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Surgery > General surgery > Flashcards

General surgery Flashcards

1
Q

pt with longterm GERD, has severe esophageal dysplastic changes. tx?

A

surgery (Nissen fundoplication) + radiofrequency ablation

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2
Q

diagnostic study (one first and then another one confirms) and tx for achalasia?

A

dx: barium swallow first -> manometry CONFIRMS
tx: balloon dilatation done by endoscopy, or myotomy

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3
Q

dysphagia with solids worse than liquids, progressing to liquids as well, is suggestive of what?

A

progressive dysphagia, it’s a mechanical/obstructive problem. seen in esophageal cancer, strictures, or rings.

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4
Q

dysphagia that is worse for liquids is suggestive of what

A

motility problem. seen in achalasia, scleroderma, esophageal spasm

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5
Q

Boerhaave syndrome vs mallory weiss

presentation and diagnostic study and treatment

A

mallory weiss = vomiting -> NON transmural esophageal tear.
dx by endoscopy
tx is laser photocoagulation (assisted by endoscopy)

Boerhaave syndrome = vomiting -> transmural tear + chest pain, fever, leukocytosis.
dx by contrast swallow (gastrograffin first, barium if negative)
tx is emergent surgery repair

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6
Q

you do endoscopy on a guy. shortly after he gets lots of pain in his throat. +/- emphysema in neck
diagnostic study + tx?

A

esophagus perforation. contrast studies and emphysema are diagnoistic
tx: prompt surgical repair

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7
Q

if clinical picture and physical exam isn’t clear enough, what study confirms dx of acute appendicitis?

A

CT

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8
Q

cancer of left colon: before surgery is done, what study needs to be done to rule out what?

A

colonoscopy, to rule out synchronous second primary

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9
Q

1st and 2nd line antibiotics for tx for pseudomembranous enterocolitis

need emergency colectomy if what? (2)

A

stop offending drug obvis (clindamycin, cephalosporins)

give metronidazole (1st choice) or vancomycin (2nd choice)

emergency colectomy if WBC>50000 and serum lactate >5, (virulent form, unresponsive to abx)

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10
Q

the high success rate treatment for anal fissure

A

calcium channel blocker ointment (diltiazem) 2% TID for 6 weeks

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11
Q

person has anal surgery for fissure, and now it won’t heal. what do you suspect they have?

A

Crohn’s disease.
anus normally heals really well
if you know person has Crohn’s dz, do not do anal surgery! find other ways to intervene

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12
Q

Pt has C. diff. what tx should you consider before colectomy? (2)

A

abx and fecal enema

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13
Q

Pt had an ischiorectal abscess drained. later starts to leak stool and have some perineal discomfort. dx? findings? tx?
what do you need to rule out?

A

fistula-in-ano

cordlike tract may be felt on exam. need to rule out necrotic and draining tumor.

tx: fistulotomy

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14
Q

if SCC of anus metastasizes to lymph nodes which ones will it be?

A

inguinal nodes

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15
Q

tx for SCC of anus

A

Nigro chemoradiation protocol FIRST

surgery after only if residual tumor

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16
Q

what landmark separates upper from lower GI tract?

A

ligament of Treitz

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17
Q

most common cause of lower GI bleed? (in older ppl or in general???)

A

diverticulosis

AV malformation

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18
Q

pt has GI bleed. you do NG tube and aspirate. no blood is retrieved and fluid is white (no bile). what areas have you excluded as source of bleeding? what do you do next?

A

upper GI up to pylorus is excluded, but duodenum is still potential source -> upper GI endoscopy should follow

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19
Q

pt has GI bleed. you do NG tube and aspirate blood. next step?

A

upper GI endoscopy

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20
Q

pt with recent history of blood per rectum. how to work them up in old vs young adult people?

A

young ppl - upper GI endoscopy only (bc it’s so much more common in young ppl)

old ppl - need both upper and lower GI endoscopy

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21
Q

blood per rectum in child. dx and study?

A

Meckel diverticulum -> technetium scan finds ectopic gastric mucosa

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22
Q

normally you would give PPI post op to prevent stress ulcers. but if they do get stress ulcers and have upper GI bleed, what is tx?

A

angiographic emoblization

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23
Q

acute abdomen. acute constant generalized pain. patient is reluctant to move, lots of guarding. xray shows free air under diaphragm. dx?

A

perforation (e.g. peptic ulcer perforation)

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24
Q

acute abdomen. acute colicky localized pain. pt moves constantly, seeking comfortable position. dx?

A

obstruction

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25
Q

child with nephrosis, ascites, culture of ascitic fluid shows single organism. dx and tx?

A

primary peritonitis. suspect in child with nephrosis and ascites (or adult with ascities and mildish acute abdomen)
tx: abx, not surgery!

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26
Q

if pt has generalized acute abdomen, they need exploratory laparotomy! so what do you need to rule out in case they don’t actually need surgery lol. and what studies to rule them out (6)
hint: think of anything that could cause abdominal or chest pain that does not require surgery

A
  1. acute abdomen from primary peritonitis (culture ascitic fluid)
  2. MI (order EKG, troponins)
  3. lower lobe pneumonia (chest xray)
  4. PE (high risk pt, like they’re immobilized)
  5. pancreatitis (amylase/lipase)
  6. urinary stones (abdominal CT)
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27
Q

timeline for using serum or urinary amylase/lipase for diagnosing acute pancreatitis?

A

use serum for 12-48 hours from onset

use urine from days 3-6

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28
Q

middle aged or older male, pain in lower left quadrant. fever, leukocytosis, +/- blood in stool. dx? tx?

A

acute diverticulitis
90% treated with NPO, IV fluids, abx. if still bad look for abscess that needs to be drained.
recurrent episodes -> surgery to remove affected bowel

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29
Q

parrot’s beak sign of bowel

A

volvulus of sigmoid colon

different from birds beak of esophagus = achalasia

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30
Q

CEA marker for:

A

colorectal carcinoma

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31
Q

CA 15-3 marker for

A

breast carcinoma

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32
Q

CA 19-9 marker for

A

pancreatic and biliary carcinomas

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33
Q

hepatic adenomas may arise as a complication of what medication?

A

birth control pills

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34
Q

hepatic adenoma significant complication:

what study for dx? tx?

A

rupture -> massive abdominal bleed

dx: CT
tx: emergent surgery

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35
Q

complication of biliary tract dz (e.g. acute ascending cholangitis) that requires percutaneous drainage

A

pyogenic liver abscess

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36
Q

what is tx for amebic abscess of liver (NOT pyogenic liver abscess from acute ascending cholangitis)

A

abx like metronidazole is first line. only do percutaneous drainage if they don’t improve

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37
Q

how to confirm dx of amebic abscess of liver

A

serology (not culture bc ameba doesn’t grow in the pus)

but this takes forever so you empirically treat with metronidazole anyways if it’s suspected

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38
Q

what kind of jaundice has modest elevation of alk phos but super high levels of transaminases?

A

hepatocellular jaundice. both fractions of bilirubin are elevated

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39
Q

what kind of jaundice has super high elevation of alk phos, modest elevated of transaminases?

A

obstructive jaundice. both fractions of bilirubin are elevated

40
Q

next step in management for suspected choledocholithiasis (risk factors for cholecystitis + obstructive jaundice + high alk phos + dilated ducts on US + nondilated gallbladder full of stones (aka it’s not cholecystitis but this is where the stone came from))

A

ERCP with sphincterotomy for dx and tx

cholecystectomy after that

41
Q

pt has weight loss and back pain. you suspect pancreatic cancer. what imaging do you do? (____this first, then _____ if that one is negative bc will find smaller tumors)

A

CT scan first.

if negative, MRCP will find smaller tumors

42
Q

type of biopsy for large pancreatic mass

A

CT guided percutaneous biopsy

43
Q

type of biopsy for ampullary pancreatic mass

A

endoscopic biopsy

44
Q

type of biopsy for pancreatic ductal neoplasm

A

ERCP guided biopsy

45
Q

type of biopsy for tiny tumors within head of pancreas

A

ultrasound guided biopsy

46
Q

pt has obstructive jaundice (dark urine, pale stools) + anemia + positive blood in stool. what do you suspect and whats next step

A

suspect pancreatic ampullary cancer -> endoscopy

47
Q

what med can abort an episode of biliary colic (like from obstructing gallstones)

A

anticholinergics

48
Q

tx for acute cholecystitis (4) (like besides the later cholecystectomy)

A

NG suction
NPO
IV fluids
antibiotics

49
Q

pt with acute cholecystitis can’t get surgery b/c theyre too sick. what should you do for temporary fix? (besides nonsurgical tx like fluids and abx)

A

percutaneous transhepatic cholecystostomy (PTC)

50
Q

acute ascending cholangitis is caused by a stone obstructing where? presentation? tx?

A

stone in common bile duct PARTIAL obstruction

presents as obstruction + super high alk phos + high fever and leukocytosis (sepsis)

tx: IV abx -> decompression by ERCP or PTC -> eventually also cholecystectomy

51
Q

stone in common bile duct with partial obstruction causes acute ascending cholangitis. what about if it completely obstructs? findings on US?

A 
obstructive jaundice (nondilated gallbladder with stones)
can also be caused by tumors (dilated and thin walled gallbladder)
52
Q

pt has an episode of cholangitis but then they also have elevated lipase and amylase. what is going on?? what do you do

A

stone blocks ampulla -> pancreatic and biliary ducts both blocked = biliary pancreatitis

tx: NPO, NG suction, IV fluids. usually stone will pass. if not -> ERCP and sphincterotomy.
+ later elective cholecystectomy

53
Q

acute pancreatitis is usually caused by _____ in women and _____ in men

A

stones in women

chronic alcoholic men

54
Q

key lab finding for EDEMATOUS acute pancreatitis

A

elevated hematocrit

55
Q

labs for acute HEMORRHAGIC pancreatitis (4 abnormalities. 2 elevated, 2 decreased)

A

low hematocrit
elevated WBC
elevated blood glucose
lower serum calcium

later: BUN goes up, metabolic acidosis, low arterial PO2

56
Q

tx/management for acute hemorrhagic pancreatitis (2 things, but be specific on abx)

A
  1. abx: carbapenems, quinolones, or metronidazole (they penetrate infected necrotic pancrease)
  2. daily CT to find the many pancreatic abscesses -> drain them
57
Q

best way to deal with necrotic pancreas where the dead tissue is well delineated, usually after 4 weeks of episode

A

necrosectomy. literally scoop out the necrotic tissue

58
Q

pancreatic pseudocyst is more likely to have complications if what? (2) in these cases you need to surgically intervene and drain it.

A

bigger (>6 cm)

older (>6 weeks)

59
Q

5 weeks after acute pancreatitis or pancreatic/upper abdominal trauma. collection of pancreatic juice outside of ducts. pressure/mass sx of early satiety, vague discomfort, and deep palpable mass. what do you suspect and what will confirm dx?

A

pancreatic pseudocyst

CT or sonogram to dx

60
Q

all abdominal hernias need to be surgically repaired except for which exceptions? (2)

A
  1. umbilical hernias in patients 2-5 yrs old. bc they may close themselves
  2. esophageal sliding hiatal hernias (bc they’re not true hernias)
61
Q

cancers that metastasize hematogenously do so to these 4 distant organs (the 2 Ls and the 2 Bs)

A

liver
lung
brain
bone

62
Q

sarcomas usually metastasize through what route (lymph blood or both) and to what organ classically?

A

hematogenously spread to lungs

63
Q

women with known BRCA gene mutation need to be screened frequently and from a young age. what study do you use to do this?

A

NOT mammography! bc its carcinogenic if done frequently

use MRI’s!

64
Q

fibroadenoma in breast , dx is confirmed by what kind of biopsy? is removal mandatory or elective?

A

fine needle aspiration (FNA) OR sonogram

elective removal

65
Q

cystosarcoma phyllodes have potential to become what?

A

malignant sarcomas

66
Q

cystosarcoma phyllodes needs what kind of biopsy to confirm dx? is removal mandatory or elective?

A

core or incisional biopsy. (FNA doesn’t work!)

mandatory removal

67
Q

term for breast dz that follow menstrual cycle.

age groups?

A 
mammary dysplasia (fibrocystic dz, cystic mastitis)
30s - 40s
68
Q

management for mammary dysplasia where multiple lumps come and go without any dominant or persistent mass

A

mammogram

69
Q

management for mammary dysplasia with a dominant or persistent mass (diff dx?)

A

either a cyst or a tumor. after mammogram, need to aspirate the mass.
if clear fluid, it was a cyst the end.
if bloody fluid -> send to cytology.
if mass persists or recurs -> formal biopsy

70
Q

20s to 40s woman with bloody nipple discharge. what do you suspect, what study confirms dx?

A

intraductal papilloma

dx: galactogram (mammogram will show other lesions if present but doesnt visualize papillomas they are too teeny tiny)

71
Q

breast abscess is seen only in what type of women?

A

lactating women

ergo, if you see a breast abscess in a non lactating woman. it’s not an abscess it’s probs cancer. rip

72
Q

tx of breast abscess

A

I and D. + biopsy to rule out malignancy

73
Q

woman has breast mass and wonky looking breast (orange peal or retraction of nipple) but she has history of breast trauma. does that rule out cancer aka do you still have to workup?

A

no. must still rule out cancer.

74
Q

tx/management for small cancer lesion of a large breast, located far away from nipple and areola

A

segment of breast removed = lumpectomy. followed by radiotherapy

75
Q

tx/management for large cancer lesion of a small breast, located close to nipple and areola

A

simple total mastectomy. no radiation

76
Q

what if anything do you do to axillary lymph nodes for resecting breast cancer when none of them are palpable? what if they are palpable?

A

not palpable -> sentinal node biopsy

palpable ones -> resected

77
Q

study that confirms dx of thyroid cancer

A

FNA of the lesion (papillary, medullary, anaplastic)

lobectomy for follicular thyroid cancer

78
Q

medullary cancer comes from what tissue/cells specifically? clinical application?

A

C cells that make calcitonin

thus calcitonin level is useful for follow up

79
Q

hairy fat lady with bunch of other hypercortisolism related signs/sx. what is the first step in workup for cushings?

A

low dose dexamethasone test.

if it suppresses cortisol, she doesn’t have cushings she’s just a hairy fat lady lol

80
Q

low dose dexamethasone = no suppression
high dose = suppression

what is the cause of this pt’s hypercortisolism and what’s next step?

A

cushing’s dz from a pituitary adenoma. get an MRI of pituitary.

81
Q

low dose dexamethasone = no suppression
high dose = no suppression

what is the cause of this pt’s hypercortisolism and what’s next step?

A

ectopic ACTH secretion (adrenal adenoma or paraneoplastic syndrome). get CT of chest/abdomen/pelvis

82
Q

pt with CNS sx and hypoglycemia. usually with fasting but sometimes attacks occur after eating (reactive hypoglycemia). what is dx?

A

insulinoma. or exogenous insulin administration (check C peptide and sulfonylurea levels)
the CNS sx are caused by the hypoglycemia

83
Q

what kind of study to find insulinoma in pancreas

A

CT with contrast

84
Q

what is nesidioblastosis and what is tx?

A

hypersecretion of insulin in newborn. requires 95% pancreatectomy

85
Q

knee jerk for severe migratory necrolytic dermatitis in a pt with mild diabetes? what other problems might they have? (3)

A

glucagonoma

can be accompanied by slight anemia, glossitis, and stomatitis.

86
Q

somatostatins and _____ can be used medically in those with inoperable endocrine tumor like glucagonoma

A

streptozocin

87
Q

pt has primary hyperaldosteronism. what test would you do to suggest if this is operable or not?

A

if aldosterone increases when sitting upright (vs lying down) = hyperplasia -> treat medically

if no changes from posture = adenoma -> CT to find. surgically resect.

88
Q

if pt has thyroid medullary cancer, what else do you need to do to complete workup?

A

look for pheochromocytoma. part of MENII! often coexist

89
Q

MENI

A
  1. pituitary tumor (prolactin or GH)
  2. pancreatic endocrine (ZES, VIP, insulinoma)
  3. parathyroid adenoma
90
Q

MENII A

A
  1. parathyroid hyperplasia
  2. thyroid medullary
  3. adrenal medullary (pheo)
91
Q

MENII B

A

Medullary thyroid carcinoma Pheochromocytoma
neuromas
+ marfinoid habitus

92
Q

chest x ray shows scalloping of ribs

A

coarctation of aorta. scalloping caused by erosion from large intercostal collaterals

93
Q

what study confirms dx for coarctation of aorta?

A

CT angio

94
Q

renovascular htn in an old man with _____________. resistant to meds and faint bruit over flank

A

arteriosclerotic occlusive disease. causing renovascular htn

95
Q

charcots triad (acute cholangitis)

reynold’s pentad (obstructive ascending cholangitis)

A

triad: RUQ pain, fever/chills, jaundice
pentad: triad + shock (hypotension,tachycardia) + CNS sx (encephalopathy)

96
Q

3 abx that can be used for infected necrotizing pancreatitis bc they can penetrate the necrotic pancreas

A

carbapenema
quinolones
metronidazole

97
Q

which one of the thyroid cancers do you need to do lobectomy to dx, b/c FNA biopsy usually doesn’t work?

A

follicular cancer

Surgery (7 decks)

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