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5 Written questions

5 Matching questions

  1. Dx of Meckel's diverticulum?
  2. 35yF s/p cholecystectomy for cholelithiasis, histology shows incidental gallbladder carcinoma. MNGT?
  3. Acute arterial occlusion, MNGT?
  4. 15yF with elevated serum Ca, low serum phosphate. DDx. MNGT?
  5. 65yM with esophageal cancer undergoes esophagectomy. In chest cavity, odorless milky fluid is found. 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 technetium pertechnetate, (
    • diagnosed using
    ***nuclear medicine scans technetium pertechnetate
  3. c 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.)
  4. d 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.)
  5. e submucosa none, muscularis radical lymph, hepatic resection, (
    The management of these patients is based on the depth of tumor penetration into the wall of the gallbladder. No further surgical intervention is required if the tumor invades superficially into the
    mucosa and submucosa. These patients are placed on surveillance programs. However, if the lesion penetrates deeper into the muscularis or perimuscular connective tissue of the gallbladder wall, a radical second procedure is undertaken which includes radical lymphadenectomy
    and partial hepatic resection.

    If a malignancy is identified at the time of initial surgery, removal
    of the regional lymph nodes, partial liver resection and, in some
    cases, pancreaticoduodenectomy are indicated.)

5 Multiple choice questions

  1. bridging veins, (
    •Subdural hemorrhages typically have a
    *crescent shape and
    *extend across suture lines covering the entire surface of one hemisphere. These are usually the result of the
    *disruption of bridging veins.
    •Epidural hematomas on the other hand have a
    *biconvex lens appearance on CT scan. They typically develop after an
    *injury to the middle meningeal artery.)
  2. transanal Excision, adjuvant chemo, (
    •Local treatment of rectal cancer
    ***is the treatment of choice in selected individuals with low-lying
    rectal cancers. The lesion must be
    -within 10 cm of the anal verge,
    -less than 3 cm in diameter,
    -less than one-fourth the circumference of the rectal wall, and
    -stage T1 or T2 on endorectal ultrasound.

    Transanal excision is the most straightforward technique of local treatment. It entails full thickness excision of the lesion into the perirectal fat with adequate margins. For early lesions into the
    submucosa only (T1),
    ***no adjuvant therapy is required unless poor prognostic features are
    present on final pathology (poorly differentiated or lymphatic/
    vascular invasion).
    • If the lesion penetrates the muscular wall (T2),
    ***adjuvant radiation therapy with or without chemotherapy is
    indicated following surgical removal.

    •Overall, the disease free survival rate is 80%.)
  3. 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.)
  4. dehisce fascia, evisce peritoneal contents, (
    Dehiscence refers to a separation of the fascial layer. Evisceration is when peritoneal contents extrude through the fascial separation.)
  5. eye, motor, verbal, 8 coma, (

    •The Glasgow Coma Scale is
    ***used to quantify a neurologic examination in patients with a head
    It is based on three elements:
    ***eye opening,
    ***motor response, and
    ***verbal response.
    The total score ranges from 3 worst to 15 best with a
    ***score of 8 or lower indicating a coma.

    Eye opening
    Spontaneous 4
    To speech 3
    To pain 2
    None 1

    Motor response
    Obeys commands 6
    Localizes pain 5
    Withdraws to pain 4
    Abnormal flexion decorticate 3
    Extension decerebrate 2
    None flaccid 1

    Verbal response
    Oriented 5
    Confused conversation 4
    Inappropriate words 3
    Incomprehensible sounds 2
    None 1)

5 True/False questions

  1. Colonoscopy. Most common finding on polyp biopsy.ta, (
    •Villous adenoma is a premalignant condition. The incidence of
    carcinoma in a polyp depends on the histology type and size of the
    •Tubular adenomas are the most
    *common type of polyps 60-80%, but are the
    * least likely to harbor carcinoma less than 5% if smaller than 1 cm
    in diameter.
    •Villous adenomas are the least common type, but overall the
    *most likely to contain malignant foci 50% if greater than 2 cm in


  2. HPI of Meckel's diverticulum?Asx, GI bleed, (
    •Meckel's diverticuli are usually found incidentally, although they
    can present with
    ***painless lower GI bleeding or
    ***confused with acute appendicitis. They are usually found within)


  3. Abdominal pain out of proportion to examination. DDx?mesenteric ischemia (
    Severe abdominal pain is the hallmark presentation of
    • acute mesenteric ischemia.)


  4. Tx for peripheral arterial occlusive diseaserevasc, 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


  5. palpable breast lesion suspicious on mammogram. MNGTneedle core (
    The management of a breast lesion has become more complex as our
    knowledge regarding breast cancer development and treatment has
    continued to grow.
    •The gold standard for evaluation of a suspicious lesion on mammogram
    is a core needle biopsy.)