The Limitations of Mammography Include

8/12/2019 The Limitations of Mammography Include

1/79

The limitations ofThe limitations of

mammography includemammography include((A) 1015% false negative rateA) 1015% false negative rate

(B) 10% false positive rate(B) 10% false positive rate

(C) difficulty visualizing tumors in the tail of pence(C) difficulty visualizing tumors in the tail of pence

(!) all of the a"ove(!) all of the a"ove

(#) none of the a"ove(#) none of the a"ove


2/79

Explanation:Explanation:

$here is a 1015% false negative rate of current mammography &n 'omen$here is a 1015% false negative rate of current mammography &n 'omen0 years old* nearly +5% of invasive "reast cancers are not visualized0 years old* nearly +5% of invasive "reast cancers are not visualized$his drops to 10% for 'omen 505 years old Almost 10% of patients 'ho$his drops to 10% for 'omen 505 years old Almost 10% of patients 'hohave routine screening mammography are as,ed to return for additionalhave routine screening mammography are as,ed to return for additionalstudies $his is to "etter clarify the a"normality $he additional studies maystudies $his is to "etter clarify the a"normality $he additional studies may

include additional mammographic vie's or ultrasounds* or it may re-uireinclude additional mammographic vie's or ultrasounds* or it may re-uireinvasive studies such as a "iopsy .ammograms in general are lessinvasive studies such as a "iopsy .ammograms in general are lesssensitive in younger 'omen 'ith dense "reast tissue Breast implants maysensitive in younger 'omen 'ith dense "reast tissue Breast implants mayalso o"scure a mammographic evaluation /outine mammography has aalso o"scure a mammographic evaluation /outine mammography has adifficult time visualizing lesions deep against the chest 'all* lateral in the taildifficult time visualizing lesions deep against the chest 'all* lateral in the tailof "reast* or inferior in the inframammary foldof "reast* or inferior in the inframammary fold

Bi"liographyopans ! &maging analysis of "reast lesions &n 2arris 3/*Bi"liographyopans ! &maging analysis of "reast lesions &n 2arris 3/*

4ippman .#* .orro' .* et al (eds)*4ippman .#* .orro' .* et al (eds)* Diseases of the BreastDiseases of the Breast* +nd ed* +nd edhiladelphia* A 4ippincott* 6illiams 7 6il,ins* +000* 1+819hiladelphia* A 4ippincott* 6illiams 7 6il,ins* +000* 1+819


3/79

Phyllodes tumorsPhyllodes tumors

(A) present in postmenopausal 'omen(A) present in postmenopausal 'omen

(B) are often malignant(B) are often malignant

(C) re-uire mastectomy "ecause of their high recurrence(C) re-uire mastectomy "ecause of their high recurrenceraterate

(!) tend to recur(!) tend to recur

(#) are responsive to hormonal manipulation(#) are responsive to hormonal manipulation


4/79

ExplanationExplanation :: hyllodes tumors* also ,no'n as cystosarcoma phyllodes* are stromal tumors $hey are 'ellhyllodes tumors* also ,no'n as cystosarcoma phyllodes* are stromal tumors $hey are 'ell

circumscri"ed and do not have a true capsule $he cut surface of one of these tumors tends to "ecircumscri"ed and do not have a true capsule $he cut surface of one of these tumors tends to "emucoid $here are numerous small pro:ections that ma,e surgical enucleation difficultmucoid $here are numerous small pro:ections that ma,e surgical enucleation difficult

hyllodes tend to occur in an older population than fi"roadenomas (;As) ;As are also stromalhyllodes tend to occur in an older population than fi"roadenomas (;As) ;As are also stromaltumors* and it is thought that phyllodes may arise from these "enign tumors hyllodes tend totumors* and it is thought that phyllodes may arise from these "enign tumors hyllodes tend tooccur in the fourth decade of life .ost of these tumors present as painless masses that areoccur in the fourth decade of life .ost of these tumors present as painless masses that are

round and smooth


5/79

The most common etiology ofThe most common etiology of

senescent gynecomastia issenescent gynecomastia is

(A) cirrhosis(A) cirrhosis

(B) testicular tumor(B) testicular tumor

(C) renal disease(C) renal disease

(!) idiopathic causes(!) idiopathic causes

(#) drug induced(#) drug induced


6/79

ExplanationExplanation

:: Dynecomastia is the "enign proliferation of "reast glandular tissueDynecomastia is the "enign proliferation of "reast glandular tissuein males $his tends to occur in infancy* at pu"erty* and in old agein males $his tends to occur in infancy* at pu"erty* and in old age

Dynecomastia results from an im"alance of the normal hormonalDynecomastia results from an im"alance of the normal hormonalmilieu or a change in "reast tissue sensitivity to estrogen $hemilieu or a change in "reast tissue sensitivity to estrogen $he

testes secrete 5% of the total "ody testosterone and only 15% oftestes secrete 5% of the total "ody testosterone and only 15% ofthe circulating estradiol $he vast ma:ority of circulating estradiol isthe circulating estradiol $he vast ma:ority of circulating estradiol isfrom the peripheral conversion of testosterone and adrenal steroidsfrom the peripheral conversion of testosterone and adrenal steroidsvia the aromatase enzyme .ost of the hormones are "ound to se?>via the aromatase enzyme .ost of the hormones are "ound to se?>hormone "inding glo"ulin (2BD)* a protein formed in the liverhormone "inding glo"ulin (2BD)* a protein formed in the liver2BD has a higher affinity for androgens than estrogen An2BD has a higher affinity for androgens than estrogen Anim"alance in any of these path'ays may results in an increase ofim"alance in any of these path'ays may results in an increase offree estrogen as compared to "ound estrogen (;ig 15>5)free estrogen as compared to "ound estrogen (;ig 15>5)


7/79

TamoxifenTamoxifen

(A) is an estrogen receptor (#/) agonist(A) is an estrogen receptor (#/) agonist

(B) is an #/ antagonist(B) is an #/ antagonist

(C) has "een sho'n to decrease the incidence of(C) has "een sho'n to decrease the incidence ofrecurrent "reast cancer "y %recurrent "reast cancer "y %

(!) has "een sho'n to decrease the ris, of future "reast(!) has "een sho'n to decrease the ris, of future "reast

cancer "y % in high>ris, patientscancer "y % in high>ris, patients

(#) all of the a"ove(#) all of the a"ove


8/79


:: $amo?ifen* a selective estrogen receptor (#/) agonist antagonist* first$amo?ifen* a selective estrogen receptor (#/) agonist antagonist* firstcame into the mar,et in the 10s &t is a 'ell>studied drug $he antagonistcame into the mar,et in the 10s &t is a 'ell>studied drug $he antagonisteffects of tamo?ifen are related to its competitive "inding of the estrogeneffects of tamo?ifen are related to its competitive "inding of the estrogenreceptor* especially in "reast tissue $his results in a reduced transcriptionreceptor* especially in "reast tissue $his results in a reduced transcriptionof estrogen related proteins and effective "loc,ade of cell cycle in D1 $hisof estrogen related proteins and effective "loc,ade of cell cycle in D1 $his

in turn then translates to ineffective tumor gro'thin turn then translates to ineffective tumor gro'th $amo?ifen has apparent estrogen agonist effects on the endometrial lining*$amo?ifen has apparent estrogen agonist effects on the endometrial lining*

as sho'n "y the increase in endometrial cancer found in 'omen "eingas sho'n "y the increase in endometrial cancer found in 'omen "eingtreated 'ith the drug $his ris, is a"out 1% $he cancers are usually foundtreated 'ith the drug $his ris, is a"out 1% $he cancers are usually foundin stage & and are very treata"le &n addition* there is an increased ris, ofin stage & and are very treata"le &n addition* there is an increased ris, ofvenous em"olic phenomena that is related to the estrogen agonist effectsvenous em"olic phenomena that is related to the estrogen agonist effects$amo?ifen also increases "one density and improves lipid profiles="oth$amo?ifen also increases "one density and improves lipid profiles="oth

related to #/ agonist activity $he ma:or side effects that 'omen complainrelated to #/ agonist activity $he ma:or side effects that 'omen complaina"out 'hile ta,ing tamo?ifen are hot flashes and sleep distur"ances=a"out 'hile ta,ing tamo?ifen are hot flashes and sleep distur"ances=similar to menopausal symptoms attri"uted to decreased estrogensimilar to menopausal symptoms attri"uted to decreased estrogen


9/79

A 34-year-old lady is referred to your office for evaluation of breast pain. he describes the pain as burning!A 34-year-old lady is referred to your office for evaluation of breast pain. he describes the pain as burning!

occasionally sharp in nature. "t is mostly located in the subareolar area and seems to be fairly #ell locali$ed.occasionally sharp in nature. "t is mostly located in the subareolar area and seems to be fairly #ell locali$ed.

%hen as&ed #hen the pain occurs! she states that it is al#ays present and is very troublesome to her. 'n%hen as&ed #hen the pain occurs! she states that it is al#ays present and is very troublesome to her. 'n

physical examination! she has dense glandular tissue throughout both breasts! but no discrete nodules.physical examination! she has dense glandular tissue throughout both breasts! but no discrete nodules.

(our #or&ing diagnosis at this point is noncyclical breast pain.(our #or&ing diagnosis at this point is noncyclical breast pain.

(our next step in management is(our next step in management is

(A) reassurance(A) reassurance

(B) start a diuretic(B) start a diuretic

(C) refer her to a psychologist(C) refer her to a psychologist

(!) give a steroid in:ection(!) give a steroid in:ection

(#) perform a surgical e?cision of the painful(#) perform a surgical e?cision of the painfulareaarea


10/79


:: .astalgia* or "reast pain* is a common.astalgia* or "reast pain* is a common

complaint and a common reason for referral to acomplaint and a common reason for referral to a

"reast center #valuation of "reast pain should"reast center #valuation of "reast pain shouldinclude a thorough history and e?amination 6ithinclude a thorough history and e?amination 6ith

a good history* you can "egin to categorize thea good history* you can "egin to categorize the

pain $ypical types of mastalgia can "epain $ypical types of mastalgia can "e

descri"ed as cyclical pronounced* noncyclical*descri"ed as cyclical pronounced* noncyclical*trauma* musculos,eletalEchest 'all* andtrauma* musculos,eletalEchest 'all* and

miscellaneous uncommon causemiscellaneous uncommon cause


11/79

Cyclical pronounced pain is the most common &tCyclical pronounced pain is the most common &t

is related to the menstrual cycle* especiallyis related to the menstrual cycle* especially

ovulation $he average age is 9 years atientsovulation $he average age is 9 years atientscomplain of FheavinessF and FtendernessFcomplain of FheavinessF and FtendernessF

Godularity is common* especially in the upperGodularity is common* especially in the upper

outer -uadrants $his also tends to fluctuate 'ithouter -uadrants $his also tends to fluctuate 'ith

the menstrual cycle $he pain is often in thethe menstrual cycle $he pain is often in theupper outer -uadrant* may "e "ilateral* and canupper outer -uadrant* may "e "ilateral* and can

radiate do'n the armradiate do'n the arm


12/79

Goncyclical mastalgia is not related to theGoncyclical mastalgia is not related to the

menstrual cycle $he average age of themenstrual cycle $he average age of the

patient is again 9 years old $he pain ispatient is again 9 years old $he pain isdifferent from cyclical pain in that is moredifferent from cyclical pain in that is more

localized and descri"ed as a F"urningF orlocalized and descri"ed as a F"urningF or

FpullingF Godularity is typically lessFpullingF Godularity is typically lesspronounced* "ut it is present in greaterpronounced* "ut it is present in greater

than 50% of the patientsthan 50% of the patients


13/79

A 4)-year-old #oman presents #ith a * cm mass in her right breast firstA 4)-year-old #oman presents #ith a * cm mass in her right breast first

detected bydetected bymammography +,ig. -*/. 0adiographic core biopsy of the lesion ismammography +,ig. -*/. 0adiographic core biopsy of the lesion isselected for diagnosis and reveals infiltrating ductal carcinoma. he has noselected for diagnosis and reveals infiltrating ductal carcinoma. he has no

palpable axillary lymph nodes! core bx: invasive malignant! 12:P'"T"Epalpable axillary lymph nodes! core bx: invasive malignant! 12:P'"T"E


14/79

A566/ T27 staging system isA566/ T27 staging system is

(A) &(A) &

(B) &&(B) &&

(C) &&&(C) &&&

(!) &H(!) &H

(#) H(#) H


15/79

$he A3CC $G. Clinical taging$he A3CC $G. Clinical taging

ystem is as follo'system is as follo's

1 rimary tumor ($)1 rimary tumor ($)

$? primary tumor cannot "e assessed$? primary tumor cannot "e assessed $0 no primary tumor$0 no primary tumor $is carcinoma$is carcinoma in situin situ $1 tumor + cm$1 tumor + cm $+ tumor I + cm "ut 5 cm$+ tumor I + cm "ut 5 cm $9 tumor I 5 cm$9 tumor I 5 cm $ tumor 'ith e?tension to chest 'all* s,in edema or$ tumor 'ith e?tension to chest 'all* s,in edema or

ulceration or inflammatory carcinomaulceration or inflammatory carcinoma


16/79

/egional lymph nodes (G)/egional lymph nodes (G)

G? regional lymph nodes cannot "e assessed G? regional lymph nodes cannot "e assessed

G0 no regional lymph node metastasisG0 no regional lymph node metastasis

G1 metastases to mo"ile a?illary lymph nodesG1 metastases to mo"ile a?illary lymph nodes G+ metastases to fi?ed* matted or clinicallyG+ metastases to fi?ed* matted or clinically

apparent a?illary lymph nodes or internalapparent a?illary lymph nodes or internalmammary nodesmammary nodes

G9 metastases to a?illary and infraclavicularG9 metastases to a?illary and infraclavicularlymph nodes* clinically apparent internallymph nodes* clinically apparent internalmammary nodes or supraclavicular lymph nodesmammary nodes or supraclavicular lymph nodes


17/79

!istant metastasis!istant metastasis

.? distant metastasis cannot "e.? distant metastasis cannot "e

assessedassessed .0 no distant metastasis.0 no distant metastasis

.1 distant metastasis.1 distant metastasis


18/79

tage groupingtage grouping

tage 0 $isG0.0tage 0 $isG0.0 tage 1 $1G0.0tage 1 $1G0.0 tage +A $0G1.0* $1G1.0* $+G0.0tage +A $0G1.0* $1G1.0* $+G0.0 tage +B $+G1.0* $9G0.0tage +B $+G1.0* $9G0.0 tage 9A $0G+.0* $1G+.0* $+G+.0* $9G1.0*tage 9A $0G+.0* $1G+.0* $+G+.0* $9G1.0*

$9G+.0$9G+.0

tage 9B $G0.0* $G1.0* $G+.0tage 9B $G0.0* $G1.0* $G+.0 tage 9C Any$G9.0tage 9C Any$G9.0 tage Any$ AnyG .1tage Any$ AnyG .1


19/79

%hich of the follo#ing is false regarding%hich of the follo#ing is false regarding

lobular carcinomalobular carcinoma in situin situ88

(A) &t is a mar,er for increased ris, of "reast cancer(A) &t is a mar,er for increased ris, of "reast cancer

(B) .irror image "reast "iopsy is indicated(B) .irror image "reast "iopsy is indicated

(C) u"se-uent invasive cancer is more often ductal in origin(C) u"se-uent invasive cancer is more often ductal in origin

(!) $reatment is close o"servation versus "ilateral prophylactic(!) $reatment is close o"servation versus "ilateral prophylacticmastectomymastectomy

(#) rognosis is solely related to the development of su"se-uent(#) rognosis is solely related to the development of su"se-uent

cancercancer


20/79


$he histologic picture consists of many clusters of epithelial cells forming$he histologic picture consists of many clusters of epithelial cells formingislands of neoplastic cells "ut maintaining a lo"ular architecture &t occursislands of neoplastic cells "ut maintaining a lo"ular architecture &t occursmore often in premenopausal 'omen and does not form a palpa"le mass &tmore often in premenopausal 'omen and does not form a palpa"le mass &tis most commonly found as an incidental finding on "iopsy* as it does notis most commonly found as an incidental finding on "iopsy* as it does nothave any mammographic findingshave any mammographic findings

4o"ular carcinoma4o"ular carcinoma in situin situcarries a ris, of developing into an invasive ductalcarries a ris, of developing into an invasive ductalcarcinoma in 1095% of patients over a period of 15+0 yearscarcinoma in 1095% of patients over a period of 15+0 years

Because the ris, of su"se-uent "reast cancer is almost the same for "othBecause the ris, of su"se-uent "reast cancer is almost the same for "oth"reasts* mirror image "iopsies of the opposite "reast are not indicated"reasts* mirror image "iopsies of the opposite "reast are not indicated

2istologic e?aminations are generally favora"le and deaths are unusual in2istologic e?aminations are generally favora"le and deaths are unusual in'omen 'ith appropriate medical care Any treatment of'omen 'ith appropriate medical care Any treatment of in situin situcarcinoma iscarcinoma isaimed at preventing invasive diseaseaimed at preventing invasive disease

$reatment options include close o"servation or pharmacologic prophyla?is$reatment options include close o"servation or pharmacologic prophyla?isA 5>year course of tamo?ifen has "een sho'n to reduce the relative ris, ofA 5>year course of tamo?ifen has "een sho'n to reduce the relative ris, ofinvasive cancer "y 5% in 'omen 'ith 4C& urgical options such asinvasive cancer "y 5% in 'omen 'ith 4C& urgical options such as"ilateral mastectomy or "reast>conserving surgery are considered only in"ilateral mastectomy or "reast>conserving surgery are considered only inspecial circumstances in 'hich the patient may have multiple ris, factorsspecial circumstances in 'hich the patient may have multiple ris, factors


21/79

The effective osmotic pressure bet#een the plasmaThe effective osmotic pressure bet#een the plasma

and interstitial fluid compartments is primarilyand interstitial fluid compartments is primarily

controlled bycontrolled by

(A) Bicar"onate(A) Bicar"onate

(B) Chloride ion(B) Chloride ion

(C) otassium ion(C) otassium ion

(!) rotein(!) rotein


22/79


:: $he dissolved protein in plasma does not$he dissolved protein in plasma does not

pass through the semipermea"le cellpass through the semipermea"le cell

mem"rane* and this fact is responsi"le formem"rane* and this fact is responsi"le forthe effective or colloid osmotic pressurethe effective or colloid osmotic pressure

(ee ch'artz th ed)(ee ch'artz th ed)


23/79


24/79



25/79

Each of the follo#ing is a symptom of a hemolyticEach of the follo#ing is a symptom of a hemolytic

transfusion reaction E96EPTtransfusion reaction E96EPT

(A) Constricting chest pain(A) Constricting chest pain

(B) ;lushing of the face(B) ;lushing of the face

(C) 4um"ar pain(C) 4um"ar pain

(!) yncope(!) yncope


26/79


yncope is not associated 'ith ayncope is not associated 'ith a

hemolytic transfusion reaction* 'hereashemolytic transfusion reaction* 'hereas

the other listed symptoms are commonthe other listed symptoms are commonoccurrences (ee ch'artz th ed)occurrences (ee ch'artz th ed)


27/79

After drainage of a pelvic abscess! a 4-year-old patientAfter drainage of a pelvic abscess! a 4-year-old patientreceivingreceiving); oxygen is found to have the follo#ing arterial blood gases:); oxygen is found to have the follo#ing arterial blood gases:

p P'*! mm P6'*! 3) mm

most consistent #ith the diagnosis ofmost consistent #ith the diagnosis of

(A) Chronic o"structive pulmonary disease(A) Chronic o"structive pulmonary disease

(B) ostoperative pain and an?iety(B) ostoperative pain and an?iety

(C) Adult respiratory distress syndrome(C) Adult respiratory distress syndrome

(!) ostoperative atelectasis(!) ostoperative atelectasis


28/79


$he com"ination of hypo?emia that is resistant to high$he com"ination of hypo?emia that is resistant to higho?ygen concentrations and hyperventilation iso?ygen concentrations and hyperventilation ischaracteristic of the adult respiratory distress syndromecharacteristic of the adult respiratory distress syndrome(A/!) $here are four general causes of hypo?emia(A/!) $here are four general causes of hypo?emiahypoventilation* a lo' ventilation>perfusion ratio* diffusionhypoventilation* a lo' ventilation>perfusion ratio* diffusiona"normalities* and pulmonary shunting Although the firsta"normalities* and pulmonary shunting Although the firstthree conditions improve in response to an increasedthree conditions improve in response to an increasedinspired o?ygen concentration most of the hypo?emiainspired o?ygen concentration most of the hypo?emiaseen in A/! is secondary to shunting and so is notseen in A/! is secondary to shunting and so is not

ameliorated "y o?ygen $he a"normalities seen in A/!ameliorated "y o?ygen $he a"normalities seen in A/!are thought to result from in:ury to the alveolar>capillaryare thought to result from in:ury to the alveolar>capillarymem"rane that causes an increased permea"ility of themem"rane that causes an increased permea"ility of themem"rane* 'hich in turn leads to interstitial pulmonarymem"rane* 'hich in turn leads to interstitial pulmonaryedema and decreased pulmonary compliance (eeedema and decreased pulmonary compliance (eech'artz th ed)ch'artz th ed)


29/79

All of the follo#ing result from the placement of an intraaorticAll of the follo#ing result from the placement of an intraaortic

balloon pump in a patient #ith acute myocardial failure E96EPTballoon pump in a patient #ith acute myocardial failure E96EPT

(A) !iastolic "lood pressure elevation(A) !iastolic "lood pressure elevation

(B) &ncreased cardiac output(B) &ncreased cardiac output

(C) &ncreased pulmonary perfusion(C) &ncreased pulmonary perfusion

(!) &ncreased pro"a"ility of survival(!) &ncreased pro"a"ility of survival


30/79

The P) value +the P'* at #hich ); of hemoglobin is saturated #ithThe P) value +the P'* at #hich ); of hemoglobin is saturated #ith

oxygen/ indicates the position of the oxyhemoglobin dissociation curveoxygen/ indicates the position of the oxyhemoglobin dissociation curve

along the hori$ontal axis. All of the follo#ing conditions can produce aalong the hori$ontal axis. All of the follo#ing conditions can produce a

left#ard-shifted curve +decreased P)/ E96EPTleft#ard-shifted curve +decreased P)/ E96EPT

(A) Car"on mono?ide poisoning(A) Car"on mono?ide poisoning

(B) 2ypothermia(B) 2ypothermia

(C) Acidosis(C) Acidosis

(!) +*9>diphosphoglycerate deficiency(!) +*9>diphosphoglycerate deficiency


31/79


!eterminations of 50 are used to monitor the affinity of o?ygen for!eterminations of 50 are used to monitor the affinity of o?ygen forhemoglo"in* 'ith the normal value "eing appro?imately + mm 2ghemoglo"in* 'ith the normal value "eing appro?imately + mm 2g

A lo' 50* indicating an increased affinity of o?ygen for hemoglo"inA lo' 50* indicating an increased affinity of o?ygen for hemoglo"inand a decreased release of o?ygen to the tissues* causes a left'ardand a decreased release of o?ygen to the tissues* causes a left'ardshift in the o?yhemoglo"in dissociation curve 4o' red "lood cellshift in the o?yhemoglo"in dissociation curve 4o' red "lood celllevels of +*9>diphosphoglycerate ('hich occur 'hen "lood is storedlevels of +*9>diphosphoglycerate ('hich occur 'hen "lood is storedmore than + 'ee,s)* car"on mono?ide poisoning* and hypothermiamore than + 'ee,s)* car"on mono?ide poisoning* and hypothermialo'er the 50 Conversely* the natural affinity of hemoglo"in forlo'er the 50 Conversely* the natural affinity of hemoglo"in foro?ygen is decreased "y high levels of diphosphoglycerate* "yo?ygen is decreased "y high levels of diphosphoglycerate* "ycar"on dio?ide (Bohr effect)* "y heat* and "y hydrogen ions &ncar"on dio?ide (Bohr effect)* "y heat* and "y hydrogen ions &nacidosis* shifting of the o?yhemoglo"in dissociation curve to theacidosis* shifting of the o?yhemoglo"in dissociation curve to the

right (increased 50) reflects a protective mechanism to improveright (increased 50) reflects a protective mechanism to improveo?ygen supply to the tissues 2o'ever* in spite of elevations of theo?ygen supply to the tissues 2o'ever* in spite of elevations of the50* severe arterial desaturation (eg* pulmonary shunting) may50* severe arterial desaturation (eg* pulmonary shunting) mayoffset any potential gains in o?ygen availa"ility (ee ch'artz thoffset any potential gains in o?ygen availa"ility (ee ch'artz thed)ed)


32/79

The earliest manifestations of serious gram-negative infectionThe earliest manifestations of serious gram-negative infection

may consist of a triad of signs that includesmay consist of a triad of signs that includes

(A) $achypnea* hypotension* and an altered(A) $achypnea* hypotension* and an alteredsensoriumsensorium

(B) $achypnea* hypotension* and lactic acidosis(B) $achypnea* hypotension* and lactic acidosis

(C) $hrom"ocytopenia* hypotension* and lactic(C) $hrom"ocytopenia* hypotension* and lacticacidosisacidosis

(!) .ild hyperventilation* respiratory al,alosis*(!) .ild hyperventilation* respiratory al,alosis*and an altered sensoriumand an altered sensorium


33/79


$he development of mild hyperventilation* respiratory$he development of mild hyperventilation* respiratoryal,alosis* and an altered sensorium may "e the earliestal,alosis* and an altered sensorium may "e the earliestsign of gram>negative infection $his triad may precedesign of gram>negative infection $his triad may precede

the usual signs and symptoms of sepsis "y severalthe usual signs and symptoms of sepsis "y severalhours to several days Although the e?acthours to several days Although the e?actpathophysiology of this manifestation is un,no'n* thepathophysiology of this manifestation is un,no'n* thetriad of signs is thought to represent a primary responsetriad of signs is thought to represent a primary responseto "acteremia #arly recognition of the findings* follo'edto "acteremia #arly recognition of the findings* follo'ed

"y a prompt search for the source of infection* may allo'"y a prompt search for the source of infection* may allo'diagnosis and treatment prior to the onset of shoc, (eediagnosis and treatment prior to the onset of shoc, (eech'artz th ed)ch'artz th ed)


34/79

6ardiac preload is determined by6ardiac preload is determined by

(A) #nd>diastolic volume(A) #nd>diastolic volume

(B) #nd>diastolic pressure(B) #nd>diastolic pressure

(C) #nd>systolic volume(C) #nd>systolic volume

(!) #nd>systolic pressure(!) #nd>systolic pressure


35/79


tarlingJs la' of the heart states that the force of muscle contractiontarlingJs la' of the heart states that the force of muscle contractiondepends on the initial length of the cardiac fi"ers @sing terminologydepends on the initial length of the cardiac fi"ers @sing terminologythat derives from early e?periments using isolated cardiac musclethat derives from early e?periments using isolated cardiac musclepreparations* preload is the stretch of ventricular myocardial tissuepreparations* preload is the stretch of ventricular myocardial tissue

:ust prior to the ne?t contraction reload is determined "y end>:ust prior to the ne?t contraction reload is determined "y end>diastolic volume (#!H) ;or the right ventricle* central venousdiastolic volume (#!H) ;or the right ventricle* central venouspressure (CH) appro?imates right ventricular end>diastolicpressure (CH) appro?imates right ventricular end>diastolicpressure (#!) ;or the left ventricle* pulmonary artery occlusionpressure (#!) ;or the left ventricle* pulmonary artery occlusionpressure (A


36/79

Positive end-expiratoryPositive end-expiratorypressure +PEEP/ ventilation is #idelypressure +PEEP/ ventilation is #idelyused in the treatment of acute pulmonary failure. The beneficialused in the treatment of acute pulmonary failure. The beneficial

effects of PEEP include all of the follo#ing E96EPTeffects of PEEP include all of the follo#ing E96EPT

(A) !ecreased pulmonary shunting(A) !ecreased pulmonary shunting

(B) !ecreased e?travascular lung 'ater(B) !ecreased e?travascular lung 'ater

(C) &ncreased resting volume of the lung(C) &ncreased resting volume of the lung

(!) &ncreased o?ygenation(!) &ncreased o?ygenation


37/79


$he mechanism of action of ## ventilation has not$he mechanism of action of ## ventilation has not"een completely elucidated 2o'ever* the "eneficial"een completely elucidated 2o'ever* the "eneficialeffects of ## include (1) an increase in o?ygenationeffects of ## include (1) an increase in o?ygenation

(a


38/79

All of the follo#ing findings #ould indicate that a patient re?uiresAll of the follo#ing findings #ould indicate that a patient re?uires

mechanical ventilatory support E96EPTmechanical ventilatory support E96EPT

(A) /espiratory rate greater than 90 "reaths per(A) /espiratory rate greater than 90 "reaths per

minuteminute

(B) Hital capacity less than 15 m4E,g(B) Hital capacity less than 15 m4E,g

(C) .a?imal inspiratory force of 0 cm 2+arterial o?ygen gradient greater(!) Alveolar>arterial o?ygen gradient greaterthan 950 torrthan 950 torr


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$he treatment of acute respiratory insufficiency is "ased primarily on$he treatment of acute respiratory insufficiency is "ased primarily onventilatory support #ndotracheal intu"ation* prefera"ly through theventilatory support #ndotracheal intu"ation* prefera"ly through thenose* is considered the techni-ue of choice A ma?imal inspiratorynose* is considered the techni-ue of choice A ma?imal inspiratoryforce of 0 cm 2+< isforce of 0 cm 2+< is notnota criterion for ventilatory support


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%hich of the follo#ing statements about organelle%hich of the follo#ing statements about organelle

function isfunction is incorrectincorrect88

(A) $he rough endoplasmic reticulum (r#/) is the site of protein synthesis and the(A) $he rough endoplasmic reticulum (r#/) is the site of protein synthesis and thecotranslational modification of proteinscotranslational modification of proteins

(B) $he smooth endoplasmic reticulum (s#/) is the site of phospholipid synthesis*(B) $he smooth endoplasmic reticulum (s#/) is the site of phospholipid synthesis*steroid hormone synthesis* drug deto?ification* and calcium store releasesteroid hormone synthesis* drug deto?ification* and calcium store release

(C) $he Dolgi comple? is the site of vesicular pac,aging of proteins* mem"rane(C) $he Dolgi comple? is the site of vesicular pac,aging of proteins* mem"ranecomponent recycling* and posttranslational modification of proteinscomponent recycling* and posttranslational modification of proteins

(!) $he mitochondrion functions in acetyl>CoA production* tricar"o?ylic acid ($CA)(!) $he mitochondrion functions in acetyl>CoA production* tricar"o?ylic acid ($CA)cycle* o?idative phosphorylation* and fatty acid o?idationcycle* o?idative phosphorylation* and fatty acid o?idation

(#) $he lysosome contains amino acid o?idase* urate o?idase* catalase* and other(#) $he lysosome contains amino acid o?idase* urate o?idase* catalase* and other

o?idative enzymes relating to the production and degradation of hydrogen pero?ideo?idative enzymes relating to the production and degradation of hydrogen pero?ideand o?idation of fatty acidsand o?idation of fatty acids


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ExplanationExplanation : 1ysosomes contain acid hydrolases or lysosomal en$ymes that include proteases! nucleases! lipases!: 1ysosomes contain acid hydrolases or lysosomal en$ymes that include proteases! nucleases! lipases!

and galactosidases that function at an acidic p< to degrade old intracellular organelles or phagocytosedand galactosidases that function at an acidic p< to degrade old intracellular organelles or phagocytosedsubstancessubstances. 'rganelles have a relatively rapid rate of turnover +e.g.! liver mitochondria have a lifetime of. 'rganelles have a relatively rapid rate of turnover +e.g.! liver mitochondria have a lifetime of) days/ and are bro&en do#n in a process called autophagy. 'ld or damaged organelles are enveloped) days/ and are bro&en do#n in a process called autophagy. 'ld or damaged organelles are envelopedby an additional membrane to create an autophagosome! #hich fuses #ith a lysosome for degradation.by an additional membrane to create an autophagosome! #hich fuses #ith a lysosome for degradation.,or phagocytosed or endocytosed substances! these are ta&en-up into early endosomes #here some of,or phagocytosed or endocytosed substances! these are ta&en-up into early endosomes #here some ofthe materials are recycled bac& to the plasma membrane and others continue as late endosomes. @olgithe materials are recycled bac& to the plasma membrane and others continue as late endosomes. @olgihydrolase vesicles containing inactive lysosomal en$ymes fuse #ith late endosomes to form maturehydrolase vesicles containing inactive lysosomal en$ymes fuse #ith late endosomes to form mature

lysosomes. The late endosomes contain proton pumps to produce a p< environment to activate thelysosomes. The late endosomes contain proton pumps to produce a p< environment to activate thelysosomal en$ymes from the @olgi hydrolase vesicles. Although most lysosomes function in intracellularlysosomal en$ymes from the @olgi hydrolase vesicles. Although most lysosomes function in intracellulardigestion! a fe# cell types such as neutrophils and osteoclasts are able to release lysosomal contentsdigestion! a fe# cell types such as neutrophils and osteoclasts are able to release lysosomal contentsextracellularly for degrading materials. There are numerous lysosomal storage diseases +e.g.! 1+1>1+and 1>19)and 1>19)


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A 4-year-old female presents to the emergency department afterA 4-year-old female presents to the emergency department after

sustaining a gunshot #ound to the abdomen! #ith inuries to the liver andsustaining a gunshot #ound to the abdomen! #ith inuries to the liver and

large bo#el. Cespite successful resuscitation and operative intervention!large bo#el. Cespite successful resuscitation and operative intervention!

the patient dies * #ee&s later of multisystem organ failure in the intensivethe patient dies * #ee&s later of multisystem organ failure in the intensive

care unit. %hich organ most li&ely first experienced dysfunction8care unit. %hich organ most li&ely first experienced dysfunction8

(A) liver(A) liver

(B) gastrointestinal tract(B) gastrointestinal tract

(C) lung(C) lung

(!) ,idney(!) ,idney

(#) heart(#) heart


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!eath due to trauma 'ith hemorrhagic shoc, is arranged in a trimodal distri"ution immediate (at the scene)*!eath due to trauma 'ith hemorrhagic shoc, is arranged in a trimodal distri"ution immediate (at the scene)*'ithin the first + hours* and 1 'ee, or more follo'ing the in:ury &n the acute period after trauma* mortality is'ithin the first + hours* and 1 'ee, or more follo'ing the in:ury &n the acute period after trauma* mortality isattri"uta"le to massive hemorrhage or neurologic in:ury !irect in:ury to an organ contri"utes to a primary multipleattri"uta"le to massive hemorrhage or neurologic in:ury !irect in:ury to an organ contri"utes to a primary multipleorgan dysfunction in this early period &n contrast* late deaths* occurring at least 1 'ee, su"se-uent to theorgan dysfunction in this early period &n contrast* late deaths* occurring at least 1 'ee, su"se-uent to thetrauma* generally arise from secondary multiple organ dysfunction syndrome (.

.

to trauma and hemorrhagic shoc, &n the case of trauma* the prevalence of .


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/is, ;actors Associated 'ith the !evelopment of .ultiple


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A *3-year-old male presents to the emergency department after being involved in a motorA *3-year-old male presents to the emergency department after being involved in a motor

vehicle accident. 'n physical examination! he opens his eyes to painful stimulation! hevehicle accident. 'n physical examination! he opens his eyes to painful stimulation! he

occasionally mumbles incomprehensible sounds! he locali$es to painful stimulation #ith hisoccasionally mumbles incomprehensible sounds! he locali$es to painful stimulation #ith his

right upper extremity! and he #ithdra#s his left upper extremity to pain.


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A 4*-year-old male presents to the emergency department as a level " trauma after beingA 4*-year-old male presents to the emergency department as a level " trauma after being

involved in a motor vehicle accident. 'n initial examination! the patient has a @6 of involved in a motor vehicle accident. 'n initial examination! the patient has a @6 of

+locali$es to pain! no eye opening! and no verbal response/. The patient has multiple inuries+locali$es to pain! no eye opening! and no verbal response/. The patient has multiple inuries

including a long bone fracture. The patients vital signs are stable. (ou consult orthopedicincluding a long bone fracture. The patients vital signs are stable. (ou consult orthopedic

surgery! and they #ant to ta&e the patient to the operating room +'0/ to repair his fracture. Asurgery! and they #ant to ta&e the patient to the operating room +'0/ to repair his fracture. A

6T scan of the head sho#s mild-to-moderate diffuse cerebral edema. %hat is the most6T scan of the head sho#s mild-to-moderate diffuse cerebral edema. %hat is the most

appropriate course of action to ta&e #ith this patient8appropriate course of action to ta&e #ith this patient8

A) Allo' the patient to go the


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Explanation:Explanation:Although there is much de"ate regarding the precise indications for and "enefit of &C monitoring* several recent studiesAlthough there is much de"ate regarding the precise indications for and "enefit of &C monitoring* several recent studies have suggested that anhave suggested that anaggressive stance to'ard monitoring head>in:ured patients is associated 'ith a reduced ris, of mortality &n +000*aggressive stance to'ard monitoring head>in:ured patients is associated 'ith a reduced ris, of mortality &n +000*the American Association of Geurological urgeons 3oint ection on Geurotrauma and Critical Care in associationthe American Association of Geurological urgeons 3oint ection on Geurotrauma and Critical Care in association'ith the Brain $rauma ;oundation pu"lished guidelines relating to the indications for &C monitoring &n this'ith the Brain $rauma ;oundation pu"lished guidelines relating to the indications for &C monitoring &n thisrevie'* it 'as noted that &C monitoring helps in the early detection of intracranial mass lesions* limits therevie'* it 'as noted that &C monitoring helps in the early detection of intracranial mass lesions* limits theindiscriminate use of therapies to control &C that may "e potentially harmful* helps in determining prognosis* andindiscriminate use of therapies to control &C that may "e potentially harmful* helps in determining prognosis* andmay improve outcome $herefore* the Brain $rauma ;oundation guidelines state that a comatose head>in:uredmay improve outcome $herefore* the Brain $rauma ;oundation guidelines state that a comatose head>in:uredpatient (DC 98) 'ith an a"normal C$ scan should undergo &C monitoring Additionally* comatose head>patient (DC 98) 'ith an a"normal C$ scan should undergo &C monitoring Additionally* comatose head>

in:ured patients 'ith normal C$ scans should undergo &C monitoring if they have t'o or more of the follo'ingin:ured patients 'ith normal C$ scans should undergo &C monitoring if they have t'o or more of the follo'ingfeatures at admission age over 0* unilateral or "ilateral motor posturing* or a B of less than 0 mm2g Afeatures at admission age over 0* unilateral or "ilateral motor posturing* or a B of less than 0 mm2g Arevie' of the month period in 9 academic trauma centers in the @nited tates 'as completed $he purpose of this study 'asmonth period in 9 academic trauma centers in the @nited tates 'as completed $he purpose of this study 'asto e?amine variations in the care of patients 'ith severe head in:ury* to determine the proportion of patients 'hoto e?amine variations in the care of patients 'ith severe head in:ury* to determine the proportion of patients 'horeceived care according to the Brain $rauma ;oundation guidelines* and to correlate the outcome from severereceived care according to the Brain $rauma ;oundation guidelines* and to correlate the outcome from severe

traumatic "rain in:ury 'ith the care received $he results revealed* in addition to considera"le variation in the ratestraumatic "rain in:ury 'ith the care received $he results revealed* in addition to considera"le variation in the ratesof &C monitoring* that management at an aggressive center (defined as those placing &C monitors in I50% ofof &C monitoring* that management at an aggressive center (defined as those placing &C monitors in I50% ofpatients meeting the Brain $rauma ;oundation criteria) 'as associated 'ith a significant reduction in the ris, ofpatients meeting the Brain $rauma ;oundation criteria) 'as associated 'ith a significant reduction in the ris, ofmortality Another consideration regarding the patient in the a"ove -uestion is the anticipated use of intravenousmortality Another consideration regarding the patient in the a"ove -uestion is the anticipated use of intravenousfluids in the operating room under the situation of general anesthesia in 'hich the neurologic e?amination isfluids in the operating room under the situation of general anesthesia in 'hich the neurologic e?amination iscompromised 6orsening cere"ral edema and secondary neurologic in:ury may progress unnoticed 'ithout thecompromised 6orsening cere"ral edema and secondary neurologic in:ury may progress unnoticed 'ithout thea"ility to monitor &C and C 6ith all of these factors in mind* the most appropriate course of action is toa"ility to monitor &C and C 6ith all of these factors in mind* the most appropriate course of action is toconsult neurosurgery to evaluate the patient for placement of an &C monitor prior to his going to the operatingconsult neurosurgery to evaluate the patient for placement of an &C monitor prior to his going to the operatingroomroom


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"ndications for operating on gunshot #ounds to the spine include"ndications for operating on gunshot #ounds to the spine include

all of the follo#ingall of the follo#ing exceptexcept::

(A) persistent C; lea,(A) persistent C; lea,

(B) neurologic deterioration(B) neurologic deterioration

(C) compression of a nerve root(C) compression of a nerve root

(!) operate on all cases(!) operate on all cases


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:: .ost penetrating 'ounds of the spine in the @nited tates of America today are caused "y.ost penetrating 'ounds of the spine in the @nited tates of America today are caused "ygunshot 'ounds $hese are more common in ur"an areas 'here the rates of violent crimes aregunshot 'ounds $hese are more common in ur"an areas 'here the rates of violent crimes arerelatively high Civilian gunshot 'ounds cause direct in:ury to the spinal cord "y the "ullet*relatively high Civilian gunshot 'ounds cause direct in:ury to the spinal cord "y the "ullet*'hereas high velocity military 'eapons tend to cause more indirect damage from cavitation and'hereas high velocity military 'eapons tend to cause more indirect damage from cavitation andshoc, 'aves Although de"ated* surgery has "een sho'n to have little effect on recovery forshoc, 'aves Although de"ated* surgery has "een sho'n to have little effect on recovery forpatients 'ith spinal cord in:ury secondary to gunshot 'ounds to the spine ;or this reason* thepatients 'ith spinal cord in:ury secondary to gunshot 'ounds to the spine ;or this reason* thetrend seems to "e no' to treat patients 'ith gunshot 'ounds to the spine 'ithout surgery unlesstrend seems to "e no' to treat patients 'ith gunshot 'ounds to the spine 'ithout surgery unless

they have a specific indication to do so


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$his patient has acute ileitis $his may or may not "e related to CrohnJs (and most often is not$his patient has acute ileitis $his may or may not "e related to CrohnJs (and most often is notrelated to C!) $he correct procedure in this case is appendectomy only Although the appendi?related to C!) $he correct procedure in this case is appendectomy only Although the appendi?appears normal on direct e?amination* the right lo'er -uadrant 'ound or the laparoscopicappears normal on direct e?amination* the right lo'er -uadrant 'ound or the laparoscopic'ounds that the patient already has 'ould "e confusing in the future $here is no indication for an'ounds that the patient already has 'ould "e confusing in the future $here is no indication for anileocecectomy as this is an infectious process and 'ill heal 'ith anti"iotics &f this is in fact anileocecectomy as this is an infectious process and 'ill heal 'ith anti"iotics &f this is in fact aninitial presentation of C!* additional therapy 'ill "e re-uired "ut 'ill heal 'ithout surgeryinitial presentation of C!* additional therapy 'ill "e re-uired "ut 'ill heal 'ithout surgery

Acute ileitis presents 'ith right lo'er -uadrant pain* fever* and anore?ia much the same as acuteAcute ileitis presents 'ith right lo'er -uadrant pain* fever* and anore?ia much the same as acute

appendicitis &t is often caused "yappendicitis &t is often caused "y CampylobacterCampylobacteroror YersiniaYersiniaspecies $hese can "e culturedspecies $hese can "e culturedfrom the appendi? and from the patientJs stool &n one study of patients 'ith signs and symptomsfrom the appendi? and from the patientJs stool &n one study of patients 'ith signs and symptomsof acute appendicitis* nine patients had only thic,ened terminal ileum on ultrasound ;ive of theseof acute appendicitis* nine patients had only thic,ened terminal ileum on ultrasound ;ive of theseproceeded to surgery in spite of these results All nine had positive cultures ofproceeded to surgery in spite of these results All nine had positive cultures of C. jejuniC. jejuni* and all* and allrecovered easily 'ith no progression to C! $here 'ere no adverse events from therecovered easily 'ith no progression to C! $here 'ere no adverse events from theappendectomies imilarly* a study of 198 normal appendices e?cised for presumed appendicitisappendectomies imilarly* a study of 198 normal appendices e?cised for presumed appendicitisyielded positive cultures foryielded positive cultures for C. jejuniC. jejuniandand Y. enterocolitocaY. enterocolitoca At the time of surgery* the appendi? At the time of surgery* the appendi?appeared normal* "ut +% of these culture positive patients had terminal ileitis or mesentericappeared normal* "ut +% of these culture positive patients had terminal ileitis or mesentericadenitis $here 'ere no pathologic cultures ofadenitis $here 'ere no pathologic cultures of C. jejuniC. jejunioror Y. enterocolitocaY. enterocolitocaisolated from 9+isolated from 9+

normal appendices e?cised during gynecologic surgeries Although acute terminal ileitis cannormal appendices e?cised during gynecologic surgeries Although acute terminal ileitis canpresent as appendicitis and appear to "e early CrohnJs* the ma:ority are of infectious etiologiespresent as appendicitis and appear to "e early CrohnJs* the ma:ority are of infectious etiologies Bi"liography#vers B. mall "o'el &n $o'nsend C.* Beauchamp /!* #vers B.* et al (eds)*Bi"liography#vers B. mall "o'el &n $o'nsend C.* Beauchamp /!* #vers B.* et al (eds)*

Sabiston Textbook of SurgerySabiston Textbook of Surgery* 1th ed hiladelphia* A 6B aunders* +001* 89* 1th ed hiladelphia* A 6B aunders* +001* 89


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"ntraabdominal adhesions follo#ing abdominal surgery have been associated #ith"ntraabdominal adhesions follo#ing abdominal surgery have been associated #ith

all of the follo#ingall of the follo#ing exceptexcept::

(A) small "o'el o"struction(A) small "o'el o"struction

(B) infertility(B) infertility

(C) chronic pelvic pain(C) chronic pelvic pain

(!) intestinal mala"sorption(!) intestinal mala"sorption

(#) increased ris, for enterotomy on su"se-uent(#) increased ris, for enterotomy on su"se-uentlaparotomylaparotomy


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;ollo'ing laparotomy* up to 5% of patients 'ill develop adhesions Although the ma:ority of;ollo'ing laparotomy* up to 5% of patients 'ill develop adhesions Although the ma:ority ofpatients 'ill not develop any clinical conse-uences frompatients 'ill not develop any clinical conse-uences from adhesion formation* there are significantadhesion formation* there are significantmor"idities associated 'ith their development &n a retrospective study using the cottishmor"idities associated 'ith their development &n a retrospective study using the cottishGational 2ealth ervice data"ase* 5% of all readmissions follo'ing a"dominal or pelvic surgeryGational 2ealth ervice data"ase* 5% of all readmissions follo'ing a"dominal or pelvic surgeryover 10 years 'ere found to "e related to adhesions .id> and hind>gut procedures had theover 10 years 'ere found to "e related to adhesions .id> and hind>gut procedures had thehighest num"er of adhesion>related readmissions* and most admissions occurred in the first yearhighest num"er of adhesion>related readmissions* and most admissions occurred in the first yearafter surgeryafter surgery

&ntraa"dominal adhesions are the leading cause for small "o'el o"struction in the industrialized&ntraa"dominal adhesions are the leading cause for small "o'el o"struction in the industrialized'orld @p to 80% of admissions for small "o'el o"struction are secondary to postoperative'orld @p to 80% of admissions for small "o'el o"struction are secondary to postoperativeadhesions $ypes of procedures most commonly associated 'ith adhesions>related small "o'eladhesions $ypes of procedures most commonly associated 'ith adhesions>related small "o'elo"struction are gynecologic operations* appendectomy* and small "o'el operations related intestinal o"struction term improvement in pain follo'ing laparoscopic lysis of adhesions


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%hich of the follo#ing is%hich of the follo#ing is notnotan indication for surgicalan indication for surgical

intervention in ulcerative colitis8intervention in ulcerative colitis8

(A) intracta"le "loody diarrhea(A) intracta"le "loody diarrhea

(B) perforation(B) perforation

(C) to?ic colitis(C) to?ic colitis

(!) diagnosis of ulcerative colitis for more than 5 years(!) diagnosis of ulcerative colitis for more than 5 years

(#) poorly controlled e?traintestinal manifestations(#) poorly controlled e?traintestinal manifestations


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&ndications for surgical intervention in ulcerative&ndications for surgical intervention in ulcerativecolitis include intracta"le symptoms* perforation*colitis include intracta"le symptoms* perforation*to?ic colitis* increasing cancer ris,* hemorrhage*to?ic colitis* increasing cancer ris,* hemorrhage*

fulminating disease* and poorly controlledfulminating disease* and poorly controllede?traintestinal manifestations $he cancer ris,e?traintestinal manifestations $he cancer ris,after initial diagnosis is appro?imately 5%after initial diagnosis is appro?imately 5%during the first 5 years* "ut increases to 0%during the first 5 years* "ut increases to 0%at +0 years postdiagnosis $herefore* surgicalat +0 years postdiagnosis $herefore* surgical

intervention is commonly recommendedintervention is commonly recommended"eginning appro?imately 10 years after initial"eginning appro?imately 10 years after initialdiagnosisdiagnosis


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All of the follo#ing are associated #ith an increased ris& ofAll of the follo#ing are associated #ith an increased ris& of

perforation in acute colonic pseudoobstruction +'gilviesperforation in acute colonic pseudoobstruction +'gilvies

syndrome/syndrome/ exceptexcept::

(A) older age(A) older age

(B) increasing cecal diameter(B) increasing cecal diameter

(C) delay in decompression(C) delay in decompression

(!) dia"etes mellitus(!) dia"etes mellitus

(#) chronic ischemia(#) chronic ischemia


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Acute colonic pseudoo"struction is a syndrome of massive dilationAcute colonic pseudoo"struction is a syndrome of massive dilationof the colon 'ithout mechanical o"struction that develops inof the colon 'ithout mechanical o"struction that develops inhospitalized patients 'ith serious underlying medical and surgicalhospitalized patients 'ith serious underlying medical and surgicalconditions &ncreasing age* cecal diameter* delay in decompression*conditions &ncreasing age* cecal diameter* delay in decompression*and status of the "o'el significantly influence mortality* 'hich isand status of the "o'el significantly influence mortality* 'hich is

appro?imately 0% 'hen ischemia or perforation is presentappro?imately 0% 'hen ischemia or perforation is present#valuation of the mar,edly distended colon in the intensive care unit#valuation of the mar,edly distended colon in the intensive care unitsetting involves e?cluding mechanical o"struction and other causessetting involves e?cluding mechanical o"struction and other causesof to?ic megacolon such asof to?ic megacolon such as Clostri!ium !ifficileClostri!ium !ifficileinfection* andinfection* andassessing for signs of ischemia and perforation $he ris, of colonicassessing for signs of ischemia and perforation $he ris, of colonicperforation in acute colonic pseudoo"struction increases 'hen cecalperforation in acute colonic pseudoo"struction increases 'hen cecal

diameter e?ceeds 1+ cm and 'hen the distention has "een presentdiameter e?ceeds 1+ cm and 'hen the distention has "een presentfor greater than days Appropriate management includesfor greater than days Appropriate management includessupportive therapy and selective use of neostigmine andsupportive therapy and selective use of neostigmine andcolonoscopy for decompression #arly recognition and managementcolonoscopy for decompression #arly recognition and managementare critical in minimizing complicationsare critical in minimizing complications


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%hich of the statements regarding cecal volvulus is%hich of the statements regarding cecal volvulus is

notnottrue8true8

(A) Cecal volvulus accounts for 10% of cases of colonic volvulus(A) Cecal volvulus accounts for 10% of cases of colonic volvulus

(B) Cecal vovulus is thought to have a congenital etiology related to(B) Cecal vovulus is thought to have a congenital etiology related toincomplete peritoneal fi?ation of the right colonincomplete peritoneal fi?ation of the right colon

(C) /adiographic evidence of a cecal volvulus includes a large*(C) /adiographic evidence of a cecal volvulus includes a large*dilated loop of colon 'ith the loop of colon pointing to the left upperdilated loop of colon 'ith the loop of colon pointing to the left upper-uadrant of the a"domen-uadrant of the a"domen

(!) !efinitive treatment for cecal volvulus includes a right(!) !efinitive treatment for cecal volvulus includes a right

hemicolectomyhemicolectomy

(#) /eduction of the cecal volvulus 'ith fi?ation of the cecum to the(#) /eduction of the cecal volvulus 'ith fi?ation of the cecum to thea"dominal 'all provides a similar outcome to segmental resectiona"dominal 'all provides a similar outcome to segmental resection


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6hile sigmoid volvulus accounts for I80% of colonic volvulus cases*6hile sigmoid volvulus accounts for I80% of colonic volvulus cases*cecal volvulus is relatively rare* accounting for 10% of casescecal volvulus is relatively rare* accounting for 10% of casesigmoid volvulus is felt to "e Fac-uiredF through accumulation of ris,igmoid volvulus is felt to "e Fac-uiredF through accumulation of ris,factors 'hile cecal volvulus is considered FcongenitalF "ecause offactors 'hile cecal volvulus is considered FcongenitalF "ecause ofindividual anatomic variation Both sigmoid and cecal volvulusindividual anatomic variation Both sigmoid and cecal volvulus

demonstrate a large* dilated loop of colon on plain radiograph $hedemonstrate a large* dilated loop of colon on plain radiograph $heloop FpointsF to the left upper -uadrant of the a"domen 'ith a cecalloop FpointsF to the left upper -uadrant of the a"domen 'ith a cecalvolvulus and to the right upper -uadrant 'ith a sigmoid volvulusvolvulus and to the right upper -uadrant 'ith a sigmoid volvulus6hile cecope?y has "een 'ell descri"ed and does have some6hile cecope?y has "een 'ell descri"ed and does have somesuccess* the definitive treatment for cecal volvulus is rightsuccess* the definitive treatment for cecal volvulus is righthemicolectomy 'ith primary anastomosis in the appropriate settinghemicolectomy 'ith primary anastomosis in the appropriate setting

'ith resection* ileostomy* and mucous fistula in the presence of'ith resection* ileostomy* and mucous fistula in the presence ofperforation or peritonitisperforation or peritonitis


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$his patient has acute uncomplicated diverticulitis $his disease is characterized "y$his patient has acute uncomplicated diverticulitis $his disease is characterized "ylocalized diverticular perforation 'ithout a"scess formation* free perforation* orlocalized diverticular perforation 'ithout a"scess formation* free perforation* or"leeding"leeding $he ma:ority of patients present 'ith left lo'er -uadrant pain* fever* and leu,ocytosis*$he ma:ority of patients present 'ith left lo'er -uadrant pain* fever* and leu,ocytosis*ma,ing diverticulitis principally a clinical diagnosis !iagnostic dilemmas do occur* ho'ever* andma,ing diverticulitis principally a clinical diagnosis !iagnostic dilemmas do occur* ho'ever* anda 'ide differential including "o'el perforation or o"struction* appendicitis* inflammatory "o'ela 'ide differential including "o'el perforation or o"struction* appendicitis* inflammatory "o'eldisease* and ischemic colitis must "e considered An imaging study is indicated 'hen the clinicaldisease* and ischemic colitis must "e considered An imaging study is indicated 'hen the clinicalpicture is not clear* or to help guide future therapypicture is not clear* or to help guide future therapy

#ndoscopy is contraindicated in the setting of acute diverticulitis "ecause the insuflation re-uired#ndoscopy is contraindicated in the setting of acute diverticulitis "ecause the insuflation re-uiredcan distur" the tenuous seal containing the diverticular perforation and result in the conversion tocan distur" the tenuous seal containing the diverticular perforation and result in the conversion tofree perforation and a need for more urgent surgical intervention 'ith su"stantially higherfree perforation and a need for more urgent surgical intervention 'ith su"stantially highermor"idity and mortality #ndoscopy can "e useful after the acute episode has resolved tomor"idity and mortality #ndoscopy can "e useful after the acute episode has resolved toevaluate for other distal pathologic processesevaluate for other distal pathologic processes

Barium enema is also contraindicated in the acute setting for reasons similar to those descri"edBarium enema is also contraindicated in the acute setting for reasons similar to those descri"eda"ove &t is a very important part of the preparation for elective resection after recovery* as ita"ove &t is a very important part of the preparation for elective resection after recovery* as itaccurately descri"es the e?tent of involvement and severity of disease* including strictures thataccurately descri"es the e?tent of involvement and severity of disease* including strictures thatmay develop after acute diverticulitismay develop after acute diverticulitis

4aparoscopy has "een descri"ed as a highly sensitive diagnostic modality ho'ever* its invasive4aparoscopy has "een descri"ed as a highly sensitive diagnostic modality ho'ever* its invasivenature precludes its routine use for this purposenature precludes its routine use for this purpose

Both C$ and ultrasound can accurately diagnose diverticulitis C$ has a sensitivity of up to 5%Both C$ and ultrasound can accurately diagnose diverticulitis C$ has a sensitivity of up to 5%and specificity of +% Both modalities can also identify a"scesses* ma,ing it possi"le forand specificity of +% Both modalities can also identify a"scesses* ma,ing it possi"le forpatients to have early drainage of these collections C$ is generally more availa"le in mostpatients to have early drainage of these collections C$ is generally more availa"le in mostinstitutions and is su"stantially less operator>dependent C$ findings such as presence of aninstitutions and is su"stantially less operator>dependent C$ findings such as presence of ana"scess* e?traluminal contrast or air strongly suggest that conservative treatment 'ith anti"ioticsa"scess* e?traluminal contrast or air strongly suggest that conservative treatment 'ith anti"iotics'ill not "e successful'ill not "e successful

A 3 year old male presents to your emergency department complainingA 3 year old male presents to your emergency department complaining


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A 3-year-old male presents to your emergency department complainingA 3-year-old male presents to your emergency department complaining

of a large amount of bright red blood per rectum.


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4D&2 is defined as persistent gross "leeding from the rectum* 'ith or 'ithout4D&2 is defined as persistent gross "leeding from the rectum* 'ith or 'ithouthemodynamic insta"ility and hemorrhagic shoc, $his patient has early signs ofhemodynamic insta"ility and hemorrhagic shoc, $his patient has early signs ofhemodynamic insta"ility* so aggressive resuscitation must "e underta,en prior tohemodynamic insta"ility* so aggressive resuscitation must "e underta,en prior toengaging in any diagnostic studies Anoproctosigmoidoscopy is the ne?t step in hisengaging in any diagnostic studies Anoproctosigmoidoscopy is the ne?t step in hisevaluation and management


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right thigh! &nee! and hip. he also has nausea and vomiting that is bilious in nature. Although this pain has been intermittent for theright thigh! &nee! and hip. he also has nausea and vomiting that is bilious in nature. Although this pain has been intermittent for the

past year! she believes that this episode is more severe! #hich prompted her to see& assistance at the emergency room. he deniespast year! she believes that this episode is more severe! #hich prompted her to see& assistance at the emergency room. he denies

any history of prior surgery.


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:: /om"erg sign (pain do'n the inner surface of thigh* ,nee:oint* and hip) $his is referred pain from the cutaneous "ranch of the anterior division:oint* and hip) $his is referred pain from the cutaneous "ranch of the anterior divisionof the o"turator nerve* 'hich is compressed "y the hernia in the canal $he ne?tof the o"turator nerve* 'hich is compressed "y the hernia in the canal $he ne?tfeature is a palpa"le mass high in the medial aspect of the thigh at the origin of thefeature is a palpa"le mass high in the medial aspect of the thigh at the origin of theadductor muscles $he mass is "est felt 'ith the thigh fle?ed* adducted* and rotatedadductor muscles $he mass is "est felt 'ith the thigh fle?ed* adducted* and rotatedout'ard $he last feature is repeated attac,s of intestinal o"struction that passout'ard $he last feature is repeated attac,s of intestinal o"struction that passspontaneously $reatment entails operative intervention as soon as possi"le*spontaneously $reatment entails operative intervention as soon as possi"le*secondary to the high rate of strangulation $he three preferred operative approachessecondary to the high rate of strangulation $he three preferred operative approaches

are a midline transperitoneal approach* midline e?traperitoneal approach* andare a midline transperitoneal approach* midline e?traperitoneal approach* ande?posure in the thigh $he former t'o are "etter since these hernias can "e "ilaterale?posure in the thigh $he former t'o are "etter since these hernias can "e "ilateraland therefore one can e?plore the other side if needed ;igures +>+ and +>9 sho'and therefore one can e?plore the other side if needed ;igures +>+ and +>9 sho'the classical radiologic findings of anthe classical radiologic findings of an incarcerate! obturator herniaincarcerate! obturator herniacausing smallcausing small"o'el o"struction"o'el o"struction


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A H-year-old male #ith a history of peptic ulcer disease presents #ithA H-year-old male #ith a history of peptic ulcer disease presents #ithan acute onset of epigastric pain and hematemesis.


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(A) sclerotherapy(A) sclerotherapy

(B) perform a figure of eight stitch(B) perform a figure of eight stitch

(C) vasopressin infusion(C) vasopressin infusion

(!) three suture ligation encompassing the pro?imal and(!) three suture ligation encompassing the pro?imal anddistal "ranches of the gastroduodenal arteries and a @>distal "ranches of the gastroduodenal arteries and a @>type stitch to transfi? the transverse "ranch of thetype stitch to transfi? the transverse "ranch of the

pancreatic arterypancreatic artery(#) ocherize the duodenum and perform a graham(#) ocherize the duodenum and perform a grahampatchpatch


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Explanation:Explanation: $his is an e?ample of a "leeding duodenal ulcer in the$his is an e?ample of a "leeding duodenal ulcer in theposterior 'all $here are some studies that state that the incidence ofposterior 'all $here are some studies that state that the incidence ofemergent or urgent operations for "leeding duodenal ulcers has remainedemergent or urgent operations for "leeding duodenal ulcers has remainedunchanged over the past years .ost patients 'ith this disorder areunchanged over the past years .ost patients 'ith this disorder aresuccessfully treated 'ith medical or endoscopic management #ndoscopysuccessfully treated 'ith medical or endoscopic management #ndoscopy

remains the initial standard of care for the diagnosis and treatment ofremains the initial standard of care for the diagnosis and treatment of"leeding duodenal ulcers urgery is indicated 'hen there is active"leeding duodenal ulcers urgery is indicated 'hen there is activehemorrhage 'hich is refractory to endoscopic techni-ues &nitialhemorrhage 'hich is refractory to endoscopic techni-ues &nitialmanagement should include replacement of "lood volume "y large "ore &Hsmanagement should include replacement of "lood volume "y large "ore &Hsas 'ell as continuous monitoring of vital signs and urinary output #mergentas 'ell as continuous monitoring of vital signs and urinary output #mergentsurgery is also indicated 'hen transfusion is in e?cess of units in a +>hsurgery is also indicated 'hen transfusion is in e?cess of units in a +>hperiod Antrectomy and vagotomy 'as historically considered the goldperiod Antrectomy and vagotomy 'as historically considered the goldstandard for this condition secondary to lo' recurrence rate* "ut has "eenstandard for this condition secondary to lo' recurrence rate* "ut has "een

replaced "y the three suture techni-ue* 'hich has a significantly lo'erreplaced "y the three suture techni-ue* 'hich has a significantly lo'ermor"idity and mortality in the elderly* and unsta"le patient 6ith thismor"idity and mortality in the elderly* and unsta"le patient 6ith thistechni-ue* 'e add pyloroplasty and truncal vagotomy A highly selectivetechni-ue* 'e add pyloroplasty and truncal vagotomy A highly selectivevagotomy can "e done for the young* hemodynamically sta"le patient 'ithvagotomy can "e done for the young* hemodynamically sta"le patient 'ithminimal comor"iditiesminimal comor"idities


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A )-year-old male presents to the emergency room #ith aA )-year-old male presents to the emergency room #ith ahistory of melena! and most recently 3 episodes ofhistory of melena! and most recently 3 episodes ofhematemesis. The patient denies attac&s of reflux or history ofhematemesis. The patient denies attac&s of reflux or history ofpeptic ulcer disease.


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A) endoscopic cauterizationA) endoscopic cauterization

(B) vagotomy and antrectomy(B) vagotomy and antrectomy

(C) 'edge resection of gastric 'all(C) 'edge resection of gastric 'all

(!) distal gastrectomy 'ithout vagotomy(!) distal gastrectomy 'ithout vagotomy


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Explanation:Explanation: $his is an e?ample of !ielafoyJs lesion* 'hich is a vascular$his is an e?ample of !ielafoyJs lesion* 'hich is a vascularmalformation and a rare cause of upper D& hemorrhage &t is also calledmalformation and a rare cause of upper D& hemorrhage &t is also calledFcali"er>persistent arteryF $he malformation is a large su"mucosal orFcali"er>persistent arteryF $he malformation is a large su"mucosal ormucosal vessel that may "leed 'hen there is erosion into it &t is usuallymucosal vessel that may "leed 'hen there is erosion into it &t is usuallyfound along the lesser curvature* middle aged individuals* and nofound along the lesser curvature* middle aged individuals* and no

association 'ith any vascular* or peptic ulcer disease $he hemorrhageassociation 'ith any vascular* or peptic ulcer disease $he hemorrhageproduced from the lesion can "e massive and can cease spontaneously atproduced from the lesion can "e massive and can cease spontaneously attimes &t is difficult to diagnose endoscopically "ecause there is no ulcertimes &t is difficult to diagnose endoscopically "ecause there is no ulcersurrounding the lesion !iagnosis is "est achieved "y performing endoscopysurrounding the lesion !iagnosis is "est achieved "y performing endoscopyat the time of "leeding and visualizing a pinpoint mucosal defect 'ith "loodat the time of "leeding and visualizing a pinpoint mucosal defect 'ith "lood


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evere fle?ion in:uries of the cervical spine may cause unilateral or "ilateral loc,edevere fle?ion in:uries of the cervical spine may cause unilateral or "ilateral loc,edfacets $ypically* unilateral loc,ed facets result from fle?ion plus rotation in:uries* andfacets $ypically* unilateral loc,ed facets result from fle?ion plus rotation in:uries* and"ilateral loc,ed facets result from hyperfle?ion in:uries Anatomically* loc,ed facets"ilateral loc,ed facets result from hyperfle?ion in:uries Anatomically* loc,ed facetsrefer to the condition 'hen the inferior articular facets of the upper dislocated verte"rarefer to the condition 'hen the inferior articular facets of the upper dislocated verte"raslide for'ard over the superior facets of the verte"ra "elo' (;ig >1) Bilateralslide for'ard over the superior facets of the verte"ra "elo' (;ig >1) Bilateralloc,ed facets are e?tremely unsta"le given the e?tensive amount of ligamentousloc,ed facets are e?tremely unsta"le given the e?tensive amount of ligamentous

in:ury involved $he forces applied in this type of in:ury rupture the posteriorin:ury involved $he forces applied in this type of in:ury rupture the posteriorligamentous comple?* the :oint capsules* the interverte"ral disc* and* usually* theligamentous comple?* the :oint capsules* the interverte"ral disc* and* usually* theposterior and anterior longitudinal ligaments &n a"out 80% of these cases* theposterior and anterior longitudinal ligaments &n a"out 80% of these cases* thepatients 'ill present 'ith complete spinal cord in:uries Gerve root in:uries arepatients 'ill present 'ith complete spinal cord in:uries Gerve root in:uries arecommon as 'ell @nilateral loc,ed facets are more sta"le than "ilateral* and thesecommon as 'ell @nilateral loc,ed facets are more sta"le than "ilateral* and thesepatients are usually neurologically intact atients in either of these groups should "epatients are usually neurologically intact atients in either of these groups should "etreated initially 'ith closed reduction using cervical traction


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motor vehicle accident.


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mall "o'el in:uries secondary to "lunt a"dominal trauma aremall "o'el in:uries secondary to "lunt a"dominal trauma areincreasing in incidence "ecause of high velocity motor vehicleincreasing in incidence "ecause of high velocity motor vehicleaccidents and mandatory seat "elt la's (.oore* ;eliciano* andaccidents and mandatory seat "elt la's (.oore* ;eliciano* and.atto?* +00) $he Fseat "eltF syndrome is the comple? of in:uries*.atto?* +00) $he Fseat "eltF syndrome is the comple? of in:uries*'hich includes lum"ar fractures and small "o'el in:uries hysical'hich includes lum"ar fractures and small "o'el in:uries hysical

finding of ecchymoses along the anterior a"dominal 'all is referredfinding of ecchymoses along the anterior a"dominal 'all is referredto as the Fseat "elt signF and may indicate underlying small "o'elto as the Fseat "elt signF and may indicate underlying small "o'elin:uries (Apple"y and Gagy* 18)in:uries (Apple"y and Gagy* 18)

$he proposed mechanisms of in:ury include (1) crushing of "o'el$he proposed mechanisms of in:ury include (1) crushing of "o'elagainst spine* (+) tearing of "o'el from mesentery "y suddenagainst spine* (+) tearing of "o'el from mesentery "y suddendeceleration* and (9) rupture of a closed loop of "o'el under highdeceleration* and (9) rupture of a closed loop of "o'el under high

intraluminal pressure (Duarino* 2assett* and 4uchette* 15)intraluminal pressure (Duarino* 2assett* and 4uchette* 15)


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An E0 thoracotomy shouldAn E0 thoracotomy should notnotbe performed in #hat setting8be performed in #hat setting8

(A) a patient in shoc, 'ith a penetrating anterior chest 'ound(A) a patient in shoc, 'ith a penetrating anterior chest 'ound

(B) a patient 'ho sustained a penetrating chest 'ound and(B) a patient 'ho sustained a penetrating chest 'ound anddevelops precipitous shoc, after endotracheal intu"ation anddevelops precipitous shoc, after endotracheal intu"ation andpositive>pressure ventilationpositive>pressure ventilation

(C) a pulseless patient 'ith a penetrating chest 'ound suspected to(C) a pulseless patient 'ith a penetrating chest 'ound suspected tohave a massive hemothora?have a massive hemothora?

(!) a patient arriving 'ith no electrocardiogram (#CD) rhythm 'ith(!) a patient arriving 'ith no electrocardiogram (#CD) rhythm 'ith,no'n "lunt trauma to the chest,no'n "lunt trauma to the chest

#) C and !#) C and !


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Explanation:Explanation: $he primary o":ectives of resuscitative thoracotomy are (a) release of percardial tamponade (")$he primary o":ectives of resuscitative thoracotomy are (a) release of percardial tamponade (")

control of intrathoracic vascular or cardiac "leeding (c) eliminate massive air em"olism orcontrol of intrathoracic vascular or cardiac "leeding (c) eliminate massive air em"olism or"ronchopleural fistula (d) perform open cardiac massage and (e) temporarily occlude the"ronchopleural fistula (d) perform open cardiac massage and (e) temporarily occlude thedescending thoracic aorta A left anterolateral thoracotomy incision is preferred A rightdescending thoracic aorta A left anterolateral thoracotomy incision is preferred A rightthoracotomy is reserved for hypotensive patients 'ith penetrating in:uries to the right chest inthoracotomy is reserved for hypotensive patients 'ith penetrating in:uries to the right chest inneed of direct access to massive "lood loss or air em"olism An #/ thoracotomy is initiated atneed of direct access to massive "lood loss or air em"olism An #/ thoracotomy is initiated atthe level of fourth to fifth intercostal space 'ith the proper level corresponding to inferior "order ofthe level of fourth to fifth intercostal space 'ith the proper level corresponding to inferior "order of

pectoralis ma:or muscle $he incision is made through the intercostal muscle and parietal pleurapectoralis ma:or muscle $he incision is made through the intercostal muscle and parietal pleurais divided along superior margin of the ri" $he ri" retractor is inserted 'ith the handle to'ard theis divided along superior margin of the ri" $he ri" retractor is inserted 'ith the handle to'ard thea?illa ey resuscitative maneuvers are then initiateda?illa ey resuscitative maneuvers are then initiated

A pericardiotomy incision is made in the presence of cardiac tamponade and incised 'idely*A pericardiotomy incision is made in the presence of cardiac tamponade and incised 'idely*anterior and parellel to the phrenic nerve Blood clots are evacuated from the pericardium andanterior and parellel to the phrenic nerve Blood clots are evacuated from the pericardium andcardiac "leeding sites should "e controlled immediately 'ith digital pressure on the surface of thecardiac "leeding sites should "e controlled immediately 'ith digital pressure on the surface of theventricle and partially occluding vascular clamps placed on atrium or great vessels &n "eatingventricle and partially occluding vascular clamps placed on atrium or great vessels &n "eatinghearts* efforts at cardiorrhapy should "e delayed until initial resuscitation measures have "eenhearts* efforts at cardiorrhapy should "e delayed until initial resuscitation measures have "eencompleted &n the non"eating heart* suturing should "e performed prior to defi"rillationcompleted &n the non"eating heart* suturing should "e performed prior to defi"rillation

$emporary control of the "leeding can "e accomplished 'ith a s,in>stapling device Cardiac$emporary control of the "leeding can "e accomplished 'ith a s,in>stapling device Cardiac'ounds are "est repaired 'ith 9>0 nona"sor"a"le horizontal mattress sutures in the operating'ounds are "est repaired 'ith 9>0 nona"sor"a"le horizontal mattress sutures in the operatingroomroom

&n cardiac arrest* "imanual internal massage of the heart should "e instituted &f internal&n cardiac arrest* "imanual internal massage of the heart should "e instituted &f internaldefi"rillation does not restore vigorous cardiac activity* the descending thoracic aorta should "edefi"rillation does not restore vigorous cardiac activity* the descending thoracic aorta should "eincompletely cross>clamped at the level inferior to the left pulmonary hilum to ma?imize coronaryincompletely cross>clamped at the level inferior to the left pulmonary hilum to ma?imize coronaryperfusion Cardiopulmonary collapse from suspected intraa"dominal hemorrhage should "eperfusion Cardiopulmonary collapse from suspected intraa"dominal hemorrhage should "etemporized "y occlusion of the descending thoracic aorta Air em"olism should "e suspected in atemporized "y occlusion of the descending thoracic aorta Air em"olism should "e suspected in apatient 'ith penetrating chest trauma 'ho develops precipitous shoc, after endotrachealpatient 'ith penetrating chest trauma 'ho develops precipitous shoc, after endotrachealintu"ation and positive>pressure ventilation $reatment involves pulmonary hilar cross>clamping*intu"ation and positive>pressure ventilation $reatment involves pulmonary hilar cross>clamping*vigorous cardiac massage* along 'ith aortic root and left ventricle air aspiration (.oore*vigorous cardiac massage* along 'ith aortic root and left ventricle air aspiration (.oore*;eliciano and .atto? +00 ;eliciano and .atto? +00


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An unrestrained *3-year-old male drag racer involved in high-speed motor vehicle accidentAn unrestrained *3-year-old male drag racer involved in high-speed motor vehicle accident

presents to E0 #ith intense pain in right chest. The primary survey demonstrates decreasedpresents to E0 #ith intense pain in right chest. The primary survey demonstrates decreased

breath sounds over the right hemithorax #ith noted paradoxical motion of the right chest #allbreath sounds over the right hemithorax #ith noted paradoxical motion of the right chest #all

during respiration +,ig. )-/. The maor pathologic se?uela of this inury isduring respiration +,ig. )-/. The maor pathologic se?uela of this inury is

A) disruption of ventilation "ecause of parado?icalA) disruption of ventilation "ecause of parado?icalmotion of the chest 'allmotion of the chest 'all

(B) "leeding from disruption of intercostal vessels(B) "leeding from disruption of intercostal vessels

(C) underlying pulmonary contusion(C) underlying pulmonary contusion

(!) pneumothora?(!) pneumothora?

(#) splinting from chest 'all pain(#) splinting from chest 'all pain


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A flail chest consists of segmental fractures of three or more ad:acent ri"s* or one or more ri"A flail chest consists of segmental fractures of three or more ad:acent ri"s* or one or more ri" fractures 'ith associatedfractures 'ith associatedcostrochondral separation or fracture of sternum (;ig 10>5) $his causes an unsta"le or floatingcostrochondral separation or fracture of sternum (;ig 10>5) $his causes an unsta"le or floatingsegment of chest 'all that moves parado?ically during respiration (A$4* 1) A pneumothora?segment of chest 'all that moves parado?ically during respiration (A$4* 1) A pneumothora?or hemothora? may "e present A more significant in:ury* ho'ever* is associated 'ith pulmonaryor hemothora? may "e present A more significant in:ury* ho'ever* is associated 'ith pulmonarycontusion leading to hemorrhage and edema of the in:ured lung A chest 'all in:ury of thiscontusion leading to hemorrhage and edema of the in:ured lung A chest 'all in:ury of thismagnitude is also associated 'ith significant pain* and respiratory efficiency is red

The Limitations of Mammography Include

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