While playing basketball, a 29-year-old male falls on his outstretched hand with his wrist fully extended. He sees you the following day because of diffuse wrist pain and decreased range of motion. The point of maximal tenderness is on the dorsal aspect of the wrist between the extensor pollicis brevis and extensor pollicis longus tendons. There is no visible deformity. Radiographs show no fracture.
Which one of the following is the most appropriate initial treatment of this patient?
Correct Answer C: The scenario described is suspicious for an occult fracture of the scaphoid bone of the wrist. The mechanism of injury, falling on an outstretched hand with the wrist extended, combined with tenderness in the anatomic snuff box (between the extensor pollicis longus and extensor pollicis brevis tendons) raises the possibility of a scaphoid fracture even if initial radiographs are negative. In order to reduce the potential for serious complications, including vascular necrosis and non-union, it is imperative that both the wrist and the thumb be immobilized. In the case described, a thumb spica splint is the best option initially. It should be worn continuously until a follow-up evaluation, including radiographs, in 1-2 weeks.
A 65 year old woman is prescribed tamoxifen therapy following surgery for breast cancer. Which one of the following best describes the mode of action of this drug on reducing the patient's risk of recurrent disease?
Correct Answer D: The majority of breast and uterine cancers are estrogen receptor positive, indicating that these cancers may be stimulated or maintained by estrogen. Fortunately, growth in estrogen receptor positive cancers may be halted by a number of agents, such as Tamoxifen as well as many other drugs that have been developed in recent years. Tamoxifen (Nolvadex) is part of a class of anti-cancer drugs known as selective estrogen receptor modulators, or SERMs.
The drugs in this class, although all slightly different, block tumor growth by mimicking estrogen and filling up estrogen receptors which prevents the cancerous growth. Estrogens themselves have good effects in the body, but tend to "feed" breast and uterine cancers as well as increase the risk for blood clots.
Ideally, the perfect drug would have all of the good effects without any of the bad, but to date, no one drug alone does this. Tamoxifen blocks estrogen receptors in the breast, but mimics estrogen in the uterus, which may increase the risk for uterine cancer.
A 75-year-old woman has a red, swollen, warm, tender breast. She states that the condition has been present for at least several weeks, perhaps a month or two. The skin over the area looks like orange peel. On physical examination there is a fullness to the entire breast, with no discrete mass.
Which of the following is the most likely diagnosis?
Correct Answer B: Age is your first tip-off: the older the patient is with any kind of breast problem, the more likely it is to be cancer. The description is that of inflammatory carcinoma (ductal carcinoma), where the permeation of skin lymphatics has given the edema, redness, fullness, and orange peel appearance. The thick, tumor-laden skin actually masks the underlying mass, which is felt as "fullness" rather than a discreet lump.
What is the most common benign breast tumor in women under 30?
Correct Answer B: Benign breast tumors Intraductal papillomas (a) and Fibroadenomas (b) are the only two benign tumors of the five listed options. Between the two, fibroadenomas are the most common. They are smooth, rubbery, discrete, well-circumscribed, non-tender and mobile tumors which are hormone dependent.
PEARL: Fibroadenomas are the most common benign tumor of the breast in women under 30.
A 50 year old male with a large carcinoma of the distal esophagus has an associated 9 kg weight loss. To prepare for surgery, he is started on full-strength enteral nutrition via a feeding tube.
Which one of the following is the most common side effect of nasogastric tube feedings?
Correct Answer A: Nasogastric feeding is recommended for temporary feeding, usually for a period of less than 30 days. This procedure may be appropriate if dysphagia occurs abruptly after a short illness and the patient is expected to recover.
Enteral feeding often leads to diarrhea, especially if bowel function is compromised by disease or drugs, particularly broad-spectrum antibiotics. Diarrhea may be controlled by the use of a continuous drip, with a fiber-containing formula, or by adding an antidiarrheal agent to the formula. However, Clostridium difficile, which is a common cause of diarrhea in patients being tube fed, should be ruled out before using antidiarrheal agents. H2 blockers may also assist in reducing the net fluid presented to the colon. [other complications include: aspiration; ulceration of nasal and esophageal tissues, leading to stricture]
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