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General Surgery

Surgery

QuestionAnswer
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