Comprehension Questions Part 1/5

Front 1

In a woman with FNA finding malignant cells what is the next step?

Back 1

Do a core needle biopsy to stage the cancer.

FNA is only for loose cells and can't differentiate between insitu or invasive cancer.

Front 2

What is the next step in a patient found to have invasive carcinoma on core needle biopsy?

Back 2

SLND then ALND. SLND is done first in order to assess whether or not ALND is needed.

Front 3

When is axillary node radiation therapy indicated?

Back 3

After a positive sentinel node dissection, ALND shows 4 or more positive lymph nodes.

Front 4

When is breast radiation therapy indicated?

Back 4

In a breast conserving therapy.

Front 5

1) Breast tenderness, redness, and warmth by themselves are indicative of what?

2) What if the patient is post menopausal and has nontender LAD?

Back 5

1) Could be mastitis

2) Then biopsy. This could be inflammatory breast cancer.

Front 6

1) In the setting of breast chemotherapy, what is AC therapy?

2) Which drug is currently being added to traditional AC therapy?

Back 6

1) Adriamycin/Cyclophosphamide

2) Docetaxel (Taxotere)

Front 7

When is systemic chemotherapy (AC) offered for breast cancer?

Back 7

Stage II, III, IV.

Front 8

1) What is the concern when an elderly or female patient has substernal and epigastric chest pain that is not being relieved with antacid therapy?

2) What could be a concern after 1) has been allayed?

Back 8

1) Cardiac causes.

2) Hiatal Hernia. Check with CT

Front 9

What is the surgery associated with GERD that does not respond to maximal PPI therapy?

Back 9

Nissen Fundoplication

Front 10

1) What is the most appropriate diagnostic tool for a patient with suspected esophageal perforation?

2) Why is this preferred?

Back 10

1)Gastrografin Esophagogram

2) Gastrografin is water soluble. Barium swallows in the setting of perforation are associated with mediastinitis and peritonitis

Front 11

What is the most important clinical indicator of poor prognosis in a patient with esophageal perforation?

Back 11

Duration of perforation.

Diagnosis made after 24 hours results in up to 27% death.

Front 12

What is the clinical progression of spontaneous esophageal perforation?

Back 12

• Chest Pain (immediate)
  
• Subcutaneous Emphysema (1 hour)
• Pleural Effusion (6 hours)
• Fever Leukocytosis (4 hours)
• Death (>24 hours 27%)

Front 13

1) What is the primary treatment for esophageal perforation?

2) When is this treatment not indicated?

Back 13

• Surgical Repair with CT guided drainage.
  
• When patients are not suitable for surgery then endoscopic therapy can be used.

Front 14

What is the most common type of malignant melanoma?

Back 14

Superficial Spreading.

Long radial growth with rapid vertical growth.

Front 15

When is systemic chemotherapy indicated in malignant melanoma?

What are the therapies?

Back 15

Stage III - Interferon

Stage IV - Interleukin 2

Front 16

When is SLND indicated for malignant melanoma?

Back 16

For melanomas that need to be staged still.

Front 17

What is the primary treatment for malignant melanoma?

How is it measured?

Back 17

Wide margin excision.

From the edge of the mass, not the center.

Front 18

• 57 year old man presents to a physical.
  
• His prostate is normal size and shape on rectal exam but his PSA is markedly elevated.

What is the next diagnostic step?

Back 18

Transrectal U/S with prostate biopsy.

Front 19

72 year old man with incontinence and a lower abdominal mass.

What is the next step?

Back 19

Foley Catheter

This represents overflow incontinence. Pelvic U/S could be used to diagnose.

Front 20

1) A patient with being treated for prostatism has dizziness. What is it?

What is the next step?

Back 20

1) Drug Side Effect

Alpha blockers like Tamsulosin can cause orthostatic hypotension and dizziness

2) Start Tamsulosin as a nighttime dose and titrate.

Front 21

A patient with a normal prostate exam has mildly elevated PSA. What is the next step?

Back 21

Repeat PSA in 1 week.

DRE can cause slightly elevated PSA.

Front 22

What are the tests for patients suggestive of BPH?

Back 22

Renal function test (Serum Creatinine)

PSA test

Urinalysis

DRE

Front 23

When is surgery indicated for BPH? What is the surgery?

Back 23

When medical therapy fails.

TURP, transurethral resection of the prostate. Patients have to be monitored for regrowth of prostate tissue.

Front 24

• Patient with abdominal pain w/o history of abdominal surgery or hernias.
  

What is the next step?

Back 24

CT to first assess ileus vs mechanical obstruction.

Patients with mechanical obstruction will eventually require an exploratory laparotomy.

Front 25

Which if the following is an indication for surgery and which are not?

What is the treatment for the one where SBR is not indicated?

• Bowel obstruction due to midgut volvulus
• SBO after open gallbladder surgery 20 days previously
• SBO caused by gallstone ileus
• SBO jejunal atresia
• SBO with incarcerated inguinal hernia

Back 25

The only SBO that will resolve without surgery is the SBO after an open gallbladder surgery. It is usually caused by adhesions and inflammation from the surgery.

NG tube decompression and supportive care.

Front 26

A 72 year old patient has nausea and vomiting with a slightly elevated white count and a low bicarb.

What is going on?

Back 26

This patient has anion gap acidosis as evidenced by the low bicarb.

Na + K - (Cl + HCO3) =

The most probable cause in this patient is lactic acidosis caused by bowel ischemia.

Geriatric patients have minimal symptoms

A CT should be done to differentiate between intra-abdominal sepsis, obstruction, or severe fluid depletion.

Front 27

A patient with recurrent SBO and h/o abdominal surgeries is being treated inpatient with NG suction, NPO, and IV fluids for 4 days. She is improving slightly. What is the next step?

Back 27

CT to assess obstruction.

Likely do an exploratory laparotomy.

Front 28

What are the signs that would indicate surgery in a patient with a SBO?

Back 28

Persistent pain, fever, tachycardia, leukocytosis, elevated serum amylase, CT or KUB of the abdomen showing high-grade bowel obstruction.

Front 29

How can most SBO be managed?

Back 29

NPO, placement of an NG tube, close monitoring of fluid status, serial clinical examinations, lab and radiographic follow-up.

Front 30

1) Which nerve is responsible for tingling and weakness on the radial side?

2) Which nerve is responsible for tingling and weakness on the ulnar side?

Back 30

1) Median Nerve

2) Ulnar Nerve

Front 31

What diseases are associated with Carpal Tunnel Syndrome?

Back 31

• Hypothyroidism
  
• Acromegaly
• Diabetes Mellitus
• Hyperthyroidism
• Pregnancy

Front 32

What is the conservative therapy for CTS?

Back 32

Nighttime splint and NSAIDs.

Front 33

What are the two signs associated with CTS?

Back 33

Phalen's and Tinel's.

Phalen's is flexion at the wrist causing increased numbness.

Tinel's is tapping of the nerve causing paresthesia

Front 34

What test is most diagnostic but unnecessary with Carpal Tunnel Syndrome?

Back 34

EMG.

Front 35

Patient with biliary colic, U/S evidence of stones, wall thickening, dilated CBD and obstructive liver signs. (elevated AST, ALT, and Alk Phos)

What is the next treatment?

Back 35

IV Fluids, Antibiotic therapy, and ERCP

This patient has CBD stones as evidenced by dilation of the CBD and obstructive liver signs.

Front 36

If a patient has gallstones without wall thickening what are the recommendations for cholecystectomy?

What are the indications for surgery?

Back 36

Elective.

Intractable pain, Cholecystitis, multiple bouts of biliary colic, and cholangitis.

Front 37

What are the most common diseases associated with these GI symptoms?

1) Fever, Intermitten, RUQ Pain, Jaundice

2) Persistent Abdominal Pain, RUQ Tenderness, Leukocytosis

3) Intermittent Abdominal Pain and minimal tenderness over the gallbladder

4) Epigastric and Back Pain

5) Painless Jaundice with a palpable and nontender gallbladder.

Back 37

1) Cholangitis (Charcot's Triad)

2) Acute Cholecystitis

3) Biliary Colic

4) Pancreatitis

5) Periampullary Mass

Front 38

What should be suspected with fever (or hypothermia), chills, abdominal pain, jaundice with a sign of Air in the biliary tree?

Back 38

Acute Cholangitis

Front 39

Pt with RUQ tenderness and U/S showing cholelithiasis, and pericholecystic fluid.

LFTs are normal with a non-dilated CBD.

What is the appropriate management?

Back 39

NPO, antibiotics, laparoscopic cholecystectomy.

Front 40

Pt with biliary colic with a negative U/S. What is the next diagnostic step?

Back 40

HIDA scan to check for biliary dyskinesia.

< 50% ejection and possibly reproduction of symptoms with CCK injections is positive for biliary dyskinesia.

Front 41

Which GI lesion is most likely to cause anemia but not acute GI hemorrhage?

Back 41

Gastric Cancer

Front 42

What is the treatment for esophageal variceal bleeds?

Back 42

Endoscopy with sclerotherapy.

Front 43

What tests can to assess hematochezia can be done on an unstable patient?

What about on a stable patient?

Back 43

NG Tube and saline lavage and proctosigmoidoscopy can be done bedside quickly and in an unstable patient.

EGD and colonoscopy are more accurate assessments of a patient with blood loss.

Front 44

What is a complication of AAA repair causing painless hematochezia?

Back 44

Aortoenteric fistula.

Front 45

What is the best diagnostic test for localizing lower GI tract bleeding?

Back 45

Colonoscopy.

CT with IV contrast can find pooling though too.

Front 46

What is the best test to localize lower GI bleeds in patients with bleeds that have slowed or stopped?

Back 46

Tagged RBC.