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5 Written Questions

5 Matching Questions

  1. Colonoscopy. Polyp histology is villous adenoma. MNGT?
  2. Significance of atypical ductal hyperplasia
  3. 16yM with unilateral scrotal swelling. Scrotal ultrasound demonstrates intraparenchymal mass. MNGT
  4. Developmental source for Meckel's diverticulum?
  5. Risk factors for dehiscence
  1. a on needle core, 20% DCIS (
    A diagnosis of atypical ductal hyperplasia cannot be established on
    core biopsy alone. Studies have demonstrated that nearly 20% of
    patients with this diagnosis on core biopsy go on to have evidence of
    ductal carcinoma in situ or invasive ductal carcinoma after excisional
  2. b malnutrition, obesity, diabetes, uremia, malignancy, immunology, steroids, infection, coughing, NOT running stitch, (
    • Malnutrition,
    • obesity,
    •immunologic abnormalities,
    • steroid use,
    •infection, and
    •coughing, which increases intraabdominal pressures are all factors that
    increase the risk of wound dehiscence.

    Technical factors are also very important in preventing the
    dehiscence, but there is no proof that interrupted sutures are better
    than a running stitch for fascial closure.)

  3. c hemicolectomy (
    • formal right hemicolectomy is indicated due to the high probability
    of finding cancer in the specimen. A lesser operation, such as open or
    laparoscopic polypectomy, would then require a second operative
    procedure if cancer is present.)
  4. d vitelline, omphalomesenteric, antimesenteric, gastric mucosa, (
    ***remnant of the vitelline or omphalomesenteric duct and are found
    on the
    ***antimesenteric side of the ileum. They often
    ***contain ectopic gastric mucosa.
    ***Acid secretion from this leads to ileal ulceration and bleeding. )
  5. e CT, chest, abd, pelvis, serum hcg, afp, ldh, radical orchiectomy, (
    Upon the diagnosis of an intraparenchymal testicular mass, a
    • staging CT scan of the chest, abdomen, and pelvis should be obtained.
    • It is reasonable to evaluate the serum levels of beta-HCG and AFP as they may be elevated in 80-85% of patients with nonseminomatous
    germ cell tumors.
    • LDH, on the other hand, can be elevated in patients with seminomas and can be of prognostic significance.

    • Finally, if elevated, these serum markers can serve as a means to monitor the presence of residual disease and should be measured after resection of the tumor.

    Additionally, the mass should be
    • excised in order to establish a histologic diagnosis.
    • A radical orchiectomy should be performed from an inguinal approach.
    • Less invasive approaches such as biopsies or a scrotal approach to the tumor should be avoided as they can alter the lymphatic drainage and potentially adversely affect overall outcomes.)

5 Multiple Choice Questions

  1. mesocaval, splenorenal, (
    *TIPS have increased in popularity as a method for portal
    decompression. This can be performed in the acute setting. Surgical
    shunts are also an option, but are primarily reserved for stable
    patients with recurrent bleeding episodes and
    * not performed in an acutely unstable patient.
    *Mesocaval shunts connect the SMV to the IVC in a variety of manners.
    *Splenorenal shunts are actually the most common type of shunt.
    *Nonselective shunts that completely divert portal blood flow from
    the liver can actually INCREASE hepatic encephalopathy. Most surgeons
    prefer selective shunts, which preserve a component of hepatic blood
    flow and thus function. Synthetic graft material can be safely used to
    create the shunts. Postoperative mortality is directly related to the
    patient's preprocedure medical condition and degree of hepatic
    failure i.e., Child class.)
  2. ta, (
    •Villous adenoma is a premalignant condition. The incidence of
    carcinoma in a polyp depends on the histology type and size of the
    •Tubular adenomas are the most
    *common type of polyps 60-80%, but are the
    * least likely to harbor carcinoma less than 5% if smaller than 1 cm
    in diameter.
    •Villous adenomas are the least common type, but overall the
    *most likely to contain malignant foci 50% if greater than 2 cm in
  3. reverse Trandelenberg, head 30 degrees, ventricular catheter, mannitol, hyperventilation, (
    The management of
    •elevated intracranial pressure following traumatic injury has been
    extensively studied. Several interventions have been shown to be of
    benefit in the acute setting. The pressure can be relieved through
    mechanical means such as
    *elevating the head of the bed to 30 degrees or by
    *direct drainage of cerebrospinal fluid via a ventricular catheter.
    *Administration of a hyperosmotic solution such as mannitol can
    decrease intracranial pressure by reducing brain water, increasing
    plasma volume and reducing blood viscosity. )
  4. endoscopy, sclerotherapy, banding, balloon tamponade, (
    Once the patient is stabilized,
    *endoscopic evaluation of the bleeding is crucial. It can be both
    diagnostic and therapeutic.

    •Endoscopic techniques for controlling hemorrhage can include
    *banding, or
    *balloon tamponade.)
  5. b9, risk to b/l breasts, tamoxifen, (
    •LCIS is a benign diagnosis and alone does not have a risk of
    progression to an invasive cancer.
    •However, a diagnosis of LCIS does increase the risk for development
    of future breast cancer at a rate of about 1% per year. It is
    important to remember that the
    *risk is increased for both breasts. It has been shown that
    *chemo-prevention with tamoxifen can decrease the incidence of breast
    cancer by 49%.
    It is also sufficient to follow this population closely with
    *annual mammograms and
    *semiannual clinical examinations.
    *Prophylactic bilateral mastectomies are an option and result in a 90% decrease in the risk of subsequent breast cancer.
    Since a diagnosis of LCIS increases the risk of cancer in both breasts, a mastectomy of the affected side is insufficient treatment.)

5 True/False Questions

  1. 15yF with elevated serum Ca, low serum phosphate. Tx?FHH med, primary surgery (
    •The distinction is important, as patients with primary
    hyperparathyroidism benefit from surgery and those with FHH do not.)


  2. 71yM with hematemesis, hematochezia, history of ETOH detox. DDx? How do you distinguish?eso varices, duod perf, tic, AAA, hypotension, pain, distention, liver disease, (
    1. posterior perforation of a duodenal ulcer that has eroded into the gastroduodenal artery causing bleeding per rectum, tachycardia, and hypotension.
    2. Diverticulosis is a common cause of bright red blood per rectum in elderly patients but is often
    3. A ruptured AAA generally presents with hypotension and profound shock. A distended abdomen and pulsatile mass can be found on physical examination.
    4. Ruptured esophageal varices present with upper GI bleeding and hematemesis and are most often associated with patients who have chronic liver disease.)


  3. 35yM with HPI epigastric pain alleviated with food, now CC acute abdomen. CXR and KUB show no free air on upright films. MNGT?CT abd, pelvis, (

    •If the plain films did not demonstrate free air and the patient
    remained hemodynamically stable, a
    ***CT scan of the abdomen and pelvis may be indicated to try to make
    the diagnosis.)


  4. 14yM nonfocal physical exam and VSS, HPI "concussion while skiing, and blacked out". head CT with crescent shape bright lesion. Etiology?bridging veins, (
    •Subdural hemorrhages typically have a
    *crescent shape and
    *extend across suture lines covering the entire surface of one hemisphere. These are usually the result of the
    *disruption of bridging veins.
    •Epidural hematomas on the other hand have a
    *biconvex lens appearance on CT scan. They typically develop after an
    *injury to the middle meningeal artery.)


  5. 65yM with esophageal cancer undergoes esophagectomy. In chest cavity, odorless milky fluid is found. MNGT?chest tube, NPO, TPN, 7dys, ligation, (
    •Aspiration of an odorless, milky fluid from the chest cavity is
    diagnostic, although increased lymphocyte counts and triglyceride
    levels in the fluid help confirm the diagnosis.
    •Normal chyle flow is around 2 L a day. Therefore, a chylous leak can
    result in nutritional depletion as well as decreased systemic
    lymphocytes to fight infection.

    •The first therapy is
    ***placement of a chest tube to drain the chyle and to allow for
    approximation of the lung against the mediastinum.
    ***Stopping oral intake and starting
    ***total parental nutrition is usually tried
    ***for 7-10 days to see if there is spontaneous resolution of the

    •If conservative measures fail,
    ***ligation of the thoracic duct can be performed.)


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