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Free STEP3 Exam Braindumps (page: 64)

Page 63 of 202
PDF with 804 Questions

A 50-year-old man comes to the emergency room (ER) with a history of vomiting of 3 days' duration. His past history reveals that for approximately 20 years he has been experiencing epigastric pain that lasts for 23 weeks during spring and autumn. He remembers getting relief from pain by taking milk and antacids. Physical examination showed a fullness in the epigastric area with visible peristalsis, absence of tenderness, and normal active bowel sounds. What is the most likely diagnosis?

Which of the following metabolic abnormalities are typically found in the above patient?

  1. decreased antidiuretic hormone
  2. hypercalcemia
  3. hypokalemia
  4. hyperchloremia
  5. decreased aldosterone secretion

Answer(s): C

Explanation:

In a patient who is known to have had symptoms of peptic ulcer disease for many years and presents with nausea and vomiting, one should consider gastric outlet obstruction. The bstruction can be the result of an exacerbation of the ulcer and subsequent edema or it can be secondary to scar tissue formation. These patients typically describe the sensation of epigastric fullness and demonstrate visible peristalsis going from left to right. A succussion splash may be audible. The history of periodicity and pain relief by taking antacids also favors a diagnosis of previous peptic ulcer disease. Patients with an umbilical hernia will have a mass in the region of the umbilicus. Patients with acute cholecystitis usually present with the sudden onset of pain, radiating to the back, with fever and chills. Volvulus of the sigmoid colon presents with constipation and abdominal distention but vomiting is a late feature. Small bowel obstruction would be associated with a history of colicky abdominal pain, nausea, and vomiting. Additionally, patients with small bowel obstruction usually have hyperactive highpitched bowel sounds on examination



Gastrin secretion is enhanced by which of the following?

  1. antral distention
  2. antral acidification
  3. presence of fat in the antrum
  4. sympathetic nerve stimulation
  5. duodenal acidification

Answer(s): A

Explanation:

Gastrin secretion is increased by vagal stimulation, antral distention, and by the presence of protein in the antrum. Antral acidification (pH = 1.5) decreases gastrin secretion by a feedback mechanism. The same is true with duodenal acidification.



Apatient is operated on with the presumptive diagnosis of acute appendicitis. However, at operation, the appendix and cecum are found to be normal. The terminal ileum though is red, edematous, and thickened with creeping of the mesenteric fat onto the ileum for a distance of approximately 30 cm. There is no dilation of the bowel proximal to the area of inflammation.
The remainder of the small bowel is normal.

What is the appropriate operative procedure?

  1. closure of the abdomen
  2. appendectomy
  3. ileostomy proximal to the area of involvement
  4. side-to-side ileotransverse colostomy
  5. right hemicolectomy

Answer(s): B

Explanation:

From the description, the diagnosis in this patient is acute regional enteritis. The incidental finding of regional enteritis in patients operated on for the presumed diagnosis of acute appendicitis is treated medically unless there is proximal obstruction. The risk of operating on patients with regional enteritis is the formation of a fistula and/or abscess, especially if the area to be resected is involved with the disease process. However, if the cecum and the appendix are not involved, it is advisable to perform an appendectomy. In this instance, it would be safe and eliminate acute appendicitis from the differential if his symptoms recurred.



A 25-year-old male presents to your office for evaluation of a testicular mass that he found in the shower. On examination, his left testicle is larger than his right with a firm palpable mass. Ascrotal ultrasound confirms the presence of a solitary intraparenchymal testicular mass. Further management of his condition would include which of the following?

  1. close observation and repeat ultrasound in 3 months
  2. serum beta-human chorionic gonadotropin (HCG), alpha-fetoprotein (AFP), and lactate dehydrogenase (LDH)
  3. fine needle aspiration to determine if the mass is malignant
  4. transscrotal orchiectomy
  5. a 2-week course of antibiotics with follow-up clinical examination after completion

Answer(s): B

Explanation:

Testicular cancer is the most common malignancy in men between the ages of 15 and 35. It typically presents as unilateral scrotal swelling. On examination, it is important to distinguish intraparenchymal masses (usually malignant) from extraparenchymal masses (usually benign). This is easily done with scrotal ultrasound. Upon the diagnosis of an intraparenchymal testicular mass, a staging CT scan of the chest, abdomen, and pelvis should be obtained. It is reasonable to evaluate the serum levels of beta- HCG and AFP as they may be elevated in 8085% of patients with nonseminomatous germ cell tumors. LDH, on the other hand, can be elevated in patients with seminomas and can be of prognostic significance. Finally, if elevated, these serum markers can serve as a means to monitor the presence of residual disease and should be measured after resection of the tumor. Additionally, the mass should be excised in order to establish a histologic diagnosis. Aradical orchiectomy should be performed from an inguinal approach. Less invasive approaches such as biopsies or a scrotal approach to the tumor should be avoided as they can alter the lymphatic drainage and potentially adversely affect overall outcomes






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