General Surgery Flashcards
A 60-year-old Asian woman presents with epigastric pain. A chronic duodenal ulcer is found on gastroscopy. She drinks 3 glasses of red wine a day and takes NSAIDs once a week for headaches.
What is the most likely cause of the ulcer?
A. Alcoholic duodenitis B. Idiopathic C. Inflammatory bowel disease D. H pylori infection E. NSAID use
NSAID use is too little to causes an ulcer.
IBD is UC and Crohn’s disease. Crohn’s can affect any partof the gut whereas UC only affects the colon and rectum. Crohn’s has a cobblestone appearance. Crohns is more common in females,
She does drink excessively which leads me to think Alcoholic duodenal ulcer or H pylori infection.
Answer is most likely due to the alcohol.
https://www.bowelcanceraustralia.org/bowel-diseases
A 56 year old woman presents with a lump in her groin. Positive cough impulse, growth towards the groin, inferior to the inguinal ligament.
What is the lump?
A. Direct inguinal hernia. B. Indirect inguinal hernia. C. Femoral hernia. D. Saphena varix. E.Richter’s Hernia
This is not a direct inguinal hernia as it’s not in the Hasslebach triangle.
Hasslebach triangle:
- inguinal ligament ( inferior)
- inferior epigastric artery (lateral)
- Rectus abdomen (medial)
An indirect hernia will following the spermatic cord, travelling from deep ring to the superficial ring.
As she is a elderly lady it is more likely to be a femoral hernia.
Femoral hernia is a protrusion of abdominal contents in the space next to the femoral vein. Remember NAVY where Y is the groin. This space is used for the expansion of the femoral vein. The space is very tight as the medial border is the lacunar ligament - high risk for strangulation and obstruction.
This is a good explanation of all the hernias.
https://geekymedics.com/hernias-explained/
Also this explains the difference between a direct vs indirect inguinal hernia
http://armandoh.org/video/introduction-to-inguinal-hernia/
Hernia exam:
http://oscestop.com/Inguinal_hernia_exam.pdf
28 year old female who is 20 weeks into gestation presents for a check-up. Ultrasound examination reveals stones in the gallbladder. She has never experienced biliary colic nor had any problems from the stones before.
What further step should be taken?
A. Laparascopic cholescystectomy in the second trimester of pregnancy
B. Repeat ultrasound in 6 months
C. No further investigation or management is required
D. Laparascopic cholecystectomy as soon as possible
E. Laparascopic cholecystectomy after the pregnancy as possible
B. Repeat ultrasound in 6 months
Surgical treatment of asymptomatic gallstones without medically complicating diseases is discouraged. The risk of complications arising from interventions is higher than the risk of symptomatic disease. Approximately 25% of patients with asymptomatic gallstones develop symptoms within 10 years.
Persons with diabetes and women who are pregnant should have close follow-up to determine if they become symptomatic or develop complications.
http://emedicine.medscape.com/article/175667-treatment#d8 (for more info about when to treat asymptomatic gallstones)
A 32 year old female presents with a breast lump for investigation. An ultrasound of her breast was performed. What is the next step in the investigation? A. Mammography B. Core biopsy C. Fine needle aspiration D. MRI E. Excisional biopsy
The triple test refers to three diagnostic components:
• medical history and clinical breast examination
• imaging – mammography and/or ultrasound
•non-excision biopsy – fine needle aspiration (FNA) cytology and/or core biopsy.
Patient is 32 years old.
25–34 years
• Ultrasound is recommended as the first imaging modality.
• Mammography should be used in addition to ultrasound if:
• the clinical findings are suspicious or malignant or
• the ultrasound findings are indeterminate, suspicious or malignant (imaging classification
category 3, 4 or 5) or
• the ultrasound findings are not consistent with clinical findings.
• Mammography may be used in addition to ultrasound if:
• there is a strong family history of breast cancer.
Mammography is the answer
See https://canceraustralia.gov.au/sites/default/files/publications/ibs-investigation-of-new-breast-symptoms_50ac43dbc9a16.pdf
A 67year old man presents to his GP with malaise, perianal pain and frank blood on
toilet paper. Subsequent testing finds an ulcerated cancer in his lower rectum. To which
lymph nodes would this perianal cancer metastasise?
a. External iliac lymph nodes,
b. Internal iliac lymph nodes,
c. Inguinal lymph nodes
d. Pararectal lymph nodes,
e. paraortic lymph nodes
Lymphatic drainage
Most of the lymphatic vessels from the pelvis drain into groups of nodes associated with the iliac arteries and their branches.
External iliac lymph nodes receive vessels from the inguinal nodes, external genitalia, vagina, and cervix; they drain into the common iliac nodes. Internal iliac and sacral lymph nodes receive afferents from all the pelvic viscera (e.g., cervix, prostate, and rectum) and from the perineum, buttock, and thigh; they drain into the common iliac nodes. Common iliac lymph nodes drain the two preceding groups and send their efferents to the lumbar group of aortic nodes, which also receives the afferents of the testis and ovary.
The cervix drains chiefly into the external and internal iliac nodes, the body of the uterus mainly into the external iliac and lumbar nodes. The prostate drains principally into the internal iliac nodes, and the bladder into the external iliac. The upper part of the rectum drains into the inferior mesenteric nodes, the lower part (together with the upper part of the anal canal) into the internal iliac nodes. The lower part of the anal canal, as also the external genitalia, drains into the inguinal nodes.
A middle aged man has pain in LIF that develops into generalised peritonitis. A laparotomy is performed and the following is extracted: [picture] go to utah library for the pic?
a. perforated appendix
b. perforated duodenal ulcer
c. Acute colonic diverticulitis
d. Meckel’s diverticulum
e. Coeliacs
We can rule out perforated appendix and duodenal ulcer as these are on the right side.
More likely acute colonic diverticulitis.
A 64 year old man presented with 3 week history of painless obstructive jaundice.
Abdominal exam reveals a 5cm diameter, nontender, rounded mass at the right costal
margin which moves on respiration.
The mass palpated is most likely to be:
a. a cirrhotic liver
b. a bile duct cancer
c. an inflamed gallbladder
d. a pancreatic cancer
e. a distended gallbladder
Inflamed gallbladder (cholangitis) would cause pain, nausea, vomiting, fever and jaundice so not this answer. Cholangitis, caused by infection and obstruction of the common bile duct, presents with the Charcot triad of fever, jaundice, and right upper quadrant pain.3 In general, patients with cholangitis appear quite ill.
A distended gallbladder is cholecystitis - this is commonly caused by a blocked cystic duct from a gallstone.
Painless jaundice think about malignancy:
http: //bestpractice.bmj.com/best-practice/monograph/511/diagnosis.html
https: //www.ncbi.nlm.nih.gov/pmc/articles/PMC3498422/
With the limited information, leaning towards pancreatic cancer. Courvoisier’s law states that enlargement of the gallbladder with jaundice is likely to result from carcinoma of the head of the pancreas rather than a stone in the common duct. With a common duct stone, the gallbladder is usually scarred from infection and does not distend.
What is the lymphatic drainage of the colon, rectum, and anal canal?
Lymph from the colon drains into the superior and inferior mesenteric nodes (in accordance with the arterial supply of the colon). The upper part of the rectum drains into the inferior mesenteric nodes; the lower part, together with the upper part of the anal canal, drains into the internal iliac nodes; and the lower part of the anal canal, together with the external genitalia, drains into the inguinal nodes.
