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Surgery > Misc Subspecialties > Flashcards

Misc Subspecialties Flashcards

0
Q

Child with mushy fluid filled mass at base of neck, occupying supraclavicular area and extending into neck. Nxt?

A

Ct scan-cystic hygromas can extend deep into the neck and to the mediastinum. Electively remove.

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1
Q

Tx of thyroglossal cyst that recently got infected

A

Sistrunk operation- remove cyst, connection to tongue, and midline segment of hyoid bone

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2
Q

Easy way to differentiate an inflammatory vs neoplastic neck mass

A

Check back in 3 weeks! Will go away if inflammatory, if neoplastic then 3 was diff doesn’t make a grew change in course of the disease

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3
Q

Pt who smokes and drinks with a fixed mass medial to scm at level of upper notch of thyroid cartilage which Is growing

A

Mets squamous cell cancer to a jugular chain node. Do not biopsy, do Triple endoscopy looking for origin of cancer (mouth, pharynx, larynx, esophagus, trachea)

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4
Q

Work up for neoplastic process involving facial nerve

A

Gadolinium enhanced MRI

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5
Q

Woman with a 2cm mass in front of left ear, deep to skin and painless. Normal facial nerve function

A

Pleomorphic adenoma- can do fna but biopsy in office is never done. Refer to surgery

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7
Q

Pediatric unilateral ear pain or even lung looking darker on tha side

A

Foreign object

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8
Q

management for child this morning who has developed inspiratory stridor, fever, and is drooling from mouth

A

acute epiglottitis needs to be emergently xray (lateral neck) adn then off to OR for nasotracheal intubation.

also start IV antibiotics for H.infl

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9
Q

Ludwig’s angina

A

abscess of floor of mouth that can occur from a tooth infection. need tracheostomy with incision and drainage of abscess

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10
Q

person develops paralysis the next day on his face after having been treated aggressively after an accident

A

trauma to temporal bone would have caused an immediate lesion on facial nerve, but this is gradual devpt likely from edema, so noting needs to be done

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11
Q

18yo with nose bleed, he hasnt been picking his nose and there is no source of anterior bleeding

A

cocaine abuse or posterior juvenile nasopharyngeal angiofibroma

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12
Q

Nelson’s syndrome

A

pituitary adenoma enlargement after removal of adrenal glands for cushings syndrome. mass affect, hyperpigmentation

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13
Q

man with severe headache, seizures, projectile vomiting. was recently treated for acute otitis media and mastoiditis

A

brain abscess

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14
Q

after accident, develop loss of motor function, and pain and temp on both sides distal to injury, with vibration/position sense ok

A

anterior cord syndrome

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15
Q

which class of meds may minimize permanent damage after a spinal cord injury

A

corticosteroids

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16
Q

causalgia

A

sustained pain due to peripheral nerve injury, does not respond to analgesis medications.
dx: successful sympathetic block
surgical sympathectomy

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17
Q

child that has one hip that can be dislocated posteriorly with a click and then returned with a snap

A

developmental dysplasia of the hip

tx: abduction splinting

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18
Q

boy with limping, decreased hip motion, and knee pain

A

legg-perthes= avascular necrosis of femoral epiphysis.

AP and lateral X ray for dx

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19
Q

cause of hip problem in 13yo boy (limited hip motion, as hip flexed, the lex cannot be rotated internally)

A

slipped capital femoral epiphysis- emergency

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20
Q

child with fever and localized bone pain

A

acute hematogenous osteomyelitis

DONT DO XRAY- wont show for 2 weeks. do bone scan

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21
Q

woman with soft tissue tumor in thigh growing stadily

A

MRI - soft tissue sarcoma as consideration

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22
Q

homeless man with severe pain in forearm. muscles very firm and tender to palpation

A

compartment syndrome

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23
Q

open fracture with femur sticking out of the thigh

A

anything open is an ortho emergency- needs to be cleaned and reduced within 6 hours of injury

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24
Q

xrays dont show origin of a right shoulder pain. patient comes in with arm held close to body, internally rotated.

A

posterior dislocation of shoulder (can be missed on xrays)

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25
Q

patient hit the dashboard with his knees in accident,pain in right hip now with leg internally rotated

A

emergency- posterior dislocation of hip can lead to avascular necrosis

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26
Q

what vessel may be compromised in posterior dislocation of knee

A

popliteal artery

want to check pulses, and prompt reducation

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27
Q

recruit complains of localized pain in tibia after a march. specific point tenderness with normal xray

A

stress fracture= dont show up radiolofically until 2 wks later. Cast and repeat xray in 2 wks

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28
Q

what xrays to order for man with fall with fracture of femur

A

xrays at 90 degrees to each other (AP and lateral(, include joints above and below, and check other bones in the same line of force

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29
Q

how to differentiate testicular torsion from epididymitis

A

sonogram to rule out twisting

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30
Q

man with a ureteral stone develops chills, 104 fever, and flank pain

A

EMERGENCY- has obstruction and infection.

IV abx, and decompression by uretral stent or percutaneous nephrostomy

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31
Q

man with chills, fever, dysuria, and very tender prostate on rectal exam

A

IV abx for acute bacterial prostatitis without doing any more rectal exams- that could lead to septic shock

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32
Q

man with erection that hasnt gone away

A

priapism is an emergency (can damage corpora)- give alpha agonist

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33
Q

what to do with a baby scheduled for a circumcision who has a urethral opening on ventral side

A

dont do the circumcision now—-may need foreskin for hypospadias surgery

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34
Q

little girl who voids urine normally but also wet with urine all the time

A

low implantation of one ureter- empties into vagina without the sphincter. IVP for dx

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35
Q

16yo boy binge drinks and has colicky flank pain

A

ureteropelvic junction obstruction (pain esp noticed after drinking a lot of fluids)

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36
Q

asx prostate cancer is usually not treated after age

A

75

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37
Q

25yo m with painless, hard testicular mass

A

testicular cancer- immediate bhcg and afp and then radical orchiectomy. testicular cancers are usually not benign

DO NOT DO A TRANS-SCROTAL BIOPSY

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38
Q

woman leaks urine whenever she laughs, sneezes, lifts heavy objects

A

stress incontinence, need surgical repair of pelvic floor

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39
Q

test for pt presenting with bubbles of air with urine

A

sigmoid colon diverticulitis or cancer connecting to bladder

-sigmoidoscopy or cystoscopy usually dont show anything. CT scan

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40
Q

what history to check for patient presenting with an isolated thyroid nodule

A

main concern is thyroid cancer. check family history, but especially hx of LOW DOSE IONIZING RADIATION. If history present, straight to thyroidectomy

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41
Q

next step after H&P of fixed thyroid nodule

A

FNA

Note: radioactive scanning with iodine isnt an initial step, but cold nodules have a higher chance of being malignant

42
Q

nerves and structures at risk during thyroidectomy

A 
recurrent laryngeal (hoarseness)
external branch of superior laryngeal (high pitched voice altered)
parathyroid- hypocalcemia
43
Q

how would surgery for papillary cancer differ in pt with previous radiation vs not

A

previous head/neck radiation= total thyroidectomy

no radiation= limited thyroid lobectomy and isthmusectomy

44
Q

post op management after thyroidectomy

in what case is this management not helpful?

A

thyroid suppression by giving TH and iodine ablation

not helpful in medullary cancer due to tumor arising from C cells

45
Q

what scan can localize primary hyperPTH effects

A

preoperative sestamibi scan (shows enlarged parathyroid glands)

46
Q

patient with only 3 glands which are normal while patient has hypercalcemia and high PTH levels

A

find the missing parathyroid gland!

most common site- thymus

47
Q

initial treatment with acute hypercalcemia

A

calcium results in osmotic diuresis to first step is rehydration with normal saline.

  • furosemide- brisk diuresis of calcium (dont use thiazides!)
  • initiate bisphophonates
48
Q

when is surgical management indicated for secondary hyperPTH

A
  • bone pain and fractures
  • intractable pruritis
  • ectopic calcifications of soft tissue
49
Q

what to think about when pt with hyperPTH becomes uncontrollably hypertensive during the procedure

A

pheochromocytoma

50
Q

scans for pheo

A

MRI- tumor brightness
octrotide scan
MIBG scan-accumulates in chromaffin tissue

51
Q

pre-op for pheo

A

10-14 days of alpha blocker

52
Q

what is given if insulinoma cannot be resected

A

diazoxide= inhibitor of insulin release

53
Q

management for an incidental adrenal mass found on CT

A

if lesion more than 5cm= higher incidence of adrenal cortical carcinoma- surgery recommended

54
Q

most significant finding in addition to histo and TNM for prognosis of melanoma

A

presence of ulceration in primary lesion

even in stage 1 lesions, ulceration reduces survival

55
Q

management of malignant melanoma for clark level 1 and 2 lesions

A

re-excise lesion with 1cm margin,down to the deep fascia (full thickness)

56
Q

for melanoma, lymph nodes are usually just resected if palpable. when may elective node dissection done?

A

if do sentinel LN biopsy after and it is positive

57
Q

patient with a brownish discoloration on cheek that has been slowly growing

A

irregular lentigo maligna melanoma usually more superficial and spreading (better prognosis)
excision with narrow margins ok

58
Q

prognosis for pt with melanoma on sole of foot

A

poorer prognosis- these lesions tend to be thicker

59
Q

type of biopsy based on sarcoma size

A

smaller than 3cm: excisional

greater than 3cm: incisional

60
Q

surgical management of sarcoma

A

initial extensive surgery provides best control. ex: total resection of a tissue compartment (spares limb unlike amputation)- muscle length, insertion points, deep fascia

61
Q

lung lesion found on cxr after primary excision of a sarcoma

A

recurrences usually occur in first 2 yrs after resection

  • follow up with CT with contrast to find other lesions/characterize lesion
  • if sarcoma in lung= thoracic wedge resection
62
Q

a firm, tender mass in gron with nausea, vomiting, abdominal distension

A

loop of intestine could be incarcerated/strangulated in hernia

63
Q

when to start breast examinations if have first degree relative history

A

age 40 yearly mammograms, 30 if history

self breast examinations at 20yo

64
Q

“probably benign” breast lesions

“suspicious” breast lesions

A

probably benign findings warrant follow up (risk of malignancy less than 2%)
suspicious- warrant biopsy `

65
Q

which type of biopsy preferred if mammographic lesion is indeterminate

A

stereotactic core needle (better histologic diagnosis than FNA

66
Q

a woman has amorphous calcifications indicating DCIS. next step?

A

surgery is necessary,esp since some lesions diagnosed as DCIS have an infiltrative component when excised

67
Q

which pattern of DCIS has a higher malignant potential?

A

comedo pattern

68
Q

is nodal dissection needed with DCIS?

A

no unless comedo pattern

69
Q

how does LCIS differ from DCIS?

A

usually not picked up by a mass or mamography. has no risk of axillary metastasis. usually tx is close observation with checking every 6 mos

70
Q

followup steps for 60yo female with a breast mass (no FH or SH)

A

mammogram to look for lesion in both breasts
ultasound of mass if mass feels cystic
biopsy if mass feels solid
core biopsy for diagnosis, FNA for cytology

71
Q

28yo woman presenting with a breast mass

A

under 30- higher incidence of benign lesions and also more risk of radiation. Ultrasound may precede mammogram, to look for cyst and aspirate it. If solid, high likelihood of fibroadenoma- observation or elective removal

72
Q

35yo f presents with tender breasts before menstrual periods. Breasts lumpy

A

fibrocystic changes may be due to increased sensitivity to estrogen
may want to eliminate caffeine from diet
take supplemental vit E

if doesnt go away, biopsy necessary since some risk of cancer exists

73
Q

14 cm breast mass in 20 yo woman

A

phyllodes tumor (giant cell fibroadenomas)- large, bulky mass with variable malignant potential. need to widely excise.

74
Q

next steps in woman with bloody breast discharge

A

mammography to look for other problems

find the single duct that is the source and excise

75
Q

how to assess distant mets from breast cancer

A

chest xray to detect lung and bone—hes—-CT/bone scan of head
liver enzymes—yes= CT of abdomen

76
Q

how does woman’s age affect prognosis in breast cancer

A

younger at diagnosis tend to do worse

77
Q

what does an ulcerated breast lesion with an underlying mass indicate

A

inflammatory carcinoma (worse prognosis than usual infiltrating ductal carcinoma)

78
Q

what does a breast mass fixed to deeper tissues indicate

A

fixation to chest wall indicates invasion of structures outside breast

79
Q

breast cancer with LN palpable in supraclavicular area

A

stage 4 disease with distant mets- cant resect anymore

80
Q

N1 vs N2 in breast cancer

A

N1 is mets to movable nodes while N2 is fixed

81
Q

main arterial supplies to the breast

A

internal mammary (60%) and lateral thoracic (30%)

82
Q

what is spared in the MRM surgery vs a radical mastectomy

A

pectoralis major muscle

83
Q

for which patient is local radiation indicated following mastectomy

A

patients with tumors larger than 5cm, that involve margin of resection or that invade the pectoral fascia or muscle

84
Q

when can a lumpectomy/segmental mastectomy done instead of MRM

A

solitary tumor less than 5cm provided that pt is a good candidate for postop radiation

85
Q

next step in woman with 1.5 cm breast lesion with no palpable axillary nodes and negative mets workup

A

still need to sample lymph nodes- usually at levels 1 and 2 or sentinel node

sentinel node figured out via radiotracer dye

86
Q

is there a significant difference in survival btwn MRM and lympectomy with radiation

A

not for stage 1 or 2 patients

87
Q

pros and cons of MRM vs lumpectomy in younger women

A

younger- lumpectomy may be preferred for cosmetic reasons but MRM more appropriate since younger= more recurrences

88
Q

contraindications to immediate reconstruction of breast

A

primary lesions involving chest wall
extensive local or regional disease
stage 3 or 4 cancer

89
Q

followup management for node negative stage 0 and 1 cancer with small vs large tumor

A

small- radiation and no further therapy if ER neg, and hormonal therapy for ER+
chemotherapy is better tolerated in younger pre-menopausal women and can be used

larger (1-2cm)- adjuvant therapy + radiation

90
Q

what should be considered for stag 3 and 4 cancer in addition to surgery

A

neoadjuvant (prior to surgery) therapy to reduce tumor size

91
Q

a woman who had a MRM for stage 2 cancer of breast has a small lesion in suture line 5 years later

A

local recurrence- r/o with surgical or core needle biopsy
excise lesion if cancer
if had lumpectomy before, then do mastectomy

92
Q

woman with previous breast cancer surgery has a mammographic abnormality in opposite breast

A

new primary cancer likely

93
Q

patient who had a mastectomy now has decreased sensation and motor function in right leg

A

emergency! extradural mets to spine
MRI scan for dx of cord compression

Steroids, cord decompression, radiation therapy

94
Q

pregnant woman with stage 1 or 2 breast cancer

A

mastectomy or lumpectomy is safe. if in 3rd trimester, can delay radiation. Lumpectomy discouraged earlier in pregnancy due to need of radiation

95
Q

a 6yo girl presents with a firm 1cm unilateral breast mass

A

likely a breast bud- observe, reassure parents

dont excise or biopsy

96
Q

best therapy for BPH

A

TURP (transurethral prostatectomy)- chips of prostate are carved out from urethra and removed via scope

97
Q

pt with lower abdominal mass constantly dribble urine. next step

A

put in a foley first to relief obstruction

98
Q

pt with lower abdominal mass constantly dribble urine. next step

A

put in a foley first to relief obstruction

99
Q

which type of breast cancer has tendency to be negative on mammogram and also presents as focal thickening

A

invasive lobular

100
Q

screening ductal lavage

A

for high risk lesions or profiles. aspiration of areola to induce nipple discharge, analyzed through cytology.

101
Q

next step with LCIS found

A

MRM and mastectomy not yet justifiable since this is indication of subsequent cancer devpt. instead should use tamoxifen and mammogram surveillance

102
Q

man with trauma has bloody urethral meatus, distended bladder, scrotal hematoma, high riding prostate

A

posterior urethral injury associated with pelvic trauma

Surgery (4 decks)

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