USMLE Surgery

Q. Which is not true of acute appendicitis?

2012-01-12T16:27:00.003-08:00

A. Urine pregnancy test should be done in females

B. Presence of pyuria rules out appendicitis

C. Acute intermittent porphyria may mimic it

D. Diabetic ketoacidosis can present with abdominal pain

Answer B

1. Urine analysis is useful when evaluating people with appendicitis

2. Mild pyuria can occur in patients with appendicitis because of relationship of the appendix with the right ureter

3. Proteinuria and hematuria are usually associated with urological or hematological disorders

Q. Which is false about mesenteric adenitis?

2012-01-12T16:27:00.001-08:00

A. Caused by rotavirus

B. Produces fever

C. Can be confused with appendicitis

D. May cause WBC elevation

Answer A

1. Mesenteric adenitis is most frequently caused by viral pathogens, but other infectious agents have been implicated, including Yersinia enterocolitica, Helicobacter jejuni, Campylobacter jejuni, and Salmonella or Shigella species

2. An association with streptococcal infections of the upper respiratory tract, particularly the pharynx, has been reported

3. Patients with mesenteric adenitis may have RLQ pain or generalized abdominal pain

4. Free air is not a feature of the illness. Voluntary guarding and rectal tenderness are also common features

Q. Which is not true of Crohn Disease?

2012-01-12T16:26:00.003-08:00

A. X-ray findings may mimic diverticulitis

B. Has a “saw tooth” appearance on barium enema

C. Entero-cutaneous fistulas are common

D. Surgery is curative

Answer D

1. Surgery (resection of parts of the bowel) is avoided, as this does not cure the disease –Crohn disease can recur at any site in the digestive tract

2. 50% of all Crohn patients eventually undergo one or more resections to control highly active disease. Most often, this is in the terminal ileum

3. In some cases of widespread intractable Crohn colitis, removal of the colon and rectum (protocolectomy) is required. In these cases, the patient is left with an ileostomy

Q. Which is false about liver abscess?

2012-01-12T16:26:00.001-08:00

A. Gram-negative bacteria are common cause

B. Hiccups may occur

C. Can lead to jaundice

D. Amebic liver abscess is usually most common in left lobe

Answer D

1. The right hepatic lobe is more commonly affected than the left lobe by a factor of 2:1

2. Bilateral liver involvement is rare

3. The predilection for the right lobe is due to blood from the SMV and portal veins, whereas the left lobe receives IMV and splenic drainage

Q. The most common cause of liver abscess today is:

2012-01-12T16:25:00.001-08:00

A. Appendicitis

B. Biliary tree disease

C. Hydatid infections

D. Trauma

Answer B

1. Biliary tract disease is the most common cause of pyogenic liver abscess

2. Obstruction of the bile flow allows bacteria to multiply

3. Biliary disease like strictures, congenital obstructions, or malignancies can cause pyogenic liver abscess

Surgery: Wound Infection

2012-01-05T17:12:00.000-08:00

Q. A 66 year old has emergency colectomy for a bowel obstruction. Four days later, he complains of intense pain from his wound site. The wound is brawny with a small amount of rusty colored fluid draining from it. The next step is:

A. Wide local debridement

B. Hyperbaric oxygen

C. Antibiotics

D. Bedside wound care

Answer A

1. Wound infections with rusty colored fluid after surgery indicate a serious infection

2. It could be from streptococcus or even clostridium

3. The patient needs an urgent visit back to the operating room

4. Any time a florid wound infection with sepsis occurs, urgent debridement is required

Surgery: Cold leg

2012-01-05T17:11:00.001-08:00

Q. A 71-year-old is seen on day 6 after abdominal surgery. He complains of sudden onset of right leg pain. The right leg is cold and mottled. The right femoral pulses are palpable but there are no distal pulses. The most likely diagnosis is:

A. Femoral artery embolus

B. Deep vein thrombosis

C. Vasospasm

D. Femoral artery atherosclerosis

Answer A

1. Anytime a patient presents with a cold leg, an embolus must be suspected

2. Emboli may result from the heart, atrial fibrillation, or infective endocarditis. Echo is part of the work up

3. The ideal treatment to evaluate a cold leg is an angiogram

4. Embolectomy is the procedure of choice

H pylori

2012-01-04T16:58:00.001-08:00

Q. Which is false statement about H. Pylori?

A. is gram negative spiral motile bacilli

B. Is very fast growing but requires complex media

C. Is oxidase and catalase positive

D. produces urease

Answer B

1. Is very slow growing and hard to culture

2. H pylori is non invasive but proliferates in gastric mucosa

Succussion splash!

2012-01-04T16:57:00.001-08:00

Q. You are likely to hear succussion splash in a patient with:

A. Acute cholecystitis

B. Gastric outlet obstruction

C. Esophageal cancer

D. Enterocolitis

Answer B

1. Succussion splash is head when there is gastric outlet obstruction

2. This is the sound heads when there is free fluid and air in a hollow organ

3. It may be heard in pyloric stenosis

Splenic Trauma

2012-01-04T16:35:00.001-08:00

Q. Which is false about non surgical management of splenic trauma

A. Hemodynamic stability

B. No evidence of peritonitis

C. No extravasation on CT scan

D. Transfusion of less than 6 units of PRBCs

Answer D

1. If more than 2 units of PRBCs are required, surgery should be an option

Splenic abscess

2012-01-04T16:34:00.003-08:00

Q. The best method to make a diagnosis of a splenic abscess is

A. Ultrasound

B. CT scan

C. Plain x rays

D. Blood culture

Answer B

1. Ct is the best method of making a diagnosis.

Duodenal ulcers

2012-01-04T16:34:00.001-08:00

Q. Which is false about duodenal ulcers

a. Are four times as common as gastric ulcers

b. Three times more common in first degree relatives

c. More common in individuals with blood group O

d. Usually associated with low serum pepsinogen

Answer D

1. These ulcers are often associated with H pylori

2. Smoking is also a major risk factor

USMLE Step 3: Back pain and hypotension

2010-10-06T13:09:00.000-07:00

A 68 year old male presents to the ER with complaints of sudden onset of back pain. He says he has never had back pain before and denies any trauma. He says he just does not feel good and feels like he is going to die. On examination he looks ill with a blood pressure of 70/54, pulse of 110 and respiration of 18. His abdomen is tender to palpation and there is a large pulsatile mass. The next step in his management is:

A. fast track ultrasound
B. CT scan of abdomen
C. angiogram of abdomen
D. surgery
E. resuscitate and re-evaluate

Answer D

The patient above presents with a pulsatile abdominal mass and is hypotensive. This patient has a diagnosis of a ruptured abdominal aortic aneurysm unless proven otherwise. Ruptured aortic aneurysms can present in numerous ways, mimicking various abdominal pathology. When hypotension is present with a pulsatile mass, there are no further studies indicated. A vascular surgeon should be consulted and the patient needs to be typed and cross and go straight to the operating room. This scenario occurs in ER routinely and the diagnosis is usually delayed or missed.

Fast track ultrasound is a newer modality used in trauma. It can make a diagnosis of free abdominal fluid but cannot decipher the origin of the fluid or the damaged organ. It can detect an abdominal aneurysm. However, when a ruptured AAA is suspected, no further studies are indicated. In rare instances, an ultrasound will be obtained in the operating room, while the patient is being readied for surgery. CT scan in a patient with a pulsatile abdominal mass and hypotension is not advised. IT is extremely risky to take a patient to the CT suite, unmonitored for 20-30 minutes. In addition, the contrast dye further causes renal dysfunction in a patient who already has compromised blood flow to his organs.

Angiogram in a setting of a pulsatile abdominal mass with hypotension is again not advised. Today, angiograms are done only for elective cases. Transesophageal echo is an extremely attractive alternative and can be done in the OR. Patients with a pulsatile abdominal mass and hypotension need to go to the OR. Resuscitation can be done while the patient is being prepped. With a diagnosis of a ruptured abdominal aneurysm, not additional time should be wasted with resuscitation.

Educational Point:
When a patient presents with a pulsatile abdominal mass and hypotension, a presumptive diagnosis of ruptured abdominal aortic aneurysm must be entertained and the patients taken straight to the operating room.

USMLE Surgery: weight loss and low sodium?

2009-06-28T06:24:00.000-07:00

A 56 year old male presents to the ER with a persistent cough, weight loss of 15 pounds and general malaise. He claims that for the past 3 months he has not been feeling well. He did see and alternative health care professional who recommended colonic enemas to rid the body of toxins. After several sessions, he did not find any improvement. He is a heavy smoker and drinker. He has a past medical history of hypertension and gout. His medications include metoprolol and allopurinol. Physical exam reveals an emaciated male but there are no significant findings. Blood work reveals CBC 3, HCT 28, HB 9, Na 121, K 3.6, CL 98, BUN 21, Cr 1.5, platelets 312, Plasma osmalility 245 (normal > 280), concentrated urine with a Urine sodium concentration of more than 30mEq/l. which study will most likely give a clue to his diagnosis?

a. ECG
b. Cardiac enzymes
c. Chest x ray
d. Arterial blood gas
e. CT brain
f. Bone scan
g. Nerve conduction study
h. Blood culture

USMLE Surgery: Transplant?

2009-06-18T09:35:00.000-07:00

A 44 year old receives a kidney transplant for chronic renal failure. The renal transplant is a success and he is treated with cyclosporine and prednisone. Two years later, he returns to the clinic with complains of weight loss, night sweats, and a neck mass. Biopsy reveals that he has developed a lymphoma. The most common cause of a malignancy in a post transplant patient is due to?

a. HPV
b. EBV
c. Herpes simplex 1
d. Herpes simplex 2
e. CMV
f. Hepatitis A
g. Hepatitis B
h. Hepatitis C

USMLE Surgery: Resuscitation?

2009-06-18T09:25:00.000-07:00

You have a 24 year old involved in an MVA. He was brought to the ER after being found unconscious at the scene of the accident.His GCS is nine and he is mechanically ventilated. It appears that he suffered head trauma and chest contusion. His BP remains around 90/60 and he has a HR of 120. You decide to resuscitate him with normal saline. The best method to monitor his tissue perfusion is by:

a. checking capillary refill
b. check acid base balance
c. urine output
d. mental status
e. skin color
f. presence of pulses
g. evaluating response to pain
h. check temperature
i. checking BUN/Cr

USMLE Surgery: Colonoscopy?

2009-06-09T01:15:00.000-07:00

A 65-year-old male comes to your clinic because of bright red blood per rectum that has been on going for a few months. He first noticed a few drops of blood on tissue paper and occasionally noticed streaks of blood on his stools. He denies any weight loss, loss of appetite or other symptoms. He has been healthy otherwise. He is a smoker and a social drinker. His physical exam is unremarkable and his blood work is all normal. You decide to perform a flexible colonoscopy in him. In general, a flexible colonoscopy can visualize what length of the colon?

A. 40 cm
B. 60 cm
C. 80 cm
D. 160 cm
E. 200 cm
F. 250 cm

USMLE Surgery: Monitor tissue perfusion?

2009-06-08T08:22:00.000-07:00

You have a 24 year old involved in an MVA. He was brought to the ER after being found unconscious at the scene of the accident. His GCS is nine and he is mechanically ventilated. It appears that he suffered head trauma and chest contusion. His BP remains around 90/60 and he has a HR of 120. You decide to resuscitate him. The best method to monitor his tissue perfusion is by?

a. checking capillary refill
b. check acid base balance
c. urine output
d. mental status
e. skin color
f. presence of pulses
g. evaluating response to pain
h. check temperature
i. checking BUN/Cr

USMLE surgery: Flail Chest?

2009-05-14T14:20:00.000-07:00

A 26 year old is involved in a MVA. He was not wearing a seat belt and hit his chest into the steering wheel. He was conscious and stable at the time of injury. EMS quickly brought him to the ER where is found to be dyspneic and complaining of chest pain. He is immediately resuscitated and stabilized. The ER physician believes that the patient has a flail chest. Which of the following must be present to make a diagnosis of flail chest?

a. rib fracture
b. costal cartilage fracture
c. lung contusion
d. chest pain
e. dyspnea
f. flail chest
g. pneumothorax
h. hemothorax

Decreased pulmonary compliance in patients with flail chest is primarily due to

a. secretions
b. lung contusion
c. excessive pain
d. lack of oxygen
e. increased CO2
f. hemothorax

You suspect this patient has a lung contusion; the diagnosis of this entity is made by

a. arterial blood gas
b. pulse oximetry
c. V/Q scan
d. Chest x ray
e. Ultrasound
f. Blood count
g. White count
h. Respiratory rate

USMLE Surgery: Diagnostic Peritoneal Lavage?

2009-05-13T11:41:00.000-07:00

A 30 year old pregnant female is involved in a MVA. She was hit in the head by flying debris and appears confused in the ER. It is decided to perform a diagnostic peritoneal Lavage . However, it appears that she is pregnant based on her HCG. The best location to insert the needle is

a. at umbilicus
b. infra-umbilicus
c. top of fundus or uterus
d. right upper quadrant
e. left upper quadrant
f. in traube’s space
g. two finger breaths above semicircular line
h. anywhere

You inset the needle and then Lavage the abdomen with 1 liter of warm saline. What number of red cells would you consider the Lavage to be positive for intraperitoneal bleeding?

a. 100/ml
b. 1,000 /ml
c. 10,000/ml
d. 100,000/ml
e. 1,000,000/ml

You are doing surgery on a female. The procedure is a breast biopsy under local anesthesia. If an infection occurred postoperatively, the most likely bacteria will be

a. streptococci
b. diphtheria
c. s aureus
d. e coli
e. Bacteroides
f. Listeria
g. TB

Which of the following is not considered to be a risk factor wound infection?

a. cancer
b. corticosteroid therapy
c. prolonged hospitalization
d. early shaving
e. anemia
f. prior antibiotic therapy
g. long operation
h. dead space
i. foreign body
j. hematoma

What is not a risk factor for wound dehiscence?

a. Elderly patient
b. obese patient
c. ascites
d. corticosteroid therapy
e. diabetes
f. prior radiation therapy
g. use of running suture
h. increased intra-abdominal pressure
i. presence of foreign body

USMLE Surgery: Pseudo-obstruction?

2009-05-13T06:21:00.000-07:00

A 68-year-old male from a nursing home is brought to the ER with complaints of abdominal distension and pain. The patient has been throwing up for the past 3 days and does not want to eat. He did have normal BM 3 days ago. His past medical history is significant for paraplegia and diabetes. He is on several medications including aspirin, insulin, and an oral hypoglycemia. He also receives a diuretic for occasional swelling if his feet. Examination reveals a male with stable VSS, afebrile and a distended abdomen. There is minimal tenderness and Bowel sounds are high pitched. Blood work reveals Na 148 (135-145), K 2.2 (3.5-5), Cl 89, bicarbonate 22 (20-25), CBC 3, WBC 8, Hb 11, Hct 33, BUN 33, Cr 1.4 (< 1.4), Amylase and liver function tests are normal. Abdominal x rays show dilated colon and haustra markings are normal. CT scan is done but does not reveal any pathology. The physician on call believes that this is most likely a case of pseudo obstruction. If this is true than what part of the colon which should be closely monitored in this patient?

a. proximal jejunum
b. distal ileum
c. right colon
d. cecum
e. transverse colon
f. sigmoid
g. rectum
h. descending colon
i. stomach
j. duodenum

Which of the following imaging studies should not be performed in this patient?

a. CT scan
b. Gastrogaffin enema
c. Barium enema
d. Colonoscopy
e. Air enema
f. Sigmoidoscopy
g. Ultrasound
h. MRI

For the above patient, the best fluid for resuscitation should be

a. ringer’s lactate at 150 cc/hr
b. D51/2 NS at 125 cc/hr
c. D5 1/2 NS plus KCL 20 meq/l at 125 cc/hr
d. 3% NaCL
e. Hetastarch at 100 cc/hr
f. Dextran 40 at 12 cc/hr

Pseudo obstruction is believed to occur because of

a. Loss of ganglion cells
b. excess sacral parasympathetic activity
c. loss of sacral parasympathetic activity
d. decreased sympathetic tone
e. loss of auerbach's plexus

USMLE Surgery: Skin lesion?

2009-05-09T06:04:00.000-07:00

A 55 year old male comes to the surgical clinic because he has a skin lesion on his nose. The lesion has been present for a few weeks and does not appear to be getting bigger. He has no pain or itchiness. He denies any trauma. He is a full time farmer. Based on the photo, the most likely cause is

a. squamous cell cancer
b. melanoma
c. basal cell cancer
d. keratoacanthoma
e. atopic dermatitis
f. lichen planus
g. kaposi’s sarcoma
h. hemangioma

if the above skin lesion was a malignancy, which of the following features is true?

a. prognosis is poor
b. only surgery is curative
c. metastases are very rare
d. such lesions are common in orientals
e. cause is most likely related to a virus
f. usually occur on non sunexposed areas of the body

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USMLE Surgery: Abdominal pain and Fever?

2009-05-01T06:40:00.000-07:00

A 55 year old male presents to the surgery clinic with complaints of left lower quadrant pain, fever and chills. he says that for the past 3 weeks he has not been feeling well. he has no appetite. twice this week he noticed some bright red blood in his stools. he denies any weight loss, trauma or change in bowel habits but does say he has always been constipated. he has borderline hypertension and diabetes. he is on furosemide and an oral hypoglycemic. Examination reveals an individual in some distress, moderate tenderness in LLQ and guarding. There is no rebound. Rectal exam reveals a small prolapsed hemorrhoid but no active bleeding. Guaic test is positive. Blood work reveals a CBC 9, Hb 8, HCt 29, WBC 19 (normal < 10), glucose 167, BUN 12, Cr 1.6, Na 144, K 4.6, Ca 8.4 and Bicarbonate of 24.

When individuals develop abdominal pain, which of the following injury to the visceral organs is most likely to induce pain?

a. cutting
b. crushing
c. distension
d. burning
e. touching
f. pinching
g. twisting

for the individual in the above case, which is the best test that will help make a quick diagnosis?

a. Abdominal x rays
b. Ultrasound
c. CT scan
d. MRI
e. Barium enema
f. Endoscopy
g. Nuclear scan
h. digital rectal exam

The above patient undergoes the below study, the most likely diagnosis is ?

(picture courtesy of http://emedicine.medscape.com/article/367320-imaging)

a. appendicitis
b. colon cancer
c. apple core lesion
d. diverticulitis
e. volvulus
f. intussusception
g. bowel obstruction
h. polyp
i. meckel's diverticulum
j. hemorrhoids

the best treatment for the above patient is

a. surgery
b. chemotherapy
c. steroids
d. antibiotics
e. colonoscopic excision
f. bowel decompression
g. NG tube

USMLE Surgery: Hematuria?

2009-04-14T17:22:00.000-07:00

A 55 year old male presents to the surgical clinic with complains of painless hematuria. He says that over the past 3 weeks, he has noticed a lot of blood in his urine. Initially he felt that it was just excess tea that he was drinking but now it is frank blood. He did feel some pain in his left flank last week but nothing else. He is not sure if he has lost any weight. He denies any trauma, infection or use of medications. He does smoke and has diet controlled diabetes. Blood work reveals a CBC 4, WBC 10, Hb 8.4, Hct 29, Platelets 333, PT 12, PTT 36, Liver enzymes are normal, BUN 27, Cr 1.6. Physical reveals a BP of 150/90, P 90, T 38.. No mass are palpable on physical examination.

If you suspect a malignancy in the above case, which group of patients have the highest incidence?

a. Peutz jeghers
b. Klippel trennanuy syndrome
c. MEN 1
d. Von hippel landau
e. Turner’s syndrome
f. Down’s
g. Edward’s syndrome
h. Potter’s syndrome

Which of the following is not associated with the above pathology?

a. anemia
b. fever
c. hypercalcemia
d. elevated ESR
e. right sided varicocele
f. erythrocytosis
g. polyneuropathy
h. amyloidosis
i. dermatomyositis
j. hypertension

You plan to take this patient for surgery but want to make sure it has not involved which particular structure?

a. adrenal gland
b. renal artery
c. fascia covering
d. inferior vena cava
e. proximal ureter
f. spleen

Which cytokine has most frequently been used to treat cases refractory to chemotherapy?

a. IL 1
b. IL 2
c. Il 6
d. OK T3
e. Megace
f. Stem cells
g. BCG vaccine

Renal cell carcinoma accounts for approximately 3% of adult malignancies and 90-95% of neoplasms arising from the kidney. It is characterized by a lack of early warning signs, diverse clinical manifestations, resistance to radiation and chemotherapy, and infrequent but reproducible responses to immunotherapy agents such as interferon alpha and interleukin (IL)-2

Renal cell carcinoma develops in nearly 40% of patients with von Hippel-Lindau disease and is a major cause of death among these patients. Deletions of 3p occur commonly in renal cell carcinoma associated with VHL disease. The VHL gene is mutated in a high percentage of tumors and cell lines from patients with sporadic (nonhereditary) clear cell renal carcinoma.

Varicocele, usually left sided, due to obstruction of the testicular vein (2% of males.

Renal arteriography is not used in the evaluation of a suspected renal mass as frequently now as it was in the past. When inferior vena cava involvement is suspected, either inferior venacavography or MRI angiography is used. MRI is currently the preferred imaging technique. Knowledge of inferior vena cava involvement is important in planning the vascular aspect of the operative procedure.

IL-2 is a T-cell growth factor and activator of T cells and natural killer cells. IL-2 affects tumor growth by activating lymphoid cells in vivo without affecting tumor proliferation directly. In the initial study by the National Cancer Institute, bolus intravenous infusions of high-dose IL-2 combined with LAK cells produced objective response rates of 33%. In subsequent multicenter trials, the response rate was 16%. (www.emedicine com)

USMLE review: Pediatric neck mass?

2009-04-13T08:38:00.000-07:00

A 3 week old infant is seen in the pediatric clinic. the mother says everything was fine at birth and now the infant has this mass. the infant appears to be afebrile and is tolerating foods without any problem. the mother denies any trauma, recent infection or any type of family history. on physical, the mass appears soft, is non pulsatile and appears slightly bluish in color. the oral cavity appears normal. the most likely diagnosis is?

a. thyroid goiter
b. brachial pouch cyst
c. cystic hygroma
d. jugular vein aneurysm
e. thoracic duct aneurysm
f. encephalocele
g. meningocele
h. neck abscess

Q2. the mass is most commonly observed in the?

a. anterior cervical triangle
b. carotid sheath
c. retromediastinum
d. middle mediastinum
e. posterior cervical triangle

Q3. the second most common site for presentation of this pathology is in?

a. anterior mediastinum
b. axilla
c. groin
d. lung
e. spleen
f. liver
g. kidney
h. brain

Q4. the best test to study the mass is?

a. plain x rays
b. ultrasound
c. CT scan
d. MRI
e. nuclear scan
f. needle biopsy
g. angiogram

Q5. the treatment of the above disorder is?

a. inject alcohol
b. surgery
c. radiation
d. steroids
e. interferon
f. bleomycin
g. observation

for answer, write to nirihs01@hotmail.com