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MCCQE1 > General surgery > Flashcards

General surgery Flashcards

1
Q

Cardiac contraindications of elective surgery

A

EF < 35%

MI < 6 months ago

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2
Q

Smoker who needs an elective surgery. What is the recommendation before going into surgery?

A

Smoking cessation 8 weeks before surgery + nicotine patch

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3
Q

Patient with fever during the surgery.

Dx, tx, and ppx?

A

Malignant hyperthermia

Tx: O2, dantrolene, cool IV

Ppx: Ask personal or family Hx to bad reaction to anesthesia

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4
Q

Patient with fever right after surgery.

Dx, next step, tx?

A

Bacteremia

Next step: Blood culture

Tx: Vancomycin+ piptazo

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5
Q

Patient with fever at POD #1

Dx, next step, ppx?

A

Atelectasis (wind)

Next step: CxR (negative for pneumonia)

Ppx: Incentive spirometry, patient out of bed

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6
Q

Patient with fever at POD #2

Dx, next step, Tx, ppx?

A

Pneumonia (wind)

Next step: CxR (positive)

Tx: Vancomycin+ piptazo

Ppx: Incentive spirometry, patient out of bed

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7
Q

Patient with fever at POD #3

Dx, next step, ppx?

A

UTI (water)

Next step: U/A, urinary culture

Ppx: Foley out ASAP

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8
Q

Patient with fever at POD #5

Dx, next step, Tx, ppx?

A

DVT, PE (walking)

Next step: Dooppler of lower extremities

Tx: Heparin to warfarin bridge

Ppx: LMWH, patient out of bed

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9
Q

Patient with fever at POD #7

Dx, next step, ppx?

A

Cellulitis (wound)

Next step: U/S (negative for an abscess)

Ppx: Sterile field, keeping wound clean

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10
Q

Patient with fever at POD #10–14

Dx, next step, tx, ppx?

A

Abscess (wound)

Next step: U/S (positive for an abscess)

Tx: Abx + incision and drainage

Ppx: Sterile field, keeping wound clean

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11
Q

Patient in POD #3 with chest pain and test suggestive of MI.
Tx?

A

PCI, heparine

tPA is contraindicated

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12
Q

Patient in POD #5 with chest pain, you rule out MI but suspect PE.
What tests you need?

A

ABG, lower limbs U/S, CT scan

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13
Q

Causes of altered mental status in a post-op patient

A

Electrolytes, sundowning (delirium), ARDS, and delirium tremens.

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14
Q

Normal urinary output in a post-op patient

A

> 0.5 cc/kg/hr

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15
Q

Post-op Patient with decreased urinary output who has a distended bladder. Next step?

A

In-and-out cath or foley

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16
Q

Post-op Patient with decreased urinary output with no urine in bladder. Next step?

A

500 cc bolus. If improvement, then hydrate. If no change, then intrinsic renal failure

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17
Q

Post-op Patient with cero urinary output. Next set?

A

Obstruction.

Unkink the catheter

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18
Q

Patient in POD 1-2, no poop, no gas.

Erect KUB shows dilation everywhere. Dx and tx?

A

Ileus

IVF, K, move patient

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19
Q

Patient in POD 5, no poop, no gas. Erect KUB (air-fluid levels, dilation proximal to obstruction). Dx and tx?

A

Obstruction

NG tube, surgery again

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20
Q

Old patient in post op with abdominal distension, no poop, no gas. Erect KUB (normal small bowel, distended large bowel).
Dx, tx?

A

Ogilvie

Rectal tube, colonoscopy

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21
Q

Patient in post-op, loups of bowel pop out of the surgical wound.

Dx, next step?

A

Evisceration

  • Warm saline dressings
  • NEVER push it back in
  • Emergent surgery
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22
Q

Patient with painful jaundice, mild fever, mild leucocytosis, ↑AST, ↑ALT, ↑amylase, (+) murphy.

RUQ U/S showing dilated ducts

Dx, next step, tx?

A

Choledocholithiasis

Next step:
• MRCP

Tx:
• NPO, IVF, IV antibiotics
• Urgent ERCP (Endoscopic Retrograde Cholangio-Pancreatography)
• Elective cholecystectomy

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23
Q

Patient primary sclerosing cholangitis, who has jaundice, no fever, normal WBC, negative murphy, no abdominal pain.

Ct scan shows cholangiocarcinoma.

Next step and tx?

A

ERCP + Bx

Tx: resection

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24
Q

Patient with migratory thrombophlebitis, who has jaundice, no fever, normal WBC, negative murphy, no abdominal pain.

Dx, Next step and tx?

A

Pancreatic cancer

Next step: Endoscopic US with Bx

Tx: whipple procedure

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25
Q

Patient who has jaundice, no fever, normal WBC, negative murphy, no abdominal pain.

Negative CT scan, positive fecal blood test, negative colonoscopy

Dx, Next step and tx?

A

Ampullary cancer

Next step: ERCP + Bx

Tx: resection

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26
Q

Patient with stricture of the biliary tree. Tx?

A

Stenting*

*Except if Dx of primary sclerosing cholangitis, in which case the Tx is ursodeoxycholic acid while waiting for liver transplant

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27
Q

Alarm sx of GERD

A
  • Nausea, vomiting
  • Anemia
  • Weight loss

If alarm signs, EGD + Bx

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28
Q

Patient with “nocturnal asthma” (wheezing, coughing only at night).

Dx, next steps, tx?

A

GERD

Next steps:

  • If no alarm style: lifestyle modifications and PPI
  • Alarm sx or no improvement: EGD + Bx
  • Gold standard: 24-hr pH monitor

Tx:

  • PPI
  • Metaplasia: High-dose PPI Nissen Fundoplication
  • Dysplasia: Ablation
  • Adenocarcinoma: resect
  • Nissen fundoplication could be used in any context
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29
Q

Patient refers knot or ball of food stuck in the GE junction.

Barium swallow (bird’s beck deformity)

Dx, next steps, tx?

A

Achalasia

Next steps:

  • Manometry to confirm
  • EGD + Bx to rule out pseudo-achalasia (cancer)

Tx:

  • Myotomy
  • Botox or dilation if not a surgical candidate
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30
Q

Patient with progressive disphagia

Barium swallow (asymmetric mass)

Dx, next steps, tx?

A

Adenocarcinoma

Nex steps:
- EGD + Bx to confirm

  • Tx: resection
31
Q

Mallory-Weiss vs Boerhaave’s

A

Mallory-Weiss: superficial tear in the mucosa of esophagus

Boerhaave’s: transmural tear

32
Q

Patient who was drinking this weekend and now is vomiting blood.

Dx, tx?

A

Mallory-Weiss

Treat like upper GI bleed

  • 2 large bore IV
  • IVF
  • IV PPI
  • Type and cross, transfuse as needed
  • Call GI
33
Q

Patient with Hx of bullimia who is vomiting blood. She has crepitus chest, crunching, rasping sound, synchronous with the heartbeat.

Dx, next steps, tx?

A

Boerhaave’s, potential mediastinitis

Dx:

  • Gastrograffin swallow, if negative…
  • Barium swallow, if negative….
  • EGD

Tx: Surgery

34
Q

Patient with colicky abdominal pain, no gas, no stool, Borborygmi sounds, abdominal distension.

No peritoneal findings

Dx, next steps, tx?

A

Small bowel obstruction

Nest steps:

  • 1st: upright KUB showing air-fluid levels
  • 2nd: CT scan

Tx:
- If incomplete obstruction: NG tube, IVF, K+ management
- If complete: Surgery
If develops peritoneal sings: Emergent surgery

35
Q

Types of hernias according to location

A
  • Direct: Male adults, goes through the muscle
  • Indirect: baby males, through the inguinal ring
  • Femoral: female, under the inguinal ligament
  • Ventral: Iatrogenic, post-op, failure of fascia to close
36
Q

Management of a hernia

A
  • Reducible: elective sx
  • Irreducible (incarcerated): Urgent sx
  • Acute abdomen (strangulated): emergent sx
37
Q

Periumbilical pain, Pain goes to McBurney’s point, Anorexia, N/V

Dx

A

Appendicitis

No dx step needed, but CT scan is often performed in real life (not the answer in the test)

38
Q

Flushing, Wheezing, Diarrhea, Right-sided cardiac fibrosis.

Dx, next steps, tx?

A

Carcinoid

Next steps:

  • Urine 5-HIAA
  • CT scan to identify lesions

Tx: resect

39
Q

Patient with Epigastric abdominal pain, Bore to back, Positional (hurts more if lean backwards), N/V.

Dx, next steps, tx?

A

Acute Pancreatitis
- Lipase is better than amylase
- CT scan is not generally needed (only if enzimes (-) and you’re sure it’s pancreatitis)
• Also used for complications
-RUQ U/S and triglycerides aren’t for Dx but for etiology (done after Dx is confirmed and tx initiated)

Tx:
-NPO, IVF, pain meds

40
Q

Patient with acute pancreatitis who despite tx has persistent fever and leukocytosis.

Dx, next step, and tx?

A

Abscess

Next step: CT scan

Tx: abx, drainage

41
Q

Patient with acute pancreatitis who has early satiety, weight loss, and pain, and ascites.

CT scan shows pseudycyst < 6 cm

Tx?

A

Uncomplicated pseudocyst

Tx: Wait as it will likely resolve

42
Q

Patient with acute pancreatitis who has early satiety, weight loss, and pain, and ascites.

CT scan shows pseudycyst > 6 cm
Tx?

A

Complicated pseudocyst

Tx: Drain

43
Q

Patient with acute pancreatitis who in addition is hypotensive and in shock.

Dx, next step, tx?

A

Necrotizing pancreatitis (poor prognosis)

Next step: CT scan

Tx:

  • ICU
  • Necrosectomy
  • Carbapenem if infection confirmed by FNA
44
Q

Post-menopausal woman or man of any age with iron deficiency anemia.

Dx, next step?

A

Colon cancer

Next step: Colonoscopy

45
Q

Patient with alternating diarrhea, constipation and pencil thing stools.

Dx, next step?

A

Colon cancer

Next step: Colonoscopy

46
Q

Patient in whom a colonoscopy shows multiple polyps spread in the colon.

Dx, tx?

A

Familial adenomatous polyposis

Tx: colectomy

47
Q

Patient in whom a colonoscopy shows cancer

Tx?

A

CT scan, resection, chemo (folfox) + radio

48
Q

Patient with anal bleeding without pain. You suspect internal hemorrhoid.

Next step and tx?

A

Next step: anoscopy

Tx: banding

49
Q

Patient with anal pain without bleeding. You suspect external hemorrhoid.

Tx?

A

Resecting if creams and sits baths don’t work

50
Q

Risk factors and tx of anal cancer

A
  • “Like cervical cancer of the anus;” HPV causing squamous cell carcinoma
  • Anal receptive sex
  • MSM
  • HIV +

Tx: chemo and radiation regardless of stage

51
Q

Patient with Colicky abdominal pain, No fever, Normal WBC. Type abdominal pain and examples of causes?

A

Obstructive

E.g., cholelithiasis, nephrolithiasis

52
Q

Patient with Constant abdominal pain, fever, and ↑ WBC. Type of and pain?

A

Inflammatory

E.g., cholecystitis, pyelonephritis

53
Q

Patient in shock, with constant abdominal pain, and motionless. Type of and pain?

A

Perforation

E.g., peptic ulcer disease, cancer, penetrating trauma

54
Q

Patient with Pain out of proportion, Bloody bowel movement, and Sepsis.

Dx?

A

Mesenteric ischemia

55
Q

Causes of RUQ pain

A

Lung
Diaphragm
Liver
Gallbladder

Get U/S

56
Q

Causes of Epigastric pain

A 
MI
Aorta
Esophagus
Pancreas
stomach
57
Q

Causes of LUQ pain

A

Lung
Diaphragm
Spleen

Get CT + contrast

58
Q

Causes of diffuse abd pain

A

Constipation
DKA
Mesenteric ischemia

59
Q

Causes of RLQ pain

A

Kidney / ureters
Ovaries / testes
Colon = appendix

Get CT + contrast

60
Q

Causes of Supra pubic pain

A

Bladder

uterus

61
Q

Causes of LLQ pain

A

Kidney / ureters
Ovaries / testes
Colon = diverticula

Get CT + contrast

62
Q

Stages of legs ulcers

A

i: non-blanching erythema
II: Epidermis and partial dermis
III: Through epi and dermis (fascina is exposed)
IV: Muscle/bone exposed

63
Q

Bed-ridden, Wheelchair patient with ulcers in the sacrum.

Dx, tx?

A

Compresion ulcer

Roll the person q2h, out of bed, air-mattresses, wound care

64
Q

Diabetic patient with ulcer in feet.

Tx and ppx?

A

Tx:

  • Control DM
  • Elevate legs
  • Wound care
  • Amputate

Ppx:

  • Loose shoes (diabetic shoes)
  • Inspection
  • Monofilament test
65
Q

Patient with ulcer on Tips of toes. Hairless legs, Scales, Absent pulses.

Dx, next steps, tx?

A

Arterial insufficiency

Dx:

  • Ankel-brachial infex
  • Limbs U/S
  • Angiogram

Tx:

  • Stent
  • Bypass
66
Q

Patient with ulcer in Medium malleolus. Edema, Hyperpigmentation, and Induration.

Dx, tx?

A

Venous insufficiency

Tx:

  • Compression stockings
  • Elevate legs
  • Diuresis
67
Q

Leg ulcer with sinuous track that breaks and heals over and over.

Dx, next step, tx?

A

Marjolin’s (squamous cell carcinoma)

Dx: Bx

Tx: wide resection

68
Q

Risk factors for breast cancer

A
  • Exposure to estrogen (early menarche, late menopause, nulliparity, hormone replacement therapy)
  • Hx of Radiation
  • BRCA 1 and 2
69
Q

55 y-o patient with breast lump. Mammogram is positive.

Next step?

A

Core needle Bx (better than FNA and excisional Bx)

70
Q

24 y-o patient with breast lump. Next step?

A

Wait 2 cycles to see if ot resolves alone. If not, get a U/S. If positive findings on U/S, perform FNA.

71
Q

Local tx of breast cancer?

A

Radiation + Surgery
• Lumpectomy + axillary lymph node dissection + radiotherapy = mastectomy + axillary lymph node dissection
• Do the sentinel lymph node biopsy before doing the axillary lymph node dissection

72
Q

Systemic tx of breast cancer?

A

Chemo
o Doxorubicin
o Cyclophosphamide
o Paclitaxel

Targeted therapy
o Her2Neu (+) (bad prognosis): Traztusumab
o Estrogen/Progesterone receptors:
Pre menopause: Selective estrogen receptor modulators (e.g., tamoxifen)
Post menopause: aromatase inhibitors

73
Q

Patient with BRCA 1 or 2 (+). Tx?

A

Bilateral mastectomy + bilateral salpingo oophorectomy

74
Q

Side effects of tamoxifen?

A
  • DVT

* Endometrial cancer (tamoxifen is estrogen agonist in the uterus)

MCCQE1 (19 decks)

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