A 17 year old white male presents with a concerning finding on the floor of his mouth. The rounded mass in seen under his tongue. It is not tender and is not fixed. See picture:
What is the name of this finding?
Correct Answer A: Ranulas present as a swelling of connective tissue consisting of collected mucin from a ruptured salivary gland duct, which is usually caused by local trauma. Ranulas are usually asymptomatic. Treatment of ranulas involves excision of the top of the lesion in a procedure known as marsupialization.
A 58-year-old man presents to the ED with severe abdominal pain in his left lower quadrant. A plain film x-ray shows a sigmoid volvulus.
What is the appropriate management?
Correct Answer B: Decompression and untwisting of the sigmoid loop may be achieved by the passage of a sigmoidoscope per rectum. This procedure allows for rapid decompression of the distended colon, with the immediate relief of symptoms. Most patients are elderly persons, and they may be treated conservatively with this tube decompression.
Surgery is reserved for patients in whom tube decompression fails to alleviate the patient's symptoms or for those in whom signs of ischemia are suggested.
A 56-year-old man has surgery for ruptured diverticulitis. 24 hours after the surgery, he develops fever.
What is the most likely cause?
Correct Answer A: The famous mnemonic for post-operative fever is: wind, water, wound, walk. Referring to pneumonia or aspiration (once attributed to atelectasis, but a recent review suggests that is not supported by existing clinical evidence), UTI, wound infections and DVT. These happen classically during post-op days 1, 3, 5 and 7 respectively.
A 60 year old woman had an abdominal hysterectomy and salpingo-oophorectomy 3 days ago. She had an indwelling bladder catheter, which was removed in the recovery room. She has been voiding normally since then. She began ambulation on the 1st postoperative day, and has been as active as possible under the circumstances, including faithful adherence to a prescribed program of incentive spirometry. On the evening of the 3rd postoperative day, she spikes a fever, with a temperature to 39.4°C (103°F).
Which of the following is the most likely source of the fever?
Correct Answer D: The timing is our major clue. Fever on postoperative day 3 is usually from the urinary tract. The circumstances are also there: she had instrumentation of her urinary tract during the procedure. Atelectasis is usually seen on day 1, and she is doing everything possible to avoid this complication. Deep thrombophlebitis could show up this early, but is more likely to do so 5-7 days after surgery. Furthermore, the patient had adequate protection during surgery and has been moving around since early on. Intra-abdominal abscess would need at least 7-10 days to develop. This is too early for that.
Wound infection is likewise a later complication, typically seen about a week after the operation.
Correct Answer B: A patient is involved in a motor vehicle accident (MVA). He presents to the ED, during physical exam you notice he has blood at urinary meatus.
Which of the following is contraindicated at this time?
Correct Answer B: Transurethral Catheterization is contraindicated in patients who have urethral injuries. Trauma to the urethra should be suspected when a patient has blood at the urethral meatus. A patient who presents with this should be investigated with a retrourethrogram.
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