A 13-year-old white female reports a 6 month history of intermittent abdominal cramping, with each episode becoming progressively worse. Based on her history, there is no obvious relationship to eating, voiding, or defecating. She report that she has not yet begun menstruating and is not sexually active. Her weight has been stable. She appears to be in mild emotional distress about being the “last girl in her class to have a period”. She is in no physical discomfort and her vital signs are normal. Secondary sexual characteristics appear to be developing normally. She is in the 57th percentile for height and the 65th percentile for weight. A complete physical examination confirms your presumptive diagnosis.
The therapeutic procedure of choice would be:
Correct Answer C: The key to making a diagnosis of imperforate hymen, aside from the obvious finding on physical examination, lies in the systematic drawing of inferences. One can speculate that this patient’s recurrent crescendo abdominal cramping represents six menstrual sheddings, with no egress from the body. Her delay in menarche, despite normal growth parameters, offers another clue that the structural amenorrhea is present. Amounts of retained blood vary among patients; up to 3000 mL have been reported. A large volume can accumulate without causing any permanent damage, and subsequent fertility is usually normal. Hymenotomy will relieve the pressure, and normal menses should ensue.
A 57-year-old black female has a partial resection of the colon for cancer. The surgical specimen has clean margins, and there is no lymph node involvement. There is no evidence of metastasis. You recommend periodic colonoscopy for surveillance, and also plan to monitor which one of the following tumor markers for recurrence?
Correct Answer D: Carcinoembryonic antigen (CEA) (choice D) is a marker for colon, esophageal, and hepatic cancers. It is expressed in normal mucosal cells and is overexpressed in adenocarcinoma, especially colon cancer. Though not specific for colon cancer, levels above 10 ng/mL are rarely due to benign disease. CEA levels typically return to normal within 4-6 weeks after successful surgical resection.
→ Prostrate-specific antigen (PSA) (choice A) is a marker that is used to screen for prostate cancer. It is elevated in more than 70% of organ-confined prostrate cancers.
→ Cancer antigen 27-29 (CA 27-29) (choice B) is a tumor marker for breast cancer. It is elevated in about 33% of early-stage cancers and about 67% of late-stage breast cancers.
→ CA-125 (choice C) is a marker for ovarian cancer. Although it is elevated in 85% of ovarian cancers, it is elevated in only 50% of early-stage ovarian cancers.
→ Alpha-fetoprotein (choice E) is a marker for hepatocellular carcinoma and nonseminomatous germ cell tumor, and is elevated in 80% of hepatocellular carcinomas.
A 55-year-old white female presents with redness at the scar from a lumpectomy performed for stage I cancer of her right breast 4 months ago. The patient has completed radiation treatments to the breast. She is afebrile and there is no axillary adenopathy. There is no wound drainage, crepitance, or bullous lesions.
Which of the following organisms would be the most likely cause of cellulitis in this patient?
Correct Answer A: Cellulitis in patients after breast lumpectomy is thought to be related to lymphedema. Axillary dissection and radiation predispose to these infections. Non-group A hemolytic Streptococcus is the most common organism associated with this infection. The onset is often several weeks to several months after surgery.
Pneumococcus is more frequently a cause of periorbital cellulitis. It is also seen in patients who have bacteremia with immunocompromised status. Immunocompromising conditions would include diabetes mellitus, alcoholism, lupus, nephritic syndrome, and some hematologic cancers.
Clostridium and Escherichia coli are most frequently associated with crepitant cellulitis and tissue necrosis. Pasteurella multocida cellulitis is most frequently associated with animal bites, especially cat bites.
Lymphadenopathy of the head and neck at which one of the following sites is most likely to be malignant?
Correct Answer E: In patients with head and neck lymphadenopathy, supraclavicular nodes are the most likely to be malignant. Lymphadenopathy of these nodes should always be investigated, even in children. Overall, the prevalence of malignancy with this presentation is unknown, but rates of 54%-85% have been seen in biopsy series reports.
Supraclavicular nodes are the most likely to be malignant, and should always be investigated, even in children (likely represent a pathology in the mediastinum, lung or abdomen).
Which one of the following herbal preparations should be stopped for at least 7 days prior to elective surgery?
Correct Answer A: All of the herbal preparations listed are important to ask about when performing a preoperative evaluation, but the potential hypoglycemic and anticoagulant effect of ginseng requires that it be stopped at least 7 days before surgery.
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