What is the most common cause of developing a lung abscess in a post-operative patient?
Correct Answer D: Lung abscess is a necrotizing infection characterized by localized pus. It is almost always caused by aspiration of oral secretions by patients who have impaired consciousness. Symptoms are persistent cough, fever, sweats, and weight loss. Diagnosis is based on history, physical examination, and chest x-ray. Treatment usually is with clindamycin or combination β-lactam/β-lactamase inhibitors.
A 25 year old man states that he is experiencing constant and intense pain in the anal region that has been building up in intensity in the past 2 days. On exam you find a bluish purple mass at the anal margin.
What is the most likely diagnosis?
Correct Answer C: Hemorrhoids are dilated veins of the hemorrhoidal plexus in the lower rectum. Symptoms include irritation and bleeding. Thrombosed hemorrhoids are painful. Diagnosis is by inspection or anoscopy. Treatment is symptomatic or with endoscopic banding, injection sclerotherapy, or sometimes surgery.
If an external hemorrhoid develops a thrombosis, the pain is quite insistent. Patient may experience itching, burning, swelling or inflammation. The most definitive sign of a thrombosed external hemorrhoid is the color. Thrombosed external hemorrhoids develop a deep red, deep purple, blue or black tint, often appearing just underneath the skin. Thrombosed external hemorrhoids normally give a pain peak within 48 hours of the thrombosis developing, with diminishing pain after about 4 days.
Internal hemorrhoids typically present with bleeding following defecation; blood is noted on toilet tissue and sometimes in the toilet bowl. Internal hemorrhoids may be uncomfortable but are not as painful as thrombosed external hemorrhoids. Internal hemorrhoids sometimes cause mucus discharge and a sensation of incomplete evacuation. Prolapsed hemorrhoids are internal hemorrhoids that are so distended that they are pushed outside the anus.
A painful thrombosed external hemorrhoid diagnosed within the first 24 hours after occurrence is ideally treated by:
Correct Answer D: A thrombosed external hemorrhoid is described as the sudden development of a painful, tender perirectal lump. Because there is somatic innervation, the pain is intense, and increases with edema. Treatment involves excision of the acutely thrombosed tissue under local anesthesia, mild pain medication, and sitz baths. It is inappropriate to use procedures that would increase the pain, such as banding or cryotherapy. Total hemorrhoidectomy is inappropriate and unnecessary.
Which one of the following would be the best treatment option for prolapse of a fourth degree hemorrhoid that cannot be reduced?
Correct Answer D: Hemorrhoids are divided into four categories. First degree hemorrhoids bleed with defecation but do not prolapse through the anus. They are associated with mild symptoms and usually are secondary to leakage of blood from mildly inflamed, thin-walled veins or arterioles. Conservative management with dietary manipulation (addition of fiber) and attention to anal hygiene often is adequate. Recurrent rectal bleeding may require ablation of the vessels with nonsurgical techniques (e.g., injection sclerotherapy, infrared coagulation, rubber band ligation).
Second degree hemorrhoids prolapse with defecation and reduce spontaneously. These can be treated with rubber band ligation or other nonsurgical ablative techniques.
Third degree hemorrhoids prolapse and require manual reduction. There is significant destruction of the suspensory ligaments. Relocation and fixation of the mucosa to the underlying muscle wall generally is necessary. Prolapse initially can be treated with rubber band ligation, although hemorrhoidectomy may be required.
Fourth degree hemorrhoids prolapse and cannot be reduced. If treatment is necessary, these require hemorrhoidectomy.
A radial nerve injury would cause which of the following presentations?
Correct Answer A: Injury to the radial nerve results in loss of extension of the wrist, fingers and thumb. This would cause a wrist drop. The resulting difficulty in grasping objects leads to significant disability. When the nerve is injured to the extent that it will not recover and nerve repair or grafting is not possible, tendon transfers can provide some return of function.
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