Pestana General Surgery Flashcards
A patient presents with burning retrosternal pain that arises when bending over or lying down at night. The pain is relieved by antacids? How should this patient be monitored? What complication and tests if the patient has had longstanding symptoms?
GERD. Monitor by pH monitoring.
Barrett esophagus with endoscopy and biopsies.
Dysplastic changes of the esophagus are treated with?
Nissen fundoplication and radiofrequency ablation.
A women presents with chrushing pain when swallowing that is worse for liquids than solids. She now drinks fluids upright? Tests and treatments (2)?
Achalasia. X rays (megaesophagus), barium swallow then Manometry (diagnostic). Balloon dilation or Heller myomoty.
A black man with a history of smoking and drinking presents with dysphagia. He notes it started with meat, and now he struggles to swallow liquids. He admits recent significant weight loss? Tests and Treatment?
Squamous Cell Carcinoma of the esophagus. Barium swallow then endoscopy. CT Scan and palliative surgery.
An overweight man with longstanding history of GERD presents with progressive dysphagia and significant weight loss? Tests and Treatment?
Adenocarcinoma of the esophagus. Barium swallow then endoscopy. CT Scan and palliative surgery.
Alcoholic with hematemesis after forceful vomiting? Tests and Treatment?
Mallory Weiss tear (tearing of sub/mucosa of esophagus). Endoscopy and cauterization or epinephrine.
Patient presents with severe retching, vomiting, and hematemesis. Develops sudden wrenching epigastric/low sternal pain with fever and leukocytosis? Tests and Treatment?
Boerhaave syndrome (tearing of muscular layer of esophagus). Gastrofarrin swallow, followed by barium swallow if negative. Repair surgically.
What is the most common cause of esophageal perforation? What is the diagnostic clinical sign? Common symptoms?Tests and treatment?
Instrumental perforation during endoscopy. Subcutaneous emphysema in the neck. Acute substernal pain. Xray gastrografin contrast study.
Treatment of gastric adenocarcinoma? Gastric lymphoma? MALTOMA?
Surgery. Chemoradiation. Eradication of H. Pylori
An elderly patient presents with early satiety, weight loss, and anorexia? Tests and Treatment?
Gastric Adenocarcinoma. Endoscopy and biopsies. Surgical repair.
Patient with PSH of abdominal surgery presents with colicky pain, vomiting, abdominal distension, and no passage of gas or feces? Tests (signs)? Treatment?
Obstruction (adhesions). X ray - distended small bowel loops with air fluid level.
NPO, NG, IV fluids. Surgical removal.
Patient with obstruction develops fever, leukocytosis, pain, rebounding and gaurding? Complications? Treatment?
Strangulation. Sepsis. Emergency surgery.
Patient presents with diarrhea, facial flushing, wheezing, distended JVP? Test and treatment
Carcinoid tumor (small bowel metastasis to liver - most commonly appendix). CT scan. Surgical removal.
Patient complains of anorexia and mild periumbilical pain that suddenly migrates to the right lower quadrant. The pain is now sharp and severe. Tests? Treatment?
Appendicitis.
Physical exam: tenderness, gaurding, and rebound. Fever.
CBC: Leukocytosis, left shit.
CT scan - ESPECIALLY W/OUT classic symptoms.
Emergency appendicitis.
An elderly patient presents with bloody stool (4+) - melena. CBC indicates hypochromic anemia? Tests and treatment?
Right colon cancer. Colonscopy with biopsy. Right hemicolectomy.
An elderly patient presents with thin, blood coated stool and constipation? Tests and Treatment? How does treatment change for large lesions?
Left colon cancer. Flexible proctosigmoidscopic study. Full colonoscopy to assess additional lesions, CT scan for operability. Neoadjuvant chemoradiation before surgical excision if large lesion.
Colonic polyps that are premalignant (4)?
Familial polyposis, familial multiple inflammatory polyps, villous adenoma, adenomatous polyp
Colonic polyps that are not premalignant (4)?
Juvenile polyps (highly vascular- remove), Peutz Jeghers, isolated inflammatory, hyperplastic (most common)
Indications for surgical treatment of Chronic UC? Procedure?
20+ years of disease, increased steroid doses, toxic megacolon. Removal of affected colon WITH ALL of the mucosa.
A patient hospitalized for a UTI develops profuse, watery, diarrhea, with fever and leukocytosis? Test? Treatment?
Pseudomembranous enterocolitis (C. Diff). Toxin in the stool. Stop antibiotics, give Metronidazole or Vancomycin.
Internal vs. External Hemorrhoids. Presentation? Treatment?
I: Painless bleeding. Rubber band ligation.
E: Pain. Surgical removal.
A young woman presents with recent constipation and cc of severe pain on defecation with blood coated stools? Treatment?
Anal fissure. Stool softeners and calcium channel blockers.
A man in his 20’s with PMH of anal ulcers that do not resolve after surgery? Which surgical prodcedure should be preformed?
Chrohn’s disease. NO surgery for Chrohn’s of the anus.
A man presents with fever, constipation, and looks very uncomfortable, unable to even sit in the chair? Treatment?
Ischiorectal abcess. Incision and drainage.
A man with PMH of ischiorectal abcess presents with fecal soiling and perineal discomfort? Treatment?
Fistula-in-ano (from previous drainage). Fistulotomy.
An HIV+ man presents with a dungating mass growing out of the anus and metastatic inguinal nodes? Treatment?
Squamous cell carcinoma of the anus. Chemoradiation.
What is the anatomical border between the Upper GI and Lower GI
Ligament of treitz - junction between duodenum and jejunum.
Young patients bleed from the upper or lower GI predominately ?
Upper GI
A patient vomits blood. Upper or lower GI bleed? Tests?
Upper GI. Upper GI endoscopy
A patient presents with melena. Upper or lower GI bleed? Tests?
Upper GI. Upper GI endoscopy
A patient presents with red blood per rectum. Upper or lower GI bleed? Tests?
Unknown. Do NG tube, upper GI endoscopy, lower GI endoscopy.
A patient presents with active bright red bleeding per rectum. NG tube, upper GI endoscopy, and anoscopy are negative for blood? Which test can’t be used during active bleeding? Tests for fast, medium, and slow bleeders?
Lower GI bleed. Can’t use colonoscopy during active bleeding. Fast = CT angiogram. Medium = tagged red cell study. Slow = wait until bleeding stops and do colonoscopy.
Rule of 2’s for Meckel diverticulum (5)?
2% population, 2 ft proximal to ileocecal valve, 2 inches long, 2 years old, 2:1 M:F.
A young child presents with bleeding per rectum? Tests?
Meckel diverticulum. Technetium scan.
How to treat massive upper GI bleeds?
Angiographic embolization.
Patient presents with sudden, constant, very severe generalized abdominal pain. On PE, patient exhibits tenderness, gaurding, and rebounding, and no bowel sounds? Confirmatory test and sign? Treatment?
Perforated peptic ulcer. Upright xrays (free air under the diaphragm). Emergency surgery.
What are the unique combination of symptoms exhibited in an ischemic bowel?
Severe abdominal pain and blood in the lumen.
A man with cirrhosis and history of ascites presents with gaurding, tenderness, rebounding, fever, and mild leukocytosis? Tests? Treatment?
Primary peritonitis. Culture of ascitic fluid. Antibiotics.
A middle aged patent presents with peritoneal irritation in his left lower quadrant, fever and leukocytosis? Tests? Treatment?
Acute diverticulitis. CT Scan. NPO, IV fluids, antibiotics- surgery if those don’t work - Left Hemicolectomy with ostomy and Hartmann pouch.
An elderly patient who lives in a nursing home presents with severe abdominal distension, constipation, absent bowel sounds, and no passage of gas/feces? Tests and signs? Treatment?
Volvulus of the sigmoid (can often be in Cecum). X rays - air fluid levels, distended colon “inner tube”, on barium enema “parrot’s beak”. Proctosigmoidoscopy, leave rectal tube.
A cardiac patient with recent history of MI presents with an acute abdomen, severe pain, and blood per rectum. Eventually he becomes confused and looks SHOCKY? Tests? Treatment?
Mesenteric ischemia of the SMA. Arteriogram. Embolectomy.
A cirrhotic man develops right upper quadrant pain and weight loss? Tests? Treatment?
Hepatoma. A-fetoprotein in blood, CT scan. Resection.
Is primary or metastatic liver cancer more common? How is metastatic liver cancer detected?
Metastatic 20:1. CT scan.
A young woman presents to the ED and looks SHOCKY despite no history of trauma. No history of smoking or alcohol. Takes OCP? Tests? Treatment?
Hepatic adenoma. CT scan. Emergency surgery to stop the bleeding.
A young man returns from a trip to Mexico City and develops fever, leukocytosis, and a tender liver? Tests? Treatment?
Amebic liver abcess. CT scan or sonogram (you could wait 2 weeks for serology. Metronidazole.
In Hemolytic Jaundice, is the elevated bilirubin mostly conjugated or unconjugated?
Unconjugated.
Levels of bilirubin, transanimases, and ALK in Hepatocellular vs. Obstructive Jaundice
Hepato: both bilirubin elevated, very high trans, modestly elevated ALK.
Obstructive: both bilirubin elevated, modestly elevated trans, very high ALK.
An overweight woman with multiple children presents with jaundice, fever, PMH of biliary colic? Location? What are her enzyme levels? What is seen on sonogram? Confirmatory test? Treatment?
Obstructive jaundice caused by stones (choledocholithiasis - in common bile duct). Very high ALK. A non dilated gallbladder full of stones with dilated ducts. ERCP. Sphincterectomy and Cholescystectomy.
A patient presents with painless jaundice with high ALK. Sonogram displays dilated gallbladder. CT test indicates a large tumor? Treatment? Efficacy?
Adenocarcinoma of the pancreas head. Percutenous biopsy. Whipple pancreatoduodenectomy. Limited
A patient presents with painless jaundice with high ALK, anemia, and blood in the stool. CT test identifies no tumor? Test? Treatment?
Ampullary cancer. Endoscopy and MRCP (for smaller obstructions). Surgical resection.
Which cancers arise from the common duct? Risk factors (3)?Tests? Treatment?
Cholangiocarcinomas.
UC, liver flukes, thorothrast exposure.
ERCP.
Surgery +/- radiation.
Textbook presentation of Gallbladders (4)?
Fat, fecund, female, in her fourties
Patient complains of a few hours of transient right upper quadrant colicky pain that radiates to the shoulder and around the back, picks up after meals and associated with nausea. Pain woke them from their sleep? Test? Treatment?
Biliary colic from gallstone occluding cystic duct. Sonogram. It should resolve, eventual elective cholecystectomy.
Patient complains of several days of right upper quadrant pain, nausea, fever and leukocytosis. PE reveals right upper quadrant tenderness and rebounding? Location? Which sign is present? Lab values? Tests? Treatment?
Acute cholecysistis - obstruction of the cystic duct. Murphy’s sign - abdominal pain on inspiration. Slightly elevated bilirubin and liver enzymes. Sonogram (diagnostic). HIDA scan can be used next (wouldn’t be uptaken by the gallbladder).
NG Suction, NPO, IV fluids, antibiotics (not always infected).
Eventual cholecystecomy.
A diabetic patient with acute cholecystitis does not respond to treatment? Therapy?
Emergency percutaneous transhepatic cholecystostomy?
An elderly patient presents with right upper quadrant pain, high fever and leukocytosis, chills, mild jaundice? Major hepatobilliary complication? Physical sign? Tests? Treatment?
Acute ascending cholangitis. Pyogenic liver abcess. [Fever, RUG pain, jaundice] = Charcot’s Triad. Check ALK, it will be super high! IV antibiotics and ERCP, eventual cholecystectomy.
How will you know if biliary stones have impacted pancreatic function? How and where will the stones be found? Treatment?
Increasing amylase and lipase levels. Sonogram sees stones in the ampulla. NPO, NG suction, IV fluids. ERCP might be required to remove the stone.
An alcoholic with PMH of cholelithiasis presents with self limiting epigastric pain that radiates to the back, following an eating/drinking binge, accompanied by guarding, tenderness, and nausea? Tests? Treatment?
Acute edematous pancreatitis. High serum and amylase. CBC to look for high hematocrit. NPO, NG suction, IV fluids (third spacing from fluid loss).
What differences on CBC and electolyte panels exist between acute and high Ransons score pancreatitis?
Hem: lower hematocrit, elevated glucose, lower calcium (saponification), BUN increases, increasing fluid sequestration. Ranson’s criteria.
Patient is hospitalized with acute hemorrhagic pancreatitis. BUN is increasing and he is becoming acidotic. Complications? Treatment?
Acute suppurative pancreatitis. CT scans to identify pancreatic abcesses with drainage. IV antibiotics if infected.
What are the early events of pancreatitis?
Inability to secreate pancreatix zymogens, with early activation of panceatic enzymes
Patient presents a month after her last bout of acute pancreatitis with a deep palpable mass and early satiety? Tests and signs? Treatment?
Pancreatic pseudocyst. Sonogram or CT (collection of juice outside of the ducts in the lesser sac). Big (>6cm) old (>6 wks) cysts are drained, smaller are observed.
Should necrotic pancreas be removed immediately, or after a month?
After a month - allows for easier dissection
All hernias should be electively repaired except for?
Umbilical hernias in toddlers and esophageal sliding hiatal hernias.
In which patients are mammograms contraindicated?
Women under 20 or during lactation
What is the best way to biopsy a breast mass?
Mammo/sonographically guided multiple core biopsies
A 20 year old woman presents with a firm, rubbery, moveable breast mass? Tests? Treatment?
Fibroadenoma. FNA or Sonogram. Removal is optional.
A 15 year old black girl presents with a well circumscribed large breast mass? Tests? Treatment?
Giant juvenile fibroadenoma. Sonogram. Must be removed.
A 28 year old woman presents with a rapidly growing firm, palpable breast mass? Tests? Treatment?
Cystosarcoma phyllodes. Sonographically guided core biopsy. Must be removed
A 45 year old woman presents with bilateral breast tenderness that gets worse before her period, and lumps that come and go after her period? Tests? Treatment if the lumps don’t go away? Will these symptoms persist forever?
Mammary dysplasia - Fibrocystic condition. Aspiration of the cyst and cytology if bloody. If not bloody, observation is all that is needed. Symptoms end with menopause.
A women in her thirties presents with bloody nipple discharge without masses? Tests? Treatment?
Intraductal papilloma. Mammography and Galactogram (diagnostic). Surgical resection.
A young nursing mother presents with a hard, tender, red, swollen area on her breast. How should she be managed? What is the most likely offending agent?
Continued lactation, antibiotics, and analgesics. Biopsy and cultures will reveal S. Aureus infection.
Physical charactersistics of breast cancer (6)?
ill defined palpable mass, retraction of overlying skin, “orange peel” skin, eczematoid lesions of the areola, retraction of the nipple, and papillary axillary nodes
When is radiation or chemotherapy allowed during pregnancy to treat breast cancer?
Radiation: never, Chemo: 2-3 trimesters.
Treatment of resectable breast cancer?
Lumpectomy + axillary samlpling (with removal of sentinel node) + post op radiation
Which breast cancers have the worst prognosis? How is treatment different?
Inflammatory and Infiltrating ductal carcinoma. Pre-op chemotherapy.
Which breast cancer does not require axillary sampling? Treatment?
Ductal Carcinoma In situ. Lumpectomy or total simple mastectomy.
Which hormonal therapies are provided to premenopasual women with receptor positive tumor? Postmenopausal women?
Tamoxifen (estrogen receptor antagonist). Anastrozole (aromatase inhibitor).
A woman with PMH of infiltrating ductal carcinoma presents with persistent headaches? Tests? Treatment?
Metastasis to the brain or spine. MRI. Surgical resection.
A patient presents with nodules in his thyroid and is concerned about potential surgical intervention. Tests? When is surgery appropriate?
FNA - incidence of cancer is low. Thyroidectomy required for follicular cancers.
Clinical signs of hyperthyroidism (7)?
Weight loss despite appetite, palpitations, atrial fib/flutter, heat intolerance, moist skin, hyperactive, tachycardia.
A patient presents with the clinical symptoms of hyperthyroidism? Tests? Treatment?
Hyperfunctioning nodule = Hot adenoma. Labs (low TSH, hi T4), and Nuclear scan. Radioactive iodine or surgery.
A patient presents with kidney stones, a history of bone pain, and constipation? Tests and Results? Treatment?
Hyperparathyroidism. Labs - hypercalcemia, hypophosphatemia, hight PTH. X ray - rule out bone metastases. Sestamibi scan to find the offending gland. Parathyroid is removed.
A an overweight hairy faced woman, with supraclavicular fat pads,buffalo hump, obese trunk, diabetes, and hypertention shows up in your clinic. How do you determine the etiology? Treatments?
Cushing’s. Dexamethasone (ACTH analogue) suppression test with 24 hour urine analysis for Cortisol. No ACTH suppression = Adrenal adenoma. Low ACTH suppression = Not Cushing’s. High suppression = pituitary adenoma. MRI and CT scan. Surgical resection.
A patient presents with upper abdominal pain, watery diarrhea, and heartburn. The patient was treated with antibiotics against H. Pylori, but the sympoms have not abated? Tests? Treatment?
Zollinger Ellison Syndrome. Measure gastrin (patient must be off PPI), preform secretin stimulation test (high gastrin release). CT scan with contrast. Removal of pancreatic tumor and omeprazole.
Sweat tremors, Headache, lethargy, diplopia, and once had a seizure after not eating for several hours? Diffferentrial diagnosis? Tests, Treatment?dizziness, confusion, aa
Insulinoma. Could also be reactice hypoglycemia (but attacks happen after eating) or with self administration of insulin (won’t have elevated C-peptide levels). CT scan with contrast and surgical removal of the pancreatic tumor.
A newborn infant is irritable and lethargic, he is profoundly hypoglycemic? Treatment?
Nesidioblastosis = congenital hyperinsulinism. Immediate removal of the pancreas.
A patient with PMH of diabetes, anemia, glossitis, and stomatitis presents with severe, migratory necrolytic dermatitis? Tests? Treatment?
Glucagonoma. Glucagon assay and CT. Removal of the pancreatic tumor. Somatmostatin and streptozocin in metastatic disease.
A hypertensive female presents with headaches, fatigue, and muscle weakness? Tests? Differential diagnosis and tests? Treatment?
Primary hyperaldosteronism. Electrolytes - hypokalemia, alkalotic. Labs - high aldosterone and low renin. Adrenal Adenoma = Conn’s Syndrome or adrenal hyperplasia (makes more aldosterone when standing). CT scan and surgical resection.
A thin hyperactive woman presents with bouts of headaches, perspiration, papitations, and skin pallor? Tests? Treatment?
Pheochromocytoma. 24 hour urinary test looking at vanillylmandelic acid, metanephrines, or catecholamines. CT scan. Alpha blockers and surgical resection of adrenal tumor.
A young boy develops hypertension in his upper limbs? Tests and signs? Treatment? What condition is this common in?
Coarction of the aorta. CXR (scalloping of the ribs). CT angio. Surgical repair. Turner’s Syndrome.
An incidental finding of fait bruit over the flank and upper abdomen was observed in a 30 year old woman? Tests? Treatment
Fibromuscular dysplasia and resultant renovascular hypertension. Doppler scanning and CT angio. Balloon dilation and stenting.
Three stages of wound healing?
Inflammatory, proliferation, remodeling
What test to diagnose Barrett’s Esophagus?
Upper GI Endoscopy
What are the 5 sections of the colon (right to left)
Cecum, ascending, (hepatic flexure) transverse (splenic flexure), descending, sigmoid.
Red blood per rectum. Location if NG tube retrieves blood? Is Upper GI Endoscopy required?
Upper GI. Yes.
Red blood per rectum. Location if NG tube retrieves white fluid? Is Upper GI Endoscopy required?
Below the pylorus. Yes, bleeding could still be from duodenum.
Red blood per rectum. Location if NG tube retrieves green fluid? Is Upper GI Endoscopy required?
Below the Ligament of Treitz. No.
Borders of Hesselbach’s Triangle?
Medial: Rectus Abdominis
Superolateral: Inferior Epigastric Arteries
Inferior: Inguinal Ligament
Direct Inguinal Hernia. Description? Location relative to inferior epigastric arteries?
Through the abdominal wall of Hesselbach’s triangle. Medial.
Indirect Inguinal Hernia? Description? Location relative to inferior epigastric arteries? Which side is more common?
Protrudes through inguinal ring. Lateral. Right.
Which hernia is most common? Which hernia is most common in women? Which hernia is most commonly found in women?
Direct. Direct. Femoral.
Acute ruptured appendicitis (patient complained of severe RLQ pain several days ago) presents with? What is found on DRE?
Pelvic abscess - lower abdominal pain, malaise, fever. Tender pelvic mass on DRE.
Pathophysiology of diverticulosis? Why is it false? Risk factor?
Protrudes through vulnerable part of wall where vasa recta penetrates, doesn’t contain all layers of the bowel. Age and low fiber diet.
Diverticulosis symptoms?
80% asymptomatic. Massive painless GI bleeding.
Angiodysplasia? Location? Speed of bleed?
Tortuous, dilated veins in submucosa. Cecum and ascending colon. Slow bleed, often stops spontaneously.
What is the utility of monitoring CEA?
For baseline and follow up risk of colon cancer.
Most common cause of Large Bowel Obstruction?
Colon Cancer - adenocarcinoma.
