5 Written Questions

1. resection
2. mesenteric ischemia (
   Severe abdominal pain is the hallmark presentation of
   • acute mesenteric ischemia.)
3. 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.)
4. revasc, smoking cessation, pentoxifylline, cilostazol, (
   
   determined in part by the
   *severity of the symptoms.
   
   •Patients with limb-threatening ischemia, indicated by
   ***rest pain,
   ***tissue necrosis, and
   ***nonhealing wounds,
   should be considered for revascularization.
   
   •On the other hand, patients with intermittent claudication, usually
   described as an "ache" in the calf, should first be managed
   conservatively. This includes institution of
   ***lifestyle modifications such as
   ***smoking cessation,
   ***walking programs, and
   •medical therapy with
   ***pentoxifylline or
   ***cilostazol.)
5. 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. )

5 Matching Questions

1. Developmental source for Meckel's diverticulum?
2. Acute arterial occlusion, MNGT?
3. 15yF with elevated serum Ca, low serum phosphate. Tx?
4. 30yM with gastric ulcer demonstrates a tumor in his pancreas, and elevated gastrin levels. DDx
5. 45yM s/p liver txt, hypoglycemia, coagulopathy, elevated ammonia, hyperkalemia, oliguria. MNGT?

1. a ZES (
   •The Zollinger-Ellison syndrome was described in 1955, in two patients with the
   triad of
   *gastroduodenal ulcerations,
   *gastric hypersecretion, and
   *nonbeta islet cell tumors of the pancreas.)
2. b FHH med, primary surgery (
   •The distinction is important, as patients with primary
   hyperparathyroidism benefit from surgery and those with FHH do not.)
3. c 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. )
4. d 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.)
5. e 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.

5 Multiple Choice Questions

1. reassurance (
   
   All liver transplant patients have an initial rise in transaminases
   which should decrease over the first 48 hours. )
   1. 45yM s/p liver txt POD #2, rising AST/ALT. MNGT?
   2. ADH on needle core. MNGT?
   3. Acute arterial occlusion, MNGT?
   4. ADH on excisional bx. MNGT
2. endoscopy, swallow study water sol, primary repair, (
   ***Diagnosis is often made after clinical suspicion by endoscopy or a
   swallow study with water-soluble contrast. If diagnosed early within
   24 hours, a primary repair is the first approach to treatment.
   Closure is dependent on the amount of infected or necrotic tissue,
   tension on the anastomosis, etiology of the perforation, and the
   ability to adequately drain the contaminated areas. Late perforations
   may be complicated in their management, requiring several procedures
   or diversion to provide for adequate healing.)
   1. On precordial auscultation, crackles are heard. DDx
   2. On precordial auscultation, crackles are heard. MNGT?
   3. Elevated intracranial pressure, MNGT
   4. Palpable breast lesion. MNGT
3. vasopressin, octreotide, (
   The second step is to control the source of bleeding. Medical
   management may include
   *vasopressin or octreotide.)
   1. 76yM alcoholic with hematemesis. Fluids and clotting factors administered. VSS. MNGT
   2. 76yM alcoholic with hematemesis. Bleeding controlled with octreotide. MNGT
   3. 76yM alcoholic with hematemesis. DDx for source of bleed
   4. 76yM alcoholic with hematemesis. MNGT
4. reassurance unless risk, >2.5cm, sickle, diabetes, child, calcified wall, (
   The incidental finding is a gallstone within the gallbladder without evidence for inflammation.
   • For most patients with asymptomatic cholelithiasis, a cholecystectomy is not routinely performed.
   Only 20-30% of these patients will develop symptoms within 20 years.
   Moreover, only 1-2% per year will develop serious symptoms or complications from their gallstones.
   • However, certain patients are at greater risk for developing complications and should be considered for elective cholecystectomy.
   *This population includes patients with stones greater than 2.5 cm in size since they are at greater risk for obstruction.
   *Children with cholelithiasis have a high frequency of becoming symptomatic and also should be considered for early intervention.
   * In patients with sickle cell disease, acute cholecystitis can induce a sickle crisis, which can complicate surgery and as such should
   undergo elective cholecystectomy.
   • Finally, the finding of calcifications in the gallbladder wall, also known as a "porcelain gallbladder" is associated with increased risk of gallbladder carcinoma and an elective cholecystectomy should be considered.
   • Diabetes mellitus is associated with increased surgical risks with both emergent and elective cholecystectomy, and therefore diabetics should not be recommended for surgery for asymptomatic gallstones.)
   1. 32yF preop for elective cholecystectomy shows calcified "porcelain" gallbladder. DDx?
   2. 15yF with elevated serum Ca, low serum phosphate. Tx?
   3. 40yF with preop for elective gynecological surgery, demonstrates cholelithiasis on Xray, no evidence of RUQ pain nor inflammation. MNGT
   4. 16yM with unilateral scrotal swelling. DDx. Initial MNGT
5. 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.)
   1. 41yM with severe pain in left hip joint. MNGT
   2. 15yF with elevated serum Ca, low serum phosphate. DDx. MNGT?
   3. 21yM in MVA has laceration to aorta. Most common location?
   4. 71yM with hematemesis, hematochezia, history of ETOH detox. DDx? How do you distinguish?

5 True/False Questions

1. 76yM alcoholic with hematemesis. MNGT → fluid, coags, blood, (
   The initial
   •management should include
   * fluid resuscitation and
   *replacement of blood and clotting factors as needed.)

   True        False

2. 65yM s/p gastrectomy presents with abdominal pain, N/V, palpitations. 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.)

   True        False

3. Palpable breast lesion. MNGT → 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.)

   True        False

4. Signs of liver failure → hypoglycemia, coag, elev ammonia, acidosis, hyperk, oliguria, (
   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.)

   True        False

5. Dukes Colon Cancer Staging → Dukes, A bowel ball, B serosa or fat, C regional LN, D distant, (
   Dukes originally proposed a staging classification for colon cancer.
   ***Dukes' A lesions are confined to the bowel wall,
   ***Dukes' B lesions extend beyond the wall involving the serosa or
   fat, and
   ***Dukes' C lesions have accompanying regional lymph node
   involvement. TNM staging is now probably the most widely used system
   for staging.)

   True        False