Preguntas y

Respuestas 3
CIRUGA GENERAL

 Paciente originario de Chiapas, con dificultad para la

deglucin. Los estudios de imagen muestran dilatacin
esofgica importante. Cual de los siguientes rganos
podra estar tambin afectado?
A. Vejiga
B. Cerebro
C. Corazn
D. Pulmones
E. ID

 Respuesta correcta C
La enfermedad de Chagas es originada por un parasito
protozoario intracelular (Tripanosoma cruzi). Causa de
megaesfago, megacolon e insuficiencia cardiaca por
cardiopata dilatada.

 A 55-year-old woman complains to her physician that

the skin of her armpits and groin "keeps getting darker
and darker." Physical examination demonstrates
velvety brown and warty skin in the axilla and groin.
Biopsy of these lesions shows a variably hyperplastic
epidermis with many sharp peaks and valleys. Aside
from cosmetic considerations, which of the following is
the primary medical significance of these lesions?

A. They may be a sign of immunosuppression

B. They may be a sign of visceral carcinoma
C. They may be easily superinfected
D. They may be malignant
E. They may be premalignant

 The correct answer is B. The lesions are acanthosis

nigricans, which looks somewhat like a mole or wart,
but is actually due to epidermal hyperplasia. Acanthosis
nigricans can be seen in obesity, diabetes, and in
patients with underlying cancers, often
adenocarcinomas of the chest or abdomen.

 A 2-year-old child is seen for a welI-child visit in a pediatric

clinic. Abdominal examination demonstrates a palpable, nontender mass on the Ieft side of the abdomen. The mother had
no idea the mass was present and the pediatrician did not
note the presence of the mass at the child's 18-month welIchild visit. Physical examination is otherwise unremarkable.
Question CT examination demonstrates an 8-cm diameter,
roughly round, mass involving the lower pole of the kidney.
Which of the following is the most likely cause of this mass?
A. Ewing sarcoma
B. Neuroblastoma
C. Renal cell carcinoma
D. Transitional cell carcinoma
E. Wilms tumor

 The correct answer is E.

Wilms tumor is an embryonal malignancy of the
kidney that most commonly affects children from birth
to age 4, but can affect children up to about age 15.
This tumor is the second most common extracranial
solid tumor in children and tends to form large, round,
solitary masses of the kidney, although bilaterality and
multicentricity may also occur. Wilms tumors usually
present with a palpable abdominal mass, with less
common presentations including abdominal pain,
hematuria (indicating invasion of the collecting system),

 A 67-year-old man with an 18-year history of type 2 DM presents

for a routine physical examination. His temperature is 36.9 C,
his blood pressure is 158/98 mm Hg and his pulse is 82/minute
and regular. On examination, the physician notes a nontender,
pulsatile, mass in the mid-abdomen. A plain abdominal x-ray
film with the patient in the lateral position reveals spotty
calcification of a markedly dilated abdominal aortic walI.
Question Which of the following is most likely pathogenetically
related to this patient's aortic disease?
A. Atherosclerosis
B. Cystic medial necrosis
C. Kawasaki disease
D. Mnckeberg arteriosclerosis
E. Syphilis

 The correct answer is A.

This patient has an abdominal aortic aneurysm (AAA);
these
are
most
commonly
the
result
of
atherosclerosis. Hypertension and cigarette smoking
are also risk factors. AAA may be asymptomatic, or may
be associated with pain. Some aortic aneurysms are
palpable as pulsating masses in the abdomen. Abdominal
aortic aneurysms typically begin below the renal arteries
and may extend well into the iliac system bilaterally.
Calcified atherosclerotic plaques on plain films of the
abdomen can be seen in the majority of cases.

 A 67-year-old man with an 18-year history of type 2 DM presents for a

routine physical examination. His temperature is 36.9 C, his blood pressure
is 158/98 mm Hg and his pulse is 82/minute and regular. On examination,
the physician notes a nontender, pulsatile, mass in the mid-abdomen. A
plain abdominal x-ray film with the patient in the lateral position reveals
spotty calcification of a markedly dilated abdominal aortic walI.
Question The patient is taken to surgery and the abdominal aorta and
proximal common iliac arteries are replaced with a graft. Which of the
following aneurysm diameters is usually considered the threshold above
which elective surgery is recommended, unless contraindicated by other
disease?
A. 1 cm
B. 2 cm
C. 6 cm
D. 10 cm
E. 15 cm

 The correct answer is C.

This recommendation is made because larger
aneurysms have a much greater chance of rupture, and
emergency repair carries a high mortality rate. For
aneurysms larger than 5 cm, the risk of rupture is
5-10% per year

 A 3-year-old girl is seen in the emergency department with acute

abdominal pain. She has a 5-day history of vomiting and abdominal
distension. She has not passed stool during this time, and during the
past day, has been vomiting bilious materiaI. On physical examination,
she is lethargic, with a firm and tender abdomen, and peritoneal signs
are present. She is immediately referred for laparotomy for suspected
diagnoses of intussusception vs. volvulus. At surgery, approximately 20
cm of small intestine is found to be markedly distended, and is resected.
The section contains a tightly knotted ball of nematodes that are about
15 to 35 cm in length. The worms have tapered ends without hooks.
Question The worms are most likely which of the following?
A. Ancylostoma duodenale
B. Ascaris lumbricoides
C. Enterobius vermicularis
D. Strongyloides stercolaris
E. Trichuris trichiura

 The correct answer is B.

Ascaris lumbricoides is the only parasitic worm that is
likely to cause intestinal obstruction, and then only if
the worm burden is high. The description given of the
worms in the case presentation is typical. All of the
other worms listed in the choices are also nematodes or
roundworms.

 A 47-year-old woman presents to the emergency department with

cramping/colicky abdominal pain. The current episode of pain began several
hours ago, following a fatty meaI. The pain began slowly, and rose in intensity to
a plateau over the course of several hours. The patient reports that she had had
several other episodes of similar pain during the past several months, with long
intervening periods of freedom from pain. On physical examination, she is noted
to have tenderness to deep palpation in the right upper quadrant of the
abdomen near the rib cage. The patient also reports that she is experiencing
shoulder/back pain at a site she identifies near the right lower scapula, but no
tenderness can be elicited during the back and shoulder examination.
Question If this patient had refused surgical treatment, which of the following
would be the most appropriate pharmacotherapy to provide definitive treatment
and thereby relieve associated pain?
A. Ampicillin
B. CIofibrate
C. Meperidine
D. Oxycodone
E. Ursodiol

 The correct answer is E.

The question is asking, "Which of the following will
eradicate a gallstone?" When a gallstone is eliminated
the pain will subsequently be eliminated. This question
is NOT asking, "which of the following is the most
appropriate form of pain control?". Ursodiol
(ursodeoxycholic acid) is a hydrophilic bile acid that
is used to dissolve small (< 20 mm), non-calcified,
radiolucent cholesterol gallstones in patients with
functioning gallbladders who cannot undergo (or refuse)
cholecystectomy.

 A 64-year-old man with a history of coronary artery disease comes to

the emergency department with the acute onset of severe, constant,
Iower abdominal pain and rectal bleeding. He reports that he previously
has had several episodes of similar, but less severe pain. About 12 hours
after the onset of pain, the patient began passing copious bright red
blood per rectum. He denies nausea, vomiting, sick contacts, or foreign
traveI. Initial physical examination reveals a distressed man, who is
afebrile, but tachypneic, with scant diffuse abdominal tenderness to
palpation. Rectal examination is positive for blood. Laboratory studies
reveal a metabolic acidosis with an elevated serum Iactate.
Question Which of the following is the most likely diagnosis?
A. Colon carcinoma
B. Infectious colitis
C. Inflammatory bowel disease
D. Ischemic colitis
E. Necrotizing enterocolitis

 The correct answer is D.

A patient with severe abdominal pain and rectal
bleeding
with
an
unremarkable
physical
examination is likely suffering from ischemic colitis.
"Pain out-of-proportion to examination" is a classic finding
for ischemic colitis. The previous episodes of less severe
pain represent ischemic angina. An infarction has occurred,
as indicated by the rise in serum lactate secondary to the
colon's anaerobic metabolism. The history of coronary
artery disease also suggests this diagnosis, as the
atherosclerotic processes that contribute to his CAD are
also likely present in his abdominal vasculature.

 A 27-year-old woman goes to an emergency room with severe abdominal

pain. She had previously experienced similar episodes of pain that Iasted
several hours to a few days, but this episode is the most severe. She has
also been experiencing nausea, vomiting, and constipation. The
physician is left with the impression that she is agitated and somewhat
confused, and an accurate history is difficult to elucidate. The patient is
sent for emergency laparotomy, but no pathology is noted at surgery.
Following the unrevealing surgery, an older surgeon comments that he
had once seen a similar case that was actually due to porphyria.
Question The porphyrias are biochemical abnormalities in which of the
following pathways?
A. GIycogen degradation
B. Heme synthesis
C. Lipoprotein degradation
D. Nucleotide degradation
E. Urea cycle

 The correct answer is B. The porphyrias are a group

of rare, related diseases that have in common a block
in the heme synthesis pathway. The block is usually
partial rather than complete, and thus many of these
patients have only intermittent symptoms. Most cases
of porphyria present with either a neurovisceral pattern
(including both psychiatric symptoms and abdominal
pain) or with photosensitive skin lesions. These two
patterns are associated with different forms of
porphyria.

 A 27-year-old woman goes to an emergency room with severe abdominal

pain. She had previously experienced similar episodes of pain that Iasted
several hours to a few days, but this episode is the most severe. She has
also been experiencing nausea, vomiting, and constipation. The physician
is left with the impression that she is agitated and somewhat confused,
and an accurate history is difficult to elucidate. The patient is sent for
emergency laparotomy, but no pathology is noted at surgery. Following the
unrevealing surgery, an older surgeon comments that he had once seen a
similar case that was actually due to porphyria.
Question Following the surgery, the decision is made to screen for the
porphyrias that cause acute neurovisceral symptoms. Which of the
following tests would be most likely to be used?
A. Erythrocyte porphyrins
B. Total fecal porphyrins
C. Total plasma porphyrins
D. Total urinary porphyrins
E. Urinary porphobilinogen

 The correct answer is E. The acute neurovisceral

porphyrias are those that tend to present with severe
abdominal pain, often accompanied by neuropsychiatric
symptoms. The best tests to use for screening of these
diseases are urinary porphobilinogen (PBG, either
random or 24 hour) and urinary delta-aminolevulinic
acid (ALA, either random or 24 hour).