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Free STEP3 Exam Braindumps (page: 82)

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PDF with 804 Questions

You are asked to see a 64-year-old man with left lower quadrant abdominal pain that was admitted to the medicine service after a CT scan demonstrated diverticulitis of the sigmoid colon. There was no evidence for gross perforation and no abscess was identified. He had been admitted 6 months ago for the same problem and had an uneventful recovery.
Which treatment do you recommend?

  1. antibiotics only
  2. antibiotics and sigmoidectomy prior to discharge
  3. emergent sigmoidectomy
  4. antibiotics and sigmoidectomy 12 weeks after discharge
  5. antibiotics, interval colonoscopy, and subsequent sigmoidectomy

Answer(s): E

Explanation:

Diverticulitis is categorized based on its complications. Uncomplicated diverticulitis is defined as inflammation of colonic diverticuli that does not involve free intraperitoneal perforation, abscess formation, fistula formation, or colonic obstruction. This entity can be managed as an outpatient but may require inpatient admission if the pain is severe. The treatment of choice is broad-spectrum antibiotics. The majority of patients will respond well to this intervention. However, as the incidence of recurrence increases the rate of complications also rises. Therefore, it is recommended that surgical resection be performed after the second episode of diverticulitis. Prior to the operative intervention, it is important to rule out the presence of cancer. A colonoscopy should be performed after resolution of the inflammation and prior to surgical resection. It is much more sensitive than a barium enema. The operation is typically delayed until 46 weeks following discharge from the hospital. This provides adequate time for resolution of the inflammation and enables an adequate workup, which includes a colonoscopy.



Which of the following is the most appropriate treatment for a 32-year-old male with a toxic nodular goiter and compressive airway symptoms?

  1. radioactive iodine therapy
  2. propranolol
  3. propylthiouracil
  4. Lugol's solution
  5. total lobectomy

Answer(s): E

Explanation:

Toxic nodular goiter, also known as Plummer's disease, is a consequence of one or more thyroid nodules secreting inappropriately high levels of thyroid hormone independently of thyroid-stimulating hormone (TSH) control. Hyperthyroidism in patients with toxic nodular goiter is milder than in those with Graves' disease, and the condition is not accompanied by extrathyroidal manifestations such as ophthalmopathy, pretibial myxedema, vitiligo, or thyroid acropathy. Patients with toxic multinodular goiter are older at presentation than those with Graves' disease. The thyroid gland characteristically has one or more nodules on palpation. Local symptoms of compression, such as dysphagia and dyspnea, may occur. The diagnosis is suggested by a thorough history and physical examination and confirmed by documenting suppressed serum TSH level and raised serum thyroid hormone level.



Several days following an uneventful laparoscopic cholecystectomy, the pathology report reveals gallbladder cancer that is invasive into the submucosa of the specimen. The most appropriate management is which of the following?

  1. observation and close follow-up
  2. chemotherapy with a 5-fluorouracil (5-FU)-based regimen
  3. laparotomy with 23 cm wedge resection of the gallbladder liver bed
  4. laparotomy with 23 cm wedge resection of the gallbladder liver bed and regional lymphadenectomy including the portal and hepatic nodal basins
  5. radiation to the gallbladder liver bed

Answer(s): A

Explanation:

Carcinoma of the gallbladder accounts for 24% of GI malignancies. Fewer than 1% of patients undergoing biliary tract operations have carcinoma either as an anticipated diagnosis or as an incidental finding. The calcified "porcelain" gallbladder is associated with a 20% incidence of gallbladder carcinoma. Signs and symptoms of carcinoma of the gallbladder are generally indistinguishable from those associated with cholecystitis and cholelithiasis. They include abdominal discomfort, right upper quadrant pain, nausea, and vomiting. Most long-term survivors are patients who underwent cholecystectomy for cholelithiasis and in whom the malignancy was an incidental finding on the pathology report. The management of these patients is based on the depth of tumor penetration into the wall of the gallbladder



A19-year-old college student is found to have an elevated serum calcium on routine physical examination. She has a family history of hypercalcemia that has not resulted in any known symptoms. Further workup reveals a slightly elevated serum parathyroid hormone with depressed levels of serum phosphate. A 24- hour urine calcium excretion is obtained and is low. Which of the following is the correct diagnosis?

  1. familial hypocalciuric hypercalcemia (FHH)
  2. primary hyperparathyroidism
  3. secondary hyperparathyroidism
  4. tertiary hyperparathyroidism
  5. metastatic bone cancer

Answer(s): A

Explanation:

FHH, or familial benign hypercalcemia, is a rare condition characterized by asymptomatic or mildly symptomatic hypercalcemia. It is inherited as an autosomal dominant trait and the parathyroid glands are usually normal in size. The basis for the development of FHH appears to be mutations in the calcium- sensing receptor gene which regulates the parathyroid gland set point and modulates the extracellular calcium concentration. The condition may be mistaken for primary hyperparathyroidism because, in both conditions, the serum calcium and parathyroid hormone levels are elevated with a concomitant low serum phosphate. The distinction
is made by obtaining a 24-hour urine calcium excretion level. In patients with FHH, the urine calcium level is low, whereas in primary hyperparathyroidism the level is high. The distinction is important, as patients with primary hyperparathyroidism benefit from surgery and those with FHH do not.






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