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Free STEP3 Exam Braindumps (page: 59)

Page 58 of 202
PDF with 804 Questions

A 75-year-old man undergoes a right colectomy for stage 3 colon cancer. He has a history of emphysema requiring chronic steroid use. He also has diabetes and coronary heart disease. On postoperative day 2, the surgeon is called because the patient acutely began to have a large amount of pinkish, serous drainage from the wound.
There is no evidence of infection. Which of the following factors probably contributed to this complication?

  1. the surgeon used a running stitch to close the fascia instead of interrupted sutures
  2. coronary artery disease
  3. early mobilization of patient
  4. aggressive abdominal examination performed on postoperative day 1 by a medical student
  5. pulmonary disease

Answer(s): E

Explanation:

Dehiscence refers to a separation of the fascial layer. Evisceration is when peritoneal contents extrude through the fascial separation. Malnutrition, obesity, diabetes, uremia, malignancy, immunologic abnormalities, steroid use, infection, and coughing which increases intraabdominal pressures are all factors that increase the risk of wound dehiscence. Technical factors are also very important in preventing the dehiscence, but there is no proof that interrupted sutures are better than a running stitch for fascial closure



A 22-year-old male presents complaining of a 1-month history of progressive dysphagia. He reports occasional regurgitation of undigested food at night. His past medical history is noncontributory. The condition has worsened to the point that he is on a liquid diet. A contrast swallow study is shown in Figure.
What is the best treatment for this patient?

  1. proton pump inhibitors
  2. referral to a surgeon for a Nissen fundoplication
  3. calcium channel blockers
  4. serial esophageal sphincter dilations
  5. referral to a surgeon for esophagomyotomy

Answer(s): E

Explanation:

This patient has achalasia. This disorder is defined by a nonrelaxing lower esophageal sphincter (LES) and decreased peristalsis of the esophageal body. The "bird's beak" deformity is a classic sign with a dilated esophagus which tapers to a small area at the LES. Esophagomyotomy is the treatment of choice for long- standing disease. Serial botox injections and dilations can be used early in the disease process, however their long-term results are inferior to myotomy. Proton pump inhibitors can be used for gastroesophageal reflux disease (GERD). A Nissen fundoplication is also a treatment for GERD. Calcium channel blockers are sometimes used to treat other esophageal motility disorders.



A 45-year-old woman undergoes an uncomplicated thyroidectomy for a goiter. Later that night, she becomes agitated and complains of difficulty breathing. The surgeon notices some neck swelling at the incision site, but the dressing is clean.

What should the next step be?

  1. start oxygen by nasal cannula
  2. check STAT serum calcium level
  3. endotracheal intubation to protect her airway
  4. open the incision
  5. administer propranolol and morphine

Answer(s): D

Explanation:

One of the most feared complications of neck surgery is postoperative hemorrhage causing airway compromise. Any patient with neck swelling and dyspnea must be assessed for this emergently. The treatment is to immediately open up the neck wound to release the hematoma and relieve the tracheal compression.



A patient presents with a new neck mass. On examination, she has a palpable thyroid nodule and a palpable cervical lymph node on the same side. Needle biopsy of the thyroid nodule shows amyloid in the stroma.
The treatment for this patient is which of the following?

  1. total thyroidectomy and modified neck dissection
  2. resection of the involved thyroid lobe, isthmusectomy, and removal of the palpable lymph node
  3. total thyroidectomy and radiation therapy
  4. resection of the involved lobe and part of the contralateral lobe, isthmusectomy, and removal of the palpable lymph node
  5. radioactive iodine administration

Answer(s): A

Explanation:

The needle biopsy revealing amyloid makes the diagnosis of medullary thyroid cancer. Patients often present with a neck mass and palpable lymph nodes (1520%). Because of the aggressive nature of the malignancy and the fact that it is often multicentric, total thyroidectomy is the treatment of choice. Modified radical neck dissection is indicated in patients with palpable lymphadenopathy and in patients with tumors larger than 2 cm (since 60% of these patients will have lymph node involvement). Because medullary carcinoma originates from the thyroid C-cells, they do not respond to thyroxine or radioactive iodine therapy.






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