You have been called to the ER to evaluate a 58-year-old female who presented to the hospital for evaluation of a painful left foot. She noticed the pain when she awoke in the morning. She has a history of painful calf muscles when she walks. On your examination, you notice that she has an irregular heart beat, and that she has no palpable pulses and no audible Doppler signals in her left foot. It is cool to the touch and she has some decreased sensation ather toes. Which of the following is the next best step in this patient's management?
Answer(s): B
Acute arterial occlusion is a surgical emergency. However, the most important intervention is immediate heparinization. The infusion of heparin will help prevent extension of the clot. Furthermore, it will help to keep collateral vessels open. If the patient is stable enough to undergo operative intervention, a catheter embolectomy would be the procedure of choice. Physical examination findings including vascular examination and level of temperature change and altered sensation can help identify the level of the occlusion prior to operative intervention. Duplex ultrasound is not necessary to isolate the occlusion. Arteriograms are more useful in the OR following the embolectomy. Finally, if small vessel occlusion occurs, catheter-directed thrombolytics can help restore distal perfusion. Once perfusion to the threatened limb has been restored, the workup to identify the thromboembolic source should be obtained. Typical sources for emboli include atrial thrombus, valvular disease, aortic aneurysms, or iliac artery atherosclerotic disease.
You are asked to see a 74-year-old man who has been admitted for evaluation of abdominal pain. During his workup, he was found to have hemoccult positive stool and a CT scan that was concerning for a mass in his sigmoid colon.Which should be the next step in his treatment?
Answer(s): C
In the workup of a lesion identified within the colon, the gold standard for diagnosis is colonoscopy. Colonoscopy allows for biopsy of the tissue to establish a diagnosis of cancer prior to removing the mass. Furthermore, it also enables examination of the rest of the colon to rule out synchronous lesions. Barium enemas continue to have a role in diagnosis, but are more useful identifying the level of the lesion particularly in the setting of obstruction. You would not proceed straight to surgical resection unless the patient presented with an obstruction. Finally, PET scans have no role in the diagnosis of colon cancer
You are seeing a 48-year-old female in followup in your clinic. She originally presented for evaluation of a suspicious nonpalpable lesion in her right breast that was seen on her annual mammogram. A stereotactic core biopsy was done. She now returns to your office to review the results of the pathology report that confirms the presence of lobular carcinoma in situ (LCIS).How do you counsel her at this time?
LCIS is a benign diagnosis and alone does not have a risk of progression to an invasive cancer. However, a diagnosis of LCIS does increase the risk for development of future breast cancer at a rate of about 1% per year. It is important to remember that the risk is increased for both breasts. It has been shown that chemoprevention with tamoxifen can decrease the incidence of breast cancer by 49%. It is also sufficient to follow this population closely with annual mammograms and semiannual clinical examinations. Prophylactic bilateral mastectomies are an option and result in a 90% decrease in the risk of subsequent breast cancer. Since a diagnosis of LCIS increases the risk of cancer in both breasts, a mastectomy of the affected side is insufficient treatment
A 52-year-old female has been referred to you for consultation following a core biopsy of an area of calcifications seen on a screening mammogram. She has no family history of breast or ovarian cancer. She has not been taking hormone replacement therapy and has no reproductive risk factors. On physical examination, there is no palpable mass. The core biopsy results demonstrate atypical ductal hyperplasia.What should be the next step in her treatment?
The management of a breast lesion has become more complex as our knowledge regarding breast cancer development and treatment has continued to grow. The gold standard for evaluation of a suspicious lesion on mammogram is a core needle biopsy. This can be performed on palpable lesions directly, but can also be used on nonpalpable lesions using ultrasound or stereotactic guidance. A diagnosis of atypical ductal hyperplasia cannot be established on core biopsy alone. Studies have demonstrated that nearly 20% of patients with this diagnosis on core biopsy go on to have evidence of ductal carcinoma in situ or invasive ductal carcinoma after excisional biopsy. As such, if a core biopsy demonstrates evidence for atypical ductal hyperplasia, the standard of care is to proceed with an excisional biopsy to establish the diagnosis. Once this diagnosis has been confirmed, management decisions can be made including close observation with frequent screening mammograms, chemoprevention with tamoxifen, or prophylactic bilateral mastectomy.A unilateral mastectomy is not an option as a diagnosis of atypical ductal hyperplasia increases the risk of breast cancer in both breasts
You had previously seen a 24-year-old male in your office for evaluation of a suspicious looking mole. He had undergone a punch biopsy, which demonstrated a melanoma. He has no prior history of skin cancer, no family history of skin cancer, nor any history of blistering sunburns. Which of the following results in the pathology report are most predictive of outcome?
When assessing the prognosis for a patient diagnosed with melanoma, there are many factors that are involved. Tumor thickness, the presence of ulceration, the location of the lesion, the age of the patient, and the gender can all contribute. The most predictive factor is the tumor thickness. There are two measurement systems that have been developed to classify melanoma. The Clark level refers to the depth of invasion of the melanoma in terms of the anatomical layers of the skin. A second system, known as the Breslow depth, simply measures the overall tumor thickness in millimeters. Since the Breslow depth is more reproducible among pathologists, it has proven to be more accurate in the prediction of outcomes.
Post your Comments and Discuss USMLE STEP3 exam prep with other Community members:
Our website is free, but we have to fight against AI bots and content theft. We're sorry for the inconvenience caused by these security measures. You can access the rest of the STEP3 content, but please register or login to continue.