You are considering recommending surgical treatments for obesity in selected patients. All other attempts to control weight have failed in these patients, including diet education, medication, exercise, and behavior modification. Each of these individuals is a well-informed and motivated patient with acceptable operative risks and is able to participate in treatment and long-term follow-up. They strongly desire substantial weight loss because their obesity impairs the quality of their lives, and they have asked about surgical options.
Which one of these patients would meet the criteria for surgical treatment of obesity?
Correct Answer C: The National Institute of Health Consensus Development Panel recommended that surgical treatment of severe obesity be considered for any patient with a BMI > 40 or those with a BMI > 35 who have serious coexisting medical problems. Examples of such coexisting medical problems include severe sleep apnea, Pickwickian syndrome, obesity-related cardiomyopathy, and severe diabetes mellitus.
→ A 44-year-old with a BMI of 34 and degenerative joint disease of the knees that significantly limits his ability to walk (choice A) - This patient's BMI is under 35, which does not meet the criteria for surgical treatment of obesity.
→ A 45-year-old with a BMI of 36 and controlled diabetes mellitus (choice B) - This patient's BMI is over 35 and she has DM, but it's well controlled.
→ A 52-year-old with a BMI of 29 and sleep apnea (choice D) - This patient's BMI is under 35, which does not meet the criteria for surgical treatment of obesity.
→ A 55-year-old with a BMI of 29 and uncontrolled diabetes mellitus (choice E) - This patient suffers from a chronic condition but her BMI is not high enough and fails to meet the criteria for surgical treatment of obesity.
A 31-year-old white female presents with her third stress fracture of a lower extremity in the past 4 years. Her history and examination are otherwise unremarkable except for a controlled seizure disorder.
The most likely cause of her bone problem is:
Correct Answer D: Premature osteoporosis is often idiopathic or confused with type 4 osteogenesis imperfecta. The latter, however, usually presents by adolescence. Anticonvulsants, especially phenytoin, are thought to be associated with osteoporosis. Underlying causes include alcoholism, hyperthyroidism, multiple myeloma, hyperparathyroidism, and hyper-cortisol states (i.e. Cushing’s syndrome).
Which one of the following is true regarding Osgood-Schlatter disease?
Correct Answer B: Osgood-Schlatter disease is one of the most common orthopedic problems found in the young adolescent. It typically begins at the onset of the youth’s growth spurt, and complete resolution is often seen in 18-24 months. The diagnosis is generally made from the history and physical examination alone, with pain characteristically confined to the tibial tubercle.
-Pain occurs with activity and fades with rest. Pain increasing at 20degrees-30degrees of knee flexion, especially when light manual pressure is applied to the patella with side-to-side movement, is seen with patellofemoral syndrome.
-The development of pain in Osgood-Schlatter disease is insidious and is not associated with a single traumatic event.
-Sinding-Larsen-Johanssen disease involves pain, swelling, and tenderness at the inferior patellar pole due to patellar tendon inflammation at its origin.
-Effusions, instability, and loss of knee motion indicate more ominous knee conditions and are not seen in Osgood-Schlatter disease.
Which one of the following surgical procedures is associated with the highest risk for perioperative myocardial ischemia?
Correct Answer A: When deciding whether or not to recommend preoperative noninvasive cardiac testing, both patient risk factors and surgical risk factors should be taken into account. Surgical procedures associated with a high (>5%) risk of perioperative myocardial ischemia include aortic and peripheral vascular surgery and emergent major operations, especially in patients over 75 years of age. Head and neck surgery, intraperitoneal and intrathoracic surgery, orthopedic surgery, and prostate surgery carry an intermediate risk (1%-5%). Endoscopic procedures and cataract and breast surgeries are considered low-risk (<1%) procedures.
A 22-year-old male presents to the emergency department several hours after a rugby match in which he was struck in the face. His nose is bleeding.
On examination the patient has a depression in his nose on the side of impact and an outward displacement on the opposite side. Internal inspection reveals a purple area of swelling and fluctuance on the left side of the nasal septum. The remainder of the examination demonstrates no findings to suggest other facial or periorbital trauma.
Which one of the following would be most appropriate at this time?
Correct Answer D: The clinical examination of this patient reveals a septal hematoma - a blood-filled space between the cartilage and the supporting perichondrium. If improperly managed or left untreated, a septal hematoma may have a disastrous outcome, as the pockets of blood easily become infected. The resulting necrosis of the underlying cartilaginous support may result in permanent saddle nose deformity. When a septal hematoma is identified, it should be aspirated immediately or incised with the aid of local anesthesia.
When an uncomplicated nasal fracture is suspected, plain radiography is rarely indicated. In fact, because of poor sensitivity and specificity, plain radiograph may serve only to confuse the clinical picture. When findings such as CSF rhinorrhea, extraocular movement abnormalities, or malocclusion are present (none of which is present in this case), radiologic imaging by CT is indicated to assess for facial and mandibular fracture. Because there is no reason for early fracture reduction in this patient, follow-up evaluation and management can be safely scheduled after the swelling resolves, usually within 3-5 days. Reduction should be accomplished between the fifth and tenth day after injury, and before the nasal bones start to fixate.
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