Hardest CMSRN Practice Questions — Can You Answer These?

Borchardt's Triad (epigastric pain, inability to vomit, and inability to pass an NG tube) indicates an acute gastric volvulus. This is a surgical emergency where the stomach twists, leading to ischemia, perforation, or necrosis. Unlike Type I (sliding) hernias, Type II hernias are prone to incarceration and strangulation. Management: Immediate surgical consultation, NPO status, and IV fluid resuscitation. Delay in treatment carries a high mortality rate due to potential gastric infarction and sepsis.

Endoscopic Eradication Therapy (EET), specifically Radiofrequency Ablation (RFA) or Endoscopic Mucosal Resection (EMR), is the gold standard for high-grade dysplasia. Rationale: Barrett's Esophagus involves intestinal metaplasia (squamous to columnar epithelium). While PPIs manage symptoms, they do not reverse the metaplasia. EMR is used for visible nodules to stage the disease, while RFA treats the remaining dysplastic tissue. Surveillance intervals are typically every 3 months post-ablation until clearance is achieved.

Cameron Ulcers (or Cameron erosions). These are linear gastric erosions or ulcerations found at the level of the diaphragmatic hiatus in patients with large hiatal hernias. Rationale: Mechanical trauma from the stomach sliding back and forth through the hiatus, combined with local ischemia and acid exposure, causes these lesions. They often cause occult bleeding leading to chronic anemia. Management: PPI therapy and iron supplementation; surgical repair of the hernia may be necessary if anemia is refractory.

Instruct the patient to avoid carbonated beverages, chewing gum, and drinking through straws to minimize aerophagia (air swallowing). Simethicone may be used to help dissipate gas. Rationale: Gas bloat syndrome occurs because the new valve prevents the patient from belching or vomiting effectively. Patients should also be taught to eat slowly and chew thoroughly. If symptoms are severe and persistent, it may indicate the wrap is too tight, necessitating endoscopic dilation or surgical revision.

This indicates an overly tight fundoplication wrap or post-operative edema. The ""bird's beak"" sign on imaging suggests a functional obstruction at the lower esophageal sphincter. Initial management: Observation and liquid diet if due to edema (usually resolves in 2-6 weeks). If persistent, the next step is typically endoscopic balloon dilation to stretch the wrap. If dilation fails, surgical revision (re-do fundoplication) or conversion to a partial wrap (Toupet) may be required.