Jeef Surgery Notes 2-4

Front 1

A 61 year old man presents with a history of hematuria. Intravenous pyelogram shows a renal mass, and sonogram shows it to be solid rather than cystic. CT scan shows a heterogenic, solid tumor.
Dx?

Back 1

Dx: Renal cell carcinoma

Hint 1

None

Front 2

A 55 year old, chronic smoker, reports three instances in the past two weeks when he has had painless, gross, total hematuria. In the past two months he has been treated twice for irritative voiding symptoms, but has not been febrile and urinary cultures have been negative
Dx?
Diagnostic test? (2 steps)

Back 2

Dx: Bladder Cancer

Diagnostic test:
1. IVP
2. Cystogram
(With this very complete presentation some urologist would go for the cystoscopy first, but the standard sequence of IVP first and cystoscopy next is the only correct answer for an exam. An option both IVP and cystoscopy would be OK)

Hint 2

None

Front 3

A 59 year old black man has a rock-hard, discrete, 1.5cm nodule felt in his prostate during a routine physical examination
Dx?
Diagnostic test?
Tx?

Back 3

Dx: Cancer of the Prostate

Diagnostic test: Trans-rectal needle biopsy

Tx: Surgical resection after the extent of the disease has been established

Hint 3

None

Front 4

An 82 year old gentleman who has congestive heart failure and chronic obstructive pulmonary disease is told by his primary care physician that his level of prostatic specific antigen (PSA) is abnormally high. The gentleman has seen ads in the paper for sonographic examinations of the prostate, and he has one done. The examination reveals a prostatic nodule, which on trans-rectal biopsy is proven to be carcinoma of the prostate. The man is completely asymptomatic as far as this cancer is concerned. He has not evidence of metastasis either.
Tx?

Back 4

Tx: As a rule, asymptomatic prostatic cancer is not treated after age 75

(An example of technology running amock. This man should have never had the PSA in the first place, much less the sonogram and biopsy. After a certain age, most men get prostatic cancer...but die of something else)

Hint 4

None

Front 5

A 25 year old man presents with a painless, hard testicular mass.
Dx?
Diagnostic test? (2)

Back 5

Dx: Testicular cancer

Diagnostic test:
1. Pre-op Alpha-fetoprotein and Beta-HCG
2. Diagnosis is made by performing a radical orchiectomy by the inguinal route.
(That irreversible, drastic step is justified because testicular tumors are almost never benign. Beware of the option to do a trans-scrotal biopsy: that is a definitive no-no)

Hint 5

None

Front 6

A 25 year old man is found on a pre-employment chest X-Ray to have what appears to be a pulmonary metastasis from an unknown primary tumor. Subsequent physical examination discloses a hard testicular mass, and the patient indicates that for the past six months he has been losing weight for no obvious reason.
Dx?
Diagnostic test?
Tx? (2 steps)

Back 6

Dx: Testicular Cancer with metastasis.

Diagnostic test:
pre-op Blood Test for Alpha-fetoprotein and Beta-HCG levels

Tx:
1. Removal of testicle
2. Chemotherapy
(The point of this vignette is that testicular cancer responds so well to chemotherapy, that treatment is undertaken regardless of the extent of the disease when first diagnosed)

Hint 6

None

Front 7

A 60 year old man shows up in the ER because he has not been able to void for the past 12 hours. He wants to, but can not. On physical exam his bladder is palpable half way up between the pubis and the umbilicus, and he has a big, boggy prostate gland without nodules. He gives a history that for several years now, he has been getting up four or five times a night to urinate. Because of a cold, two days ago he began taking anthihystaminics, using “nasal drops”, and drinking plenty of fluids.
Dx?
Management?
Tx? (2 possible)

Back 7

Dx: Acute urinary retention, with underlying BPH

Management: Indwelling bladder catheter, to be left in for at least 3 days

Tx: long-term Alpha-blockers for symptomatic relief, or some form of Prostatic Resection

Hint 7

None

Front 8

On the second post-operative day after surgery for repair of bilateral inguinal hernias, the patient reports that he “can not hold his urine”. Further questioning reveals that every few minutes he urinates a few cc’s of urine. On physical examination there is a large palpable mass arising from the pelvis and reaching almost to the umbilicus.
Dx?
Management?

Back 8

Dx: Acute Urinary Retention with Overflow Incontinence

Management: Indwelling bladder catheter

Hint 8

None

Front 9

A 42 year old lady consults you for urinary incontinence. She is the mother of five children and ever since the birth of the last one, seven years ago, she leaks a small amount of urine whenever she sneezes, laughs, gets out of a chair or lifts any heavy objects. She relates that she can hold her urine all through the night without any leaking whatsoever
Dx?
Tx?

Back 9

Dx: Stress Incontinence

Tx: Surgical repair of the pelvic floor.

Hint 9

None

Front 10

A 72 year old man who in previous years has passed a total of three urinary stones is now again having symptoms of ureteral colic. He has relatively mild pain that began six hours ago, and does not have much in the way of nausea and vomiting. X-Rays show a 3mm Ureteral stone just proximal to the ureterovesical junction
Management? (3 together)

Back 10

Management:
1. Watch him (time)
2. Pain medication
3. Plenty of Fluids

(there is still a role for watching and waiting. This man is a good example: small stone, almost at the bladder. Give him time, medication for pain, and plenty of fluids, and he will probably pass it)

Hint 10

None

Front 11

A 54 year old lady has a severe ureteral colic. IVP shows a 7mm Ureteral stone at the ureteropelvic junction
Tx?

Back 11

Tx: Shock-wave Lithotripsy

(whereas a 3mm stone has a 70% chance of passing, a 7mm stone only has a 5% probability of doing so. This one will have to be smashed and retrieved)

Hint 11

None

Front 12

A 33 year old man has urgency, frequency, and burning pain with urination. The urine is cloudy and malodorous. He has mild fever. On physical exam the prostate is not warm, boggy or tender
Dx?
Management? (3 together)

Back 12

Dx: Urinary Tract Infections

Management:
1. start Urinary cultures
2. start Antibiotics
3. either IVP or Sonogram

Hint 12

None

Front 13

A 72 year old man consults you with a history for that for the past several days he has noticed that bubbles of air come out along with the urine when he urinates. He also gives symptoms suggestive of mild cystitis
Dx? (2 possible)
Diagnostic test?
Tx?

Back 13

Dx: Pneumaturia due to a Fistula between the bowel and the bladder.
(Most commonly from sigmoid colon to dome of the bladder, due to diverticulitis)
or Sigmoid Cancer

Diagnostic test: CT scan
(Intuitively you would think that either cystoscopy, sigmoidoscopy or contrast studies would verify the diagnosis, but they seldom show anything in this case)

Tx: Surgery will be needed

Hint 13

None

Front 14

A 32 year old man has sudden onset of impotence. One month ago he was unexpectedly unable to perform with his wife after an evening of heavy eating and heavier drinking. Ever since then he has not been able to achieve an erection when attempting to have intercourse with his wife, but he still gets nocturnal erections and can masturbate normally
Dx?
Management?

Back 14

Dx: Classical Psychogenic Impotence
(young man, sudden onset, partner-specific. Organic impotence is typically older, of gradual onset and universal)

Management: Curable with psychotherapy if promptly done
(It will become irreversible after two years)

Hint 14

None

Front 15

Even without intake, how much urine must you excrete in waste products?

Back 15

800mL/day

Front 16

Where is Na reabsorbed in the nephron? In exchange for what?

Back 16

Distal Tubule. For K and H secretion

Front 17

What patients should receive Colloids instead of Crystalloids? (7)

Back 17

Patients w/ excess Na and water, but still hypovolemic
(Ascites, CHF, post-cardiac bypass patients);

Patients unable to make Albumin
(Liver disease, transplant recipients);

Severe Hemorrhage or Coagulopathy;

ER patient w/ Flail chest due to rib fractures that progresses to Respiratory contusions

Hint 17

None

Front 18

What are the equations for calculating Maintenance Fluids/hour?
(3)

What else does this work for?

Back 18

Up to 10kg: 100mL/kg/day
(4mL/kg/hr)

11 - 20kg: 1,000mL + 50mL/kg/day for each kg above 10
(40mL/hr + 2mL/kg/hr for each kg above 10)

>20kg: 1,500mL + 20mL/kg/hr for each kg above 20
(60mL/hr + 1mL/kg/hr for each kg above 20)

Same for estimating daily Caloric expenditure
(except replace mL by kcal)

Front 19

Patient is post-surgery and on PE you notice JVD, rales, S3 and slight edema.
Dx?

Back 19

Hypervolemia

Front 20

What is the acute Tx for Hyperkalemia?
(3)

Back 20

Lower Extracellular K:

Calcium Gluconate;
Albuterol;
NaHCO3 w/ Insulin;