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5 Written questions

5 Matching questions

  1. 16yM with unilateral scrotal swelling. DDx. Initial MNGT
  2. Developmental source for Meckel's diverticulum?
  3. Tx for thyroid whose bx is amyloid
  4. 32yF preop for elective cholecystectomy shows calcified "porcelain" gallbladder. DDx?
  5. 76yM alcoholic with hematemesis. Endoscopy reveals duodenal ulcer. Sclerotherapy, tamponade, banding fails to control bleeding. MNGT
  1. a TIPS, portal shunt, (
    If endoscopic methods are ineffective, or the patient has numerous
    recurrences,
    •portal shunts can be considered.
    *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. b 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. )
  3. c total 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. 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 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.)

5 Multiple choice questions

  1. intersphincteric, NO abx, drainage, (intersphincteric is most common
    The most common cause of anorectal fistula and abscess is infection of the anal glands, which empty into the anal canal at the level of the dentate line. Classification of anal fistula is based upon the relationship of the epithelialized tract to the anal sphincter muscle and can be intersphincteric (most common), transsphincteric, suprasphincteric, and extrasphincteric (least common). A symptomatic fistula is an indication for surgery because it rarely heals spontaneously.

    Despite popular teaching, there is little use for antibiotics in the primary treatment of anal abscess. As a rule, surgical drainage is required and antibiotics are only indicated if cellulitis is present.
    ***However, those patients who are
    1. immunocompromised, have
    2. valvular heart disease, or
    3. poorly controlled diabetes
    - should always be considered for antibiotics.)
  2. sternum, subclavius, inframammary, lat dorsi, (
    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. 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.)
  4. consider barbiturate coma, craniectomy, (
    Additionally, if the ICP
    is refractory to these interventions, it is reasonable to consider a
    *barbiturate coma or potentially a
    *decompressive craniectomy.
    *Hyperventilation is used only in the acute setting to keep PaCO 2
    around 35 mmHg, which functions to decrease intracranial pressure by
    decreasing intracranial blood volume through vasoconstriction.)
  5. 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.)

5 True/False questions

  1. 18yoM with thin tall habitus has spontaneous pneumothorax repaired on left side. Where is recurence likely to occur?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.)

          

  2. 15yF with elevated serum Ca, low serum phosphate. DDx. MNGT?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.)

          

  3. Thyroid biopsy with amyloid. DDx?total 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. Elevated intracranial pressure, MNGTheparin, 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. 14yM nonfocal physical exam and VSS, HPI "concussion while skiing, and blacked out". head CT with crescent shape bright lesion. Etiology?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.)