NMS Q&A Family Medicine

98 NMS Q&A Family MedicineExamination Answers1. The answer is D. Pelvic appendicitis will not result inpain with the maneuver described. The doctor has performedthe psoas test. It would not be positive because thepsoas sign elucidates retrocaecal inflammatory processesabove the pelvic area. The obturator sign, elicited by paincausation associated upon internal rotation of the righthip, should be positive in a pelvic appendicitis. The psoassign is defined as pain elicited by the extension of the ipsilateralhip against resistance.2. The answer is C. Hemorrhagic pancreatitis, and anyother cause of hemoperitoneum, may cause any of thesigns alluded to in the main stem, for example, rupturedovarian cyst when blood escapes to sufficient extent.3. The answer is D. Functional motility disorder is mostlikely the cause of dysphagia that involved both liquidsand solids from the onset. Each of the other choices arecauses of dysphagia, but each is an example of mechanicalobstruction. Mechanical processes, except for swallowedforeign bodies, are more insidious in the development,involving solid foods early and as the dysphagia progressesto liquids become difficult to swallow as well. The courseis more or less steady. Dysphagia of that type raises a redflag and must be evaluated as soon as possible to rule outcarcinoma.4. The answer is B. Although the overall incidence of carcinomaof the stomach has been decreasing in the UnitedStates for years, carcinoma of the proximal stomach, esophagogastricjunction, and esophagus is increasing. Most physiciansfeel this is because of the increased incidence andprevalence of gastroesophageal reflux disease. The latter isrelated to the increasing prevalence of obesity. Vitamin Cintake may be protective. Lack of fruit and vegetables maybe a risk factor. Screening of asymptomatic patients of normalrisk status for carcinoma of the stomach is not recommendedbecause of the invasiveness of any effective screeningmethod and the low incidence in low-risk populations.5. The answer is E. Hyperplastic polyps (of the colon orelsewhere) have no malignant potential and are not associatedwith gastric carcinoma. However, surveillance forgastric cancer is recommended for individuals with eachof the other four risk factors. Familial adenomatouspolyposis, noted for CRC development in all persons bythe age of 40, is also thought to be a risk factor for adenocarcinomasin other sites, as is the Lynch syndrome (familycancer syndrome II, hereditary nonpolyposis CRC).Gastric ulcer with biopsy evidence of high-grade dysplasia(and also gastric metaplasia, but not benign gastriculcer) is a risk factor. Pernicious anemia is a risk factor asis atrophic gastritis, without which pernicious anemiadoes not exist.6. The answer is C. Perhaps of the greatest surprise, gastriccancer can be a screenable disease. Although a largeproportion of patients with gastric cancer are asymptomatic,if patients are chosen for high-risk status (see theexplanation given for Question 2) and upper endoscopy isutilized aggressively, the cure rate can be as high as 90%.The other choices are fruitful indications for esophagogastroduodenoscopyas well, but a degree of time urgencyis conferred for early diagnosis of gastric carcinoma.7. The answer is B. Helical CT scanning is quite accurate,with sensitivity of about 92% and specificity of 97%.This test has become nearly routine in emergency departments.A helical CT scan is especially useful in differentiatingappendicitis from salpingitis in women. Althoughplain abdominal x-rays may identify an appendicealfecalith (appendicolith) that occurs in only 5% of cases.Ultrasonography carries an accuracy of 71% to 97%. Amagnetic resonance image is helpful in children andwomen.8. The answer is A. Association of refractory PUD anddiarrhea, especially when one or more ulcers include(s) alesion larger than usual, located distal to the duodenalbulb, suggests Zollinger–Ellison syndrome. Gastrinomasoccur in the pancreas, duodenal wall, or lymph nodes, or,when associated with multiple endocrine neoplasia, type1, occur in multiples in endocrine organs such as theparathyroid glands. One-third of gastrinomas are malignant.Over 90% of patients with gastrinomas developPUD and one-third will have watery diarrhea that can bequite severe and, of course, refractory to usual treatment.Although each of the other choices are causes of diarrhea,they would have to coexist with PUD in this case, none ofwhich is found in that association.9. The answer is D. Nonselective beta-blockers have beenshown to reduce the chances of bleeding from esophagealvarices to 15% from a 25% rate in placebo-treated controlsubjects. H2 receptor blockers and proton pump blockerswould be good choices for reflux symptoms but are notreported to prevent hemorrhage from varices once theyhave developed.