General Surgery

Question 1

Gastroesophogeal reflux

Answer 1

Vague sx, hard to distinguish. pH monitoring best. Typical case- overweight person, burning retrosternal pain, heartburn when bending over/tight clothes/flad in bed, relieved by antacids or h2 blockers. If long-standing history, concern = damage to lower esoph, possible Barret- do endoscopy/biopsy

Question 2

Surgery for GERD

Answer 2

Appropriate in long-standing sx disease w/ no medical control. Necessary for ulceration or stenosis, or severe dysplastic changes. For latter, do resection, otherwise laparoscopic Nissen fundoplication. Verify acid reflux w/ pH, do endoscopy/biopsy to lower esoph, that lower esoph sphincter weak, do manometry and gastric emptying study, and a barrium swallow to see where esophagogastric jn is

Question 3

Motility problems

Answer 3

Recognizable clin patterns- crushing pain w/ swallowing = uncoordinated massive contraction, dysphagia = achalasia (solids easier than liquids). D barium swallow then manometry

Question 4

Achalasia

Answer 4

More common in woman, dysphagia worse for liquids, pt can sit up straight and wait to swallow. occasional regurg of food, x-ray shows MEGAESOPHAGUS. Dx w/ manometry, repeated dilatations or surgical myotomy (heller) for tx

Question 5

Cancer of esophagus

Answer 5

Classic progression- dysphagia w/ meath, then solids, then soft foods, liquids, then several mo. saliva. Sig weight loss. Squam CC in men w/ somoking/drinking (esp in AA). Adenocarcinoma in long-standing GERD. Dx w/ endoscopy + biopsy, barium swallow first to prevent perforation. CT scan assesses operabiilty, often just palliative :(

Question 6

Mallory Weiss tear

Answer 6

Prolonged forceful vom => BRB coming up. Endoscopy establishes dx, then photocoag

Question 7

Boerhaave syndrome

Answer 7

Prolonged forceful vom => esoph perforation. Continous, severe wrenching epigastric/low sternal pain (sudden), then fever, leukocytosis + very sick pt. Swallow gastrografin (barium only if gg no work), then emergency surg repair. Delay is BAD

Question 8

Instrumental perf of esophagus

Answer 8

Most common reason for perf, post endoscopy, sx develop. Emphysema in neck is dx, do contrast study + prompt repair

Question 9

Gastric adenocarcinoma

Answer 9

More common in elderly. Arex, weight loss, vague epigastric distress, early satiety, occasional vom blood. Endo/biopsy for dx, then CT scan to assess operability. Surgry is best therapy

Question 10

Gastric lymphoma

Answer 10

Almost as common as gastric adenocarcinoma. Tx w/ chemo/radiation. Surgery done if perforation feared as tumor melts. Low-graded lymphomatoid trans (MALTOMA) reversed by H. pylori erad

Question 11

Mechanical intestinal obstruction

Answer 11

From adhesions from prior ex-lap. Colicky ab pain + protracted vom, progressive ab distention (if low obstruction), no poo or fart. Early- high-pitched bowel sounds and colikcy pain, then silence. xray w/ distented small bowel loops, air-fluid levels. Tx NPO, NG suction and Iv fluids, hope for spont resolution, watch for signs of strangu

Question 12

Strangulated obstruction

Answer 12

Compromised blood supply, pt develops fever, leuko, constant pain, peritoneal irritation => periotnitis/sepsis. Emergency surgery required

Question 13

Mech intestinal obstruction caused by incarcerated hernia

Answer 13

Same clinic picture as strangula, but with a hernia that’s no longer reducible. Do surgery to elim hernia but- emergently post rehydration if strangulation, electively in those that re reducible and have bowel

Question 14

Carcinoid syndrome

Answer 14

Seen in pts w/ small bowel carcinoid tumor w/ liver mets. Diarrhea, face flush, wheezing, right-side vave damage. 24 hr urinary collection for 5hydroxyindolacetic acid for dx. If episodic, only high conc during attack

Question 15

Acute appendicits

Answer 15

Anorexia, vague periumbilical pain => sharp, severe, constant, to RLQ. Tenderness, guarding, rebound to right/below belly. Modest fever and leukocytosis, neutrophilia/immature forms. If not classic pres, do a CT. Then surgery

Question 16

Right colon cancer

Answer 16

Anemia (hypochromic, iron deficiency) in elderly, stool 4+ occult blood. Colonoscopy/biopsy dx, right hemicolectomy tx

Question 17

Left colon cancer

Answer 17

Bloody bowel mvts, bload coats outside of stool, constipation, narrow stool. Flexible proctosigmoidoscopic exam + biopsy dx, then full colonoscopy to rule of synchronous secondary primary. CT scan to eval operability/extend. pre-op chemo/rads if large

Question 18

Colonic polyps

Answer 18

Pre-malig possibility. Malignant potential most in familial polyposis (like Gardener), then villous adenoma, and last adenomatous polyp. Non-malig = juvenile, Peutz-Jegher, inflamm, and hyperplastic

Question 19

Chronic ulcerative colitis (CUC)

Answer 19

manage medically. Surgical if longer than 20 years, severe interference w/ nutrition, multiple hopsitals, needing high dose steroids/immuno sup, or TOXIC MEGACOLON. Definitive treatment of CUC = remove colon, including rectal mucosa

Question 20

Pseudomembranous enterocolitis

Answer 20

From c-dif, caused by clindamycin, or cephalos. Profuse watery diarrhea, cramps, fever, leuko. Look for toxin in stool, stop abx, no antidiarrheals, use metro, or vanco as alternate

Question 21

Anorectal disease

Answer 21

rule out cancer by proper p/e (including proctosigmoidoscopic exam), even if it seems benign

Question 22

Hemorrhoids

Answer 22

Bleed when internal 9tx rubber band ligation), hurt when external (need surgery if conservative fails). Internal hemmorhoids can be painful/itchy if prolapse

Question 23

Anal fissure

Answer 23

Young women, pain w/ poop/ blood streaks on stool. fear of pain => not enough pooping, refuse exam, might need anesthesia. Fissue posterior at midline. Tight sphincter cause/perpetuates problem, so relax it w/ stool softener, topical nitroglycerin, botulin, dilatation or lateral internal sphincterotomy

Question 24

Crohn’s (anal)

Answer 24

Starts w/ fissure/fistula/small ulceration, dx suspected if area fails to heal or gets worse after surgery (normally heals well)

Question 25

Ischiorectal abscess (perirectal)

Answer 25

Febrile, super perirectal pain (can't sit down or poop). P/e shows classif abscess lateral to anus, need I&D, rule out cancer w/ proper exam. if idabetes, could get bad necrotizing after, so watch

Question 26

Fistula in ano

Answer 26

Post perirectal abscess, epithelial migration from anal crypts and perineal skin make a permane ttract. pt has fecal soiling and occasional perineal discomfort. P/e shows opening/openings lateral to anus. Cordlike tract, discharge expressed. rule out necrosis/draining tumor, treat w/ fistulotomy

Question 27

squam cell carcinoma of anus

Answer 27

more common in HIV+ or homosexuals w/ receptive sex, fungating mass grows out of anus, mets in inguinal nodes. dx w/ biopsy, tx with nigro chemorads then surgery if residual

Question 28

General GI bleed stats

Answer 28

3/4 upper Gi, 1/4 in colon/rectum, few in jejunum/ileum Gi colon bleeds from angiodysplasia, polyps, divertic, cancer (old ppl). Hemorrhoids more common w/ age. Old person bleed = could be anywhere young person GI bleed= upper GI (more likely) Stats for when blood is per rectum

Question 29

Vomiting blood

Answer 29

Upper GI (nose to lig of treitz). Also if blood in NG tube when bleeding per rectum. Otherwise upper GI endoscopy

Question 30

Melena

Answer 30

Digested blood, so it is high up. Uper GI endoscopy

Question 31

red blood per rectum

Answer 31

Come from anywhere (upper Gi if came down too fast). Dx w/ NG tube if actively bleeding (bloody means its upper Gi). No blood in NG w/ white flluid? Check duod w/ upper Gi endo. No blood w/ yellow fluid (bile), then it can't be upper Gi at all

Question 32

Active bleeding per rectum, not upper GI

Answer 32

Harder work up. exclud bleeding hemorrrhoids w/ anoscopy, colonscopy not helpful during active bleeding. Two options- if bleeding more then 2ml/min, angiogram + embolization. If less than .5 ml/min, wait till bleding stops, then colonscopy. In-between, do tagged red cell study, if it puddles, angiogram. Slow test though, so pt might not be bleeding by the end. But could guide a hemicolectomy in future. Or do a colonscopy later

Question 33

Recent hx of blood per rectum?

Answer 33

if young, do Upper Gi, if old, then do full Gi endo

Question 34

Blood per rectum in child

Answer 34

Most likely Meckel's. workup w/ technetium scan, look for actopic gastric mucosa

Question 35

Massive upper Gi bleed

Answer 35

stressed, multiple trauma, or post-op pt from stress ulcers. dx w/ endo, then angio embo, or avoid by maintaining gastric pH above 4

Question 36

Acute ab pain

Answer 36

perforation, obstruction, inflamm, or ischemia

Question 37

Perf ab pain

Answer 37

Sudden onset, constant/generalized/very severe. Won't move, protects abdomen. Except in v old/sick, general peritonitis. Free air under diaphragm in upright x ray = dx. Perf peptic ulcer most common. SURGERY

Question 38

Obstructive acute ab pain

Answer 38

sudden colikcy pian, typical location/radiation. pt moves constantly, seeking comfortable position. few physical findings

Question 39

Inflamm acute abdomen

Answer 39

Gradual onset, slow build up at least 6 hrs, constant, starts ill-defined, locates to area over time, typical rads pattern. p/e of peritoneal irritation in affected area + systemic signs (leuko + fever), except in pancreatitis

Question 40

Ischemic process

Answer 40

Combine severe ab pain + blood in gut lumen

Question 41

Primary peritonitis

Answer 41

Child w/ nephrosis + ascites or adult w/ ascites + mild acute abdomen and mabes fever/leuko. Ascitic culture shows single organism (in normal acute ab, many orgs.) Tx w/ abx, not surg

Question 42

Tx for general acute ab

Answer 42

Ex-lap, no need for specific dx. if not primary peritonitis, rule out mimics of acute ab (MI, lower lobe pneumo (CXR), PE (immobile patient), and rule out non-surg things (pancreatitis and urinary stones)

Question 43

Acute pancreatitis

Answer 43

Alcoholic w/ upper acute abdomen. Classic- rapid onset inflamm, constant, epigastric, radiating through to back, nausea/vom/retching. P/e findings in upper abdomen, modest. Dx w/ serum/urinary amylase or lipase (serum 12-48 hrs, urine if 3-6days). Ct if unclear. tx = NPO, NG suction, Iv fluids

Question 44

Biliary tract disease

Answer 44

Fat woman, forties, 55 children, RUQ ab pain

Question 45

Ureteral stones

Answer 45

Sudden colicky flank pain radiating to inner thigh/scrotum/labia, sometimes urinary symptoms of urgency/frequency, microhemat in UA. Xray shows stone, CT even better

Question 46

Acute diverticulitis

Answer 46

LLQ pain (one of few! tubes/ovary in women). Pt = middle-age/beyond/ fever, leuk, p/e of peritoneal in LLQ, palpable tender mass. Ct dx, tx = npo, iv, abx. Most cool down, surg if not, elective surg if 2+ attacks

Question 47

Volvulus of sigmoid

Answer 47

Old people, signs of intestinal ob and severe ab distention, x-rays dx, show air-fluid levels in small bowel, distended colon, air-filled loop in RUQ that tapers down to LLQ (parrots beak shape). Proctosigmoidscopic exam resolves acute problem. Leave rectal tube, recurrence? do elective sig resection

Question 48

Mesenteric ischemia

Answer 48

Old ppl, develop acute ab in someone w/ a-fib or recent MI (clot from SMA). Very old dont show super acute abdomen, so late dx, w/ blood in bowel lumen + acidosis and sepsis. If early case, arterio embo saves day!

Question 49

Primary hepatroma (hepatocellular carcinoma)

Answer 49

in US, only w/ cirrhosis. vague RUQ discomfort, weight loss. Spcific blood marker = alpha-feto protein. CT scan shows location/extent, resection done if possible

Question 50

Mets to liver

Answer 50

More common than primary cancer (20:1). Found by CT f/u for 1st tumor, or b/c of rising CEA in colonic cancer. If slow growing and confined to one lobe, can resect, otherwise radioablation

Question 51

Hepatic adenoma

Answer 51

complication of OCP, can rupture and bleed massively in abdomen. Dx CT, emergency surgery

Question 52

Pyogenic liver abscess

Answer 52

Complication of biliary tract disease (Acute ascending cholangitis). Pt develops fevr, leuko, tender liver. Sonogram/CT dx, percutaneous drainage reqd

Question 53

Amebic abscess of liver

Answer 53

Men w/ mexico connection. Presentation and imaging dx similar, tx w/ metro (rarely needs drainage). Def dx froms erology (ameba not in pus), but takes 2 weeks, so just tx empirically. If improve, no drain

Question 54

Hemolytic jaundice

Answer 54

Low level (bili of 6 or 8), all unconjugated (indirect), no elevation of other, no bile in urine. W/u for why hemolysis

Question 55

Obstructive jaundice

Answer 55

Elevation of both types of bili, lil elev of transaminase, very high alk phosphatase. First, sonogram, look for dilatation of biliary ducts, also why. If stone, can't see stone in common bile duct but can see them in gallbladder (can't dilate). If malignant obstruct, large, thin-walled distended gallbladder often (Courvoisier-terrier sign)

Question 56

Obstructive jaundice from stones

Answer 56

Obese, fecund woman in forties with high alk phsoph, dilated sonogram ducts, nondil gallblader w/ stones. Do ERCP to dx, sphincterotomy, and remove duct stone. Then cholecystectomy

Question 57

Obs. Jaundice from Tumor

Answer 57

Cause- adenocarcinoma of head of pan, ampulla of Vater or cholangiocarcinoma from common duct Dx- snoogram w/ dilated gallbladder, then CT (panc cancers show up), then perc biopsy. If CT neg, ERCP next. Other cancers are smaller, but show in ERCP

Question 58

Ampullary Cancers

Answer 58

If malig obstructive jaundice w/ anemia + blood in stool. can bleed into lumen and obstruct biliary flow at once. Do endoscopy first. 40% cure rate

Question 59

Pancreatic cancer

Answer 59

Seldom cured, even with whipple (pancreatodudenotomy).

Question 60

Gallstones

Answer 60

Responsible for majority of biliary tract pathology, spectrum of disease, 4 Fs, more common in mexican and native americans. Leave asx alone!

Question 61

Biliary colic

Answer 61

Stone in cystic duct, tempt occlusion. colicky pain in RUQ, to right shoulder and beltlike to back, after fatty food. Naus/vom, but no peritonitis or systemic. self-limt (10-30 min), stopped by anticholinergics. Sonogram dx, elective surg if ya want

Question 62

Acute cholecystitis

Answer 62

Biliary colic, but then stone stays in duct, inflamm process. Constant pain, modest fever/leuk, peritonitis in RUQ. Minimal change in liver fn. Sonogram dx- stones + thick gallbladder, pericholecystic flui. HIDA shows uptake not to gallbladder. Tx = NG suction, NPO, IV fluids, abx cooldown, elective removal later. No response? emergency lap chole, or temporize with emerg perc. transhepatic cholecystotomy (DRAIN)

Question 63

Acute ascending cholangitis

Answer 63

DEADLY, stones partially block common duct => ascending infection up the duct. Old and very sick, high fever, chills, high WBC (sepsis), some high bili,key = high alk phosoph. Give IV abx + emergency decomp of common duct (ERCP or PTC or surgery). eventual cholecystectomy

Question 64

Obstructive jaundice w/ no cholangitis

Answer 64

Stones COMPLETELY block biliary obstruction

Question 65

Biliary pancreatitis

Answer 65

Stones impacted in ampulla, obstruct panc and bili ducts. Often pass spontaneously, w/ mild/short episode of cholangitis + pancreatitis. Sonogram dx gallstones, tx conservatively, if not, ERCP and sphincterotomy to dislodge

Question 66

Acute pancreatitis

Answer 66

Complication of gallstones, or alcoholics. Edematous, hemorrhagic, suppurative (abscess). => later panc pseudocyst or chronic pancreatitis

Question 67

Acute edematous pancreatitis

Answer 67

Alcoholic/gallstones pt. Epigastric/mid ab pain after heavy meal or alcohol, constant, radiates thru back, w/ nause, vom, and retching. tenderness/mild rebund in upper ab. High serum amylase/lipase (urinary later). Know it's edematous w/ elevated hematocrit. resolution follows few days of panc rest (NPO<, NG, IV)

Question 68

Acute hemorrhagic pancreatitis

Answer 68

More deadly, starts edematous, but lower hematocrit = a clue. Also see rnason's criteria- early elevated WBC and blood glucose, low serum clalcium. Hematocrit lowers by next morning, and calcium low despite tx, BUN up, mets acidosis + low arterial PO2. Terrible progrnosis, need ICU. => multiple panc abscesses, try to anticipate/drain w/ daily CT scans

Question 69

Pancreatic abscess (suppurative)

Answer 69

Someoen not getting CT scans, w/ fever + leuko after 10 days of pancreatitis. see pus collections in imaging, do perc drainage

Question 70

Pseudocyst (panc)

Answer 70

Late sequela of acute panc or panc upper abdominal trauma, in 5 weeks you see a pseudoscyst, juice outside the ducts (often lesser sac), pressure symptoms (early satiety, vague discomfort, deep palpable mass). DxCT or sonogram. Tx by size/age of psedocyst, smaller than 6 cm or younger than 6 weeksis a-ok, but too big or old means tx- drain it! perc or surg or endoscopically

Question 71

Chronic pancreatitis

Answer 71

Devastating disease, esp in alcoholics, get a calcified burned-out pancreas, steatorrhea, diabetes, and epigastric pain. Diabetes/steatorrhea controled with insulin + panc enzymes, but the pain SUCKS. ERCp shows specific pts of obstruction/dilitation, drain pancreatic duct maybe

Question 72

Abdominal hernias

Answer 72

electively repair to avoid risk of intestinal obstruction/strangulation, except for umbilical hernias in young patients under 2, and esoph sliding hiatal hernias (not true). Irreducible hernias need emergency surg to prevent strang, those that were always irreducible for years need elective repair only

Question 73

How to rule out cancer in breast disease

Answer 73

Get tissue from pathologist. Age is best correlator, quite possible by middle age, very like in old or w/ fam hx

Question 74

Mammography

Answer 74

Adjunct to p/e, start at age 40, earlier if fam hx, cant do before 20 or during lactation, can be done during pregos. Mammo guided multiple core biopsy are best way to biopsy breast masses

Question 75

Fibroadenomas

Answer 75

Young women (teens, early twenties), firm, rubbery mass, moves easily. Do FNA or sonogram to dx. Can remove if ya want

Question 76

Giant Juvenile Fibroadenomas

Answer 76

in very young adolescents, very rapid growth, remove to avoid deformity/distortion

Question 77

Cystosarcoma phyllodes

Answer 77

Late 20s, grow over many years, get real big, replace/distort entire breat, not invasive/becoming fixed. Most benign, but could become sarcoma. Do biopsy, and def remove

Question 78

Mammary dysplasia (fibrocystic disease, cystic mastitis)

Answer 78

30s and 40s (not after menopause), bilat tenderness with MC + multiple lumps that follow MC. No dom/persistent mass, do mammo, if persistent mass, gotta do aspiration. Clear fluid and mass goes away? Dunzo. Mass persists/recurs, do formal biopsy. Bloody fluid? Send to cyto!

Question 79

Intraductal papilloma

Answer 79

Young women (20-40), bloody nipple discharge. Mammogram to look for other lesions, but wont show papilloma. Use galactogram for dx, guide surgical resection

Question 80

Breast abscess

Answer 80

Only in lactating women, do i&d, but biopsy abscess wall jic

Question 81

Breast cancer

Answer 81

Think it in any woman w/ a palpable breast mass. Also ill-defined fixed mass, orange peel skin, retrac of nipple, eczematoid lesions of areola, reddish orange peel skin over mass, palpable axillary nodes. Trauma does not rule out cancer

Question 82

Breast cancer in pregos

Answer 82

Dx same way as if not pregnant, tx same except no rads during preg, and no chemo during first tri. keep baby alive!

Question 83

Mammograms w/ breast cancer show

Answer 83

Irregular area of increased density w/ fine microcalcifications that wudn't there before

Question 84

Treatment of resectable breast cancer

Answer 84

Starts w/ lumpectomy + axillary sampling + post-op rads,or modified radical mastectomy. Former only when tumor is small in relatively large breast away from nipple

Question 85

Infiltrating ductal carcinoma

Answer 85

standard form! inflamm cancer is only variant that is much worse. Other variants (lobal, medullary mucinous) have slightly better prognosis, tx same way as standard. Lobular might be more bilateral (but not enough to just chop both off)

Question 86

Ductal carcinoma in situ

Answer 86

CANNOT mets! But very high incidence of recurrence w/ only local excision, so do total simple masectomy for multicentric lesions, or lumpectomy if its all in one quarter

Question 87

Inoperable cancer of breast

Answer 87

Chemo (maybe rads), inoperable based on local extent (not mets)

Question 88

Adjuvant systemic therapy

Answer 88

Post surgery in all pts, esp if axillary nodes +. Chemo, or hormonal if receptor positive. premenopausal women get tramoxifen, post menopausal get anastrozole. Frail old women w/ tumors that aren't too bad should just get hormones!

Question 89

Persistent h/a or back pain in breast cancer pt?

Answer 89

METS! Do ct for brain mets, bone scan + x-ray (in pedicles). Radiation + braces

Question 90

Thryoid nodules

Answer 90

In euthyroid pts could be cancer (but low incidence so don't just chop it) If benign, follow but no intervent If malignant/indeterminate, do lobectomy, then do frozen section Total removal if follicular cancers, then tx w/ radioactive iodine later to get the blood-borne mets

Question 91

Thyroid nodules in hyperthyroid pts

Answer 91

Almost never cancer, might be hot. Clinical signs = weight loss (but ravenous appetite), palpitations, heat intolerance, moist skin, fidgety, tachycardia, a-fid/flutter, cofirm w/ TSH low or T4 high. Nuke scan shows nodule, tx w/ radioactive iodine or surg the hot adenoma

Question 92

Hyperparathyroidism

Answer 92

Serendipitous discovery of high serum calcium! Repeat calc, look for low phosph, rule out bone mets. If persists, do PTH determination (in light of calcium levels). Asx pts get sx at 20%/year, so elective intervention can make sense. Removal = curative, single adenoma

Question 93

Cushing

Answer 93

Round, ruddy, hairy face, buffalo hump, fat pads supra clav, obese trunk + abdominal stria, thin weak extremities, osteoporosis, diabetes, HTN, mental instability. W/u w/ low-dose dexameth suppression test. Suppressed at low dose = no disease. If no supression, do 24 hr urine cortisol (if elevated), do high-dose suppression test. If suppressed, high dose pit microadenoma. No suppresion at either dose = adrenal adenoma! Image (MRI pit CT adrenal) and remove. Also a mayo clinic algorithim, look for free urine cortisol and corticotropin levels

Question 94

ZES (gastrinoma)

Answer 94

Shows up as virulent peptic ulcer diseases, resistant and too extensive (too many ulcers!) also watery diarrhea. Measure gastrin, look for tumor w/ CT of panc. remove. Also omeprazole for mets disease

Question 95

Insulinoma

Answer 95

CNS symptoms b/c of low blood sugar when pt fasting. Ddx is reactive hypoglycemia (after eating) and self-admin of insulin. Plasma assay for disease = high hinsulin and high C, if just insuling, C is low. Do CT of pancreas/locate tumor

Question 96

Nesidioblastosis

Answer 96

Devastating hypersecretion of insulin in newborn, needs 95% pancreatectomy (NO!)

Question 97

Glucagonoma

Answer 97

Severe migratory necrolytic dermatitis, resistant to therapy, in pt w/ mild diabetes, some anemia, glossitis and stomatitis. Glucagon assay dx, Ct to locate, resect is curative. For inoperable, give somatostatin and streptozocin.

Question 98

Primary hyperaldo

Answer 98

Adenoma or hyperplasia. You see: hypoK in HTN female pt NOT on diuretics, some hyperNa, and met ALK. Aldo levels high, renin low. Postural changes (more aldo when upright) suggests hyperplasia, but lack of response is adenoma. Adrenal CT localize, surgical removal

Question 99

Pheochromocytoma

Answer 99

Thin, hyperactive women w/ attacks of pounding headache, perspiration, palp, pallor (and extremely high BP). Attacks can subside, not always sustained. start w/u w/ 24 hr urinary determination of VMA or metanephrine (more specific). Follow w/ CT of adrenal glands or radionuke studies if extradrenal chance. Tumors usually big...BE CAREFUL WITH SURGERY...alpha blockers!

Question 100

Coarctation of the aorta

Answer 100

Young, htn in arms w/ normal or low or no pressure, CXR shows scalloping of ribs (erosion for large collateral intercostals). Do CT or MRI angio, maybe arteriogram unnecessary. Surgical correction curative

Question 101

Renovascular HTN

Answer 101

Two distinct groups- young women w/ fibromuscular dysplacia or old men w/ arteriosclerotic occlusive disease. Either way, HTn resistant to usual meds, and telltale faint bruit over flank or upper abdomen. W/u of scanning + doppler of renal vessels + arteriographic visualization. therapy imperative in yong women (ballon dilatation + stenting) but more controversial in old men!