NMS Q&A Family Medicine

Surgical Issues of the Gastrointestinal Tract 9910. The answer is E. The patient has pernicious anemia.Treatment consists of parenteral monthly injections of vitaminB 12 . The reason for doing upper endoscopy at the timeof diagnosis is to rule out gastric carcinoma, the risk of whichis threefold that of the general population. The prevalenceof gastric carcinoma is 1% to 3% in pernicious anemia.11. The answer is E. A sigmoid colon (as with otherdescending colon) location is most likely to be discoveredin Duke stage A (confinement to the mucosa) because theearliest symptom is usually hematochezia, occurring wellbefore the primary tumor encircles or obstructs the colon.This location confers a 5-year cure rate of 90%. Bloodfrom tumors arising from more proximal levels is digestedand changed from a visible form in the early stages, thusnot alerting the patient until change in bowel habits oreven bowel obstruction supervenes. Fecal occult bloodscreening could, of course, detect early and curable tumorsin the more proximal locations. Thirty-two percent ofCRCs occur in the descending colon, divided into 25% inthe sigmoid and 7% in the remaining descending colon.Males are more likely than females to develop cancer inthe left or descending colon, whereas females are morelikely to develop it in the right colon. Stage B is confinedto the muscularis and if excised at that point confers a60% to 75% 5-year survival; Stage C is defined a spread toat least one lymph node involvement and survival dropsto about 25% to 50%. D is distant metastases: 5% 5-yearsurvival.12. The answer is B. The obturator sign is defined aspain upon internal rotation of the thigh with the righthip flexed. When it elicits pain deep in the lower lumbararea (as opposed to the hip joint proper or pain radiatingdown the anterior thigh), it signifies contact betweenthe internal obturator muscle and an inflammation process,usually a retrocecal appendix. The psoas maneuveris the alternative if retrocecal appendicitis is still suspectedand the obturator sign is absent (either one maybe performed before the other). With the psoas sign, theipsilateral hip is extended, and pain is elicited if there isan inflammatory process touching the psoas muscle.The Babinski sign is an abnormal plantar reflex of thefoot and toes in the presence of an upper motor neuronlesion in the opposite side of the brain or any part of thecorticospinal tract above the crossover level. The Rovsigsign is the presence of right lower quadrant pain uponrelease of deep pressure by the examining hand in theabdomen in the presence of classic appendicitis withnormal positioning wherein the organ is touching theanterior parietal peritoneum. The Murphy sign is theinhibition of inspiratory effort when the examininghand is deeply placed beneath the right costal margin inthe presence of an inflamed gallbladder. The Osler signis the presence of painful petechia-sized red spots on thehands and feet pathognomonic of subacute bacterialendocarditis.13. The answer is C. This patient has a typical presentationof pyloric stenosis. A male infant who is 2 weeks to 4months of age most typifies pyloric stenosis. Male infantsare affected four times as frequently as female infants.14. The answer is E. Intussusception is the most commoncause of bowel (as opposed to pyloric) obstructionin the first 2 years of a baby’s life. Eighty percent of casesoccur in the first 2 years of life, peaking in the time periodfrom 5 to 9 months. Male infants are affected three timesas frequently as female infants; presentation includes colickyabdominal pain, “current jelly stools,” reflex vomiting,leukocytosis, hemoconcentration, and a palpablemass. Meconium plug is a cause of obstruction in thenewborn. Hirschsprung disease is a potentially fatal conditionof the newborn in which normal peristalsis is preventedby the segmental absence of ganglion cells of themucosal and muscular layers of colon or rectosigmoidsegments of bowel. Obviously, both are causes of congenitalbowel obstruction. Carcinoma of the infant colon isextremely rare. Shigellosis is a form of bacterial dysenterythat causes profuse bloody diarrhea.15. The answer is B, 7% to 7.5%. The lifetime risk of carcinomaof the colon of about 2.5% is roughly tripled for aperson who has a first-degree relative with either coloncancer or adenomatous polyp. This translates to a 7% to7.5% lifetime risk. Because the incidence increases witheach decade of life, all the foregoing percentages are multipliedfor the upper age groups. For example, the expectedincidence of colon cancer of nearly 0.4% per 1,000 peryear at the age of 50 years would be more than 1.2% per1,000 in every year for a person with such a first-degreefamily history.16. The answer is D. Although A, B, and C are acceptablemethods of CRC screening for patients of average risk,beginning at the age of 50 years, any patient who has afirst-degree family history of CRC should begin suchscreening at the age of 40 years. Because this patient hasnow been diagnosed with a tubular adenomatous polyp,one of three precancerous types, she should undergocolonoscopy now, and this should be repeated every3 years, assuming the study reveals no cancers (see Chapter45). The presence of a single adenomatous polyp inany segment of the large intestine implies the strong possibilityof other polyps throughout the remainder of thecolon.