A 73-year-old man presents to a dermatology clinic after his family physician finds an ulcerated plaque on the dorsal surface of his nose. This lesion has changed in size and form and has bled on multiple occasions even after the patient adopted sun-protection measures. The patient’s medical history is relevant for cigarette smoking and hypertension. Physical examination reveals a poorly defined, erythematous, ulcerated plaque on the surface of the nose (see image). The lesion is diagnosed as squamous cell carcinoma, and the patient undergoes standard excision. However, the pathology report indicates an incomplete excision. Which of the following should be the next step in the management of this case?
Q42
A 37-year-old-woman presents to the emergency room with complaints of fever and abdominal pain. Her blood pressure is 130/74 mmHg, pulse is 98/min, temperature is 101.5°F (38.6°C), and respirations are 23/min. The patient reports that she had a laparoscopic cholecystectomy 4 days ago but has otherwise been healthy. She is visiting her family from Nebraska and just arrived this morning from a 12-hour drive. Physical examination revealed erythema and white discharge from abdominal incisions and tenderness upon palpations at the right upper quadrant. What is the most probable cause of the patient’s fever?
Q43
Two hours after undergoing a left femoral artery embolectomy, an obese 63-year-old woman has severe pain, numbness, and tingling of the left leg. The surgery was without complication and peripheral pulses were weakly palpable postprocedure. She has type 2 diabetes mellitus, peripheral artery disease, hypertension, and hypercholesterolemia. Prior to admission, her medications included insulin, enalapril, carvedilol, aspirin, and rosuvastatin. She appears uncomfortable. Her temperature is 37.1°C (99.3°F), pulse is 98/min, and blood pressure is 132/90 mm Hg. Examination shows a left groin surgical incision. The left lower extremity is swollen, stiff, and tender on palpation. Dorsiflexion of her left foot causes severe pain in her calf. Femoral pulses are palpated bilaterally. Pedal pulses are weaker on the left side as compared to the right side. Laboratory studies show:
Hemoglobin 12.1
Leukocyte count 11,300/mm3
Platelet count 189,000/mm3
Serum
Glucose 222 mg/dL
Creatinine 1.1 mg/dL
Urinalysis is within normal limits. Which of the following is the most likely cause of these findings?
Q44
A 62-year-old man comes to the physician for a follow-up examination after having been diagnosed with stage II adenocarcinoma of the left lower lung lobe without evidence of distant metastases 1 week ago following an evaluation for a chronic cough. He has hypertension and type 2 diabetes mellitus. He has smoked one pack of cigarettes daily for the past 40 years. His current medications include metformin, sitagliptin, and enalapril. He is 177 cm (5 ft 10 in) tall and weighs 65 kg (143 lb); BMI is 20.7 kg/m2. He appears lethargic. Vital signs are within normal limits. Pulse oximetry shows an oxygen saturation of 98%. Examination shows inspiratory wheezing at the left lung base. The remainder of the examination shows no abnormalities. A complete blood count and serum concentrations of electrolytes, creatinine, glucose, and liver enzymes are within the reference range. Spirometry shows an FEV1 of 1.6 L. The diffusing lung capacity for carbon monoxide (DLCO) is 66% of predicted. Which of the following is the most appropriate next step in the management of this patient?
Q45
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?
Q46
The patient undergoes a mammogram, which shows a 6.5mm sized mass with an irregular border and spiculated margins. A subsequent core needle biopsy of the mass shows infiltrating ductal carcinoma with HER2-positive, estrogen-negative, and progesterone-negative immunohistochemistry staining. Blood counts and liver function tests are normal. Laboratory studies show:
Hemoglobin 12.5 g/dL
Serum
Na+ 140 mEq/L
Cl- 103 mEq/L
K+ 4.2 mEq/L
HCO3- 26 mEq/L
Ca2+ 8.9 mg/dL
Urea Nitrogen 12 mg/dL
Glucose 110 mg/dL
Alkaline Phosphatase 25 U/L
Alanine aminotransferase (ALT) 15 U/L
Aspartate aminotransferase (AST) 13 U/L
Which of the following is the most appropriate next step in management?
Q47
A 58-year-old obese male has noticed the gradual development of a soft bulge on his right groin that has been present over the past year and occasionally becomes very tender. He notices that it comes out when he coughs and strains during bowel movements. He is able to push the bulge back in without issue. After examination, you realize that he has an inguinal hernia and recommend open repair with mesh placement. After surgery, the patient returns to clinic and complains of numbness and tingling in the upper part of the scrotum and base of the penis. What nerve was most likely injured during the procedure?
Q48
A 44-year-old woman presents to the emergency department with confusion starting this morning. Her husband states that she initially complained of abdominal pain, diarrhea, and fatigue after eating. She has vomited 3 times and progressively became more confused. Her past medical history is notable for morbid obesity, diabetes, hypertension, dyslipidemia, a sleeve gastrectomy 1 month ago, and depression with multiple suicide attempts. Her temperature is 98.0°F (36.7°C), blood pressure is 104/54 mmHg, pulse is 120/min, respirations are 15/min, and oxygen saturation is 98% on room air. Her physical exam is notable for generalized confusion. Laboratory values are ordered as seen below.
Serum:
Na+: 139 mEq/L
Cl-: 100 mEq/L
K+: 3.9 mEq/L
HCO3-: 24 mEq/L
BUN: 22 mg/dL
Glucose: 41 mg/dL
Creatinine: 1.1 mg/dL
Ca2+: 10.2 mg/dL
C-peptide level: normal
Which of the following is the most likely diagnosis?
Q49
An excisional biopsy is performed and the diagnosis of superficial spreading melanoma is confirmed. The lesion is 1.1 mm thick. Which of the following is the most appropriate next step in management?
Q50
A 65-year-old man presents to the dermatology clinic to have a basal cell carcinoma excised from his upper back. The lesion measures 2.3 x 3.2 cm. He has a medical history significant for hypertension and diabetes mellitus type II, for which he takes lisinopril and metformin, respectively. He has had a basal cell carcinoma before which was excised in the clinic without complications. Which of the following modes of anesthesia should be used for this procedure?
Post-op care US Medical PG Practice Questions and MCQs
Question 41: A 73-year-old man presents to a dermatology clinic after his family physician finds an ulcerated plaque on the dorsal surface of his nose. This lesion has changed in size and form and has bled on multiple occasions even after the patient adopted sun-protection measures. The patient’s medical history is relevant for cigarette smoking and hypertension. Physical examination reveals a poorly defined, erythematous, ulcerated plaque on the surface of the nose (see image). The lesion is diagnosed as squamous cell carcinoma, and the patient undergoes standard excision. However, the pathology report indicates an incomplete excision. Which of the following should be the next step in the management of this case?
A. Imiquimod
B. Photodynamic therapy
C. Mohs surgery (Correct Answer)
D. Cryotherapy
E. Radiation therapy
Explanation: ***Mohs surgery***
- **Mohs micrographic surgery** is indicated for **high-risk squamous cell carcinoma** (SCC) and incomplete excisions, especially in cosmetically sensitive areas like the nose.
- This technique allows for precise removal of cancerous tissue while preserving surrounding healthy tissue by immediate microscopic examination of excised margins.
*Imiquimod*
- This is a **topical immune response modifier** used for some superficial skin cancers like **superficial basal cell carcinoma** and actinic keratoses.
- It is generally not recommended for invasive SCC due to the risk of incomplete treatment and potential for recurrence.
*Photodynamic therapy*
- **Photodynamic therapy** (PDT) uses a photosensitizing agent followed by light exposure to destroy cancer cells, primarily for **superficial skin cancers** or pre-cancers.
- It is less effective for invasive or recurrent SCC, especially when the initial excision was incomplete.
*Cryotherapy*
- **Cryotherapy** involves freezing and destroying tissue and is typically reserved for **superficial, low-risk lesions** or non-melanoma skin cancers.
- It does not allow for margin assessment and is not appropriate for an incompletely excised, aggressive SCC.
*Radiation therapy*
- **Radiation therapy** is an option for certain skin cancers, especially in patients who are not surgical candidates or for cases with large, inoperable tumors or positive lymph nodes.
- However, for an incompletely excised SCC on the nose, **Mohs surgery** offers superior local control and tissue preservation, making it the preferred next step.
Question 42: A 37-year-old-woman presents to the emergency room with complaints of fever and abdominal pain. Her blood pressure is 130/74 mmHg, pulse is 98/min, temperature is 101.5°F (38.6°C), and respirations are 23/min. The patient reports that she had a laparoscopic cholecystectomy 4 days ago but has otherwise been healthy. She is visiting her family from Nebraska and just arrived this morning from a 12-hour drive. Physical examination revealed erythema and white discharge from abdominal incisions and tenderness upon palpations at the right upper quadrant. What is the most probable cause of the patient’s fever?
A. Pulmonary atelectasis
B. Residual gallstones
C. Urinary tract infection
D. Wound infection (Correct Answer)
E. Pulmonary embolism
Explanation: ***Wound infection***
- The presence of **erythema**, **white discharge from abdominal incisions**, and **fever** 4 days post-laparoscopic cholecystectomy strongly indicates a surgical site infection.
- This is a common complication after surgery, especially with visible signs of local inflammation and purulent discharge.
*Pulmonary atelectasis*
- **Atelectasis** typically presents within **24-48 hours post-op** and usually resolves spontaneously.
- While it can cause fever, the prominent local wound signs and the timing (4 days post-op) make it less likely to be the primary cause of fever.
*Residual gallstones*
- **Residual gallstones** would typically present with symptoms resembling acute cholecystitis or cholangitis, such as **right upper quadrant pain**, **jaundice**, or **elevated liver enzymes**, without direct signs of wound infection.
- These do not account for the **erythema and discharge from the incision sites**.
*Urinary tract infection*
- A **urinary tract infection (UTI)** would present with **dysuria**, **frequency**, **urgency**, or **suprapubic pain**, and would not explain the local wound findings.
- While surgery can increase the risk of nosocomial UTIs, the clinical presentation is primarily focused on the surgical site.
*Pulmonary embolism*
- A **pulmonary embolism (PE)** would likely cause **dyspnea**, **tachycardia**, **hypoxia**, and **pleuritic chest pain**, which are not reported in this case.
- Though prolonged immobility (e.g., long drive) is a risk factor, the specific local signs of infection are not consistent with PE.
Question 43: Two hours after undergoing a left femoral artery embolectomy, an obese 63-year-old woman has severe pain, numbness, and tingling of the left leg. The surgery was without complication and peripheral pulses were weakly palpable postprocedure. She has type 2 diabetes mellitus, peripheral artery disease, hypertension, and hypercholesterolemia. Prior to admission, her medications included insulin, enalapril, carvedilol, aspirin, and rosuvastatin. She appears uncomfortable. Her temperature is 37.1°C (99.3°F), pulse is 98/min, and blood pressure is 132/90 mm Hg. Examination shows a left groin surgical incision. The left lower extremity is swollen, stiff, and tender on palpation. Dorsiflexion of her left foot causes severe pain in her calf. Femoral pulses are palpated bilaterally. Pedal pulses are weaker on the left side as compared to the right side. Laboratory studies show:
Hemoglobin 12.1
Leukocyte count 11,300/mm3
Platelet count 189,000/mm3
Serum
Glucose 222 mg/dL
Creatinine 1.1 mg/dL
Urinalysis is within normal limits. Which of the following is the most likely cause of these findings?
A. Reperfusion injury (Correct Answer)
B. Cellulitis
C. Cholesterol embolism
D. Deep vein thrombosis
E. Rhabdomyolysis
Explanation: ***Reperfusion injury***
- The patient's symptoms of **severe pain, numbness, and tingling** in the left leg following an embolectomy, along with **swelling, stiffness, and tenderness** of the extremity, and pain on passive dorsiflexion (**pain with passive stretch**), are classic signs of **acute compartment syndrome**.
- In this context, compartment syndrome is caused by **reperfusion injury** following prolonged limb ischemia. When blood flow is restored after prolonged ischemia, the reperfusion causes **oxidative stress, inflammatory mediator release, and increased capillary permeability**, leading to **tissue edema and elevated intracompartmental pressure** that compresses nerves and vessels.
- The **2-hour timeline** post-embolectomy and the clinical triad of pain out of proportion, pain with passive stretch, and paresthesias make reperfusion injury leading to compartment syndrome the most likely diagnosis.
*Cellulitis*
- While cellulitis causes **pain, swelling, and redness**, it typically has a more **gradual onset** and is associated with warmth, erythema, and signs of infection.
- The **acute onset** (2 hours post-surgery), **severe neurologic symptoms** (numbness, tingling), and **pain with passive stretch** are not characteristic of cellulitis.
- The absence of fever, significant leukocytosis, or spreading erythema makes cellulitis unlikely.
*Cholesterol embolism*
- **Cholesterol emboli** can occur after vascular procedures and typically present with **livedo reticularis**, **"blue toe" syndrome**, **renal impairment**, or **eosinophilia**.
- While possible after arterial manipulation, the acute presentation with signs of **elevated compartment pressure** (pain with passive stretch, swelling, paresthesias) points to a pressure-related compartment issue rather than distal microembolization.
*Deep vein thrombosis*
- **DVT** causes **unilateral leg swelling, pain, and tenderness** but typically presents with a more **gradual onset** over hours to days.
- DVT would not explain the **acute severe pain with passive stretch**, **rapid neurologic symptoms** (paresthesias), or the **compartment syndrome findings** seen immediately (2 hours) post-procedure.
- The clinical picture of acute compartment syndrome better fits ischemia-reperfusion injury.
*Rhabdomyolysis*
- **Rhabdomyolysis** involves muscle breakdown due to prolonged ischemia or trauma and is characterized by **elevated creatinine kinase (CK)**, **myoglobinuria**, and potentially **acute kidney injury**.
- While rhabdomyolysis can occur **secondary to** both the initial ischemia and subsequent compartment syndrome, it is a **consequence or complication** rather than the **primary cause** of the acute compartment syndrome findings.
- The immediate clinical presentation (severe pain with passive stretch, paresthesias, swelling) reflects **elevated intracompartmental pressure from reperfusion injury**, not rhabdomyolysis itself.
Question 44: A 62-year-old man comes to the physician for a follow-up examination after having been diagnosed with stage II adenocarcinoma of the left lower lung lobe without evidence of distant metastases 1 week ago following an evaluation for a chronic cough. He has hypertension and type 2 diabetes mellitus. He has smoked one pack of cigarettes daily for the past 40 years. His current medications include metformin, sitagliptin, and enalapril. He is 177 cm (5 ft 10 in) tall and weighs 65 kg (143 lb); BMI is 20.7 kg/m2. He appears lethargic. Vital signs are within normal limits. Pulse oximetry shows an oxygen saturation of 98%. Examination shows inspiratory wheezing at the left lung base. The remainder of the examination shows no abnormalities. A complete blood count and serum concentrations of electrolytes, creatinine, glucose, and liver enzymes are within the reference range. Spirometry shows an FEV1 of 1.6 L. The diffusing lung capacity for carbon monoxide (DLCO) is 66% of predicted. Which of the following is the most appropriate next step in the management of this patient?
A. Schedule lobectomy (Correct Answer)
B. Administer cisplatin and vinorelbine
C. Schedule a wedge resection
D. Administer cisplatin and etoposide
E. Radiation therapy
Explanation: ***Schedule lobectomy***
- The patient has **stage II non-small cell lung cancer (adenocarcinoma)** without distant metastases, making surgical resection with **lobectomy** the treatment of choice for curative intent.
- While pulmonary function is somewhat impaired (FEV1 and DLCO), his overall status, age, and normal labs suggest he can likely tolerate the procedure.
*Administer cisplatin and vinorelbine*
- This combination is a common regimen for **adjuvant chemotherapy** following surgical resection in certain stages of NSCLC, or for advanced unresectable disease.
- It is not the primary treatment for a resectable stage II cancer; **surgery is preferred for cure**.
*Schedule a wedge resection*
- A **wedge resection** (sublobar resection) is typically reserved for patients with very small, peripheral tumors or those with severe comorbidities that preclude lobectomy due to poor pulmonary function.
- Given the patient's stage II disease and potentially curative intent, a **lobectomy is generally preferred** for better oncologic outcomes.
*Administer cisplatin and etoposide*
- This chemotherapy regimen is more commonly used for **small cell lung cancer (SCLC)** or for some advanced NSCLC cases, not typically for resectable stage II adenocarcinoma as a primary treatment.
- Even if used in NSCLC, it would usually be in the context of advanced disease or as part of a neoadjuvant/adjuvant approach with surgery, not as a standalone initial treatment for resectable disease.
*Radiation therapy*
- **Radiation therapy** is often used for inoperable tumors, for patients who refuse surgery, or as an adjuvant treatment.
- For a resectable stage II NSCLC, **surgery offers the best chance for cure**, making radiation therapy alone less appropriate as the first-line definitive treatment strategy.
Question 45: 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
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.
Question 46: The patient undergoes a mammogram, which shows a 6.5mm sized mass with an irregular border and spiculated margins. A subsequent core needle biopsy of the mass shows infiltrating ductal carcinoma with HER2-positive, estrogen-negative, and progesterone-negative immunohistochemistry staining. Blood counts and liver function tests are normal. Laboratory studies show:
Hemoglobin 12.5 g/dL
Serum
Na+ 140 mEq/L
Cl- 103 mEq/L
K+ 4.2 mEq/L
HCO3- 26 mEq/L
Ca2+ 8.9 mg/dL
Urea Nitrogen 12 mg/dL
Glucose 110 mg/dL
Alkaline Phosphatase 25 U/L
Alanine aminotransferase (ALT) 15 U/L
Aspartate aminotransferase (AST) 13 U/L
Which of the following is the most appropriate next step in management?
A. Breast-conserving therapy and sentinel lymph node biopsy (Correct Answer)
B. Bilateral mastectomy with lymph node dissection
C. Trastuzumab therapy
D. Bone scan
E. Whole-body PET/CT
Explanation: ***Breast-conserving therapy and sentinel lymph node biopsy***
- The patient has **early-stage (T1) breast cancer** (6.5mm mass), which is amenable to **breast-conserving therapy (lumpectomy)** as the primary surgical approach.
- A **sentinel lymph node biopsy** is essential to determine nodal status and guide further staging and adjuvant therapy, as the tumor size does not preclude nodal involvement.
*Bilateral mastectomy with lymph node dissection*
- This is an **overly aggressive surgical approach** for a small, unifocal tumor without evidence of multifocality or significant risk factors for recurrence in the contralateral breast.
- While **axillary lymph node dissection** may be indicated if the sentinel node is positive, it is not the initial preferred approach for all patients, especially with no current evidence of nodal metastasis.
*Trastuzumab therapy*
- **Trastuzumab** is a targeted therapy for **HER2-positive breast cancer**, but it is typically administered as **adjuvant therapy** (after surgery) or neoadjuvant therapy (before surgery).
- It is not the most appropriate *initial* next step before surgical management and comprehensive staging have been completed.
*Bone scan*
- A **bone scan** is used to detect **bone metastases**, but it is generally reserved for patients with **advanced-stage cancer** (e.g., T3/T4 tumor, N2/N3 nodes), symptoms suggestive of bony involvement, or significantly elevated alkaline phosphatase.
- Given the patient's small tumor size (6.5mm), normal labs, and lack of symptoms, a bone scan is not indicated as the *next* immediate step.
*Whole-body PET/CT*
- **Whole-body PET/CT** is primarily used for **staging advanced cancer** or investigating suspicious findings in symptomatic patients.
- For this small, early-stage breast cancer with no signs of distant metastasis indicated by normal blood tests, a PET/CT is **not recommended** as routine staging and carries unnecessary radiation exposure and cost.
Question 47: A 58-year-old obese male has noticed the gradual development of a soft bulge on his right groin that has been present over the past year and occasionally becomes very tender. He notices that it comes out when he coughs and strains during bowel movements. He is able to push the bulge back in without issue. After examination, you realize that he has an inguinal hernia and recommend open repair with mesh placement. After surgery, the patient returns to clinic and complains of numbness and tingling in the upper part of the scrotum and base of the penis. What nerve was most likely injured during the procedure?
A. Ilioinguinal nerve (Correct Answer)
B. Iliohypogastric nerve
C. Lateral femoral cutaneous nerve
D. Obturator nerve
E. Genitofemoral nerve
Explanation: **Ilioinguinal nerve**
- The **ilioinguinal nerve** supplies sensory innervation to the skin of the **scrotum** (or labia majora in females), the medial thigh, and the base of the penis.
- Injury to this nerve during an open inguinal hernia repair can cause **numbness and tingling** in these specific areas, consistent with the patient's symptoms.
*Iliohypogastric nerve*
- The **iliohypogastric nerve** primarily provides sensation to the skin over the **suprapubic region** and a small part of the buttock.
- Damage to this nerve would not typically result in numbness of the scrotum or base of the penis.
*Lateral femoral cutaneous nerve*
- This nerve is responsible for sensory innervation of the **lateral aspect of the thigh**.
- Its injury would lead to symptoms of numbness or pain on the lateral thigh (**meralgia paresthetica**), not the scrotum or penis.
*Obturator nerve*
- The **obturator nerve** is a motor nerve that innervates the **adductor muscles of the thigh** and provides sensory innervation to a small area of the medial thigh.
- Damage to this nerve would result in **adductor weakness** and sensory loss in the medial thigh, which does not match the patient's complaints.
*Genitofemoral nerve*
- The **genitofemoral nerve** has two branches: the genital branch (supplies the cremaster muscle and scrotal skin) and the femoral branch (supplies skin of the anterior thigh).
- While the genital branch does innervate the scrotum, injury to this nerve more commonly causes **cremasteric reflex loss** or pain radiating to the anterior thigh, and the described symptoms (base of penis) are more characteristic of ilioinguinal nerve involvement.
Question 48: A 44-year-old woman presents to the emergency department with confusion starting this morning. Her husband states that she initially complained of abdominal pain, diarrhea, and fatigue after eating. She has vomited 3 times and progressively became more confused. Her past medical history is notable for morbid obesity, diabetes, hypertension, dyslipidemia, a sleeve gastrectomy 1 month ago, and depression with multiple suicide attempts. Her temperature is 98.0°F (36.7°C), blood pressure is 104/54 mmHg, pulse is 120/min, respirations are 15/min, and oxygen saturation is 98% on room air. Her physical exam is notable for generalized confusion. Laboratory values are ordered as seen below.
Serum:
Na+: 139 mEq/L
Cl-: 100 mEq/L
K+: 3.9 mEq/L
HCO3-: 24 mEq/L
BUN: 22 mg/dL
Glucose: 41 mg/dL
Creatinine: 1.1 mg/dL
Ca2+: 10.2 mg/dL
C-peptide level: normal
Which of the following is the most likely diagnosis?
A. Propranolol overdose
B. Dumping syndrome (Correct Answer)
C. Malnutrition
D. Insulin overdose
E. Glipizide overdose
Explanation: ***Dumping syndrome***
- The patient's recent **sleeve gastrectomy** and symptoms of **abdominal pain, diarrhea, fatigue, vomiting**, and subsequent **confusion** (due to hypoglycemia) after eating are classic for **late dumping syndrome**.
- **Late dumping syndrome** occurs 1-3 hours after eating due to rapid gastric emptying causing hyperglycemia, which triggers excessive insulin release, followed by reactive hypoglycemia.
- The **low glucose of 41 mg/dL** after a meal, alongside a **normal C-peptide**, confirms reactive hypoglycemia from endogenous insulin surge (not exogenous insulin).
*Propranolol overdose*
- While propranolol overdose can cause **hypoglycemia** and confusion, the patient's other symptoms of gastrointestinal distress directly following a meal are not typical.
- Propranolol overdose would also typically cause **bradycardia**, whereas the patient is tachycardic (120/min).
*Malnutrition*
- Malnutrition is a chronic condition and typically wouldn't present with acute, post-prandial symptoms like sudden abdominal pain, diarrhea, vomiting, and acute severe hypoglycemia leading to confusion.
- While possible post-bariatric surgery, the acute timing and specific meal-related symptoms point away from general malnutrition as the primary cause of this acute episode.
*Insulin overdose*
- **Insulin overdose** would cause severe hypoglycemia and confusion, but the patient's **normal C-peptide level** makes exogenous insulin administration unlikely as the cause of hypoglycemia.
- Insulin overdose doesn't typically cause the preceding abdominal pain, diarrhea, and vomiting immediately after eating like dumping syndrome.
*Glipizide overdose*
- Glipizide, a sulfonylurea, would cause **hypoglycemia** and confusion by stimulating endogenous insulin release, leading to an **elevated C-peptide level**.
- The patient's **normal C-peptide level** rules out sulfonylurea overdose as the cause of her hypoglycemia.
Question 49: An excisional biopsy is performed and the diagnosis of superficial spreading melanoma is confirmed. The lesion is 1.1 mm thick. Which of the following is the most appropriate next step in management?
A. Surgical excision with 0.5-1 cm safety margins only
B. Surgical excision with 1 cm safety margins only
C. Surgical excision with 1-2 cm safety margins only
D. Surgical excision with 0.5-1 cm safety margins and sentinel lymph node study
E. Surgical excision with 1-2 cm safety margins and sentinel lymph node study (Correct Answer)
Explanation: ***Surgical excision with 1-2 cm safety margins and sentinel lymph node study***
- A melanoma with a **Breslow thickness between 1.01 mm and 2.0 mm** (like this 1.1 mm lesion) requires a recommended surgical margin of **1 to 2 cm**.
- For melanomas **≥0.8 mm thickness** (or those with ulceration), a **sentinel lymph node biopsy (SLNB)** is recommended to assess for micrometastasis, as it helps in staging and prognosis.
*Surgical excision with 0.5-1 cm safety margins only*
- A 0.5 cm margin is typically reserved for melanoma *in situ* or extremely thin melanomas (less than or equal to 0.5 mm), and 1 cm for lesions 0.51 to 1.0 mm, which is too narrow for a 1.1 mm lesion.
- This option incorrectly omits the **sentinel lymph node study**, which is indicated for a melanoma of this thickness.
*Surgical excision with 1 cm safety margins only*
- While 1 cm is a common margin for lesions up to 1.0 mm, a 1.1 mm melanoma usually warrants a slightly wider margin, ideally 1-2 cm.
- This option also fails to include the **sentinel lymph node study**, which is crucial for staging melanomas ≥0.8 mm thickness.
*Surgical excision with 0.5-1 cm safety margins and sentinel lymph node study*
- The recommended surgical margin for a 1.1 mm melanoma is at least **1 cm, preferably between 1 and 2 cm**, making a 0.5-1 cm range insufficient.
- Although it correctly includes the sentinel lymph node study, the **surgical margin is inadequate** for the given Breslow thickness.
*Surgical excision with 1-2 cm safety margins only*
- While the **1-2 cm surgical margin** is appropriate for a 1.1 mm melanoma, this option **incorrectly excludes the sentinel lymph node study**.
- The sentinel lymph node biopsy is a critical part of the staging and management plan for melanomas of this thickness to detect potential nodal involvement.
Question 50: A 65-year-old man presents to the dermatology clinic to have a basal cell carcinoma excised from his upper back. The lesion measures 2.3 x 3.2 cm. He has a medical history significant for hypertension and diabetes mellitus type II, for which he takes lisinopril and metformin, respectively. He has had a basal cell carcinoma before which was excised in the clinic without complications. Which of the following modes of anesthesia should be used for this procedure?
A. Moderate sedation
B. Peripheral nerve block
C. General anesthesia
D. Spinal anesthesia
E. Local anesthesia (Correct Answer)
Explanation: ***Local anesthesia***
- This is the preferred method for **basal cell carcinoma excisions**, especially for lesions of this size and location, as it provides adequate pain control with minimal systemic effects.
- The patient's prior uncomplicated excision under local anesthesia further supports its suitability and safety for this procedure.
*Moderate sedation*
- While it can provide comfort, it involves systemic medications that carry risks of **respiratory depression** and **hemodynamic instability**, which are generally unnecessary for a routine skin excision in a stable patient.
- It also requires more extensive monitoring and recovery time compared to local anesthesia.
*Peripheral nerve block*
- A peripheral nerve block might be considered for larger or deeper excisions in specific anatomical areas, but for a typical basal cell carcinoma on the back, **infiltration with local anesthetic** is usually sufficient and less invasive than a nerve block.
- It is not routinely necessary for superficial skin excisions of this nature.
*General anesthesia*
- This is **excessive and unnecessary** for a routine basal cell carcinoma excision, especially given the patient's comorbidities of hypertension and diabetes, which would increase the risks associated with general anesthesia.
- General anesthesia is reserved for very extensive resections, complex reconstructions, or patients unable to cooperate under local anesthesia.
*Spinal anesthesia*
- **Spinal anesthesia** is typically used for procedures involving the lower abdomen, perineum, or lower extremities, and it is **not indicated** for an excision on the upper back.
- It carries risks such as post-dural puncture headache and hypotension, which are unwarranted for this type of superficial surgery.
