Oral Exam Prep Surgery

Front 1

Important history & PE for AAA

Back 1

history: smoking, HTN, HLD, FH of AAA, history of connective tissue disorders

PE: tachycardia and hypotension, acute distress, mental status. Inspect mass, check all pulses, look for pallor or other signs of hypotension. Check for popliteal aneurysm.

Front 2

Tests and treatment for AAA

Back 2

Tests: U/S or CT unless you think it is ruptured (straight to OR). U/S not as sensitive. Angiogram to show lumen patency, show if iliac or renal is involved.

Treatment is surgery for non-ruptured, dilation 5.5-6 cm. Need to know size, location (prerenal, perirenal, infrarenal), CV/P status.

Options include endograft (not if close to renal arteries), endovascular repair. Immediate lap. if ruptured, clamp aorta.

Front 3

Management of ruptured vs elective AAA?

Back 3

ruptured= surgical emergency, elective you can monitor based on size (surgery after 5 cm). <5 cm 4% risk, 5-6 cm 10%, 6-7 cm 16%, 7-8 cm 30% rupture risk.

Front 4

Complications and result of treatment for AAA?

Back 4

large fluid shifts, MI, athroembolism, de-clamping hypotension, ischemic injury, acute renal injury, hemorrhage, mesenteric ischemia from surgery. Exsanguination in OR if ruptured.

Long term complications- impotence (due to interruption of hypogastric circulation or nerves on aorta), fistula formation (to duodenum or IVC), graft infection or leak, poor distal perfusion, recurrence.

Front 5

pathophys of AAA

Back 5

atherosclerotic plaque develops, tunica media and elastin degrades, aorta become suceptible to high pressures leading to dilation and aneurysm formation

Front 6

questions to ask for acute abdomen?

lab/imaging workup?

Back 6

?s: FARCOLDER, bowel symptoms, urinary symptoms, GYN if female.

labs: bHCG if female, CBC, LFTs, amylase, lipase, bili, BMP, UA. EKG to r/o MI.

imaging: upright CXR and abdominal film to look for free air, abdominal u/s, abdominal CT

Front 7

What is direct vs indirect tenderness?  Psaos, obturator signs?

Back 7

direct = inflammation at the site

indirect = peritoneal signs

psoas = extend hip and internally rotate

obturator = flex at hip and internally rotate

Front 8

DD for each location

RUQ

Back 8

RUQ: cholecystitis, perforated duodenal ulcer, hepatic abscess

RLQ: appendicits, diverticulitis, meckel's

LLQ: diverticulitis, volvulus

LUQ: splenic rupture, abscess

diffuse: SBO, leaking aneurysm, mesenteric ischemia

periumbilical: early appendicitis, SBO

suprapubic: ecoptic, torsion, abscess, psoas abscess, incarcerated hernia

Front 9

What is included in the risk assessment for anesthesia? What must be done before surgery?

Back 9

pulmonary function, COPD, cardiac status, previous reactions to anesthesia.

EKG (>40 men 50 women), CXR if >60, CBC, co-ags, BMP, type and cross

Front 10

What is ASA criteria for pre-op risk?

Back 10

1: normal healthy patient

2: mid systemic disease but no functional limitations

3: moderate to severe systemic disease with some functional limitations

4: moderate to severe systemic illness that is constant threat to life, incapacitated functionally

5: pt about to die

6: brain dead with organ harvestation

Front 11

What is the management plan for the following conditions?

external hemorrhoids

perianal abscesses

anal carcinoma

anal fissure

Back 11

EH: sitz bath, nonconstipating analgesics, fiber, excision

PA: incision and drainage

anal carcinoma: biopsy

fissure: sitz bath, fiber, botox, topical anesthetics. nitroglycerin, topical Ca blocker, lateral spinchterotomy

Front 12

What is the pathogenesis of TIA? What is amaurosis fugax?

Back 12

atherosclerotic plaque in common carotid, pieces break off and enter into cerebral circulation. Important because they ^ likelihood of stroke. 

AF is transient blindness due to occlusion of opthalmic artery. 

Front 13

Labs and testing to evaluate TIA? Managment?

Back 13

duplex ultrasound to detect flow and degree of stenosis

MRA detects functional flow and estimates plaque thickness

carotid angiogram is gold standard. 

get carotid endarterectomy if neuro symptoms from stenosis or asymptomatic w/ >70% stenosis. 

Front 14

What are the risks of carotid endarterectomy? How can you minimize risk? What is stroke risk postop?

Back 14

risk of death is low (1-2%), can injure vagus nerve, cause a hematoma, seizures. use eeg monitoring, aspirin pre-op, complete clot dissection, shunt blood bypass to protect brain from ischemia. stroke risk post-op is 5%. 

Front 15

DD of chest pain? Tests to get?

Back 15

MI, aortic dissection, PE, pericarditis, esophageal rupture, etc. 

Get an EKG, cardiac enzymes, angiogram to look for aortic dissection, chest xray. 

Front 16

What meds can you use to stabilize pt with MI? 

Back 16

ASA ­ COX inhibitor

B­blocker ­ slow heart rate via Beta1

Calcium channel blocker ­ work in two ways ­ impair muscle contractility or

vasodilation

ACEi ­ diuresis ­ by inhibiting angiotensin I → II

Diuretic ­ remove extra fluid via kidneys to decrease preload

Nitrates ­ vasodilation 

Front 17

What info would the following tests give you in setting of an MI?

ECG, stress test, echo, cardiac catheterization

Back 17

ECG ­ ST elevation or depression, inverted T waves, Q waves

Stress test ­ myocardial response when demand is increased

Echo ­ localize dyskinetic wall segments, valvular dysfunction, EF

Cardiac catheterization ­ coronary anatomy and sites of lesions 

Front 18

What are the indications for bypass surgery vs angioplasty?

Back 18

presence of left main disease (blockage of left main coronary), three vessels disease needs bypass. The simpler the problem, the more amenable it is to angioplasty and stenting. 

Front 19

What are the symptoms of PVD? What tests should you order?

Back 19

Claudication, rest pain, gangrene, poor wound healing, edema that is reduced with elevation. Order doppler study to study flow, duplex u/s ABI, arteriography to delineate arteries using dye. MRA, PVR. 

Front 20

What is dx test of choice for DVT? Treatment?

Back 20

Use u/s. Duplex combines u/s with doppler to visualize and detect flow. Contrast venography rarely used anymore. Treat with IV heparin to prevent further dvts. Follow PTT, need long term anti-coag with warfarin. 

Front 21

Findings of actue arterial occlusion? Treatment? Conesquences post-op? Long term?

Back 21

Pain, Pallor, Paresthesias, Pulselessness, Pokilothermia, Paralysis. Time is key, need to revascularize within 6 hrs. Give heparin right away, go to the OR. Don't do angio or TPA, will only delay. Balloon catheter embolectomy is procedure of choice. Watch out for compartment syndrome, may need fasciotomy. Long term needs, chronic anti-coags. 

Front 22

Findings in claudication? #1 location?

Back 22

Ischemic pain in legs, often relieved by rest. Exam for pulses, bruits, skin for ulcerations, nervous system for motor and sensory function. Hair loss, dependent rubor, loss of sensation, etc suggest chronic nature. 

superficial femoral is most common location of occlusion. 

Front 23

What to do after findings of arterial occlusion on physical exam? How do you manage claudication long term without surgery?

Back 23

Calculate the ankle-brachial index by measuring systolic arterial pressure in legs and arm with a Doppler device. Get PVR/pulse volume recordings to localize the level of the occlusion. ABI < 1.0 suggests disease, <0.3 is severe. 

Surgery depends on lifestyle of pt. Most pts don't get it. Exercise, lifestyle changes, followup is key. 

Front 24

How is aortoiliac occlusive disease managed differently than less severe PVD?

Back 24

More progressive, surgery more likely. Suggested by absent/weak femoral pulses. Don't wait for rest pain or ulceration to develop. Options afterwards are lifestyle modifications, percutaneous transluminal angioplasty for single short segment stenosis. If bilateral loss, may need an aortobifemoral bypass graft. 

Front 25

How is ulceration in a pt with claudication managed differently?

Back 25

Need to revascularize, get surgery. Angiogram is needed to assess anatomy, ulcer will likely heal with debridement and wound care after revascularization. Use grafts to bypass obstructions, balloon dilations, stents. 

Front 26

What is the clinical picture of SBO? What is the workup and management?

Back 26

Nausea, crampy pain, distenstion, no BMs, tympanitic, mildly tender. Get an upright PA and lateral CXR and flat/upright abdominal x-ray. Will see multiple air fluid levels, no air in colon or rectum. See hypochloremic hypokalemic metabolic alkalosis with paradoxical aciduria. Correct w/NS+K IVF, NG tube, serial labs and x-rays. 

Front 27

What findings would warrant surgical exploration in SBO?

Back 27

localized tenderness, very high WBC count, high temp, metabolic acidosis (suggests ischemia or necrotic bowel), or if non-surgical management fails. 

Front 28

PE and history important questions for SBO?

Back 28

surgical history, orthostatic vitals, assessment of the groin, digital rectal exam, sigmoidoscopy. 

Front 29

What are the risk factors for colon cancer? How do we screen, evaluate? What tests are needed before surgery? Treatment post-surgery?

Back 29

Age >50, personal history of polyps or cancer, FH, colorectal syndromes, UC or Crohns disease. Screen with colonoscopy at 50 or earlier if FH before 50. Evaluate with colonoscopy. 

CXR, CT abd/pelvis, LFTs ­ r/o metastasis

CEA ­ establish baseline

CBC, coags  5­FU based chemotherapy if >stage 2 disease. 

Front 30

What is done pre-op for biliary colic, cholecystitis, choledocolithiasis?

Back 30

BC: NPO, IVF, IV analgesia, can schedule surgery electively

AC: NPO, IVF, IV analgesia, IV abx. Need to do cholecystectomy within 48 hrs. 

Choledocolithiasis: ERCP to remove stones, then cholecystectomy once stable.

Front 31

What are the causes of obstructive jaundice? How would you work it up?

Back 31

Gallstones, tumor, stricture of the common bile duct (prior biliary surgery). 

Bilirubin, LFTs, Alk phos, amylase, lipase

Abdominal US ­ look at CBD

Abdominal CT

ERCP ­ if mass can be visualized ­ allows for brushings for cytology

Upper GI endoscopy and endoscopic US ­ assessment of pancreatic head , allows for assessment of tumor, local metastasis, nodes

Front 32

Important history and physical for acute groin pain?

Back 32

FARCOLDER, worse when you wake up? Bowel habits, change when bearing down, diet, nausea, vomiting, fevers, pain, past surgeries. 

Examine lying down and standing, ­ first look for any bulges or masses in groin, any visible skin changes then palpate the area and ask the patient to cough and/or bear down ­ feel for any masses or bulges and if they are reducible 

Front 33

What should be done prior to intervention for hernias? What is the appropriate intervention? What are risks of surgery?

Back 33

CBC, CT imaging. All hernias need surgery eventually, need surgery emergently if incarcerated. bleeding, infection, recurrence, nerve damage/entrapment of ilioinguinal nerve 

Front 34

Important history and physical for breast disease?

Back 34

Ask about risk factors for breast disease, nipple discharges, changes in size/shape/symmetry of the breast. Last time of mammogram, family history of breast disease. 

Exam: inspect with arms at sides, with arms raised ­ color, symmetry, size, shape, contour, dimpling, erythema, edema, thickening of skin with porous appearance. Palpate breast while patient supine, palpate all 4 quadrants and nipple­areolar complex for discharge, palpate axilla along lateral border of anterior and posterior axillary fold, medial and lateral wall of axilla and apex of axilla. 

Front 35

What diagnostic test would you order for breast disease?

Back 35

under 28 ­ ultrasound (mammogram no use because breast is too dense in this age group) over 28 ultrasound and mammogram

Both followed by FNA or core needle aspiration depending on findings of US or mammogram 

Front 36

What types of malginancy in the breast? Rx for invasive carcinoma?

Back 36

DCIS, invasive ductal carcinoma, invasive lobar carcinoma, malignant phyllodes. 

lumpectomy + radiation = mastectomy, need for sentinel lymph node dissection and possible axillary dissection, possible hormone or chemotherapy. 

Front 37

How do you stage breast cancer? What are considered important pathological aspects of the histology?

Back 37

Stage I ­ tumor is <2cm without metastasis or nodes
Stage II ­ tumor is 2­5cm without metastasis or nodes (there is stage IIA/B) Stage III ­ tumor >5cm with nodes or chest wall invasion (stage IIIA/B)
Stage IV­ distant metastasis

look at margins if did a lumpectomy to make sure got all of the cancer, look at sentinel lymph node ­ if positive have to take all lymph nodes in axilla, look for Estrogen Receptor status and if HER2 positive ­ will dictate treatment 

Front 38

What are the common causes of hypercalcemia?Differentiate between primary, secondary and tertiary hyperparathyroidism. 

Back 38

in outpatient setting ­ parathyroid adenoma

in inpatient setting ­ cancer 

primary hyperparathyroidism ­ increased production of PTH due to hyperplasia or tumor of re Pparathyroid gland

secondary hyperparathyroidism ­ increased release of PTH in response to low calcium

(hypocalcemia) ­ often seen with renal failure

tertiary hyperparathyroidism ­ increased release of PTH after long standing secondary

hyperparathyroidism and results in hypercalemia 

Front 39

Pre and peri-op mgmt of parathyroid disease?

 

Back 39

pre: need to rule out cancer with bone mets, check phosphorus, PTH, ca again, lytes, renal function. Can do sestamibi scan to localize the adenoma, makes procedure less invasive, U/S, CT MRI. 

rule out MEN 1 or 2

solitary Adenoma ­ surgical removal of adenoma (usually 1 parathyroid)

Multiple gland hyperplasia ­ remove three glands or all 4 with implantation of 30g

parathyroid tissue to retain function 

 

Front 40

What are important parts of hx in neck mass? How would you investigate?

Back 40

Radiation.

Hypo/hyperthroidism: Temp intolerance, weight change

FHx

Voice/airway changes, Dysphagia, Dyspnea 

Physical

TSH w/ US -If normal or high → FNA  -If suppressed → radioisotope scan

Hot → radioablation

Cold/warm → FNA 

Front 41

What extra investigations do you need for medullary carcinoma of the thyroid?

Back 41

Calcitonin levels

MEN 2: urine metanephrines, PTH/Ca2+

Thyroidectomy. Lateral neck dissection for palpable nodes. 80% at 10 years. Monitoring

with serum calcitonin.

 

Front 42

What extra investigations do you need for follicular carcinoma of the thyroid?

Back 42

Follicular neoplasms must have tissue biopsy, not just cytology, for proper diagnosis. Treatment involves thyroid lobectomy, which is therapeutic as well as diagnostic. 

I­131 radioablation, which is used for adjuvant therapy following surgery 

Front 43

What are the 2 common causes of hyperthyroid? Rx?

Back 43

Grave’s = radioablation

Toxic multinodular goiter = excision