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USMLE2 Surgery 5


colon polyps - in which are malignant conversion more likely? 1. familial polyposis, 2. villous adenoma, 3. adenomatous polyp
colon polyps - which are benign? 1. juvenile polyposis, 2. Peutz Jeghers, 3. inflammatory, 4. hyperplastic
pneumatosis intestinalis a sign on x-ray which is highly suggestive for necrotizing enterocolitis. It refers to gas cysts in the bowel wall.
Tx for gastric adenoCA. Tx for Gastric lymphoma? surgery for Gastric adeno. Tx for lymphoma includes eradication of H pylori, chemo, and radiation.
Sx of CA for R colon. Sx for CA of L colon. How to tx each? What if rectum is involved? R colon: anemia in elderly, 4+ occult blood in stool. Tx with R hemicolectomy. L colon: bloody BMs where blood coats outside of the stool, constipation, stool with narrow caliber. L colectomy. If rectum involved, should so pre-op chemo and radiation.
Surgical indications for UC 1. >20 years --> high rate of malignant degeneration, 2. interfere with nutritional status, 3. multiple hospitalizations, 4. need high dose steroids or immunosuppressants, 5. toxic megacolon. Tx with removal of affected colon - always inc rectal mucosa.
When does pseudomembranous colitis require emergency surgery if WBC > 50K and serum lactate >5 --> emergency colectomy
nonhealing perianal fistula - what should you consider? Crohn's disease
child passes large bloody bowel movement. What is it and how to dx and tx? Meckel diverticulum. Dx w radioactively labeled technetium scan. Tx w resection of diverticulum if not complicated. If complicated, resect diverticulum PLUS area of bowel involved. Do not remove if it's just an incidental finding in another surgery.
elevated alpha-feto-protein in old man with cirrhosis and wt loss primary hepatoma
elevated CEA in 50 yo man with nodular liver and h/o colon CA liver mets from some other primary CA
xray in 80 yo pt showing distended bowel and large gas shadow that tapers into the shape of a parrot's beak. What is it and how to tx? volvulus. Proctosignoidoscopy to relieve the obstruction and leave a rectal tube in. Possible surgery to prevent recurrance.
pt with afib develops abdominal tenderness with acidosis and distended bowel consider mesenteric ischemia
24 yo woman on OCP's since age 14 bleeding into her abdomen hepatic adenoma --> rupture
regular liver abscess vs. liver abscess in someone who came from Mexico - what is the difference in management nl liver abscess should be percutaneously drained. Liver abscess from Mexico is from amoeba and so should tx with Metronidazole (dx with serology, not aspiration of the pus).
very high alkaline phosphatase and jaundice consider obstructive jaundice (maybe gallstones)
thin-walled distended gallbladder vs. thick-walled nonpliable gallbladder thin-walled (courvoisier terrier sign) - obstructive jaundice that has been chronic and growing - should consider CA; thick-walled usu due to gallstones
Tx for cholangioCA (CA in the common bile duct) curative surgery with Whipple (pancreatoduodenectomy)
acute ascending cholangitis. How to tx? gallstone in CBD --> obstruction --> infection. If very high WBCs and very very high alk phos --> indicates possible sepsis. Tx with IV abx and emergency decompression of CBD by ERCP or PTC.
biliary pancreatitis stone in the ampulla of Vater --> obstructs both pancreatic and biliary ducts
acute pancreatitis - edematous. How to tx? after heavy meal or bout of EtOH. Key is elevated Hct. Tx with NPO, NG suction, IVF
acute pancreatitis - hemorrhagic. How to tx? What must you anticipate? Lower Hct, Ca remains low despite repletion, Bun increased, metabolic acidosis, low PO2. Need to admit to ICU and do daily CT's to anticipate pancreatic abscesses to drain them.
Ranson criteria for pancreatitis: at admission "GA LAW": Glucose >200, AST >250, LDH >350, Age >55 y.o., WBC >16000
Ranson criteria for pancreatitis: initial 48 hours "C & HOBBS" (Calvin and Hobbes): Calcium < 8, Hct drop > 10%, Oxygen < 60 mm, BUN > 5, Base deficit > 4, Sequestration of fluid > 6L
Treatment of pancreatic pseudocyst <6 cm or less than 6 weeks --> observe for spontaneous resolution. >6cm or >6 weeks --> more likely to rupture or bleed --> drain cyst (to outside, to GI tract, or to stomach)
female pt in late teens/early 20s with firm, rubbery breast mass that moves easily with palpation. What is it, how to dx, and what is the tx? fibroadenoma. Dx with US or FNA. Tx with optional resection.
13 yo girl with giant juvenile fibroadenoma showing rapid growth. How to tx? resection to avoid deformity and distortion to the breast
female pt in late 20s with slowly growing breast mass that moves easily with palpation. What is it, how to dx, and what is the tx? Consider cystosarcoma phyllodes - most are benign, but they have potential to become outright malignant sarcomas. Dx with bx (not FNA) and resection is mandatory
Pt with BL breast tenderness that is related to menstrual cycle, with multiple lumps that come and go. What is it, how to dx, and what is the tx? Mammary dysplasia - cysts. If there is no dominant mass, only need mammo. If there is a persistent mass, aspiration --> bx if not cured --> cytology if bloody fluid.
Woman in 20's to 40's with bloody nipple discharge. What is it, how to dx, and what is the tx? Intraductal papilloma. Do mammo which will be neg. Can then do galactogram --> resection.
Lactating woman with breast abscess. How to dx and tx? bx (r/o CA) and I&D.
How is breast CA dx and tx differently in pregnancy? Dx and Tx the same as if there were no pregnancy except no radiation at all, and no chemo in first trimester.
Tx of resectable breast CA [if tumor is small in large breast and away from nipple and areola - lumpectomy + axillary sampling + post-op radiation] OR modified radical
what is the most common form of BrCA? Infiltrating ductal CA
what type of BrCA has the worst prognosis? Inflammatory
What BrCA has the highest incidence of affecting both breasts? lobular
How to tx ductal CA in situ? total simple mastectomy if multicentric lesions throughout the breast (will not metastasize but will recur if not mastectomy); lumpectomy + radiation if lesion is confined to 1/4 of the breast
What causes a breast CA to be non-operable? extent of local invasion
Where does BrCA metastasize to? Brain and bone (vertebrae)
Created by: christinapham



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