MCQs Flashcards
A 38 yo woman is noted on routine physical examination to have a painless 1 cm right breast mass. There is no skin dimpling or adenopathy. An FNA is performed revealing malignant cells. Which of the following is the best next step?
A. Total mastectomy B. Partial mastectomy and radiation therapy C. PET scan and MRI of brain D. Core needle biopsy of mass E. Modified radical mastectomy
D. Even though FNA showed cancer cells, this diagnostic modality involves cytology (loose cells) and does not allow for the differentiation of invasive versus in situ breast cancer. A core needle biopsy should be performed to determine the histology of the tumour and assess receptor status and tumour biology of the cancer. PET scan + brain MRI is the systemic staging option that may be applied for a patient with invasive cancer but is not needed if the tumour turns out to be in situ only. Mastectomy and segmental mastectomy are treatment options that should be withheld until the nature and stage of the tumour is fully determined. A modified radical mastectomy is not indicated at this time given that the diagnosis of invasive breast cancer has not yet been established, and axillary staging with axillary dissection can produce greater morbidity than SLNB; therefore, ALND is rarely applied as the initial step in axillary staging
54 yo woman is noted to have 1.5 cm breast mass, which on stereotactic core needle biopsy is diagnosed as invasive carcinoma. The surgical is planning on a local tumour resection and sentinel lymph node assessment. Which of the following most accurately describes a sentinel lymph node?
A. A lymph node containing cancer metastases
B. The lymph node that is most likely to become infected postoperatively
C. The first lymph node in the lymph node basin draining a tumour
D. The only lymph node that contains metastasis
E. The surgical margins of an axillary dissection
C.
A 60 yo woman undergoes breast-conserving surgery (a lumpectomy) for a 0.3 cm tumour. The axillary lymph nodes are negative. Which of the following is the next step in therapy?
A. no further therapy and observation
B. Combined chemotherapy such as the AC regimen
C. a radical mastectomy
D. Axillary radiation
E. Radiation therapy to the affected breast
E. Radiation therapy is indicated for a patient with stage I disease treated by BCT. The addition of radiation therapy reduces the local recurrence rate from 30% to 9%. Chemotherapy may or may not be indicated in a postmenopausal patient with early breast cancer. Radical mastectomy is rarely indicated for breast cancer treatment. Axillary radiation therapy is not indicated in this patient because this treatment is generally indicated only in patients with increased risk of axillary disease recurrence, such as patients with four or more axillary lymph nodes involved with cancer.
A 62 yo woman complains of painful enlargement of her right breast. She has no family history of breast cancer. The right breast reveals warmth, redness, and right axilla nontender adenopathy. Which of the following is the best next step?
A. Oral antibiotic therapy B. IV antibiotic therapy C. Biopsy D. Observation E. PET scan
D. While it is possible for a postmenopausal or nonlactating woman with red and/or tender breasts to have developed mastitis or a breast abscess, her age and the presence of nontender axillary lymphadenopathy are highly suspicious for cancer; therefore, this patient should be assumed to have breast cancer until it is proven otherwise. A core needle biopsy or fine-needle biopsy of the tumour + punch biopsy of the involved inflamed and oedematous skin is indicated. Inflammatory breast cancer is characterised by oedema, redness, and tenderness caused by tumour occlusion of the dermal lymphatic channels. A PET scan would not be helpful to differentiate between infection and malignancy beaus both processes are associated with increase in glucose uptake and ‘positive’ findings.
Tamoxifen therapy is associated with the development of what type of cancer?
A. Bladder
B. Breast
C. Ovarian
D. Uterine
D.
A 62 yo man with congestive CHF and emphysema has sx of substernal chest pain and regurgitation after meals and at bedtime. He obtains incomplete relief of his sx with ranitidine. An endoscopy confirms mild oesophagitis. Which of the following is the most appropriate next step?
A. Reassure him that continued occurrence of sx while receiving therapy is normal.
B. Prescribe omeprazole 20 mg per day
C. Schedule him for 24 hour pH monitoring,manometry and barium oesophagogram for further evaluation.
D. Schedule him for a laparoscopi Nissen fundoplication.
E. Recommend dietary changes
B. Given the patient’s comorbidities, he is not a good candidate for surgical therapy. An important piece of this patient’s history is his history of partial relief with H2 blocker as opposed to no response a all; therefore, this history suggests that the diagnosis of GERD is a correct one and the patient may simply need to have escalation of GERD treatment. This patient should be switched to a PPI because the relapse rate associated with H2 blockers is much higher than that associated with PPI.
A 51 yo woman has a 6 month hx of substernal chest pain and vague upper abdominal discomfort. She has been taking antacid therapy with minimal relief and as had a negative upper endoscopy. Which of the following is the best next step in her workout?
A. Barium oesophagogram to evaluate for a hiatal hernia
B. Performing manometry to rule out a motility disorder such as diffuse oesophageal program spasm or achalasia
C. Referring the patient for cardiac workup as a potential cause of her chest pain
D. Referring to a psychiatrist for a possible conversion reaction
E. Performing a CT of the chest and abdomen
C. When chest or epigastric pain does not respond to antacid therapy, and especially with a negative upper endoscopy, aetioloegies other than GORD should be considered. This patient’s hx qualifies as atypical chest pain and may benefit from an exercise stress test.Documentation of a hiatal hernia does not necessarily correlate casually to her sx. Cardiac disease would be the most concerning disease, and that is why this disorder should be ruled out first. CT of the abdomen and chest may be helpful to identify other potential anatomic causes of her chest and abdo pain but should only be done after appropriate cardiac evaluations.
A 45 yo man has had a diagnosis of GORD for 3 years with treatment with H2-blocking agents. Recently, he has complained of epigastric pain. An upper endoscopy was performed showing Barrett oesophagus at the distal oesophagus. Which of the following is the best next step in the treatment of the individual?
A. Initiate a PPI
B. Advise a patient to continue to take the H2 blocker
C. Perform a laparoscopic Nissen fundoplication
D. Advise surgical therapy involving gastrectomy and oesophageal bypass
E. Discontinue the H2 blocker and initiate antacids
A. The next step in medical therapy for GORD is the addition of a PPI, which is a more effective medication for GORD. The patient has been symptomatic and developed Barret oesophagitis on an H2 bloacker, and therefore additional therapy is needed for relief of symptoms and to decrease the progression of the Barrett oesophagitis to adenocarcinoma. An antireflux surgery (such as the Nissen fundoplication) is an option but not gastrectomy and oesophageal bypass. In general, most practitioners would elect to place the patient on the more appropriate medical treatment at this time rather than proceed with fundoplication. This patient also needs endoscopic surveillance of the Barrett oesophagus.
A 24 yo man with long-standing GORD, currently taking PPIs, is being evaluated for possible surgical therapy. Which of the following is an indication for surgery?
A. Inability to tolerate PPIs
B. Inability to afford PPIs
C. Incomplete relief of symptoms despite a max dosage of medical therapy
D. The patient’s desire to discontinue medication
E. All of the above
E.
A 74 yo woman is admitted with upper GI bleeding and started on H2 blockers. She experiences another bleeding episode. Endoscopy documents diffuse gastric ulcerations. Omeprazole is added to the H2 antagonists as a therapeutic approach to the management of acute gastric and duodenal ulcers. Which of the following is the mechanism of action of omeprazole?
A. Blockage of the breakdown of mucosa-damaging metabolites of NSAIDs
B. Provision of a direct cytoprotective effect
C. Buffering of gastric acids
D. Inhibition of parietal cell hydrogen potassium ATPase
E. Inhibition of gastrin release and parietal cell acid production
D. Omeprazole irreversibly inhibits the H+-K+-ATPase in the secretory canaliculus of the gastric parietal cell.
A 55 year old man presents with an abdominal mass that is both pulsatile and expansile. Ultrasound reveals it to be 4.5 cm in diameter. What is the most appropriate management?
A. Observation with regular US
B. Surgical resection
C. Bypass graft surgery
D. Open surgical repair with insertion of prosthetic graft
E. Endoluminal repair with insertion of graft
A. It isn’t until AAAs are >5cm that surgical intervention should be considered, UNLESS there are symptoms of impending rupture (hypotension + abdo pain radiating to the back).
Which of the following genetic disorders are aneurysms most likely to be associated with?
A. Alpha-1 antitrypsin deficiency B. Von Willebrand disease C. Klinefelter syndrome D. Duchenne muscular dystrophy E. Ehlers-Danlos syndrome
E. Ehlers-Danlos syndrome is an inherited connective tissue disorder that is caused by a defect in the structure, production or processing of collagen. It, along with Marfan’s syndrome is commonly associated with the development of aneurysms.
A 62 yo man presents to ED with sudden onset, severe epigastric pain that is radiating to his back. His BP is 85/55 and his temperature is 37.0 celsius. Upon close inspection, he appears to have a distended stomach. What is the most likely diagnosis?
A. Acute Cholangitis B. Biliary Colic C. Acute Cholecystitis D. AAA E. Acute Pancreatitis
D. Classic features of a AAA that is close to rupture or that has already ruptured include sudden onset pain that radiates to the back and hypotension. Note that he does not have a fever, which typically rules out acute cholangitis and acute cholecystitis. Biliary colic does not normally present with hypotension, nor does acute pancreatitis. If anything, acute pain usually raises blood pressure.
Which of the following is not a risk factor for developing an abdominal aortic aneurysm?
A. Smoking history B. Hypertension C. Marfan's syndrome D. <50 years old E. Male gender
D. AAAs typically present in males who are >50 years old.
A 76-year-old gentleman presents to A&E complaining of severe left illiac fossa and loin pain which started 1 hour ago. He had an episode of dizziness earlier, which has settled now. On arrival he is afebrile, his HR 120/min, BP 90/50 and SaO2 98% on 2 L of O2. His past medical history includes hypertension, diabetes and coronary bypass surgery 5 years ago. After resuscitation his parameters are HR 92/min, BP 130/80. The most appropriate next step in his management would be:
A. Urine dipstick
B. KUB X-ray
C. US of renal tract
D. CT scan abdomen
D. In this particular case it is important to rule out a leaking/ruptured abdominal aortic aneurysm. Most ruptured AAAs present with either the patient already in cardiac arrest (approx 50% of cases) or with back pain. However, in some cases patients present with left iliac fossa or left loin pain and hypovolaemic shock. The latter is somewhat of an atypical presentation for a ruptured AAA. Nevertheless, patients with ruptured or leaking AAAs have presented with these features.
