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Usmle World Answers

Usmle World Answers



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Published by kbraley

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Published by: kbraley on Jul 23, 2008
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USMLE WORLD ANSWERS1.B.Isolated duodenal hematoma is treated conservatively withnasogastric tube and parenteral nutrition. This conservativeapproach has high cure rate and risk of surgery is avoided;however it is important to exclude other organ injury. IVF are notrequired as patient is hemodynamically stable; she needsnutrition until hematoma heals. Also, antibiotics are not indicatedin this patient. She is afebrile and has no symptoms suggestiveof infection. Surgery is needed only if there are other associatedinjuries or if the hematoma does not resolve w/in 2-3 wks w/ NGTand parenteral nutrition.2.A. The patient presents with signs and symptoms suggestive of necrotizing surgical infection. The clues to the correct diagnosisinclude: (1) intensive pain in the wound accompanied by feverand tachycardia, (2) decreased sensitivity at the edges of thewound and (3) cloudy-gray discharge. Diabetes is an importantpredisposing condition. The necrotizing surgical infection isusually caused by mixed gram-positive and gram-negative flora. The presence of crepitus raises the suspicion that clostridialinfection may be present, bu some streptococcal and other gas-forming organisms may also produce local crepitus. Thetreatment of necrotizing surgical infection is complex. The mostimportant step in the management of this condition is earlysurgical exploration to assess the extent of the process anddebride the necrotized tissues. Antibiotics are also important, butS. aureus is a less frequent pathogen causing this condition.General measures should include adequate hydration andglycemic control (choice D), but surgical exploration is moreurgent. The discharge should be cultured (choice C), althoughthe results are delayed. Observation (Choice E) is notappropriate, because the process spreads very quickly and is lifethreatening.3.D. The child was involved in trauma and later d/ced. He laterpresents with a deviated mediastinumand mass in left lowerchest. He has no fever or chills except for chest pain. Onediagnosis, which is frequently missed in the ER, is traumaticrupture of the diaphragm. The rupture may be small or large andis usually on the left side, as the liver protects the right side. The
diagnosis of diaphragmatic rupture is difficult and generally mostindividuals present later. Delayed presentation carries a highmorbidity. Barium swallow will be diagnostic. All diaphragmaticruptures require treatment. Surgery is best done via theabdomen in acute conditions and via the chest in chronicconditions. VATS would be diagnostic of diaphragmaticperforation on intial admission.Option A: The patient has a collection/mass in the L. chest and itmay look similar to pleural effusion. Placing a chest tuve in a ptw/ diaphragmatic perforation with bowel herniation can be adisaster, when in doubt, get a CT scan.4.B.Major veins at the base of the neck have negative pressureduring inspiration and, if injured at that moment, will suck airrather than bleed. The air embolism then leads to sudden death.Arterial injury (choice A) would have led to massive bleeding butnot to sudden death.Pneumothorax (choice C) can indeed happen when surgery isbeing done in the supraclavicula area, and a sucking soundmight even be heard. However, sudden lung collapse in a young,healthy person leads to dyspnea, not to sudden death.Sympathetic discharge (choice D) would be hard to producewhile pulling and dissection a node. If it were done, however,there would be vasoconstriction, tachycardia, perspiration andhypertension.Essentially nothing would have happened at the time had thetrachea (choice E) been injured.5.C The patient most likely has an injury to a major bronchus. Inaddition to the wretching effect of a sudden deceleration, thesecan happen when a major blow to the chest occurs at a timewhen the glottis is closed. If not recognized right away by thepresence of subcutaneous emphysema, they become evidentonce the air leak persists and the lung does not re-expand.Air embolism (choice A) is manifested by sudden death shortlyafter a patient with unrecognized injuries to the tracheobronchialtree in proximity to major intrathoracic vessels is placed on arespirator.Injured lung parenchyma (choice B) can indeed leak air andproduce a pneumothorax, but typically heals rapidly.Suction applied to a chest tube (choice D) is used to acceleratethe rate of resolution of a pneumothorax, but the large amountof air draining in this case indicates that the pleural space fills asquickly as it can be drained out.
6.C.Intramural calcification of the gallbladder (aka porcelaingallbladder) is associated with a 20% risk for progression togallbladder carcinoma. When the condition is discoveredincidentally, usually a calcified mass on an abdominal xray,prophylactice cholecystectomy is recommended to reduce therisk for progression to malignancy. As the gallbladder wall isusually thick and fibrotic, it is usually necessary to perform anopen cholecystectomy rather than a laparoscopic procedure. Inany case, a biopsy of the gallbladder wall (choice A) is notrecquired.Medical treatment with ursodeoxycholic acid (choice B) is used totreat gallstones in poor surgical candiddates and is a mainstay of treatment for primary biliary cirrhosis.Gallbladder is a highly fatal malignancy so waiting for it to showup on CT (choice E) is very risky as operative mortalityassociated with cholecystectomies is low.7.E.5 or more units of blood transfusion in a period of 24 hours isconsidered an indication for surgery.Both ligation and meso-caval shunt (choices C,D) have a highmortality rate in emergency settings. Ligation will no control theascites, which in this patient is refractory to concervativetreatment. TIPS (choice E) has a lower mortality rate. If successful, it willdecrease the variceal and portal hydrostatic pressure and hencewill decrease the bleeding and ascites. Hepatic encephalopathyis the main risk after the procedure.Sengstaken-Blakemore tube can stay in up to 48 hours withrelatively low risk for esophageal ischemia and perforation.Choice A could be the correct answer if patient had recquiredless than 5 units of blood.8.B.Oxalate stones are due to excessive GI absorption of oxalate.Hyperoxaluria occurs in patients with SBR, inflammatory boweldisease and other malabsorptive states. The increased intestinalfat binds dietary calcium, which is then unavailable to bindoxalate as usual. Therefore, increased oxalate absorption in largebowel (unabsorbed bile salts may aid this) occurs andprecipitates in kidney. Increased oxalate occurs in people whodrink large amounts of tea, coffee, beer, chocolate and ethyleneglycol overdose.

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