Surgery Oral Exam

Front 1

What is follow-up for patients with breast cancer?

Back 1

Patients should see their physician 2x a year. Annual CXR and LFTs. Patients with lumpectomy should get mammograms of affected breast every 6 months for 2 years and then yearly.

Front 2

What is the 5 year survivial for stage 1 cancer? Stage 2?

Back 2

Stage 1 = 93%
Stage 2 = 72%

Front 3

What is the false negative rate for mammograms?

Back 3

From 7-20%

Front 4

Why is surgery necessary for DCIS? What kind of surgery is done?

Back 4

If lesions remain, the 10 year risk for invasive carcinoma is >30%.
For solitary lesion: lumpectomy and radiation - no need for nodes b/c mets are rare.
Multifocal: Simple mastectomy

Front 5

What is the treatment for LCIS? Why?

Back 5

Surveillance with mammograms every 6 months. Its a malignant disease marker with 15-20% 20 year risk of Cancer. There is NO risk of axillary mets.

Front 6

The most common cause of bloody discharge:

Back 6

intraductal papilloma - requires surgical biopsy

Front 7

After the diagnosis of breast cancer, which two tests should be done to detect metastasis?

Back 7

CXR and LFTs

Front 8

What is the primary blood supply to the breasts?

Back 8

Internal mammary and lateral thoracic

Front 9

This stage breast cancer is >2cm has no nodes and no mets.

Back 9

Stage I

Front 10

This stage breast cancer is <2cm with mobile nodes or 2-5cm with no nodes and no mets.

Back 10

IIA

Front 11

This stage breast cancer is 2-5cm with mobile nodes or 5+ cm with no nodes and no mets.

Back 11

IIB

Front 12

This stage breast cancer is 5+cm with mobile nodes or any size cancer with fixed nodes. May also have skin changes, retraction, and lymphadenopathy.

Back 12

III

Front 13

This stage breast cancer has distant mets

Back 13

IV

Front 14

What is the standard treatment for stage IV breast cancer?

Back 14

Palliative radiation and chemo. Surgery may be for debulking.

Front 15

What is the standard treatment for stage III breast cancer?

Back 15

Modified radical mastectomy with neoadjuvant therapy (condult radiologist)

Front 16

What is the 5 year survival for stage 3 breast cancer? Stage 4?

Back 16

Stage 3 = 41%
Stage 4 = 18%

Front 17

What are the risks of a core needle biopsy of the breast?

Back 17

Pneumothorax, hematoma, and has a 20% false negative rate

Front 18

What are the risks of tamoxifen therapy?

Back 18

Increased risk of endometrial cancer (1.5%)
Osteoporosis, DVT, menopausal symptoms

Front 19

What is the treatment for Her2Neu receptor positive Breast CA?

Back 19

Trastuzumab (Herceptin)

Front 20

What is Valentino's appy?

Back 20

Rupture of peptic ulcer that flows down the colic gutters

Front 21

Name ten things on on the DDX for RLQ pain:

Back 21

Appendicitis, diverticulitis, TOA, Hepatitis, mesenteric lymphadenitis, gastroenteritis, kidney stone, diverticulitis of cecum, PID, ectopic, UTI, IBD, Pancreatitis and PNA

Front 22

Describe the clinical appearance of SBO

Back 22

Patient is distended, air fluid levels seen on KUB, feculent vomit, typanic abd, dehydrated. Metabolic alkalosis with hypo K and hypo CL.

Front 23

If there is crohn's in the cecum why should you not take out the appendix?

Back 23

Because it may cause a fistula

Front 24

Name the 7 causes of a fistula:

Back 24

FRIENDS: Foreign body, Radiation, Infection, Epitheliazation, Neoplasm, Distal obstruction, Stones

Front 25

How do you manage a Crohn's SBO?

Back 25

First with medical management: NPO, bowel rest, TPN and observation. If not improved in 3 weeks, may need to resect affected colon with anastamosis.

Front 26

How do you manage peri-anal disease with Crohn's?

Back 26

Drain the peri-rectal abscess and place a seton (hollow plastic tube) in the fistula and give metronidazole

Front 27

How do you treat mesenteric lymphadenitis?

Back 27

IVF

Front 28

How do you treat supperative thrombophlebitis?

Back 28

Remove the focus on infection (catheter, section of vein), IV antibiotics, consider surgical intervention.

Front 29

28 year old presents with abdominal pain, elevated WBC and large tubular structure in the retroperitoneum after vaginal delivery:

Back 29

Suppurative Thrombophlebitis: treat with exploratory celiotomy- find the ovarian vein and excise it

Front 30

Why should you do an EKG with increased calcium levels?

Back 30

Can cause short QT intervals with prolonged PR

Front 31

What is the medical treatment for hypercalcemia?

Back 31

NS to dilute, diuresis with lasix. Then begin calcitonin, Mithramycin and bisohosphonates.

Front 32

Name eleven common causes of hypercalcemia:

Back 32

Hyperparathyroidism, Sarcoidosis, Vitamin A or D intoxication, Iatrogenic (thiazides), Milk alkali syndrome, metastatic cancer, Paget's disease, Addison's disease, neoplasm

Front 33

Name four ways to test for renal artery stenosis:

Back 33

Duplex the renal arteries, radioisotope renogram (arteriogram), hypertensive IVP

Front 34

What test would you do for Cushings?

Back 34

AM/PM cortisol levels and then a low dose/high dose dexamethasone to confirm (pituitary will have suppression with high dose)

Front 35

Name five causes of uncontrollable HTN:

Back 35

1. Cushing's syndrome
2. Renal artery stenosis
3. Conn's syndrome
4. Coactation of the aorta
5. Pheochromocytoma

Front 36

What test would you do for a pheo?

Back 36

I-MIBG scan: scintography using iodine- if greater than 5cm = cancer

Front 37

What is the organ of zuckerandl?

Back 37

chrommafin body from neural crest cells located at the bifurcation of the abdominal aorta that can be the source of a pheo

Front 38

What is a pheochromocytoma?

Back 38

neural endocrine tumor of the adrenal medulla that secretes large amounts of catecholamines (epi and norepi)

Front 39

What is Conn's syndrome? Why does it cause HTN?

Back 39

aldosterone producing adenoma. Aldosterone causes the increased exchange of Na+ for K+ in the kidneys leading to hypernatremia and hypokalemia. Na+ retention leads to plasma volume expansion and hypertension:

Front 40

What ratio would you look at in Conn's syndrome?

Back 40

Renin: Aldosterone
If this ratio is > 30, this means that there is a lot of aldosterone and not very much renin

Front 41

Name three imaging tests for Conn's:

Back 41

1. CT to localize tumor
2. Iodocholesterol scan: scintography of adrenal
3. selective venous sampling of adrenal vein to look for increased aldosterone

Front 42

How do you treat Conn's?

Back 42

Spironolactone: it is an aldosterone antagonist

Front 43

How much does DCIS increase the risk for breast CA?

Back 43

35X

Front 44

What two options should be given to women with LCIS?

Back 44

Close follow up (6 month mammography) or bilateral simple mastectomy

Front 45

What is the Breslow level?

Back 45

Gives the five year survival for melaonoma by depth of invasion.

Front 46

What are the stages of the Breslow levels? What is the 5 year survival?

Back 46

I : >0.75mm >89% survival
II : 0.75-1.5 75% survival
III : 1.5 - 2.5 58% survival
IV: 2.5-4 46% survival
V: >4mm 25% survival

Front 47

What tests for mets should be done with a diagnosis of melanoma?

Back 47

LFTs and CXR

Front 48

If there is a melanoma of the face, what should be removed?

Back 48

The melanotic lesion with adequate margins. Do a superficial parotidectomy and modified radical neck dissection. Avoid the marginal mandibular branch of the facial nerve.

Front 49

What is the Halsted theroy of cancer?

Back 49

Remove the primary tumor with all lymph node drainage

Front 50

Change in mental status is due to ________ until proven otherwise:

Back 50

Hypoxia

Front 51

What are the two commmon causes of wound infection:

Back 51

Group D strep and clostridium

Front 52

An SpO2 of 70, 80, and 90 correspond to a PaO2 of what?

Back 52

40, 50, and 60. At a PaO2 of 60 the hemoglobin curve drops precipitously

Front 53

What size tube do you intubate with? Why? Where should it be placed?

Back 53

Size 8 tube becasue its the smallest a scope will fit down, tip of the tube should be 2cm above the carina, which is about the level of the clavicles.

Front 54

What is intermittent manditory ventillation?

Back 54

Has a predetermined rate but patients can breathe over the vent.

Front 55

What should initial vent settings be?

Back 55

10-15cc/kg, 10 breaths a min, FiO2 100% and weaned down to <60. PEEP of 5.
Change according to blood gas analysis

Front 56

What are the benefits and draw-backs of PEEP?

Back 56

Its good because it keeps pressure in the lungs that keeps alveoli open but is bad because it can cause a PTX, it decreases venous return and cardiac output and can cause hypotension.

Front 57

If a patient is allergic to heparin but has a PE, what do you do?

Back 57

Place a greenfield or bird's nest filter in the IVC below the renal arteries.

Front 58

What is Homan's sign?

Back 58

A sign of DVT: pain in the calf with dorsiflexsion of the foot while the knee is at 90 degrees

Front 59

Signs of DVT:

Back 59

One large leg, Doppler legs, spiral contrast CT of chest

Front 60

What causes duodeal atresia?

Back 60

Vascular insult during development that causes failure of recannalization

Front 61

Why does a child with pyloric stenosis have aciduria?

Back 61

Due to intractable vomiting, kidneys save Na+ at the expense of H+. They don't exchange it for K+ because K+ is low and they're trying to save that too.

Front 62

What tests should be done for pyloric stenosis?

Back 62

U/S or upper GI with barium.
Gastrograffin is water soluble in the peritoneal cavity but causes pneumonitis. Barium is bad in the peritoneal cavity

Front 63

What causes an inguinal hernia in children?

Back 63

Patency of the proccussus vaginalis

Front 64

What is a gastroschisis?

Back 64

Abdominal wall defect, no surrounding sac, not associated with other anomalies, small defect, diagnosed with prenatal U/S

Front 65

What is omphalocele?

Back 65

Abdominal wall defect in which the sac covers extruded viscera, associated with diapgragmatic defect, cardiac problems, pericardium and sternal cleft (Pentalogy of Cantrell)

Front 66

What pre-op medications are given to a patient undergoing CEA?

Back 66

Prophylactic antibiotics (foreign body), heparin, and dopamine to keep BP up. Give an alpha blocker pre-operatively and have nitro drip ready for HTN crisis.

Front 67

Why does a patient have a HTN crisis with CEA?

Back 67

Carotid body is clamped, body thinks you're hypotensive, releases signal to increase catecholes and blood pressure. Should inhibit carotid body with lidocaine.

Front 68

Why is a bowel prep important in repair of a AAA?

Back 68

Because you ligate the IMA which provides blood to watershed areas of the colon (splenic flexure). If there is ischemia of the bowel, patient gets ischemic colitis 2-3 days post-op. Translocation of bacteria will infect the graft.

Front 69

What preparation is important for a AAA repair:

Back 69

Get EKG and stress test, do pre-op antibiotics (foreign body) and bowel prep.

Front 70

What is Dieulafoy's ulcer?

Back 70

large tortuous ateriole in the stomach that erodes and bleeds and can cause gastric hemorrhage.

Front 71

What are options for AAA repair?

Back 71

1. Open repair with direct transabdominal approach
2. Retroperitoneal approach
3. Endograft repair

Front 72

What is the major drawback of endovascular repair of AAA?

Back 72

Endoleak: occurs in 20% of patients. Need compliant patient for good followup.

Front 73

What is an aortoenteric fistula? What causes it?

Back 73

Fistula between the aorta and duodenum caused by slow growing graft infection with S. epidermidis.

Front 74

How do you approach fixing an aortoenteric fistula?

Back 74

Endoscopy in the OR, CT to look for gas bubbles or fluid, take out the infected graft, irrigate with betadine and perfirm exta-anatomic bypass (axillobifem)

Front 75

How do you prepare a patient pre-op for removal of a pheo?

Back 75

1. alpha blocker and then beta blocker
2. Intravascular tone will decrease - need swan ganz to measure wedge
3. Type and cross for the 3 adrenal veins
4. pressors, good IVs for fluids

Front 76

What is MEN1?

Back 76

Tumos associated with menin gene defect: Pituitary, parathyroid and pancreas

Front 77

What is Men 2a?

Back 77

Tumors associated with the Thyroid, parathyroid, and adrenals

Front 78

Men2b:

Back 78

Tumors associated with submucosa, medullary thyroid, and adrenal

Front 79

Why do a trach if patient is on vent for > 2 weeks?

Back 79

To prevent tracheoinnominate fistula (bracheocephalic artery)

Front 80

What defibrillator settings are needed for V-fib?

Back 80

300 and have epi ready. This is for burn patients that may have arrythmias

Front 81

What should urine OP be in a burn patient?

Back 81

30cc/hr

Front 82

Why is myoglobin not good for kidneys? How do you fix this?

Back 82

It clogs the renal tubules. Flush with isotonic fluids and alkinalize the urine.

Front 83

Name 6 things to put on burns:

Back 83

1. Sulfamylon
2. Silvadene
3. Silver Nitrate
4. Bacitracin
4. Betadine
6. Acetic Acid

Front 84

What are the drawbacks of sulfamylon?

Back 84

painful- irritates nerve endings
Causes metabolic acidosis because its a CA inhibitor

Front 85

What are the drawbacks of silvadene?

Back 85

Transient neutropenia

Front 86

What are the drawbacks of silver nitrate?

Back 86

Metabolic alkalosis due to hypo K and hypo Na, turns everything black

Front 87

Name 6 ways to stop bleeding esophageal varices:

Back 87

1. sclerotherapy : using sodium morrhuate
2. Balloon tamponade
3. rubber band ligation
4. vasopressin
5. Somatostatin
6. Portocaval shunt

Front 88

What causes hepatic encephalpathy? How do we test for it?

Back 88

Its caused by bacteria normally detoxified in the liver
Test for it by measuring arterial ammonia

Front 89

What are Child's criteria?

Back 89

Predicts operative mortality in patient's with cirrhosis. Measures ascites, bili, albumin, and encephalopathy
A: no symptoms and no increased risk
B: well controlled ascites, moderate lab values, 15% increase
C: Ascites, encephalopathy, bad nurtrition, 40% mortality

Front 90

What is TIPS?

Back 90

transjugular intrahepatic portosystemic shunt: stent placed intrahepatically between the hepatic vein and branch of the portal vein. Is a temporary bridge to transplant

Front 91

If a mass is detected at the head of the pancreas on CT, how do you biopsy it?

Back 91

Transduodenal biopsy so that leakage goes into the stomach

Front 92

Where is the head of the pancreas?

Back 92

Above the portal vein

Front 93

Whipple procedure removes what?

Back 93

distal 1/2 of the stomach (antrum), head of the pancreas, duodenum, gallbladder, cystic duct, common bile duct, proximal jejunum and regional lymph nodes.

Front 94

Whipple is also a good procedure for what other carcinoma?

Back 94

Cholangiocarcinoma (5 year survival is 40%)

Front 95

If pancreatic cancer is unresectable in a patient with symptoms, what can be done?

Back 95

Relieve biliary obstruction with a stend placed with ERCP.
Stents are frequently infected and need replacement q3 months.

Front 96

Surgical solution to chronic pancreatitis?

Back 96

Roux en Y choledochojejunostomy: bypass from the CBD to the jejunum. This prevents alkaline gastritis.

Front 97

How do you medically treat alkaline gastritis

Back 97

Cholestyramine to decrease bile acid pool or Calcium to chelate bile acids

Front 98

What tests should be done to clincally stage colon cancer?

Back 98

CXR and LFTs and pre-op CEA level

Front 99

What preparation should be done for a bowel resection for colon cancer?

Back 99

Check labs, do bowel prep, give antibiotics (neomycin and erythromycin)

Front 100

What post-op test should be done 6 weeks s/p colon cancer resection?

Back 100

CEA

Front 101

Richter's hernia

Back 101

incarcerated or strangulated hernia involving one side of the bowel

Front 102

Littre's hernia

Back 102

hernia involving Meckel's diverticulum

Front 103

Spigelian hernia

Back 103

hernia through the linea semilunaris (spontaneous lateral ventral hernia)

Front 104

Pantaloon hernia:

Back 104

hernia sac is both direct and indirect and straddles the inferior epigastric vessels

Front 105

Grynfeltt's hernia

Back 105

hernia through superior lumbar triangle

Front 106

Petit's hernia

Back 106

hernia through inferior lumbar triangle

Front 107

Bochdalek's hernia

Back 107

hernia thorugh posterior diaphragm - usually left

Front 108

Morgagni;s hernia

Back 108

anterior parasternal diaphragmatic hernia

Front 109

Cooper's ligament

Back 109

pectineal line of pelvis

Front 110

Poupart's ligament

Back 110

attaches from the ASIS to the pubic tubercle

Front 111

Nissen

Back 111

wraps fundus 360 around LES

Front 112

Belsey Mark IV:

Back 112

270 degree wrap around the LES

Front 113

Toupe

Back 113

180 degree wrap around les

Front 114

hill repair

Back 114

posterior gastropexy: uses the arcuate ligament to re-establish the intra-abdominal position of the distal esophagus

Front 115

Collis-Nissen

Back 115

cut the stomach to lengthen the esophagus

Front 116

Heller Myotomy

Back 116

Used for achasia

Front 117

Bassini

Back 117

repair for inguinal hernia, sutures pouparts ligament to the transversus abdominus aponeurosis/conjoint tendon

Front 118

McVay

Back 118

Cooper's ligament sutured to transversus abdominis aponeurosis

Front 119

Wound infection in the first 24 hours is caused by

Back 119

Group D strep and Clostridium

Front 120

How do you kill clostridium

Back 120

PCN

Front 121

Treatment for acute hyperkalemia

Back 121

IV calcium is cardioprotective, sodium bicarbonate, glucose and insulin, albuterol, kayexalate, dialysis

Front 122

Name 6 complications after surgery

Back 122

1. Death
2. hemorrhage
3. loss of function
4. pain
5. scarring
6. Infection

Front 123

The biggest risk of giving packed RBCs is _________

Back 123

bleeding- dilutional effect on platelets