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Free STEP3 Exam Braindumps (page: 67)

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Following an uneventful appendectomy for acute appendicitis, the pathology report reveals the presence of a 1 cm carcinoid at the tip of the appendix. The patient has been otherwise asymptomatic.
What is the most appropriate intervention?

  1. formal right hemicolectomy
  2. partial cecectomy--excision of the base of the cecum at the appendectomy site
  3. no further operative intervention required
  4. total abdominal colectomy with ileorectal anastomosis
  5. partial small bowel resection

Answer(s): C

Explanation:

Carcinoids are the most common neoplasm of the appendix and arise from Kulchitsky cells, a type of enterochromafin cell. Aside from the appendix, the next most frequent site of involvement is the small bowel followed by the rectum. Appendiceal and rectal carcinoids are almost never associated with carcinoid syndrome unless metastatic disease is present. Small bowel carcinoids are more commonly multifocal, metastatic, and associated with carcinoid syndrome. The majority of appendiceal carcinoids are located at the tip and the extent of surgical resection depends on the size and resulting malignant potential. Lesions less than 1 cm rarely metastasize and therefore require only simple appendectomy as in this question. Lesions greater than 2 cm require a right hemicolectomy due to the high potential for metastasis. Partial small bowel resection is indicated for a carcinoid of the small intestine. Partial cecectomy and total abdominal colectomy are not appropriate options.



A 64-year-old diabetic male undergoes a right hemicolectomy for an adenocarcinoma of the cecum. On the first postoperative night, he becomes tachycardic and is noted to have a temperature of 102.8°F. His surgical incision is tender with erythema and murky discharge.

Which of the following is the most important intervention?

  1. begin broad-spectrum antibiotics, Tylenol, and a cooling blanket
  2. open the wound and begin hyperbaric oxygen treatment
  3. apply sterile warm compress over the incision and replace dressing
  4. open the wound, send for Gram's stain of the fluid and emergent radical debridement
  5. postoperative fever evaluation including sputum, urine, and blood cultures

Answer(s): D

Explanation:

Postoperative wound infections usually occur between the fifth and eighth postoperative days. Evidence of a wound infection within the first 24 hours after surgery should alert the physician to the possibility of necrotizing fasciitis. Necrotizing fasciitis is a lifethreatening infection most commonly caused by clostridial myositis and hemolytic streptococcus. In addition to spiking temperature, the patient may be septic with tachycardia, leukocytosis, and hemodynamic instability. On examination of the wound, crepitus (gas in the soft tissue) and a dishwater-appearing effluent may be apparent. Early diagnosis by opening the wound and sending a Gram's stain is critical. The Gram's stain will reveal a mixed flora of ramnegative rods and gram-positive cocci. Although broad-spectrum antibiotics are indicated, definitive treatment requires emergent aggressive debridement of the affected tissues. Hyperbaric oxygen treatment has no role in the acute management of necrotizing fasciitis. Diabetic patients are especially prone to necrotizing fasciitis. Fournier's gangrene is a type of necrotizing fasciitis that affects the groin and perineum. The mortality rate can be as high as 75%.



A50-year-old diabetic man is treated as an outpatient with incision and drainage and oral clindamycin for an abscess and cellulitis of the skin on his back. About a week after completing his antibiotic he develops frequent, watery diarrhea. Which of the following is the most appropriate treatment of this complication?

  1. oral levaquin
  2. intravenous metronidazole
  3. oral vancomycin
  4. oral metronidazole
  5. intravenous vancomycin

Answer(s): D

Explanation:

Nearly all broad-spectrum antibiotics may result in superinfection of the colon with Clostridium difficile. This anaerobic enteric pathogen produces a toxin that causes necrosis of the colonic mucous membrane resulting in enterocolitis (pseudomembranous colitis). The infection can occur several weeks after the discontinuation of the inciting antibiotic. The presentation varies from mild diarrhea to systemic illness with abdominal pain, fever, and leukocytosis. Severe cases may progress to colonic dilatation and perforation. Lower endoscopy reveals the characteristic yellow pseudomembranes, which represent ulceration and necrosis. The diagnosis is confirmed with either colonic wall biopsy for the organism, or more commonly with identification of the toxin in stool samples. Orally administered metronidazole is the treatment of choice. Oral vancomycin is also effective, but it is reserved for refractory cases due to its side effect profile and expense.



A62-year-old male on total parenteral nutrition (TPN) for 2 weeks following development of a postoperative enterocutaneous fistula has developed high, spiking temperatures up to 102.2°F over the last 8 hours. The only abnormal finding on physical examination is erythema and induration around his central line.
The most appropriate management is which of the following?

  1. begin broad-spectrum antibiotics and observe for 24 hours
  2. obtain blood cultures through the central line, begin broad-spectrum antibiotics and await culture results
  3. remove catheter, send tip for culture and replace with a new central line over the guide wire
  4. remove catheter, send tip for culture and establish central line at another site
  5. remove catheter, send for culture and establish peripheral intravenous line

Answer(s): D

Explanation:

A high index of suspicion is warranted for catheter sepsis in any patient who has had a central line for several days and suddenly spikes a high fever. The catheter site may have erythema, induration, tenderness, and purulent discharge extruding from the skin. Often, however, the skin appears normal. Athorough search for other possible sources of fever including pulmonary, intra-abdominal, urinary, and wound infections is always prudent. Catheter sepsis can be life threatening and early intervention is essential. Peripheral and central blood cultures should be obtained and the catheter must be removed promptly. It is contraindicated to replace the catheter over a guide wire because the skin tract is infected. It is not mandatory to treat with antibiotics unless the fever persists or signs of sepsis are present.






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