Exam

Question 1

a patient presents with acute obstipation, abdominal pain and distention, nausea and vomiting and they have a sx history of a laparoscopic pelvic surgery. We decided to get a plain film xray which shows an inverted “U”. what is the diagnosis?

Answer 1

small bowel obstruction

Question 2

what is the most common cause of small bowel obstructions?

Answer 2

adhesions

Question 3

a patient presents with acute obstipation, abdominal pain and distention, nausea and vomiting and they have a sx history of a laparoscopic pelvic surgery. We decided to get a plain film xray which shows an inverted “U”. once the patient is admitted, what is the first treatment step for this patient?

Answer 3

resuscitation with NG tube

Question 4

a patient presents with suspicious small bowel obstruction, what would their physical exams findings be? (4)

Answer 4

distention
abdominal scar
tenderness/pain on palpation
tympanic (hyperresonance) on percussion

Question 5

what divides the upper and lower GI tract and is the starting point when running the bowel?

Answer 5

ligament of treitz

Question 6

you are a PA working in gastroenterology. You have a patient who presents with multiple ulcers in the stomach and duodenum. The patient currently takes lisinopril, metformin, prilosec, zantac, and tums. We decide to order a gastrin level. Which medications should the patient discontinue before taking a serum gastrin level? (3)

Answer 6

H2 blocker
PPI
antacids

Question 7

a patient presents with tachycardia, hypotension. On plain film xray, there is free air under the diaphragm, and the patient has a history of duodenal ulcers. We suspect a perforation of a duodenal ulcer. what is the treatment?

Answer 7

surgery by graham (omental) patch

Question 8

an older woman comes in with abdominal distention for the last 3 days. She had her ovaries removed 4 years ago. She is mildly tachycardiac, but the rest of her vitals are normal. On upright films, we see air-fluid levels. what is the diagnosis?
what is the most likely cause of this?

Answer 8

small bowel obstruction

surgical adhesions

Question 9

an older gentleman is having progressive dysphagia. First he was unable to eat solids and now is having difficulty swallowing liquids. On barium swallow, we see narrowing of the esophagus. On EDG biopsy, we note squamous cell carcinoma and are concerned for invasion. What is the imaging test of choice to see how deep the tumor is?

Answer 9

endoscopic ultrasound

Question 10

a young boy is riding his bike and accidentally goes over the handle bars. He comes into the trauma bay with normal vital signs and the patient seems stable, and blood work looks good. Because of the mechanism, we are concerned so we get a CT scan which shows a grade 1 splenic laceration with no active bleed. After admitting for 24 hours and doing serial abdominal exams, the patient remains hemodynamically stable. What should we do?
a) splenectomy today
b) splenectomy in 2 weeks
c) partial splenectomy
d) call IR for embolization
e) non-operative management

Answer 10

e) non-operative management

Question 11

a trauma patient in his mid-20s had a splenectomy. We notice he left AMA and were unable to give him post-op instructions. The patient comes to the follow-up appointment. What is the most important thing we need to do before he leaves the appointment?

Answer 11

vaccines against encapsulated bacteria

Strep pneumo
H. flu
Meningococcus

Question 12

a patient in their late 80s with dementia and non-verbal, is brought in by his daughter because he seems like he is having painful swallowing. The patient wears dentures. He will not open his mouth but appears to be hemodynamically stable, but appears to be uncomfortable swallowing. What is the diagnosis? what is the diagnostic test of choice?

Answer 12

foreign body ingestion

xray

Question 13

a male in his mid 40s presents with right upper quadrant pain that radiates to his back. the pain comes and goes and is worse after a big meal. what is the diagnostic test of choice?

Answer 13

ultrasound

Question 14

a male in his mid 40s presents with right upper quadrant pain that radiates to his back. the pain comes and goes and is worse after a big meal. We are concerned for choledocholithiasis so we need an ERCP. What in the patient’s history would not allow us to perform an ERCP?

Answer 14

contrast allergy

Question 15

a young man presents in the urgent care with a testicular mass that is getting larger. the patient denies history of trauma. There is a 2cm, firm, nontender mass that does not transilluminate. What is the concern? What test should we order?

Answer 15

testicular cancer
ultrasound

Question 16

a middle aged woman with a history of an appendectomy 2 weeks ago, presents for a post-op appointment. After reviewing pathology, the patient has a 5ml (0.5 cm) carcinoid tumor of the appendix without involvement at the margins. what is the next step?

Answer 16

none needed

Question 17

a middle aged woman plays pickleball and comes in a day later with abdominal pain. She c/o anorexia, nausea, and right lower quadrant pain. Her WBC count is normal. She has a bulge located on the superficial part of her abdomen. When the patient tenses her rectus muscles by raising her head, the swelling becomes more tender and distinct on palpation. The US shows a mass of the abdominal wall. What is the diagnosis?

Answer 17

abdominal wall (rectus sheath) hematoma

Question 18

which hernia passes through the deep and superficial rings (internal inguinal ring)?

Answer 18

indirect inguinal hernia

Question 19

which hernia goes through Hesselbach’s triangle?

Answer 19

direct inguinal hernia

Question 20

what are the 2 disease processes that originate from a patent process vaginalis?

Answer 20

hydrocele
indirect inguinal hernia

Question 21

a young man in high school has a recurrence of a painful mass in the midline, above his gluteal folds. on exam, we see some midline pits and some protruding hair without masses, fluctuance, tenderness, or redness. what is the diagnosis? what is the next step?

Answer 21

pilonidal disease

benign conservative treatment (d/t no issues)

Question 22

a 30 yo female presents with bloody diarrhea, abdominal discomfort. colonoscopy shows colitis in the descending colon. the gastroenterologist takes a biopsy and diagnoses the patient with Crohn’s disease. what finding on colonoscopy + biopsy would be consistent with Crohn’s disease on pathology?

Answer 22

noncaseating granulomas

Question 23

what is the cut off for carcinoid tumor of the appendix that separates from benign and malignant?

Answer 23

< 2cm is likely benign

Question 24

a 23 yr old presents with a spleen injury and is unstable and bleeding in his abdomen. On xray, spleen is in pieces so they did a splenectomy. In clinic 2 weeks later, what should we make sure that he has done?

Answer 24

vaccines against encapsulated bacteria

Strep pneumo
H. flu
Meningococcus

Question 25

a patient presents with a small bowel obstruction, most likely from adhesions. the NG tube is suctioning and patient is doing better. When he came in, he had a foley and urine output over the last 10 hours is 20cc/hour, is this appropriate, low or high? what should we provide this patient with?

Answer 25

low fluid bolus

Question 26

a patient rectum is biopsied and the pathology shows carcinoid tumor. what are the symptoms associated with carcinoid syndrome?

Answer 26

arrhythmias bronchospasms hot flashes

Question 27

a patient presents to ER with left lower quadrant pain, fever, and vomiting. their CT scan shows a thickened sigmoid colon with inflamed diverticula that is large with a 7cm fluid collection in their pelvis. Dx? what is the treatment if the patient is stable (2)?

Answer 27

complicated diverticula antibiotics percutaneous drain

Question 28

a patient presents to ER with left lower quadrant pain, fever, and vomiting. their CT scan shows a thickened sigmoid colon with inflamed diverticula that is large with a 7cm fluid collection in their pelvis. they receive antibiotics and percutaneous drain. 1 month later, he is asymptomatic. what should we do for this patient?

Answer 28

colonoscopy in 6 weeks

Question 29

a patient presents to ER with left lower quadrant pain, fever, and vomiting. their CT scan shows a thickened sigmoid colon with inflamed diverticula that is large with a 7cm fluid collection in their pelvis. they receive antibiotics and percutaneous drain. 1 month later, he is asymptomatic so we do a colonoscopy in 6 weeks, which shows 1 large diverticula in the sigmoid colon. The patient is scared it will happen again, what should we recommend?

Answer 29

refer to surgery for possible sigmoid resection

Question 30

a patient presents with Crohn's disease and they ask in what situation they would need an immediate colectomy?

Answer 30

acute abdomen

Question 31

what does imaging show to indicate an acute abdomen? what does physical exam show to indicate acute abdomen? (3)

Answer 31

free air rigidity rebound tenderness guarding

Question 32

a patient with anal cancer; poorly differentiated squamous cell carcinoma. What is the treatment?

Answer 32

radiation + chemotherapy

Question 33

what is the best purpose of a CEA in a patient with adenocarcinoma of the colon? treatment?

Answer 33

looking for reoccurrence surgery

Question 34

where does a post-pyloric feeding tube go?

Answer 34

duodenum

Question 35

what is the 2nd most common cause of small bowel obstruction? 3rd most common?

Answer 35

bowel-containing hernia cancer

Question 36

if a patient has had a splenectomy, they will need clotting prophylaxis. what should we put them on?

Answer 36

aspirin

Question 37

what disease process is an ERCP typically used for?

Answer 37

choledocholithiasis

Question 38

what is the most likely complication of an ERCP?

Answer 38

pancreatitis

Question 39

what other imaging can be used if we want to assess a patient's biliary tree but they have a contrast allergy?

Answer 39

MRCP

Question 40

in general, how long should surgery be postponed after an MI?

Answer 40

> 6 months

Question 41

fibers located in the walls and capsules; pain is slow in onset, dull, poorly localized and protracted

Answer 41

visceral pain

Question 42

described as more acute, sharper, better localized pain sensation

Answer 42

parietal pain

Question 43

what does a tensely distended abdomen with an old surgical scar indicate?

Answer 43

adhesions; small bowel obstruction

Question 44

what does a scaphoid contracted abdomen indicate? (abdomen is sucked inwards)

Answer 44

perforated ulcer

Question 45

what does visible peristalsis indicate?

Answer 45

advanced bowel obstruction

Question 46

what does a soft doughy fullness indicate on abdominal exam? (2)

Answer 46

early paralytic ileus mesenteric thrombosis

Question 47

what does an everted umbilicus indicate?

Answer 47

increased intra-abdominal pressure

Question 48

what should we rule out if air is not seen in the stomach and colon?

Answer 48

gastric outlet obstruction

Question 49

what imaging should we order to identify the need for early NG tube placement?

Answer 49

plain film xray

Question 50

where is air not normally seen and if present, we should rule out an ileus or obstruction?

Answer 50

small intestine

Question 51

what causes ischemia, bowel wall necrosis, and perforation?

Answer 51

strangulated bowel

Question 52

what are the 3 most common causes of a large bowel obstruction?

Answer 52

cancer diverticular stricture volvulus

Question 53

why should diabetic patients taking oral hypoglycemic agents like metformin hold their dose 24 hours prior to and after IV contrast?

Answer 53

IV contrast is nephrotoxic and can lead to lactic acidosis

Question 54

what is the best indicator of fluid volume status?

Answer 54

urine output

Question 55

what is the treatment for a postop patient with hyponatremia?

Answer 55

free water restriction

Question 56

what is the treatment for a postop patient whose urine output is decreased?

Answer 56

IVF bolus

Question 57

short-term feeding tube that is post pyloric (Dobhoff tube)

Answer 57

duodenal/jejunal nasoenteric tube

Question 58

placed to decompress the stomach, relieves nausea and vomiting, can be placed pre-op if patient ate within 6 hours of surgery and commonly placed in patients with ileus or obstruction

Answer 58

gastric tube (NG tube or OG tube)

Question 59

a lactating patient presents with cellulitis around her nipple. what are the 2 most likely organisms? Dx? treatment? (3)

Answer 59

staph aureus / strep acute mastitis antibiotics moist heat continue breastfeeding

Question 60

a female patient presents with a raised tender mass near her nipple. She also has a fever, chills, sweats, and leukocytosis on CBC. Dx? treatment? (3)

Answer 60

breast abscess stop breastfeeding admit + IV antibiotics I&D in the OR

Question 61

what is the name of the system used to categorize patients who have done imaging of their breast? what are the categories and numbers?

Answer 61

BI-RADS category 0 - more imaging needed 1 - negative / normal 2 - benign findings 3 - probably benign 4 - suspicious 5 - highly suggestive of malignancy 6 - biopsy proven malignancy

Question 62

resembles pulmonary edema that does not respond to diuretics and is an inflammatory reaction. Dx? treatment?

Answer 62

acute respiratory distress syndrome mechanical ventilation

Question 63

a patient with a history of long bone/pelvic fracture presents with respiratory insufficiency, neurological changes (confusion, coma), and petechiae. Dx? treatment? (3)

Answer 63

fat embolus positive pressure ventilation diuretics external fixation or ORIF

Question 64

how does a fat embolus occur?

Answer 64

fat globules from marrow migrate into pulmonary capillary bed

Question 65

what is the most common cause of c. difficile pseudomembranous colitis? what are 2 treatment options?

Answer 65

antibiotics vancomycin or metronidazole

Question 66

the most severely damaged area in a thermal injury; the zone of coagulation where cells int he area are coagulated or necrotic and the tissue must be debrided

Answer 66

central zone

Question 67

the zone that has vasoconstriction and ischemia; the tissue is initially viable but may be converted to coagulation

Answer 67

zone of stasis

Question 68

the zone that has vasoconstriction and typically remains viable

Answer 68

zone of hyperemia

Question 69

burns that extend through the epidermis and into the papillary dermis; blistering is the hallmark

Answer 69

second degree / partial thickness

Question 70

a patient presents with a burn that is pink, moist, and painful. Dx? how does it heal?

Answer 70

superficial partial thickness (2nd degree) heals within 2-3 weeks without scarring or functional impairment

Question 71

a patient presents with a burn that is mottled pick and white, dry, and variably painful. Dx? how does it heal?

Answer 71

deep partial thickness (2nd degree) heals in 4-8 weeks with severe scarring and loss of function

Question 72

what is the treatment for a partial thickness burn (2nd degree) that has not healed by 3 weeks?

Answer 72

surgical excision + skin grafting

Question 73

burn that extends through the entire dermis and into the subcutaneous tissues.

Answer 73

third degree / full thickness

Question 74

a patient presents with a burn that is white/black, dry, and painless. upon palpation, the burn does not blanch with pressure. Dx? treatment?

Answer 74

full thickness burn (3rd degree) surgical excision + grafting

Question 75

what is a complication of burns that can impair circulation? what causes it? treatment?

Answer 75

circumferential burns / compartment syndrome capillary leak = tourniquet effect escharotomy

Question 76

a complication of burns is hypermetabolism. what can be used to decrease catabolism?

Answer 76

beta blocker

Question 77

what is the formula used to resuscitate a patient who has suffered severe burns? calculate the total volume needed per hour for a patient that weights 100 pounds and TBSA is 25.

Answer 77

parkland formula 4ml (TBSA) (body weight in kg) 4ml x 25 x 45kg = 4,500 mL / 8 hr = 563 mL/hr x 8 hours

Question 78

calculate the target urinary output for a patient that weighs 100 pounds.

Answer 78

0.5 mL/kg/hr 0.5 x 45 = 22.5 cc/hr

Question 79

an electrician presents with burns on his body and entry and exit wounds on noticed on PE. Dx? management (3)?

Answer 79

electrical injury admit to burn unit continuous cardiac monitoring fluid resuscitation

Question 80

what is the first line imaging for a patient that presents with a decreased level of conciousness?

Answer 80

CT

Question 81

what is the treatment for a patient that presents with elevated intracranial pressure while they are on their way to the OR? (4)

Answer 81

elevate head of bed elevate injured extremity secure airway hyperventilate if possible herniation

Question 82

at what GCS score does a patient need to be intubated?

Answer 82

GCS 8

Question 83

what is our main concern with a TBI?

Answer 83

preventing seizures

Question 84

being awake vs asleep vs comatose

Answer 84

arousal

Question 85

seeing a blue circle vs a red triangle

Answer 85

awareness

Question 86

awake and immediately responsive to stimuli

Answer 86

alert

Question 87

less alert by still responds to stimulation

Answer 87

stupor

Question 88

appears asleep but still responds to noxious stimuli

Answer 88

obtunded

Question 89

arousal without awareness

Answer 89

vegetative

Question 90

rupture of veins in the brain

Answer 90

subdural hematoma

Question 91

rupture of the middle meningeal artery and presents with a lucid interval

Answer 91

epidural hematoma

Question 92

a patient presents with pain that radiates to the back, crepitus, tachycardia, tachypnea, dyspnea, and hypotension. Dx? imaging (4)? treatment (2)?

Answer 92

spontaneous perforation of esophagus (boerhaave syndrome) xray esophagogram CT thoracentesis broad spectrum antibiotics surgery

Question 93

what is the most sensitive test for carcinoma of the esophagus?

Answer 93

endoscopic ultrasound

Question 94

what is the treatment for a bleeding duodenal ulcer? (2)

Answer 94

ligation of bleed + pyloroplasty

Question 95

what is the treatment for a gastrinoma AKA zollinger-ellison syndrome)?

Answer 95

surgical resection

Question 96

continuous mucosal inflammation limited to the colon that begins in the rectum and progresses proximally, without granulomas

Answer 96

ulcerative colitis

Question 97

deeply ulcerating leading to fistulas, strictures, and the ulcers look like a bear claw; with the presence of granulomas

Answer 97

crohn disease

Question 98

what does iron deficiency anemia indicate until proven otherwise?

Answer 98

colon cancer

Question 99

what is the treatment for anal cancer that is T1 or early T2 lesions?

Answer 99

wide local excision

Question 100

what is often related to infertility in men?

Answer 100

varicocele

Question 101

patient presents with extreme testicular pain with nausea, vomiting, and sweating. They have spent the last 2 days moving to their new house. on PE, there is tenderness in the inguinal canal. Dx? imaging? 2 treatment options?

Answer 101

testicular torsion ultrasound w/ doppler orchiopexy if viable orchiectomy if ischemic

Question 102

what is the imaging of choice for choledocholithiasis?

Answer 102

ultrasound

Question 103

patient presents with abdominal pain and elevated serum amylase/lipase. Dx? treatment for mild and severe?

Answer 103

acute pancreatitis lap cholecystectomy - mild ERCP +/- endoscopic sphincterotomy - severe