WiseMD Summary Questions

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Of the following options, which is the only one without a malabsorptive component? - roux-en-y - jejunoileal bypass - biliopancreatic diversion - laparoscopic gastric binding

laparoscopic gastric binding

Which one is more common: small cell or non-small cell?

non small cell

Signs of dehydration in a baby with pyloric stenosis or in general?

sunken fontanelle, decreased skin turgor, increased thirst, fatigued-appearing, decreased number of wet diapers, charred tongue

What is AVM?

Arterio-Venous Malformation: Arteriovenous malformation (AVM) is an abnormal connection between arteries and veins, bypassing the capillary system. This vascular anomaly is widely known because of its occurrence in the central nervous system, but can appear in any location. Although many AVMs are asymptomatic, they can cause intense pain or bleeding or lead to other serious medical problems. AVMs are usually congenital and belong to the RASopathies. The genetic transmission patterns of AVM, if any, are unknown. AVM is not generally thought to be an inherited disorder, unless in the context of a specific hereditary syndrome.

What does "saccular" mean in the context of aneurysms?

Asymmetrical enlargement. More likely to be caused by infection and trauma.

What findings on an upper gastrointestinal series would most likely confirm a diagnosis of pyloric stenosis?

Before the development of ultrasound, upper GI was considered the "gold standard" for the diagnosis of pyloric stenosis. This requires the baby to be given contrast which will add to the amount of substance in the stomach and sometimes can make aspiration with anesthesia an issue. The finding on upper GI diagnostic of pyloric stenosis are shouldering of the pylorus muscle protruding into the stomach and the "string sign" which is the contrast as it moves through the thickened pylorus muscle.

Which labs should you order for suspected appendicitis?

CBC SMA 7 (electrolytes) LFTs UA b-HCG (pregnancy)

Labs to order for lung cancer?

CBC (WBC, platelets) Electrolytes Serum calcium & alk phos (looking for bone met) ABG (look for hyperemia or hypoxemia)

Difference between deep 2nd degree burn and 3rd degree burn?

Deep 2nd degree: still painful. 3rd degree: usually painless from nerve loss.

Where are direct inguinal hernias found? What are the medial, lateral, and inferior borders of this area?

Direct inguinal hernias are found in Hasselbach's triangle, which is formed by the... - lateral border of the rectus abdominus muscle medially - inferior epigastric vessels laterally - and the inguinal ligament inferiorly.

During a left colectomy for left sided colon cancer, in the retroperitoneum, a firm white band-like tubular structure is seen running cephalad to caudad that shows peristalsis when pinched. What is this structure?

The ureter is a muscular structure running in the retroperitoneum from the kidney to the bladder. During colon resections, it is most frequently injured on the left when transecting the left or sigmoid colon mesentery. It is found just anterior to the psoas and crosses beneath the gonadal artery before going over the iliac vessels. When gently stimulated, it will show peristalsis.

What should be suspected in a patient a decade post-op from bariatric surgery who presents with forgetfulness, peripheral neuropathy, and has a history of frequent vomiting?

Thiamine (B1) deficiency

What kind of skin graft would you use for definitive closure for a burn victim of 80% TBSA?

Thin split thickness skin graft. - Not enough skin left and too big a wound for full thickness - Thick split thickness would lead to prolonged donor site regeneration times and risk of donor site nonhealing - Porcine xenograft and cadaveric allograft are temporary coverings and do not provide permanent wound closure.

Which labs should you order prior to bariatric surgery?

Thyroid levels (screen for hypothyroidism) Micronutrients (assess appropriate replenishment) Glycemic index (assess for DM)

Which of the following diagnostic studies is the most appropriate next step step for a child suspected of having pyloric stenosis? - Abdominal x-ray - Computed tomography of the abdomen - Barium swallow - Ultrasound of the abdomen - Water-soluble upper gastrointestinal series

Ultrasound is the modern gold standard imaging study for the diagnosis of pyloric stenosis. This study can be obtained without need for sedation and is non-invasive. The study evaluates the length and thickness of the pyloric channel. The study may also show large amount of material in the stomach with delayed gastric emptying.

What do you do for severe frostbite patients when they first come in? Assume there are no palpable pulses in the area of frostbite and that there is no detectable Doppler signal.

Urgent angiogram in patients with <24 hours of cold exposure, and tPA and subsequent continuous heparin to restore blood flow. (It is no longer best practice to wait until the area of necrosis to demarcate itself, because now we have interventional radiology.)

Role of imaging technique in identifying colon cancer: Virtual colonoscopy?

Virtual colonoscopy is a newer technique that has shown promise as an alternative to colonoscopy. Colonoscopy, Virtual Colonoscopy, Sigmoidoscopy, and Barium Enema are the most useful, sensitive and specific for evaluating mucosal lesions of the colon.

What might an aneurysm surveillance program entail?

Walking, smoking cessation, statin therapy.

Which of the following thyroid nodule characteristics is concerning for malignancy? a. Distinct borders b. Isoechoic to surrounding thyroid tissue c. Complex with cystic and solid features d. Decreased vascularity e. Presence of microcalcifications

e. Presence of microcalcifications. Discussion: Malignant thyroid nodules typically are hypoechoic to surrounding thyroid tissue. They usually have increased vascularity on Doppler ultrasound. They are usually solid in nature and can have indistinct borders. The presence of microcalcifications should make the examiner more suspicious of an underlying malignancy.

Where is the "olive" mass located in pyloric stenosis?

epigastrium. unlikely appreciated after induction of anesthesia.

If someone presents with a confirmed mesocolon hernia, what is the next step in management?

exploratory laparotamy (double-check)

What is the principle behind the hCG stimulation test?

hCG stimulates testicular Leydig cells to secrete androgens via the LH receptors.

If a woman post-op from roux-en-y gastric bypass presents with abdominal pain and nausea/vomiting without rebound or guarding, no fever, and imaging showing dilated small bowel loops, what is the most likely cause of her symptoms?

internal hernia, such as a transverse mesocolon hernia.

What does "fusiform" mean in the context of aneurysms?

Symmetrical enlargement.

What is a sports hernia?

A "sports hernia" is a musculoskeletal groin injury, not a true hernia.

An 80-year-old man is referred for evaluation of hypercalcemia and an elevated serum parathyroid hormone level. The patient has hypertension and osteoarthritis but no history of gallbladder disease, osteoporotic fractures, or kidney stones. His current medications are amlodipine for mild hypertension and simvastatin for hyperlipidemia. He has a daughter who was also recently found to have hypercalcemia. On physical examination, the patient appears thin and frail. His temperature is 98.6°F (37.0°C), pulse is 72/min, respirations are 12/min, and blood pressure is 136/86 mm Hg. No masses are palpated in the neck. The remainder of the physical examination is unremarkable. Ultrasound of the thyroid shows no abnormalities. A Tc99m-Sestamibi scan of the parathyroid glands shows no uptake. Which of the following is the best next step in management?

A 24-hour urinary calcium measurement should be performed to ensure that the patient has primary hyperparathyroidism. If familial hypercalcemia hypocalciuria is ruled out with the 24-hour urinary test, then the surgeon should discuss with the patient about a bilateral four-gland operation for likely parathyroid hyperplasia versus taking no action at this time and repeating imaging tests in six months or trying a new imaging modality.

What is a Richter's hernia?

A Richter's hernia is a condition in which only a part of the diameter of a hollow viscus is incarcerated, so that complete mechanical bowel obstruction is NOT part of the clinical presentation.

Role of imaging technique in identifying colon cancer: Barium enema?

A barium enema was a commonly used diagnostic study in the past, but is infrequently used today. Colonoscopy, Virtual Colonoscopy, Sigmoidoscopy, and Barium Enema are the most useful, sensitive and specific for evaluating mucosal lesions of the colon.

Role of imaging technique in identifying colon cancer: CXR?

A chest x-ray is routinely performed, but has a high false positive rate for identification of metastatic disease. A CXR is useful for detecting metastatic disease to the lung.

What is a Spigelian hernia?

A hernia through the semilunar line lateral to the rectus muscle is a Spigelian hernia.

What's a KUB? When might you use it?

A kidney, ureter, and bladder (KUB) study is an X-ray study that allows your doctor to assess the organs of your urinary and gastrointestinal systems. Doctors can use it to help them diagnose urinary disorders and causes of abdominal pain. For example: while managing a small bowel obstruction, post-op or non-surgical management.

What is normal phi angle of a gastric band?

A normal gastric band should have a phi angle (angle between the spinal column and the gastric band) of 4°-58°

An abdominal ultrasound is ordered. What pyloric measurements would confirm pyloric stenosis as the most likely diagnosis?

A positive ultrasound for pyloric stenosis shows a pyloric channel greater than or equal to 14 mm and a muscle thickness of greater than or equal to 4 mm. The study may also show significant residual fluid in the stomach as well as delayed gastric emptying.

How would you stage a colon adenocarcinoma that has invaded the subserosa and has spread to 2 of 18 lymph nodes?

T3N1M0 T = Tumor extends through muscular propria but not beyond outermost layer of colon N = Cancer in 1-3 lymph nodes. M = Zero metastases.

If you examine someone whose burn wound hasn't healed after several years, and has increased drainage and friability, how do you proceed in management?

Take a biopsy to make sure that there hasn't been a malignant transformation to squamous cell carcinoma, or Marjolin's ulcer.

Which lung cancer is associated (rarely) with psammoma bodies?

adenocarcinoma, but just the micropapillary subtype. (Just remember that adenocarcinoma is the most "special.")

What kind of nutritional support (route) is best for a burn patient with 70% TBSA?

Enteral nutrition

If you see an irregular mole, what is usually the next best intervention/diagnositic test? - Excisional full-thickness biopsy - Incisional full-thickness biopsy - Shave biopsy - Punch biopsy in the darkest part of the mole - Punch biopsy at the margin of the mole

Excisional full-thickness biopsy

The medial and lateral crus of the aponeurosis of the ___ form the superficial inguinal ring?

External oblique

What's a HIDA scan?

Fancy chemical name, don't memorize. But essentially allows you to take a scan of the body and visualize where the bile ducts.

Four hours after the fracture (in the previous case) has been surgically stabilized, the dorsalis pedis and posterior tibial pulses are palpable. The patient now complains of severe pain in the calf with passive motion of the foot and parasthesia in the foot. The calf is firm and tense on palpation. What is the next most appropriate step in management?

Fasciotomy. Crushing injuries and ischemic tissue beds are prone to the development of compartment syndrome with restoration of perfusion (ischemia/reperfusion injury). The clinician must always have a high index of suspicion for compartment syndrome and be prepared to proceed with immediate decompression by performing a four compartment fasciotomy in the leg.

The lacunar ligament forms the medial border of the...?

Femoral canal, deep to the transversals layer

Where are femoral hernias found? What are the boundaries?

Femoral hernias occur in the femoral canal, which is defined anatomically by... - the lacunar ligament medially, - the femoral vessels laterally, - the inguinal ligament anteriorly, and - Cooper's ligament posteriorly.

Where does fluid tend to go in the abdomen, when you're doing the physical exam?

Flanks (sides) of the abdomen

In addition to physical examination with focused respiratory exam every 6 to 12 months, which of the following surveillance studies is most appropriate to evaluate for recurrent or new cancer?

Follow up for patients with lung cancer includes serial history and physical exam and long term follow up with CT of the chest. - Chest x-ray alone is not sensitive enough to detect early recurrences locally in the lung or in mediastinal nodes. - Bronchoscopy is invasive, expensive and low yield. - Sputum sample collection is not sensitive. - MRI is also inappropriate as it is more costly than CT and less able to provide detailed resolution of the lung.

Which labs might be considered for a pediatric hernia? When might you consider these?

For children who have an underlying condition, are very young, or maybe have an premature baby: - Urinalysis? - hCG and endocrinology evaluation if both testes absent - CBC, electrolytes, and type and screen for emergent cases

An 85-year-old woman is referred for evaluation of incidental hypercalcemia noted on her last physical examination. She reports having persistent fatigue, increasing memory loss, and occasional constipation during the past several months. Laboratory studies: - High serum calcium - Low phosphorus - PTH upper end of normal - High urine calcium - Ultrasound of the neck is normal. - A Tc99m Sestamibi-scan of the parathyroid glands shows no uptake. Most likely dx?

Four hyperplastic parathyroid glands, or primary hyperparathyroidism. Her age and negative imaging studies make parathyroid hyperplasia the most likely cause of her hyperparathyroidism.

Examination shows a 1.5-cm flat, nonpigmented, waxy lesion on the helix of the left ear; obvious excoriation is apparent. Which of the following is the most appropriate next step in management?

Full dermatologic examination followed by biopsy. The lesion signs and symptoms are suspicious for a basal cell carcinoma and a biopsy is needed at this time.

What is the most likely cause of symptoms in a patient who has severe tachycardia, shoulder pain, and hypotension post op from a bariatric procedure?

anastomotic leak

A 67-year-old man has a 4-cm central left lung mass that does not appear amenable to a wedge resection. He reports being able to walk only 40 feet without becoming short of breath. He is unable to walk up one flight of stairs without stopping. Based on his functional status, the maximum amount of surgery he could tolerate is which of the following? a. Pneumonectomy b. Lobectomy c. Nonsurgical therapy d. Bilobectomy e. Tumor debulking

c. For patients who develop dyspnea with ambulation on level ground, and are unable to walk up one flight of stairs, they are typically unable to tolerate lobectomy or any resection greater lobectomy. Debulking is not of any benefit in lung cancer. Non-surgical therapy such as radiation, and/or chemotherapy are the only beneficial treatments in this scenario.

A 71-year-old woman is found to have a 2.5-cm lung nodule in the periphery of the right upper lobe. There is no evidence of lymphadenopathy on computed tomography (CT). Which of the following would be most helpful for obtaining a tissue diagnosis? a. PET scan b. Endobronchial ultrasound-guided biopsy c. CT-guided biopsy d. Sputum cytologic evaluation e. Cervical mediastinoscopy

c. Peripheral nodules are best biopsied percutaneously under image guidance with CT. - Sputum cytology has low sensitivity. - Mediastinoscopy and EBUS ('B' for bronchial!) can provide diagnoses and are useful to assess *mediastinal* nodes, but in a patient with a small *peripheral* nodule and no adenopathy, they are unlikely to provide a diagnosis. - Finally a PET may be suggestive of malignancy if the nodule has increased uptake, but a PET is not diagnostic, and a biopsy is necessary.

What is the difference between communicating versus non-communicating hydrocele?

communicating: Processus vaginalis (PV) is patent on both proximal and distal ends, or only partially obliterated; the peritoneal cavity has continuity with the scrotal sac. non-communicating: PV is only patent on distal end; proximal end is obliterated.

3 components of fast SIRS criteria?

1) altered mental status 2) rapid breathing 3) low blood pressure

What is the differential diagnosis for abdominal distention?

- Air: Obstruction - Fluid: Ascites - Mass: cancer, pregnancy

What is the differential diagnosis for nausea/vomiting?

- Bowel obstruction - gastroenteritis (diarrhea) - gastric outlet obstruction (PUD/cancer) - food poisoning - toxic ingestions

How can you identify portal venous air?

- Branching crows feet air in the periphery of the liver. - Distinguish from biliary air, which is centrally located, and benign.

Role of... CCK? Ghrelin? Secretin? Gastrin? Leptin?

- CCK is released in response to fatty foods entering the duodenum and causes contraction of the gallbladder.("causes contraction of the kallbladder.") - Ghrelin increases gastric emptying. - Secretin stimulates pancreatic secretion of bicarbonate and insulin. - Gastrin stimulates the secretion of gastric acid. - Leptin plays a role in satiety

What are some symptoms associated with the most common presentation of bowel obstruction?

- Crampy, diffuse abdominal pain - Bloating - Nausea/vomiting (bilious) - No BM or passing gas (obstipation) - Possibly prior surgical history - r/u: IBD, cancer (ask about screenings, colonoscopy above age 50, fecal occult blood testing, cardiopulmonary symptoms or smoking)

How can you identify mesenteric venous air?

- Curvilinear air, branching away from inflamed edematous small bowel possibly going into SMV

What are extra labs that could be ordered for suspected bowel obstruction, beyond the essential 4 (CBC, Amylase/lipase, UA, Chem-7)?

- Lactate - ABG

How can you identify air secondary to perforation?

- Thickened loop of small bowel at site of perforation - Feces sign: feculent material within the small bowel - Stranding and mesenteric fluid around site of perforation - Air outside of the lumen

How can you identify ischemic bowel?

- Thickened, non-enhancing bowel, with air in the bowel wall (pneumatosis) - Air both on non-dependent and the dependent surface, so you know that it's in the wall, not just in the lumen.

Bilirubin elevation (direct v. indirect) in... - cholelithiasis - biliary colic - cholecystitis - cholangitis - cholodocolithiasis: - cholangiocarcinoma: - gallstone pancreatitis: - gallstone ileus:

- cholelithiasis: 0 - biliary colic: 0 - cholecystitis: 0 - gallstone pancreatitis: +/- - gallstone ileus: ? - cholangitis: +++ - choledocolithiasis: +++ - cholangiocarcinoma: +++?

Which kinds of cancer do you want to ask about during history taking with a patient suspected of having lung cancer? (to screen for potential sources of mets?)

- colonoscopy for colon cancer - prostate exam for prostate cancer - mammogram for breast cancer

Which body systems do you want to make sure to cover in a physical exam with a patient suspected of having lung cancer?

- neurological (brain mets) - lymph nodes (distant mets) - hepatosplenomegaly (liver mets)

How do you examine ANY abdomen?

1) Inspection 2) light palpation 3) deep palpation 4) looking for special signs 5) percussion if applicable/not too painful for the patient

What imaging studies do you use for suspected bowel obstruction?

1. Abdominal plain film: supine and upright 2. Computed tomography (CT)

What are the four most common causes of small bowel obstruction?

1. Adhesions from prior surgeries 2. Incarcerated hernias 3. Inflammatory Bowel Disease (e.g. Crohn's - spasticity) 4. Cancers

What 4 essential labs should be ordered for a suspected bowel obstruction?

1. CBC (look for high WBC sign of ischemia; hemoconcentration or anemia; platelets for pre-op) 2. Chem-7 (hyporchloremic metabolic acidosis; BUN/creat - renal failure common due to volume depletion) 3. UA (UTI can lead to ileus; kidney stones can mimic bowel obstruction; fluid deficit concentrated urine) 4. Amylase/lipase (pancreatitis can imitate bowel) obstruction

What are you looking for on abdominal plain film with suspected bowel obstruction? (Upright)

1. Differential air-fluid level 2. Absence of air in the colon and rectum 3. "String of beads" sign rule of 3's: 3 cm dilation

What are you looking for on abdominal plain film with suspected bowel obstruction? (Supine)

1. Dilated small bowel 2. Absence of air in the colon and rectum rule of 3's: 3 cm dilation

If you have someone with rhabdomyolisis due to electrical burn, what is the next step in management?

1. Fasciotomy to prevent further necrosis 2. IV fluids + Mannitol to increase excretion of myoglobin 3. Administer IV NaHCO3 to alkalinize the urine to promote excretion of myoglobin

What are you looking for on an abdominal exam when suspecting a bowel obstruction?

1. Inspection: distention with air (central) or fluid (bulging flanks); visible peristalsis; erythema or skin changes; visible hernias; scars (redness, bulges) 2. Auscultation: all four quadrants. high pitched rushes or diminished bowel sounds. Quiet abdomen: 2min 3. Percussion: solid, air (tympany and hyper-resonance), or fluid, peritoneal signs (involuntary guarding) 4. Palpation: light (splenomegaly, hepatomegaly); any masses (LLQ for colon cancer); scar (look for hernias); groin (hernia - ask to bear down); tenderness in area of extended loops 5. Rectal exam: visible exam, then internal. Take occult fecal smear (should be negative)

List order of motor response in GCS.

1. None 2. Decerebrate ( 3. Decorticate posture 4. Withdraws to pain 5. Localizes to pain 6. Normal

List order of verbal response in GCS.

1. None 2. No words, only sounds 3. Words, but not coherent 4. Disoriented conversation 5. Normal conversation

Name 7 steps of appendicitis.

1. Obstruction of the lumen by lymphoid hyperplasia or fecalith 2. Continued mucous production with distention of the appendix 3. Venous obstruction 4. Arterial obstruction 5. Ischemia 6. Gangrene 7. Perforation

What are the three most common causes of ileus (non-mechanical bowel immotility?)

1. Opiates 2. Electrolyte abnormalities 3. Intra-abdominal infections (UTI, or pneumonia)

Name 7 risk factors associated with AAA.

1. Smoking 2. Hypertension 3. Family History of AAA 4. Age > 50 5. Male gender 6. Hypercholesterolemia

What are the three most common causes of large bowel obstruction?

1. Volvulus 2. Diverticulitis/ischemic strictures 3. Colorectal cancer (4. Oglevie's syndrome - orthopedic patients due to narcotic use)

List the order of eye movement responses in GCS.

1. no eye opening 2. eye opening to pain 3. eye opening to verbal command 4. eye open spontaneously

What percent of lung cancers are small cell lung cancer?

14% - third most common, after adeno (38%) and squamous (20%).

A 52 year old man suffers a neck injury with a baseball bat during an altercation. When he presents in the trauma bay, in full c-collar and spine board immobilization, he is awake, alert, oriented, and in no respiratory distress. He is verbally complaining of severe neck pain. He opens his eyes spontaneously and wrinkles his forehead on command; however, he is unable to move any of his extremities. As part of the primary survey, you calculate his Glasgow coma scale score to be:

15 (M6 V5 E4) Glasgow coma scale (GCS), along with pupillary response, is a rapid assessment of the central neurologic status. This is done in the primary survey, disability, to assess central neurologic stability and its potential to result in airway loss. The motor component in the GCS represents the patient's "best motor response" and is not to be influenced by the peripheral nervous system. Thus inability to move extremities due to a spine, peripheral nerve, or skeletal injury should be discounted.

Difference between 1st and superficial 2nd degree burn?

1st degree: intact epithelium with erythema superficial 2nd degree: loss of outer epithelium.

When do symptoms of pyloric stenosis first typically present?

3-8 weeks of age, later adjusted for preterm infants.

What is the indicated BMI for bariatric surgery?

40, or 35 w/obesity-related comorbidities

Epidemiology Matching: 95% 25% 5% 3.5% below renal artery involve iliac arteries involve renal/mesenteric arteries have associated femoral or popliteal arteries of this kind of aneurysm, 50% have AAA (pick one of the above)

95% - below renal artery 25% - involve iliac arteries 5% - involve renal/mesenteric arteries 3.% - have associated femoral or popliteal arteries If popliteal aneurysm, 50% have AAA.

When is the highest incidence of incarceration for pediatric inguinal hernias?

<6mo

Name the percent risk of rupture for each size of AAA: <5cm 5-6cm 6-7cm 7-8cm

<5cm - very low risk unless symptomatic 5-6cm - 10% 6-7cm - 16% 7-8cm - 30%

You are taking a 66-year-old man to the operating room to resect a right upper lobe lung cancer. During the operation, which 3 structures will require isolation and division?

Any anatomic lung resection involves isolation and division of 1) the pulmonary artery, 2) pulmonary vein and 3) bronchus at the level of the hilum.

Describe what you'd see on CT: A. SBO 2nd to Adhesion B. SBO 2nd Incisional Hernia C. SBO 2nd to Crohn's Disease D. SBO 2nd to Cecal Tumor E. Closed Loop Obstruction

A. You wouldn't see the adhesion, but you'd see a rapid change in stool caliber, and perhaps the transition point where bowel loops are dissented proximally. B. You could see the hernia itself, plus rapid change in stool caliber. C. You could see the inflammation ("target appearance") of the ileum, with hyperemia and dilated bowel proximal to the obstruction. D. You could see the tumor mass. Apple-core lesion, terminal ileum being with fluid-filled. Tends to affect older populations (>70yo) E. SURGICAL EMERGENCY. Risk of strangulation very high, with mortality 30-35%. Curvilinear, secondary to tethering caused by adhesion, twist of the mesentery, or hernia.

Which type of lung cancer is associated with EGFR mutation?

Adenocarcinoma (glandular, mucin-secreting, peripherally located, lung cancer most often to occur in non-smokers, type II alveoli - surfactant secreting)

Which type of lung cancer is most likely to occur in non-smokers and women?

Adenocarcinoma (glandular, mucin-secreting, peripherally located, lung cancer most often to occur in non-smokers, type II alveoli - surfactant secreting)

How do you treat someone with a high carboxyhemoglobin level (CO poisoning)?

Administration of FiO2 100%.

How do you deal with bleeding gastric varices due to splenic vein thrombosis? (presents as hemetemesis and hypovolemic shock)

Admit patient to the ICU, resuscitate, start IV PPIs, perform endoscopy, and evaluate source of GI bleed.

Alk phos elevation in... - cholelithiasis - biliary colic - cholecystitis - choledocolithiasis - cholangitis - cholangiocarcinoma - gallstone pancreatitis - gallstone ileus

Alk phos elevation in... - cholelithiasis: 0 - cholecystitis: 0 - biliary colic: +/- - gallstone pancreatitis: +/- - cholangitis: +++ - choledocolithiasis: +++ - gallstone ileus: ? - cholangiocarcinoma: +++?

A 50-year old female undergoes a total thyroidectomy for papillary thyroid carcinoma. Tumor size is 3cm and there were no involved lymph nodes. Post-operatively she undergoes radioactive iodine remnant ablation. Which of the following is appropriate long-term follow-up care for thyroid cancer surveillance?

Annual thyroglobulin measurement. Discussion: Thyroglobulin is only produced by thyroid cells and is an excellent clinical indicator of recurrence. In the setting of TSH suppression, a climbing thyroglobulin level should prompt further investigation of a possible recurrence. TSH levels should be monitored more frequently than annually to maintain TSH suppression. CT scans of the neck or chest are not indicated for routine surveillance. I131 scanning can be useful for further evaluation if a recurrence is suspected.

Which of the following is the most appropriate next step in management after diagnosing pyloric stenosis with hypochloremic, hypokalemic metabolic alkalosis with paradoxic aciduria? - Upper gastrointestinal series - Bolus administration of normal saline, 20 mL/kg - Emergent pyloromyotomy - Bolus administration of half-normal saline, 10 mL/kg plus 40 mEq potassium chloride - Administration of dextrose in half-normal saline plus 20 mEq potassium chloride, 16 mL/hr

Bolus administration of normal saline, 20 mL/kg. The patient requires resuscitation to correct dehydration, correct electrolytes and optimize operative outcomes. Sodium chloride should be the initial agent selected for resuscitation and should be delivered in a weight-based bolus. Potassium should be given cautiously in newborns and only after the patient is making urine. It is not necessary to add potassium to an IV fluid bolus in a dehydrated infant. Achieving electrolyte balance of K+>3.5, Cl>100, and HCO3 <30 is ideal.

What kind of spread are you worried about with lung cancers of the superior sulcus?

Brachial plexus, spinal invasion

Most common sources of lung mets?

Breast, colon, and prostate (all the private parts)

A 72-year-old man with chronic kidney failure secondary to type 2 diabetes mellitus is evaluated for a 3-week history of worsening fatigue and joint pain. He currently requires 3 hemodialysis sessions weekly. He adheres to his current medication regimen of atenolol, lisinopril, a phosphate binder, metformin, atorvastatin, omeprazole, and neurontin. On physical examination, temperature is 98.6°F (37.0°C), pulse is 89/min, respirations are 14/min, and blood pressure is 140/86 mm Hg. Examination of the right arm shows a well-functioning arteriovenous fistula. The remainder of the examination is unremarkable. Which of the following is the most likely cause of the hypercalcemia?

By definition, secondary hyperparathyroidism is hyperparathyroidism in a patient with chronic kidney disease or vitamin D deficiency.

A 72-year-old man undergoes left thoracotomy and left upper lobectomy to resect an apical lung cancer. A high volume of bloody drainage is noted at the chest tube (1000 ml over 12 hours). On examination, pulse is 72/min, respirations are 14/min, and blood pressure is 122/78 mm Hg. Oxygen saturation is 98% while receiving 2 L oxygen/min. What is the most appropriate next step in management?

CBC and CXR. This patient's vital signs are within the normal range. - Higher chest tube output and hypotension and/or tachycardia may prompt a more urgent return to the operating room, but with stable vital signs, a chest radiograph and checking hemoglobin / hematocrit would be the first steps. - Blood gas and CT would not help determine if there was hemorrhage. - Transfusion of a patient with normal vital signs without checking the hemoglobin level first would not be indicated. - A tagged red blood cell study is time consuming and inappropriate.

Genes associated with melanoma?

CDKN2a, INK4a, MTS1/p16, melanoma susceptibility gene (associated with pancreatic cancer). Take a family history at least 3 generations back.

Which labs should you order as you prepare a patient with confirmed colon adenocarcinoma for surgery?

CEA (good marker of recurrence) CBC (WBC, RBC) LFT (rule out liver etiology) BUN/creat (baseline) Chem-7 (metabolic risk - electrolyte abnormalities in hypertensive patient using a diuretic) PT/PTT (bleeding risk)

Role of imaging technique in identifying colon cancer: CT/MRI?

CT/MRI are useful tools for identifying distant metastases. CTs and MRIs will usually pick up larger colorectal lesions, and are most useful for detecting invasion of adjacent structures (T4 lesions) and metastatic disease.

What is the next imaging study you should do for a patient with an incidental AAA (5.8cm) after a duplex sonogram?

CTA scan to determine length, size, and relation to other structures. Has largely replaced traditional angiogram.

How do you neutralize hydroflouric acid in a burn wound after irrigating?

Calcium gluconate gel (base neutralizes acid).

Side effect of silver nitrate on burn patients?

Can cause electrolyte abnormalities from leaching.

Dakins solution (sodium hypochlorite solution, basically just bleach) on burn patients ?

Can cause redness, irritation, and pain.

Side effect of Bacitracin on burn patients?

Can cause yeasty rash.

List some of the physical exam maneuvers that you would want to do in a patient at risk for AAA?

Cardiac exam: - listen for bruit - get BP on each arm - listen to heart Abdominal exam - feel gently from each side for AAA, one hand at a time - then feel with both hands simultaneously for AAA LE exam - feel for femoral pulses - feel for popliteal pulses

Where does air tend to go in the abdomen, when you're doing the physical exam?

Central abdomen

Where are small cell lung cancer nodules usually located?

Centrally (endobronchial) at the bifurcation branch points of small airways

To localize the abnormal parathyroid gland before surgery, which of the following is the least invasive preliminary study?

Cervical ultrasonagraphy is a painless, relatively quick procedure that can be performed in the endocrine surgeon's office or in radiology. The other imaging options all require intravenous access and are therefore more invasive.

What is Charcot's triad?

Charot's triad is right upper quadrant pain, jaundice, and fever. Charcot's triad is used to describe ascending cholangitis. Ascending cholangitis is an infection of the bile duct, usually caused by bacteria ascending from its junction with the duodenum. Cholangitis is life-threatening and is regarded as a medical emergency. E.g. a stricture at the hepaticojejunostomy resulting in cholangitis.

Narrowest part of the airway in young children? In adults?

Cricothyroid junction is the narrowest part of the airway in children. Therefore, cricothyroidotomy is contraindicated in young children, and you do needle jet ventilation and eventual tracheotomy instead. In adults, the narrowest part is the vocal cords. (The exact age is not agreed upon, but up to ~12yo is considered pediatric.)

Next stage in management for intermediate thickness (1.5mm) melanoma on right shoulder?

CT of the chest.

Ovarian cysts, versus ectopic pregnancies. Tender or non-tender?

Cysts - non-tender usually, unless ruptured. Then SUPER painful. Ectopic pregnancy - tender.

A 45 year-old male presents to his PCP with unexplained weight loss and fatigue. Colonoscopy demonstrates a 2cm ascending colon mass, biopsies are consisted with adenocarcinoma. A staging CT scan is performed which shows > 10 bilateral hepatic lesions consistent with metastases. CEA is 212. Which of the following is the most appropriate course of management?

Chemotherapy alone. This patient presents with an asymptomatic primary cancer and hepatic metastases which are surgically incurable. In this setting, there is no role for resection of the primary tumor, since patients are far more likely to succumb to metastatic disease before the primary ever becomes an issue. In this case, the earliest initiation of aggressive systemic chemotherapy is most appropriate. While this pt has a very aggressive presentation, many stage IV colon cancer (with mets to the liver) can still be cured and all should be presented in a multi-disciplinary conference.

What is the most appropriate treatment post-op for resected colon cancer?

Chemotherapy. Indicated for Stage III and IV colon cancer. (Folfox and Fol-firi)

A 72-year-old man with chronic kidney failure secondary to type 2 diabetes mellitus is evaluated for a 3-week history of worsening fatigue and joint pain. He is found to have hyperparathyroidism. What would be the best initial treatment of his hypercalcemia?

Cinacalcet is a calcimimetic and is first line treatment for patients with secondary hyperparathyroidism. The other options are less likely to treat his hypercalcemia and surgery is not indicated unless he has failed medical management.

A 30 year old man is involved in a motorcycle crash and has an obvious deformity of his left leg. He complains of severe pain in the leg. On examination there is a fracture of the femur with medial displacement of the distal thigh and leg. The extremity distal to the fracture is cool, with bluish discoloration. The distal pulses are absent. The next most appropriate step in management is which of the following?

Closed reduction of the fracture. Assessment of the neurovascular status of an injured extremity is important to reduce disability. Dislocated fractures commonly result in reduced perfusion without a major injury. The first principle of fracture management when there is compromised blood flow to the distal extremity is to reduce the fracture so as to restore length and alignment of the fracture.

A patient with a history of colorectal cancer undergoes neoadjuvant radiation and chemotherapy followed by surgical resection. They are subsequently monitored for recurrence. There is no disease in the abdomen, peritoneum or liver but an isolated lung metastasis is found. Which of the following was the most likely primary site of the tumor?

Colon cancer often progresses in a stepwise fashion: regional lymph nodes, other intra-abdominal nodes, liver, and then lung. As noted previously, liver is the most common site of metastasis for colon cancer. However, the liver step (spread to the liver) may be skipped by rectal cancer before progressing to the lung due to the systemic venous drainage of the rectum. Veins from the lower rectum drain to the systemic circulation to the inferior vena cava and not via the portal venous system, hence hematogenous metastases appear in the lung rather than liver. Further, Neoadjuvant radiation is NOT given for colon cancer (its given for rectal cancer often).

Role of imaging technique in identifying colon cancer: Colonoscopy?

Colonoscopy is the gold standard for imaging the colon and can identify polyps > 5mm in size. Colonoscopy, Virtual Colonoscopy, Sigmoidoscopy, and Barium Enema are the most useful, sensitive and specific for evaluating mucosal lesions of the colon.

What type of imaging would you get if testicular torsion is suspected?

Color doppler ultrasound

A patient underwent a right hemicolectomy for a stage III, T3N1M0 adenocarcinoma. Preoperatively, her CEA was 20 which decreased to 2 postoperatively and remained at this level following adjuvant chemotherapy. On surveillance two years later, the level increased to 8 (normal <5). Her colonoscopy is unremarkable. Where is the most likely site of metastatic disease recurrence?

Colorectal cancer has a steadily increasing recurrence rate with progressing stages. A patient with an increased CEA preoperatively, should decrease to normal levels following colon resection. On subsequent follow up, CEA is monitored as one of the earliest signs of recurrence. An elevated level should prompt a look for recurrent disease. The most common site of recurrence is the liver followed by peritoneum and lung metastasis ( The liver is the most common source of recurrence due to portal venous flow). Most recurrences happen within the first 3 years post-resection.

The fibers of the internal oblique contribute to form the...?

Cremasteric muscle

Upon exploration of the inguinal canal, no hernia is found in the indirect or direct spaces. Which of the following the most appropriate strategy to determine if a femoral hernia is present?

Divide the transversalis fascia to expose the femoral canal. Femoral hernias occur medial to the femoral vessels and deep to the transversalis fascia. The transversalis fascia must be opened to expose the femoral canal. The processus vaginalis is the hallmark of an indirect, not a femoral, hernia. Dividing the round ligament will expose the transversalis fascia, but not the femoral space. While opening the peritoneum would be one way to expose the femoral canal, it may not be necessary. Intra-operative ultrasound may confirm that a femoral hernia is present, but would do nothing to expose it for repair.

A previously healthy 68-year-old white woman presents to her primary care physician 3 days after being treated in the local emergency department for a Colles fracture of her right wrist. A radiograph of her spine taken in the emergency department after her fall also showed diffuse osteopenia and new kyphoscoliosis. She takes ibuprofen as needed for mild arthritis-type pain; she also take a multivitamin and omega-3 fish oil capsule daily. On physical examination today, the patient's right arm is in a cast. She is 63 in (160 cm) tall (10 years ago: 64 in [163 cm]) and weighs 102 lb (46 kg). Her temperature is 98.6°F (37.0°C), pulse is 72/min, respirations are 16/min, and blood pressure is 128/84 mm Hg. Moderate kyphoscoliosis is noted. The remainder of the physical examination is otherwise unremarkable. Which of the following is the most appropriate imaging modality for this patient?

Dual-energy x-ray absorptiometry. This patient most likely has osteoporosis so a DEXA scan would allow quantification of the severity of this osteoporosis. A neck U/S or Sestamibi scan for hyperparathyroidism is not indicated yet as their is no laboratory evidence of hyperparathyroidism. A repeat radiograph of her right forearm or PET scan are not clinically indicated and would be a misuse of resources.

A 50 y/o man is the unrestrained driver in a motor vehicle crash and is admitted to the ED hemodynamically stable. Vital signs are: BP 110/70; HR 100. On CT of the abdomen, he is found to have a Grade III splenic laceration. He is admitted to the ICU for close monitoring. Six hours after admission he is is hypotensive with a blood pressure of 80/40 and a heart rate of 130. After transfusion of four units of packed red blood cells, he remains in shock. The most apppropriate next step in management is:

Emergent Laparotomy. In the past 2 decades, nonoperative management has become the mainstay of management for solid organ injuries in hemodynamically stable patients. However, occasionally patients fail nonoperative management and require emergent laparotomy in order to control the ongoing hemorrhage. Grade III splenic injuries are at increased risk for failure of nonoperative management represented by the need for transfusion of four or more units of blood or frank hypotension due to hemorrhagic shock.

Role of imaging technique in identifying colon cancer: Endorectal ultrasound?

Endorectal ultrasound is used to provide evidence of depth of tumor invasion. Endorectal ultrasound will give you the depth of the lesion (clinical T stage) as well as an indication if there are enlarged lymph nodes directy adjacent to the bowel wall.

Which of the following are not necessary labs pre-op? LFT BUN/Creat SMA-7 PT/PTT CXR Endoscopic ultrasound

Endoscopic ultrasound

What is mesenteric adenitis, and what would you expect to be elevated in terms of labs?

Enlargement of mesenteric lymph nodes (adenitis = lymph nodes). Can be caused by Yersinia (often preceded by sore throat/cold.) Often confused with appendicitis, RLQ pain. You would expect higher number lymphocytes.

Which of the following is the most likely underlying pathophysiology of the potassium abnormality?

Gastric losses, but MORE IMPORTANTLY, k+ loss at level of the kidney as it tries to preserve volume via aldosterone (Na+ preserved, K+ excreted.) Once K+ is depleted, H+ is also lost at the level of the kidney in exchange for Na+(paradoxic aciduria.)

What is hemobilia? how common is it?

Haemobilia is a medical condition of bleeding into the biliary tree. Haemobilia occurs when there is a fistula between a vessel of the splanchnic circulation and the intrahepatic or extrahepatic biliary system. It can present as acute upper gastrointestinal(UGI) bleeding. It should be considered in upper abdominal pain presenting with UGI bleeding especially when there is a history of liver injury or instrumentation. It's pretty rare.

High/med/low risk of colon cancer? "My stools have been maroon colored"

High. Colon cancers develop as ulcerated lesions that can bleed. Therefore patients can be guaic positive, have blood in their stools, or present with anemia and associated symptoms.

High/med/low risk of colon cancer? "I seem to be losing weight"

High. Concerning sign for any cancer.

High/med/low risk of colon cancer? "I have been having a difficult time passing my stool"

High. Patients with colorectal cancer will slowly develop obstructive symptoms, and therefore they will often first experience a change in the size of their bowel movements, constipation, or diarrhea (as only liquids are able to pass the obstruction.)

High/med/low risk of colon cancer? "The stool is very thin like a pencil"

High/med/low risk of colon cancer? "My blood counts have been low recently"

High. Suggestive of occult blood loss due to cancer.

Cricothyroidotomy

Hole through the cricothyroid...

How high is WBC in.... - cholelithiasis - biliary colic - choledocolithiasis - cholecystitis - cholangitis - cholangiocarcinoma - gallstone pancreatitis - gallstone ileus

How high is WBC in... - cholelithiasis: 0 - biliary colic: 0 - choledocolithiasis: +/- - gallstone pancreatitis: +/- - cholecystitis: +++ - cholangitis: +++ - cholangiocarcinoma: +++ - gallstone ileus:

A patient undergoes successful removal of 3.5 parathyroid glands. Eight hours after the procedure, she reports severe numbness around her mouth and tingling in the fingertips of both hands that does not resolve with 1 gram of elemental calcium. Examination of the surgical site shows no evidence of hematoma. What is the most likely diagnosis?

Hungry bone syndrome: constellation of hypocalcemia, hypophosphatemia, and hypomagnesemia after successful parathyroidectomy due to the sudden withdrawal of excess PTH. Parathyroidectomy for hyperparathyroidism may result in an imbalance between osteoblast-mediated bone formation and osteoclast-mediated bone resorption that results in rapid absorption of calcium, phosphate, and magnesium into the bones.

What's the difference between hydrocele and hernia?

Hydrocele: the bulge seen and felt on physical exam in the scrotal sac is fluid, leaked through the patent PV. Hernia: the bulge is due to intestinal protrusion through the patent PV.

A 55-year-old woman with a history of T2N1M0 estrogen receptor-negative, progesterone receptor-positive breast cancer presents to her medical oncologist 1 week after passing a ureteral stone. She underwent modified radical mastectomy of the right breast 8 months ago and completed chemotherapy with doxorubicin, paclitaxel, and cyclophosphamide 4 months ago. On physical examination, temperature is 98.6°F (37.0°C), pulse is 80/min, respirations are 15/min, and blood pressure is 120/66 mm Hg. Several hard masses are palpated beneath the surgical scar.

Hypercalcemia of malignancy. Given the patient's prior history breast cancer and the laboratory findings of hypercalcemia with a normal PTH, but increased PTH-related peptide, the patient most likely has hypercalcemia of malignancy. Primary hyperparathyroidism would have an elevated PTH. Paget's disease, Addison's disease, and sarcoidosis do not cause and increase in PTH-related peptide.

Patient's metabolic status with pyloric stenosis?

Hypochloremic, hypokalemic metabolic alkalosis with paradoxic aciduria.

During an operation for colon cancer, wound contamination and subsequent infection are always a concern. Which of the following is NOT an acceptable strategy to reduce this risk (ie. have not shown to be helpful)?

IV antibiotics for one week postoperative. The current evidence shows that a number of strategies are effective to incrementally reduce the risk of postoperative wound infection. Perioperative antibiotic immediately prior to incision are effective. Beyond the immediate perioperative time period, antibiotics do not reduce infection risk but select for more difficult to treat bacteria.

How might an abnormal abdominal plain film be mistaken for a normal abdominal exam? (supine)

If the bowel is filled with fluid instead of air, it will look normal on supine Xray.

A 65-year-old man comes to the emergency department because of vomiting, increasingly severe cramping abdominal pain, and distention for the past 12 hours. He had no history of previous abdominal surgery. Two years ago, he underwent surgical excision of a 1.5-cm tubular melanoma on his back. Plain radiographs of the abdomen show multiple air-fluid levels with several distended loops of small bowel. Which of the following is the best next step in management?

In the absence of a history of abdominal surgery, this is worrisome for small bowel obstruction due to a tumor or an internal hernia. With the patient recent history of melanoma resection, recurrence of melanoma (metastatic melanoma) a true possibility and a CT scan would help delineate the nature of obstruction and improve staging (if indeed this is due to cancer).

Why do you get nausea/vomiting with appendicitis?

Inflammation and obstruction of the appendix leads to ileus, so stuff gets backed up, leading to nausea and vomiting.

Where are indirect inguinal hernias found?

Inguinal hernias that course lateral to the inferior epigastric vessels are indirect hernias, which enter the inguinal canal through the deep (internal) inguinal ring.

How do you manage a bleeding pseudoaneurysm for celiac artery

Interventional radiology for selective angiography and embolization

Infant's behavior after each episode of emesis in presumed pyloric stenosis?

Irritable, crying, hungry

Complications of SBO

Ischemia! At the site of the obstruction, there is a vascular compromised. Bowel gets under perfused. The endemic bacteria break down the vessel wall, causing air to enter the bowel wall, up to the liver, which can lead to sepsis and death.

What is the "floor" of the inguinal Canal?

It is called Hesselbach's triangle, formed by the transversals fascia. (deepest abdominal layer, beneath internal and external oblique.)

Complications associated with pyloric myotomy? Is regurgitation one of them?

It is not uncommon for infants to have regurgitation with feeds following a pyloromyotomy. This is typically self-limited and the parents should be provided with reassurance. Complications following pyloromyotomy include transection of the pylorus or inadequate pyloromyotomy. This will require further operation or reoperation depending on whether it is recognized intraoperatively. The stomach insufflation via gastric tube while the proximal duodenum is occluded to assess for any bubbling from the bulging submucosa would indicate an inadvertent perforation of pylorus. The infant should be assessed for any signs of distress or concerning vital signs or physical exam findings such as firm or tender abdomen that may heighten suspicion or concern for a potential complication.

Which gene is NOT involved in development of colon cancer? - APC - MCC - DCC - RET - RAS

RET = RET loss of function mutations are associated with the development of Hirschsprung's disease, while gain of function mutations are associated with the development of various types of human cancer, including medullary thyroid carcinoma, multiple endocrine neoplasias type 2A and 2B, pheochromocytoma and parathyroid hyperplasia. Involved in colon cancer: MCC = Mutated in colorectal cancer DCC = Deleted in colorectal cancer APC = Adenomatous polyposis coli RAS = g-protein

What are you looking to rule out when you order LFTs in suspected appendicitis?

LFTs Should be normal. Abnormal would suggest something more along the lines of acute hepatitis, choledocolithiasis, cholangitis, acute cholecystitis.

A 48-year-old female undergoes evaluation for hoarseness. Her work-up reveals a 4.2cm right thyroid nodule. Subsequent US guided FNA reveals a Bethesda Category VI nodule, consistent with papillary carcinoma. What is the next most appropriate step in her management?

Laryngoscopy. Discussion: In patients with thyroid cancer who present with signs of invasion into adjacent structures, laryngoscopy should be performed to evaluate the function of the vocal cords pre-operatively. A nuclear medicine thyroid scan would not change management at this point in her evaluation, nor would MRI. A total thyroidectomy would be the definitive procedure of choice after laryngoscopy to evaluate her vocal cords. Although lobectomy and isthmusectomy is an appropriate definitive procedure for some thyroid cancers, this patient's age and size of tumor make it an inferior operation in this setting.

Man with significant sun exposure. Painless left lymphadenopathy. No apparent sites of lesions elsewhere. Biopsy of the axilla: positive for metastatic melanoma. PET scan: no apparent sites of uptake elsewhere. Vitals within normal limits. What do you do?

Left axillary lymphadenectomy. This patient is presenting with metastatic melanoma in the axillary with an unknown primary (MUP) with no evidence of distant disease. The incidence of MUP is 3.2%. The male to female ratio is 2:1 while the age peak is in the 4th and 5th decades. There is no great consensus on how to approach pts with MUP, but good response has been shown to treatment. Since there is no distant disease, the preferred treatment modality would be to clear the axilla and thus identify the burden of disease (and need for radiation). The pt may benefit from adjuvant chemo therapy.

A 32-year-old male presents with a 3cm left thyroid nodule. He reports cervical dysphagia. TSH levels are normal. US reveals benign characteristics and no other thyroid nodules. US guided FNA reveals a Bethesda Category II benign nodule. What is the next most appropriate step in management?

Left thyroid lobectomy and isthmusectomy. Discussion: This patient presents with a symptomatic thyroid nodule causing dysphagia. Although his FNA reveals a low-risk nodule for malignancy (0-3% based on Bethesda criteria), the nodule is still causing trouble swallowing. In a euthyroid setting, radioactive ablation is not indicated. CT scan of the neck would not provide any additional information in the decision making process. In the absence of multi-nodular goiter, a unilateral procedure is preferred.

Where does lung cancer metastasize TO?

Liver, bone, adrenals, brain (think "high-order" and "productive" locations)

High/med/low risk of colon cancer? "I have noticed some stool staining my underwear"

Low. Perirectal drainage is unlikely to be associated with cancer as this is usually due to an infection such as a fistula or abscess. Impairment of the anal sphincter muscles due to advanced rectal cancer can happen, but almost certainly the lumen of the rectum would also be obstructed.

High/med/low risk of colon cancer? "Sometimes I have a little drainage from my bottom"

A 42-year-old man is referred to a gastroenterologist for peptic ulcer disease that has been refractory to medical therapy. An endoscopic evaluation 3 weeks ago showed multiple duodenal ulcers. Eight years ago, he underwent transphenoidal resection of a pituitary adenoma. He has passed 2 ureteral stones during the past 2 years. His current medications are omeprazole and a daily multivitamin. Which of the following is the most likely underlying diagnosis?

MEN syndrome, type I (Wermer's Syndrome) is an autosomal dominant disease that results in tumors of the pituitary, pancreas, and parathyroid glands.

Next step in management for a patient with a history melanoma, presenting with headaches?

MRI of the brain, especially if the melanoma had high metastatic potential (high depth, width.)

Visible peristaltic waves are most likely to be seen in the which of the following locations in pyloric stenosis?

RUQ (with palpation of olive in epigastrium)

Nigro protocol

Rectal carcinoma protocol. Improves local control, but no survival benefit.

Which antibiotic is known for causing a metabolic acidosis, especially when applied to large % of the body?

Mafenide acetate (carbonic anhydrase inhibitor)

What is "step-off?"

Malalignment of thoracic or lumbar processes

What does "mycotic" mean in the context of aneurysms?

Means that it has been caused by an infectious process.

What does "Anastomotic" mean in the context of aneurysm?

Means that the aneurysm, or vessel wall weakening, is occurring at a branch point.

What does "Post-Stenotic" mean in the context of aneurysms?

Means that there is an obstruction, or stenosis, beyond which the turbulence of the blood flow has caused an out pouching of the vessel wall.

High/med/low risk of colon cancer? "I have bloating and vague abdominal pain"

Medium. Later in the course, as the cancer advances, and the obstruction becomes more severe, patients will develop abdominal discomfort, often described as cramping. Abdominal pain, however, is non-specific and can have many causes. Weight loss is also non-specific, but can be a late symptom and implies advanced or metastatic disease.

High/med/low risk of colon cancer? "It hurts when I have a bowel movement"

Medium. Patients with colorectal cancer will slowly develop obstructive symptoms, and therefore they will often first experience a change in the size of their bowel movements, constipation, or diarrhea (as only liquids are able to pass the obstruction.)

What is the mechanism of tetany as a downstream consequence of pyloric stenosis?

Metabolic alkalosis can lead to tetany due to lowering of circulating ionized calcium.

What would you expect on CBC for appendicitis?

Mildly elevated WBC - 12 to 15, but not as high as with ectopic pregnancy (18-20). Also look for left shift. H&H - high = dehydrated (e.g. severe gastroenteritis), low = bleeding episode (rarely with pain) or cancer (esp colon cancer) Platelets - bleeding risk

How do you treat abdominal compartment syndrome?

NG tube, plus administration of muscle paralysis (relaxes muscle & paracentesis).

What are the downsides to EVAR (Endovascular arterial repair) with stent-graft?

Need for frequent CT scanning postoperatively to ensure no endoleaks have occurred (20% of patients), requirement of appropriate anatomy

A 16 year old man is involved in a motor vehicle accident. He was unrestrained and was ejected from the vehicle for a distance of 8 feet. He is brought to the Emergency Department alert, but in obvious respiratory distress. Vital signs include HR 140 per minute, BP 60/40 mmHg, and respirations of 34 per minute. An initial assessment demonstrates tenderness to palpation over the right chest and crepitus over the right chest and neck, distended neck veins, and tracheal deviation; on auscultation of the right chest, there are no breath sounds and there is hyperresonance to percussion. The most appropriate next step in management of this patient is?

Needle decompression of right chest

False aneurysm

No arterial wall (usually due to trauma). A condensed, organized pocket of blood (hematoma) is what comprises the aneurysm .

Are most adrenal masses hormone-producing or non hormone-producing?

Non-producing

A 24 year old woman is brought to your emergency room after suffering a fall while riding her horse. She is immobilized in a rigid C-collar and on a long spine board. She is alert, unable to move any of her extremities. Her respiratory drive is weak to absent, HR 78 per minute, BP 80/52 mmHg, and her O2 sat is 98% being ventilated with Bag-mask at about 18 breaths per min (100% O2). The appropriate next step in her management would be?

Oral-tracheal intubation, maintaining in-line C-spine precautions. Hypotension without tachycardia in the presence of quadriplegia is consistent with neurogenic shock. Addition of insufficient respiratory drive to the clinical picture heightens suspicion of a high C-spine injury. In such a clinical scenario, with the loss of respiratory drive and neurogenic shock, securing the airway takes precedence and a definitive airway must be obtained.

You are treating a 50 year old man that was involved in a fire. He suffered 25% 2nd-3rd degree burns to anterior chest, neck and face. He has singed nasal hairs, and you identify stridor on your primary survey. Pulse oximetry is 88% on a 100% non-rebreather mask. A burn center is 45 miles away. The next most appropriate step prior to transfer is?

Oral-tracheal intubation.Burns, in this scenario, exhibit an effect on airway, breathing, and circulation. Singed nasal hairs, facial burns, and stridor all suggest an airway injury that threatens an eventual loss of airway due to progressive edema and swelling. Hypoxia suggests an inhalation injury. The extent of second and third degree burns will result in increased evaporative fluid loss and should be considered and treated in the circulation component of the primary survey. Of all these injuries, securing an airway (especially in light of an impending transfer) takes precedence.

A 69 y/o man is involved in a motor vehicle accident and is brought to your ED by ambulance. His vital signs are HR: 110 per minute, BP: 170/90 mmHg, respirations 35 per minute. On a physical examination, he has 10 cm scalp laceration extending across the anterior forehead, raccoon eyes, and a GCS score of 5. The next most appropriate step in the management of the patient's airway is

Orotracheal intubation. Severe closed head injury (CHI) and evidence of head trauma with GCS <= 8, needs to be aggressively resuscitated to avoid a secondary insult, i.e. hypoxia and hypotension. Patients with a GCS <= 8 run a high risk of airway loss and thus require a definitive airway (Orotracheal intubation).

Patients with a family history of melanoma who are found to carry the melanoma susceptibility gene may also be at increased risk for which other cancer type?

Pancreatic cancer

What are you looking to rule out with amylase and lipase?

Pancreatitis. Normal values do NOT preclude pancreatitis.

A 65-year-old woman is referred for evaluation of a 4-year history of worsening fatigue and memory loss. She has noticed that she is becoming increasingly forgetful, occasionally walking into a room and realizing that she is unsure why she is there. Her current medications are atenolol and simvastatin. She has no relevant family history. On physical examination, temperature is 98.6°F (37.0°C), pulse is 94/min and regular, respirations are 20/min, and blood pressure is 136/88 mm Hg. On palpation of the neck, a 2-cm, soft, non-pulsatile mass is noted in the anterior potion of the right lobe of the thyroid. Neurologic examination shows diminished reflexes bilaterally, and the patient has difficulty rising from a chair. What is the palpable mass most likely to be on further imaging?

Parathyroid adenoma. Her history, physical examination, and laboratory findings are all consistent with primary hyperparathyroidism. The most common cause of primary HPT is a parathyroid adenoma. A metastatic cervical lymph node or squamous cell cancer of the lung are unlikely causes of hypercalcemia. A thyroid nodule does not cause hypercalcemia.

A 58-year-old woman is evaluated for recurrent hyperparathyroidism 3 years after undergoing parathyroidectomy for primary hyperparathyroidism. The patient reports bone pain affecting her arms and legs. The prior operative report confirms the removal of a parathyroid adenoma but notes spillage of the adenoma during resection. The patient takes vitamin D and a multivitamin but no other medications. On physical examination, temperature is 98.6°F (37.0°C), pulse is 74/min, respirations are 16/min, and blood pressure is 128/84 mm Hg. The cervical neck incision is well healed, but several nodules are palpated over the right sternohyoid and sternocleidomastoid muscles. The remainder of the examination is unremarkable. Laboratory studies: Serum calcium 11.9 mg/dL (normal: 8.9-10.1 mg/dL) Serum phosphorus 2.3 mg/dL (normal: 2.5-4.5 mg/dL) Serum intact parathyroid hormone 180 pg/mL (normal: 10-55 pg/mL) Urine calcium 400 mg/24 hr (normal: 20-275 mg/24 hr) Which of the following is the most likely cause of the persistently elevated parathyroid hormone level?

Parathyromatosis is caused by the rupture and/or spillage of hyperfunctioning parathyroid cells into the operative bed during an initial operation. If the cells remain hyperfunctioning they cause recurrent hyperparathyroidism and present as multiple random nodules within the original operative field. The other options are unlikely given this patient's history and physical examination findings.

A 30 y/o man arrives in the ED after a tire exploded into his face. He has blood coming from his mouth and nose, and his GCS is 5. Attempts to clear his mouth of blood are unsuccessful. The next most appropriate step in the management of the patient's airway would be:

Patients with a GCS <= 8 run a high risk of airway loss and thus require a definitive airway. Endotracheal intubation is the primary definitive airway sought. In the presence of oral- maxillofacial trauma, endotracheal intubation may prove to be difficult and thus a surgical airway, cricothyroidotomy, becomes the method of choice for obtaining an urgent definitive airway.

What is Reynold's Pentad?

Reynold's pentad is Charot's triad plus shock and altered mental status. It suggests a diagnosis of obstructive ascending cholangitis.

During the operation for rectal cancer, the surgeon is careful not to injure the presacral nerve plexus. If injury occurs, which of the following are the likely sequelae?

Pelvic splanchnic nerves or nervi erigentes are splanchnic nerves that arise from sacral spinal nerves S2, S3, S4. These nerves provide parasympathetic innervations to the organs of the pelvis. These nerves course through the lateral stalks of the mesorectum. Dysfunction can occur in up to 50% of males undergoing rectal resection. This often results in difficulty emptying the bladder and erectile dysfunction. The presacral plexus is composed predominantly of sympathetic nerves. Injury most often occurs during division of the IMA pedicle and injury in this area can result in retrograde ejaculation.

How do you manage infected pancreatic necrosis?

Percutaneous drains. 35% will not require surgery.

You are assigned, by the trauma team leader, the job of taking care of the airway. You are stationed at the head of the bed taking care of a 7 year old boy that is immobilized in a c-collar and spine board. You quickly assess the airway and find that the patient has inspiratory stridor, neck swelling, and some crepitus along his right neck. The next appropriate step that you should perform is?

Proceed with oral-tracheal intubation. Team work is vital to good outcomes in the initial care of the multiply injured patient. When a team member identifies an injury (laryngeal fracture), it is important that all members understand the next appropriate intervention and then communicate the findings and appropriate intervention to the team leader.

A 45 year old man suffers multiple stab wounds to the right upper chest. He is alert and oriented but in pain. After assuring patency of his airway, you place a chest tube in the right chest based on clinical history and the physical findings. 800cc of blood is immediately returned via the chest tube. Vital signs include HR 144 per minute, BP 90/48 mmHg, respirations 20 per minute, O2 saturation of 95% on face mask. Peripheral intravenous access is unable to be placed due to the hypovolemic state. Which of the following is the best option to obtain access for fluid resuscitation?

Proper intravenous access is essential for rapid resuscitation of hemorrhagic shock. Flow dynamics dictate that the preferred access has a large diameter and a short length. These qualities will maximize flow and allow for a faster and more aggressive resuscitation of the patient. For example, a 16gauge peripheral venous catheter will allow higher flow and thus is more appropriate than a 30 cm long central triple lumen catheter. In patients who are in a state of shock, a 9 French (introducer) catheter is the access of choice if large gauge peripheral intravenous access is unobtainable.

The medial and lateral crus of the aponeurosis of the external oblique form the (deep/superficial) inguinal ring?

Superficial

What are you looking to rule out with an SMA 7, ordered for a patient with suspected pancreatitis?

SMA 7 should be pretty normal. Na, K, Cl, HC03 - lots of vomiting BUN/Creat (normal: 10:1, dehydration: 20:1) glucose: infection or sepsis

Which type of lung cancer has the WORST prognosis?

SMALL CELL LUNG CANCER. (RIP Tony.)

Role of imaging technique in identifying colon cancer: Sigmoidoscopy?

Sigmoidoscopy can only image the rectum and colon. Colonoscopy, Virtual Colonoscopy, Sigmoidoscopy, and Barium Enema are the most useful, sensitive and specific for evaluating mucosal lesions of the colon.

What color is the emesis associated with pyloric stenosis?

Simply the color of the formula or milk just consumed (not bilious, bloody, or purulent.)

What should be suspected in a patient 6 months post op from lap band surgery who presents with sudden onset severe epigastric pain and retrosternal chest pain, with nausea/vomiting and food/liquid intolerance?

Slipped band

Which type of lung cancer overall has the strongest association with smoking?

Small cell

Which kind of lung cancer arises from pulmonary neuroendocrine cells, which are responsible for making neurotransmitters, growth factors, and vasoactive substances?

Small cell lung cancer

Which type of lung cancer is most associated with paraneoplastic syndromes?

Small cell lung cancer

Which is the most significant of the following risk factors for AAA? - Age > 50 - Smoking History - Gender - Race

Smoking history

During elective open anterior repair of a R inguinal hernia, the external oblique aponeurosis is opened in the direction of its fibers. Which of the following can the surgeon expect to find beneath the external oblique (Male/Female?)

Spermatic cord/round ligament. The external oblique is the most superficial of the abdominal wall layers, and the medial and lateral crus of its aponeurosis form the superficial inguinal ring. Dividing the external oblique will expose the internal oblique layer everywhere EXCEPT the groin. In the inguinal region, the spermatic cord lies directly beneath the external oblique; the fibers of the internal oblique in fact contribute to form the cremasteric muscle. The lacunar ligament forms the medial border of the femoral canal, which is deep to the transversalis layer.

Which NSCLC (non-small cell lung cancer) is most strongly associated with smoking?

Squamous cell

Which type of lung cancer is associated with intracellular bridges on histology?

Squamous cell (epidermoid) - you see the desmosomes holding the flat cells together

Which lung cancer tends to create obstruction and distant atelectasis?

Squamous cell, because it is centrally located along large airways (2/3 central, 1/3 peripheral)

Which lung cancer has the best prognosis?

Squamous cell, because it is centrally located along large airways and therefore spreads within the chest (intra-thoracically) rather than distant (2/3 central, 1/3 peripheral)

What would be the stage of colon adenocarcinoma that has invaded the subserosa and has spread to 2 of 18 lymph nodes?

Stage III: Invasion of lymph nodes, but no metastases.

Difference between superficial 2nd degree burn and deep 2nd degree burn?

Superficial: pink, quickly blanching, moist, painful. Deep: cherry red to white, usually dry. Usually sluggish with no blanching.

Tension pneumothorax. Chest trauma in the presence of tachycardia and hypotension should precipitate an immediate rule-out of an obstructive shock phenomenon, i.e. tension pneumothorax or pericardial tamponade. This becomes even more urgent in the presence of jugular venous distention. The absence of breath sounds and presence of tracheal deviation suggests that tension pneumothorax is the more likely diagnosis.

What's the point of measuring CEA before surgery?

The CEA can be associated with colorectal, gastric, and pancreatic cancer. CEA is generally used as a tumor marker. Elevated values should return to normal after surgery; subsequent elevation may suggest recurrence.

What is the "roof" of the inguinal canal?

The aponeurosis of the external oblique. (forms the superficial inguinal ring.)

Physical examination shows clubbing of her fingers, and expiratory wheezes with poor air movement. Her heart rate is regular- 68 beats/minute, blood pressure is 124/68, and pulse oximetry is 93% on room air at rest. Results of laboratory studies show hypercalcemia (serum calcium of 12 mg/dL) and hyponatremia (serum sodium of 120 mEq/L). Computed tomography of the chest shows bulky mediastinal lymphadenopathy with multiple lung nodules. The lung nodules are most likely diagnostic of which of the following?

The clinical scenario in the patient described above is most consistent with small cell lung cancer, which may present with a syndrome of inappropriate antidiuretic hormone (SIADH). Metastatic sarcoma may present as multiple nodules, but typically does not present with mediastinal adenopathy. Adenocarcinoma and squamous cell carcinoma are primary lung malignancies also associated with smoking, but are less likely to be seen with this type of paraneoplastic syndrome. Finally, carcinoid tumors of the lung may have paraneoplastic symptoms, but these are due to increased serotonin and bradykinin, not ADH and hyponatremia. Typical carcinoid rarely presents with bulky adneopathy and multiple metastases.

The patient is scheduled to undergo mesh repair of a femoral hernia. During the procedure, the mesh must be anchored to which of the following anatomic structures?

The femoral space, where femoral hernias occur, is bounded by Cooper's ligament inferiorly. The classic McVay repair of femoral hernia approximated the conjoined tendon to Cooper's ligament to close this space. Modern mesh repairs must cover the entire femoral space and are typically fixed to Cooper's ligament inferiorly. Anchoring mesh merely to the shelving edge of the inguinal ligament anteriorly, to the conjoined tendon, or to the deep inguinal ring would not serve to close the femoral space. The iliac crest is far lateral and is not utilized in mesh repair of groin hernias.

A 65 year old man is undergoing a partial resection of the colon for cancer. During the operation, the attending asks you to describe which of the following arteries are branches of the superior mesenteric artery, the inferior mesenteric artery, or neither.

The ileo-colic, middle colic, and right colic arteries are branches of the superior mesenteric artery; the left colic and superior hemorrhoidal are branches of the inferior mesenteric artery; and the middle rectal artery arises from the internal iliac artery.

In a laparoscopic pyloromyotomy, to which layer of the pylorus is the longitudinal incision made?

The pylorus is incised to the level of the submucosa, leaving the mucosa layer intact.

What is the equivalent of the vas deferens in women?

The round ligament

What is the mechanism of the "string of beads" sign for bowel obstruction?

The small amount of air within the bowel floats to the top of the blocked fluid and shows up as a row of bubbles on upright abdominal Xray. This indicates a "high-grade" obstruction.

What does the inguinal canal contain?

The spermatic cord in men, and the round ligament in women.

Laparoscopic pyloromyotomy is ordered following appropriate resuscitation and correction of electrolyte imbalances. The pyloromyotomy is adequate when what is achieved?

The submucosa is exposed, and this incision is extended into the duodenal and gastric ends of the pylorus. The open edges of the pyloric muscularis are then grasped and moved to prove they slide independently indicating that the myotomy extends the full length of the pylorus. That is, the upper and lower half of the exposed pyloric muscle move eccentrically with manipulation. The stomach is then insufflated via gastric tube while the proximal duodenum is occluded to assess for any bubbling from the bulging submucosa, which would indicate an inadvertent perforation of pylorus.

A 54-year-old man returns to your office for follow-up 1 week after biopsy of a suspicious pigmented lesion on his right cheek. Pathologic evaluation confirmed a superficial spreading melanoma reaching a maximum depth of 4.2 mm. Which of the following is the best next step in management?

The thickness of the melanoma this concerning. This is a deep melanoma with a high incidence of metastasis at presentation. Thus a PET scan is a recommended screening tool for proper staging.

A 65-year-old woman is referred for evaluation of a 4-year history of worsening fatigue and memory loss. She has noticed that she is becoming increasingly forgetful, occasionally walking into a room and realizing that she is unsure why she is there. Her current medications are atenolol and simvastatin. She has no relevant family history. On physical examination, temperature is 98.6°F (37.0°C), pulse is 94/min and regular, respirations are 20/min, and blood pressure is 136/88 mm Hg. On palpation of the neck, a 2-cm, soft, non-pulsatile mass is noted in the anterior portion of the right lobe of the thyroid. Neurologic examination shows diminished reflexes bilaterally, and the patient has difficulty rising from a chair. What is the palpable mass most likely to be on further imaging?

Thyroid nodule. It is very difficult to palpate a parathyroid adenoma. Patients with parathyroid cancer are typically older and present with higher PTH levels. A metastatic cervical lymph node would not be inside the thyroid. A carotid body tumor would be pulsatile. Therefore a thyroid nodule is the most likely source of the palpable mass.

Why might you remove the appendix in someone with suspected appendicitis who does NOT have appendicitis, and actually has Crohns?

To rule out future confusion!

A 54 year old woman suffers 50% TBSA burn wounds after falling into a fire pit and igniting her clothes. Her wounds are all second or third degree in depth. She weighs approximately 80 kg. Based on the Parkland formula, you calculate her initial fluid rate for the first 8 hours of resuscitation to be:

Total volume = 80 kg x .5 x 4 = 16000mL. Then, 16000 x 50% = 8000mL. Then, 8000mL/8hrs = 1000mL/hour for the first 8 hours. Then, 8000mL/16hrs = 500mL/hour for the next 16 hours.

Parkland formula for fluid resuscitation

Total volume = Kg × %TBSA (2nd and 3rd degree) x 4 = Total, then 1st 8 hours you do 1/2 of that total amount, dividing by 8 hours for the hourly rate. Then the next 16 hours you do 1/4 of that (1/2 of the rest, dropping the rate by half), then the next 16 hours you do 1/4 of that (all of the rest.)

Side effect of silver sulfadiazine on burn patients?

Transient leukopenia (increased WBC count).

A 57 year old man comes to the physician with abdominal pain and constipation for the past 2 days. His appetite is diminished and he has been nauseous without vomiting. Temperature is 38.1 C, pulse 110, respirations 25, blood pressure 138/67. Physical examination demonstrates a diffusely tender abdomen with no rebound or guarding. No masses or organomegaly are identified. Rectal examination shows no masses or stool. An abdominal radiograph shows a dilated (11 cm) cecum with little or no air in the left colon and rectum. CT scan of the abdomen and pelvis demonstrate a large mass in the colon at the splenic flexure. Which of the following is the next most appropriate step in management?

Transverse Loop Colostomy. This patient most likely has an obstructing colon cancer or diverticulitis. The obstruction needs to be relieved before a perforation of the cecum occurs, and this can best be achieved by a diverting transverse loop colostomy. It is dangerous to resect and reanastamose dilated bowel as its blood supply may be compromised. A metastatic work up and chemotherapy are inappropriate in a patient with diffuse abdominal tenderness where the bowel may be compromised.

A 73 year-old male presents to the emergency room with 2 days of obstipation. A CT scan reveals a high-grade large bowel obstruction with cecal dilation to 11 cm and a large mass in the descending colon. An emergent left colectomy with end-colostomy is performed. Pathology reveals a 7cm, poorly differentiated adenocarcinoma with lymphovascular invasion tumor budding at the margins. Gross resection margins are negative. 0 of 7 LN are positive for metastatic disease. All of the following portend a higher likelihood of recurrent disease except : Presentation with obstruction Tumor budding 7 negative lymph nodes Lymphovascular Vascular Invasion Tumor Size

Tumor Size. Several histologic and clinical criteria have been found to be associated with higher rates of tumor recurrence. Histologic criteria include Lymphovascular invasion (LVI), tumor budding, poor differentiation and signet ring features. Presentation with obstruction is a clinical finding associated with a higher likelihood of recurrence, as is inadequate lymph node sampling. 12 lymph nodes are required at a minimum. Tumor size is unrelated to rate of recurrence.

What are you looking to rule out in a UA ordered for appendicitis?

UA should be pretty normal. You might see a few WBCs and/or RBCs if the appendicitis is in the pelvis, but not much. Significant blood in the urine - nephrolithiasis WBCs and bacteria - UTI, pyelonephritis, cystitis High specific gravity (above 1.030) - dehydration or nausea

In a patient with suspected anastomotic leak based on clinical signs, what is the next step in management?

UGI (upper GI) series with water-soluble contrast or CT with oral contrast

A 41 year old man is involved in a motor vehicle accident that resulted in massive blood loss, at the scene, from a traumatic lower extremity amputation. The bleeding has been controlled with a tourniquet; the patient is intubated, and is being bag ventilated when he arrives. His trauma bay vital signs are HR 121 per minute, BP 94/60 mmHg, Temperature 35.3 C (95.6 F), and he is being ventilated at 18 BPM. Full exposure is performed. With respect to the patient's temperature management, which of the following statements is correct?

Warming intravenous fluids and blood will increase patient's core temperature. Hypothermia is associated with increased mortality in the injured patient. Efforts to minimize heat loss and reversal of body cooling begins in the emergency department during the resuscitation phase of care by making sure to warm all fluids prior to infusion.

Needle jet ventilation

What are this?

What is a pantaloon hernia?

When a hernia sac straddles the inferior epigastric vessels, it is a so-called pantaloon hernia, comprising both indirect and direct inguinal hernias. (Put another way, a pantaloon hernia is the simultaneous occurrence of a direct and indirect inguinal hernia.)

A firm right groin mass is palpated and does not reduce in the supine position or with manual manipulation. Which of the following is the most likely diagnosis?

When the contents of a hernia sac cannot be returned to their normal anatomic location, the hernia is said to be incarcerated. In the acute setting, small bowel is most likely to become incarcerated, producing symptoms and signs of small bowel obstruction. This presentation is an indication for urgent surgical intervention because if left untreated, vascular compromise of the sac contents will lead to gangrene.

What is the silk glove sign, and what does it indicate?

While the child is in a supine position, the inguinal area should be palpated; when the cord structures are rolled against the pubic bone, the practitioner may feel layers of processes vaginalis slipping over one another, as if made of silk. Indicates a patent processes vaginalis.

How can you distinguish obstruction from ileus on plain film?

With an ileus, you WILL see air within the colon and rectum. With an obstruction, you WON'T see any air within the colon or rectum (because it can't pass beyond the transition point.)

Can you still get abdominal compartment syndrome after surgery, and the abdominal wall is left open?

Yes, this is still a serious risk that requires careful monitoring of vital signs.

How do you treat gallstone pancreatitis? (e.g. Right upper quadrant ultrasound shows gall bladder filled with stones, no gall bladder wall thickening, dilated common bile duct to 1 cm with evidence of choledocholithiasis)

You have to remove the gallbladder in a cholecystectomy before discharge to prevent further attacks of pancreatitis.

Chief complaint of a new nonproductive cough which has worsened over the past two months. A chest radiograph is performed to evaluate, and a 3-cm apical nodule is seen in the left lung. Which of the following is the most appropriate next step in diagnosis? a. Computed tomography of the chest b. Positron emission tomography c. Magnetic resonance imaging of the chest d. Bronchoscopy e. Repeat chest radiograph

a. Abnormalities on chest x-ray are best evaluated further with a CT of the chest to evaluate the size, location, local invasion, and associated adenopathy or effusion. - The imaging provided by MRI is most helpful to assess invasion of nerve or vascular structures, and is used selectively. - While comparing old chest x-rays may help determine if this lesion is new or stable, a repeat chest x-ray at this time is unlikely to give new information. - A bronchoscopy is an invasive test and one would not proceed with this without less invasive testing and imaging first. Furthermore, a peripheral lung mass typically can not be assessed with bronchoscopy. - Finally, a PET scan generally helps to determine stage once malignancy is confirmed, but is not the test of choice to evaluate solitary pulmonary nodules seen on chest x-ray.

Computed tomography reveals a superior sulcus tumor of the left upper lung lobe abutting the apex of the chest, with possible invasion of the area around subclavian vessels; positron emission tomography does not reveal any sites of distant disease. Which of the following diagnostic studies would be most helpful for determining the degree of tumor extension? a. Magnetic resonance imaging of the chest b. Electromyography c. Bone scan d. Ventilation/perfusion lung scan e. Mediastinoscopy

a. MRI can provide high-resolution images to assess invasion of bone, nerve and vascular structures. - Bone scan has poor resolution - Ventilation/perfusion scan does not give information about local invasion. - Electromyography may provide information about nerve conduction, but does not demonstrate the relationship of the tumor to the nerves and subclavian vessels in this area.

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