcoma Phyllodes
Clindamycin
Flagyl
Oxacillin
Augmentin
The answer is D. Augmentin. The most common bacterial etiology in human bites is strep
viridans. You are however covering for Eikenella corrodens which is a gram negative rod
which is susceptible to pcn but resistant to flagyl, clindamycin, first generation
cephalosporins and erythromycin. It is susceptible to flouroquinolones, bactrim and
augmentin. The most important treatment is good irrigation and initial wound
cleaning. Read more
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23)
0/1
You are seeing a 30-year-old male wrestler who is presenting with a painful lesion on his
upper back. He first noted a small painful area a few days ago, and the lesion has since
enlarged and became more red. He notes that others on his wrestling team have similar
lesions and have sought care elsewhere. He has no past medical history and takes no
medications.
Physical Examination of the upper back reveals a 1 × 1 cm erythematous, raised pustule
that is tender to palpation, with a 4 × 4 cm area of surrounding erythema. The remainder
of the physical examination is normal. You elect to perform an incision and drainage, and
culture. Of the following, which is the most appropriate empiric treatment?
(Select 1)(1pts)
Levofloxacin
Doxycycline
Dicloxacillin
Cephalexin
Ciprofloxacin
C. diphtheriae
Fusobacterium necrophorum
Infectious mononucleosis
Streptococcus pyogenes
Presence of leukocytosis
Depth of inflammation
Presence of purulence
The answer is C, depth of inflammation. Cellulitis and erysipelas are diffuse spreading
skin infections that not associated with underlying suppurative foci. Clinically, there is
often some degree of overlap between the two different entities. Erysipelas is
differentiated from cellulitis by the depth of inflammation; erysipelas affects the upper
dermis, including the superficial lymphatics, whereas cellulitis affects the deeper dermis
and subcutaneous fat (Mayo Clin Proc, Vol. 89;1436). Read More onCellulitis and
erysipelas from Up to Date
1/1
You are seeing a 26-year old male who just suffered severe blunt trauma in a car
accident. He has multiple injuries to his arms and legs, has a large scalp laceration and
has a pneumothorax on the left. Shortly after initial examination it is noted that he is
developing progressive subcutaneous emphysema all over his upper chest and lower
neck. What is the likely cause of this exam finding?
Ruptured Pericardium
Ruptured Aorta
Ruptured Alveoli
The answer is B. This patient has a pneumomediastinum from traumatic rupture of the
trachea or major bronchus. Fiberoptic bronchoscopy to confirm diagnosis and level of
injury and to secure an airway. Most patients undergo primary repair or possible lung
resection, although good results using selective nonoperative management have been
reported. The need for surgical repair is generally based on the risk for airway
obstruction, massive air leak, or mediastinitis. Read More
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2)
0/1
Antibiotic prophylaxis for elective inguinal hernia repair is universally recommended
( 1pts extra credit)
True Incorrect
False
Grade I
Grade II
Grade III
Grade IV
10%
25%
50%
75%
Approximately 75% of all abdominal wall hernias are seen in the groin. An Inguinal
hernia is much more common in men than women. Although femoral and umbilical
hernias are more common in female population, indirect inguinal hernia is still the most
common type of hernia in women. Age is a factor for incidence and type of inguinal
hernia; incidence increases by age 2 . Indirect hernia is more common in young and direct
hernia in the elderly. Read more
Endometriosis
Collagenous colitis
Melanosis coli
This patient has typical findings of melanosis coli, the term used to describe black or
brown discoloration of the mucosa of the colon. It results from the presence of dark
pigment in large mononuclear cells or macrophages in the lamina propria of the mucosa.
The coloration is usually most intense just inside the anal sphincter and is lighter higher
up in the sigmoid colon. The condition is thought to result from fecal stasis and the use of
anthracene cathartics such as cascara sagrada, senna, and danthron. Ectopic endometrial
tissue (endometriosis) most commonly involves the serosal layer of those parts of the
bowel adjacent to the uterus and fallopian tubes, particularly the rectosigmoid colon.
Collagenous colitis does not cause mucosal pigmentary changes. Melanoma rarely
metastasizes multicentrically to the bowel wall. Multiple arteriovenous malformations are
more common in the proximal bowel, and would not appear as described. Ref: Feldman
M, Friedman LS, Sleisenger MH (eds): Sleisenger & Fordtran’s Gastrointestinal and
Liver Disease, ed 7. WB Saunders Co, 2004, p 2305. 2) Hardman JG, Limbird LE,
Gilman AG (eds): Goodman & Gilman’s The Pharmacological Basis of Therapeutics, ed
10. McGraw-Hill, 2001, pp 1046-1047. 3) Kasper DL, Braunwald E, Fauci AS, et al
(eds): Harrison’s Principles of Internal Medicine, ed 16. McGraw-Hill, 2005, pp 231-233.
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Unit 2
6)
1/1
Which of the following statements regarding colorectal cancer (CRC) is not true?
(Select 1)(1pts)
CRC ranks as the third most common malignancy in the United States
Answer D is false. Worldwide, over 1 million people are diagnosed with CRC annually,
and there are more than 500,000 associated deaths.1 The highest rates of colorectal
carcinoma are found in industrialized countries. The rates are significantly lower in
eastern Europe, Asia, Africa, and South America.2 However, studies of Japanese
migration to the United States, Asiatic Jewish migration to Israel, and eastern European
migration to Australia show that migrants acquire the high rates of CRCs prevalent in
their adopted countries. There is little question that environmental factors, most likely
dietary, account for this.
Colon cancer is three times more common than rectal cancer. Interestingly,
epidemiologic studies indicate a rising proportion of right-sided colonic lesions. The
proximal migration of colon cancer may be associated with changing environmental
factors; however, there is no doubt that increased screening successfully detects early
lesions in an aging population. CRC ranks as the third most common malignancy in the
United States (behind prostate and lung cancer in men and breast and lung cancer in
women) and the second leading cause of cancer-related mortality. Approximately
143,000 patients are diagnosed with CRC in the United States each year, and 51,000 die
of disease.4,5 The probability of CRC developing during an individual's lifetime is about
6%. In contrast to the three previous decades, however, the overall incidence and
mortality of CRC have declined for both men and women. Age-adjusted incidence and
mortality are associated with race and ethnicity; however, the relationships are complex,
influenced by social and economic confounding factors more than tumor biology.
Clearly, CRC is associated with genetic and environmental influences. Overt risk factors
include a personal or family history of CRC or colorectal adenoma(s), a personal history
of colorectal polyps, inflammatory bowel disease (IBD), and age greater than 50. Age is
the most common risk factor. The risk of CRC increases after the fourth decade of life.13
Most individuals present with disease after the age of 60, and only 10% of CRCs are
diagnosed in individuals younger than 40.
Nonhereditary CRCs are referred to as "sporadic" and comprise 75 to 80% of all CRCs.
Genetic etiology may be identified in the remaining 20 to 25% of patients, including
family history (15 to 20%), Lynch syndrome (5%), and FAP (< 1%). Cancer can arise
within a polyp or at another site in the colon or rectum. Read more
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7)
0/1
What % of patients develop recurrent disease after curative resection of colon and rectal
carcinomas within 3 years?
(Select 1)(1pts)
20%
40%
60%
80%
The answer is D, 80%. Eighty percent of patients who recur after curative resection of
colon and rectal carcinomas do so within 3 years. Therefore, any posttreatment plan
should include regular follow-up during at least these 3 years. An additional biologic
precept in designing follow-up should take into account the efficacy of therapy once
recurrent disease is identified. It is important to note that the role of surveillance is to
identify recurrent disease that can be resected with true curative intent; early
identification of asymptomatic, incurable disease is exceedingly unlikely to improve
outcome as there are neither data nor a compelling rationale to believe that outcome
would be improved by earlier institution of noncurative treatment, such as systemic
chemotherapy.
In general, if a patient is a candidate for resection of recurrent disease (e.g., hepatic
resection), serum carcinoembryonic antigen (CEA) testing should be performed every 3
to 6 months for 2 years and then every 6 months for 5 years after resection of the primary
tumor. Chest, abdomen, and pelvis CT is recommended annually for 3 years for patients
at high risk for recurrence. PET-CT is not recommended in NCCN, ASCO, or CCO
guidelines and should not be used for the purpose of postoperative surveillance.
Colonoscopy should be performed 1 year after surgery or 3 to 6 months after surgery if
not performed preoperatively due to an obstructing lesion, and then 3 years later, and then
every 5 years, unless findings or specific risk factors dictate more frequent
evaluations. Read more
<5%
10%
20%
30%
The answer is C, 20%. As many as 20% of CRC patients have metastatic disease at the
time of the initial presentation. The need for surgical intervention in this group is not well
defined. Clearly, surgical resection or diversion is indicated in patients who present with
significant bleeding, perforation, or obstruction. In asymptomatic patients with
unresectable metastatic disease, the role of surgical resection of the primary lesion
remains controversial. In patients with resectable metastatic disease (e.g., isolated liver or
lung metastases), curative resection may be undertaken.
A recent review of 233 patients with synchronous stage IV colorectal cancer found that
217 patients (93%) never required surgical palliation of the primary tumor; 16 patients
(7%) needed emergency surgery for obstruction or perforation of the primary tumor; 10
patients (4%) were managed nonoperatively.68,122
Management of patients with synchronous resectable isolated liver metastases continues
to evolve. Multiple studies have documented improved survival after liver resection in
patients with metastatic disease confined to the liver. Patients presenting with
synchronous lesions have a worse prognosis than those presenting with metachronous
lesions.123 Many of these patients have been managed with staged resections of their
primary cancers and the liver metastases. Several groups have reported that such
combined procedures do not substantially increase surgical morbidity and mortality or
compromise cancer survival.124,125 These combined procedures should be done only in
carefully selected patients, at specialized centers where there is significant experience in
resection of both CRCs and liver tumors. Read more
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9)
0/1
You are seeing a 73-year old male who has a past medical history of
CHF, hypertension and type II diabetes. He initially presented to you
with changes in stool patterns, constipation and hematochezia. He was
found to have adenocarcinoma of the ascending colon along with
metastasis to his liver, brain and his right lung. For patient presenting
with metastatic colon cancer, which of the following treatments is not
routinely recommended?
(1pts)
Chemotherapy
Radiation
(Select 1)(1pts)
Pneumothorax
Pulmonary Contusion
Fat embolism
Pneumonia
The answer is B. Severe blunt trauma to the chest can cause rib fractures and other
immediate injuries but sometimes pathology doesn't show up until days later such as a
pulmonary contusion and myocardial contusion. The contused lung is very sensitive to
fluid overload which can lead to respiratory distress. Pulmonary contusions generally
develop over the first 24 hours and resolve in about one week. Irregular, nonlobular
opacification of the pulmonary parenchyma on chest radiograph is the diagnostic
hallmark. About one-third of the time the contusion is not evident on initial radiographs.
Chest CT provides better resolution, but rarely alters management, unless other injuries
are found. Contusions evident on CT but not plain radiograph have better outcomes.
Pain control and pulmonary toilet are the mainstays of treatment. Prophylactic
endotracheal intubation is unnecessary, but patients with hypoxia or difficulty ventilating
require airway management. While opinions vary, fluid resuscitation with crystalloid to
euvolemia appears appropriate. Common complications include pneumonia and acute
respiratory distress syndrome (ARDS). Read more
The answer is A, Upright Chest Xray followed by a chest tube. This patient is awake and
talking. He is stable enough for a chest xray followed by chest tube placement. A needle
thoracotomy to should be done if he has evidence of tension pneumothorax which would
be respiratory distress and hypotension. He will likely then need a chest tube and can be
further managed. Read More
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12)
0/1
A 65-year-old male comes in the emergency Department because of severe right-sided
chest pain following a fall off his ladder 10 feet high.
Examination shows decreased respiratory movements on the right side of the chest and
tenderness on palpation over the right mentions, his abdomen is soft and non tender.
An x-ray film of his chest shows a non displaced fracture of the right 6th and 7th ribs on
the right without signs of pneumothorax.
Which of the following is the most appropriate goal in management of the rib fracture in
this patient?
(1pts)
The answer is B. Once significant associated injuries have been evaluated and treated, the
cornerstone of rib fracture management is pain control [36-38]. Early and adequate pain
relief is essential to avoid complications from splinting and atelectasis, primarily
pneumonia. The choice of analgesia depends upon the injury, the clinician's comfort
performing nerve blocks with their potential complications, and the ease with which more
invasive treatments can be performed. Analgesia for severe and multiple rib fractures and
monitoring of admitted patients are discussed separately.
For isolated injuries (ie, single rib fracture), clinicians generally begin treatment with
nonsteroidal anti-inflammatory drugs (NSAIDs) with or without opioids. For more severe
injuries, particularly if ventilation is compromised, admission and invasive treatments,
such as intercostal nerve blocks, may be needed.
Respiratory care, including use of incentive spirometry to prevent atelectasis and its
complications, is often important. We do not recommend rib belts or binders because
they compromise respiratory function. Studies of rib belts involve small numbers of
patients and have reached contradictory conclusions [39,40]. Patients with a rib fracture
who are discharged home can also use incentive spirometry throughout the day, after
analgesics have taken effect. Holding a pillow or similar soft brace against the fracture
site reduces discomfort while using the spirometer, or when coughing.
Disposition — Several researchers recommend hospital admission for any patient with
three or more rib fractures, and ICU care for elderly patients with six or more rib
fractures [14,15]. They cite the significant correlation between these findings and
serious internal injuries, such as pneumothorax and pulmonary contusion. We suggest
hospitalization for the majority of patients with three or more rib fractures. Patients with
multiple rib fractures sustained from high-energy trauma are best evaluated at a trauma
center. Transfer should be arranged expeditiously.
Displaced rib fractures likely increase the risk of injury to the lung and proximate
intercostal blood vessels. Bleeding from such fractures can be delayed, and admission or
close observation and follow-up should be arranged for patients with displaced fractures,
depending upon clinical and social circumstances. Multiple case reports indicate that
delayed bleeding from intercostal vessels or other injuries can be life-threatening,
particularly in older patients [20,41,42].
Surgical fixation may be of benefit with some types of rib fractures, particularly those
associated with chest wall deformity, flail chest, or symptomatic nonunion. The
appropriate role of surgical fixation is discussed separately. (See "Inpatient
management of traumatic rib fractures", section on 'Surgical
management'.)
Rarely, younger healthy individuals with three rib fractures, having undergone a thorough
clinical and radiographic evaluation by clinicians experienced in trauma management,
and an appropriate period of observation (a minimum of six hours of observation,
including a follow-up chest radiograph, is needed to rule out pneumothorax), may be
discharged from the emergency department. Clinicians must also consider patient
comorbidities and clinical and social circumstances when determining disposition.
Patients with one or possibly two isolated rib fractures and no complicating factors may
be discharged home with appropriate follow-up and adequate analgesia. Uptodate
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13)
1/1
(Select 1)(1pts)
3% to 5%
5% to 10%
10% to 25%
25% to 40%
True
False Correct
The answer is False: In the setting of renal trauma, gross or microscopic hematuria is
absent in up to 5% of cases and this finding alone should not be used to preclude in those
you are suspicious of renal trauma. Read more on renal trauma
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15)
0/1
You are seeing a 48-year old male in the trauma bay after shooting himself in his right
thigh while it was in its holster.
On exam there is one wound that is about 2cm in diameter on his posterolateral right
thigh. It has since stopped bleeding after pressure was applied. His pulses are equal and
symmetrical and his neuro exam in normal. You obtain an xray which shows bullet
fragments in his thigh without evidence of fracture.
What is the next best step in treatment?
(1pts)
This patient shows no sign of arterial injury as he has no hard or soft signs of vascular
injury (see below). He has a normal neuro exam and has no fracture on xray. The only
thing that this patient needs is a tetanus update and wound irrigation.
MRI abdomen/pelvis
Ultrasound
Intravenous pyelography
None of the above
(Select 1)(1pts)
Exploratory laparotomy
Endoscopic injury to the duodenum deserves special mention here as it is a specific type
of duodenal trauma that may be commonly encountered by surgeons, even when trauma
does not make up a large part of their practice. There is literature that reports many of
these injuries being treated nonoperatively.42This is consistent with similar nonoperative
management of other isolated grade I or II injuries. However, as with any other type of
trauma, the clinical status of the patient and standard indications for laparotomy should
dictate the need for surgery.43 CT has been reported as the imaging test of choice to
diagnose perforation from endoscopy if immediate indications for laparotomy do not
exist.44 Often the pressure can be high to pursue a nonoperative approach as surgery was
likely not on the patient's or endoscopist's schedule, but clinical parameters should dictate
the appropriate course of action. Again, endoscopic trauma to the duodenum should
follow the same principles of evaluation and treatment as other mechanisms and the
patient course dictate treatment.
As noted above, operative treatment of duodenal injuries has two major components: the
repair and evaluating the need for leak "preparation." The repair itself must follow the
basic principles of all anastomosis: approximation of well-vascularized, healthy, tension-
free tissue. "Preparation" maneuvers are not required for most injuries and are debated.
They are discussed below.
For lacerations, the location and extent of tissue damage or loss are critical in deciding
the best type of repair. As noted in the literature, simple approximation is the most
common repair selected.9,45-48 This is commonly described as being done in a running
continuous fashion with monofilament suture after the edges have been debrided of any
questionable tissue. This repair choice mandates that the basic principles of bowel
anastomosis be met: approximation of tension-free, healthy, vascularized tissue.
Adequate duodenal mobilization is often required to decrease tension and should have
been done already for appropriate diagnosis.
If any of the basic principles cannot be met with simple approximation or if the resultant
repair would narrow the lumen of the duodenum, other options are available for repair.
The next option considered is often resection of the involved portion of duodenum and
primary anastomosis.48 Again, for this to have a maximal chance of success, the
anastomosis must be between well-vascularized, healthy, tension-free tissues. Another
option is a Roux-en-Y duodenojejunostomy. This is more likely to be necessary with D2
injuries not amenable to simple approximation. The pancreaticoduodenectomy with
pancreaticojejunostomy, gastrojejunostomy, and hepaticojejunostomy reconstruction
(Whipple procedure) is rarely needed in duodenal trauma and is discussed below.
Randomized comparison of one repair versus another is absent, but most reviews
consider simple approximation to be the most commonly required and most commonly
used repair.
2014. Scientific American Surgery. Hamilton, Ontario & Philadelphia, PA. Decker
Intellectual Properties Inc. ISSN 2368-2744. STAT!Ref Online Electronic Medical
Library. http://online.statref.com/Document.aspx?fxId=61&docId=2329. 10/17/2014
5:10:16 AM CDT (UTC -05:00).
20
50
75
120
In male patients, direct inguinal hernias are the most common type
Femoral hernias account for fewer than 10% of all groin hernias; however,
40% present as emergencie
Indirect
Direct
Femoral
Richter
This patient most likely has an indirect hernia as it is the most common hernia and given
the lack of other findings in the stem that is the best answer and most likely. Although a
sports hernia may lead to a traditional, abdominal hernia, it is a different injury. A sports
hernia is a strain or tear of any soft tissue (muscle, tendon, ligament) in the lower
abdomen or groin area. Because different tissues may be affected and a traditional hernia
may not exist, the medical community prefers the term "athletic pubalgia" to refer to this
type of injury.
An indirect inguinal hernia is one of the most common abdominal hernias. It is
five times more common than a direct inguinal hernia, and is seven times more frequent
in males, due to persistence of the process vaginalis during testicular descent. An indirect
hernia enters the inguinal canal at the deep ring, lateral to the inferior epigastric vessels.
It passes infromedially to emerge via the superficial ring and, if large enough, extend into
the scrotum. In children, the vast majority of inguinal hernias are indirect (see Case 3).
Incarceration represents the most common complication associated with inguinal hernias,
the incidence could be as high as 30% for infants younger than 2 months.
A direct inguinal hernia arises from protrusion of abdominal viscera through a
weakness of the posterior wall of the inguinal canal medial to the inferior epigastric
vessels, specifically through the Hasselbach's triangle. This type of hernia is termed
direct as the hernial sac directly protrudes through the inguinal wall in contrast to indirect
ones which arise through the deep ring and enter the inguinal canal. Since direct hernias
do not have a guiding path, they seldom extend into the scrotum unless very large and
chronic. Direct hernias arise usually as acquired weakness of the Hasselbalch's triangle.
Therefore, they are seen in the elderly with chronic conditions which increase intra-
abdominal pressure over a long period, e.g. COPD, bladder outflow obstruction, chronic
constipation etc. Increased abdominal pressure is transmitted to both sides and as a result,
direct hernias are usually bilateral. Compared to indirect hernia, they are less susceptible
to strangulation as they have a wide neck.
In contrast to the indirect hernia, a direct hernia is most often an acquired lesion. It
occurs when a weak spot develops in the lower abdominal musculature (the posterior
floor of the inguinal canal) due to the normal and/or abnormal stresses inflicted by living
and aging. In adults, stresses such as lifting heavy of objects, frequent coughing or
straining, pregnancy, and constipation can instigate hernia. Unlike indirect hernias, direct
hernias traverse medial to the inferior epigastric vessels and are not associated with the
processus vaginalis. The hernia consists primarily of retroperitoneal fat. Only rarely is a
peritoneal sac containing bowel encountered. Because there is typically no involvement
of a sac, they do not protrude with the spermatic cord, and as such, have a lower
incidence of incarceration or strangulation. Like indirect inguinal hernia, direct inguinal
hernias typically cause a bulge in the groin (at the top of or within the scrotum) and
usually with increased abdominal pressure. Like indirect hernias, they may or may not be
painful (usually not). By palpating the inguinal canal and asking the patient to cough
while standing, one can usually elicit the hernia. In fact, one can often times palpate an
inguinal hernia without invaginating the scrotum (as is typically taught in medical
school). Rather, by placing one's fingers over the inguinal canal and asking the patient to
cough, one can often feel the bulge against the lower abdominal wall. As direct and
indirect hernias are unreliably differentiated by physical exam alone, the need to
invaginate the scrotum to feel into the inguinal canal is often more uncomfortable to the
patient, than telling to the physician. Rarely, palpation is not even necessary, as the
hernia is large enough to be visualized. Read more on Inguinal hernias: A Brief
review
(Select 1)(1pts)
0.18%
1.18%
2.1%
6.5%
12.4%
Answer C is the only false statement as No laboratory findings are particularly specific
for duodenal or pancreatic injury. Amylase has been proposed for both pancreas and
duodenal injuries but is not specific for either one. Some have noted that amylase can be
elevated in as many as 50% of duodenal injuries, but this has not been a consistent
finding.9 An elevated amylase should prompt an evaluation of the duodenum for injury
but alone is not diagnostic. Although the highest concentration of amylase in the human
body is in the pancreas, hyperamylasemia is also not a reliable indicator of pancreatic
trauma. In one series, only 8% of blunt abdominal injuries with hyperamylasemia had
pancreatic injury.10 Furthermore, as many as 40% of patients with a pancreatic injury
may initially have a normal serum amylase.
The history of a patient with a possible blunt pancreatic or duodenal injury usually
consists of a direct blow to the epigastrium. In children, this commonly involves a bicycle
handlebar to the epigastrium; in adults, more commonly the steering wheel or a motor
cycle handle bar is involved. However, any direct blow should raise suspicion. The
patient may complain of abdominal, back, or flank pain.
Outside of the pelvis x-ray, plain abdominal radiographs to evaluate blunt abdominal
trauma are less common in the era of focused abdominal sonography for trauma (FAST)
and computed tomographic (CT) scans. Reports suggest that signs of duodenal injury on
plain radiographs are identified less than one third of the time. Retroperitoneal air, free
intraperitoneal air, or obliteration of the psoas shadow should raise suspicion for
duodenal and other hollow viscous trauma.9 Upper gastrointestinal series have also been
used to evaluate the duodenum for injury and can add to the sensitivity and specificity of
plain films, but more recently, CT has become the primary diagnostic modality.
For optimal duodenal evaluation, intraluminal contrast administered via a nasogastric
tube soon but not immediately prior to the CT scan may aid by opacification of the lumen
of the duodenal "C loop." Visualization of contrast extravasation, retroperitoneal air,
adjacent fat stranding, and unexplained fluid, as well as duodenal wall thickening, are CT
findings suggestive of potential duodenal injury. The sensitivity of CT for duodenal
injury is related to the technology of the scanner (i.e., "number of slices") and the time
interval from the injury to imaging. In a recent review, CT was considered to have an
overall sensitivity of around 76% with new-generation scanners (16- or 64-slice), having
a higher sensitivity of around 82%. Additionally, if clinical suspicion remains high after
an initial negative CT scan, then repeat imaging is warranted and may improve diagnostic
yield.
At times, duodenal hematomas can cause duodenal obstruction. This usually presents 2 to
3 days after the trauma with evidence of gastric outlet obstruction. The common
nonoperative treatment of isolated obstructing duodenal hematomas is nasogastric tube
decompression of the stomach and duodenum, nutritional support, and time.38 Repeat
imaging in 7 to 14 days is reasonable to evaluate improvement or an unexpected finding
as most duodenal hematomas will have resolved after 7 to 14 days, and continued
obstruction may reveal additional injury, prompting intervention.39-41 Enteral nutrition
is preferred to parenteral nutrition, but in the setting of a duodenal obstruction, the
parenteral route (total parenteral nutrition [TPN]) is often required as passing a feeding
tube beyond the obstruction can be difficult and surgical feeding access defeats the
purpose of "nonoperative" care.
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23)
0/1
Which of the following statements regarding hollow viscus injuries in patients suffering
from blunt trauma is not true?
(Select 1)(1pts)
Answer D is false. Unexplained intraperitoneal fluid (i.e., fluid appearing in the absence
of solid-organ injury) was the most common radiographic finding associated with blunt
bowel or mesenteric injury but often proved to be a false positive finding.
Hollow viscus injury after blunt trauma, although uncommon, can have serious
consequences if the diagnosis is missed or delayed. In a multi-institutional study of 198
patients with blunt small bowel injury, delay of as little as 8 hours in making the
diagnosis resulted in increased morbidity and mortality.2 Mortality increased in parallel
with time to operative intervention (< 8 hours to operation, 2% mortality; 8 to 16 hours,
9%; 16 to 25 hours, 17%; > 24 hours, 31%), as did the complication rate. Consequently,
it is important to have an expedient approach to the diagnosis of blunt bowel injury.
Physical examination findings such as abdominal tenderness or tachycardia may suggest
the presence of hollow viscus injury. Distracting chest or long bone injury, closed-head
injury, spinal cord injury, or intoxication, however, may compromise reliability of the
examination. In addition, it is not uncommon for blunt bowel injury to have a latent
period from the time of injury, whereby the expected signs and symptoms of such injuries
take some time to develop. Laboratory abnormalities, including elevations in white blood
cell (WBC) count, amylase, and/or lactic acid, may also point toward the presence of
hollow viscus injury but are relatively nonspecific. Provided that the patient has suffered
a low-risk mechanism of injury (such as a fall from standing or a low-speed motor
vehicle collision), hollow viscus injury is extremely unlikely in the face of a normal,
reliable physical examination and normal laboratory results. With these conditions
present, the presence of blunt bowel injury can be effectively excluded. However, the
presence of abdominal complaints, an abnormal or unreliable physical examination,
abnormal laboratory results, or a high-risk mechanism of injury (such as a high-speed
motor vehicle collision) warrants further evaluation by imaging for the presence of bowel
injury.
Particular consideration should be given to lap-and shoulder-restraint injuries, which may
be associated with an increased risk of hollow viscus injury. The "seat-belt" sign (i.e.,
ecchymosis of the abdominal wall secondary to the compressive force of the lap belt) is
associated with a more than doubled relative risk of small bowel injury.3,4 Flexion-
distraction fractures of the spine (Chance fractures) are also associated with lap-belt use,
and the presence of such fractures should raise the index of suspicion for associated
hollow viscus injury.
Ultrasonography is routinely performed early in the evaluation of blunt abdominal
trauma. It is highly specific and moderately sensitive in identifying intra-abdominal fluid,
the presence of which in a hemodynamically unstable patient is an indication for
laparotomy (in that it strongly suggests the presence of significant intra-abdominal
hemorrhage).5 Ultrasonography does not, however, reliably distinguish solid-organ
injury from hollow viscus injury—a distinction that is critical for determining subsequent
management (i.e., operative versus nonoperative) in a hemodynamically stable patient.
Computed tomography (CT) is the imaging modality of choice in stable patients who
warrant evaluation by imaging as described above. We reviewed over 8,000 CT scans
performed to evaluate cases of blunt abdominal trauma and found that the number of
abnormal radiologic findings suggesting blunt injury to the bowel, the mesentery, or both
was correlated with the true presence of injury [see Table 1].6 A CT scan
demonstrating a solitary abnormality was associated with a true positive rate of 36%,
whereas a scan demonstrating more than one abnormality was associated with a true
positive rate of 83%. Unexplained intraperitoneal fluid (i.e., fluid appearing in the
absence of solid-organ injury) was the most common radiographic finding associated
with blunt bowel or mesenteric injury but often proved to be a false positive finding. On
the basis of this experience, we developed an algorithm for the evaluation of blunt hollow
viscus injury in patients with unreliable physical examinations [see Figure 1].
Most CT scans performed in this clinical setting, however, will be negative for evidence
of intra-abdominal injury. A prospective multi-institutional trial involving 3,822 blunt
trauma patients demonstrated that the negative predictive value of a normal abdominal
CT scan was 99.63%, leading the authors to conclude that patients with a normal scan do
not benefit from hospital admission and prolonged observation.7 However, a multi-
institutional review of 2,457 cases carried out by the Eastern Association for the Surgery
of Trauma (EAST) reported a 13% incidence of blunt small bowel injury in patients with
an initial negative CT scan. These results indicate that caution should be exercised in
dismissing the presence of hollow viscus injury on the basis of a negative scan.3 This
concern is echoed by our own institutional experience, in which the incidence of injury in
patients with an initial negative CT scan was 12%.6 If CT scanning demonstrates no
suspicious findings, no further diagnostic workup of hollow viscus injury is necessary,
but the duration of the observation period depends on both the overall condition of the
patient and clinical judgment. Most patients, as supported by the negative predictive
value of the study above, will not require ongoing further observation.
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24)
1/1
What is the mean mortality rate of patients suffering from pancreatic trauma?
(Select 1)(1pts)
<3%
9%
19%
31%
The answer is C, 19%. Duodenal and pancreatic injury continues to
challenge the trauma surgeon. The relatively rare occurrence of these
injuries, the difficulty in making a timely diagnosis, and high morbidity
and mortality rates justify the anxiety these unforgiving injuries
invoke. Mortality rates for pancreatic trauma range from 9 to 34%,
with a mean rate of 19%. Duodenal injuries are similarly lethal, with
mortality rates ranging from 6 to 25%. Complications following
duodenal or pancreatic injuries are alarmingly frequent, occurring in
30 to 60% of patients.1-3 Recognized early, the operative treatment
of most duodenal and pancreatic injuries is straightforward, with low
morbidity and mortality. Read more
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25)
0/1
What percentage of patients suffering from blunt abdominal trauma develop hollow
viscus injury?
(Select 1)(1pts)
1.2%
4.8%
8.9%
13.4%
The answer is A, 1.2%. Hollow viscus injury after blunt trauma, although
uncommon, can have serious consequences if the diagnosis is missed
or delayed.Hollow viscus injury is most often the consequence of
penetrating abdominal trauma. As a result of blunt force trauma,
bowel injury occurs with relative infrequency: in one multi-institutional
analysis, only 1.2% of blunt trauma admissions had an associated
hollow viscus injury. Read more
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Unit 1
1)
0/1
You are seeing 45-year old black female again in the office who presented to you initially
for a right sided breast mass. She has no past medical history or family history of breast
cancer. On physical exam you palpated a 2 cm mass just lateral to her right nipple. You
ordered a mammogram which cam back normal. What percentage of patients who are
found to have a normal mammogram have breast cancer after biopsy of a suspicious
lesion?
(Select 1)( 1pts extra credit)
5%
15%
25%
45%
The answer is A. A diagnostic mammogram is the first imaging study performed for
a woman with a new, palpable breast mass, and should be performed even if a recent
mammogram was negative. While the false negative rate of mammograms is less than 5
percent for clinically palpable breast cancers [15], a normal mammogram does not
eliminate the need for further evaluation of a suspicious mass [5]. For women under age
30 years, the breasts are hypersensitive to radiation exposure [16]; however, if the
clinical findings are suspicious, a mammogram should be performed. Read More
Electrocardiogram
Mammography
Pap smear
Colonoscopy
Ovarian
Lung
Colon
Breast
The answer is D, Breast Cancer. Approximately 230,480 American women are diagnosed
with breast cancer annually, and 39,520 women die from this disease. Global cancer
statistics show that breast cancer is the most frequently diagnosed cancer and the leading
cause of cancer death among females, accounting for 23 percent of total cancer cases and
14 percent of cancer deaths. Breast cancer is now also the leading cause of cancer death
among females in economically developing countries.
Globally, breast cancer is the most frequently diagnosed cancer and the leading cause of
cancer death in women. In the United States, breast cancer is the most commonly
diagnosed cancer and the second most common cause of cancer death in women. In
addition, breast cancer is the leading cause of death in women ages 40 to 49 years.Breast
cancer is treated with a multidisciplinary approach involving surgical oncology, radiation
oncology, and medical oncology, which has been associated with a reduction in breast
cancer mortality. Read more from Up to date
This patient has flexor tenosynovitis which is inflammation of a tendon and its sheath.
Most acute cases of flexor tenosynovitis (FT)—which involves disruption of
normal flexor tendonfunction in the hand—result from infection. However, FT also can
develop secondary to acute or chronic inflammation from a noninfectious cause, such as
diabetes, overuse, or arthritis.
Patients with infectious FT can present at any time following a penetrating injury, with
complaints of pain, redness, and fever. Physical examination reveals Kanavel signs of
flexor tendon sheath infection, which are as follows:
Finger held in slight flexion
Fusiform swelling
Tenderness along the flexor tendon sheath
Pain with passive extension of the digit
Clinical features of gonococcal tenosynovitis include the following:
Erythema, tenderness to palpation, and painful range of
motion (ROM) of the involved tendon(s)
Fever - A common sign
Dermatitis - Also a common sign; it occurs in
approximately two thirds of disseminated gonococcal
infections; it is characterized by hemorrhagic macules or
papules on the distal extremities or trunk
Inflammatory flexor tenosynovitis
Usually the result of an underlying disease process
Presentation is indolent but progressive if therapy is not
initiated
Similar findings to those found in infectious FT eventually
present
Swelling is the most common initial finding
Hallmark is a difference in active, versus passive, flexion
As the tissue expands and impingement occurs, pain and
restricted motion ensue
Delayed presentations can have the appearance of fulminant FT with all Kanavel signs or
may involve tendon rupture if the patient delays seeking treatment long enough. Read
more
Here is a good you tube video of an examination of a patient with this FTS.
http://www.youtube.com/watch?v=qf9SW0ChsCU
upper-outer quadrant
upper-inner quadrant
lower-outer quadrant
The answer is B. The most common site of origin of breast cancer is the upper-outer
quadrant (38.5%), central area (29%), upper-inner quadrant (14.2%), lower-outer
quadrant (8.8%), and the lower-inner quadrant (5%). These percentages correlate with the
amount of tissue that is present in these quadrants. Metachronous bilateral carcinoma of
the breast has been observed in 5% to 8% of patients. Read more on Disorders of the
Breast
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Unit 2
6)
0/1
You are seeing a 42-year-old female following in the trauma bay following a high-speed
motor vehicle collision. She was was a restrained passenger and her car flipped over after
she lost control. She had to be cut out of the car and is complaining of shortness of breath
and upper abdominal pain.
She is awake and alert and her GCS is 15. Her pulse is 120/min, respirations are 28/min,
and blood pressure is 80/40 mm Hg. Breath sounds are decreased at the left lung base. An
x-ray of the chest shows opacification of the left lower lung field. You decide to place an
emergent chest tube that yields a small amount of air followed by greenish fluid. Which
of the following is the most appropriate next step in management?
(Select 1)(1pts)
Thoracoscopy
Laparotomy
The answer is D. This patient suffered a ruptured diaphragm and chest tube placement
appears to have ruptured the bowel as evidence from the greenish fluid that was returned.
She needs an emergent laparotomy to control bleeding and repair her diaphragm. Read
More
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7)
0/1
You are seeing a 20-year-old male in hospital 12 hours after he was admitted for
observation following an MVC. Initially he was complaining of left sided chest wall pain
after his car was t-boned on the passenger side. His initial physical examination showed
bruises on the anterior chest wall and upper abdominal wall. X-rays revealed fractures
of his sixth and seventh ribs on the left (but no pneumothorax or pleural effusion). A
FAST Exam did not show any free intraperitoneal fluid. Currently, he complains of
worsening epigastric pain, left shoulder pain and mild nausea. His current vitals show his
blood pressure is now 95/60 and pulse rate 115 beats/min, and O2 saturation is 96% on
room air. Which of the following is the next best step in treatment?
(Select 1)(1pts)
Transesophageal echocardiogram
This patient presents with blunt abdominal trauma with the delayed onset of hypertension
and signs and symptoms worrisome for likely splenic injury. Most common injuries are
to the spleen, liver, and less common injuries are to the hollow viscous organs in the
abdomen. Symptoms and signs suggesting splenic injury include left upper quadrant pain,
abdominal wall contusion, left lower chest wall tenderness, hypotension, and left
shoulder. Pain referred from splenic hemorrhage, hitting the phrenic nerve and diaphragm
(Kehr sign). The initial examination after blunt abdominal trauma can be unremarkable
and the symptoms can occur hours later, indicating ongoing splenic injury. The best
choice here would be an abdominal CT scan with intravenous contrast, only (no oral
contrast is needed because as little utility). This will define organ injury, assess for
presence of bleeding in all abdominal compartments, determine the need for surgery.
The spleen is the second most commonly injured abdominal organ in blunt trauma
patients. Historical studies have reported a 10% mortality with all splenic injuries;
however, isolated splenic injury mortality is less than 1%. The mechanisms of injury are
similar to those seen with liver injuries: motor vehicle collisions, autopedestrian
accidents, and falls. Similar to penetrating trauma to the liver, stab wounds to the spleen
typically result in direct linear tears, whereas gunshot wounds result in significant
cavitary injuries.
Until the 1970s, splenectomy was considered mandatory for all splenic injuries.
Recognition of the immune function of the spleen refocused efforts on splenic salvage in
the 1980s.38,39Following success in pediatric patients, NOM of splenic injuries was
adopted in the adult population and has become the prevailing strategy for blunt splenic
trauma.40
Addressing the patient's ABC's, examining the patient's abdomen, and performing
adjunctive imaging with FAST and CT are the initial steps of diagnosing a patient's
splenic injury. Hypotension with a positive FAST scan should prompt emergent
laparotomy. For patients with an identified blunt splenic injury on a CT scan, the injury
should be graded according to the AAST injury grading scale [see Table 1].3
Similar to liver injuries, the grade of splenic injury predicts failure rates and complication
rates of NOM. Other findings that should be searched for on a CT scan include contrast
extravasation (is the contrast blush contained within the spleen, or does it spill into the
peritoneum?), the amount of intra-abdominal hemorrhage (is it isolated to the splenic
fossa, or does blood extend into the pelvis?), and the presence of pseudoaneurysms.
NONOPERATIVE MANAGEMENT
It is clear, however, that 20 to 30% of patients with splenic trauma deserve early
splenectomy and that failure of NOM often represents poor patient selection.53,54 In
adults, indications for prompt laparotomy include initiation of blood transfusion within
the first 12 hours considered to be secondary to the splenic injury or hemodynamic
instability. In the pediatric population, blood transfusions up to half of the patient's blood
volume are used prior to operative intervention. Following the first 12 postinjury hours,
indications for laparotomy are not as black and white. Determination of the patient's age,
comorbidities, current physiology, degree of anemia, and associated injuries will
determine the use of transfusion alone versus intervention with either embolization or
operation. Unlike hepatic injuries, which rebleed in 24 to 48 hours, delayed hemorrhage
or rupture of the spleen can occur up to weeks following injury. Algorithms for the
management of pediatric splenic injuries exist,55 and the patient's physiologic status is
the key determinant. Rapid mobilization in patients who are hemodynamically stable with
a stable hematocrit and no abdominal pain is generally successful. Overall, nonoperative
treatment obviates laparotomy in more than 90% of cases.
Follow-up Imaging
Out of concern over the risk of delayed hemorrhage or other complications, follow-up CT
scans have often been recommended; unfortunately, there is no consensus as to when or
even whether they should be obtained. Patients with grade I or II splenic injuries rarely
show progression of the lesion or other complications on routine follow-up CT scans; it is
reasonable to omit such scans if patients' hematocrits remain stable and they are
otherwise well. Patients with more extensive injuries often have a less predictable course,
and CT may be necessary to evaluate possible complications. Routine CT before
discharge, however, is unwarranted. Outpatient CT, however, in patients who participate
in vigorous or contact sports should be performed at 6 weeks to document complete
healing before resuming those activities. A more convenient and less expensive
alternative to follow-up CT is ultrasonographic monitoring of lesions.
In penetrating abdominal injuries not suitable for NOM and in blunt abdominal injuries
when NOM is contraindicated or has failed, exploratory laparotomy is performed.
To ensure safe removal or repair, the spleen should be mobilized to the point where it can
be brought to the surface of the abdominal wall without tension. An incision is made in
the peritoneum and the endoabdominal fascia, beginning at the white line of Toldt along
the descending colon and continuing cephalad 1 to 2 cm lateral to the posterior peritoneal
reflection of the spleen; this plane of dissection is continued superiorly until the
esophagus is encountered [see
Figure 15a]. Posteriorly, blunt dissection is performed to mobilize the spleen and
pancreas as a composite away from Gerota fascia and up and out of the retroperitoneum;
this posterior plane may be extended to the aorta if necessary [seeFigure 15b].
Additionally, the attachments between the spleen and the splenic flexure of the colon may
be divided to avoid avulsion of the inferior splenic capsule. Care must be taken not to
pull on the spleen; otherwise, it will tear along the posterior peritoneal reflection, causing
significant hemorrhage. It is often helpful to rotate the operating table 20° to the patient's
right so that the weight of the abdominal viscera facilitates viscera retraction. Any
ongoing hemorrhage from the splenic injury may be temporarily controlled with digital
occlusion of the splenic hilar vessels. Once mobilization is complete, the spleen can be
repaired or removed without any need to struggle to achieve adequate exposure.
DEFINITIVE MANAGEMENT OF INJURIES
Figure 16] for partial immunocompetence in younger patients.56 Drains are not used.
Partial splenectomy can be employed in patients in whom only the superior or inferior
pole has been injured. Hemorrhage from the raw splenic edge is controlled with a
horizontal mattress suture, with gentle compression of the parenchyma [see
Enthusiasm for splenic salvage was driven by the rare but often fatal complication of
overwhelming postsplenectomy sepsis (OPSS). OPSS is caused by encapsulated
bacteria,Streptococcus pneumoniae, Haemophilus influenzae,
and Neisseria meningitidis, which are resistant to antimicrobial treatment. In
patients undergoing splenectomy, prevention against these bacteria is provided via
vaccines administered optimally at 14 days but definitely prior to hospital
discharge.57 Vaccines to be administered include Pneumovax (Merck & Co., Inc.,
Whitehouse Station, NJ), Menactra (Sanofi Pasteur, Swiftwater, PA), and Fluvirin
(Novartis, East Hanover, NJ). Revaccination remains open to debate, but some argue for
revaccination every 6 years.
2014. Scientific American Surgery. Hamilton, Ontario & Philadelphia, PA. Decker
Intellectual Properties Inc. ISSN 2368-2744. STAT!Ref Online Electronic Medical
Library. http://online.statref.com/Document.aspx?fxId=61&docId=2297. 10/17/2014
4:45:39 AM CDT (UTC -05:00).
Right; 90%
Left; 75%
Left; 25%
Right; 10%
The answer is B, left;75%. In cases of blunt trauma to the diaphragm, the injury is on the
left side 75% of the time, presumably because the liver diffuses some of the energy on
the right side. Blunt diaphragmatic injuries result in a linear tear in the central tendon,
whereas penetrating injuries are variable in size and location depending on the weapon. It
is important to identify the trajectory of penetrating injuries to determine the likelihood of
diaphragm injuries. With blunt and occasionally with penetrating injuries, the diagnosis is
suggested by an abnormality of the diaphragmatic shadow on a chest radiograph [see
Figure 5]. In patients without clear imaging results in the trauma bay, a CT scan may
identify a diaphragmatic injury.
Regardless of the etiology, acute injuries are repaired through an abdominal incision.
Thoracoscopy or laparoscopy may be used if concomitant injuries requiring laparotomy
have been ruled out. Following delineation of the injury, the chest should be evacuated of
all blood and particulate matter, and tube thoracostomy should be placed if not previously
done. Using Allis clamps to approximate the diaphragmatic edges, the defect can be
closed with a running permanent suture [see Figure 6]. Occasionally, large avulsions or
shotgun wounds with extensive tissue loss will require mesh to bridge the defect.
Alternatively, transposition of the diaphragm cephalad one to two intercostal spaces may
allow repair without undue tension. Read more
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9)
0/1
Nonoperative Management of solid-organ injuries can be pursued in hemodynamically
stable patients who do not have overt peritonitis or other indications for laparotomy.
According to contemporary data, what percentage of patients with splenic injuries are
candidates for nonoperative management?
(Select 1)(1pts)
<10%
25%
45%
60%
Spleen
Liver
Kidneys
Small Intestines
The liver is the most commonly injured solid organ in blunt trauma, comprising 5% of all
trauma admissions, and because of its size is frequently involved in penetrating trauma.
Following blunt trauma, the most commonly injured structures are the parenchyma and
hepatic veins. Blunt forces dissipate along segments of the liver and along the fibrous
coverings of the portal triad structures; the hepatic veins, however, are not so insulated.
Given its size and location within the abdomen, the liver is also commonly involved in
penetrating trauma. Stab wounds typically result in direct linear tears, whereas gunshot
wounds or shotgun wounds result in significant cavitary injuries attributable to blast
effect and the "tumbling" of the missile within the liver parenchyma. Thus, arterial injury
is more common with penetrating trauma.
Over the past 20 years, nonoperative management (NOM) of liver injuries has evolved to
become the prevailing therapeutic strategy for blunt hepatic trauma. Several concurrent
changes resulted in this paradigm change. First was the realization that diagnostic
peritoneal lavage (DPL) was sensitive but not specific for identifying intraperitoneal
hemorrhage that necessitated operative management. Surgeons recognized that many
laparotomies undertaken for a positive DPL were associated with liver injuries that did
not require intervention for bleeding.1Second, trauma surgeons noted that nonbleeding
hepatic venous injuries, if manipulated at laparotomy, often resulted in more hemorrhage
and sometimes even death.2 Furthermore, it became conspicuous that with hemostasis
achieved in the operating room, recurrent postoperative bleeding was rare. Therefore,
surgeons queried whether hepatic venous injuries, which are low-pressure system
injuries, could heal without intervention. Finally, computed tomography (CT) provided a
reliable method for diagnosing and grading liver injuries.
The spleen is the second most commonly injured abdominal organ in blunt trauma
patients. Historical studies have reported a 10% mortality with all splenic injuries;
however, isolated splenic injury mortality is less than 1%. The mechanisms of injury are
similar to those seen with liver injuries: motor vehicle collisions, autopedestrian
accidents, and falls. Similar to penetrating trauma to the liver, stab wounds to the spleen
typically result in direct linear tears, whereas gunshot wounds result in significant
cavitary injuries.
Until the 1970s, splenectomy was considered mandatory for all splenic injuries.
Recognition of the immune function of the spleen refocused efforts on splenic salvage in
the 1980s.38,39Following success in pediatric patients, NOM of splenic injuries was
adopted in the adult population and has become the prevailing strategy for blunt splenic
trauma.
Duodenal and pancreatic injury continues to challenge the trauma surgeon. The relatively
rare occurrence of these injuries, the difficulty in making a timely diagnosis, and high
morbidity and mortality rates justify the anxiety these unforgiving injuries invoke.
Mortality rates for pancreatic trauma range from 9 to 34%, with a mean rate of 19%.
Duodenal injuries are similarly lethal, with mortality rates ranging from 6 to 25%.
Complications following duodenal or pancreatic injuries are alarmingly frequent,
occurring in 30 to 60% of patients.1-3 Recognized early, the operative treatment of most
duodenal and pancreatic injuries is straightforward, with low morbidity and mortality.
2014. Scientific American Surgery. Hamilton, Ontario & Philadelphia, PA. Decker
Intellectual Properties Inc. ISSN 2368-2744. STAT!Ref Online Electronic Medical
Library. http://online.statref.com/Document.aspx?fxId=61&docId=2329. 10/27/2014
1:39:15 PM CDT (UTC -05:00).
Increasing age
Hypotension
The answer is A, female sex. Over 80% of patients with liver injuries may be managed
nonoperatively. One of the early studies to test the application of NOM in 1995 supported
its broad application, with an overall success rate greater than 85% in hemodynamically
stable patients, despite substantial hemoperitoneum documented by CT.11 Of the 8% of
patients who failed NOM, half required operation as a result of associated injuries (i.e.,
enteric or pancreatic injuries), whereas half underwent laparotomy for hepatic-related
hemorrhage. Patients who require intervention for hemorrhage typically fail NOM in the
first 24 to 48 hours.2,11,17 Patients who fail NOM due to associated enteric or pancreatic
injury have a more variable time frame to presentation17; half manifested symptoms
within 48 hours, with the remainder becoming symptomatic up to 3 weeks later. Perhaps
not surprisingly, those patients who failed NOM had failure rates associated with
increasing grades of hepatic injury, with grade V injuries having a greater than 20%
failure rate. Subsequent studies have reported failure rates of 14% in grade IV injuries
and 23% in grade V injuries.12 The most recent analysis of the National Trauma Data
Bank of severe blunt liver injuries (grade IV and V) identified that initial NOM occurred
in 73%, with a failure rate of 7%.16 Interestingly, failure of NOM was associated with
higher mortality. Predictors of failure of NOM included increasing age, male sex,
increasing Injury Severity Score, decreasing Glasgow Coma Scale score, and
hypotension. A similar study of high-grade liver injuries identified a similar pattern with
NOM initiated in 66% patients with a failure rate of 9%.18 The amount of
hemoperitoneum evident on a CT scan appears to correlate with successful management;
patients with a large amount of hemoperitoneum (i.e., blood extending into the pelvis) are
more likely to fail NOM. However, predicting which patients will ultimately require
laparotomy has yet to be accomplished. Read more
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12)
0/1
You are seeing a 34-year old female in the trauma following an MVC. He is complaining
intense diffuse abdominal pain after his car was hit from behind causing him to spin out
and crash into a wall. Initially he had a GCS of 15. His vitals showed a BP of 125/76, HR
95, RR 18, O2 of 98% on room air. On physical exam his lungs are clear and his
abdomen shows diffuse tenderness to light palpation and ecchymosis over his
epigastrium. His initial fast exam is negative but technically limited and you order a CT
scan with IV contrast of his abdomen and pelvis as you suspect a possible liver
injury. What description from the options below accurately describes a grade IV liver
laceration on CT imaging?
(Select 1)(1pts)
Sub capsular hematoma, > 50% surface area, or ruptured with active
bleeding
<10%
25%
50%
75%
The answer is A, During the last century, the management of blunt force trauma to the
liver has changed from observation and expectant management in the early part of the
1900s to mainly operative intervention, to the current practice of selective operative and
nonoperative management. A 2008 study by Tinkoff et al.4 showed that 86.3% of hepatic
injuries are now managed without operative intervention. The current reported success
rate of nonoperative management of hepatic trauma ranges from 82% to 100%. Most
blunt liver trauma (80% in adults, 97% in children) patients are currently treated
conservatively. The success of non-operative management depends upon proper selection
of the patient. The patients, who are managed non-operatively, usually have grade I and
II liver injuries, hemoperitoneum less than 900 ml and blood transfusion of less than 3
units. The contraindications to non-operative management include refractory
hypotension, signinficant fall in haematocrit, the extravasations of intravenous contrast
agent, expanding haematoma and grade IV and V liver injury on CECT abdomen. The
patients of grade III liver injuries need very close observation as they may require
surgical intervention during first 24 hours. The failure rate of non-operative management
is not more than 5% inmost studies. It seems that patients with grade VI injuries rarely
reaches to the hospital alive and are not salvageable. Therefore, such injuries are usually
documented on autopsy. Mortality from blunt hepatic trauma is about 5% and is related
to uncontrolled hemorrhage.
Interventional radiology may be needed to perform an angiogram and embolization for
bleeding or to percutaneously drain an abscess or b iloma. An endoscopic retrograde
cholangiopancreatogram (ERCP) and stent placement may be required for biliary leak.
Even when such complications of the liver injury develop, only 15% require operative
intervention. Hepatic artery angiography with embolization is an important tool for the
stable patient with contrast extravasation who is being managed nonoperatively. It can
also be invaluable for the postoperative patient who has been stabilized by perihepatic
packing or who has rebled after an initial period of stability. Angioembolization has a
greater than 90% success rate in the control of bleeding with a low risk of rebleeding and
a reduction in required volume of transfusion. Read More
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Unit 4
14)
0/1
You are seeing a 15-year-old African-American female in your office because she and
her mom are concerned about a non tender breast lump that she just noticed the other day.
On exam you note a rubbery, well-defined, nontender breast mass approximately 2 cm in
diameter. The patient denies any history of breast tenderness, nipple discharge, or skin
changes. What is most likely diagnosis?
(Select 1)(1pts)
Fibroadenoma
Cystosarcoma phyllodes
The answer is B, Fibroadenoma. Most breast masses in adolescent girls are benign.
Fibroadenoma is the most common, accounting for approximately two-thirds of all
adolescent breast masses. It is characterized by a slow growing, nontender, rubbery, well-
defined mass, most commonly located in the upper, outer quadrant. Size varies, and is
most commonly in the range of 2–3 cm. Fibrocystic disease is found in older adolescents
and is characterized by bilateral nodularity and cyclic tenderness. Benign breast cysts are
characterized by a spongy, tender mass with symptoms exacerbated by menses. Cysts are
frequently multiple, and spontaneous regression occurs in 50% of patients. Cystosarcoma
phyllodes is a rare tumor with malignant potential, although most are benign. It presents
as a firm, rubbery mass that may enlarge rapidly. Skin necrosis is usually associated with
the tumor. Intraductal papillomas are usually benign but do have malignant potential.
They are commonly subareolar and are associated with nipple discharge. These tumors
are rare in the adolescent population. Ref: Hay WH (ed): Current Pediatric Diagnosis and
Treatment, ed 16. McGraw-Hill, 2003, pp 122-123.
(Select 1)(1pts)
Cystosarcoma Phyllodes
Intraductal papilloma
Fibrocystic disease
Fibroadenoma
The answer is C. This patient has fibrocystic disease which is a nonproliferative epithelial
lesions that are generally not associated with an increased risk of breast cancer [1]. It
should be noted that terms such as fibrocystic changes, fibrocystic disease, chronic cystic
mastitis, and mammary dysplasia refer to nonproliferative lesions and are not useful
clinically, as they encompass a heterogeneous group of diagnoses [5,11]. The most
common nonproliferative breast lesions are breast cysts. Other nonproliferative lesions
include papillary apocrine change, epithelial-related calcifications, and mild hyperplasia
of the usual type [5]. Apocrine metaplasia (also referred to as a "benign epithelial
alteration") is also a nonproliferative change that is secondary to some form of irritation,
typically associated with a breast cyst. Read More
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16)
0/1
You are seeing a 25-year old white female who is presenting to your clinic with bloody
nipple discharge over the last 3 days. She denies any history of a breast lump, she is not
breast feeding and denies family history of breast cancer. Her exam shows no palpable
masses but there is scant bloody discharge coming from her left nipple. You order a
mammogram that does not show any suspicious lesions. What is the most likely
diagnosis?
(Select 1)(1pts)
Fibroadenoma
Intraductal papilloma
Cystosarcoma Phyllodes
Mammary dysplasia
The answer is B, Intraductal papilloma. The old concern over cancer is the issue, and the
way to detect cancer that is not palpable is with a mammogram. That should be the first
choice. If negative, one may still wish to find an resect the intraductal papilloma to
provide symptomatic relief. Intraductal papillomas consist of a monotonous array of
papillary cells that grow from the wall of a cyst into its lumen. Although they are not
concerning in and of themselves, they can harbor areas of atypia or ductal carcinoma in
situ (DCIS). Papillomas can occur as solitary or multiple lesions. The standard approach
to a papilloma diagnosed by core needle biopsy (CNB) is to perform a surgical excision,
particularly if atypical cells are identified [14,16-21]. In a meta-analysis of 34 studies
that included 2236 non-malignant breast papillary lesions, 346 (15.7 percent) were
upgraded to malignancy following a surgical excision [21]. Because of a risk of
malignancy, these require surgical excision.Read More
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17)
0/1
You are seeing a 24-year old female who is 4-weeks post postpartum in your clinic. She
is complaining of bilateral nipple pain over the last two days along with a nipple rash.
She notes pain both with breastfeeding and even when she is not feeding. The pain is so
bad that she didn't breastfeed her baby this morning because of the pain. Physical exam
shows erythema to both breasts along with cracking around both areolas. There are no
signs of an abscess and no induration present. What is the most likely cause of this
patient's symptoms?
(Select 1)(1pts)
Engorgement
Mastitis
Candida infection
The answer is D, Candida infection. In breastfeeding women, bilateral nipple pain with
and between feedings after initial soreness has resolved is usually due to Candida. Pain
from engorgement typically resolves after feeding. Mastitis is usually unilateral and is
associated with systemic symptoms and wedge-shaped erythema of the breast tissue.
Improper latch-on is painful only during feedings. Eczema isolated to the nipple, while a
reasonable part of the differential, would be much more unusual.
Medullary carcinoma
Mucinous carcinoma
True
False Correct
True Correct
False
True: Algorithms for clinical and imaging evaluation of palpable masses are stratified by
the age of the woman. Even in the setting of palpable masses, image guidance may
improve diagnostic accuracy. A clinically suspicious mass should be biopsied regardless
of imaging findings, as 10 to 15 percent of such lesions can be mammographically
occult. Read more
(Select 1)(1pts)
Fibroadenoma
Fibrocystic disease
Intraductal papilloma.
Cystosarcoma Phyllodes
Fewer than 40% of patients with Patients with Necrotizing Soft Tissue
Infections exhibit the classic symptoms and signs described
The answer is B, crepitus is noted in only 30% of patients with necrotizing soft tissue
infections. Patients with necrotizing soft tissue infections often complain of severe pain
that is out of proportion to their physical findings. Compared with patients who have
nonnecrotizing infections, they are more likely to have fever, bullae, or blebs [see Figure
1]; signs of systemic toxicity; hyponatremia; and leukocytosis with a shift in immature
forms. Physical findings characteristic of a necrotizing infection include tenderness
beyond the area of erythema, crepitus, cutaneous anesthesia, and cellulitis that is
refractory to antibiotic therapy.6 Tenderness beyond the borders of the erythematous area
is an especially important clinical clue that develops as the infection in the deeper
cutaneous layers undermines the skin. Early in the course of a necrotizing soft tissue
infection, skin changes may be minimal despite extensive necrosis of the deeper
cutaneous layers. Bullae, blebs, cutaneous anesthesia, and skin necrosis occur as a result
of thrombosis of the nutrient vessels and destruction of the cutaneous nerves of the skin,
which typically occur late in the course of infection.
Clinicians should be mindful of certain diagnostic barriers that may delay recognition and
treatment of necrotizing soft tissue infections.7 In particular, these infections have a
variable clinical presentation. Although most patients present with an acute, rapidly
progressive illness and signs of systemic toxicity, a subset of patients may present with a
more indolent, slowly progressive infection. Patients with postoperative necrotizing
infections often have a more indolent course. Moreover, in the early stages, underlying
necrosis may be masked by normal-appearing overlying skin. As many as 20% of
necrotizing soft tissue infections are primary (idiopathic) and occur in previously healthy
patients who have no predisposing factors and no known portal of entry for bacterial
inoculation. Finally, crepitus is noted in only 30% of patients with necrotizing soft tissue
infections. Overall, fewer than 40% of patients exhibit the classic symptoms and signs
described.7,8Accordingly, it is imperative to maintain a high index of suspicion for this
disease in the appropriate setting.Read More on Soft Tissue Infection
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23)
0/1
Which of the following choices best differentiates cellulitis from erysipelas?
(Select 1)(1pts)
Presence of fever
Presence of leukocytosis
Depth of inflammation
Presence of purulence
The answer is C, depth of inflammation. Cellulitis and erysipelas are diffuse spreading
skin infections that not associated with underlying suppurative foci. Clinically, there is
often some degree of overlap between the two different entities. Erysipelas is
differentiated from cellulitis by the depth of inflammation; erysipelas affects the upper
dermis, including the superficial lymphatics, whereas cellulitis affects the deeper dermis
and subcutaneous fat (Mayo Clin Proc, Vol. 89;1436). Read More onCellulitis and
erysipelas from Up to Date
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24)
1/1
A 23-year old male patient presents with a human bite to his right hand after an
altercation just prior to arrival. He has no past medical history and is up to date with
tetanus. Exam shows there are two small puncture wounds overlying the dorsal aspect of
his right hand over his 1stmetacarpal and does not seem to involve any
tendons or ligaments. The wound does not appear amenable to sutures for
closure and you decide to copiously irrigate it with saline and discharge him home. What
antibiotic should he receive for wound care prophylaxis?
(1pts)
Clindamycin
Flagyl
Oxacillin
Augmentin
The answer is D. Augmentin. The most common bacterial etiology in human bites is strep
viridans. You are however covering for Eikenella corrodens which is a gram negative rod
which is susceptible to pcn but resistant to flagyl, clindamycin, first generation
cephalosporins and erythromycin. It is susceptible to flouroquinolones, bactrim and
augmentin. The most important treatment is good irrigation and initial wound
cleaning. Read more
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25)
0/1
What is the most common causative pathogen of Lemierre disease, an infection of the
parapharyngeal space that leads to septic thrombophlebitis of the internal jugular vein
with bacteremia and metastatic pulmonary nodules.
(Select 1)(1pts)
C. diphtheriae
Fusobacterium necrophorum
Infectious mononucleosis
Streptococcus pyogenes
Unit 1
1)
1/1
<5%
20%
35%
50%
The answer is B, 20%. The decision to image is challenging in the wellappearing patient
with a concerning mechanism or intermediate examination. Approximately 20% of
patients with no physical evidence of chest trauma but a concerning mechanism will have
injuries on thoracic CT. Alternatively, patients with a NEXUS chest score of 0 (see Table
2, page 5) have a much lower incidence of significant findings on CT
Some 10% to 23% of patients with minimal findings on examination may still have
significant thoracic injuries.54,59 However, it is unclear what percentage of these injuries
is clinically important. Point tenderness and ecchymosis on the chest wall should raise the
concern for intrathoracic injury; however, these findings are nonspecific.55 Injuries to the
lower ribs may also indicate the presence of intra-abdominal injuries. In a 2005
prospective observational study, 3% of patients with “isolated” subjective pain or point
tenderness to the lower left ribs as the only indication for computed tomography (CT) had
splenic injuries. If patients had other indications for CT (hypotension, abdominal or flank
tenderness, pelvic or femur fractures, or gross hematuria) the rate of splenic injury was
9.4%.Read more
Hamartomatous polyp
Tubular adenoma
Villous adenoma
Tubulovillous adenoma
The answer is C, Villous adenoma. Adenomatous polyps are the most common of the
classically neoplastic polyps. About two-thirds of all colonic polyps are adenomas.
Adenomas are by definition dysplastic and thus have malignant potential. Most colorectal
cancers arise from adenomas, but only a small minority of adenomas progress to cancer
(5 percent or less). Studies reporting the average age at presentation of patients with
adenomatous polyps versus colorectal cancer suggest the time for development of
adenomas to cancer is about 7 to 10 years. Hamartomatous (or juvenile) polyps and
hyperplastic polyps are benign lesions and are not considered to be premalignant.
Adenomas, on the other hand, have the potential to become malignant. Sessile adenomas
and lesions >1.0 cm have a higher risk for becoming malignant. Of the three types of
adenomas (tubular, tubulovillous, and villous), villous adenomas are the most likely to
develop into an adenocarcinoma.
An advanced adenoma is any adenoma with high-grade dysplasia, an
adenoma that is >10 mm in size, or an adenoma with a villous
component. Adenomas without villous components are also referred to as
tubular adenomas.
A synchronous adenoma is an adenoma that is diagnosed at the same time
as an index colorectal neoplasm (a pathologically more advanced lesion).
Thirty to fifty percent of colons with one adenoma will contain at least
one other synchronous adenoma .
A metachronous adenoma is an adenoma that is diagnosed at least six
months after the diagnosis of a previous adenoma.
Ref: Fauci AS, Braunwald E, Kasper DL, et al (eds):Harrison’s Principles of
Internal Medicine, ed 17. McGraw-Hill, 2008, p 574. Read more on Approach to
the patient with colonic polyps.
Vascular Injury
Expanding Hematoma
Shattered Kidney
The answer is D. All of the above. Generally about 80-90% renal injuries treated
conservatively with remarkable resolution! Injuries requiring surgery: vascular injury,
shattered kidney and an expanding hematoma.
The goal in the management of renal trauma is to safely preserve the maximal number of
renal units, avoiding unnecessary explorations, repairs, and nephrectomies. Increasing
numbers of renal injuries, including grade IV and V injuries, are being been managed
nonoperatively. The accuracy and rapidity of helical CT, combined with the
improvements achieved in resuscitation methods, have reduced the number of renal
explorations performed.8 Currently, 36% of all penetrating renal injuries and fewer than
5% of blunt injuries necessitate operative management.9 All grade I and II renal injuries,
regardless of the mechanism of injury, can be managed with observation alone because
the risk of delayed bleeding is extremely low. Most grade III and IV injuries, including
those with devitalized parenchymal fragments and urinary extravasation, can be managed
nonoperatively with close monitoring, serial hematocrit measurement, and repeat imaging
in selected cases. Active arterial bleeding, in the absence of other associated injuries, can
be treated with emergency arteriography and selective angioembolization.
The only absolute indications for renal exploration are pedicle avulsion, pulsatile or
expanding hematoma, and hemodynamic instability resulting from renal
injury.6 Significant numbers of shattered kidneys (grade V) and renal vascular injuries
(grades IV and V) are now managed nonoperatively. The strongest predictor for
nephrectomy is severity of renal injury; however, roughly one third of all penetrating and
44% of blunt grade IV and V renal injuries are now managed nonoperatively.9,13,14In
patients who require laparotomy for associated injuries, renal exploration and
reconstruction of grade III and IV injuries may reduce the likelihood of delayed
complications. However, the need for laparotomy and surgery for other intra-abdominal
organs is associated with a higher likelihood of nephrectomy. Thus, exploration of
suspected kidney injuries (as determined by previous imaging or on-table evaluation) in
patients undergoing laparotomy for major splenic or bowel injury should be attempted by
surgeons experienced in repairing an injured kidney.9 In reality, the success of
nonoperative management for most grade III and IV injuries means that operative
intervention in cases of blunt trauma is typically limited to patients with the most severe
renal injuries, in whom conservative management fails either because of bleeding or
because of ongoing urinary extravasation despite ureteral stenting.15
A significant number of patients with a penetrating injury and a minority of those with
blunt trauma require immediate laparotomy before radiographic
evaluation.9,13 Hematuria should alert the surgeon to the possibility of renal injury, and
the presence of a perinephric hematoma visible through the mesocolon should prompt
further evaluation. If a major renal injury is suspected on the basis of the size of the
hematoma or an abnormal intraoperative intravenous pyelogram (IVP), exploration is
indicated.
2014. Scientific American Surgery. Hamilton, Ontario & Philadelphia, PA. Decker
Intellectual Properties Inc. ISSN 2368-2744. STAT!Ref Online Electronic Medical
Library. http://online.statref.com/Document.aspx?fxId=61&docId=2366. 10/20/2014
1:04:32 PM CDT (UTC -05:00).
Pancreatitis
Perforation
Grade I
Grade II
Grade III
Grade IV
12-24 hours
1-2 days
3-5 days
7-14 days
The answer is D, 7-14 days. CEA remains the prototypical solid tumor marker. Despite
its lack of specificity, if used correctly, CEA testing is a valuable addition to the process
of clinical decision making in patients diagnosed with colon or rectal carcinoma.
However, it is not an appropriate screening test. Whether sampled once or serially, CEA
cannot be used in the differential diagnosis of an unknown-but-suspected bowel problem
or malignancy. Nevertheless, when CEA concentrations are determined before primary
tumor resection, they may be of additional prognostic value; this is particularly true in
patients with stage II disease, for whom elevated preoperative CEA is a poor prognostic
marker and may influence the decision regarding whether to administer adjuvant
chemotherapy.
Serial CEA values obtained postoperatively are a potentially effective means of
monitoring response to therapy. A postoperative CEA titer serves as a measure of the
completeness of tumor resection. It should be remembered, however, that the half-life of
CEA is 7 to 14 days; therefore, postoperative baselines are best established several weeks
after resection. If a preoperatively elevated CEA value does not fall to normal within 2 to
3 weeks after surgery, it is likely that (1) the resection was incomplete or (2) occult
metastases are present. A rising trend in serial CEA values from a normal postoperative
baseline (< 5 ng/mL) may predate any other clinical or laboratory evidence of recurrent
disease by 6 to 9 months. Read more
Chemotherapy
Radiation
CRC ranks as the third most common malignancy in the United States
Answer D is false. Worldwide, over 1 million people are diagnosed with CRC annually,
and there are more than 500,000 associated deaths.1 The highest rates of colorectal
carcinoma are found in industrialized countries. The rates are significantly lower in
eastern Europe, Asia, Africa, and South America.2 However, studies of Japanese
migration to the United States, Asiatic Jewish migration to Israel, and eastern European
migration to Australia show that migrants acquire the high rates of CRCs prevalent in
their adopted countries. There is little question that environmental factors, most likely
dietary, account for this.
Colon cancer is three times more common than rectal cancer. Interestingly,
epidemiologic studies indicate a rising proportion of right-sided colonic lesions. The
proximal migration of colon cancer may be associated with changing environmental
factors; however, there is no doubt that increased screening successfully detects early
lesions in an aging population. CRC ranks as the third most common malignancy in the
United States (behind prostate and lung cancer in men and breast and lung cancer in
women) and the second leading cause of cancer-related mortality. Approximately
143,000 patients are diagnosed with CRC in the United States each year, and 51,000 die
of disease.4,5 The probability of CRC developing during an individual's lifetime is about
6%. In contrast to the three previous decades, however, the overall incidence and
mortality of CRC have declined for both men and women. Age-adjusted incidence and
mortality are associated with race and ethnicity; however, the relationships are complex,
influenced by social and economic confounding factors more than tumor biology.
Clearly, CRC is associated with genetic and environmental influences. Overt risk factors
include a personal or family history of CRC or colorectal adenoma(s), a personal history
of colorectal polyps, inflammatory bowel disease (IBD), and age greater than 50. Age is
the most common risk factor. The risk of CRC increases after the fourth decade of life.13
Most individuals present with disease after the age of 60, and only 10% of CRCs are
diagnosed in individuals younger than 40.
Nonhereditary CRCs are referred to as "sporadic" and comprise 75 to 80% of all CRCs.
Genetic etiology may be identified in the remaining 20 to 25% of patients, including
family history (15 to 20%), Lynch syndrome (5%), and FAP (< 1%). Cancer can arise
within a polyp or at another site in the colon or rectum. Read more
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Unit 3
10)
0/1
You are seeing a 61-year old female who presents with worsening shortness of breath
for two days. The day preceding her symptoms she was involved in an MVC and was
seen in your facility and diagnosed with 3 non displaced rib fractures on the right. Her x-
ray today is shown below. What is the most likely diagnosis?
(Select 1)(1pts)
Pneumothorax
Pulmonary Contusion
Fat embolism
Pneumonia
The answer is B. Severe blunt trauma to the chest can cause rib fractures and other
immediate injuries but sometimes pathology doesn't show up until days later such as a
pulmonary contusion and myocardial contusion. The contused lung is very sensitive to
fluid overload which can lead to respiratory distress. Pulmonary contusions generally
develop over the first 24 hours and resolve in about one week. Irregular, nonlobular
opacification of the pulmonary parenchyma on chest radiograph is the diagnostic
hallmark. About one-third of the time the contusion is not evident on initial radiographs.
Chest CT provides better resolution, but rarely alters management, unless other injuries
are found. Contusions evident on CT but not plain radiograph have better outcomes.
Pain control and pulmonary toilet are the mainstays of treatment. Prophylactic
endotracheal intubation is unnecessary, but patients with hypoxia or difficulty ventilating
require airway management. While opinions vary, fluid resuscitation with crystalloid to
euvolemia appears appropriate. Common complications include pneumonia and acute
respiratory distress syndrome (ARDS). Read more
The answer is A, Upright Chest Xray followed by a chest tube. This patient is awake and
talking. He is stable enough for a chest xray followed by chest tube placement. A needle
thoracotomy to should be done if he has evidence of tension pneumothorax which would
be respiratory distress and hypotension. He will likely then need a chest tube and can be
further managed. Read More
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12)
1/1
What is the estimated overall mortality from pulmonary contusions?
(Select 1)(1pts)
3% to 5%
5% to 10%
10% to 25%
25% to 40%
The answer is B. Once significant associated injuries have been evaluated and treated, the
cornerstone of rib fracture management is pain control [36-38]. Early and adequate pain
relief is essential to avoid complications from splinting and atelectasis, primarily
pneumonia. The choice of analgesia depends upon the injury, the clinician's comfort
performing nerve blocks with their potential complications, and the ease with which more
invasive treatments can be performed. Analgesia for severe and multiple rib fractures and
monitoring of admitted patients are discussed separately.
For isolated injuries (ie, single rib fracture), clinicians generally begin treatment with
nonsteroidal anti-inflammatory drugs (NSAIDs) with or without opioids. For more severe
injuries, particularly if ventilation is compromised, admission and invasive treatments,
such as intercostal nerve blocks, may be needed.
Respiratory care, including use of incentive spirometry to prevent atelectasis and its
complications, is often important. We do not recommend rib belts or binders because
they compromise respiratory function. Studies of rib belts involve small numbers of
patients and have reached contradictory conclusions [39,40]. Patients with a rib fracture
who are discharged home can also use incentive spirometry throughout the day, after
analgesics have taken effect. Holding a pillow or similar soft brace against the fracture
site reduces discomfort while using the spirometer, or when coughing.
Disposition — Several researchers recommend hospital admission for any patient with
three or more rib fractures, and ICU care for elderly patients with six or more rib
fractures [14,15]. They cite the significant correlation between these findings and
serious internal injuries, such as pneumothorax and pulmonary contusion. We suggest
hospitalization for the majority of patients with three or more rib fractures. Patients with
multiple rib fractures sustained from high-energy trauma are best evaluated at a trauma
center. Transfer should be arranged expeditiously.
Displaced rib fractures likely increase the risk of injury to the lung and proximate
intercostal blood vessels. Bleeding from such fractures can be delayed, and admission or
close observation and follow-up should be arranged for patients with displaced fractures,
depending upon clinical and social circumstances. Multiple case reports indicate that
delayed bleeding from intercostal vessels or other injuries can be life-threatening,
particularly in older patients [20,41,42].
Surgical fixation may be of benefit with some types of rib fractures, particularly those
associated with chest wall deformity, flail chest, or symptomatic nonunion. The
appropriate role of surgical fixation is discussed separately. (See "Inpatient
management of traumatic rib fractures", section on 'Surgical
management'.)
Rarely, younger healthy individuals with three rib fractures, having undergone a thorough
clinical and radiographic evaluation by clinicians experienced in trauma management,
and an appropriate period of observation (a minimum of six hours of observation,
including a follow-up chest radiograph, is needed to rule out pneumothorax), may be
discharged from the emergency department. Clinicians must also consider patient
comorbidities and clinical and social circumstances when determining disposition.
Patients with one or possibly two isolated rib fractures and no complicating factors may
be discharged home with appropriate follow-up and adequate analgesia. Uptodate
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Unit 4
14)
1/1
You are seeing a 32-year old male who presents after being kicked multiple times in his
right flank. He is complaining of severe flank pain and gross hematuria. What is the gold
standard for imaging of renal trauma?
(Select 1)(1pts)
MRI abdomen/pelvis
Ultrasound
Intravenous pyelography
This patient shows no sign of arterial injury as he has no hard or soft signs of vascular
injury (see below). He has a normal neuro exam and has no fracture on xray. The only
thing that this patient needs is a tetanus update and wound irrigation.
Cystography
Intravenous pyelography
The answer is A. This injury often follow pelvic fractures and classically present with
blood at the urethral meatus, an ability to void and a high riding or a non palpable
prostate to an intern. If you suspect urethral injury a retrograde urethrogram needs to be
performed prior to foley insertion. This procedure will locate the damage of the urethra, if
present. Inserting a Foley before this procedure is contraindicated as this can worsen the
urethral tear and potentially cause infection or a hematoma (you do not want to cause or
worsen the chance of a urethral stricture). These injuries often need surgical repair,
especially anterior urethral injuries. Some are treated with urinary diversion via
suprapubic catheter while the primary injury heals. Read more
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17)
0/1
You are seeing a 25-year old male in the trauma bay after he was involved in a motor
vehicle accident. He was thrown from his bike and is now complaining of right flank
pain. His GCS is 15 and he is awake and oriented. His BP is 125/75, HR 99, RR 18, O2
98% on room air. His physical exam is pertinent for right flank ecchymosis with mild
tenderness to palpation along with mild right upper quadrant tenderness. There is no
gross blood seen at his urethral meatus and his urinalysis shows no RBCs. True or False:
In the setting of potential renal trauma (blunt and penetrating trauma), gross or
microscopic hematuria is ALWAYS present.
(1pts)
True Incorrect
False
The answer is False: In the setting of renal trauma, gross or microscopic hematuria is
absent in up to 5% of cases and this finding alone should not be used to preclude in those
you are suspicious of renal trauma. Read more on renal trauma
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Unit 5
18)
1/1
Which of the following statements regarding hernias is not correct?
(Select 1)(1pts)
In female patients, indirect inguinal hernias are the most common type
In male patients, direct inguinal hernias are the most common type
Femoral hernias account for fewer than 10% of all groin hernias; however,
40% present as emergencie
20
50
75
120
(Select 1)(1pts)
0.18%
1.18%
2.1%
6.5%
12.4%
Indirect
Direct
Femoral
Richter
This patient most likely has an indirect hernia as it is the most common hernia and given
the lack of other findings in the stem that is the best answer and most likely. Although a
sports hernia may lead to a traditional, abdominal hernia, it is a different injury. A sports
hernia is a strain or tear of any soft tissue (muscle, tendon, ligament) in the lower
abdomen or groin area. Because different tissues may be affected and a traditional hernia
may not exist, the medical community prefers the term "athletic pubalgia" to refer to this
type of injury.
An indirect inguinal hernia is one of the most common abdominal hernias. It is
five times more common than a direct inguinal hernia, and is seven times more frequent
in males, due to persistence of the process vaginalis during testicular descent. An indirect
hernia enters the inguinal canal at the deep ring, lateral to the inferior epigastric vessels.
It passes infromedially to emerge via the superficial ring and, if large enough, extend into
the scrotum. In children, the vast majority of inguinal hernias are indirect (see Case 3).
Incarceration represents the most common complication associated with inguinal hernias,
the incidence could be as high as 30% for infants younger than 2 months.
A direct inguinal hernia arises from protrusion of abdominal viscera through a
weakness of the posterior wall of the inguinal canal medial to the inferior epigastric
vessels, specifically through the Hasselbach's triangle. This type of hernia is termed
direct as the hernial sac directly protrudes through the inguinal wall in contrast to indirect
ones which arise through the deep ring and enter the inguinal canal. Since direct hernias
do not have a guiding path, they seldom extend into the scrotum unless very large and
chronic. Direct hernias arise usually as acquired weakness of the Hasselbalch's triangle.
Therefore, they are seen in the elderly with chronic conditions which increase intra-
abdominal pressure over a long period, e.g. COPD, bladder outflow obstruction, chronic
constipation etc. Increased abdominal pressure is transmitted to both sides and as a result,
direct hernias are usually bilateral. Compared to indirect hernia, they are less susceptible
to strangulation as they have a wide neck.
In contrast to the indirect hernia, a direct hernia is most often an acquired lesion. It
occurs when a weak spot develops in the lower abdominal musculature (the posterior
floor of the inguinal canal) due to the normal and/or abnormal stresses inflicted by living
and aging. In adults, stresses such as lifting heavy of objects, frequent coughing or
straining, pregnancy, and constipation can instigate hernia. Unlike indirect hernias, direct
hernias traverse medial to the inferior epigastric vessels and are not associated with the
processus vaginalis. The hernia consists primarily of retroperitoneal fat. Only rarely is a
peritoneal sac containing bowel encountered. Because there is typically no involvement
of a sac, they do not protrude with the spermatic cord, and as such, have a lower
incidence of incarceration or strangulation. Like indirect inguinal hernia, direct inguinal
hernias typically cause a bulge in the groin (at the top of or within the scrotum) and
usually with increased abdominal pressure. Like indirect hernias, they may or may not be
painful (usually not). By palpating the inguinal canal and asking the patient to cough
while standing, one can usually elicit the hernia. In fact, one can often times palpate an
inguinal hernia without invaginating the scrotum (as is typically taught in medical
school). Rather, by placing one's fingers over the inguinal canal and asking the patient to
cough, one can often feel the bulge against the lower abdominal wall. As direct and
indirect hernias are unreliably differentiated by physical exam alone, the need to
invaginate the scrotum to feel into the inguinal canal is often more uncomfortable to the
patient, than telling to the physician. Rarely, palpation is not even necessary, as the
hernia is large enough to be visualized. Read more on Inguinal hernias: A Brief
review
The "seat-belt" sign is associated with a more than doubled relative risk of
small bowel injury
1.2%
4.8%
8.9%
13.4%
The answer is A, 1.2%. Hollow viscus injury after blunt trauma, although
uncommon, can have serious consequences if the diagnosis is missed
or delayed.Hollow viscus injury is most often the consequence of
penetrating abdominal trauma. As a result of blunt force trauma,
bowel injury occurs with relative infrequency: in one multi-institutional
analysis, only 1.2% of blunt trauma admissions had an associated
hollow viscus injury. Read more
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24)
1/1
What is the mean mortality rate of patients suffering from pancreatic trauma?
(Select 1)(1pts)
<3%
9%
19%
31%
Answer C is the only false statement as No laboratory findings are particularly specific
for duodenal or pancreatic injury. Amylase has been proposed for both pancreas and
duodenal injuries but is not specific for either one. Some have noted that amylase can be
elevated in as many as 50% of duodenal injuries, but this has not been a consistent
finding.9 An elevated amylase should prompt an evaluation of the duodenum for injury
but alone is not diagnostic. Although the highest concentration of amylase in the human
body is in the pancreas, hyperamylasemia is also not a reliable indicator of pancreatic
trauma. In one series, only 8% of blunt abdominal injuries with hyperamylasemia had
pancreatic injury.10 Furthermore, as many as 40% of patients with a pancreatic injury
may initially have a normal serum amylase.
The history of a patient with a possible blunt pancreatic or duodenal injury usually
consists of a direct blow to the epigastrium. In children, this commonly involves a bicycle
handlebar to the epigastrium; in adults, more commonly the steering wheel or a motor
cycle handle bar is involved. However, any direct blow should raise suspicion. The
patient may complain of abdominal, back, or flank pain.
Outside of the pelvis x-ray, plain abdominal radiographs to evaluate blunt abdominal
trauma are less common in the era of focused abdominal sonography for trauma (FAST)
and computed tomographic (CT) scans. Reports suggest that signs of duodenal injury on
plain radiographs are identified less than one third of the time. Retroperitoneal air, free
intraperitoneal air, or obliteration of the psoas shadow should raise suspicion for
duodenal and other hollow viscous trauma.9 Upper gastrointestinal series have also been
used to evaluate the duodenum for injury and can add to the sensitivity and specificity of
plain films, but more recently, CT has become the primary diagnostic modality.
For optimal duodenal evaluation, intraluminal contrast administered via a nasogastric
tube soon but not immediately prior to the CT scan may aid by opacification of the lumen
of the duodenal "C loop." Visualization of contrast extravasation, retroperitoneal air,
adjacent fat stranding, and unexplained fluid, as well as duodenal wall thickening, are CT
findings suggestive of potential duodenal injury. The sensitivity of CT for duodenal
injury is related to the technology of the scanner (i.e., "number of slices") and the time
interval from the injury to imaging. In a recent review, CT was considered to have an
overall sensitivity of around 76% with new-generation scanners (16- or 64-slice), having
a higher sensitivity of around 82%. Additionally, if clinical suspicion remains high after
an initial negative CT scan, then repeat imaging is warranted and may improve diagnostic
yield.
At times, duodenal hematomas can cause duodenal obstruction. This usually presents 2 to
3 days after the trauma with evidence of gastric outlet obstruction. The common
nonoperative treatment of isolated obstructing duodenal hematomas is nasogastric tube
decompression of the stomach and duodenum, nutritional support, and time.38 Repeat
imaging in 7 to 14 days is reasonable to evaluate improvement or an unexpected finding
as most duodenal hematomas will have resolved after 7 to 14 days, and continued
obstruction may reveal additional injury, prompting intervention.39-41 Enteral nutrition
is preferred to parenteral nutrition, but in the setting of a duodenal obstruction, the
parenteral route (total parenteral nutrition [TPN]) is often required as passing a feeding
tube beyond the obstruction can be difficult and surgical feeding access defeats the
purpose of "nonoperative" care.
Unit 1
1)
0/1
You are seeing 45-year old black female again in the office who presented to you initially
for a right sided breast mass. She has no past medical history or family history of breast
cancer. On physical exam you palpated a 2 cm mass just lateral to her right nipple. You
ordered a mammogram which cam back normal. What percentage of patients who are
found to have a normal mammogram have breast cancer after biopsy of a suspicious
lesion?
(Select 1)( 1pts extra credit)
5%
15%
25%
45%
The answer is A. A diagnostic mammogram is the first imaging study performed for
a woman with a new, palpable breast mass, and should be performed even if a recent
mammogram was negative. While the false negative rate of mammograms is less than 5
percent for clinically palpable breast cancers [15], a normal mammogram does not
eliminate the need for further evaluation of a suspicious mass [5]. For women under age
30 years, the breasts are hypersensitive to radiation exposure [16]; however, if the
clinical findings are suspicious, a mammogram should be performed. Read More
Antiviral medication
Needle aspiration
The answer is A, Surgical drainage and antibiotics. This patient has pyogenic
tenosynovitis. When early tenosynovitis (within 48 hours of onset) is suspected,
treatment with antibiotics and splinting may prevent the spread of the infection. However,
this patient’s infection is no longer in the early stages and is more severe, so it requires
surgical drainage and antibiotics. A delay in treatment of these infections can lead to
ischemia of the tendons and damage to the flexor tendon and sheath. This can lead to
impaired function of the finger. Needle aspiration would not adequately drain the
infection. Antiviral medication would not be appropriate, as this is a bacterial infection.
Corticosteroid injections are contraindicated in the presence of infection.
Pneumococcus pneumoniae
Clostridium perfringens
Escherichia coli
Transthoracic echocardiography
The answer is B, The patient should undergo computed tomography (CT) of the neck
with contrast. She has fever, leukocytosis, sore throat, unilateral neck tenderness, and
multiple densities on chest radiograph, suggestive of septic emboli. The combination of
these factors points strongly toward Lemierre syndrome, which is septic thrombosis of
the internal jugular vein. The diagnosis should be suspected in anyone with pharyngitis,
persistent fever, neck pain, and septic pulmonary emboli. CT of the affected vessel with
contrast would confirm the diagnosis. Treatment includes intravenous antibiotics that
cover streptococci, anaerobes, and β-lactamase-producing organisms. Penicillin with a β-
lactamase inhibitor and carbapenem are both reasonable choices (eg, ampicillin-
sulbactam, piperacillin-tazobactam, ticarcillin-clavulanate).
Chest CT would better characterize the pulmonary infiltrates, but this information would
not provide specific diagnostic information that would guide therapy.
Soft tissue radiography of the neck cannot detect jugular vein filling defects or
thromboses, which are diagnostic of septic thrombophlebitis.
Echocardiography would be helpful to exclude right-sided endocarditis as a cause of
septic emboli. However, there is nothing in the history or on cardiac examination to
suggest a cardiac source of septic emboli. Centor RM, Samlowski R. Avoiding sore
throat morbidity and mortality: when is it not “just a sore throat?” Am Fam Physician.
2011;83:26, 28. PMID: 21888123
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5)
0/1
You are evaluating a 56-year old female for a suspicious breast mass in her right breast.
Her last mammogram 2 years ago was normal and you have sent her for another
mammogram. She denies family history of cancer and has no current medical problems.
Which of the following calcification patterns is more suspicious for a ductal carcinoma in
situ?
Linear calcifications
Round calcifications
The answer is A, linear calcifications. The histologic hallmark of DCIS is the presence of
malignant-appearing cells confined to the lumen of the ductal system in the breast. DCIS
is most often diagnosed because of the presence of calcifications clustered in one area of
the breast. The calcifications suspicious for DCIS are often linear (not round), growing in
a ductal distribution. The DCIS may not be confined to the extent of calcifications, and
not all DCIS is manifested by calcification. Therefore, the size or extent of DCIS may not
be defined by the mammographic appearance. Although DCIS occasionally presents as a
mass, the presence of the mass even in the setting of a biopsy showing DCIS most often
signifies that the cancer is primarily invasive. Read more on Breast Cancer
Popcorn calcification in the breast is the classical
description for the calcification seen in involuting
fibroadenomas, which as the name suggests has a pop
corn like appearance.
Egg shell calcifications in the breast are benign peripheral
rim like calcifications
Read More on Breast Calcification patterns
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Unit 2
6)
0/1
Nonoperative Management of solid-organ injuries can be pursued in hemodynamically
stable patients who do not have overt peritonitis or other indications for laparotomy.
According to contemporary data, what percentage of patients with splenic injuries are
candidates for nonoperative management?
(Select 1)(1pts)
<10%
25%
45%
60%
Thoracoscopy
Laparotomy
The answer is D. This patient suffered a ruptured diaphragm and chest tube placement
appears to have ruptured the bowel as evidence from the greenish fluid that was returned.
She needs an emergent laparotomy to control bleeding and repair her diaphragm. Read
More
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8)
0/1
What is the reported mortality rate of isolated traumatic splenic injuries?
(Select 1)(1pts)
<1%
5-10-%
10-20%
20-30%
The answer is A, The spleen is one of the most commonly injured abdominal organs in
blunt trauma patients. Historical studies have reported 10% mortality with all splenic
injuries; however, isolated splenic injury mortality is less than 1%. The mechanisms of
injury are similar to those seen with liver injuries: motor vehicle collisions, automobile-
pedestrian collisions, falls, and any type of penetrating injury. Stab wounds to the
abdomen are less likely to cause spleen injury compared with liver injury due to the
spleen's protected location. Stab wounds to the abdomen are less likely to cause injury to
the spleen than to the liver, due to its protected location.
Until the 1970s, splenectomy was considered mandatory for all splenic injuries.
Recognition of the immune function of the spleen refocused efforts on splenic salvage in
the 1980s.1,2 Following success in pediatric patients, nonoperative management (NOM)
of splenic injuries was adopted in the adult population and has become the prevailing
strategy for blunt splenic trauma. Read more
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9)
0/1
In cases of blunt trauma to the diaphragm, the injury is on the ____ side __% of the time?
(Select 1)(1pts)
Right; 90%
Left; 75%
Left; 25%
Right; 10%
The answer is B, left;75%. In cases of blunt trauma to the diaphragm, the injury is on the
left side 75% of the time, presumably because the liver diffuses some of the energy on
the right side. Blunt diaphragmatic injuries result in a linear tear in the central tendon,
whereas penetrating injuries are variable in size and location depending on the weapon. It
is important to identify the trajectory of penetrating injuries to determine the likelihood of
diaphragm injuries. With blunt and occasionally with penetrating injuries, the diagnosis is
suggested by an abnormality of the diaphragmatic shadow on a chest radiograph [see
Figure 5]. In patients without clear imaging results in the trauma bay, a CT scan may
identify a diaphragmatic injury.
Regardless of the etiology, acute injuries are repaired through an abdominal incision.
Thoracoscopy or laparoscopy may be used if concomitant injuries requiring laparotomy
have been ruled out. Following delineation of the injury, the chest should be evacuated of
all blood and particulate matter, and tube thoracostomy should be placed if not previously
done. Using Allis clamps to approximate the diaphragmatic edges, the defect can be
closed with a running permanent suture [see Figure 6]. Occasionally, large avulsions or
shotgun wounds with extensive tissue loss will require mesh to bridge the defect.
Alternatively, transposition of the diaphragm cephalad one to two intercostal spaces may
allow repair without undue tension. Read more
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Unit 3
10)
0/1
You are seeing a 34-year old female in the trauma following an MVC. He is complaining
intense diffuse abdominal pain after his car was hit from behind causing him to spin out
and crash into a wall. Initially he had a GCS of 15. His vitals showed a BP of 125/76, HR
95, RR 18, O2 of 98% on room air. On physical exam his lungs are clear and his
abdomen shows diffuse tenderness to light palpation and ecchymosis over his
epigastrium. His initial fast exam is negative but technically limited and you order a CT
scan with IV contrast of his abdomen and pelvis as you suspect a possible liver
injury. What description from the options below accurately describes a grade IV liver
laceration on CT imaging?
(Select 1)(1pts)
Sub capsular hematoma, > 50% surface area, or ruptured with active
bleeding
<10%
25%
50%
>80%
The answer is D, > 80%. Over 80% of patients with liver injuries may be managed
nonoperatively. The liver is the most commonly injured solid organ in blunt trauma,
comprising 5% of all trauma admissions, and because of its size is frequently involved in
penetrating trauma. Following blunt trauma, the most commonly injured structures are
the parenchyma and hepatic veins. Blunt forces dissipate along segments of the liver and
along the fibrous coverings of the portal triad structures; the hepatic veins, however, are
not as resilient. Stab wounds typically result in direct linear tears, whereas gunshot
wounds or shotgun wounds result in significant cavitary injuries attributable to blast
effect and the "tumbling" of the missile within the liver parenchyma. Thus, arterial injury
is more common with penetrating trauma. Biliary trauma is more common with
central/hilar trauma, either blunt or penetrating.
Nonoperative management (NOM) of liver injuries is now the prevailing therapeutic
strategy for blunt hepatic trauma and can be employed for isolated right subcostal
penetrating wounds. Several concurrent changes resulted in this paradigm change. Over
80% of patients with liver injuries may be managed nonoperatively. One of the early
studies to test the application of NOM in 1995 supported its broad application, with an
overall success rate greater than 85% in hemodynamically stable patients, despite
substantial hemoperitoneum documented by CT.11 Of the 8% of patients who failed
NOM, half required operation as a result of associated injuries (i.e., enteric or pancreatic
injuries), whereas half underwent laparotomy for hepatic-related hemorrhage. Patients
who require intervention for hemorrhage typically fail NOM in the first 24 to 48
hours.2,11,17 Patients who fail NOM due to associated enteric or pancreatic injury have a
more variable time frame to presentation17; half manifested symptoms within 48 hours,
with the remainder becoming symptomatic up to 3 weeks later. Perhaps not surprisingly,
those patients who failed NOM had failure rates associated with increasing grades of
hepatic injury, with grade V injuries having a greater than 20% failure rate. Subsequent
studies have reported failure rates of 14% in grade IV injuries and 23% in grade V
injuries.12 The most recent analysis of the National Trauma Data Bank of severe blunt
liver injuries (grade IV and V) identified that initial NOM occurred in 73%, with a failure
rate of 7%.16 Interestingly, failure of NOM was associated with higher mortality.
Predictors of failure of NOM included increasing age, male sex, increasing Injury
Severity Score, decreasing Glasgow Coma Scale score, and hypotension. A similar study
of high-grade liver injuries identified a similar pattern with NOM initiated in 66%
patients with a failure rate of 9%.18 The amount of hemoperitoneum evident on a CT
scan appears to correlate with successful management; patients with a large amount of
hemoperitoneum (i.e., blood extending into the pelvis) are more likely to fail NOM.
However, predicting which patients will ultimately require laparotomy has yet to be
accomplished. Read more
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12)
0/1
Roughly what percentage of patients with blunt liver injury initially managed non-
operatively will go on to need surgical intervention?
(1pts)
<10%
25%
50%
75%
The answer is A, During the last century, the management of blunt force trauma to the
liver has changed from observation and expectant management in the early part of the
1900s to mainly operative intervention, to the current practice of selective operative and
nonoperative management. A 2008 study by Tinkoff et al.4 showed that 86.3% of hepatic
injuries are now managed without operative intervention. The current reported success
rate of nonoperative management of hepatic trauma ranges from 82% to 100%. Most
blunt liver trauma (80% in adults, 97% in children) patients are currently treated
conservatively. The success of non-operative management depends upon proper selection
of the patient. The patients, who are managed non-operatively, usually have grade I and
II liver injuries, hemoperitoneum less than 900 ml and blood transfusion of less than 3
units. The contraindications to non-operative management include refractory
hypotension, signinficant fall in haematocrit, the extravasations of intravenous contrast
agent, expanding haematoma and grade IV and V liver injury on CECT abdomen. The
patients of grade III liver injuries need very close observation as they may require
surgical intervention during first 24 hours. The failure rate of non-operative management
is not more than 5% inmost studies. It seems that patients with grade VI injuries rarely
reaches to the hospital alive and are not salvageable. Therefore, such injuries are usually
documented on autopsy. Mortality from blunt hepatic trauma is about 5% and is related
to uncontrolled hemorrhage.
Interventional radiology may be needed to perform an angiogram and embolization for
bleeding or to percutaneously drain an abscess or b iloma. An endoscopic retrograde
cholangiopancreatogram (ERCP) and stent placement may be required for biliary leak.
Even when such complications of the liver injury develop, only 15% require operative
intervention. Hepatic artery angiography with embolization is an important tool for the
stable patient with contrast extravasation who is being managed nonoperatively. It can
also be invaluable for the postoperative patient who has been stabilized by perihepatic
packing or who has rebled after an initial period of stability. Angioembolization has a
greater than 90% success rate in the control of bleeding with a low risk of rebleeding and
a reduction in required volume of transfusion. Read More
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13)
0/1
The liver is the most commonly injured solid organ in blunt trauma, comprising 5% of all
trauma admissions. With that being said, over 80% of patients with liver injuries may be
managed nonoperatively. Which of the following is not a predictor of nonoperative
management?
(1pts)
Female sex
Increasing age
Hypotension
The answer is A, female sex. Over 80% of patients with liver injuries may be managed
nonoperatively. One of the early studies to test the application of NOM in 1995 supported
its broad application, with an overall success rate greater than 85% in hemodynamically
stable patients, despite substantial hemoperitoneum documented by CT.11 Of the 8% of
patients who failed NOM, half required operation as a result of associated injuries (i.e.,
enteric or pancreatic injuries), whereas half underwent laparotomy for hepatic-related
hemorrhage. Patients who require intervention for hemorrhage typically fail NOM in the
first 24 to 48 hours.2,11,17 Patients who fail NOM due to associated enteric or pancreatic
injury have a more variable time frame to presentation17; half manifested symptoms
within 48 hours, with the remainder becoming symptomatic up to 3 weeks later. Perhaps
not surprisingly, those patients who failed NOM had failure rates associated with
increasing grades of hepatic injury, with grade V injuries having a greater than 20%
failure rate. Subsequent studies have reported failure rates of 14% in grade IV injuries
and 23% in grade V injuries.12 The most recent analysis of the National Trauma Data
Bank of severe blunt liver injuries (grade IV and V) identified that initial NOM occurred
in 73%, with a failure rate of 7%.16 Interestingly, failure of NOM was associated with
higher mortality. Predictors of failure of NOM included increasing age, male sex,
increasing Injury Severity Score, decreasing Glasgow Coma Scale score, and
hypotension. A similar study of high-grade liver injuries identified a similar pattern with
NOM initiated in 66% patients with a failure rate of 9%.18 The amount of
hemoperitoneum evident on a CT scan appears to correlate with successful management;
patients with a large amount of hemoperitoneum (i.e., blood extending into the pelvis) are
more likely to fail NOM. However, predicting which patients will ultimately require
laparotomy has yet to be accomplished. Read more
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Unit 4
14)
0/1
A 25 -ear obese black female presents to you with a painful breast lump along with
tenderness in both her breasts. She notes recurrent pain and multiple lumps on both
breasts that seem to “come and go” at different times during her menses. Now she has a
firm, round, mass that has not gone away for the last 5 weeks. What is the most likely
diagnosis?
(Select 1)(1pts)
Cystosarcoma Phyllodes
Intraductal papilloma
Fibrocystic disease
Fibroadenoma
The answer is C. This patient has fibrocystic disease which is a nonproliferative epithelial
lesions that are generally not associated with an increased risk of breast cancer [1]. It
should be noted that terms such as fibrocystic changes, fibrocystic disease, chronic cystic
mastitis, and mammary dysplasia refer to nonproliferative lesions and are not useful
clinically, as they encompass a heterogeneous group of diagnoses [5,11]. The most
common nonproliferative breast lesions are breast cysts. Other nonproliferative lesions
include papillary apocrine change, epithelial-related calcifications, and mild hyperplasia
of the usual type [5]. Apocrine metaplasia (also referred to as a "benign epithelial
alteration") is also a nonproliferative change that is secondary to some form of irritation,
typically associated with a breast cyst. Read More
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15)
0/1
You are seeing a 24-year old female who is 4-weeks post postpartum in your clinic. She
is complaining of bilateral nipple pain over the last two days along with a nipple rash.
She notes pain both with breastfeeding and even when she is not feeding. The pain is so
bad that she didn't breastfeed her baby this morning because of the pain. Physical exam
shows erythema to both breasts along with cracking around both areolas. There are no
signs of an abscess and no induration present. What is the most likely cause of this
patient's symptoms?
(Select 1)(1pts)
Engorgement
Mastitis
Candida infection
The answer is D, Candida infection. In breastfeeding women, bilateral nipple pain with
and between feedings after initial soreness has resolved is usually due to Candida. Pain
from engorgement typically resolves after feeding. Mastitis is usually unilateral and is
associated with systemic symptoms and wedge-shaped erythema of the breast tissue.
Improper latch-on is painful only during feedings. Eczema isolated to the nipple, while a
reasonable part of the differential, would be much more unusual.
Fibroadenoma
Intraductal papilloma
Cystosarcoma Phyllodes
Mammary dysplasia
The answer is B, Intraductal papilloma. The old concern over cancer is the issue, and the
way to detect cancer that is not palpable is with a mammogram. That should be the first
choice. If negative, one may still wish to find an resect the intraductal papilloma to
provide symptomatic relief. Intraductal papillomas consist of a monotonous array of
papillary cells that grow from the wall of a cyst into its lumen. Although they are not
concerning in and of themselves, they can harbor areas of atypia or ductal carcinoma in
situ (DCIS). Papillomas can occur as solitary or multiple lesions. The standard approach
to a papilloma diagnosed by core needle biopsy (CNB) is to perform a surgical excision,
particularly if atypical cells are identified [14,16-21]. In a meta-analysis of 34 studies
that included 2236 non-malignant breast papillary lesions, 346 (15.7 percent) were
upgraded to malignancy following a surgical excision [21]. Because of a risk of
malignancy, these require surgical excision.Read More
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17)
0/1
You are seeing a 15-year-old African-American female in your office because she and
her mom are concerned about a non tender breast lump that she just noticed the other day.
On exam you note a rubbery, well-defined, nontender breast mass approximately 2 cm in
diameter. The patient denies any history of breast tenderness, nipple discharge, or skin
changes. What is most likely diagnosis?
(Select 1)(1pts)
Fibroadenoma
The answer is B, Fibroadenoma. Most breast masses in adolescent girls are benign.
Fibroadenoma is the most common, accounting for approximately two-thirds of all
adolescent breast masses. It is characterized by a slow growing, nontender, rubbery, well-
defined mass, most commonly located in the upper, outer quadrant. Size varies, and is
most commonly in the range of 2–3 cm. Fibrocystic disease is found in older adolescents
and is characterized by bilateral nodularity and cyclic tenderness. Benign breast cysts are
characterized by a spongy, tender mass with symptoms exacerbated by menses. Cysts are
frequently multiple, and spontaneous regression occurs in 50% of patients. Cystosarcoma
phyllodes is a rare tumor with malignant potential, although most are benign. It presents
as a firm, rubbery mass that may enlarge rapidly. Skin necrosis is usually associated with
the tumor. Intraductal papillomas are usually benign but do have malignant potential.
They are commonly subareolar and are associated with nipple discharge. These tumors
are rare in the adolescent population. Ref: Hay WH (ed): Current Pediatric Diagnosis and
Treatment, ed 16. McGraw-Hill, 2003, pp 122-123.
(Select 1)(1pts)
Fibroadenoma
Fibrocystic disease
Intraductal papilloma.
Cystosarcoma Phyllodes
Medullary carcinoma
Mucinous carcinoma
Mammogram
Breast Ultrasound
Core Biopsy
Excisional Biopsy
False
Levofloxacin
Doxycycline
Dicloxacillin
Cephalexin
Ciprofloxacin
Presence of fever
Presence of leukocytosis
Depth of inflammation
Presence of purulence
The answer is C, depth of inflammation. Cellulitis and erysipelas are diffuse spreading
skin infections that not associated with underlying suppurative foci. Clinically, there is
often some degree of overlap between the two different entities. Erysipelas is
differentiated from cellulitis by the depth of inflammation; erysipelas affects the upper
dermis, including the superficial lymphatics, whereas cellulitis affects the deeper dermis
and subcutaneous fat (Mayo Clin Proc, Vol. 89;1436). Read More onCellulitis and
erysipelas from Up to Date
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24)
0/1
A 23-year old male patient presents with a human bite to his right hand after an
altercation just prior to arrival. He has no past medical history and is up to date with
tetanus. Exam shows there are two small puncture wounds overlying the dorsal aspect of
his right hand over his 1stmetacarpal and does not seem to involve any
tendons or ligaments. The wound does not appear amenable to sutures for
closure and you decide to copiously irrigate it with saline and discharge him home. What
antibiotic should he receive for wound care prophylaxis?
(1pts)
Clindamycin
Flagyl
Oxacillin
Augmentin
The answer is D. Augmentin. The most common bacterial etiology in human bites is strep
viridans. You are however covering for Eikenella corrodens which is a gram negative rod
which is susceptible to pcn but resistant to flagyl, clindamycin, first generation
cephalosporins and erythromycin. It is susceptible to flouroquinolones, bactrim and
augmentin. The most important treatment is good irrigation and initial wound
cleaning. Read more
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25)
0/1
Which of the following statements regarding soft tissue infections is not true?
(Select 1)(1pts)
Fewer than 40% of patients with Patients with Necrotizing Soft Tissue
Infections exhibit the classic symptoms and signs described
The answer is B, crepitus is noted in only 30% of patients with necrotizing soft tissue
infections. Patients with necrotizing soft tissue infections often complain of severe pain
that is out of proportion to their physical findings. Compared with patients who have
nonnecrotizing infections, they are more likely to have fever, bullae, or blebs [see Figure
1]; signs of systemic toxicity; hyponatremia; and leukocytosis with a shift in immature
forms. Physical findings characteristic of a necrotizing infection include tenderness
beyond the area of erythema, crepitus, cutaneous anesthesia, and cellulitis that is
refractory to antibiotic therapy.6 Tenderness beyond the borders of the erythematous area
is an especially important clinical clue that develops as the infection in the deeper
cutaneous layers undermines the skin. Early in the course of a necrotizing soft tissue
infection, skin changes may be minimal despite extensive necrosis of the deeper
cutaneous layers. Bullae, blebs, cutaneous anesthesia, and skin necrosis occur as a result
of thrombosis of the nutrient vessels and destruction of the cutaneous nerves of the skin,
which typically occur late in the course of infection.
Clinicians should be mindful of certain diagnostic barriers that may delay recognition and
treatment of necrotizing soft tissue infections.7 In particular, these infections have a
variable clinical presentation. Although most patients present with an acute, rapidly
progressive illness and signs of systemic toxicity, a subset of patients may present with a
more indolent, slowly progressive infection. Patients with postoperative necrotizing
infections often have a more indolent course. Moreover, in the early stages, underlying
necrosis may be masked by normal-appearing overlying skin. As many as 20% of
necrotizing soft tissue infections are primary (idiopathic) and occur in previously healthy
patients who have no predisposing factors and no known portal of entry for bacterial
inoculation. Finally, crepitus is noted in only 30% of patients with necrotizing soft tissue
infections. Overall, fewer than 40% of patients exhibit the classic symptoms and signs
described.7,8Accordingly, it is imperative to maintain a high index of suspicion for this
disease in the appropriate setting.Read More on Soft Tissue Infection
Unit 1
1)
1/1
You are seeing a 31-year-old woman who presents with worsening sore throat, dry
cough, fever, and severe neck pain over the last week. She is otherwise healthy and takes
no medications.
Her vitals show a temperature is 102.5 °F, blood pressure is 99/68 mm Hg, pulse rate is
125/min, and respiration rate is 24/min. On exam she appears ill and her neck is tender to
palpation along the left side with overlying erythema, mild induration, without
lymphadenopathy. Her pharynx is erythematous, with tonsillar enlargement and no
exudates or ulcers. Her lungs are clear to auscultation. The remainder of the examination
is normal. Her chest x-ray shows multiple bilateral infiltrates. Labs show a leukocyte
count is 19,700/µL with 16% band forms. Hgb 10.8 g/dl, BUN 34 mg/dL, serum
creatinine level is 1.8 mg/dL. Which of the following tests is most likely to establish the
diagnosis?
Transthoracic echocardiography
The answer is B, The patient should undergo computed tomography (CT) of the neck
with contrast. She has fever, leukocytosis, sore throat, unilateral neck tenderness, and
multiple densities on chest radiograph, suggestive of septic emboli. The combination of
these factors points strongly toward Lemierre syndrome, which is septic thrombosis of
the internal jugular vein. The diagnosis should be suspected in anyone with pharyngitis,
persistent fever, neck pain, and septic pulmonary emboli. CT of the affected vessel with
contrast would confirm the diagnosis. Treatment includes intravenous antibiotics that
cover streptococci, anaerobes, and β-lactamase-producing organisms. Penicillin with a β-
lactamase inhibitor and carbapenem are both reasonable choices (eg, ampicillin-
sulbactam, piperacillin-tazobactam, ticarcillin-clavulanate).
Chest CT would better characterize the pulmonary infiltrates, but this information would
not provide specific diagnostic information that would guide therapy.
Soft tissue radiography of the neck cannot detect jugular vein filling defects or
thromboses, which are diagnostic of septic thrombophlebitis.
Echocardiography would be helpful to exclude right-sided endocarditis as a cause of
septic emboli. However, there is nothing in the history or on cardiac examination to
suggest a cardiac source of septic emboli. Centor RM, Samlowski R. Avoiding sore
throat morbidity and mortality: when is it not “just a sore throat?” Am Fam Physician.
2011;83:26, 28. PMID: 21888123
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2)
0/1
What is the most reliable predictor of survival in patient's diagnosed with Breast Cancer?
tumor grade
histologic type
The most reliable predictor of survival in breast cancer is the stage at the time of
diagnosis. Tumor size and lymph node involvement are the main factors to take into
account. Other prognostic parameters (tumor grade, histologic type, and lymphatic or
blood vessel involvement) have been proposed as important variables, but most
microscopic findings other than lymph node involvement correlate poorly with prognosis.
Estrogen receptor (ER) status may also predict survival, with ER-positive tumors
appearing to be less aggressive than ER-negative tumors. Ref: Abeloff MD, Armitage JO,
Niederhuber JE, et al (eds): Clinical Oncology, ed 3. Elsevier Churchill Livingstone,
2004, pp 2399-2401.
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3)
0/1
You are seeing 45-year old black female again in the office who presented to you initially
for a right sided breast mass. She has no past medical history or family history of breast
cancer. On physical exam you palpated a 2 cm mass just lateral to her right nipple. You
ordered a mammogram which cam back normal. What percentage of patients who are
found to have a normal mammogram have breast cancer after biopsy of a suspicious
lesion?
(Select 1)( 1pts extra credit)
5%
15%
25%
45%
The answer is A. A diagnostic mammogram is the first imaging study performed for
a woman with a new, palpable breast mass, and should be performed even if a recent
mammogram was negative. While the false negative rate of mammograms is less than 5
percent for clinically palpable breast cancers [15], a normal mammogram does not
eliminate the need for further evaluation of a suspicious mass [5]. For women under age
30 years, the breasts are hypersensitive to radiation exposure [16]; however, if the
clinical findings are suspicious, a mammogram should be performed. Read More
True
False Correct
The answer is false. The addition of ultrasound improves and helps make clinical
decisions. The sensitivity, specificity, positive and negative predictive
values for clinical examination plus mammography plus US were 96.9,
94.8, 39.2, and 99.9 percent, while the corresponding values for clinical
examination plus mammography were 91.5, 87, 19.7, and 99.7 percent,
respectivelyEvaluation of a palpable breast mass requires a systematic approach to the
history, physical examination, and radiographic imaging studies to ensure a correct
diagnosis. A missed diagnosis of breast cancer is one of the most frequent causes of
malpractice claims in the United States [1-3].
The clinical manifestations and diagnostic evaluation of women with a palpable breast
mass are reviewed here. Screening and epidemiology of breast cancer, benign breast
disease, breast pain, nipple discharge, breast cysts, and breast cancer are reviewed
separately.
Breast US is often added to the initial diagnostic evaluation for women with a suspected
breast cancer if there is a palpable mass or a density is seen on mammogram. The benefit
of this approach was suggested in a series of 2020 patients (470 with a palpable mass)
who underwent clinical exam, mammography, and breast US. The systematic addition of
breast US detected eight additional malignancies, and correctly downgraded 332 cases of
suspected malignancy to no suspected malignancy (predominantly cysts or
fibroadenoma). Thus, the main benefit of breast US was improved specificity when used
in a targeted manner. . From Up to Date
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5)
0/1
You are evaluating a 56-year old female for a suspicious breast mass in her right breast.
Her last mammogram 2 years ago was normal and you have sent her for another
mammogram. She denies family history of cancer and has no current medical problems.
Which of the following calcification patterns is more suspicious for a ductal carcinoma in
situ?
Round calcifications
The answer is A, linear calcifications. The histologic hallmark of DCIS is the presence of
malignant-appearing cells confined to the lumen of the ductal system in the breast. DCIS
is most often diagnosed because of the presence of calcifications clustered in one area of
the breast. The calcifications suspicious for DCIS are often linear (not round), growing in
a ductal distribution. The DCIS may not be confined to the extent of calcifications, and
not all DCIS is manifested by calcification. Therefore, the size or extent of DCIS may not
be defined by the mammographic appearance. Although DCIS occasionally presents as a
mass, the presence of the mass even in the setting of a biopsy showing DCIS most often
signifies that the cancer is primarily invasive. Read more on Breast Cancer
Popcorn calcification in the breast is the classical
description for the calcification seen in involuting
fibroadenomas, which as the name suggests has a pop
corn like appearance.
Egg shell calcifications in the breast are benign
peripheral rim like calcifications
Read More on Breast Calcification patterns
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Unit 2
6)
0/1
Nonoperative Management of solid-organ injuries can be pursued in hemodynamically
stable patients who do not have overt peritonitis or other indications for laparotomy.
According to contemporary data, what percentage of patients with splenic injuries are
candidates for nonoperative management?
(Select 1)(1pts)
<10%
25%
45%
60%
Thoracoscopy
Laparotomy
The answer is D. This patient suffered a ruptured diaphragm and chest tube placement
appears to have ruptured the bowel as evidence from the greenish fluid that was returned.
She needs an emergent laparotomy to control bleeding and repair her diaphragm. Read
More
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8)
0/1
You are seeing a 20-year-old male in hospital 12 hours after he was admitted for
observation following an MVC. Initially he was complaining of left sided chest wall pain
after his car was t-boned on the passenger side. His initial physical examination showed
bruises on the anterior chest wall and upper abdominal wall. X-rays revealed fractures
of his sixth and seventh ribs on the left (but no pneumothorax or pleural effusion). A
FAST Exam did not show any free intraperitoneal fluid. Currently, he complains of
worsening epigastric pain, left shoulder pain and mild nausea. His current vitals show his
blood pressure is now 95/60 and pulse rate 115 beats/min, and O2 saturation is 96% on
room air. Which of the following is the next best step in treatment?
(Select 1)(1pts)
Transesophageal echocardiogram
This patient presents with blunt abdominal trauma with the delayed onset of hypertension
and signs and symptoms worrisome for likely splenic injury. Most common injuries are
to the spleen, liver, and less common injuries are to the hollow viscous organs in the
abdomen. Symptoms and signs suggesting splenic injury include left upper quadrant pain,
abdominal wall contusion, left lower chest wall tenderness, hypotension, and left
shoulder. Pain referred from splenic hemorrhage, hitting the phrenic nerve and diaphragm
(Kehr sign). The initial examination after blunt abdominal trauma can be unremarkable
and the symptoms can occur hours later, indicating ongoing splenic injury. The best
choice here would be an abdominal CT scan with intravenous contrast, only (no oral
contrast is needed because as little utility). This will define organ injury, assess for
presence of bleeding in all abdominal compartments, determine the need for surgery.
The spleen is the second most commonly injured abdominal organ in blunt trauma
patients. Historical studies have reported a 10% mortality with all splenic injuries;
however, isolated splenic injury mortality is less than 1%. The mechanisms of injury are
similar to those seen with liver injuries: motor vehicle collisions, autopedestrian
accidents, and falls. Similar to penetrating trauma to the liver, stab wounds to the spleen
typically result in direct linear tears, whereas gunshot wounds result in significant
cavitary injuries.
Until the 1970s, splenectomy was considered mandatory for all splenic injuries.
Recognition of the immune function of the spleen refocused efforts on splenic salvage in
the 1980s.38,39Following success in pediatric patients, NOM of splenic injuries was
adopted in the adult population and has become the prevailing strategy for blunt splenic
trauma.40
Addressing the patient's ABC's, examining the patient's abdomen, and performing
adjunctive imaging with FAST and CT are the initial steps of diagnosing a patient's
splenic injury. Hypotension with a positive FAST scan should prompt emergent
laparotomy. For patients with an identified blunt splenic injury on a CT scan, the injury
should be graded according to the AAST injury grading scale [see Table 1].3
Similar to liver injuries, the grade of splenic injury predicts failure rates and complication
rates of NOM. Other findings that should be searched for on a CT scan include contrast
extravasation (is the contrast blush contained within the spleen, or does it spill into the
peritoneum?), the amount of intra-abdominal hemorrhage (is it isolated to the splenic
fossa, or does blood extend into the pelvis?), and the presence of pseudoaneurysms.
NONOPERATIVE MANAGEMENT
It is clear, however, that 20 to 30% of patients with splenic trauma deserve early
splenectomy and that failure of NOM often represents poor patient selection.53,54 In
adults, indications for prompt laparotomy include initiation of blood transfusion within
the first 12 hours considered to be secondary to the splenic injury or hemodynamic
instability. In the pediatric population, blood transfusions up to half of the patient's blood
volume are used prior to operative intervention. Following the first 12 postinjury hours,
indications for laparotomy are not as black and white. Determination of the patient's age,
comorbidities, current physiology, degree of anemia, and associated injuries will
determine the use of transfusion alone versus intervention with either embolization or
operation. Unlike hepatic injuries, which rebleed in 24 to 48 hours, delayed hemorrhage
or rupture of the spleen can occur up to weeks following injury. Algorithms for the
management of pediatric splenic injuries exist,55 and the patient's physiologic status is
the key determinant. Rapid mobilization in patients who are hemodynamically stable with
a stable hematocrit and no abdominal pain is generally successful. Overall, nonoperative
treatment obviates laparotomy in more than 90% of cases.
Follow-up Imaging
Out of concern over the risk of delayed hemorrhage or other complications, follow-up CT
scans have often been recommended; unfortunately, there is no consensus as to when or
even whether they should be obtained. Patients with grade I or II splenic injuries rarely
show progression of the lesion or other complications on routine follow-up CT scans; it is
reasonable to omit such scans if patients' hematocrits remain stable and they are
otherwise well. Patients with more extensive injuries often have a less predictable course,
and CT may be necessary to evaluate possible complications. Routine CT before
discharge, however, is unwarranted. Outpatient CT, however, in patients who participate
in vigorous or contact sports should be performed at 6 weeks to document complete
healing before resuming those activities. A more convenient and less expensive
alternative to follow-up CT is ultrasonographic monitoring of lesions.
In penetrating abdominal injuries not suitable for NOM and in blunt abdominal injuries
when NOM is contraindicated or has failed, exploratory laparotomy is performed.
To ensure safe removal or repair, the spleen should be mobilized to the point where it can
be brought to the surface of the abdominal wall without tension. An incision is made in
the peritoneum and the endoabdominal fascia, beginning at the white line of Toldt along
the descending colon and continuing cephalad 1 to 2 cm lateral to the posterior peritoneal
reflection of the spleen; this plane of dissection is continued superiorly until the
esophagus is encountered [see
Figure 15a]. Posteriorly, blunt dissection is performed to mobilize the spleen and
pancreas as a composite away from Gerota fascia and up and out of the retroperitoneum;
this posterior plane may be extended to the aorta if necessary [seeFigure 15b].
Additionally, the attachments between the spleen and the splenic flexure of the colon may
be divided to avoid avulsion of the inferior splenic capsule. Care must be taken not to
pull on the spleen; otherwise, it will tear along the posterior peritoneal reflection, causing
significant hemorrhage. It is often helpful to rotate the operating table 20° to the patient's
right so that the weight of the abdominal viscera facilitates viscera retraction. Any
ongoing hemorrhage from the splenic injury may be temporarily controlled with digital
occlusion of the splenic hilar vessels. Once mobilization is complete, the spleen can be
repaired or removed without any need to struggle to achieve adequate exposure.
Figure 16] for partial immunocompetence in younger patients.56 Drains are not used.
Partial splenectomy can be employed in patients in whom only the superior or inferior
pole has been injured. Hemorrhage from the raw splenic edge is controlled with a
horizontal mattress suture, with gentle compression of the parenchyma [see
Enthusiasm for splenic salvage was driven by the rare but often fatal complication of
overwhelming postsplenectomy sepsis (OPSS). OPSS is caused by encapsulated
bacteria,Streptococcus pneumoniae, Haemophilus influenzae,
and Neisseria meningitidis, which are resistant to antimicrobial treatment. In
patients undergoing splenectomy, prevention against these bacteria is provided via
vaccines administered optimally at 14 days but definitely prior to hospital
discharge.57 Vaccines to be administered include Pneumovax (Merck & Co., Inc.,
Whitehouse Station, NJ), Menactra (Sanofi Pasteur, Swiftwater, PA), and Fluvirin
(Novartis, East Hanover, NJ). Revaccination remains open to debate, but some argue for
revaccination every 6 years.
2014. Scientific American Surgery. Hamilton, Ontario & Philadelphia, PA. Decker
Intellectual Properties Inc. ISSN 2368-2744. STAT!Ref Online Electronic Medical
Library. http://online.statref.com/Document.aspx?fxId=61&docId=2297. 10/17/2014
4:45:39 AM CDT (UTC -05:00).
<1%
5-10-%
10-20%
20-30%
The answer is A, The spleen is one of the most commonly injured abdominal organs in
blunt trauma patients. Historical studies have reported 10% mortality with all splenic
injuries; however, isolated splenic injury mortality is less than 1%. The mechanisms of
injury are similar to those seen with liver injuries: motor vehicle collisions, automobile-
pedestrian collisions, falls, and any type of penetrating injury. Stab wounds to the
abdomen are less likely to cause spleen injury compared with liver injury due to the
spleen's protected location. Stab wounds to the abdomen are less likely to cause injury to
the spleen than to the liver, due to its protected location.
Until the 1970s, splenectomy was considered mandatory for all splenic injuries.
Recognition of the immune function of the spleen refocused efforts on splenic salvage in
the 1980s.1,2 Following success in pediatric patients, nonoperative management (NOM)
of splenic injuries was adopted in the adult population and has become the prevailing
strategy for blunt splenic trauma. Read more
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Unit 3
10)
0/1
The liver is the most commonly injured solid organ in blunt trauma, comprising 5% of all
trauma admissions. With that being said, over 80% of patients with liver injuries may be
managed nonoperatively. Which of the following is not a predictor of nonoperative
management?
(1pts)
Female sex
Increasing age
Hypotension
The answer is A, female sex. Over 80% of patients with liver injuries may be managed
nonoperatively. One of the early studies to test the application of NOM in 1995 supported
its broad application, with an overall success rate greater than 85% in hemodynamically
stable patients, despite substantial hemoperitoneum documented by CT.11 Of the 8% of
patients who failed NOM, half required operation as a result of associated injuries (i.e.,
enteric or pancreatic injuries), whereas half underwent laparotomy for hepatic-related
hemorrhage. Patients who require intervention for hemorrhage typically fail NOM in the
first 24 to 48 hours.2,11,17 Patients who fail NOM due to associated enteric or pancreatic
injury have a more variable time frame to presentation17; half manifested symptoms
within 48 hours, with the remainder becoming symptomatic up to 3 weeks later. Perhaps
not surprisingly, those patients who failed NOM had failure rates associated with
increasing grades of hepatic injury, with grade V injuries having a greater than 20%
failure rate. Subsequent studies have reported failure rates of 14% in grade IV injuries
and 23% in grade V injuries.12 The most recent analysis of the National Trauma Data
Bank of severe blunt liver injuries (grade IV and V) identified that initial NOM occurred
in 73%, with a failure rate of 7%.16 Interestingly, failure of NOM was associated with
higher mortality. Predictors of failure of NOM included increasing age, male sex,
increasing Injury Severity Score, decreasing Glasgow Coma Scale score, and
hypotension. A similar study of high-grade liver injuries identified a similar pattern with
NOM initiated in 66% patients with a failure rate of 9%.18 The amount of
hemoperitoneum evident on a CT scan appears to correlate with successful management;
patients with a large amount of hemoperitoneum (i.e., blood extending into the pelvis) are
more likely to fail NOM. However, predicting which patients will ultimately require
laparotomy has yet to be accomplished. Read more
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11)
0/1
You are seeing a 34-year old female in the trauma following an MVC. He is complaining
intense diffuse abdominal pain after his car was hit from behind causing him to spin out
and crash into a wall. Initially he had a GCS of 15. His vitals showed a BP of 125/76, HR
95, RR 18, O2 of 98% on room air. On physical exam his lungs are clear and his
abdomen shows diffuse tenderness to light palpation and ecchymosis over his
epigastrium. His initial fast exam is negative but technically limited and you order a CT
scan with IV contrast of his abdomen and pelvis as you suspect a possible liver
injury. What description from the options below accurately describes a grade IV liver
laceration on CT imaging?
(Select 1)(1pts)
Sub capsular hematoma, > 50% surface area, or ruptured with active
bleeding
Spleen
Liver
Kidneys
Small Intestines
The liver is the most commonly injured solid organ in blunt trauma, comprising 5% of all
trauma admissions, and because of its size is frequently involved in penetrating trauma.
Following blunt trauma, the most commonly injured structures are the parenchyma and
hepatic veins. Blunt forces dissipate along segments of the liver and along the fibrous
coverings of the portal triad structures; the hepatic veins, however, are not so insulated.
Given its size and location within the abdomen, the liver is also commonly involved in
penetrating trauma. Stab wounds typically result in direct linear tears, whereas gunshot
wounds or shotgun wounds result in significant cavitary injuries attributable to blast
effect and the "tumbling" of the missile within the liver parenchyma. Thus, arterial injury
is more common with penetrating trauma.
Over the past 20 years, nonoperative management (NOM) of liver injuries has evolved to
become the prevailing therapeutic strategy for blunt hepatic trauma. Several concurrent
changes resulted in this paradigm change. First was the realization that diagnostic
peritoneal lavage (DPL) was sensitive but not specific for identifying intraperitoneal
hemorrhage that necessitated operative management. Surgeons recognized that many
laparotomies undertaken for a positive DPL were associated with liver injuries that did
not require intervention for bleeding.1Second, trauma surgeons noted that nonbleeding
hepatic venous injuries, if manipulated at laparotomy, often resulted in more hemorrhage
and sometimes even death.2 Furthermore, it became conspicuous that with hemostasis
achieved in the operating room, recurrent postoperative bleeding was rare. Therefore,
surgeons queried whether hepatic venous injuries, which are low-pressure system
injuries, could heal without intervention. Finally, computed tomography (CT) provided a
reliable method for diagnosing and grading liver injuries.
The spleen is the second most commonly injured abdominal organ in blunt trauma
patients. Historical studies have reported a 10% mortality with all splenic injuries;
however, isolated splenic injury mortality is less than 1%. The mechanisms of injury are
similar to those seen with liver injuries: motor vehicle collisions, autopedestrian
accidents, and falls. Similar to penetrating trauma to the liver, stab wounds to the spleen
typically result in direct linear tears, whereas gunshot wounds result in significant
cavitary injuries.
Until the 1970s, splenectomy was considered mandatory for all splenic injuries.
Recognition of the immune function of the spleen refocused efforts on splenic salvage in
the 1980s.38,39Following success in pediatric patients, NOM of splenic injuries was
adopted in the adult population and has become the prevailing strategy for blunt splenic
trauma.
Duodenal and pancreatic injury continues to challenge the trauma surgeon. The relatively
rare occurrence of these injuries, the difficulty in making a timely diagnosis, and high
morbidity and mortality rates justify the anxiety these unforgiving injuries invoke.
Mortality rates for pancreatic trauma range from 9 to 34%, with a mean rate of 19%.
Duodenal injuries are similarly lethal, with mortality rates ranging from 6 to 25%.
Complications following duodenal or pancreatic injuries are alarmingly frequent,
occurring in 30 to 60% of patients.1-3 Recognized early, the operative treatment of most
duodenal and pancreatic injuries is straightforward, with low morbidity and mortality.
2014. Scientific American Surgery. Hamilton, Ontario & Philadelphia, PA. Decker
Intellectual Properties Inc. ISSN 2368-2744. STAT!Ref Online Electronic Medical
Library. http://online.statref.com/Document.aspx?fxId=61&docId=2329. 10/27/2014
1:39:15 PM CDT (UTC -05:00).
<10%
25%
50%
75%
The answer is A, During the last century, the management of blunt force trauma to the
liver has changed from observation and expectant management in the early part of the
1900s to mainly operative intervention, to the current practice of selective operative and
nonoperative management. A 2008 study by Tinkoff et al.4 showed that 86.3% of hepatic
injuries are now managed without operative intervention. The current reported success
rate of nonoperative management of hepatic trauma ranges from 82% to 100%. Most
blunt liver trauma (80% in adults, 97% in children) patients are currently treated
conservatively. The success of non-operative management depends upon proper selection
of the patient. The patients, who are managed non-operatively, usually have grade I and
II liver injuries, hemoperitoneum less than 900 ml and blood transfusion of less than 3
units. The contraindications to non-operative management include refractory
hypotension, signinficant fall in haematocrit, the extravasations of intravenous contrast
agent, expanding haematoma and grade IV and V liver injury on CECT abdomen. The
patients of grade III liver injuries need very close observation as they may require
surgical intervention during first 24 hours. The failure rate of non-operative management
is not more than 5% inmost studies. It seems that patients with grade VI injuries rarely
reaches to the hospital alive and are not salvageable. Therefore, such injuries are usually
documented on autopsy. Mortality from blunt hepatic trauma is about 5% and is related
to uncontrolled hemorrhage.
Interventional radiology may be needed to perform an angiogram and embolization for
bleeding or to percutaneously drain an abscess or b iloma. An endoscopic retrograde
cholangiopancreatogram (ERCP) and stent placement may be required for biliary leak.
Even when such complications of the liver injury develop, only 15% require operative
intervention. Hepatic artery angiography with embolization is an important tool for the
stable patient with contrast extravasation who is being managed nonoperatively. It can
also be invaluable for the postoperative patient who has been stabilized by perihepatic
packing or who has rebled after an initial period of stability. Angioembolization has a
greater than 90% success rate in the control of bleeding with a low risk of rebleeding and
a reduction in required volume of transfusion. Read More
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Unit 4
14)
0/1
A 30-year old white female presents to your office with right breast pain. She is currently
breast feeding her healthy 4-week old infant and has been having focal tenderness,
swelling and redness to her right breast near the nipple over the last 2 days. She reports
no past medical history and is a non smoker. Given the patient’s history and physical,
which of the following inflammatory disorders is the most likely diagnosis?
(Select 1)(1pts)
Acute mastitis
Granulomatous mastitis
(Select 1)(1pts)
Fibroadenoma
Cystosarcoma phyllodes
The answer is B, Fibroadenoma. Most breast masses in adolescent girls are benign.
Fibroadenoma is the most common, accounting for approximately two-thirds of all
adolescent breast masses. It is characterized by a slow growing, nontender, rubbery, well-
defined mass, most commonly located in the upper, outer quadrant. Size varies, and is
most commonly in the range of 2–3 cm. Fibrocystic disease is found in older adolescents
and is characterized by bilateral nodularity and cyclic tenderness. Benign breast cysts are
characterized by a spongy, tender mass with symptoms exacerbated by menses. Cysts are
frequently multiple, and spontaneous regression occurs in 50% of patients. Cystosarcoma
phyllodes is a rare tumor with malignant potential, although most are benign. It presents
as a firm, rubbery mass that may enlarge rapidly. Skin necrosis is usually associated with
the tumor. Intraductal papillomas are usually benign but do have malignant potential.
They are commonly subareolar and are associated with nipple discharge. These tumors
are rare in the adolescent population. Ref: Hay WH (ed): Current Pediatric Diagnosis and
Treatment, ed 16. McGraw-Hill, 2003, pp 122-123.
Fibroadenoma
Intraductal papilloma
Cystosarcoma Phyllodes
Mammary dysplasia
The answer is B, Intraductal papilloma. The old concern over cancer is the issue, and the
way to detect cancer that is not palpable is with a mammogram. That should be the first
choice. If negative, one may still wish to find an resect the intraductal papilloma to
provide symptomatic relief. Intraductal papillomas consist of a monotonous array of
papillary cells that grow from the wall of a cyst into its lumen. Although they are not
concerning in and of themselves, they can harbor areas of atypia or ductal carcinoma in
situ (DCIS). Papillomas can occur as solitary or multiple lesions. The standard approach
to a papilloma diagnosed by core needle biopsy (CNB) is to perform a surgical excision,
particularly if atypical cells are identified [14,16-21]. In a meta-analysis of 34 studies
that included 2236 non-malignant breast papillary lesions, 346 (15.7 percent) were
upgraded to malignancy following a surgical excision [21]. Because of a risk of
malignancy, these require surgical excision.Read More
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17)
0/1
A 25 -ear obese black female presents to you with a painful breast lump along with
tenderness in both her breasts. She notes recurrent pain and multiple lumps on both
breasts that seem to “come and go” at different times during her menses. Now she has a
firm, round, mass that has not gone away for the last 5 weeks. What is the most likely
diagnosis?
(Select 1)(1pts)
Cystosarcoma Phyllodes
Intraductal papilloma
Fibrocystic disease
Fibroadenoma
The answer is C. This patient has fibrocystic disease which is a nonproliferative epithelial
lesions that are generally not associated with an increased risk of breast cancer [1]. It
should be noted that terms such as fibrocystic changes, fibrocystic disease, chronic cystic
mastitis, and mammary dysplasia refer to nonproliferative lesions and are not useful
clinically, as they encompass a heterogeneous group of diagnoses [5,11]. The most
common nonproliferative breast lesions are breast cysts. Other nonproliferative lesions
include papillary apocrine change, epithelial-related calcifications, and mild hyperplasia
of the usual type [5]. Apocrine metaplasia (also referred to as a "benign epithelial
alteration") is also a nonproliferative change that is secondary to some form of irritation,
typically associated with a breast cyst. Read More
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Unit 5
18)
0/1
You are seeing a 43-year old Hispanic female who is presenting with an enlarging mass
in her right breast. It has been present for several years and growing to it’s present size.
On examination of her right breast you note a large 10 cm mass that is mobile, firm
and rubbery. There are no palpable axillary nodes. What is the most likely diagnosis?
(Select 1)(1pts)
Fibroadenoma
Fibrocystic disease
Intraductal papilloma.
Cystosarcoma Phyllodes
Mammogram
Breast Ultrasound
Core Biopsy
Excisional Biopsy
True
False Correct
Medullary carcinoma
Mucinous carcinoma
Presence of fever
Presence of leukocytosis
Depth of inflammation
Presence of purulence
The answer is C, depth of inflammation. Cellulitis and erysipelas are diffuse spreading
skin infections that not associated with underlying suppurative foci. Clinically, there is
often some degree of overlap between the two different entities. Erysipelas is
differentiated from cellulitis by the depth of inflammation; erysipelas affects the upper
dermis, including the superficial lymphatics, whereas cellulitis affects the deeper dermis
and subcutaneous fat (Mayo Clin Proc, Vol. 89;1436). Read More onCellulitis and
erysipelas from Up to Date
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23)
1/1
What is the most common causative pathogen of Lemierre disease, an infection of the
parapharyngeal space that leads to septic thrombophlebitis of the internal jugular vein
with bacteremia and metastatic pulmonary nodules.
(Select 1)(1pts)
C. diphtheriae
Fusobacterium necrophorum
Infectious mononucleosis
Streptococcus pyogenes
Levofloxacin
Doxycycline
Dicloxacillin
Cephalexin
Ciprofloxacin
Fewer than 40% of patients with Patients with Necrotizing Soft Tissue
Infections exhibit the classic symptoms and signs described
The answer is B, crepitus is noted in only 30% of patients with necrotizing soft tissue
infections. Patients with necrotizing soft tissue infections often complain of severe pain
that is out of proportion to their physical findings. Compared with patients who have
nonnecrotizing infections, they are more likely to have fever, bullae, or blebs [see Figure
1]; signs of systemic toxicity; hyponatremia; and leukocytosis with a shift in immature
forms. Physical findings characteristic of a necrotizing infection include tenderness
beyond the area of erythema, crepitus, cutaneous anesthesia, and cellulitis that is
refractory to antibiotic therapy.6 Tenderness beyond the borders of the erythematous area
is an especially important clinical clue that develops as the infection in the deeper
cutaneous layers undermines the skin. Early in the course of a necrotizing soft tissue
infection, skin changes may be minimal despite extensive necrosis of the deeper
cutaneous layers. Bullae, blebs, cutaneous anesthesia, and skin necrosis occur as a result
of thrombosis of the nutrient vessels and destruction of the cutaneous nerves of the skin,
which typically occur late in the course of infection.
Clinicians should be mindful of certain diagnostic barriers that may delay recognition and
treatment of necrotizing soft tissue infections.7 In particular, these infections have a
variable clinical presentation. Although most patients present with an acute, rapidly
progressive illness and signs of systemic toxicity, a subset of patients may present with a
more indolent, slowly progressive infection. Patients with postoperative necrotizing
infections often have a more indolent course. Moreover, in the early stages, underlying
necrosis may be masked by normal-appearing overlying skin. As many as 20% of
necrotizing soft tissue infections are primary (idiopathic) and occur in previously healthy
patients who have no predisposing factors and no known portal of entry for bacterial
inoculation. Finally, crepitus is noted in only 30% of patients with necrotizing soft tissue
infections. Overall, fewer than 40% of patients exhibit the classic symptoms and signs
described.7,8Accordingly, it is imperative to maintain a high index of suspicion for this
disease in the appropriate setting.Read More on Soft Tissue Infection
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Unit 1
1)
0/1
A 43-year old obese male presents with worsening pain around his umbilicus over the last
2 days. He the bulging goes away when he lies down but it has continued to be stuck out
and is severely painful. Which of the following signs is an indication for immediate
surgery?
erythematous
warmth
edematous
non reducible
Hamartomatous polyp
Tubular adenoma
Villous adenoma
Tubulovillous adenoma
The answer is C, Villous adenoma. Adenomatous polyps are the most common of the
classically neoplastic polyps. About two-thirds of all colonic polyps are adenomas.
Adenomas are by definition dysplastic and thus have malignant potential. Most colorectal
cancers arise from adenomas, but only a small minority of adenomas progress to cancer
(5 percent or less). Studies reporting the average age at presentation of patients with
adenomatous polyps versus colorectal cancer suggest the time for development of
adenomas to cancer is about 7 to 10 years. Hamartomatous (or juvenile) polyps and
hyperplastic polyps are benign lesions and are not considered to be premalignant.
Adenomas, on the other hand, have the potential to become malignant. Sessile adenomas
and lesions >1.0 cm have a higher risk for becoming malignant. Of the three types of
adenomas (tubular, tubulovillous, and villous), villous adenomas are the most likely to
develop into an adenocarcinoma.
An advanced adenoma is any adenoma with high-grade dysplasia, an
adenoma that is >10 mm in size, or an adenoma with a villous
component. Adenomas without villous components are also referred to
as tubular adenomas.
A synchronous adenoma is an adenoma that is diagnosed at the same
time as an index colorectal neoplasm (a pathologically more advanced
lesion). Thirty to fifty percent of colons with one adenoma will contain
at least one other synchronous adenoma .
A metachronous adenoma is an adenoma that is diagnosed at least six
months after the diagnosis of a previous adenoma.
Ref: Fauci AS, Braunwald E, Kasper DL, et al (eds):Harrison’s Principles of
Internal Medicine, ed 17. McGraw-Hill, 2008, p 574. Read more on Approach to
the patient with colonic polyps.
Endometriosis
Collagenous colitis
Melanosis coli
This patient has typical findings of melanosis coli, the term used to describe black or
brown discoloration of the mucosa of the colon. It results from the presence of dark
pigment in large mononuclear cells or macrophages in the lamina propria of the mucosa.
The coloration is usually most intense just inside the anal sphincter and is lighter higher
up in the sigmoid colon. The condition is thought to result from fecal stasis and the use of
anthracene cathartics such as cascara sagrada, senna, and danthron. Ectopic endometrial
tissue (endometriosis) most commonly involves the serosal layer of those parts of the
bowel adjacent to the uterus and fallopian tubes, particularly the rectosigmoid colon.
Collagenous colitis does not cause mucosal pigmentary changes. Melanoma rarely
metastasizes multicentrically to the bowel wall. Multiple arteriovenous malformations are
more common in the proximal bowel, and would not appear as described. Ref: Feldman
M, Friedman LS, Sleisenger MH (eds): Sleisenger & Fordtran’s Gastrointestinal and
Liver Disease, ed 7. WB Saunders Co, 2004, p 2305. 2) Hardman JG, Limbird LE,
Gilman AG (eds): Goodman & Gilman’s The Pharmacological Basis of Therapeutics, ed
10. McGraw-Hill, 2001, pp 1046-1047. 3) Kasper DL, Braunwald E, Fauci AS, et al
(eds): Harrison’s Principles of Internal Medicine, ed 16. McGraw-Hill, 2005, pp 231-233.
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4)
0/1
What percentage of abdominal wall hernias are found in the groin?
10%
25%
50%
75%
Approximately 75% of all abdominal wall hernias are seen in the groin. An Inguinal
hernia is much more common in men than women. Although femoral and umbilical
hernias are more common in female population, indirect inguinal hernia is still the most
common type of hernia in women. Age is a factor for incidence and type of inguinal
hernia; incidence increases by age 2 . Indirect hernia is more common in young and direct
hernia in the elderly. Read more
Grade II
Grade III
Grade IV
<5%
10%
20%
30%
The answer is C, 20%. As many as 20% of CRC patients have metastatic disease at the
time of the initial presentation. The need for surgical intervention in this group is not well
defined. Clearly, surgical resection or diversion is indicated in patients who present with
significant bleeding, perforation, or obstruction. In asymptomatic patients with
unresectable metastatic disease, the role of surgical resection of the primary lesion
remains controversial. In patients with resectable metastatic disease (e.g., isolated liver or
lung metastases), curative resection may be undertaken.
A recent review of 233 patients with synchronous stage IV colorectal cancer found that
217 patients (93%) never required surgical palliation of the primary tumor; 16 patients
(7%) needed emergency surgery for obstruction or perforation of the primary tumor; 10
patients (4%) were managed nonoperatively.68,122
Management of patients with synchronous resectable isolated liver metastases continues
to evolve. Multiple studies have documented improved survival after liver resection in
patients with metastatic disease confined to the liver. Patients presenting with
synchronous lesions have a worse prognosis than those presenting with metachronous
lesions.123 Many of these patients have been managed with staged resections of their
primary cancers and the liver metastases. Several groups have reported that such
combined procedures do not substantially increase surgical morbidity and mortality or
compromise cancer survival.124,125 These combined procedures should be done only in
carefully selected patients, at specialized centers where there is significant experience in
resection of both CRCs and liver tumors. Read more
12-24 hours
1-2 days
3-5 days
7-14 days
The answer is D, 7-14 days. CEA remains the prototypical solid tumor marker. Despite
its lack of specificity, if used correctly, CEA testing is a valuable addition to the process
of clinical decision making in patients diagnosed with colon or rectal carcinoma.
However, it is not an appropriate screening test. Whether sampled once or serially, CEA
cannot be used in the differential diagnosis of an unknown-but-suspected bowel problem
or malignancy. Nevertheless, when CEA concentrations are determined before primary
tumor resection, they may be of additional prognostic value; this is particularly true in
patients with stage II disease, for whom elevated preoperative CEA is a poor prognostic
marker and may influence the decision regarding whether to administer adjuvant
chemotherapy.
Serial CEA values obtained postoperatively are a potentially effective means of
monitoring response to therapy. A postoperative CEA titer serves as a measure of the
completeness of tumor resection. It should be remembered, however, that the half-life of
CEA is 7 to 14 days; therefore, postoperative baselines are best established several weeks
after resection. If a preoperatively elevated CEA value does not fall to normal within 2 to
3 weeks after surgery, it is likely that (1) the resection was incomplete or (2) occult
metastases are present. A rising trend in serial CEA values from a normal postoperative
baseline (< 5 ng/mL) may predate any other clinical or laboratory evidence of recurrent
disease by 6 to 9 months. Read more
(Select 1)(1pts)
20%
40%
60%
80%
The answer is D, 80%. Eighty percent of patients who recur after curative resection of
colon and rectal carcinomas do so within 3 years. Therefore, any posttreatment plan
should include regular follow-up during at least these 3 years. An additional biologic
precept in designing follow-up should take into account the efficacy of therapy once
recurrent disease is identified. It is important to note that the role of surveillance is to
identify recurrent disease that can be resected with true curative intent; early
identification of asymptomatic, incurable disease is exceedingly unlikely to improve
outcome as there are neither data nor a compelling rationale to believe that outcome
would be improved by earlier institution of noncurative treatment, such as systemic
chemotherapy.
In general, if a patient is a candidate for resection of recurrent disease (e.g., hepatic
resection), serum carcinoembryonic antigen (CEA) testing should be performed every 3
to 6 months for 2 years and then every 6 months for 5 years after resection of the primary
tumor. Chest, abdomen, and pelvis CT is recommended annually for 3 years for patients
at high risk for recurrence. PET-CT is not recommended in NCCN, ASCO, or CCO
guidelines and should not be used for the purpose of postoperative surveillance.
Colonoscopy should be performed 1 year after surgery or 3 to 6 months after surgery if
not performed preoperatively due to an obstructing lesion, and then 3 years later, and then
every 5 years, unless findings or specific risk factors dictate more frequent
evaluations. Read more
Chemotherapy
Radiation
(Select 1)(1pts)
3% to 5%
5% to 10%
10% to 25%
25% to 40%
The answer is A, Upright Chest Xray followed by a chest tube. This patient is awake and
talking. He is stable enough for a chest xray followed by chest tube placement. A needle
thoracotomy to should be done if he has evidence of tension pneumothorax which would
be respiratory distress and hypotension. He will likely then need a chest tube and can be
further managed. Read More
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12)
0/1
You are seeing a 20-year old female that was stabbed in the chest by an attacker 15
minutes prior to arrival. EMS noted she was initially awake and talking but has since
become less talkative and more lethargic. Vitals signs show her blood pressure is
60/palp, heart rate 120 beats/min, respiratory rate 28/min and O2 92% on a non re-
breather. On physical exam her eyes are closed but arouses to painful stimuli and loud
voice. She has distended neck veins and muffled heart sounds. Chest exam reveals a 2-cm
wound just to left of her sternum. What is the next best step in management?
(Select 1)(1pts)
Pericardiocentesis
This young lady has been stabbed in the heart and has evidence of cardiac tamponade.
She needs an immediate percicardiocentesis. A chest tube will not help with this problem
and she is too unstable for an emegent echo or upright xray.Read more on the
initial evaluation of chest trauma
(Select 1)(1pts)
Exploratory laparotomy
Endoscopic injury to the duodenum deserves special mention here as it is a specific type
of duodenal trauma that may be commonly encountered by surgeons, even when trauma
does not make up a large part of their practice. There is literature that reports many of
these injuries being treated nonoperatively.42This is consistent with similar nonoperative
management of other isolated grade I or II injuries. However, as with any other type of
trauma, the clinical status of the patient and standard indications for laparotomy should
dictate the need for surgery.43 CT has been reported as the imaging test of choice to
diagnose perforation from endoscopy if immediate indications for laparotomy do not
exist.44 Often the pressure can be high to pursue a nonoperative approach as surgery was
likely not on the patient's or endoscopist's schedule, but clinical parameters should dictate
the appropriate course of action. Again, endoscopic trauma to the duodenum should
follow the same principles of evaluation and treatment as other mechanisms and the
patient course dictate treatment.
As noted above, operative treatment of duodenal injuries has two major components: the
repair and evaluating the need for leak "preparation." The repair itself must follow the
basic principles of all anastomosis: approximation of well-vascularized, healthy, tension-
free tissue. "Preparation" maneuvers are not required for most injuries and are debated.
They are discussed below.
If any of the basic principles cannot be met with simple approximation or if the resultant
repair would narrow the lumen of the duodenum, other options are available for repair.
The next option considered is often resection of the involved portion of duodenum and
primary anastomosis.48 Again, for this to have a maximal chance of success, the
anastomosis must be between well-vascularized, healthy, tension-free tissues. Another
option is a Roux-en-Y duodenojejunostomy. This is more likely to be necessary with D2
injuries not amenable to simple approximation. The pancreaticoduodenectomy with
pancreaticojejunostomy, gastrojejunostomy, and hepaticojejunostomy reconstruction
(Whipple procedure) is rarely needed in duodenal trauma and is discussed below.
Randomized comparison of one repair versus another is absent, but most reviews
consider simple approximation to be the most commonly required and most commonly
used repair.
2014. Scientific American Surgery. Hamilton, Ontario & Philadelphia, PA. Decker
Intellectual Properties Inc. ISSN 2368-2744. STAT!Ref Online Electronic Medical
Library. http://online.statref.com/Document.aspx?fxId=61&docId=2329. 10/17/2014
5:10:16 AM CDT (UTC -05:00).
Cystography
Placement of a urinary catheter
Intravenous pyelography
The answer is A. This injury often follow pelvic fractures and classically present with
blood at the urethral meatus, an ability to void and a high riding or a non palpable
prostate to an intern. If you suspect urethral injury a retrograde urethrogram needs to be
performed prior to foley insertion. This procedure will locate the damage of the urethra, if
present. Inserting a Foley before this procedure is contraindicated as this can worsen the
urethral tear and potentially cause infection or a hematoma (you do not want to cause or
worsen the chance of a urethral stricture). These injuries often need surgical repair,
especially anterior urethral injuries. Some are treated with urinary diversion via
suprapubic catheter while the primary injury heals. Read more
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16)
0/1
You are seeing a 25-year old male in the trauma bay after he was involved in a motor
vehicle accident. He was thrown from his bike and is now complaining of right flank
pain. His GCS is 15 and he is awake and oriented. His BP is 125/75, HR 99, RR 18, O2
98% on room air. His physical exam is pertinent for right flank ecchymosis with mild
tenderness to palpation along with mild right upper quadrant tenderness. There is no
gross blood seen at his urethral meatus and his urinalysis shows no RBCs. True or False:
In the setting of potential renal trauma (blunt and penetrating trauma), gross or
microscopic hematuria is ALWAYS present.
(1pts)
True Incorrect
False
The answer is False: In the setting of renal trauma, gross or microscopic hematuria is
absent in up to 5% of cases and this finding alone should not be used to preclude in those
you are suspicious of renal trauma. Read more on renal trauma
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17)
0/1
You are seeing a 32-year old male who presents after being kicked multiple times in his
right flank. He is complaining of severe flank pain and gross hematuria. What is the gold
standard for imaging of renal trauma?
(Select 1)(1pts)
MRI abdomen/pelvis
Ultrasound
CT abdomen/pelvis with contrast
Intravenous pyelography
Indirect
Direct
Femoral
Richter
This patient most likely has an indirect hernia as it is the most common hernia and given
the lack of other findings in the stem that is the best answer and most likely. Although a
sports hernia may lead to a traditional, abdominal hernia, it is a different injury. A sports
hernia is a strain or tear of any soft tissue (muscle, tendon, ligament) in the lower
abdomen or groin area. Because different tissues may be affected and a traditional hernia
may not exist, the medical community prefers the term "athletic pubalgia" to refer to this
type of injury.
An indirect inguinal hernia is one of the most common abdominal hernias. It is
five times more common than a direct inguinal hernia, and is seven times more frequent
in males, due to persistence of the process vaginalis during testicular descent. An indirect
hernia enters the inguinal canal at the deep ring, lateral to the inferior epigastric vessels.
It passes infromedially to emerge via the superficial ring and, if large enough, extend into
the scrotum. In children, the vast majority of inguinal hernias are indirect (see Case 3).
Incarceration represents the most common complication associated with inguinal hernias,
the incidence could be as high as 30% for infants younger than 2 months.
A direct inguinal hernia arises from protrusion of abdominal viscera through a
weakness of the posterior wall of the inguinal canal medial to the inferior epigastric
vessels, specifically through the Hasselbach's triangle. This type of hernia is termed
direct as the hernial sac directly protrudes through the inguinal wall in contrast to indirect
ones which arise through the deep ring and enter the inguinal canal. Since direct hernias
do not have a guiding path, they seldom extend into the scrotum unless very large and
chronic. Direct hernias arise usually as acquired weakness of the Hasselbalch's triangle.
Therefore, they are seen in the elderly with chronic conditions which increase intra-
abdominal pressure over a long period, e.g. COPD, bladder outflow obstruction, chronic
constipation etc. Increased abdominal pressure is transmitted to both sides and as a result,
direct hernias are usually bilateral. Compared to indirect hernia, they are less susceptible
to strangulation as they have a wide neck.
In contrast to the indirect hernia, a direct hernia is most often an acquired lesion. It
occurs when a weak spot develops in the lower abdominal musculature (the posterior
floor of the inguinal canal) due to the normal and/or abnormal stresses inflicted by living
and aging. In adults, stresses such as lifting heavy of objects, frequent coughing or
straining, pregnancy, and constipation can instigate hernia. Unlike indirect hernias, direct
hernias traverse medial to the inferior epigastric vessels and are not associated with the
processus vaginalis. The hernia consists primarily of retroperitoneal fat. Only rarely is a
peritoneal sac containing bowel encountered. Because there is typically no involvement
of a sac, they do not protrude with the spermatic cord, and as such, have a lower
incidence of incarceration or strangulation. Like indirect inguinal hernia, direct inguinal
hernias typically cause a bulge in the groin (at the top of or within the scrotum) and
usually with increased abdominal pressure. Like indirect hernias, they may or may not be
painful (usually not). By palpating the inguinal canal and asking the patient to cough
while standing, one can usually elicit the hernia. In fact, one can often times palpate an
inguinal hernia without invaginating the scrotum (as is typically taught in medical
school). Rather, by placing one's fingers over the inguinal canal and asking the patient to
cough, one can often feel the bulge against the lower abdominal wall. As direct and
indirect hernias are unreliably differentiated by physical exam alone, the need to
invaginate the scrotum to feel into the inguinal canal is often more uncomfortable to the
patient, than telling to the physician. Rarely, palpation is not even necessary, as the
hernia is large enough to be visualized. Read more on Inguinal hernias: A Brief
review
(Select 1)(1pts)
0.18%
1.18%
2.1%
6.5%
12.4%
In female patients, indirect inguinal hernias are the most common type
In male patients, direct inguinal hernias are the most common type
Femoral hernias account for fewer than 10% of all groin hernias; however,
40% present as emergencie
(Select 1)(1pts)
10%/4%
20%/10%
4%/10%
10%/20%
<3%
9%
19%
31%
Answer D is false. Unexplained intraperitoneal fluid (i.e., fluid appearing in the absence
of solid-organ injury) was the most common radiographic finding associated with blunt
bowel or mesenteric injury but often proved to be a false positive finding.
Hollow viscus injury after blunt trauma, although uncommon, can have serious
consequences if the diagnosis is missed or delayed. In a multi-institutional study of 198
patients with blunt small bowel injury, delay of as little as 8 hours in making the
diagnosis resulted in increased morbidity and mortality.2 Mortality increased in parallel
with time to operative intervention (< 8 hours to operation, 2% mortality; 8 to 16 hours,
9%; 16 to 25 hours, 17%; > 24 hours, 31%), as did the complication rate. Consequently,
it is important to have an expedient approach to the diagnosis of blunt bowel injury.
Physical examination findings such as abdominal tenderness or tachycardia may suggest
the presence of hollow viscus injury. Distracting chest or long bone injury, closed-head
injury, spinal cord injury, or intoxication, however, may compromise reliability of the
examination. In addition, it is not uncommon for blunt bowel injury to have a latent
period from the time of injury, whereby the expected signs and symptoms of such injuries
take some time to develop. Laboratory abnormalities, including elevations in white blood
cell (WBC) count, amylase, and/or lactic acid, may also point toward the presence of
hollow viscus injury but are relatively nonspecific. Provided that the patient has suffered
a low-risk mechanism of injury (such as a fall from standing or a low-speed motor
vehicle collision), hollow viscus injury is extremely unlikely in the face of a normal,
reliable physical examination and normal laboratory results. With these conditions
present, the presence of blunt bowel injury can be effectively excluded. However, the
presence of abdominal complaints, an abnormal or unreliable physical examination,
abnormal laboratory results, or a high-risk mechanism of injury (such as a high-speed
motor vehicle collision) warrants further evaluation by imaging for the presence of bowel
injury.
Particular consideration should be given to lap-and shoulder-restraint injuries, which may
be associated with an increased risk of hollow viscus injury. The "seat-belt" sign (i.e.,
ecchymosis of the abdominal wall secondary to the compressive force of the lap belt) is
associated with a more than doubled relative risk of small bowel injury.3,4 Flexion-
distraction fractures of the spine (Chance fractures) are also associated with lap-belt use,
and the presence of such fractures should raise the index of suspicion for associated
hollow viscus injury.
Ultrasonography is routinely performed early in the evaluation of blunt abdominal
trauma. It is highly specific and moderately sensitive in identifying intra-abdominal fluid,
the presence of which in a hemodynamically unstable patient is an indication for
laparotomy (in that it strongly suggests the presence of significant intra-abdominal
hemorrhage).5 Ultrasonography does not, however, reliably distinguish solid-organ
injury from hollow viscus injury—a distinction that is critical for determining subsequent
management (i.e., operative versus nonoperative) in a hemodynamically stable patient.
Computed tomography (CT) is the imaging modality of choice in stable patients who
warrant evaluation by imaging as described above. We reviewed over 8,000 CT scans
performed to evaluate cases of blunt abdominal trauma and found that the number of
abnormal radiologic findings suggesting blunt injury to the bowel, the mesentery, or both
was correlated with the true presence of injury [see Table 1].6 A CT scan
demonstrating a solitary abnormality was associated with a true positive rate of 36%,
whereas a scan demonstrating more than one abnormality was associated with a true
positive rate of 83%. Unexplained intraperitoneal fluid (i.e., fluid appearing in the
absence of solid-organ injury) was the most common radiographic finding associated
with blunt bowel or mesenteric injury but often proved to be a false positive finding. On
the basis of this experience, we developed an algorithm for the evaluation of blunt hollow
viscus injury in patients with unreliable physical examinations [see Figure 1].
Most CT scans performed in this clinical setting, however, will be negative for evidence
of intra-abdominal injury. A prospective multi-institutional trial involving 3,822 blunt
trauma patients demonstrated that the negative predictive value of a normal abdominal
CT scan was 99.63%, leading the authors to conclude that patients with a normal scan do
not benefit from hospital admission and prolonged observation.7 However, a multi-
institutional review of 2,457 cases carried out by the Eastern Association for the Surgery
of Trauma (EAST) reported a 13% incidence of blunt small bowel injury in patients with
an initial negative CT scan. These results indicate that caution should be exercised in
dismissing the presence of hollow viscus injury on the basis of a negative scan.3 This
concern is echoed by our own institutional experience, in which the incidence of injury in
patients with an initial negative CT scan was 12%.6 If CT scanning demonstrates no
suspicious findings, no further diagnostic workup of hollow viscus injury is necessary,
but the duration of the observation period depends on both the overall condition of the
patient and clinical judgment. Most patients, as supported by the negative predictive
value of the study above, will not require ongoing further observation.
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24)
0/1
Which of the following statements about duodenal or pancreatic injury is not true?
(Select 1)(1pts)
Answer C is the only false statement as No laboratory findings are particularly specific
for duodenal or pancreatic injury. Amylase has been proposed for both pancreas and
duodenal injuries but is not specific for either one. Some have noted that amylase can be
elevated in as many as 50% of duodenal injuries, but this has not been a consistent
finding.9 An elevated amylase should prompt an evaluation of the duodenum for injury
but alone is not diagnostic. Although the highest concentration of amylase in the human
body is in the pancreas, hyperamylasemia is also not a reliable indicator of pancreatic
trauma. In one series, only 8% of blunt abdominal injuries with hyperamylasemia had
pancreatic injury.10 Furthermore, as many as 40% of patients with a pancreatic injury
may initially have a normal serum amylase.
The history of a patient with a possible blunt pancreatic or duodenal injury usually
consists of a direct blow to the epigastrium. In children, this commonly involves a bicycle
handlebar to the epigastrium; in adults, more commonly the steering wheel or a motor
cycle handle bar is involved. However, any direct blow should raise suspicion. The
patient may complain of abdominal, back, or flank pain.
Outside of the pelvis x-ray, plain abdominal radiographs to evaluate blunt abdominal
trauma are less common in the era of focused abdominal sonography for trauma (FAST)
and computed tomographic (CT) scans. Reports suggest that signs of duodenal injury on
plain radiographs are identified less than one third of the time. Retroperitoneal air, free
intraperitoneal air, or obliteration of the psoas shadow should raise suspicion for
duodenal and other hollow viscous trauma.9 Upper gastrointestinal series have also been
used to evaluate the duodenum for injury and can add to the sensitivity and specificity of
plain films, but more recently, CT has become the primary diagnostic modality.
For optimal duodenal evaluation, intraluminal contrast administered via a nasogastric
tube soon but not immediately prior to the CT scan may aid by opacification of the lumen
of the duodenal "C loop." Visualization of contrast extravasation, retroperitoneal air,
adjacent fat stranding, and unexplained fluid, as well as duodenal wall thickening, are CT
findings suggestive of potential duodenal injury. The sensitivity of CT for duodenal
injury is related to the technology of the scanner (i.e., "number of slices") and the time
interval from the injury to imaging. In a recent review, CT was considered to have an
overall sensitivity of around 76% with new-generation scanners (16- or 64-slice), having
a higher sensitivity of around 82%. Additionally, if clinical suspicion remains high after
an initial negative CT scan, then repeat imaging is warranted and may improve diagnostic
yield.
At times, duodenal hematomas can cause duodenal obstruction. This usually presents 2 to
3 days after the trauma with evidence of gastric outlet obstruction. The common
nonoperative treatment of isolated obstructing duodenal hematomas is nasogastric tube
decompression of the stomach and duodenum, nutritional support, and time.38 Repeat
imaging in 7 to 14 days is reasonable to evaluate improvement or an unexpected finding
as most duodenal hematomas will have resolved after 7 to 14 days, and continued
obstruction may reveal additional injury, prompting intervention.39-41 Enteral nutrition
is preferred to parenteral nutrition, but in the setting of a duodenal obstruction, the
parenteral route (total parenteral nutrition [TPN]) is often required as passing a feeding
tube beyond the obstruction can be difficult and surgical feeding access defeats the
purpose of "nonoperative" care.
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25)
0/1
What percentage of patients suffering from blunt abdominal trauma develop hollow
viscus injury?
(Select 1)(1pts)
1.2%
4.8%
8.9%
13.4%
The answer is A, 1.2%. Hollow viscus injury after blunt trauma, although
uncommon, can have serious consequences if the diagnosis is missed
or delayed.Hollow viscus injury is most often the consequence of
penetrating abdominal trauma. As a result of blunt force trauma,
bowel injury occurs with relative infrequency: in one multi-institutional
analysis, only 1.2% of blunt trauma admissions had an associated
hollow viscus injury. Read more
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