A 60-year-old woman presents with changes in her left breast that started 1 month ago. The patient states that she noticed that an area of her left breast felt thicker than before, and has not improved. She came to get it checked out because her best friend was just diagnosed with invasive ductal carcinoma. The past medical history is significant for Hashimoto’s thyroiditis, well-managed medically with levothyroxine. The patient has a 30-pack-year smoking history, but she quit over 15 years ago. The menarche occurred at age 11, and the menopause was at age 53. She does not have any children and has never been sexually active. Her last screening mammogram 10 months ago was normal. The family history is significant for her mother dying from a myocardial infarction (MI) at age 68, her sister dying from metastatic breast cancer at age 55, and for colon cancer in her paternal grandfather. The review of systems is notable for unintentional weight loss of 3.6 kg (8 lb) in the past month. The vital signs include: temperature 37.0℃ (98.6℉), blood pressure 110/70 mm Hg, pulse 72/min, respiratory rate 15/min, and oxygen saturation 98% on room air. The physical examination is significant only for a minimally palpable mass with irregular, poorly defined margins in the upper outer quadrant of the left breast. The mass is rubbery and movable. There is no axillary lymphadenopathy noted. Which of the following characteristics is associated with this patient’s most likely type of breast cancer in comparison to her friend’s diagnosis?
Q92
A 32-year-old man presents to his primary care physician complaining of pain accompanied by a feeling of heaviness in his scrotum. He is otherwise healthy except for a broken arm he obtained while skiing several years ago. Physical exam reveals an enlarged “bag of worms” upon palpation of the painful scrotal region. Shining a light over this area shows that the scrotum does not transilluminate. Which of the following statements is true about the most likely cause of this patient's symptoms?
Q93
A 28-year-old man comes to the physician because of a 2-week history of testicular swelling and dull lower abdominal discomfort. Physical examination shows a firm, nontender left testicular nodule. Ultrasonography of the scrotum shows a well-defined hypoechoic lesion of the left testicle. Serum studies show an elevated β-hCG concentration and a normal α-fetoprotein concentration. The patient undergoes a radical inguinal orchiectomy. Histopathologic examination of the surgical specimen shows a mixed germ cell tumor with invasion of adjacent lymphatic vessels. Further evaluation is most likely to show malignant cells in which of the following lymph node regions?
Q94
A 23-year-old woman presents to the emergency department with severe abdominal pain. She states that the pain has been dull and progressive, but became suddenly worse while she was exercising. The patient's past medical history is notable for depression, anxiety, and gonococcal urethritis that was appropriately treated. The patient states that she is sexually active and does not use condoms. She admits to drinking at least 5 standard alcoholic drinks a day. The patient also recently lost a large amount of weight for a fitness show she planned on entering. The patient's current medications include oral contraceptive pills, fluoxetine, alprazolam, ibuprofen, acetaminophen, and folate. On physical exam you note an athletic young woman with burly shoulders, a thick neck, and acne on her forehead and back. On abdominal exam you note diffuse tenderness with 10/10 pain upon palpation of the right upper quadrant. Blood pressure is 80/40 mmHg, pulse is 110/minute, temperature is 99.5°F (37.5°C) and respirations are 15/minute with an oxygen saturation of 96% on room air. Intravenous fluids are started and labs are sent. A urinary ß-hCG has been ordered. Which of the following is most likely the diagnosis?
Q95
A 2-year-old female with abdominal pain undergoes laparoscopic surgery. An outpouching of tissue is excised from the ileum and sent to the laboratory for evaluation. The pathologist notes inflammation and the presence of mucosa, submucosa, and muscle in the walls of the specimen. Which of the following is the most likely diagnosis?
Q96
A 68-year-old male with past history of hypertension, hyperlipidemia, and a 30 pack/year smoking history presents to his primary care physician for his annual physical. Because of his age and past smoking history, he is sent for screening abdominal ultrasound. He is found to have a 4 cm infrarenal abdominal aortic aneurysm. Surgical repair of his aneurysm is indicated if which of the following are present?
Q97
A 50-year-old man is brought to the emergency department because of a 3-day history of left flank pain. The patient has had two episodes of urolithiasis during the last year. He initially had pain with urination that improved with oxycodone. Over the past day, the pain has worsened and he has additionally developed fever and chills. He has hypertension and type 2 diabetes mellitus. He has smoked one pack of cigarettes daily for 20 years. He does not drink alcohol. His current medications include metformin and lisinopril. The patient appears ill and uncomfortable. His temperature is 39.1°C (102.3°F), pulse is 108/min, respirations are 22/min, and blood pressure is 90/62 mm Hg. The lungs are clear to auscultation. Cardiac examination shows no murmurs, rubs, or gallops. Examination of the back shows left costovertebral angle tenderness. Physical and neurologic examinations show no other abnormalities. Laboratory studies show:
Hemoglobin 14.2 g/dL
Leukocyte count 13,900/mm3
Hemoglobin A1c 8.2%
Serum
Na+ 138 mEq/L
K+ 3.8 mEq/L
Cl-
98 mEq/L
Calcium 9.3 mg/dL
Glucose 190 mg/dL
Creatinine 2.1 mg/dL
Urine pH 8.3
Urine microscopy
Bacteria moderate
RBC 6–10/hpf
WBC 10–15/hpf
WBC casts numerous
Ultrasound shows enlargement of the left kidney with a dilated pelvis and echogenic debris. CT scan shows a 16-mm stone at the left ureteropelvic junction, dilation of the collecting system, thickening of the wall of the renal pelvis, and signs of perirenal inflammation. Intravenous fluid resuscitation and intravenous ampicillin, gentamicin, and morphine are begun. Which of the following is the most appropriate next step in the management of this patient?
Q98
A 69-year-old man is brought to the emergency department because of a 1-week history of recurring black stools. On questioning, he reports fatigue and loss of appetite over the last 3 months. Twenty years ago, he underwent a partial gastrectomy for peptic ulcer disease. The patient's father died of metastatic colon cancer at the age of 57 years. He is 163 cm (5 ft 4 in) tall and weighs 55 kg (121 lb); BMI is 20.8 kg/m2. He appears chronically ill. His temperature is 36.5°C (97.7°F), pulse is 105/min, and blood pressure is 115/70 mm Hg. The conjunctiva appear pale. Cardiopulmonary examination shows no abnormalities. The abdomen is soft and nontender. There is a well-healed scar on the upper abdomen. His hemoglobin concentration is 10.5 g/dL and his mean corpuscular volume is 101 μm3. An upper endoscopy shows a large nodular mass on the anterior wall of the lesser curvature of the gastric stump. Biopsy samples are obtained, showing polypoid, glandular formation of irregular-shaped and fused gastric cells with intraluminal mucus, demonstrating an infiltrative growth. Which of the following is the most appropriate next step in the management of this patient?
Q99
A 42-year-old woman presents to the emergency department with abdominal pain. She states that she was eating dinner when she suddenly felt abdominal pain and nausea. The pain did not improve after 30 minutes, so her husband brought her in. The patient has a past medical history of diabetes that is well-treated with exercise and metformin. Her temperature is 101°F (38.3°C), blood pressure is 147/98 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam reveals right upper quadrant tenderness and guaiac negative stools. Which of the following is optimal management for this patient's condition?
Q100
A 37-year-old man presents to the physician. He has been overweight since childhood. He has not succeeded in losing weight despite following different diet and exercise programs over the past several years. He has had diabetes mellitus for 2 years and severe gastroesophageal reflux disease for 9 years. His medications include metformin, aspirin, and pantoprazole. His blood pressure is 142/94 mm Hg, pulse is 76/min, and respiratory rate is 14/min. His BMI is 36.5 kg/m2. Laboratory studies show:
Hemoglobin A1C 6.6%
Serum
Fasting glucose 132 mg/dL
Which of the following is the most appropriate surgical management?
Abdominal emergencies US Medical PG Practice Questions and MCQs
Question 91: A 60-year-old woman presents with changes in her left breast that started 1 month ago. The patient states that she noticed that an area of her left breast felt thicker than before, and has not improved. She came to get it checked out because her best friend was just diagnosed with invasive ductal carcinoma. The past medical history is significant for Hashimoto’s thyroiditis, well-managed medically with levothyroxine. The patient has a 30-pack-year smoking history, but she quit over 15 years ago. The menarche occurred at age 11, and the menopause was at age 53. She does not have any children and has never been sexually active. Her last screening mammogram 10 months ago was normal. The family history is significant for her mother dying from a myocardial infarction (MI) at age 68, her sister dying from metastatic breast cancer at age 55, and for colon cancer in her paternal grandfather. The review of systems is notable for unintentional weight loss of 3.6 kg (8 lb) in the past month. The vital signs include: temperature 37.0℃ (98.6℉), blood pressure 110/70 mm Hg, pulse 72/min, respiratory rate 15/min, and oxygen saturation 98% on room air. The physical examination is significant only for a minimally palpable mass with irregular, poorly defined margins in the upper outer quadrant of the left breast. The mass is rubbery and movable. There is no axillary lymphadenopathy noted. Which of the following characteristics is associated with this patient’s most likely type of breast cancer in comparison to her friend’s diagnosis?
A. Mammogram is more likely to demonstrate a discrete spiculated mass
B. Worse prognosis
C. Can present bilaterally (Correct Answer)
D. Higher prevalence
E. Fibrosis is a distinguishing feature on biopsy
Explanation: ***Can present bilaterally***
- This patient's symptoms (minimally palpable, rubbery, movable mass with poorly defined margins in the upper outer quadrant) and her risk factors (nulliparity, early menarche, late menopause, family history of breast cancer in a first-degree relative) are highly suggestive of **invasive lobular carcinoma (ILC)**, which is known to be frequently **multifocal and bilateral**.
- Compared to **invasive ductal carcinoma (IDC)**, which is the friend's diagnosis and typically presents as a solitary mass, ILC often affects both breasts due to its growth pattern.
- ILC presents as a rubbery, poorly defined mass because tumor cells grow in a single-file pattern infiltrating the stroma without forming a distinct mass.
*Mammogram is more likely to demonstrate a discrete spiculated mass*
- A discrete **spiculated mass** on mammogram is characteristic of **invasive ductal carcinoma (IDC)** due to its desmoplastic reaction, not invasive lobular carcinoma (ILC).
- ILC often does not form a discrete mass and can be **difficult to detect mammographically**, sometimes appearing as architectural distortion, asymmetric density, or not at all due to its infiltrative growth pattern.
*Worse prognosis*
- **Invasive ductal carcinoma (IDC)** and **invasive lobular carcinoma (ILC)** have generally **comparable prognoses** when matched for stage and grade.
- While IDC is more common, ILC is not considered to have a better prognosis; both are invasive malignancies that have breached the basement membrane.
*Higher prevalence*
- **Invasive ductal carcinoma (IDC)** is the **most common type of breast cancer**, accounting for 75-80% of all breast cancers, making it far more prevalent than invasive lobular carcinoma (ILC).
- ILC is the second most common type, representing about 10-15% of invasive breast cancers.
*Fibrosis is a distinguishing feature on biopsy*
- **Fibrosis** is a common feature in **invasive ductal carcinoma (IDC)**, contributing to the firm, desmoplastic reaction around the tumor.
- **Invasive lobular carcinoma (ILC)** is primarily characterized by discohesive cells with loss of E-cadherin expression, growing in a single-file pattern through the stroma, and does not typically produce significant fibrosis or desmoplastic reaction.
Question 92: A 32-year-old man presents to his primary care physician complaining of pain accompanied by a feeling of heaviness in his scrotum. He is otherwise healthy except for a broken arm he obtained while skiing several years ago. Physical exam reveals an enlarged “bag of worms” upon palpation of the painful scrotal region. Shining a light over this area shows that the scrotum does not transilluminate. Which of the following statements is true about the most likely cause of this patient's symptoms?
A. Equally common on both sides
B. More common on left due to drainage into renal vein (Correct Answer)
C. More common on right due to drainage into renal vein
D. More common on right due to drainage into inferior vena cava
E. More common on left due to drainage into inferior vena cava
Explanation: ***More common on left due to drainage into renal vein***
- The patient's symptoms of scrotal pain, "bag of worms" on palpation, and lack of transillumination are classic for a **left-sided varicocele**.
- The longer course and perpendicular drainage of the **left testicular vein** into the left renal vein create higher pressure, making varicocele formation more common on the left.
*Equally common on both sides*
- Varicoceles are distinctly asymmetrical, with a well-established higher incidence on the left side due to anatomical differences.
- Bilateral varicoceles can occur but are less common than isolated left-sided ones and do not support an "equally common" distribution.
*More common on right due to drainage into renal vein*
- The right testicular vein typically drains directly into the **inferior vena cava (IVC)**, not the renal vein, which is a lower pressure system compared to the left.
- Therefore, anatomical factors do not favor varicocele formation on the right side due to drainage into the renal vein.
*More common on right due to drainage into inferior vena cava*
- While the right testicular vein drains into the IVC, this direct drainage path is associated with good venous return and a lower risk of varicocele.
- A right-sided varicocele is less common and, if present, should prompt investigation for retroperitoneal mass obstructing the IVC or right testicular vein.
*More common on left due to drainage into inferior vena cava*
- The left testicular vein typically drains into the **left renal vein**, not directly into the inferior vena cava.
- This anatomical description is incorrect and does not explain the higher incidence of left-sided varicoceles.
Question 93: A 28-year-old man comes to the physician because of a 2-week history of testicular swelling and dull lower abdominal discomfort. Physical examination shows a firm, nontender left testicular nodule. Ultrasonography of the scrotum shows a well-defined hypoechoic lesion of the left testicle. Serum studies show an elevated β-hCG concentration and a normal α-fetoprotein concentration. The patient undergoes a radical inguinal orchiectomy. Histopathologic examination of the surgical specimen shows a mixed germ cell tumor with invasion of adjacent lymphatic vessels. Further evaluation is most likely to show malignant cells in which of the following lymph node regions?
A. External iliac
B. Deep inguinal
C. Para-aortic (Correct Answer)
D. Mediastinal
E. Internal iliac
Explanation: ***Para-aortic***
- Testicular lymphatic drainage primarily follows the **gonadal vessels** back to the para-aortic lymph nodes (also known as retroperitoneal lymph nodes).
- This is the **most common site** for metastatic spread of testicular germ cell tumors.
*External iliac*
- The external iliac lymph nodes primarily drain structures in the pelvis and lower limbs, such as the bladder and vagina, not the testes.
- While they can be involved in advanced pelvic malignancies, they are not the primary drainage site for testicular cancer.
*Deep inguinal*
- The deep inguinal lymph nodes primarily drain the superficial inguinal lymph nodes, which receive lymphatic drainage from the penis, scrotum (superficial layers), and perineum.
- Testicular lymphatics bypass the inguinal nodes unless there is scrotal invasion or prior surgery involving the scrotum.
*Mediastinal*
- Mediastinal lymph nodes are involved in the lymphatic drainage of thoracic organs and can be affected in later stages of testicular cancer if there is widespread metastatic disease, particularly to the lungs.
- However, they are not the initial or primary site of lymphatic spread from testicular tumors.
*Internal iliac*
- The internal iliac lymph nodes primarily drain pelvic organs and the deep perineum.
- While they may be involved in some pelvic cancers, they are not the primary lymphatic drainage site for the testes.
Question 94: A 23-year-old woman presents to the emergency department with severe abdominal pain. She states that the pain has been dull and progressive, but became suddenly worse while she was exercising. The patient's past medical history is notable for depression, anxiety, and gonococcal urethritis that was appropriately treated. The patient states that she is sexually active and does not use condoms. She admits to drinking at least 5 standard alcoholic drinks a day. The patient also recently lost a large amount of weight for a fitness show she planned on entering. The patient's current medications include oral contraceptive pills, fluoxetine, alprazolam, ibuprofen, acetaminophen, and folate. On physical exam you note an athletic young woman with burly shoulders, a thick neck, and acne on her forehead and back. On abdominal exam you note diffuse tenderness with 10/10 pain upon palpation of the right upper quadrant. Blood pressure is 80/40 mmHg, pulse is 110/minute, temperature is 99.5°F (37.5°C) and respirations are 15/minute with an oxygen saturation of 96% on room air. Intravenous fluids are started and labs are sent. A urinary ß-hCG has been ordered. Which of the following is most likely the diagnosis?
A. Inflammation of the pancreas
B. Ectopic implantation of a blastocyst
C. Obstruction of the common bile duct by radio-opaque stones
D. Vascular ectasia within the liver
E. Ruptured hepatic adenoma (Correct Answer)
Explanation: ***Ruptured hepatic adenoma***
- The patient's history of **oral contraceptive pills**, especially with a recent history of substantial **weight loss for a fitness show** (potentially involving **anabolic steroid use**, suggested by her physical exam findings of "burly shoulders, a thick neck, and acne"), significantly increases the risk of **hepatic adenoma**.
- **Sudden worsening of severe abdominal pain** associated with exercise, signs of **hypovolemic shock** (BP 80/40 mmHg, HR 110/min), and diffuse abdominal tenderness, particularly in the **right upper quadrant**, are classic signs of a **ruptured hepatic adenoma** with hemoperitoneum.
*Inflammation of the pancreas*
- Pancreatitis typically presents with **epigastric pain radiating to the back**, often associated with nausea and vomiting, which is not fully consistent with the sudden, severe, diffuse abdominal pain and shock described.
- While **alcohol use** is a risk factor for pancreatitis, the other features (RUQ tenderness, shock, physical exam findings) point more strongly towards a ruptured hepatic lesion.
*Ectopic implantation of a blastocyst*
- While the patient is sexually active, not using condoms, and a **urinary β-hCG test** is ordered, an ectopic pregnancy would typically present with **unilateral lower quadrant pain** and vaginal bleeding.
- The profound **RUQ pain**, general abdominal tenderness, and signs of shock, combined with the other pertinent history points (oral contraceptive use, potential steroid use, athletic build), make a ruptured hepatic adenoma more likely.
*Obstruction of the common bile duct by radio-opaque stones*
- This describes **biliary colic** or **cholangitis**, which usually presents with **RUQ pain that can radiate to the back or shoulder**, often after fatty meals, and may be accompanied by fever and jaundice if infected.
- It does not typically cause **hypovolemic shock** or sudden, diffuse peritonitis like a hemorrhage would, and the pain pattern described is less indicative of stone obstruction.
*Vascular ectasia within the liver*
- While vascular ectasias (e.g., in Osler-Weber-Rendu disease) can cause **hemorrhage**, they are typically associated with different clinical contexts and often present with recurrent bleeding or anemia.
- It is a much less common cause of acute, life-threatening abdominal hemorrhage in a young woman with this specific constellation of risk factors and physical exam findings compared to a ruptured hepatic adenoma.
Question 95: A 2-year-old female with abdominal pain undergoes laparoscopic surgery. An outpouching of tissue is excised from the ileum and sent to the laboratory for evaluation. The pathologist notes inflammation and the presence of mucosa, submucosa, and muscle in the walls of the specimen. Which of the following is the most likely diagnosis?
A. Appendicitis
B. Meckel's diverticulum (Correct Answer)
C. Hirschprung's disease
D. Crohn's disease
E. Henoch-Schonlein purpura
Explanation: ***Meckel's diverticulum***
- The description of an **outpouching of tissue from the ileum** containing mucosa, submucosa, and muscle is characteristic of a **true diverticulum**, like Meckel's.
- This is the **most common congenital anomaly of the GI tract**, following the **"Rule of 2's"**: occurs in ~2% of population, located ~2 feet from ileocecal valve, ~2 inches long, presents in first 2 years of life, and may contain 2 types of ectopic tissue (gastric and pancreatic).
- The patient's age (2 years), **abdominal pain**, and pathological findings of inflammation in an ileal outpouching are classic for symptomatic Meckel's diverticulum.
*Appendicitis*
- This is an **inflammation of the vermiform appendix**, a small, finger-shaped organ projecting from the cecum, not an outpouching of the ileum wall itself.
- While it presents with abdominal pain, the surgical and pathological description of an ileal outpouching is inconsistent with an inflamed appendix.
*Hirschsprung's disease*
- This is a **congenital absence of ganglion cells** in the distal colon, leading to functional obstruction, not an outpouching of the ileum.
- Symptoms typically include severe constipation, abdominal distension, and failure to pass meconium in neonates.
*Crohn's disease*
- A **chronic inflammatory bowel disease** that can affect any part of the gastrointestinal tract, causing **transmural inflammation** and skip lesions.
- It causes inflammation and strictures but not a single, congenital outpouching of normal gut wall layers as described.
*Henoch-Schonlein purpura*
- This is a **vasculitis** affecting small blood vessels, characterized by a **palpable purpuric rash**, arthralgia, abdominal pain, and kidney involvement.
- While it causes abdominal pain, it does not involve an anatomical outpouching of the ileum documented as a surgical finding.
Question 96: A 68-year-old male with past history of hypertension, hyperlipidemia, and a 30 pack/year smoking history presents to his primary care physician for his annual physical. Because of his age and past smoking history, he is sent for screening abdominal ultrasound. He is found to have a 4 cm infrarenal abdominal aortic aneurysm. Surgical repair of his aneurysm is indicated if which of the following are present?
A. Abdominal, back, or groin pain (Correct Answer)
B. Marfan's syndrome
C. Diameter >3 cm
D. Smoking history
E. Growth of < 0.5 cm in one year
Explanation: ***Abdominal, back, or groin pain***
- The presence of **abdominal, back, or groin pain** in a patient with an AAA indicates **symptomatic aneurysm**, suggesting impending rupture or expansion, which necessitates urgent surgical repair regardless of size.
- This symptom complex signifies an increased risk of complications and makes the aneurysm an **immediate threat** to life.
*Marfan's syndrome*
- While patients with **Marfan's syndrome** are at higher risk for aortic aneurysms (often in the ascending aorta), the diagnosis of Marfan's syndrome itself is not an indication for surgical repair of an infrarenal AAA; rather, specific aneurysm characteristics (e.g., size, growth rate) would determine the need for intervention.
- The presence of connective tissue disorders like Marfan's syndrome influences repair thresholds, but it is not a standalone indication for surgery in patients with an existing 4 cm infrarenal AAA.
*Diameter >3 cm*
- An aneurysm diameter of greater than 3 cm defines an abdominal aortic aneurysm, but it is **not an automatic indication for surgical repair**.
- Elective repair is generally considered for aneurysms typically greater than **5.0 to 5.5 cm in men**, or with rapid growth, or if symptomatic, but 4 cm alone is usually managed with surveillance.
*Smoking history*
- A **smoking history** is a significant risk factor for the development and progression of abdominal aortic aneurysms, as it contributes to atherosclerosis and weakening of the aortic wall.
- However, smoking history itself is **not an indication for surgical repair**; it merely highlights the patient's elevated risk for the condition and its complications.
*Growth of < 0.5 cm in one year*
- A growth rate of less than 0.5 cm in one year would be considered a **slow or stable growth rate** for an infrarenal AAA.
- Rapid growth (e.g., >0.5 cm in 6 months or >1 cm in 1 year) is an indication for surgical repair, so **slow growth actually favors continued surveillance** rather than intervention for a 4 cm aneurysm.
Question 97: A 50-year-old man is brought to the emergency department because of a 3-day history of left flank pain. The patient has had two episodes of urolithiasis during the last year. He initially had pain with urination that improved with oxycodone. Over the past day, the pain has worsened and he has additionally developed fever and chills. He has hypertension and type 2 diabetes mellitus. He has smoked one pack of cigarettes daily for 20 years. He does not drink alcohol. His current medications include metformin and lisinopril. The patient appears ill and uncomfortable. His temperature is 39.1°C (102.3°F), pulse is 108/min, respirations are 22/min, and blood pressure is 90/62 mm Hg. The lungs are clear to auscultation. Cardiac examination shows no murmurs, rubs, or gallops. Examination of the back shows left costovertebral angle tenderness. Physical and neurologic examinations show no other abnormalities. Laboratory studies show:
Hemoglobin 14.2 g/dL
Leukocyte count 13,900/mm3
Hemoglobin A1c 8.2%
Serum
Na+ 138 mEq/L
K+ 3.8 mEq/L
Cl-
98 mEq/L
Calcium 9.3 mg/dL
Glucose 190 mg/dL
Creatinine 2.1 mg/dL
Urine pH 8.3
Urine microscopy
Bacteria moderate
RBC 6–10/hpf
WBC 10–15/hpf
WBC casts numerous
Ultrasound shows enlargement of the left kidney with a dilated pelvis and echogenic debris. CT scan shows a 16-mm stone at the left ureteropelvic junction, dilation of the collecting system, thickening of the wall of the renal pelvis, and signs of perirenal inflammation. Intravenous fluid resuscitation and intravenous ampicillin, gentamicin, and morphine are begun. Which of the following is the most appropriate next step in the management of this patient?
A. Intravenous pyelography
B. Tamsulosin therapy
C. Percutaneous nephrostomy (Correct Answer)
D. Shock wave lithotripsy
E. Ureteroscopy and stent placement
Explanation: ***Percutaneous nephrostomy***
- The patient presents with **obstructive pyelonephritis** due to a large **ureteral stone** (16 mm) and signs of **urosepsis** (fever, chills, hypotension, leukocytosis, elevated creatinine).
- **Urgent decompression** of the obstructed kidney is critical to relieve pressure, improve renal function, and control infection. A percutaneous nephrostomy provides immediate drainage, which is life-saving in this severe context.
*Intravenous pyelography*
- This is an imaging study used to visualize the urinary tract and is **contraindicated** in patients with **renal insufficiency** (creatinine 2.1 mg/dL) due to the risk of contrast-induced nephropathy.
- Furthermore, it would only provide diagnostic information and **would not address the urgent need for renal decompression** in a patient with urosepsis.
*Tamsulosin therapy*
- **Alpha-blockers** like tamsulosin can facilitate the passage of **smaller ureteral stones** (typically <10 mm) by relaxing ureteral smooth muscle.
- However, this patient has a **large stone (16 mm)**, signs of **sepsis**, and **renal obstruction**, making medical expulsive therapy ineffective and dangerous as a primary intervention.
*Shock wave lithotripsy*
- **Extracorporeal shock wave lithotripsy (ESWL)** is a non-invasive procedure for breaking up kidney stones into smaller fragments.
- It is **contraindicated** in patients with active **urinary tract infections** or **sepsis** because of the risk of disseminating the infection.
*Ureteroscopy and stent placement*
- While ureteroscopy with stent placement can relieve obstruction, it is an **invasive procedure** that may be challenging in a patient with severe sepsis and inflammation.
- **Percutaneous nephrostomy** offers a less invasive and more immediate way to achieve **decompression** in an unstable patient, with definitive stone management to follow once the infection is controlled.
Question 98: A 69-year-old man is brought to the emergency department because of a 1-week history of recurring black stools. On questioning, he reports fatigue and loss of appetite over the last 3 months. Twenty years ago, he underwent a partial gastrectomy for peptic ulcer disease. The patient's father died of metastatic colon cancer at the age of 57 years. He is 163 cm (5 ft 4 in) tall and weighs 55 kg (121 lb); BMI is 20.8 kg/m2. He appears chronically ill. His temperature is 36.5°C (97.7°F), pulse is 105/min, and blood pressure is 115/70 mm Hg. The conjunctiva appear pale. Cardiopulmonary examination shows no abnormalities. The abdomen is soft and nontender. There is a well-healed scar on the upper abdomen. His hemoglobin concentration is 10.5 g/dL and his mean corpuscular volume is 101 μm3. An upper endoscopy shows a large nodular mass on the anterior wall of the lesser curvature of the gastric stump. Biopsy samples are obtained, showing polypoid, glandular formation of irregular-shaped and fused gastric cells with intraluminal mucus, demonstrating an infiltrative growth. Which of the following is the most appropriate next step in the management of this patient?
A. Abdominopelvic CT scan (Correct Answer)
B. Stool antigen test for H. pylori
C. Laparoscopy
D. Vitamin B12 assessment
E. Treatment with PPI, clarithromycin, and amoxicillin
Explanation: ***Abdominopelvic CT scan***
- The biopsy findings of **polypoid, glandular formation of irregular-shaped and fused gastric cells with intraluminal mucus, demonstrating an infiltrative growth** are highly suggestive of **gastric adenocarcinoma**. An abdominopelvic CT scan is crucial for **staging** the cancer, assessing for **local invasion**, **lymph node involvement**, and **distant metastasis**.
- Given the history of **partial gastrectomy** (a risk factor for stump cancer), the macroscopic appearance on endoscopy, and the histological findings, further staging with a CT scan is essential to guide subsequent management, such as surgical planning or chemotherapy.
*Stool antigen test for H. pylori*
- While *H. pylori* is a risk factor for gastric cancer, the patient already has a **large nodular mass** and **biopsy-proven adenocarcinoma**. Testing for *H. pylori* at this stage would not change the immediate management and is **not the most appropriate next step** for a confirmed malignancy.
- Eradication therapy for *H. pylori* is typically indicated for **early-stage gastric cancer** (e.g., MALT lymphoma) or **pre-malignant lesions**, but not as an initial step for advanced or confirmed adenocarcinoma where staging is paramount.
*Laparoscopy*
- **Laparoscopy** is often performed after initial imaging (like CT) to confirm resectability, detect **peritoneal metastasis** that may not be visible on CT, and obtain samples for cytology. However, it is generally done **after CT staging** as CT provides a broader initial assessment of disease extent.
- Therefore, while laparoscopy may be a subsequent step, it is **not the most appropriate *next* step** before comprehensive imaging is completed.
*Vitamin B12 assessment*
- The patient's history of **partial gastrectomy** can lead to **vitamin B12 deficiency** due to the loss of intrinsic factor-producing parietal cells and altered absorption. The mild **macrocytic anemia** (MCV 101 μm3) supports this possibility.
- However, while important, addressing vitamin B12 deficiency is **secondary** to the immediate concern of **staging and managing the life-threatening gastric adenocarcinoma**. The primary focus must be on the cancer.
*Treatment with PPI, clarithromycin, and amoxicillin*
- This regimen is **triple therapy for *H. pylori* eradication**. As discussed, while *H. pylori* is a risk factor, the patient already has biopsy-proven gastric adenocarcinoma, and testing/treating *H. pylori* is **not the most appropriate immediate step** in this context.
- This treatment would not address the confirmed gastric cancer and would **delay definitive management** aimed at the malignancy.
Question 99: A 42-year-old woman presents to the emergency department with abdominal pain. She states that she was eating dinner when she suddenly felt abdominal pain and nausea. The pain did not improve after 30 minutes, so her husband brought her in. The patient has a past medical history of diabetes that is well-treated with exercise and metformin. Her temperature is 101°F (38.3°C), blood pressure is 147/98 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam reveals right upper quadrant tenderness and guaiac negative stools. Which of the following is optimal management for this patient's condition?
A. NPO, IV fluids, analgesics, antibiotics
B. NPO, IV fluids, analgesics, antibiotics, cholecystectomy within 24 hours (Correct Answer)
C. NPO, IV fluids, analgesics, antibiotics, cholecystectomy within 72 hours
D. NPO, IV fluids, analgesics, antibiotics, emergent cholecystectomy
E. NPO, IV fluids, analgesics, antibiotics, cholecystectomy within 48 hours
Explanation: ***NPO, IV fluids, analgesics, antibiotics, cholecystectomy within 24 hours***
- This patient presents with **acute cholecystitis** (RUQ pain after eating, nausea, fever, RUQ tenderness). Initial management includes **NPO status**, **IV fluids**, **analgesics**, and **broad-spectrum antibiotics**.
- Current guidelines recommend **early cholecystectomy within 24 hours** for uncomplicated acute cholecystitis in stable patients, as it reduces hospital stay, complications, and conversion to open surgery.
- Her **well-controlled diabetes** is NOT a contraindication to early surgery. Modern perioperative glucose management allows safe early intervention.
*NPO, IV fluids, analgesics, antibiotics, emergent cholecystectomy*
- **Emergent cholecystectomy** (immediate, within hours) is reserved for complicated cholecystitis with **gangrene**, **perforation**, **emphysematous cholecystitis**, or septic shock.
- This patient is hemodynamically stable with no signs of severe complications, making scheduled early surgery (within 24 hours) more appropriate than truly emergent surgery.
*NPO, IV fluids, analgesics, antibiotics*
- While these are appropriate initial measures, they do not constitute definitive management for **acute cholecystitis**.
- Without cholecystectomy, the patient remains at risk for **complications** (perforation, gangrene, recurrent cholecystitis) and typically requires surgery eventually.
*NPO, IV fluids, analgesics, antibiotics, cholecystectomy within 72 hours*
- While the **72-hour window** is the outer limit for "early cholecystectomy," it is not optimal timing.
- Delaying surgery to 72 hours offers no benefit for this stable patient with uncomplicated disease and increases the risk of complications during the waiting period.
- Well-controlled diabetes does not require delaying surgery to 72 hours.
*NPO, IV fluids, analgesics, antibiotics, cholecystectomy within 48 hours*
- **Cholecystectomy within 48 hours** is acceptable and within the early surgery window, but **within 24 hours** is preferred when feasible.
- Current evidence supports operating as early as safely possible within the first 24-72 hours, with the 24-hour timeframe showing the best outcomes for uncomplicated cases.
Question 100: A 37-year-old man presents to the physician. He has been overweight since childhood. He has not succeeded in losing weight despite following different diet and exercise programs over the past several years. He has had diabetes mellitus for 2 years and severe gastroesophageal reflux disease for 9 years. His medications include metformin, aspirin, and pantoprazole. His blood pressure is 142/94 mm Hg, pulse is 76/min, and respiratory rate is 14/min. His BMI is 36.5 kg/m2. Laboratory studies show:
Hemoglobin A1C 6.6%
Serum
Fasting glucose 132 mg/dL
Which of the following is the most appropriate surgical management?
A. No surgical management at this time
B. Laparoscopic adjustable gastric banding
C. Biliopancreatic diversion and duodenal switch (BPD-DS)
D. Laparoscopic sleeve gastrectomy
E. Laparoscopic Roux-en-Y gastric bypass (Correct Answer)
Explanation: ***Laparoscopic Roux-en-Y gastric bypass***
- This patient meets criteria for bariatric surgery with a **BMI of 36.5 kg/m2** along with significant **comorbidities** such as **type 2 diabetes** and **severe GERD**.
- Roux-en-Y gastric bypass is particularly effective for **diabetes remission** and is the most effective bariatric procedure for **resolving GERD**, making it the most appropriate choice given his symptoms.
*No surgical management at this time*
- The patient has a high BMI (36.5 kg/m2) with multiple obesity-related comorbidities including **diabetes mellitus** and **severe GERD** that have not improved with lifestyle changes and medication.
- Delaying surgical management would allow his obesity and related conditions to potentially worsen, despite his efforts to lose weight through diet and exercise.
*Laparoscopic adjustable gastric banding*
- This procedure typically results in **less weight loss** compared to other bariatric surgeries and is less effective at resolving comorbidities like diabetes and GERD.
- It carries a higher rate of **long-term complications** such as band erosion or slippage, and would not address the patient's severe GERD effectively.
*Biliopancreatic diversion and duodenal switch (BPD-DS)*
- While BPD-DS leads to the most significant weight loss and diabetes remission, it is associated with a **higher risk of surgical complications** and **severe nutritional deficiencies**.
- Given the patient's BMI and comorbidities, a less aggressive procedure like Roux-en-Y gastric bypass offers a better risk-benefit profile, especially for GERD.
*Laparoscopic sleeve gastrectomy*
- Sleeve gastrectomy is an effective weight-loss procedure, but it can **worsen or induce GERD** in some patients due to changes in gastric anatomy and pressure.
- As the patient has severe GERD, this procedure would not be the optimal choice and could exacerbate his symptoms.
