Cytoreductive surgery principles US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Cytoreductive surgery principles. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Cytoreductive surgery principles US Medical PG Question 1: The surgical equipment used during a craniectomy is sterilized using pressurized steam at 121°C for 15 minutes. Reuse of these instruments can cause transmission of which of the following pathogens?
- A. Non-enveloped viruses
- B. Sporulating bacteria
- C. Prions (Correct Answer)
- D. Enveloped viruses
- E. Yeasts
Cytoreductive surgery principles Explanation: ***Prions***
- Prions are **abnormally folded proteins** that are highly resistant to standard sterilization methods like steam autoclaving at 121°C, making them a risk for transmission through reused surgical instruments.
- They cause transmissible spongiform encephalopathies (TSEs) like **Creutzfeldt-Jakob disease**, where even trace amounts can be highly infectious.
*Non-enveloped viruses*
- Non-enveloped viruses are generally **more resistant to heat and disinfectants** than enveloped viruses but are typically inactivated by recommended steam sterilization protocols.
- Standard autoclaving conditions are effective in destroying most non-enveloped viruses.
*Sporulating bacteria*
- **Bacterial spores**, such as those from *Clostridium* or *Bacillus*, are known for their high resistance to heat and chemicals, but are usually **inactivated by steam sterilization at 121°C** for 15 minutes.
- This method is specifically designed to kill bacterial spores effectively.
*Enveloped viruses*
- Enveloped viruses are the **least resistant to heat and chemical disinfectants** due to their lipid envelope.
- They are readily **inactivated by standard steam sterilization** at 121°C.
*Yeasts*
- **Yeasts** are eukaryotic microorganisms that are typically **susceptible to heat sterilization**.
- They are effectively killed by typical steam autoclaving conditions used for surgical instruments.
Cytoreductive surgery principles US Medical PG Question 2: A 19-year-old woman presents to her gynecologist for evaluation of amenorrhea and occasional dull right-sided lower abdominal pain that radiates to the rectum. She had menarche at 11 years of age and had regular 28-day cycles by 13 years of age. She developed menstrual cycle irregularity approximately 2 years ago and has not had a menses for 6 months. She is not sexually active. She does not take any medications. Her weight is 94 kg (207.2 lb) and her height is 166 cm (5.4 ft). Her vital signs are within normal limits. The physical examination shows a normal hair growth pattern. No hair loss or acne are noted. There is black discoloration of the skin in the axillae and posterior neck. Palpation of the abdomen reveals slight tenderness in the right lower quadrant, but no masses are appreciated. The gynecologic examination reveals no abnormalities. The hymen is intact. The rectal examination reveals a non-tender, mobile, right-sided adnexal mass. Which of the following management plans would be best for this patient?
- A. Pelvic MRI should be the first-line imaging since both transvaginal and transabdominal ultrasound are inappropriate for this virginal, obese patient
- B. Clinical examination is sufficient for diagnosis since the adnexal mass was clearly palpable on rectal examination, making imaging unnecessary
- C. Transabdominal ultrasound is the appropriate first-line imaging for this virginal patient, despite reduced sensitivity due to her obesity, as transvaginal ultrasound would be inappropriate given her intact hymen
- D. The patient's obesity will not significantly affect transabdominal ultrasound quality, so transvaginal ultrasound is unnecessary even though she is virginal
- E. Transvaginal ultrasound should be performed first as it provides superior resolution for adnexal masses, regardless of the patient's sexual history or hymenal status (Correct Answer)
Cytoreductive surgery principles Explanation: ***Transvaginal ultrasound should be performed first as it provides superior resolution for adnexal masses, regardless of the patient's sexual history or hymenal status***
- **Transvaginal ultrasound (TVUS)** offers superior resolution for evaluating adnexal masses compared to transabdominal ultrasound due to its proximity to pelvic organs.
- While patient comfort and sexual history are important, an intact hymen is **not an absolute contraindication** to TVUS; it can often be performed carefully with a smaller probe or with patient cooperation.
*Pelvic MRI should be the first-line imaging since both transvaginal and transabdominal ultrasound are inappropriate for this virginal, obese patient*
- **Pelvic MRI** is a valuable diagnostic tool but is typically reserved as a **second-line imaging modality** when ultrasound findings are inconclusive or more detailed tissue characterization is needed.
- While obesity can reduce the quality of transabdominal ultrasound, and the patient is virginal, TVUS remains the **preferred initial imaging** due to its accessibility and high resolution.
*Transabdominal ultrasound is the appropriate first-line imaging for this virginal patient, despite reduced sensitivity due to her obesity, as transvaginal ultrasound would be inappropriate given her intact hymen*
- **Transabdominal ultrasound (TAUS)** would be challenging due to the patient's **obesity**, significantly limiting its sensitivity and resolution for adnexal structures.
- While TVUS may seem challenging with an intact hymen, it is **not strictly contraindicated** and offers far better diagnostic yield than a suboptimal TAUS in this scenario.
*Clinical examination is sufficient for diagnosis since the adnexal mass was clearly palpable on rectal examination, making imaging unnecessary*
- A palpable **adnexal mass** on clinical examination, while an important finding, is **not sufficient for diagnosis** without imaging.
- Imaging is essential to characterize the mass (e.g., solid, cystic, complex), size, location, and relationship to surrounding structures to guide appropriate management.
*The patient's obesity will not significantly affect transabdominal ultrasound quality, so transvaginal ultrasound is unnecessary even though she is virginal*
- **Obesity significantly impairs** the quality and penetration of transabdominal ultrasound, making it difficult to visualize pelvic organs and adnexal masses clearly.
- Therefore, transabdominal ultrasound is unlikely to provide sufficient diagnostic information in this obese patient, making the higher resolution of TVUS (even with an intact hymen) clinically advantageous.
Cytoreductive surgery principles US Medical PG Question 3: A 57-year-old female presents to general gynecology clinic for evaluation of a pelvic mass. The mass was detected on a routine visit to her primary care doctor during abdominal palpation. In the office, she receives a transvaginal ultrasound, which reveals a mass measuring 11 cm in diameter. In the evaluation of this mass, elevation of which tumor marker would be suggestive of an ovarian cancer?
- A. Alpha fetoprotein
- B. CA-125 (Correct Answer)
- C. CA-19-9
- D. Beta-hCG
- E. S-100
Cytoreductive surgery principles Explanation: ***CA-125***
- **CA-125** is the most widely used tumor marker for the detection and monitoring of **epithelial ovarian cancer**.
- Elevated levels in a postmenopausal woman with a large pelvic mass are highly suggestive of **ovarian malignancy**.
*Alpha fetoprotein*
- **Alpha fetoprotein (AFP)** is primarily associated with **germ cell tumors** of the ovary (e.g., endodermal sinus tumor) or **hepatocellular carcinoma**.
- It is not typically elevated in common epithelial ovarian cancers, which are more prevalent in older women.
*CA-19-9*
- **CA-19-9** is a tumor marker commonly elevated in **pancreatic cancer** and sometimes in **cholangiocarcinoma** or other gastrointestinal malignancies.
- While it can be elevated in some mucinous ovarian tumors, it is not the primary marker for general ovarian cancer evaluation.
*Beta-hCG*
- **Beta-hCG (Human Chorionic Gonadotropin)** is a marker for **choriocarcinoma** and other **gestational trophoblastic diseases**, as well as some germ cell tumors.
- It would not be expected to be elevated in a typical epithelial ovarian cancer in a 57-year-old female.
*S-100*
- **S-100 protein** is a marker primarily associated with **melanoma** and neural tissue tumors.
- It has no significant role in the diagnosis or monitoring of ovarian cancer.
Cytoreductive surgery principles US Medical PG Question 4: One day after undergoing an open colectomy, a 65-year-old man with colon cancer experiences shivers. The procedure was originally scheduled to be done laparoscopically, but it was converted because of persistent bleeding. Besides the conversion, the operation was uneventful. Five years ago, he underwent renal transplantation because of cystic disease and has been taking prednisolone since then. He has a history of allergy to sulfonamides. He appears acutely ill. His temperature is 39.2°C (102.5°F), pulse is 120/min, respirations are 23/min, and blood pressure is 90/62 mm Hg. Abdominal examination shows a midline incision extending from the xiphisternum to the pubic symphysis. There is a 5-cm (2-in) area of purplish discoloration near the margin of the incision in the lower abdomen. Palpation of the abdomen produces severe pain and crackling sounds are heard. Laboratory studies show:
Hemoglobin 12.5 g/dL
Leukocyte count 18,600/mm3
Platelet count 228,000/mm3
Erythrocyte sedimentation rate 120 mm/h
Serum
Na+ 134 mEq/L
K+ 3.5 mEq/L
Cl- 98 mEq/L
HCO3- 22 mEq/L
Glucose 200 mg/dL
Urea nitrogen 60 mg/dL
Creatinine 3.2 mg/dL
Creatine kinase 750 U/L
Which of the following is the most appropriate next step in management?
- A. Surgical debridement (Correct Answer)
- B. Intravenous clindamycin therapy
- C. X-ray of the abdomen and pelvis
- D. Vacuum-assisted wound closure device
- E. CT scan of abdomen
Cytoreductive surgery principles Explanation: ***Surgical debridement***
- The patient's presentation with **fever**, **tachycardia**, **hypotension**, **purplish discoloration**, **severe pain**, and **crepitus** (crackling sounds) near the incision after abdominal surgery is highly suggestive of **necrotizing fasciitis**.
- **Surgical debridement** is the most urgent and critical step to remove necrotic tissue, control the spread of infection, and improve outcomes in necrotizing soft tissue infections.
*Intravenous clindamycin therapy*
- While broad-spectrum antibiotics, including clindamycin, are essential in managing necrotizing fasciitis, they are **adjunctive to surgical debridement**, not a standalone primary treatment.
- Delaying surgery for antibiotic therapy alone would worsen the patient's prognosis and could lead to rapid progression of the infection.
*X-ray of the abdomen and pelvis*
- An X-ray might show subcutaneous **gas (crepitus)**, which is consistent with necrotizing fasciitis due to gas-producing bacteria.
- However, the clinical presentation is already highly indicative of the diagnosis, and waiting for imaging would **delay critical surgical intervention**.
*Vacuum-assisted wound closure device*
- **VAC therapy** is used for wound management to promote healing after debridement, by creating negative pressure.
- It is **not a primary treatment** for an active, spreading necrotizing infection and should only be considered after adequate surgical debridement has been performed.
*CT scan of abdomen*
- A CT scan can confirm the presence of **gas in the soft tissues** and assess the extent of the infection, providing valuable information.
- However, like X-rays, obtaining a CT scan would **delay immediate surgical intervention**, which is paramount given the rapid progression of necrotizing fasciitis.
Cytoreductive surgery principles US Medical PG Question 5: A 32-year-old man is brought to the emergency department after a skiing accident. The patient had been skiing down the mountain when he collided with another skier who had stopped suddenly in front of him. He is alert but complaining of pain in his chest and abdomen. He has a past medical history of intravenous drug use and peptic ulcer disease. He is a current smoker. His temperature is 97.4°F (36.3°C), blood pressure is 77/53 mmHg, pulse is 127/min, and respirations are 13/min. He has a GCS of 15 and bilateral shallow breath sounds. His abdomen is soft and distended with bruising over the epigastrium. He is moving all four extremities and has scattered lacerations on his face. His skin is cool and delayed capillary refill is present. Two large-bore IVs are placed in his antecubital fossa, and he is given 2L of normal saline. His FAST exam reveals fluid in Morison's pouch. Following the 2L normal saline, his temperature is 97.5°F (36.4°C), blood pressure is 97/62 mmHg, pulse is 115/min, and respirations are 12/min.
Which of the following is the best next step in management?
- A. Diagnostic peritoneal lavage
- B. Emergency laparotomy (Correct Answer)
- C. Upper gastrointestinal endoscopy
- D. Close observation
- E. Diagnostic laparoscopy
Cytoreductive surgery principles Explanation: ***Emergency laparotomy***
- The patient remains **hemodynamically unstable** (BP 97/62 mmHg, HR 115/min after 2L IV fluids) with evidence of **intra-abdominal fluid on FAST exam** (fluid in Morison's pouch).
- This clinical picture indicates active intra-abdominal hemorrhage requiring **immediate surgical intervention** to identify and control the source of bleeding.
*Diagnostic peritoneal lavage*
- **Diagnostic peritoneal lavage (DPL)** has largely been replaced by the focused abdominal sonography for trauma (FAST) exam and CT scans.
- While it can detect intra-abdominal bleeding, it is **invasive** and would delay definitive treatment in a hemodynamically unstable patient with positive FAST.
*Upper gastrointestinal endoscopy*
- This procedure is primarily for diagnosing and treating **upper gastrointestinal bleeding** or mucosal abnormalities.
- It is **not indicated** for evaluating traumatic intra-abdominal hemorrhage or hemodynamic instability following blunt abdominal trauma.
*Close observation*
- Close observation is appropriate for **hemodynamically stable patients** with blunt abdominal trauma and minor injuries or equivocal findings.
- This patient's persistent hypotension, tachycardia, and positive FAST findings rule out observation as a safe or appropriate next step.
*Diagnostic laparoscopy*
- **Diagnostic laparoscopy** is a minimally invasive surgical procedure used to evaluate the abdominal cavity.
- While it can be diagnostic, it is generally **contraindicated in hemodynamically unstable patients** as it can prolong the time to definitive hemorrhage control if a major injury is found.
Cytoreductive surgery principles US Medical PG Question 6: A 56-year-old woman is one week status post abdominal hysterectomy when she develops a fever of 101.4°F (38.6°C). Her past medical history is significant for type II diabetes mellitus and a prior history of alcohol abuse. The operative report and intraoperative cystoscopy indicate that the surgery was uncomplicated. The nurse reports that since the surgery, the patient has also complained of worsening lower abdominal pain. She has given the patient the appropriate pain medications with little improvement. The patient has tolerated an oral diet well and denies nausea, vomiting, or abdominal distension. Her blood pressure is 110/62 mmHg, pulse is 122/min, and respirations are 14/min. Since being given 1000 mL of intravenous fluids yesterday, the patient has excreted 800 mL of urine. On physical exam, she is uncomfortable, shivering, and sweating. The surgical site is intact, but the surrounding skin appears red. No drainage is appreciated. The abdominal examination reveals tenderness to palpation and hypoactive bowel sounds. Labs and a clean catch urine specimen are obtained as shown below:
Leukocyte count and differential:
Leukocyte count: 18,000/mm^3
Segmented neutrophils: 80%
Bands: 10%
Eosinophils: 1%
Basophils: < 1%
Lymphocytes: 5%
Monocytes: 4%
Platelet count: 300,000/mm^3
Hemoglobin: 12.5 g/dL
Hematocrit: 42%
Urine:
Epithelial cells: 15/hpf
Glucose: positive
RBC: 1/hpf
WBC: 2/hpf
Bacteria: 50 cfu/mL
Ketones: none
Nitrites: negative
Leukocyte esterase: negative
Which of the following is most likely the cause of this patient’s symptoms?
- A. Surgical error
- B. Post-operative ileus
- C. Wound infection (Correct Answer)
- D. Alcohol withdrawal
- E. Urinary tract infection
Cytoreductive surgery principles Explanation: ***Wound infection***
- The patient presents with **fever**, worsening **lower abdominal pain**, **tachycardia**, and **local signs of inflammation** (redness around the surgical site, tenderness) one week post-hysterectomy, with a **leukocytosis and left shift** (elevated neutrophils and bands). These findings are highly characteristic of a common **post-surgical wound infection**.
- The lack of significant drainage initially does not rule out infection, and the symptoms are localized to the surgical area.
*Surgical error*
- The operative report and intraoperative cystoscopy indicated the surgery was **uncomplicated**, making an immediate post-operative surgical error less likely to be the primary cause of these symptoms.
- While complications can arise later, the current presentation points more directly to an infectious process rather than an unnoted immediate surgical complication.
*Post-operative ileus*
- Although bowel sounds are hypoactive, the patient is **tolerating an oral diet well** and denies nausea, vomiting, or abdominal distension, which are key symptoms of a clinically significant ileus.
- Her primary complaint is localized pain and systemic signs of infection, rather than generalized abdominal distension and inability to pass flatus or stool.
*Alcohol withdrawal*
- While the patient has a history of alcohol abuse, the primary symptoms (fever, localized abdominal pain, redness around the incision, leukocytosis) are more indicative of an **infectious process** than alcohol withdrawal.
- Alcohol withdrawal typically presents with tremors, agitation, hallucinations, and autonomic instability, and while some overlap (tachycardia) exists, the overall clinical picture doesn't fit.
*Urinary tract infection*
- The urine analysis shows **negative nitrites and leukocyte esterase**, with only 2 WBC/hpf, which makes a **urinary tract infection (UTI) highly unlikely** despite the presence of some bacteria (50 cfu/mL, which is often considered contamination in a clean catch).
- The patient's symptoms are also predominantly localized to the surgical wound area rather than dysuria, frequency, or urgency.
Cytoreductive surgery principles US Medical PG Question 7: A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?
- A. "Does the diarrhea typically precede the constipation, or vice-versa?"
- B. "Is the diarrhea foul-smelling?"
- C. "Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"
- D. "Are the symptoms worse in the morning or at night?"
- E. "Can you tell me more about the symptoms you have been experiencing?" (Correct Answer)
Cytoreductive surgery principles Explanation: ***Can you tell me more about the symptoms you have been experiencing?***
- This **open-ended question** encourages the patient to provide a **comprehensive narrative** of their symptoms, including details about onset, frequency, duration, alleviating/aggravating factors, and associated symptoms, which is crucial for diagnosis.
- In a patient presenting with vague, intermittent symptoms like alternating constipation and diarrhea, allowing them to elaborate freely can reveal important clues that might not be captured by more targeted questions.
*Does the diarrhea typically precede the constipation, or vice-versa?*
- While knowing the sequence of symptoms can be helpful in understanding the **pattern of bowel dysfunction**, it is a very specific question that might overlook other important aspects of the patient's experience.
- It prematurely narrows the focus without first obtaining a broad understanding of the patient's overall symptomatic picture.
*Is the diarrhea foul-smelling?*
- Foul-smelling diarrhea can indicate **malabsorption** or **bacterial overgrowth**, which are important to consider in some gastrointestinal conditions.
- However, this is a **specific symptom inquiry** that should follow a more general exploration of the patient's symptoms, as it may not be relevant if other crucial details are missed.
*Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life*
- Quantifying pain intensity is useful for assessing the **severity of discomfort** and monitoring changes over time.
- However, for a patient with intermittent rather than acute, severe pain, understanding the **character, location, and triggers** of the pain is often more diagnostically valuable than just a numerical rating initially.
*Are the symptoms worse in the morning or at night?*
- Diurnal variation can be relevant in certain conditions, such as inflammatory bowel diseases where nocturnal symptoms might be more concerning, or functional disorders whose symptoms might be stress-related.
- This is another **specific question** that should come after gathering a more complete initial picture of the patient's symptoms to ensure no key information is overlooked.
Cytoreductive surgery principles US Medical PG Question 8: A 65-year-old man is admitted to the hospital because of a 1-month history of fatigue, intermittent fever, and weakness. Results from a peripheral blood smear taken during his evaluation are indicative of possible acute myeloid leukemia. Bone marrow aspiration and subsequent cytogenetic studies confirm the diagnosis. The physician sets aside an appointed time-slot and arranges a meeting in a quiet office to inform him about the diagnosis and discuss his options. He has been encouraged to bring someone along to the appointment if he wanted. He comes to your office at the appointed time with his daughter. He appears relaxed, with a full range of affect. Which of the following is the most appropriate opening statement in this situation?
- A. Your lab reports show that you have an acute myeloid leukemia
- B. What is your understanding of the reasons we did bone marrow aspiration and cytogenetic studies? (Correct Answer)
- C. You must be curious and maybe even anxious about the results of your tests.
- D. I may need to refer you to a blood cancer specialist because of your diagnosis. You may need chemotherapy or radiotherapy, which we are not equipped for.
- E. Would you like to know all the details of your diagnosis, or would you prefer I just explain to you what our options are?
Cytoreductive surgery principles Explanation: ***"What is your understanding of the reasons we did bone marrow aspiration and cytogenetic studies?"***
- This **open-ended question** allows the patient to express their current knowledge and perceptions, which helps the physician tailor the discussion.
- It establishes a **patient-centered approach**, respecting the patient's existing understanding and preparing them for further information.
*"You must be curious and maybe even anxious about the results of your tests."*
- While empathic, this statement makes an **assumption about the patient's feelings** rather than inviting them to share their own.
- It is often better to ask directly or use more open-ended questions that allow the patient to express their true emotions, especially given their **relaxed demeanor**.
*"I may need to refer you to a blood cancer specialist because of your diagnosis. You may need chemotherapy or radiotherapy, which we are not equipped for.”"*
- This statement immediately introduces **overwhelming and potentially alarming information** (referral, chemotherapy, radiotherapy) without first establishing the diagnosis or assessing the patient's readiness to receive it.
- It prematurely jumps to treatment and logistics, potentially causing **unnecessary distress** before the patient has processed the core diagnosis.
*"Would you like to know all the details of your diagnosis, or would you prefer I just explain to you what our options are?""*
- While it attempts to assess the patient's preference for information, this question is a **closed-ended "either/or" choice** that might limit the patient's ability to express nuanced needs.
- It also prematurely introduces the idea of "options" without first explaining the diagnosis in an understandable context.
*"Your lab reports show that you have an acute myeloid leukemia"*
- This is a **direct and blunt delivery of a serious diagnosis** without any preparatory context or assessment of the patient's existing knowledge or emotional state.
- Delivering such news abruptly can be shocking and overwhelming, potentially **hindering effective communication** and rapport building.
Cytoreductive surgery principles US Medical PG Question 9: A previously healthy 25-year-old woman is brought to the emergency department because of a 1-hour history of sudden severe lower abdominal pain. The pain started shortly after having sexual intercourse. The pain is worse with movement and urination. The patient had several urinary tract infections as a child. She is sexually active with her boyfriend and uses condoms inconsistently. She cannot remember when her last menstrual period was. She appears uncomfortable and pale. Her temperature is 37.5°C (99.5°F), pulse is 110/min, and blood pressure is 90/60 mm Hg. Abdominal examination shows a palpable, tender right adnexal mass. Her hemoglobin concentration is 10 g/dL and her hematocrit is 30%. A urine pregnancy test is negative. Pelvic ultrasound shows a 5 x 3-cm right ovarian sac-like structure with surrounding echogenic fluid around the structure and the uterus. Which of the following is the most appropriate management for this patient's condition?
- A. Intravenous methotrexate administration
- B. Uterine artery embolization
- C. Emergency exploratory laparotomy (Correct Answer)
- D. Oral doxycycline and metronidazole administration
- E. CT scan of the abdomen
Cytoreductive surgery principles Explanation: ***Emergency exploratory laparotomy***
- The patient presents with **sudden severe lower abdominal pain**, **hypotension (90/60 mm Hg)**, **tachycardia (110/min)**, **palpable tender right adnexal mass**, and signs of **anemia (Hb 10 g/dL, Hct 30%)**, along with **free fluid** on ultrasound, indicating **hemorrhagic shock due to a ruptured ectopic pregnancy or ovarian cyst**. This is a surgical emergency.
- An **exploratory laparotomy** is immediately indicated to identify the source of bleeding, control hemorrhage, and remove the ruptured structure, especially given her unstable vital signs.
*Intravenous methotrexate administration*
- **Methotrexate** is used for **unruptured ectopic pregnancies** with specific criteria (e.g., small size, stable patient, declining hCG levels), but it is contraindicated in cases of rupture due to the risk of hemorrhage.
- The patient's **hypotension** and **anemia** indicate active bleeding and hemodynamic instability, making medical management inappropriate and delaying critical surgical intervention.
*Uterine artery embolization*
- **Uterine artery embolization** is primarily used for conditions like **uterine fibroids** or **postpartum hemorrhage**.
- It is not the appropriate first-line emergency treatment for acute rupture of an ectopic pregnancy or ovarian cyst with hypovolemic shock.
*Oral doxycycline and metronidazole administration*
- **Doxycycline** and **metronidazole** are antibiotics used to treat **pelvic inflammatory disease (PID)**, which presents with symptoms like fever, vaginal discharge, and lower abdominal pain, but typically not acute hemorrhagic shock.
- This patient's presentation is an acute surgical emergency with signs of hemorrhage, not an infection requiring only antibiotic therapy.
*CT scan of the abdomen*
- While a **CT scan** could provide more detailed imaging, the patient's **hemodynamic instability** (hypotension, tachycardia) requires immediate intervention.
- Delaying definitive treatment for further imaging in acute hemorrhagic shock is not appropriate and could worsen her condition.
Cytoreductive surgery principles US Medical PG Question 10: A 50-year-old male presents to the emergency with abdominal pain. He reports he has had abdominal pain associated with meals for several months and has been taking over the counter antacids as needed, but experienced significant worsening pain one hour ago in the epigastric region. The patient reports the pain radiating to his shoulders. Vital signs are T 38, HR 120, BP 100/60, RR 18, SpO2 98%. Physical exam reveals diffuse abdominal rigidity with rebound tenderness. Auscultation reveals hypoactive bowel sounds. Which of the following is the next best step in management?
- A. Admission and observation
- B. Chest radiograph
- C. 12 lead electrocardiogram
- D. Abdominal CT scan (Correct Answer)
- E. Abdominal ultrasound
Cytoreductive surgery principles Explanation: ***Abdominal CT scan***
- This patient presents with classic signs of a **perforated peptic ulcer**: sudden severe epigastric pain radiating to the shoulders (diaphragmatic irritation), fever, tachycardia, hypotension, and peritoneal signs (rigid abdomen with rebound tenderness).
- While the patient shows signs of **early shock** (BP 100/60, HR 120), he is **conscious and maintaining adequate oxygenation** (SpO2 98%), making him stable enough for rapid CT imaging.
- **Abdominal CT scan** is the **most sensitive and specific** test for detecting free air, identifying the location of perforation, and assessing for complications (abscess, contained perforation).
- CT provides **critical surgical planning information** about the extent and location of perforation, which can guide the surgical approach.
- This should be followed by **immediate surgical consultation** and preparation for emergency laparotomy.
*Chest radiograph*
- While an **upright chest X-ray** can detect free air under the diaphragm (pneumoperitoneum), it has **lower sensitivity** (70-80%) compared to CT scan (>95%).
- In a patient who is stable enough for imaging, **CT is preferred** as it provides more information for surgical planning.
- Chest X-ray would be the appropriate choice only if **CT is unavailable** or if the patient is **too unstable** to be transported to the CT scanner.
*Admission and observation*
- This patient has **acute peritonitis** from a likely perforated viscus, which is a **surgical emergency** requiring operative intervention.
- Observation would be inappropriate and dangerous, leading to **septic shock**, **multi-organ failure**, and death.
*12 lead electrocardiogram*
- While epigastric pain can sometimes be cardiac in origin, the **peritoneal signs** (rigid abdomen, rebound tenderness, hypoactive bowel sounds) clearly indicate an **intra-abdominal pathology**.
- The pain radiation to **both shoulders** (Kehr's sign) suggests diaphragmatic irritation from intraperitoneal air or fluid, not cardiac ischemia.
*Abdominal ultrasound*
- Ultrasound is useful for evaluating **solid organ injury**, **free fluid**, and conditions like **cholecystitis** or **appendicitis**.
- However, it is **poor at detecting free air** due to bowel gas artifact and has limited sensitivity for perforated viscus.
- It would not provide adequate information for this surgical emergency.
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