Case Files Review

Question 1

Radiation tx to the liver

Answer 1

should not be done since the liver is highly susceptible to radiation injury

Question 2

PET scan infections vs. tumors?

Answer 2

both will come up as positive on a PET since they take up glucose

Question 3

Silent Aspiration

Answer 3

Complication of GERD and other patients suffering from dysphagia. Patients will aspirate stomach fluid etc into the windpipe but never cough.

Question 4

Complications of GERD

Answer 4

Barrett’s Esophagus Peptic Stricture (esophageal stricture from gastric reflux)

Question 5

Nissen Fundoplication

Answer 5

Surgical treatment for GERD and paraesophageal hiatal hernia in which the fundus of the stomach is wrapped around the LES.

Question 6

Ranitidine

Answer 6

H2 blocker H2 blockers are not as effective in treating GERD symptoms as PPIs

Question 7

First step in workup for middle aged woman with substernal and vague upper abdominal discomfort refractory to antacids?

Answer 7

Cardiac workup, before GI consult

Question 8

Efficacy of Medical vs surgical management of GERD?

Answer 8

IT seems as though they are equally efficacious (Nissen vs PPI). However, Nissen is likely indicated when GERD is refractory to high dose PPI, but in these scenarios another dx for symptoms should be strongly considered.

Question 9

Boerhaave Syndrome

Answer 9

Aka “spontaneous rupture of the esophagus.” Classic HPI is a patient retching which is followed by severe chest pain. May lead to pneumomediastinum, pleural effusions (usually L-sided), pneumothorax, and systemic infection.

Question 10

Gastrografin

Answer 10

the substance used for water soluble esophograms which is best for Boerhaave Syndrome since it will not irritate the mediastinum.

Question 11

Radiation tx to the liver

Answer 11

should not be done since the liver is highly susceptible to radiation injury

Question 12

PET scan infections vs. tumors?

Answer 12

both will come up as positive on a PET since they take up glucose

Question 13

Silent Aspiration

Answer 13

Complication of GERD and other patients suffering from dysphagia. Patients will aspirate stomach fluid etc into the windpipe but never cough.

Question 14

Complications of GERD

Answer 14

Barrett’s Esophagus Peptic Stricture (esophageal stricture from gastric reflux)

Question 15

Nissen Fundoplication

Answer 15

Surgical treatment for GERD and paraesophageal hiatal hernia in which the fundus of the stomach is wrapped around the LES.

Question 16

Ranitidine

Answer 16

H2 blocker H2 blockers are not as effective in treating GERD symptoms as PPIs

Question 17

First step in workup for middle aged woman with substernal and vague upper abdominal discomfort refractory to antacids?

Answer 17

Cardiac workup, before GI consult

Question 18

Efficacy of Medical vs surgical management of GERD?

Answer 18

IT seems as though they are equally efficacious (Nissen vs PPI). However, Nissen is likely indicated when GERD is refractory to high dose PPI, but in these scenarios another dx for symptoms should be strongly considered.

Question 19

Boerhaave Syndrome

Answer 19

Aka “spontaneous rupture of the esophagus.” Classic HPI is a patient retching which is followed by severe chest pain. May lead to pneumomediastinum, pleural effusions (usually L-sided), pneumothorax, and systemic infection.

Question 20

Gastrografin

Answer 20

the substance used for water soluble esophograms which is best for Boerhaave Syndrome since it will not irritate the mediastinum.

Question 21

Therapy for BPH

Answer 21

Initial Tx: alpha1-blocking; 5-alpha reductase Transurethral prostectomy

Question 22

Specifc alpha blockers =

Answer 22

“-zosins” or “-osins”

Question 23

Finasteride

Answer 23

5a-reductase inhibitor

Question 24

First step in 72 yo patient without abdominal surgical history or hernias with 1 week history of abdominal distension and vomiting with PE suspect for distal bowel obstruction?

Answer 24

Perform a CT scan.

Question 25

Electrolyte changes seen in ischemic bowel or extreme fluid depletion associated with a complicated bowel obstruction?

Answer 25

Anion gap metabolic acidosis (lactic acidosis)

Question 26

Issue with elderly patients with small bowel obstruction?

Answer 26

they often present asymptomatically and therefore you have to rely more on studies. ** For instance, you will commonly see an elderly patient who is afebrile with a distended abdomen without many complaints, but with a metabolic acidosis and a leukocytosis.

Question 27

“Early Small Bowel Obstruction” =

Answer 27

Bowel obstruction occurring within 30 days of an operation. Next step to these patients is either NG placement, with supportive / non-operative care, or potentially a CT scan first to potentially determine the exact cause of the issue.

Question 28

Non operative treatment for small bowel obstruction:

Answer 28

Most patients will respong between 6-24 hours of treatment * Treatment includes: NPO, NG tube, close monitoring of fluid status, labs (CBC, electrolytes, amylase, plain radiographs of abdomen).

Question 29

Signs of high grade bowel obstructions (ischemia or necrosis):

Answer 29

Persistent Pain Localized pain Fever Leukocytosis Elevated serum amylase Specific radiographic signs

Question 30

When CT for small bowel obstruction patients is not indicated:

Answer 30

* Patients with simple adhesive obstruction * Absence of indictators of complicated bowel obstruction such as: Constant pain, localized pain, fever, leukocytosis, complete obstruction.

Question 31

Most common disorders / illnesses associated with carpal tunnel syndrome:

Answer 31

* Diabetes mellitus * Hypothyroidism * Hyperthyroidism * Acromegaly * Myxedema * Pregnancy (temporary) * Autoimmune disorders * Lipomas of the canal * Bone abnormalities * Hematomas

Question 32

Most common symptoms of CTS:

Answer 32

Numbness and pain in the digits radial fingers + half of the ring finger. Positive Tinel’s and Phalen’s tests

Question 33

Treatment for CTS:

Answer 33

Initially medical: splint with slight extension + NSAIDs. Possibly local injection of steroids, but not more than 3 injections per year. Surgical Therapy: for persistent symptoms despite medical therapy

Question 34

Conditions associated with MEN-2A and 2B?

Answer 34

MEN-2A: * Medullary Thyroid Cancer

Question 35

Typical treatments and when they are indicated for a pneumothorax?

Answer 35

* Typically a chest tube alone is a fine treatment * Surgery involves resection of pleural blebs and pleurodesis. * Surgery is indicated if reexpansion has not occurred with a chest tube after 3-5 days, if there has been a recurrence or there is a very high risk of recurrence.

Question 36

Typical sings of a tension pneumothorax:

Answer 36

* Absent breath sounds on affected side * Deviated trachea towards the non-affected side as it is getting pulled in that direction. * Hypotension * CXR is clear on affected side (hemothorax will be opacified)

Question 37

Risk factors for secondary spontaneous pneumothorax:

Answer 37

* COPD * Older than 50 yo * Primary or secondary neoplasm * Infection (TB, pneumocystis) * Catamenial (pulmonary endometriosis) * Asthma * Sarcoidosis * Cystic fibrosis

Question 38

Risk factors and mechanism for primary spontaneous pneumothorax:

Answer 38

* Mechanism = rupture of subpleural blebs * Risk factors = Young age, smoking, tall & thin body habitus.

Question 39

Complications of flail chest?

Answer 39

* Lung dysfunction associated with injuries to the lungs under the flail segment * Atelectasis secondary to reduced ventilation from pain of injury.