Pallidotomy is a surgical therapy for:
Correct Answer B: Thalamotomy and pallidotomy, contralateral to the side of the body that is most affected, are most effective for the treatment of disabling unilateral tremor and dyskinesia from Parkinson’s disease.
A 26-year-old married nulliparous female consults you after her 44-year-old sister was diagnosed with ovarian cancer. Her mother died in an automobile accident at the age of 59. Her aunt was diagnosed with breast cancer at age 50. The patient is BRCA1 positive. She asks your advice on childbearing and oophorectomy.
Which one of the following would be appropriate advice?
Correct Answer B: Women with BRCA1 or BRCA2 mutations are at increased risk for breast and ovarian cancer. Prophylactic oophorectomy is often advised to reduce the risk of ovarian cancer. A recent study has shown that oophorectomy reduces the risk of both ovarian cancer and breast cancer in women with these mutations. The mean age at diagnosis of ovarian cancer in this study was over 50 years, indicating that oophorectomy can usually be delayed until childbearing is complete. Surveillance has not been shown to reduce the proportion of ovarian cancer diagnosed in late stages or to have any effect on mortality. Epidemiologic studies have consistently shown that prolonged use of OCs reduces the risk of developing ovarian cancer.
A 21-year-old white female presents to the emergency department with a history consistent with a lateral ankle sprain that occurred 2 hours ago while she was playing softball. She complains of pain over the distal anterior talofibular ligament, but is able to bear weight. There is mild swelling, mild black and blue discoloration, and moderate tenderness to palpation over the insertion of the anterior talofibular ligament, but the malleoli are nontender to palpation.
Which one of the following statements is true regarding the management of this case?
Correct Answer D: This patient has an uncomplicated lateral ankle sprain and requires minimal intervention. The Ottawa ankle rules were developed to determine when radiographs are needed for ankle sprains. In summary, ankle radiographs should be done if the patient has pain at the medial or lateral malleolus and either bone tenderness at the back edge or tip of the lateral or medial malleolus, or an inability to bear weight immediately after the injury or in the emergency department, or both. If the patient complains of midfoot pain and/or bone tenderness at the base of the fifth metatarsal or navicular, or an inability to bear weight, radiographs should be ordered.
Sprains can be differentiated from major partial or complete ligamentous tears by anteroposterior, lateral, and 30° internal oblique (mortise view) radiographs. If the joint cleft between either malleolus and the talus is > 4 mm, a major ligamentous tear is probable. Stress radiographs in forced inversion are sometimes helpful to demonstrate stability, but ankle instability can be present with a normal stress radiograph.
Grade I and II ankle sprains are best treated with RICE (rest, ice, compression, elevation) and an air splint for ambulation. NSAIDs are used for control of pain and inflammation. Heat should be applied. Early range-of-motion exercises should be initiated to maintain flexibility. Weight bearing is appropriate as tolerated and functional rehabilitation should be started when pain permits. Exercises on a balance board will help develop coordination.
An 18-year-old female basketball player comes to your office the day after sustaining an inversion injury to her ankle. She says she treated the injury overnight with rest, ice, compression, and elevation. You examine her and diagnose a moderate to severe lateral ankle sprain.
In addition to rehabilitative exercises, you advise:
Correct Answer C: In acute ankle sprains, functional treatment with a semi-rigid brace (Aircast) or a soft lace-up brace is recommended over immobilization. Casting or posterior splinting is no longer recommended. Elastic bandaging does not offer the same lateral and medial support. External ankle support has been shown to improve proprioception.
A 75 year old male presents with dyspnea on exertion which has worsened over the last several months. He denies chest pain and syncope, and was fairly active until the shortness of breath slowed him down recently. You hear a grade 3/6 systolic ejection murmur at the right upper sternal border which radiates into the neck. Echocardiography reveals aortic stenosis with a mean transvalvular gradient of 55 mm Hg and a calculated valve area of 0.6 cm2. Left ventricular function is normal.
Which one of the following is appropriate management for this patient?
Correct Answer A: Since this patient’s mean aortic-valve gradient exceeds 50 mm Hg and the aortic-valve area is not larger than 1 cm2 , it is likely that his symptoms are due to aortic stenosis. As patients with symptomatic aortic stenosis have a dismal prognosis without treatment, prompt correction of his mechanical obstruction with aortic valve replacement is indicated. Medical management is not effective, and balloon valvotomy only temporarily relieves the symptoms and does not prolong survival. Patients who present with dyspnea have only a 50% chance of being alive in 2 years unless the valve is promptly replaced. Exercise testing is unwarranted and dangerous in patients with symptomatic aortic stenosis.
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