01-02-2009, 11:26 PM
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
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