Clerkships: Surgery: Pattern recognition Flashcards

old lady
Terms Definitions
14 y/o male with recent episodes of red blood in stool presents today with RLQ pain.
Meckle's diverticulitis
40 y/o female with fever, shaking chills, N&V, right costovertebral angle and abdominal pain.
acute pyelonephritis
18 y/o male with dull, continuous lumbar pain radiating to lower abdomen after an all night beer burst.
acute hydronephrosis
24 y/o med student returned from 3rd world has wt loss, chronic cough, lethargy, weakness, pigmentation of skin and mucous membranes with epigastric and periumbilical pain.
adrenal insufficiency
30 y/o Greek immigrant with episodic excruciating abd pain preceded by headache with temp of 105F.
Familial mediterranean fever
- a hereditary inflammatory disorder
50 y/o male with history of hysterical behavior vs psychosis has severe coliky, generalized abd pain radiating to the chest and back after taking a barbituate.
70 y/o patient with history of marked weight loss and anorexia because of episodic cramping epigastric pain lasting one to three hours after eating, is more severe after large meals.
mesenteric ischemia
7 y/o boy presents with abd pain of 4 hours duration associated with anorexia, nausea, and on exam found to have severe pharyngitis with tender submandibular nodes as well as RLQ tenderness.
mesenteric adenitis
Elderly gentleman with Argyll Roberson pupils and Charcot's joints presents with sudden onset of continuous epigastric pain with hyperactive abdominal reflexes and slight tenderness but no rigidity.
tabetic crisis
- an exacerbation of pain in tabes dorsalis because of syphilis
45 y/o male presents with continuous pressing pain in epigastrium which radiates to back and neck who is diaphoretic, anxious, and has nausea and vomiting but no abd tenderness or rigidity.
4 y/o girl presents with prostration, chills, fever, tachypnea who had complained of sudden onset abd pain in both upper and lower quadrants and is found to be markedly distended, diffusely tender, with doughy feel to abd and marked leukocytosis and ultra
primary peritonitis
80 y/o female with completely negative medical and surgical history except for occasional episodes of RUQ pain presents with signs and symptoms of small bowel obstruction and found to have distended abdomen and no herniae on exam. X-ray show small bowel d
biliary colic
35 y/o illegal immigrant presents with abd pain which is associated with fever, anemia and ascites and a chest x-ray shows cavitary apical lesions.
tuberculosis peritonitis
24 y/o med student studying for step 2 develops midepigastric pain which was initially controlled with TUMS, but now is severe, diffuse and radiates to both shoulders is found to have board like abdomen.
perforated duodenal ulcers
24 y/o female in head collision is found to have mediastinal widening, a left apical cap, the left mainstem bronchus is depressed and the NG tube is seen to deviate to the right.
laceration of thoracic aorta
65 y/o male presents with a recent episode of hematemesis. On physical exam, he is found to have well healed abd scar from xyphoid to pubis and well healed ileo-femoral scars bilaterally.
aortoduodenal fistula
27 y/o male presents with a massive GI bleed after being in previous exellent health. The endoscopist sees a bleeding moderate sized vessel in the fundus of the stomach.
Dieulafoy's lesion
48 y/o male with IDDM presents with 1 day history of scrotal irritation. Exam reveals a depressed 1cm black eschar of the left scrotum.
Fournier's gangrene
70 y/o white female with pruritic, exfoliating areolar dermatitis, which has been unsuccessfully treated with steroid creams.
Paget's disease
80 y/o female presents with a chief complaint of increasing fatigue and lassitude. Routine workup uncovers a hypochromic microcytic anemia.
right colon cancer
A 54 year old obese man gives a history of burning retrosternal pain and “heartburn” that is brought about by bending over, wearing tight clothing or lying flat in bed at night. He gets symptomatic relief from antiacids, but the disease process seems
Surgery: Nissen fundoplication
A 62 year old man describes severe epigastric and substernal pain that he can not characterize well. There is a history suggestive of gastroesophageal reflux, and EKG and cardiac enzymes have been repeatedly negative.

What to do next
acid perfusion test (Berstein test) to confirm acid reflux disease
A 44 year old black man describes progressive dysphagia that began 3 months ago with difficulty swallowing meat, progressed to soft foods and is now evident for liquids as well. he locates the place where food “sticks” at the lower end of the sternum.
Carcinoma of esophagus
- barium swallow then
- endoscopy with biopsy then
- CT
A 47 year old lady describes difficulty swallowing which she has had for many years. She says that liquids are more difficult to swallow than solids, and she has learned to sit up straight and wait for the fluids to “make it through”. Occasionally she
- manometry to confirm
A 24 year old man spends the night cruising bars and drinking heavily. In the wee hours of the morning he is quite drunk and he starts vomiting repeatedly. He initially brings up gastric contents only, but eventually he vomits bright red blood.

What to d
Mallory Weiss tear
- endoscopy to confirm
A 24 year old man spends the night cruising bars and drinking heavily. In the wee hours of the morning he is quite drunk and starts vomiting repeatedly. Eventually he has a particularly violent episode of vomiting and he feels a very sever, wrenching epig
Boerhaave's syndrome: rupture of the esophageal wall due to vomiting
- gastrographin swallow to confirm
- emergent surgical repair
A 72 year old man has lost 40 pounds of weight over a two or three month period. He gives a history of anorexia for several months, and of vague epigastric discomfort for the past 3 weeks.

What to do next?
stomach cancer
- endoscopy and biopsy to confirm
A 54 year old man has had colicky abdominal pain and protracted vomiting for several days. He has developed progressive moderate abdominal distention, and has not had a bowel movement or passed any gas for five days. He has high pitched, loud bowel sounds
mechanical bowel obstruction due to adnesion
- NG suction, IVF and observation
A 54 year old man has had colicky abdominal pain and protracted vomiting for several days. He has developed progressive moderate abdominal distention, and has not had a bowel movement or passed any gas for five days. He has high pitched, loud bowel sounds
strangulated obstruction
- emergency surgery
A 54 year old man has had colicky abdominal pain and protracted vomiting for several days. He has developed progressive moderate abdominal distention, and has not had a bowel movement or passed any gas for five days. He has high pitched, loud bowel sounds
mechanical bowel obstruction due to adnesion due to incarcerated/strangulated hernia
- urgent surgery
A 55 year old lady is being evaluated for protracted diarrhea. On further questioning she gives a bizarre history of episodes of flushing of the face, with expiratory wheezing. A prominent jugular venous pulse is noted on her neck.

What to do next?
carcinoid syndrome
- serum determination of 5-HIAA
A 59 year old is referred for evaluation because he has been fainting at his job where he operates heavy machinery. He is pale and gaunt, but otherwise his physical exam is remarkable only 4+ occult blood in the stool. Lab studies show a hemogoblin of 5.
cancer of the right colon
- colonoscopy and biopsy
- blood transfusion
- hemicolectomy
A 56 year old man has bloody bowel movements. The blood coats the outside of the stool, and has been constipated, and his stools have become of narrow caliber.

What to do next?
Caner of the left colon
- endoscopy with biopsies/sigmoidoscopy
A 77 year old man has a colonoscopy because of rectal bleeding. A villous adenoma is found in the rectum and several adenomatous polyps are identified in the sigmoid and descending colon.

What to do next?
The issue with polyps is which ones are pre-malignant, and thus need to be excised, and which ones are benign and can be left alone. Premalignant include, in descending order of malignant conversion: familial polyposis, Gardner’s, villous adenoma and adenomatous polyps. Benign include juvenile, Peutz-Jeghers, inflammatory and hyperplastic.
A 42 year old man has suffered from chronic ulcerative colitis for 20 years. He weights 90 pounds and has had at least 40 hospital admissions for exacerbations of the disease. Due to a recent relapse, he has been placed on high dose steroids and immuran.
toxic megacolon
- Emergency surgery for the toxic megacolon, but the case illustrates many other indications for surgery: chronic malnutrition, “intractability” and risk of developing cancer. The involved colon has to be removed, and that always includes the rectum.
A 27 year man is recovering from an appendectomy for gangrenous acute appendicitis with perforation and periappendicular abscess. He has been receiving Clindamycin and tobramycin for seven days. Eight hours ago he developed watery diarrhea, crampy abdomin
pseudomembranous colitis
- Eventually with stool cultures, but proctosigmoidoscopy can show a typical picture before the cultures are back. Stop the clindamycin, give either Vancomycin or Metranidazole, and avoid lomotil.
A 60 year old man known to have hemorrhoids reports bright red blood in the toilet paper after evacuation.

What to do next?
bleeding from internal hemorrhoids
- In all these cases, cancer of the rectum has to be ruled out with proctosigmoidoscopic examination.
A 60 year old man known to have hemorrhoids complains of anal itching and discomfort, particularly towards the end of the day. He has perianal pain when sitting down and finds himself sitting sideways to avoid the discomfort. He is afebrile.

What to do n
External hemorrhoids
- rule out cancer
A 23 year old lady describes exquisite pain with defecation and blood streaks on the outside of the stools. Because of the pain she avoids having bowel movements and when she finally does, the stools are hard and even more painful. Physical examination ca
Annal fissure
- Examination under anesthesia and rule out cancer.
- lateral internal sphincterotomy.
A 28 year old male is brought to the office by his mother. Beginning four months ago he has had three operations, done elsewhere, for a perianal fistula, but after each one the area has not healed, but actually the surgical wounds have become bigger. He n
Annal fissure
- rule out malignancy with proper examination with biopsies. The biopsies should diagnose Crohn’s.
A 44 year old man shows up in the E.R. at 11 PM with exquisite perianal pain. He can not sit down, reports that bowel movements are very painful, and has been having chills and fever. Physical examination shows a hot, tender, red, fluctuant mass between t
ischiorectal abscess
- I & D
- still need to rule out cancer
A 62 year old man complains of perianal discomfort, and reports that there are streaks of fecal soiling in his underwear. Four months ago he had a perirectal abscess drained surgically. Physical exam shows a perianal opening in the skin, and a cord-liked
- rule out cancer with proctosigmoidoscopy
- elective fistulotomy
A 55-year old, HIV positive man, has a fungating mass growing out of the anus, and rock hard, enlarged lymph nodes on both groins. He has lost a lot of weight, and looks emaciated and ill.

What to do next?
squamous cell carcinoma of the anus
- Biopsies of the fungating mass
- Nigro protocol of pre-operative chemotherapy and radiation.
An 18 year old lady has a firm, rubbery mass in the left breast that moves easily with palpation.

What to do next?
- FNA or core biopsy
- for young people:could use sonogram
A 27 year old immigrant from Mexico has a 12 x 10 x 7 cm. mass in her left breast. It has been present for seven years, and slowly growing to it’s present size. The mass is firm, rubbery, completely movable, is not attached to chest wall or to overlying
cystosarcoma phyllodes
- tissue diagnosis
- margin free dissection
A 35 year old lady has a ten year history of tenderness in both breasts, related to menstrual cycle, with multiple lumps on both breasts that seem to “come and go” at different times in the menstrual cycle. Now has a firm, round, 2 cm. mass that has n
Fibrocystic disease
- Aspiration of the cyst. If the mass goes away and the fluid aspirated is clear, that’s all. If the fluid is bloody it goes to cytology. If the mass does not go away, or recurs she needs biopsy.
A 34 year old lady has been having bloody discharge from the right nipple, on and off for several months. There are no palpable masses.

What to do next?
intraductal papilloma
- the way to detect cancer that is not palpable is with a mammogram.
- If negative, one may still wish to find and resect the intraductal papilloma to provide symptomatic relief. Resection can be guided by galactogram, or done as a retroareolar exploration.
A 26 year old lactating mother has cracks in the nipple and develops a fluctuating, red, hot, tender mass in the breast, along with fever and leukocytosis.

What to do next?
- I&D with biopsy of abscess wall

*abscess in nonlactating breast is cancer until proven otherwise
A 69 year old lady has a 4 cm. hard mass in the right breast, with ill defined borders, movable from the chest wall but not movable within the breast. The skin overlying the mass is retracted an has an “orange peel” appearance…or the nipple became r
breast cancer
- tissue biopsy
A 62 year old lady has an eczematoid lesion in the areola. It has been present for 3 months and it looks to her like “some kind of skin condition” that has not improved or gone away with a variety of lotions and ointments.

What to do next?
Paget's disease
- tissue biopsy
A 58 year old lady discovers a mass in her right axilla. She has a discreet, hard, movable, 2 cm. mass. Examination of her breast is negative, and she has not enlarged lymph nodes elsewhere.

What to do next?
breast cancer
- mammogram
- node biopsy
A 60 year old lady has a routine, screening mammogram. The radiologist reports an irregular area of increased density, with fine microcalcifications, that was not present two year ago on a previous mammogram

What to do next?
- first attempt should be stereotactic radiologically guided core biopsy.
- If unsatisfactory, the next move would be needle localized excisional biopsy.
A 44 year old lady has a 2 cm. palpable mass in the upper outer quadrant of her right breast. A core biopsy shows infiltrating ductal carcinoma. The mass is freely movable and her breast is of normal, rather generous size. She has no palpable axillary nod
- segemental resection (lumpectomy)
- followed by radiation therapy to the remaining breast, as well as axillary node dissection to help determine the need for adjuvant systemic therapy.
A 62 year old lady has a 4 cm. hard mass under the nipple and areola of her rather smallish left breast. A core biopsy has established a diagnosis of infiltrating ductal carcinoma. There are no palpable axillary nodes.

What to do next?
modified radical mastectomy
*Lumpectomy is an option only when the tumor is small (in absolute terms and in relation to the breast) and located where most of the breast can be spared.
A 44 year old lady shows up in the Emergency Room because she is “bleeding from the breast”. Physical exam shows a huge, fungating, ulcerated mass occupying the entire right breast, and firmly attached to the chest wall. The patient maintains that the
advanced breast cancer
- nonoperable, should do chemotherapy
A 37 year old lady has a lumpectomy and axillary dissection for a 3 cm. infiltrating ductal carcinoma. The pathologist reports clear surgical margins and metastatic cancer in four out of 17 axillary nodes.

What to do next?
adjuvant therapy
- premenopausal women get chemotherapy and postmenopausal women get hormonal therapy.
A 44 year old lady complains bitterly of severe headaches that have been present for several weeks and have not responded to the usual over-the-counter headache remedies. She is two years post-op. from modified radical mastectomy for T3, N2, M0 cancer of
breast cancer metastasis to brain
- CT scan of head
A 39 year old lady completed her last course of postoperative adjuvant chemotherapy for breast cancer six months ago. She comes to the clinic complaining of constant back pain for about 3 weeks. She is tender to palpation over two well circumscribed areas
breast cancer metastasis to bone
- bone scan
A 62 year old lady was drinking her morning cup of coffee at the same time she was applying her makeup, and she noticed in the mirror that there was a lump in the lower part of her neck, visible when she swallowed. She consult you for this and on physical
most likely benign thyroid nodule

worrisome feature
- young, male, single nodule, history of radiation to the neck, solid mass on sonogram, cold nodule.
A 21 year old college student is found on a routine physical examination to have a singe, 2 cm. nodule in the thyroid gland. The young man had radiation to his head and neck when he was thirteen years old because of persistent acne. His thyroid function t
- followed by surgery
A 44 year old lady has a palpable mass in her thyroid gland. She also describes losing weight in spite of a ravenous appetite, palpitations and heat intolerance. She is a thin lady, fidgety and constantly moving, with moist skin and a pulse rate of 105.
"hot" thyroid adenoma
- free T4 to confirm
- iodine scan to localize
- surgery after beta blocker
A 22 year old male has a 2 cm. round firm mass in the lateral aspect of his neck, which has been present for four months. Clinically this is assumed to be an enlarged jugular lymph node and it is eventually removed surgically. The pathologist reports that
metastatic thyroid cancer
- thyroid scan to localize primary cancer
- surgery
An automated blood chemistry panel done during the course of a routine medical examination indicates that an asymptomatic patient has a serum calcium of 12.1 in a lab where the upper limit of normal is 9.5. Repeated determinations are consistently between
parathyroid adenoma
- PTH determination and sistimibi can to localize tumor

symptoms: stones, bones, groans
A 32 year old woman is admitted to the psychiatry unit because of wild mood swings. She is found to be hypertensive and diabetic and to have osteoporosis. (she had not been aware of such diagnosis beforehand). It is also ascertained that she has been amen
Cushing's syndrome
- AM and PM cortisol levels
- dexamethasone suppression tests
- MRI of the head looking for the pituitary microadenoma, which will eventually be removed by the trans-nasal, trans-sphenoidal route.
A 28 year old lady has virulent peptic ulcer disease. Extensive medical management including eradication of H.Pylori fails to heal her ulcers. She has several duodenal ulcers in the first and second portions of the duodenum. She has watery diarrhea.

Gastrinoma (EZ syndrome)
- measure serum gastrin
- CT/MRI of pancreas to localize tumor
A second year medical student is hospitalized for a neurological work-up for a seizure disorder of recent onset. During one of his convulsions it is determined that his blood sugar is extremely low. Further work-up shows that he has high levels of insulin
Exogenous administration of insulin
- psychiatric evaluation and counseling
A 48 year old lady has had severe, migratory necrolytic dermatitis for several years, unresponsive to all kinds of “herbs and unguents”. She is thin, has mild stomatitis and mild diabetes mellitus

What to do next?
- measure glucagon levels
- CT/MRI of pancreas to localize tumor
- surgery
* if not operable, can use somatostatin or chemo (streptozocin)
What type of acidosis are these?

- high output GI loss: ex. diarrhea
- renal tubular acidosis
non-anion gap acidosis
- due to HCO3- loss
What does this indicate?

- EKG shows tombstone pattern: fused QRS, ST, ans T waves
What imagining mordality is best to localize adrenal mass?
This is a complication of supracondylar humerous fracture.

- ischemic injury to deep flexor of the forearm.
Volkman's contracture.
What does this indicate?

- wt loss
- icterus
- palpable nontender gallbladder
Couvoisier's sign for pancreatic cancer
What is the disease?

- necrolytic migratory erythema
- diabetes mellitus
- wt loss
- serum glucagon >150 diagnostic
How to prevent the most common sequalae of alkali ingestion?
- esophageal stricture
- to prevent: use steroid and antibiotics
What is this?

- air in mediastinum after episode of vomiting and retching
Boerhaave syndrome
How to manage Boerhaave syndrome?
- surgical exploration of mediastinum by left thoracotomy
- closure of esophageal laceration with reinforcement by a pleural flap + secure chest tube drainage
What is the most useful imaging study for possible myocardial contusion?
radionuclide angiography
What is this and how to manage it?

- blunt injury to the chest
- EKG: new RBBB, ST, T wave changes
This is myocardial contusion
- diagose by radionuclide angiography
- treat with inotrophs
Name some causes of chylothorax.
- iatrogenic injury during intrathoracic surgery
- malignant invasion/compression of thoracic duct
Management of chylothorax.
1) if happens during operation: double ligation of thoracic duct
2) if discovered after surgery: low fat diet and tube thoracostomy drainage/repeated thoracentesus
List some common causes of the mass in the following area of the mediastinum:

- anteriorsuperior region
- posteriorsuperior region
- middle region
- anteriorsuperior region: goiter, thymoma, lymphoma, germ cell tumor
- posteriorsuperior region: neurogenic tumor
- middle region: cysts
What is the origin of Zenker's diverticulum?
cricopharyngeus muscle near the level of the carotid bifurcation
What are some indication for coronary bypass surgery?
- chronic diabling angina
- crescendo angina
The following conditions could be related to this tumor in the mediastum:

- myasthenia gravis
- agammaglobulinemia
- red cell aplasia
Management of thoracic outlet syndrome.
- conservative: strengthen shoulder girdle muscles
- surgical: division of scalenus and medius muscle, 1st rib resection, cervical rib resection.
What is this disease? What is the cause?

- miosis
- ptosis
- anhydrosis
Horner's syndrome
- pancose tumor: bronchogenic
List some causes of this:

- xray: air-fluid level in pericardium
- penetrating/blunt chest trauma
- gas formation by anaerobes
- iatrogenic
- diseased adjacent organ: perforated ulcers etc.
What is this disease? How to treat it?

- upper extremity claudication
- syncopy attacks
- neurologic symptoms: vertigo, confusion, dysarthria, blindness, bruit
subclavian steal syndrome
- surgical bypass treatment: carotid-subclavian or subclavian-carotid transposition
What is this disease? How to treat it?

- claudication of buttocks, thighs,
- atrophy of the legs
- penile impotence.
aortoiliac occlusive disease
- aortoiliac bypass graft
- Axillofemoral and femoral-femoral bypass
What are some causes of retrograde ejaculation?
malfunctioning bladder sphincter
- reconstruction surgery
- transurethral resection of the prostate
- medications: tamsulosin, antidepressants, antipsychotics
- diabetes peripheral neuropathy
Name some post-op infection prophylaxis.
- mechanical cleansing
- pre-op oral antibiotics 1-2 days before surgery that cover aerobes and anaerobes: neomycin, erythromycin
- parenteral antibiotics given on call to OR, single dose for no more than 24 hrs.
What to do next?

- pt scheduled for elective cholecystectomy
- had an MI 2 days ago.
postpone surgery for 6 months
What should you do pre-operatively for this patient?

- vavular heart disease
- antibiotics to cover enterococcus and gram - bacteria: ampicillin and gentamycin
What are some causes of hypermagnesium?
- treatment of pre-eclampsia with MgSO4 till depression of deep tendon reflex
- advanced renal failure
- GERD that is treated with Mg containing antacids.
- IV oversupplementation
What is this electrolyte abnormality? How to manage it?

- decreased deep tendon reflex
- CNS depression
- respiratory failure
- calcium gluconate
- insulin + glucose
- lasixs
What is the pathogenesis?

- renal stone
- ileun removal
excessive absorption of calcium oxalate from colon -> excessive urine excretion of oxalate
- unabsorbed fatty acids and ca
- unabsorbed fatty acid and bile acids increase colon's permeability to oxalate
What are the following risk for breast cancer?

- first degree relative has breast cancer postmenopausal
- first degree relative has breast cancer premenopausal
- first degree relative has bilateral breast cancer postmenopausal
first degree relative has b
- 1.8 fold
- 3 fold
- 4-5.4 fold
- 9 fold
- 5 fold
- 3-17 fold
How do you manage this patient?

- no breast mass
- family history of breast cancer
- mammogram
- physical exam every 6 month

start at age 35 or 5-10 years before the first familial case
Stage and treatment for this peripheral vascular occlusive disease.

- symptoms: none
- signs: none
- ABI: 0.8 - 1.0
Stage I
- treatment: lifestyle and risk factors
Stage and treatment for this peripheral vascular occlusive disease.

- symptoms: claudication, exertional pain
- signs: decrease/absent distal pulses
- ABI: 0.41 - 0.8
Stage II
- treatment: lifestyle change + potential intervention
Stage and treatment for this peripheral vascular occlusive disease.

- symptoms: rest pain
- signs: decrease/absent distal pulses, elevation pallor
- ABI: 0.2 - 0.4
Stage III
- treatment: lifestyle change + probable bypass
Stage and treatment for this peripheral vascular occlusive disease.

- symptoms: ulceration
- signs: distal skin breakdown
- ABI: < 0.2
Stage IV
- treatment: wound care
Stage and treatment for this peripheral vascular occlusive disease.

- symptoms: minor gangrene
- signs: dedistal gangrene
- ABI: < 0.2
Stage V
- treatment: possible amputation
T/F: Lower extremity peripheral vascular occlusive disease.

- When tissue loss is noted, multilevel disease is usually present.
What is this?

- squamous cell carcinoma that arises in areas of chronic inflammation
Marjolin ulcer
Treatment for keoid.
- steroid injection
- re-excision
Treatment for hypertrophic scars.
- re-excision
- application of silicone sheets
- pressure garments
- steroid injections
What is this?

- bluish mass behind the tympanic membrane
- tachycardia, flushing
- hearing loss, tinnitus
glomus tympanicum tumor
- need surgical removal
What is this diagnosis?

- progressive unilateral hearing loss
- tinnitus
- dysequalibrium
- facial numbness
acoustic neuroma (CN VIII)
- diagnose with MRI with gadolinium contrast or CT
- treat with surgery if stable, observation and radiation if unstable
What is this disease?

- young child
- stridor, dysphagia
- otherwise not critically ill
- HPV6,11
- diagnose with microlayrngoscopy
- treat with CO2 laser ablation
/ 110

Leave a Comment ({[ getComments().length ]})

Comments ({[ getComments().length ]})


{[ comment.comment ]}

View All {[ getComments().length ]} Comments
Ask a homework question - tutors are online