surgery Flashcards
All these methods are used to prevent thromboembolic complications in the perioperative period, except one:
A) Na-heparin
B) Colfarit (acidum acetylsalicylicum)
C) Ca-heparin
D) compression stockings
B) Colfarit (acidum acetylsalicylicum)
EXPLANATIONOne of the most frequent complications after a surgical intervention is thromboembolization (with an average risk of around 20-30% after abdominal surgeries, and 50-60% after major orthopedic and trauma surgeries). Thromboembolic prophylaxis should be carried out in patients at a high risk (e.g. history of thrombosis or myocardial infarction, elderly people, obesity, undergoing long surgery). Methods include medical therapy: conventional and low-molecular-weight heparin administered subcutaneously (started before the surgery!), and physical modalities: early mobilization, use of compression stockings, pillowing up the lower extremities. Acetylsalicylic acid (e.g. Colfarit) decreases the risk of thromboembolism by inhibiting platelet aggregation. Its effect starts around 15 minutes after administration and lasts for 3-7 days. Its side effects (e.g. bleeding complications) cannot be suspended and the patient may require platelet transfusion, thus these drugs are not suitable for preoperative prophylaxis.
All those means, methods and interventions with which we try to prevent the contamination of the pathogens are collectively called as: A) disinfection B) asepsis C) antisepsis D) sterilization
B) asepsis
EXPLANATION
All those interventions, actions and methods with which we try to prevent the contamination of the pathogens are collectively called asepsis. To reach this goal, all the instruments and materials we use during an intervention must be made free of germs (sterilization). Antisepsis means all the actions taken against the already present contamination, which can be most effectively achieved by disinfection. (See also SEB-1.65.)
The most frequent type of surgery of the repair of an inguinal hernia is: A) Fabricius surgery B) Kocher surgery C) Nissen–Rosetti surgery D) Lichtenstein surgery E) Bassini-Kirschner surgery
D) Lichtenstein surgery
EXPLANATION
Today the most widely accepted inguinal hernia repair is the tension-free Lichtenstein surgery which comes with the lowest recurrence rate. Previously the standard technique was the Bassini surgery, which was not tension-free, and the rate of recurrence could be as high as 10-15%.
Which of the following statements is true?
A) Hernia repairs are categorized as clean-contaminated surgeries
B) The average suppuration rate after clean-contaminated surgeries is around 5-15%
C) The average suppuration rate after clean-contaminated surgeries is <8-22%.
D) The average suppuration rate after clean-contaminated surgeries is >2-8%.
D) The average suppuration rate after clean-contaminated surgeries is >2-8%.
EXPLANATION
We consider a surgery clean-contaminated if the gastrointestinal, genitourinary and/or respiratory tracts are opened under controlled conditions without significant. After such surgeries the risk of infection is inevitably increased, regardless of how careful the surgical manipulation or isolation of the operating field was.
Relatives of a 63-year-old male patient discover jaundice on him. All of the following presumed diagnoses are reasonable, except one:
A) infective hepatitis B) pancreatic cancer C) chronic pancreatitis D) Crigler–Najjar syndrome E) choledocholithiasis
D) Crigler–Najjar syndrome
EXPLANATION
Based on the clinical data and etiology (alcohol abuse), the patient can have liver cirrhosis, some form of chronic hepatitis or chronic pancreatitis. Painless jaundice is often caused by a head of the pancreas cancer (see also SEB-1.29.). Similarly, an acquired infective hepatitis or even choledocholithiasis cannot be ruled out. Crigler-Najjar syndrome, however, is a fetal metabolic disorder leading to hyperbilirubinemia (see also SEB-1.169. - 1.180.).
The most common pathway of metastatic spreading in colonic cancer is:
A) via the inferior mesenteric vein
B) via the portal vein
C) lymphogenic spreading
D) intraluminar spreading
C) lymphogenic spreading
EXPLANATION
Colorectal cancer has the potential to give hematogenous metastases when penetrating the vessels of the bowel-wall as they grow. The major supplying vessels of the colon – e.g. both the superior and inferior mesenteric veins – both reach the liver via the portal vein. In colorectal cancer, however, the most common means of spreading is through the lymphatics. If the cancer infiltrates all layers of the colonic wall, lymphatic spreading is present in 90% of the cases.
Proper treatment of a furuncle on the face: A) incision, excochleation B) expression of the pus C) moist packing and antibiotics D) excision
C) moist packing and antibiotics
EXPLANATION
The venous system of the face has a direct connection with the basilar plexus in the head. Thus, any facial infection has to be treated with special care. Incision and excision are often unfavorable due to cosmetic reasons. The popular ‘self-made popping’ is strictly contraindicated.
Which histologic type of the thyroid cancer has generally the best prognosis? A) medullary cancer B) papillary cancer C) follicular cancer D) anaplastic cancer
B) papillary cancer
EXPLANATION
From the thyroid cancers the papillary type grows very slowly and is rare to give metastases. Thus, the papillary type is considered the most ‘benign’ of the malignant cancers.
The Perthes test:
A) assesses the condition of the valves in the greater saphenous vein
B) assesses the rate of blood flow towards the deep veins
C) is a sign of deep-vein thrombosis when dorsalflexion of the foot induces calf pain
D) if negative, phlebography has to be performed next
B) assesses the rate of blood flow towards the deep veins
EXPLANATION
The Perthes test is a clinical test for assessing the patency of the deep femoral vein. After placing a rubber compression band on the leg of the standing patient (under the knee or sometimes also unto the thighs -, he/she is asked to walk for some time. Emptying (collapse) of the superficial veins means a good flow towards the deep veins – this we call a negative Perthes test. If the test is positive, further evaluation tests (e.g. venous Doppler US, phlebography) are needed when planning a varicectomy. (Other references in the question A: Trendelenburg test, C: Homan’s sign).
In which disease is it most common to find an enlarged, palpable gallbladder?
A) Klatskin tumor
B) papilla of Vater carcinoma
C) cancer in the head of the pancreas
D) hepaticolithiasis
B) papilla of Vater carcinoma
EXPLANATION
In the case of a hilar or intrahepatic Klatskin tumor or biliary tract stone, the obstruction is proximal to the gallbladder, thus the gallbladder can empty freely. If the cancer is in the body of the pancreas, the distal bile duct is usually not compressed, and the gallbladder is cannot be palpated. The characteristic „Courvoisier sign” is most often present in head of the pancreas or papilla of Vater malignancies.
Select the examples of an absolute indication of surgery:
1) an injury that is so severe that the life of the patient can only be saved with a surgical intervention
2) deepening jaundice
3) intestinal obstruction
4) certain cases of gallstone disease
A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct
C) 2nd and 4th answers are correct
EXPLANATION
Answer 1 and 3: Vital (immediate) indication of surgery usually refers to perforation of a hollow viscera with consequent peritonitis, major acute bleeding, bowel incarceration, or any other medical condition where the life of the patient can only be saved with an immediate surgery. In such cases delaying the surgical intervention can lead to irreversible organ damage, development of sepsis and eventually death. Answer 2 and 4: Absolute surgical indication means that the disease is to be treated surgically – although not necessarily immediately -, otherwise permanent organ damage may develop, and the process may lead to the death of the patient. Cholelithiasis in itself is not an absolute indication, but it may lead to pancreatitis, cholangitis, cholecystitis and perforation and as such, a symptomatic cholelithiasis is considered an absolute surgical indication (see also SEB-1.42. and SEB-1.81., 1.82., 1.83., 1.84.).
Possible causes of a complete postoperative abdominal wound disruption:
1) protein deficiency
2) improper surgical technique
3) postoperative abdominal distension
4) early mobilization
A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct
A) 1st, 2nd and 3rd answers are correct
EXPLANATION
Wound dehiscence is the consequence of several predisposing factors and usually develops on the 5-8. postoperative day. It happens most often in cachectic patients, but adiposity, protein loss, the presence of ascites or sudden postoperative intra-abdominal pressure changes (e.g. coughing) or improper surgical technique is also a risk factor. Often wound suppuration lay in the background. Early mobilization is, however, not a predisposing factor. Dehiscence is often preceded by clear-bloody discharge from the wound. In the case of a total disruption, abdominal viscera may prolapse. Treatment is urgent reoperation. After suppuration and dehiscence, closure of the abdominal cavity can be challenging.
Characteristics of the lateral/indirect inguinal hernia:
1) it is less prone to incarceration
2) can cause intermittent groin pain
3) it never extends into the scrotum
4) it is often congenital
A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct
C) 2nd and 4th answers are correct
Lateral (indirect) inguinal hernias are especially prone to incarceration since the hernia has to pass through the long, curvy and relatively narrow inguinal canal. Medial (direct) hernias, on the other hand, has only a short hernial sac – if any -, and their orifice is usually wide. The characteristic intermittent pain or discomfort associated with inguinal hernias is caused by the stretching of the mesentery of the trapped bowel loop. Lateral hernias often develop in the persisting tunica vaginalis (congenital hernia) and thus the hernia sac can reach the scrotum itself (inguinoscrotal hernia) (see also SEB-1.23.).
What are those areas where the laparoscopic surgical approach has the most obvious benefits?
1) gallstone disease
2) inguinal hernia
3) gastroesophageal reflux disease (GERD)
4) adrenal adenoma
A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct
E) all of the answers are correct
When diabetes mellitus is diagnosed, the further investigations has to be carried out:
1) quantitative glucose assessment from collected urine
2) sugar profile assessment
3) glucose acetone assessment from fragmented urine using test strips
4) glucose tolerance test
A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct
A) 1st, 2nd and 3rd answers are correct
In case of lacerated wound which involves the gluteal muscle
1) wound edges should be excised
2) prophylactic antibiotics (in this case Sulfaguanidine) should be administered
3) wound cavity should be rinsed with H2O2-solution
4) the wound should only be closed if a drain tube is left in the cavity
5) wound closure should be done with running intracutaneous suture
A) 1, 2, 4 and 5 answers are correct
B) all of the answers are correct
C) 2 and 4 answers are correct
D) 1, 3 and 4 answers are correct
D) 1, 3 and 4 answers are correct
Tetanus prophylaxis is mandatory: 1) erysipelas 2) congelation 3) gunshot wound 4) bite wound 5) hydradenitis A) 1, 2 and 3 answers are correct B) 1, 3 and 4 answers are correct C) 2, 3 and 4 answers are correct D) 3, 4 and 5 answers are correct
C) 2, 3 and 4 answers are correct
EXPLANATIONTetanus prophylaxis is mandatory in every type of lacerated, bitten or gunshot wounds. In these cases the skin is damaged and soft tissues are contaminated (see also SEB-1.11). Tetanus prophylaxis is also necessary in case of congelation because of the extensive soft tissue damage. Antibiotics are notable for treating inflamed skin lesions
What could be the main sources of bleeding in patients with liver cirrhosis except esophageal varices? 1) gastritis 2) duodenal ulcer 3) gastric ulcer 4) Mallory–Weiss-syndrome 5) Barret's esophagus A) 1, 2 and 3 answers are correct B) 1, 3 and 4 answers are correct C) 1, 4 and 5 answers are correct D) 1, 3 and 5 answers are correct E) 2, 3 and 4 answers are correct
A) 1, 2 and 3 answers are correct
EXPLANATION
Gastroduodenal ulcers are the most common cause of massive gastrointestinal bleeding. Ulcer bleeding also must be excluded in known cirrhotic patients. Other important causes of bleeding can be alcoholic or erosive gastritis. Mallory-Weiss syndrome and Barrett-esophagus are less common causes of gastrointestinal bleeding, which are rare in patients with cirrhosis.
Clinical significance of basal cell cancer
1) its histological structure is not malignant
2) recurrence is frequent
3) metastases are uncommon
4) frequently develops in elderly patients
5) its only therapy is surgical
A) 1, 3 and 4 answers are correct
B) 2, 3 and 4 answers are correct
C) 1, 3 and 5 answers are correct
D) 3 and 4 answers are correct
E) all of the answers are correct
D) 3 and 4 answers are correct
EXPLANATION
Malignant skin tumor originated from the basal cells of the skin typically occurs in elderly patients. Its clinical significance is that it is unlikely to disseminate, grows slowly and rarely recurs after excision.
A physical examination by the family doctor on the right side reveals basal bruises, the patient should immediately be sent to the following tests:
A heavy smoker and known alcoholic patient arrives to the family doctor visibly having lost weight and in a weakened state, saying he has severe cough attacks, especially after drinking. After eating solid food, he vomits frequently.
1) Chest X-ray
2) abdominal ultrasound examination
3) Swallowing X-ray
4) Laboratory test
A) Answers 1, 2 and 4 are correct
B) Answers 2, 3 and 4 are correct
C) Answers 1 and 3 are correct
D) All of the answers are correct
E) None of the answers are correct
C) Answers 1 and 3 are correct
EXPLANATION
The patient has coughing attacks after drinking liquids which should raise the suspicion for an esophago-bronchial fistula or dysphagia. His smoking and alcohol abuse history, and his poor general condition can be a sign that malignancy lies in the background of the esophago-bronchial fistula. Diagnosis is possible by swallowing X-ray examination with water-soluble contrast media. In esophago-bronchial fistulas aspiration pneumonia is common, therefore chest radiography should be always performed. (Blood tests and abdominal ultrasound is also important since spontaneous esophago-bronchial fistula, periodic dysphagia, vomiting and desquamation are associated with esophageal tumors, but these tests do not affect the patient’s immediate care.) The patient has dysphagia, so he is unable to feed, he has pneumonia, and he needs hospitalization because of his respiratory complaints. (Antibiotics, mucolytic and other adjuvant therapies as well as oral or parenteral nutrition should be carried out hospital settings.) Swallowing X-ray revealed an occlusion. Although we know that is most often occurs in esophageal cancer, we still have to confirm the suspicion as the next step. Biopsy is usually taken during endoscopy. (Chest, mediastinal CT scan can provide further information on extent of the malignancy; bronchoscopy may reveal tracheal involvement the presence/location of the suspected fistulae, while an abdominal ultrasound can detect distant metastases – dominantly liver metastases. Bacteriological culture is relevant if the patient’s pneumonia is not responding to the administered antibiotics, and targeted antibiotic therapy is planned. These latter investigations are only secondary to endoscopy.) The patient has a stenosing cancer in the esophagus, infiltrating the trachea and leading to the development of an esophago-bronchial fistula. As such, this cancer is inoperable, and the esophagus can only be removed together with the trachea. Of the palliative solutions, the endoscopic tube implantation is the best choice since the tube covers the fistula eliminating the possibility of aspiration, ensures the patency of the esophagus and thus making oral feeding possible. (A feeding tube does not eliminate the possibility of aspiration, antibiotic, mucolytic and analgesic drugs are only adjuvant therapy for the development of esophago-bronchial fistula.)
In the patient, chest X-ray confirmed right sided pneumonia, swallowing could not be performed due to patient dysphagia, so the most important thing to do is:A heavy smoker and known alcoholic patient arrives to the family doctor visibly having lost weight and in a weakened state, saying he has severe cough attacks, especially after drinking. After eating solid food, he vomits frequently.
1) Antibiotic and mucolytic treatment should be applied for pneumonia
2) The patient should be treated with some minor neuroleptic agent to deal with the consequences of alcoholism
3) Because of respiratory and swallowing complaints the patient is to be hospitalized
4) The patient should be instructed to apply a feeding tube
A) Answers 1, 2 and 4 are correct
B) Answers 2, 3 and 4 are correct
C) Answer 1 is correct
D) Answer 3 is correct
E) All of the answers are correct
D) Answer 3 is correct
The swallowing test confirmed the existence of an oesophagobronchial fistula, for which the following options should be considered:A heavy smoker and known alcoholic patient arrives to the family doctor visibly having lost weight and in a weakened state, saying he has severe cough attacks, especially after drinking. After eating solid food, he vomits frequently.
1) esophageal resection by removal of the tumor
2) Endoscopic tube implantation to close the fistula and ensure nutrition
3) apply a feeding tube
4) antibiotic, mucolytic and analgesic treatment
A) Answers 1, 2 and 3 are correct
B) Answers 2 and 3 are correct
C) Answer 2 is correct
D) Answer 1 is correct
E) Answer 4 is correct
C) Answer 2 is correct
One correct answer is possible based on the key.After two years of uneventful period in the central operating room of the well-known surgical unit, the operations of nosocomial category A and B are facing infections. The cause was discovered by the surgeon and the hygienist and then reported. As a result of the report, the air ducts of the air conditioning unit were disinfected, and the bacterial filters were replaced. After the final disinfection, surgeries restarted, and the rate of wound infections reduced to an acceptable level.
1) For nosocomial category A, after sterile or clean surgery, no pathogen is expected in the surgical area.
2) For nosocomial category A, the prevalence of wound healing is 4–8%.
3) In the case of nosocomial category A, antibiotic prophylaxis is not required from a surgical aspect.
4) In the case of a blocked bacterial filter, the over pressure in the operating room is eliminated.
5) The condensation fluid of the air ducts in the air conditioner may become colonized by bacteria.
A) Answers 1, 2 and 4 are correct
B) Answers 1, 3, 4 and 5 are correct
C) Answers 2, 3 and 5 are correct
D) Answers 2, 3 and 4 are correct
E) All of the answers are correct
B) Answers 1, 3, 4 and 5 are correct
EXPLANATION
In nosocomial category A (e.g. sterile or clean surgery) no pathogen is to be expected in the surgical area. This group includes surgeries where no hollow organs are opened and there is no inflammation present. (Without this exception even an abscess surgery could fall into this category!) Moreover, in clean surgeries there cannot be thread granuloma, or other foreign substances in the surgery area. Examples of these surgeries are hernia repairs, vascular and endocrine surgeries, diagnostic laparoscopic or open interventions. In the case of nosocomial category ‘A’ the rate of wound suppuration is <1%. From a surgical point of view, only categories C and D justify the administration of prophylactic antibiotics. In the case of a blocked bacterial filter, the required overpressure in the operating room is reduced – the inflow of air is significantly less - while the outflow stays unchanged. Fluid condensation from the air in the ducts of air conditioners can lead to the proliferation of bacteria. Condense fluid is mainly produced in significant quantities when the air conditioner is operated periodically. Final disinfection should be carried out after every nosocomial epidemic and its efficacy must be confirmed with multiple cultures. The causes of the epidemic should be identified during and after the nosocomial epidemic. In addition to human factors, contamination often has technical reasons. During the epidemic and the consequent investigations, the significant medical facilities (operating rooms, outpatient offices, etc.) and patient rooms, as well as service areas are contaminated. After a thorough cleaning, disinfection of all the surfaces, mechanical equipment, airspace and devices is required to restore the aseptic conditions. Tissues dissected during a surgery themselves cannot defend against infections. The infection can come from the air of the operating room, from the hands or clothes of the surgical team, from instruments and materials used during the surgery, or from the bloodstream of the patient (endogenous infection). During the operation of an infected area, proper surgical technique should be used to avoid the direct or indirect contamination of the surgical site with pathogens. Since none of the above factors can be completely eliminated, wound infection is always a part of the surgical risk. The frequency of wound infection is one of the oldest quality indicators used beside surgical mortality and effectiveness (resectability, total healing rate). It represents the training and attention of the staff at the department, the functionality of the devices, the adequacy of the cleaning, sterilizing, surgical, and wound care processes. It affects the department’s antibiotics strategies and the internal quality control methods. Because of its complex nature, if wound infection rate starts to rise a thorough investigation of the possible causes must be carried out. The lack of monitoring of this indicator is a fundamental deficiency.
Choose the right answer!After two years of uneventful period in the central operating room of the well-known surgical unit, the operations of nosocomial category A and B are facing infections. The cause was discovered by the surgeon and the hygienist and then reported. As a result of the report, the air ducts of the air conditioning unit were disinfected, and the bacterial filters were replaced. After the final disinfection, surgeries restarted, and the rate of wound infections reduced to an acceptable level.
A) Closing disinfection should be performed daily after the final surgery.
B) Closing disinfection can be performed with a 12.5% hypochlorite solution.
C) The final disinfection can only be supervised by the head of the department.
D) Closing disinfection should be performed after each nosocomial infection and the result should be checked by bacteriological examination.
E) Final disinfection can only be ordered by the ÁNTSZ.
D) Closing disinfection should be performed after each nosocomial infection and the result should be checked by bacteriological examination.
ANSWER (sur.1.145)
E) Wound infection is part of the surgical risk.
SNWER (sur 1.146)
B) The frequency of wound infection is a quality indicator.
Diseases in differential diagnosis except:
There is no significant illness in the 63-year-old male patient. His relatives noticed the yellow color of his scleras, so he attended his family doctor who carried out a laboratory test. The family doctor received the following laboratory results: accelerated erythrocyte sedimentation rate, moderate anemia, significant serum bilirubin elevation, which was mainly direct, elevated AST and ALT, significantly elevated ALP, slightly elevated serum creatinine, elevated blood glucose, normal amylase and lipase, bilirubinuria, glucosuria.
A) infective hepatitis B) pancreatic cancer C) chronic pancreatitis D) Crigler-Najjar syndrome E) choledocholithiasis
ANSWER
D) Crigler-Najjar syndrome
In a 63-year-old patient, Crigler-Najjar syndrome is not plausible, since it is a fetal bilirubin metabolism disorder due to the lack of glucuronyl transferase (see also SEB-1.30). A significantly increased conjugated bilirubin level, usually together with increased ALP levels, is characteristic to occlusive jaundice.
Knowing the laboratory results, the family doctor referred the patient to the hospital:
There is no significant illness in the 63-year-old male patient. His relatives noticed the yellow color of his scleras, so he attended his family doctor who carried out a laboratory test. The family doctor received the following laboratory results: accelerated erythrocyte sedimentation rate, moderate anemia, significant serum bilirubin elevation, which was mainly direct, elevated AST and ALT, significantly elevated ALP, slightly elevated serum creatinine, elevated blood glucose, normal amylase and lipase, bilirubinuria, glucosuria.
A) diagnosis: acute septic cholangitis - internal medicine
B) diagnosis: infective hepatitis - infectology
C) diagnosis: obstructive icterus, chronic pancreatitis - internal medicine
D) diagnosis: obstructive icterus, pancreatic tumor? - internal medicine
E) diagnosis: obstructive icterus, choledocholithiasis - internal medicine
D) diagnosis: obstructive icterus, pancreatic tumor? - internal medicine
Based on the medical history and laboratory results the following additional laboratory tests should be carried out for differential diagnosis in the ward:
There is no significant illness in the 63-year-old male patient. His relatives noticed the yellow color of his scleras, so he attended his family doctor who carried out a laboratory test. The family doctor received the following laboratory results: accelerated erythrocyte sedimentation rate, moderate anemia, significant serum bilirubin elevation, which was mainly direct, elevated AST and ALT, significantly elevated ALP, slightly elevated serum creatinine, elevated blood glucose, normal amylase and lipase, bilirubinuria, glucosuria.
1) pancreatic function tests (Lundh test, secretion test, starch load, etc.)
2) virus-serological tests (anti-HAV IgM, HbsAG, anti-HBs, anti-HBc, etc.)
3) serum iron, iron binding capacity, stool benzidine tests
4) tumor marker tests (CEA, CA19-9, etc.)
A) Answer 1, 2 and 3 are correct
B) Answer 2 and 3 are correct
C) Answer 2 and 4 are correct
D) Only the 4th answer is correct
E) all 4 answers are correct
D) Only the 4th answer is correct
For diabetes mellitus, the following tests are required:
There is no significant illness in the 63-year-old male patient. His relatives noticed the yellow color of his scleras, so he attended his family doctor who carried out a laboratory test. The family doctor received the following laboratory results: accelerated erythrocyte sedimentation rate, moderate anemia, significant serum bilirubin elevation, which was mainly direct, elevated AST and ALT, significantly elevated ALP, slightly elevated serum creatinine, elevated blood glucose, normal amylase and lipase, bilirubinuria, glucosuria.
1) blood glucose test
2) hemoglobin A1C test
3) urine sugar depletion test
4) glucose tolerance test
A) Answer 1, 2 and 3 are correct
B) Answer 2 and 3 are correct
C) Answer 2 and 4 are correct
D) Only the 4th answer is correct
E) all 4 answers are correct
A) Answer 1, 2 and 3 are correct
Additional imaging studies needed for diagnosis:
There is no significant illness in the 63-year-old male patient. His relatives noticed the yellow color of his scleras, so he attended his family doctor who carried out a laboratory test. The family doctor received the following laboratory results: accelerated erythrocyte sedimentation rate, moderate anemia, significant serum bilirubin elevation, which was mainly direct, elevated AST and ALT, significantly elevated ALP, slightly elevated serum creatinine, elevated blood glucose, normal amylase and lipase, bilirubinuria, glucosuria.
1) pancreas scintigraphy
2) CT
3) ERCP
4) intravenous cholecystography
A) Answer 1, 2 and 3 are correct
B) Answer 2 and 3 are correct
C) Answer 2 and 4 are correct
D) Only the 4th answer is correct
E) all 4 answers are correct
B) Answer 2 and 3 are correct
If the patient’s cytological examination cannot confirm malignancy, the following should be done:
There is no significant illness in the 63-year-old male patient. His relatives noticed the yellow color of his scleras, so he attended his family doctor who carried out a laboratory test. The family doctor received the following laboratory results: accelerated erythrocyte sedimentation rate, moderate anemia, significant serum bilirubin elevation, which was mainly direct, elevated AST and ALT, significantly elevated ALP, slightly elevated serum creatinine, elevated blood glucose, normal amylase and lipase, bilirubinuria, glucosuria.
A) consider surgical exploration due to a suspected cancer
B) observe of the patient until healing of chronic pancreatitis
C) consider endoscopic sampling
D) antibiotic treatment ‘ex juvantibus’
A) consider surgical exploration due to a suspected cancer
If the cytology test is positive for malignancy, do the following:
There is no significant illness in the 63-year-old male patient. His relatives noticed the yellow color of his scleras, so he attended his family doctor who carried out a laboratory test. The family doctor received the following laboratory results: accelerated erythrocyte sedimentation rate, moderate anemia, significant serum bilirubin elevation, which was mainly direct, elevated AST and ALT, significantly elevated ALP, slightly elevated serum creatinine, elevated blood glucose, normal amylase and lipase, bilirubinuria, glucosuria.
A) radiation and cytostatic treatment, followed by surgery depending on their effectiveness
B) starting cytostatic treatment
C) surgical exploration and the evaluation of tumor resectability
D) percutaneous transhepatic drainage for palliative purposes
C) surgical exploration and the evaluation of tumor resectability
Radiological studies that play a key role in breast cancer diagnosis (3 responses possible) 1) breast ultrasound examination 2) mammography 3) PET 4) MR 5) CT A) Answers 1, 2 and 4 are correct B) Answers 1, 3, 4 and 5 are correct C) Answers 2, 3 and 5 are correct D) Answers 2, 3 and 4 are correct E) All of the answers are correct
A) Answers 1, 2 and 4 are correct
The breast cyst (one answer wrong)
A) the most common benign breast lesion
B) often gets superinfected
C) rarely needs surgical treatment
D) pneumocystography is the best diagnostic and therapeutic method
B) often gets super infected
EXPLANATION
Breast cysts are the most common benign breast disorders, their size can reach several centimeters. In previous decades, symptomatic cysts have always been surgically removed. Nowadays pneumocystography is the most accepted diagnostic and therapeutic method. The rate of recurrence after draining the cyst content and the filling the cyst with air is around 10%. Cysts should only be treated surgically if there is an intracystic growth (papilloma) or they recur. Superinfection of the cysts is very rare.
Recommended surgical treatment for a non-palpable invasive breast cancer (one answer is correct)
A) excision with guide-wire localization + axillary block dissection
B) excision with isotope localization + sentinel lymph node biopsy
C) mastectomy
D) quadrant resection + axillary block dissection
B) excision with isotope localization + sentinel lymph node biopsy
What tests would you carry out?A 48-year-old female patient was presented at the clinic with an enlarged goiter. Despite having good appetite, she complained of weight loss, being tense and nervous. Occasionally there was a feeling of palpitation, drowsiness and difficulty in swallowing.
1) neck US
2) basic metabolic tests
3) thyroid scintigraphy
4) thyroid hormone levels assessment
5) swallowing X-Ray, native trachea X-Ray
A) Answers 1, 2 and 4 are correct B) Answers 1, 3, 4 and 5 are correct C) Answers 2, 3 and 5 are correct D) Answers 2, 3 and 4 are correct E) All of the answers are correct
B) Answers 1, 3, 4 and 5 are correct
D) thyreostatics and surgery (sur1.164)
B) lobectomy on the affected side (Su1.1.65)
EXPLANATION
Based on the case history, this is probably a hyperthyroid goiter with signs of compression. The studies are aimed to clarify the stage of hyperfunction (hormone test), the reason (scintigraphy, ultrasonography) and the signs of compression (esophagus-, trachea compression, dislocation). Hot nodule refers to an autonomous adenoma. The patient should be treated to reach euthyroid status and the adenoma needs to be removed. We need to perform surgery after thyrostatic therapy. Since this is a benign tumor, there is no need for extended resection, enucleation is sufficient (radioiodine treatment is an alternative). The recurrent laryngeal nerve runs and enters the larynx behind the thyroid gland, innervating the vocal cords. In case of thyroid resection, nerve damage is a well-known surgical complication, resulting in unilateral vocal cord paralysis and symptomatic hoarseness.
What conservative treatment had been probably used to treat the limb disorders 5 years ago?A 45-year-old woman was admitted with a history of large bowel resection 5 years ago due to colonic cancer. At that time on postoperative day 4 the left lower limb got swollen, the skin tightened, shiny, warm, slightly cyanotic and pain occurred. The symptoms disappeared for conservative treatment. Three years ago, repeated left lower limb complaints began. Currently the limb is swollen again, with visible varices and ulcers on the lower extremity.
1) bed rest for 5-7 days
2) elevation of the limb
3) wearing elastic bandage or compression stockings
4) anticoagulation for 5 to 7 days with heparin followed by long-term treatment with Warfarin
5) fibrinolysis (depending on indication)
A) Answers 1, 2 and 4 are correct
B) Answers 1, 3, 4 and 5 are correct
C) Answers 2, 3 and 5 are correct
D) Answers 1, 2, 3 and 4 are correct
E) All of the answers are correct
E) All of the answers are correct
What kind of surgery would you choose in this case?A 45-year-old woman was admitted with a history of large bowel resection 5 years ago due to colonic cancer. At that time on postoperative day 4 the left lower limb got swollen, the skin tightened, shiny, warm, slightly cyanotic and pain occurred. The symptoms disappeared for conservative treatment. Three years ago, repeated left lower limb complaints began. Currently the limb is swollen again, with visible varices and ulcers on the lower extremity.
A) arterial thrombectomy
B) arterial embolectomy
C) venous thrombectomy
D) crossectomy, stripping, subfascial ligature of perforator veins
E) reconstructive arterial surgery
D) crossectomy, stripping, subfascial ligature of perforator veins
What treatment plan would you choose based on the previous diagnosis?A 78-year-old diabetic woman is admitted to the hospital due to right subcostal cramping pain, nausea, vomiting. Two days later she developed jaundice.
A) open surgery after the inflammation was gone
B) laparoscopic surgery after the inflammation was gone
C) pancreatic head resection
D) referring the patient to an Infectology Ward
E) ERCP, stone extraction and laparoscopic cholecystectomy performed next day
E) ERCP, stone extraction and laparoscopic cholecystectomy performed next day
If no source of bleeding was found with gastroscopy, what shall be the next diagnostic option?An elderly female patient is referred to an inpatient ward due to repeated episodes of melena. The patient's laboratory examination shows anemia (Ht: 25). The patient is known to have confirmed liver cirrhosis and previous upper gastrointestinal bleeding episodes, treated conservatively (endoscopy, sclerotherapy). A) rectoscopy or colonoscopy B) angiography C) ultrasound examination D) CT E) none of the above
A) rectoscopy or colonoscopy
(first done is gastroscopy)
The source of melena causing anemia - because it is digested blood - can be usually found in the upper gastrointestinal tract. This is also supported by the patient’s history. Therefore, the first investigation should be urgent gastroscopy, and other diagnostic modalities should come only if endoscopy turns out to be negative. The next step is to confirm or rule out if the bleeding source was in the large bowels. Angiography can be useful in the diagnosis of rare, small bowel or endoscopically undetectable bleeding sources. During the endoscopic management of bleeding peptic ulcers, urgent hemostatic methods (sclerotherapy and/or clipping) should be tried first to minimize the blood loss. If, however, despite every endoscopic effort re-bleeding occurs, immediate surgery becomes necessary. Therefore, such cases should be observed and treated in a surgical ward or more so in a surgical intensive care unit.
Gastroscopy revealed an acutely bleeding ulcer. What is the proper endoscopic treatment approach?An elderly female patient is referred to an inpatient ward due to repeated episodes of melena. The patient's laboratory examination shows anemia (Ht: 25). The patient is known to have confirmed liver cirrhosis and previous upper gastrointestinal bleeding episodes, treated conservatively (endoscopy, sclerotherapy). 1) notify the surgeon 2) order for blood transfusions 3) perform endoscopic sclerotherapy 4) hemostasis with endoscopic electrocoagulation 5) start steroid treatment A) Answers 1, 2 and 4 are correct B) Answers 1, 3, 4 and 5 are correct C) Answers 1 and 3 are correct D) Answers 2, 3 and 4 are correct E) All of the answers are correct
C) Answers 1 and 3 are correct
36 hours after the successful endoscopic hemostasis, the patient vomited blood again at night. Next step to do:An elderly female patient is referred to an inpatient ward due to repeated episodes of melena. The patient’s laboratory examination shows anemia (Ht: 25). The patient is known to have confirmed liver cirrhosis and previous upper gastrointestinal bleeding episodes, treated conservatively (endoscopy, sclerotherapy).
A) urgent gastroscopy
B) urgent gastroscopy and repeated endoscopic hemostasis
C) urgent colonoscopy
D) urgent surgery
E) maintaining the patient’s circulation by repeated transfusions until morning
D) urgent surgery
Method used for taking biopsy and exposure of paratracheal and praetracheal lymph nodes: A) Stemmer (Chamberlain)-biopsy B) Klassen-biopsy C) Carlens-biopsy D) Scalenus lymph node biopsy
C) Carlens-biopsy
Usually effective treatment of the pleural empyema:
A) bed rest, antibiotics and pain killers
B) early thoracotomy, decortication
C) thoracic drainage, suction therapy
D) fenestration
E) VATS suctions and drainage
C) thoracic drainage, suction therapy
Which type of the primary lung cancer is the most suitable for lung resection? A) squamocellular cancer B) adenocarcinoma C) small cell lung cancer D) large cell lung cancer E) bronchioloalveolar
A) squamocellular cancer
Left upper lobe adenocarcinoma with ipsilateral mediastinal lymph node metastasis. How would you proceed?
A) This tumor is inoperable, because not only the lung but the mediastinum is also affected. Primery radio-chemotherapy is recommended.
B) Left upper lobectomy with radical mediastinal lymphadenectomy is recommended.
C) Induction (neoadjuvant) chemo (-radio) therapy is recommended with lobectomy and radical mediastinal lymphadenectomy later on.
D) Lobectomy, lympahedenectomy followed by adjuvant oncological therapy is recommended.
C) Induction (neoadjuvant) chemo (-radio) therapy is recommended with lobectomy and radical mediastinal lymphadenectomy later on.
In spite of the improving living conditions what is the most frequent type of operation of TB patients?
A) thoracoplasty
B) extrapleural pneumolysis
C) adhaesiolysis (Jacobeus’ s operation)
D) lung resection
E) decortication
D) lung resection
Find the examination what is not included in the normal preoperative examinations list of the lung cancer patients. A) chest X-ray B) chest CT and MRI C) bronchoscopy D) pulmonary angiography E) sputum cytology F) spirometry, blood gas analysis
D) pulmonary angiography
Which parameter shows decompensated respiratory insufficiency? A) pH B) PCO2 C) PO2 D) BE E) standard HCO3
A) pH
