Surgery NBME Form 2 - Questions and Answers

Surgery NBME Form 2 - Questions and Answers 37 yo - ED 30 min after MVA arrival: abd pain vitals stable PE: abd - diffuse tenderness; dec bowel sounds supine X-ray shown - herniation of abd contents into thorax most likely dx? ruptured diaphragm hx of blunt trauma/MVA, abnormal CXR, left lower lung opacity, elevated hemidiaphragm, and mediastinal deviation MC on the left bc there's no liver to protect it CXR: herniation of abd contents into thorax 42 yo - 2 days of RU abd pain and gen itching > past 2 months: 3 episodes of similar symptoms + nausea > no fever/vomiting no PMHx; no meds 99.1 F PE: scleral icterus; mildly tender mass palp in RUQ; no peritoneal signs WBC: 10,000 BR 6, direct 5 US of RUQ: mild distention of GB w/o gallstones CT abd: 5 cm cystic structure medial to GB w/ mod dilation of prox inhtrahep ducts next step in mgnt? surgical excision of the cyst choledochal cyst cystic dilations of biliary tree - involving extra- and/or intra-hep ducts features: epigastric pain, jaundice, fever, RUQ complications: cholangiocarcinoma, hep abscess, recurrent cholangitis/panc, rupture, biliary obstruction, cirrhosis, portal HTN >remove cyst to relieve obstruction and prevent malignant transformation dx: US; ERCP - definitive tx: surgery - resection w/ biliary-enteric anastomosis 37 yo - unable to conceive w/ his wife for 3 yrs unprotected sex 4-5/wk wife has 2 kids from previous marriage gen: healthy, well-developed PE: irregular, ropy mass palp in upper L.hemiscrotum semen analysis: WNL most likely cause of pt's infertility? varicocele dilation of pampiniform venous plexus - "bag of worms" features: asymptomatic or presents w/ vague, aching scrotal pain (L > R); can disappear in supine position; does NOT transilluminate dx: US tx: surgery - varicocelectomy or ligation; interventional rads – embolization 42 yo - 2 days of R.knee pain and inability to extend R.knee > symptoms began when getting up from low chair PE: tenderness to palp along medial joint line; joint effusion; ligament stability normal; ROM 15-110 deg knee X-ray: gucci most likely dx? torn meniscus tenderness to palp along the medial joint line w/ effusion should raise suspicion > medial joint line w/o effusion = MCL protracted pain/swelling after knee injury > catching/locking that limit knee motion > "click" when knee forcefully ext dx: MRI tx: repair > complete meniscectomy > late development of deg arthritis 80 yo - severe abd pain for 4 hrs PMHx: atherosclerosis and chronic AFib PE: mild abd tenderness and absent bowel sounds; no masses/signs of peritoneal irritation occult blood: pos CBC: inc WBC (inc segs, bands; dec lymph) ABG: dec pH, pO2 abd X-ray: nonspecific gas pattern next step in mgnt? exploratory celiotomy > remember celiotomy = laparotomy homegirl having mesenteric ischemia sudden onset abd pain that is out of proportion to PE > no signs of peritoneal irritation > old don't rlly get acute abdomens - will present late w/ blood in bowel lumen ~ acidosis and sepsis will follow may be bloody stool - if gut affected classic pt: old guy whose post MI (shock) or Afib (arterial emboli) > source of clot that breaks off and lodges in SMA tx: arteriogram and embolectomy 42 yo - 1 wk of yellow eyes, nausea, R.sided abd cramps > 2 months ago: laparoscopic cholecystectomy - acute cholecystitis > intra-op cholangiography - not performed no meds vitals stable PE: scleral icterus; cardiopulmonary - gucci; abd - RUQ tenderness w/o distention/peritoneal signs; bowel sounds normal LFT: inc BR (direct 5), alk phos; AST, ALT - WNL most likely cause of jaundice?choledocholithiasis cholangiography/imaging not done previously - could miss gallstone not cirrhosis - AST, ALT - WNL not panc cancer - no weight loss/painless jaundice not post-op bile leak: def would have signs of peritonitis as bile leaks out into the peritoneum direct BR rlly high > think obstruction of some kind postcholecystectomy syndrome: > biliary causes: strictures, retained calculi, dropped calculi, tumors, sphincter of Oddi dysfunction, and calculi in the cystic duct remnant > non-biliary: PUD, GERD, panc dz, hepatocellular disorders, CAD, IBS, and intercostal neuritis 75 yo - elective repair of AAA PMHx: HTN (drug therapy) PE: palp, 6 cm aortic aneurysm ECG: normal what study most app to predict pt's risk for perioperative MI? radionuclide scan with thallium and dipyridamole to assess peri-op risk of MI - pharm stress testing for pre-op eval of heart for HF - echo pt has AAA and can't undergo typical stress tests 82 yo - 4 months of R.sided HA, joint pain, and malaise PMHx: HTN (atenolol); BL hernia repair (40 yrs ago); cholecystectomy (20 yrs ago) SHx: no cigs; social drinker PE: tenderness of R.temporal art; both temp art palp ESR: 87 (inc) next step in mgnt? prednisone therapy and temporal artery biopsy immediately homegirl has temporal/giant cell arteritis seen in pts > 50 yo inc risk of aortic aneurysm/dissection features: HAs; visual impairment (due to ophthalmic art; optic neuritis or amaurosis fugax); jaw pain w chewing; tenderness over temp art; palp nodules; polymyalgia rheumatica dx: inc ESR; biopsy of temporal art tx: high-dose prednisone - prevent blindness; f/u ESR levels; 30 yo - acneiform infection of L.axilla for 2 wks > previous infections in same region and groin PE: acute inf changes w/ purulent drainage from small sinus openings along indurated skin of axilla; multiple sinus openings along both groins/R.axilla infection most likely involves what? apocrine glands homeboy has hydradenitis suppurativa small, sinus tracks common > apocrine sweat glands become obstructed and secondarily infected > scarring and sinus tract formation