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General Surgery
Surgery
| Question | Answer |
|---|---|
| Acute abdominal pain that is colicky is generally due to: | obstruction of a narrow duct (ureter, cystic, or common bile) |
| Acute abdominal pain with blood in the lumen of the gut | Ischemic process |
| 1. How is an abdominal perforation diagnosed? 2. What is the most common cause of perforation? | 1. free air under the diaphragm in upright x-ray 2. perforated peptic ulcer |
| Cause of acute abdominal pain that first began as vague generalized pain & over a couple hours localized to one spot & became more severe. | Inflammatory process |
| 1. Acute abdomen is adult with ascites 2. Management and treatment | 1. primary peritonitis 2. culture ascitic fluid and rx with antibiotics |
| Acute abdomen in child with nephrosis and ascites | primary peritonitis |
| What must be ruled out before performing an exploratory laparotomy in a generalized acute abdomen. | 1. MI (EKG) 2. pneumonia (CXR) 3. PE (immobilized patient) 4. pancreatitis (lipase) 5. urinary stones (CT scan) |
| Treatment for pancreatitis | 1. NPO 2. NG suction 3. IV fluids |
| Best diagnostic test for individual with colicky flank pain radiating to inner thigh. | CT scan (ureteral stones) |
| Elderly patient with left lower quadrant pain 1. How to confirm diagnosis? 2. Treatment | Acute diverticulitis 1. CT scan 2. NPO, IV fluids, antibiotics; if persists, emergency resection or bowel |
| Signs of intestinal obstruction with severe abdominal distention in an elderly individual 1. What is used to confirm diagnosis? 2. Treatment | volvulus of the sigmoid 1. X-ray with air-fluid levels in the small bowel, very distended colon 2. Proctosigmoidoscopic exam |
| Acute abdomen in a patient with atrial fibrillation | mesenteric ischemia from clot that lodged in the superior mesenteric artery |
| Which two types of hernias do not require treatment? | 1. umbilical hernia 2. sliding hiatal hernia |
| What is the acute abdomen cause of the following pain radiations: 1. Pain referred to the left shoulder 2. Pain referred to the back 3. Pain referred to the right shoulder | 1. splenic hemorrhage irritating the phrenic nerve & hemidiaphragm (Kehr's sign) 2. pancreatitis 3. biliary tree |
| What causes visceral vs parietal pain? | 1. visceral is caused from distention or spasm in hollow organs 2. Parietal is caused by irritation of the parietal peritoneum usually from pus, GI secretions or urine |
| What quality of pain distinguishes visceral vs parietal pain? | 1. Visceral is usually poorly localized, dull and achy 2. Parietal is usually sharp and well-localized |
| Acute abdomen with: 1. past abdominal surgery 2. atrial fibrillation 3. history of gonorrhea | 1. adhesions 2. mesenteric ischemia 3. pelvic inflammatory disease |
| Differential for right lower quadrant pain in children | 1. appendicitis 2. meckel's diverticulitis 3. intussusception 4. mesenteric adenitis |
| Differential for left lower quadrant pain | 1. Sigmoid diverticulitis 2. Sigmoid volvulus |
| Liver capsule inflammation with history of gonorrhea or chlamydia | Fitz-Hugh-Curtis syndrome |
| 1. Progressive dysphagia to both solids and liquids simultaneously 2. What is the diagnostic test? 3. What is the treatment? | 1. Achalasia 2. barium swallow followed by manometry 3. balloon dilation by endoscopy |
| 1. Patient with weight loss, dysphagia and history of smoking and drinking. 2. What is the clinical workup | Squamous cell carcinoma of the esophagus. 2. Barium swallow to visualize esophagus followed by endoscopy and biopsy |
| What is the treatment in a patient with GERD that has developed ulceration and stenosis? | Nissen fundoplication |
| Workup of a very sick looking patient presenting with severe sternal pain after prolonged vomiting | Boerhaave syndrome - contrast swallow with Gastrografin (does not aggravate the mediastinum like Barium does) |
| Weight loss, chronic vague epigrastric distress or early satiety. What are the two differential diagnoses and treatment for each? | 1. Gastric adenocarcinoma - surgical resection 2. gatric lymphoma - chemo/radiation |
| Patient with colicky abdominal pain, vomiting, abdominal distention and previous abdominal surgery. What is the management | 1. Adhesions 2. abdominal X-ray to look for air-fluid levels; manage with NPO, NG suction and IV fluids hoping for spontaneous resolution |
| Patient with colicky abdominal pain, vomiting, abdominal distention and previous abdominal surgery. Now develops fever, leukocytosis, constant pain and signs of peritoneal irritation. | Mechanical intestinal obstruction from adhesions now has a strangulated obstruction needing emergency surgery |
| Diarrhea, wheezing, right-sided valvular damage. Diagnostic confirmation. | Carcinoid syndrome in patients with small bowel carcinoid tumor with liver metastases 2. 24-hour urinary collection of 5-HIAA |
| 1. Patient has had sharp RLQ pain for >2 days and now appears most stable. 2. Management | 1. appendicitis with abscess formation 2. CT scan. antibiotics, IV fluids, bowel rest |
| pain with flexion of the right hip against resistance | Psoas sign |
| 1. Patient with bloody bowel movements and narrow caliber stools 2. Workup? | 1. cancer of the left colon 2. flexibl proctosigmoidoscopic exam and biopsy first followed by full colonoscopy to rule out secondary sources |
| 1. Patient with crampy abdominal pain, fever and leukocytosis taking a cephalosporin. 2. What confirms the diagnosis | 1. pseudomembranous enterocolitis 2. PCR to identify toxin in stool |
| Internal hemorrhoids that have become painful and itchy | prolapsed hemorrhoids |
| 1. Exquisite pain with defecation, blood streaked stools, tear in skin posterior to anus in the midline. 2. Treatment | 1. anal fissure 2. stool softeners, topical nitroglycerin or topical nifedipine |
| 1. What should be suspected when an anal fissure does not heal despite medical or surgical intervention. 2. Clinical workup | 1. Crohn's disease 2. exam and biopsy |
| Patient with exquisite pain lateral to the anus that prevents them from sitting or having bowel movements. | anorectal (Ischiorectal) abscess |
| Patient with fecal soiling and perineal discomfort following drainage of a ischiorectal abscess. | Fistula in ano (epithelial cells migrate from anal crypts and perineal skin) |
| Where is the most likely location of bleeding in the GI tract at the following ages. 1. young patient 2. elderly patient | 1. upper GI tract (up until the ligament of Treitz) 2. equal incidence of upper and lower GI tract |
| What is the clinical workup for recent history of bleeding in: 1. young patient 2. elderly patient 3. child | 1. Esophagogastroduodenoscopy 2. EGD + colonoscopy 3. technetium scan (Meckel diverticulum) |
| Upper GI bleeding in complicated post-op patient. | stress ulcer |
| Patient with scleral icterus, elevation in bilirubin and ALP. 1. Next step in workup 2. If gallstones are found in the gallbladder, what workup follows? | 1. sonogram looking for obstruction 2. ERCP to confirm diagnosis, sphincterotomy and removal of common duct stone; cholecystectomy should follow |
| Patient with obstructive jaundice. Sonography reveals dilated gallbladder without gallstones. What are the potential causes? | 1. Adenocarcinoma of the head of the pancreas 2. adenocarcinoma of the Ampulla of Vater 3. cholangiocarcinoma of common duct |
| 1. jaundice with anemia and positive blood in stools 2. What is the first test? | 1. ampullary cancer 2. endoscopy |
| 1. colicky RUQ pain radiating to right shoulder, triggered by ingestion of fatty food. 2. Next step in workup | 1. gallstone obstructing the cystic duct 2. sonogram and elective cholecystectomy |
| 1. RUQ pain that is constant. Accompanied by fever and leukocytosis 2. Management | 1. acute cholecystitis 2. Sonogram shows stones, thick-walled gallbladder; NG suction, NPO, IV fluids and antibiotics |
| 1. RUQ pain with fever and chills, ↑ ALP 2. Management | 1. Acute ascending cholangitis 2. antibiotics and emergency decompression of common duct by ERCP |
| 1. RUQ pain with ↑ ALP, ↑ amylase, lipase 2. Management | 1. stone impacted in ampulla 2. Sonogram is diagnostic; NG suction, NPO, IV fluids and antibiotics |
| Patient with epigastric pain, elevated amylase/lipase 1. What finding establishes this as edematous pancreatitis 2. Management | 1. elevated hematocrit 2. NPO, NG suction, IV fluids |
| 1. Patient with epigastric pain, elevated amylase/lipase. Lower hematocrit. 2. What is the most common cause of death? | 1. hemorrhagic pancreatitis 2. pancreatic abscess - need serial CT scans to catch and drain immediately |
| What are symptoms of chronic pancreatitis? | 1. steatorrhea (deficiency lipase) 2. diabetes 3. constant epigastric pain |
| What is the initial test for dysphagia? | barium swallow |
| What is the workup for all anorectal problems? | 1. digital rectal exam 2. anoscopy 3. flexible sigmoidoscope |
| How are the following hemorrhoids treated: 1. internal 2. external 3. prolapse internal | 1. rubber-band ligation 2. surgery 3. surgery |
| Two most common causes of acute abdomen in the elderly patient | 1. mesenteric ischemia 2. sigmoid volvulus |
| Differential for left upper quadrant pain | 1. splenic rupture 2. splenic abscess |
| 1. Postgastrectomy patient is experiencing postprandial nausea, vomiting, syncope and palpitations. 2. What is the treatment. | 1. dumping syndrome 2. dietary modification: small, multiple low-carb meals |
| Patient with migratory necrolytic dermatitis with mild diabetes. | glucagonoma follow with CT scan |
| Patient with hypertension, high aldosterone and low renin. 1. Two causes: 2. How do you differentiate between the two? | 1. adrenal hyperplasia - levels increase when sitting up (Rx with spironolactone) 2. adenoma - levels do not change with postural changes (imaging then surgical removal) |
| 1. 23 year old woman with 2 years of hypertension and a bruit in upper abdomen. 2. Management | 1. renovascular hypertension from fibromuscular dysplasia 2. duplex scan of renal vessels, CT angio then angiographic balloon dilation |
| What is the workup for an individual with substernal pain and dyspnea following endoscopy? | 1. possible perforation 2. contrast swallow (Gastrografin) |
| What test is run to evaluate a young patient with RLQ pain who is now presenting days after it began? | CT scan to check for appendiceal or psoas abscess formation |
| Most common cause of pancreatitis in a patient that doesn't drink alcohol. | gallstones (maybe hypertriglyceridemia second) |
| Only acute abdomen cause that combines severe abdominal pain with blood in the lumen of the gut. | Ischemic process |
| What are two reasons why a surgeon may decide not to approximate a wound with sutures? | 1. defect is large and the wound edges cannot be apposed 2. the wound has a high risk of infection |
| What are the phases of wound healing? | 1. Coagulation 2. Inflammation 3. Collagen synthesis 4. Angiogenesis 5. Epithelialization 6. Contraction |
| What is Third Intention wound healing? | a delay in primary intention in which the wound is sutured closed 3-5 days after incision |
| What is the primary process affecting wound closure of: 1. secondary intention (an open surgical wound) 2. primary intention | 1. wound contraction 2. epithelialization |
| What skin lesion may form in a chronically non-healing lesion? | Marjolin ulcer, a type of squamous cell carcinoma |
| What may metabolic acidosis be contributed to in a patient with acute abdominal pain? | lactic acidosis from ischemia of bowel |
| What is the likely cause of acalculous cholecystitis? | cholestasis and gallbladder ischemia leading to secondary infection by enteric organisms |
| Patient presents with jaundice and blood in stool. | adenocarcinoma of the ampulla |
| How would you treat the following: 1. Fecal fistula draining to the outside, afebrile patient 2. fecal fistula draining inside a body cavity, febrile patient | 1. will close without therapy 2. needs drainage and probably a diverting colostomy |
| Patient with multiple peptic ulcers and elevated calcium level. | MEN-1 |
| Complication of gallstones in which a stone becomes impacted in the cystic duct and compresses the common duct resulting in CBD obstruction and jaundice. | Mirizzi's syndrome |
| 1. LLQ pain, fever 2. Confirms diagnosis | 1. diverticulitis 2. CT scan |
| Breast cancer with eczematous changes of nipple. | Paget's disease |
| Bilateral breast tenderness related to menstrual cycle. What is the workup? | 1. fibrocystic disease 2. decide if there is a dominant mass; is no then aspirate, if not then mammogram |
| Patient with several duodenal ulcers: 1. What condition do you suspect? 2. What are the first steps in diagnosis? | 1. Zollinger-Ellison 2. measure gastrin and do secretin test |
| Which metabolite is most sensitive at detecting pheochromocytoma? | metanephrines |
| Hypertension in arms with normal pressure in lower extremities. How do you diagnose? | CT angio |
| Patient with biliary obstruction. What is the most likely cause if sonogram reveals: 1. dilated gallbladder 2. non-dilated gallbladder - next step in workup | 1. tumor → CT scan 2. gallstone → ERCP |
| 1. MC breast tumor in women under 25 2. MC breast mass in postmenopausal women 3. MC breast mass in premenopausal women | ?? 1. fibroadenoma 2. invasive ductal carcinoma 3. fibrocystic change |
| What are the indications for surgery due to GERD? What surgery is needed for each indication? | 1. ulcerations/stenosis - laparoscopic Nissen fundoplication 2. dysplastic change - resection |
| First diagnostic maneuver if a patent is actively bleeding per rectum. | check upper GI tract first with NG tube to aspirate gastric contents |
| What is the treatment for: 1. pyogenic abscess 2. amebic abscess 3. Hydatid cyst | 1. percutaneous drainage 2. metronidazole 3. surgical resection under cover of albendazole (aspiration risks anaphylaxis) |
| What is a pseudocyst? | collection of pancreatic juice |
| Most sensitive laboratory test for malabsorption from chronic pancreatitis. | stool elastase |
| Young woman with blood nipple discharge? | intraductal papilloma |
| Treatment for ductal carcinoma in situ 1. multicentric lesions 2. confined to one quarter of the breast | 1. simple mastectomy with sentinel node biopsy 2. lumpectomy followed by radiation |
| What chemotherapy agents are given after breast surgery to: 1. postmenopausal females 2. premenopausal females | 1. anastrozole 2. tamoxifen |
| Thyroid nodule in a hyperthryoid patient 1. workup 2. treatment | 1. TSH, T4 first then nuclear scan to see if nodule is the source of hyperyhtroidism 2. radioactive iodine |
| Workup of thyroid nodule in a euthyroid patient | FNA |
Created by:
amichael@siumed.edu
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