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A surgeon at a certified bariatric center of excellence performs a laparoscopic sleeve gastrectomy on a 42-year-old woman with a BMI of 42 and associated hypertension. On postoperative day 1, she is doing fine and is discharged to home, which is 90 miles away. On postoperative day 2, she calls her surgeon's office with a complaint of abdominal pain and gets the answering service. She does not receive a call back from the covering bariatric surgeon. She calls the office on postoperative day 3, and a triage nurse responds telling her that the covering surgeon will call her back, but no one does. On postoperative day 5, the patient presents to her local emergency department in septic shock. CT scan shows evidence of a leak. The local emergency department does not have a bariatric sturgeon, and the on-call surgeon is not comfortable taking care of this patient. The patient is transferred back to the operating surgeon's hospital after discussion with the covering bariatric surgeon. The patient makes it to the emergency department but then dies shortly thereafter. The patient's family decides to sue. In deposition, the bariatric surgeon claims no calls were made to the covering bariatric surgeon. Who is mostly at fault for this outcome? A. The operative bariatric surgeon B. The answering service C. The covering bariatric surgeon D. The local emergency department E. The local general surgeon The Correct Answer will be at first Comment .login to see or add comments and answers

A 45-year-old man undergoes abdominal CT scan after a motor vehicle collision. CT scan reveals only an incidental 3.5-cm right adrenal lesion (<10 Hounsfield units). The patient is otherwise healthy and has no other injuries related to the collision. His electrolytes are normal. Plasma-free metanephrines are normal Which of the following steps is also appropriate to evaluate his adrenal lesion? A. MRI. B. dexamethasone suppression test. C. metaiodobenzylguanidine (MIBG) scan. D. plasma aldosterone concentration and renin activity. E. observation. ANSWER: B Adrenal incidentaloma is encountered in 3 to 8% of patients undergoing imaging for other reasons. Evaluation is directed at determining malignant potential and the lesion's functional activity Metaiodobenzylguanidine (MIBG) scanning was formerly used for localization of pheochromocytoma but has been replaced by MRI; PET scan is used in selected cases. Radiographic characteristics assist in determining malignant potential. Size and Hounsfield units (HU) on CT scan are significant predictors of malignant potential. Size less than 4 cm with 10 HU or fewer are unlikely to be malignant; therefore, further imaging such as MRI is not needed. Functional activity should be evaluated through careful history and physical examination. All patients with adrenal incidentaloma should undergo screening for cortisol excess using a dexamethasone suppression test. All patients should be screened for pheochromocytoma using plasma-free metanephrines or urinary fractionated metanephrines. Screening for aldosteronoma using plasma aldosterone concentration and renin activity can be reserved for patients with hypertension and hypokalemia

A 50-year-old housewife consulted her family practitioner with the request for something to relieve her severe heartburn. When the doctor took a detailed history, this revealed that the patient had been experiencing a burning pain for several years, which she localized to about the middle of the body of the sternum. There was no radiation of the pain. She had been self-medicating, with some success until recently, using a whole variety of proprietary indigestion and antacid tablets and medicines. The pain would come on shortly after her meals, especially her evening dinner, the main meal of the day. She also had her sleep disturbed by the pain and had noticed that this was less likely to happen if she slept propped up with pillows. She also found that the pain might come on if she stooped down, for instance to pick something up from the floor. Occasionally at night or on stooping she had noticed regurgitation of bitter-tasting fluid into her mouth, and this she had found to be particularly unpleasant, but she had never actually vomited. On direct questioning, she had never noticed the food sticking in the chest on swallowing, i.e. there was no evidence of actual dysphagia. Apart from these symptoms she was well, her appetite good and her bowels acted normally. She had had three children and had gained a lot of weight after the third pregnancy and was now quite obese. Functional enquiry was otherwise normal. Apart from her obesity and moderate hypertension (blood pressure 160/110), clinical examination was normal. https://twitter.com/DrATEFAHMED/status/1644061633625444366?s=20

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