Five weeks after the removal of a cast from a 56 year old woman's leg, she finds out that she is unable to dorsiflex her foot.
Which one of the following nerve is most likely injured?
Correct Answer E: The peroneal nerve is a branching of the sciatic nerve, which supplies movement and sensation to the lower leg, foot and toes. Trauma to the nerve can result in a condition called foot drop, where dorsiflexion of the foot is compromised and the foot drags during walking, and sensory loss to the dorsal surface of the foot and portions of the anterior, lower lateral leg.
A 35 year old intoxicated man presents to the Emergency Department with a deep laceration to his right distal forearm after putting his hand through a window. On examination, he has no sensation to his little finger and the ulnar aspect of his ring finger. Power on abduction and adduction of all fingers is markedly decreased. He is unable to flex the distal joint of his little finger. When he flexes his wrist, his hand deviates radially. The examination was otherwise normal.
What structure(s) have been damaged?
Correct Answer A:
In the above diagram, the numbers correspond to the following:
A 24-year-old male arrives at your office complaining of pain in his rectum. Examination reveals a perianal abscess.
All of the following signs are characteristic, except:
Correct Answer D: An anorectal abscess is a localized collection of pus in the perirectal spaces. Abscesses usually originate in an anal crypt. These abscesses can be very painful; perianal swelling, redness, and tenderness are characteristic. Deeper abscesses may be less painful but cause toxic symptoms (eg, fever, chills, malaise).
There may be no perianal findings, but digital rectal examination may reveal a tender, fluctuant swelling of the rectal wall. High pelvirectal abscesses may cause lower abdominal pain and fever without rectal symptoms. Sometimes fever is the only symptom.
Diagnosis is primarily by examination and CT scan or pelvic MRI for deeper abscesses. Treatment is surgical drainage.
An enlarged axillary lymph node is removed from a 61 year old female. Microscopically the nodal architecture is effaced by anaplastic gland-forming cells. Special studies on the tissue confirm the presence of estrogen and progesterone receptor proteins.
Which one of the following is the most likely diagnosis?
Correct Answer B: Metastatic cancer invades locally and spreads initially through the regional lymph nodes, bloodstream, or both. In women metastatic breast cancer may affect almost any organ in the body most commonly, lungs, liver, bone, brain, and skin. Most skin metastases occur in the region of the breast surgery; scalp metastases also are common. Metastatic breast cancer frequently appears years or decades after initial diagnosis and treatment.
Estrogen and progesterone receptors, present in some breast cancers, are nuclear hormone receptors that promote DNA replication and cell division when they are bound to the appropriate hormones. Thus, drugs that block these receptors may be useful in treating tumors with the receptors. About 2⁄3 of postmenopausal patients have an estrogen-receptor positive (ER+) tumor. Incidence of ER+ tumors is lower among premenopausal patients.
Matted or fixed axillary lymph nodes suggest tumor spread, as does supraclavicular or infraclavicular lymphadenopathy. Inflammatory breast cancer is characterized by diffuse inflammation and enlargement of the breast, often without a lump, and has a particularly aggressive course.
A previously well 54 year old woman with a three-month history of weight loss and recurring chest infections is found to have a left hilar mass on chest x-ray. Bronchoscopy and biopsy reveal small cell carcinoma. All staging investigations are normal, suggesting disease is confined to the lung.
Which one of the following treatment strategies is most appropriate?
Correct Answer E: Lung carcinoma is a malignant lung tumor usually categorized as small cell lung cancer (SCLC) or non-small cell lung cancer (NSCLC). Cigarette smoking is the major risk factor for most types. Symptoms include cough, chest discomfort, and, less commonly, hemoptysis, but many patients are asymptomatic and some present with metastatic disease. Diagnosis is suspected by chest x-ray or CT scan and confirmed by biopsy.
SCLC of any stage is typically initially responsive to treatment, but responses are usually short-lived. Surgery generally plays no role in treatment of SCLC, although it may be curative in the rare patient who has a small focal tumor without spread (such as a solitary pulmonary nodule).
In limited-stage disease, a combination of chemotherapy drugs in 4 to 6 cycles is thought to be most effective. Radiation further improves response; the very definition of limited-stage disease as disease confined to a hemithorax is based on the significant improvement in survival observed with radiation.
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