Surgery

Question 1

A female with one or more risk factors for breast cancer presents with a mass in the ———quadrant of the breast. Think: She’s at risk for cancer, and 50% of breast cancers occur in the that quadrant. Therefore, the mass is likely to be malignant

Answer 1

upper outer

Question 2

Perform breast self-examination at same time each month (———is ideal timing).

Answer 2

1 week after menstrual period

Question 3

Palpable breast masses should have a ——— biopsy (as opposed to an ———)

Answer 3

core needle

FNA

Question 4

A 42-year-old woman presents with an undiagnosed breast mass. Next step?

Answer 4

Evaluate without delay. Observation is not an option if age >30.

Question 5

A female presents complaining of nipple pain during breast-feeding with focal erythema and warmth of breast on physical exam. Dx? Workup/next step?

Answer 5

Dx: Mastitis ± breast abscess.

Next step: Workup may include ultrasound of the breast, and possible incision and drainage if fluctuance (abscess) is present.

Question 6

A female presents complaining of nipple pain with focal erythema and warmth of breast on physical exam. Dx if lactating/breastfeeding vs not lactating/breastfeeding?

Answer 6

If lactating/breastfeeding, think Mastitis ± breast abscess

If a nonlactating women presents with similar picture, consider inflammatory carcinoma.

Question 7

A 25-year-old female presents with a painful breast mass several weeks after sustaining breast trauma by a seat belt in a car accident. Dx?

Answer 7

Think: The most common cause of a persistent breast mass after trauma is fat necrosis.

Question 8

Fat necrosis of breast: exam findings and treatment?

Answer 8

Findings: Irregular mass without discrete borders that may or may not be tender; later, collagenous scars predominate.

Tx: Excisional biopsy with pathologic evaluation for carcinoma.

Question 9

Fibroadenoma: definition and risk factors?

Answer 9

Definition: Fibrous stroma surrounds ductlike epithelium and forms a benign tumor that is grossly smooth, white, and well circumscribed.

Risk factors: More common in black women than in white women. Most common breast lesion in adolescents and young females.

Question 10

Fibroadenoma: Incidence, Signs, Dx with?

Answer 10

Incidence: Typically occurs in late teens to early 30s; estrogen sensitive (increased tenderness during pregnancy).

Signs and symptoms: Smooth, discrete, circular, mobile mass.

Diagnosis: FNA

Question 11

A 20-year-old female presents with a well-circumscribed mass in her left breast. It is mobile, nontender, and has defined borders on physical exam. Think?

Answer 11

Fibroadenoma until proven otherwise.

Question 12

A female presents complaining of acute pain in her axilla and lateral chest wall, and a tender cord is identified on physical exam. Think?

Answer 12

Mondor’s disease versus chest wall infection. Confirm with ultrasound.

Question 13

Mondor’s disease most commonly develops along

Answer 13

the course of a single vein

Question 14

A 35-year-old female presents with a straw-colored nipple discharge and bilateral breast tenderness that fluctuates with her menstrual cycle. Think?

Answer 14

Fibrocystic changes. Consider a trial of OCPs or NSAIDs.

Question 15

Fibrocystic changes in breast: Presentation, exam, evaluation:

Answer 15

Presentation: Breast swelling (often bilateral), tenderness, and/or pain.

Physical exam: Discrete areas of nodularity within fibrous breast tissue.

Evaluation: Serial physical examination with documentation of the fluctuating nature of the symptoms is usually sufficient unless a persistent discrete mass is identified; definitive diagnosis requires aspiration or biopsy with pathologic evaluation. Symptoms thought to be of hormonal etiology and tend to fluctuate with the menstrual cycle.

Question 16

A 45-year-old female presents with breast pain that does
not vary with her menstrual cycle
with lumps behind the nipple–areolar complex and a history of a nonbloody nipple discharge. Think?

Answer 16

Mammary duct ectasia (plasma cell mastitis)

Question 17

There is no need for axillary node dissection in phyllodes tumor (cystosarcoma phyllodes), as

Answer 17

lymph node metastases do not occur. If malignant, will spread hematogenously.

Question 18

Phyllodes tumor (cystosarcoma phyllodes): Characteristics vs Fibroadenoma, Exam, Dx, Tx?

Answer 18

Characteristics: Indistinguishable from fibroadenoma by US or mammogram. The distinction between the two entities can be made on the basis of their histologic features (phyllodes tumors have more mitotic activity).

Exam: Large, freely movable mass with overlying skin changes

Diagnosis: Definitive diagnosis requires biopsy with pathologic evaluation.

Treatment:
- Smaller tumors: Wide local excision; Larger tumors: Simple mastectomy.
- No need for sentinel lymph node biopsy.

Question 19

A 35-year-old female presents with a 1-month history of a spontaneous unilateral bloody nipple discharge. Radial compression of the involved breast results in expression of blood at the 12 o’clock position. Think?

Answer 19

Intraductal papilloma (A benign local proliferation of ductal epithelial cells. Unilateral serosanguineous or bloody nipple discharge. Subareolar mass and/or spontaneous nipple discharge.)

Question 20

Most common cause of unilateral bloody nipple discharge:

Answer 20

Intraductal papilloma. (A benign local proliferation of ductal epithelial cells. Unilateral serosanguineous or bloody nipple discharge. Subareolar mass and/or spontaneous nipple discharge.)

Question 21

Green nipple discharge: if cyclical and nonspontaneous, likely due to

Answer 21

fibrocystic breast

Question 22

Bloody nipple discharge: if unilateral, most likely due to

Answer 22

intraductal papilloma

Question 23

Bilateral nipple discharge: if milky, consider

Answer 23

intracranial etiology, obtain prolactin level

Question 24

A 14-year-old male complains of gynecomastia. Tx?

Answer 24

Wait and watch. Perform surgery only if progressive

Question 25

Causes of gynecomastia:

Answer 25

■Increased estrogen (tumors, endocrine disorders, liver failure, obesity).

■Decreased testosterone (aging, primary or secondary testicular failure, Klinefelter’s, renal failure).

■Drugs (e.g., spironolactone).

Question 26

Most common invasive breast cancer (80% of cases) and most common breast cancer in perimenopausal and postmenopausal women?

Answer 26

Infiltrating/invasive ductal carcinoma

Question 27

Twenty percent of ——— breast carcinoma have simultaneous contralateral breast cancer.

Answer 27

infiltrating lobular

Question 28

A 65-year-old female presents with a pruritic, scaly rash of her nipple–areolar complex and a bloody nipple discharge. Think?

Answer 28

Paget’s disease. Biopsy and pathologic exam required to confirm diagnosis.

Question 29

Paget’s disease of ——— is a similar disease, presenting as a scaly, pruritic rash

Answer 29

vagina

Question 30

A 45-year-old female presents with enlargement of her left breast with nipple retraction, erythema, warmth, and induration. Think?

Answer 30

Inflammatory breast carcinoma (Most lethal breast cancer. Frequently presents as erythema, “peau d’orange,” and nipple retraction.)

Question 31

Greater than 75% of patients have axillary metastases at time of diagnosis of ——— breast carcinoma, and distant metastases are common.

Answer 31

inflammatory

Question 32

Key risk factor for breast cancer is any change that causes increased exposure to

Answer 32

estrogen without the protective effects of progesterone.

Question 33

Brest cancer associated with Li–Fraumeni syndrome , which results results from a ———
mutation.

Answer 33

p53: A tumor suppressor gene

Question 34

Both BRCA1 and BRCA2 function as ——— genes

Answer 34

tumor-suppressor

Question 35

Work up of a Breast Mass: U/S vs MRI

Answer 35

U/S can tell if solid or cystic.

MRI is good for eval dense breast tissue, evaluating nodes and determining recurrent cancer

Question 36

Workup of breast mass: Best imaging for the young breast?

Answer 36

U/S

Question 37

Workup of breast mass: ——— imaging good for determining fibroadenoma/cysto-sarcoma phyllodes.

Answer 37

U/S

Question 38

Workup of breast mass: If cystic breast mass, need ———, and if solid breast mass need ———

Answer 38

Aspiration of fluid if cystic

FNA for cells if solid

Question 39

Workup of breast mass: Send aspirated fluid for cytology if: (2)

Answer 39

its bloody or recurs x2

Question 40

Workup of breast mass - Fibrocystic changes: Presentation? Tx?

Answer 40

Presentation: cysts are painful and change w/ menses. Fluid is typically green or straw colored.

Tx: Restrict caffiene, take vitamin E, wear a supportive bra

Question 41

Workup of breast mass: Excisional biopsy if: (2)

Answer 41

palpable or if fluid recurs

Question 42

Breast cancer RFs: (4)

Answer 42

BRCA1 or 2

person hx of breast cancer

nulliparity

endo/exogenous estrogen

Question 43

DCIS tx?

Answer 43

Either excision w/ clear margins or simple mastectomy if multiple
lesions (no node sampling) + adjuvant RT.

(If small (<2 cm): Lumpectomy with either close follow-up or radiation; If large (>2cm): Lumpectomy with 1-cm margins and radiation; If breast diffusely involved: Simple mastectomy)

Question 44

LCIS key feature? Tx?

Answer 44

Feature: More often bilateral.

Tx: Consider bilateral mastectomy only if +FH, hormone sensitive, or prior hx of breast cancer
(None; bilateral mastectomy an option if patient is high risk)

Question 45

Infiltrating ductal/lobular carcinoma- Tx?

Answer 45

– If small and away from nipple, can do lumpectomy w/ ax node
sampling. Adjuvant RT. Chemo if node +. Tamoxifen or Raloxifen if ER +
– Modified radical mastectomy w/ ax node sampling w/o adjuvant RT gives same prognosis.

Question 46

Paget’s Dz - Presentation? Workup?

Answer 46

Presentation: Looks like eczema of the nipple.

Workup: Do mammogram to find the mass.

Question 47

Inflammatory carcinoma: Presentation?

Answer 47

Red, hot, swollen breast. Orange peal skin. Nipple retratction.

Question 48

Single, rubbery, mobile breast mass in a 21 yo F

Answer 48

Fibroadenoma (observe!)

Question 49

Most common cause of a bloody nipple discharge

Answer 49

Intraductal Papilloma (get this right!)

Question 50

Risk factors for breast cancer include: (7)

Answer 50

(“Basically anything that increases your exposure to estrogen increases your risk of breast cancer”)

female sex

early menarche

late menopause

nulliparity

E2 exposure

BRCA mutations

obesity (“fat contains aromatase, converts androgens to estrogens”)

Question 51

The most common breast cancer is

Answer 51

infiltrating ductal carcinoma

Question 52

Bloody nipple discharge =

Answer 52

Intraductal Papilloma on your test

Question 53

The most common breast mass in a 30-50 yo F is

Answer 53

fibrocystic change

(“If describe female with lumpy bumpy breast, think about fibrocystic change”)

Question 54

The most common breast mass in a teen/female in her 20s is

Answer 54

fibroadenoma

(“Single mobile breast mass, young female”)

Question 55

A breast mass with a peau d’orange appearance(/fever?) is

Answer 55

inflammatory breast cancer

Question 56

In a female < 30 with a breast mass, consider ——— as the first imaging test of choice

Answer 56

an ultrasound

(Want to get U/S first not mammogram in this age group because “Younger ladies tend to have very dense breasts so won’t see much with a mammogram”)

Question 57

For breast mass, ultrasound is useful for differentiating

Answer 57

cystic from solid masses

(“If see solid mass, want to biopsy”; “If see cystic mass, fna”)

Question 58

Note the potential for a ——— many years after an axillary LN dissection.

Answer 58

lymphangiosarcoma

(If suspect breast cancer and do a sentinel lymph node biopsy: if negative, done. If positive, want to do full ancillary lymph node dissection. Common complication of axillary lymph node dissection? Lymphedema. If describe patient with 10y h/o lymphedema and necrotic mass around that region and lost a ton of weight- lymphangiosarcoma!)

Question 59

In the presence of a cystic mass on breast US, consider a ——— as the next step. If you get serous fluid, ———. If you see blood, ———

Answer 59

FNA

stop here (may send for cytology) (“follow-up U/S in a few weeks: if cyst gone on next U/S, she is good to go; but if see recurrence of cyst, get biopsy”)

proceed to a biopsy

Question 60

In general, an older female (40s and upward) who presents with a breast mass needs a ———. If negative but a mass was palpated on exam, next step?

Answer 60

mammogram

some kind of biopsy must be done (excisional, core needle, etc)

Question 61

Mention of necrosis in the setting of a breast mass should clue you into

Answer 61

comedocarcinoma

(demonstrates comedonecrosis, which is the central necrosis of cancer cells within involved ducts; a comedo-type, high-grade ductal carcinoma in situ (DCIS))

Question 62

Recent physical trauma to the breast in the presence of a palpable, mobile breast mass is ——— although you should still ———

Answer 62

fat necrosis

get imaging and in an older lady, biopsy

Question 63

The first step in management of a trauma patient with a mangled, bleeding leg is

Answer 63

to ASSESS THE AIRWAY. Don’t get tunnel vision.

ALWAYS follow your ABCs!

Question 64

ABCs of Trauma:

Answer 64

■■ Airway (with cervical spine precautions)
■■ Breathing and ventilation
■■ Circulation (and Control of hemorrhage)
■■ Disability (neurologic status)
■■ Exposure/Environment control
■■ Foley/Fingerstick/FAST exam

Question 65

AVPU scale:

Answer 65

Alert
Verbal
Pain
Unresponsive

Question 66

The GCS may be used as a tool for classifying ———: severe vs moderate vs mild scores?

Answer 66

head injury

Severe head injury: GCS 8 or less
Moderate head injury: GCS 9–13
Mild head injury: GCS 14 or 15

Question 67

A 19 yo college student is brought to the ED by EMS 30 mins after getting into a severe motor vehicle accident as the unrestrained driver. On initial evaluation by EMS, his eyes are closed, his back is arched upward with his UEs in an extensor stance, and he continually moans in pain. What is his GCS score?

Answer 67

The best answer here is 5. This patient has his eyes closed (1 E), is moaning (incomprehensible sounds, 2V), and has decerebrate posturing (2M). His GCS is 5. He should be intubated ASAP.

Question 68

Next step for airway if trauma patient comes in unconscious?

Answer 68

Intubate!

Question 69

Best step for airway if GCS < 8?

Answer 69

Intubate!

Question 70

If guy stung by a bee, developing stridor and tripod posturing?

Answer 70

Intubate!

(The 2 most common errors associated with mortality in severe anaphylaxis are delays in intubation and delays in administration of epinephrine)(The cornerstone of treatment of anaphylaxis is epinephrine intramuscularly, early intubation, and aggressive fluid resuscitation.)

Question 71

If guy stabbed in the neck, GCS = 15 (“talking to you like nothing is wrong”), expanding mass in lateral neck?

Answer 71

Intubate!

Question 72

If guy stabbed in the neck, crackly sounds w/ palpating anterior neck tissues (“feels like rice crispies under his skin”)?

Answer 72

Be careful while intubating; fiberoptic broncoscope

(Crackly rice crispies subcutaneous emphysema; May have a laryngeal injury or airway injury so want to take a look at what doing with fibroptic bronchoscope if at all possible)

Question 73

If huge facial trauma (can’t see what’s nose vs face vs mouth), blood obscures oral and
nasal airway, & GCS of 7?

Answer 73

cricothyroidotomy (if can’t assess where putting airway, this is good indication to do cricothyroidotomy)

Question 74

An emergency surgical airway, cricothyroidotomy is created by puncturing through the

Answer 74

cricothyroid membrane, situated anteriorly, between the thyroid cartilage and the cricoid cartilage

Question 75

In infants, the emergency surgical airway of choice is a ———, not a ———

Answer 75

tracheostomy

cricothyroidotomy

Question 76

So you intubated your patient… next best step?

Answer 76

Check bilateral breath sounds

Question 77

So you intubated your patient… If decreased breath sounds on the left?

Answer 77

Means you intubated the right mainstem bronchus

(Equal breath sounds indicate proper placement of the ET tube)

Question 78

So you intubated your patient… (incorrectly) intubated the right mainstem bronchus – What to do? Next step?

Answer 78

Pull back your ET tube

Check pulse ox, keep it >90%

Question 79

Abdominal aortic aneurysm (AAA): presents with ——— on physical exam.

Answer 79

Pulsatile mass

Question 80

Twenty percent of patients have an ——— spleen

Answer 80

accessory spleen

Question 81

Identify the aneurysm (in each color):

Answer 81

Question 82

Identify the aneurysm on top and bottom:

Answer 82

Question 83

Aortic aneurysm may cause ———, which is a sign of leaking, dissection, or imminent rupture.

Answer 83

abdominal and/or back pain

Question 84

Thoracic aortic aneurysm is associated with (1)

Answer 84

cystic medial degeneration

Question 85

Thoracic aortic aneurysm risk factors include (4)

Answer 85

hypertension

bicuspid aortic valve

connective tissue disease (eg, Marfan syndrome)

3° syphilis (obliterative endarteritis of the vasa vasorum)

Question 86

Thoracic aneurysm with aortic root dilatation may lead to

Answer 86

aortic valve regurgitation

Question 87

Abdominal aortic aneurysm risk factors include (4)

Answer 87

***tobacco use
age
male sex
family history

Question 88

AAA may present as ——— and rupture may present as triad of ———

Answer 88

palpable pulsatile abdominal mass

pulsatile abdominal mass, acute abdominal/back pain, and resistant hypotension

Question 89

AAA often located ——— (distribution of vasa vasorum is reduced).

Answer 89

infrarenal

Question 90

The most common cause of aneurysm

Answer 90

Degenerative—due to atherosclerosis

Question 91

75% AAA presentation

Answer 91

Asymptomatic

Question 92

AAA screening criteria

Answer 92

Abdominal US one time for males age 65–75 with history of smoking.

Question 93

Assessment of acute abdominal pain should include PQRST:

Answer 93

Precipitating or palliative factors

Quality of pain: Stabbing, shooting, boring, dull

Radiation

Severity

Timing

Question 94

Think ——— in acute abdominal pain with blood in stool (positive guaiac).
Think ruptured ——— in acute abdominal pain with back pain and/or blood in urine (communicating fistula).

Answer 94

mesenteric ischemia

AAA

Question 95

Mortality for ruptured AAA is———%. (Of those who reach the hospital alive, mortality is still ———%) Mortality is further increased with (4)

Answer 95

90

50

history of CAD, hypotension on arrival, and renal insufficiency, and is also increased by inexperienced surgical team.

Question 96

You are called to the emergency department to see a 65-year-old male with a history of AAA, for which he is followed by the vascular service. He now complains of abdominal pain and reports syncope at home. Think:

Answer 96

Syncope and abdominal pain or hypotension in a patient with known AAA is presumed to be rupture unless proven otherwise. Notify the OR and mobilize your team.

Question 97

In pregnant women, iliac artery aneurysms are associated with

Answer 97

fibromuscular dysplasia

Question 98

Screening for AAA?

Answer 98

men 65-75 who have ever smoked. Do abdominal U/S.

Question 99

——— lung is a more common site for inhaled foreign bodies because main stem bronchus is

Answer 99

Right

wider, more vertical, and shorter than the left.

Question 100

Key sxs for AAA

Answer 100

pulsatile abdominal mass

Question 101

Treat AAA conservatively if:

Answer 101

if <5cm and asymptomatic, monitor growth every 3-12mo.

Question 102

Surgery indicated for AAA if:

Answer 102

> 5cm, growing <4mm/yr

(Size at which AAA is considered for surgical repair: 5.5 cm. Increasing size: >1 cm per year; monitor with CT/US every 6 months.)

Question 103

Ruptured AAA presents with (3)

Answer 103

severe sudden abdomen, flank or back pain

shock

tender pulsatile mass

Question 104

With Ruptured AAA, ——— die before reaching the hospital.

Answer 104

50%

Question 105

Post-op complications for AAA surgery: #1 cause of death

Answer 105

MI

(Myocardial infarction is the leading cause of postoperative death after AAA repair and accounts for as many as 50% of all postoperative deaths. The 5-year mortality rate from MI in patients who had preoperative evidence of heart disease is four times higher than that for patients without CAD.)

Question 106

Post-op complications for AAA surgery: Bloody diarrhea

Answer 106

Ischemic colitis

(Ischemic colitis (5%): Bloody diarrhea, elevated WBC, peritonitis)

Question 107

Post-op complications for AAA surgery: Weakness, decreased pain w/ preserved vibr, prop

Answer 107

ASA syndrome

(The anterior spinal artery syndrome refers to ischemic infarction of the spinal cord resulting from direct occlusion of the anterior spinal artery, artery of Adamkiewicz, or generalized hypoperfusion (Pattern seen with injury to the anterior portion of the spinal cord or
with compression of the anterior spinal arteries or artery of Adamkiewicz); Involves full or partial loss of bilateral pain and temperature sensation (STT)
and paraplegia (CST) with preservation of posterior column function; Often seen with flexion injuries; Carries a poor prognosis)

Question 108

Location in spinal cord and role: Dorsal columns vs CST vs STT

Answer 108

STT: anteriolateral

CST: posterolateral

Dorsal columns: posterior

Question 109

Post-op complications for AAA surgery: 1-2 yrs later if have brisk GI bleeding

Answer 109

Aortoenteric Fistula

Question 110

A 70-year-old white male with a history of hypertension develops cramping lower abdominal pain 1 day s/p AAA repair. A few hours later he develops bloody diarrhea. What’s the diagnosis?

Answer 110

Think: Ischemic colitis should be suspected in any elderly patient who develops acute abdominal pain followed by rectal bleeding. Furthermore, the most common setting for ischemic colitis
is the early postoperative period after AAA repair when impaired blood flow through the IMA may put the colon at risk.

Question 111

Ischemic colitis:

Answer 111

Acute or chronic intestinal ischemia secondary to decreased intestinal perfusion or thromboembolism:
■Embolus or thrombus of the IMA.
■Poor perfusion of mucosal vessels from arteriole shunting or spasm.

Question 112

The SMA supplies the bowel from ———. The IMA supplies ———. The ——— also has collaterals to supply the intestine.

Answer 112

the lower part of the duodenum to two-third of the transverse colon

large intestine from the distal one-third of the transverse colon to the rectum

celiac artery

Question 113

Bowel ischemia can be classified as small intestine ischemia, which is commonly known as ——— and large intestine ischemia, which generally referred to as ———.

Answer 113

mesenteric ischemia

colonic ischemia

Question 114

Two main areas in the colon prone to ischemia:

Answer 114

splenic flexure (Griffiths point) - between SMA and IMA supplies

and

rectosigmoid junction (Sudek’s point) - between the IMA and hypogastric supplies

(‘watershed’ areas, which mean the regions in the colon between 2 major arteries that supplying colon)

Question 115

Ischemic colitis often affects the

Answer 115

splenic flexure

Question 116

Symptoms and imaging findings for ischemic colitis

Answer 116

Sxs: Mild lower abdominal pain and rectal bleeding, classically after AAA repair.

Imaging:
■Plain abdominal x-ray—may reveal pneumatosis (air in bowel wall) or “thumbprinting” (submucosal edema)
■CT scan of the abdomen may reveal segmental thickening of bowel wall.
■Colonoscopy may show pale mucosa with petechial bleeding.

Question 117

A 66 year old man presents to a PCP to establish care. He has not seen a physician within the last five years. Past medical records indicate a recent colonoscopy which was negative 5 years ago. He is married to his wife of 25 years and quit smoking 7 years ago after he retired. He does not drink or use illegal drugs. He previously worked on a shipyard. Physical exam is notable only for an increased body habitus. What is the next best step in the management of this patient?
a. Upper GI Series.
b. IV Pyelography.
c. Screening CXR.
d. Cystoscopy with biopsy.
e. Abdominal Ultrasound.

Answer 117

The best answer is E, abdominal ultrasound.

-This man has a past history of smoking so the USPSTF recommends a 1 time abdominal US for men (not women) b/w the ages of 65-75 who have smoked in the past as a screen for AAA.

Question 118

If a AAA ——— is found in men, it is dealt with surgically. If ———, it is f/u with ———. Growth ——— is an indication for surgery. Another indication for surgery is a ——— AAA.

Answer 118

> 5.5 cm

< 5.5 cm

a 6 mo US

> 0.5 cm in 6 mo

symptomatic

Question 119

Remember that the biggest risk factor for a AAA is ———, not ——— (RFs are HY for most exams!).

Answer 119

smoking

atherosclerosis

Question 120

Note that a ——— is recommended to screen for lung cancer in individuals with a > 30 pack year smoking hx who currently smoke or who quit within the last 15 years aged b/w 55-80.

Answer 120

low dose annual CT

Question 121

A 56 yo M presents to his PCP with a 1 mo history of shortness of breath. CBC on admission shows a hemoglobin of 6.5 (super low), an MCV of 60 (super low), decreased ferritin/transferrin saturation with an increased TIBC. His other labs are within normal limits. He has a 45 pack year smoking history. He recently had surgery (7 months ago) for repair of an asymptomatic 6.5 cm AAA (remember treat if more than 5.5). CXR and EKG are unremarkable. FOBT is positive. What is the most likely diagnosis?
a. Hemorrhagic pleural effusion secondary to pulmonary malignancy.
b. Aortoenteric fistulizing tract.
c. Chronic blood loss secondary to an undetected colonic malignancy.
d. Chronic blood loss secondary to peptic ulcer disease.
e. Hyperviscosity syndrome secondary to an EPO secreting pulmonary malignancy.

Answer 121

The best answer here is B, an aortoenteric fistula.
-It is relatively HY to know this unusual association.
-People with a hx of AAA repair who present with sxs of anemia and a positive FOBT should clue you into a diagnosis of an aortoenteric fistula.

(Fistula b/w descending aorta and GI tract; surgical emergency - fix like pronto b/c can have life threatening hemorrhage and die which is not ideal)

(Tried to trip u up with colon cancer b/c if u see positive fobt in guy greater than 50, iron def anemia, hemoccult positive stool - thinking colon cancer; but put qualifier in question of AAA treatment, need to think aortoenteric fistula)

(For peptic ulcer disease, pain is not epigastric so that’s wrong)

(This patient’s hematocrit should be a lot higher for them to have an EPO secreting malignancy of any sort)

Question 122

Hypotension, severe tearing abdominal pain with radiation to the back, pulsatile abdominal mass - think?

Answer 122

ruptured AAA (needs to go to surgery, “almost 100% mortality”)

Question 123

Anterior Cord Syndrome is associated with loss of

Answer 123

all tracts with the exception of the posterior columns

Question 124

Anterior Cord Syndrome: The common mechanism of injury is a

Answer 124

burst fracture of a vertebral body

Question 125

Consider anterior spinal artery syndrome in the setting of

Answer 125

pain and temperature loss, bowel/bladder incontinence, and LE paralysis in the setting of an AAA repair

(Could relate to disruption of artery of Adamkiewicz)

Question 126

——— at increased risk for mesenteric ischemia (embolism) because of emboli to mesenteric arteries

Answer 126

Atrial fibrillation

Question 127

The three major mesenteric arteries that perfuse the small and the large intestines are:

Answer 127

(1) the celiac trunk, which supplies the hepatobiliary system, spleen, and proximal small bowel;

(2) the SMA, which supplies the small intestine and proximal middle colon;

(3) the inferior mesenteric artery (IMA), which supplies the distal colon and the rectum

Question 128

——— is the most common vessel involved in AMI

Answer 128

SMA

Question 129

Define AMI

Answer 129

Rapid onset of intestinal hypoperfusion. Causes include SMA embolism (50% of all AMI), SMA thrombosis (acute), Vasospasm (nonocclusive mesenteric ischemia), Venous obstruction

Question 130

Most emboli that cause AMI originate in the

Answer 130

heart (left atrial or left ventricular thrombi)

Question 131

Ninety-five percent of patients with AMI will have a history of

Answer 131

cardiovascular disease (atrial fibrillation or myocardial infarction)

Question 132

——— has somewhat of a low sensitivity for detecting arterial AMI. Therefore, if a patient has high suspicion for AMI, then patient should undergo ———
——— has high sensitivity (>90%) for detecting acute mesenteric venous thrombosis

Answer 132

CT

angiography despite negative CT results

CT

Question 133

Patients with acute mesenteric venous thrombosis should be evaluated for

Answer 133

hereditary and acquired thrombophilias

Question 134

AMI: presentation?

Answer 134

Acute abdominal pain in a pt w/ A-fib subtherapeutic on warfarin or pt s/p high dose vasoconstrictors (shock, bypass)

(surgical emergency!)

Question 135

AMI: Work up?

Answer 135

angiography (aorta and SMA/IMA)

Question 136

AMI: Tx?

Answer 136

embolectomy if thrombus, or aortomesenteric
bypass

Question 137

In a patient with a hx of Afib that presents with sudden onset abdominal POOP (pain out of proportion) to the exam, consider ——— as the underlying dx, which requires ——— for workup

Answer 137

acute mesenteric ischemia

CT angiography

Question 138

Define CMI:

Answer 138

Slow progressing stenosis (req stenosis of 2.5 vessels (Celiac, SMA and IMA).

Insidious, episodic, or constant state of intestinal hypoperfusion.

(Rarely leads to infarction of small bowel due to development of collateral circulation over time.
Can be caused by: Arterial ischemia (most common) associated with atherosclerosis of more than one mesenteric and splanchnic vessels; Venous thrombosis; Vasculitis)

Question 139

Hallmark sxs of AMI and CMI:

Answer 139

AMI: Abdominal pain out of proportion to tenderness on physical exam

(One of the distinctive findings in mesenteric ischemia is that the abdominal pain is out of proportion to their physical exam. The patient may be screaming in pain, but their initial abdominal exam can be soft with no guarding or rebound.)

CMI: “Intestinal angina”: Dull, crampy, postprandial abdominal pain leading to food aversion and weight loss

Question 140

65 yo M with a PMH of CAD presents with a 6 mo history of a 30 Lb weight loss. He has no smoking history but has regular episodes of LUQ abdominal pain that often lasts for 45 mins after every meal. He has been a missionary for the past 30 years with regular trips 8 times a year to Costa Rica. He has no history of osteoarthritis. Hct is 45% and Fe studies are normal. Total bilirubin is 0.7 and alkaline phosphatase measurements are wnl. What is the next best step in the management of this patient?
a. Trial of omeprazole.
b. Abdominal CT angiography.
c. Abdominal US to screen for AAA.
d. Endoscopic Retrograde Cholangiopancreatography.

Answer 140

The best answer is B. The most likely diagnosis here is Chronic Mesenteric Ischemia (consider in the setting of chronic postprandial pain). (Think if it as intestinal angina - when eat give gi tract a work out - why pt may stop eating and lose weight)

-There’s no smoking hx here so a screening US for AAA is not indicated. There’s no indication of biliary pathology, so an ERCP is not an appropriate first step (that’s more like for pancreatitis -found expect liver or pancreas lab abnormalities - notice this info not given).

-A trial of Omeprazole seems reasonable but severe weight loss, normal Fe studies, hx of CAD, and LUQ pain (splenic flexure- watershed region) are more consistent with mesenteric ischemia and less consistent with PUD (pain should be epigastric).

Question 141

Weight loss and postprandial abdominal pain in a old person with multiple risk factors should clue you into

Answer 141

chronic mesenteric ischemia

Question 142

Chronic Mesenteric Ischemia: Presentation?

Answer 142

Severe MEG pain after eating, food fear and weight loss. “Pain out of proportion to exam”

Question 143

CMI: Dx w/

Answer 143

duplex or angiography

Question 144

CMI: Tx w/

Answer 144

aortomeseteric bypass or transaortic mesenteric endarterectomy.

Question 145

“Scoring” of pulses:

Answer 145

0 = no palpable pulse
1+ = present, but barely palpable
2+ = normal
3+ = normal, strong
4+ = hyperdynamic, abnormally strong

Question 146

A pseudoaneurysm does not contain

Answer 146

all three layers of the arterial wall
(distinguished from true aneurysms, which are bounded by all three layers of the arterial wall)

Question 147

Contrast contains ——— and is ——— excreted.

Answer 147

iodine

Renally

(Therefore, you should use <200 cc of dye, and use with caution in patients with renal dysfunction. Ask patients about iodine and shellfish allergies. Hydrate patients prior to and after contrast use)

Question 148

You are asked to see a patient with bleeding from an angiogram puncture site. She has an oozing, pulsatile expanding mass in her groin at the puncture site. Think:

Answer 148

Expanding hematoma. Maintain direct pressure for 30 minutes. If bleeding continues, wound exploration may be indicated.

Question 149

You are asked to localize a lesion on a patient. You can palpate a femoral pulse but no popliteal or pedal pulses on the right side. Left- sided pulses are present. Think:

Answer 149

Localize lesion to the vessel above site where pulse is first lost. The lesion is likely to be in the superficial femoral artery (SFA). Tissue ischemia will extend one joint level distal to segment of artery occluded.

Question 150

The 6 Ps of acute arterial insufficiency/occlusion:

Answer 150

Pain
Pulselessness
Pallor
Paresthesia
Paralysis
Poikilothermia

(Paresthesia and paralysis are most important signs because nerves are most sensitive to ischemia)

Question 151

Acute arterial occlusion: presentation?

Answer 151

5P’s/no dopplerable pulses

Question 152

Acute arterial occlusion:
Tx w/?
– Complications = compartment syndrome during reperfusion perioddo fasciotomy watch for myoglobinuria.

Answer 152

immediate heparin + prepare for surgery

Surgery (embolectomy or bypass) done w/in 6hrs to avoid loss

Thrombolytics may be possible if: no surg in <2wks, hemorrhagic stroke

Question 153

Acute arterial occlusion:
Complications?

Answer 153

compartment syndrome during reperfusion period
(do fasciotomy watch for myoglobinuria)

Question 154

Rhabdomyolysis causes ——— release, which can cause ———

Answer 154

myoglobin

renal failure

(Maintaining a high urine output together with alkalinization of the urine can help prevent the renal failure by reducing precipitation of myoglobin in the kidney.)

Question 155

Arterial occlusion progresses to irreversible ischemia in ——— hours, depending on collateral circulation.

Answer 155

6–8

Question 156

Definition compartment syndrome:

Answer 156

Increased pressure within a compartment with subsequent compromise to the circulation and tissue function

(Muscle groups of limbs are divided into compartments by unyielding fascial membranes)

Question 157

Causes of compartment syndrome:

Answer 157

■■ Fractures.
■■ Soft tissue crush injuries.
■■ Vascular injuries.
■■ Drug overdose with prolonged limb compression.
■■ Burn injuries.
■■ Trauma.
■■ Muscle hypertrophy and nephrotic syndrome.

Question 158

Do not delay treatment of compartment syndrome! Elevation of pressure to ———mmHg for ——— hours leads to irreversible tissue death.

Answer 158

> 30 mmHg

> 8 hours

Question 159

Sxs compartment syndrome

Answer 159

5Ps

Hallmark finding: PAIN! Pain in a conscious and fully oriented person that is out of proportion to injury or findings

5 Ps of compartment syndrome:
■■ Pain
■■ Paresthesia
■■ Pallor
■■ Pulselessness
■■ Poikilothermia (sometimes paralysis listed instead)

Question 160

■ Pressure in compartment ——— mmHg usually will not produce a compartment syndrome.
■ Pressure ——— mmHg is an indication for fasciotomy.
treatment

Answer 160

<30

> 30

Question 161

Tx compartment syndrome

Answer 161

Complete fasciotomy: Goal is to decompress all tight compartments and sal­vage a viable extremity.

Question 162

A 66 yo M is sent to the medicine floor 2 days after presenting to the ED with chest pain requiring coronary catheterization and stent placement. He is in stable condition. 6 hrs after admission to medicine, he begins to complain of acute onset 10/10 pain in his left leg. Dorsalis pedis pulses are strong on the right but barely palpable on the left. The leg is exquisitely tender to palpation and appears whiter than the contralateral right extremity. What is the next best step in the management of this patient?
a. Oral Warfarin administration.
b. Vascular surgery consultation.
c. Heparin bolus administration followed by continuous infusion.
d. Emergent left lower extremity fasciotomy.
e. Serial limb exams for 2 hrs and supportive care.

Answer 162

-The best answer here is C. This patient most likely has acute limb ischemia secondary to embolization with his recent hx of a myocardial infarction.

(Sudden onset leg pain In someone with recent cardiac problems, or like an a fib history - Think acute limb ischemia; They will always try to trick you to give warfarin, but don’t do that- warfarin won’t kick in fast enough)

(HY history for acute limb ischemia- recent mi (like days after) or hx AF)

-The next step is immediate anticoagulation PRIOR to vascular surgery consultation. -It is really important to read answer choices carefully on an exam.

-Another common scenario with a similar presentation involves an individual with an “irregularly irregular beat” indicating atrial fibrillation.

-Remember the signs of compartment syndrome-POOP on passive movement of the extremity, paresthesias, poikilothermia, a tense muscle compartment, paralysis. Common associations include midshaft tibial fractures, recent burns, crush injuries, etc. Proceed to immediate fasciotomy.

(Serial exams are like almost never the correct answer on nbme)

Question 163

Pain, pallor, paresthesias, poikilothermia, paralysis, and pulselessness in an extremity-

Answer 163

compartment syndrome (immediate fasciotomy)

Question 164

Sudden onset leg pain in the setting of an irregularly, irregular interval

Answer 164

Acute Limb Ischemia

Question 165

If chronic ischemia occurs at locations other than —(3)—, the patient is likely to have a comorbid disease, such as diabetes (increased risk at —(2)— vessels) or an inflammatory disorder (increased risk at ———arteries).

Answer 165

infrarenal aorta, iliacs, or SFA

profunda femoris and tibial

axillary

Question 166

An 83-year-old female with a history of diabetes, HTN, and atherosclerosis presents with painless, monocular vision loss that lasted a few minutes and has now completely resolved. She has no other neurologic deficits. Think?

Answer 166

Amaurosis fugax or transient visual loss (transient blindness due to occlusion of the ophthalmic artery (favorite question of surgeons!))

(harbinger of an imminent stroke; Amaurosis fugax is a result of an occlusion or stenosis of the internal carotid artery circulation)

Question 167

Peripheral arterial disease clarification: sxs?

Answer 167

Pain in butt, calf, thigh upon exertion

Question 168

Peripheral arterial disease clarification: Best test? Test interpretation?

Answer 168

Ankle-Brachial Index: SBP ankle (via Doppler)/highest SBP in upper extremities.
– Normal- >1
– Claudication & Ulcers- 0.4-0.8, (use medical management)
– Limb ischemia- 0.2-0.4, surgery is indicated
– Gangrene <0.2, may require amputation

Question 169

Leg pain that is worse at night in a 60 pack year smoker-

Answer 169

Peripheral Arterial Disease.

Question 170

Drug shown to improve walking distance in the setting of PAD

Answer 170

Cilostazol (PDE inhibitor)

Question 171

Painful ulcer beneath the toes in a long time smoker-

Answer 171

ulcers secondary to PAD.

Question 172

Next best step in the management of an individual with leg pain with activity-

Answer 172

Ankle Brachial Index.

Question 173

Unilateral leg swelling and tenderness in a pregnant woman, woman on OCPs, truck driver-

Answer 173

DVT.

Question 174

Postsurgical patient with chest pain, SOB, tachypnea, right axis deviation on EKG-

Answer 174

pulmonary embolus

Question 175

About one third of apparently healthy patients with DVTs of unknown cause will be ——— within 2 years.

Answer 175

diagnosed with a malignancy

Question 176

——— is responsible for one third of upper extremity DVTs.

Answer 176

Central line placement

Question 177

Two thirds of DVTs are

Answer 177

asymptomatic

Question 178

DVT and PE: High risk after

Answer 178

surgery (esp orthopedic)

Question 179

DVT: Dx w/

Answer 179

Duplex U/S & also check for PE

Question 180

DVT: Tx w/

Answer 180

heparin, then overlap w/ warfarin for 5 days, then continue warfarin for 3-6mo

Question 181

DVT: Complications

Answer 181

post-phlebotic (thrombotic) syndrome = chronic valvular incompetence, cyanosis, and edema

Question 182

PE: Random signs =

Answer 182

right heart strain on EKG

sinus tach

decr vascular markings on CXR (westermark sign- focal peripheral hyperlucency secondary to oligemia resulting in a collapsed appearance of vessels distal to the occlusion)

wedge infarct (“Hampton’s hump” (wedge-shaped consolidation at the lung periphery)

ABG w/ low CO2 and O2

Question 183

PE: Next steps if suspected

Answer 183

give heparin 1st! Then work up w/ V/Q scan, then spiral CT. Pulmonary angiography is gold standard.

Question 184

PE: Tx w/

Answer 184

heparin warfarin overlap. Use thrombolytics if severe but NOT if s/p surgery or hemorrhagic stroke. Surgical thrombectomy if life threatening. IVC filter if contraindications to chronic coagulation.

Question 185

Ventilation/perfusion = 0 significance?

Answer 185

“Oirway” obstruction (shunt)

In shunt, 100% O2 does not improve Pao2 (eg, foreign body aspiration)

Question 186

Ventilation/perfusion = ∞ significance?

Answer 186

blood flow obstruction (physiologic dead space)

Assuming < 100% dead space, 100% O2 improves Pao2 (eg, pulmonary embolus)

Question 187

Name vessels:

Answer 187