Case Files Flashcards
What are the locoregional treatments for breast cancer
surgery and radiation therapy
what are the systemic treatments for breast cancer
chemotherapy and antiestrogen therapy
What is involved in the initial work-up for breast cancer
bilateral mammography and core needle biopsy or fine needle aspiration
What investigations (3) should be performed in a patient with stage I or II breast cancer to query mets?
CBC, LFTs, CXR
What investigations (6) should be performed in a patient with stage III breast cancer to query mets
CBC, LFTs, CXR
Bone scan, abdominal CT, brain CT
Patients with stage II or greater breast cancer should also be offered what treatment following locoregional therapy
Systemic Chemotherapy
Name the two common chemotherapy regimens used in breast cancer (Hint: FAC, AC)
1) 5-fluorouracil, doxorubicin (adriamycin), cyclophosphamide
2) Adriamycin, cyclophosphamide
What therapy is provided for estrogen or progesterone receptor positive tumors following treatment? How long is it provided?
Antiestrogen therapy (Tamoxifen), 5 years after
What is Tamoxifen used for and what is a negative clinical outcome of its use?
Antiestrogen drug used in breast cancer, associated with development of uterine cancer
What drug can be added to a chemotherapy regimen in a HER2/neu-receptor positive breast cancer?
Trastuzumab
On endoscopy a patient is seen to have a replacement of normal squamous epithelium of the distal esophagus with columnar epithelium with intestinal metaplasia. What is the diagnosis
Barrett’s esophagus secondary to GERD
List the extraesophageal complications of GERD (4)
1) laryngitis
2) reactive airway disease
3) recurrent pneumonia
4) pulmonary fibrosis
What is the risk of long-standing Barrett’s esophagus?
adenocarcinoma of the esophagus
What 4 tests should ideal be undertaken prior to antireflux surgery for GERD
1) endoscopy
2) manometry
3) 24-hour pH probe
4) barium esophagography
What are the medical treatments for GERD (3)?
PPI > H2 blocker > antacid
What is the standard surgical procedure for GERD
Nissen fundoplication (repair of hiatal hernia)
What are the inidcations for surgery for GERD (3)?
1) persistent symptoms with max-dose PPI
2) patient intolerant to PPI
3) patient does not wish to take lifelong meds
A patient presents with chest pain, subcutaneous emphysema, left pleural effusion, and pneumomediastinum after a period of severe vomiting. What is the Dx?
Spontaneous esophageal rupture (Boerhaave Syndrome)
What is the approach to treatment for an esophageal rupture (4)
1) ABCs
2) chest tube
3) Abx and fluids
4) Surgery (
What is the preferred method for diagnosing esophageal rupture? What is the most sensitive test for Diagnosis?
1) Water-soluble contrast study (Gastrografin)
2) Barium esophagogram
What are some risk associated with esophageal rupture if the diagnosis is made late (3)?
1) mediastinitis
2) fever, leukocytosis
3) death
Describe the ABCDE approach to malignant melanoma
A - asymmetry B - irregular borders C - color change D - diameter increase E - elevation
what two types of melanoma have the best prognosis? Why? How common are they?
1) superficial spreading and lentigo maligna
2) long radial growth phase
3) 1st and 3rd most common
What are the two types of melanoma that have the worst prognosis? why? how common are they?
1) nodular sclerosis and acral lentiginous
2) aggressive vertical growth phase
3) 2nd and 4th most common
What is the work-up and treatment for patient with suspect malignant melanoma (3 steps)
1) excisional or incisional biopsy
2) SLN biopsy if positive
3) surgical resection with wide margins
What are the symptoms of BPH (6)?
1) Urgency
2) weak stream
3) nocturia
4) intermittency
5) Hesitancy
6) incomplete voiding
What are the medical therapies for BPH (classes)? What are their mechanism of action?
1) alpha-1-agonist agents - relaxes smooth muscle of prostate
2) 5-alpha reductase inhibitor - inhibits testosterone metabolism
What is the surgical treatment for BPH?
Transurethral resection of the prostate
What tests should be performed to confirm the diagnosis of BPH and what other conditions must be ruled out? (4)
1) review of systems - r/o neuorologic cause
2) urinalysis - r/o UTI and bladder cancer
3) PSA and serum creatinine - r/o severe prostatism with renal involvement
4) DRE - r/o prostate cancer
what are some SSx expected in prostate cancer (3)?
1) firm/hard nodule on DRE
2) elevated PSA value
3) misshappen gland on DRE
What are the most common causes of small bowel obstruction in a child (6)
1) hernia
2) malrotation
3) meconium ileus
4) Meckel diverticulum
5) intussusception
6) intestinal atresia
What are the most common causes of small bowel obstruction in an adult (5)?
1) adhesion
2) hernia
3) Crohn’s
4) gallstone ileus
5) tumor
How can an uncomplicated small bowel obstruction be treated (4)?
1) NPO
2) fluid resuscitation
3) NG tube
4) serial labs and radiographs
What are the SSx of a complicated small bowel obstruction (5)?
1) persistent pain
2) fever/leukocytosis
3) tachycardia
4) elevated amylase
5) radiographic signs of obstruction
How should a complicated small bowel obstruction be treated
urgent laparotomy
What are some complications of complicated small bowel obstruction (3)?
1) strangulation
2) necrosis
3) insufficient organ perfusion due to third spacing
Describe the mechanism of carpal tunnel and common physical findings (4)
compression of the median nerve
results in: paresthesia of radial 3 fingers, hand weakness, symptoms worse at night, may have muscle wasting in thenar region
Describe the diagnostic tests for carpal tunnel
Tinnel - reproduce paresthesia
Phalen - reproduces paresthesia
What is the conservative management of carpal tunnel?
Night time splints and NSAIDs. May use steroid injections (limited to 2-3 per year)
What is the surgical management of carpal tunnel
Division of the flexor retinaculum
What endocrine disorders are associated with carpal tunnel
hypothyroidism, DM, hyperthyroidism, acromegaly, pregnancy
A patient presents with postprandial pain in their RUQ radiating to their labia. They are afebrile. U/S shows gallstones in the gallbladder, the common bile duct is not distended. All labs are normal. What is the Dx?
Biliary colic
What is the treatment for biliary colic?
elective cholecystectomy
A patient presents with RUQ pain that is persistent. They are mildly febrile, and have mild leukocytosis. Gallstones are seen in the gallbladder. There is no dilatation of the common bile duct. LEs are somewhat elevated. What is the Dx?
Acute cholecystitis
What is the treatment for acute cholecystitis (4)
1) NPO
2) IV fluids
3) Abx
4) cholecystectomy
A patient presents with postprandial abdominal pain, they are mildly jaundice. There are gallstones in the gallbladder and the common bile duct measures 6mm. LEs are elevated. What is the Dx?
Choledocholithiasis
What is the treatment for choledocholithiasis?
1) monitor for development of cholangitis
2) Endoscopic decompression of common bile duct
3) cholecystectomy
A patient presents with persistent epigastric and back pain. There are gallstones in the gallbladder, the common bile duct is dilated. Labs reveal leukocytosis, moderately elevated LEs, and markedly elevated amylase and lipase levels. What is the Dx?
Biliary pancreatitis
What is the treatment for biliary pancreatitis (3)?
1) NPO (bowel rest)
2) IV fluids
3) cholecystectomy
What are the clinical signs that indicate cholangitis (3)?
Charcot’s triad: RUQ pain, jaundice, fever
What is the treatment of cholangitis (3) ?
1) Abx
2) supportive care
3) ERCP decompression if severe
What are signs of an acute GI bleed (4)
1) Hx of hematemesis
2) coffee-ground emesis
3) melena
4) bleeding per rectum
What are signs of an occult GI bleed (1)
1) anemia with no signs or history of blood loss
What is the most important intervention to make in a patient with an acute GI hemorrhage?
Fluid resuscitation
What are the most common sources of non-variceal upper GI bleeds (4) ?
1) duodenal ulcers
2) gastric errosions
3) gastric ulcers
4) Mallory-Weiss tear
What is the most important investigation in a patient with an upper GI bleed
Confirmation with endoscopy (achieves diagnosis 90% of the time).
What are two methods used to achieve endoscopic hemostasis in upper GI bleeds?
1) epinephrine injection
2) thermotherapy
If NSAID use cannot be discontinued in a patient with an upper GI bleed, what therapy can be considered?
Use of prostaglandin analogue (misoprostol)
When is surgery indicated for peptic ulcer disease
PUD is massive/persistent/recurrent or a non-healing giant ulcer >3cm
What is the best method to rule out an upper GI bleed in a patient with suspected lower GI bleed
Place NG tube and aspirate - if non-bloody bilious aspirate detected, source is likely lower GI bleed
What type of “bloody stool” is expected in a bleed originating in the Upper GI tract, small bowel, or ascending colon?
Melena
What type of “bloody stool” is expected in a bleed originating in the transverse colon or descending colon, but not the anus or rectum
Maroon-coloured
What type of “bloody stool” is expected in a bleed originating from the anus or rectum?
Bright red blood stained stool or passage of blood following BM
Provide 3 modalities used to detect the location of bleed, provide them in order of sensitivity in detecting bleed and location of bleed and note any patient characteristics required prior to initiation of investigation.
1) Colonoscopy - most sensitive - patient must be hemodynamically stable
2) Mesenteric angiography - patient not required to be stable
3) Tagged RBC - detect bleed, but not location - patient does not need to be stable
What are the most common causes of painless lower GI bleed in an adult (3)
1) diverticulosis
2) Angiodysplasia
3) neoplasm
What are the most common causes of painful lower GI bleed in an adult (4) ?
1) ischemic bowel
2) IBD
3) intussusception
4) rupture abdominal aneurysm
What are the most common causes of lower GI bleed in children (3) ?
1) Meckel’s
2) IBD
3) polyps
Following vascular abdominal surgery, there is a risk of aortoenteric fistula. What is the associated clinical sign that would indicate this pathological process?
painless hematochezia
What are some benign breast changes not associated with increased risk of breast cancer (5)?
1) cysts
2) ductal ectasia
3) fibroadenoma
4) fibrosis
5) mild hyperplasia
What are some breast changes that are associated with increased risk of breast cancer (3)?
1) moderate or severe hyperplasia
2) atypical hyperplasia
3) positive family history
What chemoprevention agent can be used to prevent BC in high-risk patients? What is its mechanism of action?
Tamoxifen, antiestrogen (risk of uterine cancer and thromboembolism)
What pertinent points in a patients history (familial) increase their risk of breast cancer (4) ?
1) first degree relative with positive history
2) … worse if Dx was premenopausal
3) … worse if disease was bilateral
4) BRCA positive gene
What is the recommended screening program for a high-risk patient wrt breast cancer
Yearly mammogram after 35 or 5-10 years prior to index case.
A patient is recovered from a house fire and has a dry, red, and blistered oropharynx. What is the first step in treatment?
Intubate
What is the half-life of CO in the blood when a patient is on 100% oxygen?
40-60 minutes
How should fluid resuscitation proceed in a burn patient
1) If TBSA
Describe a third degree burn in terms of its affected location, characteristics, course, and treatment
1) fully through dermis
2) white or dark in appearance, painless
3) Heal via epithelial migration from periphery and contraction
4) excise and graft
List 4 creams/treatments used in treating burns. Provide their penetration depths and side effects.
1) silver salfadiazine - does not penetrate eschar
2) Sulfamylon - penetrates eschar, painful to apply and can cause metabolic acidosis
3) Silver nitrate - does not penetrate eschar, can cause hyponatremia and hypochloremia
4) Pig skin - growth factors promote epithelialization
A patient with peripheral vascular occlusive disease is also at risk of developing what other complications (2)
1) coronary
2) cerebral
A patient has an ABI of 0.5 in the left leg. What symptoms would be present (2)? Are pulses palpable?
1) claudication and exertional pain
2) pulse will certainly be diminished, they may be absent
A patient has an ABI of 0.3, what is the likely treatment?
bypass (also lifestyle modifications)
A patient has an ABI
1) gangrene
2) amputation
What are the 2 surgical interventions used in peripheral vascular occlusive disease, and what are their indications?
1) angioplasty - best for short, focal, and concentric stenosis
2) Bypass - if lesions are numerous and diffuse, then bypass is best. Bypass also used if vessel is occluded.
Bypass has a better success rate when done: proximally or distally?
Proximally
In penetrating thoracoabdominal trauma a CXR should be obtained, what four signs should you look for?
1) pneumothorax
2) hemothorax
3) pericardial effusion
4) intra-abdominal free air
What signs are indications for celiotomy in penetrating abdominal trauma
rigidity, guarding, or significant tenderness distal to the stab wound
Provide five diagnostic approaches to penetrating wound injuries
1) observation
2) local wound exploration
3) diagnostic peritoneal lavage
4) CT
5) exploratory laparotomy
What are the indications for ‘observation’ as treatment in the case of penetrating wound injury
Patient is stable. Observe for 24-48 hours for peritoneal findings or hemodynamic instability.
What are the indications for local wound exploration? When do the findings indicate the need for further exploration?
Patient is stable. Penetration of the anterior abdominal fascia indicates need for further investigation.
When are the findings of diagnostic peritoneal lavage considered positive (4)
1) 10 ml of blood on aspiration
2) aspiration of fecal contents
3) 100,000/mm3 RBC on lavage
4) >500/mm3 WBC on lavage
Diagnostic peritoneal lavage and CT scan are not sensitive in detecting what injury?
Diaphragmatic injury
Diagnostic laparoscopy is not sensitive in detecting what injury? If this injury is suspected, what method should be used to investigate?
Hollow viscus injury
Investigate with celiotomy is suspected
What 3 diagnostic tests can be used to investigate traumatic rupture of the aorta
1) aortogram
2) CT angio
3) TEE
What is the appropriate surgical treatment for aortic rupture
exploration and repair
What is a concern with pulmonary contusion? How is it treated (3) ?
Patient at risk for shunting and hypoxia Tx: 1) supportive care 2) intubation 3) fluid restriction (to reduce edema, provided patient's volume status is appropriate)
What are the radiographical findings indicating aortic rupture (3) ?
1) widened mediastinum
2) left pleural effusion
3) loss of aortic knob
Describe the typical presentation of acute appendicits (5) ?
1) vague pain in periumbilical region
2) N/V
3) urge to defecate
4) gradual localization of pain to the right lower quadrant with localized peritonitis
5) perforation within 24 hrs in 20% of cases
What % of patients with appendicitis present with the typical presentation?
50%
What is required in terms of investigations to diagnose patients with the typical presentation of appendicitis (4)?
1) H&P
2) CBC with diff
3) urinalysis
4) pregnancy test
What are the diagnostic options for patients with atypical findings but clinical suspicion of acute appendicitis (4)
1) CT
2) U/S
3) Observation and serial labs
4) Diagnostic laparoscopy
When is CT indicated for use in diagnosing acute appendicitis (3)?
1) atypical presentation
2) signs of inflammatory process (pain, fever, leukocytosis)
3) Gynecologic pathology not suspected (in females)
When should U/S be used when investigating acute appendicitis?
There is suspicion of gynecologic involvement in a female patient. U/S is more sensitive at detecting pelvic pathology than CT.
When should observation and serial labs be used when investigating acute appendicitis (2)?
1) Disease is clinically suspected
2) No current signs of pain, fever, leukocytosis
When is diagnostic laparoscopy indicated when investigating for acute appendicitis?
Inflammatory process of unknown source present
What is the typical treatment for patients with a confirmed DVT? confirmed PE? who are otherwise healthy?
1) DVT - heparin for systemic anticoagulation with 3 months treatment of warfarin
2) PE - heparin for systemic anticoagulation with 6 month treatment of warfarin
What is the treatment for a patient with confirmed PE and documented hypercoagulability?
Lifelong treatment with anticoagulants (warfarin)
When is thrombolytic treatment indicated for PE/DVT
1) Massive PE. No contra-indications present - recent surgery or severe closed head injury (
Which has a higher likelihood of developing into a PE: a proximal DVT or distal DVT?
Proximal
What are the clinical signs (2) and lab findings (WBC, EKG, CXR, and cardiac enzymes) in a case of PE?
1) SOB
2) Chest pain
3) All labs normal
What is a contraindication to heparin use in PE?
heparin induced thrombocytopenia
What is the gold standard diagnostic test for PE. What is the next best option and what are its limitations?
Pulmonary angiography (high M&M rates) CT Pulmonary angiography (good at detecting large vessel PEs, insensitive to subsegmental PEs)
What are the recommendations for colon cancer screening. When should they be repeated if positive findings?
Colonoscopy every 10 years from age 50.
If adenomatous polyp identified and removed, repeat colonoscopy in 3 years. Once clear, investigate every 5 years.
What a some clinical symptoms associated with colorectal cancer (4)
1) rectal bleeding
2) change in bowel habits (caliber, diarrhea)
3) obstruction
4) perforation with peritonitis
What sign is more common in patients with right sided colon cancer?
Anemia (patients less likely to suffer from obstruction or change in caliber of stool)
What is the appropriate met work-up in patients with colorectal cancer (2), and what is done for invasive adenocarcinomas?
1) CXR
2) CT abdomen and pelvis
3) resection of the colon (extent depends on blood supply and lymph drainage)
What is provided to patients with colon cancer with nodal involvement following ressection (Stage III disease)?
Adjuvant chemotherapy - 5-fluorouracil, leucovorin, oxaliplatin
Describe the difference between a low anterior resection (LAR) and an abdominoperineal resection (APR) in the treatment of rectal cancer?
LAR spares the anal sphincter complex allowing for anastomoses. ARP requires permanent colostomy.
What treatment is provided to patients with invasive rectal carcinoma prior to surgery?
Neoadjuvant chemoradiotherapy
What tumor marker is tracked for follow-up in patients with a positive history for colorectal cancer?
carcinoembryonic antigen (CEA)
Provide 4 patient groups at high risk of colorectal cancer in order of most at risk to least at risk.
Familial adenomatous polyposis (FAP), familial cancer, hereditary nonpolyposis colorectal cancer (HNPCC), history of IBD (UC).
What are signs and symptoms suggestive of a soft tissue sarcoma in the extermities (4)?
1) mass greater than 5cm in diameter
2) no history to indicate hematoma
3) firm and non-tender
4) No skin changes indicating infection or inflammation
What is the first step in working up a soft tissue sarcoma
core or fine needle biopsy
What are favorable characteristics of a soft tissue sarcoma that indicate a positive prognosis (3)?
Size
What is the standard treatment for soft tissue sarcomas
wide local resection to achieve negative margins. Radiation therapy for stage 2 or 3 disease.
Where do soft tissue sarcomas typically metastasize to?
Lung
Provide 5 (2 physical and 3 genetic) factors that predispose a patient to sarcomas
1) prior chemo or radiation
2) lymphedema
3) Neurofibromatosis
4) Retinoblastoma
5) Familial polyposis coli
What is the first step in working up a thyroid nodule?
Fine needle aspiration
Fine needle aspiration of a thyroid nodule reveals a follicular (cellular) histology. What are the next steps (2)? What finding is more suggestive of carcinoma?
1) Review TSH - operate if it is normal or high
2) Perform radioactive iodine take-up test
3) “cold” nodules at higher risk of carcinoma
List 3 pertinent findings that increase the likelihood a thyroid nodule is carcinogenic?
1) Positive Hx of head or neck irradiation (40% likelihood)
2) “Cold” nodule on radioactive iodine test (20% likelihood)
3) Positive FamHx of MEN2 carcinomas
When is surgery indicated on a benign thyroid lesion?
compressive symptoms present - trachea, esophagus, recurrent laryngeal function disrupted
What population is at highest risk of primary spontaneous pneumothorax? What is the cause?
Tall, thin, young males (+/- smokers). Due to rupture of subpleural belbs.
What are the risk factors for secondary spontaneous pneumothorax (5)
1) Occur in patients >50
2) COPD
3) Neoplasm
4) infection (TB)
5) CF
When is surgery indicated for first-time spontaneous pneumothorax (5)?
1) significant air leakage (3+ days)
2) lung fails to re-expand
3) patient at high recurrence risk (past contra-lateral involvement, bullous disease)
4) patient lives in remote air
5) Patients occupation (scuba diver, pilot)
Surgery is indicated after how many episodes of primary spontaneous pneumothorax?
after 2nd recurrence (3 episodes)
What features are associated with acute lung injury (4)?
1) acute onset
2) PaO2:FiO2
Provide some lung pathologies that are included under the umbrella of acute respiratory insufficiency (7)?
1) aspiration
2) pneumonia
3) PE
4) lung contusion
5) ARDS
6) Atelectasis
7) Cardiogenic pulmonary edema
Provide 4 clinical manifestations of acute respiratory distress syndrome (ARDS)
1) PaO2:FiO2
What are the 3 phases of wound healing and what significant steps occur in each?
1) Inflammation - sterilize wound site. Growth factors for fibroblasts and keratinocytes
2) Proliferation phase - fibrin-fibrinogen matrix
3) Remodeling phase - less vascular, collagen cross-linking, increased strength
Provide clinical factors (4) and technical factors (2) that contribute to fascial dehiscence
1) infection
2) nutrition
3) corticosteroids
4) DM
5) failed surgical technique
6) light anesthetic
What sign indicates the presence of fascial dehiscence. When is surgery indicated (3)?
Drainage of serous or serosanginous fluid
1) risk of evisceration
2) risk of enterocutaneous fistula
3) Sepsis
Differentiate secondary from tertiary peritonitis
secondary - peritonitis due to spillage of microbes into the peritoneum during perforation or following surgery. Can result post-operatively due to insufficient Abx administration.
Tertiary - diminished host response resulting in peritonitis despite corrective surgical or Abx intervention. Low virulence, opportunistic pathogens commonly seen (s. epidermidis, Candida)
What is at the top of the DDx for a febrile patient in the post operative period following abdominal surgery
Intra-abdominal infection
What is the treatment for secondary peritonitis (2)?
1) control source of microbial spillage
2) initiate pre-emptive antibiotic treatment against anaerobic and gram-negative aerobic bacteria
What diagnostic test is best for detecting an intra-abdominal abscess originating from a deep surgical space infection. What is the treatment (2).
CT of abdomen and pelvis
1) percutaneous drainage
2) open drainage if not accessible percutaneously
What is short bowel syndrome, what are its characteristics (4)
Loss of small bowel (
What is the treatment for short bowel syndrome?
Nutritional support - parenteral feeding with gradual shift to enteral feeding as bowel adapts.
What are some negative sequelae of parenteral feeding (4)
1) intestinal atrophy
2) IV line sepsis
3) cost
4) increase M&M (liver dysfunction)
What medical therapy can be used to support enteral feeding in short bowel syndrome (2)?
1) reduce gastric motility - loperamide, codeine phosphate
2) reduce gastric secretions - PPI, octreotide
What are the most common causes of short bowel syndrome in adults (2)?
1) Crohn’s disease
2) mesenteric infarction
What are the most common causes of short bowel syndrome in infants (2)?
1) Necrotizing enterocolitis
2) small bowel volvulus
what type of liver tumor is associated with oral contraceptive use? What are the symptoms of this tumor (2)? what is the corrective treatment
Hepatic adenoma
1) hemorrhagic
2) can undergo malignant transformation
Tx: surgical resection
What are the two most common benign liver tumors? When is surgical resection indicated?
Hemangioma - surgery indicated if mass effect present (pain), unable to rule out malignancy, or rupture
Focal nodular hyperplasia - mass produces symptoms, malignancy cannot be ruled out
What type of liver tumor should never be biopsied?
Hemangioma - risk of hemorrhage
Angiography is the appropriate imaging modality in which types of liver tumors (2)?
Hemangioma and focal nodular hyperplasia
What is the gold standard imaging modality for metastatic adenocarcinoma?
CT angioportography
What is the gold standard imaging modality for hepatocellular carcinoma?
Laproscopic U/S
which liver tumors should be biopsied (3)?
1) adenoma
2) hepatocellular carcinoma
3) metastatic adenocarcinoma
What type of cancer most commonly causes secondary liver tumors?
colorectal cancer
What are the tumor markers for hepatocellular carcinoma (2)?
AFP and Ferritin
What are some SSx of diverticulitis (4)?
1) LLQ pain
2) fever/leukocytosis
3) tachycardia
4) peritonitis
How is uncomplicated diverticulitis treated (2)?
1) Nonoperative, outpatient basis
2) Nonoperative, admission to hospital, IV Abx, bowel rest, observation
When should patients with uncomplicated diverticulitis be considered for surgery (3)?
1) immunocompromised
2) age
How is complication diverticulitis treated? What are some complications associate with complicated diverticulitis (3)?
Surgical resection of sigmoid colon
1) Perforation with local fluid collection or abscess
2) Intestine obstruction due to inflammatory process or stricture
3) Diverticular fistulas (bladder, vagina, skin, bowel)
What is the most common cause of GI tract fistulas?
Diverticulitis
What is the critical diameter for repairing an AAA
> 5cm
What are the two treatment options for repairing an AAA? When are they used?
1) Open repair - gold standard
2) Endovascular aneurysm repair (EVAR) - used in patients who have increased risk of complications during open repair (CAD, COPD…)
What are the clinical signs of AAA rupture (3)?
1) back pain
2) hypotension
3) pulsatile epigastric mass
What are the 2 most common cause of pancreatitis?
alcohol intake and gallstones
What is the clinical picture for pancreatitis (3) and what are some relevant lab findings (2).
1) Severe epigastric pain radiating to the back
2) N/V
3) Fever
4) elevated amylase and lipase
Provide the ranson criteria that predict prognosis for pancreatitis on admission (5)?
1) WBC >16
2) glc >200
3) Age >55
4) AST > 250
5) LDH > 350
What should be provided when necrotizing pancreatitis is noted on abdominal CT?
IV Abx (imipenem/cilastatin) for presumed associated infectious process.
Outline the treatment of acute pancreatitis (5)
1) IV fluids
2) maintain ventilation (adequate O2)
3) Ensure organ perfusion (renal)
4) Gastric decompression via NG tube
5) CT scan if not resolved in 3-5 days, ?necrosis -> IV Abx
What is indicated in gallstone pancreatitis with elevated bilirubin?
ERCP to decompress with cholecystectomy before discharge.
What are the most common causes of bloody nipple discharge pathologically. Are they benign or malignant
1) intraductal papilloma - benign
2) Duct ectasia - benign
3) Carcinoma - malignant
What should be the work-up for bloody nipple discharge?
bilateral mammography and U/S to R/O cancer.
In a premenopausal woman, what test should be done first if the patient complains of nipple discharge
pregnancy test
What tumor can increase prolactin levels leading to milky white breast discharge?
pituitary adenoma
What is the work-up and treatment in suspect diffuse papillomatosis disease of the breast?
Ductogram, excision (increased BC risk)
What are the SSx of breast carcinoma (4)?
1) bloody or serous nipple discharge
2) inverted nipple
3) skin changes
4) new mass
What are the five most common sites that lung cancer metasize to?
1) contralateral lung
2) liver
3) adrenals
4) Brain
5) Bone
Which type of lung cancer has a more favourable prognosis?
non-small cell
What is the most common presenting factor in patients with a primary lung cancer?
cough
Treatment of early stage non-small cell lung cancer in a patient who is otherwise healthy and has sufficient PFTs is what?
Surgical resection
What is the treatment of a patient with late stage non-small cell carcinoma or extensive small cell carcinoma?
palliative chemo and radiation
What is the treatment for stage III non-small cell lung cancer or limited small cell carcinoma?
definitive chemo and radiation
What are the common types of periampullary cancers (4)
1) cancer of the pancrease
2) distal bile duct cancer (cholangiocarcinoma)
3) duodenal cancer
4) Cancer of the ampulla vater
What treatment is indicated for patients with tumor or benign disease localized to the area surrounding the ampulla of Vater?
Whipple resection
What are common SSx of cancers of the pancreatic head (5)?
1) obstructive jaundice
2) weight loss
3) DM
4) abdominal pain
5) gastric outlet obstruction
In patients with locally advanced or metastatic pancreatic cancer that are jaundiced and itchy, what treatment should be offered to them?
Stenting to improve biliary obstruction
What is the physiological mechanism that causes the electrolyte imbalances in hyperparathyroidism?
PTH inhibits resorption of phosphorus and bicarb in the renal tubule. Increase chloride resorption due to increased bicarb excretion.
What are the electrolyte imbalances seen in primary hyperparathyroidism (5)
1) high Ca
2) high Cl
3) low Bicarb
4) low phosphorus
5) Cl:Phos level > 33:1 indicates primary hyperparathyroidism
What are the 2 most common causes of hypercalcemia?
Primary hyperparathyroidism and malignancy
The urine output in primary hyperparathyroidism is high or low? What is the PTH level?
High. If low, it is familial hypocalciuric hypercalcemia. PTH is high in both disease.
What are the renal, CV, and GI complications of hyperparathyroidism?
renal - stones
CV - HTN, LVH, calcification of myocardium and left valves
GI - peptic ulcer, pancreatitis
How is hyperparathryoidism Dx (2)?
1) lab findings
2) high intact PTH level
What is the treatment for hyperparathyroidism and when is it indicated (2)?
parathyroidectomy
indications - symptomatic patients, or asymptomatic patients
What are the SSx of chronic mesenteric ischemia (2), what is the most common cause?
1) food fear, post-prandial pain
2) significant weight loss
3) atherosclerotic occlusive disease
How is chronic mesenteric ischemia Dx (3)?
1) ateriography (gold standard)
2) MRA
3) Duplex
How is chronic mesenteric ischemia Tx (3)?
Revascularize
1) antegrade aortomesenteric bypass
2) aortic endarterectomy
3) retrograde bypass from iliac artery
Describe acute mesenteric ischemia (3)
1) surgical emergency
2) affects SMA
3) laparotomy
List some major clinical predictors of cardiac complications in a preop patient (4)
1) unstable coronary syndrome
2) decompensated CHF
3) significant arrhythmia
4) severe valvular disease
List some moderate clinical predictors of cardiac complications in a preop patient (4)
1) Mild angina
2) prior MI
3) compensated or Hx of CHF
4) DM
List some minor clinical predictors of cardiac complications in a preop patient (5)
1) Age
2) abnormal EKG
3) non-sinus rhythm
4) low functional capacity
5) HTN (uncontrolled)
Describe the SSx for peptic ulcer disease (3)
1) epigastric abdominal pain (constant)
2) improves with food
3) worse at night or in morning
Describe the types of gastric ulcers and their relation to acid secretion (5)
1) Type 1 - occurs on lesser curvature, little acid
2) Type 2 - same location as type 1, often duodenal involvement, high acid
3) Type 3 - 2cm to pylorus (prepyloric), high acid
4) Type 4 - 2cm to gastroesophageal junction, low acid
5) Type 5 - drug induced (NSAIDs)
What types of gastric ulcers have the highest risk of complications (obstruction, perforation, hemorrhage)?
The ones associated with high acid output - type 2 and 3.
What are two etiologies of duodenal ulcers?
H. Pylori and NSAID use
What are some diagnostic tests that can be used for H. pylori (4)?
1) serum study
2) urea breath test
3) rapid urease assay
4) biopsy with culture and histology
H pylori is best erradicated with triple therapy of 2 weeks using either OAC, OMC, or OAM. What are these drugs?
O - omeprazole (PPI)
A - azythromycin
M - metronidazole
C - clarithromycin
What are the drugs used to treat gastric ulcers (4)?
1) PPI (best)
2) H2 antagonist
3) antacids
4) postaglandin analogues (misoprostol)
8-12 weeks treatment with maintenance therapy thereafter
When is surgery indicated on for gastric or duodenal ulcers (4)?
1) obstruction
2) perforation
3) intractable course - no resolution within 3 months, or recurrence within a year.
4) hemorrhage
Provide the treatment for intractable gastric ulcers depending on the type (4).
1) type 1 - distal gastrectomy (Billroth I)
2) Type 2 - vagotomy and Billroth I or II
3) Type 3 - same as type 2
4) Type 4 - ressection of ulcer, treatment is difficult
5) Type 5 - medical therapy only
When is a FAST scan used in favour of a CT scan in a trauma situation?
When the patient is hemodynamically unstable
What is a CT scan insensitive in detecting in trauma injuries?
Hollow viscous injuries
Name some SSx of myasthenia gravis (5), what disease is it commonly associated with?
1) ptosis
2) diplopia
3) dysarthria
4) dysphagia
5) respiratory complications
- associated with thymoma (15% of MG patients)
What is the treatment for myasthenia gravis (3)?
1) anticholinesterase drugs
2) glucocorticoids (prednisone)
3) immunosuppressive drugs (azathioprine, cyclophosphamide)
What is the most common mediastinal tumor, where is it located?
Neurogenic tumors, located in posterior mediastinum
What is the Dx and Tx of thymoma?
Anterior surgical resection is both diagnostic and therapeutic. Consider chemo and radiation if thymoma in advanced stage. Biopsy rarely needed beforehand, CT and CXR useful in investigating extent of disease prior to resection.
What are the clinical findings when investigating for testicular cancer (3)?
1) nontender mass
2) not transilluminating
3) man
Describe the work-up for testicular cancer (3)?
1) H&P with U/S
2) investigate tumor markers AFP and BHCG
3) Investigate for mets - CT abdomen, CXR
What is the treatment for confirmed testicular cancer? How does this change if the cell type is confirmed to be a seminoma?
Radical (inguinal) orchiectomy
- Seminomas are very sensitive to chemo/rad, treat with neoadjuvant therapy and then surgically resect if disease is advanced enough to require.
Where does testicular cancer metastasize to first?
retroperitoneal lymph nodes
What is the most common type and subtype of testicular cancer?
1) germ cell (vs. stromal cell)
2) Seminoma
What are the SSx of an anal fissure (3)?
1) Intense pain with defecation
2) constipation
3) anoderm tear in posterior anal canal
Provide the 4 grades of internal hemorrhoids
1) grade 1 - hemorrhoid visible on inspection
2) grade 2 - hemorrhoid prolapses but reduces spontaneously
3) grade 3 - hemorrhoid requires manual reduction
4) grade 4 - nonreducible hemorrhoid
Provide the four types of fistula-in-ano based on the Parks criteria
extrasphinteric, transsphincteric, suprasphincteric, intersphincteric
What is the treatment for anal fissures (4)?
1) sitz bath
2) stool softener
3) NG
4) internal sphincterotomy
What are the treatment for hemorrhoids as per their grade (4)?
1) G1 - diet change
2) G2 - diet, band ligation
3) G3 - band ligation, hemorrhoidectomy
4) G4 - hemorrhoidectomy
What is the treatment for fistula-in-ano (2)
1) drainage
2) fistulotomy
An adrenal incidentiloma is found on CT in a patient, what is the DDx, what is the most likely diagnosis (4)?
1) nonfunctioning adenoma (most likely)
2) functioning adenoma - pheochromocytoma, aldosterone-producing adenoma, cortisol-producing adenoma
3) Neoplasm - adrenocortical carcinoma, metastases
4) Other - myelolipoma, cysts, hemorrhage
What is the most common cancer that produces mets to the adrenal gland?
lung
Describe some of the clinical SSx that would be expected in the different types of functional adrenal adenomas (3)?
1) pheochromocytoma - hypertension, headache, palpitations, sweating (profuse)
2) aldosterone-producing adenoma - few SSx. Headache, HTN, muscle cramps and weakness
3) Cortisol-producing adenoma - (Cushing’s). truncal obesity, moon facies, thin extremities, fat pad, hirsutism, bruising, abdominal striae
Describe the assessment of the 3 types of functional adrenal adenomas?
1) pheochromocytoma - 24-hour urine for metanephrine, normetanephrine, and VMA. Or plasma free metanephrine levels.
2) aldosterone-producing adenoma - serum potassium (low), serum aldosterone (high), serum renin (low)
3) cortisol-producing adenoma - 1mg dexamethasone suppression test.
What are the steps in working-up and adrenal incidentiloma found on CT (4)?
1) functional assessment (pheo, aldos, cort)
2) anatomic assessment (CT or MRI)
3) PET scan in patient with known cancer
4) FNA only if solitary non-functioning lesion
What are some CT findings that may indicate an adrenal mass if malignant (5)?
Suspect adrenocortical carcinoma if:
1) irregular margins
2) inhomogenous density
3) areas of decreased attenuation
4) local invasion
5) size >6cm
When is surgery indicated for adrenal incidentilomas (5)?
1) all functioning tumors
2) nonfunctioning tumors >4cm
3) tumors that are
What are the imaging investigation used to determine location of a pheochromocytome once biochemical tests are determined to be positive (2)?
1) CT/MRI
2) MIBG scan
What is the preoperative therapy provided to patients with pheochromocytoma (2)? What is the concern?
1) A-antagonist 2 weeks prior to surgery to resolve hypertension and correct reduced plasma volume
2) B-blocker to reduce reflex tachycardia associated with a-blockade
3) Concern is acute hypotension following resection.
What are the SSx of femoral hernias?
Generally asymptomatic, if symptoms occur consider incarceration of the hernia in the differential.
Describe the complications of a hernia (3)
1) Incarceration - bowel contents are trapped
2) strangulation - blood supply is compromised (ischemia, necrosis, perforation)
3) Obstruction can occur if incarcerated or strangulated
Describe the site of protrusion for the 3 common types of hernias
1) Indirect hernia - exit superior to inguinal ligament, lateral to inferior epigastric vessels
2) Direct hernia - exit through Hesselbach triangle, bound by inguinal ligament, inferior epigastric vessels, and rectus abdominus.
3) Femoral ligament - bound by the inguinal ligament superiorly, femoral vein laterally, and pubic ramus medially
What is the most common type of hernia?
Indirect inguinal
When is a prosthetic mesh contra-indicated in hernia repair
If bowel is compromised (risk of infection).
What tissue layers are typically effected by necrotizing soft tissue infections (NSTI) (2)?
1) subcutaneous fat
2) Dermis
What are the most important therapies for NSTI (2)?
1) Wide and rapid surgical debridement
2) Broad spectrum Abx (or Abx tailored to species following C&S)
What are the SSx of NSTI (3)?
1) Hx of minor trauma
2) edema beyond spread of erythema
3) Pain beyond severity of wound
What are the late findings of NSTI (3)?
1) crepitation
2) skin vesicles
3) focal necrosis
What species are most likely to cause a perineal presentation of NSTI?
mixed gram-negative aerobes and anaerobes
What species causes gas gangrene NSTI, what is the effective treatment?
Clostridial species, penicillin (?hyperbaric therapy)
What species produces a “flesh eating infection” (NSTI)? What is the appropriate treatment?
Group A streptococcus, clindamycin and penicillin.
What are the SSx of toxic shock syndrome in NSTI (4)?
1) mental obtundation
2) hyperdynamic shock
3) multiple organ dysfunction
4) pathologic response beyond severity of presenting wound
What does fournier gangrene affect? what is the causative agent?
1) Scrotum
2) streptococci species
What is the typical presentation of a Wilms tumor (2), what does it affect, and what age groups are most affected by it?
1) Palpable abdominal mass
2) Hematuria
3) Kidney
4) Age 1-5
Provide a system based DDx for abdominal masses in neonates (5)
1) Renal - hydronephrosis, Multicystic dysplastic kidney
2) Genital - ovarian mass/cyst/teratoma/torsion
3) GI - meconium ileus, mesenteric cyst
4) Retroperitoneal - adrenal hemorrhage, neuroblastoma
5) Hepatobiliary - hemangioendothelioma
Provide a system based DDx for an abdominal mass in children (
1) Renal - wilms tumor, hydronephrosis
2) retroperitoneal - neuroblastoma
3) GI - appendiceal abcess, intussusception
4) Hepatobiliary - hepatoblastoma, HCC
5) Genital - ovarian mass, undescended testicle
What is the treatment for a wilms tumor (3)?
1) surgical resection
2) chemotherapy
3) Radiation if tumor spillage occured
What is the most effective surgery for morbid obesity?
roux-en-y gastric bypass
what are the patient criteria necessary for consideration of gastric bypass surgery (3)?
1) failed diet, exercise, medical therapy
2) BMI >35 with comorbidity or BMI >40
3) commitment to postop diet modification, exercise, and follow-up
What are the clinical manifestations of ITP (5)?
1) ecchymoses
2) gum bleeding
3) purpura
4) excessive vaginal bleeding
5) GI bleed
What is the mechanism by which the spleen acts in ITP (2), what clinical finding suggests a different diagnosis
1) primary: production of antiplatelet IgG
2) secondary: sequestration and destruction of platelets
3) splenomegaly not typically seen in ITP
What is required to confirm the Dx of ITP (2)?
diagnosis of exclusion, must R/O other causes
1) low plt
2) bone marrow biopsy demonstrating normal or hypercellular megakaryocyte count
What are the functions of the spleen (2)
1) immune role - cellular and humoral immunity and phagocytic activity
2) blood filtering role - removal of erythrocytes and plts
What are the appropriate treatments for ITP (2)? What is a prognostic factor for surgical success?
1) corticosteroids
2) splenectomy
3) those who respond to corticosteroid therapy typically respond to splenectomy
What is the major complication of splenectomy? what are some SSx (5)? what are the causative agents and what is the prophylactic treatment (3)?
1) overwhelming postsplenectomy sepsis
2) malaise/headache/nausea/confusion -> shock and death
3) s. pneumo, h. influ, n. meningitidis (encapsulated bacteria)
4) provide vacine for pneumococcus, H. influ, and meningococcus
Chron’s disease can be either intra-abdominal, perianal, or both. Provide 3 pathologies associated with intra-abdominal and 3 associated with perianal disease
1) intra-abdominal: stricture, perforation, inflammation
2) perianal: anal stricture, fistulas-in-ano, abscesses
Describe the medical management approach to mild to moderate Crohn’s disease choosing from antimicrobial, anti-inflammatory, immunomodulatory, or anti-TNF treatments. Provide specific drug names, their role in treating active disease or as maintenance therapy, and 1 common side effect for each drug.
1) Antimicrobial therapy: metronidazole, used in active or maintenance therapy, SE: Nausea, poorly tolerated in long-term
2) Anti-inflammatory therapy: 5-ASA derivatives, maintenance therapy, SE: GI upset
Describe the medical management approach to moderate to severe Crohn’s disease choosing from antimicrobial, anti-inflammatory, immunomodulatory, or anti-TNF treatments. Provide specific drug names, their role in treating active disease or as maintenance therapy, and 1 common side effect for each drug.
1) Immunomodulators: corticosteroids, used to treat active flare-ups, not useful in maintenance therapy, SE: Cushing’s
2) Immunomodulators: Azathioprine and 6-MP, used for maintenance following corticosteroid treatment, SE: bone marrow suppression
3) Immunomodulators: Methotrexate, used to treat active disease or in maintenance, SE: Bone marrow suppression (reserved for patients who fail with AZT or 6-MP)
Describe the medical management approach to refractory Crohn’s disease choosing from antimicrobial, anti-inflammatory, immunomodulatory, or anti-TNF treatments. Provide specific drug names, their role in treating active disease or as maintenance therapy, and 1 common side effect for each drug.
1) Anti-TNF: infliximab, useful in refractory illness and in fistulizing perianal disease, SE: opportunistic infections
What are the surgical options for Chron’s disease (3), when are they indicated?
Surgery when disease refractory to medical treatment or when stricture is causing obstruction.
1) bowel resection
2) stricturoplasty
3) abscess drainage
When is surgery indicated for UC (5)?
1) fulminant colitis
2) toxic megacolon
3) dysplasia
4) cancer
5) refractory illness
What are the SSx of fulminant colitis (3)?
1) abdominal pain
2) fever
3) sepsis
How does toxic megacolon relate to fulminant colitis?
toxic megacolon = fulminant colitis + colonic distension (>6cm)
What is the treatment for fulminant colitis or toic megacolon (4)?
1) fluid resuscitation
2) IV Abx
3) maximize medical therapy
4) colectomy if condition does not respond to medical therapy
When a dysplastic-associated lesion or mass is found in an UC patient, what is the appropriate treatment?
colorectal resection
What are the clinical signs of UC (4)?
1) Mucosal involvement begins at anus and travels proximally
2) watery diarrhea
3) crampy abdominal pain
4) urgency
What are the extraintestinal manifestations of UC (6)?
1) ankylosing spondylitis
2) uveitis
3) scleroderma
4) sclerosing cholangitis
5) arthritis
6) hypercoagulable state
What are the broad medical categories of medical therapies used to treat UC (4)?
1) anti-inflammatory
2) antimicrobial
3) steroids
4) anti-TNF
What are 3 surgical procedures available for UC that eliminate the risk of rectal cancer?
1) total proctocolectomy with permanent ileostomy
2) total proctocolectomy with ileal pouch-anus anastomosis
3) total proctocolectomy with continent ileostomy
What is at the top of the DDx for unconjugated hyperbilirubinemia in a neonate? How is it treated?
1) hemolytic diseases
2) exchange transfusion
What are three pathological conditions that should be considered in conjugated hyperbilirubinemia in the neonate?
1) Biliary atresia
2) Choledochal cyst
3) Infection - TORCH
What are the clinical findings, studies required for Dx (4), and treatment for biliary atresia?
1) clinical: none specific, jaundice
2) Dx: HIDA scan, U/S, liver biopsy, intraoperative cholangiogram
3) Portoenterostomy (Kasai procedure)
What are the clinical findings, studies required for Dx (4), and treatment for choledochal cyst?
1) clinical: abdominal mass, possible cholangitis
2) Dx: U/S, HIDA
3) Hepaticojejunostomy
What does TORCH stand for with respect to jaundice in the neonate?
toxoplasmosis other agents rubella cytomegalovirus herpes simplex virus
What are three compllications that may be seen following surgical management of biliary atresia?
1) cholangitis
2) cessation of bile flow
3) portal hypertension
What are the SSx (3)of cholangitis following Kasai procedure for biliary atresia and what are the appropriate treatments (2)?
1) fever
2) leukocytosis
3) elevated bilirubin
4) steroids
5) Abx
