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Surgery nbme review

-gross or microscopic hematuria: get a CT of the abdomen to identify location of lesion if they are stable
Abdominal trauma
-penetrating (GSW, stab): get an EXLAP
-blunt (MVC): if hemo unstable get FAST/DPL. IF +FAST=exlap. If -- =look for chest/spine look for other injuries. If
stable: get a CT scan

40yo m with T2dM develops a tender, fluctuant mass just inside the anal verge. T39. Glu 350. Next step in
management? Patient has a perirectal abscessSURGICAL INCISION AND DRAINAGE

52yoF BRBPR and on exam is found to have prolapsed internal hemorrhoids that are manually reducible. Next step?
colonoscopy (never assume bleeding is from hemorrhoids)

27yo M has a RLQ pain for last 2 weeks with following barium enema. Dx: Barium shows no haustra (lead pipe).
Diagnosis is IBD/crohns

60yo M comes to ED with LLQ abdominal pain, no peritonitis. He has been admitted in the hospital in the past for
this pain. WBC 20. Next? CT. he has diverticulitis
-localized perf/phlegmon: abx/bowel rest
-abscess: IR drainage
-diffuse peritonitis/diffuse pneumoperitoneum: get surgery. Air under diaphragm/spleen.
Hinchey criteria

40yo M has h/o recurrent pneumonia with scarring of the R lung base seen on radiographic imaging. Severe
halitosis. Dx: aspiration 2ndary to zenker diverticulum. Outpouching of the esophagus. A pseudodiverticulum.
Involves mucosa and submucosa only. Get barium swallow. NO ENDOSCOPY DUE TO HIGH RISK OF PERF.
Tx: cripharyngeal myotomy

70yoF brought from nursing home to Ed with worsening abd pain, distention and fever. KUB shows distended loops
of small bowel with gas in the small bowel as well as in the biliary tree. Cause?
Gallstone ileus.
Riglers triad: pneumobilia, SBO and gallstone in SB (usually RLQ iliac fossa)
Tx: laparoscopic removal of stone or propulsion of impacted stone

30yo F purpura to upper extremities. Bruises easily with minor trauma. Bone marrow has increased
megakaryocytes. Pathophys: Ab (from spleen) attacks platelet antigen
Dx: ITP
ITP children: spontaneous remission. Usually s/p uri
Adults:

30yoM has gradual but progressive abdominal distention and develops a fluid wave. Paracentesis shows chylous
fluid. Dx: lymphoma

50yoM has PMH of remote L femur fx complicated by L femoral DVT as a result. He has an ulcer to the medial
malleolus on distal LLE. Pathophys: arterial insufficiency

60yo F has bilateral LE claudication with walking and a soft femoral bruit is heard in the L femoral artery. Next step?
ABI ankle brachial index: normal is 1. Means patient has noncompressible lower extremity vessels.

70yo M undergoes L carotid endarterectomy and on POD1 returns to ED with headache. HR 80, BP 180/90. CT head
shows intraparenchymal cerebral hematoma. Cause: HTN
Cerebral hyperperfusion syndrome: occurs after carotid endarterectomy, focal seizure/neurological deficit. GET a
CT scan and control BP in the ICU for intensive BP control

15yo M fell off his bike and c/o R chest pain. CXR shows R pneumothorax. Next step? Observation because minimal

40yo M has undergone excision of sebaceous cyst of L scrotum. Pt returns to ED on POD1 with erythema and
induration of the scrotum extending into the perineum and inguinal folds. T39 HR 100 BP 130/80 WBC 20 glu 350.
Next step: Pt has fourniers gangrene (infection of perineum/scrotum)-type of nec fasc. Treatment: debridement

70yo F has h/o breast CA treated with WLE and radiation. Now has gradual onset of urinary incontinence BLE
paraplegia and loss of sensation from below the nipples. Motor strength is normal in UE. What is the level of the
lesion: thoracic spinal cord T4

35yo F is a secretary who c/o pain with typing and loss of sensation to the 2
nd
and 3
rd
digits. +tinel sign. Best study:
nerve conduction study

18yo M c/o pain in L knee after football practice. Pt has joint line tenderness of the proximal tibia, along with a
joint effusion. Dx?medial meniscus tear

8 y/o M brought to pediatrician due to gradual worsening of pain in LLE, antalgic gait. Avascular necrosis. Dx: legg-
calv berthe disease. Treatment: traction, braces and PT

13 yo M has pain in thigh after falling. Pt walks with a waddling gait. Dx: slipped capital femoral epiphysis
(dislocated femur)

15yo F has RUQ pain, WBC 12, T bili 6. Abd u/s shows normal GB, but also an additional cystic mass next to the CBD.
Management: pt has choledochal cyst.
Types: 1. Fusiform dilatation of CBD
2. saccular diverticulum from CBD
3. choledochocele at ampulla
4a: multiple intrahelpatic and extrahepatic
IV b: multiple extrahepatic
V: multiple intrahepatic
All these carry significant risk of cholangiocarcinoma.

30yo M and his wife are attemptint to conceive. Wife has 2 children from previous marriage. He has normal exam
except for irregular cordlike structure in L upper scrotum. Dx: cryptorchidism/undescended testicle

20 yo F is POD 5 s/p hysterectomy. Has RLL consolidation. WBC 18 T38.5 HR 110. BP 120/8-0. Sputum shows gram
negative rods: pseudomonas! Because nosocomial pneumonia. Treatment: get patient off the ventilator!
-gram + cocci: MRSA until proven otherwise

40 yo F undergoes exlap for lower abdominal pain presumed to be of gyn origin. Appendix is inflamed and
appendectomy performed without preop consent. Best explanation?
Implied consent that is life threatening that is indicated at time of surgery

30yoM in recovery after extubation from inguinal hernia repair. Pt desats and ABG PCO2 60, PO2 60. Next step?
Reintubate patient.
Postop respiratory failure:
-tongue is most common cause of upper airway obstruction
-atelectasis is mcc of hypoxia
-prolonged paralysis is mcc of need for emergent reintubation

40 yo F given prochlorperazine for postop nausea. Develops restlessness, muscle stiffness and her head is twisted
to the side. Next step?
Give Benadryl.
She has extrapyramidal side effects from anesthesia/torticollis

30 yo F s/p parathyroidectomy for parathyroid adenoma. On POD 1 she ha sperioral numbness and tingling. Serum
Ca 6.8. next step: generally after surgery the remaining glands are suppressed, so unless patient has severe
symptoms, generally observe for their other glands to work again. OBSERVE

40yo F falls while stepping off curb and is diagnosed with T12 fx. Ca 11, Pi 11 AP 600. Dx: Pagets disease:
pathologic fracture with very high AP

30yo M with recurrent infection of glands of the L axilla, requiring serial excision and debridements. What affected
gland is the etiology?
Apocrine glands

67 yo F undergoes laparotomy and there is discovery of a 4x7 cm mass in the tail of the pancreas. Biopsy: serous
cystadenoma. Next step: excise, distal pancreatectomy

30 yo F has occasional palpitations, holosystolic murmur with midsystolic click. Dx: MVP

50yo M holosystolic murmur radiating to axilla which disappears when pt is in R lateral decubitus position. Dx:
mitral regurgitation

35 yo F undergoes informed consent by the physician for exploratory procedure due to chronic pelvic pain. Consent
witnessed by husband. After given narcotics preanesthesia, pt becomes anxious and states she does not want the
procedure anymore. Next step? Confirm informed consent from husband. Treat anxiety with benzodiazepine and
proceed with operation

30 yo F has a solitary cystic mass in the R ovary. 2 months later, she complains of lower abd pain, and repeat U/s
shows enlargement with sepatation: next step: unilateral salpingooophorectomy

30 yo M has uunilateral flank pain radiating to groin. UA shows: patient has stones. Ua has RBC

4 yo M with unilateral pain to L eye, conjucntival injection and small cyst present on the eyelid. Dx: chalazion

70 yo F has sudden unilateral loss of vision in L eye. Ophto shows pale retina with thin walled arteries: dx: CRAO

50yo M undergoes RUE aV fistula for hemodialysis and on POD 1 has hypotension and tachycardia. Dx: highoutput
CHF

40 yo F with PMH of scleroderma develops progressive abd pain, peritoneal signs. CT shows distended colon with
cecal diameter 12 cm. next step? Toxic megacolon, scleroderma, so distended colon.
LAPAROTOMY