Name: Shila Manandhar Roundtable 2 with Dr.

Steven Mills, UCIMC, Thursday, June 21, 2012 Instructions: There are 10 questions below. Please explain each choice for each question. This will not be graded but be prepared to discuss each question at the roundtable session. To get credit, this must be emailed to Ahmayeda@uci.edu prior to the review session.

1.

A. B. C. D.

A 47-year-old male sustains a stab wound to the left upper quadrant of his abdomen. He complains of minimal pain. He is alert and hemodynamically normal, and the results from his abdominal examination show no abnormalities. Which of the following statements is true? Abdominal CT is sensitive in the detection of diaphragm injuries The FAST examination reliably rules out intra-abdominal injury (only 50% sensitivity for abdominal injury) FAST better for blunt trauma Local wound exploration revealing fascial penetration is an absolute indication for celiotomy. The patient should be admitted for a 24- to 48-hour observation period.
Do local wound exploration

Answer and Explanation: D. Since the patient has no stab wounds he can be kept for observation to see if any hemodynamic instability symptoms develop. You should also perform a CXR to rule out pneumothorax or hemothorax. 2. A 40-year-old woman with a 15-year history of chronic diarrhea and a diagnosis of UC is referred for consideration for total proctocolectomy with ileal pouch-anus anastomosis to eliminate future cancer risks. During the colonoscopy, you notice that the disease involves the entire colon and terminal ileum, with sparing of the rectum. What is the most appropriate treatment? A. Proctocolectomy with ileal pouch-anus anastomosis B. Total abdominal colectomy with ileal-rectal anastomosis Could do B C. Repeated biopsy of the rectum and involved portions of the colon and ileum D. Total proctocolectomy with the construction of continent ileostomy
Can tx rectum with topical steroids and spare rectum, also can have incompetent ileocecal valve

Answer and Explanation: C. In UC the rectum is always involved. Since the rectum is spared in this case there is a chance she could have Crohns instead in which case it would be contraindicated to perform a total proctocolectomy. Repeated biopsy would help to clarify the correct diagnosis. 3. A 28-year-old woman undergoing an obstetric ultrasound during the second trimester of pregnancy and is found to have gallstones in her gallbladder. She claims to have had indigestion with frequent belching throughout her pregnancy. Which of the following is the most appropriate treatment? A. A low-fat diet until the end of her pregnancy and then a post-partum laparoscopic cholecystectomy B. Elective laparoscopic cholecystectomy during the second trimester C. Follow-up after completion of her pregnancy D. Open cholecystectomy during the second trimester Answer and Explanation: C. Her symptoms may be pregnancy induced so you need to reevaluate her after she gives birth to determine if her gallstones were the true cause.

4. Which of the following conditions does not indicate the need for operative repair in the patient described at the beginning of the case? A. Presenting 11 months later with an AA that is 5.5 cm in size B. Unexplained back pain in a 4.2-cm aneurysm and normotensive C. Bilateral embolization to all his toes D. Presenting 3 years later with shock and severe abdominal pain E. The AAA is 4.3 cm on ultrasound 2 years later Answer and Explanation: E. Surgery for an AAA is indicated only if it is greater than 5.5 cm. This patient only needs to be monitored with repeated ultrasound. 5. A 57-year-old woman develops an acute onset of respiratory distress 7 days following colectomy for adenocarcinoma of the colon. She had been doing well up until this time. The physical examination reveals diminished breath sounds at the lung bases. The CXR reveals atelectasis of the left lower lobe segment. Which of the following is the most appropriate treatment at this time? A. Provide supplemental oxygen and begin chest physiotherapy No abx no pneumonia B. Provide supplemental oxygen and initiate chest physiotherapy and antibiotic therapy C. Begin antibiotic therapy and immediate bronchoscopy to open up the lungs D. Provide supplemental oxygen, obtain venous duplex scans of the lower extremities and a lung V/Q scan, and consider starting heparin therapy
Do CT angio to check for PE

Answer and Explanation: D. Patient is likely experiencing a PE so we want to make sure shes oxygenated and check for PE. The duplex checks for a possible DVT which could have embolized, resulting in a PE. The heparin therapy would be the treatment of choice for PE. 6. A 75-year-old man develops hematochezia and presents with hemodynamic instability. The patients vital signs improve slightly with crystalloid and packed red cells infusion. Which of the following is considered the most appropriate next step(s) in management? A. EGD, proctosigmoidoscopy, and a barium enema No BE B. NG tube, proctosigmoidoscopy, and a tagged RBC scan with or without mesentery Useless test angiography NG irrigate to make sure u see bile C. NG tube, mesentery angiography, and colonoscopy D. EGD and colonoscopy
Egd take longer

Answer and Explanation: B. Placing a NG tube helps to evaluate for a possible upper GI bleed. The proctosigmoidoscopy helps visualize the most distal 25 cm segment of the colon to see if there is any occult bleeding. The RBC scan identifies active bleeding at a rate of 0.1 mL/min or more and is used as a screen before doing mesentery angiography to help to localize the bleeding site. Colonoscopy should only be done in stable patients. 7. A 35-year-old woman with two children and no previous surgeries has noticed increased fatigue and a whitish nipple discharge. Which of the following is the next step? A. Determination of the thyrotropin level B. Imaging of the sella turcica C. Measurement of the human chorionic gonadotropic level D. Ultrasonography of the breasts

Answer and Explanation: C. Since she is lactating she might be pregnant so you want to first rule out pregnancy. If her pregnancy test is negative, her galactorrhea may also be secondary hypothyroidism, pituitary adenoma, or resulting side effects of medications. 8. A 59-year-old woman presents to her primary care physician with complaints of pneumaturia or air in the urine and recurrent urinary tract infections. She has a prior history of diverticulitis occurring 6 months ago. Which of the following is an appropriate next step? Prev hysterectomy A. Order a CT scan of the abdomen to look for a colovesical fistula Colovesicular fistula dx with CT B. Schedule the patient for cystoscopy to look for a fistula opening C. Order a barium enema to demonstrate a possible fistula D. All of the above Answer and Explanation: d. CT, cytoscopy, and BE can all be used to diagnose a colovesical fistula and help localize the fistula tract. Diverticulitis is and infection of diverticula, which are sac like protrusions of the colonic wall that develop where vasa recta penetrate the colon since these are areas of weakness. Symptoms include LLQ pain, fever, increased WBC. If not perforated treat with antibiotics- Flagyl and Cipro for anerobes and gram negatives, NPO, IV fluids, and NG suction. 9. A 35-year-old male complains of dyspnea and left leg pain. He undergoes a V/Q scan, which is interpreted as being of low probability for PE. Which of the following is the most accurate statement? A. The probability of PE is less than 1% B. The probability of PE is as high as 40% C. The next test should be a determination of the serum D-dimer level D. Pulmonary angiography should be performed to definitively rule out PE Answer and Explanation: B. Due to the patients symptoms he likely has a DVT making the likelihood of him having a PE very high. To further evaluate the patient youd want to do a venous duplex scan. 10. A 45-year-old male has had a diagnosis of GERD for 3 years with treatment with H-2 blocking agents. Recently, has had complained of epigastric pain. An upper endoscopy was performed showing Barretts esophagus at the distal esophagus. Which of the following is the best next step in the treatment of this individual? A. Initiate a PPI. B. Advise the patient to continue to take the H-2 blocker C. Advise surgical therapy involving gastrectomy and esophageal bypass D. Discontinue the H-2 blocker and initiate antacids Answer and Explanation: A. You want the patient to take a PPI in addition to the H2 blocker to help relive his symptoms and prevent the progression of Barrets to adenocarcinoma. The patient would also have to undergo endoscopic surveillance to monitor the progression of his Barrets. Barrets esophagitis is intestinal metaplasia of the esophagus from its normal squamous epithelium.