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5 Written questions

5 Matching questions

  1. 65yM with esophageal cancer undergoes esophagectomy. In chest cavity, odorless milky fluid is found. MNGT?
  2. Abdominal pain out of proportion to examination. DDx?
  3. 35yM with HPI epigastric pain alleviated with food, now CC acute abdomen. CXR and KUB show no free air on upright films. MNGT?
  4. 41yM with severe pain in left hip joint. MNGT
  5. 71yM with hematemesis, hematochezia, history of ETOH detox. DDx? How do you distinguish?
  1. a mesenteric ischemia (
    Severe abdominal pain is the hallmark presentation of
    • acute mesenteric ischemia.)
  2. b 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. c 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. 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
    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 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.)

5 Multiple choice questions

  1. carcinoma (20% incidence of gallbladder carcinoma. Signs and symptoms of carcinoma of the gallbladder are generally indistinguishable from those associated with cholecystitis and
    cholelithiasis. They include abdominal discomfort, right upper
    quadrant pain, nausea, and vomiting. )
  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. indium, intraop us, (
    •These tumors are associated with MEN I.
    These tumors occur predominantly in the pancreas, duodenum, antrum,
    and peripancreatic lymph nodes, but can also occur at distant sites
    like the ovary. Isolated tumors are found in 50%, and multiple tumors
    in 50%, but there is a higher incidence of multiple tumors in MEN I.
    *Tumors are malignant in 50%, with
    *metastases to the regional lymph nodes and the
    Once the diagnosis has been established, tumor localization can be
    achieved with
    •indium-labeled octreotide scan,
    •CT with fine cuts through the pancreas,
    •MRI, or
    •selective angiography.
    None of these tests are highly sensitive, and often the tumors are not
    localized until the time of exploration and intraoperative-directed
  4. medullary cancer (
    The needle biopsy revealing
    •amyloid makes the diagnosis of
    ***medullary thyroid cancer.)
  5. exlap (
    •However, if the patient did show signs of increasing toxicity and
    evidence for sepsis, such as hypotension or mental status changes, it
    would be reasonable to
    ***proceed with an exploratory laparotomy to make the diagnosis. Upper
    ENDOSCOPY is NOT indicated in the acute management of a perforated
    duodenal ulcer )

5 True/False questions

  1. 21yM in MVA has laceration to aorta. Most common location?decel, distal to left subclavian at 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. Significance of atypical ductal hyperplasiaall breast, LN, preserve pec major, same survival, (
    The Halsted radical mastectomy involves removal of all breast tissue, lymphadenectomy, and removal of the pectoralis major. The modified radical mastectomy preserves the pectoralis major muscle thus decreasing the morbidity of the surgery with the same survival. The modified radical mastectomy does include a lymph node dissection. The anatomic limits of the modified radical mastectomy include the sternum medially, the subclavius muscle superiorly, the inframammary fold inferiorly, and the latissimus dorsi muscle laterally. )


  3. 76yM alcoholic with hematemesis. DDx for source of bleedeso varices, gastritis, duodenal ulcer, (
    In patients with liver failure, the •source of an upper GI bleed is
    *esophageal varices in 50%,
    *gastritis in 30%, and
    *duodenal ulcers in only about 10%.
    Esophageal variceal bleeding is a potentially fatal complication of
    portal hypertension.


  4. 45yM smoker often experiences pain at night while lying in bed, and the pain improves with positioning of the affected extremity. Ddx? 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.)


  5. Risk factors for dehiscencethrough 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.)


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