In elderly patients with asymptomatic gallstones, which one of the following is an indication for elective cholecystectomy because of the increased risk of gallbladder carcinoma?
Correct Answer D: Carcinoma of the gallbladder is a rare condition, and prophylactic cholecystectomy to prevent its occurrence is therefore usually not justified. The exception is when chronic calculous cholecystitis is present. This condition is associated with a 20% incidence of gallbladder carcinoma.
When presenting with appendicitis, patients over the age of 65 are more likely than younger patients to have which one of the following?
Correct Answer D: Older patients with appendicitis are more likely to present without classic signs and symptoms. Elevated WBC counts, rebound tenderness, guarding, and fever as less reliably seen. As a result of delays in diagnosis, perforation is found in over 65% of elderly patients at the time of diagnosis.
Which one of the following statements is most accurate regarding the presentation of acute appendicitis in the elderly?
Correct Answer B: Self-treatment and delayed presentation of acute appendicitis is common in the elderly, leading to higher perforation and complication rates. Anorexia, an expected finding in younger patients, may not be present, while nausea and vomiting are reported in roughly half of elderly patients. The description of the pain may be vague and the pain poorly localized.
A 15-year-old black male presents to the emergency department with a chief complaint of fever, abdominal pain, nausea, and anorexia. In addition to the usual laboratory evaluation, which one of the following imaging modalities would be most accurate in confirming a diagnosis of appendicitis?
Correct Answer D: A retrospective review of 650 patients with suspected appendicitis showed a sensitivity of 97% and a specificity of 98% for spiral CT. In patients in whom the clinical diagnosis was uncertain, sensitivity was 92% and specificity was 85%. Two prospective studies comparing ultrasonography with spiral CT have favoured spiral CT (choice D). CT scans have been shown to have an accuracy of 97% in diagnosing appendicitis.
→ Abdominal radiography (choice A) has low specificity and sensitivity for the diagnosis of acute appendicitis.
→ Air contrast barium enema (choice B) also has low accuracy.
→ Ultrasonography (choice C) is used in women who are pregnant and women in whom there is a high degree of suspicion of gynecologic disease.
→ Limitations of MRI (choice E) include increased cost, decreased availability, and increased examination time compared to CT.
A 37-year-old white female who has had silicone breast implants for 17 years is concerned about the risk of developing joint problems from the implants. You discuss studies concerning risks of connective tissue disease in women who have silicone breast implants and:
Correct Answer D: Despite widespread publicity and legal wrangling, a large meta-analysis of women who have had silicone breast implants has produced no evidence of any significant increase in the risk for connective tissue disease in women who have these implants.
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