A 26 year old male was brought to the Emergency Room right after he underwent a motor vehicle accident. He suffered multiple traumatic fractures including a significant head trauma. He suddenly became dyspneic and tachypneic complaining of chest discomfort and has a Syncopal episode. His blood pressure dropped to 70/50 mmHg, pulse is 140/min, and respirations are 30/min. CT angiogram shows a massive obstruction in the main pulmonary artery with saddle shaped extension into both pulmonary arteries.
What is the most appropriate line of management for this patient?
Correct Answer B: Massive pulmonary embolism often presents with a sudden onset dyspnea, tachycardia, and hypotension. The best treatment is to give a fibrinolytic agent such as streptokinase; however, our patient is a multi-trauma patient and we do not want to put him at risk for an intracranial bleeding or a bleeding elsewhere. So the best intervention would be a pulmonary embolectomy.
Heparin is very good for clot stabilization; however it will not dissolve the already existing clot in our patient. The patient is unstable; embolectomy is life saving!
A green field filter is an Inferior vena cava filter that is placed when a patient has recurrent DVT occurrence or when there is a contraindication to heparin.
Percutaneous coronary intervention (PCI) would be warranted if the patient has an acute MI.
A 74-year-old man undergoes transurethral resection of the prostate (TURP). Specimen shows low grade carcinoma in 5% of the specimen.
What is the most appropriate intervention at this time?
Correct Answer A: In transurethral resection of the prostate (TURP), a thin cylindrical instrument (resectoscope) is inserted through the urethra where it's surrounded by prostate tissue. An electrical loop cuts away excess prostate tissue to improve urine flow.
In a man with advanced age if the tissue shows low grade (Stage T1a - Incidental histologic finding in 5% or less of the tumor resected) it is ok to observe without any further aggressive intervention. Options for more advance cases of prostate carcinoma include prostatectomy and radiation.
An 86-year-old woman develops ankle edema at the right medial malleolus. The area has a superficial ulcer and surrounding scarring.
What is the most likely specific reason for this presentation?
Correct Answer B: This is a case specifically of perforator incompetence involving the veins of the lower extremity.
Under ordinary circumstances the bulk of venous blood moves strictly from the superficial to the deep system. Failure of the valves of communicating perforator veins can permit a significant volume of blood to flow from deep veins backward into the superficial system, producing local congestion and venous hypertension.
More important, perforator incompetence allows the extremely high pressures generated within deep veins by the calf muscle pump to be communicated to the superficial veins, which are not strong enough to tolerate the pressure. This high pressure produces excessive venous dilatation and secondary failure of superficial vein valves. This is one of the major mechanisms for the development of superficial venous incompetence and varicose veins.
Claudication would present as calf pain in particular during exercise. Caused usually by atherosclerosis of the arteries that supply the muscles of the lower extremity.
A man has one of his testis removed for testicular cancer. His fertility now will be:
Correct Answer A: The removal of one testicle will not make a difference in height, strength, fertility, or sperm production in the other testicle. The only consideration that one might consider would be cosmetic surgery, in which an artificial testicle could be implanted to give the appearance of a second testicle.
Which one of the following statements regarding varicoceles is true?
Correct Answer E: Most varicoceles appear in adolescence, occur on the left side, and are asymptomatic. When the clinical examination findings are equivocal, high-resolution color-flow Doppler ultrasonography is the diagnostic method of choice. Surgical repair of large varicoceles can reverse testicular growth arrest, with catch-up growth occurring within 1 - 2 years.
Varicoceles are the most common surgically correctable cause of subfertility in men and the goal of surgery is to maximize chances for fertility. Varicoceles in men are common, with an incidence of approximately 15%. The appearance of a varicocele on the right side only, or in a child less than 10 years of age, is abnormal and may indicate an abdominal or retroperitoneal mass.
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