Surgery: Gen Surg

Question 1

Pt bitten by a snake with ellipitcal eyes, pits behind nostrils, big fangs and rattlers in tail. On physical exam there is 2 fang marks 2 cm apart, as well as local edema and ecchymotic discoloration. Area is very painful and tender to palpation. Dx? Management?

Answer 1

Pt has been evenomated by rattle snake. Need to type and cross match blood, check coaug studies. Give Crofab.

Question 2

Pts burned area is dry, white, leathery, anesthetic and circumferential all around arms and forearms. Dx? Management?

Answer 2

Circumferential burn with eschar. Area under can develop massive edema and cut off circulation. Do doppler studies for pulses and check cap refill. May need to do Escharotomy if signs of compromised circulation occur.

Question 3

1. Pt bitten by spider with a red hourglass mark in her belly. Dx? Rx? 2. Pt says he was bitten by a bug and shows necrotic center with surrounding halo of erythema. Dx? Test?

Answer 3

Black widow spider (spiderman) IV calcium glocnate. Brown Reculuse Spider Bite. Dapsone.

Question 4

Pt with HLD, DM type 2 presents with 10/10 pain but no rebound, guarding or rigidity. Decreased Bowel Sounds. Dx? Best initial test? Most accurate test? Rx?

Answer 4

Ischemic bowel disease (mesenteric ischemia) 1. CT scan 2. Angiography. Normal saline IV then surgical removal of necrotic bowel.

Question 5

Pt presents with progressive worsening abdominal pain in the epigastric area that radiates to right shoulder. On physical exam there is rebound, guarding and rigidity. Dx? Test? Rx? Complication?

Answer 5

Gastric ulcer perforation from peptic ulcer disease when pts are non-compliant. AXR best initial which shows free air under diaphragm. CT most accurate. NPO, NG, IV and Abx. Surigical repair will need to take place. Complication is pancreatitis due to gastric juices activating pancreatic enzymes causes a rise in amylase and lipase

Question 6

Name to 2 Causes that can lead to abdominal abscess. Test Rx?

Answer 6

Invasive procedures and inflammatory conditions (Diverticulitis, Pancreatitis and Appendicitis) CT. I and D and abx.

Question 7

Continuous uncontrolled passage of fecal material (>10ml) for at least one month in an individual > 3 yrs of age. Best initial test? Most accurate test? Rx?

Answer 7

Fecal incontinence. Hx + Flexible Sigmoidoscopy or Anoscopy. 2. Anorectal manometry. Rx: 1. Fiber and training exercises. 2. Dextranomer/hyaluronic acid. (Solesta). 3. Colorectal Surgery.

Question 8

Young woman presents with severe pain with defecation and blood streaks on the outside of the stools. Stools are hard and painful. She refuses to allow anyone draw her buttocks apart on physical exam. Dx? Test? Rx?

Answer 8

Anal Fissure (tear in anal canal) Cancer still has to be ruled out so do colonscopy under anesthesia. Stool softners, CCBs and Botox injections may help.

Question 9

44 yo male presents with exquisite perianal pain. He cannot sit down, reports bowel movements are very painful. Has fever and chills. Dx? Rx?

Answer 9

Ischiorectal abscess. I and D.

Question 10

Perianal discomfort. Fecal streaks soiling underwear. Had Perirectal abscess drained surgically. On physical exam there is a perianal opening in the skin, and cordlike tract can be palpated going toward the inside of the anal canal. Brownish purulent discharge. Dx?

Answer 10

Anal fistula.

Question 11

HIV positive male has fungating mass growing out of anus, rock hard, enlarged lymph nodes in both groins. He looks emaciated and ill. Dx?

Answer 11

Squamous cell carcinoma of the anus.

Question 12

Pt being treated for multiple medical problems suddenly vomits large amounts of bright red blood. Dx? Rx?

Answer 12

Stress Ulcer. Was to be on PPI prophylaxis. May require angiography with embolization.

Question 13

82 yo man with colicky abdominal pain. Has not passed stool or gas. Tympanic abdomen with hyperactive bowel sounds. AXR shows distended loops of small and large bowel and very large gas shadow that is located in RUQ and tapers toward the LLQ with the shape of a birds beak. Dx? Rx?

Answer 13

Sigmoid Volvulus. Endoscopic Intervention will relieve obstruction.

Question 14

T. bili 12, Indirect 7, Direct 5. Alk phos mildly elevated and transaminases very high. Dx?

Answer 14

Hepatocellular jaundice due to hepatitis. Can be viral.

Question 15

T. bili 22, Direct is 16, Indirect 6 and minimally elevated transaminases. Alk phos 6x upper limit of normal. Weight loss. US shows dilated intrahepatic ducts, dilated extrahepatic ducts and very distended thin walled gallbladder. Dx?

Answer 15

Malignant obstructive jaundice by gallstone. Silent Obstructive jaundice caused by tumor (pancreatic tumor)

Question 16

T bili 22, Direct 16, Indirect 6, Minimally elevated tranasminases. Alk phos 6 x upper limit of normal. US shows dilated intrahepatic ducts, dilated extrahepatic ducts, very distended thin walled gallbladder. CT scan shows dilated ducts and nothing else. ERCP shows narrow area in the distal common duct, and a normal pancreatic duct. Dx? Rx?

Answer 16

Malignant Choloangiocarcinoma. Whipple.

Question 17

What condition can occur on POD 3-5? Test? Rx?

Answer 17

Water. UTI. CBC, UA (Check for nitrates and leukocyte esterase and Culture (for oraganism and specificity.) Rx underlying bug.

Question 18

What condition can occur on POD 5-7? Test? Rx?

Answer 18

Walking. DVT or IV thrombophlebitis. Prevent with mobilization and subcu hep for DVT prophylaxis. Change IV access lines?*. Doppler US and Spiral CT angio if PE signs occurred. D-Dimer if unclear. For thrombophelbitis culture IV tips. Heparin 5 days then bridge to warfarin 3-6 months.

Question 19

What condition can occur on POD 7 ? Test? Rx?

Answer 19

Wound (Wound infection and Cellulitis). Keep check surgical wounds for erythema, swelling and tenderness or leakage of fluid. change dressings everyday. I and D if infection or cellulitis occurs.

Question 20

What condition can occur on POD 7-15? Test? Rx?

Answer 20

Wonder drug and deep abscess (Drugs and deep abscess formation) CT to see the extent of the abscess. Then CT guided percutaneous drainage.

Question 21

1. For a pt that is burned. How fast should the transfusion startin adult? 2. How fast should it be in a child? 3. What is the formula to calculate the rate for 24hrs?

Answer 21

1. 1L in the first hour 2. In child 20ml/kg in the first hour 2. UP to 50% x kg x 4cc/ml of ringers lactate.

Question 22

What is the management of extensive burn?

Answer 22

1. Rehab from day one, Tetanus prophylaxis, clean wound and apply Silver Sulfadiazine (Dont use on eye instated use topical abx for eye burns). Or Mafenide for extensive burns but dont use it everywhere because it causes acidosis and hurts) 2. Pain Meds IV 3. 3-4 Skin graft for the skin that did not regenerate. 4. After 1-2 days NG suction and G tube for nutritional support is needed.

Question 23

73 yo old obese mother of 6 has RUQ that began 3 days ago. The pain was colicky at first but has been constant for 2.5 days. She has tenderness to deep palpation, muscle gaurding and rebound in the RUQ. She has temp spikes of 104 and 105 with chills. WBC is 22,000 with shift to left, T Bili is 5, Alk phos is 2,000 (20x upper limit of normal) Dx? Test? Rx?

Answer 23

Acute Ascending Cholangitis. Diagnosis is clear. US if diagnosis is unclear can confirm dilated ducts. Rx: IV abx, fluids and pain meds. ERCP or PTC to decompress the biliary tract.

Question 24

73 yo old obese mother of 6 has RUQ pain that began 6 hrs ago and colicky in nature. Pain radiates to right shoulder and back. Has N/V. Pain has been constant for past 2 hrs. Tenderness to deep palpation, muscle gaurding and rebound of the RUQ. Temp is 101. WBC 12,000 and LFTs are normal. Dx Test? Rx?

Answer 24

Acute Cholecystitis. Diagnosis is clear. Can do US if unclear. Will show dilated ducts. IV abx and fluids and pain meds Emergent Cholecystecomy.

Question 25

Alcoholic man, emesis, epigastric pain 12 hrs after eating a large meal. The pain is constant and radiates to back. Afebrile, mild tachy, serum amylase is 12000 and Hematocrit is 40%, WBC 18,000, Glucose 150, Ca 6.5. Pt is given IV fluids and pain meds. NG suction, Kept NPO. Next morning Hematocrit drops to 30%. Ca has remained 7% despite Ca administration. BUN 32. Metabolic Acidosis has developed with low arterial P02. Dx? Management ?

Answer 25

Hemorrhagic pancreatitis. Supportive. This is 8 Of the ransons criteria. Death by hemorrhagic pancreatitis is by pancreatic abscess that will need to be drained as soon as they appear.

Question 26

Alcoholic man, emesis, epigastric pain and early satiey. Large epigastric mass felt deep w/in abdomen and actually hard to fine. He was discharged from Hospital 5 weeks ago after successful treatment for acute pancreatitis. Dx? Test? What other stetting can this develop? Management?

Answer 26

Pancreatic psuedocyst. Can also develop 2/2 to trauma ie MVC . US. CT confirms. Small cyst that have been present

Question 27

Name the breast condition: 1. Breast with orange peel appearance of skin 2. Hard mass ill-defined borders, moveable from chest wall but not breast, retracted nipple 3. Eczematoid lesion in the areola. Give the management for all. (Same management)

Answer 27

1. Inflammatory breast cancer 2. Invasive adenocarcinoma 3. Pagets breast carcinoma. Mammogram then core biopsy of lesions.

Question 28

Suspicious cyst in young girl? Suspicious lump in old woman?

Answer 28

1. US then FNA 2. Mammography then Core Needle Biopsy.