easy - showman

[ArchivalUser]

An 18-year-old woman comes to the emergency department
because of hematemesis. She had participated in
an œall-night drinking binge at her college, and she
took multiple aspirin tablets the next morning for the
hangover. There was no prior vomiting until the time
when she had the hematemesis. On arrival at the emergency
department, an upper gastrointestinal endoscopy
is promptly done, which confirms a diagnosis of acute
erosive gastritis with no other upper gastrointestinal
pathology. Gastric lavage with ice-cold saline is performed
and the bleeding stops. Laser photocoagulation
or electrocautery are not used, and pitressin is not
infused. She remains hemodynamically stable throughout
the procedure and is sent home 2 hours later. Four
hours after discharge, she returns complaining of
severe, constant chest pain. She is in acute distress, has
a temperature of 41 C (105.8 F), is having chills, and
looks very ill. Physical examination shows the presence
of crepitation to palpation in the upper chest and lower
neck, and chest x-rays confirm the presence of air in the
mediastinum and the subcutaneous tissues. The most
appropriate next step in management is
(A) antibiotics and observation
(B) barium swallow
© emergency laparotomy
(D) emergency thoracotomy
(E) repeat upper gastrointestinal endoscopy
39. A 63-year-old woman has a lumpectomy and sentinel
node biopsy for a very small infiltrating ductal carcinoma
of the right breast. The final pathology report shows that
the tumor measures 1 cm in its largest diameter, has clear
surgical margins, and is strongly positive for estrogen and
progesterone receptors. Three nodes are removed from
the axilla, and one of them contains metastatic cancer.
The surgery is performed under local anesthesia because
she is in borderline heart failure due to a pre-existing cardiomyopathy.
The radiotherapists are confident that they
can minimize scatter to the heart, and are willing to provide
the recommended radiation to the remaining breast.
Systemic therapy in this woman should include
(A) adriamycin
(B) estrogen
© progesterone
(D) radiation to potential metastatic sites
(E) tamoxifen

[ArchivalUser]

is it a,d ???

[ArchivalUser]

D , E

[ArchivalUser]

SHOWMAN BEST OF LUCK FOR EXAM I HAVE ALSO ON THE SAME DAY.

[ArchivalUser]

b

e

[ArchivalUser]

no its not on 2o ..after 20 not on 20

[ArchivalUser]

39
e

The correct answer is E. The presence of axillary
metastasis requires the use of systemic therapy, and she
is an ideal candidate for tamoxifen: she is postmenopausal,
had a very small primary tumor, and is
strongly positive for estrogen and progesterone receptors.
Recent ongoing studies have shown that a new
class of drugs called aromatase inhibitors, which completely
block estrogen by blocking aromatase, the
enzyme that helps produce it, may work even better
than tamoxifen.
Adriamycin (choice A) is one of the chemotherapeutic
agents commonly used for breast cancer, but the cardiac
toxicity of that drug contraindicates its use in this
patient.
The presence of estrogen and progesterone receptors
does not mean that the patient would benefit from the
administration of those hormones (choices B and C),
but rather, that blocking them would have therapeutic
value.
Radiation therapy (choice D) is not systemic therapy;
it is local therapy. In the future, this patient might benefit
from such modality if specific distant metastasis
are identified, but at the present time there is no indication
to irradiate potential metastatic sites, which
would include the liver, the lungs, the brain, and all of
her bones.

[ArchivalUser]

B
E

[ArchivalUser]

38d

The correct answer is D. The sequence of events here is
classic for iatrogenic, instrumental perforation of the
esophagus, and the presence of air in the mediastinum
and the neck is diagnostic. This is not an asymptomatic
radiologic finding; she has severe mediastinitis. Early
surgical intervention and repair is mandatory.
Antibiotics and observation (choice A) is an acceptable
strategy when an upper gastrointestinal endoscopy is
followed routinely by Gastrografin swallow, the study
shows a tiny leak, and the patient is completely asymptomatic.
It is not wise, however, when rip-roaring mediastinitis
is present. In the latter, early repair is literally
life saving, whereas delayed repair leads to all kinds of
complications.
We already know the esophagus is perforated. The surgeons
may wish to know the exact location of the hole
to plan their surgical approach, but in that case the
choice would be Gastrografin swallow. Barium (choice
B) is irritating to the mediastinum. It should not be the
first choice.
Emergency laparotomy (choice C) would have been the
answer if the stomach had been perforated rather than
the esophagus. In that case the presentation would have
included an acute abdomen rather than mediastinitis,
and the history would have included aggressive therapeutic
interventions in the stomach, rather than just
looking and washing.
It is not a good idea to put an endoscope down the
esophagus (choice E) when we think the esophagus is
perforated.We are bound to make the hole bigger if we
do so.

[ArchivalUser]

thanks showman