Surgery oral examination reviews

SURGERY ORAL EXAMINATION REVIEWS, JASON FISHER
BREAST MASSES

SAMPLE QUESTION  A 42 year-old woman comes into your office with the chief complaint of
feeling a mass in her left breast while showering. Describe your workup. • Take a history designed to flush out HPI and identify any RF’s for breast CA.
• Perform physical exam looking for:
--Character of the mass (smooth, mobile, firm) --Dimpling of skin --Lymph nodes (axillary, cervical, clavicular) • Perform mammography or ultrasound next. (can perform FNA prior to imaging but only for
aspiration, NOT for biopsy, as aspiration alone will not interfere with imaging, but FNA Bx will) • Perform FNA of the breast mass AFTER imaging  Discard fluid if non-bloody; no cytology
• Perform incisional, excisional, or core biopsy if:
--PE bloody nipple d/c or nipple ulceration --Mammographic suspicion (micro-Ca, spiculated) --Pt's concern of breast abnormality --FNA  bloody fluid, solid mass, or palpable mass after aspiration The biopsy or FNA results return a diagnosis of infiltrating ductal carcinoma, how do you proceed now? Pay attention to the question, as it may ask specifically how to Tx the mass, and not the whole disease • Treatment for the primay lesion, the breast mass, includes:
--Identification of Estrogen and Progesterone receptors in all biopsy / FNA specimens --Modified Radical Mastectomy +/- Reconstruction --Lumpectomy + Radiation (tumors < 5cm) Both treatments have similar local recurrence and survival rates Both can be bolstered with adjuvant chemotherapy and/or Tamoxifen depending on receptors • Regional treatment, the axillary region, along with the primary excision, allows for staging:
--Axillary node dissection, levels I and II (lateral and deep to pectoral minor) • Stage the patient's disease IIIA = tumor >5cm, mobile nodes
IIIB = any size tumor, ipsilat int mamm nodes IV = mets (including ipsilat supraclavic node) • Evaulate for signs of systemic disease:
--Bilateral mammogram (contralateral breast) --Provide chemotherapy based on systemic findings OR positive nodes / est/prog receptors The biopsy or FNA results return a diagnosis of DCIS, how do you proceed now? • Treatment for the primary lesion, the breast mass, includes:
--If < 5mm, remove with clear margins and f/u
--If 5mm - 2cm, lumpectomy with 1 cm margins and radiation
--If > 2cm or diffuse breast involvement, Total (simple) mastectomy
Axillary node dissection has no role in true DCIS if there is no microinvasion
Major risk with DCIS is development of infiltrating ductal CA in same breast
Suspect DCIS if diffuse microcalcifications are seen on mammorgraphy
SURGERY ORAL EXAMINATION REVIEWS, JASON FISHER
UPPER GI BLEED

SAMPLE QUESTION  A 55 year-old man calls your answering service on a Saturday c/o burning
pain in his upper abdomen, nausea, dark brown vomit & ↓ appetite. How do you proceed: • Take a history designed to flush out HPI and identify any RF’s for GI bleeding.
--Have you had similar episodes in the past? --"COLD-REARS" of pain (esp Referred) --Any assoc syncope, ∆MS, fatigue, thirst? • Perform physical exam looking for:
--Epigastric or Lower Quadrant tenderness? --Any periotneal signs / guarding / rebound? • Insert large peripheral IV lines for resuscitation purposes and Foley to monitor fluid status
--Blood should be sent for Type & Xmatch, as well as CBC/Lytes/Coags/LFTs/Amylase • Perform NGT placement and aspiration
--Determine rate & amount of blood lost; warm H2O lavage to remove clots and allow EGD • Send for an upright KUB if pt is stable enough
• Perform EGD examination of esophagus and stomach
--Biopsy only if mass associated with duodenal ulcer --Biopsy ALL gastric ulcers, obtaining multiple specimens --Look for stigmata of ulcer hemorrhage  visible vessel, clot over ulcer, necrotic base If EGD fails to Dx source of UGI bleed, & blood persists in NGT mesenteric angiography. EGD reports a 1.5cm ulcer on the posterior aspect of the duodenal bulb, 2 cm from the gastric pylorus, with no evidence of active bleeding, but a clot covers the ulcer. EGD sclerotherapy is performed. What is your biggest concern with this ulcer location and how would you proceed with managing this patient? • Ulcer of the posterior duodenum  may erode gastroduodenal A  bleeding & pancreatitis
• Ulcer of the anterior duodenum  perforation more common than posterior  free air
• If pt is stable with no evidence of bleeding, proceed with medical management:
--H2 Receptor Antagoinists  heal 70% of ulcers by 4-6wks --Proton-Pump Inhibitors  heal 95% of ulcers by 4-6wks --Adjunctive antacids and sucralfate --Advise pt to avoid ASA, EtOH, and cigarettes Pt presents to the ER 2 weeks later with acute upper abdominal pain, hypotensive, and appearing acutely ill. After IV fluids and NGT lavage, EGD reveals an actively bleeding ulcer in the posterior wall of the duodenum. What are the indications and the options for surgical management? • Indications for surgical intervention in duodenal / peptic ulcer disease:
("I-HOP")
--Goals of surgery in PUD are to correct the above indication AND decrease acid secretion • Physiology behind decreasing gastric acid secretion via truncal vagotomy:
--G-cells in antrum of stomach release gastrin, which is one stimulus for the parietal cells of the stomach fundus to secrete acid. AcH also directly stimulates acid secretion, as well as stimulates histamine secretion from ECL cells. By removing AcH stimulus, there is no stimulation of the G-cells in the antrum (especially if antrum is removed), no direct stimulation of the parietal cells, and no stimulation of H2 release from the ECL cells. • Types of surgery for PUD depend on pt's clinical presentation and goals of treatment:
omental patch over duodenal perf in unstable pt / poor op candidate. --Truncal Vagotomy and Pyloroplasty  resect 1-2cm of each vagal trunk at distal esoph, thereby decreasing gastric acid secretion and emptying, and thus requires pylorplasty to facilitate gastric emptying **Not good procedure for OBSTRUCTION --Truncal Vagotomy and Antrectomy  remove antrum in addition to vagotomy, reconstruct with Billroth I (gastroduodenostomy) or II (gastrojejunostomy) **Good procedure for Perforation, Obstruction, or Intractability **Procedure with LOWEST RECURRENCE rate and HIGHEST DUMPING rate **Procedure with the HIGHEST MORTALITY --Proximal Gastric Vagotomy (Highly Selective)  no drainage procedure needed; fibers to **Ideal procedure in setting of INTRACTABILITY **Contraindicated in concomitant pyloric / prepyloric ulcer **Procedure with HIGHEST RECURRENCE rate and LOWEST DUMPING rate **Procedure with the LOWEST MORTALITY SURGERY ORAL EXAMINATION REVIEWS, JASON FISHER

SAMPLE QUESTION  A 23 year old male is brought to the ER after receiving multiple injuries in
a MVA. EMS reports a BP of 80/palp, pulse of 130, and an RR of 36. What do you do? • Evaluate airway-breathing-circulation. Regarding airway:
--Consider spinal immobilization when evaluating airway integrity (backboard + collar) --Patient speaking?  If yes, airway is intact --Be extra concerned about pt’s with maxillofacial fractures or crushed trachea. --1st maneuver to establish airway  chin-lift / jaw-thrust; if success  oral / nasal airway --Nasotracheal intubation is CONTRAINDICATED in maxillofacial fractures or apnea • Assess the patient’s breathing:
--Inspect Breathing  RR, cyanosis, tracheal shift, open chest wound, assymmetry --Auscultate, Percuss, and Palpate Chest --Attempt to rule out  airway obstruction subcutaneous emphysema (ptx until proven otherwise) • Evaluate the integrity of the patient’s circulation:
--Place 2 large-bore IVs in upper extremities & infuse LR (total volume = 3X what was lost) • Assess the presence of any disability in the patient after ABC’s are secure.
--Evaluate  Mental Status, Pupils, Motor/Sensory status --GCS, 3-15, scores eye opening (4), motor response (6), verbal response (5), T if intubated --Blown pupil present? ipsilateral CN III --Check movement at all extremeties and test for presence of any gross sensation defect • Obtain adequate exposure and environment for the patient.
--Completely disrobe patient --Thorough exploration and palpation of pateint during 2o survey --Keep a warm environment (Hypothermia  acidosis, arrhythmia, and coagulopathy) You manage to secure an airway in the patient via endotracheal intubation, he appears to have no breathing abnormalities, and two large bore IVs have been placed w/ LR flowing free. The pt’s GCS is 9T and he has been completely disrobed in the trauma suite. What do you do next? • Proceed with secondary survey of the patient: Peform head-to-toe physical exam:
--Continue to obtain vital signs as resuscitation continues --Examine ears  hemotympanum or otorrhea = basilar skull fracture --Examine eyes  traumatic hyphema of the anterior chamber; raccoon eyes --Examine nose  --Examine jaw  mandibular malocclusion evaluated by asking pt to “bite down” --Evaluate ribs  lateral and anterior-posterior compression of thorax --Evaluate abdomen  peritoneal signs; should decompress w/ NGT sphincter tone, blood, rigid sigmoidoscope --Evaluate pelvis  r/o fractures via lateral and anterior-posterior compression --Evaluate extremities  r/o compartment syndrome, fractures (especially hip dislocation) • Obtain an “AMPLE” history from the patient or from friends/family members:
• Draw a blood sample to obtain (1) Type and Crossmatch, (2) ABG, and (3) Hematocrit
• Place a Foley Catheter to monitor urine output. Contraindications to immediate Foley:
--High-riding ballotable prostate on DRE Consider retrograde urethrogram if urethral disruption suspected • Order any necessary imaging studies:
--AP-CXR  r/o great vessel injury (wide mediastinum, loss of knob) --Lateral Cervical spine film --AP-Pelvis Film --AP-KUB • Consider performing DPL, FAST, or CT Scan if abdominal injury suspected
You successfully complete your primary and secondary surveys, having stabilized the patient to a BP of 120/90 and a HR of 85. Blood is drawn & imaging studies are ordered. When the studies return, you discover a ______ injury. How do you treat this injury and what are the indications to operate? • Subcutaneous emphysema  no Tx unless upper airway compression; r/o PTX • Tension pneumothorax  tube thoracostomy in midaxillary line, 4th intercostal space • Open pneumothorax  intubate w/ pos pressure vent, chest tube, and 3-sided dressing • Massive hemothorax  IV fluids, chest tube; Operate if bleeding continues at > 200cc/hr • Flail chest  intubate with pos pressure vent and PEEP prn • Cardiac tamponade  IV fluid bolus, pericardiocentesis, mandatory surgical exploration • Compartment syndrome  four-compartment fasciotomy of the lower extremity • Zone I Penetrating Neck Injury  arteriogram before exploration • Zone II Penetrating Neck Injury  surgical exploration first • Zone III Penetrating Neck Injury  arteriogram before exploration • Penetrating Neck Injury Superficial to Platysma  no surgical exploration needed • Gunshot to Abdomen  exploratory laporotomy • Stabbing to Abdomen  exploratory laporotomy IF peritoneal signs, bleeding, visible bowel • Penetrating Colon Injury  Stable w/ minimal fecal spill: primary repair =/- resection Unstable w/ major fecal spill: colostomy and resection • Small Bowel Injury  primary closure or resection and primary anastamosis • Penetrating Rectal Injury  diverting proximal colostomy, close perforation, presacral drainage • Extraperitoneal or Minor Bladder Rupture  Foley and observe • Intraperitoneal or Major Bladder Rupture  Operative closure in three layers • Pelvic Fracture  external fixators, IVF/blood, supraumbilical DPL, A-gram w/ embolization Do not enter pelvic hematoma in OR for (+) DPL unless major arterial injury • Irreparable Duodenal and Pancreatic Head injury  Whipple • Minor Pancreatic Injury  drainage SURGERY ORAL EXAM REVIEWS, JASON FISHER
SMALL BOWEL OBSTRUCT

SAMPLE QUESTION  A 42 year old man presents to the ER with a 3-day history of crampy
abdominal pain, nausea, and vomiting. He has not had a bowel movement in 3 days. Describe your work-up and initial treatment of this patient. • Take a history designed to flush out the HPI and identify any RF’s for small bowel obstruction:
--Have you had similar episodes in the past? --Is there FH of cancer? Recent wt loss? --Meds (coumadin, anti-AcH, diuretics, narcotics)? --Any h/o IBD, volvulus, Meckel’s? --History of gallstones, colic, or endometriosis? Paralytic ileus commonly mimicks SBO, often 2o to post-op, hypoK, meds, inflammation, retroperitoneal hemorrhage, sepsis/shock, or SCI. Pt’s usually have NO bowel sounds. Want to rule out colonic obstruciton and ischemic bowel / mesenteric ischemia • Perform a physical exam looking for:
--HR, BP, Orthostatics, RR  Hypovolemia? --Peritoneal signs  guarding, percusion --Temperature, Tachycardia, Tachypnea  ?OR --Rectal exam  impaction, mass, blood • Draw blood to perform laboratory evaluation, including Lytes, CBC, Type and Cross, and U/A
• Perform routine imaging studies of the abdomen:
--Upright CXR  free air? --Flat and Upright KUB  dilated bowel loops --If Dx uncertain, perform barium enema BEFORE performing UGI w/ small bowel f/t UGI series with small bowel follow-thru has NO ROLE in a known complete SBO On exam, the pt is tachycardic, normotensive, and normothermic, with hyperactive bowel sounds. Rectal exam is negative and there is no abdominal mass present. KUB reveals distended loops of small bowel with air fluid levels and scant air in the colon. Labs are pending. How do you proceed? • Initial treatment is conservative nonoperative therapy:
--Nasogastric decompression --IV Fluids (LR or D5½NS +20-40mEq KCl) --Place Foley; ideal u/o = 0.5-1.0 ml/kg/hr • Objective parameters which lower the threshold to operate in pt’s w/ SBO:
• Based on radiographic and clinical findings, determine if SBO is partial vs. complete
--Partial  presence of flatus, BM, colonic air; not specific --Pt’s w/ partial SBO should be managed nonoperatively at first UNLESS peritoneal signs --80% of partial SBO will resolve with conservative management --Complete  no flatus or BM, no colonic air; presence of these Sx does NOT r/o complete --Pt’s w/ complete SBO should be managed operatively at first UNLESS h/o previous SBO’s --80% of complete SBO will not resolve with conservative management SURGERY ORAL EXAMINATION REVIEWS, JASON FISHER
COLON CANCER

SAMPLE QUESTION  A 66 year old man arrives at the ER with c/o light-headedness. He
describes passing dark tarry stools 3-4x in the past week. He does not smoke or drink. • Take a history designed to flush out the HPI and identify any RF’s for lower-GI bleeding:
--Fam Hx of colon CA? Diet, Smoke, EtOH? --Any recent weight loss, anorexia, ∆bowel habits? --Hx of hemorrhoids or diverticulosis? --Any N/V +/- blood, abd pain? • Perform a physical exam looking for:
--HR, BP, Orthostatics, RR  Hypovolemia? --Peritoneal signs  guarding, percusion --Abdominal distention, tenderness, masses? • Insert large peripheral IV lines for resuscitation purposes and Foley to monitor fluid status
• Draw blood to perform laboratory evaluation, including Lytes, CBC w/ MCV, Type/Cross
• Perform imaging to localize the source of bleeding:
--Place NG Tube to r/o UGI bleed (look for bile) --Tagged RBC Scan (bleeds 0.1 ml/min) The pt is normotensive with a HR = 104. Abdomen is soft, nt/nd, with normal BS. Rectal exam reveals heme-positive melenotic stool in the rectal vault. Hgb is 8.1 with an MCV of 72. LFT’s are normal. Colonoscopy reveals sessile fungating mass proximal to hepatic flex, not ammenable to endoscopic tx. The lesion is biopsied and reveals adenocarcinoma. How do you now proceed? • What are some of the types of polyps typically found on colonoscopy? * = ↑ca risk
--Neoplastic  tubular*, villous*
--Hamartomatous Peutz Jegher*, juvenile
• Which symptoms of colon CA are more common with the side of the lesion?
large diameter: anemia, melena > BRBPR small diameter: change in bowel habits, obstruction,scant blood • Preoperative preparation for colon CA resection
--CBC, Chem10, PT/PTT, T&C, LFT, CEA, U/A --Pelvic CT if suspect rectal CA --Bowel preparation: Golytely until clear, PO Abx (1g neo + 1g erythro +/- flagyl x 3doses) IV Abx (cefoxitin or cefotetan;clinda+aztreonam at least 30min preop) Want to rule out any distant metastases before proceeding to surgical treatment Rectal cancers should have Preoperative Staging via transrectal ultrasound • Treatment is surgical excision with the following parameters:
--Remove regional lymphatics +/- sentinal node --Margins of AT LEAST 2cm, >5cm desirable • Attempt to stage the cancer after resection to decide definitive therapy:
--TMN  T1:submucosa, T2:muscularis propria, T3:thru propria no serosa, T4: thru serosa • Decide on any adjuvant therapy after surgical resection
adjuvant chemotherapy with 5-FU and leucovorin --T4 or Positive Margins  adjuvant radiation therapy --No role for radiation therapy in Duke’s Class C --T3 Rectal Cancer  --Neoadjuvant still controversial in T2/T3 Rectal CA  5-FU acts as radiosensitizer • Provide follow-up screening of this patient post-op
PE, guiac, CEA every 3mos x 3yrs/6mos x 2yrs --90% of colorectal recurrences occur within 3 years after surgery --Routine colonoscopy at 1 year, 3 years, and 5 years post-op, and then q3 years Normal recommendations for screening: 1) Annual DRE with guiac at age 50, if positive  colonoscopy 2) Colonoscopy surveillance every 10 years after age 50 or Flexible Sigmoidoscopy every 5 years after age 50 or Flexible Sig plus Barium enema every 10 years after age 50 Recommendations for CRC screening if pos FH 1) Annual DRE with guiac at 10 yrs prior to when family member was diagnosed 2) Colonoscopy surveillance every 5 years after that SURGERY ORAL EXAMINATION REVIEWS, JASON FISHER
VASCULAR DISEASE

SAMPLE QUESTION  A 68 year-old man comes to you for his annual physical and complains of
cramps and leg pain in the right calf after walking. How would you work this up? • Take a history designed to flush out the HPI and identify any RF’s for peripheral vascular dz:
--Does pain occur consistently at certain distances? --Do you smoke? Are you sedentery? --Is the pain relieved by rest? Is it reproducable? --Does the pain begin in the calf or lower back? --Is there any pain at rest / during the night? --Is there family Hx of vascular disease? • Perform a physical exam looking for:
--Pulses: DP, PT, Pop, Fem, Radial, Carotid --Decreased hair, shiny skin, thick nails --Doppler the pulses above as well as palpate --Listen for bruits at same points and abdomen --Palor on elevation and rubor on dependency The patient describes his symptoms as occuring always when he walks 4 blocks, but denies rest pain. He has a h/o significant CAD and a 40pack year smoking history. Diminished pulses are detected in the right DP and PT, but no ulcers or atrophy present. ABI = 0.6 and PVRs are diminished below the knee. What is the differential for lower extremity pain and how would you treat this patient initially? • The differential for lower extremity pain includes:
• Appropriate initial treatment for claudication involves:
--↓RFs (smoking, BP, cholest, diet, weight loss) --Exercise—stimulate collateral vessel growth --Only about 20% of patients with PVD will fail medical management What are indications and options for sugical treatment of this disease? • Indications for surgical intervention in arterial occlusive disease
• Different surgical options for PVD treatment
--Angiogram of the affected limb should be obtained preoperatively --Surgical graft bypass • Determinants of bypass graft patency include several factors
--Presence of underlying ESRD --Intimal hyperplasia at anast SAMPLE QUESTION  A 77 year-old man presents to the ER complaining of brief loss of vision
in his right eye, occuring several times over the past 2 weeks. How do you assess him? • Take a history designed to flush out the HPI and identify any RF’s for cartoid vascular disease:
--Is the vision loss in a shade-like pattern ? --Any history of stroke, TIA, or syncope? • Perform a physical exam looking for:
--Pulses: DP, PT, Pop, Fem, Radial, Carotid --Doppler the pulses above as well as palpate --Listen for bruits at same points and abdomen --Full neurologic exam w/ cranial nerves as well The patient does not associate any other problems with his vision loss, and describes the temporary blindness like a shade coming down over his eyes. He describes an extensive smoking history as well as recent CABG surgery, but no PMHx of stroke. Bruits are present bilaterally and your neurologic exam is normal. Cartoid duplex ultrasound reveals 75% stenosis on the left and 50% stenosis on the right. How do you proceed from here? • Indications to perform carotid endarterectomy include:
--NASCET Trial  Stenosis of 60% or more in an asymptomatic patient --ACAS Trial  Stenosis of 70% or more in a symptomatic patient Stenosis of 50% or more in symptomatic patient with multiple TIAs • The preoperative work-up of any patient undergoing CEA
• Surgical considerations during endarterectomy:
--Use of shunt  depends on surgeon; pt can tolerate 20-30min carotid occlusion; shunts carry small but some risk of embolizaiton; all results equal --Monitor for cerebral hypoperfusion  MS, distal stump pressure, EEG, near-infrared spec --Dacron patch closure --Structures encountered during dissection  Platysma, facial vein, superior thyroid A, Omohyoid (prox) and digastric (dist) muscles, Hypoglossal nerve, Facial nerve, Vagus nerve • Postoperative follow-up and complications after CEA include:
--Follow-up duplex studies are valuable to track progression of contralateral disease --Ipsilateral recurrence after CEA is rare --Stroke (1-5% depending on if Sx) --Thrombosis  ASA should be given postoperatively SURGERY ORAL EXAMINATION REVIEWS, JASON FISHER
HEPATOBILIARY DZ

SAMPLE QUESTION  A 73 year old man goes to the ER complaining of RUQ pain of 3 days
duration. He has had a fever and felt chills intermittently. How do you proceed. • Take a history designed to flush out the HPI and identify any RF’s for acute cholangitis:
--Pain assoc with meals or relieved by antacids? --History of gallstones or cholecystectomy --Noticed any changes in the color of his urine? • Perform a physical exam looking for:
• Provide IV Fluids for resuscitation and IV antibiotics if suspecting acute cholangitis
--Should ascertain adquate urine output—foley --Antibiotics should have gram negative coverage  Ecoli, Klebsiella, Pseudo, Enterobact --75-80% with cholangitis respond to fluid and ABx alone --Less than 50% with cholangitis 2o to CA will respond to fluid and ABx alone • Laboratory evaluation is often helpful, and blood should be drawn during initial resuscitation
--Elevated TB and Alk Phos --Send for blood cultures (prior to ABx ideally)—pos in 25% The diagnosis of acute cholangitis is made based on history, physical and labs. Fluids and antibiotics were begun, and laboratory values showed leukocytosis with markedly elevated TB and AlkPhos and mildly elevated transaminases. The patient appears stable presently. How do you now proceed? • Perform imaging to help identify source of CBD obstruction after pt has received resuscitation:
--Ultrasound  detects CBD dilatation, less good for CBD stones --ERCP/PTC  diagnostic and therapeutic possibilities—get brushings if possible --PTC better radiographic procedure for prox dz, strictures, and malignancy --ERCP better radiographic procedure for distal dz, --CT Scan  good for detecting cholangitis secondary to malignancy • Common causes of common bile duct obstruction leading to cholangitis include:
--Extrinsic Compression (pancreatitis / psuedocyst) --Instrumentation of bile ducts (ERCP / PTC) • Determine whether disease process is suppurative vs nonsuppurative
--Nonsuppurative Dz  generally incomplete obstruction, responds to ABx, milder Sx Tx  IVF and ABx with definitive treatment later --Suppurative Dz  generally complete obstruction, less responsive ABx, Reynolds pentad Tx  IVF and ABx with decompression via ERCP, PTC, or surgery • The various modalities of emergency biliary duct decompression include:
Distal CBD Stones, Proximal CA, Nondilated bile ducts Proximal Obstruction, Altered biliary anatomy, Dilated bile ducts --Surgical Indications  ERCP/PTC fail, Recurrent CBD Stones, 1o CBD Stones, Multiple large stones, Stones in the Hepatic ducts --Definitive treatment for benign strictures and for intrahepatic stones with recurrent

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