A 25 year old male patient presents to your clinic complaining of heaviness in his scrotum. His past medical history is unremarkable. He does not smoke or drink alcohol. His family history is noncontributory. Physical exam is normal except for a painless, hard mass in his right testicle. You order a testicular ultrasound which reveals a solid mass arising from the right testicle 2x2 cm.
What should you do next?
Correct Answer D: The first rule of thumb in your clinical practice: DO NOT HARM! A solid mass arising from the testicle in a young adult is likely to be malignant! Surgical referral for high inguinal orchiectomy should be warranted.
A biopsy of a suspicious mass of the testicle is contraindicated because it can result in spillage of cancer cells, which can spread through lymphatics and blood vessels.
Reassurance or follow up in a case suspected to have cancer is never appropriate. Never take biopsy from a suspicious solid testicular mass!
A 45-year-old white male is admitted to the intensive-care unit after being pinned in a car wreck for 2 hours. He has sustained several broken bones and crush injuries to both thighs. On admission his urine is clear but the next morning it is burgundy colored. Some fresh urine is drawn from his Foley catheter and sent for analysis, with the following results:
You immediately order a CBC which shows his hematocrit to have dropped 4 percentage points overnight. Visual inspection of the serum shows it is clear.
The color of his urine is most likely due to:
Correct Answer A: A positive dipstick for hemoglobin without any RBCs noted in the urine sediment indicates either free hemoglobin or myoglobin in the urine. Since the specimen in this case was a fresh sample, significant RBC hemolysis within the urine would not be expected.
Myoglobin is released when skeletal muscle is destroyed by trauma, infarction, or intrinsic muscle disease.
→ If the hematuria were due to trauma there would be many RBCs visible on microscopic examination of the urine.
→ If a transfusion reaction occurs, haptoglobin binds enough free hemoglobin in the serum to give it a pink coloration. Only when haptoglobin is saturated will the free hemoglobin be excreted in the urine.
→ Free hemoglobin resorption from hematomas does not occur.
→ Porphyria may cause urine to be burgundy colored, but it is not associated with a positive urine test for hemoglobin.
Which one of the following is more likely to be associated with ulcerative colitis rather than Crohn’s disease?
Correct Answer E: Long-standing ulcerative colitis (UC) is associated with an increased risk of colon cancer. The greater the duration and anatomic extent of involvement, the greater the risk. Initial colonoscopy for patients with pancolitis of 8-10 years’ duration (regardless of the patient’s age) should be followed up with surveillance examinations every 1-2 years, even if the disease is in remission.
All of the other options listed are features typically associated with Crohn’s disease. Virtually all patients with UC have rectal involvement, even if that is the only area affected. In Crohn’s disease, rectal involvement is variable. Noncontinuous and transmural inflammation are also more common with Crohn’s disease. Transmural inflammation can lead to eventual fistula formation, which is not seen in UC. Toxic megacolon (choice E) is more characteristic of ulcerative colitis than it is Crohn's disease. It presents as dilated colon accompanied by abdominal distention, and sometimes fever, abdominal pain, and shock.
→ The absence of rectal involvement (choice A) is incorrect. The rectus is often affected in ulcerative colitis.
→ Transmural involvement of the colon (choice B) is most likely to be noted in Crohn's disease.
→ Segmental noncontinuous distribution of inflammation (choice C) is a characteristic feature of Crohn's disease.
→ Fistula formation (choice D) commonly occurs in Crohn's disease
A 56-year-old black male has pain and tingling in the medial aspect of his ankle and the plantar aspect of his foot. He jogs 3 miles daily and has no history of any injury. The symptoms are aggravated by activity, and sometimes keep him awake at night. The only findings on examination are paresthesias when a reflex hammer is used to tap just inferior to the medial malleolus.
This patient probably has:
Correct Answer E: Entrapment of the posterior tibial nerve or its branches as the nerve courses behind the medial malleolus results in a neuritis known as tarsal tunnel syndrome. Causes of compression within the tarsal tunnel include varices of the posterior tibial vein, tenosynovitis of the flexor tendon, structural alteration of the tunnel secondary to trauma, and direct compression of the nerve. Pronation of the foot causes pain and paresthesias in the medial aspect of the ankle and heel, and sometimes the plantar surface of the foot.
→ The usual site for a stress fracture is the shaft of the second, third, or fourth metatarsals.
→ A herniated nucleus pulposus would produce reflex and sensory changes.
→ Plantar fasciitis is the most common cause of heel pain in runners and often presents with pain at the beginning of the workout. The pain decreases during running only to recur afterward.
→ Diabetic neuropathy is usually bilateral and often produces paresthesias and burning at night, with absent or decreased deep tendon reflexes.
Which one of the following confers the greatest risk for postoperative pulmonary complications in non cardiothoracic surgery?
Correct Answer B: Postoperative pulmonary complications are important contributors to the risks associated with surgery and anesthesia. Significant postoperative pulmonary complications include atelectasis, pneumonia, respiratory failure, and exacerbation of underlying chronic lung disease.
Risk factors for postoperative pulmonary complications can be divided into patient-related factors, procedure-related factors, and laboratory factors. Patient-related risk factors include advanced age, functional dependence, COPD, and heart failure. Of these, advanced age confers the greatest risk, with risk beginning to increase after age 50. One study found an odds ratio of 5.63 for those age 80 and above.
Procedure-related risk factors include aortic aneurysm repair, non-resective thoracic surgery, abdominal surgery, neurosurgery, emergency surgery, general anesthesia, head and neck surgery, vascular surgery, and prolonged surgery.
The only laboratory predictor supported by good evidence is a serum albumin level <30 g/L.
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