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MCCQE1 > General surgery > Flashcards

General surgery Flashcards

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1
Q

Cardiac contraindications of elective surgery

A

EF < 35%

MI < 6 months ago

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2
Q

Smoker who needs an elective surgery. What is the recommendation before going into surgery?

A

Smoking cessation 8 weeks before surgery + nicotine patch

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3
Q

Patient with fever during the surgery.

Dx, tx, and ppx?

A

Malignant hyperthermia

Tx: O2, dantrolene, cool IV

Ppx: Ask personal or family Hx to bad reaction to anesthesia

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4
Q

Patient with fever right after surgery.

Dx, next step, tx?

A

Bacteremia

Next step: Blood culture

Tx: Vancomycin+ piptazo

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5
Q

Patient with fever at POD #1

Dx, next step, ppx?

A

Atelectasis (wind)

Next step: CxR (negative for pneumonia)

Ppx: Incentive spirometry, patient out of bed

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6
Q

Patient with fever at POD #2

Dx, next step, Tx, ppx?

A

Pneumonia (wind)

Next step: CxR (positive)

Tx: Vancomycin+ piptazo

Ppx: Incentive spirometry, patient out of bed

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7
Q

Patient with fever at POD #3

Dx, next step, ppx?

A

UTI (water)

Next step: U/A, urinary culture

Ppx: Foley out ASAP

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8
Q

Patient with fever at POD #5

Dx, next step, Tx, ppx?

A

DVT, PE (walking)

Next step: Dooppler of lower extremities

Tx: Heparin to warfarin bridge

Ppx: LMWH, patient out of bed

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9
Q

Patient with fever at POD #7

Dx, next step, ppx?

A

Cellulitis (wound)

Next step: U/S (negative for an abscess)

Ppx: Sterile field, keeping wound clean

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10
Q

Patient with fever at POD #10–14

Dx, next step, tx, ppx?

A

Abscess (wound)

Next step: U/S (positive for an abscess)

Tx: Abx + incision and drainage

Ppx: Sterile field, keeping wound clean

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11
Q

Patient in POD #3 with chest pain and test suggestive of MI.
Tx?

A

PCI, heparine

tPA is contraindicated

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12
Q

Patient in POD #5 with chest pain, you rule out MI but suspect PE.
What tests you need?

A

ABG, lower limbs U/S, CT scan

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13
Q

Causes of altered mental status in a post-op patient

A

Electrolytes, sundowning (delirium), ARDS, and delirium tremens.

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14
Q

Normal urinary output in a post-op patient

A

> 0.5 cc/kg/hr

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15
Q

Post-op Patient with decreased urinary output who has a distended bladder. Next step?

A

In-and-out cath or foley

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16
Q

Post-op Patient with decreased urinary output with no urine in bladder. Next step?

A

500 cc bolus. If improvement, then hydrate. If no change, then intrinsic renal failure

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17
Q

Post-op Patient with cero urinary output. Next set?

A

Obstruction.

Unkink the catheter

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18
Q

Patient in POD 1-2, no poop, no gas.

Erect KUB shows dilation everywhere. Dx and tx?

A

Ileus

IVF, K, move patient

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19
Q

Patient in POD 5, no poop, no gas. Erect KUB (air-fluid levels, dilation proximal to obstruction). Dx and tx?

A

Obstruction

NG tube, surgery again

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20
Q

Old patient in post op with abdominal distension, no poop, no gas. Erect KUB (normal small bowel, distended large bowel).
Dx, tx?

A

Ogilvie

Rectal tube, colonoscopy

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21
Q

Patient in post-op, loups of bowel pop out of the surgical wound.

Dx, next step?

A

Evisceration

  • Warm saline dressings
  • NEVER push it back in
  • Emergent surgery
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22
Q

Patient with painful jaundice, mild fever, mild leucocytosis, ↑AST, ↑ALT, ↑amylase, (+) murphy.

RUQ U/S showing dilated ducts

Dx, next step, tx?

A

Choledocholithiasis

Next step:
• MRCP

Tx:
• NPO, IVF, IV antibiotics
• Urgent ERCP (Endoscopic Retrograde Cholangio-Pancreatography)
• Elective cholecystectomy

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23
Q

Patient primary sclerosing cholangitis, who has jaundice, no fever, normal WBC, negative murphy, no abdominal pain.

Ct scan shows cholangiocarcinoma.

Next step and tx?

A

ERCP + Bx

Tx: resection

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24
Q

Patient with migratory thrombophlebitis, who has jaundice, no fever, normal WBC, negative murphy, no abdominal pain.

Dx, Next step and tx?

A

Pancreatic cancer

Next step: Endoscopic US with Bx

Tx: whipple procedure

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25
Patient who has jaundice, no fever, normal WBC, negative murphy, no abdominal pain. Negative CT scan, positive fecal blood test, negative colonoscopy Dx, Next step and tx?
Ampullary cancer Next step: ERCP + Bx Tx: resection
26
Patient with stricture of the biliary tree. Tx?
Stenting* *Except if Dx of primary sclerosing cholangitis, in which case the Tx is ursodeoxycholic acid while waiting for liver transplant
27
Alarm sx of GERD
* Nausea, vomiting * Anemia * Weight loss If alarm signs, EGD + Bx
28
Patient with "nocturnal asthma" (wheezing, coughing only at night). Dx, next steps, tx?
GERD Next steps: - If no alarm style: lifestyle modifications and PPI - Alarm sx or no improvement: EGD + Bx - Gold standard: 24-hr pH monitor Tx: - PPI - Metaplasia: High-dose PPI Nissen Fundoplication - Dysplasia: Ablation - Adenocarcinoma: resect - Nissen fundoplication could be used in any context
29
Patient refers knot or ball of food stuck in the GE junction. Barium swallow (bird’s beck deformity) Dx, next steps, tx?
Achalasia Next steps: - Manometry to confirm - EGD + Bx to rule out pseudo-achalasia (cancer) Tx: - Myotomy - Botox or dilation if not a surgical candidate
30
Patient with progressive disphagia Barium swallow (asymmetric mass) Dx, next steps, tx?
Adenocarcinoma Nex steps: - EGD + Bx to confirm - Tx: resection
31
Mallory-Weiss vs Boerhaave’s
Mallory-Weiss: superficial tear in the mucosa of esophagus Boerhaave’s: transmural tear
32
Patient who was drinking this weekend and now is vomiting blood. Dx, tx?
Mallory-Weiss Treat like upper GI bleed - 2 large bore IV - IVF - IV PPI - Type and cross, transfuse as needed - Call GI
33
Patient with Hx of bullimia who is vomiting blood. She has crepitus chest, crunching, rasping sound, synchronous with the heartbeat. Dx, next steps, tx?
Boerhaave’s, potential mediastinitis Dx: - Gastrograffin swallow, if negative… - Barium swallow, if negative…. - EGD Tx: Surgery
34
Patient with colicky abdominal pain, no gas, no stool, Borborygmi sounds, abdominal distension. No peritoneal findings Dx, next steps, tx?
Small bowel obstruction Nest steps: - 1st: upright KUB showing air-fluid levels - 2nd: CT scan Tx: - If incomplete obstruction: NG tube, IVF, K+ management - If complete: Surgery If develops peritoneal sings: Emergent surgery
35
Types of hernias according to location
- Direct: Male adults, goes through the muscle - Indirect: baby males, through the inguinal ring - Femoral: female, under the inguinal ligament - Ventral: Iatrogenic, post-op, failure of fascia to close
36
Management of a hernia
- Reducible: elective sx - Irreducible (incarcerated): Urgent sx - Acute abdomen (strangulated): emergent sx
37
Periumbilical pain, Pain goes to McBurney’s point, Anorexia, N/V Dx
Appendicitis No dx step needed, but CT scan is often performed in real life (not the answer in the test)
38
Flushing, Wheezing, Diarrhea, Right-sided cardiac fibrosis. Dx, next steps, tx?
Carcinoid Next steps: - Urine 5-HIAA - CT scan to identify lesions Tx: resect
39
Patient with Epigastric abdominal pain, Bore to back, Positional (hurts more if lean backwards), N/V. Dx, next steps, tx?
Acute Pancreatitis - Lipase is better than amylase - CT scan is not generally needed (only if enzimes (-) and you’re sure it’s pancreatitis) • Also used for complications -RUQ U/S and triglycerides aren’t for Dx but for etiology (done after Dx is confirmed and tx initiated) Tx: -NPO, IVF, pain meds
40
Patient with acute pancreatitis who despite tx has persistent fever and leukocytosis. Dx, next step, and tx?
Abscess Next step: CT scan Tx: abx, drainage
41
Patient with acute pancreatitis who has early satiety, weight loss, and pain, and ascites. CT scan shows pseudycyst < 6 cm Tx?
Uncomplicated pseudocyst Tx: Wait as it will likely resolve
42
Patient with acute pancreatitis who has early satiety, weight loss, and pain, and ascites. CT scan shows pseudycyst > 6 cm Tx?
Complicated pseudocyst Tx: Drain
43
Patient with acute pancreatitis who in addition is hypotensive and in shock. Dx, next step, tx?
Necrotizing pancreatitis (poor prognosis) Next step: CT scan Tx: - ICU - Necrosectomy - Carbapenem if infection confirmed by FNA
44
Post-menopausal woman or man of any age with iron deficiency anemia. Dx, next step?
Colon cancer Next step: Colonoscopy
45
Patient with alternating diarrhea, constipation and pencil thing stools. Dx, next step?
Colon cancer Next step: Colonoscopy
46
Patient in whom a colonoscopy shows multiple polyps spread in the colon. Dx, tx?
Familial adenomatous polyposis Tx: colectomy
47
Patient in whom a colonoscopy shows cancer Tx?
CT scan, resection, chemo (folfox) + radio
48
Patient with anal bleeding without pain. You suspect internal hemorrhoid. Next step and tx?
Next step: anoscopy Tx: banding
49
Patient with anal pain without bleeding. You suspect external hemorrhoid. Tx?
Resecting if creams and sits baths don’t work
50
Risk factors and tx of anal cancer
- “Like cervical cancer of the anus;” HPV causing squamous cell carcinoma - Anal receptive sex - MSM - HIV + Tx: chemo and radiation regardless of stage
51
Patient with Colicky abdominal pain, No fever, Normal WBC. Type abdominal pain and examples of causes?
Obstructive E.g., cholelithiasis, nephrolithiasis
52
Patient with Constant abdominal pain, fever, and ↑ WBC. Type of and pain?
Inflammatory E.g., cholecystitis, pyelonephritis
53
Patient in shock, with constant abdominal pain, and motionless. Type of and pain?
Perforation E.g., peptic ulcer disease, cancer, penetrating trauma
54
Patient with Pain out of proportion, Bloody bowel movement, and Sepsis. Dx?
Mesenteric ischemia
55
Causes of RUQ pain
Lung Diaphragm Liver Gallbladder Get U/S
56
Causes of Epigastric pain
``` MI Aorta Esophagus Pancreas stomach ```
57
Causes of LUQ pain
Lung Diaphragm Spleen Get CT + contrast
58
Causes of diffuse abd pain
Constipation DKA Mesenteric ischemia
59
Causes of RLQ pain
Kidney / ureters Ovaries / testes Colon = appendix Get CT + contrast
60
Causes of Supra pubic pain
Bladder | uterus
61
Causes of LLQ pain
Kidney / ureters Ovaries / testes Colon = diverticula Get CT + contrast
62
Stages of legs ulcers
i: non-blanching erythema II: Epidermis and partial dermis III: Through epi and dermis (fascina is exposed) IV: Muscle/bone exposed
63
Bed-ridden, Wheelchair patient with ulcers in the sacrum. Dx, tx?
Compresion ulcer Roll the person q2h, out of bed, air-mattresses, wound care
64
Diabetic patient with ulcer in feet. Tx and ppx?
Tx: - Control DM - Elevate legs - Wound care - Amputate Ppx: - Loose shoes (diabetic shoes) - Inspection - Monofilament test
65
Patient with ulcer on Tips of toes. Hairless legs, Scales, Absent pulses. Dx, next steps, tx?
Arterial insufficiency Dx: - Ankel-brachial infex - Limbs U/S - Angiogram Tx: - Stent - Bypass
66
Patient with ulcer in Medium malleolus. Edema, Hyperpigmentation, and Induration. Dx, tx?
Venous insufficiency Tx: - Compression stockings - Elevate legs - Diuresis
67
Leg ulcer with sinuous track that breaks and heals over and over. Dx, next step, tx?
Marjolin’s (squamous cell carcinoma) Dx: Bx Tx: wide resection
68
Risk factors for breast cancer
- Exposure to estrogen (early menarche, late menopause, nulliparity, hormone replacement therapy) - Hx of Radiation - BRCA 1 and 2
69
55 y-o patient with breast lump. Mammogram is positive. Next step?
Core needle Bx (better than FNA and excisional Bx)
70
24 y-o patient with breast lump. Next step?
Wait 2 cycles to see if ot resolves alone. If not, get a U/S. If positive findings on U/S, perform FNA.
71
Local tx of breast cancer?
Radiation + Surgery • Lumpectomy + axillary lymph node dissection + radiotherapy = mastectomy + axillary lymph node dissection • Do the sentinel lymph node biopsy before doing the axillary lymph node dissection
72
Systemic tx of breast cancer?
Chemo o Doxorubicin o Cyclophosphamide o Paclitaxel Targeted therapy o Her2Neu (+) (bad prognosis): Traztusumab o Estrogen/Progesterone receptors: Pre menopause: Selective estrogen receptor modulators (e.g., tamoxifen) Post menopause: aromatase inhibitors
73
Patient with BRCA 1 or 2 (+). Tx?
Bilateral mastectomy + bilateral salpingo oophorectomy
74
Side effects of tamoxifen?
* DVT | * Endometrial cancer (tamoxifen is estrogen agonist in the uterus)

MCCQE1 (19 decks)

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