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Free STEP3 Exam Braindumps (page: 79)

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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. While you are in the process of working up the patient he becomes hypotensive and tachycardic. Bright red blood per rectum is now noted. The most likely explanation for his condition is which of the following?

  1. ruptured esophageal varices
  2. diverticulosis
  3. ruptured abdominal aortic aneurysm (AAA)
  4. ruptured splenic artery aneurysm
  5. erosion of the gastroduodenal artery

Answer(s): E

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.



You are a second-year surgery resident and have just left work after a 30-hour shift. On your way home you witness a recent collision where there is an obviously injured pedestrian. Several bystanders are providing care for the injured victim. You elect to keep driving. Awitness at the scene recognizes you as a physician and reports you to the authorities for neglecting to stop to provide care. As a consequence of your actions, which of the following will most likely happen?

  1. You will lose your medical license.
  2. You will be found guilty of negligence in a court of law.
  3. You will have your medical license suspended.
  4. You will have no legal action taken against you.
  5. You will be subject to a malpractice suit.

Answer(s): D

Explanation:

As a practicing physician, you are not required to stop at an accident and care for the injured, as you have not established a doctorpatient relationship. As such, there are no legal requirements for physicians to assist in the care of accident victims outside of their employment (i.e., hospital, ER, clinic). It is also important to realize that under the Good Samaritan law, individuals who provide aid to the injured or ill are protected from prosecution for unintentional injury or wrongful death. It is also important to be familiar with local laws. For example, in some states, this law only applies to people who are trained in basic first aid. (The state of Vermont requires any bystander to render aid until proper authorities arrive). In the situation presented above, you most probably would not be faulted for not assisting in the care of the injured person and there would be no grounds for legal action.



A 35-year-old 80-kg male was transported to the regional burn center at your hospital after suffering second- and third-degree burns from the eruption of a brush fire fueled with gasoline. He was intubated by EMS to secure his airway for transport. On arrival, he is found to have burns across his face, anterior neck, chest, and anterior abdomen, as well as bilateral circumferential upper extremity burns.

What do you estimate the total body surface area (TBSA) of his burns to be?

  1. 30%
  2. 35%
  3. 40%
  4. 50%
  5. 60%

Answer(s): C

Explanation:

Burn injuries can be very serious and very intimidating for the patient and physician alike. In an ER setting, the most efficient way to estimate the extent of the burn injury is to use the "rule of nines." In determining the percentage of the TBSA that is involved, it is important only to consider second- and third-degree burns in this calculation. In this system, the head and neck are 9%; each arm represents 9%; the anterior trunk, posterior trunk, and each lower extremity carry a value of 18%; the genitalia are estimated to be 1%. For the patient in this question, the burns cover his anterior face and neck (4.5%), anterior trunk (18%), and bilateral upper extremities (18%) for a TBSA of approximately 40%. Having identified the extent of the thermal damage, it is critical to initiate resuscitation immediately. The thermal injury itself causes the release of many inflammatory mediators that result in a profound capillary leak. As a result of this profound increase in capillary permeability, the patient's intravascular volume and thus overall perfusion can drop rapidly and dramatically. In order to compensate, burn patients will require aggressive fluid resuscitation. Furthermore, as in any trauma situation, the fluid used in the initial resuscitation should be isotonic such as Ringer's lactate. The Parkland formula (4 mL/kg/%TBSA) is a common equation used to estimate the fluid needs in the first 24 hours for thermal injuries. Typically, one-half of this total volume is given in the first 8 hours. In this particular case, an 80-kg man with 40% TBSA burns would require 12.8 L of fluid in the first 24 hours. So for the first 8 hours, you would plan to run isotonic fluid at 800 mL/h.



A 35-year-old 80-kg male was transported to the regional burn center at your hospital after suffering second- and third-degree burns from the eruption of a brush fire fueled with gasoline. He was intubated by EMS to secure his airway for transport. On arrival, he is found to have burns across his face, anterior neck, chest, and anterior abdomen, as well as bilateral circumferential upper extremity burns. Over the first 8 hours of his resuscitation, you estimate that he will require which of the following?

  1. 500 mL/h of isotonic fluid
  2. 600 mL/h of isotonic fluid
  3. 600 mL/h of hypertonic fluid
  4. 800 mL/h of isotonic fluid
  5. 800 mL/h of hypotonic fluid

Answer(s): D

Explanation:

Burn injuries can be very serious and very intimidating for the patient and physician alike. In an ER setting, the most efficient way to estimate the extent of the burn injury is to use the "rule of nines." In determining the percentage of the TBSA that is involved, it is important only to consider second- and third-degree burns in this calculation. In this system, the head and neck are 9%; each arm represents 9%; the anterior trunk, posterior trunk, and each lower extremity carry a value of 18%; the genitalia are estimated to be 1%. For the patient in this question, the burns cover his anterior face and neck (4.5%), anterior trunk (18%), and bilateral upper extremities (18%) for a TBSA of approximately 40%. Having identified the extent of the thermal damage, it is critical to initiate resuscitation immediately. The thermal injury itself causes the release of many inflammatory mediators that result in a profound capillary leak. As a result of this profound increase in capillary permeability, the patient's intravascular volume and thus overall perfusion can drop rapidly and dramatically. In order to compensate, burn patients will require aggressive fluid resuscitation. Furthermore, as in any trauma situation, the fluid used in the initial resuscitation should be isotonic such as Ringer's lactate. The Parkland formula (4 mL/kg/%TBSA) is a common equation used to estimate the fluid needs in the first 24 hours for thermal injuries. Typically, one-half of this total volume is given in the first 8 hours. In this particular case, an 80-kg man with 40% TBSA burns would require 12.8 L of fluid in the first 24 hours. So for the first 8 hours, you would plan to run isotonic fluid at 800 mL/h.






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