A 12-year-old boy with lower abdominal pain and nausea for 3 hours duration was brought to the emergency department by his mother. On examination, the child was found to have a swollen and tender scrotum. There were no signs of external injury and the child was otherwise healthy.
The correct course of action for this patient would be:
Correct Answer D: The correct course of action would be to treat the patient with analgesics and antiemetic and to request an urgent urological consult (choice D). Testicular torsion should be considered in any child presenting with acute onset pain and swelling of the scrotum. If the onset is less than 6 hours, emergency manual detorsion can be attempted. If successful, bilateral orchiopexy should be performed later. If the onset is more than 6 hours or manual detorsion is unsuccessful, surgical detorsion and orchiopexy is needed.
→ Delay in surgical exploration, generally over 8 hours (choices A, B, and C), may result irreversible ischemic injury to the testis necessitating orchiectomy.
→ Although Doppler sonography (choice E) can be useful to differentiate between testicular torsion and acute epididymitis, imaging studies should not delay urological opinion or surgical exploration.
Key point: Testicular torsion must be considered in any male presenting with "acute scrotum." If the torsion of the testis can be corrected, by manual detorsion or surgery, within 6 hours from onset, the testis could be salvaged.
A 48-year-old farmer presents to your office with skin ulcer on the side of his nose. He said that this ulcer started as a nodule and then ulcerated one year ago. His dermatologist prescribed topical creams but there was no response. On examination, the ulcer was deep, rounded with rolled beaded edges, and indurated base. Cervical lymph nodes were not enlarged.
What is the treatment of choice for this patient?
Correct Answer D: This patient presents with Basal Cell Carcinoma (BCC). The unresponsiveness to topical creams supports this diagnosis. The site of ulcer on the side of the nose is the commonest site for BCC. Being a farmer who is exposed to sun rays all day is a risk factor for BCC. A typical BCC has a rolled out edge, often beaded and the floor shows scabbing at some places and breaking at others. The treatment of choice for this patient is Mohs micrographic surgery (choice D). The goal of this surgery is to remove the cancerous cells completely with the least possible cosmetic damage.
This technique can save the greatest amount of healthy tissue and has the highest cure rate, 99 percent or better. It is often used for tumors in cosmetically important areas around the eyes, nose, lips, and ear. Using local anesthesia, the surgeon removes the cancer layer by layer, examining each one microscopically until the margin around the cancer is free of cancer cells.
The clinical quotes for cure rate of Mohs surgery is from 97% to 99.8% after 5 years for newly diagnosed BCC, decreasing to 94% or less for recurrent basal cell cancer. Radiation oncologists quote cure rate from 90 to 95% for BCCs less than 1 or 2 cm, and 85 to 90% for BCCs larger than 1 or 2 cm. Surgical excision cure rate varies from 99% for wide margin (4 to 6 mm) and small tumor, to as low as 70% for narrow margins applied to large tumors.
→ Radiotherapy (choice A) is also used in treatment of (BCC), but radiation may be used for tumors that are hard to manage surgically and for elderly patients or others who are in poor health. Cure rates are around 90 percent, but the technique can involve long-term cosmetic problems and radiation risks.
→ Cryosurgery (choice B) can be used in treatment of BCC, but it is the treatment of choice for patients with bleeding disorders or an intolerance to anesthesia. This method is used less commonly today, and has a lower cure rate than the surgical techniques, approximately 85-90 percent depending on the physician’s expertise.
→ The effectiveness of the excisional surgery (choice C) does not match that of Mohs and produces cure rates around 90 percent.
→ Topical 5-fluorouracil (5-FU) (choice E) has been FDA-approved for superficial BCCs.
Key point: Choice of treatment for BCC is based on type, size, location, depth of penetration of the tumor, patient’s age, general health, and the expected outcome to his or her appearance. Mohs surgery allows for the removal of a skin cancer with very narrow surgical margin and a high cure rate. The cure rate with Mohs surgery cited by most studies is between 97% and 99.8% for primary basal cell carcinoma, the most common type of skin cancer.
A 27-year-old male is brought to the emergency department after a car accident. He had a head on collision with another car and hit his chest on the steering wheel. On physical examination the patient’s vital signs are temperature 37.4°C, blood pressure 105/65 mmHg, pulse is 110 bpm, and respirations are 35/min. On observation of the patient’s chest wall, the chest moves inward on inspiration and outward on expiration. Auscultation reveals decreased breath sounds on the left side.
What is the most likely diagnosis?
Correct Answer E: This patient’s chest wall motion on spontaneous breathing is known as paradoxical chest wall motion and is characteristic of flail chest (choice E). This occurs when 3 or more ribs are broken compromising the structural stability of the chest wall. Paradoxical chest wall motion is unlikely to be noted if less than 3 ribs are involved. The best initial study to confirm 3 broken ribs is chest X-ray. Respiratory insufficiency in these patients may be minimal or severe and tachypnea is often present. The degree of respiratory insufficiency is typically related to the underlying lung injury (pulmonary contusion), rather than the chest wall abnormality.
→ Cardiac tamponade (choice A) is incorrect. Consider cardiac tamponade in a patient with Beck’s triad of hypotension, jugular venous distension, and distant, muffled heart sounds. Other clues are pulsus paradoxus, which is a drop of 10 mmHg systemic blood pressure on inspiration and electrical alternans on ECG.
→ Diaphragmatic rupture (choice B) occurs in about 5% of chest wall trauma and majority of diaphragmatic rupture cases are related to motor vehicle crashes. The left side is more likely to rupture and is involved in 75% of cases. Common symptoms are chest pain, abdominal pain, and dyspnea. Physical examination has limited diagnostic value but it may reveal decreased breath sounds, auscultation of bowel sounds in the chest, and dullness to percussion of the chest.
→ Tension pneumothorax (choice C) is characterized by decreased breath sounds on auscultation of the affected side of the chest and contralateral deviation of the trachea.
→ Tracheal rupture (choice D) presents with hemoptysis, dyspnea, dysphonia, and subcutaneous emphysema (air bubbles that can be palpated underneath the skin of the chest).
Key point: Flail chest results from chest injury with 3 broken ribs or more. It is characterized by paradoxical chest wall motion.
A 25-year-old male is brought to the emergency department after he was thrown off his motorcycle following a collision with an automobile. He was stabilized by paramedics, who brought him to the ED. While he denies any loss of consciousness, he describes a sensation of wanting to urinate but being physically unable to. On physical examination, his abdomen is diffusely tender to palpation. There is blood at the meatus of the penis. After fluid resuscitation, a radiograph of the pelvis is taken and demonstrates a fracture of the pubic symphysis.
What is the most appropriate next step in the investigation of this patient’s genitourinary tract’s injury?
Correct Answer B: This patient’s history of traumatic injury to the pelvis, his inability to urinate, and the findings of blood at the urethral meatus are suggestive of urethral injury. In males, the urethra is divided into the anterior and posterior sections by the urogenital diaphragm. Most pelvic fractures resulting from road traffic accidents are associated with injuries to the posterior urethra.
Similar to any other trauma case, initial management should start with stabilizing the patient by giving fluid resuscitation to those with blood loss and hypotension. Presence of blood at meatus precludes any attempt at urethral instrumentation, until the entire urethra is adequately imaged. Retrograde urethrography (choice B) is considered the gold standard imaging for evaluating urethral injury and is the best next step in the management of this patient.
→ Ultrasonography (choice A) is not a routine investigation in the initial assessment of urethral injuries but can be very useful in determining the position of the pelvic hematomas and the high-riding bladder when a suprapubic catheter is indicated.
→ Abdominal and pelvic CT scan (choice C) is useful in defining the distorted pelvic anatomy after severe injury and assessing associated injuries of penile crura, bladder, kidney, and intraabdominal organs. However, it is not part of initial assessment of urethral injury and would not be the best next step in the evaluation of this patient.
→ Urethral catheterization (choice D) is contraindicated in pelvic injuries with blood at the urethral meatus as it could convert a partial tear into a complete one. Retrograde urethrography should be done first.
→ Voiding cystourethrography (choice E) is done after about 4 weeks when a delayed repair is being considered. This allows urethral healing and is preceded by suprapubic cystostomy as it is performed through the suprapubic catheter. Therefore, voiding cystourethrography would not be the next step in the management of this patient as the suprapubic catheter would have to be in place few weeks earlier first.
Key point: Traumatic injury to the pelvis, inability to urinate, and blood at the penis meatus are suggestive of urethral injury. Retrograde urethrography is considered the gold standard imaging for evaluating urethral injury.
A 62-year-old diabetic with stage 2 renal dysfunction is evaluated for knee pain that has mildly interfered with his usual activities over the past 3 months. On examination he is mildly tender over the medial joint line. A knee radiograph shows moderate medial joint space narrowing. In addition to low-impact exercise, which one of the following would you recommend initially?
Correct Answer E: In most patients with noninflammatory osteoarthritis (OA) initiating drug treatment with a non-opioid analgesic such as acetaminophen (paracetamol, APAP) (choice E) is recommended. APAP is preferred in this setting because of the greater safety of this approach, compared with the use of nonsteroidal antiinflammatory drugs (NSAIDs), most of which are associated with increased cardiovascular, gastrointestinal, and other risks.
→ In patients with an inadequate response to APAP, with inflammatory OA, or with severe pain (eg, consistently with use or at rest) the use of an orally administered non-selective NSAID or a COX-2 selective NSAID is recommended, because of the greater efficacy of NSAIDs compared with APAP for relief of pain from OA and their antiinflammatory properties, which APAP lacks. Renal dysfunction is a contraindication to the use of NSAIDs.
→ Intra-articular injections should not be considered first-line treatment for symptomatic OA of the knee. They are recommended for short-term pain control, with the evidence for hyaluronic acid being somewhat weak.
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