SESAP Questions
===============


**Category 11, Items 34 and 35**

A 32-year-old construction worker who lives in northwestern Missouri began a new job working on a large pig farm a week before the x-rays shown were obtained. He has a 15-pack year history of smoking. A chest x-ray taken a year ago was normal. Eight months ago, he had an attack of “walking pneumonia,” with severe cough, dyspnea, and wheezing that cleared slowly over seven days without antibiotics. Since then, he has lost weight, first slowly, then more rapidly; he is about 20 lb below his normal weight.

![Figure1](http://canjsurg.ca/https://www.canjsurg.ca/content/cjs/43/1/11/F1.medium.gif)

[Figure1](http://canjsurg.ca/content/43/1/11/F1)

He now has severe chest pain, more on the left than the right, and extending from his left shoulder across his back to his right shoulder. He has a chronic cough, but no wheezing or shortness of breath. He has had nightsweats. His tuberculin test is negative, and his histoplasmin test is positive. Bronchoscopy with washings is negative.

**Item 34**. The next step in management should be

1.  video-assisted thoracoscopic surgery (VATS) and biopsy

2.  thoracotomy and resection

3.  transthoracic needle aspiration

4.  thoracentesis

5.  repeat bronchoscopy with brushings

**Item 35**. If the procedure reveals sulfur granules, management should include

1.  amphotericin B

2.  fluconazole

3.  thoracotomy and resection

4.  chloramphenicol

5.  penicillin

For each of the incomplete statements above, select the one answer that is best of the 5 given for each item.

For the critique of these items see page 28.

## Footnotes

*   (Reproduced by permission from *SESAP No 10 1999–2001 Syllabus* Volume 2. For enrolment in the Surgical Education and Self-Assessment Program, please apply to the American College of Surgeons, 633 North St. Clair St., Chicago IL 60611, USA.)