MASS QUIZLET 1

3 absolute indications for general surgery (according to Jim)

Perforation, obstruction, failure of conservative treatment

MC contents of a hernia

omentum > small bowel > colon

MC type of hernia

inguinal hernia

Incarcerated or strangulated?

Painful, enlarged, irreducible

Incarcerated

Incarcerated or strangulated?

Ischemic/loss of blood supply leading to systemic toxicity

Strangulated

MC inguinal hernia

indirect

Direct inguinal hernias are (medial/lateral) to the inferior epigastric artery

medial

Indirect inguinal hernias are (medial/lateral) to the inferior epigastric artery

lateral

Hernia that is more common in women than men

Femoral

MCC of indirect inguinal hernia

patent processus vaginalis

Treatment for strangulated hernia

Emergent surgery

MC type of stone to be found in the GB

cholesterol stone

MC bacterial cause of cholecystitis

E. coli

MC surgical complication

bile leak

Patient presents with RUQ pain that is precipitated by fatty foods and large meals. Pain refers to her R shoulder and she is jaundiced and febrile. What is the 1st test of choice to assess for GB stone

Ultrasound

What is the most accurate test to rule in or out chole?

HIDA scan

Patient's US is positive for GB stone and bilirubin comes back elevated. What is the next best step?

ERCP

Empiric antibiotics for someone with acute chole before surgery

Ceftriaxone and Metronidazole

GB ejection fraction of <_____% is diagnostic for biliary dyskinesia

<30%

MCC of SBO

adhesions

2nd MCC of SBO

hernia

MC complication of SBO

dehydration

MCC of death in patients with SBO

hypokalemia --> cardiac event (electrolyte imbalance)

Patient presents with abdominal distension, vomiting and obstipation. What do you expect to hear when you listen to his belly?

high pitched bowel sounds (if early obstruction)

Treatment for SBO

IV fluids

NGT

NPO

surgery (definitive)

colonic pseudo-obstruction

Ogilvie's syndrome

MC location of Ogilvie's syndrome

cecum and R colon

MCC of appendicitis

E. coli

MCC of acute abdomen in 12-18yo

Appendicitis

Patient has periumbilical pain that radiates to the RLQ accompanied by nausea, anorexia and positive obturator and psoas sign. How will you treat ?

Unasyn or Zosyn

+ Lapappy

MANTRELS for appendicitis

Migration to RLQ

Anorexia

N/V

TTP in RLQ

Rebound

Elevated temp

Leuckocytosis

Shift of neutrophils

What imaging do you order to assess for appendicitis

CT with contrast: periappendiceal fat stranding

MCC of diverticulitis

E. coli

MC location of diverticulitis

sigmoid colon

Patient presents with LLQ pain, low grade fever and diarrhea. How will you image?

CT with contrast

Treatment for diverticulitis

Cipro + Metronidazole + clear liquid diet

Bacterial inflammation of the mesenteric lymph nodes

mesenteric adenitis

Recent history of alcoholism/vomiting, chest pain and subcutaneous emphysema. most likely diagnosis?

Mallory-Weiss (Meckler's triad)

Diagnostic test of choice for Mallory-Weiss

Endoscopy: shows superficial longitudinal mucosa erosions

21 year old patient presents to ED after celebrating her birthday last night and states she saw blood in her vomit this morning after vomiting all night. She is no longer bleeding and she is stable. How do you treat?

PPI (surgery not indicated)

MCC of variceal bleed

cirrhosis

Prevention of variceal bleeds

Propranalol for portal HTN

Pharm treatment for variceal bleed

Octreotide bolus

MCC of pancreatitis

alcohol, gallstones

40 year old male with a history of chronic alcohol abuse presents to the ED complaining of severe epigastric pain that radiates to his back and is relieved when sitting forward. What imaging will you order?

CT A/P test of choice

Also an US to look for stones

Why do patients with pancreatitis become hypocalcemic?

necrotic fat binds to calcium, drawing it out of the serum

MCC of UGIB

peptic ulcer disease

MC location for an ulcer in the GI tract to form

duodenal mucosa

MCC of PUD

H. pylori

NSAIDs

Gastric or duodenal ulcer?

Caused by increased damaging factors

Pain better with meals

Duodenal ulcers

Gastric or duodenal ulcer?

Caused by decreased protective factors (NSAID)

Pain worse with meals

Gastric ulcers

T/F: Endoscopy is always indicated if gastric ulcer, but only indicated for duodenal if refractory to treatment

True

Treatment for PUD

Quadruple therapy: PPI, flagyl, tetracycline, bismuth

MCC of primary spontaneous peritonitis

alcoholic cirrhosis; E. coli

Paracentesis findings in primary spontaneous peritonitis

>250PMNs

Treatment for primary spontaneous peritonitis

Cefotaxime or Ceftriaxone

Prophylaxis for a patient with ascitic cirrhosis (prevention of primary peritonitis)

Bactrim or Cipro

MC form of peritonitis

secondary; trauma induced or from perforated ulcer/pancreatitis/diverticulitis

T/F: secondary peritonitis is usually polymicrobial

True

Treatment for secondary peritonitis

Gent and Clinda

Patient with diagnosed secondary peritonitis develops insidious onset of worsening fever and is found to be hypotensive. Rotating nurse also endorses increased output from the patients drains. The patient is already on Gent and Clinda for secondary peritonitis. What is the treatment?

exploratory laparotomy

Add an antifungal

How do you distinguish an upper GIB from a lower GIB

put an NG tube down and aspirate (must get back bile). If no blood with bile, its not an UGIB

Which is more common, upper or lower GIB

Upper GIB

Black stools: where is the source?

upper GI tract; cecum or higher

Maroon stools: where is the source?

Right colon

Bright red stools: where is the source?

Left colon or rectum

If patient is actively bleeding, what do you get next?

If the above is positive, what do you get next?

If the above is negative, what do you do next?

Bleeding scan

Bleeding scan +: get angiogram

Bleeding scan -: observe

When can you do a colonoscopy on a patient with rectal bleeding?

once bleeding as stopped

Treatment for GI bleeding

NPO

IVF

reversal of coags (FFP)

60 year old male presents to primary care with a vague complaint of feeling tired and weak for the past 2 months. He states he has been having frequent bouts of diarrhea and that he has lost 25 pounds in 3 months without intention. CBC shows anemia. What are you suspicious for?

colon cancer

get a colonoscopy

Colon cancer screening guidelines

Start at 45

If first degree relative: start 10 years before their age at diagnosis

If screening normal: every 10 years

MC parts of the colon to be affected by ischemic colitis

watersheds; splenic flexure and rectosigmoid junction

MC artery occluded in mesenteric ischemia

superior mesenteric artery

Patient presents with severe abdominal pain, but on exam his pain is out of proportion to your physical findings. What will you order first?

CTA abdomen

MC type of invasive breast cancer

Infiltrating ductal carcinoma (75%)

Are breast cancer lumps usually painless or painful?

Painless and hard

Woman presents for a mammogram and it is difficult to read due to the density of her breasts. What is the best next step?

Ultrasound the breasts

Gold standard test for DVT (patient with recent surgery, immobilized and unilateral leg swelling and pain)

US

Imaging for PE

CTA

Treatment for wound abscess post-op

Empiric abx and I&D

Your patient is 3 days post op after an open procedure on a ruptured appy. She has had chronic diarrhea and fatigue since waking up from surgery. What is the treatment? What must you rule out?

Percutaneous drainage (pelvic abscess) by IR

Must rule out C-diff

New mom just had a C-section and is 3 days post-op. You are called to the floor because she has copious amounts of straw colored fluid draining from the wound and the wound appears to not be closing appropriately. How will you close?

Retention sutures

Patient is 3 days post-op from a bowel resection and is not progressing as you would expect a patient to be on day 3. She is showing signs of full blown sepsis. What is the diagnosis and treatment?

Anastomotic leak

Re-exploration and GI diversion

Patient is 3 days post op from lap chole and is still anuric. What is the most likely diagnosis and treatment?

Small bowel injury

Re-exploration and bowel resection

Patient just had her gallbladder removed and is still having RUQ abdominal pain. What will you order for imaging and what is the treatment?

HIDA

ERCP/CBD stent placement

What kind of wound does this describe?

Gets bigger and bigger/worse and worse

neuropathic wound

What kind of wound does this describe?

Waxes and wanes in severity

Venous insufficiency

What kind of wound does this describe?

Often involves feet and toes

neuropathic

What kind of wound does this describe?

Involves lesions between the knee and the ankle

venous insufficiency

T/F: granulation tissue is a good sign of wound healing

True

Normal transcutaneous oximetry reading (oxygen in the skin)

40mmHg

What kind of wound does this describe?

Lower extremities with no pulses/low ABI

Little to no hair on feet/legs

Skin is shiny

Desquamation found on LATERAL malleolus

Arterial insufficiency

What kind of wound does this describe?

Swollen legs; "hourglass" shape

Hemosiderin staining; darkened/purple skin

Scaling and varicosities

Desquamation found on MEDIAL malleolus

Leg pain worse with standing, better with ambulation and elevation

Venous insufficiency

Which stage pressure wound?

Nonblanchable erythema but skin is intact

Stage I

Which stage pressure wound?

Involves epidermis/dermis; blisters or abrasions

Stage II

Which stage pressure wound?

Full thickness skin loss down to subcutaneous tissue

Stage III

Which stage pressure wound?

Extending to muscle/bone supporting structures

Stage IV

T/F: sinus tract cultures are not diagnostic in patients with chronic osteo

True

Treatment for Impetigo

Mupirocin

Treatment for animal bites

Amox-Clav