Summary of Essentials Ch. 1-

Question 1

Location of femoral hernia?

Answer 1

Posterior and inferior to the inguinal ligament and medial to the femoral vein

Question 2

Cause of indirect vs. direct inguinal hernia?

Answer 2

Indirect - congenital (patent processus vaginalis)

Direct - acquired weakness in Hesselbach’s triangle?

Question 3

Location of indirect inguinal hernia?

Answer 3

Lateral to inferior epigastric vessels, through the deep and superficial ring

Question 4

Location of direct inguinal hernia?

Answer 4

Medial to inferior epigastric vessels, through the superficial ring only

Question 5

Imaging for hernia?

Answer 5

Clinical diagnosis, none needed

CT scan only if dx unclear (as in morbid obesity)

Question 6

Asymptomatic hernias can be observed - exceptions?

Answer 6

Femoral hernias, inguinal hernias in infancy

Question 7

Management of symptomatic indirect and direct hernias?

Answer 7

Indirect - open the sac, reduce, perform high ligation

Direct - do NOT open, reinforce floor with mesh

Question 8

Rx incarcerated hernia?

Answer 8

Attempt reduction, then repair semi-electively

Question 9

Rx strangulated hernia?

Answer 9

Urgent surgery

Question 10

Rx umbilical hernia in children?

Answer 10

Repair if persistent >age 4, if defect >2 cm, if progressive enlargement after age 2

Question 11

Describe physical exam of a breast mass suspicious for cancer

Answer 11

Firm with irregular borders

Question 12

When is nipple discharge suspicious for breast cancer?

Answer 12

Bloody, spontaneous, unilateral, uniductal, associated with a mass, >40 y/o

Question 13

Most common cause of palpable breast mass?

Answer 13

Fibrocystic disease

Question 14

Most common malignancy neoplasm of the breast?

Answer 14

Invasive ductal carcinoma

Question 15

Most common breast neoplasm in premenopausal women?

Answer 15

Fibroadenoma

Question 16

Work-up of all new breast masses?

Answer 16

Triple test -> physical exam, imaging, tissue sample

If 30 or younger - U/S
If >30 - mammogram + U/S
Tissue diagnosis if clinically suspicious regardless of imaging findings
Core needle biopsy better than FNA

Question 17

Drug for HER-2 + breast cancer?

Answer 17

Trastuzumab

Question 18

Drug for premenopausal ER+ breast cancer?

Answer 18

Tamoxifen

Question 19

Rx post-menopausal ER+ breast cancer?

Answer 19

Anastrozole (aromatase inhibitor)

Question 20

Type of calcification suspicious for cancer on mammogram?

Answer 20

Fine, linear, branching, pleomorphic microcalcifications

Question 21

DCIS vs. LCIS in terms of progression?

Answer 21

DCIS can progress to invasive cancer if left unresected

LCIS is only a marker for the development of future ipsilateral AND contralateral invasive breast cancer

Question 22

Manage DCIS?

Answer 22

Lumpectomy to negative margin

Question 23

Manage LCIS found on excisional biopsy?

Answer 23

Depends on risk factors
If low risk -> observation or tamoxifen
High risk -> prophylactic bilateral mastectomy

Question 24

Manage LCIS found on core biopsy?

Answer 24

Excision biopsy to rule out adjacent or associated ductal or lobular cancer

Question 25

Which coronary artery is most commonly affected in ACS? What does it supply and what EKG changes are seen?

Answer 25

LAD | Anterior wall of left ventricle, anterior 2/3 of intraventricular septum - V2, V3, V4

Question 26

Initial management of ACS?

Answer 26

Aspirin, clopidogrel, Gp2b3a antagonist, heparin, beta-blocker, nitro, statin, orphine

Question 27

Management of STEMI?

Answer 27

Cath suite within 90 minutes for PCI | Systemic thrombolysis if PCI not immediately available

Question 28

Management of NSTEMI?

Answer 28

Most do not require PCI | Elective cardiac cath on selective basis

Question 29

Indications for urgent/emergent CABG?

Answer 29

Cardiogenic shock Failed PCI Presenting >12 hours after initial insult

Question 30

Indications for elective CABG?

Answer 30

Left main CAD Multivessel disease of other coronaries Failed PCI or not amenable to PCI

Question 31

Systolic crescendo-decrescendo murmur loudest at the upper right sternal border + S4?

Answer 31

Aortic stenosis

Question 32

What happens to murmur as aortic stenosis worsens?

Answer 32

Flow across the valve decreases and the murmur will become quieter and be heard later

Question 33

Rx aortic stenosis?

Answer 33

Surgical valve replacement; if poor candidate, valvuloplasty or transcatheter valve replacement

Question 34

Dx aortic dissection?

Answer 34

CXR (widened mediastinum) CT chest with IV contrast Unstable - OR with TEE

Question 35

Management of aortic dissection (immediate)?

Answer 35

Immediate control of BP - beta-blocker preferred unless suspected tamponade or severe aortic regurgitation

Question 36

Manage type A dissection (involves ascending)

Answer 36

Immediate operative repair

Question 37

Manage type B dissection?

Answer 37

Admit to ICU for BP control; surgery only if evidence of malperfusion or ongoing pain

Question 38

Work-up of incidental adrenal mass noted on CT?

Answer 38

24-hour urine free cortisol level or low-dose dexamethasone suppression test -> hypercortisolism Serum aldosterone/plasma renin ratio >30 -> hyperaldosteronism Catecholamine or metanephrine levels -> pheo

Question 39

Management of functional adenoma?

Answer 39

Adrenalectomy

Question 40

Management of non-functional adenoma?

Answer 40

<4 cm - observe 4-6 cm - adrenalectomy if good surgical risk >6 cm - adrenalectomy Do NOT biopsy

Question 41

Cause/Dx of primary hyperparathyroidism?

Answer 41

Excess PTH secretion -> hypercalcemia and osteopenia Elevated Ca2+ with high or inappropiaitely normal PTH level

Question 42

Cause/Dx of secondary hyperparathyroidism?

Answer 42

Decreased serum Ca2+ with increased PTH

Question 43

Indications for parathyroidectomy in asymptomatic patients with primary HPT?

Answer 43

Serum Ca2+ level 1.0 mg/dL greater than upper limit of normal Creatinine clearance <60 mL/min T-score

Question 44

Indications for parathyroidectomy in secondary PTH?

Answer 44

High PTH despite bmedical management, bone pain, pruritis, progressive renal disease, osteopenic fractures, calciphylaxis

Question 45

What can be done to localize a solitary adenoma?

Answer 45

Sestamibi scan + thyroid U/S

Question 46

Manage pheochromocytoma?

Answer 46

Medical conditioning with alpha-blockade for at least 2 weeks (phenoxybenzamine) Beta-blockade if tachycardia and/or arrhythmia Adrenalectomy

Question 47

Most important initial test for thyroid mass?

Answer 47

TSH

Question 48

Thyroid nodules should be evaluated with ___. If TSH is elevated, get a ___.

Answer 48

U/S; radioactive iodine scan

Question 49

What type of thyroid nodules have low risk of malignancy?

Answer 49

Iodine-avid and hot

Question 50

Thyroid nodules that should undergo FNA?

Answer 50

Size >1 cm or suspicious or increasing in size

Question 51

Management of FNA results if inadequate?

Answer 51

Repeat FNA

Question 52

Management of FNA results if benign?

Answer 52

Observe

Question 53

Management of FNA results if AUS/FLUS?

Answer 53

Repeat FNA

Question 54

Management of FNA results if suspicious for follicular neoplasm?

Answer 54

Diagnostic thyroid lobectomy; if malignant, complete thyroidectomy

Question 55

Management of FNA results if suspicious for malignancy?

Answer 55

Diagnostic or total thyroidectomy

Question 56

Management of FNA results if malignant?

Answer 56

Total thyroidectomy, possible neck dissection

Question 57

What must be excluded prior to surgery in all patients with an FNA diagnosis of medullary thyroid carcinoma?

Answer 57

Pheochromocytoma