Surgery Rotation 13

Question 1

What are the 4 combinations in which sodium can enter the body

Answer 1

Bound to neg charge = NaCl or NaHCO3

Or in exchange for another positive = H+ or K+

Question 2

What are the ways we can convince the kidney to fix metabolic alkalosis

Answer 2

Provide KCl (5-10 mEq/hr)

This way the kidney will either exchange Na for K or absorb Na with Cl

So that the kidney will not exchange Na with H (don’t want to lose more acid) or absorb Na with HCO3 (don’t want to absorb more base)

Question 3

What is Meniere disease

Answer 3

•	Increased pressure and volume of endolymph
•	Features:
o	Recurrent vertigo
o	Ear fullness/pain
o	Unilateral sensorineural hearing loss 
o	Tinnitus

Question 4

Treatment of Prinzmetal / Vasospastic angina

Answer 4

• Calcium channel blocker (preventive)

- Sublingual nitroglycerin (abortive)

Question 5

Tx of relapsing remitting MS

Answer 5

interferon-beta

Question 6

Treatment of A-fib in a patient with hemodynamic instability

Answer 6

Direct current cardioversion

Question 7

What is the cause of S3 heart sound

Answer 7

Rapid flow of blood from atria to ventricles

Caused by volume overload (e.g. CHF, mitral/tricuspid regurg)

Question 8

What is the cause of S4 heart sound

Answer 8

Atrium contracting against a stiff ventricle (e.g. hypertrophic cardiomyopathy, aortic stenosis, LV hypertrophy)

Question 9

Causes of acute pancreatitis

Answer 9

I GET SMASHED

Idiopathic. Gallstones. Ethanol. Trauma. Steroids. Mumps. Autoimmune. Scorpion sting. Hypertriglyceridemia/hyoercalcemia. ERCP. Drugs.

Question 10

Components of MEN1

Answer 10

Parathyroid hyperplasia, pituitary adenoma, pancreatic tumor

Question 11

Components of MEN2a

Answer 11

Parathyroid hyperplasia, medullary thyroid cancer, pheochromocytoma

Question 12

Components of MEN2b

Answer 12

Pheochromocytoma, medullary thyroid cancer, Marfanoid/Mucosal neuromas

Question 13

How do you diagnose a sarcoma

Answer 13

(painless enlarging mass)

Dx with biopsy (NOT FNA)

Question 14

Tx of soft tissue sarcoma

Answer 14

Wide, local excision or amputation + radiotherapy

Question 15

Where do sarcomas usually spread to first?

Answer 15

Lungs (hematogenously)

Question 16

Tx of sarcoma met to lungs

Answer 16

Can do wedge resection if it is the only met and primary tumor is under control

Question 17

Progression to liposarcoma

Answer 17

99% do NOT come from lipoma

Question 18

Presentation and tx of thyroglossal duct cyst

Answer 18

Midline mass that moves when tongue moves

Remove surgically

Question 19

Test to assess for reflux

Answer 19

Esophageal pH testing

Question 20

Test to assess for achakasia

Answer 20

Mannometry

Question 21

Test for a pt with clinically obvious chronic gerd

Answer 21

Endoscopy and biopsy to look at damage

Question 22

Management of barrets esophagus

Answer 22

Nissen fundiplocation

Or intensive therapy of acid (eg PPI - omeprazole)

Question 23

Testing prior to Nissen

Answer 23

Make sure Gerd is the cause. Mannometry to make sure esopageal contraction is good. Gastric emptying test to check pyloric sphincter. Barium swalllow to locate GE junction

Question 24

Diagnose: liquids more difficult to swallow than solids

Answer 24

Achalasia

Vs. cancer where solids are harder

Question 25

Gastroschisis - presentation, associated disorders, complications

Answer 25

Gastroschisis = viscera not covered by sac Defect lateral to midline Not usually associated with other disorders May be atretic or necrotic requiring removal; short gut syndrome

Question 26

Omphalocele - presentation, associated disorders

Answer 26

Covered by sac; midline Associated with other disorders

Question 27

Diagnose: 4 wk old infant with non-bileous vomiting and "olive" mass

Answer 27

Pyloric stenosis

Question 28

Metabolic complications of pyloric stenosis

Answer 28

Hypochloremia; metabolic alkalosis

Question 29

Tx of pyloric stenosis

Answer 29

Surgery = myotomy

Question 30

Diagnose: 2 wk old infant with bileous vomiting. Pregnancy complicated by polyhydramnios

Answer 30

``` Intestinal atresia (narrowing or absence of portion of intestine) Duodenal atresia = double bubble on XR ``` Or annular pancreas

Question 31

What disorder is associated with intestinal atresia

Answer 31

Down Syndrome

Question 32

Diagnose: 1 wk old baby with bileous vomiting, draws up his legs, has abd distenstion

Answer 32

Malrotation and volvulus

Question 33

Diagnose: 3 day old newborn that has not passed meconium

Answer 33

Meconium ileus (consider cystic fibrosis) Hirschsprung disease (biopsy will show no ganglia)

Question 34

Diagnose: 5 day old former 33 weeker develops bloody diarrhea

Answer 34

Necrotizing enterocolitis

Question 35

Describe XR of necrotizing enterocolitis

Answer 35

Pneumocystis intestinalis (air in wall)

Question 36

Tx of necrotizing enterocolitis

Answer 36

NPO, TPN (if nec), abx, resection of necrotic bowel

Question 37

Diagnose: 2mo old baby has colicky abd pain and current jelly stool w/ sausage shaped mass in the RUQ

Answer 37

Intussusception Barium enema is dx and tx

Question 38

Medical tx of BPH

Answer 38

Tamsulosin (a1-antagonist which relaxes smooth muscle) or finasteride (5a-reductase inhibitor)

Question 39

Surgical tx of BPH

Answer 39

TURP

Question 40

Tx of prostate cancer

Answer 40

Surgery, radiation, leuprolide or flutamide

Question 41

Best test to diagnose kidney stones

Answer 41

CT

Question 42

Tx of kidney stones

Answer 42

If stone <5mm, hydrate and let it pass. If >5mm, do shock wave lithotripsy. Surgical removal if >2cm.

Question 43

Diagnosis of testicular torsion

Answer 43

Do STAT doppler U/S -will show no flow (contrast w/ epididymitis)

Question 44

Tx of testicular torsion

Answer 44

Can surgically salvage if <6hrs. Do orchiopexy to BOTH testes.

Question 45

Location and presentation of osteosarcoma

Answer 45

Usually occurs in metaphysis – distal femur or proximal tibia (knee region) Imaging reveals a mass with sunburst appearance and lifting of periosteum (Codman triangle) -THINK: osteoSarComa (S = sunburst and C = Codman)

Question 46

Location and presentation of Ewing Sarcoma

Answer 46

Arises in the diaphysis of long bones Lytic bone lesions X-ray reveals “onion-skin” appearance – tumor grows within medullary center of bone, pushing outwards and causing periosteum (outer layer) to lay down new layers of bone - THINK: eWING = Chicken WINGS and onion rings

Question 47

Why give epi with lidocaine

Answer 47

To prevent systemic absorption

Question 48

Next step in management of pt with suspected esophageal cancer

Answer 48

Barium swallow BEFORE endoscopy and biopsy so you know obstruction and don’t rupture esophagus

Question 49

Tx of Mallory Weiss tear

Answer 49

Endoscopy. Can maybe do photocoagulation

Question 50

Differentiate Mallory Weiss vs boerhaave

Answer 50

B will have horrible pain and appear very sick M is just vomiting blood

Question 51

Management of suspected boerhaave

Answer 51

No endoscopy - can worsen tear No barium - will spill out and worsen problem Do gastrographing swallow first - water soluble and safer than barium. But gives poor quality pictures. May miss perforation If gastrograph is negative then do barium to be sure

Question 52

Tx of confirmed esophageal rupture

Answer 52

Surgery