USMLE WORLD ANSWERS

1. B.
Isolated duodenal hematoma is treated conservatively with
nasogastric tube and parenteral nutrition. This conservative
approach has high cure rate and risk of surgery is avoided;
however it is important to exclude other organ injury. IVF are not
required as patient is hemodynamically stable; she needs
nutrition until hematoma heals. Also, antibiotics are not indicated
in this patient. She is afebrile and has no symptoms suggestive
of infection. Surgery is needed only if there are other associated
injuries or if the hematoma does not resolve w/in 2-3 wks w/ NGT
and parenteral nutrition.

2. A.
The patient presents with signs and symptoms suggestive of
necrotizing surgical infection. The clues to the correct diagnosis
include: (1) intensive pain in the wound accompanied by fever
and tachycardia, (2) decreased sensitivity at the edges of the
wound and (3) cloudy-gray discharge. Diabetes is an important
predisposing condition. The necrotizing surgical infection is
usually caused by mixed gram-positive and gram-negative flora.
The presence of crepitus raises the suspicion that clostridial
infection may be present, bu some streptococcal and other gas-
forming organisms may also produce local crepitus. The
treatment of necrotizing surgical infection is complex. The most
important step in the management of this condition is early
surgical exploration to assess the extent of the process and
debride the necrotized tissues. Antibiotics are also important, but
S. aureus is a less frequent pathogen causing this condition.
General measures should include adequate hydration and
glycemic control (choice D), but surgical exploration is more
urgent. The discharge should be cultured (choice C), although
the results are delayed. Observation (Choice E) is not
appropriate, because the process spreads very quickly and is life
threatening.

3. D.
The child was involved in trauma and later d/ced. He later
presents with a deviated mediastinumand mass in left lower
chest. He has no fever or chills except for chest pain. One
diagnosis, which is frequently missed in the ER, is traumatic
rupture of the diaphragm. The rupture may be small or large and
is usually on the left side, as the liver protects the right side. The
 diagnosis of diaphragmatic rupture is difficult and generally most
individuals present later. Delayed presentation carries a high
morbidity. Barium swallow will be diagnostic. All diaphragmatic
ruptures require treatment. Surgery is best done via the
abdomen in acute conditions and via the chest in chronic
conditions. VATS would be diagnostic of diaphragmatic
perforation on intial admission.
Option A: The patient has a collection/mass in the L. chest and it
may look similar to pleural effusion. Placing a chest tuve in a pt
w/ diaphragmatic perforation with bowel herniation can be a
disaster, when in doubt, get a CT scan.

4. B.
Major veins at the base of the neck have negative pressure
during inspiration and, if injured at that moment, will suck air
rather than bleed. The air embolism then leads to sudden death.
Arterial injury (choice A) would have led to massive bleeding but
not to sudden death.
Pneumothorax (choice C) can indeed happen when surgery is
being done in the supraclavicula area, and a sucking sound
might even be heard. However, sudden lung collapse in a young,
healthy person leads to dyspnea, not to sudden death.
Sympathetic discharge (choice D) would be hard to produce
while pulling and dissection a node. If it were done, however,
there would be vasoconstriction, tachycardia, perspiration and
hypertension.
Essentially nothing would have happened at the time had the
trachea (choice E) been injured.

5. C
The patient most likely has an injury to a major bronchus. In
addition to the wretching effect of a sudden deceleration, these
can happen when a major blow to the chest occurs at a time
when the glottis is closed. If not recognized right away by the
presence of subcutaneous emphysema, they become evident
once the air leak persists and the lung does not re-expand.
Air embolism (choice A) is manifested by sudden death shortly
after a patient with unrecognized injuries to the tracheobronchial
tree in proximity to major intrathoracic vessels is placed on a
respirator.
Injured lung parenchyma (choice B) can indeed leak air and
produce a pneumothorax, but typically heals rapidly.
Suction applied to a chest tube (choice D) is used to accelerate
the rate of resolution of a pneumothorax, but the large amount
of air draining in this case indicates that the pleural space fills as
quickly as it can be drained out.
6. C.
Intramural calcification of the gallbladder (aka porcelain
gallbladder) is associated with a 20% risk for progression to
gallbladder carcinoma. When the condition is discovered
incidentally, usually a calcified mass on an abdominal xray,
prophylactice cholecystectomy is recommended to reduce the
risk for progression to malignancy. As the gallbladder wall is
usually thick and fibrotic, it is usually necessary to perform an
open cholecystectomy rather than a laparoscopic procedure. In
any case, a biopsy of the gallbladder wall (choice A) is not
recquired.
Medical treatment with ursodeoxycholic acid (choice B) is used to
treat gallstones in poor surgical candiddates and is a mainstay of
treatment for primary biliary cirrhosis.
Gallbladder is a highly fatal malignancy so waiting for it to show
up on CT (choice E) is very risky as operative mortality
associated with cholecystectomies is low.

7. E.
5 or more units of blood transfusion in a period of 24 hours is
considered an indication for surgery.
Both ligation and meso-caval shunt (choices C,D) have a high
mortality rate in emergency settings. Ligation will no control the
ascites, which in this patient is refractory to concervative
treatment.
TIPS (choice E) has a lower mortality rate. If successful, it will
decrease the variceal and portal hydrostatic pressure and hence
will decrease the bleeding and ascites. Hepatic encephalopathy
is the main risk after the procedure.
Sengstaken-Blakemore tube can stay in up to 48 hours with
relatively low risk for esophageal ischemia and perforation.
Choice A could be the correct answer if patient had recquired
less than 5 units of blood.

8. B.
Oxalate stones are due to excessive GI absorption of oxalate.
Hyperoxaluria occurs in patients with SBR, inflammatory bowel
disease and other malabsorptive states. The increased intestinal
fat binds dietary calcium, which is then unavailable to bind
oxalate as usual. Therefore, increased oxalate absorption in large
bowel (unabsorbed bile salts may aid this) occurs and
precipitates in kidney. Increased oxalate occurs in people who
drink large amounts of tea, coffee, beer, chocolate and ethylene
glycol overdose.
 Choice A: calcium stones associated with conditions causing
hypercalciuria such as sarcoidosis, immobilization, Cushing
syndrome and RTA. Treatment is to increase fluid intake and use
of thiazide diuretics (NOT lasix).
Choice C: struvite stones form in the collecting system and
become infected with urea splitting organisms. Conditions
required for formation of struvite stones are high urine pH,
magnesium, ammonium and carbonate levels.
Choice E: cysteine stones are rare and occur as part of an
inherited disorder of defective renal transport. Stone formation
begins in childhood and are a rare cause of staghorn calculi.

9. D.
The woman is having clear signs of peritoneal irritation,
immediately after the onset of pain. Most likely, a peptic ulcer
has perforate and highly irritating stomach or duodenal contents
have spilled into peritoneal cavity and have descended
producing lower abdominal pain.
A lot of gynecological conditions could give similar complaints
but because of patient’s PMH, perforated PU should be ruled out
first.
Upright abdominal x-ra is positive for air under the diaphragm in
the majority of cases of intestinal perforation. If negative, U/S, CT
and DPL may be indicated.

10.E.
The clinical scenario described is suggestive of acute adrenal
insufficiency. Acute onset of nausea, vomiting, abdominal pain,
hypoglycemia, and hypotension after a stressful event (e.g.,
surgical procedure) in a patient who is steroid-dependent is
typical. A very important clue to the correct diagnosis in this
patient is the past medical history (lupus) indicative of
preoperative steroid use. Exogenous steroids depress pituitary-
adrenal axis and a stressful situation can precipitate an acute
adrenal insufficiency.
(Choice B) DKA is also manifested by nausea, vomiting, and
abdominal pain; however, you will see hyperglycemia, and you
usually do not see hypotension.
(Choice D) Intestinal obstruction is not accompanied by
hypoglycemia, even though you can see all the rest.
(Choice G) Insulin-induced hypoglycemia is manifested by
autonomic activation, but nausea, vomiting, and abdominal pain
is not the common presentation. Also, hypotension is not
typically seen.
 Severe allergic reaction (Choice F) usually immediately follows
the injection of a drug and is frequently accompanied by
bronchospasm and urticaria/edema.
Atelectasis (Choice H) is an early postoperative complication
characterized by fever and is much less dramatic in presentation.
An abscess (Choice C) is a late postoperative complication.

11.C.
Apart from the acute pancreatitis, this patient’s clinical picture is
highly suspicious of two things: hypergastrinemia (recurrent
peptic ulcers) and hyperparathyroidism (hypercalcemia). So,
serum parathyroid levels and gastrin levels should be performed
first (Option C).
She may have multiple endocrine neoplasia (MEN I) that is
characterized by tumors of anterior pituitary, parathyroid and
pancreatic islet cells. MEN II is less likely, but can’t be excluded
at this moment as well. MEN II is characterized by
pheochromocytoma, medullary carcinoma of thyroid and
parathyroid tumors. Serum calcitonin (for medullar carcinoma of
thyroid) and VMA will be ordered if there is suspicion of MEN II
(Option E). Acid output studies are not reliable for resected
stomach (Option A).
Educational Objective:
Recurrent peptic ulcers with hypercalcemia are best explained by
MEN type 1.

12.D.
Twenty to thirty percent of duodenal injuries follow blunt trauma,
when the duodenum is compressed between the spine and an
external solid structure like a steering wheel, lap belt (as in this
case), etc. The second portion of the duodenum, being
retroperitoneal and the least mobile, is most commonly injured.
Isolated duodenal injuries can be easily missed. Patient may
complain of epigastric or right upper quadrant pain, with or
without peritoneal signs; however, presentation may be very
subtle and requires a high degree of suspicion for diagnosis.
Retroperitoneal air or obliteration of right psoas margin on
abdominal x-ray is very suggestive. CT scan of the abdomen,
with administration of oral contrast material, confirms the
diagnosis of duodenal injury. If CT scan is not available, upper GI
study with gastrograffin, and if negative, with barium can be
used.
(Choice A, E) Plain CT scan of the abdomen and USG are not
sensitive for duodenal injuries, though they would diagnose the
associated injuries.
 (Choice B) DPL is not sensitive for duodenal injuries, as the
second part of the duodenum is the most commonly injured
portion and is retroperitoneal.
(Choice C) The patient is hemodynamically stable with no signs
of penetrative abdominal injury; so, exploratory laparotomy is
not warranted.
Educational Objective:
Duodenal injuries are best diagnosed with CT scan of the
abdomen with oral contrast or an upper GI study with
gastrograffin, followed by barium, if necessary.

13.C.
Early detection of gastric cancer has crucial importance in
successful management of gastric cancer because surgical
removal of the affected tissues remains the mainstay of the
therapy. Unfortunately, almost 90% of patients with gastric
cancer are diagnosed at stages III-IV; radical resection is very
complicated or impossible in these patients. Evaluation of the
extent of the disease after the diagnosis has been made is
important in choosing an appropriate management strategy. A CT
scan is commonly employed for staging the disease and
revealing metastases, especially liver metastases.
Laparoscopy (Choice B) can be used to evaluate the patients
further and can detect up to 20% of peritoneal metastases
missed by a CT scan.
Laparotomy (Choice E) is required eventually in most of the
patients for radical or palliative surgery with the exception of the
patients with unresectable disease.
Hypoalbuminemia (Choice A) is sometimes detected in patients
with gastric cancer, but it has little diagnostic significance.
Serologic markers (Choice B) are of negligible use in these
patients.
Educational Objective:
A CT scan is a standard diagnostic tool employed in patients with
newly diagnosed gastric cancer to evaluate the extent of the
disease. In most of the patients, surgery is the treatment of
choice.

14.B.
Mediastinitis, hemorrhage and large pericardial effusion may
account for the widening of the mediastinum. This patient, most
likely, has mediastinitis. Antibiotic therapy alone (Choice E) is not
sufficient for this very serious disease. Mediastinitis needs
thoracotomy for debridement, drainage, and antibiotic therapy
(Choice B).
Fever, leucocytosis, tachycardia and pain might be the signs of
postpericardiotomy syndrome (Choice A), however a “small
amount of pericardial fluid” can’t cause widening of mediastinum
seen on chest x-ray. For the same reason pericardial puncture
(Choice D) is not needed.
Postoperative mediastinal hemorrhage (Choice C) is less likely on
the 10th day; moreover it can’t explain the fever and
leucocytosis.
Educational Objective:
Recognize the mediastinitis, a post CABG complication by
systemic signs of inflammation, chest pain, breathlessness and
mediastinal widening on chest x-ray; it is a serious condition and
it requires thoracotomy for debridement and drainage.