docnikki
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1.A 77-year-old woman comes to the physician because of a 2-day history of cramping abdominal pain and distention accompanied by nausea and vomiting. She is otherwise healthy and has no history of abdominal operations. Her temperature is 37.4 C (99.4 F), blood pressure is 110/86 mm Hg, pulse is 112/min, and respirations are 24/min. Cardiopulmonary examination shows no abnormalities. Examination of the abdomen shows distention and mild diffuse tenderness; bowel sounds are high-pitched. An x-ray film of the abdomen shows air-fluid levels throughout the small bowel and air in the liver; there is no gas in the colon or free air. Which of the following is the most likely diagnosis?
A
) Adhesive small-bowel obstruction
B
) Cecal cancer
C
) Gallstone ileus
D
) Intussusception
E
) Mesenteric infarction
F
) Ruptured appendicitis
G
) Small bowel lymphoma
2. Four hours after undergoing a cesarean delivery at term followed by tubal ligation, a 37-year-old woman, gravida 2, para 2, has dizziness and confusion. The operation was uncomplicated, and blood loss is estimated to be 800 mL. Patient-controlled epidural analgesia has been moderately effective for pain. Her blood pressure now is 80/40 mm Hg, decreased from 120/72 mm Hg intraoperatively, and pulse is 152/min, increased from 96/min intraoperatively. Breath sounds are decreased bilaterally. No murmurs are heard. Abdominal examination shows distention and tenderness. Bowel sounds are absent. The incision is intact with no drainage. She is disoriented to person, place, and time. Her hematocrit is 23%; preoperative hematocrit was 35%. Which of the following is the most likely cause of the hemodynamic changes?
A) Epidural-related hypotension
B) Insufficient intraoperative fluid replacement
C) Postoperative intra-abdominal hemorrhage
D) Supine hypotensive syndrome
E) Underestimated intraoperative blood loss
3.An 18-year-old man comes for an examination prior to participation in school sports. He states that he has had a dull ache in the scrotum since being hit in that area during a basketball game 2 months ago. Examination shows a 2-cm, hard, nontender mass in the right testicle. The mass does not transilluminate or change in size when the patient is placed in the supine position. Which of the following is the most likely cause?
A) Cystic dilations of the efferent ductules
B) Dilated pampiniform venous plexus
C) Fluid accumulation within the tunica vaginalis testis
D) Germinal cell tumor
E) Vascular trauma
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| 92306
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1) C) Gallstone ileus
2) A) Epidural-related hypotension
3) D) Germinal cell tumor
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| nadiabarati
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C
C
D
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| docnikki
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92306 can u explain the answer to 2nd quest?
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| robin082006
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1) C) Gallstone ileus
2) A) Epidural-related hypotension, anesthesia effects, similar to uw Q
3) D) Germinal cell tumor
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| Aashi
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Epidurals--->doesnt decrease the hct -->here there is significant fall in the hct > 10 points ,moreover epidurals produce hypotension during the induction or during the labor,not 4 hrs later,the only S.E of epidurals hrs after induction is just post op urine retention .....fall in hct happens due to bld loss--->and the only choice that makes some sense here is C---->Postoperative intra-abdominal hemorrhage ( probably due to placental previa--->that might be the obstetrical indication for C/S too)
GL
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| robin082006
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aASHI, HYPOTENSION AFTER anesthesia due to venous pooling, I still remember this q
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| Aashi
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well i didnt disagree abt the S.E of epidural..It is hypotension due to the sympathetic blockade--->that is y anesthsiologist gives a dose of phenyephrine to counteract this S.E--->but epidurals doesnt decrease the HCT--->blood transfusion is not the remedy for epidural induced hypotension..
Here this pt had a considerable amt of BLEED--->dropping the HCT significantly--->this is not due to epidural
I remeber the q ur talking abt in UW-->a lady who is in first stage of labor-->she had an epidural and then she became hypotensive--->yep there she dint have any source of bleeding,her hct was normal,and the reason for that hypotension is periperal VD and venous pooling due to symp blockade--->this scenario is diff this pt preop and post op hct has significant diff-->this is due to an intraop bleed--->and she is in hypovolemic shock
GL
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| robin082006
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oh, I did not pay attention to HCt, i am affected by other person's answers, thanks
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| docnikki
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I agree with u ashi..thanks for the nice explaination. really apprciate ur responses. wish u gl!
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| rezaaa
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there is one thing that confuses me, couldnt the hematocrit have fallen due to the surgery as there was 800 ml blood loss during the surgery as well?
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| rezaaa
Forum Senior
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or maybe its distractor
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| Drtweetie
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now that u bring up that point, rezaa
q asks which one is responsible for the hemodynamic changes:
Her Hct drops 4 hours after surgery. The better answer for the hemodynamic change is blood loss during surgery, because post-op hemorrhage would not cause such a drastic change in BP and Hct suddenly!
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| treblechar
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doctors, kndly explain your answers in the first and last questions. thanks
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| rezaaa
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drtweetie what in your opinion is the answer then
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| Step2300
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I have to go with "C" for #2. I'm looking at the distention and tenderness although I realize that may be accepted since she just had a C-section, but I'm assuming they mean an amount more than you would suspect with a C-section.
If we're going with blood loss as the cause, that's a pretty big miscalculation. I'm assuming they are giving her NS so if they underestimated her blood loss shouldn't that cause a relatively high Hct (since her blood isn't getting as diluted). It would account for her hypotension although it is still quite severe.
I guess this is just a long way of saying that I think "C" is right for #2.
Also I haven't really reviewed Renal/GU yet so could somebody explain #3? I get that transillumination shows that it isn't fluid. I still remember that much from the hell that was my surgery rotation.
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| Ivonne
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C
C
D
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| Korotkoff
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Hello Ivonne,
I disagree with your 3rd answer. Can't it be hematoma? I would have picked E.
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| drshvetasm
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CCD
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| sherry39
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c
e
e....h/o trauma
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| guangyu
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B
C
D
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| farnsworth
Forum Newbie
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C
C
D
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| guangyu
Forum Elite
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Change my mind, the first answer is C
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| guangyu
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Factors that alter the differentiation of the primordial germ cell, resulting in the presence of an embryonal stem cell, can increase the risk of NSGCT. These factors include a history of testicular cancer in the contralateral testis, cryptorchidism, gonadal dysgenesis, exposure to prenatally high estradiol levels, exposure to chemical carcinogens, trauma, and orchitis. Furthermore, associations with childhood inguinal hernias and any cause of testicular atrophy have been observed.
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