Humood's Summary and Questions PDF

‫‪Humood’s Summary‬‬ ‫‪Done by: Deem Alsultan‬‬ ‫ﻣﻼﺣظﺔ‪ :‬اﺿﻔت ﻣﻠﺧص ﻟﻣواﺿﯾﻊ ﺣﻣود ﻣﻊ‬ ‫اﻷﺳﺋﻠﺔ اﻟﺧﺎﺻﺔ ﺑﻛل ﻣوﺿوع ﺗﺣﺗﮫ‬ ‫ﺑﺎﻟﺗوﻓﯾﻖ ﻟﻠﺟﻣﯾﻊ اﺗﻣﻧﻰ ﻣﺎ ﺗﻧﺳوﻧﻲ ﻣن ﺧﺎﻟص‬ ‫اﻟدﻋﺎء‬  ABC A...

‫‪Humood’s Summary‬‬ ‫‪Done by: Deem Alsultan‬‬ ‫ﻣﻼﺣظﺔ‪ :‬اﺿﻔت ﻣﻠﺧص ﻟﻣواﺿﯾﻊ ﺣﻣود ﻣﻊ‬ ‫اﻷﺳﺋﻠﺔ اﻟﺧﺎﺻﺔ ﺑﻛل ﻣوﺿوع ﺗﺣﺗﮫ‬ ‫ﺑﺎﻟﺗوﻓﯾﻖ ﻟﻠﺟﻣﯾﻊ اﺗﻣﻧﻰ ﻣﺎ ﺗﻧﺳوﻧﻲ ﻣن ﺧﺎﻟص‬ ‫اﻟدﻋﺎء‬  ABC A 1) O2 sat 88% Indication to intubate 2) GCS 8 3) Unconscious options All are indications to intubate. In addition, we use an oxygen mask as pre-oxygenation for a conscious alert patient, but the fbest way is orotracheal intubation if f the patient is unconscious or moaning. Let’s suppose the same patient had a face fracture (mandible), in that case go for a s cricothyrotomy. B Typically in cases such as tension pneumothorax which is treated by needle decompression. Never choose needle decompression before intubation as it’s wrong in the SMLE despite what UTD says. Follow the sequence. C IV fluid and circulation control, then proceed with imaging if no disabilities exist. Always follow ATLS in every case before choosing anything else. NS Severe vomiting -> hypochloremic hypokalemic metabolic alkalosis (loss of Cl and K). Treated with normal saline. Severe diarrhea -> metabolic acidosis (loss of HCO3 and K). Treated RL with ringer lactate. Both hypokalemia and hyperkalemia affect the heart rhythm. Hypokalemia (Flat T wave) is treated with oral potassium. Hyperkalemia (Peaked T wave) is treated with calcium gluconate, and the second line is SABA/Insulin. Dialysis for refractory cases. Severe hyponatremia (NA below 12 ) -> neurological symptoms. Treated with hypertonic saline. Feeding bestis enteral If the patient doesn’t have an adequate oral intake, we need to provide nutrition in an inpatient setting. First, check the GI function, if it’s not functioning properly start with parenteral nutrition (IV access). Otherwise, enteral feeding is indicated. An acute case below 1 month? 2 Start with NGT. Risk of aspiration? Go with NJT. Both are initial D measures if the question asked for such. A chronic case more than 1 month? Initiate resuscitation with gastrostomy. Risk of aspiration? Go with Djejunostomy. Both are considered the most appropriate management/ 2 best in a chronic case. Wound closure 1) Open scalp laceration within 6 hours? Primary closure/suturing as it is within the 24 hour window. 2) Injury reached the tendons and nerves? Primary repair of structures is indicated. 3) Exposed necrotic skin? Secondary closure. 4) What if it’s not infected? VAC. Exposed non infected 240 2 A. Oxygen mask B. Cricothyroidotomy C. Endotracheal intubation D. Tracheostomy 241 A. Ringer lactate iv fluid B. Blood transfusion C. Tourniquet on the thigh D. Orotracheal intubation 242 A. aryngeal mask B. Orotracheal C. asotracheal D. Cricothyrotomy 24 10 A Tracheostomy tube B Cricothyroidotomy C Orotracheal tube D aso haryngeal air ay 244 100 0 40 120 4 0 A ntubation and oxygen B. Ra id infusion of crystalloid C. eedle decom ression D. mg adrenaline 24 100 0 0 1 2 2 inserting iv line la arotomy oxygen mask CT 24 1 A inhalation in ury B carbon monoxide toxicit 24 A elective intubation B C observation C advice atient to take analgesia 24 110 0 2 1 A. CT B. ast C. nitial assessment and resuscitation D. Ex loratory laboratory 24 11 A normal saline B half C hy ertonic saline 2 0 A. Calcium gluconate B.insulin and salbutamol C. Dialysis 1 2 2 1 A. ain management B. Blood control C. aintaining function D. Decrease soft tissue trauma 2 2 A. ain control B. o er limb ray C. ulse al ation rimary survey. A sim le and fast hysical exam should al ays be the first ste. 2 A Direct ressure on the ound B ressure above the ound on femoral artery C a ly tourniquet 2 4 A. astrostomy B. e unostomy C. T 2 gastrostomy e onostomy aranteral nutrition T 2 A. econdary closure B. Debridement ith rimary closure C. Debridement ith granulation D. eave it for granulation 24 2 A. rimary re air to in ured structures B. Debridement ith rimary closure C. Debridement ith secondary intention D. Debridement ith acuum assisted closure AC 2 A. Debridement ith a skin graft B. Debridement ith assisted vacuum C. Debridement ith rimary closure D. Debridement Dressing ith secondary closure 2 A. O en the fascia B. Antibiotics C. lace a vacuum assisted closure AC device D. ound debridement  Trauma Chest trauma Tension Pneumothorax Hyperresonance on percussion and decreased breath sounds on the same side, tracheal shifting to the opposite side. Raised JVP. Treated by needle decompression. Open Pneumothorax Suspect it if you notice a suction sound from a lacerated wound, then go for Tx J three side dressing. If not in the options? Go for a chest tube. Cardiac tamponade Raised JVP, low BP (weak thread pulse), muffled heart sounds. Bilateral clear 3eck'striad lungs. Treated by pericardiocentesis. Hemothorax Stony dull on percussion due to fluid, flat JVP (because of hypovolemia). Treated by inserting a chest tube. Flail chest Multiple broken ribs and paradoxical breathing. No additional signs. Treated by analgesia + assisted ventilation. Tx Cardiac contusion Signs of ecchymosis on the chest, bounding pulse, arrhythmia. Pulmonary contusion New lung infiltrates post MVA. Tracheobronchial Injury Similar to tension pneumothorax, but has signs of subcutaneous emphysema and pneumomediastinum. Diagnosed by a bronchoscopy. Tube placement Chest tube -> between the 4th and 5th ICS midaxillary line Therapeutic needle -> at the 2nd ICS midclavicular line Needledecomp Diagnostic needle -> between the 8th and 10th ICS midaxillary line Thoracotomy indication 1500ml after chest tube insertion, or 200-250cc within 2-4h  Abdominal trauma STAB Stable -> CT Unstable -> Laparotomy BLUNT Stable -> CT Unstable -> FAST Approach to management after FAST as an initial step: Stable and positive -> CT Stable and negative -> Routine examination Unstable and positive -> Laparotomy Unstable and negative -> DPL Immediate laparotomy: Positive CT findings, Positive FAST if unstable, omentum is seen, evisceration, peritonitis, or abdominal rigidity. Neck trauma asymp observe Zone 1 -> CT-A if +ve -> Endovascular repair If +ve bronchogram or esophagram -> open repair Zone 2 and 3 if asymptomatic -> observe Zone 2 symptomatic -> immediate open repair Zone 1 Zone 3 symptomatic -> CT-A if +ve -> endovascular repair Unstable (expanding hematoma, uncontrolled hemorrhage) = ligation in all zones  Chest Trauma Qs 62- 32 years old MVA. prominent neck veins and marked decreased breath sound on right side of the chest. A tension neumothorax B hemothorax C cardiac tem onade Full recall. However, it’s enough to diagnose tension pneumothorax. Cardiac tamponade requires the beck’s triad: 1) low BP 2) muffled heart 3) raised JVP. As for hemothorax, suspect it if you find stony dullness on percussion and flat JVP. In our question, the JVP is distended. Tension pneumothorax is the most common presentation and all the details in the question lead us to it. 63- 25 year old female involved in a snowmobile accident. She is currently dyspneic with respiratory rate of 40 breath per minute. Breath sound are markedly diminished on the right side And raised JVP. Which of the following is the first step in the management. A. Chest tube insertion B. ericardiocentesis C. eedle decom ression D. Chest x ray Clear case of tension pneumothorax. 64- Trauma to axilla and lateral chest wall, fracture 4&5 ribs , while examination , suction sound was sourced from lacerated wound on fractured ribs (no vital data) , next: A. Chest tube B. ntubation C. rgent Thoracotomy D. Dressing three side Open pneumothorax. Initiate management with a three side dressing. Definitive treatment requires closure of the chest wall defect and a chest tube away from the site of injury. 65- Patient had a stab wound in the chest. Came with weak thread pulses, raised JVP, Equal Bilateral Air Entry in both lungs. What's the diagnosis? A. neumothorax B. Cardiac tam onade C. ulmonary contusion The beck’s triad in this case is missing muffled heart sounds, but by exclusion tamponade is still the right answer. Equal bilateral lung sounds excludes pneumothorax which is unilateral. Weak thread pulse excludes cardiac contusion because it presents with a bounding pulse in addition to arrhythmia and ecchymosis. Side note: Weak thread pulse = low BP. 66- Chest gun wound entry was lateral to left nipple and exit point below left scapula, patint suddenly become worse w/ raised JVP , on auscultation Normal air entry and muffled heart sound, most appropriate management? A fluid bolus B ericardiocentesis C mmediate thoratom The beck’s triad is present here. 67- Patient sustained a chest stab wound injury, on examination there was Stony dullness over right chest and tracheal deviation to the left, what is the diagnosis? A. O en neumothorax B. Tension neumothorax C. assive emothorax Stony dull immediately excludes tension pneumothorax, as that one presents with hyperresonance. Hemothorax is treated with a chest tube. 68- A patient with Anterior chest trauma with bruising in the sternum. Patient vitally stable, clear cardiac and respiratory exam, except for pounding pulse. ECG: Arrhythmia X-ray: Sternal Fracture. Echo: Normal What is the diagnosis: A. neumothorax B. Cardiac contusion C. Cardiac Tam onade D. entricular ru ture Strong bounding pulse, arrhythmia on ECG, and chest ecchymosis. 69- 61 years old women sustain MVA to here left chest brought to ER vitally stable no open wound admitted for observation, couple of hours later developed suddenly SOB only, initial CXR reveled 3-7 left ribs features. Repeated CXR showed well demarcated left lung infiltarate. What is the diagnosis? A E B flial chest C cardiac contusion D ulmonary contusions The keyword is lung infiltrates. 70- Patient with blunt chest injury resulted in fracture in 3rd, 4th and 5th ribs in more than one site. What is the initial treatment? A. ntubation B. Assisted ventilation C. fluid. Clear case of flail chest. A missing keyword which is most likely in the full recall is paradoxical breathing. Start management with analgesia, then go for assisted ventilation. 71- 35y.o male brought to ER after road traffic accident , complaining of right side chest pain, he is conscious, alert & oriented. Surgical emphysema in upper chest and neck. Chest X- ray shows Rt sided pneumothorax & pneumomediastinum. What is the diagnosis A Tension neumothorax B O en neumothorax C Tracheobronchial in ury D emo neumothorax Subcutaneous emphysema and pneumomediastinum. 72- A 50 year old sustained blunt trauma to the chest with persistent pneumothorax and significant air leak through double intercostal tubes most appropriate next procedure ? A. Re osition of CT B. rom t thoracotomy C. Endotracheal intubation D. ibero tic bronchosco y Significant pneumomediastinum. Tracheobronchial injury is diagnosed by bronchoscopy. 73- Trauma patient with hypotension, X-Ray reveled: Trachea shifted to the right, expanded lungs and widened mediastinum. What is the diagnosis? A. assive hemothorax B. neumothorax C. Thoracic aorta ru ture D. ontaneous neumothorax Mediastinal widening and expanded lungs in addition to tracheal shifting commonly present in a case of aortic injury. Side note: there’s another recall with ruptured esophagus instead of aortic rupture in addition to tracheal shifting to the left, but I believe it is a bad recall as the symptoms are not relevant. 74- Post RTA patient complex femoral fracture and tension pneumothorax, chest tube inserted and transporting to higher center, in transit the patient is desatting and tachypnoec- cardic what to do? A. ntubation B. othing C. Check for bleeding form fracture site D. Confirm lacement of chest tube Side note: Chest tube -> between the 4th and 5th ICS midaxillary line Therapeutic needle -> at the 2nd ICS midclavicular line Diagnostic needle -> between the 8th and 10th ICS midaxillary line 1500ml or 200cc within 2-4 hours = thoracotomy. 75- Trauma case (about pleural effusion on?) chest tube inserted. After 15 min there was blood in the water under seal the amount was 1500 mL, how to manage? A Thoracentesis B Tube thoracostomy chest tube C thoracotomy 76- Adult post RTA, was brought the ER in a tertiary hospital, patient is alert and conscious. CT done which showed: Injury to the thoracic aorta and splenic laceration with free fluid in the abdomen. (Not perisplenic). BP: 90/67. HR: 45 bpm. What’s the next step? Laparotomy is always done before thoracotomy. And A urgent la arotomy. now, we start with abdominal trauma below. B urgent thoracotomy. C refer the atient to a hos ital ith vascular surgeon  Abdominal Trauma Qs 77- Patient presents with stab wound to the abdomen. After wound exploration, you found anterior abdominal fascia penetration. His vitals were stable. What is your next step? A CT abdomen B R abdomen C Ex loratory la arotomy D Diagnostic la arosco y Abdominal fascia penetration does not warrant laparotomy. 78- Young guy is stabbed in anterior abdomen in a fight after a football match. He presented to emergency with a 1 cm laceration that is 3 cm above umbilical. He has no pain and vitally stable. What is the best management? A. D B. ound ex loration C. a arotomy D. CT scan Wound exploration is not correct. Go with CT and follow the ATLS. 79- 5 years old with stab wound in lower chest, has abdominal distension Fast shows free fluid in abdomen All vitals normal except O2 90 What is the most appropriate management: Thoracotomy Tube thoracostomy Ex l la ratomy Angioemboli ation Positive FAST and the patient is stable, so the next step should be CT as we have no urgent need to rush to the OR just yet. By exclusion only, laparotomy. 80- Patient of stab wound measuring 2 cm penetrating injury with minimal bleeding and partially omentum exposed, patient is vitally stable, CT report negative findings, Next step management: A. Observation B. Close the ound C. eave the ound o en D. a arotomy Omentum was seen, so go for laparotomy even if the patient is hemodynamically stable. 81- MVA came and resuscitation was done after that the patient deteriorated BP 90/60 what to do next? A. ast B. Ex la Unstable. 82- Patient after Motor vehicle accident at ER, vitally stable, on examination showed Lift hypochondrium tenderness and ecchymosis What is the Most Appropriate test: A. CT B. A T C. D D. a arotomy 83- Blunt trauma, stable patient, FAST showed intraperotineal fluid. Next step? A. CT B. Ex la Since we already did FAST and the patient is stable go for CT scan. If the CT is positive go for laparotomy regardless of vital signs. 84- 55 year old involved in MVA and sustained a blunt trauma to his abdomen. He his hypotensive 90 / 63 and HR 104. He is not responding to fluid. FAST is negative for fluid in pericardium, chest or abdomen. What is the next best step ? A. a arotomy B. CT scan C. D D. A T Blunt trauma + unstable so we did FAST first, but since it’s negative we go for DPL this time. 85- Post RTA, abdomen mild tenderness all over, conscious oriented, Not rigid or severely tender abdomen Fast: positive for moderate fluid collection Bp: 90/50 He received 2L crystalloid without improvement What is next: avage Ex loratory la arotomy Ct scan Positive FAST and the patient is unstable. 86- A 44 year old lady was hit by a vehicle, and brought to the emergency room conscious, on 100% 02, received 2 liters of normal saline and 2 liters of blood. Blood pressure 60/40 mmHg Examination confirmed abdominal rigidity. 145 beat /Heart rate min CXR and pelvic x-ray were normal. Which of the following is the most appropriate step? A D B A T C CT scan abdomen D surgical ex loration Blunt + unstable so normally we would choose FAST. However, due to abdominal rigidity we need to go straight for laparotomy. 87- Patient after RTA with sever lower back pain, what to do until the surgeon comes: A. CT hole s ine B. lextion extension test C. Restriction of s ine movement D. elvic binder A similar recall: How to exclude cervical injury? Cervical CT scan. 88- A female get high energy accident (high velocity) with seat belt sign , On X- ray has chance fracture. What will associated with this fracture? A Duodenal erforation B astric erforation C e unum erforation D ena cava erforation Seatbelt + Chance fracture. 89- A 25 years old man was brought to the ER after being involved in a motor vehicle accident. He opened his eyes spontaneously and responded appropriately to verbal commands. His respiration wasz shallow and he had a left chest wall contusion. He was able to shrug his shoulders but unable to move his elbows or lower limbs. BP 80/40, HR 70, RR 30. Which of the following is the most likely cause of hypotension? A. Cardiac tam onade. B. nternal hemorrhage. C. igh s inal cord in ury. D. Tension neumothorax. Low BP + low HR. Neurogenic shock. 90- Patient underwent surgery after abdominal gunshot splenectomy pancreactomy removal of parts of intestine and did Hartman procedure. Second day he deteriorate what the most appropriate next step? A-Exploration B-US C-X-RAY D-CT Unclear question, but if the patient deteriorated it’s safe to assume laparotomy is a safe answer. 91- Patient with penetrated neck in the zone 3 and he is having active bleeding , CTA report shows : Avascular injury what is the best management? A p n an pri ar r pair B En o a lar C p n an li ation 92- Neck penetrating injury on zone 1 with emphysema, next step? A xploration B CT a an n C An io oli ation  Urology – Surgery notes DDx of Hemiscrotum: Strangulated Testicular Appendicular Epididymitis inguinal Hydrocele torsion torsion hernia Onset Acute = < 12 hrs < 1 day > 1 day -Absent -Blue dot sign -Unilateral cremasterix +ive -Vertical/longitudinal swelling Sx reflux illumination testis -Impalpable -Horizontal test testis testis Increased US Reduced vascularity vascularity Mx Urgent surgery Peritoneal Injuries:  Intraperitoneal = laparotomy/open repair  Extraperitoneal = catheter drainage then reassess after 2wks.  Urethral Injury = suprapubic catheter + retrograde urethrogram Undescended Testis: - Palpable = orchidopexy - Impalpable = diagnostic laparoscopy; if it’s abdominal. Hematuria – Next step: Renal Stones: Initial Invx = US Definite (best) Invx = CT without contrast Management: - < 5mm = spontaneous - 6-14 = depends - > 15mm = urology surgical mx -  12 A. B Ray B. ltrasound C. CT D. R 1 4 uretre stone a endicitis ancreatitis cholecystitis 14 4 double stent conservative E 1 1 A. Testicular torsion B. nguinal hernia C. Testicular a endages torsion D. E ididymoorchitis 1 14 A. Testicular torsion B. Orchitis C. ydrocele 1 12 2 A Testicular torsion B A endicular torsion C Cry..orchitis D ydrocele 1 A testicular torsion B E idydomorchitis C ncarcerated inguinal hernia D Testicular a endicular torsion 1 hydrocele Cyctocyle 20 A. u ra ubic catheteri ation B. Catheter Drainage for eeks then reassess C. Catheter drainage for eeks then re air  21 A. Cystosco y B. olly s Catheter C. u ra ubic catheter D. CT elvis 22 cystosco y folly catheter retrograde urthrogram fluorosco ic cystogram 2 1 A. eft orchido exy B. Diagnostic la arosco y C. ait till years 24 A. Ecto ic testis B. ndescended testis C. Testicular torsion D. Retractile testis 2 2 41 A. Age B. Obesity 2 A Cystosco y B CT abdomen C v yelogram D s 2 2 A Abx for uti B oley catheter C Cysosco y and tur 2 re eat urinalysis rine cytology Renal Bio sy Cystosco y 2 A Ask for serum creatinine B Do erum albumin C re eat urine analysis in fe days D end her for bio sy  Orthopedics – Surgery notes Eddosed Urgent reduction  pale hand = surgical exploration  Warm hand = k-wire fracture open Junkss open reduction go Adults-6yrs: urgent reduction + intramedullary nail Children close reduction —> debridement —> IM nail or external fixation; if soft tissue MOPE swelling present Next step = measure compartment pressure Definite mx = fasciotomy  00 A oral antibiotic B o en fixation C surgical debridement D external fixation 01 1 A. Close reduction and fixation ith ntra medullary nail B. O en reduction and fixation ith external fixation C. antibiotics ound irrigation s linting D. ound ex loration 02 A. urgical ex loration B. rgent reduction and ire fixation C. CT angiogra hy D. linting and observation 0 A. Observation B. urgical ex loration C. Do ler D. CT angiogra hy 04 0 A. Traction and observation B. A lication of avlic arness C. Reduction and fixation ith intramedullary nail D. Reduction and s ica cast a lication 0 0 A. Traction and observation B. Reduction and fixation ith External fixation C. Reduction and fixation ith flexible intramedullary nail D. Reduction and s ica cast a lication 0 0 A. Close reduction and fixation ith External fixator B. Close reduction and fixation ith ntra medullary nail C. O en reduction and fixation ith late scre s D. Casting  0 12 A. i dislocation B. e tic hi C. eck of femur fracture D. li ed Ca ital emoral E i hysis 0 100 0 A. CT elvis B. elvic binder a lication C. Right lo er limb skin traction D. O erative fixation 0 A. nternal fixation B. Closed reduction C. External fixation D. External fixation ith four fasciotomies 10 40 A. lint and elevation B. rgent fasciotomy and External fixation C. Com artment ressure measurement D. CT angiogra hy 11 2 A. ulmonary embolism B. e sis C. at embolism D. ound infection  Thoracic – Surgery notes b b PE: ECG SIGI Invx:  Pregnant = 1)DUS (compressed US) , 2)V/Q ratio  In general = 1)D-dimer , 2)CTA = spiral CT Mx: 1. LMWH: 40mg prophylactic, 40mg BID therapeutic 2. UFH (if CKD/renal failure): 5k IV prophylactic, 10k IV therapeutic 3. tPA or embolectomy (if saddle PE or unstable), give IVC if tPA C/I or in the recovery room. 4. Rivaroxiban (if chronic case) ALI: Algorithm: Heparin —> ABI —> US (venous or arterial ‫ >— )ﺣﺳب‬CT Angio —> Conventional Angio Preventive measure: - Exercise program; enhance walking speed - Smoking cessation; enhance prognosis - Aspirin; prevent CVD Classes of ALI: - Class I = moderate pain with good sensation - Class II = severe pain with somewhat sensation - Class III = no pain with absent sensation  Amputation (+ incase of acute on chronic) Mx of ALI: 1. Preventive and lifestyle 2. Catheter tpa 3. Embolectomy; incase of Afib or cardiac abnormalities 4. Amputation; as mentioned above Pulmonary 28 - Pregnancy typical DVT symptoms then developed PE, how to dx? A- Ct Embolism B- D dimer C- V/ Qs D- Us for lower limbs Compressed US initially, but if it fails go with V/ scan as the definitive choice for a pregnant woman. 2 - Patient did heamorrhoidectomy 2 weeks ago now came with sob ( given ecg but was not clear) What is the confirmatory test? A..spiral ct B..echo C..ecg D..dimer In the exam, the ECG was probably showing sinus tachycardia. Go for D if asked for an initial test. 2 1- Elderly kc of htn well controlled c/o confusion and irritability. He was fine except when he injured his left thigh days ago and he was bed bound ever since. VS shows hypotension and o2 of 88% Also shows tachycardia and he has arrhythmia on ecg A - PE B - cerebral infraction C - brain hemorrhage D - arrhythmia History of a bedridden patient eventually leading to massive PE with ECG changes and CNS symptoms. 2 2- Case of pulmonary embolism , hypotensive pt, and they mention saddle emboli in CT A- warfarin B- enoxaprin C- thrombolectomy saddle massive. Go for thrombolysis/thromboectomy, whichever is in the choices. 2 3- 3 year old male have sudden SOB and chest pain was shifted to ICU, diagnosed with Massive PE (no vitals were mentioned) what is the next initial step Heparin infusion TpA 2 4- Patient with DVT then developed PE, ( no evidence of renal failure in the case) Which of the following most appropriate management A- Aspirin B- Foundaparinux C- IV heparin (no enoxaparin) D- Revaorxaban LMWH would be preferred, so with these choices go for B. According to UTD, Rivaroxaban is more suitable to be used as an indefinite anticoagulant management but for this case we need an acute treatment. UFH is less useful in PE. 2 - A 3 year old woman is brought to ER after a fall at home. She is diagnosed with left hip fracture (see lab results) Weight 82 kg Sodium 136 (normal) Potassium 4.2 (normal) Creatinine 68 (normal) What is the best order by the admitting orthopedic surgeon to prevent deep vein thrombosis? A. Aspirin 81 mg PO daily B. Enoxaparin 4 mg SC daily C. Fondaparinux 1 mg SC daily D. Heparin sulfate 1 , units IV BID To prevent DVT, choose a prophylactic dose as outlined earlier. 2 6- Patient presented with DVT what regimen to use A- Aspirin 61 mg B- Enoxaparin 4 mg SC C- Fondaparinux 2 mg D- Hepatin 1 , U IV Since the patient already has DVT, we need a therapeutic dose. 2 - A 66 years old female admitted to general surgery ward after major rectal surgery, on the second day she developed leg swelling on the side of the operation. investigations showed DVT on the femoral vein. the best management to this patient is A. LMWH. B. Thrombolytic therapy. C. Warfarin. D. Inferior vena cava filter. 2 8- Old pt after rectal surgery he is not doing well after in the recovery he start to have leg pain he developed DVT from the popliteal to the femoral.. A. Enoxiparen B. Heparin C. Warfarin D. IVC The keyword is patient in the recovery room. This is a case of PCD (severe DVT with absent pulse) which is typically managed by thrombolysis but it’s contraindicated due to the recent surgery within 24 hours. 2 - patient with recent rectal surgery comes to you with absent pulses up to the femoral area. How will you manage such a case? a. Unfractionated heparin b. Enoxaparin c. IVC filter d. Thrombolysis A somewhat similar case of post-op DVT becoming severe enough to cause limb ischemia, so the first line treatment should be thrombolysis. In another recall thrombolysis isn’t available, so in that case go for heparin.  Acute Limb Ischemia Qs 2 -6 O male admitted with MI. after two days of discharge he developed severe pain in his left leg. What is the most likely cause? A. Acute arterial thrombosis B. Acute Arterial Embolus C. DVT D. Neuropathy Cardiac embolus. Acute arterial embolus presents more acutely than thrombosis. 2 1- 6 O male presented to ER with acute left lower limb pain for 3 hours. Associated with numbness and absent pulse. ECG Atrial fibrillation. What is the best next step? A. Heparin B. CT Angiography C. Arteriography D. U/S doppler Cardiac related, so this is caused by an embolus. The best treatment is embolectomy. 2 2- Patient with chronic limb ischemia, presented with sudden leg pain, diminished popliteal and distal pulses in right leg, and diminished distal pulse with intact popliteal in the left, what s the appropriate next action? A. Heparin B. CT angio C. US D. conventional angio 2 3- year old male diagnosed with acute lower limb ischemia. I.V heparin andl.V fluid fluid started. What is the most appropriate next step in this patient management ? A. -A B. DSA C. US-Duplex D. Immediate embolectomy US after Heparini ation. 2 4- Pt had decreased sensation and painful left leg while walking relieved with rest. Examination Left leg palpable femoral and popliteal but distal are not palpable. Right leg palpable femoral and poplitteal. dista veins are not palpable. -What is the appropriate investigation? A) CT angiography. B ) Vascular US. C) Conventional angiography. D) magnetic resonance angiography Most appropriate investigation ( t next step) -> CT-A 2 -6 O male presented to ER with severe right leg pain and absent pedal pulse. Which of the following is the most diagnostic investigation? A. B. MRA C. Conventional angiography D. Ultrasound doppler 2 6- 3 year old male had a pelvic fracture from MVC rollover 2 months back that treated surgically. Before 2 hours he started to complain of sever left LL pain. Femoral pulses are intact. I.V heparin started and venous US is negative. What is the the best management? A. Catheter thrombolysis B. Embolectomy C. Observation D. Amputation Catheter thrombolysis is preferred unless they give history of a cardiac cause. 2 - 61 year old female known case of A. Fibrillation. Presented to the emergency department with 3-4 hours history of sever leg pain. On examination palpable femoral pulse and absent popliteal. Associated with diminished sensation and altered motor function. What is the most appropriate management ? A. Amputation B. CT-A C. Embolectomy D. Catheter thrombolysis As explained earlier, cardiac cause? Embolectomy. 2 8- Old patient long history of leg claudication for 2 months , present with leg pain and ABI.3 and , CTA show artery occlusion more than 3 cm what to do? A- amputation B- thrombolysis C- embelctomy A case of acute on chronic. Chronic history of PAD followed by an acute episode of ALI. 2 - Diabetic patient walks for 3 meters then feels pain in his legs and must rest, What probably is the causes? A- Varicose vein B- Arterial causes C- infection D- Diabetic neuropathy Clear case of peripheral artery disease. 28 - Elderly male known case of high blood pressure presented with lateral malleolus ulcer. What is the first test to do ? A. CT-A B. ABI C. US duplex D. VT venogram Start with an ABI then go for an US. 281- DM with hx of pad, had pain when he walks 3 m and relieved by rest what will you do A- CTA B- vascular ultrasound C- conventional Angio D- MRA US next, angiography best. 282- Patient with PAD has 1 -meter claudication s, DM, heavy smoker, not getting better. How to improve his walking distance? A. Supervised exercise program B. Strict glycemic control C. Smoking cessation A to improve his walking distance specifically, but smoking cessation is superior overall. 283- Patient knowing for DM And HTN and history of right leg pain increased by exertion, on examination absent popliteal pulse on right leg Which one of the following indicates acute limb ischemia A-intermittent claudication B-rest pain C-scar for iliofemoral bypass in left leg D-swelling Rest pain goes with ALI. Intermittent claudication goes with PAD/chronic limb. 284- 3 years old patient come with medial leg ulcer. The most likely diagnosis is A- Diabetic B- Venous hypertension C- Atherosclerosis D- Buerger s disease. 28 - 6 years old woman presents to the clinic with a non-healing ulcer over her right lateral malleolus, she is hypertensive. pulse is normal and her local exam shows dark discoloration of the skin around the ulcer and viable ulcer bed, best next step is? A. CT angiogram B. Venous duplex US C. Arterial doppler US D. Conventional angiograph US initially. In this case, venous US because of the dark discoloration and a viable ulcer bed. 286- Elderly smoker known case of poorly controlled DM comes with ulcers on tip of three of his toes, diminished dorsalis pedis bilaterally, however, intact popliteal pulse, what’s the initial management? A. Amputation B. Long term anticoagulation C. Immediate surgical intervention D. Diet modification and lifestyle changes If dietary modification isn’t in the choices, go with debridement. 28 - Diabetic patient with pseudo hyperepitheliali ation in situ, what should we do? A. Amputate toe B. Ulcer debridement C. Follow up D. Repeat biopsy. 288- Case of Abdominal Aortic Aneurism (AAA) and the patient is hemodynamic unstable, present after he ate food with severe abdominal pain despite taking analgesic. He became confused and unconscious later in the hospital. Examination revealed Tender and pulsatile mass in the abdomen, BP low. What is your most appropriate management? A. US B. CT C. Exploratory Laparotomy As a general rule, whenever you encounter a question in the bank that goes like case of it means they were giving you the symptoms, not the diagnosis. Known case of is a different story.  Bariatric Surgery notes Indications: BMI 35 w/comorbid or 40 Procedures: duednum iron Best way to lose weight: Post Op Infection - Surgery notes Algorithm in post-surgery infections: 7 4 4cm Open the wound = I/D = remove stitches/clips —> CT —> percutaneous drainage. - Antibiotic = small size - Percutaneous drainage (CT before) = > 4.4cm - Laparoscopy = multiple collections - Laparotomy = unstable Seroma: ~Tender/non tender swelling of the wound post-hernia repair Tx: wound dressing 26 - A female patient went to obesity clinic for advice regarding surgical methods of weight loss. After full explanation by the surgeon, which of the following is the most efficient/effective way of weight reduction? A) Intensive Exercise B) Lifestyle Modifications C) Orlistat The very best is surgery, followed by lifestyle modification. The third best is a medication called Orlistat. Remember, we can only offer bariatric surgery in patients with a BMI of over 4 , or over 3 if co-morbidities exist. 266- Patient Obesity wants weight reduction no other conditions all normal question ask what is the most important to do to decides the type of surgery? A. Barium swallow B. Ct abdomen C. Ultrasound abdomen D. Upper gi endoscope 26 - Patient came after 3 days after Roux-En- surgery complaining of fever chill and left shoulder pain, best diagnostic investigation? A. CT with contrast B. Endoscy C. Laparoscopy D. Exploratory laparatomy A, even if the blood pressure is /6 in another recall. If the patient presented after sleeve, go with endoscopy. 268- 2 -year-old lady presents with central abdominal pain for three days, nausea and vomiting for one day. Her surgical history includes laparoscopic sleeve gastrectomy 6 years ago. Physical examination reveals dehydrated with distended abdomen and exaggerated bowel sounds. What is the likely diagnosis? A - Incisional hernia B - Internal hernia C - Intussusception D - Adhesion Hx of sleeve. If hx of roux-en , choose internal hernia. 26 - patient 3 days post sleeve gastrectomy, he is presented with mild RU pain,upon examination there was mild tenderness with no signs of peritonitis vitals BP 1 /8 HR 133 what is the cause? A- gastric leakage B- sepsis C- decreased oral hydration D- inadequate analgesia A according to Thawaba. 234- Patient with perforated appendicitis after surgery had pus from wound, pain locali ed to the surgical site. No guarding no fever what best initial treatment is A. Antibiotics B. Open drainage. C. Imaging guided drainage D. Wound exploration 23 - 2 year old male Pt 8th day post surgery with wound site redness tenderness with purulent discharge.. most appropriate? A. IV antibiotics B. CT abdominal C. open drainage D.exploratory laparoscopy 236- A 42-year-old woman underwent an uneventful laparoscopic cholecystectomy, 2 weeks later, she present to the Emergency Department with vague abdominal pain. CT scan Large collection in the subhepatic area. Which of the following is most appropriate next step? A. Operative drainage B. CT-guided drainage C. Laparoscopic drainage D. ERCP with biliary stent placement 23 - Post appendectomy female came with LR abdomen mild tenderness Ex Normal By CT there is 2 2 collection in Retrocecal A. Exploring laparotomy B. percutaneous drainage symptomatic C. laparoscopic D. conservative with Anitbiotic 238- A 36 y.o male known case of crohns for 1 years, presented to ER C/O abdominal pain, fever, vomiting and diarrhea, O/E there is abdominal tenderness. CT showed 12 1 collection and ileo-jejunal fistula. How to manage? A-Laproscopic drainage B-Percutaneous drainage C-Open drainage D-Open drainage with fistula resection. 23 - Patient post appendectomy, came for regular follow up post-surgery, no active complaints, on exam he has seroma which drains freely from the opening of the wound, no erythema no pain no fever, what is the appropriate management? A. Observation B. Open wound exploration C. Regular wound dressing D. US guided drainage A case of a serous fluid collection called seroma.  Breast - Surgery notes Triple Assessment: 2yrs if no risk gerry Mx of each breast disease: Features of each breast disease: Fibroadenoma Phyllode Fibrocystic changes Mobile rubbery, related to Rapid growth, not related Multiple bilateral masses, milky, ‫دورة‬ to ‫دورة‬ painful Intraductal papilloma Duct ectasia Fat cyst/necrosis Green discharge, inverted Bloody discharge Skin retraction + ecchymosis nipple Montgomery follicles Paget diseases Non tender lumps in areola Erythema + pruritus + confined to nipple Mastitis Abscess Mastitis + fluctuating mass or any other Features Erythema + firm swelling feature Aspiration Tx Antibiotics I/D; > 5cm, thin/ischemic/necrotic skin In case of Family Hx of Breast Ca: First screen patient then rest of family for BRCA gene 30- 32 y/o women presented to clinic complaining of left breast pain and nipple bloody discharge No family history of breast cancer Normal breast and lymph node examination Which of the following is most appropriate test? A- CT B- MRI C- US D- Mammogram Since the patient is younger than 40 years old, we go for an US. 31- 37 years old female her father has colon cancer when he was 55 and her mom had breast cancer when she was 43, asking about screening? A.She should do mammogram annually B.Start mammogram at 4 C.Start mammogram at 4 and colonoscopy at D.Colonoscopy at Because of family history, start mammography 10 years prior to her mother’s onset of breast cancer. No family history? Wait until she is 40 years old. 32- 40 year old female presented with a left breast mass. US and Mammogram showed a complex mass. What is the next step in management? A. Aspirate B. Core needle biopsy C. Excision D. Follow up 12 months from now Triple assessment approach. Imaging was done, so the next step is biopsy. 33- 55 years old female came with bilateral breast pain + bilateral green discharge from multiple ducts. Imaging: Multiple dilated ducts, not suspicious. What to do? A. us guided needle biopsy B. Interval follow up imaging C. Galactogram D. MRI breast In a typical breast case, after going for imaging the next step is biopsy. However, this patient has physiologic bilateral nipple discharge which could have a variety of different colors, but the most important keyword is multiple ducts and bilateral. If it was unilateral + green = a clear case of duct ectasia so only then we would choose biopsy. 34- A 35 year old lady presents with a left nipple bloody discharge, by imaging it was suggestive of Intraductal papilloma. What to do next? A. Left Central Duct excision B. Observation C. Interval follow up imaging D. image guided biopsy Bloody nipple discharge indicates a case of intraductal papilloma. 35- 35yo Female with RT bloody/or green nipple discharge mamo negative, us shows bilateral duct dilation and something on Rt breast ddx(IDP,duct ectasia etc..) next? A-duct excision B-core needle biopsy C-galactography D-mastectomy Bad recall, but it’s certainly a case of intraductal papilloma (bloody) rather than duct ectasia (green). Although both are treated similarly, if we had a case of bilateral green discharge then that’s physiological. In the case of papilloma? It can be bilateral or unilateral. 36- 60 years old female came with bloody nipple discharge Most appropriate steps to her management: A- mammogram annually B- start ultrasound C- MRI Due to her age it should be mammography now, not annually. If it comes like this go with US. We only go with an MRI if both mammography and US are negative. 37- 36 years old female came for routine check. The report was as follows:US: can't remember the details) Comment: BI-RADS III / propably benign CT: multiple fibrous tissues with no calcifications How will you nanage this patien? A-Follow up after 6 months B-Core biopsy C-MRI breast 38- A woman with a left breast mass for 9months. Mammogram: speculated mass with suspicious microcalcification and axillary lymph node involvement, BI-RAD V (probable malignancy), next step? A. Excisional biopsy B. core Biopsy C. Modified radical mastectomy Core needle biopsy, also referred to as true-cut biopsy in some recalls. Be sure to review the BI-RAD scores. 39- women with 11*12 breast mass, 340-Patient presented with a mass in the breast, which was growing according to her in the past several years, on Examiantion there was a 15x15 mass, upon doing fna It was a “cystosarcoma phyllodes” What is the appropriate management ? A- chemo B- radio C- mastectomy D- MRM As explained at the start of this section, we go for a simple mastectomy due to the size. 40- women with 11*12 breast mass, examination showed no palpable LN. Core biopsy was taken and showed malignant phyllode tumor, what’s the next appropriate step? a. WLE b. PET scan c. Chest CT without contrast d. Simple mastectomy As this is a case of malignant phyllodes, we need to go for chest CT with contrast first to stage the cancer, but since the option here is without contrast go for simple mastectomy. 41- 4.5cm malignant phyllodes management ? A- WLE B-mastectomy In a malignant case, we either go for WLE with radiation or mastectomy. It would be preferred to go for WLE with radiation due to the small size so we can conserve the cosmetic appearance of the breast, but it’s missing here. 42- 53y did mammogram now and was normal, when she should do again? A-6m B-1y C-2y D-3y Mammography screening is done annually in the range of 40 to 50 years old. Afterwards, every two years according to the USPSTF. 43- Female in her 47 , single, positive family history of breast cancer. Underwent routine mammography which showed bilateral increased density and glandular pattern. Core needle biopsy showed atypical ductal hyperplasia. What’s the appropriate management? A. wide surgical excision. B. Simple mastectomy The keyword is atypical ductal hyperplasia. 44- A 24-year-old lady presents with a hard, mobile, well-circumscribed painless left breast mass that has been increasing in size from the past few months and was NOT related to her menstrual cycle. The most like Diagnosis is? A. Fat cyst B. Fibroadenoma C. Fibrocystic changes D. Phyllodes Classic case of phyllodes. 45- Around 20 YO patient presented with breast mass that increased in size during the past year. On palpitation, a mobile mass was noted in the RLQ of right breast, measured to be around 8*10 cm. Skin thinning around the lesion was noted. What is the diagnosis? A. Mastitis B. Phyllode C. Fibroadenoma Both Fibroadenoma and Phyllodes continuously grow, but the difference is that Phyllodes grow rapidly and also cause thinning of the overlying skin. 46- Female 20 years recently develop mass 2x2 cm that is oval in shape and smooth wall. what is your Dx? A - breast cyst B- fibroadenoma C - fibrocystic cancer D - intraductal carcinoma An oval shaped mobile mass. A missing keyword is the relation between the mass and the menstrual cycle, unlike Phyllodes. There’s another recall with multiple oval masses which is again, a case of fibroadenoma. Another recall: 21 year old female presented to your clinic with a 2 month history of right breast lump. It started as 2 cm in size oval shaped and mobile lump. The lump size fluctuate around menstruation. What is the diagnosis? A. Breast cyst B. Normal breast tissue in young people C. Fibroadenoma D. Phyllode 47- A 46-year-old female presents with a painful mass 1x2 cm in the upper outer quadrant of the left breast. There are areas of ecchymosis laterally on both breasts. There is skin retraction overlying the left breast mass. What is the most likely diagnosis? a) Fat necrosis b) thrombophlebitis c) hematoma d) Intraductal carcinoma e) sclerosing adenosis The keyword is skin retraction overlying the breast in addition to ecchymosis. 48- Multiple small breast masses bilateral get worse prior menses A. Fibrocystic B. Fibroademoa 49- Female in 33 w present with multiple follicle around the areola of nipple smooth round and painless A. Montgomery’s Follicles B. breast cyst C. Lactiferous duct Confined to the areola. D. Mondor s disease 50- Female patient with unilateral nipple dryness, crust and oozing discharge..bilateral breast ultrasound and mammography are normal. what is the next step? A. Follow up US in 6 month. B. Prescribe steroid ointment. C. Nipple biopsy D. Referral to dermatology Case of paget disease. As always, the next step after imaging is core needle biopsy. 51- 35 year old asymptotic lady is seen for counselling regarding her breast cancer screening. Her mother was diagnosed with breast cancer at age of 67 y and her sister was diagnosed with breast cancer at age of 45 y, She had no history of breast biopsies. What would you recommend for her screening? 1- Annual CBE and Mammogram alternating with breast US 2- Annual CBE and Mammogram alternating with breast MRI 3- Annual CBE and Breast US alternating with MRI until she reach 4 then you start with annual mammogram 4- Annual CBE and Mammogram The patient is 35 years old, and her sister developed cancer at 45 years old, so start mammography 10 years early. 52- 50 year old asymptotic lady is seen for counseling regarding her breast cancer screening. Her 30 years old sister was recently diagnosed with breast cancer, and her mother diagnosed with breast cancer at age of 70. She had no history of breast biopsies. What would you recommend for her screening? 1- Annual CBE and Mammogram alternating with breast US 2- Annual CBE and Mammogram alternating with breast MRI 3- BRCA gene testing for her 4- BRCA gene testing for her sister Since her sister developed breast cancer quite early, it makes us suspect BRCA. First, confirm that the affected patient has the gene, then start annually screening the entire family if the BRCA gene is positive. 53- breast mass behind nipple, on US there is hypoecoich lesion cyst what next ? A- FNA B- core biopsy C- exicional biopsy D- reassess after Another recall: 26 year old female presented with a tender breast lump. US was done and showed simple cyst. She does not have any family history for breast cancer. What is the best management? A. Aspirate B. MRI C. Excision D. Antibiotics We aspirate breast masses only in a case of cyst. 54- Women in her 50’s with hard non tender immobile breast lump with tethering and red skin, dx? Fibroadenoma Duct ectasia Carcinoma of breast Breast cyst Skin tethering? This is cancer. 55- 32y female present with 4cm fibroadenoma with hyperplasia and atypia What is the most significant risk factor for breast cancer? Her age Presence of hyperplasia Presence of atypia Fibroadrnoma si e 56- Lady with fibroadenoma underwent excision Histopathology result: fibroadenoma + invasive ductal carcinoma What is the management? A Radiotherapy B Chemotherapy C Mastectomy D High risk screening protocol Both DCIS and invasive ductal are treated with surgery. However, if it were a case of LCIS, go with D. 57- Breast feeding mother with red swelling in the exam there redness tenderness but no Fluctuation What is most appropriate management? A-flucloxacillin B-Aspiration C-I D Erythema, swelling, no other skin changes, and no fluctuation. Clear case of mastitis. 58- breastfeeding woman presents with a localized mass on the right upper quadrant of her right breast with swollen axillary lymph nodes. What is the most likely diagnosis? A. Breast abscess B. Mastitis C. Breast cancer D. Duct ectasia Presence of mass and swollen axillary LN. 59- Female postpartum presented with breast pain on examination there was local erythema, tenderness and thinning of skin how will you manage? A observation B incision and drainage C antibiotics Due to the thinning of skin. In breast abscess, any skin changes aside from redness require I&D. 60- Lactating women present with right breast pain for 6 day. On examination , hot tender swelling lateral to the right areola. Pt started to take floxacillin Us/ Cystic lesion, thickened content , ddx could be galactocele, abscess, complicatedcyst for correlation. What next 1. incision and drainage 2. repeated aspiration 3. Exisional biopsy I had this question in my exam. In the full recall, the cyst was 3*4cm and there were no skin changes that warranted I&D. 61- Lady with treated breast carcinoma. Didn’t mention treatment given to her. When can she get pregnant? A. 2 years. B. months. C. 3 months. D. years.  Thyroid irst, we ha e to do a physical e am for assessment, followed by TSH and T , then it depends on the TSH alue. ow TSH o a thyroid scan to chec the upta e in a hyperthyroidism case o upta e Subacute thyroiditis has nec pain iffuse ra es also if positi e antibody odular if sin le, multinodular oiter if multiple nodules. Always initiate treatment for hot nodules with an antithyroid dru first to reach in euthyroid status pre ent thyroid storm , followed by AI or sur ery. o with near total thyroidectomy if compressi e symptoms e ist such as dyspha ia , or thyroditis if the patient failed medical treatment, or if they ha e e opthalmos. edically, if I you had to choose between beta bloc ers and an antithyroid dru , o with beta NSAID bloc ers first for symptomatic treatment. re nant in the first trimester D Th hoose propylthiouracil. Blank 2 B nly choose A for cold solid nodules. ormal or hi h TSH ltrasound to assess the nodule s, then A nodules if the si e is cm or bi er. If both nodules are smaller than that, follow up with ultrasound. Afterwards, it depends on the ethesda classification for cold thyroid nodules repeat A follow up with S repeat A hemithyroidectomy near total is preferred o er hemithyroidectomy near total thyroidectomy If a dia nosis of hypothyroidism is made, start le othyro ine and reassess after wee s. Titrate the dose dependin on the follow up isit. If the TSH isn’t mentioned in the question, pretend that it’s normal. Always follow the approach step by step. If the TSH is normal and there’s clinical suspicion, repeat TSH unless there’s a history of radiofrequency ablation. Thyroid cancer follow up 1) Papillary and Follicular are followed up by Thyroglobulin 2) Medullary is followed up by Calcitonin Most common thyroid cancer associated with autoimmune thyroiditis is Lymphoma (not Lymphoblastic) followed by Papillary. Neck nodule Thyroglossal cyst (central) moves with tongue protrusion. Treated surgically. O Cystic hygroma (lateral) has clear lymphatic fluid. The initial O treatment is sclerotherapy, best is surgical. 1- 3 years old male patient underwent US to neck for another reason and accidentally discover nodule in the right lobe, low TSH high T4, what is the proper investigation? A. adioacti e iodine scan. B. emithyroidectomy. C. F A. D. Follow up. Low TSH case. In other words it’s hyperthyroidism thus the next step is thyroid scan. 2- unilateral neck swelling in the RT side by investigations : hot thyroid nodule remaining of the gland cold TSH is low, T3, T4 high No LN enlargement (dx hyperthyroidism toxic nodule) What is the initial Treatment? A antithyroid dru B thyroidectomy C emithyroidectomy D radioacti e iodine Achieve euthyroid status first with an antithyroid medication, then go for radioactive iodine, or near total thyroidectomy if there is presence of eye symptoms or compressive symptoms. 3- A patient presented with history of hyperthyroidism and exophthalmos. TSH is low with High T4 and T3. On thyroid scan there is increase uptake and suggestive of thyroid nodular goiter (right sides 1/2cm), which of the following is the best management? A i ht hemithyroidectomy. B ubtotal thyroidectomy. C ear total thyroidectomy. Near total thyroidectomy due to the presence of eye D adioacti e ablation. symptoms. Can't find near-total in the options? Go with total. 4- A thyroid mass, TFT is not mentioned, US: large cystic mass with small solid mass, what is the best next step in management? A. F A from cystic. B. F A from solid. As explained earlier, we only take samples from solid nodules. In C.. another recall, let’s say you had to choose between FNA cystic and D. hyroid scan. biopsy solid, go for biopsy solid. 5- 48 yo lady with diffuse goiter, high T4 low TSH, US show bilateral thyroid nodules , right 3x4 in size , left is 1x2 size what to do? A. F A both B. F A the lar er one C. total thyroidectomy The sizes are in CM, and they’re both bigger than 1*1cm, so we need to FNA both. 6- Let’s assume we had the same case with an US showing bilateral thyroid nodules. The right nodule being 3x4mm in size, and the left is 1x2mm. Next? A. F A both B. F A the lar er one C. total thyroidectomy D. Follow up with Because both are smaller than 1*1cm. 7- 3x4mm in size, and the other nodule is 1x2cm. Next? A. F A both B. F A the lar er one C. total thyroidectomy D. follow up 8- 25 years old female with thyroid nodule, TSH and T4 normal. FNA cytology done classified as Bethesda 3. What is the most appropriate management? A. epeat F A. B. obectomy. C. e othyroxine. Side note: lobectomy = hemithyroidectomy. D. otal thyroidectomy. 9- 40 years old male with left neck mass, thyroid ultrasound done and showed 1.5*2 cm cold mass, FNA cytology revealed suspicious follicular neoplasm, which of the following the best initial management? A. eft hemithyroidectomy. B. epeat F A. C. rescribe thyroxine. D. adioacti e ablation. Follicular neoplasm = Bethesda 4, so go for hemithyroidectomy. 10- 45 years old female known case of hypothyroidism on levothyroxine with high TSH. The patient is scheduled for elective surgery. What is the most appropriate management? A. ncrease le othyroxine dose. B. top le othyroxine before the sur ery. C. ostpone the sur ery until euthyroid is restored. D. roceed with the sur ery and prescribe thyroxine after the sur ery. As explained earlier, never proceed with surgery until you achieve euthyroid status. 11- 55 years old patient was diagnosed with autoimmune thyroiditis, with a history of progressive enlargement of the right lobe of the thyroid. FNA report: malignant cells. Which of the following is most likely the type of thyroid malignancy? A apillary. B edullary. C Anaplastic. D ymphoma. Lymphoma. If not present, go with papillary. If you see lymphoblastic in the options, then it’s wrong. 12- 32 years old male with neck mass and dysphagia, US done and showed mass 2*3 cm, FNA cytology reveled hypercellular of large poorly cohesive spindle-like shape cells, labs showed high calcitonin, Which of the following is the most likely diagnosis? A. apillary. B. edullary. C. Anaplastic. D. Follicular. Calcitonin? Medullary thyroid cancer. 13- Middle age Pt with papillary thyroid cancer , planned for total thyroidectomy how to follow up ? A serial post op B calcitonin C D hyro lobulin Papillary and follicular are followed up by thyroglobulin. But if it was medullary cancer? Go with calcitonin. 14- 36 year-old female presented with left neck mass 2x2cm in posterior angle of mandible. US: Normal thyroid, left large LN with cystic component. FNA: All smear shows follicular thyroid What is the most likely diagnosis? A. etastatic thyroid cancer B. Apparent thyroid C. Ectopic thyroid D. hryo lossal cyst This is a case of papillary thyroid cancer metastasizing to the lymph nodes. 15- 35 years old female underwent thyroid lobectomy for hot thyroid nodule 3x3, 8mm papillary will defined focus was found distant to the lesion with no lymph or vascular invasion, what is the appropriate management? A Completion thyroidectomy. B Follow up months. C A. D obectomy. Since the size is only 8mm, simply follow up. We go with total thyroidectomy if it’s 1cm or bigger. 16- A patient underwent thyroidectomy, immediately developed shortness of breath and respiratory distress after extubation. Upon examination both vocal cord are in semi-closed position. What is the best next step to secure the airway? A Cricothyrotomy B e intubate. C asal canula. D Bedside tracheostomy. A case of bilateral vocal cord paralysis post-thyroidectomy. Requires immediate reintubation. 17- A female patient underwent left thyroid lobectomy, post surgery she complaining of sever shortness of breath and pointing to her neck, what is the next step? A a e her bac to. B Bedside tracheostomy. C asal cannula. D Bedside wound exploration. This question has a few different recalls when it comes to the wording in the answers. The correct answer is opening the wound immediately due to the hematoma. 18- A patient post thyroidectomy was unable to maintain a high-pitched voice. Which of the following is the injured nerve? A. uperior laryn eal B. nferior laryn eal C. ecurrent laryn eal D. External laryn eal. High pitched voice = superior laryngeal nerve. 19- A patient post thyroidectomy then developed hoarseness of voice and aspiration. Which of the following is the injured nerve? A. uperior laryn eal B. nferior laryn eal C. ecurrent laryn eal D. External laryn eal. Hoarseness = recurrent laryngeal nerve. 20- 4 years old boy, developed large neck swelling on the left side. On exam it is large 10cm in size, US FNA showed clear lymphatic fluid What is the appropriate management? A ur ery B bser ation C Chemotherapy D adiotherapy This is a case of cystic hygroma, a lateral neck mass with clear lymphatic fluid. Initial: sclerotherapy. Best: surgery 21- A child with painless neck nodule that moves up and down, moves up with tongue protrusion. What is the most likely diagnosis? A. Dermoid cyst. B. hyroid nodule. C. hyro lossal cyst. D. arathyroid nodule. Midline mass and moves with tongue protrusion. Another recall asking about management? Go with surgery. 22- Pregnant lady, not sure about the gestational age. Presenting with signs and symptoms of hyperthyroidism. Which of the following is most contraindicated? A thyroidectomy. B radioacti e iodine. C propranolol. D methima ole. 23- Patient admitted to the ICU due to pneumonia then developed thyroid symptoms (hypo or hyperthyroid symptoms I don’t remember, but no symptoms suggesting graves or subacute thyroiditis) Labs: TSH low T3 low T4 low What’s the diagnosis? A ra es disease B ic euthyroid sic ness C ashimoto thyroiditis Because of the lab values. D ubacute thyroiditis 24- Woman has controlled hypothyroidism on 175 mcg levothyroxine. In the last 3 months, the doctor raised the dose to 200 mcg. She is otherwise normal (see labs). Labs: T4 (normal) T3 (normal) TSH= 17 (high). What is the best explanation for the lab findings? A. mall dose. Normal T4 + High TSH = Poor compliance. T4 improves B. oor compliance. quickly by taking levothyroxine, but the TSH requires C. Ectopic thyroid. daily compliance long term or it will continue to stay D. econdary hypothyroidism high. If the patient had actual good compliance and the TSH is still high? Then we need to increase the dose 6 weeks after the last appointment. 25- case of hyperthyroidism and palpation. What will you do for her as initial management? A. B. ethima ole C. ropranolol In real life, you would start both methimazole and propanolol at the same time. In the SMLE though go for propanolol first for symptomatic relief. 26- Long case of a medullary thyroid cancer (diagnosis given) what is the appropriate management? A ub total thyroidectomy B otal thyroidectomy C emithyroidectomy Follow the Bethesda classification. Case of thyroid cancer? Go for near total thyroidectomy. If that’s not available in the options, go for total thyroidectomy. 27- Case of an asthmatic patient complaining of shortness of breath in supine with dysphagia, CT scan done and showed midline mass, what is the most likely diagnosis? A. ymphoma. B. hymoma. C. oiter. D. un nodule. A thyroid goiter that led to compressive symptoms (dysphagia). The patient needs surgery. 28- A patient post thyroidectomy had arm spasm during blood pressure measurement, what is your next step? A i e anal esia. B a e blood pressure a ain. C Chec calcium le el. D Administer Calcium luconate. Hypocalcemia as a complication of thyroidectomy. 29- 19 year old pt found accidentally lump in her throat she did tsh was normal and did FNA was inadequate a epeat F A b can c emo e thyroid d Follow up Inadequate FNA means the Bethesda score is 1, so you have to repeat FNA now.  Pancreatic Pseudocyst - Surgery notes Epigastric pain with past Hx of pancreatitis weeks ago. Investigation of choice (initial and gold) = CT Treatment: o Observe; most cases o Endoscopic (internal) drainage; +6wk +6cm 6 o Percutaneous (external) drainage; infected Walled off Pseudocyst Abscess I necrosis Fluid Homogenous Heterogeneous Associated sx Fever Drainage Endoscopic Percutaneous Liver Abscess - Surgery notes Amebic Hydatid Pyogenic Organism E.Histolytica Echinococcus Developed countries RF India/Mexico 2ndry to cholangitis Thick wall + hypodense Bloody diarrhea fluid Features + Daughter cysts Fever High LFT Initial: Albendazole Antibiotics + Tx Metronidazole Definite (daughter cyst present): Percutaneous drainage Surgical deroofing  Triphasic CT is the diagnostic test (if only US done) 223- Picture of Two huge echinococcosis hydatid cyst but si e wasn’t mentioned, asking what most appropriate initial step? A. Albenda ole B. Surgical deroofing C. Percutaneous drainage D. Liver resection 224- scenario about hydatid cyst 1 13 with daughter cysts, what is the management? A. Surgical deroofing B. Percutaneous aspiration C. Right hepatectomy 22 - 36 old male at ER C/O Right abdominal Pain, O/E fever, anorexia, weight loss, tenderness in R and Lower intercostal margines also patient is toxic Temp. 3. (I think but it was elevated) wbc high, bilirubin high US cystic lesion without septates CT homogenous (not sure) and THICK WALL with Peripheral enhancement - What s most appropriate A. Ceftriaxone B. Metronida ole Case of pyogenic liver abscess, which is the most common C. Surgical drainage cause of liver abscess by far in developed countries. The most D. Percutaneous drainage appropriate management is drainage. As for the initial step, go with Ceftriaxone since we have to start it in all patients in addition to drainage. 226- Male patient came from India RU pain.. on and off fever for 3 weeks. raised LFT , high WBC (Neurtrophol % Lymphocytes 2 %). image showed homogenous hypoechoic mass in the liver. a) hydatid cyst b) TB abscess c) amebic abscess As mentioned previously pyogenic abscess is the most common d) pyogens abscess one, but since the patient came from India and has been febrile for 3 weeks we will go with amebic abscess. 22 - 4 yo man with returns from a trip to Mexico and develops fever, chills, and RU pain. WBC count is 2. US shows an intrahepatic fluid collection. CT scan shows 12 cm single abscess with a peripheral rim of edema. This condition is best treated with? A. Percutaneous drainage and Abx B. Metronida ole C. Albenda ole Mexico is another endemic area for amebic abscess. What if we D. Surgical drainage removed it from the question? The answer would change to A. 228- O male presented to the hospital complaining of fever, bloody stool and tenesmus for 3 days. Abdominal examination reveled abdominal distention. What is the most likely diagnosis? A. Ascaris B. Amebiasis C. Giardiasis D. Rotavirus 22 - Case of Pancreatitis weeks ago. Now she has epigastric tenderness and cannot tolerate food with vomiting each time. By ultrasound, you found large about 12x1 cm mass with thick wall and fluid inside which is heterogenous and non-liquefied. Labs 346 amylase, WBC 1. What is the diagnosis? A. Pancreatic Pseudocyst B. Pancreatic Abscess C. Walled off pancreatic necrosis Heterogenous fluid, making it a case of walled off necrosis. If homogenous fluid? Pseudocyst. If febrile? Abscess. What if none of it was mentioned to begin with? Pseudocyst since it’s the most common presentation. 23 - Pancreatitis weeks ago. Now she has epigastric tenderness and cannot tolerate food with vomiting each time. By ultrasound you found large about 12 1 mass with thick wall and fluid inside. Labs 346 amylase, Wbc 1 k. What is the diagnosis? A. Pseudocyst B. Abscess C. Walled off necrosis (Didn’t specify homogenous OR heterogenous) No fever, and no mention of a heterogenous collection. 231- 2 Patient diagnosed with acute pancreatitis 3 weeks ago, now present to ER Complain of mild abdominal pain and tenderness, US showed cyst measure 4 cm, how you will manage? A. Observation B. Internal drainage C. External drainage D. Surgical remove 4 weeks and 4cm, so keep observing for now. Afterwards, go for internal drainage. 232- Case of pancreatic cyst for Ws with collection was 18 cm x 24 cm how to manage? A- Percutaneous drainage B- Endoscopic drainage C- Surgical drainage No additional details that would change the answer (fever/heterogenous), so go for endoscopic drainage. 233- one was typical pancreatic pseudocyst, diagnosis mentioned in the , also the patient was observed for 6 weeks and the cyst getting bigger, what is appropriate management? -laproscopy drainage -percutaneous drainage -excision of the cyst -I dont remember maybe it was observe Bad recall. There are two possible explanations 1) the 4th option is endoscopic drainage, which would make it the correct choice since we always manage pseudocysts through an internal drainage. 2) if the 4th option is unrelated, the other possibility is that the recaller forgot to mention some important details in the question. Fever? Heterogenous fluid? The answer in that case would be percutaneous drainage.  Hepatobiliary - Surgery notes Investigation of choice: US (even if obese) Alcoholic Hepatitis: Very high AST and ALT , AST/ALT ratio 2:1 Hepatocellular Carcinoma: Screening: 1. US 2. Triphasic CT (definite) 3. US Follow up every 6m (incase of cirrhosis) Treatment: surgical excision, TACE (> 5cm or multiple)  Avoid contact sports in hemangioma  Female taking OCP = liver adenoma = stop OCP (or reduce carbs/fatty meals)  Diabetic pt with hepatic sx and no lab values? NAFDL Ascending cholangitis Biliary pancreatitis Cholecystitis RUQ pain CBD dilatation Sx Charcot triad No jaundice Epigastric/RUQ pain +ive Murphy Initial: US Invx US US Best: CT Tx ERCP drainage Conservative Lap cholecystectomy Asymp stable Asymp sludge Gallstone ileus stone Triad: Pneumobilia Sx SBO Ectopic gallstone Invx CT Tx Lap chole No f/u Klatskin tumor Pancreatic Ca Ampullary Ca Gallbladder Shrunken Enlarged Hepatic ducts Dilated intrahepatic Dilated intrahepatic Dilated extra/intrahepatic Coursevoir D painless mass Jaundice 1 1- Patient obese, history of jaundice for 1 week with anorexia and abdominal pain, examination showed right upper quadrant tenderness, no history of medication or disease, what is initial step? A. MRCP B. Abdominal US C. CT D. Biopsy 1 2- 4 -year-old patient complains of recurrent episodes of upper abdominal pain for the past 2 week with fever. On examination, the patient is jaundiced, the abdomen abdomen is soft with marked tenderness all over Blood pressure /6 mmHg Heart rate 13 /min Respiratory rate 18 /min Temperature 38 C indirect bilirubin Direct bilirubin 2 Total bilirubin 2 Alkaline phosphatase 4 Amylase 14 Ultrasound CBD of 1.4 cm with dilatation of intrahepatic ducts. Which of the following is the most likely diagnosis? A. hepatitis B. cholangitis C. pancreatitis D. acute cholecystitis Charcot triad. Cholangitis is treated with an ERCP. 1 3- 46 y.o male present with epigastric pain heavy dinking alcohol, Exam mild epigastric tenderness previous multiple hospitali ation Labs amylase normal Bp. 11 /6 Hr 11 Dx? A- Acute pancreatitis B- chronic pancreatitis C- esophgial varisis D- pancratic psodocyst Heavy alcoholic and multiple hospitali ations. 1 4- RU pain, for 12 hours, no fever, no jaundice. U.S findings non thickened G.B wall with multiple gall stones, CBD is obsecured , what’s your diagnosis A. Acute Pancreatitis B. Obstructive jaundice C. Acute Cholecystitis D. Ascending cholangitis No Charcot triad, and the findings are not relevant for cholecystitis. 1 - A 3 -year-old woman presents to the ER with a history of right upper quadrant pain side hours with nausea and vomiting. On examination there was a marked abdominal tenderness. Abdominal ultrasound demonstrates peri-cholecystic fluids, thick gallbladder wall with positive sonographic Murphy s sign. Which of the following is the recommended treatment? A. Conservative treatment and interval cholecystectomy B. Insertion of percutaneous cholecystestomy tube C. Emergency laparoscopic cholecystectomy D. Emergency open cholecystectomy Classic case of cholecystitis. The patient presented in the first 2h so go for lap chole. But if past it? Treat conservatively then schedule for elective lap chole in 6 weeks.  1 6- 3 y/o complaining of abdominal pain radiating to the back associated with vomiting he did gastric sleeve 3 months back. US gallbladder sludge with no stone normal cystic duct EBC normal Amylase What is the most appropriate investigation? A. Endoscopic US B. Endoscopic sphincterotomy C. Laparoscopic cholecystectomy D. Open cholecystectomy Sludge is a small stone. Treat it just like you would with a typical cholecystitis. 1 - Pt has RU pain radiating to the scapula, nausea and vomiting, U/S shows small gall bladder stones mm polyp, what is the management? Lap chole. Observation Radical cholecystectomy Repeat US after 3 months If any of the following are present refer for surgery 1) SI E >1 CM 2) S MPTOMATIC 3) AGE > Otherwise? No need for follow up. 1 8- A patient with epigastric pain admitted to hospital, U/S shows gallstones with dilated CBD. Now he is stable and labs are normal except high amylase 2. What is the appropriate next step? A. ERCP B. CT abdomen C. cholecystectomy now D. cholecystectomy after 6 months ERCP then lap chole in the same admission. 1 - Patient develop surgical emphysema neck chest abdomen after ERCP, which organ was injured or perforated? A. Esophagus B. Stomach C. Pancreas D. Duodenum 2 - Old patient came for elective cholecystectomy you find out he was admitted 2 weeks ago in icu for management of MI, what will you do? A- do it in this admission B- delay it 6 weeks C- delay it 6 months D - no need to do it anymore 2 1- Post laparoscopic cholecystectomy, a patient was discharged home. He presented 4 days later with RU pain and fever. Examination revealed temperature of 38 C and tender fullness at RU. Labs showed high WBC level and normal Bilirubin and liver en ymes. Antibiotic therapy was started. What is the next step? A. ray abdomen B. US abdomen C. CT scan abdomen D. Tc-HIDA scan 2 2- A woman post lap cholecystectomy complaining of SOB and ascites confirmed by US. Management? A. ERCP B. Abx C. Exploration D. Percutaneous drainage We did the US in the prior question, so time for drainage. 2 3- A 41 years old man underwent a laparoscopic cholecystectomy, days back started to experience severe abdominal pain and distension. Examination revealed a tender and distended abdomen. Bp 1 HR 1 3 Temp 3. ,,revealed the presence of ascites. which of the following is the most appropriate management A) ERCP B) percutaneous drainage C) Exploratory laparotomy D) diagnostic laparoscopy Vitally unstable or has peritonitis? Laparotomy. Definitive? ERCP after US and percutaneous drainage. 2 4- A 3 -year-old woman who is 1 -week pregnant and know case of gallstone presents to the Surgical Clinic complaining of recurrent attacks of biliary colic for the last weeks. Which of the following is the most appropriate management? A. immediate laparoscopic cholecystectomy B. laparoscopic cholecystectomy after delivery C. laparoscopic cholecystectomy in 2nd trimester D. laparoscopic cholecystectomy in 3d trimester 2 - A patient is presented with jaundice. U/S shows a shrunken gallbladder with dilatation of intrahepatic ducts. What is the most likely diagnosis? A- Acute Cholecystitis B-Gall Bladder Stone C-CBD Stone D- klatskin tumor 2 6- A year old man presents with progressive jaundice, dark urine, and right upper quadrant pain and distention. On physical examination he has a palpable gall bladder. Imaging shows an enlarged gall bladder and dilated Intrahepatic duct. Amylase 481. diagnosis is A. klatskin tumorn B. Pancreatic cancer C. Cholecystitis D. Mirri i’s syndrome 2 - elderly, epigastric pain for 3m, wt loss, jaundice and dark urine There was dilatation of intrahepatic and extrahepatic duct Labs cholestatic picture (They did not mention if the gallbladder is palpable or shrunk ) ) A. Klatskin tumor B. Gall bladder cancer C. Ampullary cancer 2 8- There was a question about a lady known case of gallstones for 1 years presented with abdominal pain and fatigue There was air in biliary system, what is the diagnosis? A. Gallstone ileus B. Acute Cholecystitis C. Acute pancreatitis 2 - Elderly with abdominal pain amd abdominal distention, He shows signs of obstruction, on imaging there is air fluid levels and pneumobilia (air in biliary ducts), What s the next step in investigation? A- Gastrograffin test B- Barium swallow C- Abdominal CT D- US Go for CT in gallstone illeus. 21 - A case of young male asymptomatic presented abnormal LFT. He is a smoker and drinks alcohol in the weeknds. Labs showed high AST ALT (2 1 ratio) Tbilli and slightly high iron and TIBC and very high ferritin (4 ). What is the cause of his abnormal LFT? A-hemochromatosis B-alcoholic hepatitis C-cholangitis AST/ALT ratio 2 1? Alcoholic hepatitis. If the labs simply showed high ferritin the answer would be A. Now, what if we had no lab values at all in the question in a case of a diabetic patient? Go for NAFLD. 211- Patient known case of ulcerative colitis did MRCP and showed intra and extra hepatic duct strictures, what is the diagnosis? A. Cirrhosis B. Primary biliary cholangitis C. Primary sclerosing cholangitis First, we have to do an US. Afterwards, for further workup it depends Autoimmune hepatitis -> ANA, ASMA Primary biliary cholangitis -> AMA. Primary sclerosing cholangitis -> MRCP 212- oung female suddenly developed jaundice and fatigue. She high ALP and high bilirubin. No splenomegaly or hepatomegaly. US no finding. MRCP multiple foci of stricture and dilatation. What is best initial next step? A. Liver biopsy B. Antinuclear antibody C. Repeat US D. Colonoscopy This is a very similar case. We should look for ulcerative colitis due to the association between the two. 213- patient admitted in CCU after MI, complicated by pneumonia, during admission he had RU pain, US showed pericholecystis fluid with thick GB wall, Mx? US guided cholecystostomy tube Urgent open cholecystectomy This ICU patient is unable to tolerate lap chole, so go for cholecystostomy tube. 214- 3 years old patient presented with new onset jaundice , weight loss and other symptoms , CT shows lesions in % of the liver , most appropriate investigation 1-Colonscopy 2- Upper GI endoscopy 3- Percutanous liver biopsy 4- Diagnostic laproscopy A case of metastatic liver cancer. Colorectal cancer is the most common cancer metastasi ing to the liver. 21 - Alcoholic, right hypochondriac pain and i think weight loss ,alpha fetoprotein is high No other labs ,Image CT showed multiple lesion in liver and cirrhosis A-Hepatocellular carcinoma B-pancreatic cancer 216- A case of chronic Hepatitis C presents with RU mass. Investigations show 6 x 6 cm hepatocellular carcinoma. What is the best management? A - Chemotherapy B - Radiotherapy C - Transcatheter arterial chemoemboli ation (TACE) D - Surgical resection 21 - known case of liver cirrhosis secondary to Hepatitis C has completed treatment. Hepatitis C RNA is negative. How will you follow up this patient? a. Regular screening with AFP b. Regular screening with ultrasound c. Liver biopsy d. No follow up is required Due to the presence of cirrhosis. 218- case that was postive for Hep C, came now for followup, labs show HCV Antibody and HCV RNA negative What to do ? A- Liver biopsy B- Liver ultrasound C- Repeat HCV RNA after 6m D- No need for further intervention If symptomatic, repeat RNA now. If the patient had recent exposure, repeat RNA in 6 months. 21 - A patient with cirrhosis and his dr. want to screen him for Hepatocellular carcinoma, what is the best diagnostic test? Abdominal US Triphasic CT Screening? Ultrasound. Confirmatory? Triphasic CT. Could be a bad recall, but since it mentioned screening specifically the best way is with an US. Another recall What is a risk factor for HCC? Hepatitis B. 22 - Smoker and obese female patient on combined OCP, at imagining there is 4x4 cm hepatic hemangioma. What is the most important thing to advise the pt.? A. Decrease high carbohydrate and fatty meals B. Stop smoking C. Eat diet rich in fiber D. Stop OCP 221- Smoker and obese patient, at imagining there is 4x4 cm hepatic hemangioma. What is the most important thing to advise the pt ? A. Decrease high carbohydrate and fatty meals B. Stop smoking C. Eat diet rich in fiber D. Avoid excessive sport 222- years old with Ischemic Heart Disease (IHD), Diabetes mellitus (DM) Admitted to ICU with severe pneumonia and was treated with Antibiotics. After 3 days of admission, he developed hypotension and treated with hydration and inotrope, on admission lab was normal After 3 days, LFT was abnormal Total Bili is 2 (increased), very high AST and ALT (1 ), mild increase in LDH, US done and showed unremarkable findings, what is the diagnosis? A. Ischemic hepatitis B. Intravascular hemolysis C. ICU related jaundice D. Acalculous cholecystitis  Cholecystectomy:  Golden period for cholecystectomy: first 72hrs  If past it = elective lap cholecystectomy in 6wks  ERCP always done before lap cholecystectomy Complications: Stable —> US —> drainage —> ERCP (definite) Unstable —> laparotomy  Cholecystectomy in pregnancy = done in 2nd trimester  MI with stent = lap cholecystectomy in 6wks Colorectal - Surgery notes Algorithm: 1. Sigmoidectomy if pt has obstruction 2. Colonoscopy and Bx 3. CT for staging 4. Surgery if not already done Colorectal Screening: at Soyo If normal risk pt: - Annual FOBT - Sigmoidoscopy every 5yrs - Colonoscopy every 10yrs (if +ive FHx every 5yrs) Right colon Ca Left colon Ca Sx Bleeding/Anemia Obstruction Tx Colonoscopy Sigmoidectomy followed by colonoscopy Ogilvie Syndrome Sigmoid volvulus Dilated colon without mechanical Sx Obstrucion, U shaped colon, empty rectum obstruction -Endoscopy detorsion Tx Decompressive rectal tube -Colonoscopy and semi-elective surgery -Hartman surgery (unstable or failed) Mesentric Ischemia Sx IHD pt + diffuse abd pain Invx CT angio 1 3- 4 -year-old women medically free with no personal or family history of cancer. Asking about when to to start colon cancer screening? A- no need for screening for her case B- Start now and every years C- Start at years with annual colonoscopy D- Strat at with annual Fecal occult blood 1 4- 1 years old female medically surgically free, with no family history of colon cancer, which colon cancer screening test is appropriate for her? A. years Colonoscopy B. Annual Fecal Occult Blood Colonoscopy every 1 years Sigmoidoscopy every years Annual FOBT 1 - A 46 years old asymptomatic man. His mother recently died of metastatic colon cancer. She was diagnosed with colon Cancer years ago at age 6 years. Which of the following is the most appropriate colorectal cancer screening strategy for this patient? A- Colonoscopy every years B- Colonoscopy every 1 years C- CT Colonography every 1 years D- Fecal immunochemical testing every years Again, every 1 years. His mother was diagnosed at 6 , but what if they diagnosed her at ? In that case, we would go for colonoscopy every years. 1 6- 43male have family history of colon cancer underwent sigmoidoscopy for polyp removal Histopathology showed tubular adenoma completely removed..how to follow? A-3-6 month B-3years C- years D-no need Repeat colonoscopy in 3 years. 1 - What type of polyp with highest risk of cancer? A. Villous B. Tubular C. Tubulovillous 1 8- After resection of a pedunculated polyp the results was benign adenoma and patient has no family history of colon cancer what to advice for reduction of colon cancer? A. Prophylactic sigmoidectomy B. Prophylactic colectomy C. Annual colonoscopy D. Lifestyle modification 1 - A 4 years old male smoker has an adenoma removed from his colon. Pathology report shows a benign lesion. What advice should you give this patient to prevent him from getting colon cancer? A. Eat a low-fiber diet. B. Eat a high-protein diet. C. Colonoscopy every year. D. Stop smoking and start exercising 18 - An old male patient was admitted as a case of large intestinal obstruction. He underwent rigid sigmoidoscopy that showed a mass in the sigmoid region. A biopsy was taken and came back as adenocarcinoma. What is the best next step? A - Colonoscopy B - CT abdomen C - MRI pelvis D - Sigmoidectomy A case of large obstruction, hence why we need to go for surgery first. If the patient is not currently obstructed? Colonoscopy. 181- Elderly patient presented to OPD with change in bowel habit (constipation) and streaks of fresh blood on stool. Rectal exam revealed a mass. Colonoscopy and biopsy confirmed adenocarcinoma at 6 cm from anal verge. What is the next step in management? A. Surgery B. CT chest and abdomen C. Neo adjuvant radiotherapy D. Chemotherapy We did colonoscopy already. Now, we have to stage for metastasis. 182- 6 years man presents to your clinic and looks weak , dehydrated, pale , thin and emacitaed. he complains of anal itching , discomfort from the pas few months. On examination, you find an anal mass that is 2 cm away from the anal verge , cauliflower like and friable. What is your most likely diagnosis? A- Anal Cancer B- Rectal Cancer C- condyloma accuminatae The keyword is cauliflower like mass. 183- Old male patient lethargic and pale with weight loss for 2 months, by Examination there was 2nd degree hemorrhoid low hemoglobin, what’s the diagnosis? A. Rectal cancer B. Cecal cancer C. Hemorrhoids D. Sigmoid cancer An example of right sided cancer with anemia. 184- Old patient who has constipation on and off with streaking of blood in the stool with no fulness in the rectum ( no mention of pain )? A. Sigmoid cancer B. rectal cancer C. chronic hemorrhoid. Anemia, and red streaks of blood in the stool due to the location of D. cecal cancer the cancer. 18 - A 4 - year old patient complains of perianal swelling, fresh bleeding per rectum and weight loss over the last 3 months on examination, there is a mass 1 cm from the anal verge. She has no obstructive symptoms (see report), Biopsy Adenocarcinoma. MRI abdomen Locali ed lesion with craniocaudal extension of 3 cm with associated lymphadenopathy. 11 / mmHg 6 / min 18 / min 36.6 C CT scan chest No evidence of metastasis. Which of the following is the most appropriate treatment? A- Diversion colostomy B- Low anterior resection C- Concurrent chemoradiation D- Abdominoperineal resection In rectal adenocarcinoma, neo-adjuvent chemoradiation is a must regardless of the surgical procedure. 186- Elderly female, asymptomatic maybe or just fatigued. Labs showed microcytic anemia what to do NE T? A/ Occult fecal blood B/ Endoscopy colonoscopy Old age anemia suspect right sided cancer. 18 - A 3 year old Male, known to have schi ophrenia on medication, presented to ER with recurrent abdominal distention and constipation. Was normal on examination and vitally stable. Abdominal ray dilated colon lumen 1 cm CT No obstruction Best management? a-Decompression colonoscopy with rectal tube. b-emergency colectomy. c-Lt side colostomy. d-lower barium enema. Dilated colon without a mechanical cause. A case of ogilvie syndrome. 188- Elderly with vomiting, constipation, abdominal distention. Upon imaging they described a shape going towards the right upper quadrant, what’s the dx? -Rectosigmoid cancer -Sigmoid volvulus -obstruction -closed loop The shape they are describing is U, in addition to a coffee bean sign on xray. 18 - A 6 year old patient known case of Atrial Fibrillation presented to the ER complaining of severe diffuse abdominal pain for 4 hours. High WBC. Vitally stable. What’s the initial test? A. US B. CT C. Diagnostic laparoscopy D. Unrelated B, CT-A is more correct. Most likely a case of mesenteric ischemia although ischemic colitis is another DDx and we use CT for it. Another recall 1 - yrs old man k/c of IHD, central abdominal pain vitally stable, amylase 6 , WBC normal, abdominal x ray dilated small bowl with thickened wall what’s the dx? A. Pancreatitis B. Intestinal obstruction C. Perforated ulcer D. mesenteric ischemia  Appendicitis - Surgery notes Investigation of choice: - Child or pregnant = US - Elderly = CT - Male: o Alvarado < 6 = CT o Alvarado 7-10 = Laparoscopy Signs in appendicitis: - Rovsing = LLQ —> RLQ pain - Bluberg’s = rebound tenderness in RLQ - Psoas = retro-cecal appendicitis - Obturator = pelvic appendicitis Appendicular Mass: 1. Percutaneous drainage Then Interval appendectomy in 6wks 2. Colonoscopy if old 93- 9 year old came with an 8 hours history of abdominal pain and nausea. What’s the most common surgical emergency: A Appendicitis. B intussusception. C cholecystitis. D pancreatitis. 94- Child with clear case of appendicitis, most appropriate investigation to reach diagnosis? C US is enough. No need to cause unnecessary radiation. 95- 25 y.o female, married, with 12h of RLQ pain, N/V. Vitally stable. No labs provided. Next? A. C B. C. Dia nostic laparoscopy D. Exploratory lap. It could be ectopic, so with these choices go for an US next as it may be enough. Ideally, we would order a pregnancy test first then go for CT if the Alvarado score is less than 7 and the ectopic pregnancy has been excluded. 96- Young female came to ER c/o RIF pain for 12 hours, on PE: there is tenderness in Suprapupic + RIF , and no rebound tenderness, WBC high 14k On US : inconclusive What is the next step ? A C B open appendectomy C dia nostic laparoscopy D rans a inal In this question, they already did an US and it was useless. Again, the correct answer should be pregnancy test. It seems to be a typical case of appendicitis but why rush to CT and cause potential harm if the patient turned out to be pregnant? Between these two options, the most likely answer is transvaginal US since not only is it the preferred way to diagnose an ectopic pregnancy, but it would also diagnose ovarian cysts. Lastly, the question specified “what is the next step” s