Which anatomic location is the most common site of extra-adrenal pheochromocytomas?
Answer(s): C
Pheochromocytomas arise from neuroectoderamal cells and are most often found within the adrenal medulla. Ten percent of all pheochromocytomas are located outside of the adrenal gland along the embryologic path of the adrenal gland. The most common site of an extra-adrenal pheochromocytoma is in the paraaortic area.
A45-year-old man was kicked several times in the abdomen in a bar fight. He came to the ED and noted that he has not voided for 24 hours. Insertion of a Foley catheter revealed gross hematuria, which persisted after irrigation. A CT scan of the abdomen and pelvis is obtained that does not show any evidence of renal laceration. ACT cystogram is then obtained and is shown in Figure. Appropriate management of this injury includes which of the following?
Answer(s): D
Bladder ruptures are highly associated with pelvic fractures. They typically present with hematuria and are typically evaluated with CT cystogram in the setting of trauma. The management of the injury is defined by the location of the rupture. If the rupture remains contained in the extraperitoneal space the treatment is Foley catheter drainage, which allows the bladder to heal spontaneously. However, if the patient has an open pelvic fracture or has other intraabdominal injuries requiring operative exploration, the bladder injury should also be repaired. If imaging of the urinary tract demonstrates rupture of the bladder contents into the peritoneal cavity, operative exploration with a two-layer closure of the defect is the standard of care. Asuprapubic catheter is then placed to help protect the repair.
A 54-year-old male presents to the ED with acute onset of severe abdominal pain. His history is significant for gnawing epigastric pain that radiates to the back for several months. Physical examination demonstrates mild hypertension and tachycardia as well as a rigid "board like" abdomen with generalized rebound tenderness and hypoactive bowel sounds. Rectal examination reveals dark hemoccult positive stools without gross blood.Which of the following would be the next appropriate step in management?
Answer(s): A
The patient's history of gnawing epigastric pain is consistent with ulcer disease. His presentation is that of a perforated duodenal ulcer. The most appropriate first step is to obtain upright plain films of the chest and abdomen to look for free intraperitoneal air. Although the patient is in mild distress, he is not toxic and it is reasonable to confirm your suspicion with radiologic studies. If the plain films did not demonstrate free air and the patient remained hemodynamically stable, a CT scan of the abdomen and pelvis may be indicated to try to make the diagnosis. However, if the patient did show signs of increasing toxicity and evidence for sepsis, such as hypotension or mental status changes, it would be reasonable to proceed with an exploratory laparotomy to make the diagnosis. Upper endoscopy is not indicated in the acute management of a perforated duodenal ulcer and this patient is currently in significant distress and discharging to home with delayed follow-up is unwise. The patient most likely has a posterior perforation of a duodenal ulcer that has eroded into the gastroduodenal artery causing bleeding per rectum, tachycardia, and hypotension. Diverticulosis is a common cause of bright red blood per rectum in elderly patients but is often painless and not consistent with the presentation of this patient. A ruptured AAA generally presents with hypotension and profound shock. A distended abdomen and pulsatile mass can be found on physical examination. Ruptured esophageal varices present with upper GI bleeding and hematemasis and are most often associated with patients who have chronic liver disease.
A 54-year-old male presents to the ED with acute onset of severe abdominal pain. His history is significant for gnawing epigastric pain that radiates to the back for several months. Physical examination demonstrates mild hypertension and tachycardia as well as a rigid "board like" abdomen with generalized rebound tenderness and hypoactive bowel sounds. Rectal examination reveals dark hemoccult positive stools without gross blood. While you are in the process of working up the patient he becomes hypotensive and tachycardic. Bright red blood per rectum is now noted. The most likely explanation for his condition is which of the following?
Answer(s): E
You are a second-year surgery resident and have just left work after a 30-hour shift. On your way home you witness a recent collision where there is an obviously injured pedestrian. Several bystanders are providing care for the injured victim. You elect to keep driving. Awitness at the scene recognizes you as a physician and reports you to the authorities for neglecting to stop to provide care. As a consequence of your actions, which of the following will most likely happen?
As a practicing physician, you are not required to stop at an accident and care for the injured, as you have not established a doctorpatient relationship. As such, there are no legal requirements for physicians to assist in the care of accident victims outside of their employment (i.e., hospital, ER, clinic). It is also important to realize that under the Good Samaritan law, individuals who provide aid to the injured or ill are protected from prosecution for unintentional injury or wrongful death. It is also important to be familiar with local laws. For example, in some states, this law only applies to people who are trained in basic first aid. (The state of Vermont requires any bystander to render aid until proper authorities arrive). In the situation presented above, you most probably would not be faulted for not assisting in the care of the injured person and there would be no grounds for legal action.
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