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111 Cards in this Set
- Front
- Back
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Difference between SCC and adenocarcinma of esophagus.
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SCC
- affects African Americans more than Caucasians - etiology: corrosive esophagitis (hot liquids, alcohol, cigarette smoke, previous radiation). Association with tylosis, Plummer-Vinson, achaladia. - arise from upper and mid-esophagus - radiosensitive Adenocarcinoma - affect Caucasians more than African Americans - etiology: GERD, Barrett esophagus - arise from cardioesophageal junction - not radiosensitive |
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What is the surgical management for Ellison-Zollinger syndrome (gastrin >200pg/ml)?
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- tumor resection with highly selective vagotomy (prevent metastases)
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What to do next?
- duodenal ulcer - gastrin level 150pg/ml |
suspicious Zollinger-Ellison syndrome
- do secretin stimulation test to confirm * no need to confirm if gastrin level > 20pg/ml |
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Which organ is often involved in idopathic retroperitoneal fibrosis? what are some medical and surgical treatment?
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ureteral obstruction
- medical: steroids (immunosuppressive) - surgical: ureteral lysis with intraperitoneal transplantation. Biopsy must be taken to exclude malignancies. |
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What triad is this? What disease is this?
- hypoglycemic attacks precipitated by fasting or exertion - fasting glucose <50 - symptoms relieved by oral or IV glucose |
Whipple's triad - insulinoma
- attacks mediated by epinephrine relaseased due to hypoglycemia |
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Treatment for epidermoid carcinoma of the anus.
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- combined chemotherapy and radiotherapy
* metastases to inguinal nodes, perirectal nodes, and mesenteric nodes |
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What to do next?
Abd xray shows distended colon. |
- proctosigmoidoscopy to r/o sigmoid volvulus
- if negative, suspect cecal vovulus. Do celiotomy since barium enema may rupture the colon. |
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T/F
Most premenopausal breast cancers are hormonal sensitive. |
F.
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Management of breast cancer during pregnancy.
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- modified radical mastectomy for stage I and II (<4cm)
- chemotherapy is safe for fetus during 2nd and 3rd trimester - patients who require chemo during 1st trimester may opt for therapeutic abortion |
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What to do next?
- areolar skin rash - nipple eczema and erosion - breast mass |
This is Paget's disease: originate from retroareolar lactiferous duct. Mass is likely to be infiltrating ductal carcinoma.
- modified radical mastectomy |
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What is this disease?
- increase in serum gastrin after IV secretin injection |
Zollinger-Ellison
- >50% are malignant and 40% have metastases at the time of diagnosis |
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How to prophylax for thyroid storm during thyroidectomy?
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PTU
methimazole |
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Treatment for cystosarcoma phylloides.
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wide local excision
* if too big, may need mastectomy |
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Which thyroid cancer is this?
- hurthle cell - hematogenous spread - treated with subtotal/total thyroidectomy and I131 |
follicular carcinoma
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Which thyroid cancer is this?
- amyloid deposits in stroma |
medullary carcinoma
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Which thyroid cancer is this?
- lymphatic spread - good prognosis |
papillary carcinoma
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What are the treatment options?
- stage I breast cancer in premenopausal women |
1. lumpectomy with axillary lymph node dissection and adjuvant radiation therapy
2. modified radical mastectomy |
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What are the treatment options?
- familial breast cancer - biopsy showing atypia |
bilateral prophylactic simple mastectomies
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What are the treatment options?
- lobular carcinoma in situ |
close surveillance for cancer by twice yearly exams and yearly mammogram
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What are the treatment options?
- ductal carcinoma in situ |
1. wide excision
2. wide excision + radiation therapy |
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Where are the level 1,2,3 axillary nodes?
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level 1: lateral to the pectoral minor
level 2: deep to the pectoral minor level 3: medial to the pectoral minor |
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What is the difference in the report between FNA and core needle biopsy for breast mass?
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FNA: identify cancer but can not differentiate invasive cancers from in situ cancers.
Core needle biopsy: provides histologic diagnosis |
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What tests should you stage stage I and II breast tumors with?
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- CBC
- LFTs - CXR |
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What tests should you stage stage III breast tumors with?
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- CBC
- LFTs - CXR - bone scan - abdominal CT - brain CT or MRI |
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At what stage breast cancer should you consider systemic chemotherapy in addition to radiation therapy?
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stage II
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What are some systemic chemotherapeutic drugs used for breast cancer?
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-- FAC (5-fluorouracil/doxorubicin/cyclophosphamide)
- AC (doxorubicin/cyclophosphamide) - addition of HER2 receptor antagonist (trastuzumab) - anti-estrogen therapy (tamoxigen) |
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What to do next?
- 45 y/o female underwent lumpectomy for a 0.5 cm tumor. - axillary nodes are negative |
this is stage I breast cancer
- treat with radiation |
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What is the diagnosis?
- 62 y/o female - painful enlargement of R breast, warmth, redness. - R axilla nontender adenopathy |
inflammatory breast mass
* postmenopausal/nonlactating women with red and tender mass should be assumed to have breast cancer until proven otherwise. |
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What is the side effect of tamoxifen?
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uterine cancer
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Pathogenesis of GERD and complications.
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Pathogenesis: diminished LES function, impaired esophageal clearance, excess gastric acidity, diminished gastric emptying, abnormal esophageal barriers to acid exposure
Complications: - peptic stricture - barrett's esphagus - extra-esophageal complications: laryngitis, RAD, recurrent pneumonia, pulmonary fibrosis |
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Who needs further work up for GERD?
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- long standing or atypical symptoms (wheezing, cough, hoarseness)
- recurrence of disease after cessation of medical therapy - unrelieved symptoms when taking maximum-dose PPIs |
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What are some studies for GERD workup?
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- endoscopy: may reveal Barrett's esophagitis
- barium esophagogram: may reveal hiatal hernia, shortened esophagus, gastric outlet obstruction - pH monitor/pharyngeal pH monitor - manometry: evaluate competency of LES - nuclear scintigraphy: evaluate gastric emptying |
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What are some behavioral therapy fir GERD?
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- avoid caffeine, alcohol, high fat meals
- avoid meals within 2-3 hrs of bedtime - elevation of head of the bed - smoking cessation |
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What is a contraindication of fundoplication for GERD?
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- gastric outlet obstruction
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What is the diagnosis?
- acute onset of chest pain after vomiting |
Boerhaave syndrome
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Boerhaave syndrome:
What symptoms may also be present besides chest pain? |
- pleural effusion
- mediastinitis |
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You suspect Boerhaave's syndrome in a patient, how would you diagnose it?
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- water soluble contrast esophagogram: gastrografin. pt should be in right lateral decubitus position
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What happens when treatment for Boerhaave's syndrome is delayed?
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sepsis with signs of systemic infection (tachycardia, fever, leukocytosis)
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Treatment for Boerhaave's syndrome.
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- resuscitation (ABC)
- antibiotics - OR: surgical drainage, debridement, repair, diversion. |
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Which is a more sensitive test, barium or gastrografin esophagogram?
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Barium
- but it is associated with mediastinitis and peritonitis. |
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Boerhaave syndrome:
when can you still perform a primary repair? |
perforation is less than 24 hrs duration.
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What should you look for in a pigmented skin lesion?
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A: asymmetry
B: border C: color D: diameter E: enlargement/elevation |
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What are the 4 types of melanoma?
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- superficial spreading: most common
- nodular sclerosis: poor prognosis - lentigo maligna - acral lentiginous |
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Name some compounds that block UVA.
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titanium dioxide
zinc oxide |
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Melanoma: how big should the excional margin be?
- melanoma in situ |
0.5 cm margin
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Melanoma: how big should the excional margin be?
- lesions < 1.5mm thickness |
1 cm margin
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Melanoma: how big should the excional margin be?
- lesions 1.5-4mm thickness |
2 cm margin
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Melanoma: how big should the excional margin be?
- lesions > 4mm thickness |
> 2cm margin
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T/F: Patients with intermediate depth melanoma (0.76-4mm) seem to have a longer survival after prophylactic lymph node dissection.
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True
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When is adjunctive therapy for melanoma useful?
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stage III
- interferon 2A stage IV - high dose interleukin 2 |
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DDX for BPH.
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- urethral stricture
- UTI - prostatitis - prostate cancer - neurologic conditions |
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What is the diagnosis?
- frequent urination of small amounts - incomplete voiding - slow urine flow - voiding at night - hesitancy at the beginning of urine flow |
BPH
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What are some medical treatment for BPH?
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1. alpha 1 antagonist
- doxazosin 2. 5-HT reductase inhibitor - finasteride |
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What to do next?
- BPH - renal compromise - elevated serum creatinine - palpable bladder |
urgent urological intervention
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What to do next?
- patient worried about prostate cancer because of family history - normal DRE - PSA is 3.2 (nl is 2.5) |
repeat a week later
- mild elevation of PSA may be seen immediately after DRE |
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Complications of small bowel obstruction.
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- strangulation
- bowel necrosis - sepsis - aspiration pneumonia due to vomiting - prerenal azotemia due to fluid loss |
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Next step management of SBO.
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- NG suction to decompress
- fluid resuscitation - foley to monitor urine output - exploratory laparotomy depending on degree of obstruction |
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What is the diagnosis?
- bilious vomiting, no passing flautus or BM, intermittent abd pain that became constant - fever, tachycardia, leukocytosis, increased amylase |
complicated SBO
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Name two closed loop bowel obstruction.
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- incarcerated in a tight hernia defect
- intestinal volvulus |
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Name some causes of SBO in children.
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- hernia
- malrotation - meconium ileus - Meckels - intussusception - intestinal atresia |
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Name some causes of SBO in adults.
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- adhesion
- hernia - Crohn's - gallstone ileus - tumor |
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What imaging should you use for a suspicious SBO?
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CT
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What is this?
- SBO - persistent tachycardia after restoration of intravascular volume |
- unresolved inflammation from small bowel ischemia and/or necrosis
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What is the difference in clinical presentation between proximal and distal SBO?
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- proximal SBO: more bilious vomit
- distal SBO: more distention, less vomit. deculent vomit in long standing distal SBO (bacterial overgrowth) |
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What to do next?
- SBO - persistent leukocytosis |
high suspicion of complications
- early surgical intervention or additional diagnostic evaluation |
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What imaging study can help you differentiate between mechanical bowel obstruction and ileus?
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UGI/SBFT: upper gastrointestinal and small bowel follow through
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What to do next?
- 67 y/o male with SBO 25 days following abdominal surgery. - elevated WBC - anion gap acidosis |
ischemic bowel or severe fluid depletion
- CT to confirm intra-abdominal sepsis or high grade obstruction - surgical therapy |
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What is this disease?
-34 y/o diabetic female - numbness and pain in R hand that wakes her up at night, especially the thumb. - start to drop objects |
carpal tunnel syndrome (median nerve compression)
- treat with nighttime splint and NSAIDs |
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Name some endocrine diseases that are associated with carpal tunnel syndrome.
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- DM
- myxedema - hyperthyroidism - acromegaly - pregnancy |
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Name the structures in the capal tunnel.
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- median nerve
- 9 wrist flexor tendons |
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What muscles in the hand are innervated by median nerve?
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- flexor pollicis brevis
- opponens pollicis - abductor pollicis brevis |
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What is the indication of surgical treatment for carpal tunnel syndrome?
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intractable symptoms that are refractory to medical management.
- complete division of transverse carpal ligament extending distally from the ulnar side of the median nerve |
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What is the diagnosis?
- common bile duct dilation >5mm - elevated LFTs |
choledocholithiasis
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Upper GI bleeding:
Sequence of management. |
1. resuscitation: NG suction, intubation for massive bleeding
2. diagnosis: endoscopy 3. treatment: endoscopic therapy (thermotherapy, electrocoagulation, ethanol/epi injections), surgery for massive bleeding, nonhealing giant ulcers (>3cm). |
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NSAID induced ulcers:
What should you do if patient has to take NSAIDs? |
- prostaglandin analogues: misoprostol
- use COX2 inhibitors but may induce thrombosis |
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What are some common causes of lower GI bleed in children and adolescents?
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- meckel's diverticulum
- inflammatory bowel disease - polyps |
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What are some common causes of lower GI bleed in adults over age 60?
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- diverticulosis
- angiodysplasia - neoplasm |
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Where would you find angiodysplasia in the gut most frequently?
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- cecum
- ascending colon |
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What is the diagnosis?
- breast focal thickening - negative mammogram |
invasive lobular carcinoma
- can be detected by MRI and ultrasound |
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What are the following risks for breast cancer?
- first degree relative has breast cancer postmenopausal - first degree relative has breast cancer premenopausal - first degree relative has breast cancer bilaterally and postmenopausal first degree relative has breast cancer bilaterally and premenopausal - BRCA gene carrier - atypical hyperplasia |
- 1.8 fold
- 3 fold - 4-5.4 fold - 9 fold - 3-17 fold - 5 fold |
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How do you manage this patient?
- no breast mass - family history of breast cancer |
- annual mammogram
- physical exam every 6 month start at age 25 or 5-10 yrs prior to the earliest familail case |
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When is interval appendectomy indicated?
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Treatment for appendicitis complicated by abcess or phlegmon
- broad spectrum antibiotics - CT guided drainage - appendectomy after several wks |
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What is the appropriate treatment?
- PE - hemodynamically stable |
anticoagulation therapy for 6 months
- heparin infusion - oral warfarin - sub-Q low MW heparin |
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What is the appropriate treatment?
- massive PE - hemodynamically unstable |
pulmonary embolectomy
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What is the appropriate treatment?
- uncomplicated DVT |
anticoagulation therapy for 3 months
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What is the first step in evaluating a nonsymptomatic thyroid nodule?
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FNA
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What to do next?
- FNAB of thyroid nodule: cellular - TSH low |
I-123 scintigraphy
- if hyperfunction: follow up and therapy - if hypofunctioning: operate * cellular FNA means follicular or Hurthle cell, malignancy is based on capsular or vascular invasion which FNA can not tell. |
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What are some indication for thyroidectomy?
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- malignancy
- progressive nodule enlargement and compressive symptoms |
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What is the likely diagnosis?
- 58 y/o male POD7 sigmoid colectomy and colostomy for a perforated diverticulitis - intermittent fever since the operation - fever, tachycardia, high WBC - distended belly, tender throughout, anorexia |
intra-abdominal infection
- CT abdomen and pelvic - CT guided percutaneous drainage if abscess is identified - extention or modification of antimicrobial regimen |
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Management of superficial surgical site infections.
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infectious processes above the fascia
- wound exploration - drainage of infected material - may need systemic antibiotic therapy |
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Management of deep surgical site infections.
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infectious processes involving the fascia
- CT |
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What is seondary peritonitis and how to manage it?
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Spillage of endogenous microbes into the peritoneal cavity following viscera perforation.
- extend or modify the antibiotic regimen |
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What is tertiary peritonitis and how to manage it?
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Failure of patient to recover from intra-abdominal infections despite surgical or antimicrobial therapy because of deminished host peritoneal response.
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T/F: a febrile post-op patient who has had andominal surgery for an infectious process is presumed to have an intra-abdominal infectious complication until proven otherwise.
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True
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What is the some dual-agent therapy for intra-abdominal infections?
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- aminoglycoside (gentamycin/neomycin/tobramycin) + metronidazole/clindamycin
- 2nd/3rd gen ceph + metronidazole/clindamycin |
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What is the most common cause of short bowel syndrome?
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- Crohn's disease and mesenteric infarction in adults
- necrotizing enterocolitis and small bowel volulus in infants |
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What kind of bridging nutrition should be advised when someone switch from long term perenteral to enteral feeding?
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- AA: ornithine, glutamine
- TG - soluble and short chain fatty acids These promotes gut adaptation. |
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What is the most common benign liver tumor?
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hemangioma is the most common
second most common is focal nodular hyperplasia |
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Treatment for small asymptomatic adenomas.
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- cessation of oral contraceptives
- close surveillance at 3-6 month intervals |
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What imaging studies are good for evaluating liver mass?
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- CTA
- MRI - angiography: gold standard but invasive |
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What is a common cause of intussusception in adults?
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benign neoplasm: lipoma, hemangioma
malignant tunor: GIST |
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What is the embryonic precursor of meckel's diverticulum?
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omphalomesenteric duct
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T/F: internal herniation associated with a mesenterodiverticular band should be treated with resection of the band and the Meckel diverticulum.
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True
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Conditions such as Crohn's disease that interfere with the function of terminal ileum may result in what findings?
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- bile acid diarrhea
- gallstone formation - megaloblastic anemia |
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What are some contraindications of lap cholecystectomy?
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- coagulopathy
- cirrhosis - portal HTN - generalized peritonitis |
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What is the ranson criteria for acute pancreatitis and what are the assoicated mortality rate?
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Ranson criteria
- age > 55 - WBC > 16000 - AST> 250 - LDH> 350 - glucose > 200 0-2: 2% mortality 3-4: 15% 5-6: 40% 7-8: 100% |
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What is the most appropriate treatment for nodular adrenal hyperplasia or bilateral mass?
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medical treatment:
spironolactone |
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What thyroid tumor is this?
- nodule in the upper lobe of the R thyroid - hypocalcemia |
medullary carcinoma
- calcitonin lowers serum Ca |
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What to do next?
- two or more episodes of sigmoid diverticulitis |
elective resection
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What is the most common cause of GI tract fistulas?
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diverticulitis
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DDX of bloody breast discharge.
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- intraductal papilloma
- ductal ectasia - carcinoma - infection |
