General Surgery

Question 1

Treatment of pancreatic pseudocyst

Answer 1

6 and 6 rule: 6 weeks and 6 cm. If < 6 weeks and < 6 cm, you just wait and watch, then repeat the CT in 2 weeks to assess for resolution.

Failure to resolve in 6 weeks, or larger than 6 cm warrants intervention.

Question 2

How to prevent hospital acquired pneumonia?

Answer 2

The only way to prevent this is to get the patient BREATHING; this is done with Incentive Spirometry which reminds the patient to open up their lungs.

Question 3

What is a Marjolin ulcer?

Answer 3

It is cancer

ulcer that can be anywhere and repeatedly breaks and drains but never heals

Needs wide resection following biopsy.

Question 4

Breast cancer treatment

Answer 4

Her2Neu positive –> Trastuzumab

ER/PR positive–> if pre-menopausal use SERMS (Raloxifene) or post-menopausal use Aromatase-inhibitors (Anastrozole)

SERMs and Aromatase-inhibitors are never combined

Question 5

What is Ogilvie syndrome?

Answer 5

REALLY OLD patient who also has TOTAL COLONIC DILATION

Get a rectal tube for decompression or neostigmine

Question 6

What is Paralytic Ileus?

Answer 6

Most common thing following surgery. It just means the body hasn’t caught up yet. The ENTIRE GI SYSTEM will be dilated. The patient just needs to move around and eat, while we need to correct their potassium.

Question 7

No urine post surgery management

Answer 7

6 hours without a void post-op warrants an in-and-out cath to assess for post-residual voids. If high, leave catheter. If low, give fluids. If all else fails, look for intrinsic renal disease.

Question 8

Treatment for DVT/PE

Answer 8

Day 5 post-op a DVT/PE is likely

Use an ultrasound to diagnose and a heparin drip to coumadin bridge to treat DVT

CT scan to diagnose and a heparin drip to coumadin bridge to treat PE

Question 9

Treatment for patient with peritoneal sign

Answer 9

“Air under the diaphragm” means “ruptured hollow viscous” and equals “peritoneal sign,” which means “acute abdomen.” Any of those words means to immediately go to exploratory laparotomy.

Question 10

Young healthy female with breast lump

Answer 10

In a woman with no risk factors (<30, no history of cancer or radiation, no family history to suggest BRCA 1/2) a breast lump doesn’t need investigation; it’s likely related to the menstrual cycle and needs 1 or 2 cycles to pass to see what happens.

Question 11

Colicky flank pain without leukocytosis and without fever that radiates to the groin

Answer 11

Flank pain that radiates to the groin and is associated with hematuria is a kidney stone.

Diagnose it with a CT scan of abdomen without contrast.

Question 12

Post op fever day 10

Answer 12

Probably an abscess

Make sure with ultrasound or CT scan

Question 13

What is Ranson criteria?

Answer 13

Estimate mortality in patients with acute pancreatitis

11 parameters,5 assessed at admission and 6 more during the next 48 hours

higher score= worse mortality

Question 14

Treatment for patient with necrotizing pancreatitis actively worsening into ARDS?

Answer 14

Pancreatitis can lead to ARDS.

Early intubation, PEEP, and proning (prone positioning) can save their life.

CT scan of pancreas and FNA biopsy to confirm infection
THEN IV meropenem

Question 15

Treatment for anal fissures

Answer 15

Get them to poop regularly by using sitz baths, botulinum, and topical lidocaine

Docusate and senna to soften stool

Lateral internal sphincterotomy is the ultimate therapy for when medications fail.

Question 16

Management of Partial bowel obstruction

Answer 16

Complete bowel obstruction is treated with emergent surgery, partial bowel obstruction is treated with conservative measures (NG tube, IV Fluid, NPO)

Question 17

Management of compartment syndrome in the abdomen

Answer 17

Leave the abdomen open, let the swelling go down, and try to close later

leave it open with temporary absorbable mesh (wound vac)

Question 18

Management of diverticulitis

Answer 18

Fever, leukocytosis and acute abdomen

Diverticulitis is a perforation of the diverticula

1st diagnose w/ CT scan with IV contrast

Treat w/ IV ciprofloxacin (gram -) and metronidazole (anaerobes)

Question 19

Older person with progressive, painless jaundice, weight loss, and a smoking history

Answer 19

Most likely diagnosis is pancreatic cancer

1st- CT scan…..if (+)

THEN endoscopic ultrasound which allows us to visualize the mass through the lumen of the gut and take directed biopsies for confirmatory diagnosis.

Question 20

Only cancers diagnosed by removal are

Answer 20

Renal cell carcinoma
Lymphoma
Testicular cancer

No biopsies are performed, only resection, and we use that as our “biopsy”

Question 21

Patient with right-sided valvular fibrosis, diarrhea, and hot flashes / flushing

Answer 21

Classic for carcinoid

Carcinoid is an intestinal neuroendocrine tumor that releases serotonin.
Serotonin is metabolized by the liver and the lungs, thus why it must metastasize to become symptomatic, and it also explains why only the right sided heart valves are affected

Diagnose with Urinary 5-HIAA

Question 22

Management of pyogenic abscess

Answer 22

Pyogenic abscess - a bacterial abscess in the liver

Complication of ascending cholangitis

Antibiotics are insufficient on their own to cure the abscess.

tx: Drainage of the abscess, aspiration of the pus, and culture and sensitivities from the aspirate to target antibiotic treatment

Question 23

Treatment of echinococcus

Answer 23

Liver abscess

Open resection of the lesion

Risk of anaphylaxis is great should the cyst rupture

Question 24

Treatment of Entamoeba Histolytica

Answer 24

Entamoeba Histolytica causes liver abscess

Drawing titers for ameba first THEN treat with metronidazole

Question 25

Fever and leukocytosis after a bout of acute pancreatitis is likely to be from?

Answer 25

Pancreatic abscess

Do CT scan to find out

Treatment is surgical drainage and antibiotics

Question 26

elevation of the UNconjugated bilirubin is indicative of

Answer 26

Hemolysis- Only way to get an acute onset of an elevated, unconjugated bilirubin is hemolysis

Start with blood smear to find type of hemolysis going on

Question 27

Days after surgery and Post op fever

Answer 27

Day 1: Atelectasis

Day 2: Pneumonia

Day 3: UTI

Day 5: DVT

Day 7+: Wound

Question 28

Combination of obstructive jaundice and heme-positive stool

Answer 28

Lesion that could both obstruct the lumen of the biliary tree and bleed into the lumen of the GI tract is AMPULLARY CANCER

Require an ERCP for visualization and biopsy. It is curable with resection.

Question 29

Acute cholecystitis on ultrasound

Answer 29

Pericholecystic fluid, thickened gallbladder wall, and gallstones

Fever, leukocytosis, and a positive Murphy’s sign, and there will be no elevation of the bilirubin (since the stone is in the cystic duct and not in the common bile duct)

Question 30

RUQ cancer on ultrasound

Answer 30

Distended, thin-walled gallbladder with biliary dilatation

pruritus, jaundice, and no pain

weight loss, dark urine, or clay-colored stools.

Question 31

Acute choledocholithiasis on ultrasound

Answer 31

Dilated biliary tree, no obstructing stone (will not be visible on US but need ERCP), gallstones in the gallbladder

Painful jaundice, elevated bili especially Direct, no fever, no leukocytosis, no inflammation,

Question 32

Cardiotoxic breast cancer chemotherapy

Answer 32

CHF is a side effect of breast cancer chemotherapy; early, reversible disease is caused by Trastuzumab while late, irreversible disease is caused by a dose-dependent cardiotoxicity by Doxorubicin or Daunorubicin.

Question 33

AST and ALT are in the thousands. What causes this?

Answer 33

1. Acetaminophen overdose
2. Acute viral hepatitis
3. Autoimmune hepatitis
4. Shock liver (hypotensive ischemic hit)
5. Budd-Chiari
6. Aflatoxin (death-cap mushrooms)

Question 34

What is the Child- Pugh scoring system?

Answer 34

Score for Cirrhosis Mortality

Components of the Child-Pugh score are serum albumin, bilirubin, INR, and the presence of ascites and encephalopathy.

Any single derangement on the Child-Pugh scoring system is a marker for 30% mortality. Decompensated liver disease has a high perioperative mortality.

Question 35

Breast cancer screening recommendations for patients at high risk

Answer 35

Very high risk patients receive MRI screening annually. Look for a history of Hodgkin’s Lymphoma with Mantle Radiation or BRCA1/2 carriers who have not yet had a mastectomy.