Q & A

Question 1

A 38 y.o. woman is noted on routine physical exam to have a painless 1-cm R. 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
c. PET scan and brain MRI
d. core needle biopsy of mass
e. modified radical mastectomy

Answer 1

d. core needle biopsy of mass

Question 2

A 54 y.o. woman is note to have a 1.5 cm breast mass, which on stereotactic core needle biopsy is invasice carcinoma. The surgeon is planning on a local tumor resection and sentinel lymph node assessment. Which o f the following most accurately describes a sentinel lymph node?

Answer 2

c. the first lymph node draining a tumor

Question 3

A 60 y.o. woman undegoes breast conserving surgery (a lumpectomy) for a 0.3cm tumor. The axillary lymph nodes are negative. Which of the following is the next step in therapy.

Answer 3

Radiation to the affected breast

Question 4

A 62 y.o woman complains of painful enlargement of her R. breast. SHe has no family hx of breast Ca. The right breast reveals warmth, redness and R. axilla nontender adenopathy. Which is the next best step?

Answer 4

Observation - inflammatory breast disease - caused by tumor occlusion of dermal lymphatics
-can do core needle or FNA

Question 5

Which of the following is considered appropriate tx for a 53 y.o. woman who develops two liver mets two years following L. modified radical mastectomy, chest wall radiation, systemic chemo, Tamoxifen for her T2N2 ER+, HER2neu negative invasive ductal carcinoma.

Answer 5

Aromatase Inhibitor - for ER+ tumor or systemic chemo

Question 6

A 62 y.o. man with CHF and emphysema has sx of substernal chest pain and regur after meals and at bedtime. He obtains incomplete relief of his sx with Ranitidine. An endoscopy confirms mild esophagitis. Which of the following is the most approp next step?

Answer 6

given his comorbidities (CHF and Emphysema) he is NOT a good candidate for surgery.
-he got some relief with H2 blockers
Dx: GERD…so move to PPI (Omeprazole) 20mg/day

Question 7

A 52 y.o. woman has a 6 month hx of substernal chest pain and vague upper abd discomfort. She has been taking antacids w. minimal relief and has a negative upper endoscopy (EGD). Which of the following is the next best step

Answer 7

Refer to Cardiology for workup

Question 8

What is an EGD?

Answer 8

It is a study that allows docs to see inside the mucosal layer of esophagus, stomach and duodenum.

Question 9

A 45 y.o. man dx w. GERD for 3 years tx with H2 blockers. Recently he has complained of epigastric pain. An upper endoscopy was performed showing Barret’s esophagus at the distal esophagus. Which of the following is the best next step in treating them?

Answer 9

Start PPI…since it is GERD

-they developed Barret’s esophagitis on an H2 blocker

Question 10

A 26 y.o. man is brought to the emergency center for severe chest pain and upper abdominal pain. He is dx with esophageal perf. Which of the following is the most likely etiology of the condition.

Answer 10

hospital induced-IATROGENIC

Question 11

60 y.o. man has a 10 yr hx of achalasia. His dysphagia has been worsening and he underwent an esophageal dilation; shortly after this procedure he develops acute chest pain, tachycardia and fever 6 h later. Most appropriate diagnostic procedure?

Answer 11

Gastrograffin esophagogram

• water-soluble esophagram is 90% accurate in identifying esophageal perforation.
• GET surgery ASAP

Question 12

30M with melanoma biopsied from L. forearm. The initial path finding revealed this lesion with a maximal depth of 1.5mm and microscopically uninvolved margins. What’s tx?

Answer 12

Thorough skin exam, wide local excision w. 2-cm margins, lymphoscintography and SLN biopsy

Question 13

57M with normal shaped prostate with normal size. PSA is 38ng/mL [

Answer 13

biopsy w. transrectal U/S

Question 14

72M with lower abdominal mass and constantly dribbles urine. Which of the following is th best next step?

Answer 14

foley

Question 15

79F w. no previous abdominal surgery has intermittent distension and pain of 1w’s duration and persistent vomiting for 1d. Her phys exam does not reveal any hernias and is consistent with a distal SBO. She is afebrile and WBC is 4000. What is next step?

Answer 15

CT

Question 16

72m, afebrle, N/V following appendectomy at age 25. WBC is 18000, Na: 140, K 4.2, Cl: 105, HCO3- is 14. Which is the best therapy?

Answer 16

SURGERY- he has low bicarb caused by lactic acid, reflecting ischemic bowel or severe fluid depletion.

Question 17

32M w. N/V following appendectomy performed 20d ago. no fever, abdomen slightly tender and distended. WBC is 12K, Cl-105, HCO3- 14. What is best tx?

Answer 17

Dx: Volvulus (early SBO usually due to adhesion or persistent inflammation)
-can be made by barium enema to relieve volvulus

Question 18

65F w. postprandial RUQ pain, N/V over 12h. The pain is persistent and radiates to her back. She is afebrile and her abdomen is tender to palpation. U/S shows cholelithiasis, gallbladder wall thickening and dilated CBD. Labs: WBC: 130000, AST 220, ALT 240, alk phos 385 and direct bili 4.0. Which is best tx?

Answer 18

admit
provide IVF
begin antibiotic
recommend ERCP

Question 19

45M seen in ED for abdominal pain. Presumed acute cholecystitis is made, Which is most consistent with dx?

Answer 19

painless jaundice with palpable and non-tender gallbladder

Question 20

69M presents with confusion, abdominal pain, shaking chills, rectal temp of 94 and jaundice. An abdominal radiograph shows air in the biliary tree. What is Dx?

Answer 20

acute cholangitis - Charcot’s triad - fever, jaundice and RUQ pain - it is life threatening

Question 21

33F presents with RUQ pain Temp of 38. Her abdomen is tender imn RUQ and her liver function tests are all within normal limits. WBC is 12000. U/S reveals gallstones with the gallbladder pericholecystic fluid and a CBD measuring 4.5mm in diameter. What is the management?

Answer 21

laparoscopic cholecystetcomy

Question 22

30F presents with postprandial upper abdominal pain that has been recurrent over the past several months. She has underdone U/S of the gallbladder that has NOT shown stones. The liver studies have been normal. What’s the next step?

Answer 22

obtain CCK stimulated HIDA scan

Question 23

Cholecytitis

Cholelithiasis

Choledocolithiasis

Ascending cholangitis-

Answer 23

-stones in the gallbladder; not causing any inflammation
Management: cholecystectomy

-inflammed, thickened gallbladder, pericholecystic fluid constant pain w. small fever
Management: cholecystectomy before it progresses

-stone goes into the common bile duct; that can cause jaundice and pancreatitis; Sx: painful jaundice
Management: ERCP

-infection from stasis of bile because of obstruction of the CBD; pain, jaundice, VERY SICK;
Tx: urgent ERCP…must relieve the obstruction to get the bacteria our
Abx (GNR and anerobes) sphincterotomy; eventuall cholecystectomy

Question 24

55M undergone upper endocsopy. He is told by his gastroenterologist that although this disordr may cause anemia, it is unlikely to cause acute HI hemorrhage. Which is the Dx?

Answer 24

Gastric cancer- asymtomatic until late in the course- chronic occult blood loss

Question 25

32M comes to ED w, hx of vomiting large amounts of bright red blood. What is first step in tx?

Answer 25

replenish FLUIDS

Question 26

65M with upper GI bleed. NG tube is places with bright red fluid aspirated. After 30mins of saline flushes, the aspirate is clear. Which of the following is the most accurate statement

Answer 26

he will rebleed

Question 27

52M with alcoholism and known cirrhosis comes into the ED with acute hematemesis. Bleeding esophageal varices are found in UGD. Which of the following is most like effective tx?

Answer 27

Endoscopic sclerotherapy

Question 28

Causes of UGI bleeds

Answer 28

NSAIDs
Peptic ulcer disease
Alcohol–>esophageal varices
kids: extrahepatic portal venous hypertension

Question 29

75M with hematochezia develops hypotension and tachycardia. VS improve with crystalloid and packed red blood cell infusion. Which of the following is considered next most appropriate?

Answer 29

• NG tube
• Proctosigmoidoscopy
• Tagged RBC scan with or without mesentery angiography- identifies active bleeding but the images obtained may not localize the GI tract site accurately.

Question 30

Which condition is almost always assoc with painless hematochezia?

Answer 30

Aortoenteric fistula occurring after abdominal aortic aneurysm repair

Question 31

66F presents with having passed several maroon colored stools earlier in the day. She complains of feeling light headed following these episodes. The patient ha s hx of HTN and osteoarthritis. She takes NSAIDs daily. Her initial HCT is 34% and her BP improves with initial IVF. During a 4-hr period of observation in the EDm she remains stable without further passage of stools. Next step in management?

Answer 31

Colonoscopy

Question 32

Most common causes of lower GI bleeding?

Answer 32

angiodysplasia and diverticulosis

Question 33

72F presents with abdominal pain and passing bloody stools. PMH of HTN, NIDDM, CAD. BP is 90/60, P: 120bpm, T: 38.8. There is evidence of peritonitis. What is the most appropriate tx?

Answer 33

abdominal CT with oral and IV contrast

-since she has fever, pain, atherosclerotic disease you should entertain ischemic colitis, which is painful

Question 34

44F underwent stereotactic core biopsy of a suspicious mammographic lesion in the L breast. The biopsy revealed lobular carcinoma n situ. Which of the following is the most appropriate management recommendation.

Answer 34

LCIS is a marker for subsequent breast cancer
surgery is needed if LCIS W. ATYPIA
Answer:
Raloxifene- has fewer thromboembolic complications
Need long term surveillance
Raloxifene, clinical exam and mammogram q6 months

Question 35

46M intoxicaed was driving down the highway in the wrong dirrction when his vehicle struck a pickup truck head on. He presents with HR 130, BP 90/60 and RR: 30breaths/min. His pupils are 5mm and PERRL; does not open his eyes to painful stimulus. His oxygen sat with face mask is 86%. In addition to the possibility of closed head injury, what other factors most likely is contrubitin go the low GCS?

Answer 35

hypoxia

Question 36

30M with second degree burns over the anterior chest and abdomen measuring approx 20% TSA?

Answer 36

Early excision of entire burn wound with autologous split thickness skin graft application. –reduces sepsis