Surgery - ROSH Boost Exam

Most surgical site infections occur in the late postoperative phase, between days ____ after the procedure, but may be up to 90 days if an implant is involved.

5 and 30

3 types of surgical site infections

superficial incisional

deep incisional

organ / space

The initial management of surgical site infections includes ______

(+) fluctuance or drainage

wound exploration and debridement.

(indirect/direct) inguinal hernias pass into the scrotum

indirect

What disorders are associated with multiple endocrine neoplasia type 2?

Pheochromocytoma, hyperparathyroidism, amyloidosis, and medullary thyroid carcinoma.

initial screening test for pts with suspected ZES

fasting serum gastrin level and gastrin pH

Diagnosis is made if gastric pH is < 2 and the serum gastrin level is > 10 times the upper limit of normal (1,000 pg/mL).

ZES

gastric pH level in ZES

< 2

For patients with high suspicion for ZES but who do not meet the diagnostic criteria, a _____ may be helpful in aiding diagnosis

secretin stimulation test

72-year-old woman presents to the clinic with bilateral lower extremity edema for the past 3 months. The patient reports an aching pain in her legs that is worse with prolonged sitting or standing.

chronic venous insufficiency

lower extremity pain (often described as heaviness or aching) and edema

chronic venous insufficiency

Telangiectasia and reticular veins are common, mild, and early findings

chronic venous insufficiency

Symptomatic patients with suspected venous insufficiency should undergo further evaluation with _____ to identify the presence of superficial, perforator, and deep venous reflux

venous duplex ultrasonography

Patients may also have skin hyperpigmentation, which is due to hemosiderin staining and inflammation, and lipodermatosclerosis, which is a fibrosing panniculitis that presents with hyperpigmentation and induration.

chronic venous insufficiency

non-pitting edema think

lymphedema

pain exacerbated with walking and improved with rest

PAD

pain worse with prolonged standing / sitting still with feet in a dependent position

chronic venous insufficiency

leg swelling improves with walking

chronic venous insufficiency

Elevating the extremities improves the pain of ____

chronic venous insufficiency

Elevating the extremities exacerbates the pain in patients with severe ___

PAD

68-year-old woman presents to the clinic with pain in her legs for 4 months.

She feels the pain in her lower legs, the right side being more intense, after she walks three blocks in her neighborhood. She reports relief from the pain with rest. She reports no trauma or injuries to her feet. On physical examination, the dorsalis pedis pulse of the right foot is 1 and 2 on the left foot. A couple of nonhealing wounds are noted to the right lower extremity.

PAD

chronic venous insufficiency

no venous ulcers present

tx?

compression stockings

are compression stockings used for PAD

no

initial step in PAD management

prevent 2* cardiovascular events

- smoking cessation

- antiHTN therapy

- antilipid therapy

- antiplatelet therapy

- weight reduction

trial supervised exercise therapy

leg skin appearing shiny, dry, and hairless

PAD

Diagnosis of H. pylori infection is made by ____ or ____

H. pylori fecal antigen test

urea breath test

tissue samples from upper endoscopy ulcer are urease +

H pylori

Patients with _____ present with hearing loss, tinnitus, and disequilibrium. Additional symptoms include trigeminal and facial nerve dysfunction.

acoustic neuromas (vestibular schwannoma)

how to dx acoustic neuromas (vestibular schwannoma)

brain MRI with gadolinium contrast

an inner ear disorder that typically presents with episodic (recurrent episodes) of vertigo, fluctuating hearing loss, tinnitus, and aural fullness

ttacks often last for hours at a time and can be associated with nausea and vomiting. Following the acute attack, patients will feel excessively fatigued

meniere dz

The mainstay treatment for Ménière disease is _____

____ may be used in an acute attack

a low-sodium diet and diuretics

vestibular suppressants such as meclizine

What condition is associated with bilateral acoustic neuromas?

Neurofibromatosis type 2.

Patient presents with gradual hearing loss, tinnitus, balance disturbance

acoustic neuromas (vestibular schwannoma)

Most commonly caused by CN VIII (vestibulocochlear) tumor

acoustic neuromas (vestibular schwannoma)

Compromised blood supply of the hernia contents

strangulated hernia

Trapping of the hernia contents within the hernia sac

incarcerated hernia

what ABI indicates calcification / warrants referral to vascular specialist

> 1.4

what ABI is normal

1-1.4

what ABI is severe arterial dz

< 0.5

what ABI is arterial dz

0.9 or less

What medical conditions are most likely to cause falsely elevated ankle-brachial index measurements?

Diabetes and end-stage kidney disease.

MC gastric carcinoma

adenocarcinoma

If anal fissures are located laterally, search for ____

pathologic etiologies (e.g., Crohn disease)

What symptoms comprise the Reynolds pentad?

Fever, jaundice, abdominal pain, hypotension, and mental status changes.

Which vaccinations are recommended for patients who are undergoing splenectomy?

Haemophilus influenzae type b

Pneumococcal

Meningococcal

Other recommended immunizations not based on spleen status (e.g., zoster, seasonal influenza, SARS-CoV-2)

diverticulitis abx

cipro + metro

What infectious diseases should be screened for prior to initiating therapy with tumor necrosis factor-alpha inhibitors?

Hepatitis B and tuberculosis.

What group of medications should be avoided with known thoracic aortic aneurysms due to increased risk of dissection and rupture?

Fluoroquinolones

Many patients are asymptomatic or have minor symptoms.

Symptoms that may be present include dyspnea on exertion, fatigue, anginal chest pain, palpitations, presyncope, and syncope, particularly during or immediately following exertion

HOCM

Physical exam findings include bisferiens carotid pulse in severe disease, which is a double pulse noted during systole in the peripheral pulse.

A left ventricular lift may also be present.

A loud systolic murmur is present along the left sternal border that increases with Valsalva maneuver and upright posture and decreases with squatting

HOCM

True or false: continuing beta-blockers during pregnancy is recommended in patients with hypertrophic cardiomyopathy.

True

A 48-year-old man presents with abdominal pain. It is diffuse and developed suddenly about 20 minutes ago. He has a history of coronary artery disease and atrial fibrillation. On physical examination, the patient appears toxic, is crying out, and is writhing in pain. His temperature is 100.7°F, heart rate is 135 bpm, blood pressure is 84/52 mm Hg, respiratory rate is 24/minute, and oxygen saturation is 98% on room air. His abdomen appears distended but soft, there are hypoactive bowel sounds and no rebound tenderness. The patient displays abdominal guarding. Laboratory studies show a white blood cell count of 13.2 × 109/L and lactic acid level of 6 mg/dL.

what does he have

acute mesenteric ischemia

imaging for acute mesenteric ischemia

CTA

Patients will present classically with severe abdominal pain that is out of proportion to physical exam finding

acute mesenteric ischemia

What are the three major mesenteric vessels?

Celiac artery, superior mesenteric artery, and inferior mesenteric artery.

Colonoscopy is recommended for patients _____ after acute diverticulitis to assess the extent of a patient’s diverticular disease and exclude a concomitant colonic cancer. The only exception is patients who have had a colonoscopy performed within the past year.

6 to 8 weeks

what labs in DM pts preoperatively

serum glucose

A1C

EKG

serum creatinine

What is the goal intraoperative blood glucose level range?

Between 110 and 180 mg/dL

hyperparathyroidism:

bone pain

muscle twitching

perioral numbness

seizures

bone pain

muscle twitching

hypocalcemia

perioral numbness

hypocalcemia

seizures

severe hypocalcemia

“stones, bones, groans, and psychiatric overtones.”

hyperparathyroidism

MCC of hypercalcemia

hyperparathyroidism

high pth

high calcium

low phosphorus

hyperparathyroidism

shoulder / arm pain

horner syndrome (ipsilateral eye droop, pupillary constriction, posterior displacement of eye, absent sweating)

weakness and atrophy of hand muscles

pancoast syndrome

The chief finding is facial and upper extremity edema, but symptoms and signs also include dyspnea and neurologic manifestations

SVC syndrome

Superior sulcus tumor

pancoast tumor

What are some psychotropic agents that may induce galactorrhea?

Antipsychotics, monoamine oxidase inhibitors, neuroleptics, selective serotonin reuptake inhibitors, and tricyclic antidepressants

what type of ulcer feels worse with eating

gastric

diet for gastroparesis

low fat

low fiber

scintigraphy food retention test for gastroparesis

A positive test is defined as:

retention of > 10% of gastric contents after 4 hours

or

> 60% gastric retention after 2 hour

a useful prokinetic agent that can help improve gastric motility, but it is only recommended after dietary modification has been tried

metoclopramide

other prokinetics: domperidone, erythromycin

Which of the following is the correct mechanism of action of thioamides (methimazole, PTU)?

Interferes with the enzyme thyroid peroxidase, preventing the oxidation of iodine

mechanism: blocks thyroid hormone release

lithium

What adjunctive medication lowers serum T4 and T3 concentrations when given with methimazole?

cholestyramine

What is the first-line therapy for rickets?

ergocalciferol

MC location LBO

sigmoid colon

MCC LBO

colorectal cancer

Tx LBO

NGT, surgery

autoimmune condition affecting intrahepatic bile ducts

MC seen in women between age 40-60

characterized by a slow onset of increasing fatigue

Pruritus is also a hallmark of this disorder

Other findings: jaundice, esophageal varices, hepatosplenomegaly

Primary biliary cholangitis (PBC)

To confirm the diagnosis, antimitochondrial antibodies are tested.

Primary biliary cholangitis (PBC)

First-line treatment of primary biliary cholangitis (PBC)

ursodeoxycholic acid

Most commonly caused by an autoimmune T-cell-mediated attack on the intralobular bile ducts

Primary biliary cholangitis (PBC)

burn injury --> infection

pseudomonas aeruginosa

burn injury / pseudomonas abx

Ceftazidime plus tobramycin

grape-like odor

blue/green skin discoloration

pseudomonas

When a burn wound is infected with _____, it has been described visually as previously re-epithelialized areas "melting away."

MRSA

Patients with what chronic disease should avoid aminoglycosides?

Kidney disease

most often diagnosed between 30 and 40 years of age (although diagnosis can occur at any age)

It is more common in men and more frequently observed in those who do not smoke

Risk factors include irritable bowel disease (IBD), ulcerative colitis, Crohn disease, and other autoimmune disorders

Primary sclerosis cholangitis (PSC)

a progressive, autoimmune liver disease in which inflammation, fibrosis, and strictures of the biliary ducts of the liver lead to cholestasis and liver failure

Primary sclerosis cholangitis (PSC)

Lab results may show elevated alkaline phosphatase (a characteristic finding).

As an autoimmune condition, antinuclear antibodies and smooth muscle antibodies may be positive

Primary sclerosis cholangitis (PSC)

Many patients are asymptomatic, although some patients may report right upper quadrant abdominal pain, jaundice, fatigue, and pruritus.

In late-stage disease, patients may have jaundice, gastrointestinal bleeding, and ascites.

The physical exam may reveal hepatomegaly or splenomegaly.

Primary sclerosis cholangitis (PSC)

what imaging for Primary sclerosis cholangitis (PSC)

cholangiography

liver biopsy: onion skin fibrosis

tx of Primary sclerosis cholangitis (PSC)

no gold standard

immunosuppressants and prednisolone

ERCP with balloon dilation may be therapeutic

liver transplant

considered a premalignant condition and can progress to cholangiocarcinoma

Primary sclerosis cholangitis (PSC)

pts with Primary sclerosis cholangitis (PSC) should be monitored for what

cholangiocarcinoma

fat-soluble vitamin deficiencies

cholestatic pattern with ↑ alkaline phosphatase, +p-ANCA

Primary sclerosis cholangitis (PSC)

What is a complication after subarachnoid hemorrhage (SAH) that can lead to delayed cerebral ischemia?

vasospasm

What is the most frequent complication of acute cholecystitis?

Gangrenous cholecystitis