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Free STEP3 Exam Braindumps (page: 71)

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PDF with 804 Questions

A60-year-old woman presents with an abnormal cluster of microcalcifications on a routine mammogram, and undergoes a needle-localized excisional biopsy. The pathology is shown in Figure. When counseling the patient regarding her surgical options, which of the following statements would be correct?

  1. Modified radical mastectomy differs from a Halsted mastectomy in that the pectoralis major is spared in the modified radical approach.
  2. Modified radical mastectomy differs from Halsted mastectomy in that an axillary lymphadenectomy is not performed in the modified radical approach.
  3. The anatomic limits of the modified radical mastectomy include the sternum medially and the anterior border of the serratus anterior muscle laterally.
  4. Injury to the thoracodorsal nerve during mastectomy results in a "winged scapula."
  5. Lymphedema occurs mainly as a complication of the Halsted radical mastectomy and should not be seen after modified radical mastectomy.

Answer(s): A

Explanation:

The Halsted radical mastectomy involves removal of all breast tissue, lymphadenectomy, and removal of the pectoralis major. The modified radical mastectomy preserves the pectoralis major muscle thus decreasing the morbidity of the surgery with the same survival. The modified radical mastectomy does include a lymph node dissection. The anatomic limits of the modified radical mastectomy include the sternum medially, the subclavius muscle superiorly, the inframammary fold inferiorly, and the latissimus dorsi muscle laterally. The surgeon must identify the thoracodorsal nerve and the long thoracic nerve, which innervate the latissimus dorsi muscle and the serratus anterior muscle, respectively. Damage to the long thoracic nerve results in a "winged scapula." After a complete dissection of level I, II, and III lymph nodes, the use of radiation therapy needs to be critically evaluated because of the long-term morbidity of lymphedema.



A 45-year-old man undergoes a distal esophagectomy for Barrett's esophagus. During his hospital course, a left chest tube is placed for an effusion. Milky white fluid is found to come out through the tube.

Which of the following statements is most accurate about this condition?

  1. Diagnosis can be confirmed by checking the lymphocyte count and triglyceride level in the fluid.
  2. This condition requires immediate surgical intervention to repair.
  3. The chest tube should be removed due to the possibility of an iatrogenic source of infection.
  4. Usually found on the right if due to a traumatic source.
  5. The use of TPN is contraindicated until the condition resolves.

Answer(s): A

Explanation:

Damage to the thoracic duct can be seen as a complication following distal esophagectomy or any procedure that involves dissection into the cervical region. It is most commonly seen on the left if iatrogenic. Aspiration of an odorless, milky fluid from the chest cavity is diagnostic, although increased lymphocyte counts nd triglyceride levels in the fluid help confirm the diagnosis. Normal chyle flow is around 2 L a day. Therefore, a chylous leak can result in nutritional depletion as well as decreased systemic lymphocytes to fight infection. The first therapy is placement of a chest tube to drain the chyle and to allow for approximation of the lung against the mediastinum. Stopping oral intake and starting total parental nutrition is usually tried for 710 days to see if there is spontaneous resolution of the leak. If conservative measures fail, ligation of the thoracic duct can be performed.



A 60-year-old man with hypertension, hyperlipidemia, and peripheral vascular disease requires coronary artery bypass graft surgery.

Which of the following vessels would be the most appropriate conduit for his coronary artery bypass graft?

  1. left axillary artery
  2. internal mammary arteries
  3. ulnar artery
  4. common femoral vein
  5. femoral artery

Answer(s): B

Explanation:

Finding a conduit for use in coronary artery bypass grafting can sometimes be a challenge since these patients often have diffuse atherosclerotic disease. The left internal mammary artery is most commonly used. Bilateral internal mammary arteries can be used, however this increases the chances of sternal healing problems. Saphenous vein grafts are used in patients with multivessel disease, although this may not be an option in patients with deep vein thrombosis (DVT), venous insufficiency, or arterial insufficiency to the legs (because they will not heal the harvest wound). Radial arteries, the right gastroepiploic artery, and inferior epigastric arteries have also been used.



The family of a patient recently diagnosed with esophageal cancer requests more information regarding the disease.
You tell them which of the following?

  1. The incidence of SCC of the esophagus is rising more rapidly than adenocarcinoma.
  2. Premalignant conditions include caustic esophageal burns, Plummer-Vinson syndrome, and tylosis.
  3. It is more common in women than men.
  4. Smoking is not a risk factor for esophageal cancer.
  5. Barrett's esophagus increases the risk for esophageal SCC.

Answer(s): B

Explanation:

Esophageal cancer is increasing in incidence in North America, largely due to the rise in incidence of esophageal adenocarcinoma. Premalignant lesions for esophageal cancer include: Barrett's changes, radiation esophagitis, caustic esophageal burns, Plummer-Vinson syndrome, leukoplakia, esophageal diverticula, ectopic gastric mucosa, and tylosis. It is more common in men, and smoking is clearly a risk factor along with alcohol. Barrett's esophagus requires frequent surveillance examinations with biopsies and increases the risk for adenocarcinomas of the esophagus at the gastroesophageal junction.






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