5 Written questions
5 Matching questions
- 16yM with unilateral scrotal swelling. Scrotal ultrasound demonstrates intraparenchymal mass. MNGT
- 35yM with HPI epigastric pain alleviated with food, now CC acute abdomen. CXR and KUB show no free air on upright films. MNGT?
- 35yM with HPI epigastric pain alleviated with food, now CC acute abdomen. MNGT?
- 21yM in MVA has laceration to aorta. Dx test
- 18yM with thin habitus, presents with spontaneous pneumothorax. MNGT
- a chest tube, pain, o2, serial CXR, thoracotomy, bleb resection, (
Spontaneous pneumothorax is usually found in young males. A tall, thin habitus is common. Eighty-five percent of patients are found to have
pulmonary blebs on the affected side.
•The correct management is
*placement of a chest tube,
*oxygen supplementation, and
*serial chest x-rays to monitor resolution.
*Thoracotomy is required if the pneumothorax does not resolve with a
chest tube or if there is a persistent air leak.
*Bleb resection and
*pleurodesis is usually performed at the time of operation to prevent
future bleb rupture and to promote adhesion of the lung to the chest
*Thoracotomy is also offered to patients after a recurrence to prevent
•Fifty percent of patients will have a recurrence on the ipsilateral side after a spontaneous pneumothorax.)
- b 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.)
- c CXR, widened mediastinum, CT, aortogram, (
•Diagnosis is difficult, but is suggested by a
*widened mediastinum on chest x-ray and
*confirmed with a CT scan of the chest
*or an aortogram.)
- d 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.)
- e 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
5 Multiple choice questions
- 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.)
- primary vs FHH, PTH, 24hr urine, (
•FHH, or familial benign hypercalcemia, is a rare condition
characterized by asymptomatic or mildly symptomatic hypercalcemia. It
is inherited as an
*autosomal dominant trait and the
*parathyroid glands are usually normal in size.
The basis for the development of FHH appears to be mutations in the
calcium-sensing receptor gene which regulates the parathyroid gland
set point and modulates the extracellular calcium concentration. The
condition may be mistaken for primary hyperparathyroidism because, in
both conditions, the
*serum calcium and
*parathyroid hormone levels are elevated with a
*concomitant low serum phosphate.
•The distinction is made by obtaining a
*24-hour urine calcium excretion level.
*In patients with FHH, the urine calcium level is low,
*whereas in primary hyperparathyroidism the level is high.)
- malnutrition, obesity, diabetes, uremia, malignancy, immunology, steroids, infection, coughing, NOT running stitch, (
• steroid use,
•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.)
- 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.)
- 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 True/False questions
On precordial auscultation, crackles are heard. DDx → 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.)
30yM with gastric ulcer demonstrates a tumor in his pancreas, and elevated gastrin levels. DDx → ZES (
•The Zollinger-Ellison syndrome was described in 1955, in two patients with the
*gastric hypersecretion, and
*nonbeta islet cell tumors of the pancreas.)
16yM with unilateral scrotal swelling. DDx. Initial MNGT → us, intra malignant, extra b9, (
• Testicular cancer is the most common malignancy in men between the ages of 15 and 35.
* It typically presents as unilateral scrotal swelling. On examination, it is important to distinguish
* intraparenchymal masses usually malignant from
* extraparenchymal masses usually benign.
* This is easily done with scrotal ultra-sound.)
Tx for Meckel's diverticulum? → resection
35yM with HPI epigastric pain alleviated with food, now CC acute abdomen. BP 90/60, pt is derilious and toxic appearing. MNGT? → 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 )