Madigan General Surgery MSIII Quiz

Explanation:

Appendicitis should be high on your differential diagnosis for this young healthy male. However, other disease processes should be considered in the differential diagnosis. Both Meckel's Diverticulitis and Mesenteric Lymphadenitis can cause acute right lower quadrant abdominal pain. Other diagnoses to consider are nephrolithiasis, terminal ileitis (infectious or inflammatory), torsion of the epiploic appendix, omental torsion, urinary tract infection, right sided diverticulitis, inflammatory bowel disease, cholecystitis, and many more. In females, the differential diagnosis includes conditions of the reproductive tract such as ovarian torsion, ovarian cysts, pelvic inflammatory disease, and endometriosis.

Explanation:

Depending on the clinical scenario, it may be acceptable to manage a patient with a small bowel obstruction operatively or nonoperatively. Operative management usually involves and exploratory laparotomy or laparoscopy with lysis of adhesions (division of adhesion causing the obstruction). Nonoperative management of a small bowel obstruction typically involves decompressing the GI tract with an NG tube, maintaining the patient NPO, and maintaining hydration with IV fluids until the patient displays some return of bowel function. Magnesium citrate and enemas may be used in patients with constipation. However, constipation has a very different pathophysiology than a small bowel obstruction and the treatment for the two disease processes are not the same.

Explanation:

R-En-Y gastric bypass and sleeve gastrectomy are both options for patients who meet clinical criteria and desire surgical treatment of their morbid obesity. Distal gastrectomy with Billroth II reconstruction may be employed in conjunction with a vagotomy for the treatment of recalcitrant peptic ulcer disease. These procedures are rarely performed today due to the efficacy of modern antacid medications (PPI's and H2 blockers).

Explanation:

Gallbladder/biliary tract pathology includes the following diagnoses: biliary dyskinesia, symptomatic cholelithiasis (AKA biliary colic), acute cholecystitis, chronic cholecystitis, choledocholithiasis, cholangitis, ascending cholangitis. Of these diagnoses, ascending cholangitis is considered the condition that requires the most expeditious intervention (drainage of the bile duct). Emergent cholecystectomy is not required for any of the diagnoses listed above. Patients with acute cholecystitis are typically admitted to the hospital, started on antibiotics, and taken for cholecystectomy within the first 24 to 72 hours.

Explanation:

Patients with a palpable breast mass that, based on physical exam and radiographic studies, is concerning for malignancy should undergo tissue sampling prior to open biopsy or excision of any type. Tissue sampling is performed efficiently using ultrasound guidance and a core biopsy needle. Fine needle aspiration is not routinely used in the diagnosis of breast cancer as the diagnostic yield is typically poor. Once a diagnosis of cancer is made, a surgical plan to include treatment of the primary tumor (lumpectomy vs mastectomy) and axillary lymph node sampling (axillary lymph node biopsy vs axillary dissection) can be discussed with the patient.

Explanation:

Most women with early stage breast cancer elect for breast conservation therapy (BCT). The treatment of the primary tumor includes lumpectomy and radiation therapy (XRT). Lumpectomy is not typically offered to patients with breast cancer who refuse or are not eligible to receive XRT. Patients who do not receive XRT usually undergo mastectomy. All patients with invasive breast cancer undergo some form of axillary lymph node sampling. Currently the most common and least invasive method is via sentinel node biopsy. Axillary lymph node sampling is essential in order to assign the patient the correct pathologic stage. Pathologic staging is essential in order to decide the need for additional medical, surgical, or XRT therapies.

Explanation:

A surgical procedure is always required in patients who desire a cure for their colon cancer. Colon cancers are surgically excised by removing a segment of colon proximal and distal to the lesion and a generous portion of the adjoining colonic mesentery. Wedge resections of colonic masses are not oncologically sound surgical procedures. This procedure would lead to a high recurrence rate and does not obtain a sample of the colonic mesentery which provides addition staging information.

Explanation:

First line treatment for most hemorrhoids (internal or external) usually involves stool softeners, fiber, increased oral hydration, and possibly Sitz baths. Surgery is reserved for failure of medical therapy. The one exception to this rule is the acutely thrombosed hemorrhoid (presenting within 24 hours). This condition is treated by surgically evacuating of the clot.

Explanation:

A fluctuant perirectal abscess should be treated with incision and drainage. Depending on the size, pain level, comorbidities, associated findings, the procedure could be performed in the clinic or in the operating room. Patients should always be counseled that a fistula in ano may develop after the procedure and appropriate follow up should be advised. Oral or IV antibiotics without surgical drainage is insufficient treatment for an obvious perirectal abscess.

Explanation:

Females CAN develop both indirect and direct inguinal hernias. While females do not have a spermatic cord and thus do not have a persistent processus vaginalis, their equivalent embryologic structure is known as the Canal of Nuck. Women with a patent Canal of Nuck can develop an indirect hernia. Direct hernias in women and men occur through the same anatomic structures and boundaries (Hasselbach's triangle).

Explanation:

All children (regardless of age) who present with an incarcerated umbilical or inguinal hernia should be taken urgently to the operating room for surgical reduction and repair of the hernia. Young children, typically less than 5 years old, with reducible umbilical hernias can be safely observed as many of these umbilical hernias will resolve spontaneously. All children of any age with a reducible inguinal hernia should undergo elective hernia repair. Inguinal hernias do not resolve spontaneously and always require repair. Younger infants and children are at increased risk of incarceration of inguinal hernias.

Explanation:

The five 5 W's is a common mnemonic to remember the causes of post-op fever.

1. Walking (DVT/PE)

2. Wind (atelectasis)

3. Wound (surgical site infection)

4. Water (Urinary tract infection)

5. Wonder drugs (drug fever)

Watery Diarrhea is not a common cause of post-operative fever. Antibiotic associated colitis (c-diff colitis, not rotovirus) can cause a fever, but is a less common cause of post-op fever than the 5 W's.

Explanation:

Hypothermia, coagulopathy, and acidosis is known is known by many names (bloody viscous cycle, trauma triad of death, etc). The triad is multifactorial and self sustaining. It typically occurs in patients sustaining multiple serious traumatic injuries and massive blood loss. The cycle is best treated by employing preventative strategies (control of hemorrhage, patient warming, blood product replacement). For patients who develop this often lethal triad, the surgical principles involve control of surgical bleeding, packing to control non-surgical bleeding, contamination control, temporary abdominal closure, rapid return to ICU for continued resuscitation, and planned return to the OR in 12-24 hours. Definitive repair of nonlethal injuries is delayed until the patient is stabilized. This surgical approach is known as "damage control surgery".

Explanation:

Blunt abdominal solid organ injury is a common injury encountered by trauma and general surgeons. Commonly injured solid organs within the abdomen include the liver, spleen, kidneys, and pancreas. Surgeons can typically manage moderate grade blunt abdominal solid organ injury successfully by utilizing a nonoperative approach. Patients who are hemodynamically unstable or exhibit persistent bleeding may need more aggressive therapy to include interventional radiology procedures or laparotomy.