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Surgery - Case Files > Cases 1-15 > Flashcards

Cases 1-15 Flashcards

1
Q

Acute onset chest pain after vomiting

- also expect?

A

Boerhaave syndrome - spontaneous esophageal perforation
Also expect: subQ emphysema + left-sided effusion
Need vomiting so think: alcohol binge, eating bad food, etc.

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2
Q

Most spontaneous esophageal ruptures occur where?

A

Distal 1/3 of esophagus

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3
Q

Most esophageal perforations are due to?

A

Iatrogenic causes, especially endoscopy

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4
Q

Best initial diagnostic test to confirm esophageal rupture?

A

Water-soluble contrast esophagogram

(gastrografin esophagogram)

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5
Q

How do you mangage Boerhaave syndrome?

A

ABC’s - manage airway, breathing, circulation
Place left chest tube
Fluid resuscitation
Broad-spectrum antibiotics
Water-soluble contrast study of the esophagus

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6
Q

Pneumomediastinum w/ abdominal pain and 4 hours later, fever + leukocytosis

A

Spontaneous esophageal perforation (Boerhaave)

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7
Q

Why do you need to have a high clinical suspicion for esophageal rupture?

A

Duration between the event and corrective surgery determines outcome. Infection and sepsis result from diagnostic or treatment delay.

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8
Q

Left-sided effusion + acute chest pain…what is your next question?

A

Have you been vomiting? If so = spontaneous esophageal perforation

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9
Q

33 yo Female painless breast mass slowly enlarging x3 months
Hard, nontender 3cm mass in upper outer quadrant of left breast. Left axilla w/o abnormalities.
Next step?

A

Obtain tissue for diagnosis
If malignancy confirmed, proceed w/ staging
(which should include bilateral mammography)

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10
Q

Two options for breast cancer malignant treatment

A
  1. ) Surgery first, then adjuvant therapy

2. ) Systemic chemotherapy to first shrink the tumor, then local surgical therapy (called neoadjuvant)

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11
Q

Tests to order to work-up breast cancer

A

Core Needle biopsy (not FNA)
Bilateral mammography
CBC, Liver function, CXR

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12
Q

If pt desires breast conservative therapy (BCT), what treatment route?

A 
Neoadjuvant therapy (chemo to shrink then surgery)
Use MRI to determine if BCT is a good option
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13
Q

FNA

  • describe
  • limitations
A

Fine needle aspiration - small-gauge needle under vacuum for cytologic analysis
Can identify cancer cells but CANNOT differentiate invasive from in situ cancers

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14
Q

Core needle biopsy

A

Large-bore 10-14 gauge needle biopsy

Provided histologic diagnosis

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15
Q

How search for mets in breast cancer?

A

PET + brain MRI

positron emission tomography

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16
Q

Level 1 & 2 axillary node dissection ALND vs.

Sentinal lymph node biopsy SLNB

A

SLNB: remove nodes w/ high blue dye/radioactivity (satisfactory staging + less morbidity than ALND)
When SLN is + for mets, complete level 1&2 dissection of axilla preferred

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17
Q

When add systemic therapy in breast cancer?

A

Stage III, or IV – known metastatic diseases
- surgery followed by chemo
- chemo to shrink then surgery
Stage II recurrence with local resection alone = 30-44%
- so majority of stage II pt’s are offered chemo

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18
Q

When use trastuzumab?

A

Breast cancer tumors that overexpress HER2/neu receptors
- receptor antagonist
aka Herceptin

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19
Q

When use aromatase inhibitors?

A

Breast cancer tumors that are Estrogen-receptor positive

  • get survival benefit
  • low SE’s
  • especially used in post-menopausal women
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20
Q

38yo F, painless 1cm right breast mass
No dimpling, no adenopathy
FNA reveals malignant cells
What is best next step? Why?

A

Core needle biopsy of mass

  • determine histology of tumor
  • assess receptor status
  • assess tumor biology of the cancer
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21
Q

60yo F, breast-conserving surgery for 0.3cm tumor
Axillary LN negative
What do? Radiation? Observation? Chemotherapy? Radical mastectomy?

A

Radiation therapy to affected breast will reduce local recurrence rate from 30% with just local resection to 9% with surgery + radiation.
Chemotherapy may or may not be indicated in postmenopausal woman w/ early breast CA
Radical mastectomy is rarely indicated

22
Q

62yo painful enlargement of right breast. Warmth, redness, and right axilla non-tender adenopathy. Next best step?

A

Observation - assume it’s breast cancer so don’t go down the road of antibiotics assuming it’s just inflammation.

23
Q 
Pt has T2N2 ER+ HER/2neu negative invasive ductal carcinoma w/ 2 mets to liver. Treatment? 
A. Aromatase inhibitor
B. Trastuzumab
C. Radiation to liver
D. Liver resection
A

A. aromatase inhibitor - due to the ER+ tumor

Radiation - liver is highly susceptible to radiation injury

Could add systemic chemotherapy w/ Taxotere (Docetaxel)

24
Q

48yo M burning epigastric & substernal pain daily x 4 mo
Worse when lies down and after meals
Early morning wheezing + hoarseness x several months
PPI for 12 weeks = partial resolution of symptoms
Diagnosis? Mechanisms?

A

GERD + silent aspiration + pharyngitis

Diminished LES tone/function
Impaired esophageal clearance
Excess gastric acidity
Diminished gastric emptying

25
Q

Complications assoc w/ GERD?

A

Peptic stricture (narrowing/tightening)
Barrett esophagus
Extraesophageal complications

26
Q

Hoarseness + wheezing in setting of GERD?

A

Atypical symptoms

- think silent aspiration + pharyngeal reflux

27
Q

Suspected GERD, but lack of response to PPI. What next?

A

Endoscopy to rule out other pathology as PPI’s provides symptom relief in 95% of GERD pt’s.
Surgical therapy may be indicated such as Nissen fundoplication

28
Q

Which better for GERD? PPI? H2 blockers?

A

H2 okay for mild reflux

PPI’s are far more effective for GERD

29
Q

GERD…Barrett Esophagus…

A

…esophageal adenocarcinoma

30
Q

Hiatal hernia & GERD

A

When LES is abnormally located in chest (as w/ hiatal hernia), the antireflux mechanism may be compromised at the gastroesophageal junction.

31
Q

Mainstay treatment for GERD?

A

PPI - acid suppression

High dose PPI often required for severe/refractory symptoms

32
Q

51yo F 6mo hx substernal chest pain + vague upper abdominal discomfort. Antacid therapy provides minimal relief. Negative upper endoscopy. Next best step?

A

Cardiac workup - cardiac disease would be most concerning disease so rule this out first.

33
Q

24yo on PPI for long-standing GERD. What are indications for surgical intervention?

A
  1. Inability to tolerate PPI’s
  2. Pt’s desire to discontinue medication
  3. Incomplete relief of symptoms despite max dose of PPI therapy
34
Q

Long-standing GERD symptoms or

GERD symptoms refractory to medical treatment

A

Indications for diagnostic endoscopy

35
Q

What is one of the most reliable clinical indicators of GERD?

A

Response to PPI

36
Q

What is most reliable objective indicator of GERD?

A

24-hour pH monitoring

37
Q

Numbness in 3 fingers, pain wakes her at night

Thumb especially affected; drops objects

A

Median nerve compression at wrist leading to paresthesias of radial 3 fingers +/- hand weakness
Carpal Tunnel Syndrome

38
Q

What is incised in carpal tunnel release surgery?

A

Transverse carpal ligament

39
Q

How reproduce carpal tunnel pain?

A

Tinel sign = percuss medial nerve at wrist

Or gravity induced wrist flexion

40
Q

Who is affected by carpal tunnel?

A

Women 3x > men

Diabetes, hyperthyroid, pregnancy, myxedema, acromegaly, autoimmune

41
Q

Why carpal tunnel worse at night?

A

Edema

Tenosynovitis

42
Q

Imaging for Carpal Tunnel?

A

CT and MRI are rarely needed
MR has greatest sensitivity & specificity
Radiographs to detect arthritis or fractures
Electrophysiologic studies may be helpful

43
Q

Treatment for Carpal Tunnel?

A

Conservative: splints esp at night + NSAIDs
Local steroid injections 80-90% effective
(but symptoms return)
Intractable symptoms = surgery

44
Q

Carpal tunnel surgery

A

Complete division of transverse carpal ligament extending distally from ulnar side of medial nerve.
Post-Op: splint wrist in slight extension for 2 weeks

45
Q

30yo numbness & tingling of right thumb + index finger
Pain at night; Tinel sign +
Nighttime splint; 3 months later, symptoms worse
Electrophysiologic study results = equivocal
Best next step?

A

MRI of wrist.
When clinical present but EMG are equivocal, MRI can assist in diagnosis.
No imaging is routinely needed in evaluation of CTS normally

46
Q

Most prevalent symptoms of GERD

A

Heartburn, regurgitation, dysphagia, epigastric pain

worse when lying down

47
Q

How do we diagnose GERD?

A

Clinically; proven w/ response to PPI/H2

48
Q

What are some common H2 antagonists?

A

Ranitidine, Cimetidine, Famotidine, Nizatidine

block the action of histamine at the histamine H2 receptors of the parietal cells in the stomach

49
Q

Regurgitation vs. Vomiting

A

Regurg is passive

Vomit is muscle driven

50
Q

FDA warnings on PPI’s

A

Increased C. diff
Increased osteoporosis & long bone fracture
Reduces effects of clopidogrel/plavix
(also kidney, early onset Alzheimer’s)

51
Q

Treatment for GERD if meds aren’t appropriate/working?

A

First, prove it’s GERD: further diagnostics
Endoscopy, 24 hour esophageal pH, manometry, esophagram/upper GI; and biopsy
Then fundoplication (nissen = 360 fundus wrap)
(>90% successful)

52
Q

How treat H. pylori?

A

PPI + amoxacillin + clarithromycin

alternatives: metro (flagyl), tetracycline, levoflox

Surgery - Case Files (3 decks)

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