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Free STEP3 Exam Braindumps (page: 58)

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PDF with 804 Questions

Which of the following is a contraindication to sentinel lymph node biopsy in breast cancer?

  1. clinically negative axillary examination
  2. multicentric disease
  3. lesion under the nipple
  4. history of previous breast biopsy
  5. patient preference for breast conservation

Answer(s): B

Explanation:

Sentinel lymph node biopsy offers an alternative to full axillary dissection as a diagnostic tool in breast cancer with clinically negative axillary lymph nodes. Patients are injected with technetium-labeled sulfur colloid and isosulfan blue dye. A gamma probe is used along with the visual cues of the blue dye to identify the "sentinel node." The theory is that if this node is negative for malignancy, the rest of the axilla will be negative as well. This spares these patients from an unnecessary axillary lymph node dissection and the morbidity that it entails. Patients with a positive sentinel lymph node require further therapy. Contraindications to the procedure include palpable axillary lymph nodes (because the diagnosis of axillary metastasis is apparent), multicentric disease, and a history of reaction to the blue dye (anaphylaxis and urticaria have been reported). If the lesion is very close to the axilla, there may be too much background radiotracer activity to discern the sentinel node. Lesions under the nipple are quite amenable to this procedure. There are several studies showing that the accuracy and success of this technique is related to surgeon experience. Surgeons are required to perform 2030 procedures with some supervision or confirmation of results before relying completely on sentinel node biopsy



A 45-year-old male was involved in a motor vehicle collision. He was a restrained passenger in a high speed, head-on collision with a death at the scene. He is brought to the ED unresponsive with a pulse of 140, a BP of 70/30, and a SpO2 of 80%. He has multiple facial lacerations, a dilated right pupil, a contusion on his chest, and a distended abdomen. The medic team has placed two large-bore IVs and given him 2 L of lactated Ringer's solution.

The initial step in the care of this patient is:

  1. Given the mechanism, low oxygen saturation, and the presence of a contusion on his chest, the patient likely has a pneumothorax. A chest tube should be placed immediately.
  2. The patient should be taken to the OR immediately for laparotomy since he is hemodynamically unstable with abdominal distention indicating an abdominal source of life-threatening hemorrhage.
  3. The patient should be intubated using in-line traction to protect his cervical spine before continuing the assessment.
  4. Because of the facial lacerations, there is a possibility of facial fractures making endotracheal intubation risky. An emergent cricothyroidotomy should be performed.
  5. A central line should be placed immediately to continue the resuscitation.

Answer(s): C

Explanation:

The first step in any trauma assessment is the primary survey. This consists of:
A--airway maintenance
B--breathing and ventilation
C--circulation
D--disability/neurologic status
E--exposure/environment
The first priority in any trauma patient is to establish an airway. In an unconscious patient with decreased saturations, endotracheal intubation is indicated. While facial lacerations may indicate fractures, these patients can often be successfully orally intubated. This should be attempted first, but if this technique is unsuccessful, a cricothyroidotomy should be performed to secure the airway. Once an airway has been established, you can address breathing/ ventilation by auscultating breath sounds and evaluating for end- tidal CO2 using a capnometer. It is at this point where a life-threatening tension pneumothorax can be identified and treated. The next step is to evaluate the circulation. This includes getting adequate intravenous access. The patient described has two large-bore IVs, which should be sufficient for the initial resuscitation. Central venous access is indicated only if adequate access cannot be established peripherally. It is here that evaluation for intra-abdominal hemorrhage can be conducted using ultrasound or diagnostic peritoneal lavage.



A 45-year-old male receives a cadaveric liver transplant for alcoholic cirrhosis. Postoperatively, the patient is taken to the surgical intensive care unit (SICU). There is concern for primary nonfunction of the allograft.

Which of the following is a sign of this?

  1. coagulopathy with an INR of 2
  2. normalizing albumin level
  3. hyperglycemia requiring an insulin drip
  4. initial rise of transaminases
  5. high urine output

Answer(s): A

Explanation:

Early clinical decline in a transplant patient is concerning for primary organ failure. This can be related to donor issues, technical issues, or donor organ ischemia. Signs of liver dysfunction include hypoglycemia (as the liver is unable to perform gluconeogenesis), coagulopathy with elevated prothrombin times, elevated ammonia levels, acid-base changes (unable to clear lactate via the Cori cycle), hyperkalemia, and oliguria. All liver transplant patients have an initial rise in transaminases which should decrease over the first 48 hours.



A50-year-old man undergoes a sigmoid colectomy and colostomy for perforated diverticulitis of the midsigmoid colon. The surgeon reports a difficult dissection in the pelvis secondary to adhesions of the sigmoid colon to the abdominal wall. On postoperative day 1, the patient reports appropriate abdominal pain. His pulse is 100 and BP 120/60. He has made 400 mL of urine over the past 8 hours. The urine in the Foley bag is blood-tinged.

He reports no problems with his urination preoperatively. What is the appropriate management?

  1. Remove the Foley catheter. The irritation of the catheter is probably causing the hematuria.
  2. Increase his IV fluids and add bicarbonate in case this is rhabdomyolysis.
  3. Start antibiotics for a urinary tract infection.
  4. Order an intravenous pyelogram to assess for ureteral injury.
  5. Send a prostate-specific antigen (PSA) to screen for a prostatic process.

Answer(s): D

Explanation:

Ureteral injuries are a well-known complication of pelvic surgery. The risk is greatly increased in the setting of inflammation, which can make the ureters difficult to identify. Intravenous pyelogram is a sensitive test for injury. CT scan and retrograde pyelogram are also diagnostic options. Injuries identified early are usually amenable to primary surgical repair, making early diagnosis essential. Delayed recognition usually results in a staged repair requiring urinary diversion with percutaneous nephrostomy tubes.






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