Preguntas y

Respuestas 5
Ciruga General

 Clinical Scenario 1. A 30-year-old man sustains blunt

head trauma and is unconscious. His urine output
exceeds 1,500 mL per hour despite only receiving
maintenance intravenous fluids. He becomes profoundly
hypernatremic. Which of the following is the next step in
the initial management of this patient?

 Answer. This patient has blunt head trauma and

diabetes insipidus, characterized by high volume, low
osmolality urine. This, untreated, may result in profound
dehydration and hypernatremia. Treatment is
conservative, with replacement of free water
intravenously

 Clinical Scenario 5. A 20-year-old woman presents

after a skiing accident. She is alert and talking but not
moving. Her blood pressure is 80/55 mm Hg, and her
pulse is 80 beats/minute. What is the etiology of her
shock, and what should the workup include to aid in the
diagnosis?

 Answer. Neurogenic shock from a probable cervical

spine fracture. Workup should include a complete spine
evaluation.

 Clinical Scenario 23. A 39-year-old woman complains

of right upper quadrant pain. She also has nausea and
fatigue. She has a history of ulcerative colitis. Physical
examination reveals icteric sclera. Laboratory studies
reveal elevated transaminases. What is the next step in
the management of this patient?

 Answer. This patient likely has primary sclerosing

cholangitis. This condition results in stenosis or
obstruction of the ductal system. ERCP may reveal
thickening and stenosis of the biliary ductal system.

 Clinical Scenario 59. A 45-year-old man who smokes

presents with progressively increasing cough, sputum
production, and fever for the past 4 days. In the past
day he has also noticed the development of right upper
quadrant abdominal pain. On examination, he has
diminished breath sounds at the right base, with
dullness to percussion. Abdominal examination shows
minimal tenderness in the right upper quadrant, with no
Murphy sign. What is the diagnosis?

 Answer. He most likely has a right lower lobe

pneumonia irritating his diaphragm, which is leading to
his right upper quadrant pain.

 Clinical Scenario 63. A 23-year-old man is seen in the

emergency department after a motor vehicle accident.
He was an unrestrained passenger. He is able to breathe
on his own but tells you that each breath is extremely
painful. You note that a segment of his chest wall
appears to sink inwards with each respiration, and that
when he exhales this same segment does not move with
the rest of the chest wall. Vital signs are stable. The
patient has no other obvious traumatic injuries. The
arterial blood gas reads as follows: 7.3/55/85/25. What is
the most appropriate next step in management?

 Answer. This describing flail chest. This occurs when four

or more ribs are fractured in at least two locations, leading
to paradoxical movement of the chest wall during
respiration. This commonly occurs after trauma such as a
motor vehicle accident. The true danger in patients with
flail chest is the frequent underlying pulmonary contusion.
In this patient we see a blood gas indicative of a decreased
respiratory effort, suggesting that he is not properly
respiring. We would need to inubate this patient and
provide mechanical ventilation in light of the marked
respiratory distress.

 Clinical Scenario 20. A 73-year-old woman undergoes a computed

tomography (CT) scan for abdominal pain and is found to have
thickening of the terminal ileum. She is also noted to have multiple
mesenteric lymph nodes that are enlarged to more than 2 cm. A
colonoscopy is performed that shows no abnormalities of the colon,
but when the terminal ileum is entered, a friable intraluminal mass
is encountered. The biopsies of this mass are read as diffuse large
cell non-Hodgkin lymphoma. Positron emission tomography and CT
confirm involvement of the terminal ileum but are also read as
showing multiple mediastinal nodes involved with the disease. Bone
marrow aspiration is negative for lymphoma.
Should this patient undergo a wide resection of the diseased
terminal ileum prior to starting chemotherapy?

 Answer. No. The patient has stage III non-Hodgkin

lymphoma and should be treated with chemotherapy
and possibly radiotherapy to the mediastinum. The only
indication for surgical exploration in this patient would
be if she should start bleeding from the terminal ileum
or if the involved area should perforate.

 Clinical Scenario 16. A 25-year-old man presents to the

emergency department with a history of 6 months of variable
right lower quadrant abdominal pain, which acutely worsened
over the past 12 hours so that he now rates it as 8 on a scale of
10, with 10 being the most painful. He also reports that he has
been having diarrhea and low back pain for about 3 months.
Computed tomography scan shows stranding of the mesentery
in the right lower quadrant. On insertion of a laparoscope, you
note that the terminal ileum and cecum are markedly inflamed,
with some fat wrapping of the terminal ileum, although the
appendix appears normal.
What is your next step in this operation?

 Answer. Close the camera incision and treat the patient

for Crohn disease. Even if the base of the cecum is
uninvolved, appendectomy is contraindicated in the
presence of Crohn disease due to an unacceptably high
rate of enterocutaneous fistulization.

 A 30-year-old man consults a physician because he has been having increasing

difficulty swallowing both solids and liquids. Physical examination of the patient is
noncontributory. Barium swallow studies show a mostly dilated esophagus with
slow passage of barium into the stomach. The very distal part of the esophagus
appears narrowed into a "bird's beak." Esophageal manometry shows incomplete
relaxation of the lower esophageal sphincter in response to swallowing, high
resting lower esophageal pressure, and absent esophageal peristalsis.
Question 1 of 5. The manometry and barium swallow studies most strongly
support which of the following diagnoses?
/ A. Achalasia
/ B. Adenocarcinoma
/ C. Barrett esophagus
/ D. Squamous cell carcinoma
/ E. Systemic sclerosis

 The correct answer is A. The most likely diagnosis is

achalasia. This condition is a neurogenic esophageal
disorder that can occur at any age, but frequently is
diagnosed when individuals are between the ages of 20
and 40. Characteristically, the swallowing difficulties
involve both solid food and liquids. The manometry
findings illustrated are typical; the barium swallow
findings may be as illustrated or may instead show
diffuse esophageal dilation without the "bird's beak"
near the lower esophageal sphincter.

 Question 2 of 5. This patient's condition is most likely

due to which of the following?
/ A. Acid reflux
/ B. Cancerous destruction
/ C. Candida infection
/ D. Fibrosis of the esophageal wall
/ E. Lack of ganglion cells

 The correct answer is E. Individuals who have

achalasia have been found to have a deficiency of
inhibitory ganglion cells within the esophageal wall.
This lack causes an imbalance in excitatory and
inhibitory neurotransmission, with the result that the
lower esophageal sphincter tends to have a higher-thannormal muscle tone and relaxes only with difficulty.

 Question 3 of 5. Which of the following regulators

would most likely inhibit the lower esophageal sphincter
in normal individuals?
/ A. Acetylcholine and substance P
/ B. Substance P and nitric oxide
/ C. Substance P only
/ D. Vasoactive intestinal polypeptide and acetylcholine
/ E. Vasoactive intestinal polypeptide and nitric oxide

 The correct answer is E. Physiologically important

inhibitors of the lower esophageal sphincter include
nitric oxide and vasoactive intestinal polypeptide.
Physiologically important substances that stimulate the
lower esophageal sphincter include acetylcholine and
substance P.

 Question 4 of 5. Which of the following medications is

used to directly relax the lower esophageal sphincter?
/ A. Diphenoxylate
/ B. Famotidine
/ C. Granisetron
/ D. Isosorbide dinitrate
/ E. Metoclopramide

 The correct answer is D. Commonly used

medications to relax the lower esophageal sphincter in
patients with achalasia include nitrates such as
isosorbide dinitrate (remember that nitric oxide
physiologically inhibits the lower esophageal sphincter)
and calcium channel blockers such as nifedipine (which
inhibit calcium flow into the smooth muscle of the lower
esophageal sphincter, thereby inhibiting contraction.)
For patients in whom medical therapy fails, other
options include paralysis of the lower esophageal
sphincter with intrasphincteric injection of botulinum
toxin, pneumatic dilatation, and a Heller myotomy
(which interrupts the muscles of the lower esophageal

 Question 5 of 5. Worldwide, which of the following

parasitic diseases is most likely to produce a disorder
that clinically resembles this patient's condition?
/ A. Ascariasis
/ B. African sleeping sickness
/ C. Chagas disease
/ D. Cysticercosis
/ E. Malaria

 The correct answer is C. Chagas disease, which is

found in South and Central America and is due to
infection with Trypanosoma cruzi, can involve the heart,
colon, and esophagus. The esophageal involvement
clinically closely resembles achalasia.

 A 35-year-old woman consults a physician because she has been having

trouble swallowing. She also often experiences chronic heartburn. The
physician performs a screening physical examination, and notices that the
skin of her hands appears tight and shiny. On specific questioning, she
reports having often experienced color changes in her hands from white to
blue to red.
Question 1 of 5. Which of the following is the most likely cause of the
patient's difficulties with swallowing?
A. Achalasia
B. Adenocarcinoma
C. Chagas disease
D. Scleroderma
E. Squamous carcinoma

 The correct answer is D. The tip-off is the reference

to the patient's skin changes that are typical for
scleroderma, also known as systemic sclerosis.
Scleroderma is a disease that may be either
predominately limited to the skin or involve many body
systems, including the musculoskeletal system,
gastrointestinal tract (with esophageal involvement
most often symptomatic), cardiorespiratory system, and
renal system. Esophageal dysfunction is a common
complication of scleroderma. In most patients, the
skin changes are obvious, even if the patient has not
been previously diagnosed. Rarely, the skin changes
may be noticed at an earlier stage, in which the skin of

 Question 2 of 5. The color changes described on the

patient's hand are most likely due to which of the
following?
/ A. Arteriolar spasm
/ B. BIood clots at sites of vascular injury
/ C. Large artery spasm
/ D. PIatelet clots
/ E. Stasis blood clots

 The correct answer is A. The color changes described

are typical for Raynaud's phenomenon, which occurs
because of changes in perfusion due to arteriolar
spasm. Raynaud's phenomenon is common in
scleroderma, largely because the subintimal hyperplasia
of small vessels characteristic of scleroderma can
reduce the luminal diameter by more than 75%. Some
authors argue that the vascular changes seen in
scleroderma are actually the insult that triggers the
subsequent development of fibrosis.

 Question 3 of 5. Additional findings on physical examination

include noting that the skin changes are limited to areas distal to
the elbow and knee, the presence of calcified nodules on the
extensor surfaces of the forearms, and the presence of
telangiectasias on the forearms. This suggests that this patient
has which of the following?
/ A. Bauer syndrome
/ B. Charcot syndrome
/ C. CREST syndrome
/ D. Crigler-Najjar syndrome
/ E. Dandy-Walker syndrome

 The correct answer is C. These findings, together

with esophageal dysfunction and Raynaud's
phenomenon (both of which this patient has), are called
the CREST syndrome, also known as limited
cutaneous scleroderma. This form of scleroderma has a
better long-term prognosis than when the skin changes
also involve the trunk (diffuse scleroderma) and more
internal organs are additionally involved.

 Question 4 of 5. If this woman's involved skin were

biopsied, which of the following would most likely be
seen?
/ A. CIeft separating the dermis and subcutaneous
tissues
/ B. Epithelial cell hyperplasia
/ C. Marked dermal fibrosis
/ D. Narrowing of the basal lamina of small capillaries
/ E. Thickening of rete pegs

 The correct answer is C. In scleroderma, early

changes (at the point at which the hands appear
swollen, rather than with tight, thick skin) show edema
with perivascular infiltrates of CD4+ T cells. At this
stage, the collagen fibers are swollen and beginning to
degenerate. The smaller vessels may show basal lamina
thickening (not narrowing as in choice D) and
endothelial (not epithelial as in choice B) cell damage
and proliferation. With time, the characteristic marked
dermal fibrosis develops, which tends to both narrow
(not thicken as in choice E) the rete pegs and attach
the dermis tightly (compare with cleft formation as in
choice A) to subcutaneous tissues.

 Question 5 of 5. More than 90% of the patients with

the limited cutaneous form of this disorder make which
of the following autoantibodies?
/ A. Anti-centromere
/ B. Anti-DNA topoisomerase l
/ C. Anti-double-stranded DNA
/ D. Anti-Golgi
/ E. Anti-ScI-70

 The correct answer is A. All forms of scleroderma are

thought to have a strong autoimmune component, and
glucocorticoids and azathioprine are used to suppress
the inflammatory complications of scleroderma. (Other
drugs that can be used in therapy include penicillamine,
which inhibits collagen cross-linking, NSAIDS for pain,
and ACE inhibitors to protect the kidney if hypertension
or renal damage occurs.) The anti-centromere
antibody is quite specific for CREST syndrome (96% of
cases), and is only seen in a minority of patients with
diffuse scleroderma (mainly those with Raynaud's
phenomenon) and rarely in systemic lupus
erythematosus and mixed connective tissue disease.