Final Exam Flashcards by Michael Matheney

72 year old man scheduled to undergo robotic prostatectomy for adenocarcinoma of the prostate. PMH is unremarkable and he takes no meds. What is he best management to reduce the risk of thromboembolic complications?

Subcutaneous LMWH

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62 year old woman with morbid obesity, DM, HTN, CKD, undergoes elective right hip replacement under general anesthesia. What is the primary goal of postoperative fluid management in this patient?

She should be maintained at euvolemia

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28 year old woman who is G1P0 and is 20 weeks into pregnancy presents with a 2cm, hard, nontender mass in the upper outer quadrant of her left breast. She first noticed the mass a month before she got pregnant. It has been enlarging for the past two months. What is the proper form of management?

Excisional biopsy of the mass

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42 year old man referred for enlarging reducible inguinal hernia. He has a history of cirrhosis and hepatitis c. You are trying to assess the level of associated risk with his liver disease. What are the components of the meld score important for this patient?

Bilirubin

INR

Creatinine

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A 68 year old man is seen in clinic with a right reducible inguinal hernia that is uncomfortable at times. He has a history of HTN and suffered an uncomplicated anterior wall MI that was fixed with Thrombolytic therapy. He has been on BBs, statins, and aspirin. Regarding hernia repair in this patient, what is the most appropriate Decrease his risk of cardiac complication?

If possible, surgery should be postponed for 6 months following complication

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An 82 year old man undergoes a screening colonoscopy and is found on biopsy to have adenocarcinoma of the sigmoid colon. PMH is significant for HTN and dilated cardiomyopathy. What finding is most likely to increase his risk of peri operative complications?

Audible S3 gallop

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A 52 year old woman with insulin dependent DM is scheduled to undergo a bilateral mastectomy with sentinal lymph node biopsy at 730 AM. Peri operative glucose management of his patient is best achieved with what?

Half the usual dose of long acting insulin the morning of surgery

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32 year old woman presents to the Ed with an incarcerated ventral hernia. She has ESRD and undergoes dialysis 3 days a week. She underwent surgery for a perforated duodenal ulcer 2 years ago. On physical exam she has a tender, nonreducible mass in the midline of her epigastric incision. Emergency surgery is planned. What drug is most likely to produce life threatening Hyperkalemia in this patient?

Succinylcholine

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A 72 year old man presents to the clinic to discuss the risks associated with CABG. The term informed consent refs to what?

The process wherein the patient and surgeon decide on a plan

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You are in the preoperative evaluation clinic seeing patients scheduled for surgery. Who should have an EKG?

55 year old hypertensive man being evaluated for CEA

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A 46 year old woman underwent a total thyroidectomy for a multinodular goiter. On he second postop morning she complains of Perioral tingling and numbness at her fingertips. The most likely additional finding in this patient will be…

Carpopedal spasm

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A 36 year old woman underwent a totally parathyroidectomy for Hyperparathyroidism and had 2 hyperplastic adenomas removed. One half of the right inferior gland was implanted on the SCM muscle. On pod 1, she complains of generalized muscle clamps and she is slightly confused. What is the most likely diagnosis?

Severe Hypocalcemia

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A 63 year old woman had a celiotomy for recurrent bowel obstruction. One week postop she develops a high output enterocutaneous fistula. Subsequent evaluation indicates the fistula involves her distal small bowel. The most appropriate fluid for replacing loss from a fistula is…

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A 38 year old woman recovering from a lap choley returns to the office on pod 5 complaining of RUQ pain. She is mildly jaundiced. Subsequent workup suggests a bile leak and percutaneous drain is placed after an ERCP is unsuccessful. Over the next 24 hours, almost 600 ml of bile colored fluid is collected from the drain. The electrolyte composition is closest to what?

Na 130; CL 100; k 4; bicarbonate 25

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A 68 year old woman underwent a subtotal gastric resection for a distal gastric cancer. Her stomach was reconstructed with a gastrojejunostomy. On pod 3, a large amount of bilious drainage is noted to be coming from a drain placed in her RUQ. This most likely represents what?

A biliary leak from a duodenal stump

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A 2 week old boy is brought to the Ed because of nonbilious vomiting, lethargy, and low UOP. The boy is somnolent. His abdomen is nontender. US shows a hypertrophied Pylorus. The most likely metabolic derangement is…

Hypochloremic, Hypokalemic, metabolic alkalosis

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A 17 year old girl with anorexia Nervosa is admitted to the hospital for total Parenteral nutritional support. Two days after the start of her treatment, she experiences proximal muscle weakness with visual changes. The patient most likely has…

Hypophosphatemia

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A 34 year old man is admitted for surgery for a perforated appendix. He has diabetes that he controls with oral medications. During the preop work up he is noted to have a severely elevated glucose and his serum sodium is 124. The Hypernatremia should not be treated initially because with hyperglycemia…

Measured serum sodium concentration decreases as a response to the dilution created by the osmolarity gradient created by an increase in serum glucose

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A 28 year old man is admitted following a motorcycle crash in which he sustained a fractured left tibia, multiple left rib fractures, and a head injury. One week after the surgery he is suspected of having SIADH because of dependent edema and a persistent low UOP in spite of normal vital signs. He has a serum sodium of 130 and his Hgb and hematocrit have decreased to 9.2 and 28% respectively. The most appropriate treatment for suspected SIADH would be…

Water restriction to less than 1000ml per day

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A 40 year old man comes to the Ed with a 4 day history of N/V. He has burning abdominal, epigastric pain for at least one week. He takes BBs for HTN. His temp is 37.5 degrees Celsius, bp on admission is 110/90, his pulse is 95, and rr is 14. He weighs 80 kg. What lab test would provide the most assistance in diagnosing this patient?

Serum electrolytes

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You are currently treating an 85 kg, 20 year old female who is 5’4’’ for perforated duodenal ulcer and sepsis. This patient is classified as…

Obese- high risk of nutritional deficiency

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What is the nutritional value of food sources from lowest to highest?

Lipids, proteins, carbs

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Where are most oral meds absorbed at?

The duodenum

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A 37 year old man is admitted to the hospital with a history of abdominal pain, dehydration, and HTN. He is found to have a perforated gastric ulcer and undergoes a partial gastrectomy. He is started on TPN on postop day 2 and over the next 3 days develops anemia and respiratory distress. What is the most likely caus of his symptoms

Reeding syndrome

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A 53 year old man presents with diffuse diarrhea and a fever. He is currently undergoing nutritional replacement via tube feedings because of gastric outlet obstruction. The possible causes for his disease include infectious or complications from the tube. What would indicate that this diarrhea is a result of tube feedings?

High osmolarity feedings

A 42 year old woman transitions from PN to EN and she is requiring approximately 1900kcal/day. He nurse caring for her wishes to know when they will stop the PN. Her PN can be safely stopped when her EN caloric intake reaches what percent of her PN?

66%

A 45 year old man has a history of gastric outlet obstruction secondary to ️Chronic ulcer disease and is referred to you for treatment. He is 5'9 and weighs 135 lbs. He has lost 25% of his body mass over the last three months and needs nutritional reflection. What are his calculated body weight and caloric needs?

160 lbs/ 1545kcal

Patients who require blood transfusions are at the greatest risk for what infection?

HBV

A 40 year old man is known to have Von Willebrand disease. He undergoes and appendectomy and has ongoing ️Bleeding at he surgical site which persists despite the application of pressure. The best treatment option at this time is the administration of what..l

Cryoprecipitate

Woman scheduled for a hysterectomy is taking a number of Otc supplements. Which one is associated with increased ️Bleeding?

Garlic

A 55 year old male with severe symptomatic anemia after GI ️Bleeding is rapidly transfused with 3 units of PRBC. He begins to experience severe muscle cramps. The most likely finding on an EKG would be...

Prolonged QT interval secondary to ST segment elongation Due to citrate binding up the calcium

A 75 year old woman is 3 days post total right knee replacement. She develops left leg swelling and a duplex ultrasound confirms a left DVT. She is started on LMWH she begins to develop nosebleeds, bleeding from her IV site, and some bleeding from her wound. What is the best test to assess bleeding in ibis patient?

Anti Xa activity We know the pt is going to be elevated

A 22 year old man crashed his motorcycle into a tree and is brought to the Ed. He was unconscious and intubated at the scene. Two large bore IVS were placed and infusions of 2L normal saline were administered en route to the Ed. On arrival to the Ed, his BP is 80/40 and his pulse is 130/min. He has a flail chest on his right side. Chest tube was placed and yielded 500mL of blood. His abdomen is tender and a focused abdominal sonography for trauma shows a lot of fluid in his abdomen. His pelvis is unstable, and he has severe deformities of both femurs and a compound fracture in his right leg. What is the optimal use of blood product transfusion for this patient?

Initial transfusion of RBCs, FFP, and platelets in a 1:1:1 ratio may improve his outcome

A 72 year old woman has acute respiratory failure as the result of a head injury. What intervention can help prevent ventilator-associated pneumonia?

Keeping the head of th bed elevated

A 52 year old woman in the sicu following a motor vehicle rash develops AKI with ruptured spleen a Nd hemorrhagic shock. What finding is an urgent indication for renal replacement therapy?

Hyperkalemia

A 45 year old man presents with the acute onset of dyspnea and chest pain. PE is confirmed by the CT angiogram. He has a history of HIT. The most appropriate manage to initially includes...

Argatroban -Direct thrombin inhibitor

A 70 year old woman is brought to the ICU with respiratory failure after undergoing a sigmoid resection for perforate diverticulitis. Which ventilator mode would assume the most work of breathing?

Assist control ventilation

A 56 year old man develops ARDS after a bowel resection for ischemic bowel. With an FiO2 of 50% and PEEP of 5,Chris pao2 is 52 torr. What would increase his oxygenation?

Increasing the peep

A 45 year old man with a history of IBD requiring steroids has been admitted to the ICU following a high-speed motorcycle accident. On his fifth post operative day following a splenectomy and bilateral internal fixation for femur fractures,he develops hypotension refractory to 3000ml IV saline Bolus and dopamine infusions. He is afebrile. O2 sats on room air is 96%. Lab studies are notable for Hcrt 36, Na 120. Chest ct is normal. What the fuck do you do

Give hydrocortisone

A variety of patients were evaluated for surgery. Which one is peri procedural antibiotics considered standard care of issue?

A patient who requires an open repair of an abdominal aortic aneurysm

A patient with seen right before his hemicolectomy needs IV prophylactic antibiotics when?

One hour before his surgery

What is the recommended treatment protocol to prevent tetanus?

Administration of 0.5 ml absorbed tetanus toxin

GCS score on woman who moans, opens eyes to painful stimulation, and has Decorticate posturing

Man falls from a ladder and sustains rib fractures and a splenic laceration. His physiologic state is beset described as

Class III hemorrhagic shock

Girl with very complicated burn calculation

45%

Burn area least painful to a patient

Hands

Woman who's sleeve caught fire and has circumferential burns on her forearm. What would provide the best functional and cosmetic outcome for the patient

Tangential excision and full thickness grafting

If you were to follow Scarpa's fascia Medially to the scrotum, it would turn into what structure?

Dartos fascia

Signs and symptoms most consistent with an Obturator hernia would be

Intermittent bowel obstruction

Operative report says richters hernia. What was the most likely finding at a time of first hernia repair?

A non circumferential incarceration of the bowel wall

Man with left sided inguinal hernia and history of previous surgery. What repair is a relative contraindication?

Total Extraperitoneal laparoscopic surgery

Man has an epigastric hernia.what is the diagnosis

Dia stasis recti

Man with Barrett's esophagus and low grade dysplasia. Management of this patient should be to

Repeat endoscopy in 6 months with repeat 4 quadrant biopsy of the Barrett's

Man has early stage 1 esophageal adenocarcinoma and history of some crazy surgical shit. The best treatment plan for this patient is

A trans hiatal esophagectomy with gastric pull up

What is the mechanism of action of sibutramine and what are its associated side effects?

SSRI; HTN

Pt comes in with a gastric ulcer that is negative for malignancy but isn't responding to medical management. What therapy is most appropriate for this patient?

Antrectomy with Truncal vagotomy

Woman has history of epigastric pain and nausea without vomiting. She's had an ant rectory with vagal Myotomy and biliroth I reconstruction for treatment of a non healing pyloric ulcer. What drug would be most useful for this patient?

Cholestyramine

What best characterizes small bowel absorptive function?

Is closely linked to Na-coupled nutrient absorption

Man with FAP has a proctocolectomy and his family asks where an affected relative might develop an extra colic malignancy?

Periampullary duodenum

65 year old man presents to the hospital with occasional bouts of hematochezia. Best step to Id the location of this bleed at this time is...

Technetium-labeled RBC scan

Man who farts out of his penis. What work up should be done

Ct scan

Man presents with a large gallstone in the neck of the gallbladder and surrounding inflammation involving the CBD. What is the most likely diagnosis

Mirizzis syndrome

Pt presents with the signs of a gastrinoma. What is the most likely location

Descending duodenum

A pancreaticoduodenectomy is planned. In addition to the gastroduodenal artery, what additional artery must be ligated to complete the procedure?

Inferior anterior pancreaticoduodenal artery

Pt has pancreatic cancer with a liver metastasis and a bile duct Hamartoma. What is the best procedure to do at this time?

Pancreaticoduodenectomy "Whipple procedure"

Pt with Hepc has a 7 cm mass in his liver. Is not Cirrhotic in appearance and biopsy shows minimal ️fibrosis. Best course of action?

Resection

Pt with cirrhosis is brought to the Ed after vomiting blood. Has undergone banding for esophageal varices in the past with no relief. Next step in management?

Trans jugular Intrahepatic portocaval shunt

Woman has nausea and bloating and is found to have a cystic lesion in the liver. Has a thick wall and multiple septations. What is the diagnosis and management?

Cystadenoma ; resection

Man arrives in trauma bay with grade III liver laceration, multiple rib fractures, and a right lower lung contusion. No free air on abdominal ct. What is the best way to monitor the liver injury?

Observation with close monitoring

What pharmacologic medication is used to treat liver failure with asterixis?

Lactulose

Woman with painful and swollen nipple who treated it with warm compresses and ejecting yellow fluid. What is the best management for this now.

Antibiotics followed by excision of the subareolar ducts and fistula tract

Woman with Breast cancer. What's her stage?

III

What is the best way to follow someone with Amradax therapy?

History and physical examination every 6 months and an annual mammogram

Man has a gastrinoma in his pancreatic tail. Prior to the pancreatectomy, what lab test is most appropriate?

Calcium

Woman has thyroid cancer but her mother had history of Tumors in her pancreas and in her adrenal glands. Her serum calcitonin is elevated. What other test do you need?

Urinary Catecholamines

Pt after being in a MVCbis discovered to have an adrenal mass. Gives dimensions and says it has regular borders. What is the next step in management?

Repeat ct

Pt has recurrent ITP. When is the best time to giver her a pneumococcal vaccine?

2 weeks before splenectomy

Pt has a low platelet count and is oozing from puncture sites and is also about to go get a splenectomy. When is the best time to administer platelets?

After the splenic artery has been clamped

Pt is having ️Chronic leg ulcers that aren't healing and she also has RA and HTN. Takes some crazy drugs and also has neutropenia. What is the next best step in management

Splenectomy

Pt had a splenectomy following an accident and has tibia and fibula fractures. He is intubated. When is the best day to administer the pneumococcal vaccine?

On the day of hospital discharge

What factor is the highest risk for development of an AAA?

Personal history of an elective popliteal aneurysm repair

Woman keeps a blood pressure diary and they are all elevated. PE shows a carotid bruit. Also gives bun and creatinine as normal. What is the most likely diagnosis?

Fibromuscular dysplasia of a renal artery

Pt with aorta femoral claudication needs what in addition to smoking cessation?

Bilateral aorta femoral bypass

Donor is identical twin. What Immunosuppresion is needed?

None

Pt on Immunosuppresants after a transplant includes tacrolimus, okt3, prednisone,band Mycophenylate. He develops HTN, tremors,band increased LFTs due to which one?

Tacrolimus

What is the longest time a liver can be kept on ice without ischemic injury

18 hours

What is the MOA of Alemtuzumab

Depletes t and b lymphocytes

Man with chronic renal failure is being evaluated for transplant. What is the best immunologic test to detect antigens from the cellular arm of the immune response in this patient?

Mixed lymphocyte culture

Man with ️Decreased glucose tolerance is on many immunosuppresants. Which one is causing this?

Tacrolimus

Boy getting a lung transplant from his brother with a six antigen match. What is the best immunosuppressive regimen?

Combination

What best describes Moh's therapy for skin cancer?

A specialized surgical technique used to excise skin cancers in areas where there is a need to preserve normal tissue

Pt with a suspicious mass in his neck and has a history of SCC in his left cheek. PET is suspicious. What do you do?

FNA

73 year old woman just had a hemicolectomy for cecal adenocarcinoma. Abdomen is progressively distending and her vital signs are showing signs of shock. She is rushed back to the or where 1500ml of blood is found in the abdomen. Why?

Inadequate surgical Hemostasis during the first operation

43 year old man is in the ICU for acute pancreatitis and his blood pressures will no raise. His fluid balance is fifteen liters positive and his abdomen is tense with a pressure of 30. What is the principle cause of his ongoing hypotension?

Venous return

Pancreatitis question with bit chart of la values

Three liters of isotonic crystalloid

ETCO2

Should be about 40 Tells you your endotracheal tube is in the right spot Is not a substitute for pco2

Diffuse axonal injury

️Occurs after angular trauma Will have loc Dx: ct scan with loss of gray/white division Tx: You dead bruh

Tx of ️Cord compression

Dexamethasone Presents as urinary or bowel incontinence or erectile dysfnxn

Man with inguinal hernia repair. 2 weeks out, with a normally healing wound, what would be seen on biopsy?

Predominately collagen with scarce inflammatory cells

Postop antibiotic regimen for a guy who got Cefoxitine before hand

There is no need

Man who has signet ring cells on gastric ulcer biopsy. What should his diagnostic workup include?

Diagnostic laparoscopy

Boy hit his stomach on a bicycle. Mom says a year to a ct scan showed malrotation. What does this kid have?

Midgut Volvulus

What fistulous complication of Crohn's often requires surgery?

Enterovesical

35 year old woman in clinic because of diarrhea after meals and progressive weight loss for the last 6 months. She has Crohn's disease and has had multiple operations. What post surgical scenario might be most consistent with short bowel syndrome as en etiology for her symptoms?

Less than 60cm of small intestine preserved

43 year old woman has small intestinal tumor. You are discussing the embryologic origins of tumors with her. You suspect that her tumor has arisen from the APUD system. What lesion is the most likely diagnosis?

Carcinoid tumor

83 year old Asian man with history of recurrent gallstones presents with fever, jaundice, RUQ pain. Treatment includes...

Resuscitation, IV abx, and urgent ERCP to relieve the bile duct obstruction

62 year old man comes in because his eyes are yellow. PMH is notable for HTN and obesity.elevate ALK phos, bilirubin, and LFTs. What's he got?

Choledocholithiasis

Pt wants to know benefits from open and laparscopic cholecystectomy. She should know that

Laparoscopic cholecystectomy can be safely performed in patients who have had open abdominal surgery

29 year old pt has had know gallstones since her last pregnancy 2 years ago. Her lab results reveal an elevated ALK phos, bilirubin, and LFTs. After administering IV meds for pain and nausea, what is the most reasonable next step?

ERCP w/ sphincterotomy and gallstone removal if labs don't improve

Biggest rf for developing gallstones

Female gender

Woman with hep c and severe emphysema is found to have hepatocellular carcinoma. Why can't she get a liver transplant?

Severe pulmonary disease

Woman has a partial mastectomy and lymph node biopsy of her Breast. She is complaining of numbness and tingling in the posterior aspect of her upper left arm. Injury to what explains her symptoms?

Intercostal brachial nerve

Woman has a tender lesion in her Breast that is hypoechoic. The next best step in management is to...

Aspirate the lesion

67 year old man in the Ed with back pain and abdominal pain. 2 weeks ago he was diagnosed with an AAA during a CT for a kidney stone. What is the best management for the patient at this time and the rationale?

Endovascular repair since it is associated with improved survival compared open AAA repair for a ruptured AAA

Man is considering a heart transplant. If he is compliant with his Immunosuppresion,what is the 1 year survival rate

80%

Question asks for TNM staging

T1bN0M0

Pt has been in the trauma ICU getting antibiotics for 42 days. He's scheduled for surgery but has an elevated pt and PTT. Why?

Vitamin k deficiency

Pt has a clot in his femoral vein and is found to have protein c resistance. What best explains these findings?

Factor V neutralization is impaired

Woman is in the ICU for hypotension and respiratory failure. Sputum sample shows gram pos cocci in chains and x ray shows lobe consolidation. The principle reason for the increase in Hgb is plasma volume depletion from...

Diffuse interstitial fluid accumulation

Woman in the ICU has been on a ventilator for 6 days. Has a central line but no IV. Also has e.coli. The most likely source for the infection is the...

Urinary tract

37 year old man admitted to the burn unit 6 hours after sustaining 60% TBSA full and deep partial thickness burns. What is the best choice for preventing burn wound sepsis in this patient?

Excision and grafting within 5-7 days of the injury

76 year old woman in the hospital recovering for 10 days following an emergency laparotomy for a perforated diverticulum. On POD 5 she developed a wound infection and the skin staples were removed. Which of the following places her at greatest risk for incisional hernia formation?

Wound infection

Most useful test to diagnose T stage of a mans esophageal tumor

Endoscopic ultrasound

38 year old man presents to the ER complaining of abdominal pain, Nausea, non-bilious vomiting, diarrhea, and palpitations. Recently underwent antrectomy with some biliroth I shit. What drug would be most helpful for this patient?

Somatostatin

Woman has 3 days of abdominal pain and nausea. She has pain in the LLQ. What is the best choice for managing the pt at this time.

Order a ct scan of the abdomen and pelvis

78 year old woman is sent to the Ed from a local nursing home because of pain and distention for the past 12 hours. She has dementia and a history of chronic constipation. An acute abdominal series shows dilated colon loops and no free air. What is the most likely diagnosis?

Colonic Volvulus