P5-Surgeryy

Patient had chest trauma and 3⁄4 rib fracture. Inspection of the chest showed paradoxical chest movement. What is the management? (No choices were provided)

: management of rib fracture: - Usually no surgery necessary - Analgesia o NSAIDs o Opiates o Local nerve block or epidural catheter - Intubation with positive pressure ventilation in severe flail chest (bridge to surgery) - In case of pneumothorax or hemothorax: thoracic drainage and thoracic surgical intervention - Indications for surgery o Significant chest wall deformity o Severe flail chest o Nonunion Amboss: Blunt trauma 54

Diabetic patient with lateral malleolar ulcer. What is the treatment? A- surgical debridement

: A Amboss: diabetes mellitus 48

Case of acute cholecystitis. What is the management? A- Early laparoscopic cholecstectomy B- Late laparoscopic cholecystectomy C- Open cholecetectomy

: A - Laparoscopic cholecystectomy is considered the "gold standard" for the surgical treatment of gallstone disease. - Acute cholecystitis - Patients with acute cholecystitis, who are surgical candidates, should undergo cholecystectomy as soon as they are fully resuscitated, and the most qualified surgeon is available. Early cholecystectomy has been associated with improved patient outcomes compared with interval cholecystectomy. UpToDate: laparoscopic cholecystectomy 30

5 years old child was found to have one testis in the scrotum and the other in the inguinal area. What is the next step in management? A- orchiopexy B- orchiectomy C- wait tell puberty D- GnRH

: A - Surgical treatment of undescended testes is recommended as soon as possible after four months of age for congenitally undescended testes and definitely should be completed before the child is two years old (ideally before one year). In children with testicular ascent later in childhood, surgery generally should be performed within six months of identification. - Orchiopexy is a well-established surgical procedure for repositioning undescended or ectopic testes that are palpable - Exploratory surgery for the nonpalpable testis is diagnostic and potentially therapeutic. UpToDate: Undescended testes (cryptorchidism) in children: Management 38

Testicular pain with absent cremaster reflex for 4 hours, and there is a clinical picture of torsion. What to do? A. Surgical exploration

: A - The clinical features of testicular torsion include the acute onset of moderate to severe testicular pain with profound diffuse tenderness and swelling and a negative cremasteric reflex on physical examination. The classic finding is an asymmetrically high-riding testis with its long axis oriented transversely instead of longitudinally related to shortening of the spermatic cord from the torsion ("bell clapper deformity"). - Treatment for suspected testicular torsion is urgent surgical exploration with intraoperative detorsion and fixation of the testes. Delay in detorsion of a few hours may lead to progressively higher rates of testicular nonviability. Manual detorsion should be performed if surgical intervention is not immediately available. UpToDate: Evaluation of acute scrotal pain in adults 17

Young female with thyroid mass, normal TSH. Sample results of FNA came inadequate. What is your next step? A. Repeat FNA

: A A nondiagnostic biopsy is cytologically inadequate. It is critical that the absence of malignant cells not be interpreted as a negative biopsy if no or scant follicular tissue is obtained. For patients with nondiagnostic FNA biopsies, we repeat the FNA in approximately four to six weeks, using ultrasound guidance if not used for the first FNA UpToDate: Diagnostic approach to and treatment of thyroid nodules 25

29 Years old male did sleeve gastrectomy 6 days ago. He presented to the ER complaining of persistent vomiting since operation, yet there is nothing significant on examination, and his ABG normal (they presented the ABG as numbers). His US is normal. What is the management? A- reassurance

: A After bariatric surgery, it is not unusual for patients to experience some extent of nausea, vomiting, and mild food intolerance. Generally, though, if patients can stay hydrated and tolerate a thin liquid diet, they will not need readmission or workup for the aforementioned causes of early morbidity. Patients with mild gastrointestinal symptoms are generally kept on a liquid diet for one to two weeks after the operation and slowly transition to more solid forms of food over the next one to two months. Surgical edema is typically the cause of these symptoms, which should be self-limited. Patients who continue to present with recurring or worsening symptoms should undergo further workup for more serious complications Sleeve gastrectomy serious complications: Bleeding — Bleeding can occur from the gastric or short gastric vessels during dissection of the greater curve. Most of the bleeding problems associated with SG occur from the staple line after transection of the stomach Stenosis — Narrowing or stenosis can create gastric outlet obstruction. The presentation varies depending on the severity of the obstruction and can include dysphagia, vomiting, dehydration, and the inability to tolerate an oral diet. The gastroesophageal junction and the incisura angularis are the two most common areas where stenosis occurs, and this can be diagnosed by an upper gastrointestinal series. Gastric leaks — Gastric leaks after SG are one of the most serious complications and can occur in up to 5.3 percent of patients. Most leaks are due to local factors at the site of the staple line, such as inadequate blood supply and oxygenation, which impede the healing process. Leaks can also be due to gastric-wall heat ischemia, a consequence of the heat generated by the cautery used during dissection of the greater curve. Although the blood supply to the stomach is robust, the gastroesophageal junction tends to be an area of decreased vascularity and thus more prone to leaks. Additionally, the stomach tends to be thinner at the angle of His, and some authors suggest that the large staple height used by many surgeons may not adequately seal this area of the stomach Reflux — Gastroesophageal reflux after SG presents with classic symptoms such as burning pain, heartburn, and regurgitation. It can occur as an early and late complication. UpToDate: Late complications of bariatric surgical operations - Bariatric operative procedures: Thirty-day morbidity and mortality 57

In case of trauma, what is CT important for? A- retroperitoneal injury

: A Approach to penetrating abdominal trauma History: details such as number of shots heard, amount of blood loss at the scene of injury, and position of patient when shot or stabbed Preliminary assessment and care Prehospital and hospital trauma care Resuscitative and stabilization procedures (e.g., rapid transfusions, CPR) indicated if the patient is hemodynamically unstable Tetanus prophylaxis Broad spectrum antibiotic prophylaxis Analgesics, anxiolytics Surgical management Emergency exploratory laparotomy indicated in Evisceration Signs of peritonitis Hemodynamic instability Bleeding detected in nasal tube or rectal examination Penetrating object still in situ (risk of precipitous hemorrhage on removal) Free air under the diaphragm Assess for peritoneal or retroperitoneal penetration and intra-abdominal bleeding FAST exam CT/MRI imaging Local wound exploration Diagnostic peritoneal lavage (DPL) Diagnostic laparoscopy Conservative management Indications: surgical treatment not required Measures Close monitoring of vital signs Serial physical examinations Blood analysis to monitor hemodynamic state Approach to penetrating chest trauma Preliminary assessment and care: See "Preliminary assessment and care" in approach to penetrating abdominal trauma above. Emergency procedures Tube thoracostomy or a needle decompression for tension pneumothorax Placement of an occlusive dressing, taped on three sides, for a sucking chest wound Emergency thoracotomy indicated in Cardiac tamponade Hemodynamically unstable patient Cardiac arrest that occurred at, or after, presentation Unstable patient and/or penetrating object still in-situ Assessment of injury cause and severity Ultrasound (Extended Focused Assessment with Sonography in Trauma, EFAST) Chest x-ray and/or CT if patient is stable Others: echocardiography, endoscopy, bronchoscopy, angiography Further management Close monitoring of vital signs Continual reassessment Appropriate surgical repair after hemodynamic stabilization Approach to penetrating neck trauma Preliminary assessment and care: See "Preliminary assessment and care" in approach to penetrating abdominal trauma above. In case of presence of hard signs: Immediate intubation and surgical exploration: in cases with hemodynamic instability, expanding hematoma, or clear signs of tracheal/esophageal injury Emergency tracheostomy: if integrity of larynx is in question Further management Determine injury extent: CT angiography (best initial test), esophagram, panendoscopy Gunshot wound: conservative or surgical management based on injury extent Stab wounds Patients with no signs of severe vascular or organ injury, can be safely observed Penetrating trauma to the extremeties The approach is based on anatomic location and whether major vessel injury is suspected No major vessels in the vicinity of the tract of the penetrating object: conservative management Stable patients with a penetration tract in the vicinity of major vessels and local signs (pain/tenderness), but no systemic signs of hypovolemia, should undergo further diagnostic testing: Plain x-ray: evaluate extent of bony injury Contrast CT angiography: evaluate vascular injury Doppler ultrasonographic evaluation: evaluate vascular injury in cases with poor renal function, in which contrast CT is contraindicated Patients exhibiting 'hard signs' of arterial injury: urgent surgical exploration, hemorrhage control, and repair In case of combined injury to arteries, nerves and bones: start with stabilization of bone (fracture reduction etc.) → vascular repair → nerve repair Amboss: penetrating trauma 67

4 years old patient came to the clinic with umbilical hernia that is without any symptoms. What is next? A- Reassure B- Surgery C- Band

: A Because the natural course of the umbilical ring is eventual closure, most umbilical hernias will spontaneously resolve. In general, asymptomatic children with an umbilical ring that continues to decrease can be observed, regardless of their age. UpToDate: Care of the umbilicus and management of umbilical disorders 2

Before an adrenal gland operation, what should you give the patient? A- Hydrocortisone

: A Before proceeding to a surgical excision, all patients must undergo a complete hormonal assessment to determine the secretory activity of the tumor. It is particularly important to identify those with cortisol-producing tumors. These patients, even those with mild hypercortisolism, have some degree of hypothalamic-pituitary-adrenal (HPA) axis suppression and require glucocorticoid coverage to prevent postoperative adrenal insufficiency. If it is pheochromocytoma: Preoperative blood pressure management: combined alpha and beta-adrenergic blockade - First, a non-selective alpha blocker is given: phenoxybenzamine blocks alpha- 1 and alpha-2 adrenoceptors equally and irreversibly (see alpha blockers).. - After sufficient alpha-adrenergic blockade, a beta blocker may be started for additional blood pressure control and control of tachyarrhythmias. UpToDate: Treatment of adrenocortical carcinoma Amboss: pheochromocytoma 51

Charcot's triad is used for the diagnosis of which of the following: A- acute cholangitis

: A Charcot triad is present in approx. 26-72% of patients with cholangitis. Clinical features of cholangitis: Charcot cholangitis triad - Abdominal pain (most commonly RUQ) - High fever - Jaundice (less common) Reynolds pentad: Charcot cholangitis triad PLUS hypotension and mental status changes Amboss: Cholelithiasis, choledocholithiasis, cholecystitis, and cholangitis 53

Anal fissure treatment: A- surgical Treatment is lateral internal sphincterotomy

: A Conservative First-line treatment for most anal fissures Includes: Dietary improvement (e.g., adequate ingestion of dietary fiber and water) Stool softeners (e.g., docusate) Anti-inflammatory and analgesic creams and/or suppositories (e.g., 2% lidocaine jelly) Sitz baths Local anesthetic injection Topical vasodilator therapy: calcium channel blocker gel (e.g., nifedipine) or glyceryl trinitrate ointment (GTN) Interim Persistent symptoms despite > 8 weeks of conservative therapy → endoscopy to exclude IBD If IBD is excluded, then the patient should receive definitive surgical treatment. Outpatient procedures Botulinum toxin A (BTX) injection into the internal anal sphincter Surgical Indicated when conservative treatment is unsuccessful The risk of fecal incontinence (e.g., high in multiparous or elderly patients) determines the type of surgical intervention. Low risk Sphincterotomy (e.g., lateral internal sphincterotomy) Anal dilatation (although there is a high risk of fecal incontinence with this procedure) High risk Anal advancement flap Fissurectomy (excision of the fissure) Amboss: Anal fissures 69

Patient post RTA presented with head trauma and polyuria. His osmolality is low in urine and high in blood. What is the diagnosis? A- diabetes insipidus

: A Etiologies: Secondary (∼ ⅔ of cases) - Brain tumors (especially craniopharyngioma) and cerebral metastasis (most common: lung cancer and leukemia/lymphoma) - Neurosurgery: usually after the removal of large adenomas - Traumatic brain injury, pituitary bleeding, subarachnoid hemorrhage - Pituitary ischemia (e.g., Sheehan syndrome, ischemic stroke) - Infection (e.g., meningitis) Clinical features: - Polyuria with dilute urine - Nocturia → restless sleep, daytime sleepiness - Polydipsia (excessive thirst) - In cases of low water intake → severe dehydration (altered mental status, lethargy, seizures, coma) and hypotension Amboss: diabetes insipidus 78

Male complaining of reflux and post prandial discomfort. This is a main complaint in his family. What is the risk factor for esophageal cancer? A- surgery Barrett esophagus

: A I honestly have a big question mark here, but here is what I could find about Barrett esophagus being a risk factor and its relation to surgery: Adenocarcinoma Risk factors Gastroesophageal reflux: Barrett's esophagus (A condition in which the esophageal squamous epithelium is replaced by columnar epithelium and Goblet cells (intestinal metaplasia) due to longterm reflux esophagitis. Considered a precancerous condition for esophageal adenocarcinoma.) Obesity Smoking Achalasia Localization: mostly in the lower third of the esophagus Squamous cell carcinoma (SCC) Risk factors Alcohol consumption Smoking Diet low in fruits and vegetables Drinking hot beverages Achalasia Nitrosamines exposure (e.g., cured meat, fish, bacon) Plummer-Vinson syndrome Caustic strictures Diverticula (e.g., Zenker's diverticulum) Radiotherapy Esophageal candidiasis Betel or areca nut chewing Localization: mostly in the upper two-thirds of the esophagus TREATMENT Curative Indication Locally invasive disease that has not invaded surrounding structures High-grade metaplasia in Barrett syndrome Methods Neoadjuvant chemoradiation For downstaging → potentially allows for later resection As definitive treatment in patients with proven complete response (e.g., during endoscopy) Surgical resection Endoscopic submucosal resection for removal of superficial, epithelial lesions Subtotal or total esophagectomy with gastric pull-through procedure or colonic interposition Palliative Indication: patients with advanced disease (majority of patients) Methods: Chemoradiation Stent placement Other endoscopic treatments (e.g., laser therapy) Amboss: esophageal cancer 70

After appendectomy, a patient got abdominal infection by enterococcus faecium. He is allergic to penicillin. what are you going to give him? A- vancomycin

: A In the absence of suspected endocarditis or critical illness, enterococcal bacteremia may be treated with monotherapy Treatment of bacteremia due to susceptible enterococci consists of ampicillin

7 years old boy brought by his parents. He has nausea and severe vomiting for 20 minutes. Now, he is semi-comatose. The parents mentioned that he had the same episode two weeks ago for 5 minutes without deterioration in consciousness. On examination there is right testicular mass that does not transilluminate with light. What is the best next step? A- Surgical exploration.

: A Intermittent testicular torsion, characterized by the sudden onset of acute and intermittent sharp testicular pain and scrotal swelling, with rapid resolution (within seconds to a few minutes) and long intervals without symptoms, should be considered in all boys with a history of such scrotal pain and/or swelling without other identifiable causes In one review of 50 patients with intermittent testicular torsion, 26 percent reported nausea or vomiting, and 21 percent reported that the pain awakened them from sleep. Physical findings of intermittent testicular torsion may include horizontal or very mobile testes, anterior epididymis, or bulkiness of the spermatic cord from partial twisting. These findings are usually present to varying degrees on physical examination. However, the clinical and radiographic evaluations of some boys with intermittent torsion may be normal, highlighting the importance of immediate follow-up for recurrent or worsening pain. All boys suspected to have intermittent testicular torsion should have an ultrasound that includes imaging of the spermatic cord. Although the testes may have normal architecture and flow, in some cases views of the cord show a whirlpool sign or a pseudomass. Boys with intermittent complaints, normal physical examination, and an unremarkable ultrasound of the testis spermatic cord at the time of presentation should have a follow-up evaluation within seven days unless pain recurs sooner. Ultrasound for intermittent torsion is at best 75 percent sensitive, and the diagnosis of this condition remains clinical. The diagnosis of testicular torsion can be made clinically. Thus, when clinical findings are definitive for testicular torsion (eg, acute onset of severe testicular pain in association with nausea or vomiting, absent cremasteric reflex, and testicular tenderness and swelling and high-riding or transverse position), the clinician should promptly consult a surgeon with pediatric urologic expertise to evaluate the patient and make a decision regarding operative exploration and repair. UpToDate: Causes of scrotal pain in children and adolescents 64

What are the electrolyte abnormalities in pyloric stenosis? A- hypochloremic hypokalemic metabolic alkalosis

: A Laboratory tests - Hypochloremic, hypokalemic metabolic alkalosis, a classic result, is now uncommon because infants are typically diagnosed and treated early. o The loss of gastric hydrochloric acid from emesis results in increased bicarbonate and decreased chloride concentrations in the blood. o Hypokalemia usually occurs in infants that have been vomiting for many days or even weeks. - Hyponatremia or hypernatremia may be present Amboss: hypertrophic pyloric stenosis 74

Duodenal perforation treatment: A- simple closure with omental patch "Graham omental patch"

: A Perforated duodenal ulcers can generally be treated by closure with a piece of omentum (Graham patch) or, for perforated ulcers close to the pylorus, by truncal vagotomy with pyloroplasty (incorporating the perforation). Both approaches are simple and expedient, and the results have generally been good UpToDate: surgical management of peptic ulcer disease 52

Patient involved in RTA was transmitted to nearby limited facilities hospital, and the physician decided to refer him to advanced facilities hospital. The patient is unconscious. What is the most important thing that should be maintained during the transfer? A-intubation

: A Prehospital trauma care - Prehospital care of trauma patients is situation-dependent and centered on stabilization of the patient and prompt transport to a hospital. - Nonmedical personnel trained in basic life support may provide life- saving interventions (see "Basic life support" in the learning card cardiopulmonary resuscitation). - Emergency services personnel typically perform an abbreviated version of the primary survey - Low-threshold interventions that may be performed by emergency personnel prior to transport to a hospital include, but are not limited to: o Placement of a cervical collar (if cervical spine trauma is suspected based on primary survey or mechanism of injury) o Intubation or oxygen delivery via nasal cannula (if respiratory distress or altered mental status is suspected) o Administration of intravenous fluid (if hemorrhage or hypotension is suspected) o Administration of analgesia o Placement of tourniquets or pressure bandages for control of bleeding Amboss: Management of trauma patients 76

Which of the following cancers should be screened for even without symptoms? A- Colon cancer B- Pancreatic cancer

: A Recommended screening tests for certain cancers even without symptoms according to CDC: - Breast cancer: Mammograms are the best way to find breast cancer early, when it is easier to treat. - Cervical cancer: The Pap test can find abnormal cells in the cervix which may turn into cancer. - Colorectal Cancer: Colorectal cancer almost always develops from precancerous polyps (abnormal growths) in the colon or rectum. - Lung cancer: The USPSTF recommends yearly lung cancer screening with low-dose computed tomography (LDCT) for people who have a history of heavy smoking, and smoke now or have quit within the past 15 years and are between 55 and 80 years old. - Other cancers: Screening for ovarian, pancreatic, prostate, testicular, and thyroid cancers has not been shown to reduce deaths from those cancers. The USPSTF found insufficient evidence to assess the balance of benefits and harms of screening for bladder cancer and oral cancer in adults without symptoms, and of visual skin examination by a doctor to screen for skin cancer in adults. CDC: How to Prevent Cancer or Find It Early 24

Picture of obstructive jaundice and cholangitis. The patient is on IV antibiotics. US shows dilated ducts and the gallstones. What is the next step in management? A- ERCP B- Cholecystectomy

: A Supportive therapy - Analgesia: NSAIDs, opioids - Fluid and electrolyte correction Intravenous antibiotics Biliary drainage and decompression - Timing: perform within 24-48 hours - ERCP is the treatment of choice, possibly in combination with: o Sphincterotomy (for cholangitis due to cholelithiasis or choledocholithiasis) or stent placement (acute suppurative cholangitis) - Percutaneous transhepatic cholangiography (PTC) if ERCP is unsuccessful or unavailable o In this procedure, contrast material is injected into the bile ducts through the insertion of a transhepatic needle. o PTC allows therapeutic interventions such as infected bile drainage and biliary tract stone extraction. - Surgical decompression if no other route feasible Prevention of recurrence - Interval cholecystectomy if gallstones are present o Timing: recommended within 6 weeks Amboss: Cholelithiasis, choledocholithiasis, cholecystitis, and cholangitis 28

Patient presented with anterior abdominal stab wound. The omentum is bulging out through wound. What would you do? A- Exploratory laparotomy

: A Surgical management Emergency exploratory laparotomy indicated in Evisceration: A condition in which the viscera are present outside of the body, typically after trauma or surgery. For example, in case of wound dehiscence after abdominal surgery, small intestine may eviscerate from the peritoneal space due to an increase in intra-abdominal pressure. Signs of peritonitis Hemodynamic instability Bleeding detected in nasal tube or rectal examination Penetrating object still in situ (risk of precipitous hemorrhage on removal) Free air under the diaphragm Assess for peritoneal or retroperitoneal penetration and intra-abdominal bleeding FAST exam CT/MRI imaging Local wound exploration Diagnostic peritoneal lavage (DPL) Diagnostic laparoscopy Amboss: penetrating trauma 65

12 years old male with testicular pain. Testicle is horizontally lying, mildly elevated, with no swelling or erythema of scrotum. What to do next? A- surgical exploration B- rehydration

: A The case is highly suggestive of testicular torsion EXCEPT for the "no swelling or erythema of scrotum" part. - The clinical features of testicular torsion include the acute onset of moderate to severe testicular pain with profound diffuse tenderness and swelling and a negative cremasteric reflex on physical examination. The classic finding is an asymmetrically high-riding testis with its long axis oriented transversely instead of longitudinally related to shortening of the spermatic cord from the torsion ("bell clapper deformity"). - Treatment for suspected testicular torsion is urgent surgical exploration with intraoperative detorsion and fixation of the testes. Delay in detorsion of a few hours may lead to progressively higher rates of testicular nonviability. Manual detorsion should be performed if surgical intervention is not immediately available. UpToDate: Evaluation of acute scrotal pain in adults 16

A 32 years-old alcoholic male patient is brought to the emergency department with the history of vomiting large amount of bright red blood. Physical examination revealed splenomegaly and ascites. Which of the following is the most likely source of bleeding? A- Esophageal varices.

: A The features are highly suggestive of portal hypertension. Depending on the cause, portal hypertension may be either acute or chronic. Acute portal hypertension arises from acute portal vein thrombosis, while chronic portal hypertension may be due to chronic thrombosis, cirrhosis, or schistosomiasis. - Signs and symptoms of the underlying disease (e.g., cirrhosis, right-sided heart failure) - ↑ Blood flow via portosystemic anastomoses o Via paraumbilical veins and epigastric veins → caput medusae o Via rectal veins → hemorrhoidal or anorectal varices o Via veins of the gastric fundus and distal 1/3 of the esophagus, leading to: Esophageal varices: risk of life-threatening esophageal variceal bleeding (hematemesis) Gastric varices: melena o Consequences: impaired liver function (see cirrhosis) - Congestive splenomegaly, followed by signs of hypersplenism (e.g., thrombocytopenia) - Upper gastrointestinal bleeding from portal hypertensive gastropathy, gastrointestinal ulcers, or diffuse lower gastrointestinal bleeding - Transudative ascites The vomiting of blood. Etiologies include esophageal variceal bleeding (which usually produces large amounts of bright red blood), peptic ulcers, gastritis, and stomach cancer. Amboss: portal hypertension 59

Patient presents with abdominal pain. An abdominal CT was done showing 2cm adrenal adenoma. What to do next? A- Metanephrines and cortisol level B- resection

: A The maximum diameter of the adrenal mass is predictive of malignancy. Most adrenal adenomas are less than 4 cm in diameter. In contrast, most ACCs are greater than 4 cm in diameter when discovered. As noted above, computed tomography (CT) scanning can usually distinguish adenomas from ACCs. Magnetic resonance imaging (MRI) is complementary to CT, in that local invasion and involvement of the vena cava are more readily identifiable Adenomas secreting low levels of cortisol and pheochromocytoma are sufficiently common that all patients with an adrenal incidentaloma should be screened for these disorders. In addition, hypertensive patients should be screened for primary aldosteronism, even if the serum potassium concentration is normal. the European Network for the Study of Adrenal Tumors (ENSAT) recommends performing the following tests to determine the secretory activity of the tumor: fasting blood glucose, serum potassium, cortisol, corticotropin (ACTH), 24-hour urinary free cortisol, fasting serum cortisol at 8 AM following a 1 mg dose of dexamethasone at bedtime, adrenal androgens (dehydroepiandrosterone sulfate [DHEAS], androstenedione, testosterone, 17- hydroxyprogesterone), and serum estradiol in men and postmenopausal women The ENSAT also recommends that plasma metanephrines or urinary metanephrines and catecholamines be obtained in all patients to exclude pheochromocytoma and that plasma aldosterone and renin be obtained in patients with hypertension and/or hypokalemia (as mentioned above, "Adenomas secreting low levels of cortisol and pheochromocytoma are sufficiently common that all patients with an adrenal incidentaloma should be screened for these disorders". Therefore, checking for metanephrines and cortisol level should be done next.) UpToDate: Clinical presentation and evaluation of adrenocortical tumors 11

What is the treatment of recurrent esophageal varices bleeding? A- Atenolol B-Nifedipine

: A The preferred strategy for patients who recover from their first episode of variceal bleeding consists of endoscopic variceal ligation plus a beta blocker because this combination is effective for preventing rebleeding UpToDate: Prevention of recurrent bleeding from esophageal varices in patients with cirrhosis 7

What is the management of ductal breast cancer? A- Surgical excision

: A The treatment approach primarily depends on the histopathologic classification and disease stage and involves a combination of surgical management and systemic therapy (chemotherapy, hormone therapy, targeted therapy). Patient preference for more or less aggressive management also plays a significant role in selecting the treatment approach. Invasive carcinoma: - Early stage disease o Breast-conserving therapy (BCT): lumpectomy followed by radiation therapy Contraindications: large tumor-to-breast ratio, multifocal tumors, fixation to the chest wall, excision with negative tumor margins (> 2 mm) not guaranteed, clustered microcalcifications on imaging, involvement of the skin or nipple, a history of chest radiation Surgical margins need to be tumor free. Otherwise, repeat resection or consider mastectomy. Consider mastectomy for anyone unable to undergo BCT or who requests a more aggressive management. o Intraoperative lymph node evaluation Sentinel lymph node biopsy: assesses potential lymphatic spread of cancer cells to the axillary lymph nodes

Patient with neck mass. The biopsy showed thyroid follicular cells. What is the diagnosis? A- ectopic thyroid

: A Thyroid ectopia is defined as functioning thyroid tissue found anywhere other than the usual anatomic location of thyroid gland. Ectopic thyroid is usually located along the normal path of thyroid gland descent but rarely can also be found in the mediastinum, heart, esophagus, or diaphragm. Ectopic thyroid tissue is derived from abnormalities in migration of the medial anlage and hence typically does not contain C cells. The most common site of ectopic thyroid is a lingual thyroid. The wall of a thyroglossal duct cyst is the second most common site for ectopic thyroid tissue. The ectopic tissue is usually found in the form of small groups of follicles and is present in 25 to 65 percent of cysts examined histologically. Up to 1 to 2 percent of patients presenting with what appears to be a TGDC have an ectopic thyroid gland Most cases of thyroid ectopia manifest as simple TGDCs in conjunction with a normally developed and located thyroid gland. Some thyroid ectopia function normally, but approximately one third of patients present with hypothyroidism. If hypothyroidism develops, the mass may enlarge as a result of stimulation by thyrotropin (TSH). Ectopic thyroid tissue may enlarge during puberty or pregnancy. Treatment with thyroid hormone supplementation is usually sufficient for suppression, but surgical excision may become necessary. UpToDate: Thyroglossal duct cysts and ectopic thyroid 56

Case of perianal swelling and perrectal bleeding. Investigation: it is 1 cm from anal verge. Biopsy: adenocarcinoma (rectal). What is the management? A- abdominal perineal resection B- low anterior resection C- chemo/radio

: A Tumors in the lower rectum (ie, tumors within 5 cm of the anal verge) may require an abdominal perineal resection (APR) if a curative resection cannot be achieved with sphincter- sparing procedures. Alternatives to APR for patients with lower rectal tumor have evolved and include the following: - For selected patients with small lower rectal tumors, local excision techniques may offer local control and survival rates that are comparable to APR while preserving sphincter function. - For patients with larger or more invasive lower rectal tumors, preoperative (neoadjuvant) radiation therapy (RT) and chemoradiotherapy have been utilized to promote tumor regression in an attempt to convert a planned APR into a sphincter- sparing surgical procedure, such as low anterior resection (LAR). UpToDate: Overview of the management of rectal adenocarcinoma 23

A collection was found behind the gallbladder post cholecystectomy. How to drain it? A- Percutaneous drain B- Open drainage C- Laparoscopic drain

: A Typically, the stent is left in place for approximately four to six weeks. If a percutaneous drain is in place, the drainage should be less than 10 cc per day prior to removing the stent. In our experience with minor bile leaks, placing the percutaneous drain to gravity drainage (rather than continuous bulb suction) shortly after initial stent placement with close monitoring for symptomatic improvement may help to avoid a continuous vacuum into the drain, thereby allowing bile to drain through the stent into the duodenum (rather than into the percutaneous drain). However, this approach has not been studied in trials. In patients without a percutaneous drain, the stent should only be removed once the patient appears well clinically (eg, absence of pain, fever, jaundice, and abdominal distension). (I didn't find that the other 2 are used in the drainage anywhere) UpToDate: Endoscopic management of complications from laparoscopic cholecystectomy 20

Post colectomy, a paracolic collection was found. What is the management? A- Ultrasound guided drainage B- open drainage

: A Ultrasound and CT are often used to guide percutaneous drainage of well-defined fluid collections in the abdomen or chest, e.g. pancreatic pseudocysts, or abscesses, e.g. paracolic or subphrenic. Essential Surgery: PRINCIPLES OF SURGICAL CARE: Diagnostic techniques 22

40 years old woman with no pain but you noticed jaundice. She has high direct bilirubin and high ALT. What is your diagnosis? A- Carcinoma in head of pancreas

: A Unconjugated hyperbilirubinemia - Increased hemoglobin breakdown o Hemolysis (e.g., glucose-6-phosphate dehydrogenase deficiency, sickle cell anemia, spherocytosis, hemolytic disease of the fetus and newborn, and blood transfusions) o Dyserythropoiesis (e.g., thalassemia, pernicious anemia, erythropoietic porphyria, and sideroblastic anemia) o Resolving hematoma or internal hemorrhage (e.g., in trauma patients or postoperatively) - Impaired hepatic uptake of bilirubin o Drugs (e.g., rifampin, probenecid, sulfonamides) o Portosystemic shunt - Defective conjugation of bilirubin o Inherited hyperbilirubinemia: Gilbert syndrome and Crigler-Najjar syndrome o Neonatal jaundice o Liver disease: hepatitis (e.g., viral, autoimmune, toxic/alcoholic), cirrhosis, Wilson disease o Hyperthyroidism Conjugated hyperbilirubinemia - Decreased excretion/reuptake of bilirubin o Inherited disorders: Dubin-Johnson syndrome, Rotor syndrome, and progressive familial intrahepatic cholestasis) - Intrahepatic cholestasis o Liver disease (e.g., hepatitis or cirrhosis) o Primary biliary cholangitis o Drugs (e.g., estrogens, arsenic) o Postoperative cholestasis: precipitated by hypotension/massive blood loss with subsequent hepatic ischemia requiring transfusions o Sepsis o Pregnancy o Infiltrative process (e.g., tuberculosis, sarcoidosis, and amyloidosis) - Extrahepatic cholestasis (biliary obstruction) o Choledocholithiasis o Inflammatory processes (e.g., primary sclerosing cholangitis, acute and chronic pancreatitis, and abscesses) o Malformations of the bile ducts (e.g., postoperative/inflammatory strictures, and biliary cysts) o Parasitic infection (e.g., liver flukes) o Postoperative bile leaks or biliary duct strictures o Tumors (pancreatic cancer, cholangiocellular carcinoma, gallbladder cancer) A malignancy of the pancreas. Most common type is ductal adenocarcinoma, often located in the pancreatic head. Usually asymptomatic in early stages, then presents with belt-like epigastric pain that radiates to the back, jaundice, weight loss, and a painless, enlarged gallbladder. Risk factors include smoking, high alcohol consumption, and chronic pancreatitis. Amboss: jaundice and cholestasis 63

Baby with projectile vomiting and urge to drink (feeling hungry). What is the diagnosis? A- pyloric stenosis

: A he classic presentation of infantile hypertrophic pyloric stenosis (IHPS) is the three- to six- week-old infant who develops immediate postprandial vomiting that is nonbilious and forceful (often described as "projectile" vomiting). The infant then demands to be re-fed soon afterwards (a "hungry vomiter"). UpToDate: infantile hypertrophic pyloric stenosis 75

Smoker patient has chronic GERD. An upper scope was done, and it showed high grade dysplasia. What is next? A- refer for possible esophagectony B- follow up by scope after 6 months C- chemo/radio

: A (the better A, is endoscopic eradication therapy but esophagectomy works) Most patients with high-grade dysplasia or intramucosal carcinoma should undergo endoscopic eradication therapy with the goal of removing all of the dysplastic and metaplastic tissue. Generally, esophagectomy is no longer used as first-line treatment for dysplasia, but only in special circumstances, such as in patients unwilling to accept the uncertainties regarding the long-term results of endoscopic eradication therapy. UpToDate: Barrett's esophagus: Surveillance and management 6

Esophageal adenocarcinoma treatment: A- resection

: A Curative Indication Locally invasive disease that has not invaded surrounding structures High-grade metaplasia in Barrett syndrome Methods Neoadjuvant chemoradiation For downstaging → potentially allows for later resection As definitive treatment in patients with proven complete response (e.g., during endoscopy) Surgical resection Endoscopic submucosal resection for removal of superficial, epithelial lesions Subtotal or total esophagectomy with gastric pull-through procedure or colonic interposition Palliative Indication: patients with advanced disease (majority of patients) Methods: Chemoradiation Stent placement Other endoscopic treatments (e.g., laser therapy) Amboss: esophageal cancer 68

Patient with bloody stained nipple discharge, you're suspecting intraductal papilloma. What is the next step? A- Excision

: A if there are no diagnostic choices Definition: solitary or multiple benign lesions that arise from the epithelium of breast ducts Etiology: unknown Epidemiology Peak incidence: 40-50 years Solitary lesions: ∼ 48 years Multiple lesions: ∼ 41 years Clinical features Solitary lesions Most common cause of bloody nipple discharge Large, central lesion Palpable breast tumor close to or behind the nipple Multiple lesions Usually asymptomatic but may cause nipple discharge in rare cases Peripheral lesions

Diabetic patient with left lateral malleolar ulcer. What investigation would you order? A- venous duplex of affected leg B- CT angiography C- bilateral venous duplex

: B The only hint in the question is that this patient has diabetes, and the A,s provided are aiming at either venous or arterial causes of ulcer. Therefore, I believe the question is aiming at peripheral artery disease. Ankle-brachial index (ABI): First-line diagnostic test (high specificity and sensitivity) Imaging: While vascular imaging is not necessarily required for diagnosis, it is useful to determine the site ad severity of arterial stenosis or occlusion (especially preoperatively and postoperatively) Color-coded duplex ultrasonography Digital subtraction angiography (DSA): gold standard CT angiography MR angiography Oscillography The only modality is the A,s is CTA, so I think it's the A, UpToDate: Clinical features and diagnosis of lower extremity peripheral artery disease - Approach to the differential diagnosis of leg ulcers Amboss: Peripheral arterial disease 44

A pregnant woman, G2 P1+0, in her 10th week of gestation. She had gallstones for years and is on medication. Now, she is having pain. When to do cholecystectomy? A- 1st trimester B- 2nd trimester C- 3rd trimester

: B - Laparoscopic cholecystectomy can be offered to women in any trimester requiring cholecystectomy, although it is technically more challenging near term - If recurrent bouts of biliary colic occur, we feel that primary surgical management during pregnancy is reasonable because recurrence is common with conservative therapy and surgical therapy appears to be safe for mother and fetus. For these women, cholecystectomy is ideally performed in the second or early third trimester. - The decision to offer cholecystectomy for biliary colic during pregnancy is based upon the clinical scenario, gestational age, and other factors. o For pregnant patients with a first episode of biliary colic, we suggest initial supportive care. If symptoms of biliary colic (pain, nausea/vomiting) cannot be controlled with dietary manipulation, surgery should be offered. o For patients with recurrent bouts of bothersome pain, or who are unable to gain weight at an acceptable rate due to the symptoms, cholecystectomy is reasonable. o If biliary colic occurs near term, we avoid cholecystectomy and reevaluate the patient after delivery. We generally wait six weeks following delivery to allow the mother to recover from the delivery, bond with the infant, and regain her strength. UpToDate: gallstones in pregnancy 35

75 years old male with back pain and urinary symptoms (obstructive). His alkaline phosphatase is high, and PSA is 80. what is the most likely Dx A- BPH B- prostate cancer

: B - Pain is the most common manifestation of bone metastases. Pain from bone metastases is typically insidious at onset and slowly increases in severity over weeks to months. However, there are exceptions, such as a pathologic fracture or the sudden onset of back pain that accompanies the collapse of a cancer-containing vertebral body. Although bone pain due to metastasis is commonly described as aching (such as a toothache), nerve root entrapment, a common complication associated with vertebral metastases, may cause a burning and/or radiating type of pain. - The most common abnormal laboratory findings observed in men with bone metastatic prostate cancer are a rising serum prostate-specific antigen (PSA) level, an elevation in serum alkaline phosphatase, and anemia. However, these laboratory abnormalities are not useful in either establishing or ruling out the diagnosis of bone metastasis in men with prostate cancer. UpToDate: Bone metastases in advanced prostate cancer: Clinical manifestations and diagnosis 26

Female, in reproductive age, came by an ambulance post RTA. What is the 1st thing you have to do? A- check for pregnancy B- ABC

: B A clear, simple, and organized approach is needed when managing a severely injured patient. The primary survey promulgated in Advanced Trauma Life Support™ (ATLS™) provides such an approach. The primary survey consists of the following steps: Airway assessment and protection (maintain cervical spine stabilization when appropriate) Breathing and ventilation assessment (maintain adequate oxygenation) Circulation assessment (control hemorrhage and maintain adequate end-organ perfusion) Disability assessment (perform basic neurologic evaluation) Exposure, with environmental control (undress patient and search everywhere for possible injury, while preventing hypothermia) UpToDate: Initial management of trauma in adults 72

Patient post cholecystectomy on day 8 (or 9) develops right mouth corner pain and fever 38.5oC. What is the management? A- Paracetamol B- Antibiotic C- CT

: B Acute infection of the parotid gland can be caused by a variety of bacteria and viruses. Acute bacterial suppurative parotitis is caused most commonly by Staphylococcus aureus and mixed oral aerobes and/or anaerobes. It often occurs in the setting of debilitation, dehydration, and poor oral hygiene, particularly among elderly postoperative patients. Suppurative parotitis is characterized by the sudden onset of firm, erythematous swelling in the preauricular area, over the parotid gland, sometimes extending to the angle of the mandible. This is associated with exquisite local pain and tenderness, and there may be complaints of trismus and dysphagia. Erythema was present in only 30 percent of cases initially in one series. Systemic findings of high fevers, chills, and marked toxicity may be present, but one series reported that only 31 percent of patients had fever and 34 percent had leukocytosis. Initial treatment of suppurative parotitis includes hydration and intravenous antibiotics. Since suppurative parotitis may potentially spread to deep fascial spaces of the head and neck and is potentially life-threatening, outpatient management with oral antibiotics is not advised. Surgical incision and drainage should be implemented if there is no clinical response after 48 hours of treatment with empiric intravenous antibiotics. UpToDate: Suppurative parotitis in adults 42

Diabetic and hypertensive patient with BMI>40 (you are given the weight and height to calculate the BMI). He tried to reduce his weight. Alas, his tries are in vain. He is not on medications. What's next? A- Medications to reduce weight B- Sleeve surgery C- Diet D- Exercise

: B Candidates for bariatric surgery include adolescents and adults with a BMI ≥40 kg/m2, or a BMI of 35 to 39.9 kg/m2 with at least one serious comorbidity, who have not met weight loss goals with diet, exercise, and drug therapy UpToDate: Obesity in adults: Overview of management 3

Child tripped on a toy and fell on the right leg. His leg was trapped within the toy, and he is complaining of pain. what type of fracture do you expect? A- Spiral facture of femur B- Spiral fracture of tibial C- Hairline fracture

: B Children with toddler's fractures typically present with limp or failure to bear weight on an extremity after minor trauma, such as tripping or falling a short distance. The mechanism usually suggests rotational force through the tibia with the foot and ankle fixed. Riding down slides on another person's lap has been shown to be a risk factor for injuries of the lower leg, including toddler's fractures. Occasionally, no history of trauma is elicited, but onset of symptoms should be acute. History of subacute, or insidious onset of extremity pain or limp should broaden the differential to include inflammatory disorders or malignancy. JUCM: An Updated Approach to Toddler Fractures 15

Young patient with breast lump. On examination, an oval mass with smooth surface 2*2cm. what is the most likely diagnosis? A- fibroadenoma B- cyst C- breast cancer

: B Cyst: Simple cysts are very common with a prevalence of 50 to 90 percent. They are fluid- filled, round, or ovoid masses derived from the terminal duct lobular unit. Breast cysts can present as breast masses or mammographic abnormalities. Cysts are common in women between 35 and 50 years old. Acute enlargement of cysts may cause severe, localized pain of sudden onset. Fibroadenoma: Fibroadenomas are the most common benign tumor in the breast, accounting for one half of all breast biopsies. Simple fibroadenomas are benign solid tumors containing glandular as well as fibrous tissue. Fibroadenomas usually present as a well-defined, mobile mass on physical examination or a well-defined solid mass on ultrasound. Breast cancer: The "classic" characteristics of a cancerous lesion include a hard, immovable, single dominant lesion with irregular borders. However, these features cannot reliably distinguish a benign from a malignant tumor. UpToDate: overview of benign breast disease, Clinical features, diagnosis, and staging of newly diagnosed breast cancer 31

What is the most important thing to do before reduction of fracture? A- Check vascular status (pulse) B- Give analgesia

: B In cases of neurologic or vascular compromise, immediate closed reduction of any displaced fracture should be performed. Persistent deficits despite reduction mandate emergent referral to an appropriate surgeon, or transfer if such care is unavailable. Should no emergent conditions exist, immediate reduction is not required. Adequate anesthesia must be obtained prior to reduction. UpToDate: Distal radius fractures in adults 19

Child with vascular malformation in the lower limb. What symptom is indicative for intervention? A. Pain B. Claudication

: B Indications for intervention — Repair of AVF is indicated for patients with: - Clinical symptoms related to the AVF including: o Arterial steal from significant diversion of blood into the venous system manifested by claudication or distal limb ischemia o Significant edema or venous insufficiency due to venous hypertension o Heart failure in instances of high-flow fistula - Progressive enlargement under ultrasound surveillance - Large AVF following stab, gunshot, or other projectile injury - Iatrogenic AVFs that do not seal spontaneously (generally accepted duration is AVF that persists for greater than one year) UpToDate: Acquired arteriovenous fistula of the lower extremity 73

15 years old patient with scrotal pain and absent cremasteric reflex. What is the diagnosis? A- Varicocele B- Testicular torsion C- Epididymitis D- Indirect hernia

: B The clinical features of testicular torsion include the acute onset of moderate to severe testicular pain with profound diffuse tenderness and swelling and a negative cremasteric reflex on physical examination. The classic finding is an asymmetrically high-riding testis with its long axis oriented transversely instead of longitudinally related to shortening of the spermatic cord from the torsion ("bell clapper deformity"). UpToDate: evaluation of acute scrotal pain in adults 37

Diabetic patient presents with lateral malleolar ulcer. He has reduced pulse. What to do? A- Duplex affected leg B- Duplex both legs C- CT angiography

: C There is diabetes which is suggestive of either arterial or neuropathic, and the pulses are reduced which is suggestive of arterial. Besides, the A,s provided are aiming at either venous or arterial causes of ulcer. Therefore, I believe the question is aiming at peripheral artery disease. Ankle-brachial index (ABI): First-line diagnostic test (high specificity and sensitivity) Imaging: While vascular imaging is not necessarily required for diagnosis, it is useful to determine the site ad severity of arterial stenosis or occlusion (especially preoperatively and postoperatively) Color-coded duplex ultrasonography Digital subtraction angiography (DSA): gold standard CT angiography MR angiography Oscillography The only modality is the A,s is CTA, so I think it's the A, UpToDate: Clinical features and diagnosis of lower extremity peripheral artery disease - Approach to the differential diagnosis of leg ulcers Amboss: Peripheral arterial disease 45

Diabetic patient presents with lateral malleolar ulcer. His pulse is intact. What to do? A- Duplex affected leg B- Duplex both legs C- CT angiography

: C There is diabetes which is suggestive of either arterial or neuropathic. However, the pulse is preserved and nothing in the A,s is pointing at neuropathic. Therefore, I believe the cause is venous insufficiency. Test of choice: duplex ultrasonography - Presence of venous reflux confirms diagnosis of CVI (Retrograde flow lasting > 0.5 seconds.) - Examine patency of deep vein - Examine sufficiency of superficial and perforating veins UpToDate: Clinical features and diagnosis of lower extremity peripheral artery disease - Approach to the differential diagnosis of leg ulcers Amboss: Chronic venous disease 46

Case of acute appendicitis. Fecalith and abscess are seen on CT. What is the management? A- open Appendectomy and drainage B- laparoscopic appendectomy and drainage C- percutaneous drainage

: C - If imaging studies demonstrate an intra-abdominal or pelvic abscess, computed tomography- or ultrasound-guided drainage can often be performed percutaneously or transrectally. Studies suggest that percutaneous drainage of appendiceal abscesses results in fewer complications and shorter overall length of stay than surgical drainage. It also allows inflammation to subside before appendectomy, thereby negating the need for a more extended bowel resection (eg, ileocecectomy) in some cases. - Patients with a small (≤3 cm) appendiceal abscess may undergo immediate appendectomy. Larger (>3 cm) abscesses should be treated with intravenous antibiotics and percutaneous drainage first, although immediate appendectomy is required if the abscess is not amenable to percutaneous drainage. The size is deciding factor whether go for immediate appendectomy or percutaneous drainage first. However. I believe the question was aiming at percutaneous drainage since it is debatable whether you go with laparoscopic or open appendectomy UpToDate: management of acute appendicitis in adults 21

Young male with right lower abdominal pain and tenderness and low grade fever. On abdominal x-ray, radioopaque material was seen (small at iliac crest site). What is the management? A- urgent urology consultation B- non contrast CT C- appendectomy

: C - On abdominal radiograph or CT, a high attenuation stone may be seen in the right iliac fossa. CT is more sensitive than plain film. Up to 25% show laminated calcification. - Abdominal pain is the most common symptom and is reported in nearly all confirmed cases of appendicitis, right lower quadrant (right anterior iliac fossa) abdominal pain. - The early signs of appendicitis are often subtle. Low-grade fever reaching 101.0°F (38.3°C) may be present. The physical examination may be unrevealing in the very early stages of appendicitis since the visceral organs are not innervated with somatic pain fibers. However, as the inflammation progresses, involvement of the overlying parietal peritoneum causes localized tenderness in the right lower quadrant and can be detected on the abdominal examination. UpToDate: Acute appendicitis in adults: Clinical manifestations and differential diagnosis Radiopaedia: appendicolith 27

Patient with deep wound 10 cm in front of the thigh. What's your best next step? A. tourniquet at level of the femoral B. tourniquet above wound level C. apply good pressure at wound site D. call vascular surgery doctor

: C External control of any visible hemorrhage should be achieved promptly while circulating volume is restored. For open wounds with ongoing bleeding, manual compression should be done with a single 4 × 4 gauze and a gloved hand. Covering the wound with excessive dressings may permit ongoing unrecognized blood loss that is hidden underneath the dressing. Blind clamping of bleeding vessels should be avoided because of the risk to adjacent structures, including nerves. This is particularly true for penetrating injuries of the neck, thoracic outlet, and groin, where bleeding may be torrential and arising deep within the wound. In these situations, a gloved finger placed through the wound directly onto the bleeding vessel can apply enough pressure to control active bleeding. The surgeon performing this maneuver must then walk with the patient to the OR for definitive treatment. For bleeding of the extremities, it is tempting to apply tourniquets for hemorrhage control, but digital occlusion will usually control the bleeding

Trauma patient in hospital. When to give him vaccine for pneumococcal conjugate? A. 2 days B. 1 week C. 2 weeks

: C Patients with impaired splenic function are at risk for severe and overwhelming infections with encapsulated bacteria (eg, Streptococcus pneumoniae), bloodborne parasites, and other infections that the spleen plays an important role in controlling. Key measures for preventing such infections include patient and family education, vaccination against encapsulated bacteria and influenza, and use of prophylactic antibiotics. most patients with impaired splenic function require: - The 13-valent pneumococcal conjugate vaccine (PCV13) followed by the 23- valent pneumococcal polysaccharide vaccine (PPSV23) ≥8 weeks later - Others For patients undergoing emergency splenectomy, vaccine series should be started 14 days after splenectomy. If vaccinations were given prior to postoperative day 14, it is reasonable to repeat these vaccinations eight weeks after the initial doses were given. UpToDate: Prevention of infection in patients with impaired splenic function 79

Which of the following is a hard sign of penetrating injury: A- Weak pulse B- Skin color change C- bruit

: C Penetrating neck trauma hard signs: - Expanding hematoma - Severe active bleeding - Shock not responding to fluids - Decreased or absent radial pulse - Vascular bruit or thrill - Cerebral ischemia - Airway obstruction In case of presence of hard signs: o Immediate intubation and surgical exploration: in cases with hemodynamic instability, expanding hematoma, or clear signs of tracheal/esophageal injury o Emergency tracheostomy: if integrity of larynx is in question Penetrating trauma to the extremities' hard signs: - Hard signs of arterial injury include active hemorrhage, expanding or pulsatile hematoma, bruit or thrill over the wound, absent distal pulses, and extremity ischemia. - Patients exhibiting 'hard signs' of arterial injury: urgent surgical exploration, hemorrhage control, and repair Amboss: Penetrating trauma 18

Patient after pancreatitis episode develops upper GI bleeding. Scope was done, and a gastric fundus bleeding was found. Duplex ultrasound showed splenic vein thrombosis with patent portal vein, sclerotherapy was done. what is next in management? A-Portocaval shunt B-Distal spleen renal shunt C- Splenectomy

: C Splenic vein thrombosis: Can occur in 10% of patients with chronic pancreatitis Pathophysiology: inflammation of the splenic vein → thrombus formation → left-sided portal hypertension → gastric varices Clinical features: can present with upper GI bleeding, ascites, and splenomegaly Diagnosis: ultrasound with doppler, CT/MR angiography Treatment Acute: anticoagulation and/or thrombectomy Chronic and symptomatic: splenectomy Amboss: Chronic pancreatitis - complications - splenic vein thrombosis 10

Advanced breast cancer that is fixed unilaterally. the breast mass is involving the skin. What is the next step in management? A- bone scan B- CXR C- core biopsy D- excisional biopsy

: C The diagnostic approach involves clinical assessment, radiographic imaging, and biopsy. Clinical assessment: Certain constellations of patient characteristics should raise suspicion for malignancy in a breast lump, warranting further assessment. Radiographic imaging: Mammography: Although mammography does not confirm the diagnosis, it is primarily useful for early detection of breast abnormalities! Breast ultrasound: - Distinguish between solid lesions and benign cysts - Evaluate axillary, supraclavicular, and infraclavicular lymph nodes - Provide guidance in interventional procedures (fine needle aspiration, core needle biopsy) Biopsy: - Core needle biopsy (CNB): confirms the diagnosis (preferred test) and can distinguish between noninvasive and invasive carcinoma based on histology

Known diabetic and hypertensive patient presents with lateral malleolar ulcer. His pulses are preserved. What to do? A. CTA B. MRA C. Conventional angiography D. Venous duplex US

: D There is diabetes which is suggestive of either arterial or neuropathic. However, the pulse is preserved and nothing in the A,s is pointing at neuropathic. Therefore, I believe the cause is venous insufficiency. Test of choice: duplex ultrasonography - Presence of venous reflux confirms diagnosis of CVI (Retrograde flow lasting > 0.5 seconds.) - Examine patency of deep vein - Examine sufficiency of superficial and perforating veins UpToDate: Clinical features and diagnosis of lower extremity peripheral artery disease - Approach to the differential diagnosis of leg ulcers Amboss: Chronic venous disease 43

Patient presented with irritability and bloating 3 days after undergoing gastric sleeve. What to do? A- upper endoscopy B- laparotomy C- stool analysis D- reassurance

: D I checked for irritability and bloating as complications of gastric sleeve and no reference mentioned them. Here are the complications that require medical attention according to UpToDate: Bleeding — Bleeding can occur from the gastric or short gastric vessels during dissection of the greater curve. Most of the bleeding problems associated with SG occur from the staple line after transection of the stomach Stenosis — Narrowing or stenosis can create gastric outlet obstruction. The presentation varies depending on the severity of the obstruction and can include dysphagia, vomiting, dehydration, and the inability to tolerate an oral diet. The gastroesophageal junction and the incisura angularis are the two most common areas where stenosis occurs, and this can be diagnosed by an upper gastrointestinal series. Gastric leaks — Gastric leaks after SG are one of the most serious complications and can occur in up to 5.3 percent of patients. Most leaks are due to local factors at the site of the staple line, such as inadequate blood supply and oxygenation, which impede the healing process. Leaks can also be due to gastric-wall heat ischemia, a consequence of the heat generated by the cautery used during dissection of the greater curve. Although the blood supply to the stomach is robust, the gastroesophageal junction tends to be an area of decreased vascularity and thus more prone to leaks. Additionally, the stomach tends to be thinner at the angle of His, and some authors suggest that the large staple height used by many surgeons may not adequately seal this area of the stomach Reflux — Gastroesophageal reflux after SG presents with classic symptoms such as burning pain, heartburn, and regurgitation. It can occur as an early and late complication. UpToDate: Late complications of bariatric surgical operations 41

Patient presented with pain during and after bloody defecation. What is the diagnosis? A- Hemorrhoids B- Anal fistula C- Anal fissure D- Abscess

: Not enough information to decide They most probably were aiming for anal fissure since the question was focusing on pain in relation to defecation (and it is the A, that was given with the question). However, it is still not enough to say for certain that it is anal fissure. Nevertheless, here is the clinical manifestation of each A,: Anal fistula: - Patients with an anorectal fistula usually present with a "nonhealing" anorectal abscess following drainage, or with chronic purulent drainage and a pustule-like lesion in the perianal or buttock area. Patients experience intermittent rectal pain, particularly during defecation, but also with sitting and activity. Patients may also experience intermittent and malodorous perianal drainage and pruritus Abscess: - Patients with an anorectal abscess often present with severe pain in the anal or rectal area. The pain is constant and not necessarily associated with a bowel movement. Constitutional symptoms such as fever and malaise are common. Purulent rectal drainage may be noted if the abscess has begun to drain spontaneously. - On physical examination, an area of fluctuance or a patch of erythematous, indurated skin overlying the perianal skin may be noted in patients with a superficial (eg, perianal) abscess. Patients with a deeper (eg, supralevator) abscess, however, may not have any physical findings on external examination, and the abscess can only be felt via digital rectal examination or by imaging. Hemorrhoids: - proximately 40 percent of individuals with hemorrhoids are asymptomatic. Symptomatic patients usually seek treatment for hematochezia, pain associated with a thrombosed hemorrhoid, perianal pruritus, or fecal soilage. - Hemorrhoidal bleeding is almost always painless and is usually associated with a bowel movement, although can be spontaneous. The blood is typically bright red and coats the stool at the end of defecation or may drip into the toilet. Occasionally, bleeding can be copious and can be exacerbated by straining. In rare cases, chronic blood loss can cause iron deficiency anemia with associated symptoms of weakness, headache, irritability, and varying degrees of fatigue and exercise intolerance Anal fissure: - Patients with an acute anal fissure present with anal pain that is often present at rest but is exacerbated by defecation. Pain that intensifies with defecation often lasts for hours following the act, which is a debilitating symptom. Although anal pain is the cardinal symptom of a fissure, anal fissures can also be associated with anal bleeding (usually hematochezia). Anal fissures are often misdiagnosed as hemorrhoidal disease due to both diagnoses being so common, and due to shared signs and symptoms. A thorough physical examination helps to differentiate these two problems from one another. The hallmark symptom of anal fissures is pain, usually of a severe degree and almost always exacerbated by defecation. Hemorrhoids can be associated with discomfort, though unless a thrombosed external hemorrhoid is present, the discomfort is milder and less related to defecation. Internal hemorrhoids do not typically cause discomfort, though they can be associated with anal bleeding, as can anal fissures. UpToDate: Anal fissure: Clinical manifestations, diagnosis, prevention - Anorectal fistula: Clinical manifestations, diagnosis, and management principles - Hemorrhoids: Clinical manifestations and diagnosis - Perianal and perirectal abscess 39

Case scenario of intussusception. What is the gold standard investigation? A- barium enema

: US is the method of choice to detect intussusception. Enema has both diagnostic and therapeutic value. - Ultrasonography is the method of choice to detect intussusception. A "bull's eye" or "coiled spring" lesion is seen, representing layers of the intestine within the intestine - Typical presentation — Patients with a typical presentation (eg, infant or toddler with sudden onset of intermittent severe abdominal pain with or without rectal bleeding) or characteristic findings on radiography or ultrasound, may proceed directly to nonoperative reduction using hydrostatic (contrast or saline) or pneumatic (air) enema, performed under either sonographic or fluoroscopic guidance. In these cases, the procedure is both diagnostic and therapeutic. - Atypical presentation — For many other patients, the diagnosis is unclear at presentation, especially in children who are younger or older than the typical age group for intussusception. In this case, initial workup may include abdominal ultrasound or abdominal radiographs, provided that these studies do not significantly delay the definitive treatment of intussusception. If the ultrasound supports the diagnosis of intussusception, nonoperative reduction is then performed, provided that the child has normal vital signs and no signs of peritonitis UpToDate: Intussusception in children 60

Unilateral neck mass in the right side. Investigations showed hot thyroid nodule, and the rest is cold thyroid. There is no LN enlargement. What is the treatment? A-Total thyroidectomy

: further investigations are required to determine the appropriate management for the cytology: TREATMENT Well-differentiated cancers: Surgical management: primary treatment of choice (see thyroid surgery) Intrathyroidal tumor < 1 cm: hemithyroidectomy Intrathyroidal tumor 1-4 cm: hemithyroidectomy or total thyroidectomy Intrathyroidal tumor > 4 cm, extrathyroidal spread, or metastasis: total thyroidectomy with neck dissection Evidence of regional lymph node spread: therapeutic neck dissection Postoperative management Radioiodine therapy : often conducted 4-6 weeks after surgery to destroy remaining thyroid tissue or metastases Thyroid hormone therapy with L-thyroxine after thyroidectomy TSH suppression Reduces the risk of stimulating remaining malignant tissue Administer the highest possible dose (according to the patient's tolerance) Only administer after radioiodine therapy! Poorly differentiated cancers: Total thyroidectomy with adjuvant radiochemotherapy if operable Radiochemotherapy if locally advanced, inoperable Amboss: thyroid nodules - thyroid cancer 71

Breast feeding mother's nipple is inverted and slit like. What is the most likely diagnosis? A- Ductal ectasia B- Breast cancer

: insufficient information to differentiate between the 2 The A, given by the question writer was (A) so here is the clinical features of ductal ectasia: Unilateral greenish or bloody discharge Nipple inversion Firm, stable, painful mass under the nipple (may mimic breast cancer) May progress to a breast abscess Amboss: benign breast conditions 33

Elderly patient with sacral ulcer. What is the management? A- Debridement and skin graft B- Primary closure (I think dressing was one of the choices)

: need more info to determine the choice of treatment - Stage 1 skin injuries can be covered with transparent film for protection. The development of a stage 1 pressure injury should be taken as an indication that the patient is at high risk for more serious ulcer development, and intensive preventive measures should be taken. - Stage 2 pressure injuries require a dressing that maintains a moist wound environment [37]. These wounds generally require little debridement, and thus we avoid wet-to-dry dressings. Rather, we use a semiocclusive (transparent film) or occlusive dressings (hydrocolloids or hydrogels) so that any necrotic tissue that is present is digested by enzymes normally present in the wound base

Patient with right and left intrahepatic ducts dilatation and small gallbladder. What's the most likely diagnosis? A- Klatskin tumor

: need more info to determine the exact diagnosis Other differentials: - Hepatocellular carcinoma - Ampullary carcinoma - Pancreatic carcinoma - Choledocholithiasis - Cholangitis As for Klatskin tumor (hilar cholangiocarcinoma), this is the approach: UpToDate: Clinical manifestations and diagnosis of cholangiocarcinoma BMJ: Cholangiocarcinoma 5

Patient with continuous vomiting, and he is dehydrated. X ray shows multiple air fluid levels. on examination, there is swelling in the groin that is distended and tender on touch. What is the diagnosis? A. Strangulated hernia B. obstructed hernia

: the information given is not enough to decide but I believe B is closer For patients who present with nausea, vomiting, and abdominal distention associated with a history of groin pain or mass, bowel obstruction due to bowel incarceration or strangulation should be suspected. For most patients with incarcerated hernia and/or strangulation, additional imaging is generally not necessary prior to surgical exploration and repair. For patients with clinical features of bowel obstruction in whom the diagnosis of groin hernia is not clear and who do not have indications for immediate surgical exploration, CT is generally more useful than ultrasound. Although obtaining CT scan may not alter the management plan for exploration and repair, it may add valuable information concerning the organs involved or the extent of bowel strangulation. Strangulated hernias are differentiated from incarcerated hernias by the following: - Pain out of proportion to examination findings - Fever or toxic appearance - Pain that persists after reduction of hernia Intense pain is suggestive of strangulation with ischemic bowel. UpToDate: Classification, clinical features, and diagnosis of inguinal and femoral hernias in adults Medscape: Abdominal Hernias Clinical Presentation 81

Case of distended abdomen and vomiting. There is a picture of obstruction. What is the diagnosis? A- volvulus B- ischemia C- ulcerative colitis D- Crohn's disease

: the question depends on the picture and it wasn't provided, and they A,ed (A) This is a picture of sigmoid volvulus: https://radiopaedia.org/cases/sigmoid-volvulus-13 13

Ankylosis spondylitis or cervical disc prolapse best investigation? A- CT B- MRI

: there are 2 different disorders with 2 different imaging modalities Cervical disc prolapse: MRI or CT for foraminal compression Ankylosing spondylosis: X-ray of the cervical spine (not in the choices) For ankylosing spondylitis: Definite changes on plain (conventional) radiography are characteristic of AS, while patients with nr-axSpA by definition exhibit normal or minimally abnormal radiography of the SI joints but may have abnormal MRI findings (eg, bone marrow edema [BME]) of the joints that support the diagnosis of axSpA. Radiographic findings of the sacroiliac (SI) joints range from subtle joint-space narrowing and sclerosis to erosive change and may eventually result in bony ankylosis (fusion). Radiographic changes may also occur in the spine, particularly in patients with AS. For cervical disc prolapse: A radiculopathy is a pathologic process affecting the nerve root with clinical manifestations that may include pain, motor and sensory symptoms, and reflex change. Most radiculopathies arise from nerve root compression. The two predominant mechanisms of compressive cervical radiculopathy are cervical spondylosis and disc herniation. Some causes of nondegenerative radiculopathy include infection (especially herpes zoster and Lyme disease), nerve root infarction, infiltration by tumor, infiltration by granulomatous tissue, root avulsion, and demyelination. Magnetic resonance imaging (MRI) is currently the study of choice in most patients for the initial neuroimaging evaluation of the cervical spine. Computed tomography (CT) myelography is the traditional "gold standard" for the diagnosis of foraminal compression and remains superior to MRI in the distinction of osteophyte from soft tissue material. Flexion and extension plain films are important in the setting of trauma and/or myelopathy, and are helpful to evaluate for possible spondylolisthesis. Imaging studies of the cervical spine may be completely normal in nondegenerative radiculopathy. UpToDate: Clinical features and diagnosis of cervical radiculopathy - Clinical manifestations of axial spondyloarthritis (ankylosing spondylitis and nonradiographic axial spondyloarthritis) in adults 47

Patient, recovered from acute pancreatitis episode, presents 6 weeks after with vomiting, epigastric fullness, and no fever. CT is done, and it shows cystic collection behind the pancreas. What is the most likely diagnosis? A-Pseudo cyst B-Pancreatic abscess C-Pancreatic necrosis

: A UpToDate: Clinical manifestations and diagnosis of acute pancreatitis 9

Patient with a stab wound. What to do next? A- Local wound exploration

: A Approach to penetrating abdominal trauma History: details such as number of shots heard, amount of blood loss at the scene of injury, and position of patient when shot or stabbed Preliminary assessment and care Prehospital and hospital trauma care Resuscitative and stabilization procedures (e.g., rapid transfusions, CPR) indicated if the patient is hemodynamically unstable Tetanus prophylaxis Broad spectrum antibiotic prophylaxis Analgesics, anxiolytics Surgical management Emergency exploratory laparotomy indicated in Evisceration Signs of peritonitis Hemodynamic instability Bleeding detected in nasal tube or rectal examination Penetrating object still in situ (risk of precipitous hemorrhage on removal) Free air under the diaphragm Assess for peritoneal or retroperitoneal penetration and intra-abdominal bleeding FAST exam CT/MRI imaging Local wound exploration Diagnostic peritoneal lavage (DPL) Diagnostic laparoscopy Conservative management Indications: surgical treatment not required Measures Close monitoring of vital signs Serial physical examinations Blood analysis to monitor hemodynamic state Approach to penetrating chest trauma Preliminary assessment and care: See "Preliminary assessment and care" in approach to penetrating abdominal trauma above. Emergency procedures Tube thoracostomy or a needle decompression for tension pneumothorax Placement of an occlusive dressing, taped on three sides, for a sucking chest wound Emergency thoracotomy indicated in Cardiac tamponade Hemodynamically unstable patient Cardiac arrest that occurred at, or after, presentation Unstable patient and/or penetrating object still in-situ Assessment of injury cause and severity Ultrasound (Extended Focused Assessment with Sonography in Trauma, EFAST) Chest x-ray and/or CT if patient is stable Others: echocardiography, endoscopy, bronchoscopy, angiography Further management Close monitoring of vital signs Continual reassessment Appropriate surgical repair after hemodynamic stabilization Approach to penetrating neck trauma Preliminary assessment and care: See "Preliminary assessment and care" in approach to penetrating abdominal trauma above. In case of presence of hard signs: Immediate intubation and surgical exploration: in cases with hemodynamic instability, expanding hematoma, or clear signs of tracheal/esophageal injury Emergency tracheostomy: if integrity of larynx is in question Further management Determine injury extent: CT angiography (best initial test), esophagram, panendoscopy Gunshot wound: conservative or surgical management based on injury extent Stab wounds Patients with no signs of severe vascular or organ injury, can be safely observed Penetrating trauma to the extremeties The approach is based on anatomic location and whether major vessel injury is suspected No major vessels in the vicinity of the tract of the penetrating object: conservative management Stable patients with a penetration tract in the vicinity of major vessels and local signs (pain/tenderness), but no systemic signs of hypovolemia, should undergo further diagnostic testing: Plain x-ray: evaluate extent of bony injury Contrast CT angiography: evaluate vascular injury Doppler ultrasonographic evaluation: evaluate vascular injury in cases with poor renal function, in which contrast CT is contraindicated Patients exhibiting 'hard signs' of arterial injury: urgent surgical exploration, hemorrhage control, and repair In case of combined injury to arteries, nerves and bones: start with stabilization of bone (fracture reduction etc.) → vascular repair → nerve repair Amboss: penetrating trauma 66

Case of abdominal distention, constipation, vomiting. Investigation? A- CT B- US (No Xray in choices)

: A Bedside imaging study — Abdominal ultrasonography may be useful for the diagnosis of small bowel obstruction in patients who cannot undergo CT scanning due to contrast allergies, pregnant patients, and critically ill patients for whom ultrasonography can be performed at the bedside. Ultrasound is also increasingly used in the emergency department to evaluate abdominal pain and to assess for occult hernias, which may be the site of incarcerated small bowel UpToDate: Etiologies, clinical manifestations, and diagnosis of mechanical small bowel obstruction in adults 14

A patient with achalasia. Repeated attempt of balloon expansion was done, yet the patient relapsed again. What is the management? A- myotomy

: A For patients who elect to undergo pneumatic dilation, surgical myotomy or peroral endoscopic myotomy (POEM) can be performed subsequently if symptoms persist despite several attempts at pneumatic dilation UpToDate: overview of the treatment of achalasia 58

Patient who underwent laparoscopic cholecystectomy came with discharge from the middle. What is the management? A- daily dressing B- wound inspect C- exploration

: A Surgical site infection — Wound infection is less common following laparoscopic compared with open procedures

Appendicitis patient 4th day post OP developed diffuse abdominal pain, distension, vomiting and sluggish bowel sounds. Abdominal x-ray showed Multiple air/fluid levels. What is the diagnosis? A- ileus B- adhesions and small bowel obstruction

: A The presentation is suggestive of ileus UpToDate: postoperative ileus 29

Variceal bleeding case. What to give initially after resuscitation? A- Octeotide

: A UpToDate: Methods to achieve hemostasis in patients with acute variceal hemorrhage 8

Where must a 12 years old sit in the car, so he/she can avoid injuries in accidents? A- in the front unrestrained B- in the back restrained C-in a child chair in the back

: B 40

Lymphedema case with intact pulse. What is the investigation? A- MRA B- B- Venous douplex No lymphschintography in choices

: B as an initial investigation Duplex ultrasound should be performed on every patient with lymphedema to assess the patency and competency of the venous system (ie, rule out deep venous thrombosis) and to identify the presence of venous reflux. The grayscale (B-mode) evaluation of tissue layers in the affected limb can also provide information on the etiology, as well as the severity of lymphedema. Cross-sectional imaging using magnetic resonance (MR) or computed tomography (CT) may identify enlarged lymph nodes or other lesions that can cause lymphatic obstruction. MR or CT imaging of the extremity can detect the presence of increased interstitial fluid (honeycomb appearance), but this finding is nonspecific. Common CT findings in patients with lymphedema include thickening of the skin, thickening of the subcutaneous compartment, increased fat density, and thickened perimuscular aponeurosis. Common MR findings include circumferential edema, increased volume of subcutaneous tissue, and marked thickening of the dermis. MR can differentiate the cutaneous edema of lymphedema from other types of limb swelling such as lipedema and phlebedema. Lymphoscintigraphy is the primary imaging test used for diagnosis and functional assessment of the lower extremity lymphatics. Radioactive tracer injected into the dermis in the foot may demonstrate slow or absent lymphatic flow, areas of dermal backflow, and abnormalities of lymphatic uptake. This study can evaluate the larger superficial lymphatic vessels and nodes, but not the deep transport lymph vessels. MR lymphangiography and ICG lymphangiography are used predominantly for mapping prior to surgery, rather than for diagnostic purposes. Identification of patent lymphatic channels is necessary to perform lymphovenous bypass. UpToDate: Lower extremity lymphedema 12

40 years old lady underwent mammogram and US. Mammogram showed fibrous and glandular tissue, and US showed multiple cysts, BIRAD 3. What to do? A- Core biopsy B- Excision biopsy C- Annual screening D- Short duration follow up

: D UpToDate: Breast imaging for cancer screening: Mammography and ultrasonography 32

Treatment of pancreatic pseudocyst 10cm:

: Treatment (Only indicated for symptomatic cysts