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Free STEP3 Exam Braindumps (page: 78)

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PDF with 804 Questions

A 24-year-old male is involved in a house fire. His sputum is carbonaceous and he has suffered second- and third-degree burns to 65% of his total body surface area (TBSA). He is intubated in the ED without difficulty. A capnometer is placed at the end of the endotracheal tube and there is positive change in color. Examination of his chest reveals bilateral equal breath sounds. Suddenly he experiences ECG changes and goes into cardiac arrest. Which of the following drugs is most likely to be responsible for this event?

  1. etomidate
  2. rocuronium
  3. succinylcholine
  4. midazolam
  5. ketamine

Answer(s): C

Explanation:

Succinylcholine is a depolarizing neuromuscular blocking agent that can cause arrhythmias including bradycardia and junctional rhythms because of vasotonic effects. Additionally, succinylcholine is associated with a transient hyperkalemia that can be profound in patients with burns or those who have experienced significant crush injury and result in cardiac arrest.



Which anatomic location is the most common site of extra-adrenal pheochromocytomas?

  1. duodenum
  2. inferior pole of the kidney
  3. paraaortic area
  4. parasplenic area
  5. peripancreatic area

Answer(s): C

Explanation:

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?

  1. urinary catheter drainage
  2. urinary catheter drainage with continuous bladder irrigation
  3. bilateral nephrostomy tubes
  4. exploratory laparotomy with oversewing of the bladder wall
  5. observation

Answer(s): D

Explanation:

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?

  1. order upright chest and abdomen x-rays
  2. obtain a CT scan of the abdomen and pelvis
  3. plan for upper GI endoscopy
  4. take patient to the OR for immediate exploratory laparotomy
  5. schedule the patient to be seen in surgery clinic in 1 week

Answer(s): A

Explanation:

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.






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