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Flashcards in Surgery Deck (247):
0

Most common type of esophageal diverticula?

Pharyngoesophageal ( Zenker's Diverticula)

1

Most common cause of esophageal perforation?

Iatrogenic

2

Most potent physiologic stimulus for pepsinogen release?

Food

3

The highest perforation rate after a caustic esophageal injury occurs during?

Ulceration and granulation phase

4

Surgical management of uncomplicated Barrett's esophagus?

Anti-reflux procedure

5

The most effective surgical treatment for GERD?

Nissen fundoplication

6

Surgical treatment for ACHALASIA?

Heller's myotomy +/- Partial fundoplication

7

Most common primary esophageal motility disorder?

Nutcraker/Supersqueezer esophagus

8

The only tumor virtually restricted to the Parotid gland?

Warthin's tumor (Papillary cystadenoma lymphomatosum)

9

Where are foreign bodies in the head and neck most commonly found?

Ear

10

A deep neck infection may extend down to the mediastinum through?

Substernal space of Burns

11

Most common malignant tumor of the parotid gland?

Mucoepidermoid carcinoma

12

Most common malignant tumor of the minor salivary glands?

Adenoid cystic carcinoma

13

Most common brachial cleft anomaly?

2nd brachial cleft

14

Most common type of malignancy arising from a thyroglossal duct cyst?

Papillary carcinoma

15

Highest perforation rate after a caustic esophageal injury occurs during?

Ulceration and granulation phase

16

Surgical treatment of uncomplicated Barrett's esophagus?

Anti-reflux procedure

17

Most effective surgical treatment for GERD?

Nissen fundoplication

18

Gold standard in the diagnosis of GERD?

24 hour pH monitoring

19

Most common organism responsible for acute otitis externa?

Pseudomonas aeruginosa

20

Most common primary tumor of the middle ear?

Glomus jugulare/ glomus tympanicum

21

Nasopharyngeal carcinoma is best treated by?

Chemo-radiotherapy (Cisplatin/5-FU)

22

Structures preserved in a modified radical neck dissection?

Sternocleidomastoid muscle

Internal jugular vein

Spinal accessory nerve

23

A "butterfly shaped" ulcer involving the hard palate?

Necrotizing sialometaplasia

24

Otologic meningitis is usually due to?

H. Influenza type B

25

Painless mass of the jaw associated with an impacted teeth?

Ameloblastoma (Adamantinoma)

26

Form of mucus retention cyst that involves th sublingual gland?

Ranula

27

Single most important predictor of survival in breast cancer?

Axillary lymph node metastasis

28

Breast cancer type confirmed by the presence of intracytoplasmic mucin?

Lobular CA

"Indian file configuration"

29

Paget's disease may be confused with type of melanoma?

Superficial spreading melanoma

30

Most frequent site of metastasis for breast cancer?

Bone (vertebra)

31

Most important risk factor in the development of breast CA?

Gender

32

The level of axillary lymph nodes are based on this structure?

Pectoralis minor

33

Chronic inflammatory condition of the nipple areola complex that originates from areolar glands?

Hidradenitis suppurativa

34

Epidemic puerperal mastitis is most often transmitted via?

Suckling neonate

35

Kaposi's sarcoma is treated primarily by?

Radiation

36

A rare but aggressive cutaneous malignancy arising from neuroendocrine cells?

Merkel cell carcinoma

37

Tumors arising from areas of previous radiation/lymphedema?

Angiosarcoma (Stewart-Treves Syndrome)

38

Mainstay of treatment for severe necrotizing soft tissue infections?

Wide debridement

39

Gold standard in the diagnosis of Pulmonary Embolism?

Pulmonary Angiogram

40

Most dreaded complication of placing a Swan Ganz catheter?

Pulmonary artery rupture

41

Most common cause of graft loss post kidney transplant?

Recipient death (Cardiovascular causes) - 1st

Allograft nephropathy - 2nd

42

A lethal and rapidly progressive soft tissue infection caused by microaerophilic streptococcus?

Meleney's synergistic gangrene

43

Microsatellite instability is the hallmark of what hereditary cancer syndrome?

Lynch Syndrome (HNPCC)

44

Organism most elevated in primary liver cancer and germ cell tumors?

AFP

45

Most commonly mutated gene in human cancer?

P53

46

Earliest known genetic alteration in colorectal cancer?

APC gene

47

The sudden multiple appearance of seborrheic keratoses?

Lesser Trelat sign

48

Stressed induced hyperglycemia is primarily due to?

Peripheral resistance to insulin

49

Basic caloric requirement of a normal healthy adult?

25 kcal/kg per day

50

Reduced REE is characteristic of this phase of surgical metabolism?

Ebb phase

51

The primary source of energy during the stressed state?

Fat (50-80%)

52

Stressed induced hyperglycemia is primarily due to?

Peripheral resistance to insulin

53

Basal caloric requirement of a normal healthy adult?

25 kcal/kg per day

Mild stress - 25-30
Moderate stress - 30
Severe stress - 30-35
Burns - 35-40

54

A 60-year-old man with carcinoma of the esophagus is admitted with severe malnutrition. Nutritional support is to be initiated. What should be his daily caloric intake?

30 kcal/kg body weight/day

55

Reduced REE (resting energy expenditure) is characteristic of this phase of surgical metabolism?

EBB phase

56

The primary source of energy during the stressed state?

Fat (50-80%)

57

How many kilocalories does Liter of D5LR provides?

170kcal

58

Systemic proteolysis following injury is mediated primarily by?

Glucocorticoids

59

Development of dry, scaly dermatitis and alopecia while on prolonged par enteral treatment is most likely due to?

EFA deficiency

Differentiate VS Zinc deficiency
-----"Eczematoid rash", diffuse/intertrigenous areas

60

A 42 y/o man with small-bowel fistula has been receiving TON within standard hypertonic glucose-amino acid solution for 3 weeks. The patient is noticed to have scaly, hyperpigmented lesions over the acral surfaces of elbows and knees, similar to enterohepatic acrodermatitis. What is the most likely cause of the condition?

Zinc deficiency

61

The most common fluid disorder in surgical patients?

Extracellular volume deficit

62

A 30 y/o man with a history of Crohn's disease of the small bowel is admitted with enterocutaneous fistula. The daily output from the fistula is 2L. The approximate composition of the fluids in mEq/L is which of the following?

Na - 140
K - 5
Cl - 104
HCO3 - 30

63

In cases of persistnt hypocalcemia/hypokalemia, one should request for?

Serum magnesium levels

64

The most important treatment of metabolic acidosis?

Restore perfusion with volume resuscitation

65

Characteristic early acid base picture of sepsis?

Respiratory alkalosis

66

Following an infection, a 68 y/o woman developed gram-negative septicemia. Which statement is true for gram-negative bacterial septicemia?

Adverse changes can be accounted for lipid A release

67

IVF of choice for patients with closed head injuries?

Hypertonic saline

68

The earliest stage of hemostasis?

Vascular constriction

69

The average lifespan of platelets?

7-10 days

70

Inherited platelet disorder of adhesion?

Bernard-Soulier syndrome

71

A 75 y/o man is found to have prolonged bleeding from intravenous puncture sites. Platelet aggregation is inhibited by which of the following?

Aspirin

72

The most common abnormality of hemostasis in surgical patients?

Thrombocytopenia

73

Treatment of choice for patients with Von Willebrand's disease?

Intermediate purity Factor 8/ DDAVP

74

A 24 y/o woman is scheduled for an elective cholecystectomy. The best method of identifying a potential bleeder is which of the following?

A complete history and physical examination

75

The most common indication for blood transfusion in surgical patients?

Volume replacement

76

After undergoing a transurethral resection of the prostate, a 65 y/o man experiences excessive bleeding attributed to fibrinolysis. It is appropriate to administer which of the following?

Aminocaproic acid

77

A 22 y/o man is brought into the emergency department in profound shock after a fall from the fourth floor of a building. After resuscitation, small bowel resection and hepatic segmentectomy are performed at laparotomy. He receives 15 U of packed RBCs, 4 U of fresh-frozen plasma, and 8 L of Ringer's lactate. On closure, diffuse oozing of blood is noted. What is the most likely cause?

Platelet deficiency

78

Most important management of immediate transfusion reaction?

Stop the transfusion

79

A 64 y/o woman undergoing radical hysterectomy under general anesthesia is transfused with 2 U of packed RBCs. A hemolytic transfusion reaction during anesthesia will be characterized by which of the following?

Bleeding and hypotension

80

Shock that occurs in the setting of adequate intravascular volume?

Cardiogenic shock

81

A 30 y/o man is brought to the emergency department following a high-speed car accident. He was the driver, and the windshield of the car was broken. On examination, he is alert, awake, oriented, and in no respiratory distress. He is unable to move any of his four extremities; however, his extremities are warm and pink. His vital signs on admission are HR 54 bpm and BP 70/40 mmHg. What is the diagnosis?

Neurogenic shock

82

The preferred test in the diagnosis of cardiac tamponade?

Echocardiography

83

Persistently elevated base deficit in a trauma patient is usually due to?

Ongoing bleeding

84

First priority in the treatment of trauma?

Ensuring an adequate airway

85

A 32 y/o female falls from the tenth floor of her apartment building in an apparent suicide attempt. Upon presentation, the patient has obvious head and extremity injuries. Primary survey reveals that the patient is totally apneic. By which method is the immediate need for a definitive airway in this patient best provided?

Orotracheal intubation

86

The most common indication for intubation?

Altered mental status

87

Surgical airway of choice in patients with laryngeal fractures?

Tracheostomy

88

An 85 y/o ventilator-dependent male was endotracheally intubated 10 days ago. He remains unresponsive and is not a candidate for early extubation. The intensive care unit (ICU) attending elects to perform tracheostomy at the bedside. During the procedure, copious dark bold is encountered. This is most likely due to transection of which of the following:

Anterior jugular vein

89

Tracheostomy is performed uneventfully in a 79 year old ventilator-dependent encephalopathic male. After several spontaneous breaths, however, the patient stops breathing. The anaesthesiologist continues to assist the patient's breathing for several minutes, after which the patient again breathes spontaneously. The most likely cause of apnea is:

Preoperative respiration was driven by hypoxia

90

Immediate management of patients with tension pneumothorax?

Needle thoracostomy (2nd ICS MCL)

91

Thoracostomy

4th or 5th ICS MAL

92

Tube thoracostomy is employed in each of the following conditions EXCEPT:
A. Total right pneumonectomy
B. Chylothorax
C. Hemothorax from rib fracture
D. Spontaneous pneumothorax
E. After an Ivor-Lewis procedure

A. Total right pneumonectomy

93

A 70 y/o man is brought into the emergency department following his injury as a passenger in a car crash. He complains of right side chest pain. Physical examination reveals a respiratory rate of 42 breaths per minute and multiple broken ribs of a segment of the chest wall that moves paradoxically with respiration. What should the next step be?

Needle thoracostomy

94

Trauma patients with hypotension have lost approximately how much of blood volume?

30-40% (Class III shock)

95

The most reliable indicator for organ perfusion during resuscitation?

Urine output

96

The most common cause of cardiogenic shock/cardiac failure in trauma patients?

Tension pneumothorax

97

Prior to catheterization in stable patients at risk for urethral injury, one should perform?

Urethrogram

98

Gold standard in the diagnosis of presence of intra-abdominal injuries?

DPL

99

Hemobilia is characterized by the triad of?

RUQ pain
UGIB
Jaundice

QUINCKE's triad

100

Most commonly injured part of the diaphragm?

Left hemidiaphragm

101

Duodenal hematoma is best diagnosed by?

Barium/contrast study (coiled spring sign)

102

A 60 y/o man is attacked with a baseball bat and sustains multiple blows to the abdomen. He presents to the emergency department in shock and is brought to the operating room (OR), where a laparotomy reveals massive hemoperitoneum and a stellate fracture of the right and left lobes of the liver. Which of the following, techniques should be used immediately?

Packing the liver

103

The Pringle maneuver is used to control bleeding coming from?

Liver

104

A 33 y/o man presents to the emergency department with a gunshot injury to the abdomen. At laparotomy, a deep laceration is found in the pancreas just to the left of the vertebral column with severance of the pancreatic duct. What is the next step in management?

Distal pancreatectomy

105

Left sided medial visceral rotation

Mattox maneuver

106

Right sided medial visceral rotation

Catell Maneuver

107

Anatomic structure violated in penetrating neck injuries?

Platysma

108

Neck region easiest to evaluate?

Zone II

109

The most sensitive CXR finding suggesting tear of the aorta?

Widened mediastinum

110

The safest way to lower down ICP?

Ventriculostomy

111

Single most important factor predicting burn related mortality?

Burn size

112

Burns that extend into the reticular layers of the dermis?

2nd degree (Deep Partial Thickness Burn)

113

The standard technique for determining burn depth?

Clinical observation

114

Recommended fluid resuscitation solution for burns?

PLR

115

Management of patients with significant intra oral/pharyngeal burns?

Immediate ET intubation

116

The definitive diagnosis of burn wound sepsis can be made by?

Wound culture

Tx:
parenteral antibiotics
Early wound excision and grafting

117

Early signs of sepsis

Sudden glucose intolerance

Hypothermia

Thrombocytopenia

118

Predominant organism causing fatal burn wound infection?

Pseudomonas sp.

Differentiate VS Melting graft wound syndrome

Melting graft wound syndrome is due to STAPHYLOCOCCUS AUREUS

119

Antidote for chemical burns caused by hydrofluoric acid?

Calcium

120

Malignancy most commonly developing from a Marjolin's ulcer?

Squamous Cell CA

121

Impaired wound healing due to Zinc deficiency is called?

Acrodermatitis Enteropathica

122

Major cell responsible for wound contraction?

Myofibroblast

123

The first cells to enter the wound site during wound repair?

Neutrophils

124

The mechanical strength of a scar is regained after?

NEVER

125

Non-absorbable sutures

- not biodegradable and permanent

NYLON
PROLENE
STAINLESS STEEL
SILK (Natural, can break down over years)

126

Absorbable sutures

- Degraded via inflammatory response

VICRYL
MONOCRYL
PDS
CHROMIC
CAT GUT (natural)

127

NATURAL SUTURES

- biological
- cause inflammatory reaction

CATGUT (intestine of cow or sheep)
SILK (silkworm fibers)
CHROMIC CATGUT

128

SYNTHETIC SUTURES

- synthetic polymers
- do not cause inflammatory response

NYLON
VICRYL
MONOCRYL
PDS
PROLENE

129

MONOFILAMENT SUTURES

- single stranded of suture material
- minimal tissue trauma
- smooth tying but more knots needed
- examples: NYLON, MONOCRYL, PROLENE, PDS

130

MULTIFILAMENT (braided)

- fibers are braided or twisted together
- more tissues resistance
- easier to handle
- fewer knots needed
- examples: VICRYL, SILK, CHROMIC

131

The layer of the GIT that imparts the greatest tensile strength and greatest suture holding capacity?

Submucosa

132

The main characteristic that distinguishes the healing of fetal wounds?

Lack of scar formation

133

Pressure ulcer stage when there is partial thickness skin loss?

Stage II

Stages:
I - nonblanchable erythema of intact skin
II - full thickness skin loss, not thru fascia
III - FT skin loss + muscle and bone involvement

134

Suture removal

Average time frame is 7-10 DAYS.

Face: 3-5 DAYS
Neck: 5-7 DAYS
Scalp: 7-12 DAYS
Upper extremity, trunk: 10-14 DAYS
Lower extremity: 14-28 DAYS
Soles, palms, back or over joints: 10 DAYS

(Note: any suture with pus or signs of infections should be removed immediately)

135

Virus implicated in the development of Burkitt's lymphoma?

EBV

136

The most common arrhythmia seen during laparoscopy procedures?

Bradycardia

137

Organism most commonly implicated in human bite wounds?

Eikenella corrodens

Differentiate VS Animal bites

Animal bites (Pasteurella multocida)

138

Taxanes blocks tumor growth at mitosis through?

Formation of excess microtubule polymerization

139

A lethal and rapidly progressive soft tissue infection caused by microaerophilic Streptococcus?

Meleney's synergistic gangrene

Differentiate VS Fournier's Gangrene

(Fournier's gangrene - polymicrobial, involves genitalia, perineum or abdominal wall)

140

Most common complication after placing a central venous line?

Arrhythmia

141

An 85 y/o male is admitted to the ICU in septic shock. A pulmonary artery (PA) catheter is placed. The PA catheter does not directly measure which one of the following?
A. PA systolic pressure
B. PCWP
C. Systemic vascular resistance
D. Right ventricular diastolic pressure
E. Right atrial pressure

C. Systemic vascular resistance

142

A 68 y/o man has a history of myocardial infarction. He undergoes uneventful left hemicolectomy for carcinoma of the colon. In the recovery room, he is hypotension and given a fluid bolus of 500mL Ringer's lactate over 30 minutes. He is intubated, and his neck veins are distended. His HR is 130bpm, his BP is 80/60mmHg, and his urine output is 20mL over the last hour. What should be the next step in his management?

Insertion of a Swan-Ganz catheter

143

The sudden multiple appearance of seborrheic keratoses?

Lesser Trelat sign

144

A 29 y/o female develops a pigmented lesion on the right thigh. With reference to a pigmented lesion, there is an increased risk of developing melanoma if it is identified with which of the following?

Congenital nevocellular nevi

145

Type of nevus that most often occur in a "bathing trunk" distribution?

Giant hairy nevus (congenital)

146

Most common skin malignancy?

Basal Cell CA

147

A method of serially excising a tumor until it is entirely removed?

Moh's micrographic surgery

148

A 65 y/o light complexioned male presents with a solitary scaly plaque like lesion on his forearm present for many years. The lesion is 0.5 cm in diameter. Shave biopsy reveals intraepithelial squamous cell carcinoma. (Bowen's disease) incompletely excised.

Excision and repair of this area, ensuring clear surgical margins

149

Type of melanoma with the best prognosis?

Lentigo maligna

150

Treatment of melanoma?

Surgical

151

Extent of lymph node dissection

Groin?
Axilla?
Face, ear, anterior scalp?

Groin - removal of SUPERFICIAL (inguinal) and DEEP (iliac) nodes

Axilla - removal of LEVELS I, II, III

Face, Ear, Anterior scalp - plus SUPERFICIAL PAROTIDECTOMY and MRND

152

A 40 y/o premenopausal patient has a biopsy showing focal lobular carcinoma in situ (LCIS) in the area of calcification. With regard to the LCIS, you should tell the patient which of the following?

She should just be observed closely

153

A 46 y/o woman presents to you for evaluation of a breast mass. The patient does not perform breast self-examination and she had never noticed the mass prior to this time. Her past medical history is unremarkable. She has no prior history of breast complaints or trauma. The findings from the physical examination is unremarkable except for the breast examination. A hard, nontender 4 cm mass in the upper outer quadrant of her left breast. The left axilla is without abnormalities. Examination of the right breast without abnormalities. Examination of the right breast reveals no dominant mass or axillary adenopathy. What is your next step?

Bilateral diagnostic mammogram

154

Form of mucus retention cyst that involves the sublingual gland?

RANULA

Differentiate VS Epulis

(Congenital Epulis - MAXILLA)
(Epulis Gravidarum - GINGIVA, RESOLVES POST PARTUM)

155

A 41 y/o patient presents to your office with a biopsy proven invasive ductal cancer in the upper outer aspect of her left breast, a suspicious palpable left axillary lymph node, and diffuse calcifications throughout the rest of the breast proven to be DIC on stereotactic biopsy. The best surgical option is:

Modified radical mastectomy

156

A 36 y/o woman presents with a substantial unilateral breast enlargement. She had presumed that this was normal, but on examination, a large, firm tumor is palpated by the attending physician. There is early erosion on the skin. A favourable outlook can be anticipated if the lesion is which of the following?

Cystosarcoma phyllodes

157

A 62 y/o man undergoes excision of a cylindroma of the submandibular gland. He is most likely to have an injury to which?

Lingual nerve

158

Painless mass of the jaw associated with an impacted teeth?

Ameloblastoma (Adamantinoma)

X-ray appearance: "soap bubble sign"

159

A 58 y/o woman undergoes excision biopsy of a tumor in the left posterior triangle of her neck. Histology suggests that this is a metastatic cancer. What is the most likely site of the primary tumor?

Piriform fossa

161

A 16 y/o boy complains of difficulty in breathing through his nose. Endoscopy reveals a tumor infiltrating the nasopharynx. Histology reports this as a juvenile nasopharyngeal angiofibroma. The boy's anxious mother requests information concerning the lesion. What should she be told?

It may proceed to destroy surrounding bone

162

A 9 month old girl is brought to the physician's office for noisy breathing. The child is otherwise healthy, and her gestation and delivery were uncomplicated. On physical examination, mild inspiratory stridor is heard. What is the most likely cause of stridor in an infant?

Laryngomalacia

163

Triad of ACHALASIA

Hypertensive LES

Aperistalsis of esophageal body

Failure of LES to relax

164

Adenocarcinoma is the predominant malignant lesion in which of the following?

Hard palate

165

There is immune mediated destruction of myelin confined to the CNS leading to slowing of conduction and neurological dysfunction

MULTIPLE SCLEROSIS

166

There is immune mediated destruction of myelin in the PNS; illness is often triggered by an infection

Gullain-BarrΓ© syndrome

167

Gold standard in the diagnosis of GERD?

24 hour pH monitoring

168

Surgical treatment of choice for ACHALASIA?

Heller's myotomy +/- partial fundoplication

169

A 48 year old man presents for evaluation of burning epigastric and substernal pain that has recurred almost daily for the past 4 months. He says that these symptoms seem to be worse when he lies down and after meals. He denies difficulty swallowing or weight loss. The patient has been taking a proton pump inhibitor regularly over the past 12 weeks with partial resolution of his symptoms. His past medical history is significant for frequent early morning wheezing and hoarseness that have been present for the past few months. The patient has no other known medical problems and he has had no prior surgeries. He consumes alcohol occasionally but does not use tobacco. On examination, he is moderately obese. No abnormalities are identified on the cardiopulmonary or abdominal examination. What is the most likely diagnosis?

Barrett's esophagus

170

A 43 year old man presents to the ER with severe abdominal pain and substernal chest pain. The symptoms began 12 hours earlier after he consumed a large amount of alcohol. Subsequently, he vomited several times and then went to sleep. A short time thereafter, he was awakened with severe pain in the upper abdomen and substernal area. On PE, the patient appears uncomfortable and anxious. His temperature is 38.8C, Pr 120 b/min, BP 126/80 and RR 36/min. The lungs are clear bilaterally with decreased breath sounds on the left side. The cardiac examination reveals tachycardia and no murmurs. The abdomen is tender to palpitation in the epigastric region, with involuntary guarding. Laboratory studies reveal that his WBC is 26,000 and that his Hgb, Hct, and electrolyte levels are normal. The serum amylase, Bilirubin, AST, ALT, and alkaline phosphatase values are within normal limits. A 12-lead ECF shoes sinus tachycardia. His chest radiograph reveals moderate left pleural effusion, a left pneumothorax, and pneumomediastinum. What is the most likely diagnosis?

Boerhaave's syndrome

171

The highest perforation rate after a caustic esophageal injury occurs during?

Ulceration and granulation phase

172

Most frequent encountered surgical disorder of the small intestine?

Mechanical small bowel obstruction

173

Diagnosis of small bowel obstruction

CT scan - 70-90%

174

Standard treatment for small bowel obstruction

Expeditious surgery

175

Post operative ileus is said to be prolonged when the duration exceeds

3 days

176

To distinguish post operative ileus from post operative SBO, it is best request for

CT scan

177

Initial test in the diagnosis of intestinal fistulas?

CT scan with contrast

178

Spontaneous closure of fistulas usually occurs in?

2-3 months

179

Most common presentation of Meckel's Diverticula in adults?

Intestinal obstruction

180

Hallmark clinical presentation of acute mesenteric ischemia?

Abdominal pain

181

A 66 year old man is admitted to the coronary care unit because of new-onset atrial fibrillation. After 24 hours, he develops acute onset of abdominal pain and distention, and on examination he is found to have diffuse peritonitis. The patient undergoes exploratory laparotomy with resection of necrotic bowel. Post operative treatment for this patient?

Systemic heparinization

182

Most common cause of obscure GI bleeding in adults

Small intestinal dysplasia

183

The most sensitive test in the diagnosis of iatrogenic duodenal perforation

CT scan with contrast

184

Earliest lesion characteristic of Crohn's disease?

Aphthous ulcer

185

The area of colon most susceptible to ischemia

Splenic flexure (Griffith's point)

186

The transition point between columnar rectal mucosa and squamous anoderm

Dentate line/ Pectinate line

187

Predominant bacterial isolate in the colon

Anaerobes

188

A 62 year old man presents to the ER with a 1-week history of left lower quadrant abdominal pain and diarrhea. He complains of increased pain, nausea, vomiting and fever. He has had two prior episodes of similar left lower quadrant pain that resolved with antibiotic treatment alone. He has no cardiac or pulmonary risk factors. On examination, his blood pressure is 140/180, heart rate 100/min and temperature 37C. His abdomen is soft and mildly distended with left lower quadrant tenderness to palpation. He does not have evidence of generalized peritonitis. His write blood cell count is 20,000/mm3. How would you confirm the diagnosis?

Whole abdominal CT scan

189

Most common site of diverticulitis

Sigmoid colon

190

The safest procedure to perform on unstable patients with St. IV diverticulitis

Sigmoid colectomy with end colostomy

191

Most common complication of colostomy

Parastomal hernia

192

A "lead pipe" colon is characteristic of?

Advanced ulcerative colitis

193

Surgical procedure of choice for chronic ulcerative colitis

Restorative pronto elections with ideal-pouch anastomosis

194

Poplyposis syndrome with melanin spots on lips and buccal mucosa

Puts-Jeghers Syndrome

195

Colorectal carcinomas most commonly metastasize to the?

Liver

196

First line of treatment for anal epidermoid carcinoma?

Chemo-radiotherapy

197

Primary peritonitis is diagnosed by?

Peritoneal aspiration GSCS

198

At open operation a normal appendix is found. What is the most common procedure a surgeon should do if he finds a normal appendix

Removal of appendix

199

Most common cause of appendicitis in children

Lymphoid hyperplasia

200

The most accurate way of diagnosing acute appendicitis

None.

History and PE must be at least 85% accurate
CT scan and ultrasound

201

The single most sensitive test of liver function

INR/FVII/F5 - coagulation function

202

Vitamin K is most effective in what type of jaundice?

Post-hepatic cause (obstructive)

203

Rare cause of post-sinusoidal cirrhosis due to hepatic vein thrombosis?

Budd Chiari Syndrome

204

A 42 year old woman with a known history of esophageal varices secondary to hepatitis and cirrhosis is admitted with severe hematemesis from esophageal varices. Bleeding persists after pitressin therapy. What would the next step in management involve?

Transjugular intrahepatic portasystemic shunt ( TIPS)

205

The risk of first variceal bleeding is best prevented by?

B-blockers

206

The most critical treatment of acute variceal bleeding

Prompt endoscopic intervention

207

Selective shunt that is contraindicated in patients with as cites

Distal splenorenal shunt (Warren Shunt)

208

A 43 year old woman prevents with a sudden onset of abdominal pain. She denies abdominal complaints. Her systolic blood pressure is 88mmHg on evaluation and becomes stable at 120mmHg after the infusion of 2 L of intravenous fluid. The abdominal examination demonstrates no peritoneal signs. Her bowel sounds are hypoactive and there is mild right upper quadrant tenderness. The hematocrit value is 22%. A computed tomography (CT) scan is performed and demonstrates free intraabdominal blood and a 5-cm solid mass in the right hepatic lobe with evidence of recent bleeding into the mass. The patient denies recent trauma, weight loss, a change in bowel habits, hematemesis, or hematochezia. No prior history of oral contraceptive pills intake. What is the most likely diagnosis

Liver hematoma with hemorrhage

209

Most common benign tumor of the liver

Simple hepatic cyst

210

Benign solid liver tumor associated with a central scar

Focal modular hyperplasia (FNH)

211

Hepatocellular cancer variant with the best prognosis

Fibrolamellar variant

212

Recommended treatment for solitary pyogenic liver abscesses

Percutaneous drainage

213

Maximum amount of diseased liver that can be resected

60%

214

Initial imaging modality of choice in patients with biliary tract disease

Ultrasound

215

Gallstones that occurs in patients with cirrhosis/hemolytic disorders

Black pigment stones

216

Most common indication for cholecystectomy

Recurrent biliary colic

217

A 46 year old woman presents with a 5-hour history of abdominal pain that began approximately 1 hour after a large dinner. The pain initially began as dull ache in the epigastrium but then localized in the RUQ. She describes some nausea but no vomiting. Since her presentation to the emergency department, the pain has improved significantly to the point of her being nearly pain free. She describes having had similar pain in the past with all previous episodes being self-limited. Her past medical history is significant for type II diabetes mellitus. On physical examination, her temperature is 38C, and the rest of her vital signs are normal. The abdomen is non distended with minimal tenderness in the RUQ. Findings from liver examination appear normal. The rectal and pelvic examinations reveal no abnormalities. Her CBC reveals a WBC count of 13,000 serum chemistry studies demonstrate total bilirubin 0.8 mg/dL, direct bilirubin 0.6mg/dL, alkaline phosphatase 100 UIL, AST 45 UIL, and ALT 30 U/L. Ultrasonography of the RUQ demonstrates stones in the gallbladder, a thickened gallbladder wall, and a common bile duct diameter of 4.0 mm. What should you tell the patient?

She should be scheduled for an elective laparoscopic cholecystectomy

218

Gold standard in the diagnosis of choledocholithiasis?

ERCP

219

A CBD stone diagnosed 1 year after cholecystectomy is classified as?

Retained stone

220

Initial treatment of patients with cholangitis

IV antibiotics and fluid resuscitation (85% response)

Elective decompression

221

Most dreaded complication of laparoscopic cholecystectomy

CBD injury

222

Surgical management of choice for acute acalculous cholecystitis

Percutaneous US/CT guided cholecystostomy

223

Cholangiocarcinoma most commonly involves

Hepatic duct bifurcation "Klatskin tumor"

224

Most common cause of acute pancreatitis worldwide

Gallstones

225

Most specific serum marker for acute pancreatitis

Serum lipase

226

Gold standard test for the assessment of severity of acute pancreatitis

CT scan with contrast

227

Most common cause of death in acute pancreatitis

Infection

228

Most common cause of chronic pancreatitis

Alcohol consumption and abuse

229

Most common complication of chronic pancreatitis

Pseudocyst

230

Most commonly mutated gene in pancreatic adenocarcinoma

K-ras

231

A palpable nontender gallbladder seen in patients with peri-ampullary tumor?

Courvossier's gallbladder

232

The current diagnostic and staging test of choice for pancreatic cancer?

Spiral CT scan with contrast

233

Etiology for the severe pain experienced by patients with pancreatic cancer

Invasion of retroperitoneal nerve

234

Drug used for palliative treatment of advanced pancreatic cancer

Gemcitabine

235

Most dreaded complication of Whipple's procedure

Disruption of the pancreatic-jejunostomy

236

Most common pancreatic endocrine neoplasm

Insulinoma

237

Endocrine tumor of the pancreas with necrolytic migratory erythema

Glucagonoma

238

Most common islet cell tumor after insulinoma

Non functioning Islet-cell tumor

239

Most common anomaly of the spleen

Accessory spleen

240

The process by which the spleen removes intracellular substances

Pitting

241

The most common indication for splenectomy

Trauma

242

Test that will distinguish auto-immune from other hemolytic anemias

(+) direct Coombs tests

243

Gold standard in the diagnosis of GERD?

24 hour pH monitoring

244

Surgical treatment of choice for ACHALASIA?

Heller's myotomy +/- partial fundoplication

245

A 48 year old man presents for evaluation of burning epigastric and substernal pain that has recurred almost daily for the past 4 months. He says that these symptoms seem to be worse when he lies down and after meals. He denies difficulty swallowing or weight loss. The patient has been taking a proton pump inhibitor regularly over the past 12 weeks with partial resolution of his symptoms. His past medical history is significant for frequent early morning wheezing and hoarseness that have been present for the past few months. The patient has no other known medical problems and he has had no prior surgeries. He consumes alcohol occasionally but does not use tobacco. On examination, he is moderately obese. No abnormalities are identified on the cardiopulmonary or abdominal examination. What is the most likely diagnosis?

Barrett's esophagus

246

A 43 year old man presents to the ER with severe abdominal pain and substernal chest pain. The symptoms began 12 hours earlier after he consumed a large amount of alcohol. Subsequently, he vomited several times and then went to sleep. A short time thereafter, he was awakened with severe pain in the upper abdomen and substernal area. On PE, the patient appears uncomfortable and anxious. His temperature is 38.8C, Pr 120 b/min, BP 126/80 and RR 36/min. The lungs are clear bilaterally with decreased breath sounds on the left side. The cardiac examination reveals tachycardia and no murmurs. The abdomen is tender to palpitation in the epigastric region, with involuntary guarding. Laboratory studies reveal that his WBC is 26,000 and that his Hgb, Hct, and electrolyte levels are normal. The serum amylase, Bilirubin, AST, ALT, and alkaline phosphatase values are within normal limits. A 12-lead ECF shoes sinus tachycardia. His chest radiograph reveals moderate left pleural effusion, a left pneumothorax, and pneumomediastinum. What is the most likely diagnosis?

Boerhaave's syndrome

247

The highest perforation rate after a caustic esophageal injury occurs during?

Ulceration and granulation phase