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5 Written questions

5 Matching questions

  1. 76yM alcoholic with hematemesis. Undergoes portal shunt. What types used for stable patient for recurrent episodes?
  2. Acute arterial occlusion, MNGT?
  3. 71yM with hematemesis, hematochezia, history of ETOH detox. DDx? How do you distinguish?
  4. Tx for Meckel's diverticulum?
  5. 65yM s/p gastrectomy presents with abdominal pain, N/V, palpitations. MNGT
  1. a heparin, catheter embolectomy, no arteriogram, no duplex, (
    •Acute arterial occlusion is a surgical emergency. However, the most
    important intervention is
    *immediate heparinization.
    The infusion of heparin will help prevent extension of the clot.
    Furthermore, it will help to keep collateral vessels open. If the
    patient is stable enough to undergo operative intervention, a
    *catheter embolectomy would be the procedure of choice.
    Physical examination findings including vascular examination and level
    of temperature change and altered sensation can help identify the
    level of the occlusion prior to operative intervention.
    *Duplex ultrasound is NOT necessary to isolate the occlusion.
    *Arteriograms are more useful in the OR following the embolectomy.
    •Finally, if small vessel occlusion occurs,
    *catheter-directed thrombolytics can help restore distal perfusion.
    Once perfusion to the threatened limb has been restored, the workup to
    identify the thromboembolic source should be obtained.
    •Typical sources for emboli include
    *atrial thrombus,
    *valvular disease,
    *aortic aneurysms, or
    *iliac artery atherosclerotic disease.)
  2. b small, low carb, cholestyramine, no ppi, (
    These symptoms can be managed by
    *eating small, low carbohydrate meals throughout the day.
    •Postvagotomy diarrhea is related to the
    *rapid transit of unconjugated bile salts and is effectively
    *treated with cholestyramine.
    * [NOT] Proton pump inhibitors are not a useful therapy for alkaline reflux.)
  3. c 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.)
  4. d 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
    painless.
    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.)
  5. e resection

5 Multiple choice questions

  1. paraaortic (along the embryologic path of the adrenal gland.)
  2. eso perf, (
    "Hamman's crunch" is precordial crackles heard on auscultation
    that correlate with heart sounds in the setting of mediastinal
    emphysema and is
    •suggestive of esophageal perforation.
    *** When present along with subcutaneous emphysema of the chest and
    neck, pneumomediastinum from an esophageal perforation is the most
    likely diagnosis. The most common cause of esophageal perforation is
    iatrogenic, but it may be spontaneous (Boerhaave's syndrome) or
    secondary to a malignancy or stricture.)
  3. liver failure, new txt, (
    •Signs of liver dysfunction include
    ***hypoglycemia as the liver is unable to perform gluconeogenesis,
    ***coagulopathy with elevated prothrombin times,
    ***elevated ammonia levels,
    ***acid-base changes unable to clear lactate via the Cori cycle,
    ***hyperkalemia, and
    ***oliguria.
  4. through int inguinal ring, in spermatic cord, (
    A direct hernia comes through the medial inguinal canal floor and is
    found behind the spermatic cord. An indirect hernia passes though the
    internal inguinal ring, and thus can be found within the spermatic
    cord. The spermatic cord also contains the vas deferens, the
    testicular artery, lymphatics, and nerve fibers.)
  5. 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
    leak.

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

5 True/False questions

  1. Deceleration injury. Most common damage to aorta?lig art ( •In deceleration injuries, laceration involving the aorta most frequently occurs just distal to the left subclavian artery at the level of the ligamentum arteriosum. This is where the aorta is fixed and thus more susceptible to shear forces. The tear may be complete or partial.)

          

  2. 45yM s/p liver txt POD #2, rising AST/ALT. MNGT?relax hip, ext rotate, flex, (
    The joint space is most relaxed when the
    *hip is flexed and externally rotated.
    This tends to be the least painful position for patients with
    •septic arthritis.)

          

  3. Tx for thyroid whose bx is amyloidtotal thyroidectomy, no radioactive iodine, (
    total thyroidectomy is the treatment of choice.
    •Modified radical neck dissection is indicated in patients with
    ***palpable lymphadenopathy and in patients with
    ***tumors larger than 2 cm since 60% of these patients will have
    lymph node involvement
    Because medullary carcinoma originates from the thyroid C-cells, they
    ***do not respond to thyroxine
    ***or radioactive iodine therapy.)

          

  4. 45yM smoker often experiences pain at night while lying in bed, and the pain improves with positioning of the affected extremity. Ddx? MNGT?upright CXR, upright KUB, free air, (

    The patient's history of gnawing epigastric pain is consistent with
    •ulcer disease. His presentation is that of a
    •perforated duodenal ulcer. If patient is in mild distress, but he is not toxic and it is
    reasonable to confirm your suspicion with radiologic studies. The most appropriate
    *** first step is to obtain upright plain films of the chest and
    abdomen to look for free intraperitoneal air.)

          

  5. 35yF s/p cholecystectomy for cholelithiasis, histology shows incidental gallbladder carcinoma. MNGT?small, low carb, cholestyramine, no ppi, (
    These symptoms can be managed by
    *eating small, low carbohydrate meals throughout the day.
    •Postvagotomy diarrhea is related to the
    *rapid transit of unconjugated bile salts and is effectively
    *treated with cholestyramine.
    * [NOT] Proton pump inhibitors are not a useful therapy for alkaline reflux.)

          

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