NURS 5461 SURGERY ORAL EXAM
QUESTIONS WITH CORRECT ANSWERS
Initial Assessment - ANSWER I would first assess the patient's general
appearance and vital signs, and determine if there's any need for immediate
resuscitation
HPI - ANSWER onset, location, and character of pain
associated symptoms (3-5 elements)
PMH - ANSWER I would ask about any relevant PMH including major
cardiopulmonary disease, immunocompromised status, malnutrition
PSH - ANSWER any surgeries in the same anatomic region
Meds - ANSWER I would ask if patient is currently taking any meds, including
blood thinners and immunosuppressants
Allergies - ANSWER anesthesia, antibiotics, latex, iodinated contrast
FHx - ANSWER I'd ask about any relevant family history including major
cardiopulmonary disease and adverse reaction to anesthesia
SHx - ANSWER I'd ask about any relevant social history including tobacco,
alcohol, IV drug use
ROS - ANSWER I'd perform a 14-point ROS focusing on cardiac, pulmonary
and constitutional symptoms
History Clean Up - ANSWER Does the patient have any other relevant PMH,
PSH, Meds, or allergies?
Physical Exam - ANSWER I'd perform a comprehensive head-to-toe physical
exam, focusing on cardiopulmonary and abdominal exams
,CBC Components - ANSWER WBC, Hgb, Hct, Plt
BMP Components - ANSWER Na, K, Cl, HCO3-, BUN, Cr, Glucose
CMP Components - ANSWER BMP + albumin, AST/ALT/ALP, total bilirubin
Coags - ANSWER PTT, PT/INR
Management - ANSWER 1. Appropriate medical and surgical treatment
2. Surgery indications, specific type, basic steps
3. Post-Op Care
Differential for SBO - ANSWER 1. Adhesive SBO
2. Hernia: incarcerated/strangulated
3. Post-Op Ileus
4. LBO/Constipation
SBO indications for surgery - ANSWER 1. Bowel ischemia: patient looks in
acute distress
2. Closed loop obstruction
3. Incarcerated hernia
SBO HPI - ANSWER 1. Characterize obstruction symptoms:
N/V, obstipation/constipation, last BM/flatus, abdominal pain and distension.
2. Timing: onset, duration, symptom progression, prior episodes
3. Associated symptoms
Gastroenteritis: fever/chills, diarrhea, recent illness
Hypovolemia: light-headed/dizzy, syncope, low urine output
Cancer: weight loss, night sweats, bloody stool
SBO History - ANSWER PMH: SBO, Hernia, Cancer
PSH: abdominal surgeries (adhesions), prior hernia repairs
Meds: loperamide, opioids (both cause constipation)
Allergies
FH: CRC or IBD
SH: tobacco use
,SBO Physical Exam - ANSWER 1. Vitals, general appearance, cardiopulm:
acute distress/toxic (bowel ischemia)
2. Abdomen: inspection (skin changes, distension), percussion, palpation,
peritoneal signs (rebound, guarding)
3. If hernia present: reducible?
4. Rectal: assess constipation/LBO
SBO Labs - ANSWER CBC and lactate: increased WBC and lactate (bowel
ischemia)
BMP: renal function and electrolytes (hypokalemia for post-op ileus)
SBO Imaging: XR - ANSWER 1. Abdominal XR Series: supine (bowel
distension), upright abdo (air-fluid levels), upright CXR (air under diaphragm)
2. SBO XR: dilated loops of SB (> 3 cm), air-fluid levels, decompressed colon
3. LBO XR: dilated loops of colon (>6-9 cm), distal compression, coffee-bean
sign (sig volvulus), fecal loading
4. Ileus XR: dilated small bowel without distal decompression
SBO Imaging: CT - ANSWER 1. Allows to see level of obstruction, cause, and
severity
2. Place decompressive NG tube prior to CT to allow for contrast
3. SBO: dilated SB proximal to transition point, decompressed distally, failure
of contrast to pass
4. Closed loop SBO/volvulus: multiple transition points
5. Bowel compromise/perforation: reduced bowel wall enhancement, wall
thickening, air in bowel wall
SBO Plan for all patients - ANSWER 1. NPO, NG tube, IVF
2. Resuscitate and correct electrolyte abnormalities
3. Monitor fluid status with NG tube and urine output
Adhesive SBO - ANSWER History: obstipation, N/V
Exam: abdominal distension, tympany
Imaging: dilated SB and transition point
Adhesive SBO Non-Operative Management - ANSWER For patients w/o
bowel ischemia
, 1. Serial abdominal exams and lab studies for 2-5 days
2. Gastrograffin challenge after 12 hours of NG tube decompression
Improvement: decreasing NG tube output (<150 cc/8 hr) or change from bilious
to serous
OR: failure of gastrograffin to pass or no improvement after 5 days
Adhesive SBO Operative Management - ANSWER For patients with closed
loop obstruction or small-bowel volvulus or ischemia
History: fever, worsening pain
Exam: tachycardia, peritonitis
Labs: lactic acidosis, leukocytosis
Imaging: mesenteric edema, reduced bowel enhancement, free-air
Steps: ex-lap, lysis of adhesions, SB resection
Hernia SBO Findings - ANSWER Exam: non-reducible hernia
Imaging: transition point at hernia neck
Strangulated: incarcerated hernia with bowel ischemia
Exam: hernia tenderness, skin changes, peritonitis
Hernia SBO Management - ANSWER Strangulated: Operative management
1. Primary hernia repair, ex-lap, SB resection
Incarcerated: attempt manual reduction in ER and if reduced, will need future
hernia repair due to risk of recurrent strangulation. If not reduced: OR
Gallstone Differential - ANSWER 1. Acute cholecystitis: stone blocking cystic
duct
2. Choledocholithiasis: stone in common bile duct
3. Cholangitis: stone blocking CBD and infection
4. Gallstone pancreatitis: stone blocking pancreatic duct
Gallstone HPI - ANSWER 1. Characterize pain: location, provoking/palliating,
quality, radiation
2. Timing: onset, duration, progression, previous episodes, relationship to meals
3. Associated symptoms: F/C, N/V/D/C, bile obstruction (jaundice, acholic
stools, coca-cola urine)
QUESTIONS WITH CORRECT ANSWERS
Initial Assessment - ANSWER I would first assess the patient's general
appearance and vital signs, and determine if there's any need for immediate
resuscitation
HPI - ANSWER onset, location, and character of pain
associated symptoms (3-5 elements)
PMH - ANSWER I would ask about any relevant PMH including major
cardiopulmonary disease, immunocompromised status, malnutrition
PSH - ANSWER any surgeries in the same anatomic region
Meds - ANSWER I would ask if patient is currently taking any meds, including
blood thinners and immunosuppressants
Allergies - ANSWER anesthesia, antibiotics, latex, iodinated contrast
FHx - ANSWER I'd ask about any relevant family history including major
cardiopulmonary disease and adverse reaction to anesthesia
SHx - ANSWER I'd ask about any relevant social history including tobacco,
alcohol, IV drug use
ROS - ANSWER I'd perform a 14-point ROS focusing on cardiac, pulmonary
and constitutional symptoms
History Clean Up - ANSWER Does the patient have any other relevant PMH,
PSH, Meds, or allergies?
Physical Exam - ANSWER I'd perform a comprehensive head-to-toe physical
exam, focusing on cardiopulmonary and abdominal exams
,CBC Components - ANSWER WBC, Hgb, Hct, Plt
BMP Components - ANSWER Na, K, Cl, HCO3-, BUN, Cr, Glucose
CMP Components - ANSWER BMP + albumin, AST/ALT/ALP, total bilirubin
Coags - ANSWER PTT, PT/INR
Management - ANSWER 1. Appropriate medical and surgical treatment
2. Surgery indications, specific type, basic steps
3. Post-Op Care
Differential for SBO - ANSWER 1. Adhesive SBO
2. Hernia: incarcerated/strangulated
3. Post-Op Ileus
4. LBO/Constipation
SBO indications for surgery - ANSWER 1. Bowel ischemia: patient looks in
acute distress
2. Closed loop obstruction
3. Incarcerated hernia
SBO HPI - ANSWER 1. Characterize obstruction symptoms:
N/V, obstipation/constipation, last BM/flatus, abdominal pain and distension.
2. Timing: onset, duration, symptom progression, prior episodes
3. Associated symptoms
Gastroenteritis: fever/chills, diarrhea, recent illness
Hypovolemia: light-headed/dizzy, syncope, low urine output
Cancer: weight loss, night sweats, bloody stool
SBO History - ANSWER PMH: SBO, Hernia, Cancer
PSH: abdominal surgeries (adhesions), prior hernia repairs
Meds: loperamide, opioids (both cause constipation)
Allergies
FH: CRC or IBD
SH: tobacco use
,SBO Physical Exam - ANSWER 1. Vitals, general appearance, cardiopulm:
acute distress/toxic (bowel ischemia)
2. Abdomen: inspection (skin changes, distension), percussion, palpation,
peritoneal signs (rebound, guarding)
3. If hernia present: reducible?
4. Rectal: assess constipation/LBO
SBO Labs - ANSWER CBC and lactate: increased WBC and lactate (bowel
ischemia)
BMP: renal function and electrolytes (hypokalemia for post-op ileus)
SBO Imaging: XR - ANSWER 1. Abdominal XR Series: supine (bowel
distension), upright abdo (air-fluid levels), upright CXR (air under diaphragm)
2. SBO XR: dilated loops of SB (> 3 cm), air-fluid levels, decompressed colon
3. LBO XR: dilated loops of colon (>6-9 cm), distal compression, coffee-bean
sign (sig volvulus), fecal loading
4. Ileus XR: dilated small bowel without distal decompression
SBO Imaging: CT - ANSWER 1. Allows to see level of obstruction, cause, and
severity
2. Place decompressive NG tube prior to CT to allow for contrast
3. SBO: dilated SB proximal to transition point, decompressed distally, failure
of contrast to pass
4. Closed loop SBO/volvulus: multiple transition points
5. Bowel compromise/perforation: reduced bowel wall enhancement, wall
thickening, air in bowel wall
SBO Plan for all patients - ANSWER 1. NPO, NG tube, IVF
2. Resuscitate and correct electrolyte abnormalities
3. Monitor fluid status with NG tube and urine output
Adhesive SBO - ANSWER History: obstipation, N/V
Exam: abdominal distension, tympany
Imaging: dilated SB and transition point
Adhesive SBO Non-Operative Management - ANSWER For patients w/o
bowel ischemia
, 1. Serial abdominal exams and lab studies for 2-5 days
2. Gastrograffin challenge after 12 hours of NG tube decompression
Improvement: decreasing NG tube output (<150 cc/8 hr) or change from bilious
to serous
OR: failure of gastrograffin to pass or no improvement after 5 days
Adhesive SBO Operative Management - ANSWER For patients with closed
loop obstruction or small-bowel volvulus or ischemia
History: fever, worsening pain
Exam: tachycardia, peritonitis
Labs: lactic acidosis, leukocytosis
Imaging: mesenteric edema, reduced bowel enhancement, free-air
Steps: ex-lap, lysis of adhesions, SB resection
Hernia SBO Findings - ANSWER Exam: non-reducible hernia
Imaging: transition point at hernia neck
Strangulated: incarcerated hernia with bowel ischemia
Exam: hernia tenderness, skin changes, peritonitis
Hernia SBO Management - ANSWER Strangulated: Operative management
1. Primary hernia repair, ex-lap, SB resection
Incarcerated: attempt manual reduction in ER and if reduced, will need future
hernia repair due to risk of recurrent strangulation. If not reduced: OR
Gallstone Differential - ANSWER 1. Acute cholecystitis: stone blocking cystic
duct
2. Choledocholithiasis: stone in common bile duct
3. Cholangitis: stone blocking CBD and infection
4. Gallstone pancreatitis: stone blocking pancreatic duct
Gallstone HPI - ANSWER 1. Characterize pain: location, provoking/palliating,
quality, radiation
2. Timing: onset, duration, progression, previous episodes, relationship to meals
3. Associated symptoms: F/C, N/V/D/C, bile obstruction (jaundice, acholic
stools, coca-cola urine)
